A Welcome Invitation
At the end of a busy clinic day last September—after seeing someone for concussion follow up and before starting procedures—I paused to grab a coffee and check email. In between the spam and pestering from my editor, a message leaped out. It was an invitation from the Australian branch of a well-known pharmaceutical company inviting me to visit Australia for 2 weeks in November. I had been an investigator on 5 clinical trials of calcitonin gene-related peptide (CGRP) monoclonal antibodies (MAbs) with this company, presented their data at key conferences, and published articles about these drugs in peer-reviewed journals. The message said this made me a logical choice to give a series of lectures and visit general neurologists and headache specialists just as CGRP Mabs were arriving on the sandy shores down under. The Aussie doctors, they found, had lots of questions and concerns. Would I please consider it?
Consider it I did—for about as long as it takes to say, “shrimp on the barbie.” This was a chance to check out a bucket-list destination during its glorious summer, just as Connecticut’s trees dropped their last leaves and we hunkered down for another winter slog. I’d get to visit storied university hospitals with names reminiscent of the British Empire—the Royal Melbourne, Liverpool Hospital, and Monash Medical Center—and have the opportunity to speak with leading headache specialists down under, discussing the most revolutionary breakthrough in headache medicine in a generation. Suffice to say, my arm did not suffer from twisting.
Brisbane, Tea, and the Pharmacy Benefits Scheme
After sorting through the logistics of leaving my practice for, as they say in Oz, a fortnight, I jetted halfway around the globe, from New York through Los Angeles, arriving 25 long hours later in subtropical Brisbane, Queensland. As the sun set, the early evening air was humid and slightly acrid from a series of wildfires raging in the parched brush to the south and west.
The following jet-lagged morning, after downing a full-on English breakfast, I met my handler Diana, and we headed to our first stop, Mater Hospital. On the way, Diana told me she emigrated to Australia from Hong Kong as a teenager, received her doctorate in molecular biology from the University of Sydney, and was doing neuroblastoma genetics work when she was recruited for the position of medical director for the company sponsoring my trip. Deciding to make the jump from academics to industry was easy, she said, because, “I couldn’t make a living at Uni” (I learned, Uni is Aussie slang for university). She was happy in her role, although she worked more hours than at Uni, and didn’t get to see enough of her young daughter.
Mater Hospital, like most medical centers in Australia, is divided into private and public sectors; our visit was to the private side. Australia has government-sponsored universal medical coverage for all citizens and private care with additional fees and quicker appointments. If hospital admission is needed, private care provides swankier rooms and services along with less pestering by registrars (ie, residents).
I presented at the Neurology Department weekly journal club, which, deliciously, was followed by tea, leading me to wonder why we don’t have tea after medical meetings in the US? I reviewed cases and discussed the CGRP MAb experience back home. Here, I learned about Australia’s pharmacy benefits scheme (PBS), which not only limits access to new drugs but routinely runs out of money less than halfway through the funding year. The neurologists I encountered were rather sanguine about it though, and “You get what you get, mate,” was a recurring theme.
Interestingly, Australia’s universal health care system is called Medicare and funded by a 2% tax on citizens administered by national, state/territory, and local bureaucracies. Shortfalls are covered by dipping into a general fund. Apparently, at least when it comes to medicines, shortfalls abound. For example, although onabotulinumtoxinA injections for treatment of chronic migraine are covered by PBS (for those who have tried and failed at least 3 other preventive medicines), the funds that cover the injections often run out by late spring each year. This leaves patients and clinicians scrambling. People who can afford to pay for the remainder of the year continue; those who cannot—well, they just get more migraines and pray for January to hurry up and arrive. “You get what you get, mate.”
That evening we had a dinner meeting at Clovelly Estate, a picturesque winery. As was to be the pattern throughout my trip, dinner meetings comprised 5 segments: introduction and discussion of migraine by a local headache specialist (tonight was Catherine Aeiry), followed by a local case presentation (Nicole Limberg discussed medication overuse). Then I spoke about CGRP in general, the company’s phase 3 data, and presented a few cases. Diana spoke next, discussing the nuts and bolts of her product (eg, it must be refrigerated). Last, came Jen, a benefits specialist from New Hampshire who fell in love with an Aussie and emigrated 13 years and 2 kids ago. Her job was to discuss the Pharmaceutical Familiarization Protocol, or PFP. This program, negotiated between the government and pharmaceutical companies, allows a neurologist to start a grand total of 10 people on a new CGRP MAb shot. Not per week, or month, but 10 total. This put our ability to hand out samples and access free prescriptions for new drugs in the US in a different light—sometimes you just don’t know a good thing when you have it.
Sydney, Researchers, and Work Arounds
The following morning, I flew south to Sydney. Dense, white smoke from brush fires appeared like shower steam from 30,000 feet. I wondered how many cottonwoods, acacias, and eucalyptus were being consumed, and thought of our own infernos in California. When I landed, I had a few small-group meetings at the Royal North Shore Hospital (public side this time), followed by a presentation at the headquarters of my pharmaceutical company sponsor. It was good to review clinical data with researchers, reinforcing the connection between what they do and how it translates into improving lives. The following morning included appointments with noted headache specialists Con Yiannikas, Julia Thompson, and Alessandro Zagami. Here I learned how they worked around the 10-patient PFP limit for CGRP MAbs. They simply “borrowed” the allowed 10 from nonheadache specialists. Professor Yiannikas admitted with a wink, “I ask my stroke, MS, and movement disorders guys to give me their 10.” By collecting others’ chits, he had been able to start over 100 people on 1 of the CGRP MAbs.
At dinner that night, overlooking a beautiful sailboat-studded inlet, Professor Zagami entertained us with complicated cases, grilling attendees in a way I hadn’t seen since I was at Queen Square, ages ago. It was fun, all back and forth and good-natured ribbing, and something we should do more of in the US. Headache expert Bronwyn Jenkins lectured next, followed by me, Diana, and then Jen.
The next morning I shared breakfast with Paul Spira, who trained with the late Jim Lance, a world-renowned Australian neurologist and his friend for 5 decades, in a leafy courtyard adjacent to the private offices Paul shared with his daughter, also a neurologist. Then I hustled off to grand rounds at Liverpool Hospital.
I had the weekend to discover Sydney and visited Manly and Bondi beaches, the Rocks, Barangaroo, Mrs. Macquarie’s Chair, and, of course, the iconic Opera House. My fitness tracker recorded 23,870 steps, all leading to a much-needed pint at Sydney’s oldest pub, The Fortunes of War, at the end of a long day. I was beginning to get used to the place.
Across the Outback to Western Australia
My next flight was westward, over the barren outback, to Perth—the most isolated metropolis on earth. It seemed incredulous that a city of over 1 million people conjured itself up on the shores of nowhere, Western Australia (or Wa, as everyone called it). Perth was a mining capital for a century in an area known for gold, nickel, and exquisite opals. No headache specialists were out this far, and I spent the day with general neurologists, including Julian Rodriguez, who allowed me to sit in on his morning clinical appointments. I met Colin, a laborer, with chronic cluster headache; Annette, mother of 5 with chronic migraine, and Lucy, a Uni student with atypical facial pain. As Julian rushed through patients, his French bulldog, who had just undergone an anterior cervical discectomy, snored sonorously at his feet. The Australians have roughly half as many tricks in their bag as we do in the US for migraine prevention and acute treatment, yet Julian made do. He was, nevertheless, looking forward to his 10 CGRP MAb trial patients, and scheming about who to hit up for 10 more.
The Melbourne Audience
The visit to Perth was brief, and after a dinner presentation at the Matilda Bay Restaurant, I jetted the following morning to Melbourne, that most European of Australian cities. Known for its coffee culture (I had to figure out the difference between a “long black,” and a “short white”), fine food, winding alleys dotted with shops and restaurants, and government-sanctioned graffiti, Melbourne seemed decidedly different from the rest of Oz, exuding an edgy, urbane feeling of “not quite down under.”
I toured and lectured at the storied Royal Melbourne. Grand rounds commenced in an old-school lecture hall, with ascending rows of unadorned wooden benches. That week, The Royal Melbourne hosted a visiting group of 37 Chinese neurologists, so the auditorium was standing room only. After my presentation, a visiting Chinese neurologist, came up to thank me for the talk, and to my surprise, placed a small gift in my hand: a silk purse containing a jeweled good luck charm.
After similar tours and talks at the Monash and Frankston Hospitals, our dinner presentation in Melbourne was the jewel in the 2-week tour crown with the largest audience. At the Melbourne Westin, 70 physicians gathered, with many more tuning in from rural areas via simulcast. Christina Sun-Edelstein, who trained with Larry Newman at St. Luke’s Roosevelt in New York before emigrating, kicked things off. Following her was Catherine Stark, whose father Richard (also in attendance) is regarded as the preeminent headache specialist in Melbourne. Diana, Jen, and I rounded out the program, followed by a spirited question-and-answer session, including queries relayed from the outback and beyond. A dinner that was supposed to end at 9:30 pm went well past 11:00 pm.
As I boarded my final flight back to the States, I sorted through my impressions of Australia—the country, the people, and their practice of medicine. Having flown coast-to-coast, I can attest to the huge size of Australia, which, geographically, is the same size as the continental US, although with fewer than 25 million inhabitants. Most everyone lives within spitting distance of the ocean, and the climate is dry and getting drier, causing droughts and the relentless wildfires. The cities are stunning, and the populace was every bit as friendly and fun loving as I imagined—think Canadians, with a slightly more relaxed atmosphere. Everyone under age 40 has multiple conspicuous tattoos. There seemed to be fewer homeless people on the streets than in a typical US city. Surfing is popular despite the numbingly cold water. Jacarandas, exploding with purple majesty, are my new favorite trees. Everyone seems to hate the ibis, a long-beaked bird colloquially known as bin chicken. Vegemite…well, that should—must, really—stay in Oz. People call their doctors by first names, and a neurologist wouldn’t be caught dead wearing a white lab coat. The only kangaroos and koalas I saw were in the airport giftshop, and I was thankful to have avoided black snakes, box jelly fish, and the dreaded Huntsman spider (look that one up on the internet, if you dare).
Despite the rationing of new medicines like the CGRP MAbs, the health system seems to be doing something right. Australia was ranked second in the 2018 Commonwealth Fund ranking of health care in 11 developed countries. The US finished last. I had spoken to as many Aussies as I could, from hotel staff to waiters, Uber drivers, and others, about healthcare in their country. To a person, they were all pleased with it, liking both the inexpensive public system (no copays for doctor and emergency room visits) and the ability to go private when the need arose. In fact, the government encourages all permanent residents to buy supplemental private insurance, which discounts premiums by age—the earlier in life you buy in, the lower the premiums.
As for the neurologists I interacted with—they seemed, well, refreshingly happy. They had heard about physician burnout in the US and were keen to know more about it from me. I deferred, mostly. Electronic medical records were slithering like an outback adder into their workday, as were bundled payments, pay for performance, and the rest of modern medicine that drives us, half a globe away, batty. Burnout, like the dreaded box jelly fish, would wash up on their shores soon enough. I figured I’d let them enjoy ignorant bliss for as long as possible. They were warm and gracious hosts, those Aussies—it was the least I could do.
2. Behan, Pamela. Solving the Health Care Problem: How Other Nations Have Succeeded and Why The United States Has Not. SUNY Press, New York, NY.
4. The Commonwealth Fund. US Ranks Last Among Seven Countries on Health System Performance Measures. https://www.commonwealthfund.org/publications/newsletter-article/us-ranks-last-among-seven-countries-health-system-performance Accessed December 12, 2019.
5. Australian Government. Latest national visitor survey (NVS) results. Domestic. https://www.tra.gov.au/Domestic/domestic-tourism-results. Accessed December 12, 2019.
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