Medical Forum WA 07/14 Public Edition by Medical Forum WA

High-Voltage Medicine t Budget Response t GP Advocacy t Letters & Columns t Menâ&#x20AC;&#x2122;s Health & Dermatology

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Contents

July 2014 14

FEATURES

LIFESTYLE

14 20 22 28

Spotlight: Justin Langer on Fatherhood Trailblazer: Dr Frank Jones and Politics GP Help for Homeless Mindful of Violence Adverse Drug Reactions

45 45 48

NEWS & VIEWS 3 4

12 18 18 19 24 44

Editorial: GPs in No Man’s Land? Letters: Preserve Training Quality – Dr David Chessor Specialists and Telehealth – Dr Toby Pearn Morality Without Reward – Dr Ian Maddox Answers to Medicare – Dr Colin Hughes Obstetrics & Newborns – Dr Helena Goodchild Standing Up for Girls – Prof Ajay Rane Mental Health – Ms Alison Xamon Have You Heard? Obituary: Dr Neill Openshaw Beneath the Drapes Mitigating Risk in Practice It Takes a Village to Treat Diabetes Dr Linda Selvey in the Philippines

MAJOR SPONSORS medicalforum

48 50 51 52 53

Alan Charters Prize Winners – Hsern, Usha & Madeleine Fermoy Estate – Dr Martin Buck Car Review: BMW 650i Gran Coupe – Dr Mike Civil Travel: Singapore Connection – Dr Bruce Bridges Social Pulse: GP Education; Avant-AAPM Seminar Music: Opera; WASO; Beethoven for Kids Theatre: Henry V Funny Side; Ancient Anecdote Competitions

E-POLL 3 16 23 24 28

Budget and Disability Pensions; ED Payments GP Advocacy & Research Alcohol & Violence Medicare Locals & Smartphones Adverse Drug Reactions

July l Pol

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

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

ISSN: 1837–2783

John Alvarez Cardiothoracic Surgeon Peter Bray Vascular Surgeon Joe Cardaci Nuclear & General Medicine Chris Etherton-Beer Geriatrician & Clinical Pharmacologist Philip Green General Practitioner: Rural Mark Hands Cardiologist

ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510)

Clinical Contributors

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

We ask Clinical Contributors to provide a phone number should a doctor wish to clarify a management issue.

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

TONY 33 DR CACCETTA

Journalist Mr Peter McClelland journalist@mforum.com.au

Sun-Damaged Skin

DR PHILIP SINGH GRAHAM 33 Steroid-Induced 35 DR FURNESS Dermatitis

Update: Blepharitis

DAVID 37 DR MILLAR When Testosterone is in Contention

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

JERARD 38 DR GHOSSEIN Testicular Cancer

ARIS 39 A/PROF SIAFARIKAS Referral for Short Stature

JENNY 39 DR BROCKIS Men and Health Checks

ALLAN 41 DR QUIGLEY

MS KYLIE DUNJEY Time and Happiness

Clinical Q&A: ‘Crystal Meth’

DAN 27 DR MCAULLAY Primary Care to Close the Gap

s in PicturePulse Social 48 Page

GRAEME 29 PROF MARTIN Solutions to Food Crisis

Exercise in Heart Failure

Guest Columnists

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

ANDREW 40 A/PROF MAIORANA

BRENDAN 30 DR MCQUILLAN Respect Rights of Road Users

SEAN 31 DR STEVENS GP-Specialist Divide

medicalforum

Editorial By Dr Rob McEvoy Medical Editor

GPs In No Man’s Land?

General practitioners concerned about the future of general practice in the current political climate may wonder about investing in any representative group. While traditionally the AMA has claimed to represent GPs, it does this with only 26% (or 6,151) of GPs nationally as current financial members (1). The RACGP’s political advocacy some years back was judged unfavourably. Things have changed since then. Proud of acquiring specialist status for its model of the generalist GP, in my view, the college has to cater for doctors who cannot, or do not want to, reach that standard. Otherwise, some of its 27,500 members (2) can be picked off unfairly. The college is right in linking standards in general practice with things like income and red tape, and spurred on by recent proposed federal government changes, is lobbying hard. When we polled 165 GPs this edition, 76% said they “would you like to see the RACGP take on a greater political advocacy role for General Practice” (with 16% against the idea, and the rest undecided). Of the 66 GPs who offered comment, over half we judged as taking sides, with 15 anti-RACGP (five pro) and three anti-AMA (seven pro). [See P16 for details] Moreover, in an e-Poll of 147 GPs late last year, most (28%) said they did a better job of representing themselves, ahead of either the AMA (21%) or RACGP (25%). All this points to GPs disenchanted with their current political advocacy and the necessity for any representative group to do some serious, inclusive opinion gathering – and be prepared to alter stance according to that opinion. In the current situation where doctor hip pockets are under threat, both demands

on representative organisations and memberships are said to increase. The problem for the AMA is that if GP members are in the minority, and if GPs and specialists disagree over local issues such as medical research funding, caesarean rates, patient billing, and religious influences over public hospitals, it is hard to come up with a policy that works for everyone. Having vocal members doesn’t automatically translate into representing the majority point of view. Caesareans in WA might be an example. There are divergent views and many people have interests in particular outcomes, either way. History tells us that when polarity exists around medical procedures that are subject to social pressures, such as circumcision, the medical profession has to come up with something that separates science and fashion, and educate the public on this.

Here’s a sample of GP opinion. When we surveyed 165 WA GPs for their response to the question, “Do you believe WA’s Caesarean Rate is appropriately linked to medical and obstetrical complications?” 41% said No, 31% said Yes, and 28% were Undecided. This gap widened with female GPs – 51% answered No (cw. 35% of males) while 24% said Yes (cw. 35% males). Those who answered ‘No’ were given a supplementary question, “Where do you believe most inappropriate linkage occurs?” and gender differences disappeared as 72-73% of respondents said inappropriate linkage was in the Private Sector while 1719% said it was in both Private and Public Sectors. If our sample is a true representation of a majority GP opinion that our profession is performing caesareans not linked to medical and obstetrical complications, does the profession need to act?

Debates on this and things like religious administration of public hospitals is something our professional groups can lead, rather than comment on later. (1) A full time WA GP pays $1476 to join; AMA WA did not provide requested GP membership figures. (2) By our estimate around 70% of RACGP members might be interested in RACGP advocacy; $1195 joining fee for a full time GP.

July l Pol

Amongst GPs surveyed, 165 opted to respond to questions on caesareans and advocacy (this editorial), Budget inspired questions (below), and others (see Contents). Thanks to those who took part.

Do you believe those under age 35 who receive the Disability Support Pension should have the accuracy of their disability claims reviewed?

Yes

81%

11%

Uncertain

Do you think government should withdraw existing incentive payments to Emergency Departments that are meeting 4-hour rule targets?

Yes

36%

41%

Uncertain

23%

Winner of our e-Poll prize is Dr SD.

Rural Bond Reaps a New Reward Making a decision at 17 years of age that would ripple on for the next 16 years prompted Dr Penny Wilson to reflect on the pros and cons of the Medical Rural Bonded Scholarship in her Guest Column. It won her the 2013 Medical Forum Guest Column Award. Penny picked up her certificate from the magazine’s Medical Editor Dr Rob McEvoy (pictured) recently and said that she had become something of a goto person for young people contemplating applying. While the scholarship continues, her column prompted CEO of WAGPET, Dr Janice Bell, to suggest that coercion was not the answer to workforce issues and registrar training should count towards the return of service period. To refresh your memories, use the QR code or visit www.medicalhub.com.au and use the search field. medicalforum

Scan the QR code to read Penny Wilson’s article

Letters to the Editor

Training quality must be preserved Dear Editor, The recent changes announced to the Australian General Practice Training program (AGPT) have left many people, including GP Registrars, asking questions about what the future holds for GP training and the profession more broadly. It’s important to stress that the quality of AGPT is world-class. Registrars overall have a high level of satisfaction with training, and doctors achieving fellowship of ACRRM and/or RACGP are highly, and appropriately, skilled. It is essential that the most important parts of AGPT are protected to ensure a quality training program in the future. One of the strengths of training under GPET has been the formal oversight from within the profession. GPRA believes that training under the Department of Health (DoH) from 2014 onwards must include a formal mechanism by which the DoH can regularly seek advice from experts within the profession. The tender process for new training providers creates many more questions. Registrars are clear that there are core features of training that must be protected to preserve quality. These include the apprenticeship model of training, notfor-profit training providers with an unwavering focus on education quality, and the continuing oversight of training by the two GP colleges, RACGP and ACRRM. Dr David Chessor, Chair, General Practice Registrars Australia

Specialists slow to use telehealth Dear Editor, When I flick through Medical Forum and get to the clinical services listings, it strikes me how few mention telehealth referrals. As a country GP, I rarely refer to specialists who don’t do telehealth. I have a list of those that do and use them but Perth-based specialists are incredibly slow to start using this compared to the eastern states. I sometimes use eastern state specialists for telehealth – cases that clearly won’t need specialist procedures can be dealt with by eastern state specialists (otherwise, I will need to re-refer). Perth-based specialists have refused to do telehealth with me because they ‘don’t have the equipment’ but how is this possible? Find me a specialist who doesn’t have an iPhone and/or an iPad. These have built in 4

HD cameras, and Skype works perfectly well. A web cam from your desktop costs $25. Skype is free to download and takes five minutes to set up. Essentially, instead of those phone calls for advice from a rural GP, such as myself, for which there is no payment other than goodwill, a telehealth consult can be scheduled that does pay. Patients who already see a specialist who doesn’t do telehealth now often change to another who does, at my suggestion. I have shared my list with colleagues and know they are doing the same. The patients love it. For my patients to go to a specialist ‘free’ public clinic in Perth, it costs them two days off work, 1400km of travel, and overnight accommodation. They get a pittance back from the PATS scheme. They would often rather pay a few hundred dollars for a private specialist consult without having to leave town. Procedural specialists don’t seem to want to do telehealth because the patient has to come and see them for the procedure. But rural patients can have the initial consult via telehealth, then travel just once to Perth for the procedure, and then have follow-up by telehealth – one trip instead of three. Dr Toby Pearn, GP, Esperance

Being moral without reward dear Editor, I was astonished to read Dr Phillip Noble’s letter [Outrage is Relative, June edition]. His implication that concern for the welfare of one’s fellow creatures is impossible without encouragement or threat from a “personal god” is astounding. I can assure Dr Noble that for mature thinking members of society, moral behaviour is possible even without the promise of godly approval. Dr Ian Maddox, City Beach

And, believe me, the moment you charge a co-payment, patients will demand a longer consultation and bring their shopping list to get their money’s worth. Medicare has already costed reducing the rebate for a standard consultation by $5 and loading consultations over 15 minutes by $10. We could all be working for $300 an hour and only see four patients holistically, comprehensively and with huge job and patient satisfaction. Dr Colin Hughes GP, Midland

Obstetrics and newborns, South Metro Area Dear Editor, From December 2, 2014, the Maternity, Gynaecology and Neonatal services currently provided at Kaleeya Hospital will transfer to Fiona Stanley Hospital. It is ‘business as usual’ until then. Transfer of maternity services will occur over a short period and will not impact on the quality and safety of neonatal and maternity services in the South Metropolitan area. When Fiona Stanley Hospital (FSH) opens later this year, it will become a leading maternity provider – 35 inpatient beds, six birthing suites, an assessment area with four bays, two assessment rooms that can double as birthing suites, a water birth suite, and 18 neonatal cots. FSH will be offering care for high-risk pregnancies (at a level not previously offered in the South Metro Area) as well as low-risk care that includes GP shared care. Later this year, GPs will be able to visit the FSH maternity facilities for a Q&A session with the head of Obstetrics and Gynaecology, Dr Sunanda Gargeswari, as well as a refresher in antenatal shared care. Those interested are invited to email me at helena.goodchild@health.wa.gov.au Dr Helena Goodchild, Kaleeya Hospital Liaison GP

Answers to Medicare Dear Editor, You have been warned! For years I have tried to explain that it is the sixminute medicine that is the problem with bulk billing – 60% of all consultations are for one ticket of entry according to BEACH. We know bulk-billing clinics ask patients to return for a second problem. Only by extending a basic consultation to 15 minutes can we ever hope to do the things we are supposed to in terms of preventative care.

Continued on P6

We welcome your letters. Please keep them short. Email to editor@mforum.com.au (include full address and phone number) by the 10th of each month. You can also leave a message at www.medicalhub.com.au. Letters may be edited for legal issues, space or clarity medicalforum

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Letters to the Editor Continued from P4

Standing up for girls Dear Editor, I was heartened to see Medical Forum bringing the issue of female infanticide and feticide in India to the attention of WA doctors [Film Takes on Brutal Tradition, April]. It is estimated that 60 million girls have been ‘killed’ since 1984 in India (Lancet, 2006). The gender ratios in 2012 are worse than they were in 2001 – now around 750 girls to 1000 boys in the worst-affected states such as Haryana. Why the intransigence? There are strict laws against sex determination and procuring infanticide and/or feticide. The answer lies in the demand for this cultural anomaly. Everybody wants a wife, a mother but not a daughter and it cuts through religion, rurality, economic strata and educational level. The notion to have a ‘first born’ son as a good omen prevails while economic strains like dowry also push some parents to ‘avoiding another girl’. The Past Prime Minister Manmohan Singh called it a national shame, the current Education Minister Hon. Smriti Irani was applauded for a fantastic speech at an International Women’s conference last month. Why then this lack of concern and shame at grass-roots level? Prof Sanjay Patole and I took upon ourselves to address this issue by making a Bollywood film called Riwayat in 2011. The idea was to use this medium to reach

the populous of India. Nominated for 14 international awards and winning five has given the issue world-wide airing, but it is preaching to the converted. The movie was not accepted well in India. The industry failed to support the concept, saying it lacked ‘masala’ and was too close to unpalatable truths. The atrocities against the ‘female’ still continue and we continue to look for support to bring its messages to the masses since they have been shunned by the Government and the industry. Prof Ajay Rane, James Cook University, Townsville

Mental health doesn’t stand still Dear Editor, Outrage, passion, the numbers and not standing still were the themes of your contributors on mental health [May edition]. Geoff Diver is right to be outraged at his family’s experience; an important community service that should relieve his family’s trauma, the Coroners Court, has instead added to it. Tim Marney is also right in seeing the better integration of services as essential, the alternative being care that is too late, at too high a cost and poor outcomes. The WA Association for Mental Health (WAAMH) represents services that support

people with mental health issues and their families to live fulfilling and contributing lives. We welcome the additional funding for mental health acute services in the state budget but like Tim Marney, we know that the long-term solutions involve a greater focus on prevention, innovation and community intervention. We know that people who work in mental health have great passion. Like Chief Psychiatrist Dr Nathan Gibson, WAAMH wants people who work in mental health to see their work as rewarding and valued, which is why development and training is a key WAAMH function. We also believe the new Mental Health Bill will bring significant benefits for people undergoing compulsory treatment, but only if its implementation is well planned and resourced. Around two thirds of people with severe and persistent mental illness do recover but stigma and low expectations remain critical barriers to them. While the Federal Budget brought welcome funding for youth mental health, Headspace, nurse incentives and Personal Helpers and Mentors (PHaMs), the introduction of co-payments and the withdrawal of income support for young people threaten to undermine prevention, worsen the already appalling lifespan gap for people with mental illness and impose long-term costs to the community. Mental health doesn’t stand still. All eyes will be on WA’s 10-Year Mental Health Services Plan and the National Mental Health Review. Ms Alison Xamon, President, WA Association for Mental Health

Curious Conversations

Doctor Electric Dr Peter Terren is a consultant general physician in Bunbury with a fascination for all-things electric. If I could go back in time I’d… have a chat to the great inventor, Nikola Tesla. I’d let him know just how far his electrical inventions have come in 150 years. And I’d also ask him for a few Tesla Coil tips. What do you think you’ll be remembered for? Not my medicine! However, my stunts with Tesla Coil sparks have been seen by 20 million people around the world on more than 20 different TV segments. I regard myself as an ordinary bloke who loves tinkering in the shed. But I’m tinkering with 6

extraordinary things like 10-foot sparks, electrical explosions, lasers, magnetic levitation, radioactivity, electronics and the world’s brightest LED bike-light. Long exposure photography makes these images spectacular!

and esoteric images and I’m completely selftaught. [See cover image]

Medicine is an interesting profession because… it has taken me a decade of formal medical specialist training and ongoing structured learning to become just another country specialist. Compare that with my ‘interesting’ hobby. I have worldwide recognition for unique high-voltage stunts

The three people I’d most like to invite to dinner would be…Nikola Tesla and two gorgeous blondes, if my wife agrees.

If I had five minutes with Dr Kim Hames I’d tell him that… I didn’t know who he was until you asked me. Politics isn’t on my bucket list.

My most embarrassing medical moment was…not having a clue about Dr Kim Hames. O medicalforum

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Incisions

When Time = Happiness Relationships WA’s Ms Kylie Dunjey says even the busiest of doctors need to stop and evaluate their lives as an investment for the future.

ast-forward the movie of your life: where do you want to be at the end of your working years? If your ideal is like a scene from the movie, The Gilded Cage, reclining at a table surrounded by your family and friends, there are some things that might fuel this scenario and others that may jeopardise it. After 40 years of research into marital stability and divorce prediction, Dr John Gottman identified predictors of divorce. t Harsh start-ups: Your discussions begin with criticism, sarcasm or harsh words. t The Four Horsemen: Criticism, contempt, defensiveness and stonewalling (withdrawal) invade your communication. t Flooding: Your partner’s negativity is so overwhelming that it leaves you shellshocked. Your heart rate increases, your blood pressure mounts and your ability to process information is reduced. You disengage emotionally from the relationship. t Failed Repair Attempts: Efforts to deescalate tensions during a touchy discussion fail to work.

If some of these markers are creeping into your relationship, it’s time to take stock and perhaps seek some relationship counselling. Couples in this position are unlikely to be able to solve their problems unaided. Health professionals can get such positive affirmation in the workplace that home can seem comparatively unimportant or unappreciative. Relationships, like everything else, need intentional time, energy and focus – commodities that are often in short supply for the professional couple. What are healthy relationships characterised by? t Commitment to growth – Both personal and relationship. t Prioritising connection – Creatively plan opportunities for meaningful connection, not simply time together. t Trust – Feeling safe and being known. t Accepting influence – Honouring and respecting your partner’s desires and needs. t Assertive communication – Rather than passive or aggressive. t Express fondness and appreciation – Be

intentional. Look for opportunities to do this on a daily basis. t Listening well – Clarifying that you have heard what was meant, rather than what is said. Serious disagreements and the need to say things that are going to be hurtful are necessary in healthy relationships. But we stand a better chance of being heard if we have made solid deposits into our relationship bank account. Gottman suggests the ratio of positives to negatives should be around 5:1. Identifying the way in which our partner ‘hears’ love is a highly effective way to make deposits. Gary Chapman, author of Five Love Languages, suggests gift giving, words of affirmation, physical touch, quality time and acts of service as effective ‘languages’. The premise is that each of us hears love more effectively in some forms than others. Where time and energy are in short supply, it makes sense to be efficient and accurate in communicating love and least because it is an essential part of a commitment to growth as a loving partner. O References on request

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medicalforum

Q Justin Langer talks to the Western Warriors

Spotlight

Justin Langer on Being Dad The former cricketing Test great knows the difficulty of stepping over the threshold from a busy work-life to being a father to four girls.

Justin Langer and his wife, Sue, haven’t quite produced the full cricketing complement of 11. Nonetheless his four girls, Jessica, Ali Rose, Sophie and Grace would form a handy slips cordon. The former Test batsman and current coach of the Western Warriors spoke with Medical Forum about the pleasures and vicissitudes of fathering. “It’s hard being a dad, particularly the first time around. The job doesn’t come with a textbook. I think I was probably a bit obsessive with the first one but by the time Grace came around we were pretty comfortable watching her crawl around in the dirt.” “That said, our oldest daughter is 17 and in a lot of ways Sue was a single mother when I was spending a long time away from home. When I was assistant coach for the Australian team I was gone for 11 months! I’m in my bed a lot more, now that I’m based here at the WACA. It’s so much better being close to home and my family and I’m more accessible as a father than I’ve ever been in the last 20 years.”

“One thing I’ve learnt from the Fathering Project [see Medical Forum, July 2013], and Dr Bruce Robinson in particular, is that it’s so important for my daughters to see that I treat Sue with care, kindness and respect. They, in their turn, will expect to be treated the same way in their own relationships.” “It’s a big responsibility being a husband and father. How we deal with those relationships is important because our children mirror us and bad manners and poor language is easily replicated. But we’re only human and the Langer home is not a complete Zen cave. It’s not rainbows and butterflies every day!”

Men are powerful role models The increasing divorce rate has significant socio-economic repercussions and, says Justin, the absent male is a significant factor. “It’s often the case that some young boys don’t have a lot of contact with older men. If dad’s not around it follows that uncles and male friends probably won’t be either. Despite a wonderful nurturing mother there are certain, and quite different, strengths a child can get from a male mentor.”

Justin acknowledges the demands of a busy career and the transition to stepping in the front door as a father.

“I’ve had those throughout my life and it’s been critically important. I learnt wonderful values from my own father about honesty and a strong work ethic. He’s my hero and I have a magnificent relationship with him.”

“We all talk about work/life balance, don’t we? I’m mindful of it and I try to be really present when I’m home with Sue and the children. I do my best to leave my phone alone but my mind does tend to be ticking all the time. It’s a daily challenge, if I’m completely honest.”

Justin Langer was notoriously tough on himself during his cricketing career, particularly when he was dropped from the Australian XI in 2001. There are some inherent dangers, he says, with the increasing professionalism of sport and that regime shouldn’t extend to the junior level.

Justin is well aware of the need to provide a model of appropriate behaviour towards women.

“I was watching Sophie playing Under 12 netball last year and was appalled at the attitudes of some parents and coaches. The

Fathering in the moment

kids were placed under a lot of pressure and it’s supposed to be fun. I left feeling quite despondent. Sport has become so professional and I worry about the effect this has on young children.”

Teaching children resilience Though Justin is no fan of the ‘no-one loses’ ethos either. “I think it’s a lot of rubbish quite frankly. There’s nothing wrong with having a winner and loser, that’s what sport is all about. It’s a contest. In both winning and losing there are great lessons to be learnt. Being able to bounce back builds layers of resilience. Life can be a tough and bumpy road. It’s critically important that young people learn how to rise above those bad days.” Sadly, the words ‘men’s health’ and ‘suicide’ are increasingly placed in the same sentence. And parenthood as a stressor is an acknowledged causal factor. Becoming a father, particularly for the first time, can be a daunting experience. “I certainly felt that, and it’s not helped by the fact that Australian men feel they shouldn’t show their emotions. But you’re crazy if you don’t because it leads to absolute desperation and worse. I had a particularly tough time in England during the 2001 tour and only after opening up and talking with Adam Gilchrist and John Buchanan did it begin to change for the better.” “It was the same old thing of not wanting to appear weak.” O

By Mr Peter McClelland

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Have You Heard?

Dengue via Brazil Revellers may return to WA from the World Cup with dengue fever, for which doctors have no specific treatment (soccer fans will likely increase the 2013 figure of 1800 Australians returning home with dengue). Why? Dengue rates have increased++ in the Americas due to mosquito vector spread – an estimated 500 million people at risk. One WHO press release we recently received didn’t mention Brazil (coincidence?) even though the country reported 1.4 million cases of dengue in 2013, with over 500 deaths. Brazilian cities present the greatest risk, not the Amazon! The same Aedes aegypti mosquito also transmits the chikungunya and yellow fever viruses (the latter has a vaccine). Dengue has already found its way to Queensland mossies via returning travellers.

Putting mates down

Men with ED

The Autumn edition of MDA National’s member publication runs an interesting editorial from A/Prof Julian Rait, which relates to the competitive nature of doctors, particularly specialists. He said we are prone to demean other practitioners, sometimes for good reason but often to ‘big note’ ourselves. MDA has noted that patient complaints or claims are “not infrequently” the result of criticism from colleagues that can be unfair and unnecessarily distressing to patients. The mix of waning community trust for doctors, more litigious patients, and unfavourable looks through the retrospectoscope is not want MDA wants. In wartime it used to be “loose lips, sink ships”!

Ultrasound extracorporeal shockwave therapy – used at varying intensities for renal stone fragmentation, enhanced bone and soft tissue healing, and angiogenic effects in coronary artery disease – now tackles erectile dysfunction (ED) with a presumed vascular component (e.g. diabetes, CVS disease). About 8 in 10 selected patients are said to respond to one or two courses of treatment using painless zapping, bilaterally, at multiple points along the corpus cavernosa and crus with results in a month that last about two years. It’s best for mild-moderate ED of 3-5 years, in both non-responders and responders to PDE5-inhibitors. Given that ED can herald a coronary artery event, the vascular connection makes sense. WA Sexual Health Centre offers the treatment.

Waste not, want not Remaining GP networks and Medicare Locals are winding up by June 30, when funds run out – EGMs and Liquidator’s meetings. MLs will morph into the government’s latest reincarnation, facts not fully known at this stage. Affected doctors are understandably disillusioned – they took ages to accept divisions, became apoplectic at the mention of Medicare Locals, and do not look favourably on the latest. Given the lack of experienced and community-minded people to work on new boards etc., it’s no wonder.

Study into IVF men’s fertility

WA’s GP training Following the Budget shakeup of GP Training, WA’s successful single tender WAGPET has reassured those involved that it is business as usual for trainees until early 2016. We understand that three other smaller States are in a similar boat. Not so for the bigger states on the eastern seaboard where multiple providers are in for a shakeup and some rationalisation. WA Health will fund the ensuing shortfall in the 2015 Community Residency Program following federal withdrawal from PGPP Program funding this year. This affects up to 25 FTE junior doctor community positions in 100 rotations across outer-metropolitan, rural and remote WA – encouraging training in general practice is the name of the game.

Unfair dismissal claim against TSH The Fair Work Commission began a preliminary hearing into the unfair dismissal claim of the former manager of Better Hearing Australia WA, Ms Julie Edmonds, against Telethon Speech and Hearing (TSH) in May. The hearing was adjourned for the parties to negotiate.

Juggling workforce and training Workforce and training issues are not simple. Things like: reciprocity between Oz and UK, Ireland, Canada, USA, NZ but not South Africa (docs that is, not nurses); international workforce shortages in neonatology and midwifery; the need for all-rounder skills for docs and nurses going bush in WA (when much nurse training is single certificate these days, and credentialing an experienced South African doc in obstetrics, emergency, and minor surgery is a two-year job); differences in clinical team make-up at the new FSH (recruiting made more difficult by uncertain start-up dates); and overseas senior graduates competing for training positions in WA hospitals. A lot to juggle.

Young men between 20 and 22 years who were conceived by IVF are being sought for a fertility study being conducted by the Women & Infants Research Foundation’s (WIRF) Dr Rhiannon Halse. It will investigate their testicular function to determine if their sperm count is affected by their parents’ fertility problems. The controls will be drawn from the Raine Study cohort and results will contribute to a larger study of offspring of IVF. Prospective participants should phone Rhiannon on 9430 1443, 0439 266 434 or email rhiannon.halse@uwa.edu.au.

Orthocell set to list After announcing in May its acquisition of intellectual property from UWA relating to manufacture of tendon stem cell treatment, the Murdoch University–based, regenerative tissue company Orthocell opened an Initial Public Offer (IPO) in June hoping to raise $8m in capital. KTM Capital and John Poynton’s Azure Capital along with Orthocell CEO Paul Anderson are leading the IPO with a series of roadshows around the country. The offer was expected to close late June or early July with the company expected to list on the ASX around mid-July.O

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Trailblazer

Show GPs Some Respect General Practice, says Mandurah GP Dr Frank Jones, is the key to high quality, cost effective healthcare, so it’s time Governments seriously. ime for Governmen nts to take it serio GPs discretionary powers

The 2014 Federal Budget has created some serious challenges for the medical profession, and for general practice in particular, making it a turbulent time to be throwing your hat into the medical politics ring. For long-time Mandurah GP Dr Frank Jones, the latest controversy has given him more reason to run for the presidency of the Royal Australian College of GPs this month – the only West Australian candidate in a field of five. Frank is no political babe in the woods, having chaired the WA faculty of the RACGP and represented it on national council for the past 3½ years, the past 10 months as national vice-president. The College has been outspoken critic against some of the Budget measures, particularly the $7 co-payment. “Every doctor understands there are fiscal limitations for the health dollar and the College is not against fee for service but the co-payment is bad policy. It will cause people in lower-socio economic groups to present later and sicker and will cost more down the track. We know that.” “And it may affect other areas of general

While the Government may not know those affected by its policies, GPs certainly do. “How can you charge an elderly demented patient you have known for the past 30 years,” Frank said. “We know our patients and have made the call many years ago who we charge and who we don’t charge. The Government wants to stop bulk-billing for the large cohort of people we call ‘the working well’ – the co-payment is the wrong way to go about it. It is discriminating against the wrong people.” One of the core tenets of Frank’s election campaign is to lift the profile and respect for general practice and, in turn, for the RACGP. Q GP Dr Frank Jones

practice as well, even to discouraging caring doctors from doing home visits. They are forcing GPs to charge this co-payment. If we don’t, there is a $5 reduction in the rebate. They have already frozen GPs’ rebates for the last 18 months and this will drop it another $5. Plus a GP won’t get the incentive payment unless they charge the co-payment.”

“I’ve felt for a long time that the Government and other specialist colleges look on general practice as the poor cousin. We have this system in Australia that if you are a procedural specialist you get paid so much more than if you are a thinking specialist, which is really what general practitioners are. We do procedures, of course we do, but the expert generalist is at the core of an efficient health system – our skills are eminently adaptable.”

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“Our health system perpetuates this myth that procedural medicine in the hospital environment is somehow cleverer than being a community-based generalist.” “In general practice, we can’t measure outcomes as well as other areas of medicine. Intuitively we know our patients think we do a really good job but measuring it is sometimes difficult. We need to tell our patients’ stories to show politicians and hospital specialists just what we do.” “GPs have a longitudinal clinical continuity with patients and that makes us a very distinct from other specialties. We provide continuous care that has prevention embedded into each and every consult. That’s what the government doesn’t understand. With every patient I’ve seen this morning there has been a preventative element which will save the community so much more money than just item group service. We need to keep hammering that message.”

Advocacy role for RACGP Just how the hammering will be done is a subject of debate within the College and judging by the sceptical responses in our e-Poll, there are some who need to be convinced it has the ticker. “There are certainly differing opinions within the college, as you would expect with almost 26,000 members, so there will be divergence of opinion. But I don’t believe you can go to

Government to whinge, they won’t listen; you have to go with solutions – well-thought out, constructive suggestions. But we need simple, consistent messages about what general practice does.” While the AMA nationally and in WA has historically had a strong lobbying and industrial role, the College’s roots are in education and training, though Frank believes the Government is listening to the College more in recent years. “Fundamentally, the RACGP is an academic college – that’s what we do, we teach, we research, we set quality – they are its foundation pillars. We also have strong opinions on the future of GP training because that, too, is implicated in this budget. Quality education is paramount and the general practice profession must be at the centre of it. We have to maintain control of standards.” “But as far as advocacy is concerned, this is relatively new territory for our College but I think our members are looking to

Q Downtime: Coming from Wales, Dr Frank Jones is a self-confessed rugby tragic and president of the Mandurah Red Prawn Rugby Veterans. Here he is as 2012 World Golden Oldies Rugby Festival in Japan. If not the rugby field, it’s a few tunes on the ukulele.

us for more leads. The AMA has a bigger presence in Canberra, and while they do some good stuff for GPs, they don’t represent general practice. The College has the biggest GP representation of any organisation in Australia. Should the College be more of a lobbyist group? It’s an interesting concept and certainly we have had discussions along those lines.”

Clear, consistent message “We have to be very clear what our goals are because there’s no point in doing it halfheartedly. We also have to ensure that if you Continued on P16

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Trailblazer

July l Pol

Continued from P15 are going to set those high standards, you deliver on them, so I think we have to be a little careful.” Caution wasn’t uppermost in Frank’s mind in 1981, when he, as a young Welsh doctor, and his wife swapped the soft green Welsh dales for the dusty red pindan of Kalgoorlie for a 12-month adventure with the RFDS. “I didn’t have a clue where Kalgoorlie was. It was just two lines at the back of the BMJ but we loved Australia from the word go. I loved the RFDS. It’s the best job for any young doctor who has completed their general practice training because you are on your own. I adored it.” “We would have stayed in Kalgoorlie long term but we love the ocean, so at the end of 1983 we decided we weren’t going back to the UK and found a four-man practice in Mandurah and that’s where we settled.” When Frank and his young family were establishing in Mandurah, it was a sleepy regional town of 15,000, just the way he liked his medicine – personal, caring and involved in his patients from cradle to grave. He’s clung to those values despite the practice morphing into a bustling medical centre with 19 FTE medical positions and various allied health, reflecting Mandurah’s boom to a city of 80,000.

GPs and community hospitals There are tinges of regret not least the widening divide between Mandurah’s GPs and its hospital.

of the hospitals. I still have admitting rights and look after my palliative care patients there, but my phone calls to the hospital over the past 18 months have diminished dramatically. I understand those reasons, they have resident staff. But I think GPs do have a critical place to play in community hospitals.” “We know our patients, we know their circumstances and, with no disrespect to our hospital colleagues, sometimes they don’t know the full history and there is a tendency to over-investigate and over-treat and keep them in a bit too long. I think it’s a golden opportunity that’s been lost in community hospitals and I hope it will be revisited in the future.” “You train a doctor 5-6 years in medical school, 4-5 in registrar positions including procedural training and then GP training, to all of a sudden not be considered clever enough or efficient enough to have admitting rights. What an enormous waste of talents.” “We talk about continuity of care but there’s a huge gap between hospital and general practice that shouldn’t exist and with the communication tools of the 21st century that’s just crazy. Wouldn’t it be nice if the GP’s name was at the head of the bed alongside the specialist colleague. Patients would have the comfort of knowing that their GP was looking after them and taking part in their hospital care.” “It is an incredible privilege being a GP.”O

“I don’t blame anyone for this, but as the town has got bigger, GPs are being edged out

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Doctors on Research & Advocacy

Do you agree with the RACGP: that if any money is collected as a GP co-payment it should go back into primary care research? Yes

32%

45%

Uncertain

23%

Would you like to see the RACGP take on a greater political advocacy role for General Practice? Yes

76%

15%

Uncertain

COMMENTS WA GPs strongly support the RACGP taking on a greater political advocacy on their behalf with more than three quarters of the 165 e-Poll respondents urging them on. Of the 63 who left a comment, one thought a College member should run for parliament while another thought more militancy was required. The effectiveness of both the RACGP and the AMA to stand up for general practice was brought into question by a number of doctors – some thought the AMA was more professional and had trained advocates, while others thought the RACGP was not inclusive enough and not up to the task. One doctors put it: “RACGP is for education and standards. AMA is for political advocacy.” “History has shown that when the RACGP gets involved in advocacy, the government has succeeded in ‘Divide and conquer’ against the AMA and thereby weakened the profession,” one said. But for many who responded, it was with concern for general practice that was uppermost with one pleading to “stop the slow destruction of general practice” and another: “GPs need a strong voice with political clout. Does the RACGP have this? It ought to.” “GPs need representation and unification. Someone needs to effectively advocate on behalf of us. Why should we continue to subsidise ‘free’ health care by accepting pitiful MBS rebates that in no way reflect our effort, training and experience?” “I believe GPs are not respected enough. The nurses union and pharmacy guild are so much more powerful. Such a shame. GPs should be strongly supported and backed up in every possible way to make it sustainable to run a smooth and dynamic practice with the patients’ health and wellbeing a priority.” ED: There was no apparent gender influence.

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Obituary colleagues. I had the opportunity to thank Neill for ‘a job well done’ at our last appointment. His work has allowed me to resume my lifestyle and has greatly improved my quality of life.”

Anthea Openshaw: “This photo was taken just before he died, on the beach near his home. Neill always loved the beach – it was one of his favourite places in the world. He loved that he could drive his 4wd along Stratham Beach for miles.”

Brian Walsh, Yabberup “I was first referred for shoulder pain after around 10 years’ of scans and treatments didn’t amount to any results. Not only are my shoulders back to 100% but it was also very relieving to have someone explain exactly why I was feeling the pain and what he was doing to fix it. I’m sure I’m one of many who held Dr Openshaw in high regard.” Shannon Mosedale, Bunbury

Q Dr Neill Openshaw

eill Openshaw died suddenly last January in Bunbury, aged 49. Anthea lost her husband, the four kids lost their Dad, and the town lost a trusted orthopaedic surgeon. For those who did not know Neill, people close to him describe him as a man of few words, conscientious in his work, and who loved family life, the beach, and the bush. He was a rugby enthusiast with a sense of purpose and good humour, once you got passed the gruff exterior. He hated incompetence, bureaucracy and taking phone messages and had a liking for fast cars and the challenge and mastery of a practical job.

Many doctors would laugh that he had many of the markings of an orthopaedic surgeon! He set up orthopaedic practice in Bunbury in 2006 with his young family, having visited the town as a registrar 10 years earlier. As part of Neill’s living for others, Anthea and the children agreed to his wish to be an organ donor. While there are many fond memories to look back on, we at Medical Forum believe doctors live on through the good work they do in their communities. So, we have chosen to publish the reflections of six of Neill’s patients as a way of celebrating his life:

“Dr Neill Openshaw had an air of quiet competence that was both reassuring and offered patients the confidence that in his hands, all would be well. He was an experienced and highly regarded orthopaedic surgeon. I was fortunate to be a patient for relatively minor

X Esperance GP Dr Louise Pearn has been made a fellow of the Australian College of Rural and Remote Medicate. X The former Director of the Harry Perkins Institute of Medical Research, Prof Peter Klinken, is the new Chief Scientist of WA. X In other biotech news, Virax Holdings, which is developing immunotherapies, has appointed scientist Mr Rob Crombie as managing director. X Mr Lou Panaccio, a non-executive director of Sonic Healthcare, will take on the chairmanship of biotech company Avita Medical. He replaces 18

knee surgery and was treated with respect and consideration.” Yvonne Robinson, Busselton “I was referred at my own request, based on the positive recommendations from friends and

the interim chair Mr Ian Macpherson after the resignation of Mr Dalton Gooding late last year. Mr Gooding stepped down after a shareholder revolt over the company’s remuneration report at November’s AGM. X Fair Game WA, chaired by Emergency registrar Dr John van Bockxmeer, has won a Community Services Excellence Award for its work in Derby. X The CEO of UnitingCare West, Ms Susan Ash, has been made an officer of the Order of Australia for her work in social policy development, reform and implementation, and for the provision of services to people in need.

“He was a wonderful man – gentle and caring, with a wry smile; I always felt very safe in his care. This was very important to me after a previous very bad experience. He won my confidence on the very first visit; he never rushed me into surgery knowing my trepidation.” Pauline Paull, Bunbury “I am very honoured to have had the privilege to have known Dr Neill Openshaw both as a colleague and more recently as a patient. Although a quiet man of very few words, he was always professional with an exemplary manner.” Marina Osborn, Bunbury “I have had both hip replacements performed him. The first was due to pain in my left hip. Now.[…]. three years since my second operation, I have movement free of pain, and do not think of my new hips, but carry on with my active lifestyle, working full time and keeping fit from my Karate training. It is a credit to Dr Openshaw for the huge improvement in my lifestyle. The improvement in my walking with no limp and the confidence I regained was a great lift for me personally.” Alan Burdett, Bunbury. O

X Mr John Hancock, son of mining magnate Mrs Gina Rinehart, has joined the board of Royal Flying Doctor Service WA. X Ms Natalie McCormack is the new executive officer of Activ. She was previously at Perth North Medicare Local and SCGH. X Obstetrician and gynaecologist Dr Michael Gannon has been elected unopposed AMA WA president. X NSW neurosurgeon A/Prof Brian Owler is the new national President of the AMA winning from WA’s Prof Geoffrey Dobb. Victorian Emergency specialist Dr Stephen Parnis is the new vice-president. medicalforum

Practice Management

Receptionists: Directors of First Impressions A practice with watertight procedures and receptionists trained in them are the best mitigators of risk. health unit. She was retested and found to be HIV positive. She had infected her partner, who sued â&#x20AC;&#x201C; both the contracted doctors and the practice company. The doctors resolved the claim and pursued the practice for contribution.

The role of the medical practice receptionist to mitigate legal and clinical risk should not be underestimated. That was the powerful message delivered to about 50 of WAâ&#x20AC;&#x2122;s reception staff from general practice, specialties and allied health by Avantâ&#x20AC;&#x2122;s medico-legal risk adviser Ms Marianna Kelly. â&#x20AC;&#x153;The receptionistâ&#x20AC;&#x2122;s role is so varied, itâ&#x20AC;&#x2122;s valuable to discuss where things can go wrong and what systems can counteract that,â&#x20AC;? she said. The education seminar in May, organised through Avant and AAPM, took attendees through a real case study that resulted in a damages claim against two doctors and then later against the practice, which Marianna used to highlight system failures, especially how vital it was to keep patient contact details, including current phone numbers, updated.

Essential elements to reduce risk t 1BUJFOU EFUBJMT JODMVEJOH QIPOF OVNCFST should be updated every visit. t "MFSUT BOE QSPDFEVSFT GPS UFTU USBDLJOH and recalls; everyone in the practice to comply. t %PDUPS CVEEZ TZTUFN BOE BQQSPQSJBUF alerts on patients records. Q (l to r) Keynote speaker Avantâ&#x20AC;&#x2122;s Marianna Kelly, with AAPM Committee member Laura Harnett, and Avantâ&#x20AC;&#x2122;s WA Manager Claire Turton.

day and to come back in a few weeks for the results.

â&#x20AC;&#x153;This case study underlines just how important practice systems are and the vital role of receptionists. You are not just a receptionist, you have one of the most stressful jobs in the practice,â&#x20AC;? Marianna told the group.

Three days later, the pathology provider phoned the practice Medical Director (MD) to say the HIV test was equivocal and needed to be repeated. The MD told the receptionist to send the patient a recall letter. He made a brief note in the records.

Using this example she said a string of small undetected errors could lead to adverse outcomes. Patient LB returned to a practice, now forming part of a large bulk-billing practice that had retained her contact details from five years earlier.

The patient returned several weeks later over another matter and consulted with another doctor, who also assessed the previous test results as fine except for a positive Chlamydia test, for which treatment was started. The patient left assuming her HIV test results were clear, and told her partner she was clear.

She requested tests for a range of STDs, particularly HIV, before starting a new relationship. She saw Dr A, who took the blood tests and counselled the patient, also advising her she was going off on leave that

About 6-7 weeks later, the front desk told the MD the patient had not contacted the surgery. He ordered them to ring her but her details were inaccurate; it took some weeks to track her down with the help of the public

Q Glen Forrest Medical Centre staff (l to r) Debbie Willis, Maria Clark and Sue Temby, were impressed, saying the seminar offered valuable information and highlighted the need for training, auditing and trialling. For those keen to learn more Avant annually sponsors five AAPM scholarships for the Diploma or Certificate IV in Professional Practice Management at the UNE.

Q Young Lockridge Medical Centre staff were on hand to learn of Avantâ&#x20AC;&#x2122;s tools and resources offered to practices to reduce risk â&#x20AC;&#x201C; (l to r) Joanna Harders, Matthew Westerside and Melissa Schaeffer.

t " UIPSPVHI TZTUFNT BVEJU t "QQPJOUNFOU USBDLJOH XJUI B QFSNBOFOU record of cancellations. t 'PMMPX VQ PG SFGFSSBMT UP FOTVSF continuity of care. t 1BUJFOU DPNQMBJOUT IBOEMJOH UIBU TBUJTÄ&#x2022;FT patients and leads to better practice. t "EFRVBUF USBJOJOH GPS BMM TUBÄ&#x152; JO UIFJS expected tasks â&#x20AC;&#x201C; customer service, IT, triage, basic first aid including CPR, privacy legislation, etc. with follow-up competency assessment. Keep an education register. t (PPE DPNNVOJDBUJPO CPUI WFSCBM BOE written; including regular practice meetings, grievance procedures and online and social media protocols. While the outcome was unfavourable for the practice, Marianna said it demonstrated the pivotal role receptionists play in the efficient and safe running of a practice.

Seminar Comments

Q For the women representing the Australind/Eaton Medical Centre, (l to r) Julie Hall, Renae Nichols and Heather McRobb, it was satisfying to have confirmed that their practice protocols and systems were functioning well. They were also interested in Mariannaâ&#x20AC;&#x2122;s tips for dealing with difficult patients.

Avant and AAPM together supporting and recognising Australiaâ&#x20AC;&#x2122;s Practice Managers This article is supported by an educational grant to Medical Forum from Avant.

medicalforum

Q Dr Andrew Davies, right, conducts a clinic at one of the drop-in centres in Northbridge

Feature

Mobile Care for Homeless The relationship between the health system and the homeless can be thwarted by prejudice and defensiveness, barriers that some GPs are working hard to break down. Last year, 2178 people of ‘no fixed address’ fronted up to WA hospital emergency departments for a total of 4611 visits – a little more than two visits a year each. So far this year [up to May 31], 877 people have done the same for a total of 1900 visits. The Australian Bureau of Statistics (ABS) also released its estimates of national homelessness late last year and found 105,237 people – or 0.5% of the Australian population to be without an ‘adequate dwelling’. They are sobering statistics but no surprise to Dr Andrew Davies who since 2008 has run Mobile GP – one of the few organisations that provide GP services to Perth’s homeless – out of his West Leederville surgery and at several drop-in centres around the city and suburbs. In fact, without services like Andrew’s and others, the emergency department figures would look a lot worse. Mobile GP’s model of care is based on the medical team visiting drop-in centres or shelters where people regularly attend for a meal. It seemed to Andrew that people might be more willing and able to address some of their healthcare issues at a drop-in centre, which could provide a level of privacy while providing the same service as offered in a fixed surgery. Currently there are five doctors and six nurses working for the group. In 2012, Mobile GP conducted more than 9500 consultations and the practice continues to grow at an alarming rate. With funding from the State Government and some private supporters, it conducts five clinics a week at three drop-in centres, two sessions a week at Drug and Alcohol Therapeutic Communities, four clinics a week 20

at homeless shelters, eight clinics for those people who have found accommodation and are transitioning into the community and a youth clinic in Balga.

Falling through the cracks One of the things that still surprises Andrew is how frighteningly easy it is for some people to find themselves with nowhere to live. “There’s no question that the boom shoved accommodation out of some people’s orbit. There are people you wouldn’t expect to be homeless who are. Nobody wants to end up on the street. I can think of only one patient who would have said that and only at the start because she had been systematically abused

base because there were repeating patterns in his own practice. “Two thirds of people will have a past or current drug or alcohol problem; half will have a mental health issue; and half will have a chronic health issue, most commonly chronic pain. Diabetes is 2-4 times more common than in the general community and morbidity and suicide is 52% more common.” “It’s not surprising that the homeless present at EDs, but they present late. If you’re hungry and got a cold, your health is not a priority. It’s only when you become seriously ill with pneumonia do you rock up to ED. Figures show homeless people are eight times more likely than the rest of the population to present late and, of course, their hospitalisation is much longer.”

Problems with prescribing Drug and alcohol abuse is common among Andrew’s patients, which makes prescribing, especially opiates and benzodiazapines tricky because these drugs have a street value.

by her parents and her siblings. She didn’t want to be homeless, she just didn’t want to be abused.” “There are also physical reasons for homelessness, which are often underplayed. A person can suffer a bad injury at work, or fall ill, lose their job and that spiral continues unless they have a support network.” Andrew said little research had been conducted into the health of the homeless in Australia, instead he used findings of research conducted in the US and Canada Health as a

“Most decisions are taken out of our hands because many of our patients have been on the methadone program or suboxone and they’re registered with the Health Department, so we can’t prescribe Schedule 8 drugs without a specialist review. A lot of the people we are seeing just don’t qualify.” “Our policy for benzodiazapines is a weekly dispensing scenario and if there are any mishaps or we’re worried about them, we restrict how much they get at a time. We have some patients who are on daily dispensing and some who are under pharmacist supervision and must take the drug on the spot. Reliable patients we take a behavioural approach, trying to get them to deal with their drug dependency issues.” medicalforum

â&#x20AC;&#x153;For those who have pain and are not registered and we feel that opiates are an option as part of their management, we roughly follow a slightly adapted version of guidelines from the University of Washington with an opiate risk tool plus our own drug screens.â&#x20AC;? â&#x20AC;&#x153;When a person is on a drug of dependence, itâ&#x20AC;&#x2122;s not hard to monitor them because you know they will come back. However, it is a really difficult area and one that involves trial and error. A lot of patients we see are already on quite high doses, particularly of the benzodiazapines, and we work steadily to get their doses down.â&#x20AC;?

â&#x20AC;&#x153;With this [diabetic] group itâ&#x20AC;&#x2122;s very difficult to get their blood sugars down to anything like a reasonable level, but it is very dependent on the individual and their actual circumstances.â&#x20AC;? And that is perhaps the key. Homeless people are individuals, who in different circumstances would not be seeking out the services of Mobile GP or other street services. â&#x20AC;&#x153;The system can treat these people quite badly. Their contact with the hospital system doesnâ&#x20AC;&#x2122;t usually start well, they are often extremely unwell and they can be drug-affected as well. The triage system is quite judgemental so itâ&#x20AC;&#x2122;s not a good recipe for fruitful interaction on either side.â&#x20AC;?

Treating the person and the problem â&#x20AC;&#x153;When I give talks to health professionals I encourage them to see the barriers these people face and try to treat people where they are at. At times thatâ&#x20AC;&#x2122;s challenging.â&#x20AC;? â&#x20AC;&#x153;As a doctor, you do have to take a different treatment approach. The system has failed many of these people and most have had a major traumatic incident in their life which has precipitated their homelessness. Itâ&#x20AC;&#x2122;s about developing trust so that you can help them long term.â&#x20AC;?

Self-management is possible When it comes to chronic disease such as diabetes, Andrew says there are patients who are well able to self-manage their chronic disease while living on the street while itâ&#x20AC;&#x2122;s much harder for others who lead quite chaotic lives.

â&#x20AC;&#x153;This is real medicine and these people are really sick but thereâ&#x20AC;&#x2122;s no text book for this kind of work but there are benefits. With continuity of care, we see improvements in peopleâ&#x20AC;&#x2122;s health and that in turn has a cost benefit to the system roughly in the order of 7:1.â&#x20AC;?O

By Ms Jan Hallam

Pictures: Tony McDonough/Raw Image

Table 1: ED Attendances for â&#x20AC;&#x2DC;No Fixed Addressâ&#x20AC;&#x2122; Calendar Year

Patients

Attendances

2009

1113

2319

2010

1341

2587

2011

1544

3017

2012

1759

3309

2013

2178

4611

2014 YTD

877

1900

Full details available on request.

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Feature

Violence and the Reasons Behind It A Buddhist monk, a psychiatrist and a police commissioner discuss how we can tackle violence in ourr society.

needs to be done, not just controlled on a regulatory basis, but the community needs to be far better educated than what we’ve managed to do so far.”

In January, the NSW parliament passed ‘one-punch’ legislation as a response to alcohol fuelled-violence in Kings Cross which saw Sydney man Daniel Christie king hit and subsequently die from his injuries. Maximum penalty: eight years’ jail. In 2008, the WA parliament passed similar legislation – unlawful assault causing death – after a sustained campaign by family and friends of 21-year-old Leon Robinson, who was bashed to death outside a pub on Christmas Day in 2002. Maximum penalty: 10 years’ jail.

UWA Adjunct Professor of psychiatry Dr David Castle says there have always been violent young men but while young men are more likely to Q Prof David Castle be extra-punitive and attack when under stress, social and development issues come into play.

While its early days for the NSW Act, there is currently a five-year review of the WA legislation, which in essence, means those accused of this type of assault cannot raise a defence of accident. Since its introduction, 12 people have been convicted. However, legislative and punitive deterrence is not uppermost in the mind of an angry, drunk young man at 2am on a Sunday morning yet it is ever-present in the minds

Q Ajahn Brahmavamso Mahatheram

of police on duty in our entertainment precincts. Police Commissioner Karl O’Callaghan told Medical Forum that according to Drug Use Monitoring in Australia (DUMA), alcohol was responsible for about 30% of those in custody committing violent offences; methamphetamine about 15-16%. “Alcohol is the most significant driver of crime in WA, not just violent crime but property crime and family violence and more

“You would be hard pressed to find any society that doesn’t have issues with aggression and violence and while they are not always perpetrated by males, the large majority of incidents are. Opportunities need to exist in the school system to examine these sorts of issues and teach young people how to manage anger better, but when kids see media reports involving people like James Packer and David Gyngall street brawling, or their sporting heroes fighting in pubs and clubs, it isn’t great modelling either.”

Win one of 5 $200 Gift Vouchers Tackling stigma and discrimination against people living with hepatitis C We acknowledge the dedication and high quality services provided by many health care workers, such as those in your practice. We are calling on you to support our anti-discrimination project C the person not the disease. In the month of July to coincide with World Hepatitis Day (28th July) HepatitisWA will be embarking on a large anti stigma and discrimination media campaign which will raise awareness of hepatitis C, with a view to increasing access to testing, treatment and care. There are a number of resources available on the website which we hope you will find useful. To win and make a difference, visit the website www.ctheperson.com.au and sign the pledge. All eligible entrants will go into the draw to win one of 5 $200 gift vouchers drawn on World Hepatitis Day (28th of July 2014). Campaign has been reproduced with permission from Hepatitis NSW’s “C the person not the disease” campaign.

medicalforum

Ajahn Brahmavamso Mahatheram, abbot of the Bodhinyana Buddhist Monastery in Serpentine, believes society needs to look to itself for the root causes of violence. “There is an ancient story of an elephant of good character which starts misbehaving. A wise Buddhist monk stays with the elephant overnight to meditate and discovers robbers using its enclosure. So 2500 years ago, it was discovered that you are influenced by your surroundings and your peers and the images that go into your mind. Of course, it doesn’t affect everybody but enough to create violence in the community, which spreads with exposure.” “We don’t give our young people enough strategies to deal with violent thoughts. And that’s where there is a huge interest and investment in mindfulness training, which is really Buddhist meditation with a makeover. It encourages people to be aware of their emotional world and once there is awareness, there is an ability to control and choose between positive and negative emotions.” “This training, this fundamental skill, is

& July l Alcohol Violence Pol

In September last year there was almost unanimous agreement that alcohol overuse was behind unnecessary violence and antisocial behaviour and 91% believed education rather than prohibition was the answer. In this, our July e-Poll, 165 GPs gave their response.

Select up to four (4) responses you think most appropriate to reduce alcohol-fuelled street violence...

effective for all ages. It can work in schools, it helps rehabilitate people in prisons – it can help everyone.” “In all the times I’ve been to prison I’ve never seen a criminal, or a murderer or a rapist or a thief. I have seen people who have committed those crimes. By these labels we totally ignore the person they are. I once asked a professor of psychiatry how he treats schizophrenia and he replied ‘I do not treat schizophrenia in my unit, I treat the other part of the patient’. His results were a standout.” “By acknowledging the person, whoever they are or whatever they’ve done, they see that part of themselves as well.” “People are only just starting to realise that the victims are not the only ones who are hurt. I know that is a politically incorrect sentiment but we must see the whole picture and treat the problem, rather than just the person who has exhibited the problem. We are all interconnected.” While David’s clinical experience gives him insight into methamphetamine aggression, particularly in acute hospital settings, he agrees with the WA Police Commissioner that alcohol presents a more damaging problem. “There is a massive imperative for governments to crank back their support of the alcohol industry. Personally, I don’t think there should be any linkage between alcohol advertising and sporting events.” “It’s incongruous that governments say they are tough on drugs and yet allow alcohol to be broadly and widely available as well as actively promoted even to under-age young people.” Karl O’Callaghan believes the alcohol industry drives the perception that the problem of violence is fuelled by illicit drugs. “Terrible things do happen to people under the influence of illegal drugs. There is the involvement of organised crime, and drug usage has a terrible impact on families – I

Restrict hours of licensed premises in “hot spots”

21%

Stronger policing of laws prohibiting alcohol sales to intoxicated patrons

23%

More police and stronger penalties

16%

More targeted education e.g. around issues of respect and tolerance

20%

More night buses and taxis in entertainment precincts

19%

None of the above

16%

Uncertain

8.4%

medicalforum

In January the recommendations from the review of the Liquor Control Act proposed to clamp down on secondary supply to underage drinkers. The recommendations remain on the Minister for Racing and Gaming’s desk and the Police Commissioner believes the difficulty lies in the number of competing interests. “The alcohol lobby is very strong and there are recommendations in there which have been made by police and health that will be unpalatable to the industry itself,” he said. But he emphasizes that regulation can only do so much, that the community must also drive the action for change. “The frustration for us is that we won’t be able to change much simply by regulating and charging people all the time. The future of managing the alcohol problem in the community is to start with young children... our next generation of drinkers.” O

By Ms Jan Hallam

PLEASE REFER THEM TO HOLYOAKE.

As a leading provider of alcohol and other drug treatment services for over 35 years, Holyoake assists over 4,000 people a year. We have a wide range of programs to address your patients’ needs – no matter who they are and how they are affected.

75%

am a family that has been affected by methamphetamine use, so I know very well the devastation it causes. But far more damage and far more cost to the health and justice systems are done by alcohol than all the illicit drugs put together.”

ALCOHOL OR DRUGS AFFECTING YOUR PATIENTS DIRECTLY OR INDIRECTLY?

Should we fit breath alcohol devices that govern the ignitions of cars driven by serial drinkdrivers? Yes

Q WA Police Commissioner Karl O’Callaghan

Call Client Services on 9416 4444 or email clientservices@holyoake.org.au www.holyoake.org.au

Counselling and Support Life Changing

Feature

It Takes a Village to Treat Diabetes The Diabetes Program at Perth North Metro Medicare Local has many spokes. Medical Forum placed a middle-aged, male diabetic at the hub to see how it works. It’s a double-whammy for anyone to be told they’ve got diabetes and then, a few months later, find out they’ve got cancer to contend with as well. Mr Chris Kirwin, a 55 year-old Director at WorkSafe found himself in that position earlier this year.

The former has changed radically after speaking with the diabetes educator and the dietician. I’ve had six cans of Guinness sitting in the fridge since September and they’re not likely to be consumed any time soon.” “The whole thing’s been smooth and

“I’m pretty used to being poked and prodded by lawyers in court and you learn to roll with the punches. But the diabetes absolutely surprised me! After the usual run of tests the phone call came to see my GP, Dr Keith Ananda, again. I thought ‘oh no, I’ve done something wrong’. That was in September last year and then, four months later, I was diagnosed with prostate cancer.”

seamless. My GP put together a care plan and referred me to the Medicare Local and their allied health professionals. They gave me a good education on all the things I needed to know such as setting goals, keeping a diary of food intake and logging blood levels. You can even connect with Bluetooth and get a graphical representation.” “I must be doing the right things because all the measurements are fine. With the diet, exercise and Diformin (500mg) my BSL is flat-lining at 5.9. The entire Medicare Local ethos is centred on teamwork and good communication.” “It’s been a positive experience and my wife’s been fantastic. She’s been supporting me from the beginning and now we go to the gym together. I want to prolong my health and before all this I wasn’t paying much attention to it.”

Chris stresses the value of a productive and ongoing relationship with a GP coupled with the allied health services at PNML.

GP Dr Keith Ananda, from the Scarborough Beach Medical Centre, applauds his patient and the services of PNML.

“In my line of work I was transferred a lot so I used to change doctors quite frequently. It’s more stable now. I’ve got a good rapport with Keith, I like him a lot and now I’ll be seeing him a lot more!”

“Certainly from a diabetes point of view Chris has done really well. And he’s had to contend with prostate cancer and manage both conditions at the same time. When patients are as compliant as Chris everything runs pretty

“I’ve lost 22kg since being diagnosed through a combination of diet and exercise.

Q Patient Chris Kirwin, centre, and his diabetes management team: Dr Keith Ananda, top, dietician Ms Felicity Willis, right, and educator Ms Teresa Di Franco.

ll o P e

MEDICARE LOCALS

M Medicare Locals are to change under federal government direction. From what you understand so far about those changes, how do you regard them?

Negatively

21%

Positively

14%

Uncertain

65%

COMMENTS 52 of the 165 GP respondents left a comment and most thought Medicare Locals were a waste of money and should be abandoned, labelling them “white elephants”; “useless money-spending red-tapers”; “irrelevant” and “political nonsense so far removed from real life it is a joke”. One said MLs gave less direct support to GPs in rural areas compared to the previous set-up. Of the few who thought they had potential, lamented the constant changing/rebranding of primary care services. Several thought MLs should be adjusted, not scrapped. One doctor said: “MLs provide a great service to too few and at great cost”. A supporter wrote: “Without them it is likely we will return to a much less personalised service which will be more costly and less efficient” and another described them as “very useful especially in areas of high need”.

SMARTPHONE APPS

Have you heard of a smartphone ‘app’ that you think improves patient care in some way?

Yes

35%

52%

Uncertain

13%

ED: Six respondents said they could recommend apps to help patients monitor their diabetes. We hoped to profile 1–2 next month. medicalforum

smoothly but some people donâ&#x20AC;&#x2122;t have quite the same understanding of the long-term complications.â&#x20AC;? â&#x20AC;&#x153;The services at PNML are invaluable because they reinforce that message.â&#x20AC;? â&#x20AC;&#x153;The other aspect is that not only are the Medicare Local support services directed at newly diagnosed diabetic patients but also to people requiring ongoing management. Once youâ&#x20AC;&#x2122;re linked into the system thereâ&#x20AC;&#x2122;s regular follow-up.â&#x20AC;? Dr Keith Ananda sees a distinct advantage in the centralisation of services at PNML, not least for the patientâ&#x20AC;&#x2122;s hip-pocket. â&#x20AC;&#x153;The fact that both the diabetes educator and the dietician are co-located is important. Itâ&#x20AC;&#x2122;s easier to get a comprehensive summary sent to our practice and on to the patient. Itâ&#x20AC;&#x2122;s exceedingly rare that thereâ&#x20AC;&#x2122;s a breakdown in communication. And the fact these services are free is a bonus. That translates to a costsaving for the patient who would otherwise have to use more expensive options on a personal care plan.â&#x20AC;?

Budget changes loom The Medicare Local model will change after the current federal budget, which has Keith concerned. â&#x20AC;&#x153;There would be huge implications for patients if they lost support from allied health professionals in their own community. In essence, there would be added out-ofpocket expenses and that may well affect compliance levels. North Metropolitan, and others like it, is part of the process of establishing a comprehensive plan for patients with chronic diseases. Itâ&#x20AC;&#x2122;s important theyâ&#x20AC;&#x2122;re well-funded by government to ensure that care plans, regular reviews and referrals are done in a systematic and formal manner.â&#x20AC;? While Keith freely acknowledges the busy schedule of most GPs, heâ&#x20AC;&#x2122;s a firm believer in grabbing every chance to spread the word. â&#x20AC;&#x153;The core message is prevention because the long-term complications are serious

and costly. These days, despite the time pressures on a GP, you really have to focus on opportunistic screening. If a mother comes in with a couple of overweight children Iâ&#x20AC;&#x2122;ll make the most of that opportunity to have a chat about diet.â&#x20AC;?

Ms Felicity Willis is the accredited dietician at PNML and sees her role as supporting the GP and empowering people to self-manage their diabetes.

are triaged according to their needs and advice from their GP. We run a series of group sessions. The first is an introduction with input from the dietician and the physiotherapist and the second covers complications, medications and advice from a podiatrist.â&#x20AC;? â&#x20AC;&#x153;Everyone in my family has diabetes so I guess it might be heading my way sometime.â&#x20AC;?

â&#x20AC;&#x153;We have the luxury of spending time with people such as Chris at a baseline appointment and then at three, six and 12 months. And, if needed, I see them more frequently than that. These services are free.â&#x20AC;?

Despite that, the future may not be unduly bleak. Some important research is being done including a study at Fremantle Hospital into pre-diabetic men and testosterone levels, says Teresa. And Chrisâ&#x20AC;&#x2122;s case is both satisfying and rewarding.

Medicare Locals are designed to be part of the fabric of community medicine and Felicity is hopeful for their future, at least in the short-term.

â&#x20AC;&#x153;When you see good outcomes it makes it all worthwhile. The Medicare Local model makes it a lot easier for people to manage their diabetes.â&#x20AC;?O

â&#x20AC;&#x153;There have been comments about funding cuts in the recent budget. Iâ&#x20AC;&#x2122;m under the impression that weâ&#x20AC;&#x2122;re safe until 2016. Thatâ&#x20AC;&#x2122;s important because primary health care in this context is playing a major role in addressing diseases like diabetes.â&#x20AC;?

By Mr Peter McClelland

DIABETES SERVICES

â&#x20AC;&#x153;Speaking about Chris specifically, the parameters his GP gave us indicated obesity was an issue and both the Diabetes Educator and I spoke about that at the first appointment. Weâ&#x20AC;&#x2122;ve seen a vast improvement with Chris but for others itâ&#x20AC;&#x2122;s not quite so rapid. Nonetheless, theyâ&#x20AC;&#x2122;re being educated about the condition and hopefully that will give them some goals to improve their selfmanagement.â&#x20AC;? â&#x20AC;&#x153;A lot of the same doctors refer to the program, but we have a large catchment area [see right] and Iâ&#x20AC;&#x2122;m not sure all GPs are fully aware of what we can do to help.â&#x20AC;?

Ms Teresa DiFranco the PNML Diabetes Educator/Pharmacist reiterates the importance of a coordinated approach and acknowledges a personal dimension to this increasingly pervasive disease.

t 1/.- DPWFSFE UIF MPDBM HPWFSONFOU BSFBT PG 8BOOFSPP +PPOEBMVQ BOE PG 4UJSMJOH BCPVU QFPQMF PWFS B TR LN BSFB

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25 doctors are currently taking the ﬁrst course. The second course commences Saturday 26 July, 9:30am – 12:30pm for 10 weekly sessions at The Law Lecture Theatre, 1st Floor, Law Building University of Western Australia.

Windlestone Education does not hold an Australian Financial Services Licence and does not provide ﬁnancial advice of any kind. Windlestone Education is a provider of education services only. Windlestone Education is not afﬁliated with either the University of Western Australia or the University of Melbourne. 26

medicalforum

Guest Column

Primary Care to Close the Gap The commitment to Indigenous health has seen improvements to services but have they improved health outcomes, asks researcher Dr Dan McAullay PhD.

rof Neil Thomson reflected in Medical Forum [May Edition] on his 37 yearsâ&#x20AC;&#x2122; experience working in Indigenous health. His piece identified the key indicators of health (life expectancy and infant mortality), how these have improved and how major contextual events have led to positive change. One of those contextual changes has been the growth of Aboriginal Medical Services from the first established in 1971, and the $4.6b commitment to Closing the Gap initiative, with $1.6b to be spent on health alone. As a member of the Nyoongar community of the South West and a health services researcher, I consider it is now time to focus on outcomes, their importance and the need to monitor and evaluate care alongside them. It is also time to consider what role practitioners can play in shifting these outcomes.

medicalforum

There is no doubt that the large financial and policy investment by Federal, State and Territory governments has gone a long way to addressing these disparities. However, despite these investments there has not been the major shift in outcomes we might have hoped. There are now estimated to be more than 150 Aboriginal Community Controlled Health Services (ACCHS). Of these, there are 20 in WA, which are now intrinsic components of the primary health care system. However, what is in unclear is the role these services and indeed all primary health care providers play in changing outcomes. Social determinants continue to be the overriding driver of outcomes. There is little published evidence demonstrating primary health careâ&#x20AC;&#x2122;s contribution to addressing this disparity in health outcomes and the burden of disease experienced by Aboriginal people. Having worked across a number of related practice, policy and research settings there is now a

demanding need for primary health care research in this area. I write this as we wait with interest and concern at the proposed budgetary changes to Medicare proposed by the Federal government. If they pass unchanged as proposed it is even more important to study outcomes and how these legislative changes will impact on them. However, regardless of these changes, there are some important efficiencies that can be made in the system. One of these is to foster an environment that values and encourages integration across the health care system. Primary health care providers are essential to connecting what at times are disparate parts of the system. If we embark on a process of integration we may be able to see improvement in outcomes. ED: Dr McAullay is a consultant on Aboriginal child health and is affiliated with ECU, Telethon Kids Institute and the Australian Primary Health Care Research Institute (ANU).O

Feature

Drugs, Doctors and Patients â&#x20AC;&#x201C; ADRs Doctors prescribe drugs to good effect, mostly, but how do we react when prescriptions react unfavourably? Medical Forumâ&#x20AC;&#x2122;s interest in this topic grew from our story of a woman in her 30s who suffered a stroke while taking the oral contraceptive pill (OCP). We wondered if any of her attending doctors reported this possible serious drug reaction? Earlier, we had written about high rates of medications amongst elderly Australians, particularly those in aged care facilities. These prompt the question, how well does the opt-in reporting system protect medication users?

applied to Australia, this means about 120,000 drug reactions went unreported in 2012 alone. Are there significant health impacts from this?

The importance of reporting

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It is undeniable there is marked underreporting by health professionals and others but the question is why â&#x20AC;&#x201C; time pressures, not wanting to dob, uncertainty over who is responsible, poor understanding of what to report, fear of bureaucracy, leaving it to others, competing interests, or something else? We have learnt from WAâ&#x20AC;&#x2122;s Fluvax controversy in 2010 that inadequate reporting may be costly for both consumers and the public purse. An estimated 90-95% of adverse drug reactions are not reported to regulators, according to some researchers (1). When

July

ll e-Po

The TGA requests the reporting of adverse events involving any drugs or vaccines (whether prescription, over the counter or complementary) but in particular: t 4VTQFDUFE BEWFSTF FWFOUT JOWPMWJOH OFX medicines and vaccines (a vaccine reaction reported to State Health will be forwarded to the TGA) t 4VTQFDUFE ESVH JOUFSBDUJPOT

t 4FSJPVT BEWFSTF FWFOUT JOWPMWJOH UJNF PÄ&#x152; work; hospital admission; increased hospital stay; extra investigation or treatment; danger to life; death; or birth defects.

Who reports? 2012 statistics show only 5% of ADR reports were directly from GPs, 11% from hospitals (which includes hospital pharmacists), 13% from Health Departments, 7% from community pharmacists and 4% from consumers. The lionâ&#x20AC;&#x2122;s share, about 57%, were from pharmaceutical companies, with reports more than doubling between 2008-12.

ADRs: Whatâ&#x20AC;&#x2122;s happening in Western Australia 165 General Practitioners responded to this editionâ&#x20AC;&#x2122;s e-Poll (64% male). Thanks to those who passed on valuable information on ADRs â&#x20AC;&#x201C; there were no significant differences in responses linked to gender.

1. Which of the following statements most closely aligns with what you do in reporting a possible Adverse Drug Reaction (ADR) to the TGA?

2. If you had to put a figure on it, what proportion of possible adverse drug reactions do you report to the TGA? 0%

23%

Rarely report, as very few adverse reactions encountered.

27%

1-25%

43%

26-50%

Mostly forget to do it, despite encountering adverse reactions.

12%

51-75%

76-99%

100%

Limit my reports to those I consider most serious

39%

I report the majority of possible reactions

Other

Doesnâ&#x20AC;&#x2122;t apply

Doesnâ&#x20AC;&#x2122;t apply 8%,

Uncertain 8%

It is mandatory for â&#x20AC;&#x2DC;pharmasâ&#x20AC;&#x2122; to pass any serious report to the TGA within 15 days, although the TGA encourages health professionals to report directly to them rather than through drug sponsors or manufacturers. About one third of reports received by the TGA in 2013 were submitted online, the remainder by email, fax, bluecard, etc. Our survey of GPs in WA shows that knowledge of ADR reporting systems is lacking. For example, most doctors should be getting emailed drug alerts from the TGA, yet only 5% in WA are using this service.

Your access to report data The TGA introduced the publicly searchable Database of Adverse Event Notifications (DAEN) in 2012. [ED. This database contained no record of the adverse event of our young female patient.] It searches both medicines and medical devices, as far back as 1971 and up until three months ago (see www.tga.gov.au/daen/daen-entry.aspx) In 2010, the Medicines Safety Update replaced the Australian Adverse Drug Reactions Bulletin, published every two months in Australian Prescriber. On the TGA website are also: t "VTUSBMJBO 1VCMJD "TTFTTNFOU 3FQPSUT â&#x20AC;&#x201C; the TGAâ&#x20AC;&#x2122;s evaluation of recently registered prescription medicines including effectiveness and safety information. t 1SPEVDU *OGPSNBUJPO 1* BOE $POTVNFS Medicine Information (CMI) for prescription and some non-prescription medicines. t "MFSUT XIJDI (1T DBO TVCTDSJCF UP Reference (1) Hazell L, Shakir SAW. Under-reporting of adverse drug reactions: A systematic review Drug Saf 2006: 29(5); 385-396 - http://www.cs.berkeley.edu/~daw/ teaching/c79-s13/readings/AdverseDrugReactions. pdf O

ADRS: HOW TO REPORT? t A3FQPSU B 1SPCMFN BU XXX UHB HPW BV t 4VCNJU WJB .*.4 POMJOF JG SFHJTUFSFE t VTJOH B A#MVF $BSE PSEFSFE GSPN PS BES SFQPSUT!UHB HPW BV PS EPXOMPBE BU UIF 5(" XFCTJUF

By Dr Rob McEvoy

ED. 39% of respondents to question 1 said they limited their reports to those they considered most serious (and another 12% said they mostly forgot to do this). In question 2, a similar proportion of GPs (43%) said their reporting to the TGA amounted to a quarter or less of ADR possibilities encountered, and another 23% said they did not report any ADRs. 28

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Guest Column

Food Crisis – What are the Solutions? UWA agricultural scientist Prof Graeme Martin says that clear thinking and decisive action now will avert a food and climate crisis in the future.

Examples: genetically inherited resistance to blow-fly infestation to replace the ‘mules’ operation (removal of perineal skin without anaesthesia); genetic selection and better management for neonatal lamb survival.

ver the next few decades, our ability to meet humanity’s need for food will be challenged as two sets of forces collide – demand for food will escalate with rapidly increasing human population, but our capacity to produce food will be compromised because our agricultural lands are coming under pressure from climate change, land degradation, and urbanisation. Added complications are the growing demand for animal protein in developing nations and the competition for land from biofuels.

Animal products and human health Ignoring antibiotic resistance, the management of human health is generally moving from control of infectious diseases to control of lifestyle diseases. This is directly relevant to the future of livestockbased foods. Obviously, the ‘clean’ in CGE addresses the risk of contamination and food safety, but food health is a much broader issue and includes dietary balance for humans, as well as the concept of ‘nutraceuticals’ such as the conjugated linoleic acids (CLA) found in meat and milk. (Take note: Grass-fed ruminants produce more CLAs than grain-fed ruminants). Should dietary CLAs be proven to improve human health, we will be ready.

So, how do we feed the world without destroying the planet? We need to reassess all of our options with an open mind, including food industries based on ruminant animals such as cattle and sheep. The current popular view is that ruminants cause more problems than they solve. Two common cries: t ćFJS DPOUSJCVUJPO UP HMPCBM XBSNJOH – ruminants probably produce 12% of Australia’s emissions; this might be a dribble compared to the flood from electricity production, but it must be addressed; t ćF AXFTUFSO EJFU JODMVEFT UPP NVDI NFBU – a luxury has become a staple source of energy and protein, and a major contributor to health issues in developed countries; better balance is needed.

Caution in our approach Considering the looming food crisis, we must be careful of a simplistic approach such as ‘abandon animal industries’. The value of ruminants is that they are basically a mobile fermentation vat that can digest biomass that we humans cannot digest, then convert it into food that we can, namely milk and meat. Monogastric animals (pigs, chickens) cannot do this. Instead, especially in industrialized settings, they have to be fed what is effectively potential human food. To find an intelligent solution to food security, we need to address the issue of balance in the human diet, rethink the roles of the intensive chicken and pig industries … and ask the cows to eat grass! In this context, UWA’s livestock scientists have developed a vision for ‘clean, green and ethical’ (CGE) livestock management that is relevant to Australia and being demonstrated on a real farm in the UWA Future Farm 2050 Project.

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UWA Future Farm 2050 Project The CGE vision Clean: reduced dependence on drugs, chemicals and exogenous hormones. There is considerable market pressure to do this anyway, but how can we do it? We manage the environment and genes of our animals. Proven examples: male pheromones to control the reproductive system rather than hormone treatments; genetically inherited resistance to gastro-intestinal nematodes to replace drugs (to which the worms are now resistant, anyway). Green: livestock industries have led to feral pests, landscape damage, and pollution. Ruminants burp methane, a greenhouse gas that is 23 times stronger than carbon dioxide, and their carbon footprint is exacerbated by infertility because females that fail to reproduce are effectively producing only methane. This magnifies the consequences of delayed puberty, postpartum infertility, embryo mortality and postnatal mortality. How can we change it? Again, we manage the environment and genes of our animals. Proven examples: discovery of Australian native forage plants that reduce methane output; genetic selection for reduced methane emissions; improve fertility and fecundity. Ethical: the obvious issue here is animal welfare, often seen by farmers as reducing productivity. In fact, it improves productivity. How do we do it? We manage the environment and genes of our animals.

Clearly, business as usual will not be good enough. Rather than wait for the world to panic, the UWA Future Farm 2050 Project aims to define and implement the ‘ideal’ farm for its environment now – both the raising of animals and crops – and show that it is profitable. The UWA Future Farm aims to strengthen links between food producers and food consumers (primarily city inhabitants), and between the university and our communities and industries. This means engagement with producers and local authorities and, most importantly, with city and rural schools. Finally, UWA Future Farm must also demonstrate a commitment to the conservation of biodiversity. Australia is a world champion in biodiversity loss – from 2000-2010, the number of threatened fauna rose from 332 to 432. Australian farmers are responsible for about 60% of our national landscape so they must be seen as part of the solution, not the cause of the problem. This concept is built into the ‘green’ aspect of CGE management, but the Future Farm will go further by re-establishing biodiversity in the non-profitable parts of the farm and integrating biodiversity management into all farm practices. Further reading: http://theconversation.edu.au/biodiversity-and-farmingfinding-ways-to-co-exist-6331 Nature (London) 507, 32-34 (2014). www.nature.com/ news/agriculture-steps-to-sustainable-livestock-1.14796 www.ioa.uwa.edu.au/research/future-farm O

Guest Column

Respecting Rights of All Road Users Cyclists and motor vehicle drivers must share the road, says cardiologist Dr Brendan McQuillan.

many are less than 18 years of age.

edia articles have promoted the mistaken view that cyclists who disregard traffic regulations are the cause of most multivehicle cyclist related crashes. In fact, Australian data consistently contradicts this with the motor vehicle at fault in about two thirds of crashes.

The columnist should not be aggrieved, however, as our children pay in other ways. Between 2000 and 2009, more than 130 children were killed or seriously injured while cycling on WA roads. In fact many did not make it to the roads as they were struck while riding on the footpath by a car travelling on a driveway.

It is disappointing to read a newspaper column (The Sunday Times, Memo: Cycling Egomaniacs. You don’t own the road) that portrays cyclists as arrogant road hogs undeserving of a motorist’s consideration just four days after a young woman was killed while riding her bicycle in Mt Lawley. The subject is too serious to be handled in such an uninformed and insensitive way. We are asked to be grateful that on this particular morning, the columnist was actually paying attention to the road user in front of her. Inattention was the major contributing factor to 24% of fatal motor vehicle crashes in WA in 2011. More than 15% of the crashes causing cyclist death and serious injury result from a sideswipe from a vehicle travelling in the same direction as the cyclist, similar to the circumstances described in this article. Fortunately the writer did not expect praise for not killing a cyclist “because a lot of cyclists are basically ungrateful dickheads”. Perhaps a traffic conviction would be sufficient reward? Such a portrayal is effectively promoting

Cycling is the fourth most popular physical activity for children with 60% of them cycling regularly. Cyclists younger than 18 are more likely to be at fault in bicycle-motor vehicle crashes and less likely to be wearing helmets, with inattention and inexperience important contributing factors. Perhaps education might be a more appropriate response than running them over in a car?

motorist aggression towards cyclists. On WA roads between 2000 and 2009, over 500 cyclists (57% of the total) were killed or seriously injured in incidents involving another vehicle on roads with a posted speed limit of less than or equal to 50km/h. How much does our progress on these suburban streets need to be impeded before we can justifiably kill someone? We are told, “the details are irrelevant” as “the people who actually pay for licence and registration” are wrongly blamed. In fact, over 85% of cyclists also own motor vehicles and pay the same fees. Of those who do not,

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

Senior Financial Adviser Authorised Representative 296710

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

WA roads are becoming more congested and we are increasingly frustrated by traffic delays but there is no data that cyclists significantly contribute to this problem. In fact increasing cycling can reduce traffic congestion. Cyclists are convenient scapegoats and vulnerable road users on whom to vent drivers’ frustrations. Education and reinforcement of current regulations regarding the use of bicycle helmets and road rules for cyclists are essential. While it is easy to promulgate worn stereotypes in search of ironic humour, causing death or serious injury to a cyclist while driving a car is never funny. O References on request

GESB Award Winning Financial Adviser Les has over 14 years experience as a licensed ﬁnancial adviser with over 5 years as a Senior Financial Adviser with GESB Financial Advice and is a multiple award winner of the GESB Financial Adviser of the Year. Les has specialised knowledge to create tailored tax-effective strategies to maximise your beneﬁts from: GESB West State Super GESB Gold State Super

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Guest Column

The GP-Specialist Divide Dr Sean Stevens says we are attracted to what we do because of who we are. Excellence in our work is encouraged by mutual respect.

t’s one of the biggest decisions that faces every graduating medical student – specialise or do general practice? The first inkling I had that I should do general practice was when my favourite was doing outpatient clinics and seeing the people I’d help fix during their recent hospital stay. After a stint as a medical registrar I did a GP term and knew I’d found my vocation. I have the utmost respect for my specialist colleagues. Our medical system is world class and built on the precept of the GP being the gate-keeper, sorting out most conditions and being able to refer to the expert knowledge of our specialist colleagues when needed. Sometimes, however, the respect for our different roles is not always reciprocated. The constant refrain I get from the basic GP registrars who land in my surgery from the teaching hospitals is, “I had no idea general practice was so hard”. The teaching hospital notion that general practice is dealing with coughs, colds and sore holes and then referring on anything complicated is so far

from the truth that I’d challenge anyone who holds that view to sit with me for a day! To my mind the main difference between a career as a GP and a specialist are those of status, pay, variety and clinical uncertainty. Different specialties tend to attract different personality types, in my experience. There are exceptions to every rule of course. If you like attention to detail and prefer avoiding patient contact, you’re probably better off as a pathologist or radiologist.

To my mind the main difference between a career as a GP and a specialist are those of status, pay, variety and clinical uncertainty. If you love procedures, keeping busy and less chit-chat, then surgery beckons. If you have a strong academic bent, like ongoing study and enjoy learning a great deal about a

narrow field then physician training may well be your thing. If, like me, you like variety, long-term patient/family relationships, the challenge of dealing with multiple conditions and dealing with complex social issues, then general practice is your calling. It’s just that in my 16 years in the profession, I’ve found GPs dealing with an increasingly complex case load of chronic disease due to our ageing and fattening population. We deal with prevention, acute illnesses, chronic illnesses, diagnostic dilemmas, minor procedures, psychological/psychiatric issues – and maybe all in the same consult! I sometimes wonder if I would prefer being a specialist. I don’t think you can really know the answer without doing the job for yourself but I strongly suspect for me, the answer would be no. At the end of the day, we all have a difficult job to do and we need to respect each other’s roles. We’re all built differently and we each need to find our own niche in this broad church that is the medical fraternity. O

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CLINICAL UPDATES

Managing sun damaged skin W

hen actinic/solar keratoses develop, why and how should we treat them? Actinic keratoses may progress to squamous cell carcinoma (SCC), but they can also regress or remain stable.

Both actinic keratoses and squamous cell carcinoma demonstrate p53 mutations, suggesting they may exist along a malignant spectrum. They are often bothersome and a nuisance to patients, causing rough skin and catching on clothing. There is no universal or sweeping rule that can be applied to answer the question of how we treat them. There are many options and considerations when choosing an appropriate treatment.

Treatment options Cryotherapy is a useful spot treatment. It is ideal for scattered individual lesions or hypertrophic actinic keratoses. It can cause hypopigmentation (particularly on the face) and ulceration (particularly on the lower legs) if over-applied. Do not freeze pigmented lesions without a firm diagnosis prior (a lentigo maligna melanoma may mimic a pigmented actinic keratosis). Efudix™ (5-fluorouracil), Aldara™ (imiquimod), Picato™ (ingenol mebutate)

and Solaraze™ (diclofenac) are the available topical therapies for actinic keratoses. Treatment regimens vary, depending on the patient, prescribing doctor, topical therapy chosen and site of application. Diclofenac has the longest treatment duration (months), but less of an inflammatory reaction. Imiquimod and 5-fluorouracil have intermediate treatment durations (weeks), but there is often an inflammatory reaction, which may require time away from work. Ingenol mebutate is a relatively new treatment offering the shortest inflammatory reaction and treatment duration (days). Repeat and combinations of topical therapies are often used and required to maintain sustained long-term efficacy. Topical keratolytics such as salicylic acid help to reduce the roughness and scale of actinic damage, improving feel and cosmesis, particularly on the limbs. Topical retinoids, such as tretinoin, assist with facial photo-rejuvenation, for those with milder actinic damage. Photodynamic therapy (PDT) is a useful field treatment for actinic keratoses but its use may be limited by availability, cost and patient discomfort. A photosensitising cream is applied to the actinic keratoses followed by

The cure is the problem – steroid-induced dermatitis? S

teroid-induced dermatitis requires a back-to-basics approach to manage patients who are frustrated by their condition. These cases remind us that prescribing steroids for facial use must be well thought out and monitored.

It is seen as a result of using topical corticosteroids for an extended period of time, usually two months. It can be seen after shorter or longer durations, or even infrequent intermittent use. In rare cases it can occur with inhaled or systemic steroid use. Affecting the face, it usually presents as a papular or pustular eruption, with varying

Q Perioral dermatitis

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degrees of erythema and scaling. The erythema is usually confluent and can even be quite diffuse in severe cases. Most patients will describe burning and pruritus, with “sensitivity” or even pain. If extra-facial sites are affected then other diagnoses have to be considered.

Always consider other causes These include seborrhoeic dermatitis, atopic dermatitis, rosacea, acne, contact dermatitis (allergic or irritant), infections and lupus. Skin scrapings, swabs, and even a skin biopsy can be quite helpful – especially in those that present atypically, fail to respond to management, or are recurrent. If an allergic contact dermatitis is suspected, patch testing may help, and a full contact history is required. The difficulty in most cases is the patient’s dependence upon the steroid – they believe it is helping them. They will also be concerned about the original problem that required the steroid in the first place. Hence, they are not happy to stop the steroid. For me, this is the most important focus of the consult. I spend plenty of time hearing them out and

By Dr Tony Caccetta, Dermatologist, Perth Dermatology Clinic. Tel 9328 5007. irradiation with red or blue light. Carbon Dioxide (CO2) Laser Resurfacing is a useful treatment for actinic cheilitis. Like PDT, it may be limited by availability and cost. The inflammatory reaction can be brisk and require significant after care. Acitretin is a useful chemo prophylactic for those with severe actinic damage and squamous cell carcinoma. This is commonly used for patients who develop multiple squamous cell carcinomas in the setting of immunosuppression and organ transplantation. Acitretin can have significant side effects and is a teratogen. Nicotinamide may be a useful treatment in the future, as it may prevent the immunosuppressive effects of UV light on the skin. A firm knowledge and understanding of these treatments coupled with experience in their use will assist the practitioner in achieving the best patient outcomes. O Author competing interests – no relevant disclosures.

By Dr Philip Singh, Murdoch Dermatology Services. Tel 9366 1951 explaining the conundrum that steroid use is now the main problem.

Basic approach to management Incorporate a gentle soap-free cleansing regimen morning and night. Use preservative-free and fragrance-free moisturisers. Avoid any exacerbants, including cosmetics, other topical medications, “facials”, etc. Strict photoprotection is required. Manage patient expectations; advise that the eruption will flare before getting better, that time (up to months) is required but complete resolution is the norm. Consider step-down or tapered topical steroid withdrawal in very severe cases (to minimise flare response). Consider tetracycline or macrolide antibiotic (e.g. doxycycline 50mg BD until clear, taper off over a few weeks). Don’t hesitate to contact your Dermatologist.O

Author competing interests: no relevant disclosures. 33

medicalforum

CLINICAL UPDATE

Update: blepharitis By Dr Graham Furness, Ophthalmologist

use of gentle baby shampoo, can be used to clean the lids and lashes. Cleaning the lids helps remove skin flakes, eye discharge, foreign particles and bacteria, all of which irritate the lids and eyes and contribute to blepharitis.

lepharitis’ covers a wide selection of inflammatory disorders of the eyelid margins and adjacent structures that may also be part of more widespread dermatologic conditions, including rosacea and seborrhea. The causes of blepharitis are often poorly understood. The condition is generally incurable, and the goal of treatment is to reduce the signs and symptoms and make the eyes more comfortable

Eyelid tear quality important The eyelids have a series of glands that help form the tear layer that covers the eyes. Some glands make up the watery parts of tears, other glands make up an oily part that keeps the tears stable and keeps the eyes comfortable. The glands that make up the oily components are called Meibomian glands. When the tear layer is well formed, the eyes are generally comfortable and see well. Blepharitis affects the Meibomian glands, either by reducing or stopping oil secretion, or by making the secretion of poor quality and irritable to the eye.

Symptoms There are several types of blepharitis but these may contain common signs and symptoms. Symptoms that affect the eyes can include stinging, burning, watering, blurred vision, grittiness and itchiness. Signs can include chronic redness of the eyes and edge of the eyelids, flaking of skin and crusting of the edges of the eyelids and the development of styes on the lid edges. Blepharitis may be caused by chronic low-

Eye drops also help. These can vary from simple artificial tears that bring comfort, to steroid drops that reduce inflammation, and even antibiotic eye drops to deal with bacteria on the eyes and lids contributing to this condition. Q Unstable tear ﬁlm causes grittiness and intermittent watering

grade infection of the eyelids, chronic inflammatory disorders of the skin such as rosacea, and also by seborrhea, where the oil secretion of the Meibomian glands is of a poor quality. These different causes require different treatments.

Q Lid margin redness, sometimes with crusting around lashes

General treatment Blepharitis is generally incurable. The goal of treatment is to suppress the cause of the particular type of blepharitis the person has and to bring comfort to their eyes. Warm compresses, face cloths soaked in warm water, can be rested against the closed eyelids for several minutes at a time. The warmth helps the oil flow out of the Meibomian glands which is healthy for the glands and helps restore the tear layer. Massaging the eyelids can also help the glands deliver oil better. Hygiene of the eyelids is also important. Over-the-counter lid scrubs, or even the

In some cases, especially those cases associated with dermatologic conditions such as rosacea, systemic treatment such as low doses of tetracycline given orally over several months may help. Tetracycline is an antibiotic but also helps modify the body’s inflammatory immune response so that inflammation is lessened on the eyelids and greater comfort is given to the sufferer. O Declaration: Perth Eye Centre P/L, managing the Eye Surgery Foundation, supports this clinical update through an independent educational grant to Medical Forum. Author: No competing interests.

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CLINICAL UPDATE

When testosterone replacement is in contention P

atients with testosterone deficiency as a result of pituitary and/or gonadal dysfunction may be suitable for testosterone replacement therapy. More contentious is the clinical picture of possible hypogonadism with no history of antecedent causes and low borderline testosterone levels (just above PBS qualifying criteria for testosterone prescription).

Screening Possible clinical indicators of hypogonadism are: t t t t t t

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It is important to determine if other possible causes of these symptoms are involved (e.g. metabolic syndrome) and to remember that men over the age of 40 or so, undergo a natural decline in testosterone of 2-3% per year.

Why show caution with testosterone therapy?

picture of testosterone deficiency becomes less clear and testosterone levels are beyond the PBS threshold for replacement (i.e. two morning bloods <8nmol/L, or 8â&#x20AC;&#x201C;15nmol/L and LH >13.5U/L) the decision to trial testosterone replacement for three months first requires a thorough risk:benefit analysis for each patient and full patient education. For example, is reduced libido a compensation for erectile dysfunction and is a reduction in energy levels the direct result of physical inactivity and visceral obesity, rather than testosterone deficiency? During the trial, changes in the clinical picture are monitored as testosterone is increased (preferably 20nmol/L or above).

Which method of testosterone delivery? The most commonly prescribed methods are either transdermal preparations such as AxironTM, TestogelTM and Androforte5TM

Two recent observational studies found a significantly increased risk of cardiovascular events among groups of men over age 65 with a history of heart disease, who were prescribed testosterone. On the other hand, various studies have shown that testosterone replacement significantly reduces insulin resistance, fasting blood glucose, HbA1c, cholesterol, waist circumference and waist-to-hip ratio. As well, the strongest independent risk factors for coronary artery disease are increasing age and male gender, which usually coincides with a marked fall in serum bioavailable testosterone. Clearly, these contradictory views require further research.

The assessment of borderline cases The Case Study (see inset) presents a clearcut case of someone likely to benefit from testosterone replacement. As the clinical medicalforum

or intramuscular preparations such as Reandron 1,000TM or SustanonTM. The advantages of daily transdermal application is that the dose can be more easily titrated, the patient does not need to attend every three months and, in theory, daily applications provide some diurnal rhythm of testosterone. However, with some topical preparations about 15% of men do not absorb testosterone sufficiently for this to be an effective treatment. Intramuscular preparations are excellent for men who have trouble remembering to apply topical testosterone or who are nonresponders. The down side is the need for 10-12 weekly consultations and fluctuating testosterone from high to low during the injection cycle. O References available on request

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Testosterone replacement (TR) does not cause prostate cancer but may fuel cancer cell growth. This risk can be mitigated by initial examination, ongoing questioning for prostatism, and monitoring PSA levels every six months. Androgen-induced increases in haemoglobin and haematocrit levels in some patients can increase the risk of stroke or DVT. Again this risk can be mitigated by regular (six monthly) testing and therapeutic venesection as required.

By Dr David Millar, WA Sexual Health Centre, Hollywood Specialist Centre, Nedlands. Tel 93891400

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CLINICAL UPDATE

Testicular cancer

By Dr Jerard Ghossein, Urologist, Mt Lawley. Tel 9224 2185

esticular cancer represents just over 1% of all male neoplasms (706 new cases in Australia during 2010), the most common solid (i.e. non haematogenous) cancer in men aged 18 to 39, of which 90-95% are seminomas and non-seminomatous germ cell tumours (NSGCT). Most are Stage 1 at the time of diagnosis. Testicular tumours show excellent cure rates. This is due to early diagnosis, careful staging and treatment with a combination of surgery, chemotherapy and radiotherapy to which testicular tumours are extremely sensitive. Testicular cancer is uncommon in boys under 15 and in men over 60, with the incidence of NSGCT peaking in the third decade of life, and pure seminoma in the fourth decade. Infants and boys below 10yo may develop yolk sac tumours and 50% of men over 60 with testicular tumours will have lymphoma rather than a tumour of testicular origin. Benign stromal tumours of the testis make up less than 5% of adult testicular tumours.

Risk factors Regular testicular self-examination and yearly scrotal ultrasound is recommended for men with risk factors. These include a history of cryptorchidism, Klinefelter’s syndrome, familial history of testis cancer in first-grade relatives, presence of contra lateral tumour and infertility. (A possible association between testicular microlithiasis and cancer has not been confirmed, so routine surveillance is not recommended for microlithiasis.)

Diagnosis Patients usually present with a painless testicular mass, often detected following

Q Non-seminomatous tumour replacing almost the entire testis.

a history of minor trauma, for which a thorough examination should include examining for lymphadenopathy and abdominal masses. A scrotal ultrasound should be performed for a suspected testicular tumour – a malignancy generally appears as a hypoechoic mass. Serum tumour markers (AFP, HCG, and LDH) are used in both the diagnosis and follow up – their initial values and kinetics pre and post op are important for staging and prognostic purposes. If a combination of clinical and ultrasound findings suggests a testicular tumour then urgent referral for review is recommended.

Treatment depends on staging If a testicular tumour is suspected then an inguinal orchidectomy would be performed with en bloc removal of the testis and the spermatic cord on the affected side. Frozen section is seldom used due to a high false negative rate. Further treatment depends on the type and stage of tumour. Testicular tumour staging uses the TNM system, which takes account of: the degree of local extension (pT stage) on histopathology of any orchidectomy specimen; retroperitoneal and mediastinal lymphadenopathy on CT imaging; and tumour markers.

Q Ultrasound scan of right testis showing hypoechoic testicular lesion suspicious of primary testicular malignancy. 38

Stage 1 seminoma: Retroperitoneal recurrence risk is 15-20%, for which cisplatin chemotherapy or para-aortic radiotherapy may be considered. An alternative is continued surveillance with regular CT scanning, depending on available facilities and patient compliance with the strict follow-up regime. Chemotherapy and radiotherapy for disease recurrence or

progression past Stage 1 disease has very good outcomes. Stage 1 NSGCT: Risk stratification is according to histopathology that includes evidence of vascular invasion. For low risk patients (no vascular invasion, no significant embryonal element) close, long term followup is recommended. For patients unwilling to comply, adjuvant chemotherapy or nerve sparing retroperitoneal lymph node dissection can be considered. In higher risk patients (vascular invasion) two courses of BEP chemotherapy (bleomycin, etoposide, cisplatin) are recommended. For higher grade tumours of these types, adjuvant treatment is chemotherapy (most common in Australia) or retroperitoneal lymph node dissection. Treatment for other types of testicular cancer would be dependent on tumour type and staging.

Fertility and follow up Aside from the effect of orchidectomy on fertility, patients who may be candidates for post-operative chemotherapy are advised to consider sperm banking because of the high incidence of oligo and azoospermia following chemotherapy. Improvement in sperm count post chemotherapy occurs in up to 80% of patient after five years, and the probability of a normal sperm count at five years is around 58%. Follow up is rigorous, comprising physical examination, tumour markers, and imaging. Their frequency and timing depends on tumour type, stage and prior treatment. Patients unwilling or unable to comply may be offered more aggressive/alternative treatment initially. O Author competing interests – no relevant disclosures

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CLINICAL UPDATE

Referral for short stature W

ith almost 70% of referrals to the Department of Endocrinology at Princess Margaret Hospital related to short stature, puberty and thyroid disorders, and wait times for appointments as long as 9-12 months, it is hoped that standardised referral-templates will reduce wait times and doubling-up of investigations. As well, cooperation with referring practitioners and patient satisfaction will improve. This article introduces our approach to short stature, not related to failure-to-thrive.

If the reason for referral is primarily to consider growth hormone therapy for short stature, take particular notice of the boneâ&#x20AC;&#x201C;age analysis. If this shows fused growth plates >13.5 years in girls or >15.5 years in boys, then no endocrine referral is needed because there are no treatment options to increase height once growth plates are fused.

When to worry t 1PPS IFJHIU WFMPDJUZ BTTPDJBUFE XJUI symptoms suggestive of a brain tumour â&#x20AC;&#x201C; these may need urgent MRI of brain and pituitary. t *G B DIJME JT TIPSU BOE JO QVCFSUZ UIJT may increase the urgency of referral.

By Clin A/Prof Aris Siafarikas, Dept Endocrinology and Diabetes, Princess Margaret Hospital. Tel 9340 8090

Facts to remember: t *G XFJHIU JT EFDSFBTJOH NPSF UIBO MFOHUI height, refer to gastroenterology prior to endocrinology. t $POTJEFS HFOFUJDT SFGFSSBM JG EZTNPSQIJD features are present. t 3BOEPN HSPXUI IPSNPOF MFWFMT BSF /05 useful, please consider measuring IGF-I and IGF-BP3 instead. t *(' * MFWFMT XJMM PGUFO CF MPX JO QBUJFOUT with low weight and may NOT be

indicative of growth hormone deficiency. t .JEQBSFOUBM IFJHIU .1) FRVBUJPO JT DIFFERENT for boys and girls: MPH = [(motherâ&#x20AC;&#x2122;s height) + (fatherâ&#x20AC;&#x2122;s height)] Ăˇ 2, plus 6.5cm in boys and minus 6.5cm in girls Note: Detailed information on criteria for therapy with subsidised growth hormone in Australia can be obtained under: www. pbs.gov.au/info/browse/section-100/growthhormone-programme. O

Clinical findings

Pre-referral workup

Referral essentials

Current height less than 1st percentile for age on CDC growth charts, or Crossing percentiles downwards on repeated growth measurements at least three months apart.

Evaluation of mid-parental target height. TSH, free T4, full blood count, liver function tests, urea and electrolytes, calcium, alkaline phosphatase, coeliac screening (anti-tissue transglutaminase â&#x20AC;&#x201C;IgA and -IgG), urinalysis. X-ray left hand and wrist for boneâ&#x20AC;&#x201C;age analysis if more than 2 years of age. Consider: IGF-I (Insulin like growth factor-I). IGF-BP3 (Insulin like growth factor binding protein 3). and for females: karyotype for Turner syndrome.

All clinical notes and laboratory results including growth chart. Please include information on parental height and onset of puberty. Boneâ&#x20AC;&#x201C;age results. Please have parent bring a copy of boneâ&#x20AC;&#x201C;age x-ray (CD or film) to visit.

CLINICAL OPINION

Men and health checks By Dr Jenny Brockis, GP and Lifestyle consultant. Tel 0408 092 078

very hour, four men are said to die from conditions that are potentially preventable. Men, on average, drink more alcohol, smoke more, engage in more high risk activities, have higher levels of obesity and diabetes and die an average of five years earlier than women.

a healthy lifestyle includes regular checkups, appropriate to their age.

In a recent poll of over 1100 men, 58% had private health insurance and a family physician that they knew and liked, but didnâ&#x20AC;&#x2122;t attend for regular health checks. An additional 36% said they would only go to their doctor if they were extremely sick.

Women are often grateful to have the opportunity to coax, cajole and nudge their male partners into going for a checkup. Providing women with a handout on preventative health initiatives for men may be gratefully received as ammunition to help them get their counterpart over the surgery threshold.

Making male health checks as normal as going to the footy needs an ongoing push. The common excuses given include: â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m fine, why go if Iâ&#x20AC;&#x2122;m not sick?â&#x20AC;? or â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m too busy.â&#x20AC;? Perceptions can change. For example, who would have forecast the growth of menâ&#x20AC;&#x2122;s cosmetics and grooming products 10 years ago? Whatâ&#x20AC;&#x2122;s needed is a fresh approach to engage men in the idea that a normal part of medicalforum

The two main helpful strategies are to first engage men to raise awareness of what is normal. Second is removing the barriers to access the health checks.

Engage your allies to help

The business of promoting health awareness requires all surgery staff to actively participate and could include events such as a healthy menâ&#x20AC;&#x2122;s breakfast, sporting event or menâ&#x20AC;&#x2122;s health information session. Public Campaigns like Movember have been very successful at elevating awareness

of the need for menâ&#x20AC;&#x2122;s health checks and making them appear as a normal part of staying well in our society.

Remove the barriers Men donâ&#x20AC;&#x2122;t like going to doctorsâ&#x20AC;&#x2122; surgeries, so take the message to them, to their work, and sporting and community events. Men donâ&#x20AC;&#x2122;t like waiting but often they are worried about taking time off from work, or their priority is that work comes first. Busy executives, with long working days and travel commitments and shift workers, are often grateful to find a doctor who provides flexible consulting hours. Meet them on their turf â&#x20AC;&#x201C; use community and workplace support. The rapid growth of Menâ&#x20AC;&#x2122;s Sheds has provided an excellent avenue for doctors to provide information and hold discussions about menâ&#x20AC;&#x2122;s health issues. The DIY Health Toolbox provided to these types of groups employs user friendly items that feature positive health messages and referral pathways. Why not have your own male health toolboxes to hand out in your surgery? O References available on request. 39

CLINICAL UPDATE

Exercise in heart failure T

Tips for patients to keep exercise safe:

oday, patients with chronic health conditions ride bikes, work out in the gym and walk the City to Surf, all in the interest of keeping healthy. Regular exercise also benefits people with heart failure â&#x20AC;&#x201C; several studies have shown that regular aerobic exercise confers survival benefits. Moreover, resistance exercise improves muscle strength and endurance and can help restore muscle mass.

Prolonged rest used to be a cornerstone of heart failure management. So why the policy about-face? The rationale is simple; heart failure changes body physiology to mimic profound physical deconditioning, including peripheral vasoconstriction, changes in skeletal muscle metabolism, and in severe disease, muscle wasting. Add in activity avoidance, and patients with heart failure can enter a downward spiral of exercise intolerance that eventually makes even modest physical tasks difficult. The good news is that regular exercise, given the right advice for comfort and safety, can reverse these changes. Patients can improve their ability to undertake daily physical tasks, from domestic chores to playing with grandchildren, which brings a better quality of life.

By A/Prof Andrew Maiorana, School of Physiotherapy and Exercise Science, Curtin University & Advanced Heart Failure and Cardiac Transplant Service, RPH.

Such exercise causes people to: breathe more heavily without getting puffed out; exert muscles without needing to stop; and sweat lightly rather than perspire profusely. For many people with heart failure, initial exercise for 30 minutes may seem unattainable. However, this time can be broken into multiple bouts of exercise over the day, for a cumulative effect on a personâ&#x20AC;&#x2122;s health. In fact, for people just starting or those who have low fitness, exercise in (at least) 10 minute intervals, with breaks in between, will improve exercise tolerance. Durations of exercise bouts are increased as tolerated.

How much exercise?

How safe is exercise for people with heart failure?

Guidelines are similar to those for the general population â&#x20AC;&#x201C; to accumulate at least 30 minutes of moderate intensity activity on most days of the week.

Exercise at a moderate intensity is very safe â&#x20AC;&#x201C; no deaths have been reported in over 120,000 patient hours of exercise, in published trials of exercise training.

t 4UBSU DPOTFSWBUJWFMZ CVJME VQ HSBEVBMMZ t -FBSO UP SFBE CPEZ TJHOBMT F H HFUUJOH TP puffed that a conversation becomes difficult is probably overdoing it. t %PO U FYFSDJTF JG TJHOT PS TZNQUPNT PG worse or poorly controlled heart failure are present (i.e. weight gain >2kg over 48 hours, worsening SOBOE, unusual palpitations, orthopnea or PND). t %PO U FYFSDJTF JO UIF IFBU t "EKVTU FYFSDJTF UP BDDPVOU GPS Ä&#x2DC;VDUVBUJOH health and medications.

What type of exercise is best? Two forms of exercise should be included: i) Aerobic exercise is endurance activity that can be maintained for extended periods (at least 10 minutes) and is the most effective exercise for improving cardiorespiratory fitness e.g. walking and cycling. (The guideline of 30 minutes of moderate intensity exercise refers to aerobic exercise.) ii) Resistance exercise (usually lifting weights) improves muscle strength, which is important for tasks such as carrying shopping, gardening and even getting up from a chair. An appropriate intensity is when a weight can be lifted 15 times with good technique and without straining, but there is localised muscle fatigue. Resistance exercise needs to be conducted 2-3 times a week to be effective. O

Introducing Western Australiaâ&#x20AC;&#x2122;s ďŹ rst comprehensive specialist liver centre. Based in the new McCourt Street Medical Centre, The Liver Centre WA will provide expert care for all forms of liver disease and cancer. Our team of Hepatologists, Surgeons, Specialist Nurses and Dietitians will thoughtfully approach each patientâ&#x20AC;&#x2122;s clinical condition with a commitment to long-term appropriate treatment.

Led by Prof Luc Delriviere and Prof Gary Jeffrey, Surgical and Medical Heads of the West Australian Liver Transplant Service at Sir Charles Gairdner Hospital, The Liver Centre WA will create a central point of referral for the integrated management of any liver condition and liver cancer including hepatocellular carcinoma, cholangiocarcinoma and colorectal metastases. Abdominal wall, biliary and bariatric surgery will also be available under the care of Prof Luc Delriviere and Dr Stephen Watson.

The Liver Centre, WA McCourt Street Medical Centre Unit 10 / 2 McCourt Street, West Leederville 6007 PO Box 6273, Swanbourne 6010 T: (08) 6163 2800 F: (08) 6163 2809 E: welcome@thelivercentrewa.com.au W: www.thelivercentrewa.com.au 40

medicalforum

Q&A Clinical

Q A

â&#x20AC;&#x153;With more â&#x20AC;&#x2DC;Crystal Methâ&#x20AC;&#x2122; available these days, what in particular should concern doctors.â&#x20AC;?

Methamphetamine, or crystal meth, is now second only to cannabis in terms of prevalence of use, and is one of the most problematic illicit drugs for health services. The illicit market is supplied from large overseas or smaller backyard laboratories in Australia. Sold as a powder or in crystal form, Response: Dr Allan methamphetamine is injected or Quigley, Director Clinical vaporised in a glass pipe and inhaled. Services, Next Step Drug & In the 2010 National Drug Strategy Alcohol Services Household Survey, 3.4% of Western Australians aged 14 and over selfreported amphetamine or methamphetamine use in the last 12 months, with use being highest in people aged 20-29 years. Methamphetamine is rapidly addicting and can profoundly change a personâ&#x20AC;&#x2122;s mental state and behaviour including aggression, violence and acute psychosis. Police arrest, ED presentation and psychiatric hospital admission can result. While the outâ&#x20AC;&#x201C;ofâ&#x20AC;&#x201C;control methamphetamine user reported in the media can be an everyday reality for acute health services, alcoholâ&#x20AC;&#x201C;related hospitalisations are many times higher. Less severe patterns of methamphetamine use are also common to general practice. The patient may present seeking help for withdrawal symptoms that can include irritability, mood swings and insomnia. Other substance use disorders, anxiety, depression, PTSD and trauma may also be present. Their partner or parents may be desperate and concerned about the personâ&#x20AC;&#x2122;s wellbeing and the disruption they are currently bring to relationships and family life. While alcohol and opioid dependence have specific pharmacological treatments such as acamprosate, naltrexone and methadone, the pharmacological treatment of methamphetamine dependence is largely symptomatic â&#x20AC;&#x201C; antipsychotics, benzodiazepines and antidepressants are the medications of choice. More complicated problems can be referred to a local Community Alcohol and Drug Service for specialist assessment and counselling. In 2011-12, amphetamine type stimulants accounted for 18% of all treatment episodes provided by the alcohol and drug treatment services in WA (compared with 47% for alcohol). Amphetamine users can be difficult patients to engage as they are often irritable, restless and impatient and focused on shortâ&#x20AC;&#x201C;term solutions and medication. Symptomatic treatment for mood swings, anxiety, depression or insomnia should usually be dispensed in small quantities (e.g. no more than 3 daysâ&#x20AC;&#x2122; medication) to avoid misuse. Patients and families benefit from counselling and brief interventions effectively provided in primary care. At times, there may be more contact with a patientâ&#x20AC;&#x2122;s partner or a parent than themselves. Early treatment can be frustrating for all involved but over time many patients do very well, which can be very rewarding for the treating doctor. O

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Prof John Yovich

Reproduction Across Borders â&#x20AC;Ś WAâ&#x20AC;&#x2122;s unnecessary and onerous laws During the 1980s, WA was at the forefront of assisted reproduction, introducing well-managed IVF and ART procedures to the world. Accolades were forthcoming from European, American and Asian colleagues, who sought Western Australian help but the mood in Perth was very different. The political response to a GLIĂ&#x20AC;GHQW PHGLFDO VRFLHW\ and anxious community was to rely on feminist social scientists of the day who held views about â&#x20AC;&#x153;exploitingâ&#x20AC;? womenâ&#x20AC;&#x2122;s bodies for commercial gain, causing multiple pregnancies, or worse, â&#x20AC;&#x153;usingâ&#x20AC;? women to treat male problems. Further, east coast colleagues were unhappy about WA capturing the limelight, and exploited the fears and tribulations. This all caused WA to rush into legislation â&#x20AC;&#x201C; the WA Human Reproduction Act (1991) â&#x20AC;&#x201C; and the additional Surrogacy Act %RWK HQVXUHG WKH SURFHVV ZRXOG EH D GLIĂ&#x20AC;FXOW MRXUQH\ DQG RQO\ SRVVLEOH LQ D WUXO\ DOWUXLVWLF VHWWLQJ L H QR Ă&#x20AC;QDQFLDO recompense for donors or surrogates. The bottom line is that an increasing number of West Australians travel overseas to mainly India and Thailand, seeking young egg donors and surrogate women for their embryos. They by-pass some of the worldâ&#x20AC;&#x2122;s best IVF centres in Perth and surrogates have their pregnancies managed where maternal and perinatal mortality is sub-optimal compared to Australia. At a recent Brisbane symposium, we heard that over 1000 Australian women returned from Asia last year seeking to have their accompanying child registered as their own, succeeding where DNA evidence ZDV FRQĂ&#x20AC;UPDWRU\ From my perspective, the WA HRT Act (1991) confers no positive value and should be repealed. We are adequately covered by the Medical Act (1884 plus amendments) and an Australian Code of Practice (2014 upgrade) under the Reproductive Technology Accreditation Committee, a self-regulatory body linked to the HIC for Medicare rebates. Furthermore, the Surrogacy Act should EH DGMXVWHG DORQJ WKH OLQHV RI 4XHHQVODQG ZKLFK LV OHVV RQHURXV for patients. A more mature community outlook is needed â&#x20AC;&#x201C; some Ă&#x20AC;QDQFLDO UHFRPSHQVH IRU GRQRUV DQG VXUURJDWHV IRU WKHLU DFWV RI assistance.

ED: Further assistance Treatment services through the Alcohol and Drug Information Service (ADIS) on 9442 5000 or 1800 198024.

NOW AT 2 LOCATIONS

Booklet: Psychostimulants Information for Health Care Workers at www.dao.health.wa.gov.au/Informationandresources/ Publicationsandresources/Healthprofessionals

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

medicalforum

PERTH & BUNBURY

Medical Students

Shaping a Medical Career Three young medical students travelled to remote and challenging locations in Uganda, Swaziland and China as participants in the prestigious Alan Charters Prize. “It was a different ballgame in Africa. Half the things I see in lectures and textbooks you just don’t see in Perth. It’s all there in Kisiizi.” Hsern had a somewhat unusual entry into medicine transferring across from the Dental faculty at UWA.

Q Hsern Tan with some children of Kisiizi in Uganda.

hen Hsern Tan, the winner of the 17th annual Alan Charters Prize, stepped onto the dusty street outside Entebbe Airport in Uganda it was the beginning of a wonderful albeit confronting experience. Hsern was en route to the remote village of Kisiizi.

“It was a cultural shock going from the departure lounge in Doha airport complete with a Ferrari shop to Entebbe airport where there was no computer and customs officers took down my passport details by hand!”

“I just couldn’t see myself doing dentistry for the rest of my life. I found it a bit limited in its focus whereas medicine has such a wide range of specialties. I’m interested in head and neck anatomy and hopefully heading for ENT surgery where there’s lots of cool toys and gadgets.”

“One doctor covers all the specialties from paediatric surgery to burns and orthopaedics. It was quite amazing!” Hsern says on a practical level, there’s a distinct difference between his experience at Kisiizi and the difficulties of hospital rotations as a final-year medical student in Perth. “Here there are a lot of students and we’re all competing for available places. A lot of it comes down to how proactive the student is and if you display a real interest, you can be involved quite a lot.” 42

“I had pretty realistic expectations because I’d done a stint in Bangalore, India. You think you’re pretty ready for a medical placement in rural Africa but the poverty was confronting.” “One of the hardest things going through medical school is having the confidence to make decisions and manage patients well. In Siteki, particularly in relation to infectious diseases, it reinforced the importance of good clinical assessment and going back to basics when taking a patient history and making an initial examination.” “I was in Carnarvon last year at the Rural Clinical School, which was a great

“It’s also a specialty that’s easy to set up in terms of travelling to developing countries. I’m a committed Christian and I’ve been blessed with opportunities, so I believe you should give something back.”

“But it’s the dream of every medical student to do lots of ‘hands on’ stuff and I had plenty of opportunity in Kisiizi. They have seven doctors in a 300-bed hospital serving a population of around 300,000. I spent most of my time on the surgical ward and even got to intubate a patient.” “They have a general medical, surgical, maternity, paediatrics and psychiatry ward and I was exposed to a lot of different cases. It’s a completely different world because the medical staff are so resource poor but manage to cope with very little equipment.”

reaffirmed some of the basic tenets of effective practice and was an invaluable opportunity to develop decision-making skills.

experience. Indigenous health is a real issue and we have similar problems to those in Africa. HIV affects about 26% of the Swaziland population and it was a shock to see patients a few years older than me [Usha is 24] who are already Stage 4.”

Q Usha Manickavasagar, centre, in Siteki, Swaziland.

The trip to Africa prompted Hsern to reflect on a broader level regarding expatriate medicine and its relationship with developing countries. “You go to these countries for a few weeks, do some interesting work and feel good about yourself. I expanded my medical knowledge but I felt a bit uneasy. What have I really contributed? What have I left behind?” Usha Manickavasagar is no stranger to medicine in a challenging environment. Her trip to the village of Siteki in Swaziland

Usha grew up in Port Hedland so is well aware of the impact of doctor shortages in rural areas and her trips to India and Africa have shaped her preference for a career in general medicine. In the meantime, her next hurdle is her intern year. “It’s certainly been helpful having older sisters who are in medicine. They’re both at RPH, one as a resident and the other a registrar. I know what’s coming.” The Guangxi province near the South China Sea is a sensitive political area close to the border with Vietnam. Madeleine Kannegiesser-Bailey went to the small provincial city of Beihai and found it to be an eye-opening experience. “There were good days and bad days. It was medicalforum

“There is a large discrepancy between the major cities in China with world-class facilities and rural areas with no primary care. In the provinces you have patients presenting with late-stage diseases and there’s been cases of bribery to gain preferential treatment.” Madeleine freely admits that her career direction has been shaped by her elective placement. “It’s given me a strong impetus to advocate for the profession and take all these opportunities for professional development.”O

Q Madeleine Kannegiesser–Bailey in Guangxi Province, China.

quite isolated with little Western influence and not many people spoke English. I don’t speak Mandarin and I was the only student from Australia so it was quite challenging. If I wanted to travel somewhere, I’d have to show the driver a photo of the destination!” Madeleine provides a disturbing picture of the hazards of practising medicine in the People’s Republic of China. “One of the local doctors had worked for eight years in a bone-marrow transplant team at a major hospital in Beijing. He told me the story of a well-respected professor who delivered a poor prognosis to a leukaemia patient. The next day he came back, locked the doctor in his office, threw flammable liquid over himself and threatened to set him alight.” “It stems from the belief in some of the poorer rural areas that Western medicine can cure everything. They’re not aware of its limitations and this isn’t helped by the Chinese Communist Party which publishes optimistically inflated expectations. It’s a catalyst for violence against doctors.” medicalforum

Ed: The annual prize is named after Dr Alan Charters (1903-1996) a long-time teacher of tropical medicine at UWA. It is awarded to the three Level 5 students who give the best presentation on their elective placement with a specific focus on social and public health issues.

By Mr Peter McClelland

Food is Medicine

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Public Health

WORKING

IN THE

BIG PICTURE

The typhoon in the Philippines last November took Dr Linda Selvey into the heart of the devastation and gave some insights into the politics at play. Dr Linda Selvey has many strings to her bow â&#x20AC;&#x201C; medical doctor, cancer researcher, public health advocate, environmentalist and, more recently, academic at Curtin Universityâ&#x20AC;&#x2122;s School of Public Health. Late last year Linda travelled to the Philippines as one of only a handful of Australian doctors chosen by WHO to assist with efforts to prevent diseases spreading after Typhoon Haiyan left 6166 dead and 28,626 injured. i* E EFTDSJCF NZTFMG BT B 1VCMJD )FBMUI .FEJDJOF 4QFDJBMJTU XIP T JOUFSFTUFE JO UIF CJH QJDUVSF * GJOE JU GVMGJMMJOH UP IFMQ PO B MBSHFS TDBMF DPNQBSFE XJUI B POF PO POF BQQSPBDI "GUFS )BJZBO JU XJMM CF ZFBST CFGPSF UIF IFBMUI TFSWJDFT SFDPWFS JO UIF 1IJMJQQJOFT w 5IF QBTTJPO UP FOHBHF PO B CSPBE DBOWBT JT SFGMFDUFE JO -JOEB T GPDVT PO UIF IVNBO QBQ JMMPNB WJSVT GPS IFS 1I% 4IF TUVEJFE XJUI 1SPGFTTPS *BO 'SB[FS BU BO FBSMZ TUBHF PG IJT TUFMMBS DBSFFS i* E BMXBZT XBOUFE UP EP NFEJDBM SFTFBSDI BOE BU UIF UJNF UIF LOPXMFEHF CBTF JO JNNVOPMPHZ XBT HSPXJOH SBQJEMZ *U XBT B WFSZ FYDJUJOH UJNF UP CF JO UIBU GJFME * N UFBDI JOH B VOJU BU $VSUJO FOUJUMFE &QJEFNJPMPHZ PG *OGFDUJPVT %JTFBTFT TP UIPTF BSFBT BSF DMPTF MZ MJOLFE BOE GMPX JOUP UIF BSFB PG EJTFBTF TVSWFJMMBODF w i* XFOU UP UIF 1IJMJQQJOFT KVTU BGUFS 5ZQIPPO

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Role of aid agencies -JOEB TVHHFTUT UIBU TPNF PG UIF TNBMMFS PSHBOJTBUJPOT BSF TPNFXIBU QSPUFDUJWF PG UIFJS QBUDI i5IF DVSSFOU USFOE JT UP NBOBHF EJTBTUFST PO B MPDBM MFWFM TP XIFO WBSJPVT BHFODJFT DPNF UP IFMQ * UIJOL UIFSF T BO POVT PO UIFN UP TFF UIFNTFMWFT BT QBSU PG UIF CJHHFS QJD UVSF .BOZ PG UIFN BSF JO UIF GJFME GPS B TIPSU UJNF BOE UIFZ SF QSJNBSJMZ BOTXFSBCMF UP UIFJS EPOPST 5IFSF IBT UP CF CPUI CFUUFS DPNNV OJDBUJPO BOE B XJMMJOHOFTT UP UBLF EJSFDUJPO w "GUFS UIF )BJZBO EJTBTUFS UIF BGGFDUFE SFHJPO BUUSBDUFE B HMPCBM SFTQPOTF XIJDI UP B DFS UBJO FYUFOU FYBDFSCBUFE UIF QSPCMFN i" MPU PG DPVOUSJFT BSPVOE UIF XPSME IBWF B TUSPOH DPOOFDUJPO XJUI UIF 'JMJQJOP QFPQMF 5IFZ GPSN B MBSHF EJBTQPSB BOE DPOTFRVFOUMZ UIBU NFBOT B MPU PG TNBMMFS PSHBOJTBUJPOT DPNF PVU PG UIF XPPEXPSL 5IBU T B XPO EFSGVM UIJOH CVU JU NBEF B DPIFSFOU SFTQPOTF DPPSEJOBUJPO PG UIJT EJTBTUFS NVDI NPSF DIBM MFOHJOH w i5IF DPODFQU PG UIF 4VQFS 5ZQIPPO JT B OFX POF CVU JU T MJLFMZ XF MM TFF NPSF PG UIFTF FWFOUT w

Q Dr Linda Selvey

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Mr Peter McClelland

medicalforum

Wine Review

AgeYouth Perfect Blend of

2013 Fermoy Estate Semillon Sauvignon Blanc

By Dr Martin Buck

.Z QFSTPOBM QSFGFSFODF XJUI 4BVWJHOPO #MBOD 4FNJMMPO CMFOET JT GPS FOPVHI PG UIF 4FNJMMPO UP HJWF UIF SFTVMUBOU CMFOE B GVMM QBMBUF 5IJT IBT B MJWFMZ HSBQFGSVJU BOE MJNF OPTF XJUI HSFBU EFQUI BOE GJOJTI 5IFSF JT CBMBODF BOE DPNQMFYJUZ NBLJOH UIJT B TPMJE QFSGPSNFS *O B SFHJPO PG QMFOUZ UIFSF JT OP TIPSUBHF PG HSFBU DIBSEPOOBZT CVU 'FSNPZ JT BMM BCPVU CBMBODF BOE B CJU PG #VSHVOEZ

* IBWF WJTJUFE 'FSNPZ &TUBUF PO B DPVQMF PG PDDBTJPOT CVU OPU GPS B GFX ZFBST 5IF WJOFZBSE BOE DFMMBS EPPS BSF MPDBUFE JO BO JEZMMJD MPDBUJPO PGG $BWFT 3E JO .BSHBSFU 3JWFS * SFNFNCFS B CFBVUJGVM FWFOJOH QMBZ JOH QFUBORVF XJUI B HMBTT PG DBCFSOFU JO POF IBOE TPBLJOH VQ UIF WJOFZBSE TDFOFSZ 5IF PSJHJOBM PXOFST FTUBCMJTIFE UIF WJOFZBSE JO BT POF PG UIF GJSTU JO UIF OFX EFWFMPQ JOH .BSHBSFU 3JWFS SFHJPO "O JOJUJBM IB IBWF CFFO JODSFBTFE UP IB PG QSFEPNJ OBUFMZ $BCFSOFU BOE 4FNJMMPO 5IFSF IBT CFFO B SFDFOU DIBOHF JO PXOFSTIJQ CSJOH JOH B OFX ZPVOH XJOFNBLJOH UFBN BOE BO VQEBUF PG UIFJS MBCFMMJOH 'FSNPZ &TUBUF JT B QSPWFO QFSGPSNFS JO UIF .BSHBSFU 3JWFS SFHJPO BOE UIF DVSSFOU XJOFT BSF B DPMMJ TJPO PG "VTUSBMJBO GSVJU BOE TVCUMF 'SFODI JOGMVFODFT 5IFSF BSF TPNF WFSZ JOUFSFTUJOH XJOFT BOE * UIJOL * NJHIU IBWF UP SFUVSO GPS B NPSF EFUBJMFE UBTUJOH BOE BOPUIFS HBNF PG QFUBORVF

2012 Fermoy Estate Chardonnay 5IJT XJOF IBT BSPNBT PG OFX 'SFODI PBL XJUI NBOEBSJO BOE DJUSVT IJOUT 5IFSF JT B CSJMMJBOU NPVUI GJMM PG OFDUBSJOF GMBWPVST BOE B DSJTQ BDJE GJOJTI 5IF PBL JOGMVFODF JT EFMJDBUF BMMPXJOH UIF GSVJU GMBWPVST UP TIJOF 5IJT XJOF XJMM FBTJMZ EFWFMPQ GVSUIFS BOE JT SFDPNNFOEFE

2011 Fermoy Estate Cabernet Merlot 5IF SFE XJOF QPSUGPMJP IJHIMJHIUT UIF NBUVSF GSVJU BWBJMBCMF BOE UIJT CMFOE JT B HSFBU WBMVF XJOF &OUJDJOH BSPNBT PG QMVNT DJHBS CPY PBL BOE QMVNT HJWF DPNQMFYJUZ 5IF QBMBUF JT XFMM CBMBODFE XJUI TPGU UBOOJOT *U T B NBUVSF XJOF XJUI HPPE DFMMBSJOH QPUFOUJBM

2012 Fermoy Estate Cabernet 5IJT JT ZPVOH BOE MJWFMZ GPS B SFE XJOF BOE TIPXT GBOUBTUJD GSVJU XJUI NFMMPX TPGU UBOOJOT 5IFSF JT MJLFMZ NPSF FYQFOTJWF PBL UIFSBQZ JO UIJT XJOF BOE JU TIPXT * SFBMMZ MJLF JU BOE BN IBSE QSFTTFE UP TFQBSBUF JU GSPN B ZPVOH #PSEFBVY *U IBT HSFBU DFMMBSJOH QPUFOUJBM

2011 Fermoy Estate Shiraz 5IJT 4IJSB[ PS QFSIBQT 4ZSBI XBT UBTUFE MBTU BOE CZ OP NFBOT BO BOUJ DMJNBY *U IBT QMFOUZ PG KBNNZ GSVJU BOE PBL BSPNBT XJUI TPNF QFQQFS GSVJU BOE CBMBODFE PBL GMBWPVST "MM UIF SFET TIPX UIF CFOFGJUT PG NBUVSF GSVJU BOE HSFBU XJOFNBLJOH

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Car Review

ROCKERS R OCKERS RELIVE RELIVE

A CLASS ACT The new BMW Coupe is a big dose of luxury and performance which puts Dr Mike Civil in a spin. The latest 650i BMW Gran Coupe with M-Sport Package certainly has an imposing presence as it sits on the dealership forecourt. It is one of those cars that looks perfect in Sapphire Black – Henry Ford, who famously commented “it is available in any colour, sir, providing its black” – would be pleased.

nels to watch. I still can’t quite understand why you would choose to go and sit in your car rather than your lounge to watch the latest episode of Top Gear, but it does underline the level of sophistication and wizardry available in the Coupe.

It has the incredible combination of luxury and performance and you rapidly appreciate the level of luxury when the salesman takes 15 minutes to ‘briefly’ go over its many features.

If you did choose to watch a movie in your car, you could pick a lot worse locations than the front seat of a BMW Coupe. The leather interior is sublime, with excellent air conditioning and the added feature of air conditioned seats though perforated leather. Having first decided that this was probably an unnecessary gimmick, I changed my mind when remembering how shirts get stuck to sweating skin on those long hot drives to meetings in the Perth heat.

In pride of place, and dominating the centre of the dashboard, is the high definition screen that displays GPS navigation, what your mobile phone is doing, what the radio is playing and myriad of other fancy functions. No longer do you need to ferret in the glove box for the car owner’s manual, it is on the screen. Once your mobile phone has been ‘found’ by the ever present blue tooth technology, you can check emails, have your text messages read out to you (yes, I did say ‘read’ out to you) and do more mundane things such as make calls, without taking your attention too far from the road ahead.

Intuitive wizardry But, that’s not all. If you are stationary, you have a full complement of TV chan46

Unlike some modern cars that are overloaded with electronic gizmos, BMW has mastered a more intuitive use of technology. Despite some initial nervousness, it was really very straight forward.

The seat can be moved to any number of positions, offering different levels of lumber support, side support, upper back support and even parts of the body you didn’t think needed supporting! All electronic, of course. But, enough of the creature comforts… how does the car go?

Granny to Gran Prix Needless to say there is keyless entry and a big ‘start/stop’ button. The car is automatic, with manual override. There

are flappy paddle gear changes if you so wish and a number of different ‘ride’ set-ups. These range from an environmentally friendly ‘frugal’ mode, to two levels of ‘comfort’ mode and finally two levels of ‘sport’ mode. To reassure the friendly salesman, I move away from the dealership in the default ‘comfort’ mode. With ooddles of V8 power on tap, I wend my way back home in the Saturday morning traffic. Perth has chosen this particular weekend to end the long Summer drought and there is a steady light rain falling. Regardless of my concerns about bringing the car back in one piece, I just have to see what difference ‘sport’ mode makes. While waiting at traffic lights, I move the necessary switch. There appears to be a lot going on for a few seconds. I know that the suspension is being firmed up, the steering possibly being tightened, the ECU being remapped, but I did not expect to ‘feel’ the changes being made. It is almost as if the car is having a pit stop and a team of BMW mechanics are running over the car and making the necessary adjustments. The difference is clear but without a private testing track and the weather limiting, there will be no envelope-pushing performances this weekend.

Invisible performance Acceleration is effortless, braking very reassuring and handling generally per-

medicalforum

Supporting young men with Androgenetic Alopecia Rising awareness and social acceptance is prompting more men in their teens and early 20â&#x20AC;&#x2122;s to seek advice for Androgenetic Alopecia. Nedlands based, immediate past president of International Society of Hair Restoration Surgery, Dr. Jennifer Martinick says hair loss can be devastating for young men. Psychological effects, feelings of loss of youth, identity and sexuality can lead to depression or suicidality. These men are vulnerable, often misinformed and try ineffective, unscientific /expensive â&#x20AC;&#x2DC;snake oilsâ&#x20AC;&#x2122; to regrow hair, leaving them disappointed/out-of-pocket. General practitioners should be sensitive, supportive, reassure and advise about clinically approved medical /surgical treatments. Quick Facts: 1 70% of men suffer Androgenetic Alopecia 2 Onset: puberty to fifties 3 Family History: not always positive 4 Polygenic inheritance 5 5alpha reductase increases DHT production ,miniaturising terminal follicles 6 Gradual Loss, usually following a classical pattern with retained occipital fringe

fectly neutral. My only criticism is that the â&#x20AC;&#x2DC;other worldâ&#x20AC;&#x2122; level of luxury numbs you to the high level of performance of the car. The only real indication that I am pushing along at a fair rate of knots is the way everyone else is so slow and, of course, the heads-up display panel. As a lover of performance cars, I appreciate the need to be able to feel that you are going quickly, but still be friends with the necessary speed limits. Without that heads-up display I would be rapidly pushing my luck, and then handing over my licence to our friendly lads in blue. Despite a slight loss of that visceral connection to the road that you get with out-and-out sports cars, the BMW 650i Coupe is a very accomplished machine. Supreme levels of luxury and all manner of in-car aids mean that every trip is a pleasure. Itâ&#x20AC;&#x2122;s a little too classy for me, but thatâ&#x20AC;&#x2122;s my problem and not a flaw of the Beamer. O

BMW 650I GRAN COUPE 1SJDF PG DBS UFTUFE ESJWF BXBZ . 4QPSU 1BDLBHF JT B OP DPTU PQUJPO 5FTU DBS DPVSUFTZ PG "VUP $MBTTJD 7JDUPSJB 1BSL

CONSULTATION CRITERIA 1. Exclude other causes of hair loss Patchy loss? Consider Alopecia areata, Cicatricial alopecias, Trichotillomania, Syphilitic Alopecia, Tinea Capitis Diffuse loss? Consider Telogen Effluvium, medication side effect, dietary deficiencies, systemic disease Consider scalp biopsy or Dermatology referral. 2. Support and empathy It is normal for men to be concerned with body image; there is no shame getting help. Have them express their feelings and assess for depressive symptoms; consider counseling. 3. Educate patient Hair loss continues throughout life. Medical treatments are effective short /medium term. Surgical hair transplantation is the only permanent treatment. 4. TGA Approved Treatments Minoxidil 5% topically daily. Minoxidil up-regulates VEGF, retaining and regrowing hair. Finasteride 1mg daily Finasteride, a 5 alpha reductase inhibitor, blocks over 70% DHT. It regrows terminal hairs in the vertex and midscalp. Recent claims of persistent sexual dysfunction after cessation of Finasteride have caused controversy. Clinical trials covering nearly 13 million total patient years have shown no definitive link. Lasercomb 655 nanometre wavelength stimulates mitochondrial activity 2mm into the skin. Research suggests a decrease in cell apoptosis. Note: all other commonly advertised medications/remedies do not have TGA approval and lack evidence for efficacy or safety Surgical hair transplantation Modern hair transplantation provides permanent and natural results. Patients interested in surgery or those who have failed with medical treatment can be referred to a hair loss physician who can assess them for suitability for surgery. Further information: www.ishrs.org or Dr. Jennifer Martinick 9386 1104. Author of the article is Dr Sara Kotai MBBS Hons.

medicalforum

Travel

Singapore

Connection

Singapore has been a longtime stopover hub for Perth travellers. There is so much to do on the island nation you may want to stretch your stay for a few days. IBWF B CBMM "U FWFSZ UVSO TPNFUIJOH OFX JT PO PGGFS o UIF ESJOL XJUI B WJFX SPPGUPQ TXJNNJOH QPPM FYUSBPSEJOBSZ JOEPPS BOE PVUEPPS HBSEFOT OJHIU MJGF HBMMFSJFT BOE EJT QMBZT XJUI BSDIJUFDUVSF UP NBSWFM BU UIFNF QBSLT BOE NPSF *O GBDU UIF DJUZ BOE TVS SPVOET IBWF B %JTOFZ 8PSME GFFM UP UIFN &WFO BGUFS GJWF EBZT ZPV XJMM SVO PVU PG UJNF

Singapore has strong links to Perth â&#x20AC;&#x201C; the same time zone, the home of many fee-paying students, and a popular destination for medical conferences (e.g. recent combined RACS and ANZCA conference). It may seem too conďŹ ned as a long-term prospect for space-loving Australians, but it is clean, modern, tourist-friendly, safe and diverse for the visitor.

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Social Pulse

k A APM-Avant Ris Seminar risk

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Bethesda GP Educatio n

Bethesda Hos pital hosted a GP educat evening on br ion east cancer m an delivered by Dr R ichard M agement artin, Dr Wen Chan Yeow and Dr Farr ah Abdul Azi z

held a Avant and AAPM ar at the in m se t managemen Club. Nedlands Yacht

Q The older architecture of the Fullerton contrasts nicely with the newer Pavilion and restored Waterboat House.

Q 1. Avant Presenter Marianna Kelly with Avant state manager Ms Claire Turton. 2. AAPMâ&#x20AC;&#x2122;s Ms Laura Harnett and Ms Karin Tatnell. 3. Ms Belinda Marmion and Ms Helen Lane, from Mead Medical.

Q Dr Richard Martin, Dr Jennette Kelsall, Dr Farah Abdul Aziz, A/Prof Yasmin Naglazas

medicalforum

Q As you take the walkway through the Marina Bay Sands Hotel to the Gardens by the Bay, Singapores neat skyline, roads and Singapore Flyer catch your attention.

Q Chinatownâ&#x20AC;&#x2122;s streets have a bustling and shambolic atmosphere that many visitors enjoy.

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Q The Cloud Forest dome, one of two massive climate controlled homes for plants and a global warming educational centre.

Q A view of the Marina Bay Sands Hotel and Skypark from within the fully enclosed Cloud Forest dome.

By Dr Bruce Bridges

GPs Imaging Educational

Imaging Cen tral â&#x20AC;&#x2122;s Dr Sanj ay Nadkarni Dr Mark Ham and lin hosted an education din for GPs at th e University ner Club to discu managemen ss pain t for osteopor osis.

Q Top; Dr Vasanthi Thev, Dr K. Jayaraman and Dr G. Gargett Above: Dr Geoff Emery, Dr Henrietta Byran

Q 1. (L to R) Dr Jeff Veling, Dr Peter Tallentine, Dr Jennifer Pike 2. (L to R) Dr Vasanthi Thevarajah, Dr Mark Hamlin, Dr Allan Hutchinson 3. (L to R) Joel Scaddan, event organiser Sarah Wilson, Dr Yuranga Weerakkody

Music Travel

Something for All Ages JJuly uly l is i music i monthh iin nP Perth ertth with i h some world world-class ld class l music-makers heading our way. Q James Clayton

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medicalforum

Theatre

WAR & PEACE As we commemorate the wars of the 20th century this year, Bell Shakespeare company digs 400 years ago for the complexities of courage and sacrifice.

Q Damien Ryan

‘We few, we happy few, we band of brothers’’ These words may have been written over 400 years ago capturing the nationalism of the English on the eve of the ‘glorious’ Battle of Agincourt, but Henry V’s stirring speech in Shakespeare’s play has found itself whipping up patriotic fervour on a world stage ever since.

the French though thousands are slaughtered.”

It is regularly appropriated by kings, queens and politicians (maybe even a few sporting coaches) but most famously by Winston Churchill as the Battle of Britain waged over London skies in 1941.

“London was bombed for 71 nights – 57 of them, consecutively. It became a way of life to head into these shelters and the boys of the Boys Club, who had been missing a lot of school, started to read and recite plays. They would rehearse five nights then on the Thursday night they would put on a performance. It became an anticipated entertainment for those in the shelter.”

And for director Damien Ryan, it was this recent evocation that has inspired his production of Henry V for Bell Shakespeare, which heads to Perth this month. Damien admits to having a troubled relationship with this play and has sweated over how to bring it to a modern theatre audience.

The good, bad and ugly “It’s an ugly story that aggrandises war in many ways. Henry is a godlike hero in England, yet he starts a pre-emptive war against a sovereign country and does it with corrupt church funds. He moans that he doesn’t have enough men to beat

“And yet within the play are ambiguities and it’s in these spaces, a story I read years ago came to me. It was about a group of boys, known as the Boys Club, who were said to have performed for people huddling in at a bomb shelter at Marble Arch at the height of the Blitz in 1941.”

“Henry V was heavily performed during World War II, with Churchill using it in his own orations and, of course, Sir Laurence Olivier dedicated his film of Henry V to the pilots of the Battle of Britain.”

Ambiguities abound This sense of a boys’ own adventure underground is contrasted starkly by the world being bombed to shreds above them and when Damien returned to

Shakespeare’s text, he believed its ambiguities allowed for this split narrative – the excitement of a story about war with its tales of courage and heroism and its brutal, destructive reality. “War does bring out amazing human qualities and virtues in some moments and unthinkable violence and brutality in others. I’ve never been able to confirm it, but it is said the boys’ bomb shelter took a direct hit and many people died.” When Medical Forum spoke to Damien, he wasn’t sure how his play would end. “It will be worked on in rehearsal. What Shakespeare gives us is a coda. Soon after Agincourt, Henry dies, England loses France and England bleeds. He says it was futile and led nowhere. With these young boys telling the story as war rages above them, there is a great sense of sacrifice – they are the young people who are always sacrificed in war.” Damien has assembled an exciting cast of young actors, who with little more than cardboard props and cricket wickets for swords, wage a war for peace. O Henry V tours WA this month – at the Albany, July 19; Heath Ledger Theatre, July 23-26; Geraldton, July 29 and Mandurah, August 1.

By Ms Jan Hallam medicalforum

Travel

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From: Diseases of Modern Life, by Benjamin Ward Richardson, MD, MA, FRS, 1876. The evils of physical overwork are often increased by admixture of labours which are not akin. This fact is frequently evidenced in the volunteer movement. To men already engaged in active outdoor pursuits, volunteering may, for a time, be harmless; but to those who are confined within doors all day, violent exercise at drill or on march, after the ordinary work is over, is most prejudicial.

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Entering Medical Forum's COMPETITIONS is easy! Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' link (below the magazine cover on the left).

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81 PSYCHIATRIST WANTED

BIBRA LAKE - Psychiatrist wanted Are you intending to start Private Practice? This is a sheer walk in! Part time, sessional or full time - all enquiries welcome. Furnished consulting rooms available at: Bibra Lake Specialist Centre, 10/14 Annois Road, Bibra Lake WA 6163 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 ALBANY t 4U $MBSF T JT B OFX GBNJMZ QSBDUJDF CBTFE in Albany t 4NBMM GSJFOEMZ QSBDUJDF t 'VMM UJNF OVSTJOH BOE BENJOJTUSBUJPO support t 1BUIPMPHZ PO TJUF t 'VMM PS QBSU UJNF (1 XBOUFE UP KPJO PVS team t 4QFDJBM JOUFSFTU JO TLJO XPVME CF JEFBM t $VSSFOUMZ OP %84 VOMFTT XJMMJOH UP work in afterhours period t (1T OPU SFRVJSJOH TVQFSWJTJPO SFRVJSFE Please contact practice manager Belinda Elliott Tel: 9841 8102 Email: belinda@stclare.com.au Or send your CV through and we will get back to you.

NURSING POSITION VACANT WEMBLEY DOWNS Casual Practice Nurse Ocean Village Medical Centre in Wembley Downs, require a casual practice nurse (RN). Modern fully computerised private and bulk billing practice. We are a non-corporate practice. Contact anthony.lau@ovmc.com.au for more details

URBAN POSITIONS VACANT WOODLANDS Woodlands Family Practice Great opportunity for FT/PT VR doctor in a well-run, newly extended, inner metro, mixed billing, privately owned practice. Call Dr Mary McNulty or Dr David Jameson, 9446 2010 or email laura@wfpwa.com.au

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

AUGUST 2014 - next deadline 12md Thursday 10 th July - Tel 9203 5222 or jen@mforum.com.au

medical forum Day Medical

APPLECROSS Reynolds Rd 7 Day Medical Centre. Weekday Dr wanted (full-time or parttime) sessions available. Mixed billing, Dr owned, no weekend work required, Nurses. Contact PM Rita on manager@rrmed.com or 9364 6633

SEVILLE GROVE Seville Drive Medical Centre (AON/DWS) requires a Female GP, VR/Non VR to join our team. P/T or F/T. Privately owned and run centre, great clinical support team, allied health and friendly admin team. Please contact Rebecca on 08 9498 1099 or manager@sevilledrivemedical.com

NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient CBTF DPNQVUFSJTFE BDDSFEJUFE XJUI nurse support. Ring Helen 9227 0170.

GOSNELLS Ashburton Surgery. VR female GP needed. Flexible hours. 75% of billings. 3 Dr surgery. Fully equipped with nursing support. Email: angiesurgery@gmail.com or Phone Angie 0422 496 594 or 9490 8288 MADELEY 73 /PO 73 (FOFSBM .FEJDBM Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new nonDPSQPSBUF QSBDUJDF XJUI GFNBMF NBMF General Practitioners. Sessions and leave negotiable, salary is compiled from takings rather than drawings. Up to 70% of billings paid (dependant on experience) Please contact Jacky on 0488 500 153 or E-mail to jacky-steven@live.co.uk WEMBLEY DOWNS Ocean Village Medical Centre in Wembley Downs, require a VR GP. Modern fully computerised private and bulk-billing practice with practice nurse. We are a non-corporate practice. Contact anthony.lau@ovmc.com.au for more details. GOSNELLS GP wanted VR or Non VR Corfield Doctors Surgery is looking for VR or Non VR GP to join the family practice. Would offer 70% of the income and state of the art surgery with Pathology on-site . Send your CV to Practice Manager corfield.doctors@gmail.com 51 o 9398 9898. HILTON GP. Wanted / Sessional/ P/Time. 73 (1 UP KPJO ZST FTUBCMJTIFE (FOFSBM 1SBDUJDF JO UIF )JMUPO BSFB (1 T Accredited: Computerised with fulltime nurse support. Service growth potential. Contact Practice Manager on 9337 8899

LANGFORD (Qualifies as DWS) Due to the recent departure of a male colleague and the impending departure PWFSTFBT JO 4FQUFNCFS PG POF PG PVS long term female colleagues, Langford Medical Centre requires a full time GP to commence ASAP. Donâ&#x20AC;&#x2122;t miss this unusual opportunity. This is the perfect time to commence at Langford with a ready-made full patient list. We are a modern well-equipped, accredited, predominantly bulk billing practice. Situated south of the river, Langford is one of the closest practices to the CBD that still qualifies as a district of workforce shortage. For confidential enquiries please contact PM Rita on 9451 1377 Email: manager@langfordmedical.com.au KALLAROO North of River practice requiring A/Hâ&#x20AC;&#x2122;s GP UP XPSL 4VOEBZT o QSJWBUF CJMMJOH XJUI nurse support. Contact Practice Manager 0488 963 749 Email jmarkouloop@iinet.net.au

YOKINE Part-Time VR GP required for a small privately owned practice in Yokine. Female GP preferred to help our existing female GP . Family friendly practice with nursing support and a lovely team of receptionists. Our GPâ&#x20AC;&#x2122;s have full autonomy. Private billing. Fully computerised. Accredited. On-site pathology. Allied health rooms attached next to the practice. Excellent remuneration is offered to the right applicant, but we are not in an area of need. Please contact Jayne Jayne@swanstsurgery.com.au or Dr Peter Cummins peterc@swanstsurgery.com.au for further information. ROLEYSTONE PT/FT VR Female GP required for a GP clinic in Roleystone. A friendly and efficient working environment. Well-equipped consulting and treatment rooms, fully computerised, accredited and busy practice. Contact: practicemanager@roleystonefmc.com.au

MANDURAH GP required for established, accredited Practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed by experienced Registered Nurses. Generous remuneration. No DWS please. No on call. Contact Ria 9535 4644 Email: mandmedi@wn.com.au

MANDURAH Full time VR GP required for busy established, accredited practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed by 10 doctors and 4 experienced Registered Nurses. Generous remuneration, no DWS please. No on call. Contact Ria 9535 4644 Email: Mandmedi@wn.com.au MT LAWLEY ECU medical centre, P/T VR GP required well equipped, accredited practice, RN support. Caring for University community. No weekends or after hours. Flexibility of hours and days can be accommodated. Contact Dr Rob Chander Email: r.chandler@ecu.edu.au Phone: 6304 5618 SHENTON PARK Churchill Health Centre A part-time position is available up to 4 sessions per week for a GP with special interest in womenâ&#x20AC;&#x2122;s health care and paediatrics. We have modern spacious consulting rooms and work in a friendly relaxed atmosphere with flexible working hours. We are a private billing practice so there is a guaranteed minimum income. For further enquiries or to lodge your resume please Email â&#x20AC;&#x201C; Marie at admin@churchillhealth.com.au NORTH BEACH Close to the beach! Opportunity for a P/T or F/T GP to join our privately-owned practice. Flexible hours and mixed billing. An interest in womenâ&#x20AC;&#x2122;s health an advantage. On site pathology, psychologist and nurse support. Please contact Helen or David 9447 1233 to discuss or Email: reception.nbmc@ bigpond.com KWINANA â&#x20AC;&#x201C; Chisham Avenue Medical Centre Full time or Part time VR GP required for a busy long established medical centre. Mixed billing, fully accredited with pharmacy and pathology on site. Please contact Bili on 9419 2122 or Email: chishamave@westnet.com.au

CLAREMONT You keep 100% of billings in this brand new clinic. Second branch of a very busy and well established walk-in bulk billing practice. Looking for GPs with unrestricted provider number. Located in a modern complex with free access to the gym and pool. You pay only a flat daily rate to cover overheads To establish in this area and be your own boss, please contact Dr Ang 9472 9306 or Email: thewalkingp@gmail.com SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979 NEDLANDS Fantastic opening for a VR GP who seeks work life balance. Next to UWA and Swan River in a busy shopping centre. FT or PT with 70% of billings for suitable candidate. Mostly private billing. Full accredited. Pathology onsite. FT Registered Nurse. Allied health services next door. Call Suzanne on 08 9389 8964 or Email: nedlandsdoctor@yahoo.com.au

DUNCRAIG MEDICAL CENTRE OSBORNE CITY MEDICAL CENTRE Require a female GP for both practices. Existing patient base. Flexible hours. Excellent remuneration. Modern, predominantly private billing practice with full time Practice Nurse. Fully computerised. Please contact Michael on 0403 927 934 Email Dr Dianne Prior: dianne@duncraigmedicalcentre.com.au

APPLECROSS Obstetric GP t 3FRVJSFE GPS CVTZ 1FSUI QSBDUJDF NJOT from CBD t %84 MPDBUJPO t .JEXJGF TVQQPSU t 3FMPDBUJPO QBDLBHF BWBJMBCMF For more information or to apply please contact office@apollohealth.biz or Phone: 08 6142 9275

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

AUGUST 2014 - next deadline 12md Thursday 10 th July - Tel 9203 5222 or jen@mforum.com.au

medical forum PERTH CBD Full and part time VR GPS to join our busy inner city practice located in the Hay Street Mall. Non corporate, mainly private billing, accredited, fully computerised with full admin and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates Please contact Debra on 0408 665 531 to discuss or Email: drogers@perthmedicalcentre.com.au GIRRAWHEEN Doctors required for The New Park Medical Centre Girrawheen. 0QFOJOH JO +VMZ XF BSF TFFLJOH '5 and PT GP’s to join the team. Enquires to Dr Kiran on 0401 815 587 Email: kiranpkumar@hotmail.com

We make Aged Care work for GP’s Medical Practitioners for Aged Care (MP+AC) is seeking doctors to join its team providing medical services to residents of various Residential Aged Care Facilities throughout the Perth metro area. Our efficient service delivery model maximises the doctor’s earning potential. 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 contact: Caroline Claydon - MP+AC Mobile: 0433 269 532 or Email: caroline@rapattoni.com.au

NEW PRACTICE - Inner Northern Suburb Located in an inner northern suburb, approximately 5 mins from the CBD. In a prime location on a main road, with good exposure and ample parking at the front and rear. Also next door to a 7-day pharmacy. With recent retirements in the area, this is the perfect opportunity for an enthusiastic GP or group of GPs. Generous percentage offered and interest in ownership considered. Administrative and nursing services will be provided, along with pathology collection on-site. Call 0414 287 537 for details. BULLCREEK PT/FT VR GP required for Accredited, Privately owned, Friendly Family Practice Please call – 9332 5556

83 GREENWOOD Greenwood/Kingsley Family Practice In today’s market where there is an oversupply of GPs, are you feeling frustrated that you have to work exceedingly long hours and with little take home income? Are you pressurised to bulk-bill in order to stay afloat on today’s competitive GP market? Are you committed to offer quality personalised services to your patients? Are you to looking for likeminded GPs to work with? Come and have an obligation free confidential chat with us. "WFSBHF HSPTT CJMMJOH UP a day achievable for GPs who offer exceptional services to our clients. Contact Dr Chao 0402 201 311 or Email shenychao@hotmail.com Sorry we do not have DWS status

GP Opportunities in WA Available Now

Looking for a positive change in your career? Due to continued growth, IPN is currently looking for GPs for opportunities within our Medical Centres. As a valued GP, you will enjoy freedom, ﬂexibility and clinical sovereignty, with a busy patient base. Each centre is run by a Practice Manager and the team is supported by a Business Manager.

It's July already! Don't let 20 D Do 14 slip away without 2014 doing s something mething for you. To make a conﬁdential enquiry about GP Opportunities pportunities in WA or to ﬁnd out more, contact Aillinn on:

0467 804 4 050 aillinn.mcgoldrick@ipn.com.au cgoldrick@ipn.com.au Supporting Better Medicine www.ipn.com.au AUGUST 2014 - next deadline 12md Thursday 10 th July - Tel 9203 5222 or jen@mforum.com.au

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Are you looking to buy a medical practice? As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience.

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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!

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Specialists – opportunity for easy private practice in Fremantle!

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

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

AUGUST 2014 - next deadline 12md Thursday 10 th July - Tel 9203 5222 or jen@mforum.com.au

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