Medical Forum 02/14 Public edition by Medical Forum WA

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Are you Ready? t Reform: Pace of Change; Rebates; Leaders; Accreditation t Stroke Management Resources t Clinical Trends Across Disciplines t Guest Columns; and more t Christmas Social Photos

February 2014 www.mforum.com.au

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Contents

February 14 14

DOCTORS

DRUM

FEATURES

GUEST COLUMNS

16 18 36 46

Trailblazer: Dr Kathleen Mallory Dr Rob McEvoy Guest Column Award: Dr Penny Wilson Stroke Management in WA Clinical Trends Christmas 2013 in Pictures

25 26 27

NEWS & VIEWS 6 27 31

Editorial: We, the Innovators and Reformers Online Breast Cancer Module Finance Education for Docs

28 29 33

Good Things About Change Dr Denis Carragher Numbers in Primary Care Dr Colin Hughes The Surgeon’s Blueprint Dr David Morrison (PhD) Leadership in a New Age A/Prof David Watson Improving Doctor Co-operation Dr Victor Tan Retirement is Not Easy! Dr Margaret Smith Forged Scripts Alert Ms Jane Carpenter

LIFESTYLE 42 44 45

Medicos take up Blackwood Challenge Sigrid Thornton in Streetcar Named Desire Palmer Wines Review Dr Craig Drummond

EPOLL/EVENTS 8 10 40

MAJOR SPONSORS medicalforum

Doctors Drum: ‘Doctors vs the Pace of Change’ e-Poll: Practice Accreditation WA Health Conference

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

MEDICAL FORUM MAGAZINE 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez Cardiothoracic Surgeon

Michele Kosky AM Consumer Advocate

Peter Bray Vascular Surgeon

Mike Ledger Orthopaedic Surgeon

Joe Cardaci Nuclear & General Medicine

Stephan Millett Ethicist

Chris Etherton-Beer Geriatrician & Clinical Pharmacologist

Kenji So Gastroenterologist

Philip Green General Practitioner: Rural

Alistair Vickery General Practitioner: Academic

Mark Hands Cardiologist

Olga Ward General Practitioner: Procedural

Clinical Contributors

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 Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au

A/PROF SYDNEY SACKS IBS, FODMAPs and Breath Tests Page 5

DR TIM GATTORNA Sports-related Sudden Cardiac Death Page 7

DR TIM BATES Thrombolysis: A Treatment Going Begging? Page 18

DR DAVID BLACKER Thrombolysis Explained Page 22

DR CHRISTOPHER ETHERTON-BEER Current Controversies in Stroke Page 23

DR ERIN GODECKE (PhD) Neuroplasticity: Why Early Rehab is Better Page 35

PROF YEE LEUNG O&G: We Can, but Should We? Page 36

MR BARRY EPSTEIN Molecular Medicine Page 36

A/PROF MARKUS MELLOH Spinal stenosis surgery decider? Page 37

DR GRAHAM THOM Atopic Dermatitis Page 37

PROF DANNY FATOVICH Medical Decision Making Page 39

A/PROF LUCY GILKES Teaching Medicine at UWA Page 39

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.

REGULAR CONTENT 3

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

Letters

Invest in Training, Mr Sebastian Leathersich

Response, Prof William Hart

Have You Heard?

Medicolegal: Giving Evidence Ms Karina Hafford

Beneath the Drapes Funny Side Competitions

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Apology and Retraction TO:

The Australian Medical Association (WA) Incorporated Mr Paul Boyatzis Associate Professor Rosanna Capolingua Professor Bernard Pearn-Rowe

We, Dr Robert McEvoy, Ms Jenette Heyden and Rakabee Pty Ltd (being the company through which we publish Medical Forum WA magazine (Magazine) and maintain the website at www.medicalhub.com.au (Website) published an article in April 2011 concerning the AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We each now accept that the article contained some material that was without foundation and that we unreservedly retract and which may have led readers to draw damaging conclusions about AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We apologise for any damage the article has caused AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We also accept that Mr Boyatzis, Associate Professor Capolingua and Professor Pearn- Rowe were hurt and distressed by some subsequent articles we published and we regret this.

Dr Robert McEvoy

Ms Jenette Heyden

Rakabee Pty Ltd

Date: September 2013

Letters

Invest in Training Dear Editor, Professor Hart’s opinion piece (Do We Need A Third Med School?, November edition), says a third urban medical school in WA will make inroads into tackling the medical workforce shortage in rural and regional areas. The WA Medical Students Society believes that without first investing throughout the medical training pipeline, the addition of more students into the health care system will only exacerbate the existing problems in an under-resourced medicalforum

and over-subscribed training environment. We do not contend that there is a shortage of doctors in rural areas; indeed, we support genuine programs to increase the number of practitioners working in these regions. We also recognise the importance of excellent clinical training to ensure WA communities receive the highest quality care we can provide. Unfortunately, the Curtin University proposal shows no genuine commitment to improve the distribution of medical practitioners in WA, and will jeopardise the quality of training of medical students state-wide. This year, two graduates of UWA did not secure state internships – after years of training, these doctors would be lost to the

Australian health system if not given the final year of training required for them to be registered practitioners. These issues are not confined to interns. There are RMOs who remain jobless this year despite being in a declared “area of need”, and there were over 2000 applicants for specialist training (including generalist training) in WA last year with only 700 positions available. The state government has committed to provide just 310 internships by 2015, when WA’s two current medical schools are expected to produce over 340 graduates. Adding 100 extra graduates to this number will serve only to increase the number of graduates without internships and waste resources teaching students who cannot complete their training to become doctors. continued on page 4

Letters

continued from page 3 Professor Hart has correctly identified that we face a challenge in workforce distribution, with the maldistribution of doctors in WA leading to rural and regional workforce shortages. However, unlike existing medical schools, such as James Cook University, Curtin has shown no genuine commitment to address this shortage. The only interventions shown to increase the proportion of graduates going on to work in rural areas are recruiting students from rural backgrounds, or training students in rural clinical schools. Neither of these will be achieved by Curtin’s proposal in metropolitan Perth, which proposes to recruit just 20% of students from rural backgrounds (well below the 25% at UWA, and the 33% recommended by a recent senate enquiry). Before considering a third medical school, it is imperative that we invest in the long-term sustainability of our healthcare system to ensure continued quality of undergraduate training and to alleviate the bottleneck in the postgraduate training pipeline (see www.wamss.org.au).

Mr Sebastian Leathersich, President WA Medical Students’ Society

Response Mr Leathersich states that Curtin has shown no genuine commitment to address the regional maldistribution of doctors. This is not correct. Curtin’s own geographical position, ethos of education and student selection policy will increase the likelihood that Curtin graduates will work in underserviced areas, both geographic and disciplinary. We will, of course, place students in rural and regional training environments – the outer suburbs of Perth as well as rural areas need doctors badly. Mr Leathersich repeats a misunderstanding that Curtin will recruit only 20% of our intake from rural backgrounds. We actually aim for 25% rural PLUS ANOTHER 20% from disadvantaged backgrounds. I agree that the pre-existing undersupply of doctors has resulted in pressure on postgraduate training. We don’t currently have enough doctors to supervise our young trainees. This must be carefully managed and resolved. But the WA health system

will continue to grow rapidly. On current projections, WA medical graduate numbers peak in 2016. By 2021, when a first cohort of Curtin graduate could become interns, these doctors will be in positions to provide the required supervision and the postgraduate training pressures will have eased. Why should Western Australians continue to endure the worst levels of access to medical care of any State in Australia? And why should the only medical training avenues available for Western Australian students be of seven years duration, rather than five (being cheaper to students and government, adding two more years of productivity)?

Prof William Hart, Head of Medical Education, Curtin University

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By A/Prof Sydney Sacks Chemical Pathologist

Irritable Bowel Syndrome, FODMAPs and Breath Tests Irritable Bowel Syndrome (IBS) affects about 15% of the population and presents with bloating, distension, excessive flatus and altered bowel habit (diarrhoea and less frequently constipation) which can cause significant morbidity and distress. Note that IBS should only be diagnosed after organic bowel disease has been carefully excluded. The aetiology of IBS is thought to include heightened GIT neural responses, alterations to the gut microbiome and poor absorption (and consequent gut bacterial metabolism) of certain dietary carbohydrates termed FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosacharides and Polyols). FODMAPs include the sugars lactose (milk products) fructose (fruits and sweeteners), fructans (fructose polymers in cereals and many vegetables especially onions and garlic) galactans (galactose polymers in legumes) and the polyols sorbitol (high in deciduous fruits), mannitol and xylitol (used as â&#x20AC;&#x153;sugar freeâ&#x20AC;? sweeteners). Lactose intolerance due to loss of gut lactase activity after weaning is actually the norm in non-Caucasian adults (present in 90% of Asians and Africans). North Europeans are the only population to have persistent lactase activity as they have a mutation of the MCM6 gene (only 10% of North Europeans are lactose intolerant). Fructose is well absorbed by the Glut2 transporter provided accompanied by equimolar quantities of glucose (consequently sucrose IS well absorbed), but may be poorly absorbed in some individuals (by the Glut-5 transporter) when the fructose/glucose ratio is high as in honey, pears and fruit juices. Fructans and galactans are poorly absorbed as humans lack the specific hydrolases needed for their breakdown. Polyol absorption is limited as absorption is by simple diffusion and gut pore size is too small for complete absorption when dietary intake is large. Poor small bowel absorption of the FODMAPs results in their arrival at the colon, where bacterial fermentation generates hydrogen. About 35% of individuals are colonised by methanibrevibacter smithii which converts this hydrogen to methane.

Neither hydrogen nor methane is generated by human metabolic processes and their presence indicates bacterial fermentation of dietary carbohydrates. Hydrogen and methane can cause distension, discomfort and flatus. These gases also enter the bloodstream and are then excreted by the lungs in expired air, which is the rationale for performing hydrogen and methane breath tests. High FODMAP diets have been shown to generate increased breath hydrogen and methane in normal individuals as well as in IBS patients, however, the levels are not as high in normals and normals are generally not symptomatic (even normals will, however, have flatus and/or diarrhoea after consuming a tin of baked beans or a packet of dried apricots). Shepherd and Gibson have shown that over 70% of IBS patients have significant improvement of symptoms when put onto a low FODMAP diet. This has proved to be a major advance in the treatment of IBS, however, the diet can be very restrictive and requires commitment and usually dietician support for compliance. The diet can be tailored to the individual patient depending on whether lactose intolerance or fructose malabsorption is present.

Breath Tests Breath tests are a useful alternative to an initial full FODMAP elimination diet followed by gradual reintroduction of food types and Shepherd and Gibson include fructose and lactose breath testing in their suggested diagnostic and therapeutic approach. Analysis of end-expiratory breath is performed after challenging the patient with a drink containing the carbohydrate of interest, preferably by using a hydrogen/ methane/oxygen analyser. Inexpensive analysers that measure only hydrogen are available but these are prone to false negative results as FODMAP malabsorption in patients who are mainly methane producers (up to 30% of patients) may not be detected. As end expiratory air contains the highest hydrogen and methane levels but the lowest oxygen levels, breath hydrogen and methane levels should be

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corrected using the breath oxygen levels for reliable results. Correction for oxygen levels cannot be done if only hydrogen is measured. Meticulous preparation for the breath test is important; patients should not have had a colonoscopy or antibiotics during the previous four weeks, not had probiotics for the previous two weeks, not had laxatives for three days, had a low fibre diet (e.g. steak and white rice) with no fruit or vegetables the previous day. It is advisable to initially exclude the presence of small intestinal bacterial overgrowth (as this may present with similar symptoms to IBS). A breath test is performed after a glucose load, which is normally rapidly and completely absorbed in the small bowel and thus is not available for bacterial fermentation unless small intestinal bacterial overgrowth is present. A rise of breath hydrogen or methane shortly after glucose ingestion is consistent with bacterial overgrowth which is usually treated with antibiotics. Lactose and fructose breath tests are then performed and depending on whether malabsorption of these FODMAPs is present or not, a diet is tailored to the patient.

Breath testing at Clinipath Pathology: Hydrogen and methane breath testing for small intestinal bacterial overgrowth and all the common FODMAPs are now available at Clinipath Pathology. Each FODMAP is tested separately at a cost of $105 per FODMAP; in some cases a $30 Medicare rebate is available. Tests should be booked by phoning 9476 5200 for an appointment.

Patient Resources for low FODMAP diets Printable one-page guide to FODMAP content of common foods: www.ibsgroup.org/brochures/fodmapintolerances.pdf Monash University Smartphone App: www.med.monash.edu/cecs/gastro/fodmap/ iphone-app.html. Reference: Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. P Gibson, S Shepherd: J Gastroenterology & Hepatology 25 (2010) 252-258

Editorial By Dr Rob McEvoy

We, the Innovators and Reformers

Medical Editor

The medical profession’s status, perhaps partly built on secrecy, is being eroded. It is impossible to hold on to authority when everyone who comes in the door is a potential expert, thanks to ‘Dr Google’. Yet we are being asked to take part in the urgent fixing of community health. ‘More of the same’ will not work. True innovators and reformers are required. But the profession has never attracted risk takers, for good reasons. Which health organisations can deliver?

‘experts’. Add to this, failure to properly assign roles, not framing discussion as problem-solving, not priming participants for critical thinking, and not giving someone the job of fully exploring unique information, then innovative solutions evaporate. Instead, you can end up with mutual enhancement; shared common information increases the organisation’s aura of competence and credibility and allows it to validate others but true innovation and reform, thinking ‘outside the box’, has no strategic advantage.

For starters, those organisations that recognise it’s healthy for an innovative team to compete and dispute, especially where people with different skills are being asked to apply them to complex tasks. In this setting, overreliance on shared information, especially if incomplete, means points of difference and perhaps innovative solutions never get an airing. Add team members in entrenched positions who seek support of those positions, then less popular, novel information that spurs change goes begging.

Our new medical graduates, post-graduates of another sort, may bring additional experience to the interdisciplinary teams – doctors, nurses, dietitians, pharmacists etc. – we are told are needed to improve clinical care, reduce drug taking and keep patients out of expensive hospitals and overloaded EDs. They may do better or they may make up a more dysfunctional group of competitive individuals with even more entrenched positions.

Innovation suffers further if social positions are linked to decision-making; people down the pecking order don’t offer ideas because they fear it may cost them in the face of

Whatever happens, good leaders are important. If there is friction and breakdown in communication, as will happen, boosting positive team interaction becomes important; finding a common purpose and

accommodating differences in professional status and values. The medical profession is good on producing transformational leaders – high expectations who lead by example – but if they are focused too much on co-operation, all you get is consensus and conformity. This is where inclusive leaders come into their own – individual voices and unique perspectives will be valued. Neither pure consensus nor entirely negative responses get the job done; a healthy tension between the two improves performance. Doctors can feel ownership of change. As I sometimes joke, ‘Australians need another war to get them working together’, meaning a common enemy can unite. And the health system is under attack. The pressure is on us to compromise on professional priorities and approach. We will step forward more readily to have our say, and be part of innovation and reform, if we feel the distinguishing attributes of our profession are threatened. It’s that healthy tension again – between feeling included and feeling threatened – that motivates us. O

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Western Cardiology

Sports-related Sudden Cardiac Death The health benefits of regular exercise are well documented with respect to primary and secondary prevention of cardiovascular disease. In the face of a rising epidemic of obesity and diabetes the community promotion of regular physical exercise is an important public health issue. Exercise, however, can trigger an acute cardiac event causing sudden cardiac death. There is a difference in SCD rates/ outcomes between competitive athletes versus recreational athletes (as covered by this article). This is a rare and devastating event, which usually occurs in a young and apparently healthy individual where underlying cardiovascular disease is not diagnosed until after the event. The public exposure and media attention from such events often creates community debate and uncertainty.

The current state of play Data obtained on 10.9 million long distance runners compiled prospectively between 2000-2010 in the United States demonstrated a low overall risk of cardiac arrest and sudden death (SD) during marathons and half-marathons (59 arrests, incidence rate 0.54 per 100,000 participants) with a mean age of runners with cardiac arrest 42+/- 13 years.1 This is consistent with findings from two large prospective, European observational studies addressing sports related sudden death in the general population where an incidence rate of 0.5-2.1 per 100,000 person-years was reported.2,3 This compares favourably with 35.5 per 100,000 person-years for non-exercise related out-of-hospital cardiac arrest (OHCA).

Role of age and sex There was a male predominance (more than 10 fold higher compared to women), which cannot be totally explained by the difference in participation rates and could be postulated to be associated with the known higher prevalence of coronary disease in

young and middle-aged men compared to women. Most cases occurred in previously healthy men aged 35-65 years old. Young competitive athletes, generally defined as those participating in an organised sports program requiring regular training and competition, had a higher risk of sports related sudden death (SD) compared with young non-competitive sports participants.

Relationship of age to aetiology and survival Coronary artery disease (CAD) is the major cause of sports-related SD in people >35 years old and symptoms, mainly chest discomfort, were reported in the days preceding the sports-related SC in 12.7%. Interestingly, there was a favourable survival compared to non-exercise-related cardiac arrest (46% vs 17%) in victims >35 years old, but not victims <35 years. The difference in survival between younger versus older individuals is probably best explained by the age specific pattern of underlying cardiac disease. Younger persons who have cardiac arrest are more likely to have had hypertrophic cardiomyopathy (HCM), and resuscitation in cases of HCM is reportedly less successful than in other conditions. In contrast, older patients who have had cardiac arrest are more likely to have had ischaemic heart disease (IHD). Better neurological outcomes occurred in the exercise related OHCA than non-exercise group. Survival and improved outcome was linked to early recognition, early bystander CPR and automated external defibrillator (AED).

Dr Tim Gattorna MBBS (Syd) FRACP

About the author Tim Gattorna is a cardiologist and electrophysiologist whose areas of interest include cardiac arrhythmias (including catheter ablation), along with the implantation and management of cardiac devices. He has a clinical appointment at Royal Perth Hospital and Western Cardiology.

at different levels, with a health benefit that greatly outweighs the risk of dying due to exercise. Public health programmes to improve bystandersâ&#x20AC;&#x2122; lifesaving behaviour and the early use of AEDâ&#x20AC;&#x2122;s are important initiatives to prevent exercise related sudden death. Measures aimed at identifying asymptomatic individuals at risk remain a challenge in the general population. From a practical viewpoint the appropriate assessment and management of the underlying cardiovascular risk profile seems a reasonable place to start. More specifically the topic of SCD in young athletes will be addressed in a future article. References 1. Kim et al. Cardiac Arrest during long distance running races. NEJM 2012; 366: 130-140 2. Marijon et al. Sports Related Sudden Death in the General Population. Circulation. 2011; 124: 672-681 3. Berdowski et al. Exercise-related out-of-hospital cardiac arrest in the general population: incidence and prognosis. Eur Heart J doi:10.1093/eurheart/eht401

Comments Regular physical activity remains a vital component of improved long-term health outcomes, including cardiovascular benefits. However, specific symptoms or complaints (e.g. chest discomfort, syncope during exercise) should not be ignored. On the basis of current evidence, the general population should be encouraged to exercise

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Guest Column

Good Things About Change Dr Denis Carragher gives his retrospective take on the ďŹ rst Doctors Drum topic for 2014.

y medical journey has been fascinating and challenging, following a slightly rocky start that included my Irish GP father dissuading me from starting medicine, which dutifully led to veterinary medicine (missed out on a Vet Hospital place) and a trial of dentistry for 18 months before becoming convinced this was a bad choice. I transferred to medicine. I recall my Prof of Medicine saying, â&#x20AC;&#x153;Medicine was akin to a shipâ&#x20AC;&#x2122;s journey and we have only left the harbour mouthâ&#x20AC;?. Forty plus years later, I am not sure we have travelled much further and each day I realise how much I donâ&#x20AC;&#x2122;t know (will the â&#x20AC;&#x2DC;Thought Policeâ&#x20AC;&#x2122; want to re-credential me?), and I also realise that some medical â&#x20AC;&#x2DC;factsâ&#x20AC;&#x2122; have not proved to be all that enduring and indeed many have been reversed and revised. It reminds me of another favourite saying of

my late Prof, â&#x20AC;&#x153;Learning from experience, learning to make the same mistake with increasing confidenceâ&#x20AC;?. Hurrah for the Cochrane Database. When I took my fledgling steps in medicine, access to blood tests, x-rays and other investigations, was entirely in the realm of hospitals. In the community, the care of the patient depended on the physicianâ&#x20AC;&#x2122;s skill and care, which encompassed the whole of life from cradle to the grave. Perhaps the fragmentation of today is better!? Medicine in the â&#x20AC;&#x2122;60s was considered an art and a science. Today, the same is true, with maybe more of an emphasis on science. In my opinion, the truly good doctor is skilful, empathic and humble, be they GP or consultant, as well as available. There is concern in many quarters that our recent cohorts of medical graduates and students lack empathy. Not so during

my involvement with students from Notre Dame and UWA â&#x20AC;&#x201C; most are very empathic and certainly knowledgeable. They have had the advantage of excellent curriculums and tutoring, unlike early approaches to medical teaching of â&#x20AC;&#x2DC;see one, do one and then teach oneâ&#x20AC;&#x2122;! Medicine has had a constantly changing landscape, with opportunities on offer that have led to a very satisfying life. I am sure this will continue on if we avail ourselves of those opportunities â&#x20AC;&#x201C; ahead of modern graduates are excitement, danger and strife, and challenges brought on by a multitude of vicissitudes. Had I been warned on leaving medical school, armed with the confidence, certainty and knowledge, that the world might be quite unrecognisable 40+ years hence, I might have had second thoughts. But then, perhaps not.O

Doctors Drum: â&#x20AC;&#x2DC;Doctors vs the Pace of Changeâ&#x20AC;&#x2122;

ARE YOU

READY? Dragged kicking and screaming, or champing at the bit? Is our authority being questioned fairly? Where are the innovators and reformers? Can we ever keep up? Working faster and harder, not smarter? Is IT friend or foe? Who will lose out? Join your colleagues for a thought-provoking and entertaining Q&A, with Russell Woolf and our interesting panel Go to www.doctorsdrum.com.au to

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Opinion

GP Accreditation â&#x20AC;&#x201C; How Valued? MM P 1 F

Medical Forum published a guest column by Mr Tim Spokes a co-practice principal in Kalgoorlie about accreditation standards not keeping up with the demands of modern general practice. We wanted to get a broader reader view and asked GPs in an e-Poll what they thought. N = 147 GPs

Without general practice accreditation, do you believe the quality of health care delivered in general practice would decrease, overall?

Yes

26%

Maybe

31%

37%

Unsure

DO you believe the majority of things required of general practices undergoing accreditation are appropriately targeted to improve quality of patient care?

In your practice, are you asked to comply with anything to meet accreditation requirements that you regard as not helpful to quality patient care?

Yes

31%

Yes

52%

53%

28%

Unsure

16%

Unsure

20%

Comments from WA Doctors Small practices are disadvantaged in the process said one: â&#x20AC;&#x153;Regular staff meetings are silly in a small practice where the staff interaction is already regular, eg one doctor, one receptionist.â&#x20AC;?

We asked for comment and got 41 responses which were mostly negative. Of the positive comments, one doctor was adamant in support of accreditation: â&#x20AC;&#x153;It should be mandatory with or without benefits attached.â&#x20AC;? Another said the process helped keep small practices up to date, while another acknowledged that it was good in theory but in practice the process took a lot of time and effort for negligible gain.

Several doctors believed accreditation was more about creating a bureaucracy than standards. â&#x20AC;&#x153;Some basic standards would be fine but has now gone way too far just to justify the whole industry. I hate the way it stresses our staff and we have found some of the referees downright rude.â&#x20AC;?

One doctor believed accreditation had lifted standards enormously over time and it was important to have them spelt out. However, â&#x20AC;&#x153;patient feedback is too costly an exercise in current Fourth standards. Empires are created for firms marketing these tools!â&#x20AC;? Another supporter believed accreditation had improved their practice though added â&#x20AC;&#x153;it can become overdone.â&#x20AC;? One doctor thought the process was reasonable but bemoaned the necessity. â&#x20AC;&#x153;Unfortunately, it is too easy to cut corners on health care delivery in general practice without some form of accreditation.â&#x20AC;? The critics decried the time and money spent, not to mention the stress on staff, with no apparent evidence that it improved patient care, in fact one said it encroached on their core business â&#x20AC;&#x201C; patients. One doctor wrote: â&#x20AC;&#x153;The patient

has no awareness whatsoever if a practice is accredited or not.â&#x20AC;? The moving goalposts were a frustration for a number of doctors: â&#x20AC;&#x153;Once you jump through the current hoops, they add more the next time. Where is the evidence to show it improves patient care?â&#x20AC;? Another shed some light on demands: â&#x20AC;&#x153;Inevitably more expense for less benefit â&#x20AC;&#x201C; we need an electric bed now next time around? Every bed??â&#x20AC;?

A couple of respondents said accreditation should be used as guidelines for quality General Practice, not as income sources. â&#x20AC;&#x153;Comparative data against peer groups on patient management would be a more useful guide to quality general practice (some of these used to be done through Medicare and prescribing data),â&#x20AC;? wrote one. Another believed there should be a system such as yearly appraisals to identify poor performing GPs. The last word goes to Dr X who wrote: â&#x20AC;&#x153;The [current] system measures process and administration and should be much more outcomes focused. Give me a good conscientious doctor rather than a crap one with good admin and process any day!!

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Have You Heard? Co-payment argued

4VQQPSU GPS WPMVOUFFST Our December e-Poll of 233 doctors showed 55% of GPs and 70% of specialists were willing to lose income and give their time to any overseas program that could use their skills. The DoH says it will cover employees’ income loss. Each year, under Community Service Leave administered by the Global Health Alliance WA (which sends nurses and midwives to Tanzania currently), around 100 health workers (including doctors) are given two weeks paid leave to help people in developing countries. The volunteer group may pay travel and accommodation costs.

The Commission of Audit has suggested that anyone who is not a pensioner or healthcare cardholder should pay $5 in an attempt to cut unnecessary GP visits (family members only pay after 12 bulk billed family visits p.a.). Health Consumer Council ED Frank Prokop was reportedly against the idea, suggesting consumers don’t make unnecessary visits and it would put pressure on EDs. AMA spokespeople are reported as saying a $5 fee was a price signal that would hurt many people who might then think twice about seeing a doctor. Then came a RACGP press release that explained fears that government would simply reverse the $6 incentive payment to doctors who bulk bill, make this the patient moiety that GPs would have to collect. Specialists would be unaffected. Like the ceiling on training cost tax exemption, this will become a political football.

Help for ‘grandcarers’ We examined the issue of the rising number of grandparents raising of their children’s children in our Aged Care edition. Now the WA Government is trialling a financial support scheme for 2500 ‘Grandcarers’ that would give them $400 for the first child under 16 and $250 each for other children. Wanslea Family Services will administer the scheme and get $100,000 to expand its support services including respite, an information line and nine support groups.

Knee prosthesis withdrawal Do your patients have a Smith & Nephew Journey Bi-Cruciate Stabilised (BCS) knee replacement in place? The Australian Orthopaedic Association’s National Joint Replacement Registry (AOANJRR), which highlighted problems with some metal-onmetal hip replacements, has the Journey BCS, launched in 2006, as having a higher than expected rate of revisions due to pain and instability (rate of 1.59 per 100 observed component years compared to 0.72 for others, or a yearly cumulative revision of 7% at 5 years compared to 3.8% for others). Smith & Nephew has issued a hazard alert and withdrawn the femoral implant component, which in effect means Journey BCS. There have been about 3300 implanted in Australia, 110 in WA. The TGA has been proactive after being criticised for inaction in the past. Watch this space. 12

about cash bonuses to Mr Dolphin, and Bioscience added it was not impressed by Avita’s performance in commercialising ReCell. The company’s share price has fallen from a 10-year high of over $5 to just 10 to 12 cents. At time MF went to press Avita was trading at 14c.

Abuse victims recognised The Country High School Hostels Ex Gratia Scheme (closed December 31), has paid 90 (from 105 applications) former hostel residents who suffered abuse; payments of up to $45,000, totalling $3.2m. Community Services Minister Tony Simpson acknowledged that the payout was not the victims’ primary motivation but rather the recognition of abuse. The scheme follows Judge Peter Blaxell’s inquiry into abuse of children at St Andrew’s Hostel in Katanning.

Liquor Act review

Kaleeya to close

The comprehensive review of the Liquor Control Act makes 141 significant recommendations. WA Police laid it on the line with extensive submissions on most subjects, especially secondary supply and licence restrictions. Youth organisations such as Youth Affairs Council, the CCYP and, of course, the McCusker Centre and Healthway got stuck into advertising of alcohol. And mostly the committee listened. Small bars get a reprieve but the Australian Hotels Association is fuming, saying the report caters to police and health at the expense of retailers. The Police Commissioner dismisses this claim anyway. The Health Minister wants time to consider. See www.rgl.wa.gov.au

The 75-bed Kaleeya Hospital in East Fremantle will close in late November, 2014, and its services will transfer to Fiona Stanley and Fremantle Hospital. FSH will take on Kaleeya’s obstetrics, gynaecology and neonatal services and its sub-acute services, such as aged care, will be taken up at Fremantle. Elective surgery will be divided between the two. The Kaleeya site will be sold as prime real estate, and the Minister says no job losses for either the 168 clinical or 64 non-clinical staff.

Executive pay causes blow-up Shareholder unrest over executive pay at Avita Medical, which took over ReCell, the commercial incarnation of Prof Fiona Wood’s spray-on skin, has led to the resignations of CEO Dr William Dolphin and chairman Mr Dalton Gooding. The interim CEO is CFO Mr Timothy Rooney and Mr Ian Macpherson is chairman. Mr Gooding remains on the board. Reportedly, Avita’s two biggest shareholders, Australian Ethical Investment and Bioscience Managers, were concerned

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Trailblazer

Conﬁned to What? Kathy Mallory was fresh back from her regular canoeing session with a friend when Medical Forum asked her for some insights. She first offered that doctoring in general practice has involved few restrictions, despite paraplegia.

Katharine Mallory’s

Story

“I do less procedural work like skin excisions because it’s hard for me to work with both hands independently and in balance. The examination couch I work with is modified so I can get my wheelchair under it and can get quite close to the patient. This is important for getting a good view for Pap smears,” she explained. She anticipated that anaesthetics and obstetrics would throw up difficulties but not so other day-to-day tasks. “Patients tend to remain on the chair when I do my respiratory or cardiovascular examinations. And if the hand basin doesn’t have a cupboard underneath, I can wheel up closer to it. But that’s about it.” “Funnily enough, when I first started looking around at practices, some didn’t have a suitable ramp or a disabled access toilet, which is quite surprising in this day and age,” she recalled, adding that she had avoided work at some Kalgoorlie practices for those reasons. The relationship she forms with patients is somewhat different but in a positive way. The occasional new patient gives her a surprised look. Most stay with her. The age groups and style of problems she deals with are much the same as any GP. She ensures someone in the practice can take over excisions and everyone is aware she responds slower in emergency situations. “When you have been practising as long as I have, you stop thinking of yourself as being any different,” she said, using the example of her Aboriginal health work for five years as typical of patient responses. “By and large Aboriginal people are very appreciative of people who try to understand them and deliver culturally appropriate health care. In a way, the less affluent a community and the more need, the less judgemental they will be of someone with a disability,” she reflected. This probably explains why over the years she has had proportionally more patients with disability. “I suspect they feel there might be more empathy and understanding. If anything, I’m perhaps a bit harder on them because I expect them to get on with life, especially when I feel they accept that disability just equates to living on a pension. Culturally, I grew up in a world where I was told I would get through it and I automatically expected I would get back to medical school.” 14

fall during a university bush hike broke her thoracic spine; she was airlifted out and then spent three months in hospital. Aged just 22, paraplegic from the waist down and in ﬁfth year medical school, Kathy started her recovery. It was six months before she could do her elective in Welkom, a mining town she had earlier set her sights on, except now she was in a wheelchair. Brought up as a tough South African, and without any insurance payout, she completed studies and returned as an intern to the same mining town. It was here she met her husband-to-be, a mining engineer. Marriage and two children followed soon after, and around 13 years ago they moved to Kalgoorlie, where both worked, him in the mines and her in Aboriginal health. The family relocated to Perth in 2007 and Kathy now consults in general practice in Byford and, as a proud mum, supports her 17-year-old daughter’s attempt to enter medical school.

“I’ve made some big inroads with patients with mental health issues. Perhaps they perceive that life hasn’t been all rosy for me, and their doctor really understands them and there is common ground.” Mental toughness has helped her get through. “I’ve been living with a disability a long time so things are a lot easier now. The first couple of years were harder – everything was a challenge, even getting dressed in the morning. Everything took so much longer. I had a bout of depression shortly after leaving the rehab unit but later, when I could cope with the physical challenges, the mental side felt OK.” “So getting back into swimming was emotionally and physically therapeutic for me. Sport is one of the important things for me – physical activity leads to mental wellbeing.”

When discussing the medical profession’s response to disabilities she feels GPs have a way to go but she describes Shenton Park hospital staff as “amazing”, given she has been confined to bed for weeks there due to orthopaedic spinal problems. “I have never been a patient person, which is one thing I have definitely learned – to be patient with life and that some things just take time.” Still, she has no big five-year plan. “I kind of take life as it comes. My husband is a mining engineer and mining does things when it wants. I think if I was going to try and control my life too much I would have been a very miserable person long ago. In five years I hope I am still canoeing, still working, and still enjoying being a mum and a wife.”O

By Dr Rob McEvoy

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Guest Column Award Guest Column

Bonded to the Bu sh

Stand Up, Speak Out

Dr Penny Wilson is wisdom of a decision a rural ‘conscript’ by choice but won ders about the made at the threshol d of her formative years.

n 2001, at the age of 17, I was one of the first medical students to take up a Medical Rura l Bonded Scholarsh (MRBS). The deal ip was $20,000 a year durin payment of g medical schoo l in return for six years of rural service after fellowship.

Before we completely consign 2013 to the Medical Forum vaults it’s important to celebrate the contribution of our guest columnists who once again provided fascinating insights from all conceivable angles on issues that affect life and the profession.

We salute all our columnists who took time out from their crazy, hectic schedules to share their thoughts with readers and colleagues and we look forward to another outspoken year in 2014.

In compiling the shortlist of 10 for the 2013 Medical Forum Guest Column Award, the MF team reviewed 57 columns representing views as diverse as decriminalisation of the sex industry to the perils (and joys) of donning the Lycra and hopping on a bike. There were professional and medical issues canvased such as the shortage of GP supervisors, surgical mortality audit, practice accreditation and palliative care.

The winner of the 2013 Medical Forum Guest Column Award is Dr Penny Wilson who wrote with searing honesty in the August edition about the pros and cons of taking up a Medical Rural Bonded Scholarship in 2001 at the aged of 17 in “Bonded to the Bush”. She scored consistently high scores from all five judges.

We are grateful to all these people who have been prepared to put themselves on the line and speak out about the things that concern them, amuse them, distress them or just plain annoy them. They all help make the dialogue within the pages of Medical Forum so vigorous and relevant.

“I’d been thinking about the issues for a long time, but having to articulate them in a onepage column really helped me to focus on the points I was trying to convey. It has also prompted me to consider how else I might go about trying to make improvements for other present and future MRBS scholars.”

As we did last year, we asked members of our advisory panel of Dr John Alvarez, Ms Michele Kosky, Dr Joe Kosterich, and Dr Olga Ward as well as the national president of the Australian Medical Writers Association, Dr Justin Coleman, to adjudicate the shortlist.

Penny said that feedback from colleagues had also been positive.

support I’ve received from senior colleagues, including the thoughtful response from Dr Janice Bell in the following edition of the magazine.”

“I was surprised that a lot of people didn’t know the scheme existed before reading my column and have responded with varying degrees of outrage, surprise, interest and concern. I feel particularly humbled by the

“Family and friends wondered if was I was comfortable expressing such personal concerns in a public forum, but that goes with the territory of being a blogger and writing about issues close to my heart.”

The Winner

For Penny, writing the column helped clarify her views.

I didn’t actua lly sign on the dotte d line until I was 18, but if I had decided to pull out of the MRB S after starting the course, I would have lost my place at university and my medical career would have been over before it began. So once I had was essentially locke accepted it I d in for the next 16 or more years . Although I intell ectua lly knew what the scholarship involved, I really don’t think I had the maturity to fully understand the psychosocial implications of that decision and I can’t help but feel that my younger self was somewhat taken advantage of. It’s now 13 years down the track Q Dr Penny Wilson and performs a caesar I have finally come ian and, inset workin to the end of years g for RFDS training to becom of e a GP obstetricia that I have to do n. I’ve this and that if my recently commenced life circumstances chang my rural return MRBS GP traine of service, work ing e and I want or es can always chose as a locum travel need to return to the city, to under take rural ling all I could not do so over the country training via the without in the hope of findin major penalties. FARGP or ACRR M pathw I would be requi place I’d like to ga ays but this would red to settle down in for repay the scholarship increase their rural the next few years. I’m waitin amount but, more commitment to important ly, would g to see if the benef eight years or more, with of the scholarship lose my Medicare its no recognition of outweigh the costs. provider number additional servic the – and therefore I don’t mean to e. be unable to under take clinic sound ungrateful; al work – for up What’s more, the I was very glad to have to 12 years. That's a pretty abilit y to increase had the scholarship and big stick. maintain skills during my unive after fellowship rsity years. I didn’ My biggest conce is limited by a maximum of two t come rn has always been from a wealt hy week family so it allow s of metropolita the potential impact up-sk illing per year. ed me to n on relationships focus on my studie Thankfully, the and s and live reasonably family. Alas, disclo return of service requiremen comfortably. It also sing my mandatory ts are fairly flexib years’ rural servic influenced me to six with participant le, e has been met with pursu some fantastic rural s only required less-t han-enthus a medicine opportuni e to work part-time (an avera iastic response by such as the John ties ge of 20 hours a the few Flynn Scholarship serious partners week each mont h, for Scheme, I've had along the fifth year Rural a minimum nine Clinical School way. More recently I mont hs a year) to fulfil their and a rural had the heartbreak rotation in my intern obligations. ing situation of a relati ship year. onship ending largel I don’t see why that As a result of these because it was time y flexibility could experiences, I have n’t for me to head bush, be extended to allow overwhelmingly an when the other us positive attitude to use some person was tied of the time to work towards country practice. to the city by his work comm in metropolitan I believe it can provi areas if itments. it helped us gain an interesting, challe de or maintain a speci The scholarship nging and rewar fic skill set. For exam also has some frustr ding career pathway ple, and wish that it ating career implication couple of caesarean allow ing me do a was s. Any rural traini perceived that way lists a mont h at ng by the profession done as a registrar a local metro as a politan hospital whole rather than does not count towar would help me keep it being stigmatised the return of servic ds my surgical skills an inferior optio as e period, which sharp and benef n that people need is a signif icant disinc it the rural communitie to be entive. Allow ing coerced into doing s I serve. registrars . to tick off some of their Havin rural time durin g a Medical Rural My experiences training would g Bonded Scholarship of the past few mont encourage regist has given me many hs since starting my rars to train benef its over the more appropriate rural but its restrictions years ly for reinforced my positi service have only continue to cause they will do as fellow the type of work ve view and I’m Do I think I made anxiety. s. confident that I the will emerge a broad up? The jury is still right choice in signing For GPs, this would lyout. Ask me again skilled doctor who include acquiring years’ time. O in five can cope with anyth the emergency skills However, I still ing. which are funda mental feel uneasy about to rural practice the fact and hard to get exposure to as a metropolita n GP registrar. Of /'&+%#.f orum course,

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5IF +VEHFT

Left to right; President of the Australian Medical Writers Association Dr Justin Coleman, Dr Olga Ward, Dr Joe Kosterich, Ms Michele Kosky, Dr John Alvarez

President of the Australian Medical Writers Association Dr Justin Coleman Dr Olga Ward Dr Joe Kosterich Ms Michele Kosky Dr John Alvarez

“It’s an issue which I suspect will become more relevant as increasing numbers of MRBS scholars start to finish their training and begin their rural service period. I’ve been contacted by a number of bonded medical students as well as those thinking about it seeking information and advice. So if nothing else, hopefully the sharing of my experiences is helping others heading down the same path.”

Columns published from November 2012 and October 13 were eligible for the award. All five judges found it hard to choose a winner. Justin had this to say: “Thanks again for the opportunity to judge some wonderful medical writing. Congratulations to Medical Forum for providing columnists with a sturdy soap box from which to vent!” Judges made special mention of Mr Paul Dessauer’s pre-WA election column on drug policy in the March edition. And Justin applauded Dr Victoria Buntine’s column on the death of her 15-year-old son: “I have rarely been so moved by a columnist ... Extraordinary.”

5IF 4IPSUMJTU Congratulations to these columnists for making it to the shortlist of the 2013 Medical Forum Guest Column Award. t %S 4DPUU #MBDLXFMM GPS Reclaiming Dignity for Everyone November 2012; t %S 1FOOZ 'MFUU GPS Challenge of the Boom Generation, November 2012; t .S 1BVM %FTTBVFS GPS Drug Policy Needs Debate; February 2013; t A.T .BSZ %PF GPS Inspiration from Tragedy; April 2013; t .T 3FCFDDB %BWJFT GPS Decriminalisation is a Health Issue; April 2013; t .T +VMJB 4VUUPO GPS It’s a Question of Equality, August 2013; t .S 5JN 4QPLFT GPS Changing Times, But Nothing Changes, September 2013 t %S 7JDUPSJB #VOUJOF GPS Doctor-Parent: What Could Be Worse? October 2013 t .S 4IBVO /BOOVQ GPS Age of Rage and Reconciliation, October 2013 O

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4USPLF .BOBHFNFOU

If Mum or Dad Had a Stroke... t 4USPLF SFIBCJMJUBUJPO TFSWJDFT BSF MBDLJOH many stroke survivors struggle with basic daily living in WA: o 53% struggling with unmet mobility needs (45% nationally) o 82% have unmet needs associated with memory (75% nationally) o 71% have unmet needs relating to speech difficulties (58% nationally).

Stories by Dr Rob McEvoy

Stroke management in WA lacks direction and resources, if you talk to patients and clinicians involved. The biggest gaps appear to be around rehabilitation, both acute-care in hospital stroke units and long-term community services, as well as acute thrombolysis for the 20% of stroke victims who might benefit. At first glance, stroke management appears as a growing cost burden, but prevention, clot lysis and neuroplasticity all offer hope. We just have the logistics of our vast State to consider and the fact that stroke lacks the sexiness and quick turnaround that attracts government funding. But everyone has a mum or dad and the reality is going to bite soon. Prevention seems to be working, with stroke prevalence decreasing but absolute numbers increasing due to an ageing population. The National Stroke Foundation is lobbying for well-resourced community rehabilitation, to liaise better with carers if nothing else, and stroke units that can drive recovery with their multidisciplinary teams. It is no longer best practice to leave someone dribbling in the corner and say this is as good as it gets. The principle of thrombolysis is good. Start a stroke patient on treatment within three hours of stroke onset, after determining there’s a clot and excluding contraindications, and the patient’s long-term outcome and need for rehabilitation improve. However, the devil is in the detail, with consumer awareness campaigns, clinician disagreements, geographical isolation, and medicolegal concerns all influencing the final outcome in major ways. Plus Shenton Park rehab will close and move to Fiona Stanley Hospital soon. Many of the long-term services have been disbanded or devolved to geriatricians, especially when you had to be under 65 years to qualify for stroke services. How all this ends up is uncertain but there is a sense that we are now reclaiming lost ground. 18

According to the WA office of the National Stroke Foundation (NSF), specialist care in stroke units is associated with better outcomes for patients, both in terms of survival rates and reduced disability (fallen from 45% of cases to 35%). NSF says WA is far behind other states: t PG TUSPLF QBUJFOUT BSF VOBCMF UP access a stroke unit, with 24% of stroke unit beds taken up by non-stroke patients due to resource issues. t 0OMZ PG UIPTF TVJUBCMF GPS thrombolysis (or 1% of stroke survivors) access this treatment (and what of rapid ambulance triage of stroke patients?).

Dr Erin Lalor, CEO National Stroke Foundation, says stroke units reduce hospital stays and readmission rates, as well as better relieve unnecessary pain and suffering. “We are talking about access to support and services to help with everyday activities; eating, walking, thinking and communicating. Hospitals and community services continue to be ill-equipped to provide essential stroke treatment and ongoing support meaning Australians are disabled when they shouldn’t be,” she said. Figures from AIHW show informal carers play an important role in the care and recovery of stroke survivors – an estimated 75,000 provided assistance to people with stroke and disability in 2009, more than half caring for a loved one for 40 hours or more each week.O References National Stroke Audit, Acute Services. 2013 Report: Needs of Stroke Survivors in Australia, NSF 2013

t ćF TJ[F PG 8" NBLFT SFNPUFOFTT B NBKPS battle.

Thrombolysis.............................. Dr Timothy Bates, Head of the Stroke Service at Swan Districts Hospital, discusses why his thrombolysis service treats only about 5% of the potential clinical load. The biggest reason thrombolysis is underutilised is that the 20% of stroke patients who might benefit – about 400 per annum in WA – do not get to the right people inside the initial critical four and half hours, sometimes for good reasons, but the upshot is that about 5% get treated (or about 24 cases in four years, at Swan Districts Hospital). “We could easily double our thrombolysis rate in Midland if people turned up within the timeframe. The idea is that it brings the thrombolysis service, which is usually a tertiary hospital service, closer to the community.” medicalforum

Stroke Survivor Now Campaigns Richard Haley was awake and working, the next minute he had collapsed with a stroke. His determination has given him a second chance. Richard Haley’s life was saved with a clot retrieval procedure at Royal Perth Hospital three years ago at the age of 57. A mechanical engineer from the oil industry, he intended to retire at age 65 but a heart attack and stroke beat him to it. Since then, his tenacity during recovery makes him a living testament to neuroplasticity and the bearer of a good news story as StrokeSAFE Ambassador.

“It was a shock to me. It wasn’t on my radar after having a heart attack. Stroke was something older people get, then they dribble and die. I was just working at home, then I smashed to the ground. I was partially conscious and managed to get to the phone and ring for an ambulance, but it was touch and go. There was no warning, like with the heart attack where you sat down and didn’t feel well, you are drilling a hole then just hit the deck face first.”

“Considering what I have been through I’m doing pretty well. I have just got my driver’s licence back and I’m happy living down here in Mandurah. I’m doing rehab continuously and I’m constantly seeing improvements. Three years ago I couldn’t speak. You have got to want to do things and work hard,” he said.

From victim to advocate

Things were not happy three years ago. “I had a clot and the clot busting medication was working but then I had a series of clots and it got to the stage where I was locked in. I got an arrhythmia that was causing clots to travel and lodge in the base of my brain. I had three code blues over a few days and am lucky to be alive,” he said. He remains on anticoagulants, the exact source of his clots remains unknown, and tackling his heart rhythm problems remains stymied by a “pretty massive heart attack” in the past.

What is his favourite message when he visits community groups to talk [he did 20 last year]? “Know your numbers, which is all about understanding your blood pressure and other important things like cholesterol levels, waist measurement, and BMI and just getting into a lower risk group. The other thing is knowing how to recognise a stroke early, so you get to the hospital and maybe get thrombolysed.” “We don’t go into deep medical areas [during the talks]. We are there to give the messages on how to make people strokesafe. We just say the chances if they get help early are phenomenally better than doing nothing.” That’s where the FAST acronym comes in – face, arms, speech and time (the latter meaning the 4.5 hours window for

A Treatment Going Begging? He said the features of stroke often go unrecognised by health consumers who may battle it out rather than seek acute assessment. The Stroke Foundation’s StrokeSAFE campaign aims to reverse that trend but it needs a stronger voice. Timothy has been involved with helping them raise community awareness. He said other medical people also have a role to play. “We also need a phone message on hold regarding stroke awareness at GP surgeries. It should be like chest pain – don’t drive or ring your GP, call an ambulance.” Yet, he said that because of the critically short window of opportunity, anyone living a moderate distance from a stroke service, say in the Wheatbelt, is not going to get to thrombolysis treatment in time. “Likewise, anyone who needs thrombolysis who is at a general practice probably won’t get it, because the time it has taken them to recognise what is going on, make an medicalforum

Q Stroke victim Mr Richard Haley was virtually left to his own devices when it came to rehab.

thrombolysis). Reactions from people he talks to have varied. “Stroke is something that people are only just getting comfortable talking about. It was something that used to happen to others and didn’t have a lot of profile. But a lot of people I talk to are taking the message on board because they all know someone who cares for someone who has had a stroke or suchlike. It’s mainly women – say 70-80% – because men don’t want to know about health.”

This is one dilemma for any stroke service: to encourage patient action through general practices but then deal directly with patients to avoid damaging delays.

“Last week I talked to the Anglican Church fellowship group in Mandurah and there was a chap who said he wished he had heard the talk three weeks ago because he was with a friend who felt dizzy, couldn’t move his arms and he went to bed and died. He was stubborn, as men are.”

Should the patient present to a stroke service on time, experts and a CT scanner must be at hand.

He left the group with his usual book marks, fridge magnets and booklets with the FAST message.

“CT is there to rule out bleeding, not to diagnose thrombosis, although you can often see the clot in the artery on a good quality CT. You are looking for two things mainly – brain that is already dead from a stroke that is older than you think, or whether there is a haemorrhage. The false negative rate for haemorrhage is close to zero.”

Rehab need not be depressing

appointment, sit in the waiting room, and chat to the GP probably suggests the stroke is too mild or too much time has lapsed.”

As a stroke survivor, Richard is fired up about rehabilitation, or the lack of it in WA.

The stroke team at Swan District Hospital in Midland has consultants on-call who have had neuroradiology training for accurate

“Having a stroke is the worst feeling in the world because you totally lose your independence and become reliant on the system or your spouse. Things like driving a car, playing golf or cooking – you can’t do any of that; you have to rely on someone else.” He was a self-sufficient bachelor before he had his stroke.

continued on page 22

continued on page 20

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4USPLF'"45 instigators

continued from page 19 “In hospital, you feel relatively safe because you are surrounded by people who understand your condition and know all about stroke – the doctors, OTs and PTs are on your wavelength. When you leave hospital you sit by yourself at home, or surrounded by friends and family who have no idea of where you are at and there is very, very little support for them.” “A lot of people who have had a stroke go home and get depressed. This means a lot of relationships break down. In my case, I was rescued by the state head trauma unit who contacted me when I was going through a few weeks that were a nightmare. It was really hard to cope and they came down and helped me. It was about me learning how to adjust psychologically and realising there is life after stroke.” “I was completely locked in and taught myself to walk, talk and type and do all the things I normally do. But a lot of people are not told this, instead they are told this is as good as you are going to get. Attitudes have not changed and medicos have not heard about brain plasticity.” “We had a lady at our stroke group who read the book, The Brain That Changes Itself, and she had been in a wheelchair for 10 years and taught herself to walk. She said what she

Jane at the local branch of the National Stroke Foundation says a lot of stroke ambassadors are stroke survivors, who are very inspiring and uplifting for people, but we should spare a thought for people trapped in rural settings. Telehealth offers them something.

had learnt had made a huge difference to the quality of her life, just to be able to go to the toilet by herself…” “You have got to drive yourself. It’s hard. There doesn’t appear too many people involved in post-stroke care.” “When you have had a stroke you don’t have the same recall as you used to. I used to have an IQ of 160 and my hobby was theoretical physics and now I have a brain that feels more like a cabbage. It’s so frustrating. You have a brain that doesn’t work.” See Neuroplasticity article, page 35

NSF has produced a pack, My Stroke Journey, providing information on local resources. Poor communication and lack of funding has been its worst enemies. “We are aware families are overwhelmed at first, so we need to have conversations with people as part of ongoing support. Stroke victims may not be able to communicate,” Jane said. The Stroke Association gets no government funding although stroke is a leading cause of disability. By comparison, after-care has progressed remarkably in the UK, once it was funded. “These are people who have paid their health dollar. What’s the alternative, let them sit in the corner, dribble and die. It’s a fallacy that people who are in their 80s and 90s are having strokes, when we see people in their working years being affected. They need the support of government,” she said. O

WA Calendar of Events 2014 February 5th

Breakfast Seminar

Marketing Your Practice

Practice Managers

Matilda Bay Restaurant, Crawley

6th

Webinar/ eSeminar Staying Safe on the Frontline

Receptionists

on-line

Practice Managers, Principals, + All staff

Boatshed, South Perth

Conference Joint AAPM / PMAANZ

Practice Mangers / Receptionists

Wellington, New Zealand

20th Webinar/ eSeminar New to the Role Toolkit

Intermediate Practice Managers

on-line

17th Webinar/ eSeminar Corporate Governance & the Director

Advanced Practice Managers

on-line

14th All Day Seminar

Management Practice Managers, Principals, + All staff

Perth Venue to be advised

17th Networking Seminar Hosted by Avant & AGM

March 7th / 8th

April HR + IR & Clinical Governance, Marketing and Issue

May 1st

Webinar/ eSeminar Managing Mental Health Receptionists & Challenging Patients

15th Webinar/ eSeminar Managing Risk & Compliance within Your Practice.

For further information and membership please contact via email wa@aapm.org.au or visit www.aapm.org.au

on-line

Intermediate Practice Managers

on-line

Intermediate Practice Managers

on-line

June 19th Webinar/ eSeminar Herding Cats Leading Your Team to a Common Outcome

medicalforum

GP Saw the Signs Dr Jenny Tang just happened to be in the right place at the right time for another stroke victim in her 30s – doing a fill-in session at this patient’s usual general practice but armed with the memories of what a stroke in a younger woman could mean. Jenny had witnessed the recovery of her young sister from stroke brought on by a congenital defect. “At the back of my mind was the thought of the consequences of missing the diagnosis of stroke in a young woman, as in the case of my sister. From experience it was always something on my diagnostic radar, even though the person in front of me was low risk,” she said. Jenny says she has no sixth sense, just some personal experience, and what she did was part and parcel of general practice. “I guess most important is to always listen to the patient. She had presented a few times and I had to take things from a new and different perspective and reassess, even to

Q Dr Jenny Tang

do the physical exam again. In her case, I think she had developed very subtle signs suggestive of stroke.” The patient was despatched quickly to Joondalup ED with a covering letter. For her part, Dr Tang’s involvement 20 years earlier in her sister’s long road to recovery – learning to talk and walk again – meant

she knew how important early diagnosis was when it came to prognosis. “You feel humbled when patients say ‘thank you’ but as in this case, the diagnosis was not a great one for the patient so you tend not to dwell on it too much. I’m just happy to have been there at the right time.” Her patient would agree. O

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Thrombolysis Explained #Z %S %BWJE #MBDLFS /FVSPMPHJTU BOE 4USPLF 1IZTJDJBO 4$()

hrombolysis for acute ischaemic stroke using tissue plasminogen activator (tPA) received TGA approval in August 2003 but it remains a surprisingly controversial treatment with potential divisions between Emergency Physicians and Stroke Specialists (Insight on SBS, Oct13). Points raised by the â&#x20AC;&#x2DC;anti-tPAâ&#x20AC;&#x2122; group are well made but most Stroke Specialists working actively in the field advocate tPA use in appropriate circumstances.

3JTLT WT CFOFGJUT tPA can re-open (recanalise) occluded blood vessels, particularly within the initial three-hour time window and particularly when there is only a small thrombus burden. The difficult paradox is an increased risk of haemorrhage and death in the short term, versus a superior chance of good neurological outcome in the intermediate and longer term â&#x20AC;&#x201C; by the 3-6 month follow-up, a greater percentage of survivors have good or even excellent neurological outcomes compared with placebo2,3. To complicate the issue, decisions on risk vs. benefits need to be made urgently, often by patients whose judgement is impaired by the stroke itself. Usually I explain tPA risks and benefits to patients and their relatives using the results of the NINDs study (NEJM 1995;333:15817), which selected patients according to certain criteria, used a non-contrast CT brain scan, and commenced treatment within three hours of symptom onset:

t PG U1" USFBUFE QBUJFOUT IBE BO excellent neurological outcome at three months, compared with 38% in the placebo group. t PG UIPTF USFBUFE TVÄ&#x152;FSFE BO FBSMZ symptomatic intracranial haemorrhage, even when carefully selected, and about half of those died. At three months, overall death rates were statistically the same in both groups. There may be simpler and better ways to present this information to patients, and the creation of an agreed â&#x20AC;&#x153;patient information scriptâ&#x20AC;?, might be a useful collaboration between ED and stroke specialists.

Patient selection process Once inclusion and exclusion criteria are applied to patient selection, the time of stroke onset is critical, often requiring collaboration from witnesses and relatives. The essential tests are a blood pressure measurement, a BSL, a FBP and a CT scan. â&#x20AC;&#x153;Time is brainâ&#x20AC;? â&#x20AC;&#x201C; an estimated 2 million brain cells are lost for each minute during an ischaemic stroke, so assessment must be streamlined and efficient but the assessing team must keep an open mind and consider stroke mimics.

would you say to peers/patientâ&#x20AC;&#x2122;s family/ lawyers when asked â&#x20AC;&#x153;Why didnâ&#x20AC;&#x2122;t you give tPAâ&#x20AC;? to a patient who does badly? Second, what answer to, â&#x20AC;&#x153;Why did you give tPAâ&#x20AC;? to a patient who had an intracerebral haemorrhage as a complication? This useful mental exercise helps reduce insomnia later!

tPA administration tPA is administered at a dose of 0.9mg/kg, up to a maximum dose of 90mg; 10% as a bolus over a minute, and the remainder over one hour. Neurological and blood pressure observations are performed every 15 minutes during the infusion, and hourly for up to 24 hours. Blood pressure should be lowered to <185/105 during the 24 hours after tPA. A small number of patients (about 2%) may develop peri-oral angioedema as a side effect. The original tPA licensure states it should only be given by clinicians familiar with acute stroke assessment, and in appropriate facilities. The WA State protocol suggests tPA use in hospitals with stroke units; currently in WA that is RPH, SCGH, Fremantle and Swan District Hospitals. On-site access to neurosurgery is NOT a necessary requirement.

All clinicians administering tPA must be able to interpret the acute CT of the brain, sometimes viewed off site. The focus is on trying to minimise the door-to-needle time; at SCGH we aim for 30 minutes during office hours.

Clinicians at the stroke units in Perth are involved with constant case review, audit and research, including my own study combining tPA with intravenous minocycline, to try and reduce the chance of haemorrhagic transformation. O

It is helpful to review all data, and be clear nothing is missed, before proceeding. At this stage, answer two questions. First, what

References available on request.

â&#x20AC;&#x153;When it goes wrong it can go horribly wrong. So organisation and expertise is essential. At the very least an organised stroke team and ward is essential.â&#x20AC;?

â&#x20AC;&#x153;The over 80s benefit as much if not more than the younger people. And older people have made it clear they just do not want to be handicapped, so treatment like this is what they want.â&#x20AC;?

A Treatment Going Begging? continued from pg.18 interpretation of the CT and cases are seen urgently by a consultant carrying the stroke pager, usually in ED. With the CT done, a few basic blood tests and the history look for other contraindications. â&#x20AC;&#x153;They are ruled out by haemorrhage, on anticoagulants, itâ&#x20AC;&#x2122;s a wake-up stroke, abnormal blood pressures or sugars and a non-stroke event,â&#x20AC;? Tim elaborated. If not ruled out clinically, which takes about an hour, you then need informed patient consent [see above] before commencing the hour-long thrombolysis treatment. This all has to happen within that window of opportunity. â&#x20AC;&#x153;Because thrombolysis has a 2-6% complication rate of haemorrhage [of which about half will die, most within the first 24 hours], you donâ&#x20AC;&#x2122;t want to give it to someone who is mild and might go home in a few days with a mild deficit.â&#x20AC;? 22

Given the risks, why is thrombolysis (which costs around $2500 each infusion) still on the treatment agenda? â&#x20AC;&#x153;Stroke thrombolysis, particularly given in the first three hours, reduces disability at 6 and 12 months and 2 years. It improves your quality of life and likelihood of survival free of handicap but it doesnâ&#x20AC;&#x2122;t make you live longer. Thatâ&#x20AC;&#x2122;s what weâ&#x20AC;&#x2122;ve seen in our own stroke data â&#x20AC;&#x201C; at 12 months a third of our patients have died, even the ones who have gone home. It doesnâ&#x20AC;&#x2122;t make you live longer, but it makes you live better. It should make any rehabilitation you need shorter, and reduce your need for institutional care.â&#x20AC;? At SDH, the average age for thrombolysis is about 70 years.

As treatment is potentially deadly and volumes are low, there are medicolegal fears that lack of expertise will inflate complication rates and destroy the service. Everyone is cautious and it is hard to come up with an accurate cost-benefit with such small numbers. â&#x20AC;&#x153;The Germans have a truck with a CT scanner and doctor in the back, they do the scan and if needed give thrombolysis on the way back to the hospital.â&#x20AC;? In WA, we are working hard to give registrars enough experience to become competent in giving treatment, which includes experience at the other thrombolysis centres at SGGH, RPH, and Fremantle hospitals.O medicalforum

Current Controversies in Stroke #Z 1SPG $ISJTUPQIFS &UIFSUPO #FFS (FSJBUSJDJBO $MJOJDBM 1IBSNBDPMPHJTU 68" 31) #FOUMFZ 4USPLF 3FIBCJMJUBUJPO 6OJU

troke incidence and mortality have declined impressively (due to healthier lifestyles and improved medical management of vascular risk factors). However, the ageing population brings a steady increase in the overall burden of stroke, through death and disability in our community.

Which antiplatelet strategy for the secondary prevention of JTDIBFNJD TUSPLF Trial data confirm that combined aspirin and dipyridamole is superior to aspirin alone. Dipyridamole therapy is most commonly limited by headaches, which are often short lived. Clopidogrel may be an acceptable alternative to aspirin monotherapy in patients intolerant of aspirin or dipyridamole, and its use may also be advised in some patients e.g. recent coronary stenting.

What about acute anti-platelet therapy? Aspirin monotherapy is generally recommended. Combined aspirin and clopidogrel has been associated with an increased risk of bleeding complications. However, a recent large Chinese study suggests that early initiation and short-term use of aspirin and clopidogrel benefits high risk patients and can be considered for carefully selected Asian patients with highrisk TIA or minor stroke (further trial data awaited).

When to treat with statins and ACE inhibitors?

The PBS subsidises statin therapy for all patients with established vascular disease. Uncommon adverse effects are myopathy and liver function test abnormalities.

Management of non-valvular atrial fibrillation Under treatment of non-valvular AF is a common problem. Warfarin therapy reduces the relative risk of recurrent stroke by two to three times that achieved with aspirin therapy. However, the absolute risk difference may be small and in patients at low risk of stroke, benefits from warfarin therapy may be outweighed by the additional risk of bleeding complications. In these patients, aspirin therapy may be an acceptable alternative. Objective scores to evaluate risk are helpful (e.g. â&#x20AC;&#x153;CHADS2â&#x20AC;? to assess stroke risk and â&#x20AC;&#x153;HAS-BLED to assess bleeding risk, see www. nps.org.au search â&#x20AC;&#x153;decision toolsâ&#x20AC;?). Warfarin remains the most studied oral anticoagulant. Newer oral anticoagulant therapies (such as dabigatran and rivoroxaban) may offer a cost effective alternative in select patients e.g. those difficult to maintain on warfarin.

0SHBOJTBUJPO PG BDVUF TUSPLF DBSF BOE management

Thrombolysis offered within three hours of onset to select patients improves by 12% (absolute) the number of survivors with no or minimal disability at three months, but increases the risk of intracerebral haemorrhage from 1% to 6%. Other recommended routine investigations are ECG, blood glucose, FBC and biochemical parameters. Other investigations include thrombophilia screening (uncommonly required), carotid imaging (carotid territory symptoms), echocardiography and longer ECG monitoring (non-diagnostic ECG findings and clinical suspicion of cardio-embolic stroke), or more specialised investigations (e.g. angiography and trans-esophageal echo). Best practice for acute disabling stroke is integrated multidisciplinary care within a Stroke Unit. Stroke Unit care appears to decrease morbidity and mortality without an increase in the length of stay, with benefits independent of age or stroke severity. However, services are not uniform across Australia. Support for rural or remote doctors, and appropriate care for their patients with stroke, is a particular challenge.O

All patients need immediate CT to exclude intracranial hemorrhage and other pathologies. (Some advocate MR or perfusion imaging because of the higher diagnostic yield, but such imaging is not always accessible.)

Trials of acute blood pressure lowering and acute statin therapy have thus far been disappointing. However, when there is established vascular disease, patients should be considered for treatment that blocks the renin angiotensin system, and a statin, for secondary prevention. Even moderately hypertensive and normotensive patients may benefit from ACE-inhibitor therapy for prevention of vascular events (as opposed to treatment of hypertension per se). Common toxicities that limit therapy include hypotension, cough and angioedema. Calcium channel blockers and diuretics can also be considered, particularly when ACE-inhibitor therapy is complicated by hypotension, hyperkalaemia and renal impairment. Hypotension (particularly if symptomatic), persistent hyperkalaemia or marked deterioration in renal function means that treatment may need to be reduced or withheld.

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medicalforum

Guest Column

Numbers in Primary Care Midland GP Dr Colin Hughes links Medicare remuneration directly to quality in general practice, and suggests an alternative.

et again GPs have been shafted by Medicare in not allowing any increase in rebates. Why is it that GPs go through the same angst year after year, time after time? Feeling poorly done by compared to their specialist colleagues. Take this morning’s surgery.

Mrs T a Filipina grandmother aged 77 was recently seen in hospital after an episode of chest pain. After discussing with her the consequences of the cyclone on her family back home, her fears and concerns, I reviewed the hospital discharge letter.

to print out relevant results and wrote two referral letters, and then made an executive decision to stop her warfarin and switch to a NOAB having worked out her CHASDS2 and HASBLED score. Some 40 minutes later my receptionist buzzed to let me know four patients had been waiting for over 30 minutes. For my work with this patient I could bill the grand amount of $68. Yes, I could have charged privately and maybe would have got my cash after she had paid her rent and groceries. Poor fool me, I bulk-billed.

It asked if I could follow up with referrals to her local gynae clinic for management of her prolapse, referral and investigation of her ongoing anaemia and review of her warfarin post IHD and paroxysmal AF.

Yet it doesn’t have to be this way. Medicare has modelled the proposal to move to 15-minute time bands and load the 15-29 minute time band and above to $75 and $125, respectively, and reduce the price for a standard consultation to $30.

After review of her numerous letters on file (she wasn’t my regular patient) and a comprehensive examination, I proceeded

This has been rejected by the RACGP who are committed to improving the PIP by patient registration and multi-morbidity care

plans rather than changes to fee-for-service. Yet we all know how the current fee structure rewards fast throughput medicine. Academic trials have shown that seeing a patient for longer reduces the number of consultations per year, so we wouldn’t need more GPs or longer consulting hours. How would it feel to reduce our load to just four patients an hour and be able to practise quality medicine? To have a simplified Medicare schedule without a plethora of item numbers that can be maximised by the big clinics and nurse practitioners? It is time for all GP representative bodies to seriously look at the proposal. I urge readers to contact their political representatives and voice their concerns and support for a simpler, fairer system. O

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Guest Column

The Surgeon’s Blueprint 3D printing uses complex and sophisticated technology that RPH biomedical engineer, Dr David Morrison PhD, says beneﬁt both surgeons and patients.

The 3D data is processed, generating toolpaths which control how the 3D printer head will move during the build. The tool-paths are sent to the printer which constructs the object layer by layer from the ground up. A small model can take an hour while larger, more complex models can take up to three days. The operator doesn’t even need to be there until printing is complete.

t all begins with the CT. With a good CT, anything is possible. So, welcome to the new and exciting technology that is 3D printing! No doubt you’ve seen media reports of 3D printing producing everything from consumables to weapons. What you may not know is that 3D printing has proven itself to be a fantastic technological development in the medical world.

Complex scoliosis surgeries can be planned, tumour resection margins located and custom (patient specific) implantable medical devices designed and prototyped. By utilising 3D printing technology, surgery times can be reduced resulting in cost savings. More importantly, the outcomes for the patient are superior in terms of recovery time, functionality and cosmesis. RPH has been using 3D printing since 2008. As with any new technology, there’ve been teething problems. Think of the dramas with the humble office copier! When we need help it takes a lot more than one phone-call to the IT department. Blocked print heads, complex models collapsing mid-print and mysterious

Q 3D skull model showing defects prior to surgery.

miss-feeds are all obstacles to be overcome. A 3D printer can be used to produce any anatomical model or prototype a new implant. RPH focuses mainly on hard-tissue, but it’s equally possible to design and print models of soft-tissue structures. A typical case involves taking CT data and creating a 3D object. Any artefacts from the imaging need to be removed. It is also possible to remove any existing components during the modelling process, such as failed hip implants which will be explanted as part of the surgery.

The finished model has a resolution comparable to that of the CT source-data. Anatomical models can be sterilised for reference in theatre, which is most useful for patients with atypical anatomy and working with minimal exposures. It’s not uncommon for surgeons to operate with the models directly adjacent to the exposure, constantly referring back and forth between the model and the patient. Unlike the latter, the model can be flipped over and the surgeon can drill into bone with confidence knowing they will not stray into soft tissue. The 3D printers are utilised as part of a statewide service for bio-modelling and customimplant design for both adult and paediatric cases. O

medicalforum

Guest Column

Leadership in a New Age What to do with the colleague who is disaffected and disillusioned? Former President of MDA National A/Prof David Watson explores this difﬁcult dilemma.

he last two decades have seen dramatic changes in the technology of medicine. Our capacity to do more and better things for patients continues to expand. Equally dramatic is the changes in expectation of those patients we serve and the regulators who increasingly influence the way we serve. The need to develop better clinical leadership, model more collaborative behaviours and address difficulties around poor performers stand out. Notwithstanding the increased regulation we live with, if we do not address these issues well, the regulators will, and badly. Clinical leadership has always been visible. However, we are moving into an era where that leadership is much more collaborative and less autocratic than it has been. Most evident in the operating room, where many practices in patient safety and quality have been drawn from the airline industry, the day of the ‘surgeon god’ has passed in favour of a more level platform of responsibility and participation. Inevitably that will transmit to all forms of practice as will the ‘working-in-

teams’ that goes with it, and which forms part of student selection in many medical schools. However, it is the more difficult question of what to do about poor performers that the greatest difficulties arise. There is no agreement on how to measure performance for doctors in practice. Notwithstanding the moves in other countries as well as early shifts in Australia towards some form of recertification, it will prove a difficult task. It is easier in procedural disciplines where there are some broad measures of performance used by hospitals, clinical colleges and institutional accrediting bodies. However, it is at the individual practitioner level that the greatest difficulties arise. Whilst we all think we know who does badly, it is another thing to prove it and start a process of improved performance that is fair, objective and capable of changing clinical behaviour for the better. In the fee-forservice environment, there is no allowance for funding improvement activities. Even in the salaried parts of the public system, cost pressures are making it more difficult for practitioners to improve their skills.

Medicine has failed to adopt one of the most important aspects of the airline industry which was to build into practice the costs of ongoing training and skills improvement no matter how a practitioner was remunerated. One of the silent areas of difficulty for us is the colleagues who do not want to be in the discipline they currently occupy or in medicine at all. This can affect practitioners of all ages but is probably more likely to affect younger colleagues. With the move to vocational training now embracing all disciplines, it is very difficult for any of us to change disciplines even part way through training, let alone later on. It is even more daunting to leave medicine at a stage in life when family, debt and other responsibilities appear to lock us in. These are practitioners who need special assistance to change direction because if they cannot, they pose a potential risk to colleagues and patients due to their dissatisfaction. Whilst it is difficult to find objective data on the size of the problem, anecdotally it is significant and hard to manage. O

Breast Cancer Online Prof Christobel Saunders has written an online module devised to help rural doctors current with the diagnosis and management of breast cancer. The younger woman with early breast cancer – what do I need to know? addresses the physical and psychosocial issues relevant to women with early breast cancer. The course will be re-accredited for next RACGP triennium, so numbers are likely to build beyond the current 250 (37 from WA).

Q Dr Louise Marsh, GP and tenor saxophonist for the band Doxy

although nothing struck her as particularly eye-opening, she was happy to give ‘6 out of 10’ for Practical Useful Information, Delivery You Can Relate To, and Recommend to Others. The module is free through the Australian College of Rural and Remote Medicine’s online learning service RRMEO. O

“With increasing capacity to care for rural cancer patients closer to home — notably with the opening of the Bunbury Cancer Centre and new Albany hospital — it is increasingly important for rural GPs to understand how they can diagnose and help manage patients with breast cancer,” Christobel said. Given that face-to-face training is difficult, the online training module, sponsored by Cancer Australia, offers a relevant alternative for rural doctors.

no problems with access or content. We asked her what she has found particularly helpful from the course.

Dr Louise Marsh from Margaret River Medical Centre, one of the larger group practices in that town, did the online course and told Medical Forum there were

“I kept a copy of a couple of the flow charts about which investigations to do and when. These have been handy a few times since,” she said, adding that

medicalforum

Guest Column

Improving Doctor Co-operation New fellow Dr Victor Tan uses his experiences with WAGPET, DITs and RACGP WA to suggest a community term for all junior doctors to help build co-operation.

term in general practice for all junior doctors in training will either make them better hospital doctors or confirm general practice as their path. The PGPPP* is currently marketed to hospital would-be GP registrars, as a ‘try before you buy’ approach (87 residents placed in 2013). More interns and residents are in the training pipeline, with relatively fewer hospital placements. Differences I observe between hospital and community medicine suggest community placements have a bigger part to play. Fundamentals. Hospital doctors are specialist in acute, episodic care. I had previously thought that most medicine was practised within the walls of a hospital. But where did patients come from and where do they go after hospital discharge? Who sorts out all these meds? GPs are the specialists in undifferentiated illnesses, continuity of care, and whole person care. Patients often tell you, “I’ve got a great GP who looks after me”.

Communication skills. We are taught in general practice to listen to the patient i.e. let the patient talk for the first two minutes and they will most likely tell you the diagnosis. In hospital, it seems like only 10 seconds before you interrupt and ask 20 questions. My conclusion would often depend on the leading questions asked – that’s if I had a chance to take a proper history in the hospital setting. Working in partnership. A patient referred for investigation of DVT had a battery of tests ordered. A well-meaning medical school colleague included a sleep study, but it was much easier for the GP to sort out possible OSA. Another patient was discharged after acute renal failure, with clear instructions for weekly UEC monitoring. His clinical condition and UEC did not follow the discharge letter ‘script’ and it was easier for me to sort it out with the helpful renal consultant (who advised about easier ECHO follow-up in the community setting). The alternative was another hospital visit. I’ve seen both sides of the story.

Keeping perspective. If I were to return to work as a hospital doctor (I have no plans for this, as being a GP is the best job), I’d feel much more confident with history taking, differential diagnoses and having an overall perspective of the patient and the health system. There are numerous challenges to this, such as safety – a trainee supervised by a registrar or consultant not on site, compared to the GP in the next room – or funding, such as hospital-Medicare cost shifting. All important issues that we can work together to sort out. O ED: *Postgraduate General Practice Placement Program (PGPPP) was introduced in 2003 by the Commonwealth government to encourage junior doctors to undertake short supervised placements in general practice to inform their career choice. WAGPET has delivered PGPP placements since 2005.

2014 ESIA GP Educational Dinner The tuning fork - an instrument of value A hands on approach to dizziness Middle ear and sensori-neural tinnitus Severe and profound hearing loss in children Strategies for hearing in noisy environments

Join us as we serve up the latest in ear health Ear Science Institute Australia is hosting its annual GP Educational Dinner on Tuesday 18th March at the UWA Club. This event is RACGP accredited. Bookings are essential. To reserve your place visit www.earscience.org.au/gpdinner or call 6380 4900 before 13th March 2014. 28

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Guest Column

Retirement Is Not Easy! After 55 years in medicine, %S .BSHBSFU 4NJUI is ﬁnding the third age full of exciting challenges but she still misses her patients.

give them a meal and in the time around the table, with a glass of wine, I realise how much medicine and the teaching of it has changed.

ew beginnings are not always welcome or easy. I retired in December 2011 after 55 years of medical practice and it felt like the end of the road. But 10 years before this I had taken a fork in the road, having recovered from major surgical complications (temporary colostomy, permanent urostomy), to work half time and write two books Is It Me or My Hormones? and Now and Then – a Gynaecologist’s Journey..

In order to have this student contact I had to become registered again with APHRA although I do not have any patient contact at all. Music has always been my solace. I sing in a local choir, having previously sung for many years in Collegium Musicum at UWA. I have learnt to play the cello.

Along the way, I had delivered thousands of babies and helped Too much time is spent at my thousands of women through the Q School of Philosophy biscuit baking team (Margaret Smith centre). Food for the mind as computer, now struggling with menopause transition. Now I had well as the body. the awful Windows 8, which is come to a full stop. I remembered designed for younger people who like lots (where about 2,000 items are distributed a joke I heard years before, about a man, of Apps. I also struggle with my Samsung to affected people). This was very pleasant known for his optimism, who fell from a 20 Galaxy 2 phone, which tries to tell me how to work until I was given the job of telephonist, storey building. As he passed the 12th storey do things rather than let me just make phone he was heard to say “well I’m alright so far”! where having to listen to complaints and calls. It took me weeks to work out how to some very odd foreign accents from often Where to go? What to do? I was used to a text! distressed customers is taxing indeed. No one schedule and to being on call. Freedom felt I spend one morning a week (with a team of else would volunteer for this job so I am now very odd. four), baking biscuits for those who attend stuck with it! I missed my patients but was glad to escape classes at the School of Philosophy. I am a I do part time lectures at University of Notre the warfare about HRT and was very sad that student and also teach part time there. so many women who would have benefited Dame Medical School and am privileged to One downside to busy retirement is a lack from it missed out. (I am still on it myself, have a PPD group (personal and professional of time to read good books, something I aged 80 plus.) development) of 9-10 students each year. I love. I do read Medical Forum each month see them monthly at my home for a couple For the first year of retirement I was not which keeps me in touch with the medical of hours. They present cases and we discuss feeling all right. Over this ‘transition’ year I fraternity. Thanks to all the contributors and not so much the medical management as the developed my new framework. I now do a our energetic editor! O weekly session as a volunteer at WA Ostomy ethical and personal issues that arise. I then

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Medicolegal

Giving Evidence in Court Time in court may not feel like an effective use of a doctorâ&#x20AC;&#x2122;s time but knowing why, what and how beforehand can help, says Ms Karina Hafford, Medical Lawyer at Slater & Gordon. If you have treated someone, whether or not you have provided a medical report, you may be required to give evidence about this case Q Ms Karina Hafford in court. Health professionals are obliged to assist courts in the administration of justice. This may be an inconvenient, difficult and unnerving experience.

4VCQPFOBT UP HJWF FWJEFODF A subpoena is an order to attend court, produce documents and give evidence as a witness. Courts have extensive powers regarding failure to answer subpoenas. Usually, the subpoena is â&#x20AC;&#x2DC;servedâ&#x20AC;&#x2122; at your practice rather than your home. It will specify a date and time for attendance at court, usually the start date of the trial. Unfortunately, a precise time for giving evidence cannot be allocated but often arrangements can be made to minimise lost time. If the patientâ&#x20AC;&#x2122;s lawyer serves the subpoena and you have concerns about the relevance or ambit of your evidence, you can contact the lawyer to discuss. Otherwise, you are unable to discuss the details of your patientâ&#x20AC;&#x2122;s condition or treatment or provide documentation without the patientâ&#x20AC;&#x2122;s express authority or an authority from a court.

Sometimes you may consider your evidence is unlikely to assist the patientâ&#x20AC;&#x2122;s case and may even hinder it. However, there may be a good reason you are being called, such as to prove the chain of treatment received. The decision as to whose evidence is required is made by the lawyer. Discuss any concerns with the lawyer who served the subpoena.

Being called as a witness You are not expected to know the rules or procedures of courts and can rely on the court for guidance. In most cases, you must wait outside the courtroom while other witnesses are giving evidence. When called to the witness box, you will be asked to take an oath or affirmation. Each court or tribunal has its own procedures and forms of address, the most common being â&#x20AC;&#x2DC;Your Honourâ&#x20AC;&#x2122; when addressing the judge. You will first be examined by the barrister (a lawyer who specialises in courtroom advocacy) for the party who has called you to give evidence. During the examination you may need to refer to your notes and the barrister may also ask to see them. Both you and the barrister must ask the judgeâ&#x20AC;&#x2122;s permission for this. If you have prepared a report for the lawyers you may be shown the report before it is recorded as a piece of evidence (an â&#x20AC;&#x2DC;exhibitâ&#x20AC;&#x2122;). You may be asked to read the report aloud. On some occasions you may be interrupted

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by argument on relevance or appropriateness of a particular question. The opposing party may then cross-examine you. In some jurisdictions the opposing partyâ&#x20AC;&#x2122;s barrister may seek to view your hand written notes and cross-examine you about those notes. Following the crossexamination, the initial barrister is entitled to question you again (called a re-examination).

Giving evidence This may be unfamiliar and daunting. You are not expected to be a polished performer nor be able to remember every piece of information. Although cross-examination may feel like an attack, you should not feel you are being personally impugned. In most cases, your evidence will not be the subject of dispute, but will play a part in the wider issue under determination. The following hints may be helpful: t -JTUFO DBSFGVMMZ UP FBDI RVFTUJPO *G VOTVSF of a question, ask for it to be repeated. t %P OPU WPMVOUFFS JOGPSNBUJPO CFZPOE UIBU necessary to answer the question. t $POÄ&#x2022;OF ZPVS PQJOJPO UP ZPVS Ä&#x2022;FME PG expertise. If you are asked a question that is outside your expertise, state this is the case. t %P OPU EJTQMBZ JSSJUBUJPO BU UIF RVFTUJPOT asked. Stay calm and composed. t 5SZ UP FYQMBJO FWJEFODF JO MBZ UFSNT XIFSF possible. t #F PCKFDUJWF BOE JNQBSUJBM

Fees for attending court The lawyer who requested you give evidence is required to pay you a reasonable fee for the time spent in giving evidence. The fee will usually reflect the time you are away from your practice but will generally not fully compensate you for cancelled appointments. Seek advice from your professional body.O

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Crunching the Numbers The business side of medical practice can be almost of foreign language to some doctors. Education, says a ďŹ nance expert, is the key. â&#x20AC;&#x153;But even within the latter group there are significant variations. The size of medical practices varies enormously. Radiologists, for example, often work in very large organisations. That diversity is interesting and it will make for some robust and challenging discussion but the structure of the course is inclusive.â&#x20AC;?

In Medical Forumâ&#x20AC;&#x2122;s latest readership survey published in November, the feedback doctors were telling us was that the business side of medicine and running a practice was often neglected in the face of more pressing issues with patients and the medical and bureaucratic dilemmas they bring.

Finance for Doctors will build a logical framework with some coherent financial theory combined with case studies of actual medical practices.

Business lecturer Dr Sam Wylie, who conducts the MBA program at the Melbourne Business School, is launching a 10-week short course at the UWA campus for doctors to help them create a coherent framework for making decisions about their own wealth. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;d like to stress that this is not financial planning. There are plenty of people doing that already and their focus is selling rather than education. At the end of this course, doctors will be able to have a much more elevated conversation with their financial planner and, most importantly, be able to understand and critically evaluate whatâ&#x20AC;&#x2122;s being put in front of them.â&#x20AC;? The world of finance is complex area and Sam readily agrees that itâ&#x20AC;&#x2122;s very difficult for anyone to jump through all the hoops and hurdles, but particularly so for doctors. â&#x20AC;&#x153;We all want our doctors to be highly knowledgeable within what is sometimes a comparatively narrow field. And in the case of a specialist I want him or her to be an absolute expert on my particular problem!â&#x20AC;?

â&#x20AC;&#x153;The beautiful thing about finance is that it all fits together, itâ&#x20AC;&#x2122;s really applied economics. Itâ&#x20AC;&#x2122;s like Meccano!â&#x20AC;? Q Dr Sam Wylie and wife Tracey

â&#x20AC;&#x153;That can create problems in managing their own finances. Thereâ&#x20AC;&#x2122;s no doubt that many doctors are interested in the workings of the financial sector, as a group theyâ&#x20AC;&#x2122;re uniformly intelligent and they usually have around the same level of background knowledge.â&#x20AC;? â&#x20AC;&#x153;Doctors are highly specialised and extremely busy so they often donâ&#x20AC;&#x2122;t have the opportunity to learn fundamental business skills. And nor do they need to have formal certification. Their own financial skills are important but they donâ&#x20AC;&#x2122;t need to prove that to anyone else.â&#x20AC;?

â&#x20AC;&#x153;Most doctors, like everyone else, are a little apprehensive when dealing with the world of finance. I hear people say, â&#x20AC;&#x2DC;I donâ&#x20AC;&#x2122;t know what I donâ&#x20AC;&#x2122;t know and Iâ&#x20AC;&#x2122;m not sure where Iâ&#x20AC;&#x2122;d go to find out.â&#x20AC;&#x2122; My aim is to give people the ability to make important decisions with a degree of confidence.â&#x20AC;? O

Sam said the latest ABS figures reveal that there are about 73,000 GPs and 27,000 specialists registered in Australia.

BENEATH the Drapes X Fulham Medical Centre was announced WAGPET Training Practice of the Year 2013 at the recent awards night. Dr Elaine Lee is GP Registrar of the Year and Dr Andrea Gomes took out the Prevocational Community Medicine Award. X Curtin Universityâ&#x20AC;&#x2122;s Professor Gill Lewin has been awarded the 2013 Council on the Ageing (COTA) Western Australia Champion for Seniors Award. X MDA Nationalâ&#x20AC;&#x2122;s CEO, Mr Peter Forbes, announced at the AGM in November that he would retire in June. Also announcing their retirement from the board were West Australian A/Prof David Watson and Prof Guy Van Hazel. X Ms Jenni Perkins will act as the Commissioner for Children and Young People for the next 12 months, following Ms Michelle Scottâ&#x20AC;&#x2122;s departure. X Orthopaedic surgeon Dr Michael Halliday was named St John of God Murdoch Hospitalâ&#x20AC;&#x2122;s Doctor of the Year for 2013.

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â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m aiming to develop an intuitive approach so that doctors will have an idea where they can expect to find real value in an investment opportunity. Itâ&#x20AC;&#x2122;s also important that they know how to eliminate some of the risks in structures such as family trusts, corporations and self-managed superannuation funds.â&#x20AC;?

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Guest Column

Forged Scripts Alert Pharmacist Ms +BOF $BSQFOUFS from the DoH outlines how we all struggle with electronic sophistication, amongst other things, when it comes to forged scripts.

ach year the Department of Health is alerted to hundreds of forged Schedule 8 prescriptions, most detected by vigilant pharmacies. However, it is thought this represents only a small proportion of the total fraudulent scripts for drugs channelled into the illicit market. Unfortunately, most Schedule 4 forgeries are still likely to escape detection and be dispensed.

Most forgeries reported are for oxycodone and morphine. In 2013 there were also forgeries for pseudoephedrine, modafinil, zolpidem and multiple different benzodiazepines. Forgeries for alprazolam are on the increase. The people involved are well organised and their methods complex. One of the most common forgeries seems to involve the theft of prescription stationery (traditionally from a medical practitionerâ&#x20AC;&#x2122;s house or car). More recently, thefts are of multiple sheets of A4 printer stationery â&#x20AC;&#x201C; difficult to detect and often unnoticed. Modern scanning and printing techniques mean this stolen stationery can then be used to prepare forgeries that are indistinguishable

from the real thing, even including Medicare and PBS authority requirements. Many forgeries are identified where a pharmacist rings a medical practitioner for confirmation of unfamiliar handwriting. When stolen pads are identified and a scam with multiple forgeries on the same stationery is known, the Department issues a global alert to all pharmacies. During 2013, 14 such alerts were issued. Prescribers should be aware of the need for strict security for prescription stationery, including that used in laser printers. The use of electronic prescription exchange systems, is strongly encouraged at both the medical practice and pharmacy. Drug seekers can also use a variety of techniques to persuade prescribers to write them a prescription. Scams reported include use of altered documents. In one case, a patient with genuine chronic pain used multiple Medicare cards at various practices to set up different identities. Falsified letters from specialists and altered hospital discharge summaries are also seen. This can relate to unusual medical

conditions. A patient with good knowledge of a rare condition and an extensive investigative history used this to persuade many GPs to simultaneously prescribe fentanyl lozenges for many months. As the patient was not palliative and the scripts nonPBS, they were not identified by Medicare. In another case, a practice manager used access to both stationery and prescribing software to print prescriptions for other people for personal gain; using a doctorâ&#x20AC;&#x2122;s password and fictitious user profiles. Prescribing software should only allow an authorised prescriber to generate a prescription and be protected with secure password access. With oxycontin reportedly selling at $1 per mg on the street there is a strong incentive to fraudulently obtain prescription pharmaceuticals for diversion. Any prescriber who wants to check the Schedule 8 prescription history for a patient they are treating, should call the Pharmaceutical Services Branch on 9222 4424 (8.30am-4.30pm, Monday to Friday).O

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CLINICAL UPDATE

Neuroplasticity: Why early intensive rehab is better

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he extraordinary potential for neuronal plasticity in the human central nervous system has recently been uncovered. The adult cerebral neural network is no longer thought of as unyielding and incapable of large change and the implication for stroke survivors is exciting. Neuroplasticity is the changing or adaptation of neural pathways due to experience and learning; the synaptic exchanges that occur in normal learning such as in learning a new language, cooking a new recipe or playing a musical instrument. Very early aphasia rehabilitation after stroke can harness these neuroplastic changes for improved patient outcomes.

What the history can reveal Repetition is the major component of new learning but it takes more than repetition to be efficient and effective at a skill. Skill development and mastery requires: i) repetition in high doses or massed practice, ii) task specificity or â&#x20AC;&#x2DC;train as you playâ&#x20AC;&#x2122; and iii) task saliency or â&#x20AC;&#x2DC;meaningful practiceâ&#x20AC;&#x2122;. In short, to learn a task, an adult human needs to complete over 3000 â&#x20AC;&#x2DC;task specificâ&#x20AC;&#x2122; repetitions, in an environment that emulates the â&#x20AC;&#x2DC;real worldâ&#x20AC;&#x2122; to achieve skill competency. At a cellular level, such high dose, task-specific and meaningful practice results in neuronal long-term potentiation (LTP), which is the rapidly induced and sustained efficiency of neural transmission at a synapse that results in learning and memory.

4P XIBU IBQQFOT BGUFS CSBJO JOKVSZ Stroke leads to cell death and subsequent brain tissue changes. Primary changes include cellular oedema in the infarcted area and the penumbra (area immediately surrounding the infarction) and causes decreased electrical activity due to metabolic disruption. Diaschisis also results, where there is loss of electrical activity in areas related by function but not local to the infarction. The penumbra and perilesional areas are hypoperfused and incapable of normal function, however, electrophysiological function remains relatively normal â&#x20AC;&#x201C; important because, predominantly, these areas are recruited to subsume function of the infarcted tissue during early neurorecovery. Secondary changes to the neuronal tissue occur as a direct consequence of the insult and occur in a temporal sequence. Collectively, these processes underlie neurorecovery and allow the brain to regain function after injury. They are: transneuronal degeneration; denervation supersensitivity; resolution of diaschisis; upregulation; collateral sprouting; and synaptogenesis. Transneuronal degeneration is the degeneration of tissue that loses its usual connections to the infarcted area. Denervation supersensitivity applies to the penumbra where the cells that have medicalforum

lost function become supersensitive to any residual electrical input. Resolution of diaschisis is the process of regaining the electrical activity that has previously been lost to areas distant to the infarcted tissue. Unmasking or upregulation refers to the recruitment of previously present but inactive tissue connections and collateral sprouting involves the regeneration of axonal and dendritic branches. Lastly, synaptogenesis is the formation of new synapses.

Theories of brain recovery following JOKVSZ Restitution is the neurorecovery of a lesioned area and promotes the theory that function in this area is not entirely lost but is unable to be accessed in the usual way. Skills are regained through activities that promote denervation supersensitivity, upregulation, collateral sprouting, and synaptogenesis. This model suggests that as diaschisis resolves, existing neural pathways resume activity and the functions subserved by the involved neural systems are restored. During this time-limited repair phase (days to three months post-onset), function previously attributed to the lesioned area is now assumed by the immediately adjoining penumbra and perilesional areas and in cases of large infarction, the contralateral homologue. Substitution assumes that functional improvement is the result of system reorganisation. This model is thought to primarily use synaptogenesis and upregulation to achieve learning. This reorganisation results in a new functional system to accommodate the loss of function (in the lesioned area) by brain regions distant but related to the lesion. Substitution is thought to commence after three to six months post-onset, continue well into the chronic phase and for as long as learning potential is present.

days post stroke, however, are believed to be the â&#x20AC;&#x2DC;window of opportunityâ&#x20AC;&#x2122; for neuronal changes to occur. Very early (acute) and early (subacute) post stroke rehabilitation is believed to harness the effects of spontaneous recovery through therapeutic activities that include high levels of task specific practice in meaningful environments. Very early (two days to two weeks) and early (within the first month) rehabilitation is designed to drive the strengthening of neural networks through synchronous neuronal firing. This synchronous neuronal firing is thought to enhance LTP and minimise independent and incorrect neuronal activation that produces maladaptive behaviours and inaccurate skill acquisition. Research in very early aphasia rehabilitation showed that 45-60 minutes of aphasia therapy per day; five days per week resulted in significant improvement over what is expected of usual ward-based care which (in WA) is an average of 11-14 minutes per week in the first month of recovery. That improvement is equivalent to the difference between someone speaking in single words and someone talking in sentences without assistance. It means the difference between independent home living and someone requiring residential aged care. O References available on request

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8IZ FBSMZ JOUFOTJWF SFIBCJMJUBUJPO enhances recovery Small clinical trials support the â&#x20AC;&#x2DC;earlier is betterâ&#x20AC;&#x2122; rehabilitation concept but results are yet to be substantiated in larger trials (AVERT, VERSE). The first 90 35

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most. Patients given Bevacizumab in recurrent disease achieved more benefit (OCEANS trial) compared to those having first-line therapy. Drug cost alone per cycle for a 65kg patient is between $2400-$4800.

nnovations may add significant cost to the community with variable benefits to the individual and society. Consider these innovations in Obstetrics and Gynaecology and ask, “We can, but should we?”

Robotic-assisted surgery The surgeon performs the operation via a console that remotely manipulates the operating instruments. In the US roboticassisted hysterectomy is on the rise (0.5% to ~10%, from 2000 to 2013). Because roboticassisted surgery often takes longer and costs more its position is uncertain (RANZCOG Position Statement, 2013). It will cost an extra $960m-$1.9b annually in the US if all hysterectomies are done with robotic assistance. “At a time of fiscal responsibility and transparency in health care, the use of expensive medical technology should be questioned when less-costly alternatives provide equal or better patient outcomes” (ACOG Presidential Statement, March 14, 2013).

Uterine transplant The first ever Workshop in Human Uterine Transplantation will be held on February 20, 2014. The Swedish team will teach the basics and prerequisites of establishing such an undertaking. In congenital absence of a uterus, surgical removal, or some therapeutic treatments, uterine transplantation is the only chance of a pregnancy. From four human case reports, no live pregnancies have been

reported. Uterine transplantation is not a life-saving organ transplant. Protocols are needed that comply with guidelines from the WHO Guiding Principles on Human cell, tissue and organ transplantation and the Transplantation Society of Australia and New Zealand. A highly skilled multidisciplinary team is required for this small volume, highly specialised procedure. No doubt there will be pressure to establish the first human uterine transplant unit in Australia. Should the states vie for this auspicious milestone?

Molecular and genetic technologies Bevacizumab (Avastin), a humanised VEGF-neutralising monoclonal antibody, when added to standard first-line therapy for advanced epithelial ovarian cancer, increased progression-free survival from 22.4 to 24.1 months (randomised ICON 7 trial), and from 10.3 to 14.3 months (double-blind randomised GOG 218 trial). Neither study showed an overall survival advantage, and Avastatin increased side effects (hypertension, haemato-toxicity, viscus perforation) and worsened quality of life (ICON 7). The subgroup of patients with suboptimal primary surgical debulking may benefit

Molecular medicine #Z .S #BSSZ &QTUFJO Proteomics International

eveloping a new medicine takes about $US 1.1 billion and 10-12 years and the key expense is failure (Forbes). To meet this challenge, pharmaceutical companies are looking to new models that include molecular diagnostics. One form of this is proteomics, the analysis of proteins using mass spectrometer and supercomputers.

#JPNBSLFST A vital tool in molecular medicine is the biomarker – any measurable substance, structure or process that predicts outcome or disease. Historically, biomarkers were based on DNA mutations. The first protein 36

biomarker was serum PSA. Diagnostic biomarkers can diagnose a disease earlier and with more accuracy, possibly before any clinical signs or symptoms occur. A prognostic biomarker highlights risk for disease (e.g. BRACA1 and BRACA2 genetic variants for breast and ovarian cancer); perhaps also used to stratify participants in clinical trials and thus reduce costs. A predictive biomarker would identify the patient’s response to therapy. A pharmacodynamic biomarker can assess a biological response after therapy, such as monitor the effective dosage of a drug.

Non-invasive prenatal testing (NIPT) is a screening test for mothers at high risk of carrying a fetus with a chromosomal abnormality. Maternal blood taken after 10 weeks gestation is analysed for cell free DNA using parallel sequencing (shotgun approach) or DNA sequencing (targeted approach). Both maternal and fetal cell free DNA is detected and the fetal fraction increases as gestation advances. In high-risk mothers, the test has a 99.5% sensitivity and 99.8% specificity for Trisomy 21 (lower for Trisomy 13 and other atypical chromosomal abnormalities). A positive NIPT result should be confirmed by a diagnostic test (CVS or amniocentesis). Maternal conditions may be inadvertently detected. NIPT currently costs about $800 (not covered by Medicare) and adds $4988 to current calculated costs of $51,372 per Trisomy 21 case confirmed. The testing is currently not performed in Australia and is not subject to NATA regulations. Guidelines for NIPT in Australia are currently being developed. Expert counselling should be provided. Downstream benefits include the potential for early detection of chromosomal abnormalities and prenatal interventions with neuroprotectors (with acknowledgement to Prof Jan Dickinson).O References available on request.

New discoveries Several discovered proteomic biomarkers are undergoing commercialisation. The complexity of disease suggests a set of biomarkers (i.e. signature) might characterise any disease or complication. The challenge with a protein-based biomarker is to discover it first; this requires a good study that involves careful patient selection, detailed data on those participating, and the elimination of potentially confounding variables. Protein biomarkers must then be validated with FDA approved immunoassays. Proteomics International has discovered a panel of protein biomarkers in patients with diabetic kidney disease. The company has now assayed and validated four biomarkers that are differentially expressed in diabetic nephropathy compared to ‘normal’ diabetes. The next phase is analysis for prognostic value. O medicalforum

Spinal stenosis surgery decider? .FEJDBM 'PSVN MPPLT JOUP UIF WBMVF PG " 1SPG .BSLVT .FMMPI T SFTFBSDI EFTJHOFE UP IFMQ TQJOBM TVSHFPOT UBDLMF UIJT QSPCMFN XJUI DPOmEFODF

Everyone knows lumbar spinal stenosis is associated with nerve root entrapment and surgery can help. The problem is accurately predicting who benefits from what surgery. With about a third of the elderly diagnosed with spinal stenosis not responding favourably to surgery, it is time for reappraisal, according to A/Prof Markus Melloh. He is developing a promising new test that measures epidural pressure as an indicator of stenosis. Currently, MRI yields both false negatives and positives, when compared to that ultimate measure of success, response to surgery. The older you get, the harder it is to measure clinically relevant spinal stenosis or dural sac narrowing from imaging. Even more recent MRI changes such as the â&#x20AC;&#x2DC;sedimentation signâ&#x20AC;&#x2122; are inconsistent. Pressure measurement can be used before and during surgery to help select which spinal segments require surgical decompression, as an adjunct to MRI and

clinical examination. In just 10 cases in a proof-of-concept trial, using a catheter and transducer during surgery, they found the epidural spinal pressure increases about threefold at the site of compression and there is no swing in Q A/Prof Markus Melloh pressure associated with breathing or pulse below the obstructed level. â&#x20AC;&#x2DC;Spinal stenosisâ&#x20AC;&#x2122; as a diagnosis is wide open. Markus puts it another way. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s a real mess. There is no clear evidence on the definition of spinal stenosis, on accuracy of diagnostic tests, on surgical or nonsurgical treatment and we donâ&#x20AC;&#x2122;t know which signs stem from spinal stenosis. Itâ&#x20AC;&#x2122;s realised now that we donâ&#x20AC;&#x2122;t have a gold standard for the diagnosis and what we do,â&#x20AC;? he said.

One problem is overdoing surgery, by operating on multiple levels and turning things into major surgery by having then to stabilise with rods and screws. Older people are most at risk of this, whereas using their pressure measuring technique, only a single level might need surgery. â&#x20AC;&#x153;Before thinking about surgery, you can measure pressures, perhaps enter the spine below and push the catheter up and get a diagnosis. Using a non-magnetic catheter [tantalum] this allows an MRI to be performed at the same time to choose the affected level.â&#x20AC;? â&#x20AC;&#x153;I would hope that operation time would be reduced by one third because you are not decompressing segments you would otherwise be unsure of,â&#x20AC;? he said, adding that less complex surgery means fewer complications. â&#x20AC;&#x153;I would expect that a good proportion of patients would not need an operation at all. It is hard to say how many.â&#x20AC;?O

Atopic dermatitis and the epidermal barrier %S (SBIBN 5IPN %FSNBUPMPHJTU 4PVUI 1FSUI 31) BOE 1.)

e now have an enhanced understanding of epidermal barrier dysfunction in the pathogenesis of atopic dermatitis (AD), predominantly at the stratum corneum, with its two-phase structure of terminally differentiated keratinocytes in an extracellular lipid matrix. Impairment of the epidermal barrier results in water loss, increased susceptibility to irritants, allergens and microbial pathogens and altered skin pH, creating a cycle of further barrier impairment and inflammation.

In AD, defects that may contribute to epidermal barrier dysfunction include filaggrin gene mutations, increased serine protease activity, and epidermal lipid abnormalities.

Filaggrin mutations These are now considered the most important genetic predisposing factor in AD. Filaggrin is a key component of the epidermal barrier â&#x20AC;&#x201C; initially it aggregates keratin filaments in the granular layer, and is subsequently degraded into natural moisturising factors (NMFs), which have humectant properties, maintain skin pH and inhibit bacterial colonisation. Filaggrin medicalforum

factor in the progression of this atopic march.

â&#x20AC;&#x2DC;nullâ&#x20AC;&#x2122; mutations (a complete loss of filaggrin expression), confer an odds ratio of 3-3.5 for the development of AD. However, filaggrin mutations alone are not sufficient to account for AD â&#x20AC;&#x201C; they are only present in about one third of cases, and they also cause ichthyosis vulgaris, which can occur independently of AD. The pathogenesis of AD is likely to involve complex interactions between barrier dysfunction and immune dysregulation.

The â&#x20AC;&#x2DC;atopic marchâ&#x20AC;&#x2122; There is increasing interest in epidermal barrier dysfunction and the â&#x20AC;&#x2DC;atopic marchâ&#x20AC;&#x2122;. That is, AD is usually the first manifestation of atopy; one third of affected children subsequently develop asthma, and two thirds develop allergic rhinitis. AD may be a causal

Sensitisation to allergens may occur due to penetration through the defective skin barrier. Sensitised T cells may then travel to lymphoid tissues of the respiratory tract, provoking the expression of asthma or allergic rhinitis when respiratory exposure to these allergens occurs. Other mechanisms are also proposed, including the production of thymic stromal lymphopoietin (TSLP), which is produced in affected skin and may have effects on bronchial responses to allergens.

Understanding helps management It is good to provide parents and patients some explanation of these concepts which may to reinforce the importance of general skin care measures such as avoiding soaps and applying emollients regularly, improve compliance and help patients understand the long-term nature of AD management. While further longitudinal studies are needed, the possible causal role of AD in the progression of the â&#x20AC;&#x2DC;atopic marchâ&#x20AC;&#x2122; provides rationale for AD in infants and children to be treated actively and seriously. O References available on request.

CT radiation figures weâ&#x20AC;&#x2122;d like you to notice we include a radiation dose estimate on every 128 Slice CT scan report

Imaging Central is an independent radiology practice delivering the same dose reduction technology as Princess Margaret Hospital for Children: SaďŹ re Iterative Reconstruction CARE Dose kV CARE Dose 4D Adaptive Dose Shield

Australian Adult MDCT DRLs - (95% Cl) (Dose Length Product, mGy.cm) 1200

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In 2011, the Australian Radiation Protection and Nuclear Safety Agency conducted the Australian National Diagnostic Reference Level Survey. The data established a measure of multi-slice detector CT doses for current diagnostic imaging practice in Australia, allowing individual practices to compare their doses against those of their peers.1 At Imaging Central, it is easy to compare our dose achieved with others as we include it on every CT report.

1 Australian Government, Australian Radiation Protection and Nuclear Safety Agency., viewed 29th Jan 2013 http://www.arpansa.gov.au/services/ndrl/index.cfm 2 Imaging Central Practice Reference Level Dose measured from Oct - Dec 2013

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National Dose Reference Levels

Head to our website for more information about our dose reduction technologies

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Abdo Chest Lumbar Pelvis Abdo Pelvis Spine Imaging Central

p:389284 6900 f: 9284 2955 w: www.imagingcentral.com.au a: 345 Stirling Highway, Claremont 6010

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Medical decision making 1SPG %BOJFM 'BUPWJDI &NFSHFODZ .FEJDJOF 68" 31)

Ds are experiencing increasing demands which challenge us to think differently and to be aware of how clinical practices are often reversed. Indeed, waning clinical skills and lack of confidence in clinical judgment promotes a bias toward intervention, especially the overuse of diagnostic testing. The fundamental principle of medical practice should be that clinical decisionmaking is the integration of clinical expertise with patient values, using the best available evidence. Unthinking adherence to clinical guidelines causes harm, and many benefits are overstated. Many journals report data on benefits in relative terms, which maximise the appearance of benefit but report harms in absolute terms, which minimise them. This is distorting. The concept of ‘shared decision making’ is now stressed as it becomes clearer that virtually all medical interventions have both positive and negative aspects and that patients should have some say in many of these decisions.

Numbers needed to treat There is a way of understanding how much modern medicine has to offer individual patients. The simple statistical concept of Number-Needed-to-Treat (NNT) offers a measure of the impact of a medicine or

therapy by estimating the number ber of patients that need to be treated ted in order for one person to benefit. The concept is statistical, but intuitive, for we know that not everyone is helped by a medicine or intervention — some benefit, some are harmed and some are unaffected. Knowledge and use of the NNT allows both doctors and their patients to better understand what can be expected from particular treatments, ments, tests and screening processes.

Applying The NNT If, for example, in-hospital adult myocardial infarction (AMI) mortality were decreased from 10%, using standard therapy alone, to 8% with the addition of drug X, then the absolute improvement would be 2%. That is, two patients’ lives would be saved for every 100 patients treated with drug X, using mortality as the measured endpoint. Two per 100 is the same as 1 per 50, so the NNT to prevent one death is 50 patients. What of harmful effects (Number-Neededto-Harm, NNH)? What if drug Y produced a benefit in 5% of patients and caused harm in

10% — the NNT for benefit would be 20 (100/5) and the NNH would be 10 (100/10). One may decide to not give the drug because the potential harm may exceed the potential benefit. Readers are referred to www.thennt.com created by Dr David Newman and his colleagues. It goes into detail about NNT and provides a number of authoritative examples. These can be individualised by using the ‘customize this NNT’ tab. Studies indicate that both patients and doctors make better decisions using such tools.O

Teaching medicine at UWA " 1SPG -VDZ (JMLFT 68" (FOFSBM 1SBDUJUJPOFS

ajor changes to medical education at UWA this year means that the MBBS, which has been delivered since 1956, is changing to a four-year postgraduate doctor of medicine (MD). This will be a ‘stand-alone’ degree with no prerequisite undergraduate units.

clinical context. The cornerstone of this will be clinician-led, small-group tutorials focusing on carefully designed clinical cases that integrate information from the various disciplines. Students are expected to be active participants in these sessions, researching and providing the content and working collaboratively with their group.

Selecting graduates to undertake medicine widens the academic and socio demographic diversity of the student population and brings maturity and experience to the learning environment. The curriculum aims to develop all the attributes we seek in new doctors – the ‘PLACES’ themes of Professionalism, Leadership, Advocacy, Clinician, Educator and Scholar, which are woven into every element of the curriculum.

E-learning will play a key role with online resources and a world-class library with access to major medical databases. The days of rote-learning hefty textbooks are thankfully over. Students will learn how to pose challenging clinical questions and find the best answer themselves. This gives them the foundation to continue to learn once they graduate.

When studying the biomedical sciences in the early years there will be a strong emphasis on early clinical exposure and applying acquired information to the medicalforum

We all know how quickly medicine changes! Students will be given some flexibility in their learning over the four years, through tracking their professional development with an e-portfolio, allowing them to identify their

strengths and weaknesses and plan learning around a variety of flexible options. This is essential when you have a student cohort from such diverse backgrounds. Pathology and laboratory medicine teaching has also changed. In large e-learning suites, students in small groups will use high resolution screens to see detail not possible looking down a microscope. Students will be required to complete a significant scholarly activity over the course of the MD degree. One option is service learning; students develop a close relationship with a community organisation and contribute significantly to it. However, the more things change, the more they stay the same. In the senior years, there is no substitute for the integrity and strength of learning in clinical environments, with a real stethoscope, in real situations, on real patients.O 39

*OOPWBUJPOT 5SFOET

WA Health’s Wish List for 2014 Each year, the WA Health Conference showcases innovations in public health and rewards excellence. It is also provides some indication of where health in WA is heading, by bouncing off so many diverse interests in one place. This potpourri of excerpts is just that.

young and work with local people. He was confident it will make an enormous difference (like many before him have been confident).

ealth Minister Dr Kim Hames read from a prepared speech but diverted from it for a spot of humour. On a serious note, his comments were heavily swayed towards IT use: the new Telehealth Research Centre (the Health Dept linking up with CSIRO boffins); teleophthalmology services focused on Aboriginal and older Australians in the Goldfields and Great Southern; and the 550 video conference sites ready to go in WA Health. He wants to improve cohesiveness of telehealth services, and is firmly fixed on the Ontario network model where the relevant

Q Health Minister Dr Kim Hames

NGO trains people and keeps equipment. Medical Forum has written about poor ear health in Aboriginal children, and the flowon effect. Dr Hames said his government was responding to lobbying from ear specialists when it announced $6m over the next four years to place 0.2-0.3 Aboriginal health workers in every Aboriginal health community to monitor the hearing of the

Q NEHTA CEO Peter Fleming

EHTA CEO Peter Fleming was naturally enthusiastic about everything e-health but eyes glazed over when he mentioned the PCEHR as part of the national strategy delivered in August 2012. His view is that with health data in one place we will save an enormous amount of time; and we are on the cusp of this now. He alluded to the 3000 or more medical terms commonly used in our communications and NEHTA’s attempts to finalise these so we have “interoperability – so transactions can move from one location to another”. While some fondly remember the bloopers emerging from each hospital’s typing pool, he pointed to the imminent rollout of an Australian medical terminology system in Victorian hospitals, followed by the ACT.

Peter spoke of medication management as a proving ground for saving health dollars. Australians currently spend $18b a year on medication, which result in about two million adverse drug events a year and about 150,000 hospitalisations and 20003000 deaths as a consequence. “We hope to bring all this information into one box so that management systems can help stop a proportion of the adverse drug events,” he said. Information sharing for self-help is another NEHTA priority. People with chronic disease, indigenous folk, the elderly, and mothers with newborn are the four main target groups.

SIRO’s Dr David Hensen represented the CSIRO’s e-health Research Centre, in which WA Health has invested, no doubt to increase productivity and prevent ill health. “Changes in e-health delivery in the next 50 years will be massive. Building capacity through hospitals is not enough. We need to think of ways to improve our effectiveness and efficiency; to make our assets really work for us, which is where e-health and telehealth can make a big difference,” he said. He called for innovation among health workforce and accurately collected data for its primary use, which can then be reused for population health, research and funding allocation.

Encryption was one basic infrastructure that had taken time to get right. He expects discharge, referral, and medication information to be used soon and for 50% of public hospitals to send automated discharge information to the PCEHR, starting this month. Q CSIRO’s Dr David Hensen

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PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Dr John Yovich

Male surgeries â&#x20AC;Ś advancing Andrology Services at PIVET In fertility management, embracing the male has been a challenge, with most fertility clinics reluctant to look beyond WKH VSHUP MDU , KDG WKH EHQHĂ&#x20AC;W RI OHDUQLQJ $QGURORJ\ IURP British Urology experts Bill Hendry and John Pryor in the 70s and integrated their ideas into PIVET and opened up new ideas in WKLV FRQWURYHUVLDO Ă&#x20AC;HOG 5HIHUULQJ SDWLHQWV WR 8URORJLVWV ZLWKLQ DQ integrated fertility service is optimal as the contribution of each partner is interactive and generally quite complex.

Q Prof Bruce Robinson

David illustrated some practical e-health examples: preventing bed block in Queensland hospitals under 80-90% occupancy; tele-ophthalmology initially with WA Country Health Services and now up and running in the Goldfields; the Emergency Telehealth Service for WACHS (see Medical Forum June edition); the Remote Eye visual support now used in China and providing licensing revenue; and a cardiac rehab service delivered in Brisbane via a mobile phone that resulted in consumer convenience, interaction, uptake and adherence, with clinical results.

We are pleased to announce that Consultant Urologist, Darren Katz, will be offering andrological services to PIVET patients. Darren brings the most advanced ideas and procedures following his fellowship and research training at Sloan-Kettering Cancer Center in New York. There Darren had an attachment to the Weill-Cornell Medical Center where he learnt the most advanced Andrology procedures directly from pioneers Peter Schlegel and Marc Goldstein. These are now all available at PIVET and include:

hairman of State Health Research Advisory Council, Dr Bruce Robinson, asked for more funding for research from State Health, a stance fully endorsed by the conference session coordinator Dr Gary Geelhoed.

Microsurgical vas reconstructions â&#x20AC;&#x201C; vasovasostomy and vasoepididymostomy

Dr Robinson talked about the courage needed to invest in research and how innovation through research is important. â&#x20AC;&#x153;Cures donâ&#x20AC;&#x2122;t grow on trees, they come from research,â&#x20AC;? he suggested.

Varicocele ligation â&#x20AC;&#x201C; the microsurgical subinguinal technique has caused the Cochrane Dr Darren Katz, a Urologist totally dedicated to Andrology in all its aspects. database to revise its previously negative attitude to varicocele surgery.

He said imbedded State Health research improves staff recruitment and morale, saves government money by demonstrating efficiencies, helps us handle our ageing population, and provides hope to people and is therefore good public relations. He described the NHMRC grant success rate of 5% as â&#x20AC;&#x153;humiliatingâ&#x20AC;? for a state with 10% of the population. The Canadian example of Alberta was used â&#x20AC;&#x201C; $300m invested from resources sector royalties now returning $80m per year for research, with NHMRC funding increasing from 5% to 14% as well. The Melbourne football club, Prof Barry Marshall and Prof Bill Musk were used to drive home points. â&#x20AC;&#x153;Ministers have been more and more supportive but they have been constrained by what Treasury and other people think. Unless there is a ground swell it doesnâ&#x20AC;&#x2122;t happen. So the Minister announced the first go at this, $30 over four years, the Future Health Program to try to reduce the NHMRC decline. The AMA has recommended $40m a year but we know that wonâ&#x20AC;&#x2122;t get it back â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s gone too far down. SHRAC originally requested $100m a year, which is what got it back in Canada,â&#x20AC;? he said. â&#x20AC;&#x153;We need $40m pa to become competitive. So we have to ask the Premier and Health Minister to put in money big time, for the sake of WAâ&#x20AC;&#x2122;s reputation, let alone the health of our children.â&#x20AC;? He said they are thinking through KPIs for research to be accountable, similar to activity based funding.O

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MESA & TESA â&#x20AC;&#x201C; sperm aspirations using microsurgical directed sperm recovery; this enables optimum recovery of quality samples, including increased success for non-obstructive cases such as Sertoli-cell only (SCO) and Klinefelterâ&#x20AC;&#x2122;s Syndromes. Advanced male diagnostics DQG VSHFLĂ&#x20AC;F SURFHGXUHV LQFOXGLQJ Mullerian cysts and ejaculatory duct obstructions. Male reproductive endocrinology. Darrenâ&#x20AC;&#x2122;s broad Andrology knowledge includes hypogonadism states in the male, such as Kallmanâ&#x20AC;&#x2122;s Syndrome. He has published extensively in this area. Cases referred to PIVET (or directly to Darren Katz) will be appropriately managed in an integrated model and directed to his regular procedural list, where nearly all will be day-cases worked up in concert for IVF and ICSI procedures, as required.

NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY

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

Team Event

t e S s o c Medi n o h t a r up Ma e g n e l l a h C Q Pemberton GP Dr Mick Dewing and the infamous broken paddle.

It was a case of the young guns versus the wise heads at the Blackwood Marathon Relay â&#x20AC;&#x201C; with all eyes on this yearâ&#x20AC;&#x2122;s return contest. Heading bush is a great circuitCSFBLFS GSPN UIF QSFTTVSF PG QBUJFOUT *O MBUF mWF NFEJDPT o %S %VTUJO )BMM %S #FO 8BMBXTLJ %S 1FUFS %FXJOH BOE IJT GBUIFS %S .JDL %FXJOH BOE %S "OHFMJLB &MTNBOO o UPPL QBSU JO UIF #MBDLXPPE .BSBUIPO Relay in Pemberton. The medicos were spread over several teams which comprise five members â&#x20AC;&#x201C; a runner, a canoeist, a swimmer, an equestrian and a cyclist. The race begins in Boyup #SPPL BOE GJOJTIFT JO #SJEHFUPXO BGUFS LN PG UISJMMT TQJMMT BOE B GFX MBVHIT /PU TVSQSJTJOHMZ UIFSF T TPNF GSJFOEMZ SJWBMSZ CFUXFFO %VTUJO T UFBN PG ZPVOHTUFST and their older counterparts. The former, #SBOOJHBO T -BX BOE UIF MBUUFS B MPDBM UFBN called the Geegelup Racers with Pemberton (1 .JDL %FXJOH PO UIF DBOPF MFH BSF TUJMM DPOUFTUJOH UIF TVCKFDU PG .JDL T BMMFHFE CSPLFO QBEEMF i5IF (FFHFMVQ 3BDFST SFDLPO UIF QBEEMF incident distorted the final result but we still XPO DPOWJODJOHMZ * UIJOL UIFJS SVOOFS IBE B DBMG JOKVSZ BT XFMM 5IFZ BSF PVS QBSFOUT HFOFSBUJPO TP UIFSF T B DPNQFUJUJWF FMFment,â&#x20AC;? said haematology senior registrar Dr Dustin Hall. 42

%VTUJO SBO UIF LN SVOOJOH DPVSTF through some beautiful scenery and TQFOU UIF NBKPSJUZ PG JU MPPLJOH VQXBSET â&#x20AC;&#x153;The run consists almost entirely of hills. *U T BMM VQ BOE EPXO TPNF PG UIFN BSF RVJUF TUFFQ BOE IBMG JT PO HSBWFM TP JU T harder than the City to Surf. The weather was beautiful at the start but warmed up for the cyclists.â&#x20AC;? i5IF #MBDLXPPE NBSBUIPO XBT B OJDF way to finish a busy year. I had my phyTJDJBO FYBNT BOE UIFO IBE UP TUVEZ GPS haematology at the same time our son, Owen, was born. The event is a great opportunity to spend time with famJMZ BOE DPMMFBHVFT 8F SF UIJOLJOH BCPVU TIBLJOH VQ UIF SPMFT UIJT ZFBS #FO BOE * do a lot of cycling together so we might do a swap.â&#x20AC;? %S #FO 8BMBXTLJ B 5IJSE "WFOVF Surgery GP, reserves high praise for the iron-woman who charged past him when he was about to start his cycle leg. She competed in every single discipline and crossed the finish line ahead of her ironman husband. i*U T BO FOKPZBCMF EBZ BOE JO UFSNT PG .JDL %FXJOH BOE IJT (FFHFMVQ 3BDFST UIF DPNQFUJUJWF TUSFBL DPNFT NPSF GSPN us than it does from them. They are in their 50s and 60s, but we did grab a

Q Dr Angelika Elsmann on the equestrian leg of the marathon

Q GP Dr Ben Walawski bliztes the opposition in the bike leg.

NJOVUF MFBE XIFO .JDL T QBEEMF CSPLF w i)F T CFFO EPJOH UIF #MBDLXPPE GPS UIF MBTU ZFBST BOE UIFSF T BMXBZT B TUSPOH NFEJDBM presence at the event. Dr Doug Cordell was in a managerial role in 2013 but competed the year before that and Dr Peter Bath in a team called Old Docs did the cycle leg. He was very JOUFSFTUFE JO NZ UJNF CVU UIBOLGVMMZ * FEHFE IJN PVU UIBOLT UP B ZFBS BHF EJGGFSFODF w i* SPEF B -PPL DBSCPO GJCSF SPBE CJLF BOE

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UIBOLGVMMZ IBE OP QVODUVSFT *O UIF QBTU * WF done the Half-Iron Man in Busselton but at UIF NPNFOU * N QSFUUZ NVDI DPOGJOFE UP UIF lounge room with stay-at-home-dad duties.â&#x20AC;? #FO TJOHT UIF QSBJTFT PG UIF #MBDLXPPE BT B XFMDPNF DJSDVJU CSFBLFS GSPN UIF QSFTTVSFT PG XPSL i*U T B HPPE UBMLJOH QPJOU XJUIJO UIF QSBDUJDF "OHFMJLB &MTNBOO XIP BMTP XPSLT BU 5IJSE "WFOVF SPEF IFS IPSTF GPS BOPUIFS UFBN BOE her daughter, Katie was our equestrian competitor.â&#x20AC;? i"T EPDUPST JU T JNQPSUBOU UP TUBZ GJU BOE BDUJWF *U T BMTP TPNFUIJOH UP XPSL UPXBSET UISPVHIout the year that has a competitive element BOE B TPDJBM TJEF BT XFMM *U T HSFBU UP HFU PVU PG UPXO BOE XF FOKPZFE TPNF &MEFSUPO DBCFSOFU sauvignon along the way.â&#x20AC;? The equestrian leg is the most problematic PG BMM GJWF EJTDJQMJOFT BU UIF #MBDLXPPE .BOZ HSPVQT EPO U UFDIOJDBMMZ AGJOJTI CFDBVTF UIFZ EPO U IBWF B IPSTF BOE SJEFS UP DPNQMFUF UIF UFBN %S "OHFMJLB &MTNBOO SPEF GPS B UFBN DBMMFE 0WFS 5 4IF XBT UIF POMZ GFNBMF BOE IBEO U NFU BOZ PG UIF PUIFST CFGPSF UIF TUBSUing gun. i* XBTO U TVSF XIJDI UFBN * E FOE VQ PO "T B GFNBMF BOE B WFUFSBO * IBE RVJUF B GFX options!â&#x20AC;? i5IF UFBN BTLFE NF IPX MPOH * UIPVHIU * E UBLF UP GJOJTI UIF LN DPVSTF * FTUJNBUFE BSPVOE NJOVUFT BOE JU UPPL NF UXP NJOVUFT MFTT UIBO UIBU * WF HPU B UIPSPVHICSFE IPSTF BOE TIF XBT LFFO UP HFU HPJOH TP * TQFOU UIF FOUJSF UJNF USZJOH UP LFFQ IFS VOEFS DPOUSPM particularly on the downhill sections.â&#x20AC;? â&#x20AC;&#x153;I got a phone-call during the event from Pete %FXJOH BTLJOH NF IPX UIF SJEF XBT HPJOH * UPME IJN * XBT TUJMM EPJOH JU * UIJOL JU XBT TBCPtage and they were trying to slow me down.â&#x20AC;? 5IF TXJN MFH JTO U %S 1FUFS %FXJOH T TQFDJBMUZ BOE JO QSFWJPVT ZFBST IF T EPOF UIF SVO BOE UIF paddle sections. i*U XBT UIF GJSTU TXJNNJOH FWFOU * E FWFS EPOF BOE UIF XBUFS XBT DPME BOE EBSL * EPO U UIJOL * MM QVU NZ IBOE VQ GPS UIBU BHBJO * E SBUIFS EP UIF SVO TP OFYU ZFBS #FO BOE * NJHIU IBWF UP do a selection time-trial.â&#x20AC;? i5IF #MBDLXPPE BUUSBDUT B SBOHF PG DPNQFUJtors from those who have just thrown a team UPHFUIFS UP FMJUF BUIMFUFT *U T GBNJMZ GSJFOEMZ too. When I finished my swim I gave my raceCJC UP UIF OFYU QFSTPO BOE XBT IBOEFE CBDL B CBCZ *U XBT %VTUJO T TPO 0XFO BOE UIF UFBN was running out of hands.â&#x20AC;?

QBSU PG .JDL T MJGF â&#x20AC;&#x153;I competed in the inaugural 1978 race and have only missed two since then. In fact, my social life has revolved around the event for the last 35 years. You always see a lot of people JO UIF NFEJDBM QSPGFTTJPO BU UIF #MBDLXPPE w â&#x20AC;&#x153;For a non-sportsman such as me the canoe MFH JT SFMBUJWFMZ FBTZ JU T POMZ LN BOE * LOPX UIF SJWFS MJLF UIF CBDL PG NZ IBOE * IBSEMZ IBWF to train for it and still manage to do a respectable time. Well, most years anyway.â&#x20AC;?

5IJT ZFBS PO UIF MBTU XFFLFOE JO October, your team can follow in their GPPUTUFQT :PV MM OFFE B QBJS PG SVOOJOH TIPFT B LBZBL B CJDZDMF TPNF 5POZ "CCPUU 4QFFEPT BOE B IPSTF #MBDLXPPE .BSBUIPO 3FMBZ www.mccays.com.au/theevent O

By Mr Peter McClelland

i5IF ZPVOHTUFST CFUUFS MPPL PVU o OFYU ZFBS * MM be 25 minutes faster!â&#x20AC;?

Star

Joke A reader sent us these pesky but hilarious medical typos.

Posterior colon dysfunction [posterior column]

**Recto-orbital headache [retro-orbital headache]

Spontaneous virginal delivery

Tropical application [topical] A septic technique [aspectic] Frame and magnum [foramen magnum] Consolation of sx [constellation]

Synthetic innovation [sympathetic innervation] Tree lined [streamlined] prescription Extra-premarital features [pyramidal]

â&#x20AC;&#x153;If any doctors out there want to be as awesome as we are they should head for the #MBDLXPPE PO UIF MBTU XFFLFOE PG 0DUPCFS w

**Intra-faecal pain pump [intra-thecal] basil ganglier [basal ganglia]

Inflammable cardiac defibrillator [implantable]

1FUF T GBUIFS .JDL JT B SFBM WFUFSBO PG UIF race.

Post nasal depression [post-natal]

Peak systolic philosophy [velocity]

Cerebro-sponge fluid [cerebrospinal]

Lettuce [lattice] like rash consistent with livedo reticular

i.Z EBE CMBNFT B CSPLFO QBEEMF GPS IJT TMPX DBOPF UJNF BOE TBJE UIFZ XPVME WF CFBUFO VT JG JU IBEO U CFFO GPS UIBU 5IBU T EFGJOJUFMZ OPU UIF DBTF &WFO XJUIPVU UIF QBEEMF GBJMVSF XF would have been faster than them.â&#x20AC;?

Fractured neck of thenar [femur] Sense of old faction [olfaction]

** = favourites!

5IF #MBDLXPPE CZ IJT PXO BENJTTJPO JT B CJH

medicalforum

Theatre

SIGRIDâ&#x20AC;&#x2122;S DESIRE

for

STREETCAR Black Swan State Theatre Companyâ&#x20AC;&#x2122;s first main-stage production brings a stellar lineup together for a classic play.

a adaptations of Streetcar since its Broadway QSFNJFSF JO XJUI .BSMPO #SBOEP BT Q Stanley). Most recently, we have seen it S JOGMVFODJOH 8PPEZ "MMFO T Blue Jasmine J XJUI BOPUIFS DMBTTJD "VTUSBMJBO BDUPS $BUF X #MBODIFUU UBLJOH PO UIF #MBODIF UZQF SPMF #

There are few moments in cinema that surpass Marlon Brandoâ&#x20AC;&#x2122;s testosteroneDIBSHFE DIBSBDUFS 4UBOMFZ ,PXBMTLJ standing on a steamy New Orleans TUSFFU TDSFBNJOH PVU GPS IJT XJGF 4UFMMB *U T UIF DMJNBY PG 5FOOFTTFF 8JMMJBNT HSJUUZ EFFQMZ MBZFSFE QMBZ BOE TVCTFRVFOU mMN A Streetcar Named Desire XIJDI IBT CFDPNF B classic in both the celluloid and stage canon. /FYU NPOUI #MBDL 4XBO 4UBUF 5IFBUSF Company is offering an increasingly rare opportunity to see this iconic play with the added bonus of being able to watch iconJD "VTUSBMJBO BDUPS 4JHSJE 5IPSOUPO JO UIF lead role of faded Southern belle Blanche Dubois. 8IFO 4JHSJE TQPLF UP Medical Forum last month, she was both thrilled and a little EBVOUFE BCPVU UBLJOH PO #MBODIF i*U T BO BNB[JOH SPMF JO BO JDPOJD QMBZ BOE * N OPU GPPMJOH NZTFMG JU DPNFT XJUI B DFSUBJO BVEJFODF FYQFDUBUJPO *U T NZ KPC UP JOUFSQSFU #MBODIF CVU * IBWF UIF MVYVSZ PG B generous rehearsal period in Perth to develop the character.â&#x20AC;? i0OF PG UIF HSFBU UISJMMT XJMM CF XPSLJOH XJUI #MBDL 4XBO T BSUJTUJD EJSFDUPS ,BUF $IFSSZ who is a real Tennessee Williams aficioOBEP 4P QFPQMF DBO FYQFDU B QSPEVDUJPO PG great depth.â&#x20AC;? 4JHSJE IBT CFFO B QBSU PG UIF "VTUSBMJBO FOUFSUBJONFOU MBOETDBQF TJODF IFS CSFBLthrough film roles in the Man from Snowy River films and Getting of Wisdom alongside Judy Davis. Her lead role as magistrate -BVSB (JCTPO JO UIF "#$ TFSJFT SeaChange CSPVHIU IFS JOUP NJMMJPOT PG QFPQMF T MPVOHF room. 44

4JHSJE CFMJFWFT JU T UIF TUSFOHUI BOE SFMFWBO4 DDZ PG 5FOOFTTFF 8JMMJBNT XPSL UIBU LFFQT inspiring directors. i i* UIJOL Blue Jasmine JT 8PPEZ "MMFO T IPNi age to Tennessee Williams and perhaps a IF I XBT JOTQJSFE CZ TFFJOH $BUF T 4ZEOFZ Theatre Company production of Streetcar T JO /FX :PSL #VU UIFSF BSF FTTFOUJBM EJGGFSJ ences in characters and plot between Blue e JJasmine BOE UIF PSJHJOBM XPSL BOE GPS NF JJU T B DBTF PG UIF PSJHJOBM NBUFSJBM JT CFTU w

Q Kate Cherry

But the consummate actor loves the thrill of new incarnations and the stage, at the moment, is luring her on. Blanche is B CJH DIBSBDUFS UP DMJNC "T BO BHFJOH impoverished beauty, and an alcoholic to boot, Blanche brings her deluded sense PG 4PVUIFSO TOPCCFSZ JOUP IFS TJTUFS T UJOZ /FX 0SMFBO T GMBU XIJDI TIF TIBSFT XJUI IFS CSVUJTI FY NBSJOF IVTCBOE 4UBOMFZ *U T B QSFTTVSF DPPLFS GPS FWFSZ BDUPS PO stage. i5IFSF T B UXJOHF PG BOYJFUZ GPS FWFSZone moving into a new play. In Streetcar, #MBODIF HPFT UP B WFSZ EBSL QMBDF BOE * N BOUJDJQBUJOH FYQFSJFODJOH TPNF PG UIBU w â&#x20AC;&#x153;But the real world insulates actors from GBMMJOH JOUP UIBU QMBDF XJUI IFS *U T UFSSJGJDBMMZ important for actors to have a firm foundation in their own lives to insulate them from the vagaries of the profession.â&#x20AC;? There have been many productions and

i,BUF $IFSSZ T QSPEVDUJPO XJMM CF DMBTTJD i 8JMMJBNT JO BMM JUT EFQUI BOE DPNQMFYJUZ *U 8 JT B QMBZ UIBU TQFBLT PG JUT UJNF BOE TQFBLT J loudly for today.â&#x20AC;? l Sigrid says the Perth production is blessed with a top-drawer creative team, with sumptuous costumes and sets designed by Christina Smith and lighting designed CZ .BUU 4DPUU "DDMBJNFE DIPSFPHSBQIFS Chrissie Parrot will be on hand to coach movement. The stars are aligning for what should be a special production. O

By Ms Jan Hallam

WIN 5IF TFBTPO PQFOT BU UIF )FBUI -FEHFS Theatre March 15 and continues until "QSJM 'PS ZPVS DIBODF UP XJO B EPVCMF UJDLFU UVSO UP UIF $PNQFUJUJPOT page 52.

medicalforum

and Drink Palmer 2012 Margaret River Sauvignon Blanc

By Dr Craig Drummond Master of Wine

" MFBO DSJTQ GSVJU ESJWFO TUZMF 5IF OPTF EJTQMBZT B QVOHFODZ XIJDI * FOKPZ JO SBs. The flavours are of grapefruit with a lean/green herbal edge and minerality SFGMFDUJOH UIF FBSMZ QJDLFE MPXFS BMDPIPM TUZMF .BLFT GPS HPPE FBSMZ UP JOUFSNFEJBUF ESJOLJOH

Palmer Wines is easy to spot driving along Caves Rd into the wonderful seaside settlement of Dunsborough. First to catch oneâ&#x20AC;&#x2122;s eye is the red .BEJTPO TQPSUT DBS QBSLFE QFSNBOFOUMZ BEKBDFOU UP UIF FOUSBODF Then we see the impressive Tuscanstyled restaurant and cellar sales area. The restaurant I can certainly SFDPNNFOE IBWJOH TQFOU NZ NPTU recent birthday there and was very impressed.

Palmer 2011 Margaret River Chardonnay "OPUIFS MFBO FBSMZ QJDLFE TUZMF 8JUI BMDPIPM MFWFM BU POMZ o MPX GPS BO "VTUSBMJBO $IBSEPOOBZ o UIF DIBSBDUFST BSF MJOFBS BOE EFGJOFE 5IFSF BSF BSPNBT PG OFDUBSJOF BOE GMBWPVST PG XIJUF QFBDI XJUI B NJOFSBM CBDLCPOF 0BL JT OPU PWFSUMZ FWJEFOU UBLJOH B NPSF TVQQPSUJOH SPMF 4JNJMBSMZ UIF GPDVT JO UIJT XJOF EPFT OPU TVHHFTU B MPU PG MFFT DPOUBDU 5IJT XJOF IBT UIF BDJE TUSVDUVSF BOE AHSJU to go a few years. Palmer 2010 Margaret River Merlot " CJH SJQF .FSMPU 'VMM CPEJFE XJUI IJHI BMDPIPM JO CBMBODF 5IF BSPNBT BSF DPNQMFY XJUI ESJFE GSVJUT BOE B UPVDI PG FBSUI 5IF QBMBUF EJTQMBZT CMBDL DIFSSZ BOE QMVN XJUI GJSN iDIFXZw UBOOJOT BOE BNQMF JOUFHSBUJOH PBL 5IJT XJOF TIPXT HPPE MFOHUI BOE B OJDF TXFFU GSVJU GJOJTI " WFSZ HPPE "VTTJF .FSMPU

The vines, however, are grown in the very notable Margret River sub regions of Wilyabrup and Cowaramup. This is a family owned operation. Stephen and Helen Palmer planted vines in 1977, initially with HVJEBODF GSPN DPMMFBHVF %S .JLF 1FUFSLJO 7JOFZBSET IBWF HSPXO UP IB BOE XJUI production only 6000 cases annually, it would seem that selected fruit is going into the Palmer wines, while other fruit is sold on. The plantings are predominated by the mainstream regional varieties of Cabernet Sauvignon, Sauvignon Blanc, 4IJSB[ .FSMPU $IBSEPOOBZ BOE 4FNJMMPO The wines have reached a new level in recent years having been made by the very FYQFSJFODFE .BSL 8BSSFO "NPOHTU OVNFSPVT BDDPMBEFT PG QBSUJDVMBS OPUF BSF .PTU 4VDDFTTGVM &YIJCJUPS BU UIF "VTUSBMJBO 4NBMM 8JOFNBLFST 4IPX and 2012, and a silver medal with the 2007 $BC 4BW BU UIF -POEPO *OUFSOBUJPOBM 8JOF $IBMMFOHF BOE BMTP UIF 8*"8" XJOF industry award for the Most Outstanding Cellar Door/Wine Tourism Facility.

Palmer 2010 Margaret River Cabernet Sauvignon " SFTUSBJOFE TUZMF TIPXJOH TPNF BVTUFSJUZ XIJDI XJMM NFMMPX XJUI UJNF 5IF nose shows the earth and gravel of Margaret River, the palate has generous CMBDLCFSSZ BOE B MPU PG TQJDF GPS $4 5IFSF JT QMFOUZ PG GSVJU XFJHIU JO UIJT XJOF "OPUIFS ZFBS PS UXP XJMM CSJOH JU BMM UPHFUIFS

Palmer 2010 Margaret River Shiraz My choice of this tasting. The aromas are enticing with wonderful menthol, DBNQIPS BOE DMPWFT 5IF QBMBUF JT TUJMM CVSTUJOH XJUI ZPVUI 5IFSF T MPBET PG GMBWPVS XJUI TQJDZ CMBDLCFSSZ BOE QMVN MVTI BOE TXFFU PO UIF NJE QBMBUF 5BOOJOT BSF GJOF BDJE GJSN BOE PBL JOUFHSBM "O JNQSFTTJWF XJOF PG QPXFS BOE CBMBODF XJUI MFOHUI DPNQMFYJUZ BOE B GJOF GJOJTI *O GPS B MJGFUJNF

WIN a Doctor's Dozen! What is the name of Palmer Winesâ&#x20AC;&#x2122; XJOFNBLFS Answer:

...................................................................................................................

ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, February 28, 2014. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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4PDJBM 1VMTF

al Bethesda Hospit e season with a cocktail

Q Dr David Soﬁeld

l celebrated th Yacht Club. Bethesda Hospita g the Claremont in ok lo er ov e sit party on d the crowd and Sofield serenade id av D r in Naglazas D ist og Urol CEO A/Prof Yasm d an ng Fo le ea N Chairman Dr l year. toasted a successfu

Q Dr Greg Hogan and Dr Richard Martin

Q Bethesda Medical Director Dr Alister Turner, Dr Duncan McLellan and Mr Rederico Paci

Q Dr Karim Ghanim and Ms Christine Phillips

Q Dr Rob and Mrs Libby Fitzpatrick and Dr Isavel Carija

Q Mrs Lyn and Dr Ian Wallace and Ms Lisa Hill

4U +PIO PG (PE 4VCJBDP Freshwater Bay Yacht Club was the venue for the SJOG Subiaco Hospital’s Christmas function, a cocktail reception for invited guests. CEO Dr Lachlan Henderson described the group’s progress at their flagship hospital, with some humorous anecdotes to lighten the night.

Q Drs D Mitchell and K Siddique, Junior medical officers 46

Q SJG Subiaco CEO Dr Lachlan and Cathy Henderson

Q Dr Michelle Ammerer and husband Mr David Foti and, A/Prof Jurgen Passage and wife Kylie.

Q Husband and wife team, Mark (Nurse Manager) and Coco Flynn medicalforum (Administrative Assistant)

Q Ms Mary Turner, Ms Sheila Harloe, Dr Craig Turner and Ms Jenny Heyden

Clinipath

Q Dr Victoria Buntine (Subiaco Station MC), Ms Debbie Rigby, Dr Sue Martin, Ms Petra Konowalous, and Dr Susan Clarke (Oxford St Medical)

Mosmans has tmas function at ris Ch y og ol th Pa ath at the end of each The yearly Clinip t laborator y staff ee m to of es tic ac pr r and spoke brief ly become iconic fo welcomed guests e helo ar f-t H -o n te do sta l or ra G year. CEO Dr e to a new cent ov m g in nd pe og yâ&#x20AC;&#x2122;s im Clinipath Pathol Osborne Park in y or at or art lab

Q The tall and the not-so-tall: Dr Mathew Wright, Dr Jennifer Ng, Ms Elise Chong and Dr Christopher Cook

Q All smiles: Mr Tony Kiernan, Dr Catherine Keating, Dr Fatin Wajdi and Dr Colin Stevens

Q Dr Helen Hankey, Mr Edwin Jones and Dr Judy Cole

medicalforum

Q Mr George Panayotou, Dr Natalie Sumich (Garden City MC), and Ms Roz Epps (Clinipath Regional Mgr)

Q Dr Lyn Stotlze and Dr Chris Quirk

Q Experience to burn: Dr John Whitelaw and Dr Owen King 47

4PDJBM 1VMTF

are Ramsay Health C as Party at the Crown’s grand

tors’ Christm Paul Ramsay. The Ramsay Doc r of Ramsay, Mr de un fo t for by ed nd te m was decked ou ballroom was at msay, the ballroo Ra od of wo ry ly ol ist H in M ts. ers’ thirs Themed The took care of danc r ba l ta ys cr a d dancing an invited guests. ott mingled with CEO Mr Peter M

Q Dr Tony and Jill Morgan

Q Mr Paul Ramsay, Mrs Wendy and Dr Mike Davis

Q Mrs Nadia and Dr Jonathon Armstrong

Q Mrs Carly and Roger Cook MLA and Hollywood CEO Peter Mott

Q Dr Craig and Mrs Caroline Smith, with Mrs Fiona and Dr Craig Schwab

Q Dr Ryan Craig, Dr Margaret Sturdy, Dr Jack Springer, Dr Suzanne Gray and Dr John Maxwell

Q Mrs Julie and Dr Tony Geddes, Dr Julian Rodrigues and CEO JHC Mr Kempton Cowan

Q Dr Peter and Mrs Heather Kell, with Mrs Julie and Dr Ryan Craig

R ACGPWA

General alian College of The Royal Austr get together nual Christmas Practitioners’ an lle was er in West Leed vi at College House tch up ca to s GP -working a chance for hard festive fun. and share some with colleagues Frank Jones, WA Faculty, Dr President of the dstrom N Ms Malvina or and WA manager te. sta e th nd m arou welcomed GPs fro

Q A/Prof Frank Jones and Ms Anna Gelavis Q 48 8

Q Dr Robert Mars

h and Ms Jill Terry

Q Dr Peter Ammon and Mrs Sally Stanford Q SJGH Murdoch CEO Mr John Fogarty with Dr Michael and Mrs Melanie Halliday,

VSEPDI 4U +PIO PG (PE . Hospital Mr John Fogarty

God Murdoch a marquee CEO of St John of ristmas event in Ch al nu an st fir d lake. Almost s hosted hi esque gardens an ur ct pi l’s ita sp ho ening, with jazz overlooking the rs enjoyed the ev ne rt pa eir th d eon Dr Michael 250 doctors an orthopaedic surg ich wh Year. at t, en entertainm 13 Doctor of the the hospital’s 20 d re cla de s wa Halliday

Q Dr Robert Genat and Dr Karl Stoffel

Q Dr Kai Goh and Dr Phillip McGeorge

Q Dr Nigel Barwood, Dr Alan Rhonas and Dr Dean Lisewski

Q Dr Abdullahi Ma za, Ms Enobong Iny ang and Dr Immanuel Inyang

medicalforum

Q Ms Helen McAllister, Dr Charlie and Mrs Tracey Crompton

Q SJG Health Care Group CEO Dr Michael Stanford and Dr Sue Ulreich

Q Dr Julie Dockerty, Dr Jill Orford and Dr Ian Rogers

Q Dr Earnest Mukwevho and Dr Marie Fernando

Q Ms Wendy Ward ell and Ms Malvina Nords trom 49

4PDJBM 1VMTF

Q Ms Kylie Harrison and Dr Colin Hughes

Q Dr Enzo Almonte, Corina Almonte, Chris Hones and Dr Cynthia Innes

MPHZ P I U B 1 I U S 1F 4LJO N B O B O F )F Pathology relaxing ways to celebrate

re t many mo the festive Thereâ&#x20AC;&#x2122;s no and herald r a ye sy eagues u b a ds and coll the end of ng to frien ti r Wayne at D ch e n er a h Thatâ&#x20AC;&#x2122;s w season th . ay B log y a d il g Mat erth Patho overlookin nan from P ee ly H ve er ti et ec P r resp Smit and D Patholog y w. Lam Skin n joy the vie a en n d ee n H a d n w an o d d in ts to w invited gues

Q Mr Leigh Richardson and Dr Patricia Dowsett

Q Dr Wayne Smit, Dr Tom and Mrs Dawn Grieve 50

Q Dr Peter and Mrs Margaret Heenan

Q Dr Sean Ryan, Ms Olivia Nguyen and Dr Tony Cacetta

Q Mr Gerhard Saueracker and Dr Kath Fordham

Q Dr Lisa Feng and Dr Zhouming Chu

Q Dr Will Thornton, Dr Yasir Syed Jehan, Dr Kanwai Roomi

medicalforum

funnyside e

Q Q Always Read the Instructions

student, however, XSPUF

In case you needed further proof that the human race is doomed to stupidity, here are some label JOTUSVDUJPOT PO DPOTVNFS HPPET

â&#x20AC;&#x153;First, we need to LOPX IPX UIF NBTT of Hell is changing in time. So we need to LOPX UIF SBUF UIBU TPVMT BSF NPWJOH BOE MFBWJOH )FMM * UIJOL we can safely assume that once a soul gets to Hell, it will not leave. Therefore, no souls are leaving.

t 0O B IBJSESZFS o %P OPU VTF XIJMF TMFFQJOH #VU UIBU T the only time I have to XPSL PO NZ IBJS

t 0O B CSBOE PG GSP[FO dinners â&#x20AC;&#x201C; â&#x20AC;&#x153;Serving TVHHFTUJPO %FGSPTU w UIBU T AKVTU B suggestion).

"T GPS IPX NBOZ TPVMT BSF FOUFSJOH )FMM MFU VT MPPL BU UIF EJGGFSFOU SFMJHJPOT JO the world today. Some of these religions state that if you are not a member of their religion, you will go to Hell.

t 1SJOUFE PO UIF CPUUPN PG B UJSBNJTV dessert â&#x20AC;&#x201C; â&#x20AC;&#x153;Do not turn upside downâ&#x20AC;?. (Well...duh, a bit late)! t 0O . 4 #SFBE 1VEEJOH o i1SPEVDU will be hot after heating.â&#x20AC;? (...and you thought?) t 0O B CSBOE PG DIJMESFO T DPVHI NFEJDJOF â&#x20AC;&#x201C; â&#x20AC;&#x153;Do not drive a car or operate NBDIJOFSZ BGUFS UBLJOH UIJT NFEJDBUJPO w (We could do a lot to reduce the rate of industry accidents if we could just get those five-year-olds with colds off those GPSLMJGUT

t 0O BO PWFS UIF DPVOUFS TMFFQJOH QJMM o i8BSOJOH .BZ DBVTF ESPXTJOFTT w BOE * N UBLJOH UIJT CFDBVTF

t 0O B CSBOE PG QFBOVUT o i8BSOJOH DPOUBJOT OVUT w UBML BCPVU B OFXT GMBTI

t 0O B 4XFEJTI DIBJOTBX o i%P OPU attempt to stop chain with your hands or genitals.â&#x20AC;? (was there a lot of this happening somewhere?)

Since there are more than one of these religions and since people do not belong to more than one religion, we can project that all souls go to Hell. With birth and EFBUI SBUFT BT UIFZ BSF XF DBO FYQFDU the number of souls in Hell to increase FYQPOFOUJBMMZ /PX XF MPPL BU UIF SBUF PG DIBOHF PG UIF WPMVNF JO )FMM CFDBVTF #PZMF T -BX states that in order for the temperature and pressure in Hell to stay the same, the WPMVNF PG )FMM IBT UP FYQBOE BT TPVMT BSF BEEFE 5IJT HJWFT UXP QPTTJCJMJUJFT *G )FMM JT FYQBOEJOH BU B TMPXFS SBUF UIBO the rate at which souls enter Hell, then the temperature and pressure in Hell will JODSFBTF VOUJM BMM )FMM CSFBLT MPPTF 0G DPVSTF JG )FMM JT FYQBOEJOH BU a rate faster than the increase of souls in Hell, then the temperature and pressure will ESPQ VOUJM )FMM GSFF[FT PWFS

Q Q A Devil of a Time The following is a question given on a VOJWFSTJUZ FOHJOFFSJOH FYBN

cannot be true, and thus I am sure that )FMM JT FYPUIFSNJD BOE XJMM OPU GSFF[F w 5IJT TUVEFOU SFDFJWFE UIF POMZ "

Q Q Be Prepared â&#x20AC;Ś for Anything " HJSM BTLT IFS CPZGSJFOE UP DPNF PWFS Friday night and have dinner with her parents. Since this is such a big event, the girl announces to her boyfriend that after EJOOFS TIF XPVME MJLF UP HP PVU BOE NBLF love for the first time. Well, the boy is ecstatic, but he has never IBE TFY CFGPSF TP IF UBLFT B USJQ UP UIF pharmacist to get some condoms. The pharmacist helps the boy for about an hour. He tells the boy everything there is UP LOPX BCPVU DPOEPNT BOE TFY "U UIF SFHJTUFS UIF QIBSNBDJTU BTLT UIF CPZ IPX NBOZ DPOEPNT IF E MJLF UP CVZ B QBDL QBDL PS GBNJMZ QBDL 5IF CPZ JOTJTUT PO UIF GBNJMZ QBDL CFDBVTF IF UIJOLT IF XJMM CF SBUIFS CVTZ JU CFJOH IJT first time. 5IBU OJHIU UIF HJSM UBLFT IFS CPZGSJFOE UP UIF EJOOFS UBCMF XIFSF UIF HJSM T QBSFOUT BSF TFBUFE 5IF CPZ RVJDLMZ PGGFST UP TBZ grace and bows his head. " NJOVUF QBTTFT BOE UIF CPZ JT TUJMM deep in prayer, with his head down. 10 minutes pass, and still no movement from the boy. Finally, after 20 minutes with his head down, the girlfriend leans over and whispers to the boy, â&#x20AC;&#x153;I had no idea you were this religious.â&#x20AC;?

So which is it?

#POVT 2VFTUJPO *T )FMM FYPUIFSNJD HJWFT off heat) or endothermic (absorbs heat)? Most of the students wrote proofs of UIFJS CFMJFGT VTJOH #PZMF T -BX HBT DPPMT PGG XIFO JU FYQBOET BOE IFBUT XIFO JU is compressed) or some variant. One

If we accept the postulate given to me by Teresa Banyan during my first year, â&#x20AC;&#x153;...that it will be a cold day in Hell before * TMFFQ XJUI ZPVw BOE UBLF JOUP BDDPVOU the fact that I still have not succeeded in IBWJOH TFYVBM SFMBUJPOT XJUI IFS UIFO

5IF CPZ UVSOT BOE XIJTQFST CBDL i* had no idea your father was a pharmacist.â&#x20AC;?

Ancient

Anecdotes

'SPN %S +PIO 2VJOUOFS

From: To his wife by Walter Reed, 1900. Only 10 minutes of the old century remain. Here I have been sitting, reading that most wonderful book, â&#x20AC;&#x153;La Roche on Yellow Feverâ&#x20AC;? written in 1853. Forty-seven years later it has been permitted to me and my assistants to lift the impenetrable veil that has surrounded the causation of this most wonderful, dreadful pest of humanity and to put it on a rational and scientific basis. I thank God that this has been accomplished during the latter days of the old century. May its cure be wrought in the early days of the new!

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Medical Administration Officer required full-time to oversee all aspects of UIF NFEJDBM SFWFOVF DZDMF NBOBHFNFOU QSJODJQMFT RVBMJUZ BTTFTTNFOU SFWFOVF PQFSBUJPOT QPMJDZ BOE QSPDFEVSFT QBUJFOU BENJOJTUSBUJPO BOE NFEJDBM DPEJOH "QQMJDBUJPOT UP CF TFOU UP $BSPMJOF (FOFSBM .BOBHFS 1FSUI (1 1UZ -UE Email: caroline@theheights.com.au EMG Machine (Keypoint Medtronic) portable 'VMMZ DPNQVUFSJTFE 5PTIJCB DPNQMFUF XJUI $BSU QSJOUFS BOE BMM OFDFTTBSZ software. Used minimally ie. as new $PTU 4FMM $12,000 ono Phone 9381 9934 or 0431 369 292

FOR LEASE MURDOCH #SBOE OFX .FEJDBM 4VJUF GPS -FBTF BU UIF OFX 8FYGPSE .FEJDBM $FOUSF TRN DPNQMFUF GJU PVU BOE POF DBS CBZ 3FBEZ UP MFBTF CZ .BSDI "QSJM Please contact: reception@ccwa.net.au WEST PERTH t .PEFSO VQ NBSLFU .FEJDBM 3PPN GPS MFBTF TRN

t 4VJU .FEJDBM 4QFDJBMJTU %S T BOE PS allied health t -BSHF SFDFQUJPO XBJUJOH SPPN BMGSFTDP BSFB TIBSFE XJUI FYJTUJOH DMJOJD t 1SFNJTFT MPDBUFE JO 8FTU 1FSUI t 4LJO .BOBHFNFOU BOE $PTNFUJD .FEJDJOF $MJOJD PQFSBUF JO UIF same building t 1BSLJOH BWBJMBCMF CBZ

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SOUTH FREMANTLE Consulting Rooms available in prestigious South Freo location. t $POWFOJFOUMZ MPDBUFE PO 4PVUI 5DF just a few hundred yards from Fremantle Hospital. t *OUFSFTUFE NFEJDBM BMMJFE IFBMUI practitioners seeking consulting rooms with reception facilities for full occupancy or one or more days per week are encouraged to apply. Attractive sub-letting arrangements available for a furnished or unfurnished room with onsite parking. t 3PPN BWBJMBCMF .BSDI CVU other day occupancy arrangements now available. t 5XP TFOJPS $MJOJDBM 1TZDIPMPHJTUT SVO a well-established practice here DPOTVMUJOH UP BEVMUT BEPMFTDFOUT and children. Phone: Administrator Jodee on 9433 6002 Email: reception@fremantleclinicalpsychology.com.au Web: www.fremantleclinicalpsychology.com.au SUBIACO /FX .FEJDBM 4VJUF GPS SFOU EBZT XFFL Outstanding opportunity to secure beautifully fitted suite with 3 consulting rooms. Excellent location opposite SJOGH in Subiaco. *ODMVEFT DBS CBZT Phone: 0412 699 228 SUBIACO Fully supported Sessional Suites available JO NPEFSO PGGJDF $IVSDIJMM "WFOVF (PPE TJ[FE DPOTVMUJOH SPPNT SFDFQUJPO and waiting area. Parking space included. Phone: Lorraine 9370 9733 for further information or Email: admin@mercyanaesthetics.com.au MURDOCH .VSEPDI 4QFDJBMJTU $FOUSF CSBOE OFX stylish large rooms. Please email you interest to admin@sleepmed.com.au

BEACONSFIELD Opportunity to lease recently renovated rear building adjacent to established medical practice. "QQSPY TRN UPUBM XIJDI JODMVEFT 2 large consulting rooms with shared reception area and toilet with onsite pathology collection centre. *O QSJNF MPDBUJPO PO 4PVUI 4USFFU with close proximity to St. John of God .VSEPDI 'JPOB 4UBOMFZ )PTQJUBM Fremantle Hospital. $POUBDU & .BF -JN 0423 282 762 / 9335 9884

79 JOONDANNA New medical centre in Joondanna. 0OMZ LN GSPN $#% &YDFMMFOU QPTJUJPO PO 8BOOFSPP 3E XJUI ample parking. Suit GPs and / or allied health. Pharmacy and pathology on-site. 'PS GVSUIFS EFUBJMT DPOUBDU 8FTMFZ 8JMMJBNT Ph 0414 287 537 Email williams.wesleyk@gmail.com

WEST LEEDERVILLE Specialists Consulting Suite Part or Whole Building (up to 250 sq m) Onsite Parking Easy Access to Freeway and Bus/Train Services Phone 9380 6457

AVELEY Suitable for dental practice and/or allied IFBMUI TFSWJDFT FH 1IZTJPUIFSBQZ 1TZDIPMPHZ 1PEJBUSJTU 3BEJPMPHZ FUD .FEJDBM DFOUSF MPDBUFE JO UIF TBNF CVJMEJOH Located in a fast growing community CFTJEF B TIPQQJOH DFOUSF DMPTF UP TFDPOEBSZ TDIPPMT QSJNBSZ TDIPPMT DIVSDI BOE $IJME $BSF $FOUSF $POUBDU 0400 814 091 WEST LEEDERVILLE 4FTTJPOBM SPPNT BWBJMBCMF NPSOJOHT or afternoons. $MPTF QSPYJNJUZ UP 4+0( "NQMF QBSLJOH CBZT

$POUBDU -J[ 0438 924 710 NEDLANDS Hollywood Medical Centre 4FTTJPOBM TVJUFT QFS TFTTJPO JODMVEJOH SFDFQUJPO QBUJFOU QBZNFOUT Full service extra cost. Various days available. $POUBDU 4VF BU admin@cardiovascularcare.com.au / 9389 8658

MURDOCH New Wexford Medical Centre â&#x20AC;&#x201C; St John of God Hospital 2 brand new medical consulting rooms available: t TRN BOE TRN t %VF GPS DPNQMFUJPO .BSDI t DBS CBZ QFS UFOBODZ Lease one or both rooms. For further details contact James Teh 6OJWFSTBM 3FBMUZ 0421 999 889 james@universalrealty.com.au

FOR SALE 2 MEDICAL SUITE(S) 10 McCOURT STREET WEST LEEDERVILLE Y TRN NFEJDBM TVJUF T XJUI UXP DBS CBZT FBDI /FX DBSQFUT QBJOU XPSL BOE ready for immediate occupation. (03%0/ 56$,&3 3 & 0408 093 731 gtrealestate@iinet.net.au

3FBDI FWFSZ LOPXO QSBDUJTJOH EPDUPS JO 8" UISPVHI .FEJDBM 'PSVN $MBTTJGJFET

Kinetic Health is changing its name to Sonic HealthPlus On Monday, 31 March 2014 Kinetic Health will be changing our name to Sonic HealthPlus. This name change reďŹ&#x201A;ects a closer alliance with our parent company, Sonic Healthcare. Our service offerings will remain the same, and the closer relationship will allow us to harness Sonicâ&#x20AC;&#x2122;s worldwide capabilities and expertise, and spearhead entry into global markets where services such as occupational health are in demand. Sonic HealthPlus is a subsidiary of the Independent Practitioner Network which in turn is part of Sonic Healthcare. If you are interested in being part of the Sonic HealthPlus team, please contact us at 1300 793 004. MARCH 2014 - next deadline 12md Friday 14th February - Tel 9203 5222 or jen@mforum.com.au

medical forum PSYCHIATRIST WANTED

BIBRA LAKE - Psychiatrist wanted "SF ZPV JOUFOEJOH UP TUBSU 1SJWBUF 1SBDUJDF 5IJT JT B TIFFS XBML JO 1BSU UJNF TFTTJPOBM PS GVMM UJNF BMM enquiries welcome. Furnished consulting rooms available at: #JCSB -BLF 4QFDJBMJTU $FOUSF "OOPJT 3PBE #JCSB -BLF 8" Existing private psychiatrist one day a week at this location. 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

RURAL POSITIONS VACANT DUNSBOROUGH %VOO #BZ 4VSHFSZ JT TFFLJOH B GVMM UJNF or part time GP to join our busy privately owned practice in the South West. We are fully accredited and computerised. Flexible working hours with no after hours on call. Fantastic career and lifestyle opportunity. $POUBDU %S /JDL $BSS PO Email: nickcarr@dunnbaysurgery.com.au.

URBAN POSITIONS VACANT GIRRAWHEEN %PDUPST SFRVJSFE GPS 5IF /FX 1BSL .FEJDBM $FOUSF (JSSBXIFFO 0QFOJOH JO 'FCSVBSZ XF BSF TFFLJOH '5 BOE 15 (1 T UP KPJO UIF UFBN &ORVJSFT UP %S ,JSBO PO 0401 815 587 Email: kiranpkumar@hotmail.com GOLDEN BAY PT female GP required. 'VMMZ DPNQVUFSJTFE %84 QSJWBUF CVMLCJMMJOH 'VMMZ BDDSFEJUFE 1SBDUJDF /VSTF POTJUF pathology. $POUBDU 4IFFMBHI 08 9537 3738 &NBJM $7 UP QSBDNBO!FGUFM OFU BV

PALMYRA Palin Street Family Practice requires B GVMM PS QBSU UJNF 73 (1 8F BU UIJT QSJWBUFMZ PXOFE GVMMZ TFSWJDFE computerised practice enjoy a relaxed environment with space and gardens. &BSO PG NJYFE CJMMJOHT For further information call -ZO PO PS %S 1BVM #BCJDI on 0401 265 881.

BALLAJURA /PSUIFSO 4VCVSCT %84 "SFB #BMMBKVSB Permanent/part time GP wanted Ballajura .FEJDBM DFOUSF .JYFE CJMMJOH CVTZ QSBDUJDF OVSTJOH TUBGG #FTU 1SBDUJDF MPUT PG QPUFOUJBM Female GP will be preferred 0488 222 238/chibilitism@yahoo.com

CLARKSON 8BOUFE (1 'VMM UJNF 73 'VMMZ DPNQVUFSJTFE BDDSFEJUFE OPO DPSQPSBUF GSJFOEMZ QSBDUJDF 1SBDUJDF OVSTF QBUIPMPHZ QIBSNBDZ $MPTF UP USBOTQPSU %84 QSBDUJDF (PPE SBUFT $POUBDU .BSL 0403 179 402 Email : markpol@iinet.net.au JOONDALUP CANDLEWOOD MEDICAL CENTRE GP required to join our friendly team for After Hours work immediate start 8FFLEBZT o QN BOE 4BUVSEBZ QN Very Attractive remuneration 1SJWBUFMZ PXOFE "(1"- BDDSFEJUFE general practice Fully computerised $POUBDU .JDIFMMF 9300 0999

WOODLANDS Woodlands Family Practice (SFBU PQQPSUVOJUZ GPS 15 '5 73 (1 in a recently extended busy privately owned practice. $BMM %S .BSZ .D/VMUZ PO 9446 2010 Email: mary@wfpwa.com.au

FREMANTLE Fremantle Womenâ&#x20AC;&#x2122;s Health Centre SFRVJSFT B GFNBMF (1 73 UP QSPWJEF NFEJDBM TFSWJDFT JO UIF BSFB PG XPNFO T IFBMUI PS EBZT QX *U JT B DPNQVUFSJTFE QSJWBUF BOE CVML CJMMJOH QSBDUJDF XJUI OVSTJOH TVQQPSU scope for spending more time with QBUJFOUT BOE QSPWJEFT SFDFOUMZ JODSFBTFE remuneration plus superannuation and generous salary packaging. '8)$ JT B OPU GPS QSPGJU DPNNVOJUZ facility providing medical and counselling TFSWJDFT IFBMUI FEVDBUJPO BOE HSPVQ activities in a relaxed friendly setting. Phone: 9431 0500 or Email: %JBOF 4OPPLT EJSFDUPS!GXID PSH BV PS %BXO /FFEIBN clinical-manager@fwhc.org.au BENTLEY (1 73 OFFEFE GPS QSJWBUFMZ PXOFE GBNJMZ orientated practice. NJOT GSPN 1FSUI $#% "(1"- BDDSFEJUFE GVMMZ DPNQVUFSJTFE VTJOH .% 1SBDTPGU Private and Bulk Billing. 4VQQPSUFE CZ DMJOJDBM BOE $%. OVSTFT operating from purpose built practice. 8F PGGFS PG CJMMJOHT $POUBDU "MJTPO PO 0401 047 063 FREMANTLE General Practice in Fremantle requires 73 (1 '5 PS 15 GPS QSJWBUFMZ PXOFE family practice. "DDSFEJUFE DPNQVUFSJTFE XJUI GVMM UJNF Nurse support. 1IPOF 1SBDUJDF .BOBHFS 9336 3665 SORRENTO 7 3 (1 GPS B CVTZ .FEJDBM $FOUSF in Sorrento. 6Q UP PG UIF CJMMJOH $POUBDU 0439 952 979

NORTH PERTH 7JFX 4USFFU .FEJDBM SFRVJSFT a GP F/T or P/T. 8F BSF B TNBMM QSJWBUFMZ PXOFE practice with a well-established patient CBTF DPNQVUFSJTFE BDDSFEJUFE XJUI nurse support. 3JOH )FMFO 9227 0170 MANDURAH (1 SFRVJSFE GPS FTUBCMJTIFE accredited Practice. -BSHF DMJFOU CBTF OFXMZ SFOPWBUFE private practice. Well-equipped medical centre staffed by FYQFSJFODFE 3FHJTUFSFE /VSTFT Generous remuneration. /P %84 QMFBTF /P PO DBMM $POUBDU 3JB 9535 4644 Email: mandmedi@wn.com.au NORTH BEACH $MPTF UP UIF CFBDI Opportunity for a P/T or F/T GP to join our privately-owned practice. Flexible hours and mixed billing. "O JOUFSFTU JO XPNFO T IFBMUI an advantage. 0O TJUF QBUIPMPHZ QTZDIPMPHJTU BOE nurse support. 1MFBTF DPOUBDU )FMFO PS %BWJE 9447 1233 to discuss or Email: reception.nbmc@ bigpond.com BIBRA LAKE (1 ' 5 03 1 5 $PNQVUFSJTFE XFMM FRVJQQFE BDDSFEJUFE private billing family practice. Nurse and pathology support available. *OUFSFTU JO XPNFO T IFBMUI EFTJSBCMF For further information contact %S 3PESJHVFT PO 0417 181 070 Email: bibramed@iinet.net.au

APPLECROSS Full Time GP wanted - Weekend sessions also available. " SBSF PQQPSUVOJUZ UP KPJO 3FZOPMET 3E %BZ .FEJDBM $FOUSF IBT KVTU QSFTFOUFE itself as a long term colleague moves out of general practice. $PNNFODJOH OPX EPO U NJTT PVU PO ZPVS DIBODF UP KPJO UIJT QSJWBUF CJMMJOH WJCSBOU practice with immediate access to a full patient data base. $POGJEFOUJBM FORVJSJFT UP UIF QSBDUJDF manager 9364 6633 KARDINYA Kelso Medical Group requires P/T GP %84 BGUFS IPVST POMZ This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest JO $%. BOE NJOPS TVSHJDBM QSPDFEVSFT -PDBUFE JO ,BSEJOZB JO OFXMZ SFGVSCJTIFE premises with onsite pathology and allied health with growing patient base. $VSSFOUMZ TVQQPSUFE CZ (1 T BOE 3/ T www.kelsomg.com.au Please call 0419 959 246 for further information.

PERTH GP Opportunity %P ZPV FOKPZ USBWFM "SF ZPV MPPLJOH GPS BO BMUFSOBUJWF UP (FOFSBM 1SBDUJDF Travel Medicine may be for you. t 5SBJOJOH 1SPWJEFE t (PPE JODFOUJWFT t &YDFMMFOU UFBN t &TUBCMJTIFE OBUJPOBM OFUXPSL PG USBWFM clinics providing excellent support t 4FTTJPOBM IPVST t 0OHPJOH &EVDBUJPO JT FODPVSBHFE t 5SBWFM NFEJDJOF 5SPQJDBM .FEJDJOF Occupational medicine 8F SFRVJSF (1 o 73 BO BEWBOUBHF Team Player Send resume to anthony.pace@medibankhealth.com.au CURRAMBINE Sunlander Medical Centre is seeking B (FOFSBM 1SBDUJUJPOFS UP KPJO PVS .JYFE Billing Practice. 1SJNF MPDBUJPO NJOVUFT GSPN 1FSUI $#% and 5 minutes from the beach. 73 BOE OPO 73 DPOTJEFSFE Full Time and Part time positions available 0O TJUF 3FHJTUFSFE /VSTF 1FSUI 1BUIPMPHZ BOE 9 3BZ EFQU %FOUJTU BOE 1IZTJPUIFSBQJTU XJUIJO PGGJDF and we are located next to a Pharmacy. $POUBDU 4JSPW .BIBSBK PO 0438 740 307 or sunlandermedical@gmail.com CHURCHLANDS Herdsman Medical Centre %VF UP UIF SFDFOU TVEEFO QBTTJOH PG POF PG PVS (1 DPMMFBHVFT XF BSF TFFLJOH B GVMM time General Practitioner. We have an established patient base and are committed to high quality family medicine. Special interests are welcomed. No Botox or Naturopathy. 'VMMZ 1SJWBUF CJMMJOH QSBDUJDF BT PG *OUFSFTU JO CPUI NBMF BOE GFNBMF health welcome. )PVST IPVST QFS XFFL We have a full time practice nurse and our practice is fully computerised. 1MFBTF TFOE ZPVS $7 UP QSBDUJDFNBOBHFS! herdsmanmedical.com.au or call %S $BNFSPO (FOU BU UIF QSBDUJDF on 9383 7111 All enquiries treated with absolute confidentiality. WEST PERTH '5 (1 SFRVJSFE GPS PVS GSJFOEMZ BDDSFEJUFE and fully computerised general practice. 0VS CVTZ QSBDUJDF TFSWFT B ZPVOH professional demographic as well as providing specialist sexual health services. With one of our doctors moving on this provides an exciting opportunity for an enthusiastic practitioner to join our practice with an established patient base. 73 XJUI JOUFSFTUT JO GBNJMZ QMBOOJOH BOE sexual health preferred. $POUBDU 4UFQIFO PO 0411 223 120 Email: stephen@westperthmedicalcentre.com.au

MARCH 2014 - next deadline 12md Friday 14th February - Tel 9203 5222 or jen@mforum.com.au

medical forum Osborne City OSBORNE CITY OSBORNE CITY MEDICAL CENTRE requires a GP. 'MFYJCMF IPVST FYDFMMFOU SFNVOFSBUJPO .PEFSO QSFEPNJOBOUMZ QSJWBUF CJMMJOH practice with full time Practice Nurse. Fully computerised. 1MFBTF DPOUBDU .JDIBFM PO 0403 927 934 KINROSS ,JOSPTT %84 JT MPPLJOH GPS B 73 GVMM UJNF (1 This privately owned and managed QSBDUJDF XJMM PGGFS VQ UP CJMMJOH UP UIF right doctor. 7BSJPVT MPDBUJPOT /PSUI 4PVUI BWBJMBCMF Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com

We make Aged Care work for GPâ&#x20AC;&#x2122;s .FEJDBM 1SBDUJUJPOFST GPS "HFE $BSF .1 "$ JT TFFLJOH EPDUPST UP KPJO its team providing medical services to SFTJEFOUT PG WBSJPVT 3FTJEFOUJBM "HFE $BSF Facilities throughout the Perth metro area. Our efficient service delivery model NBYJNJTFT UIF EPDUPS T FBSOJOH QPUFOUJBM t 'MFYJCMF TFTTJPOT .POEBZ UP 'SJEBZ t (SFBU BENJO TDIFEVMJOH TVQQPSU t 3FNPUF MPH JO UP QBUJFOU SFDPSET t 3/ QSPWJEFE CZ .1 "$ UP BTTJTU EPDUPS t #FUUFS VUJMJTBUJPO PG EPDUPS T UJNF t 1BZNFOU PG HSPTT SFDFJQUT t &RVJUZ JOWPMWFNFOU QPTTJCMF For more information or confidential discussion about work options please DPOUBDU 3PMMP 8JUUPO o $IJFG &YFDVUJWF 0GGJDFS .1 "$ Tel. 9389 8291 or .PCJMF 0417 921 632 or Email: rollo@mpfac.com.au

THORNLIE 73 (1 SFRVJSFE GPS BO "(1"- BDDSFEJUFE DPNQVUFSJTFE OPO DPSQPSBUF QSBDUJDF Full time nursing support. No afterhours. Friendly support staff. 3BQJEMZ HSPXJOH QBUJFOU CBTF 0VUFS .FUSP 7JTB TQPOTPST Excellent renumeration and conditions. $POUBDU 9267 2888 / 0403 009 838 Email: thornliemedicalcentre@hotmail.com MOSMAN PARK Full or Part time GP wanted. " SBSF PQQPSUVOJUZ UP KPJO B GSJFOEMZ OPO DPSQPSBUF GVMMZ DPNQVUFSJTFE QSBDUJDF JO .PTNBO 1BSL Hours and days flexible. 3FNVOFSBUJPO PG HSPTT CJMMJOHT Tel: Tabs on 9385 0077

CLOVERDALE 15 '5 73 (FOFSBM 1SBDUJUJPOFS SFRVJSFE GPS established practice. 1SFEPNJOBOUMZ CVML CJMMJOH 'VMM UJNF 3/ /PO $PSQPSBUF .FEJDBM $FOUSF TJUVBUFE JO B .FEJDBM $PNQMFY -PDBUFE OFYU EPPS UP $IFNJTU Physiotherapist and Pathology. 3FNVOFSBUJPO PG PG JODPNF Phone Anne 0421 128 144 CANNING VALE /PO 73 PS 73 (1T XBOUFE GPS CVML CJMMJOH NFEJDBM DFOUSF JO $BOOJOH 7BMF %84 MPDBUJPO NJOT GSPN 1FSUI $#% CJMMJOHT #JMMJOHT TJNJMBS UP UIBU PG B mixed billing practice. Generous relocation fee. 'VMM UJNF OVSTF GPS &1$ BOE PO TJUF pathology/allied health. $POUBDU H@WJOV!ZBIPP DPN

KOONDOOLA 73 (1 SFRVJSFE GPS B XFMM FTUBCMJTIFE QSJWBUFMZ PXOFE QVSQPTF CVJMU QSBDUJDF with onsite pathology and pharmacy. %84 TUBUVT Ă&#x17E; Please email groupmanager@westnet.com.au PEARSALL Pearsall Medical Centre is looking GPS B 73 GVMM UJNF (1 This privately owned and managed QSBDUJDF XJMM PGGFS VQ UP CJMMJOH UP UIF right doctor. Other locations North available. Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com MT HAWTHORN Mt Hawthorn Medical Centre requires a 15 '5 73 (1 UP KPJO PVS QSJWBUFMZ PXOFE practice with a well-established patient CBTF DPNQVUFSJTFE BDDSFEJUFE XJUI nurse support. " NPOFUBSZ JODFOUJWF BGUFS NPOUIT service with us. 1IPOF 3PTF 9444 1644

DUNCRAIG DUNCRAIG MEDICAL CENTRE requires a female GP FYJTUJOH QBUJFOU CBTF BT -BEZ %S NPWJOH to Albany) 'MFYJCMF IPVST FYDFMMFOU SFNVOFSBUJPO .PEFSO QSFEPNJOBOUMZ QSJWBUF CJMMJOH practice with full time Practice Nurse. Fully computerised. 1MFBTF DPOUBDU .JDIBFM PO 0403 927 934 &NBJM %S %JBOOF 1SJPS dianne@duncraigmedicalcentre.com.au

NEDLANDS 'VMM UJNF PS TFTTJPOT BWBJMBCMF GPS 73 (1 JO non-corporate family practice. 1SFEPNJOBOUMZ QSJWBUF CJMMJOH weekends optional. $MPTF UP 68" JO TIPQQJOH DFOUSF JO UIF process of being accredited. 'VMM UJNF QSBDUJDF OVSTF DBSF QMBOT JNNVOJTBUJPO &$( 4QJSP Please contact Suzanne at 9389 8964 or Email: nedlandsdoctor@yahoo.com.au 73 (1 3FRVJSFE GPS NEW PRACTICE located in an ASGC-R2 location east of Perth. This brand new practice is the perfect opportunity for a GP to work in the inner regional area of Perth located BQQSPYJNBUFMZ NJOT GSPN UIF $#% This large community with no current servicing (1 T JT MPDBUFE OFYU EPPS UP B CVTZ QIBSNBDZ BOE DBO BDDPNNPEBUF GVMM UJNF (1 T "ENJO and nursing services will be provided along with QBUIPMPHZ POTJUF 3FMPDBUJPO JODFOUJWF NBZ apply to this location. For more information please call 0419 959 246 Email: admin@ppdgroup.com.au BALGA Balga Plaza Medical Centre has now opened in the Balga Plaza shopping centre and is steadily growing. 8F BSF JO UIF QSPDFTT PG FYQBOEJOH BOE looking for enthusiastic GPs to be part of this exciting process. Generous locum percentage offered and interest in ownership considered. $POUBDU CBMHBQMB[BNFEJDBM!HNBJM DPN Phone: 0427 794 419

LANGFORD (Qualifies as DWS) -BOHGPSE .FEJDBM $FOUSF JT MPPLJOH GPS B GVMM UJNF (1 UP DPNNFODF JO 'FC .BSDI 8F BSF B NPEFSO XFMM FRVJQQFE BDDSFEJUFE mixed billing practice. Situated south of UIF SJWFS -BOHGPSE JT POF PG UIF DMPTFTU QSBDUJDFT UP UIF $#% UIBU TUJMM RVBMJGJFT BT B district of workforce shortage. For confidential enquiries please contact 1. 3JUB PO 9451 1377

81 MANDURAH .BOEVSBI DPBTUBM MJGFTUZMF NJOVUFT from Perth. 73 OPO 73 EPDUPS SFRVJSFE TIPSU UFSN PS long term. No weekends or after hours. Good remuneration. $MJOJD IBT GVMM UJNF OVSTFT QBUIPMPHZ QTZDIPMPHZ IFBSJOH DFOUSF EFSNBUPMPHJTU and orthotics. $POUBDU QSBDUJDF NBOBHFS &MBJOF 9535 8700 Email: elaine@mandurahdoctors.com.au MADDINGTON .BEEJOHUPO %84 JT MPPLJOH GPS B 73 full-time GP. This privately owned and managed QSBDUJDF XJMM PGGFS VQ UP CJMMJOH UP UIF right doctor. Other locations South available. Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com PERTH CBD 'VMM BOE QBSU UJNF 73 (14 UP KPJO PVS CVTZ inner city practice located in the Hay 4USFFU .BMM /PO DPSQPSBUF NBJOMZ QSJWBUF CJMMJOH BDDSFEJUFE GVMMZ DPNQVUFSJTFE XJUI GVMM BENJO and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates 1MFBTF DPOUBDU %FCSB PO 0408 665 531 to discuss or Email: drogers@perthmedicalcentre.com.au BENTLEY Rowethorpe Medical Centre is a OPO QSPGJU GSJFOEMZ QSBDUJDF TFFLJOH B part time GP to provide visits to our onsite residential aged care facilities. Practicebased consultations are also available. t 'VMMZ DPNQVUFSJTFE t /FXMZ SFOPWBUFE QSFNJTFT t .PEFSO FRVJQNFOU t 0OTJUF QBUIPMPHZ t )PVST UP TVJU ZPV 'PS FORVJSJFT QMFBTF DPOUBDU +BDLJF on 6363 6315 or 0413 595 676

Looking for a sea change? We may have the job for you. If you have ďŹ nished your GP training or looking for a subsequent term placement or an experienced GP looking for a change for the better, phone Jill on 08 97521133 or email jill@busseltondoctors.com.au.

3FBDI FWFSZ LOPXO QSBDUJTJOH EPDUPS JO 8" UISPVHI .FEJDBM 'PSVN $MBTTJGJFET

Busselton is located on the pristine shore of Geographe Bay in the Margaret River Wine Growing region, just a short 2 hour drive from Perth.

MARCH 2014 - next deadline 12md Friday 14th February - Tel 9203 5222 or jen@mforum.com.au

medical forum Specialists – opportunity for easy private practice in Fremantle! Ellen Health (Ellen Street Family Practice) will be moving from 59 Ellen Street Fremantle, to the beautiful old Beacon Theatre - 69 Wray Avenue (corner Hampton Road), Fremantle, co-located with pharmacy, pathology and allied health. Doctor-owned and managed, Ellen Health is a multi-disciplinary team, providing excellence in health care. We invite specialists to join the team, offering an instant referral base with our established general practice, and with the ease and comfort of fully serviced new rooms.

We are recruiting specialists and VR-GPs now. Enquiries to Dr Catherine Douglass 0421 520 767 www.ellenhealth.com.au

ARE YOU

READY FOR

A CHANGE?

Looking for dedicated GP’s and Specialists who love the South West and want to stay – move across to our state of art practice – we have oodles of space. You can have your own room. Excellent working conditions with limited after hours needed through Bunbury After Hours GP Clinic. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073 GPs Wanted - South Metro Multicultural Health Clinic (Belmont, 39 Belvidere Street )

*HQHURXV KRXUO\ UDWHV )OH[LEOH ZRUNLQJ KRXUV &OLQLFDO DQG QXUVLQJ VWDII VXSSRUW 0RGHUQ ZHOO HTXLSSHG IDFLOLWLHV )XOO\ FRPSXWHULVHG

GPs Wanted - GP After Hours Clinics in Belmont, Armadale and Rockingham

*HQHURXV KRXUO\ UDWHV 0RGHUQ ZHOO HTXLSSHG IDFLOLWLHV )XOO\ FRPSXWHUL]HG DQG DFFUHGLWHG FOLQLFV 3ULYDWH DQG %XON %LOOLQJ RSWLRQV &OHULFDO DQG QXUVLQJ VWDII VXSSRUW For more information contact Liz Williams at 08 6253 2100 or l.williams@baml.com.au

MARCH 2014 - next deadline 12md Friday 14th February - Tel 9203 5222 or jen@mforum.com.au

medical forum

Medical Centre in East Victoria Park, Western Australia Requires GPs for weekday work. Best possible terms offered. Earn 70% of billings. Best possible location, stand-alone site integrated with a pharmacy and pathology, located next to the very busy Park Shopping Centre, ample free parking. Together with an active marketing plan, this will be a very busy Medical Centre having easy access to residents in all surrounding suburbs. (Non VR IMG doctors may also apply for afterhours and weekend work)

Apply now. sel@parkmedicalgroup.com.au (Phone: 0411 87 6677)

For Sale/For Lease Opposite Bentley Hospital

There are plenty of options with these three properties. Buy; lease; move right in; refurbish, extend, or redevelop. The choice is yours. Located directly opposite the Bentley Hospital they present an outstanding opportunity to establish a medical practice or allied health service. Total land area is 3,483m2 with large frontages to both Mills & Doust Street. The individual lot details: 21 Mills Street â&#x20AC;&#x201C; 1,449m2 *NQSPWFNFOUT JODMVEF DPNNFSDJBM PGÂžDFT PG N2 DBS CBZT VOEFSDPWFS

23 Mills Street - 1,063m2 %FWFMPQNFOU TJUF XJUI QPUFOUJBM DPNNFSDJBM VTF 45$" 25 Mills Street â&#x20AC;&#x201C; 971m2 Purpose built consulting/treatment rooms with ample parking

Offers invited. For brochure and further details phone Jason Hughston on 9473 7777 or 0408 902 907 jhughston.victoriapark@ljh.com.au

ljhooker.com.au MARCH 2014 - next deadline 12md Friday 14th February - Tel 9203 5222 or jen@mforum.com.au

medical forum

Venosan Diabetic Socks

The Magic of Silver for Sensitive Feet No Compression

Are you wanting to sell your medical practice? As WA’s only specialised medical business broker we have sold many medical practices to qualified buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible.

Silver Ion Therapy

We are committed to maintaining confidentiality.

Contains the antimicrobial silver yarn Shieldex® which enhances a balanced foot climate.

You will enjoy the benefit of our negotiating skills.

Brad Potter on 0411 185 006

We’ll take care of all the paper work to ensure a smooth transition.

Tested and proven in controlling over twelve types of bacterial and fungal infections common on the feet and legs. t

To find out what your practice is worth , call:

Silver yarn - is permanent and cannot be washed out of the socks.

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Ph: 9315 2599 www.thehealthlinc.com.au

Keeps feet cooler in the summer and warmer in the winter

Comfort for The Patient t

Soft-Spun Cotton - Ultra soft cotton

Fully cushioned foot and fully cushioned sock

Comfortable for arthritic patients

Flat Seam Safety No noticeable seams due to hand-linked toe section. This reduces chafﬁng and blistering that could result in infection and skin ulceration.

Non-restricting cuffs

Stress Physician | Mandurah | Part time CVS are a leading cardiology practice providing high quality diagnostic stress testing services. We are seeking medical practitioners to work at our new Mandurah clinic one or two days per week. We welcome you to contact us if you have: • Registration with the Australian Medical Board • Medical Indemnity Insurance • Life Support skills or experience • Commitment to outstanding patient care As a Stress Physician, you will work with state of the art diagnostic equipment, conducting quality specialist testing and developing your diagnostic ECG skills. Training will be provided and an attractive remuneration package and working conditions are available. CVS East Fremantle, Joondalup, Karrinyup, Leeming, Mandurah, Midland, Mount Lawley, Nedlands, Rockingham.

– avoids restriction of circula-

tion.

Colours – available in Silver (essentially a white sock with Silver yarn) & Black.

Sizes – available in 3 sizes (Small, Medium & Large).

85% take home,

enjoy ﬂexible hours, less paperwork, & interesting variety...

Equipment Provided - WADMS is a Doctors’ cooperative Essential qualifications: s General medical registration. s Minimum of two years post-graduate experience. s Accident and Emergency, Paediatrics & some GP experience.

Your WA Consultant – Jenny Heyden RN Tel 9203 5544 or Mob 0403 350 810

så så så så

Fee for service (low commission).så Non VR access to VR rebates. 8-9hr shifts, day or night. så Bonus incentives paid. 24hr Home visiting services. så Interesting work environment. Access to Provider numbers.

Supplement your income: Are you working towards the RACGP? – we have access to provider number for After Hours work. Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.

Contact Trudy Mailey at WADMS

(08) 9321 9133

F: (08) 9481 0943 E: trudy.mailey@wadms.org.au www.wadms.org.au WADMS is AGPAL registered (accredited ID.6155)

MARCH 2014 - next deadline 12md Friday 14th February - Tel 9203 5222 or jen@mforum.com.au

MEDICARE ELIGIBLE MRI SERVICES FOR GPs GP Referred Medicare Eligible MRI Services for Patients 16 Years of Age and Over 1. Head MRI

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2. Cervical Spine MRI

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3. Acute Knee MRI

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GP Referred Medicare Eligible MRI Services for Patients Under 16 Years of Age 1. Head MRI

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2. Spinal MRI

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3. Knee MRI for internal joint derangement following radiographic examination 4. Hip MRI

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5. Elbow MRI following radiographic examination where a significant fracture or avulsion injury is suspected that will change management 6. Wrist MRI following radiographic examination where scaphoid fracture is suspected

GPs can refer to any of our 7 MRI locations for each of the above listed items t Currambine t Duncraig t Hollywood Hospital t Kelmscott t Mandurah t t SJOG Murdoch Hospital t SJOG Subiaco Hospital t

MRI APPOINTMENT BOOKING LINE

9320 1288 www.skg.com.au