Medical Forum 12/14 Public Edition

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Christmas Wishlist t FSH Momentum t Controlling New Outbreaks t Food Labelling Changes t Travel Medicine; Precocious Puberty; STIs t Doctors Drum: Politics in Medicine

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Contents

December 2014

14

19

22

16

FEATURES

LIFESTYLE

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46

16 19 22

Trailblazer: FSH Chief Dr Robyn Lawrence Dr Paul Armstrong: Man vs Wild Mr Jock Barker’s Big Issue Doctors Drum: Who Calls the Shots?

47 48 49 50

NEWS & VIEWS 3 4

4 12 19 20 21

Editorial: Year in Review Letters: PHNs – More Questions than Answers – Dr Martin Whitely, PhD Community Must Lead Right-to-Die Change – Ms Alannah MacTiernan Obligations to Those Who Suffer – Prof Stephan Millett Fees and Funds – Change is Needed – Dr Peter Campbell We Assist, Not Intervene – Dr Michael Aitken Curious Conversations – Dr Alison Creagh Have You Heard? Beneath the Drapes The Health of Obstetrics Health Star Rating – Will it Work?

52 54 55

Island Hopping in Greece – Dr Bruce Bridges Satire: Ms Wendy Wardell and Budget Airlines Funny Side John Duval Wines – Dr Louis Papaelias Social Pulse: Clinipath Opening; RACGP WA Faculty Awards Night; Bethesda Foundation Charity Ball; Amana Living Awards Night; WADMS launch Arts – Dr Who Spectacular; Fringe production; Les Miserables Competitions Thriller! Live

2014ISHES

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Greetings Feature See P27

W BESTOM WA'S FR A LTH LS H E S I ON A ES eature PROF s Greetings F Christma

te suppor s and r reader y New Yea ll our hes a nd a Happ is w m as a al Foru ri st m Medic Mer ry Ch a

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rs 23

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PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

INDEPENDENT ADVISORY PANEL for Medical Forum Michele Kosky AM Consumer Advocate Mike Ledger Orthopaedic Surgeon Stephan Millett Ethicist Kenji So Gastroenterologist Alistair Vickery General Practitioner: Academic Olga Ward General Practitioner: Procedural

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Clinical Contributors

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EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

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DR MARK HANDS Overview of Atrial Fibrillation

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DR JAMES HARRAWAY FAQs for Prenatal Testing

DR AIDAN PERSE 37 Polio and the War

PROF TOM BRETT 37 Q&A Multimorbidity

on Terror

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

DR LEWIS 39 MARSHALL New STI Management Guidelines

Ovarian Cancer

Pitfalls in Offering Travel Advice

DR GLYNIS PRICE 44 Pubertal Variations and Pubarche

Guest Columnists

MARISA 10 DR GILLES Striving for Equity

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN Thinking Hats

DR JASON TAN JENNIFER 41 Options 42 DR SISSON for High Risk

JUSTIN 28 DR COLEMAN

SALLIE 23 DR FORREST Australia Isolated on Climate Change

MR CLINTON 24 HEAL Sharpen Up Melanoma ma Detection n

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Editorial

By Ms Jan Hallam

Vital Signs; Prognosis Unclear

Managing Editor

L

ooking back over the year, there have been some watershed moments in WA health recorded in our pages that will resonate for many years to come. Fiona Stanley Hospital began its staged commissioning signalling the sometimes painful transition of services and the closure of smaller hospitals. Doors open, doors close. Medicare Locals, demonised and distrusted by some – yet barely three years old – were swept away in a political king wave taking baby, bathwater and some promising good work with it. In six months’ time, Primary Health Networks will emerge on whatever foundations remain of their long list of predecessors. However, the transparency of the process has been woeful, not just for the taxpayer but for those courageous few who are staging bids for the three PHNs in WA. Information has been scant and slow to appear leading to a playing field that looks anything but level. The Federal Government wants the PHNs

to operate as professional businesses. That’s no bad thing necessarily – everyone wants to see the taxpayer dollar work hard and effectively. However, this model – open to all – leaves the door wide open for corporationstyle development and there is only one real motive along that road – profit.

could talk about. Some were well into ‘trial’ collaborations with general practice where fund members would get preferential treatment. Add the serendipitous privatisation of Medibank Private and suddenly we’re all talking about the cost of care and not the quality of, and access to, care.

The ‘P’ word cropped up again in our investigations into private health funds, a debate that still rages in this edition [see Letters]. There is real and growing anxiety from every corner of health about the future of public (Medicare) and private health insurance and, importantly, who calls the shots when it comes to patient care.

This year saw the election of Mandurah GP Dr Frank Jones to the national presidency of the RACGP. In simpler times it would be cause for some parochial flag waving and then back to business, but these times are far from simple. Elevating the general practice message in Canberra needs all the wise heads it can get.

At the last Doctors Drum of the year [see P22] one specialist expressed his concern that health funds were now telling him what he could and couldn’t do for his patients. That is managed care in anyone’s language.

But no one man or organisation can do that alone. Retired MHR Dr Mal Washer at October’s Doctors Drum urged the medical profession (perhaps more accurately, individuals – you, him, her, us) to get off its hands, draw a line in the sand and fight for a fair and just health system. That’s easier said than done, Mal… but it is a start. O

It may also be a sign of things to come. In July, private health funds held their annual conference and primary care, specifically general practice, were all they

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Letters to the Editor

PHNs – more questions than answers Dear Editor, Even well-planned and executed policy changes have inevitable teething problems. The oldest of the Medicare Locals is just three. This was barely enough time to iron out the kinks. Nonetheless, the Abbott Government has determined that the Medicare Local model is fundamentally flawed and decided to rip it up and start again. Whether this is a fair analysis or driven by politics and ideology is largely an academic debate, because one thing is certain, change is coming. The most striking aspect of the imminent change from WA’s eight Medicare Locals to three Primary Health Networks (PHNs) is how little is known about the process. Although potential players may be positioning themselves to bid, the formal tender process has not begun.

WA will there be a loss of local knowledge? And how will the interests of difficult (and expensive) to service consumers be protected? Potential for Local ‘For Profit’ Monopolies – Although there have been assurances that PHNs will only deliver services in ‘exceptional circumstances’ there are no clear guidelines as to what these circumstances may be. In addition, for-profit organisations can tender to be PHNs. Therefore it is possible that using taxpayer funds, profit-driven businesses may procure services from themselves, particularly in isolated areas where there are no alternatives. How these potential conflicts of interests will be managed is unclear. Hopefully time will show that these concerns were unfounded, but at this relatively late stage there are simply too many questions and too few answers. Dr Martin Whitely, A/Executive Director, Health Consumers Council of WA

As shown by the Rudd Government’s home insulation program, rushed implementation often equates to botched implementation. Therefore the July 1, 2015, deadline for PHNs to be fully operational seems naively optimistic.

Community must lead rightto-die change

From a consumer perspective there are number of concerns about the imminent change:

For many decades, a very sizeable majority of Australians have supported people with a terminal illness having the right to choose when to die.

Continuity of Service – As Medicare Locals wind down and inevitably lose staff and focus, will consumers suffer? Isolated and Unprofitable Consumers – With one PHN servicing all of regional

Dear Editor,

This is a pro-life position. The prospect of a good, dignified death is life enhancing. Indeed in jurisdictions where voluntary

euthanasia is permitted, around one third of those who jump through the legislative hoops to gain authorisation to be prescribed the drugs do not use them. Just knowing that the pain and indignity can be ended if it becomes unbearable, gives value to those last months or years of life. Notwithstanding strong community sentiment in favour of people having control over their own life, politicians generally have been wary of supporting legislation. Change will only happen if there is an active community campaign that assures politicians that supporting this legislation will not be a net electoral negative for them. This is what happened with abortion law reform, which was equally controversial. There is a legitimate concern that elderly people might be pressured into this step by greedy families – or just by their own concern about being a burden on others. This is one of the reasons why the draft legislation is proposing rigorous hurdles to overcome before having access to the relevant drugs, including assessment by two general medical practitioners and a psychiatrist. The Parliamentary group supporting the legislation has advice that it is within the constitutional capacity of the Federal Parliament to legislate for the provision of these medical services. We believe it is better to have a law that is equally available to all Australians rather than to leave it to individual states and territories. The legislation protects the right of medical practitioners to elect not to provide these services for reasons of conscience. Professional opinion is obviously mixed but Continued on P6

Curious Conversations

Tuning up for Christmas The cello will be in fine tune this Christmas for Dr Alison Creagh from the Women’s Health Services in Northbridge. What I’d most like for Christmas is… 500 hours of house cleaning and gardening services. Why do these jobs always fall to the bottom of the priority list?

If I could play one piece brilliantly on the cello it would be… a piece written just for me by the marvellous Australian composer, Elena Kats-Chernin. Or, with my musical trio in mind, Beethoven’s Piano Trios – he was such a brilliant composer. But really ANYTHING in tune, given the rust that has accumulated on my cello! 4

The saddest moment I’ve ever had as a doctor was… when one of my patients with severe mental health issues, who had finally connected with a mental health professional and was feeling more hopeful about the future, was suddenly told that this professional would no longer see her. I knew that she had lost all hope, and that her long-threatened suicide was now almost inevitable.

The place I’d most like to live is… somewhere cooler with wonderful wildflowers. Anywhere on the south coast of WA would be lovely. A few books I rave about to friends are… ooh, how to choose? Marina Lewycka’s, We Are All Made of Glue for its beautiful writing, its portrayal of diversity and its surprisingly evil social worker; Graeme Simsion’s, The Rosie Project for an entertaining but painful portrayal of a man with Asperger’s; and the Commisario Brunetti detective novels by Donna Leon, just because they’re set in Venice! O

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Letters to the Editor Continued from P4 it was pleasing to see 51 % of practitioners polled in WA considered voluntary euthanasia as ‘an acceptable option’. Next step is to mobilise all those people who keep telling pollsters they believe in the right to die with dignity, so thought may translate into action. Ms Alannah MacTiernan, Federal Member For Perth

Obligations to those who suffer Dear Editor, Discussion on assisting people to die often rests on a supposed right to die [Engaging in the Dying Debate, November]. In Australia, there is clearly no legal right to be assisted to die, so, if there is a right to assisted death, it must be a moral right. In terms of moral rights, the right being claimed is best thought of as a welfare right – a right to get help to do what you need. Rights, once agreed, tend to settle disputes but in the case of a supposed right to die, the right itself is unresolved and remains problematic. So perhaps it is appropriate to dispense with talk of rights and find other more helpful concepts. Let us then talk of obligations. Using obligations as a basis for moral decisionmaking can help us become pro-active in difficult situations. Rights, on the other hand generally push us into reacting to claims made by others. We can readily agree that we have

obligations to others: the obligation not to cause unnecessary harm is one. Another might be an obligation to ask what help another person needs. If we have an obligation not to cause unnecessary harm and to ask what help another needs, do these prevent us from helping someone to die? An answer to this hinges on what harm is. If we start by assuming that death is always a harm, the answer is clear: do not assist people to die. However those who witness the suffering of terminally ill people frequently report death as being welcome, as a relief from suffering. Suffering is a harm in anyone’s view, but if death is a welcome relief from suffering, must death always be considered a harm? Let us put that question on hold and agree that we have certain obligations to those who are suffering. We can recognise that we have an obligation to limit suffering and argue that, in extremis, ending suffering requires ending life. That is one way. But we also have an obligation to optimise hope – not just any hope, and not false hope but what philosopher John Nolt calls satisfiable hope. This is the hope that Christian Rossiter (a quadriplegic totally reliant on care) was given by Chief Justice Martin of the WA Supreme Court in judgements relating to Brightwater Care Group and Mr Rossiter in 2009. The Court’s finding had two effects – it first clarified “the legal obligations under Western Australian law of a medical service provider… [when] a mentally-competent patient … clearly and unequivocally stipulates that he does not wish to continue to receive medical services which, if discontinued, will inevitably lead to his death” – and, secondly, it gave Mr Rossiter

hope that he could end his suffering. Mr Nitschke is right when he says the medical profession will be compelled to confront the issue of euthanasia. But the rest of the community must confront this first so that it becomes possible – at law – to bring an end to suffering and to bring hope that there may be an early end to their suffering. Prof Stephan Millett ED: Prof Millett is a moral philosopher who lives in Perth

Fees and funds – change is needed Dear Editor, I would like to comment on your editorial [One Gap Too Far?, October] with respect to gaps and fees. This is a very vexed question affecting the medical profession but I think a few things need to be clarified. Firstly, private health insurance was never designed to cover surgeons’ and doctors’ fees. Its main function is to cover the so-called hidden costs, which are hospital bed fees, theatre fees, cost of prosthesis, etc. It has been estimated that for a single surgical experience in a private hospital the actual medical fees would represent less than 15% of the total overall cost of that procedure. This is not widely known by the vast majority of patients as it is never communicated to them by the various health funds. Secondly, legislation, some years ago now, required health funds to produce a no or known gap product with very little consultation with the medical profession. Though most health funds deny it, it became apparent that the rebates they were prepared to pay was about 35% greater than the Medicare rebated fee. Subsequently, all health funds have continued to offer their co-payment based on their MBS item numbers. This is a very flawed situation. The MBS item number is not a relative value figure and never has been. It was designed as a co-payment the Australian Government was prepared to make to its citizens to help offset some of their health care costs. This situation has never been changed. With failure to keep in line with CPI, the MBS system is grossly out of touch with reality. Thirdly, it is impossible for a group of doctors to meaningfully discuss a schedule of fees that is commensurate with the complexity of surgery and degree of care so the various health insurance companies can adequately cover their patients because the

Continued on P8 6

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Major Sponsor: Western Cardiology

Overview of Atrial Fibrillation

Dr Mark Hands Clinical Associate Professor (UWA), Interventional Cardiologist

About the author Atrial fibrillation (AF) is the most common clinically relevant arrhythmia encountered in general practice. The prevalence rate in the overall population is approximately 1%. This increases with age reaching approximately 10% in those over age 80. It can present with a wide variety of symptoms including palpitations, chest pain, dyspnoea, reduced exercise tolerance, presyncope/ syncope, transient ischaemic attack, stroke and/or other thrombotic complications. Some patients have no symptoms at all. AF, based on the duration of the arrhythmic episode, is described as paroxysmal (<7 days), persistent (>7 days), or permanent. Paroxysmal AF is predominantly a disease of pulmonary veins. The left atrial myocardial cells extend into the proximal portion of the pulmonary veins. The arrhythmia is triggered by abnormal foci of rapidly firing myocardial cells within these regions. These subsequently spread to involve both atria. Persistent or permanent AF is complex. Whilst triggers in the proximal pulmonary veins initiate the arrhythmia, abnormalities in the atrial tissue tend to promote AF re-ignition. AF maintenance is associated with larger atria, fibrosis, ischaemia, re-entrant circuits with numerous extrinsic factors contributing to adverse atrial remodelling.

therapy should be considered early for catheter ablation. This procedure is aimed at restoring and maintaining sinus rhythm. It does not eliminate the need for anticoagulation. The latter is determined by the CHA2DS2VASc score (see below). Rate control strategy This is an alternative to rhythm control, especially in patients with persistent and permanent AF and of an older age. Medications slowing the AV node (i.e. beta blockers, non dihydropyridine calcium antagonists and digoxin) are most commonly used. If there is still inadequate control after maximally tolerated pharmacotherapy, AV node ablation (AVNA) and pacemaker insertion can be considered. This is more commonly considered for the elderly, taking note that it renders the patient irreversibly pacemaker dependent. Again it does not remove the need for anticoagulation. Importantly, permanent right ventricular pacing can induce or worsen left ventricular dysfunction in some patients who may then require biventricular pacing to improve cardiac function.

Thromboembolic risk management The left atrial appendage (LAA) is the predominant source of emboli in patients with nonvalvular AF and embolic stroke. Up until recently, warfarin has been the mainstay of anticoagulation. The arrival of the novel oral anticoagulants (apixaban, dabigatran, rivaroxaban) have increased the options without the need for regular monitoring. Unless contraindicated, patients with CHA2DS2VASc score of 2 are anticoagulated, those with score of 0 are not and those with score of 1 may receive either anticoagulation or aspirin for thromboembolic protection. Where anticoagulation is contraindicated or ineffective, patients may be considered for non-surgical, non-pharmacological percutaneous LAA occlusion. Two devices (Watchman and Amplatzer) are currently available (Figure 1). Patients considered for this procedure include those with specific contraindication for anticoagulation, previous intracranial haemorrhage, recurrent gastrointestinal bleeding, co-morbidities that increase the risk of bleeding and perhaps patients with recurrent ischaemic events on optimal anticoagulation. It is a relatively low risk procedure (2-4% complication rate) with high success rate (about 95%). The procedure is approved in Australia.

Management There are two aspects to treatment i.e. cardiac rhythm management and anticoagulation. Rhythm management either involves attempts to restore sinus rhythm or control the rate (i.e. accepting AF, but with adequate ventricular rate control). The choice between rhythm or rate control is predominantly determined by symptoms, duration of AF, age of patient and associated comorbidities. Rhythm control strategy Appropriate in symptomatic patients usually of younger age. First-line approach is use of antiarrhythmics (e.g. Sotalol, Flecainide or Amiodarone). Patients who remain symptomatic despite medical

Dr Mark Hands graduated from UWA with Honours (Dux) and trained in cardiology at Sir Charles Gairdner Hospital and Brigham Women’s Hospital, Harvard Medical School. He is an interventional cardiologist in private practice at Western Cardiology (chairman), Clinical Associate Professor (UWA) and emeritus consultant cardiologist at SCGH. In addition to general cardiology and echocardiography his special interests include investigation and treatment of acute and chronic ischemic heart disease. Dr Hands’ interventional procedural skills include coronary angiography, angioplasty and stenting in stable angina and in acute unstable angina and acute myocardial infarction and cardiac pacing.

Q Fig 1: Percutaneous Delivery of Watchman LAA Closure Device.

Image provided courtesy of Boston Scientific. Š 2014 Boston Scientific Corporation or its affiliates. All rights reserved.

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Letters to the Editor Continued from P6 ACCC would consider this to be a form of price fixing. I have had personal experience of this when I was Secretary of the Shoulder and Elbow Society of Australia. Any attempt to reach consensus on appropriate fees was thwarted by ACCC regulations. The AMA and our various colleges need to lobby the Government to rectify the situation so that meaningful discussion can finally be undertaken. Fourthly, I totally agree that all patients should be given a clear accurate quote as to the potential costs of their surgical procedure or medical intervention. This should be supplied to the patient so they have adequate time to consider and also to seek the services of other practitioners if they consider the quote is prohibitive. I believe that our various medical professional bodies should be the arbiters of what is a fair and relevant fee for services but meaningful changes will only come with political change. Dr Peter Campbell, Orthopaedic Surgeon, Subiaco

We assist, not intervene Dear Editor, I agree with Dr Donald Clark who wrote in response to the recent articles published on caesarean sections in Western Australia [August edition] – one a feature article on Dr Janet Hornbuckle, and the second a straw poll of 40 health consumers. It is hard to believe that a poll of 40 random health consumers is likely to add to the scientific debate on what is an

appropriate caesarean section rate. To dress what is effectively an opinion piece up as some form of science on a small nonrepresentative poll is inappropriate. There seems to be a bias against private obstetrics. Dr Hornbuckle further perpetuates this bias when comparing the debates on home birth policy to indigenous women’s health, which are quite separate issues. The recent Coroner’s Court Enquiry in WA into home birth deaths is very sobering. In the September edition there was a letter from Dr Sarah Bays on behalf of the Australian College of Midwives WA Branch which makes a number of inaccurate and misleading claims. To claim that private obstetricians routinely have a case load of 40 deliveries per month was inaccurate, and then to imply that this is the reason why she believes there is a high rate of so-called intervention is completely personal opinion and also misleading. There is evidence from extensive demographic data collection within Australia in recent years that clearly links the increased rate of medical assistance in child birth, including caesarean section rates, with changes in patient characteristics of the population having babies, that is pregnant women are older and more obese than previously. Age and obesity both increase obstetric risk, and those two factors alone are the major reason for the increase in caesarean section rate. It is very easy to criticise caesarean section rates without looking at the true reasons for the increase. Never forget that Australia has one of the safest maternity health care systems in the world. It is high time we change the terminology from obstetric ‘intervention’ to obstetric ‘assistance’ in order to see it as it truly is.

Les Conceicao (MBA MIR BA Grad Dip FP FFin AFP)

Senior Financial Adviser Authorised Representative 296710

08 6462 1999 | www.morgans.com.au/perth Level 20, 140 St Georges Tce Perth WA 6000

The vast majority of Australian women are extremely happy with the maternity care they receive. Dr Mike Aitken, President (Elect), National Association of Specialist Obstetricians and Gynaecologists (NASOG) References on request O

Editorial Comment Readers have asked about Major Sponsors‌ Major Sponsors of Medical Forum magazine work within the WA medical community. Each feels the need to offer something extra to the medical profession. We value their distinctive contribution to this reputable industry publication. Medical Forum was founded over 20 years ago by two people working within the profession, and the improved quality and readership of the publication since then speaks volumes for all involved. Independence, dedicated WA focus, and ethical behaviour are the cornerstones of the publication’s success. Major sponsorships are offered on that basis.

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Dr James Harraway (Genetic Pathologist), Sonic Healthcare and Dr Henry Preston (Pathologist) Clinipath Pathology.

FAQs for Prenatal Testing Over the last five years, a non-invasive predictive screening test for common chromosomal abnormalities has been developed. This article outlines the applications and pitfalls of the test, which is available through Clinipath Pathology.

What is NIPT? The non-invasive prenatal test (NIPT) screens for common chromosomal abnormalities. The test involves fragments of fetal DNA found in maternal blood. The test has high sensitivity and specificity for the targeted abnormalities, compared with other screening tests, but this is not 100% as false positives or negatives can occur. Therefore, all positive results should be confirmed by invasive testing if termination of pregnancy (TOP) is being considered.

What do these tests screen for? In Singleton Pregnancies a) Aneuploidies* of chromosomes 13, 18, 21 b) Additional optional screens can include: i) Aneuploidies of chromosomes X & Y (this also discloses genetic sex of fetus); variable in their clinical severity, which should be addressed in pre-test genetic counselling. ii) Aneuploidies of chromosomes 9 & 16. iii) Five microdeletion syndromes: 1) 22q11.2 deletion, 2) 1p36 deletion, 3) Angelman/Prader-Willi, 4) Cri-du Chat, 5) Wolf-Hirschhorn; microdeletions often arise de novo, are individually rare but collectively are more common (about 1/1500 combined incidence, for this panel); at the same time results from routine first trimester screening may be normal. In Twin Pregnancies a) Aneuploidies of chromosomes 13, 18, 21 in all pregnancies. b) Additional optional screen for Y chromosome material (i.e. whether at least one twin has one or more Y chromosomes)

8IBU JT /05 TDSFFOFE GPS i)

Less common or ‘atypical’ chromosomal abnormalities (that comprise about 20% of all chromosomal abnormalities, and occur more often when there are ultrasound-detectable fetal structural anomalies or high risk scores on standard prenatal screening).

ii) Single gene disorders such as Huntington disease or Cystic Fibrosis iii) Non-genetic disorders (neural tube defects, placental abnormalities, IUGR)

How is NIPT used clinically for $PNNPO "OFVQMPJEJFT 9 and Y)? With no Australian guidelines to refer to, the following should be considered: a) NIPT is not intended to replace other prenatal screening. Fetal ultrasound/’standard’ prenatal screening can give information on non-genetic conditions and standard screening also separately estimates the risk of chromosomal abnormalities. b) NIPT is most useful for patients of intermediate to high risk (e.g. 1/50 1/1000). The negative predictive value (NPV) of a ‘no aneuploidy detected’ result is high in this patient group (although not 100%). These may include patients: with advanced maternal age; personal/family history of aneuploidy; and those with intermediate to high risk on the combined first trimester screen. The positive predictive value (PPV) is high in this patient group, but because false positive results can occur, confirmatory invasive testing is recommended for any positive NIPT result, if TOP is being considered. c) Appropriate pre-test counselling in low risk patients. The NPV of a “no abnormality result� will be very high, but PPV will be significantly lower in low-risk patients, who should be counseled accordingly. Confirmatory invasive testing would be strongly recommended for a positive result if TOP is being considered.

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au

d) NIPT is an inappropriate stand-alone test in ‘very high-risk’ patients. Patients with ultrasound detected fetal structural abnormalities, or a very high risk on the first trimester screen for aneuploidy (e.g. combined FTS risk >1/50) should be considered for invasive testing, because the NPV of NIPT for chromosomes 13, 18, 21, X and Y will be slightly lower, and the incidence of ‘atypical’ chromosome abnormalities increased.

How is NIPT used clinically for 5SJTPNZ BOE .JDSPEFMFUJPOT NIPT may be appropriate in selected patients (see below), bearing in mind that where the incidence of abnormalities is low, so is the PPV. a) Trisomy 9 or 16. In patients with a prior history, if trisomy is detected, referral for genetic counselling is indicated. (In the general patient population, NIPT usefulness is restricted because these abnormal pregnancies almost always result in miscarriage, and PPV will be relatively low.) b) Microdeletion Panel. Invasive testing is the only definitive test for microdeletions, so while NIPT may be useful for those who wish to avoid invasive testing, its usefulness for the general patient population is limited by a relatively low PPV.

How is the Test Requested? t 5IFSF JT B TQFDJGJD SFRVFTU GPSN which must be signed by both doctor and patient. t "WBJMBCMF GSPN XFFLT HFTUBUJPO t " QBUJFOU BQQPJOUNFOU JT OFDFTTBSZ UP meet special collection requirements. t 'VSUIFS JOGPSNBUJPO SFHBSEJOH /*15 JT available from Ms Natalie Park on 08 9371 4424 * Aneuploidies are any deviation from an exact multiple of the haploid number of chromosomes.

Incisions

Striving for Equity Midwest Physician %S .BSJTB (JMMFT understands it when people say we can get too involved but she doesn’t necessarily agree.

S

ince becoming a doctor in 1983, I’ve gravitated to working with the most vulnerable in society. There is a lot of talk about everyone being born equal but this is far from the truth. There is no such thing as ‘the level playing field’; on the one hand we have people born with privileges such as loving families, good education and freedom from violence and on the other hand we have those who are homeless, living in war-torn countries, or without basic amenities such as clean water and adequate food. Even in this lucky country, pockets of our society are significantly disadvantaged and this includes our Aboriginal community, those who are incarcerated, those who inject drugs and people with Hepatitis C and HIV. As doctors, equity means striving for the same outcomes in everyone, and some disadvantaged people need more of what we can give to achieve that. The people I work with have had difficult and complex lives complicated by abuse of alcohol and other drugs. I have worked in my local prison (11 years), supported people living with HIV and Hep C, and worked in Aboriginal

needs to be holistic and includes providing transport to see sick family or attend funerals, and providing money for emergency housing. Ironically, often those in society who require more facilities receive less – the best parks and sports centres are located close to the expensive districts and often the worst parts of town are isolated and become ghettos of poverty and unrest.

health (23 years). We still have a long way to go to Close the Gap – not without an increased investment in education and subsidised food and housing. Some have accused me of doing too much and getting too personally involved but health care in these environments must go beyond doing investigations and providing medication. It

The social gradient in Australia has a lot to be desired – far from improving, the gap between the very poor and the very rich is growing. Nordic countries are a great example of how to redistribute wealth to support the disadvantaged that helps everyone resulting in less crime and a more level society. As doctors we have a duty to advocate for the disadvantaged members in our community. In the words of Frank Scott MD, MS: “We must identify community needs and then devise effective approaches to address them. See the need, grasp the need, meet the need... how and who we serve depends on who and where we are” (see www.ajpmonline.org). O

Doctors’ Service Awards – NOMINATIONS NOW OPEN N Rural Health West will once again celebrate the achievements of outstanding and extraordinary rural doctors at the 2015 Rural Health West Doctors’ Service Awards. Wesfarmers provides the recipients of the following special awards with $5,000 to contribute towards professional development: z The Award for Outstanding Service to Rural and Remote Health z The Award for Extraordinary Contribution to Outreach Services z The Award for Remote and Clinically Challenging Medicine WA Country Health Service will also sponsor two special awards in 2015: z The Award for Above and Beyond – Community First z The Award for Outstanding Hospital Doctor

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11

Have You Heard?

months of hard slog to have the PHNs ready for business by July 1. In the last edition, we wrote incorrectly that Panorama Health was the largest MedicareLocal with 1.2m people and 1000GPs. In fact those figures are for the proposed North Metro PHN. O +()$ T XBUFSTIFE ZFBS O

ACCC talks tough

As we reported [September edition], there was considerable backlash against the apparent lack of transparency in the relationship doctors have with pharma under the proposed edition 18 of Medicines Australia’s Code of Conduct. The Code sets the standards for the marketing and promotion of prescription pharmaceutical products in Australia by member companies. The ACCC planned to endorse the Code with the proviso that any ‘transfers of value’ to individual healthcare professionals must be reported, rather than be ‘opt-in’ under the proposed Code. The AMA, which originally supported MA’s edition 18, has reportedly told the ACCC that any new transparency regime should be delayed for a year so doctors can ‘think about and plan for their ongoing relationships’ with pharma. The profession has had five years to consider it, given the ACCC approval of edition 17 was interim, to introduce greater transparency and increase disclosure.

It’s been a massive year for St John of God Health Care with stage one of the $236m Murdoch Hospital redevelopment complete, the acquisition of Mercy Hospital in Mt Lawley and the Midland public/private health campus on time and on budget. There was also good news on the business side as well with its annual report showing the Not-For Profit had posted revenue of $1.16b in the 2013-14 year, up from $1.07b the previous year. Its surplus rose 47% to $76.7m.

O

O 4FDSFU TRVJSSFMT Transparency is not the first word that springs to mind when talking about the proposed Primary Health Networks either. Medical Forum has not heard of any other WA bidder than the three we wrote about in the November edition but there could be others. There’s been speculation in other states about private health funds coming on board. While bidders are racing to submit their applications, there is no public information about governance, which is crucial. How will these massive organisations translate care to patients to improve health outcomes? No detail. How will outcomes be measured? What will be their KPIs? Again, no detail. The Government is scheduled to make its decision sometime this month (or perhaps the New Year, who knows) and then it’s six 12

O

The genes made me do it!

Cruise ship bar staff are worried for their jobs if largely abstaining Chinese patrons replace Australian passengers because there will be no work for them to do. Some attribute this to the older generation of ex-Communists not familiar with alcohol. However, heading into Christmas, it is interesting to note that, while almost 100 genes relate to alcohol metabolism, the two major ones appear to be alcohol dehydrogenase (aversive) and aldehyde dehydrogenase (addictive). About 20-40% of people from East Asia have a point mutation, resulting in high levels of acetaldehyde after alcohol with flushing, tachycardia, headache, nausea, and emesis from small amounts of alcohol. This mutation is much less common among European and North American populations.

Potent cocktails

Readers will be familiar with the work of Geraldton GP Dr Kathleen Potter’s research into deprescribing for the elderly in Aged Care Facilities [most recently, November edition]. The October edition of the TGA’s Medicine Safety Update shows what timely research it is. For instance, up to 30% of hospital admissions for patients older than 75 are medication related (and up to 75% preventable); 82% of people in RACFs take on average seven different medications (20% take more than 10); polypharmacy in the elderly is associated with worse physical and social functioning, more falls, delirium etc, and reduced adherence to essential medicines. An MJA article seems to come to the same conclusions as Kathleen that deprescribing is likely to produce more benefits than harms overall, with caution needed on some drugs. O

allergy; no heavy metal tests for non-specific symptoms and no history of exposure; no tests for Lyme disease for non-specific symptoms in the absence of travel to endemic areas; no serum tumour markers unless monitoring cancers that produce these markers; no routine test for lipids if a limited life expectancy; and no D-dimer assay in lowrisk outpatients where imaging can exclude venous thrombo-embolism. As well as clinical validity and utility, cost-effectiveness is behind the campaigns to address current inappropriate requesting trends.

Pathologists urge restraint

Health cost cutting has reached the Royal College of Pathologists of Australasia (RCPA) which has targeted inappropriate pathology testing with these guidelines: No surveillance urinalysis in the elderly without UTI signs and symptoms; no screening for Vitamin D deficiency; no PSA screening in men with no symptoms and life expectancy less than 10 years; no routine pre-operative screening for low-risk surgery; no IgG4 allergy tests, total IgE, or indiscriminate RAST batteries for

O 4FBSDI JT PO GPS QBJO MFBE About a year ago, we reported that Rossmoyne couple Geoff and Moira Churack had donated $1m to the University of Notre Dame for the establishment of The Churack Chair of Chronic Pain Education and Research. Geoff has chronic neuropathic pain. The university is on a nationwide hunt for a medical specialist to take the lead. Also contributing to the project is SJGHC. A ND spokesperson said there was no timeline at this stage for the decision though earlier the better. The university is hoping to raise a further $1m to ensure the longevity of the chair and program. O

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13

Trailblazer

FSH: A Stitch in Time… Fiona Stanley Hospital is open, now the real work begins with its Executive Director, Dr Robyn Lawrence, leading by example. Q FSH Executive Director Dr Robyn Lawrence

Media hype has surrounded the opening of Fiona Stanley Hospital (FSH). As it transitions soon from commissioning to full day-to-day operations, Dr Robyn Lawrence will come into her own. As executive director she has overall responsibility for all clinical services at FSH and the State Rehabilitation Services. FSH is brimming with enthusiasm. The hospital promises patient comforts, there is team spirit as clinical services are commissioned, and organisers are respectfully afforded leeway during the initial honeymoon period. Dr Lawrence said she is relatively new but feels it is all about selecting the right people for their respective jobs. “A huge amount of effort has gone into selecting this team, which has shown an amazing level of commitment. From the executive to the staff arriving on site, the energy and passion is huge. It is absolutely palpable. People are here for the challenge,” she said.

5IF SJHIU QFPQMF GPS UIF KPC Each of the four clinical service streams has two Co-Directors, one medical and the other ancillary health and nursing. She prefers to let those in charge of each large clinical stream get on with it, with clear parameters around budget, safety, quality and service delivery. “They run their business and I support them to do that. It’s all about the people. The skill of our directors has grown immensely. Good functioning teams are all about people and their relationships. If you want to stand on ceremony or your position on the organisational chart, it is very hard to do business.” She wants people who can get their heads around the detail and know what’s going on around them, people who share trust and respect, and can work as a team. This includes being able to work through disagreement constructively. 14

“Soon we’ll be a fully operational hospital with all the challenges that come with that, which can be quite draining. It’s OK while it’s all exciting – you can come in at ridiculous hours in the morning and finish late, but once you get into the more humdrum way of life, that becomes more challenging.” “I don’t want to lose the culture that we’ve built so far. Maintaining that is my biggest challenge because if I do that, the rest will keep working for itself.” She will take suggestions from anyone, including the younger ones who have travelled and seen different things, and she is aware that busy clinicians can easily lose heart if changes don’t go as they had hoped.

8IZ BENJOJTUSBUJPO BT B DBSFFS QBUI Maintaining the personal caring for every patient, every day, as she saw in some clinicians, was a challenge she was going to struggle with. At the same time, she was enticed by the broader influence of administration on health outcomes. “When I trained, you were taught to look at the patient in front of you and their needs, and that’s really important. But the reality is you can forget there is another patient behind them, and another, and 15 more on the waitlist. So how do we get the best for everyone in that group? That is the real challenge for clinicians because everyone wants to provide the best care for every patient.” The public system has both pluses and minuses. The medical workforce is often unchanging. Her perceptions around worklifestyle trends have a generational flavour (she has two boys in their teens). “We had some young doctors coming through who were quite brutal about where they were going and what they were going to do, with not a lot of altruism. Many of those doctors are my vintage or a bit younger.” With the emergence of postgraduate medical degrees, she describes some with amazing

skills beyond her expectations and she thinks if they bring some of those skills to FSH in the formative phase, this will be hugely beneficial. “Another thing that has changed is the expectation that early clinical years are paid training – when I graduated you had to train but it was never in my mind that you had ‘x’ percentage of time paid for to study. Now we give highly paid study time during the day.”

Her legacy and clinical ideals “If I could say every one of my clinical units was delivering evidence-based care in the most efficient way possible and reviewing what they were doing to ensure the best quality outcomes for patients, within budget, then I would think I had done a fantastic job.” Of course, funding and its appropriate use, underpins everything. “We are all coming to terms with the expectation that we have a fixed bucket of money. We know that some Third World countries, with life expectancy just 10 years less than us, deliver health care on one twentieth of our budget. If you look at it that way, it’s not difficult to deliver good health care within what we have. Unfortunately, we have models that are so entrenched it is difficult to turn it around.” She said innovation was the key to moving forward and meeting demand. This includes the electronic health record, to help reduce waste across the hospital-community interface. Access to allied health, psychological medicine, and community-run chronic disease programs are also prominent in her thinking, not to mention preventive health, from her time at Princess Margaret Hospital. “I’m a huge advocate of early intervention, especially in the early childhood period. Otherwise we are just chasing our tails.” O

By Dr Rob McEvoy medicalforum

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'FBUVSF

New Disease Outbreaks: Man vs Wild The Ebola outbreak has elements of déjà vu for Dr Paul Armstrong – patterns that should interest most doctors. Medical Forum investigates. The head of Communicable Disease Control at the HDWA, Dr Paul Armstrong, says the questions his department has been fielding about Ebola are not new. “I’ve Q Dr Paul Armstrong been working in that field for the last 15 years – we had SARS, then Avian influenza, then the Swine Flu pandemic, then MERSCoV last year and Ebola this year, so it is par for the course. Once you have been through a couple of these you realise there are lots of similarities,” he said. He explained that his comments were by no means comprehensive and were based on his personal impressions and experience. With any public health response, politics can override the scientific medical approach. Infections like Ebola are not immune to this possibility. Dr Armstrong says that accessing accurate information early is very important.

and eaten by humans. In the past, there have been relatively small outbreaks in forested remote areas in Zaire.” Changes in farming practices also affect the animal-human interface. “For example, the 1998 Nipah virus outbreak in Malaysia, where an intensive piggery was close to a forest with fruit bats; the pigs became infected by eating bat droppings and then spread it to humans. Cultural practices also have an impact, from trade in pets such as tropical fish or giant Gambian rats [monkey pox outbreak], to the continuing bush meat trade.” It seems that as the planet gets ‘smaller’, the potential for fresh outbreaks on a larger scale is increasing. The source of infection is not new, he said, looking back on important infectious diseases such as tuberculosis [cows], HIV [monkeys], Ebola and SARS viruses, and the Australian Hendra virus [all originally from bats]. Animals can be both amplifying hosts in vector borne diseases or the original source of infection.

“The Communicable Diseases Network across Australia meets every fortnight to discuss communicable disease issues from around the country and keep a watching brief on what is happening overseas. We can look at what is the risk to Australia, and what we can do to mitigate that risk.”

“Kangaroos are considered the intermediary amplifying host for RRV and Barmah virus, both vector borne diseases [mosquitos].”

“The Ebola virus is a case in point. A lot of people turn to the notion of putting up screens to stop it coming in, but unless we treat it at source, it will potentially snowball. Merely trying to stop it coming in is not a tenable option – we can’t just look after ourselves.”

“Avian influenza in humans has killed several hundred people. And there are about 200 million people in Asia and SE Asia who have close or direct contact with fowl every day, so that close contact is a worry for the development of pandemic influenza strains. It was said the H5N1 bird flu strain was going to change its genetic make-up and turn into something that is more adaptable to humans, but this hasn’t occurred.”

This takes us to three important points about newly emerging infectious disease outbreaks – most are zoonoses acquired from animals and risk to Australians depends on virulence and the risk of interaction with infected humans.

Zoonoses acquired Paul estimates that about 75% of outbreaks of new infectious diseases in recent decades have been acquired from animals – these may be organisms that have been around for a long time and re-emerge, while some, such as SARS, are probably new. “A lot of understanding comes from changes in the animal-human interface that leads to infections. Humans are now living closer to animal populations. There is evidence in bats of serological exposure to the Ebola virus, and the theory is they infect non-human primates and other mammals that either die or are shot 16

Virulence and human interaction The fear is that viruses that jump from animals to humans will mutate and become more transmissible amongst humans.

Ebola is a highly virulent virus, with up to 90% mortality. This makes it a health ‘hot potato’ as any contact is potentially catastrophic. “When Ebola was in isolated parts of the Democratic Republic of Congo [previously Zaire], it wasn’t such an issue for Australia because the number of people coming to Australia from there was very small. For the first time, Ebola has spread to the capital cities. There are now about six people a week coming to Australia from the three main affected countries in West Africa, so we need to put in more effort.”

Q Ebola, SARS and Hendra viruses all originate from bats.

worked (e.g. in 1919 the Australian Spanish flu pandemic was successfully delayed about a year). People are now more mobile and move rapidly. At airports, Border Security often does not know where people come from if they have skipped from country to country. Exit screening at the airports of affected countries is not foolproof. Retrospective tracking of contacts for MERSCoV or SARS infection outbreaks have shown rapid global spread through travel hubs like the Middle East or Hong Kong. Moreover, the incubation period of infectious diseases goes a long way in explaining why border control is problematic. “Whenever anyone looks at screening at airports, they find that people who have the infection slip through, mainly because they travel before their symptoms commence. A disease like influenza, where you can be infectious before you get the symptoms, makes border screening even less effective. Infections like SARS or Ebola, where you are only infectious after you develop symptoms, have a better chance of being picked up and the passenger isolated. But for Ebola the incubation period is 21 days so they might come here on day 1 and get symptoms later.” O

By Dr Rob McEvoy

This is not the ‘good old days’ when quarantine in Sydney harbour or Albany medicalforum

Hollywood Private Hospital welcomes da Vinci Xi to WA The da Vinci Xi Surgical System is the most advanced surgical robot in Western Australia and is only at Hollywood Private Hospital ࠮ 6W[PTPZLK MVY H range of specialties including urology, ENT, gynaecology and general surgery ࠮ +LZPNULK MVY LɉJPLUJ` HUK ease of use ࠮ >PSS IL [OL platform for future technologies

The next frontier in minimally invasive surgery The da Vinci Xi Surgical System is a tool that utilises advanced, robotic, computer technologies to assist surgeons with operations. With revolutionary anatomical access, the da Vinci Xi has broader capabilities than prior generations of the da Vinci system. It can be used across a wide spectrum of minimally invasive surgical procedures and has been optimised for complex, multi-quadrant surgeries.

For more information please contact: Dr Daniel Heredia, Director of Medical Services, Hollywood Private Hospital (08) 9346 6249

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WE’RE BIG IN HEALTH

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'FBUVSF

Childhood Lost; Life Regained Life has been tough for ‘child migrant’ Jock Barker but his doctor has stood by him through the years. It wasn’t the greatest start in life and then it got a lot worse. Placed in an orphanage at birth in Aberdeen, Scotland and then shipped as a ‘child migrant’ to Boys Town in Bindoon has left a legacy of bitter regret and mental health issues for 80-year-old Jock Barker. “The nuns at the orphanage were awful. They were abusive, violent and we all got regular beatings. I don’t know which was worse, my first 11 years in Scotland or the next six at Bindoon.� “It was stinking hot when we docked at Fremantle, we had to strip off all our clothes and put on a pair of worn khaki trousers and a shirt. Then we were herded onto the back of a truck and driven to Bindoon. It was slave labour using young kids from all over the UK, we had no socks or shoes and sometimes we had to work in a quarry.�

The physical and mental effects of child abuse are well documented. The combination of a caring GP and an opportunity to have his voice heard at an official level has gone some way to relieve the pain of Jock’s traumatic early years. “I’ve been seeing a wonderful GP for many years now, Dr Gerald Westhoff [Perth Medical Centre, Hay Street Mall], and he really looks after me. I still get severe migraines and that’s not too surprising after the beatings they dished out at Bindoon.� “Once I asked Brother Kearney if I could learn some sort of trade because I didn’t want to be a labourer all my life. Without a word of warning he smashed my head open with his walking stick and yelled, ‘get back to work you lazy little bastard!’ While I was on the ground he was kicking the shit out of me.�

“The nuns stitched me up, I needed 23 stitches in my head and I’ve still got the $)*-% .*(3"5*0/ "/% "#64& scar to prove it. A dentist would turn up occasionally and t #FUXFFO BOE PWFS DIJMESFO NJHSBUFE UP

Australia under approved schemes. t 5IF 3PZBM $PNNJTTJPO IBT SFDFJWFE DBMMT MFUUFST BOE FNBJMT IFME QSJWBUF TFTTJPOT t #Z +VOF UIF $PNNJTTJPO IBE IFME QVCMJD hearings including Perth t $POUBDUT 5IF $IJME .JHSBOUT 5SVTU PS 5FM XXX DIJMEBCVTFSPZBMDPNNJTTJPO HPW BV

Q Jock Barker

pull out teeth, without anaesthetic of course. Sometimes a doctor would come out to Bindoon but they didn’t seem to know what was going on. They didn’t ask too many questions either.� “It hasn’t been easy for me. I still get upset quite a lot and I was a heavy smoker. I used to get on the booze quite a bit too. I’ve calmed down now that I’m older but the damage has been done. “I appeared before the Royal Commission into Child Abuse earlier this year and they were sympathetic and listened to me with kindness and respect. It felt good to tell my story at last.� O

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X WA’s Chief Health officer Professor Tarun Weeramanthri has been awarded the Sidney Sax Public Health Medal by the Public Health Association of Australia in recognition for his 10 years work in both WA and the Northern Territory. X Prof Helena Liira, from Finland, will take up the UWA Chair of General Practice in January. X Mr Paul Andrew is the new head of Lotterywest. X Murdoch University researchers Prof Steve Wilton and Prof Sue Fletcher have received almost $800,000 from the NHMRC to develop genetic drugs to treat rare diseases. X Prof Ryan Lister (Perkins Institute and UWA), Dr Marc Pellegrini (Walter and Eliza Hall Institute) and Dr Nicolas Plachta (EMBL Australia and the Australian Regenerative Medicine Institute) have each been awarded a $1.2m fellowship for research in their respective fields. X St John of God Health Care has appointed former Victorian Health Minister the Hon Robert Knowles to the board. medicalforum

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News & Views

The Health of Obstetrics

T

he ongoing tension between midwife and obstetrician groups is discernible in the Australian Clinical Indicator Report, released recently, and which looks at comparative figures from 2006 to 2013. For obstetrics, the report examined 18 clinical indicators amongst 184 Health Care Organisations (HCOs or hospitals) across Australia. In WA, 59 HCOs reported, 41 public and 18 private. Australia-wide, five clinical indicators for obstetrics were said to follow a statistically undesirable trend while three showed a desirable trend. Medical Forum covered caesarean rates in our August edition (see * below), where we discovered that it was difficult to answer many questions succinctly while private obstetricians were not obliged to record reasons for interventions. This report goes well beyond caesareans. Here are some of the national figures: t PG QSJNJQBSB VOEFSHP JOEVDUJPO of labour t PG QSJNJQBSB VOEFSHP BO instrumental vaginal birth t PG QSJNJQBSB VOEFSHP DBFTBSFBO section [In WA, 18-25% public, 32-41% private]*

t PG EFMJWFSJFT BSF WBHJOBM GPMMPXJOH previous caesarean (VBAC) [In WA, 6-18% public, 1-3% private.]* t BOE PG QSJNJQBSB respectively, underwent surgical repair for 3° and 4° tears t PG XPNFO VOEFSHPJOH DBFTBSFBO received a blood transfusion Commentary was provided separately by RANZCOG and ACM (Australian College of Midwives). RANZCOG comment included: t %FDSFBTJOH TQPOUBOFPVT WBHJOBM CJSUIT are likely because of: risk-averse women; increasing maternal age; and reduced maternal parity – all more prevalent in the private than public sector. t *OEVDUJPO SBUFT XFSF IJHIFTU JO 8" and further national increases were likely because induction improves fetal outcomes in the presence of pregnancy complications and will mostly not increase caesarean rates. t 3JTJOH JOTUSVNFOUBM CJSUIT XFSF EVF UP greater uptake of regional anaesthesia. t 4UFBEZ 7#"$ SBUFT NJHIU VOEFSHP GVUVSF decline with 2012 data showing better fetal outcomes and less severe maternal haemorrhage in woman undergoing repeat

caesarean rather than a planned vaginal birth. t 6OEFS SFQPSUJOH PG ÂĄ UFBST JO QSJWBUF hospitals may be due to birth suite (rather than OT) repair. Alternatively, if the tears are unrecognised, further training is needed. t 5SBOTGVTJPO SBUFT BSF EPVCMF JO UIF QVCMJD sector, perhaps reflecting a more ‘at risk’ case mix and less experienced surgeons than in the private sector. ACM comment included: t $MJOJDBM JOEJDBUPST TIPXFE JODSFBTFE intervention in labour and birth without a corresponding improvement in infant indicators. t *OWFTUJHBUJPO JT SFRVJSFE UP FYQMBJO statistical differences between risk-adjusted women managed in private versus public hospitals. t 1VCMJD QSJWBUF EJÄŒFSFODFT SFNBJO concerning, particularly the choice of labour and birth interventions for primiparous women. t 'JHVSFT BSF OPU JOUFSQSFUBCMF XIFO JU comes to women’s preferred option for birth after caesarean or the outcomes of targeted programs directed at VBAC. O

By Dr Rob McEvoy

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News & Views

Seeing Stars and Healthier Eating The debate has been long and arduous but Australia now has an agreed method to rate the nutritional value of manufactured food. Will it work?

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he Health Star Rating (HSR) on food packaging was given the green light in June by the Federal and State Health Ministers. But while the process has been long and, at times, controversial, the agreement will help consumers make more informed food choices.

Government, the HSR was seen as a fair compromise because Australian consumers were familiar with the star rating for products such as white goods. The more stars the healthier the food.

Dr Christina Pollard (PhD) is a dietitian and research fellow at Curtin University who has been observing the past four years of intense negotiation unfold. She told Medical Forum that the system will give consumers a quick, easy symbol with which to compare foods, but food companies need to come to the party and put it on all their products to make it work. “If only one product in a range has a HSR, it may not necessarily be the healthiest, but even then, the consumer has some idea how healthy that product is and they can look at the existing nutritional panel on the other products for fat, salt or added sugar content to compare,” she said. While many dietitians and public health specialists were pushing for the traffic light system, which has been adopted by the UK

“There are positive signs with retailers Coles and Woolworths saying they will put it on their home-brand products but they must all be labelled for the system to work easily for consumers. Nonetheless, their commitment is vital.”

“Some cereals are more nutritious that others and people will probably need help to choose the healthier options between them, so the HSR is an attractive marketing niche.” It may take some time for consumers to see the shelves full of stars. Food manufacturers have been given a five-year implementation period with a progress review after two years from June 27.

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The marketing potential of the HSR is great, Christina said, particularly for manufacturers of products like breakfast cereal where there were many competing varieties.

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The voluntary nature of the HSR is the next hurdle.

There are also a number of foods that won’t have a HSR as it is only for processed foods– fresh fruit and vegetables are exempt; special purpose foods such as infant formula and food, formulated supplements, sports foods and Special Medical Purpose foods are not to carry HSR. Alcohol and kava are also not to carry HSR. Health professionals are united in their hope that the HSR will be applied universally to all processed foods, but as Christina said, right now, the important thing is that consumers use it so manufacturers can see the benefit to them. “There is widespread acceptance of any symbol to make information on the front of packs less confusing and the HSR does that. There are a lot of claims on packaging that mean nothing, like ‘natural’, and other claims that don’t have any nutritional criteria. We need to be focusing on removing those things as well.” “In some ways it’s a miracle that the industry has lined up behind the HSR. The fact everyone is supporting it and sees the potential of it, highlights the credibility and the hard work that’s gone into the devising the system.” O

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Politics in Medicine

Who Calls the Shots?

It was a provocative title which prompted lively discussion from the panel and the audience at the last Doctors Drum breakfast for 2014. Spearheaded by former Liberal MHR Dr Mal Washer, the panel of GP Dr Tim Koh, specialists Dr Mark Hands and Dr Simon Turner, consumer advocate Ms Michele Kosky and State Opposition Health Spokesman Mr Roger Cook grappled with a number of farranging issues confronting the profession. Chief among them was the apparent disregard by politicians of sound, long-term health planning because of the pressures of the short-term political cycle. Panel and audience alike saw this as a fundamental problem with the current health care system as it faces the enormity of chronic disease in the community. Waste of time, effort and money for woeful outcomes were the result.

There were a couple of sabres rattling for state secession countered by a centralist argument but there were not too many keen for that fight. Better by far, thought the many, to do the best they can for their patients – the outcomes were more certain than to wade into the murky seas of politics. O

Mal Washer gave some brilliant insights into the day-to-day lobbying of federal ministers and urged the profession to shake off its reticence and engage with politicians to find solutions to the big issues facing the health system. To be effective, he said, doctors needed to be organised and motivated. Key message: Politicians don’t want problems, they want solutions.

Q Opposite page from top: t .S (VZ $BMMBOEFS 1SPG 8JMMJBN )BSU Dr Colin Hughes, Dr Rob McEvoy t %S (FPSHF $SJTQ BOE %S -ZOEB 4FMWFZ t %S $FDJM 8BMLMFZ BOE .ST /PMB 8BTIFS t 5IF $SPXE t %S $ZOUIJB *OOFT %S 4JNPO .PTT Dr Jenny Rogers, Dr James Latto and Dr Harsha Chandaratna

That was cold comfort for some in the room who had done their fair share of evidencebased solution-making only to have their ideas discounted because it didn’t fit the ideological agenda of the day. The bearpit of climate politics also raised concern [see Guest Column opposite]. Vested interests came in for scrutiny. One doctor expressed his concern about the growing influence of private health funds on his practice, which he believed was moving very close to dictating how he cared for his patients. Some in the room, especially those from rural areas, expressed their frustration at the fragmentation of the system and the many layers of bureaucracy that operated in isolation from each other. Doctors’ attempts to duly comply with one could end up with them contradicting another. The pragmatic answer to the time-poor doc: put it into the too-hard basket.

Q This page from top: t .S 3VTTFMM 8PPMG %S 4JNPO 5VSOFS Mr Roger Cook and Dr Mal Washer t .T .JDIFMF ,PTLZ .S 3VTTFMM 8PPMG Dr Mark Hands, Dr Simon Turner t %S "OESFX #SJUUP %S -VDZ (JMLFT BOE Prof David Watson t 1SPG ,JOHTMFZ 'BVMLOFS GPSFHSPVOE next to Dr Alistair Vickery

Doctors Drum supported by:

(VFTU $PMVNO

Australia Needs Climate Policy Eroding climate change legislation has left Australia isolated in a world that is increasingly seeing the health imperative to take decisive action, says %S 4BMMJF 'PSSFTU.

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ast month, the agreement between the US and China over climate change made it the hottest topic of conversation at the G20 Summit. It follows an extraordinary UN Climate Summit in New York in October, with 120+ heads of state attending including US President Obama and UK PM David Cameron; absent was Tony Abbott. In New York, 400,000 people took to the streets in support of climate action, while in Melbourne the crowds reached 30,000. As the US President called on all nations to play their fair part in addressing climate change, Australia received international condemnation for its failure to attend. The Summit was called to urge countries to increase their commitments for next year’s major global climate negotiations in Paris, after the disappointing Copenhagen outcome five years ago. Alarmingly, Canada and Australia appear to have formed an alliance to do the opposite. Australia is the first nation to wind back effective climate change policy when it repealed the carbon tax. In contrast China emissions has announced plans for a national n trading scheme and the US is implementing significant measures. Australia Austra risks missing

the boat as a renewable energy and low carbon global economy emerges. Crucially, Australia’s actions have health ramifications; climate change is not just about polar bears, is it about you and me too. Climate change threatens public health with increases in weather extremes, food and water scarcity, polluted air and changes to infectious disease conditions, all leading to potential geopolitical instability. Equally important is the immediate health benefits that result from efforts to address climate change. It is no coincidence that Obama recently announced his signature carbon emissions reduction policy from inside a hospital. He said that reducing pollution from coal-fired electricity generation by 30% by 2030 could be justified on health grounds alone – America would avoid up to 6600 premature deaths, up to 150,000 asthma attacks in children, and up to 490,000 missed work or school days. It seems short-sighted for the Australian government to be now considering slashing or scrapping the Renewable Energy Target. This previously bipartisan policy has costeffectively reduced fossil fuel electricity generation and has played an important part in Australia’s climate change efforts. The government-commissioned review did not consider the impacts on health, in contrast to developed practice internationally. A 2011 US EPA review of the Clean Air Act concluded that every dollar spent on cleaner air produced $30 in health benefits. A 2009 study estimated the annual externalised costs of fossil-fuel generated electricity in Australia to be $2.6 billion. Doctors for the Environment Australia (DEA) has highlighted the importance of including health impacts in any review of policy affecting energy generation in Australia. Schemes that limit air pollution from fossil fuels are effective public health policies. DEA members, including Professor Fiona Stanley, and other health experts recently wrote an open letter to the Prime Minister requesting climate change on the agenda of the upcoming G20. Will the health sectors concerns be heeded? O ED: Dr Sallie Forrest is a GP registrar and a WA representative on the National Management Committee of DEA.

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Sharpen Up Melanoma Detection Clinton Heal established MelanomaWA to assist people like him – and he has some tips arising from his nine-year journey with melanoma. eft undiagnosed, melanoma has a poor prognosis. Moreover, it’s a young person’s disease – the most common cancer for 15-39 year olds, males and females. Early detection is the most important tool for prevention, which is where family doctors come in, something I have stressed since first getting melanoma.

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outcomes. One thing I would say to a GP is if there is ever any doubt when examining a skin lesion, address the doubt with a biopsy. It is much better to call a patient and say, ‘That lesion we biopsied and sent off actually turned out to be melanoma’, than to have them come sometime later with melanoma in other parts of the body.

My personal journey with melanoma started when, aged 22, it appeared suddenly as a metastasis in my neck. This initial tumour was removed from the left parotid gland in September 2005. The primary was never found and it is believed that it regressed after years of sitting silently on my skin, undetected. I’ve had 35 metastases removed over the last nine years. I went on to create MelanomaWA to offer support for those who have found themselves on a similar journey.

Proper early detection involves regular updates with the latest news and developments around skin cancer, having proper equipment, and listening carefully to your patients’ concerns. It includes weighing up the physical trauma of removing a lesion against improving the patient’s mental state by ruling out skin cancer.

These days, the public is more informed and engaged in how to protect themselves from skin cancer. Early detection is crucial and GPs have a pivotal role in finding and removing the primary melanoma before it can grow and spread.

My personal experience is the vast majority of people diagnosed with melanoma report effective treatment by their GPs. This needs to continue. GPs always need to be mindful of ‘traps for the unwary’ when performing a skin screening. A misdiagnosis can occur when skin cancer has an atypical appearance. A nodular melanoma, for example, can look more like a pimple, or recurring lump. Amelanotic melanoma can be flesh-coloured and not the big scary black mole that everyone has been trained to look for. Unfortunately, at MelanomaWA we meet people whose melanoma was diagnosed at a late stage with very poor prognosis and

For those given news of a melanoma diagnosis, reactions and emotions vary. We are here to help. The team at MelanomaWA is available for support, to build up that all-important confidence for those dealing with the diagnosis, including their family and friends. We empower patients with coping strategies, information and lifestyle choices. O ED: MelanomaWA.org.au or Tel 9322 1908

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Docs Need Evidence, Not Marketing Australian Medical Writers Association chair Dr Justin Coleman explains why his profession should break doctor-pharmaceutical ties.

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octors owe it to their patients to distance themselves from the marketing and promotional aspects of pharmaceutical companies. The culture of inviting salespeople into medical practices for one-to-one marketing is so ingrained that when I recently questioned the value of drug reps via the ‘No Advertising Please’ campaign, many doctors protested strongly, some with vitriol.

Patients, when informed by surveys that this promotional activity is common, can recognise the potential conflict of interest, yet somehow many doctors can’t. The argument that (most) doctors make no profit from the marketing doesn’t alter the fact that their prescriptions channel enormous sums of other people’s money—patients’ and taxpayers’. Patients quite reasonably prefer prescribing decisions based on patient benefit rather than on which rep recently visited. Where cost does feature, the doctor’s ethical duty is to reduce health system costs rather than increase pharma profits. The latter ‘duty’ is surprisingly often touted by doctors when

confronted with incontrovertible evidence that seeing drug reps is associated with more expensive prescribing. The argument becomes confusingly circular because pharma profit is ploughed back more into marketing than research. Thus, the reps pay for themselves, many times over. The argument that reps don’t actually influence prescribing habits is absurd— and only ever proffered by doctors, never by pharma. It is immediately dismissed with evidence yet, in the wake of my ‘No Advertising Please’ campaign, this was the most common defence. I should have been forewarned: a classic survey by Steinman found only 1% of doctors felt reps had a significant effect on their own prescription choices, yet 51% agreed reps influenced other doctors! One wonders if the remaining 49% believe the $6 billion annual spend on (US) reps is written off as a charity. Once we accept the evidence that seeing reps results in huge costs to our health system, it is legitimate to ask whether the money is well spent – high costs might be justifiable if patient outcomes improve commensurately. In my view, outcomes would need to improve

a lot, and the evidence should be consistent, particularly as the pharmaceutical industry has had decades to collect data favouring their case. So, what is the sum total of evidence ever published anywhere in the world showing that patient outcomes are better if their doctor sees drug reps? Nil. Not a skerrick. A systematic review (Spurling) looked at everything published since 1966. Unfortunately, evidence about patient outcomes was limited (a blind RCT would require pharma co-operation, with obvious risks for them), but every study showed either no change or less appropriate prescribing by doctors who saw reps. Not a single study, weak or strong, showed patient benefit – nor has pharma pointed to one, despite repeatedly claiming patient benefit. The default position should be to avoid marketing visits, thereby protecting your patients and the health budget, unless (substantial) new evidence persuades otherwise. Until then, spend your valuable educational time learning about medications via independent sources. O ED: Dr Justin Coleman is founder of the ‘No Advertising Please’ campaign.

You no longer need to travel. Perth Cardio Murdoch Clinic Opening January 2015 With internationally recognised expertise in clinical management and research, our cardiologists are leaders in their fields. From January 2015, Perth Cardio will open doors at its new south of the river clinic in Wexford Medical Centre – Murdoch Hospital. That means, for patients in the south, world-class cardiology care just got a whole lot closer. Visit perthcardio.com.au to find out more. LEADERS IN C ARDIOLOGY | ECHO | ECG | HOLTER MONITORING | ECHO | TOE | E XER CISE STRESS TESTING

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2014 BEST WISHES FROM WA'S HEALTH PROFESSIONALS Christmas Greetings Feature

Medical Forum wishes all our readers and supporters a Merry Christmas and a Happy New Year medicalforum

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mas t s i r Ch tings t Gree ture Fea 4 201

Christmas Greetings Feature

5IBOL ZPV GPS ZPVS DPOUJOVFE support and I look forward UP XPSLJOH XJUI ZPV JO My warmest greetings for the festive season and for a prosperous New Year. With best wishes, Kannan Venugopal

An Aquatic Christmas Dr Matt Wright Head of Haematology FSH I was teaching in Port Moresby, PNG, and went snorkelling off a remote island. A local fisherman stopped for a chat and told me he had abdominal pain. There I was, a beautiful day on a stunning island with the patient lying on the sand and me in board-shorts. Diagnosis? Splenomegaly‌ yes, bulk-billed.

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Dr Mini Zachariah 5P BMM NZ SFGFSSJOH EPDUPST and colleagues. A Merry Christmas and a Safe & Happy New Year.

From all of us at the SleepMed team and Dr Keihani, we thank you for all your wonderful support throughout the year.

5IBOL ZPV GPS ZPVS DPOUJOVFE TVQQPSU BOE * MPPL GPSXBSE UP XPSLJOH XJUI ZPV JO Warmest wishes Mini

Wishing you an abundance of friends, happiness, and fun this holiday season and beyond. Deus ex Machina Prof Daniel Fatovich RPH Emergency Physician I saw a patient on Christmas Day who’d taken an overdose. When I asked him why, he told me he’d been given a computer game as a present and the computer beat him!

We look forward to assisting and serving your patients in 2015.

SEASON‘S GREETINGS

We sincerely appreciate your continued support and goodwill throughout 2014. We wish you, your staff & your families all the joys of this holiday season on behalf of the Doctors and staff at SKG Radiology.

Dr Sue Ulreich Ulreich, CEO & Radio Radiologist www.skg.com.au

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5IBOLZPV GPS ZPVS DPOUJOVFE TVQQPSU UISPVHIPVU 8F XJTI ZPV all a very joyful festive season. Warmest wishes Dr Peter Hugo, Dr Aparna Baruah & staff

Dr Yovich & all the staff at PIVET wish you & your families a joyful festive season & thank you for your continued support. For all appointments & enquiries:T: (08) 9422 5400 | E: info@pivet.com.au Visit www.pivet.com.au for more information

Action Replay Dr Peter Melvill-Smith Psychiatrist I was working in a busy ED on Christmas Day in South Africa. A nurse asked me to assess a distressed and seemingly delusional female patient named Mary who told me she’s just given birth to baby Jesus in the examination room. Sure enough, there was a healthy newly-born infant lying in the hand-basin. We transferred Mary to the obstetric ward where she celebrated the big event with many others who believed her!

Dr Phil McGeorge Dr Phil McGeorge and his team would like UP UIBOL ZPV GPS ZPVS TVQQPSU JO All the very best for a Merry Christmas and a Happy New Year. ar.

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Traces of Christmas Dr John van Bockxmeer Emergencyy Registrar It was about six weeks after Santa’s Big Day D Out. O t A four year-old patient had developed an unseasonable, persistent cough with no atopic history and all other family members were fit and well. After failing to respond to various forms of treatment a CXR revealed a foreign body shaped suspiciously like a Christmas tree decoration in his lung!

MXSolutions Comprehensive Practice Management Software for Health Professionals 3FH BOE 4BMMZ XPVME MJLF UP UIBOL BMM PVS DVTUPNFST for their continuing support and wish you a

Merry Christmas We look forward to assisting you in 2015 and adding new features to the Mx you love! Call Reg on 0402 916 108

A Fine Cut Dr Rob Davies Urologist

Dr Phil McGeorge and %S 5[F -BJ XPVME MJLF UP UIBOL ZPV GPS ZPVS TVQQPSU JO

It was 1988 and I’d snuck into the Gnangara pine plantation with my new girlfriend to lop off a branch for a Christmas tree. ‘Is this illegal?’ she asked. ‘Strictly speaking, yes’ I replied. After telling her that theoretically we could be arrested her eyes lit up. ‘I’m so excited,’ she said. ‘This is the first illegal thing I’ve ever done in my life!’ I almost dropped her there and then. PS. We’ve just celebrated our 23rd wedding anniversary.

All the very best for a Merry Christmas and a Happy New Year.

SEASON'S GREETINGS Dr Victor Chan and staff Wish to thank all GPs who have supported them during the year.

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MERRY CHRISTMAS and a HAPPY NEW YEAR to all doctors 32

Mr Marek Garbowski Vascular & Endovascular Surgeon 5P BMM NZ SFGFSSJOH EPDUPST BOE DPMMFBHVFT thank you for your outstanding and continued support UISPVHIPVU * MPPL GPSXBSE UP XPSLJOH XJUI ZPV JO Wishing you, your loved ones and your staff a joyous, healthy and safe holiday season and all the best for the New Year.

The Cardiologists and Staff of Western Cardiology wish all a very Merry Christmas and Happy New Year. Thanks to all referring doctors for their support during the year. We look forward to continuing quality care for your patients in the future. Dr Mark Hands Dr Eric Whitford Dr Stephen Gordon Dr Philip Cooke Dr Brendan McQuillan %S +PIBO +BOTTFO Dr Paul Stobie Dr Chris Finn Dr Eric Yamen

%S +PF )VOH Dr Michelle Ammerer %S -VJHJ % 0STPHOB Dr Darshan Kothari %S "OESF ,P[MPXTLJ %S 5JN (BUUPSOB Dr Stephen Shipton Dr Devind Bhullar

Marek Garbowski & Staff at Perth Vascular Clinic www.perthvascularclinic.com.au 46#*"$0 +00/%"-61 #6/#63: (&3"-%50/

Christmas Comes Early Professor Lyn Beazley former WA Chief Scientist I was in Oxford studying nerve cell death. It was pretty ‘cutting edge’ stuff back then and I had all but given up on getting a result. After seven weeks work – 42 days, the same number at the end of the Douglas Adams Universe – it finally turned up on Christmas Eve. An early Christmas present a long way from home!

Drs Omar Khorshid, Toby Leys, Matthew Scaddan & Paul Khoo wish all our referring doctors and colleagues an enjoyable and safe Christmas and New Year. We look forward to working with you all in 2015.

All here at Venosan thank our referrers, clients and colleagues for their wonderful support throughout the year. We wish you all a safe and happy Christmas and a prosperous New Year. Jenny Heyden 3/ Consultant Venosan WA

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“The sight of the star P

M M M E &N M 6C54

St John of God Health Care wishes our doctors and everyone working in Western Australia’s health care community a blessed and joyful festive season. Our hospitals, pathology, home nursing and social outreach services will continue to grow in the New Year and we look forward to working with you in 2015.

Bunbury Hospital | Geraldton Hospital | Midland Public & Private Hospitals (Opening November 2015) Mt Lawley Hospital | Murdoch Hospital | Subiaco Hospital | Pathology | Health Choices | Social Outreach

www.sjog.org.au 34

A Working Christmas Dr Adele Thomas GP Mary, in her late 70s, turned up with some small, black stones and told me they’d come from her belly. I examined her and found an inflamed area with a tiny hole in the right upper abdomen. Squeezing it produced several more gall stones. She refused to go to the ED because she had a Christmas client waiting at the pub. Apparently she was a part-time ‘working gal’ and we had to arrange surgery around her ‘professional’ appointments.

Roo Ha-Ha Dr Stuart Adamson Midwest Aero

Wishing all our referring doctors & patients a joyful festive season

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Medical Service My most unusual 25th December occurred when three of our orphan, hand-raised juvenile kangaroos got into the family room and decided to have a boxing match with the Christmas tree and pile of presents. The aftermath looked like the remains of a Kangaroo Zombie Xmas Apocalypse and then they had the temerity to lounge around in the wreckage waiting for their milk bottles!

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Wishing you all a Jolly Merry Christmas and a Refreshingly new approach to a Minimally Invasive Vascular Happy New Year. With Best Wishes from John Teasdale and all our Friendly Staff at WA Vascular Centre. Calls for advice are Welcome–my Mobile: 0419832279 Perth, Fremantle, Joondalup, Mandurah, Northam

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Prostate MRI complements men’s imaging services at Perth Radiological Clinic Multi-parametric MRI is emerging as the examination of choice for imaging the prostate.

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CLINICAL UPDATE

Polio and the war on terror T

he WHO has been striving towards, and is nearer to, making polio the second disease (after smallpox) to be eradicated from the world by vaccination. At the beginning of 2014, there were only three polio endemic countries remaining – Pakistan, Afghanistan and Nigeria. Unfortunately, there has been a resurgence of Polio during the year, which has implications for travellers.

1PMJP BOE QPMJUJDT In 2003, religious and political leaders in northern Nigeria responded to fears that anti-fertility agents and HIV had contaminated the polio vaccine. The subsequent boycott of the polio vaccination program resulted in an outbreak, which spread across Africa through Chad and Sudan. In 2005, polio emerged in Yemen and then via Mecca on to West Java in Indonesia. All outbreaks were traced to the Northern Nigeria outbreak. The vaccination program was resumed after sourcing an acceptable Sabin vaccine. After the 2011 death of Osama Bin Laden, it emerged the CIA had used the polio vaccination campaign to access the Bin

Laden compound in Abbottabad to obtain DNA samples and confirm his identity. This undermined trust in the humanitarian efforts to eradicate polio in Pakistan. It is not all bad news though. The vaccination program in India has resulted in the last case of Polio being recorded in 2011. Early this year WHO declared India the 4th last country to eradicate polio. There has been resurgence in parts of Africa and the Middle East since then. In May, the director general of the WHO declared a public health emergency. There are currently 10 countries of concern and the American CDC currently lists 28 countries as high risk.

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For example, the homeless have more chronic illnesses, higher mortality rates, and make poor use of available health services – all of which contribute to increased direct and indirect health care costs. Primary care appears best positioned to offer the best coordinated, team-based management for these patients but all too often the ‘Inverse Care Law’ means those in greatest need generally receive the worst treatment. Evidence-based medicine has spawned best practice guidelines, often based on trials medicalforum

Vaccination can be incorporated in the tetravalent Tetanus Diphtheria Pertussis vaccine or be given as a separate polio vaccine. However, travellers to certain regions may need an internationally recognised certificate (akin to a Yellow Fever certificate) to prove their recent polio vaccination, in order to meet WHO and other country requirements when crossing borders. This WHO website provides the latest advice www.polioeradication.org O Author competing interests: nil relevant disclosures. Reader questions? Contact the author on 9336 6630.

*NQMJDBUJPOT GPS QSBDUJDF Australia, by virtue of political stability and an effective vaccination program, is at no risk of a polio outbreak. The primary vaccination schedule with a single adult booster dose will provide lifelong protection. As such, it is relatively easy to protect travellers going overseas.

Q“How is multimorbidity important to doctors?” One of the great challenges for health care today is how to manage patients with multiple chronic conditions (multimorbidity). As populations continue to age, and both health services and technologies improve survival, more and more people have multimorbidity in their later years. However, multimorbidity exists across the entire age spectrum and in both sexes, with marginalised and disadvantaged patients showing it earlier, often in their middle years.

By Dr Aidan Perse, Travel Health 'SFNBOUMF

on individual diseases in isolation. Herein is a dilemma. Such guidelines may not be ideal for managing multiple conditions that behave not only cumulatively but often synergistically. The side effects of treating one condition, such as osteoarthritis, can in turn exacerbate another, such as heart failure or peptic ulceration. Patient-centred care – as opposed to disease-centred care – is very applicable. The aim is to treat the whole person in an integrated, linked manner. Quality of life may be the main aspiration, rather than increased longevity. Treatment at home may be the best option. Too often an illness event, where family or community support is lacking, means these patients cannot continue to live at home. Once hospitalisation occurs, the growth in medical expenses is exponential. Investment in primary care resources to prevent hospitalisation does not attract the same amount of media coverage as ambulances queuing up outside Emergency Departments. The political will to change is slow and inevitably linked to self-interest.

Clinical Q&A By Prof Tom Brett, %JSFDUPS (FOFSBM Practice and Primary Health Care Research, University of Notre %BNF 'SFNBOUMF Primary care teams are becoming more comprehensive – nurses, podiatrists, dieticians and counsellors are regularly engaged by practices. Multimorbidity management is made easier. Patients want and need this type of care, where the disease-centred approach does not get priority. Primary care researchers need to substantiate all this, working with peak national research bodies such as the NHMRC to generate patient-centred research topics that have real community and consumer involvement. Countries with the best medical services invariably have the highest quality primary care services. O D. Prof Brett has researched multimorbidity management in primary care.

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Primary Care Health Network News

Primary Care in the Spotlight Nearly 150 people attended the Primary Care Forum on 24 October to workshop how to improve primary care across the State and to meet others involved in the sector. Organised by Department of Health Western Australia Primary Care Health Network, the Forum explored the availability and scope of primary care services, and their link with tertiary, general and specialist hospitals. Representatives attended from general practice, RACGP, health services, allied health, non-government organisations, and also included consumer and carer advocates. “The Primary Care Forum provided an opportunity to consider how we can improve primary care in WA and also how the introduction of Primary Health Networks can enhance the delivery of care to our patients,� said Dr Mike Civil, Clinical co-lead, Primary Care Health Network.

The workshops focused on the areas of communication, system financing and performance, demand management, and integration. Primary Care Health Network Co-Leads Dr Aesen Thambiran and Dr Mike Civil will now review the numerous opportunities identified by workshop participants. WA Health has 18 health networks which comprise over 3500 consumers, doctors, nurses, midwives, allied health professionals, carers and policy makers, who care about improving health services in WA. They were established after a major review of health services in 2003 to enable a new focus across all clinical disciplines towards prevention of illness and injury and maintenance of health. For more information about the Forum, or to find out when the report will be available from the website, contact healthpolicy@health.wa.gov.au, call 9222 0200, or join WA Health Networks (www.healthnetworks.health.wa.gov.au) to be kept informed of the Primary Care Health Network’s activities.

Clinical Co-Leads Primary Care Health Network

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“It also enabled like-minded, passionate primary care stakeholders to network and share ideas.� Key topics of discussion on the day included: t FYQMPSJOH PQQPSUVOJUJFT UP QBSUOFS XJUI UIF OFX $PNNPOXFBMUI funded Primary Health Networks to provide a seamless transition of care for consumers between primary care and the hospital sector. t TVQQPSUJOH 8" )FBMUI JO EFNBOE NBOBHFNFOU TFSWJDF integration, communication, and system financing and performance strategies through engagement and collaboration with the primary care sector. t JEFOUJGZJOH JTTVFT BOE LFZ UIFNFT UP JOGPSN UIF EFWFMPQNFOU PG a statewide implementation plan for the WA Primary Health Care Strategy 2011.

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Dr Mike Civil Dr Civil has worked as a general practitioner in Kalgoorlie, and now Kalamunda and High Wycombe. He has been extensively involved with the Royal Australian College of General Practitioners, and in particular with Standards of General Practice, eHealth and Telehealth. Presenting widely on the Personally Controlled eHealth Record, Dr Civil sees that the role of GPs is crucial to the focus and coordination of primary care. Dr Aesen Thambiran Dr Thambiran is the Medical Director of the Humanitarian Entrant Health Services for the North Metropolitan Health Service. He previously worked as a general practitioner in Lockridge for many years. Dr Thambiran brings both public and private sector experience to this role. He believes that the major challenges facing the health system provide opportunities for broad-ranging policy and clinical reform.

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New STI management guidelines #Z %S -FXJT .BSTIBMM 4FYVBM )FBMUI 1IZTJDJBO 'SFNBOUMF )PTQJUBM

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exually transmitted infection rates continue to rise in WA and nationally. Chlamydia remains the commonest notifiable infection. Gonorrhoea and syphilis are increasing and more likely to present to GPs than previously. Many STIs are asymptomatic. Knowing whom to test, for what, in the absence of symptoms, is important. Recently launched national guidelines for managing sexually transmitted infections were designed to make this simpler.

Launched concurrently at the GP14 conference in Adelaide and the Australasian Sexual Health conference in Sydney, the Australian STI Management Guidelines for Use in Primary Care were developed under the aegis of the Australasian Sexual Health Alliance (ASHA) with a grant from the Australian Government Department of Health. ASHA is a subcommittee of the Australasian Society for HIV Medicine (ASHM). Other organisations involved in the development of the Guidelines included the Royal Australasian College of Physicians, Australasian Chapter of Sexual Health Medicine, Australian Primary Health Care Nurses Association, Family Planning Alliance, Australian Indigenous Doctors Association, Royal Australian College of General Practitioners, Australian College of Nurse Practitioners and the Australasian Society for Infectious Diseases.

6TFS GSJFOEMZ POMJOF SFTPVSDF This online resource for health professionals (http://sti.guidelines. org.au) provides support in the prevention, testing, diagnosis, management and treatment of STIs. Primary care providers in WA now have access to the latest recommendations. There are links to appropriate resources (including the WA Silver Book and the national contact tracing manual) as well as printable patient information sheets. The website consists of three interlinked sections: Management by specific STIs; Symptoms and Syndromes; and Populations and Situations. There are sections dealing with taking a sexual history and the asymptomatic check-up. It is easy to find what tests should be done in certain circumstances. If the patient presents with specific symptoms then searching under the syndrome will reveal the investigations and presumptive appropriate treatment. Information about specific diseases is also easily found.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Prof John Yovich

Fertility Future ‌ blastocysts from the freezer Increasingly, pregnancies derived from ART (assisted reproductive technology) arise from embryos which have been cryopreserved. During my early training years in London (1976-80), I worked with David Whittingham DQG H[SORUHG WKH Ă€UVW KXPDQ HPEU\R cryopreservation techniques. These were slow-freeze methods which actually proved PRGHUDWHO\ VXFFHVVIXO HQDEOLQJ :$¡V Ă€UVW frozen embryo babies in 1986. In recent WLPHV ZH KDYH DSSOLHG D YLWULĂ€FDWLRQ technique using the Cryotop method developed by our colleague from Tokyo, Masa Kuwayama.

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Other laboratory advances including solid-state incubation and sequential culture media has led to improved rates of blastocyst development which, in Australia, has translated into elective single embryo transfers (eSET) and consequent reduction in multiple pregnancies (currently <5% at PIVET). In fact PIVET’s policy has been increasingly to freeze the best embryos, especially when the overall prognosis is reduced. )ROORZLQJ WKDZ WHUPHG ZDUPLQJ IROORZLQJ YLWULÀFDWLRQ blastocysts re-expand over 1-2 hours and, again eSET is performed, mostly in an HRT cycle. The results have proven relatively spectacular with an overall 54% pregnancy rate and the highest livebirth rate per initiated cycle in Australia (shown in the latest 2014 ANZARD results) – Top of the WAZZA yet again with FETs.

The guidelines take into account the national antibiotic guidelines and are the result of much work by national experts in the field. This website will be highly useful for GPs who may not see STIs often, but need to make confident management decisions. For GPs who use the WA Silver Book, be assured that the new guidelines are compatible with that resource. O References on request.

Author competing interests: nil relevant disclosures. Reader questions? Contact the author on 9431 2376.

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NOW AT 2 LOCATIONS PERTH & BUNBURY

For ALL appts/queries: T:9422 5400 F: 9382 4576 E: info@pivet.com.au W: www.pivet.com.au

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39

Pharmaceutical advertising deliberately removed from this page

CLINICAL UPDATE

Options for women at high risk of ovarian cancer O

verall, the lifetime risk of ovarian cancer for an Australian woman is 1 in 77 or 1.3%. Familial cancer syndromes carry a much higher risk and make up about 13% of ovarian and fallopian tube cancers. Such syndromes include the breast-ovarian cancer syndrome caused by mutations in either of the breast cancer susceptibility genes BRCA1 or BRCA2, which increases the lifetime risk of ovarian cancer to as high as 46% and 23%, respectively. The cumulative risk of breast cancer by age 70 years for BRCA1 and BRCA2 mutation carriers is 57% and 49%. Lynch Syndrome (hereditary nonpolyposis colon cancer syndrome) carries up to a 13% lifetime risk of ovarian cancer and a 60% risk of endometrial cancer. A strong family history of ovarian cancer in the absence of a known mutation may also increase risk: the lifetime probability of ovarian cancer increases from 1.3% in a 35-year-old woman without a family history of ovarian cancer to 5% if she has one first-degree relative, and 7% if she has two relatives, with ovarian cancer.

*OUFOTJWF TDSFFOJOH TVSWFJMMBODF Screening with pelvic ultrasound and serum CA125 has not been shown to improve survival and clinicians and patients should not be falsely reassured by negative screening test results. Even with intensive screening, many ovarian cancers are diagnosed at an advanced stage and screening in high risk women is currently not recommended. In a large cohort of 3563 women (the UK Familial Ovarian Cancer Screening Study), 30.8% (4 of 13) of incident screen-detected cancers were early stage. Women who had not been screened in the year before cancer diagnosis were more likely to have advanced stage disease compared to women screened in the preceding year (85.7% vs 26.1%), suggesting the importance of adherence to the screening schedule. The study did not assess mortality but suggests that screening might lower risk for women until they are ready to undergo surgery.

By Dr Jason Tan, (ZOBFDPMPHJD 0ODPMPHJTU 80.&/ $FOUSF

to use oral contraceptives until they are ready to undergo definitive treatment.

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Women considering RRSO should be counselled about menopausal symptoms including hot flushes, sleep disturbance, mood changes, and sexual health issues such as dyspareunia due to vaginal atrophy and decreased libido. Early menopause increases osteoporosis risk but studies have reached different conclusions about its impact on cardiovascular mortality.

Bilateral risk-reducing salpingooophorectomy (RRSO) is the most effective treatment to decrease ovarian cancer risk in high risk women. In BRCA mutation carriers, RRSO also decreases the risk of subsequent breast cancer; studies show a 96% reduction in risk of gynaecologic malignancies and up to a 75% decrease in the risk of breast cancer, following RRSO. Women with Lynch syndrome, a familial cancer predisposition associated with defective DNA mismatch repair, have a high risk of endometrial cancer and surgery should include hysterectomy as well as RRSO. The data regarding endometrial cancer risk in BRCA mutation carriers is inconclusive and hysterectomy at the time of RRSO in BRCA carriers is at the discretion of the clinician and the patient. RRSO is the only treatment shown to decrease mortality in high risk women and because the prevalence of an occult cancer at elective surgery is 4-8%, this is best performed by a certified gynaecologic oncologist.

0UIFS DPOTJEFSBUJPOT The possibility that ‘ovarian’ cancer originates in the distal fallopian tube has led to interest in bilateral salpingectomy, followed by bilateral oophorectomy after menopause. Until there are high quality studies demonstrating the efficacy of this approach, RRSO is most appropriate. Tubal ligation decreases ovarian cancer risk in the general population but limited studies in high risk women have failed to show that tubal ligation is protective, making this inappropriate as a risk-reducing treatment.

Compared to natural menopause, in which hormone levels decrease gradually and the ovaries continue to produce androgens, women who undergo RRSO will have an abrupt decrease in serum estrogen and may have lower androgen levels. The latter has been hypothesized as a cause of low libido but there are no high quality data to support this and androgen replacement in these women is not generally recommended. Few studies have addressed the concern regarding an increased risk of breast cancer with the use of HRT in women following RRSO. A prospective cohort which included 321 BRCA mutation carriers following RRSO did not show a significant increase in the incidence of breast cancer among women who used HRT compared with those who did not (14% vs 12%) but the duration of follow-up was short. There are no studies which address the effect of HRT on peritoneal cancer risk following RRSO. Many groups recommend the use of HRT until the age of 51 years, which is the average age of natural menopause. O The author acknowledges the assistance of gynaecologist Dr Paul Cohen in preparing the article.

Author competing interests: no relevant disclosures. Reader Questions? Contact the author 9468 5188

$IFNPQSFWFOUJPO Oral contraceptive use decreases the risk of ovarian cancer. A meta-analysis of 18 retrospective studies of oral contraceptive use in BRCA mutation carriers showed that ever use was associated with a 50% decrease in the risk of ovarian cancer. There was no evidence of an increased breast cancer risk in oral contraceptive users, or in the first 10 years after cessation of use. High-risk women should be advised medicalforum

41

CLINICAL UPDATE

Pitfalls in offering travel advice T

ravel Medicine involves a risk assessment for each person travelling. Factors assessed include country of destination, time of year and season, accommodation choices, mode of travel, known exposures, activities planned, disease outbreaks, underlying co-morbidities and general health, past vaccinations and personal travel history. The following discusses some of these factors.

Use resources wisely Outbreaks of infectious diseases are increasing. Most specialising travel clinics would be up-to-date with these, world-wide. GP practice software may provide travel medicine advice but care should be taken when interpreting this. The CDC Yellow Book, The Australian Immunisation Handbook, the NHS website Fit for Travel and WHO all have good quality and readily accessible information. Travellers to remote and developing countries are best to register on the Smart Traveller website beforehand, in case issues arise at the travel destination. The website has warnings regarding regional disease outbreaks and security risks. Advice on travel insurance and accessing medical care are crucial.

Q Hoi An market in Vietnam

6QEBUF DPNNPO WBDDJOBUJPOT Generally, we update all routine vaccinations. In Australia dT is recommended in adolescence and at age 50; we update travellers every 10 years as most risk injury and contamination of any wound with soil. Pertussis is a risk (over 700 cases in WA to July this year) so combining with tetanus, vaccination makes sense. Measles outbreaks have occurred in many countries (only one third outbreak-free, so far this year; WHO). Those born in WA between 1967 and 1981 are likely to have not been fully vaccinated. Varicella vaccination should be considered for those with no history of chickenpox. Hepatitis B, according to the WHO, should 42

Q )PJ "O NBSLFU JO 7JFUOBN XJUI DIJDLFOT XBTIFE under nearby bridge.

be a standard vaccine. In WA, everyone aged 26 and under should now be vaccinated. Influenza is the most common vaccinepreventable disease associated with travel; with a year-round risk in tropical countries.

A5SBWFM WBDDJOFT OFFEFE Hepatitis A and typhoid are recommended for most travellers entering Africa, Asia and South America; infection risk includes those staying in 5-star hotels as well as those travelling longer term or backpacking; those returning overseas to visit friends and relatives usually have a greater risk of infection. Rabies vaccinations are now known to give life-long cover after a standard primary course. They are expensive but many travel clinics offer a cheaper (off label) method of intradermal vaccination, which requires extra time. Destination is the strongest risk predictor: SE Asia, Africa and India in particular. Over 50% of bites needing treatment occur within the first 10 days of a trip to SE Asia, and longer more adventurous travel generally presents greater risk. Prior vaccination simplifies post exposure treatment, so that rabies immunoglobulin (often difficult to obtain) is not needed and post-exposure vaccination is greatly simplified (i.e. less disruption to travel plans). Japanese Encephalitis is mosquito borne throughout Southern and SE Asia. Vaccination, which can be expensive, is recommended for those spending a month or more in rural areas, particularly in the wet season. The risk to travellers is low but infection consequences can be severe (with a third dying, a third with residual neurological, behavioural or memory issues). After discussing risks and vaccination costs associated with travel plans, the patient makes the final decision.

Changing behaviour to minimise risk Substantial effort needs to go into presenting ways of minimising food and water borne disease: hand washing and use of hand sanitisers; avoiding at risk foods such as salads, raw seafood and buffets; eating where there is a high turnover of food, whether

#Z %S +FOOJGFS 4JTTPO Medical Director, The Travel Doctor, Perth restaurant or street food; and safe water consumption options. A travel kit for emergency self-treatment, tailored to the type of travel and patient expectations may help including usual medications for gastroenteritis, rehydration, infection and nausea or vomiting. Avoiding mosquitos will reduce the risk of dengue, malaria, Japanese encephalitis and other insect-borne diseases. Some of these infections lack vaccines (e.g. dengue), while others are expensive (Japanese Encephalitis). Malaria tablets reduce the risk of severe disease but are not 100% effective. Common sense is emphasised for avoiding animal bites, tattoos and piercings, unsafe sex, accidents and breaking local laws and customs.

Q Tubing in the Mekong in Laos

Then you have travel advice linked to location or activity, such as: t 5SFLLJOH JO TPNF SFNPUF BSFBT o JODSFBTFE malaria risk. t #BDLQBDLJOH o GPPE BOE XBUFS CPSOF disease and STIs. t )JNBMBZBT BOE "OEFT o BMUJUVEF TJDLOFTT t 4XJNNJOH JO -BLF .BMBXJ o schistosomiasis. t 5VCJOH UIF .FLPOH JO -BPT o leptospirosis. t #BSFGPPU JO NBOZ DPVOUSJFT o IPPLXPSN and strongyloides.

Know your limitations You can’t know everything, especially when situations change almost daily. Most legal claims arise from inadequate pre-travel advice or delay or missed diagnosis of an exotic disease. Here are some tips to avoid them: t #F BXBSF PG ZPVS MJNJUBUJPOT o JG ZPV EPO U know, say so. t 4FMFDU XIJDI BSFBT ZPV BSF DPNGPSUBCMF with and keep up-to-date. t #FDPNF GBNJMJBS XJUI TVJUBCMF SFTPVSDFT t 'PS NPSF DPNQMFY TDFOBSJPT CF QSFQBSFE to refer. t 1SPWJEF XSJUUFO BEWJDF XIFSF QPTTJCMF O Author competing interests: nil relevant. Reader questions? Contact the author on 6467 0900

medicalforum

PRP - ROTATOR CUFF REPAIR*

Figure 1: Pre repair ultrasound rotator cuff shows a swollen supraspinatus tendon with a full thickness tear at its insertion. Figure 2: Post repair " ! function.

Rotator cuff tears are an increasingly common cause of morbidity in the ageing population. Corticosteroid injections and surgery are common management options. There is a need for non surgical options to treat rotator cuff tears. This report is on the clinical and imaging outcome in a patient who underwent non surgical percutaneous repair using Platelet Rich Plasma (PRP) for a degenerative full thickness rotator cuff tear.

Case report: A 73 year old physically active right side dominant lady complained of right shoulder pain for about two months. This did not respond to two ultrasound guided subacromial subdeltoid bursal corticosteroid injections. She had been caring for her husband and had an injury working in their farm. Preprocedural clinical examination at IGTC revealed painful limitation of shoulder abduction to less than 90 degree. Ultrasound examination showed a full thickness partial width recent foot print tear of the right supraspinatus with degenerative tendinosis of most of the tendon and enthesopathy at the insertion (Figure 1). Percutaneous repair with autologous Platelet Rich Plasma (PRP) was performed into the supraspinatus tendon under direct ultrasound imaging control after local anaesthetic. At 8 weeks follow up post PRP repair she had marked reduction in pain with improvement in shoulder movement. At seven and ten months follow up there was complete relief from pain with full range of movement of the right shoulder and she was able to lift bags of potting mix in her farm. At ten month follow up, ultrasound performed by the author (figure 2) showed neo tendon tissue in place of the tear defect. She is completely pain free now for 2 years after percutaneous repair for her full thickness rotator cuff tear.

Summary: Autologous platelet rich plasma (PRP) is a relatively new percutaneous repair option for full thickness rotator cuff tears in suitable patients.

*WORLDS FIRST REPORT ON PRP FROM WESTERN AUSTRALIA

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MBBS (Ind) MRCP (UK) FRCR(Lon) FRANZCR

Interventional Radiologist Suite 3, 55 Hampden Road Nedlands WA 6009

info@imageguidedtherapyclinic.com medicalforum

ph 6389 2776 fx 6389 2778

IGTC is a trademark owned by Shashi Pty Ltd. Any unauthorised use is strictly prohibited.

www.igtc.com.au

43

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FERTILITY SPECIALIST

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medicalforum

CLINICAL UPDATE

Pubertal variations & pubarche A

lthough the onset of puberty occurs across a wide range of ages in normal healthy children and adolescents, less than 5% of girls and boys are considered outside the norm and start puberty before 8 years and 9 years, respectively, or after 14 years. Once begun, puberty usually follows an orderly tempo over the next 3-4 years.

It is important to note that the appearance of pubic hair, or pubarche, does NOT indicate the onset of puberty. It results from a gradual increase in the production of adrenal androgens (adrenarche) and is regulated independently to puberty. Although it usually occurs around the time of puberty, adrenarche may precede puberty by 1-2 years.

In girls, parental concerns are usually about possible early menarche and how their daughter will cope emotionally, practically and socially. It may be very reassuring that menarche normally occurs at least two years after the onset of breast growth, and often even later in girls with an early puberty. In boys, parental concerns usually centre on the short stature that accompanies delayed puberty and that may result in bullying at school, and decreasing ability to keep up with peers in sport. Children need referral for evaluation and possible treatment if: (1) their puberty falls outside normal parameters, or (2) there is an abnormal tempo or pattern of puberty e.g. menarche before breast growth or very rapid/excessive development of pubertal changes, or (3) there is concern that the child will not cope with early puberty.

(VJEFMJOFT GPS SFGFSSBM The following situations may prompt referral, and supplying the additional information assists in triaging patients.

#Z %S (MZOJT 1SJDF Paediatric Endocrinologist, PMH

If breast growth in a girl less than 8 years: Progressive breast growth over time Yes/No Cyclical changes in breast growth Yes/No Rapid increase in breast growth Yes/No Vaginal bleeding Yes/No Growth spurt Yes/No Pubic hair development Yes/No Family history of early puberty Yes/No Headaches/visual changes Yes/No Marked skin freckling/birthmarks Yes/No

Definitions: 1. Precocious puberty: Girls – growth of breasts beginning under 8 years of age Boys – enlarging testes (>3cc or 25mm in length) beginning under 9 years of age 2. Premature Pubarche/Adrenarche: Growth of pubic hair without signs of puberty in a child under 8 years 3. Delayed Puberty: No signs of puberty by age of 14 years

Please consider these tests and sending copies of results and/or name of provider:

To allow timely triage of patients, please supply this information.

Please consider these tests and sending copies of results and/or name of provider:

Author competing interests: nothing to declare.

FSH, LH, oestradiol/testosterone, TSH and a bone age (X-Ray left hand and wrist) If pubic hair growth in a child < 8 years, please note: Accelerated growth Yes/No/Don’t know Clitoral hypertrophy Yes/No /Don’t know Acne/adult body odour Yes/No Penile/testicular growth in boys Yes/No Breast growth in girls Yes/No

Bone age (X-Ray left wrist and hand), 17 OHP (hydroyprogesterone), DHEA-S (dehydroepiandrosterone-sulphate), and testosterone. O

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Travel

f o s t e r Sec g n i p p o H d n Isla

There are many ways of getting around the Greek islands and once you get out of the tourist centres, it’s time to unwind and relax.

i* WF KVTU HPU CBDL GSPN UPVSJOH UIF (SFFL JTMBOETw JT B HSFBU conversational starter. How it ďŹ nishes UIPVHI EFQFOET PO XIFUIFS UIF TUZMF PG UPVS NBUDIFE ZPVS QSFGFSFODFT BOE was long enough. 4PNF QFPQMF GMZ JOUP TBZ $SFUF PS 3IPEFT JTMBOET IBWF BJSTUSJQT TUBZ JO UIF GJWF star hotel overlooking the beach, wander the ancient walled city markets, and fly home again. Some wheel light suitcases or carry backpacks, island hop the main ports using the busy ferries (catamarans are fast but more weather sensitive), stay in a range of accommodation and spend extra days at select destinations that take their fancy. 0UIFST TJHO PO B DSVJTF CPBU GSPN CJH MVYVSZ TIJQ UP CBSFCPBU GPPUFS BOE FYQFSJFODF the islands from the sea – you spend more UJNF BU TFB FJUIFS FOKPZJOH UIF PO CPBSE

46

entertainment or wind in the sails and water over the gunnels. -FU T GBDF JU UIFSF BSF UPP NBOZ JTMBOET UP TFF JO POF USJQ 5PVS PSHBOJTFST BSF HPPE at picking those clustered together which offer accessibility (whether by sea or air) BOE JOUFSFTUJOH TJHIUT 5PVST PO TNBMM TBJM ing craft take account of the prevailing OPSUI XFTUFSMZ EVSJOH "VHVTU 4FQUFNCFS and the most productive tours follow the XJOE TPVUI FBTU GSPN "UIFOT UIF $ZDMBEFT islands) or tour the Greek islands just north of Evia island (the Sporades). 5IF (SFFL JTMBOET BOE (SFFDF JUTFMG SFMZ on tourism. You won’t be ripped off, few people will hassle you, and out of Athens (where most of the population lives) the pace is relaxed. Destinations where fer ries call in are, by necessity, touristy so if you want uncrowded venues, women in black dresses herding goats, or donkeys

rather than beach buggies, you will need to arrange a stopover elsewhere on the island. Smaller yachts call at secondary ports, often earlier in the day (to ensure a mooring, FTQFDJBMMZ JO TFBTPO o UIJT USBOTMBUFT JOUP shorter hops and less time at sea. However, a good slice of the day is spent cruising, TP TPNFXIFSF PO CPBSE GPS OPO TBJMPST to enjoy (bigger catamarans are best and they lean less), toilets that store (so toilet paper can go down the ‘heads’), breakfast and lunch provided, and snorkelling gear for BMM DBO CF JNQPSUBOU 8JUI BCPVU QBT sengers, it’s a lucky dip on whether you all match up.

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We’re All Going On a Summer Holiday Please pay attention to the ight steward for this important announcement. (PPE NPSOJOH BOE UIBOL ZPV GPS DIPPTJOH UP nZ XJUI "TDIFBQBTDIJQT "JS UIF OFX TVC CVEHFU "VTUSBMJBO BJSMJOF 1MFBTF QBZ BUUFOUJPO UP UIF safety announcement. Unlike certain OBUJPOBM DBSSJFST XF EPO U TQFOE NPOFZ SFDSVJUJOH ASFTUJOH BDUPST BOE DFMFCSJUJFT UP NBLF BNVTJOH QBSPEJFT KVTU UP XJO LVEPT PO :PV5VCF *O GBDU we care as little for your safety as we do your dignity, but the Civil Aviation "VUIPSJUZ NBLFT VT EP UIJT MFU T HFU JU PWFS XJUI BOE MJTUFO VQ

Speaking of sanitary needs, most sew erage systems in Greece do not handle toilet paper, so it is disposed of in bins in the cubicles. For hygiene conscious health professionals this can be a real challenge, especially as you head out for your fantastic Greek meal. When booking accommodation, make sure ZPV BTL GPS QFSNBOFOU OPO TNPLJOH SPPNT a toilet system you want and, if you book as a couple but under different names (as doc tors are prone to do), they understand you may want a double bed and not twin share. "TL ZPVS USBWFM BHFOU UP BSSBOHF QJDL VQ from the airport so once you clear customs you only have to worry about finding your name held up by the driver. O

By Dr Bruce Bridges

Q Far left: You might have arrived on one of the yachts in the harbour below? Q Left: Ermoupolis (on Syros) was once Greece’s main port and is now capital of the Cyclades, with its marble streets. High above the Platia Miaouli (central square) is the Greek Orthodox neoclassical church, a prize for the walk, matched only by the view. Q Above Inset: As you gaze towards the Rhodes harbour from your luxury hotel, imagine your next Greek island trip aboard a luxury cruise ship.

medicalforum

Your captain today is Mr Bobo, who is with us as part of an exchange program with UIF 1SJNBUF %FQBSUNFOU BU 5BSPOHB ;PP to which we provide uneaten airline meals for the monkeys to fling at the tourists. Apparently, intelligent apes are unable to distinguish between this and their usual readily available projectile matter, but airline

Humour

Laugh Lines

Q Smaller harbours offer the intimacy of meals by the water’s edge, with few tourists around (this one is in the northern port Loutra on Kythnos).

By Ms Wendy Wardell

food has been deemed safer for both the flinger and the flingee, as long as the mon keys don’t eat it. Mr Bobo has undergone a full day of inten sive training in the flight simulator, where he graduated dux of his class, largely because he chewed off fewer knobs than his peers. However, please don’t be alarmed if you hear terrified screeching from the cockpit. Mr Bobo’s pretty cool with flying, but the Flight Engineer is only human. You will have noted, on being herded aboard, that we have embraced new technology to eradicate the need to print boarding passes and merely swiped your credit card instead. -VDLJMZ ZPVS DSFEJU DBSE JT JODMVEFE JO ZPVS free cabin baggage allowance, along with a small tissue with which you may care to NPQ ZPVS CSPX JO UIF FWFOU PG BO JO GMJHIU emergency. Should this fairly unlikely event occur, you can access the lifejacket stowed under your seat. Your credit card will auto matically be debited with a sum that will be determined by the rate of descent of the air craft and the likelihood that Ascheapaschips Air will be required to pay damages once the wreckage has been recovered. Cabin crew will now indicate the location PG UIF FNFSHFODZ FYJUT GJUUFE XJUI UPLFO operated turnstiles to facilitate the smooth exit of those passengers who opted for the Survivor Fare upgrade. Should the plane ditch in the sea, we advise you to wave frantically to any passing plane as soon as you have placed the lifejacket over your head, as the cardboard from which it’s constructed isn’t suitable for immersion JO XBUFS 5IF MJGFKBDLFU JT BMTP equipped with a whistle, as a nice little tune may help dis tract you from your imminent demise. Planes in the Ascheapaschips fleet are subjected to rigorous QSF GMJHIU UFTUJOH PO UIF GJSTU 5IVSTEBZ PG NPTU NPOUIT BT long as our maintenance facil ity in Bangladesh isn’t under water at the time. Kind of ironic really, given the contri bution we’re making to global warming. 5IBOL ZPV GPS GMZJOH Ascheapaschips Air. We hope that you enjoy your flight today, and, in the absence of a long hard look at your standards, book your next journey with us. O 47 47

funnyside e

A Morality Tale Q Q Rest of the World

Version

The squirrel works hard in the withering heat all summer long, building and improving his house and laying up supplies for the winter. The grasshopper thinks he’s a fool, and laughs and dances and plays the summer away. Come winter, the squirrel is warm and well fed. The shivering grasshopper has no food or shelter, so he dies out in the cold. THE END

Q Q The Australian Version 5IF TRVJSSFM XPSLT IBSE JO UIF XJUIFSJOH heat all summer long, building his house and laying up supplies for the winter. 5IF HSBTTIPQQFS UIJOLT IF T B GPPM BOE MBVHIT and dances and plays the summer away. Come winter, the squirrel is warm and well fed. A social worker finds the shivering grasshopper, calls a press conference and demands to know why the squirrel should be allowed to be warm and well fed while others less fortunate, like the grasshopper, are cold and starving. 5IF "#$ TIPXT VQ UP QSPWJEF MJWF DPWFSBHF PG UIF TIJWFSJOH HSBTTIPQQFS with cuts to a video of the squirrel in his comfortable warm home with a table laden with food.

5IF NFEJB JOGPSNT people that they should be ashamed that in a country of such wealth, this poor grasshopper is allowed to suffer while others have plenty. 5IF -BCPS 1BSUZ (SFFOQFBDF "OJNBM 3JHIUT BOE 5IF (SBTTIPQQFS )PVTJOH Commission of Australia demonstrate in front of the squirrel’s house. Bill Shorten rants in an interview with -BVSJF 0BLFT UIBU UIF TRVJSSFM HPU SJDI PGG the backs of grasshoppers, and calls for an immediate tax hike on the squirrel to make him pay his ‘fair share’. In response to pressure from the media, the Government drafts the &DPOPNJD &RVJUZ BOE (SBTTIPQQFS "OUJ Discrimination Act, retroactive to the CFHJOOJOH PG TVNNFS 5IF TRVJSSFM T UBYFT are reassessed. He is taken to court and fined for failing to hire grasshoppers as builders of his home, and an additional fine for contempt when he told the court the grasshopper did not want to work. 5IF HSBTTIPQQFS JT QSPWJEFE XJUI B Housing Commission house and the TRVJSSFM T GPPE JT TFJ[FE BOE SFEJTUSJCVUFE to the more needy members of society – in this case the grasshopper. Without enough money to buy more food, to pay the fine and his newly imposed retroactive taxes, the squirrel has to EPXOTJ[F BOE TUBSU CVJMEJOH B OFX IPNF

Food is Medicine

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Book TODAY at ]ZVai]nk^iVa^in#Xdb#Vj$igV^c^c\ 48

" Minutes special shows the grasshopper finishing up the last of the squirrel’s food, though spring is still months away, while the Housing Commission house he is in, crumbles around him because he hasn’t bothered to maintain it. He is shown to be taking drugs. Inadequate government funding is blamed for the grasshopper’s drug ‘illness’. 5IF HSBTTIPQQFS HFUT BSSFTUFE GPS TUBCCJOH an old dog during a burglary to get money for his drug habit. He is imprisoned but released immediately because he has been in custody for a few weeks. He is placed in the care of the probation service to monitor and supervise him. Within a few weeks he has killed a guinea pig in a botched robbery. A commission of enquiry, that will FWFOUVBMMZ DPTU NJMMJPO BOE TUBUF UIF obvious, is set up. Additional money is put into funding a drug rehabilitation scheme for grasshoppers. 5IF HSBTTIPQQFS EJFT PG B ESVH PWFSEPTF 5IF NFEJB CMBNF JU PO UIF PCWJPVT GBJMVSF of government to address the root causes of despair arising from social inequity and his traumatic experience of prison. 5IFZ DBMM GPS UIF SFTJHOBUJPO PG B NJOJTUFS any minister. 5IF UBYFT PG UIF TRVJSSFM UIF EPHT BOE UIF victims of the burglaries are increased to pay for law and order, and they are told UIBU UIFZ XJMM IBWF UP XPSL CFZPOE because of a shortfall in government funds. THE END

CLASSICS

QUOTE

My grandmother started walking five miles a day XIFO TIF XBT 4IF T OPX BOE XF EPO U LOPX where the hell she is. – Ellen DeGeneres

medicalforum

Wine Review

Mr Duval The Impeccable

Q Winemaker John Duval

By Dr Louis Papaelias 2013 Plexus (White)

As chief winemaker at Penfolds GSPN UP +PIO %VWBM XBT SFTQPOTJCMF BNPOHTU PUIFS UIJOHT GPS UIF QSPEVDUJPO PG "VTUSBMJB T A'JSTU (SPXUI (SBOHF 4IJSB[ 5IJT JODMVEFT UIF MFHFOEBSZ (SBOHF OBNFE as wine of the year by the American magazine, Wine Spectator. Under the NFOUPSTIJQ PG .BY 4DIVCFSU BOE %PO Ditter, he oversaw a vast range and number of wine styles. Wines such BT #JO #JO BOE 4U )FOSJ XFSF made under his watchful eye.

5IJT XJOF JT B CMFOE PG .BSTBOOF 3PVTTBOF BOE 7JPHOJFS 5IFTF UISFF 3IPOF WBSJFUJFT IBWF CFFO TLJMGVMMZ CMFOEFE BOE WJOJGJFE JO QSFNJVN DBTLT 5IF SFTVMU JT B UFYUVSFE XJOF GVMM PG GMBWPVS BOE CPEZ XJUI OP DPBSTF FEHFT 5IFSF JT GSVJU in abundance and a crisp savoury finish. It reminded me of some of the better examples of Spanish Albarino wines that will match and stand up to a wide range of food flavours.

2012 Plexus (Red) We are now in serious wine territory. A cornucopia of ripe fruit and spice on the nose. Palate is equally highly flavoured with seductive suggestions of black cherry and cassis that carry through to a beautifully balanced and long GJOJTI 5IJT TIPXT UIF DMBTT UIBU DPNFT GSPN PME WJOFT .BEF GSPN 4IJSB[ (SFOBDIF BOE .PVSWFESF

As chief winemaker he also became well acquainted with the premium vineyards of South Australia and their individual growers. In short, this man, before starting his own wine business, had formidable experience in premium wine production involving grape selection and top quality winemaking.

2012 Entity Shiraz 8F BSF OPX JO WFSZ TFSJPVT XJOF UFSSJUPSZ .BEF GSPN PME WJOF 4IJSB[ TPVSDFE GSPN #BSPTTB BOE &EFO 7BMMFZT 5SBEJUJPOBMMZ NBEF XJUI NJOJNBM JOUFSGFSFODF JU XBT NBUVSFE JO 'SFODI PBL GPS NPOUIT %FTQJUF UIF PBL USFBUNFOU UIF EFFQ SJQF NPVUI GJMMJOH GMBWPVS PG 4IJSB[ JT XIBU QSFEPNJOBUFT 5BOOJOT BSF GJOFMZ FONFTIFE BEEJOH EFMJDJPVT DPNQMFYJUZ UP B MPOH QFSTJTUFOU finish. As in the Plexus, a wine of impeccable balance and flavour. A joy to drink OPX CVU XJMM SFWFBM NVDI NPSF JO UIF OFYU ZFBST

As you would expect, he has an outstand ing wine palate that fully comprehends the concepts of finesse and balance in wine. Flavour intensity and palate length are also not lost on him. I had the privilege of assist ing him judge at the Perth and Mount Barker wine shows some years back, gaining first hand experience of his exceptional talents. He insists that he is not trying to make BOPUIFS (SBOHF 5IJT JT DMFBS XIFO UBTUJOH his wines. Above all else, they display deep GMBWPVS XJUI GJOFTTF BOE CBMBODF 5IFZ FQJU omise what can be achieved in the Barossa with careful vineyard selection and meticu lous vinification. I tasted three of the four wines produced. 5IFZ BSF BMM PVUTUBOEJOH FYBNQMFT EFMJDJPVT now and I can confirm that they are defi nitely food friendly. Knowing their pedigree, however, I suspect that they will blossom HJWFO TPNF DFMMBSJOH UJNF 5IJT HVZ LOPXT his stuff!

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49

4PDJBM 1VMTF

M -BVODI $MJOJQBUI 0GGJDJB g doctors, architects, builders, project mreantreagatereds antoda

l we cluded referrin Patholog y and al . Invited guests in re and Clinipath ca in Osborne Park lth y ea or H at c or ni lab So h m at ip fro in ff Cl sta w e or ne th seni gst all g of the attention in amon re official openin ace caught your guided tour befo sp d pment) ui an eq ht te lig t ica en pl e. Ambi ancy (e.g. du nd du re e at It was impressiv er lib ild g in the bu ing ion. There was de 200 staff workin t ou ab modern automat ith -bed W y. s, a nurse-run 15 ow th in capacit consulting room and room for gr ur improved fo s e, ha ac t sp lo s’ or m2 of flo e pathologist th , rk wo ck e ha at one time, 5000 e g th nt many tests ar d machines doin uipment has mea eq ew N treatment area an s. ce fa ce, the smiles on immensely. Hen red interstate. rate and not refer cu ac e or m r, ste fa

Q Pathologist Dr Michael Watson explains new features to a tour party.

Q Celebrating the end of a relatively trouble-free transition. Ms Gayle Van Oss, Ms Nicola Russell and Natalie Park

Q Ms Cyndy De Wolde (Clinical Nurse Manager) takes Sonic Healthcare dignitaries on a tour of the 15-bed treatment area, nearby the specialists consulting rooms.

Q (l to r) Dr Rob McEvoy, Mr Paul Alexander and Dr Malcolm Parmenter

Q (l to r) Mr Christopher Wilks (CFO Sonic Healthcare), Dr Colin Goldschmidt (CEO Sonic Healthcare), Mr Bill McConnell (Biochemistry & Toxicology, Clinipath) and Dr Gordon Harloe (CEO Clinipath Pathology)

Q Automation everywhere!

3 "$(1 8" "XB SET /JHIU

Q Dr James Ogundipe, Dr Tim Koh, Dr Frank R Jones, Ms Dhee Jagadish and Dr Jagadish Krishnan

Q New Fellow Dr Astrid Valentine and her family

50

Q New Fellow Dr Magdy Twodros and his family

RACGP WA facu lty welcomed 95 new Fellows at its annual ceremon y at the State Th eatre Centre. Dr Rosenow and Dr Ann Vanessa Hyde-Sm ith achieved the highest exam resu lts and Dr Jagadi sh Krishnan took out the faculty’s ‘Legend’ Award for his work with in WA. Dr Alan IMGs Leeb’s work on th e SmartVax app acknowledged at was the college’s natio nal conference wh he won the Peter ere Mudge Medal. It was Dr Frank Jo awards night as nes’ last state chairman an d hands over the to Dr Tim Koh. reins Dr Jones became the college’s natio president in Oct nal ober.

Q New Fellow Dr Candice Leeb, mother Mrs Rona Leeb and father (and award winner) Dr Alan Leeb

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#FUIFTEB 'PVOE B

UJPO

The Bethesda Fo undation’s inaugu ral charity ball wa rocking affair w sa ith a crowd of m edicos and hosp soaking up the so ital staff unds of Billy Joel ’s band at the Hya Regency. The foun tt dation is chaired by Dr Neale Fong the patrons grou and p includes busin esswomen Rhon and Mar yanne Be da Wyllie ll and photograph er Russell James hospital’s 70th an . The niversar y was al so good cause to the heels. The ni kick up ght raised $ $50, 660.

Q Dr David Gillett and Hayley Benbow

Q Libby Oakes and Dr Tim Jeffery

Q Dr John Love and Jo Love

Q Helen Round, chair of Bethesda’s Medical Advisory Committee Dr David Sofield, and Anne Filmer

FSBEF #BMM "NBOB T .BTRV ll was an opportunity

Masquerade Ba Amana Living’s staff. Home Care its hard-working to te bu tri y pa to OT assistant Rom ager Di Bennett, re among Operations Man ren Partington we Ka nt ta ul ns co R Romo, H night. owledged on the those to be ackn affer Pictures: Leon Sh

Q Former DG of Health Kim Snowball and former head of WACHS, Dr Felicity Jeffries

8"%.4 Christmas Part y

n e also now know WADMS (who ar its ld he s) Visit as Doctor Home ing for Practice er th ga as tm Chris at Doctors and staff Members, Locum ity un rt po op was an at Matilda Bay. It ank all their th to S M D for WA also launching a t supporters whils ility a social responsib new initiative – a on e ur ec MediS partnership with ng. t Doctor Shoppi ba m co to m progra r D ard Member Here WADMS Bo ests. addresses the gu lle vi Jamie Prendi

Q Di Bennett

Q Amana CEO Ray Glickman with Rom Romo

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Suite 15, Unit 1B,20 16Kearns YampiCrescent, Way, Applecross 6155 Willetton,

51

Arts

e s g u n n i e r V i nF Fur Summer means festival season and the Fringe kicks off early in the New Year.

'SJOHF 8PSME 'FTUJWBM IFBET JOUP JUT mGUI ZFBS PG TIBLJOH VQ 1FSUI T FOUFSUBJONFOU TDFOF 4VDI JT JUT QPXFS UP QVMM JO CJH BOE OFX DSPXET UIBU TPNF PG UIF 4UBUF QFSGPSNJOH BSUT DPNQBOJFT BSF KPJOJOH UIF QBSUZ 5IF #MBDL 4XBO -BC IBT BOOPVODFE JUT Fringe offering with brilliant young director -BXSJF $VMMFO 5BJU UBDLMJOH UIF QSPWPDBUJWF David Ives play, Venus in Fur, at the Studio 6OEFSHSPVOE PQFOJOH PO +BOVBSZ 5IF QMBZ JT JOUSJHVJOH XJUI *WFT ESBXJOH PO UIF OPWFMMB Venus in Furs, by Austrian writ FS -FPQPME WPO 4BDIFS .BTPDI TFOTBUJPOBMMZ MBCFMMFE UIF GBUIFS PG NBTPDIJTN CVU -BXSJF suggests also an early feminist, who arguably reclaimed sexual equality for women. -BXSJF JT BT FRVBMMZ FOUISBMMFE CZ JOTJHIUT the play brings to the theatrical process – the inherent power plays between director BOE BDUPS NBMF BOE GFNBMF PWFS UIF DPVSTF of an audition.

/FXMZ NJOUFE 8""1" HSBEVBUF 'FMJDJUZ McKay takes on the role of Vanda – the young actress with beauty, brains and the ability to use both at the same time. Adam #PPUI JT UIF QMBZXSJHIU EJSFDUPS 5IPNBT who doesn’t stand a chance – or does he hold all the cards? You will have to go along to find out! 8IFO -BXSJF TQPLF UP Medical Forum she was bubbling with enthusiasm for the mate rial. Phrases such as ‘Confronting’, ‘funny’ it’s ‘got the lot’ pepper her dialogue. “It’s a page turner. While there is the overt portrayal of sexual tension [some would also add manipulation] it’s a powerful exploration of the craft of theatre. It’s a rare opportunity for an audience to see just what happens in UIF SFIFBSTBM TQBDF IPX BDUPST BOE EJSFD UPST UBML BCPVU QMBZT BOE IPX UIF JEFBT BOE directions are formed. It’s all quite enticing.� i5IPTF NPNFOUT BSF NBHJD GPS NF &WFO though there’s all this sexual tension and provocative sexual and relationship politics

Q Venus in Fur Picture: Robert Frith

at play, the power is seeing the perfor mance behind the scenes. It is art imitating life, imitating art ‌ it’s beautifully hilarious.â€? Another intriguing aspect of the play, and POF UIBU -BXSJF TBZT TIF IPQFT UP FYQMPSF later, are the changes of meaning, subtle and otherwise, when the age of the char acters shift from the convention of young woman, older man. “We don’t know how old Vanda is and it occurred to me what a different story it becomes depending on the age of the play FST NBMF BT XFMM 5FBNJOH VQ ZPVOHFS women with older men told me a lot and worked for my current interpretation.â€? “As the layers of power and potential of the young woman are revealed it shapes the outcome. But change those dynamics and it alters the interpretation and it would be fun to revisit that, it would be a completely different play.â€? O

By Ms Jan Hallam

Who is the Man! There are few more enduring characters on TV than Doctor Who, just ask Peter Davison who will be forever the ‘Fifth Doctor’.

8IFO UIF ZFBS PME 1FUFS %BWJTPO UPPL on the role of the Fifth Doctor in the iconic ##$ 57 TIPX Dr Who JO 4FDPOE %PDUPS 1BUSJDL 5SPVHIUPO UPPL IJN BTJEF and advised him to stick to just three years as the time travelling Doctor or face being typecast. Peter told Medical Forum that he’d envis aged that this episode of his career would just fade quietly into the background of his life. In fact, it’s probably the longest job on 57 o PODF UIF %PDUPS BMXBZT UIF %PDUPS While he has had a rich and varied acting career since, he frequently pops up in the TFSJFT BOE SFMBUFE FWFOUT BOE XJUI CFJOH UIF UI BOOJWFSTBSZ PG UIF TIPX he’s been more than happy to oblige. 0ODF B MJUUMF DSJUJDBM PG IJT PXO TDSJQUT 1FUFS UIJOLT UIF SFWJUBMJ[FE TFSJFT VOEFS UIF DVS 52

rent producer Stephan Moffatt is just what the Doctor ordered. i5IF DVSSFOU XSJUFST EJSFDUPST QSPEVD ers and actors have all grown up as Doctor Who fans and they have done wonders for UIF TIPX 5IFZ IBWF HJWFO UIF TFSJFT B MJNJUMFTT IPSJ[PO 5IF PSJHJOBM DPODFQU PG B time lord in a time machine is tremendously exciting for writers and why science fiction JT BO FWFS FYQBOEJOH HFOSF 5P IBWF TVDI BO FOJHNBUJD OPO WJPMFOU DIBSBDUFS MJLF UIF Doctor, well he’s what we’d like to be ‌ a godlike figure sorting out everyone’s prob lems and putting things aright that have gone horribly wrong.� 1FUFS JT IFBEJOH UP 1FSUI JO +BOVBSZ OPU so much in the guise of the good Doctor but as narrator and guide in the Doctor Who Symphonic Spectacular with the WA

Q Picture: Lucas Dawson

4ZNQIPOZ 0SDIFTUSB JOUSPEVDJOH .VSSBZ Gold’s music from the new era of the show, as well as an array of Dr Who bad dies including the Cybermen and the Daleks who will be patrolling the aisles of the Perth "SFOB 5IFSF XJMM BMTP CF QSPKFDUFE AWJTJUB UJPOT GSPN 1FUFS $BQBMEJ T UI %PDUPS 0WFS UIF ZFBST 1FUFS IBT NFU Dr Who fans in their thousands across the world and he says the thing that unites them is they all seem to know far more about the show than him! “I don’t feel overwhelmed by that – when I do these tours, I’m appearing very much as me and I do have my own passion for the series but I can’t compete with these fans’ vast vaults of knowledge.� Doctor Who Symphonic Spectacular is at UIF 1FSUI "SFOB PO +BOVBSZ O

medicalforum

Musical

Baby, y Look at Him Now New show, new baby ‌ life is an adventure for Michael Cassel.

*G UIFSF T OPU FOPVHI PO QSPEVDFS .JDIBFM $BTTFM T NJOE QSFQBSJOH UP PQFO UIF NBTTJWF NVTJDBM Les Miserable in the New Year at the Crown Theatre, somewhere between mSTU QSFWJFX PO %FDFNCFS BOE PQFOJOH OJHIU TFWFO EBZT MBUFS IF will also be taking his wife, Camille, to a Perth maternity ward for the birth of their second child. “We will be giving birth to a West Australian, which adds another level of excitement to the Perth show,� he told Medical Forum. And if he or she bursts into the world with a hefty set of lungs, Dad just might look to expanding the cast. Not that show, inspired by the Victor Hugo DMBTTJD JT TIPSU PO ESBNB 5IF XPSME IBT been gripped by the raw power of the music and story ever since UK producer extraordi naire Cameron Mackintosh first brought it to UIF TUBHF ZFBST BHP H Z H

Q Michael Cassel and 5IJT 4JMWFS and found an orchestra Cameron Mackintosh and a massed choir and lo A nniversar y BOE CFIPME QFPQMF BOE revival adds got along.� a new dimen TJPO XJUI )VHP T MJUUMF LOPXO TLFUDIFT T MJUUMF LOPXO TLFUDIFT i* UI i* UIPVHIU A0, UIJT JT HPPE PG UIF NFBO TUSFFUT PG UI DFOUVSZ 1BSJT fun’, so the second year I roped in [radio projected onto the stage. TIPDL KPDL> "MBO +POFT UP IPTU JU 5IF DJSDMF was complete when Alan introduced me to i5IJT NVTJD IBT DSJTTDSPTTFE UIF HMPCF GPS his manager Harry M. Miller and I began a quarter of a century and the great Victor work experience with Harry in my school Hugo story, the phenomenal music and lyr IPMJEBZT 5IBU T XIFSF JU BMM CFHBO GPS NF w ics make it a powerful experience but the creative team, particularly the set design, has added something new and exciting with Hugo’s artworks,� Michael said. “I have lost count how many times I’ve seen the show but every time, there’s something new to take in. It’s a show that DPOUJOVFT UP FOUFSUBJO BOE BNB[F w And considering Michael has been in show CJ[ PG IJT ZFBST UIBU T B CJH DBMM His entre to the theatre world is worthy of a musical itself. Having been mesmerised by )BSSZ . .JMMFS T QSPEVDUJPO PG Jesus Christ Superstar BT B ZPVOHTUFS UIF ZFBS old Michael wrote to the impresario offering his services, which were politely declined. “Harry wrote back suggesting it would be best if I finished high school. So I threw myself into amateur dramatics in my home town of Kiama of the south coast of NSW. It wasn’t long before I realised I was better at organising than performing, so I threw myself into my first production which was UIF MPDBM $BSPMT CZ $BOEMFMJHIU JO XIFO * XBT w “I gave myself a year to plan it with the hope of attracting a couple of hundred peo ple. I roped in some stars from Neighbours

medicalforum

Q Picture: Michael Murphy

medicalforum m

Michael’s career has been blessed with NFOUPST BU UIF UPQ PG UIFJS HBNF 5ISPVHI working with Miller, he met connections that would lead him to an extraordinary career with Disney which has seen him stage productions of The Lion King in Australia, Shanghai and New York as well BT UIF CMPDLCVTUFS UI BOOJWFSTBSZ SFWJWBM in South Africa. He and Camille moved to New York where he worked on a number of Broadway shows for Disney until the lure of home and new producing opportunities called. “Global Creatures rang and asked if I was interested in launching a swag of projects – Walking with Dinosaurs and musicals Strictly Ballroom and King Kong – in the region. As always seems to happen in this business, once I returned, Cameron Mackintosh called and I’m now on this BNB[JOH BEWFOUVSF XJUI Les Mis.� It’s a long way from the Kiama Carols by Candlelight but there would be many who never doubted Michael Cassel’s ability to put on a great show! O

By Ms Jan Hallam 53 53

$PNQFUJUJPOT

EnteringAsMedical Messiah seasonForum's approaches, Perthis celebrates $0.1&5*5*0/4 easy! the glorious music of Handel in two top-

Simply visit www.medicalhub.com.au and click on the shelf productions – the annual '$0.1&5*5*0/4' link (below the magazine cover on the left).

Music: Collegium 4ZNQIPOJD $IPSVT 4FF 4BSB .BDMJWFS BOE 5FEEZ 5BIV 3IPEFT XJUI the Collegium chorus in Handel’s majestic Messiah. In the November issue we featured Sara Macliver CVU GBJMFE UP DSFEJU UIF QIPUPHSBQIFS 3IZEJBO -FXJT

Collegium Symphonic chorus and orchestra, with a stellar line-up of Australian soloists, Movie: Birdman and WASO and Chorus with Birdman is a black comedy with Michael Keaton playing an international line-up. actor – famous foran portraying an iconic superhero –struggling to mount a Broadway play. In the days leading up to opening night, he battles his ego and attempts to recover his family, his career, and himself. In cinemas, January 15

Collegium’s performance is on December 20 at the Perth Concert Hall.

Winner Doctors Dozen Celebrating with Turkey 'MBU

movie tickets A couple of rk past has da in the dim, al only Medic been the for t en om m ng Forum winni , l Paediatrician Developmenta MM U B IB 5 g in el Dr Brad Jong O PG a McLaren UIF DFMFCSBUJP changed with DI XJMM IFMQ JO IJ X sa FO ve lo P[ % ad Br Vale %PDUPS T e November. HSFBU versary in lat ni JUI an X MMT ng DB di SF ed his w BCFSOFU BOE BSHBSFU 3JWFS D F GPDVT GVMM CPEJFE . B EJTUJODU XJO JUI X OZ DB VT 5 UP JQ US B SFMJTI

Movie: Wild 3FFTF 8JUIFSTQPPO CSJOHT BMJWF CFTUTFMMJOH BVUIPS $IFSZM Strayed’s extraordinary autobiography where after years of heroin addiction, reckless behaviour and the destruction of IFS NBSSJBHF TIF UBLFT PGG UP IJLF TPMP NPSF UIBO LN PO UIF 1BDJGJD $SFTU 5SBJM In cinemas January 22

Movie: The Interview

MEDICAL F ORUM $10 .50

%BWF 4LZMBSL +BNFT 'SBODP BOE IJT QSPEVDFS "BSPO 3BQPQPSU 4FUI 3PHFO SVO UIF QPQVMBS DFMFCSJUZ UBCMPJE 57 TIPX Skylark Tonight. When they discover that North ,PSFBO EJDUBUPS ,JN +POH VO JT B GBO PG UIF TIPX UIFZ MBOE an interview with him. As Dave and Aaron prepare to travel to Pyongyang, their plans change when the CIA recruits them. In cinemas, January

8*//&34 '30. 5)& 0$50#&3 *446& Movie – Pride: %S 4BMMZ 1SJDF %S #JCJBOB 5JF %S 5POZ $POOFMM %S -BXSFODF $IJO %S (SBIBN )PDLJOH %S .FJMZO )FX %S (BWJO -FPOH %S +BNFT 'MZOO %S +FOT #VFMPX %S %POOB .BL Movie – The Drop: %S 5BNTJO $PVUUT %S (SFH (MB[PW %S 3PCFSU .D8JMMJBN %S #SFOEBO $POOPS %S +BOF %FBDPO %S :PIBOOB ,VSOJBXBO %S #BSSZ -FPOBSE %S #SFUU #BJSE %S .JDIFMMF -VZ %S $PMJO 4UFXBSU

Gold Med Medicine al

OCTOBER 2 014

t Head, Sho ulders, Knees & An kles t Midland – Going Pub lic t GPs & Hea lth Funds t Primary Car e Research t E-Poll: Ins urers in the Spotlig ht

medicalforum

54 Major Sponsors

October 2014 ww

Acclaimed director and writer Mike Leigh (Secrets & Lies) brings to the screen the story of British Romantic water-colourist JMW Turner (played by Timothy Spall who won best actor at Cannes). Turner, who was considered a controversial figure in his day, is now regarded as one of the world’s pre-eminent landscape painters known as “the painter of light�. In cinemas, December 26

g n i l l i r h AT Legacy

Musical

Movie: Mr Turner

Musical Theatre: Les Miserables Start the New Year with a touch of class as UIJT UI BOOJWFSTBSZ QSPEVDUJPO PG #PVCMJM BOE SchÜnberg’s legendary musical Les MisÊrables, opens at the Crown. Victor Hugo’s powerful TUPSZ BOE IJT MJUUMF LOPXO TLFUDIFT DPNF BMJWF on centre stage as Simon Gleeson marches tri VNQIBOUMZ JOUP UIF MFBE SPMF PG +FBO 7BMKFBO Crown Theatre, Previews start December 31, opening night, January 7, Medical Forum performance, January 7

5IFBUSF 7FOVT JO 'VS Based on the David Ives play, this Fringe World QSPEVDUJPO GSPN #MBDL 4XBO 4UBUF 5IFBUSF Company, gives the audience a bird’s eye view of not only the audition process (fascinating as it is) but also the sexual power games between a young, beautiful actress and the experienced director. What is real, what is fantasy? Studio Underground, State Theatre Centre, January 15

.VTJD %PDUPS 8IP 4ZNQIPOJD 4QFDUBDVMBS 5IF GJGUI %PDUPS 1FUFS %BWJTPO B GFX $ZCFSNFO and Daleks and the odd space monster or three KPJOT 8"40 GPS UIF Doctor Who Symphonic Spectacular DFMFCSBUJOH UIF UI BOOJWFSTBSZ PG UIF ##$ T QIFOPNFOBMMZ TVDDFTTGVM TIPX 5IF UI %PDUPS NBLFT B ADZCFS BQQFBSBODF XIJMF 8"40 QMBZ NVTJD GSPN UIF TFSJFT Perth Arena, January 31

.PWJF 'PMJFT #FSHÒSF *TBCFMMF )VQQFSU TUBST BT UIF MPOH NBSSJFE TPNFUIJOH #SJHJUUF XIP XJUI IFS IVTCBOE Xavier breeds cattle. As her children all leave she looks for diversion and impulsively sets off for Paris under the guise of a doctor’s appointment and a new world unfolds. In cinemas, December 11

Opera – Il Travatore: %S "NJS 5BWBTPMJ Theatre – Hay Fever: Dr Deirdre Speldewinde Movie – Folies Bergeres (replacing Decoding Annie Parker): %S +FO .BSUJOT %S -FBOOF )FSFEJB %S .BZ "OO )P %S (FPGG .VMMJOT %S /PSNBO +VFOHMJOH %S .BY 5SBVC %S .BSJOB %VOOF Dr Dermot Kearney, Dr Paul Kwei, Dr Hilary Clayton

medicalforum

A show heading to Perth from London’s West End seeks to reclaim the sensational work of King of Pop Michael Jackson from his sensationalised life.

5ISJMMFS -JWF 0QFOFE BU UIF -ZSJD 5IFBUSF JO -POEPO PO +BOVBSZ TJY NPOUIT CFGPSF .JDIBFM +BDLTPO EJFE in controversial circumstances. Then, among the tabloid DIBUUFS "ESJBO (SBOU B MPOH UJNF BTTPDJBUF PG +BDLTPO T QVU UPHFUIFS TFRVFODFT PG UIF TJOHFS T HSFBUFTU IJUT GPS B TQFDJBM FWFOU UP DFMFCSBUF IJT DBSFFS NVTJD BOE JDPOJD QFSGPSNBODF TUZMF 4JY NPOUIT MBUFS +BDLTPO XPVME CF EFBE CVU UIF -ZSJD CFDBNF B .FDDB GPS +BDLTPO GBO BT Thriller Live! continued thrilling. Now JO JUT TJYUI ZFBS NBLJOH JU UIF MPOHFTU SVOOJOH TIPX JO UIF -ZSJD T ZFBST JU IBT CFDPNF B DFMFCSBUJPO PG UIF NVTJD UIBU XPO U MFU your feet stand still. 5IF TIPX JT PQFOJOH BU UIF $SPXO 5IFBUSF UIJT NPOUI XJUI B local and imported cast bringing to life songs such as I Want You Back, ABC, Can You Feel It, Off The Wall, The Way You Make Me Feel, Smooth Criminal, Beat It, Billie Jean, Rock With You, and, of course, Thriller to life. 5IF TIPX T "VTUSBMJBO QSPEVDFS 5PSCFO #SPPLNBO TBJE UIBU +BDLTPO T MFHBDZ XBT TUSPOHFS UIBO FWFS i5IFSF XBT TVDI DPOUSPWFSTZ PWFS UIF MBTU GJWF ZFBST PG .JDIBFM +BDLTPO T MJGF UIBU JU PWFSTIBEPXFE KVTU XIBU BO JODSFEJCMF CPEZ of work he had produced and what an incredible artist he was. As time moves on, people are remembering and focusing on him as the artist and performer. I think the legend is stronger now than when he died. He’s left an incredible legacy.� Perth is the first stop in the national tour. It opens on December BOE SVOT VOUJM %FDFNCFS O

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medical forum WANTED TO BUY OR LEASE GP PRACTICE REQUIRED Looking to buy or lease. In Perth’s northern suburbs. EPDUPS QSBDUJDF DWS Area. Call Eric on 0469 177 034 an leave a message

FOR LEASE NEDLANDS Medical Specialist Consulting Rooms and Treatment Room t 'VMMZ TFSWJDFE DPOTVMUBUJPO SPPNT at Hollywood Specialist Centre t 4FDSFUBSJBM TVQQPSU oIJHIMZ FYQFSJFODFE long term staff t (FOJF TPMVUJPOT QSBDUJDF management software t 0OMJOF .FEJDBSF DMBJNT t 5FMFIFBMUI DPOTVMUBUJPO GBDJMJUJFT t 1BQFSMFTT QSBDUJDF TVQQPSUFE t 5SFBUNFOU SPPN o BWBJMBCMF GPS ambulatory procedures t "DDFTT UP )PMMZXPPE 1SJWBUF )PTQJUBM for inpatient care and theatre bookings supported t *OQBUJFOU CJMMJOH TVQQPSUFE Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager, 4VJUF )PMMZXPPE 4QFDJBMJTU $FOUSF .POBTI "WFOVF /FEMBOET 8" Phone: 9389 1533 &NBJM TVJUF IPMMZXPPE!CJHQPOE DPN MURDOCH New consulting suite including separate treatment room available in Wexford Medical Centre. Full time or sessional basis. Very reasonable rates. Contact Dianne 0409 379 795 MURDOCH NEW Wexford Medical Centre Attached to the St John of God Hospital, in vicinity of the Fiona Stanley Hospital. Modern, newly fitted out medical consulting room. 4FTTJPOBM NFEJDBM EFOUBM SPPNT BWBJMBCMF Please contact wexfordmedical@outlook.com for more information. APPLECROSS Applecross Medical Group is a major medical facility in the southern suburbs. Current tenants include GP clinic, pharmacy, dentist, physiotherapy, fertility clinic and pathology. Both the GP clinic and pharmacy provide a 7-day service. The high profile location (corner of Canning Hwy and Riseley Street Applecross), provides high visibility to tenants in this facility. A long term lease is available in this facility - with the current layout including 4 consulting rooms, procedure room and reception area. Would suit specialist group, radiology or allied health group. Contact John Dawson – 9284 2333 or 0408 872 633

MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: cford@cyllene.uwa.edu.au MURDOCH Available now. Suite in Murdoch Medical Clinic for lease or sessional use. Well-appointed 16sqm consulting room, shared use of large reception/waiting area and tea room. Rates available on enquiry Contact: Ian Dowley 9366 1769 or: ian@flexphysiotherapy.com.au MURDOCH Brand new Medical Suite for Lease at the new Wexford Medical Centre. 106 sqm, complete fit-out and ready to lease. Please contact: reception@ccwa.net.au NEDLANDS Hollywood Medical Centre - 2 Sessional Suites. Available with secretarial support if required. Phone: 0414 780 751 NEDLANDS Available now. Use of rooms at Chelsea Village on M T W only. Easy parking. Nicely appointed examination room would suit non procedural e.g. medicolegal examinations or paramedical. You open up, have sole use when required, then lock up. Occasional use or long term. Flat $275 per day use. Contact Dr Peter Burke 0414 536 630 MURDOCH SJOG Murdoch Medical Clinic within SJOG Hospital t TRN PO TU GMPPS DMPTF UP MJGUT t 4FDVSF VOEFSDPWFS DBS CBZ t $VSSFOUMZ DPOTVMU SPPNT X XBUFS t -BSHF SFDFQU XBJUJOH SPPN LJUDIFO t 0OF PG POMZ GFX TVJUFT XJUI QSJWBUF 8$ t %VDUFE 3 $ BJSDPOEJUJPOJOH t "WBJMBCMF G GVSOJTIFE NJE MBUF +VOF The perfect suite for the medical specialist or allied health service where a private Toilet is required or preferred Frana Jones 0402 049 399 Core Property Alliance 9274 8833 frana@corepropertyalliance.com.au

MURDOCH Consulting room for lease at the new Wexford Medical Centre at Murdoch. Well lit, spacious sessional consulting rooms for lease. For further information please contact Murdoch Specialist Physicians on 9312 2166 or email us at admin@murdochspecialistphysicians.com.au

MURDOCH New Wexford Medical Centre – St John of God Hospital 2 brand new medical consulting rooms available: t TRN BOE TRN t DBS CBZ QFS UFOBODZ Lease one or both rooms. For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au MURDOCH Brand new modern consulting rooms available for sessional lease at the new Wexford Medical Centre. For more information: Email: reception@paragonsp.com.au or Call 0403 323 168

SPECIALISTS WANTED Cockburn Super Clinic GP Cockburn Central is looking for Specialist’s to join them at their new state of the art medical centre. This is an exciting opportunity to become part of our team in an integrated health facility located within the new Cockburn Super Clinic and close to Fiona Stanley Hospital. Part time, sessional or full time all enquires welcome. For further information email: hr@betterhealthcare.com.au

PSYCHIATRISTS INVITED

BIBRA LAKE - Psychiatrist wanted Are you intending to start Private Practice? This is a sheer walk-in! Part time, sessional or full time - all enquiries welcome. Furnished consulting rooms available at: Bibra Lake Specialist Centre, 10/14 Annois 3PBE #JCSB -BLF 8" Currently 4 practising Psychiatrists and clinic is open Tuesday to Friday 7-day pharmacy and GP surgery next door are added advantages. 5 minute drive to St John of God and upcoming Fiona Stanley hospital. Phone Navneet 9414 7860

ALBANY

RURAL POSITIONS VACANT

Private Psychiatric Practice A great opportunity to live and work in scenic Albany by taking over an established private practice. Providing private psychiatric care for Great Southern Region (Population: approximately 50 000) Good supportive network of skilled General Practitioners sharing in the care and management of Psychiatric patients. No private hospital and patients needing inpatient care are transferred to Perth. No after hours work. Peer review groups with Psychiatrists working at Public Mental Health. Phone Felicity: 9847 4900 or email

ALBANY t 4U $MBSF T JT B OFX GBNJMZ QSBDUJDF CBTFE in Albany t 4NBMM GSJFOEMZ QSBDUJDF t 'VMM UJNF OVSTJOH BOE administration support t 1BUIPMPHZ PO TJUF t 'VMM PS QBSU UJNF (1 XBOUFE UP KPJO PVS UFBN t 4QFDJBM JOUFSFTU JO TLJO XPVME CF JEFBM t $VSSFOUMZ OP %84 VOMFTT XJMMJOH UP work in afterhours period t (1T OPU SFRVJSJOH TVQFSWJTJPO SFRVJSFE Please contact practice manager Belinda Elliott Tel: 9841 8102 Email: belinda@stclare.com.au Or send your CV through and we will get back to you.

pietclaassen45@hotmail.com

LOCUMS WANTED NEDLANDS HOLLYWOOD MEDICAL CENTRE Two new, large professional, well presented consulting rooms within specialist suite at Hollywood Medical Centre Full/part time lease or sessional basis available Available furnished or unfurnished Shared reception, office and patient waiting area Please contact Michelle/Emma on 08 6389 0244 for further details Or email Info@perthcolorectal.com.au

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KINROSS Urgent locum / permanent position VR or Non VR GP, PT/FT to start ASAP. Privately owned DWS location practice. Support available for those having interest in skin cancer, cosmetic mole removal. 0OTJUF 1BUIPMPHZ QIZTJP QTZDIPMPHJTU podiatrist. Practice open 7 days. Great rates. Contact: sanjaykanodia2000@yahoo. com or call 9304 8844

URBAN POSITIONS VACANT ASCOT Part-Time VR GP required for our well established Accredited Privately Owned Friendly Family Practice in Redcliffe. We are fully computerised, using Best Practice software. Nurse is support available. Non DWS area. Please call – 9332 5556

FEBRUARY 2015 - next deadline 12md Wednesday 15th January – Tel 9203 5222 or jen@mforum.com.au

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medical forum

CLAREMONT Growing GP practice located in the trendy suburb of Claremont. 80% of billings or $1000 a day whichever is greater. Looking for VR GPs with unrestricted provider number on a part-time or full time basis. Fully computerised with on-site pathology and RN support. Located in a modern complex with access to the gym and pool. For further information please contact Dr Ang on 9472 9306 or Email: thewalkingp@gmail.com ROLEYSTONE PT/FT VR Female GP required for a GP clinic in Roleystone. A friendly and efficient working environment. Well-equipped consulting and treatment rooms, fully computerised, accredited and busy practice. Contact: practice.manager@roleystonefmc.com.au

FREMANTLE Fremantle GP After Hours Clinic require GPs for evening and weekend work. We are classified as an area of unmet need and therefore are able to employ OTDs who qualify to work in this area. We have ongoing vacancies and casual shifts available. Generous hourly rate. Please contact either Marina.trevino@FremantleML.com.au or FGPAHManager@FremantleML.com.au or 9319 0555 GOSNELLS Ashburton Surgery. VR GP needed. Private billing. Flexible hours. 75% of billings. %S TVSHFSZ 'VMMZ FRVJQQFE XJUI nursing support. Email: angiesurgery@gmail.com or Phone Patrick 0403 756 338 or 9490 8288 RIVERTON RIVERTON MEDICAL CENTRE is looking for a Part-Time VR GP. Access to full-time practice nurse. Fully computerised practice. Friendly working environment. Pay negotiable. Ring Dr Sovann on 0412 711 197 if interested.

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity for FT/PT doctor in a State of art clinic, inner-metro, Nursing support, Pathology and Allied services on site. Private billing. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979 Email: o_takla@yahoo.com

CANNING VALE Rare Opportunity; Canning Vale Canning Vale Medical centre will have a room available from January 2015 for an established VR doctor wanting to relocate their practice to new rooms and join our team. Full management services are provided by doctor owned practice operating for 15 years under the same management. Continuous accreditation, finalist for AGPAL practice of the year last year, full nursing support, computerised with referees available for suitable candidate. Visit us at www.canningvalemedical.com.au Confidential enquires Dr. Neda Meshgin 0414641963 or dr.meshgin@canningvalemedical.com

WEST PERTH FT GP required for our friendly, accredited and fully computerised general practice. The practice has been growing rapidly and we are moving into new premises with an extra consulting room. We serve a young, professional demographic as well as providing specialist sexual health services. This is an exciting opportunity for an enthusiastic practitioner to join our practice. VR with experience in family planning and women’s health preferred. Contact Stephen on 0411 223 120 Email: stephen@westperthmedicalcentre.com.au

HELENA VALLEY GP F/T OR P/T Required Fully computerized and accredited modern practice with nursing and admin support. Well equipped treatment room. Onsite psychologists, podiatrist and pathology services available. Attractive remunerations and long term career opportunity. Located in Helena Valley WA. Email expression of interest to hemcadm@bigpond.net.au SCARBOROUGH Grand Prom Medical Centre Scarborough requires a full time VRd GP to replace retiring long established GP. Our practice is fully accredited and well supported by excellent reception staff and practice nurses. We use Best Practice software and are a Private Billing practice. No after hours work required. Please contact Dr Lucy Gilkes or Dr Andrew Britto on 0408 029 326 or 08 9245 1515. Email gpmc@westnet.com.au

COMO Want variety in your work? Special interest opportunities at the Well Men Centre in Como. Part time GP’s for our Perth Mole Clinic, Skin Cancer Screening Service and for our Holistic Health Management Programme. Call 9474 4262 or Email: wellmen@optusnet.com.au SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979 WEST LEEDERVILLE Great Lifestyle! Part time (up to full time) VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: glenstreetpractice@iinet.net.au or call Jacky, Practice Manager on 9381 7111 / 0488 500 153 ELLENBROOK Exciting opportunities for VR GPs to join the vibrant team at Ellenbrook Medical Centre. Full time and part time positions available. Email your CV to ellenbrookfmc@gmail.com All applications considered.

General Practitioner (VR) required for Saturdays Gosnells Healthcare Centre is a newly established Bulk Billing Medical Centre situated in the Gosnells Central Shopping Centre. t 8F SFRVJSF B (FOFSBM 1SBDUJUJPOFS (VR) for Saturdays t $POTVMUBUJPO IPVST BSF OFHPUJBCMF t (PTOFMMT JT %84 GPS (FOFSBM QSBDUJUJPOFST t 5IF QSBDUJDF JT GVMMZ FRVJQQFE and computerised t .JOJNVN IPVSMZ SBUF PG QFS IPVS or 70% of billings, whichever is greater. t 'PS GVSUIFS JOGPSNBUJPO QMFBTF contact Joe Ranallo on 0418282796 or at joe.ranallo@ppsportal.com.au

MANDURAH GP required for accredited, established friendly practice with FT RN support with a special interest in skin cancer medicine. Coastal lifestyle only 40 minutes from Perth Contact mail@modernmedicalclinics.com.au

THORNLIE Thornlie Medical Centre is looking for a part- time doctor to fill our growing multicultural practice. We can offer: t GMFYJCMF IPVST t FYDFMMFOU SFNVOFSBUJPO t HSFBU UFBN FOWJSPONFOU t OPO DPSQPSBUF OP CJOEJOH DPOUSBDUT t 0VUFS .FUSPQPMJUBO "SFB (SBOU Applicable, (16km from Perth CBD) t GVMM UJNF OVSTJOH t NPEFSO CVJMEJOH XJUI TFQBSBUF TFDVSF parking for doctors. The successful applicant should be: t 7PDBUJPOBMMZ 3FHJTUFSFE t .VMUJ MJOHVBM XPVME CF CFOFGJDJBM particularly with Chinese Dialects. Please contact Donna: 08 9267 2888 OR email enquiries and CV to thornliemedicalcentre@hotmail.com

KINGSLEY

Fantastic opportunity. A modern state-of-the-art, paperless clinic. 100% private billing. 'MFYJCMF IPVST ZPVS DIPJDF PG QBUJFOU case load, treat the patients you want. &NBJM SFTVNF DPWFS MFUUFS UP km@kingsleymedical.com.au www.kingsleymedical.com.au

WINTHROP Female VR Doctor required to join our busy private billing practice in an ideal location in Winthrop. Perfect for a long term commitment. All requirements provided for, including full nursing support in a large medical centre. Please contact Cathy on (08) 9310 4400 or email CV to admin@hatherleymedical.com.au.

Produced right here in Western Australia! Full Colour Personalised Practice Newsletter -RLQ RYHU VDWLVÂżHG PHGLFDO SUDFWLFHV DFURVV $XVWUDOLD ZKR SURYLGH Health News DV D YDOXDEOH SDWLHQW VHUYLFH LQ WKHLU SUDFWLFH ,W DVVLVWV ZLWK DFFUHGLWDWLRQ DQG ZH GR DOO WKH ZRUN IRU \RX 9HU\ UHDVRQDEO\ SULFHG DQG D Free Trial Offer IRU WKRVH VWDUWLQJ RXW 6LPSO\ SKRQH -HQQ\ on 9203 5599.

FEBRUARY 2015 - next deadline 12md Wednesday 15th January – Tel 9203 5222 or jen@mforum.com.au

medical forum GREENWOOD Greenwood/Kingsley Family Practice The landscape of general practice is changing, and it is changing forever. Are you feeling demoralised by the recent Federal government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? It doesn’t have to be this way!! Come and speak to us and see the different ways in which we operate our general practice. Be part of the game changer! Our practice is located north of the river. Sorry we are not DWS. Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion. MINDARIE Harbourside Medical Centre is looking for a GP preferable VR FT/PT, Accredited medical centre, onsite pathology, fully equipped and nurse, up to 70% billing. Contact 0417 813 970 or Email: mmutahar@harboursidemedicalcentre.com.au LESMURDIE OR HIGH WYCOMBE Full time or Part time VR GP’s required in Lesmurdie or High Wycombe %84 "0/

- Privately owned with mixed billing - Nursing support - Fully computerised - Teaching practice - Allied Health - Special interest and skills supported - Hills location Contact Karin on 0438 211 240 or karintatnell@yahoo.com.au

ARE YOU READY FOR A CHANGE? We are looking for specialists and GP’s to join the expanding team! Tenancy and room options available for specialist’s. Procedural GP’s and ofďŹ ce based GP’s well catered for. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. * full-time/part-time/sessional * medical systems and secretarial support * adjacent to Fiona Stanley Hospital More information phone: 9366 1802 or email: diane.car@sjog.org.au

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ARE YOU LOOKING FOR DOCTORS FOR YOUR MEDICAL PRACTICE? Australian Medical Visas is owned and run by 2 Practice Managers based in WA, who have over 20 years experience of the UK and Australian healthcare systems. We currently have a number of doctors who are looking for positions in Australia. We are able to assist practices with all paperwork involved including the migration process (if required). Please visit our website www.australianmedicalvisas. com.au or contact Jacky on 0488 500 153 or Andrea on 0401 37 1341.

CANNINGTON Southside Medical Service is an accredited practice located in Cannington area. We are a family practice and offer mixed billings. We have positions for a GP to join PUIFS (1 T DVSSFOUMZ XPSLJOH It is a well-positioned practice, close to the Carousel Shopping Centre. Phone: 9451 3488 or Email: practicemanager@southside.com.au BUTLER Connolly Drive Medical Centre. Brand new, non-corporate, computerised, fully equipped, 17 bed medical centre. RN support, pathology, allied health. Abundant patients. DWS. Dr Ken Jones needs a VR GP to join him in this major, state of the art facility. Email: ken@cdmedical.com.au or call Ken Jones on 9562 2599 (direct line).

Reach every known practising doctor in WA through Medical Forum Classifieds...

FEBRUARY 2015 - next deadline 12md Wednesday 15th January – Tel 9203 5222 or jen@mforum.com.au

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medical forum for LEASE

Southern Suburbs GP required for after-hours & weekends Non-VR Dr’s encouraged to apply. Send applications to hr@betterhealthcare.com.au

EXMOUTH Brand new premises available for entrepreneurial GP. Be the ďŹ rst private GP in town, with opportunity to focus on occupational and dive medicine as well as family practice. Wonderful lifestyle with stunning scenery and wildlife to explore. Contact draburkett@live.com

Mandurah VR general practitioner required for busy general practice in Mandurah, near Peel Health Campus.

Our busy, well-run clinic requires part-time GPs for ongoing sessional work; working with domestic, international students and staff. t 'MFYJCMF TFTTJPO UJNFT BWBJMBCMF .POEBZ UP 'SJEBZ t (SFBU PQQPSUVOJUZ UP XPSL JO B WJCSBOU EZOBNJD FOWJSPONFOU XJUI EJWFSTF OFFET t 8F PGGFS OFX QSFNJTFT BOE DBO TVQQPSU ZPV XJUI B UFBN PG FYQFSJFODFE OVSTFT QTZDIPMPHJTUT BOE GSJFOEMZ BENJOJTUSBUJWF TUBGG t &YDFMMFOU SFNVOFSBUJPO PG CJMMJOHT oCVMLCJMMFE BOE QSJWBUF BOE GSFF SFTFSWFE PO DBNQVT QBSLJOH BWBJMBCMF "O JOUFSFTU JO BOE FYQFSJFODF XJUI XPSLJOH XJUI ZPVOH QFPQMF NFOUBM IFBMUI TFYVBM IFBMUI BOE USBWFM IFBMUI JT FTTFOUJBM 1MFBTF DPOUBDU -JTB $SBOmFME 5FBN -FBEFS .VSEPDI )FBMUI BOE $PVOTFMMJOH 4FSWJDF PO PS email l.cranďŹ eld@murdoch.edu.au

Accessible via public transport and just a few minutes off Kwinana Freeway. Private mixed billing group practice providing quality comprehensive family care for over 50 years to Mandurah and the surrounding community. Our team features primary health physicians, specialists and allied health professionals. Treatment room facilities, procedures room, skin clinic, travel clinic, nurse practitioner, practice nurses, reception, medical secretary, accounts, administration staff are here to support you. Specialist, allied health services, pharmacy co-located in the same building. The practice is open 7 days a week. No DWS. To apply please email: manager@mmcmandurah.com.au

ARE YOU WANTING TO SELL A MEDICAL PRACTICE? As WA’s only specialised medical business broker we have sold many medical practices to qualiďŹ ed buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible. We are committed to maintaining conďŹ dentiality. You will enjoy the beneďŹ t of our negotiating skills. We’ll take care of all the paper work to ensure a smooth transition.

To ďŹ nd out what your practice is worth, call:

Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au

FEBRUARY 2015 - next deadline 12md Wednesday 15th January – Tel 9203 5222 or jen@mforum.com.au

medical forum

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General Practitioners Needed headspace #VOCVSZ JT TFFLJOH FYQSFTTJPOT PG JOUFSFTU GSPN (FOFSBM Practitioners or General Practices that are willing to contract to the centre UP EFMJWFS CVML CJMMFE TFTTJPOT UP ZPVOH QFPQMF UP BOE XIP BSF t :PVUI GSJFOEMZ t *OUFSFTUFE BOE PS FYQFSJFODFE JO BSFB PG NFOUBM IFBMUI t ,FFO UP XPSL JO B NVMUJEJTDJQMJOBSZ UFBN headspace #VOCVSZ QSPWJEFT t (1 DPOTVMUBUJPO SPPN t 1SBDUJDF /VSTF TVQQPSU t .FEJDBSF CJMMJOH

t $BS QBSLJOH PO TJUF t "ENJOJTUSBUJWF TVQQPSU t $PMMFHJBM TVQQPSU

5P FYQSFTT ZPVS JOUFSFTU JO UBLJOH VQ UIJT PQQPSUVOJUZ QMFBTF DBMM the Centre Manager Nicky Smith on 9729 6800 for a conďŹ dential discussion or email nicky@headspacebunbury.org.au

MEDICAL SUITE – For Lease South Terrace, South Perth Purpose built medical suite vacant and available now. Reception / waiting / 2 consulting rooms (14.2sqm and 15.6sqm). More information and inspection contact:

KUNUNOPPIN - Wheatbelt

Marcia Everett CEO/Director of Nursing South Perth Hospital 9367 0275

Friendly rural community based solo GP practice (RA4) attached to the local hospital requires a full time General Practitioner VR to work 4 days a week. Doctor services at 3000 people community of 4 shires with small clinics in Beacon, Bencubbin and Mukinbudin. Opportunity to use a vast scope of practice. Ĺ” Ĺ” Ĺ” Ĺ” Ĺ” Ĺ” Ĺ” Ĺ” Ĺ”

Up to 70% of billings Rural GP incentive payments Emergency Department work in district hospital 50km away WACHS SIHI incentive payments for ED work Service local Kununoppin Hospital 4 bedroom House and car provided Family is encouraged Fully accredited practice Private and bulk billing at Dr discretion

Please send CV to cmcghie@rho.net.au or call Christine on 0439 003 434

Medical Practitioners Opportunities available in regional WA or Darwin for GPs. Our company specialises in providing pre-employment, injury management and health and wellness services to industry. You will be an experienced doctor who can provide exceptional care to and communicate well with our patients and clients. You will be dedicated to ongoing professional development and enjoy working collaboratively within a multi-disciplinary team. Candidates eligible for full registration in Australia who have passed AMC exams are invited to apply. An attractive salary package will be negotiated with the successful applicant. Interested candidates should send a CV and covering letter to Sally Harris, COO at REDiMED, sharris@redimed.com.au or telephone 61 8 9230 0900. (Email enquiries preferred in the ďŹ rst instance).

With a reputation built on quality of service, Optima Press has the resources, the people and the commitment to provide every client with the finest printing and value for money. 9 Carbon Court, Osborne Park 6017 } Tel 9445 8380

FEBRUARY 2015 - next deadline 12md Wednesday 15th January – Tel 9203 5222 or jen@mforum.com.au

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