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September 2015 www.mforum.com.au
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Editorial
Standing up to Bullies It started with the sexual harassment claims of female surgical trainees and the floodgates have opened since. It now depends on how many ‘conflict’ or ‘overcoming adversity’ scenarios can be presented to the media to keep this issue in the spotlight. Insidiously, bullying has been allowed to permeate our profession, originally tolerated because academic bullying was seen to keep everyone on their toes. Unfortunately, it has allowed in a raft of self-interested bullies whose abuse of power and position has entrenched them in positions they might otherwise struggle to fill. Sexual harassment and discrimination are now serious issues. If these people were on the wharves, not in the wards, someone might deck them and promptly sort out any abuse of position. This mismatch of power and its abuse features strongly in the harrowing stories of child abuse (see P8) brought out by the Royal Commission. Medical Forum hears of similar abuse directed at medical professionals, most commonly those in training positions who have much to lose if they stand up to abusers (April edition). Mind you, the abusers have a lot to lose too. That is why they have become smarter with their abuse, enlisting the support of the masters of what you can get away with legally if you have deep pockets, the legal profession. Those involved don’t really care about ethics and professional standards in medicine, they are more in tune with what it all costs and how costs can be used as a weapon, albeit subtly at times. Costs are the reason why doctors are advised repeatedly by legal representatives not to defend an assault on their reputation or to put their head above the parapet. Intimidation through cost is part and parcel of what insurers work with these days, including MDOs. This scourge partly explains why the Legal Practice Board in WA is big on practitioners not using their position, title or costs to make threats and intimidate individuals.
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MEDICAL FORUM
EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au
We have the national president of the medical students saying bullying is an issue for medical students who feel powerless to act. And just about every older doctor or nurse from varied professional realms can trot out unsavoury stories of ‘bullies I have known’. I remember Australian trainees were welcome in the UK because they worked hard and told overbearing bullies in the UK system where to go, probably because they had little to lose. Medical Forum has repeatedly reported the profession’s distrust of the Medical Board’s impartiality, something I predict is not going to go away while nt AHPRA’s lawyers do the grunt work for Medical Boards, which in themselves lack transparency. As I once pointed out to a lawyer, doctors work in a different world where trust (not mistrust) is the lifeblood of what they do. Amongst the profession, there is a lack of confidence in the complaint processes, Dr Rob McEvoy and fear of adverse consequences, two things that the national Board chairman Dr Joanna Flynn points to as explaining why discrimination and bullying go unreported (MJA 2015; 203 (4): 163). She needs to look more closely in her own back yard (see P10). I wonder if she felt health professionals were fence sitters or content to be bystanders when she said: “It is time for all of us to accept responsibility for the culture and reputation of our profession and work to create environments in which respect is the dominant quality of relationships with our colleagues, trainees and patients.”? Maybe they were simply bullied into that position instead?
Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au
Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au
SEPTEMBER 2015 | 1
September 2015
Contents
10
14
18
16
FEATURES 10 Snowball Review into Registration 14 Spotlight: Mr George Jones 16 Surrogacy: For Love or Money 18 Trailblazer: Dr Carlo Bellini
NEWS & VIEWS 1 Editorial: Standing Up to Bullies 4 Letters:
4 6 8 10 12 21 26 33 36
NPS Data Mining Dr Philip Green NPS Response AHPRA and Process A/Prof Robyn Collins Transparency and Accreditation Mr Tim Spokes Why I Went Corporate Dr Peter Winterton Curious Conversations: Dr David de la Hunty e-Poll: Financial Planning Minister On Doctor Training Flexible Aged Care Have You Heard? Students in the Kimberley Medical Admin on Parade Beneath the Drapes GPCE Perth 2015
LIFESTYLE 38 Travel: Dr Amanda Wilkins in Bologna 40 Funny Side 41 Wine: Secret Selection from Wine Thief Dr Craig Drummond
42 43 44
Comedy: Stand Up for Mental Health Greta Bradman: Broadway to La Scala Competitions
See Page 18
MAJOR SPONSORS 2 | SEPTEMBER 2015
MEDICAL FORUM
Clinical Contributors
27
Dr Andre Kozlowski Update: Aspirin in Cardiology
30
Dr Colin Somerville The Low Allergy Pet Myth
30
Dr David Roberts Effects of Attachment Parenting
31
Dr Astrid Arellano Tuberculosis in WA
33
Dr Chris Dhepnorrarat What Masquerades as Sinusitis
34
Prof Sergio Starkstein Psychosis in the Elderly
37
Dr Steve Ward Assessing Iron Overload
37
Dr James Salvaris App: Diagnostic Imaging Pathways
Guest Columnists
8
Mr Sacha Mahboub Child Abuse Royal Commission
23
Dr Margaret Smith Holding on to Empathy
25
Dr Donna Mak Relationships the heart of medicine
25
Ms Frances Cook Understanding Eating Disorders
Conferences Deliver Important Messages This issue we feature three conferences that put the spotlight on general practice and medical administration. At the GPCE conference (see P36), WAGPET was there flying the flag and there seems plenty to wave about. Pictured here (far left) WAGPET’s Samantha Korzec (left) promotes training opportunities to Dr Catriona McCracken. Despite the turmoil of last year’s Federal Budget decisions regarding training organisations, WAGPET has this year witnessed fierce competition for its 180 GP training places for both general and rural pathways, which are likely to be fully subscribed. Medical administrators from the Royal Australians College of Medical Administrators and (pictured) the Australian College of Health Service Management (see P26) shared ideas and strategies as rising costs continue to threaten quality health care delivery.
INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Michele Kosky AM (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Mike Ledger (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM SEPTEMBER 2015 | 3
Letters to the Editor
NPS data mining Dear Editor, Bill Chapman’s letter (August, 2015) on the NPS “data mining research” has prompted me to write about my experience. I was offered to be recruited into this research. I was assured that everything would be completely confidential. When I started filling in the documents I quickly realised that I (that is the Doctor) could be easily identified. In my case the postcode plus length of time in General Practice would immediately and uniquely identify me. This is not the first time. I stopped contributing to the MABEL research because of similar concerns. The MABEL research required providing significant personal financial information. I could easily be identified from the demographics based on postcode, age and number of doctors in the Practice. The researchers do not seem to understand the implications of these types of situations. Dr Philip Green, GP, Australind ........................................................................
NPS Comment Our question. “The main thing to emerge [from August edition’s letter] is practices can be on-selling prescribing data to NPS without notifying any locum doctor this is happening. What is NPS doing about that?” RESPONSE: NPS MedicineWise When a practice participates in MedicineInsight, the onus is on the principal GP (or owner of the practice) to inform all GPs at the practice that the practice has signed up to participate in MedicineInsight. There is a clause in the Practice Agreement specifying that as the signatory on the Agreement, the practice principal warrants that all GPs in the practice have been provided with a copy of the GP consent form issued by NPS MedicineWise. The GP consent form contains comprehensive information regarding the MedicineInsight program. Note also that data from practices participating in MedicineInsight is not being “on-sold” to NPS MedicineWise. Practices that have signed up to MedicineInsight are not paid for their data. The value for practices is in the evidence-based reports and analysis
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.
provided back to inform, validate and improve clinical decision-making and data quality, and ultimately support improved patient care.
We need to dig deeper
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As co-owner of two medical practices, I have been following with interest your columns on transparency in regards to our accreditation and regulatory organisations.
AHPRA and process Dear Editor, Re Dr P Hanrahan letter (August edition): AHPRA and the WA Board of the Medical Board of Australia communicate directly with the people who make a complaint (notification) and the doctors who are the subject of regulatory assessment and investigation. We do not breach confidentiality and do not provide a commentary about these interactions with third parties. Equally, the Board and AHPRA take seriously our responsibility to make sure all regulatory processes are fair and legally robust. Nationally consistent processes are in place to make sure of this. There is no room in these processes for ‘corridor conversations’ with individual Board or panel members to shape the progress or outcome of specific matters. All decisions about individual registered practitioners are made by Boards or their delegate Committees: panels or Tribunals. There are structured processes in place to support fair decision making and make sure all doctors are afforded natural justice. Policies in relation to conflicts of interest are actively managed. Any decision-maker with prior knowledge of or involvement in a matter does not take any part in future decisionmaking. There is also a separate, nationally mandated and consistently applied process for complaints about AHPRA or Board members, which are different from notifications about individual practitioners. Information is published on our website at https://www. ahpra.gov.au. A/Prof Robyn Collins, AHPRA State Manager ED: The AHPRA State Manager also wrote to Medical Forum, a letter not for publication addressing the issues raised by Dr Hanrahan’s letter. He was cc’d and wrote to us refuting the content of her letter. For Medical Forum to be further involved we need to see all relevant correspondence from both parties. The style of communication appears to be a problem. (See P10)
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Dear Editor,
Accreditation, as we all know, is a sought-after approval. It says you are working within minimum expected standards set by a third party who visits and monitors your progress, and it comes at a cost, indeed, a rather large cost. In addition, and probably the bigger attraction, is the Practice Incentives Program and Nurse Incentive Program etc. If you are not accredited then you can’t receive these incentives. Given the costs of running a medical practice (staff alone attract insurance, wages, superannuation and payroll tax), PIPs and NPIPs don’t even come close to paying a week’s wages for a single nurse in a 5 GP FTE practice. With the Government freeze on Bulk Bill Item Numbers yet politicians seeing no need for personal restraint (chopper ride anyone?), one would expect transparency to be foremost in all our minds. However, therein lies the problem. Transparency does not imply “Publically Acceptable” or “Ethics” or “Moral Actions”, it simply says you have worked within the rules. We need transparency to tell us where our money goes and what it is being used for because that money is becoming increasingly difficult to earn in general medical practice. Transparency is the least we can expect from regulatory bodies and government departments such as the Taxation Office. It doesn’t help that a parliamentary inquiry has unearthed billions of dollars of tax avoiding behaviour by major corporates. So what is the value of the word transparency? Well let’s face it, it looks good, it sounds good, it sometimes claims the scalps of slow-moving politicians but it’s not what we are seeing that is important, it’s what lies beneath that we don’t get to see. All the above-ground stuff is distraction!
continued on Page 6
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Letters to the Editor continued from Page 4 We have to dig deeper away from the distractions to see the world as it really is, and where our money is going Mr Tim Spokes, practice owner, Kalgoorlie ........................................................................
sĂĽ #APITALĂĽCOSTSĂĽOFĂĽINNERĂĽURBANĂĽLANDĂĽNEEDEDĂĽ to accommodate a practice and the associated cost of rates, land tax, water rates, insurances etc. These somewhat ďŹ xed costs are not directly related to the number of practitioners or even indeed turnover. sĂĽ ,OCALĂĽ#OUNCILĂĽRULESĂĽONĂĽPARKING ĂĽUSUALLYĂĽ based on the number of consulting rooms, which makes it non-viable to run a bigger practice unless one is fortunate enough to have Council parking.
Why I went ‘corporate’ Dear Editor,
sĂĽ #OMPLIANCEĂĽCOSTSĂĽE G ĂĽACCREDITATION ĂĽ afterhours etc.
I recently sold the Mt Hawthorn Medical Centre to Ochre Health. My late father established the practice in late 1951 and I have been practising there since 1979.
sĂĽ %VER ESCALATINGĂĽCOSTSĂĽOFĂĽCOMPUTERISATIONĂĽ and keeping up-to-date with hardware and software.
Ever since corporatised general practice emerged on the Australian medical landscape I have been a very vocal opponent as I feel that what patients, especially those with chronic illness, need and want is quality compassionate continuity of care in familiar surrounds. What has changed? The times, and we must change with them (as said Cicero in 44BC). Many factors have created the perfect storm for the demise of small inner urban general practices. The future lies in either the bigger group practice of ďŹ ve or more FTE doctors or the corporate practice that has staff to keep their eye on the cash register with business acumen. In today’s terms this often results in at least 10 or more practitioners, many doing a few sessions, which brings difďŹ cult human resource management and a lack in continuity of care. This intrudes on one of the primary tenants of good general practice. These are some reasons for the ďŹ nancial demise of the small inner urban general practice: sĂĽ &EDERALĂĽGOVERNMENTĂĽRESTRICTIVEĂĽRULESĂĽONĂĽ areas of work force shortage; so called DWS, based on statistics not necessarily reality in the ďŹ eld.
sĂĽ &EEĂĽFORĂĽSERVICEĂĽISĂĽNOĂĽLONGERĂĽVIABLEĂĽASĂĽTHEĂĽ main source of income, brought on by successive governments. You embrace other items such as EPC to stay ďŹ nancially viable, which in turn needs full-time nursing staff. The critical break-even point for this lies outside what the small inner urban general practice can offer.
Apology Financial Planning We forgot to publish your responses to this e-Poll question in our June edition. Sorry. Results are very interesting, with around half busy doctors admitting that unexpected family events have been costly. The example that triggered this question was when a teenager goes ‘off the rails’ and makes a call on the ‘distribution’ to him/her in the family trust that the accountant has setup to minimise tax. There e-Poll are many other examples, brought about by breakdown in family relationships. Has there been an instance where you or someone close to you has faced ďŹ nancial loss because of unexpected family events? No Yes Uncertain Doesn’t apply
46% 40% 4% 10%
sü 0ATIENTS üUNWILLINGNESSüTOüPAYüFOR QUALITYü service. sü 0RACTITIONERüCHANGES üPOORüKNOWLEDGEü of the realities of running a practice; the expectation of instant return when in practice; and so-called life-work balance choices. The future of general practice is not good without major structural changes. The window dressing to date has not delivered what is needed. The true implementation of relative value recommendations needs to occur – that a general practitioner earns in a week what some specialists generate in a morning is not delivering value to the Australian community. The fact is that quality old-style general practice is vastly under rewarded. The Australian people, your patient, will ultimately bear the cost of this in both their hip pocket and the quality of care they receive.
We welcome your letters and leads for stories. Please keep them short. Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. Letters may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.
Dr Peter Winterton AM, GP, Mt Hawthorn
Curious Conversations
Power of the Pen Wordsmith Dr David de la Hunty has a love for the elegant sentence and a sense of humour. The saddest moment I’ve ever had in medicine was‌ breaking the news to a young, profoundly deaf patient that she was going blind from Retinitis Pigmentosa (Usher’s Syndrome). It’s frustrating to know that molecular biological science is close to cracking some of these devastating genetic diseases but the cure is still a long way off. When I’m not working I love to‌ write speculative ďŹ ction. Everyone needs a creative outlet and nobody wants to see a 51-year-old try-hard strutting across a stage holding an electric guitar.
6 | SEPTEMBER 2015
Two people I really admire are‌ my wife, Dr Moira de la Hunty, who hasn’t let her own battle with Addison’s disease get in the way of her devotion to family or deect her from working as a professional artist. My mother, Olympian Shirley de la Hunty (Strickland), who had wonderful careers in both sport and science. If I could choose the words on my tombstone they’d be‌ plagiarised from Spike Milligan – ‘I told you I was ill.’ The book I’m reading at the moment is‌ The Seven Daughters of Eve, by Bryan Sykes. It’s an amazing journey into the science of human origins read through the evolutionary record of DNA. MEDICAL FORUM
After Hours on call cardiologist: Ph 08 9382 6111 SJOG Chest pain Service 0411 707 017
Incisions
Abuse Must Stop Mr Sacha Mahboub writes here as part of his testimony to the Royal Commission in Child Sexual Abuse about his time at the Neerkol* orphanage where he lived from the ages of six to 17. On a daily basis I, along with the other residents, was told that “we were not invited to come to the orphanage, we were there because our parents didn’t want us in the first place and therefore we were less than worthless”. This led me to believe that I was worthless and denied me the opportunity to develop self-confidence and build self esteem during my formative years. This is still evident in my life today. Every morning on waking I would be in fear of the flogging that I would receive that day. In the school room if you got your lessons wrong or did not know the answers, you were flogged in the most derogatory manner. Sister Mary Ignatius stood me in front of the class and bent me over the desk with my trousers down around my ankles and beat me so severely I eventually defecated in front of the class. The constant fear of a severe thrashing left me unable to study. On another occasion Sr Mary Ignatius grabbed me by the ears and repeatedly smashed my head against the wall that left me with a bleeding head and a cut several inches long. I could tell no one for fear of a further thrashing. I now understand why medical advice was never sought – it would have been an indictment of the nuns and their cruel and unchristian behaviour. My older sister Lyn was also incarcerated in this institution but in the 11 years we were there we were never allowed to meet. This robbed me of the opportunity of growing
up and sharing a life (for what it was worth) and life experiences with a sibling. Sadly she passed away this year spending her last years with severe depression that affected all of her relationships.
practices of Neerkol to survive…I used sex to get what I needed in life because this is what I was taught. I couldn’t differentiate between love and lust, and I never acquired this skill until I was in my late 40s.
The physical abuse received at the hand of the nuns was horrendous enough but the added sexual abuse by the dormitory prefects was so vile and degrading that my constant prayer every night was to die – not to wake up again so that I could be spared the floggings and the regular sexual abuse. I had no idea what sex was, or its purpose in life at this young age, but what I was soon to find out was that it was less traumatic to yield to the sexual acts than it was to fight them. How does a small child living in constant fear each day defend himself against bigger teenage boys who are put in a position of power? The care that we got from them was being taken out to a back room by the prefect where he would force his erect penis down our throats and force us to give fellatio and any other acts that he may desire on the night. What lesson do you think I learnt here? After a while I learnt that if you succumbed to your predator and didn’t buck the system, even though you didn’t like or believe in the morality of the behaviours … your life [was] easier within the dormitory.
As a 74 year old man I can tell you that I have lived a life full of anger, hate, self doubt, feelings of worthlessness and isolation. I have had major issues in dealing with my sexual orientation and forming meaningful relationships. I have cried myself to sleep at night on countless occasions, I have feared for my sanity and I have often prayed for death. Regardless of the life I have made for myself, this cancer that was Neerkol still does and always will hang over my head and I will never be free.
When I finally left the orphanage I was so screwed up emotionally, morally and physically that I had no idea how to conduct myself in normal society. I had to rely on the horrendous
ED. West Australian Mr Sacha Mahboub was a young boy of six when he and his older sister were made wards of the state and put into custodial care at St Joseph’s Home, in Neerkol, Queensland, in 1947. He submitted a statement of impact to the Royal Commission into Institutional Child Sexual Abuse in April and again in July detailing 11 years of abuse and the lifelong legacy of what they endured. Sacha has given Medical Forum permission to reproduce this edited version of that confidential statement. If you wish to find out more, you can search the Royal Commission website at www. childabuseroyalcommission.gov.au A public hearing was held into St Joseph’s Orphanage, Neerkol, in April 2015 at the Rockhampton Court House. www.childabuseroyalcommission.gov.au/
Answers (at last) on IMGs and Training With the furore over the establishment of a third medical school in WA, we thought it pertinent to ask the Government just how reliant the state was on international medical graduates (IMGs) in the running of the public health system. There have been anecdotal reports that both Fiona Stanley Hospital and the soon-to-open Midland Public Hospital have a high proportion of IMGs on staff.
in nominated specialties have been made for most if not all public hospitals. The list was long and comprehensive.
Specialty areas currently recruiting IMGs most were psychiatry, obstetrics and gynaecology and orthopaedic surgery.
When it came to AoN assessment criteria, the WA Department of Health looked at each application on a case-by-case basis including labour market testing. Advertising must be both State-wide and national for maximum local response.
It took some political intervention to get the answers but after more than 12 months of trying we finally got somewhere. The Opposition Health spokesman took up the challenge and the Health Minister responded via parliamentary questions on notice. Medical Forum posed six questions regarding the definition of an Area of Need (AoN), the numbers and capacities of IMGs in the system and what role recruitment agencies played.
As of May 31, 778 IMGs were in the public health system – 270 were in specialist college training positions. This figure is interesting in the context of vociferous campaigning by AMA WA and medical students who attacked the Curtin Medical School decision on the grounds of existing shortage of training positions for local graduates.
The Minister said only WACHS worked with registered recruitment agencies for public sector vacancies. The agencies could be remunerated up to 12.5% of the stated doctor’s income for the tenure of the appointment up to a total of 12 months when they are filling a permanent or locum vacancy. It could be a one-off payment if the doctor has accepted a fixed-term contract, or across multiple payments for days worked for locum doctors on a medical services agreement.
The Health Minister Dr Kim Hames said that while AoN determinations might not be specific to hospitals or health services, AoNs
8 | SEPTEMBER 2015
The AMA WA has since denied in the media that its opposition to the new medical school had anything to do with the effect increased local graduates could have on its commercial recruiting arm, AMA Recruit.
We did a quick sum – a rural GP contract for $150,000pa as recently advertised would earn an agency more than $18,000. The full lists of IMGs and recruitment agencies are on our website www.medicalhub.com.au. Notably absent from the agency list were AMA Recruit and Rural Health West.
MEDICAL FORUM
MEDICAL FORUM
SEPTEMBER 2015 | 9
Feature
Snowball Review Finally Released Everyone agrees that AHPRA, Medical Boards and National Law need improvement but maybe a looming national election has weakened resolve? With just nine of 33 recommendations adopted from the Independent Review of the National Registration and Accreditation Scheme for Health Professions, this document appears lost in a sea of bureaucracy. Is this a sign of government frightened to make any decisions prior to an election, or are the nine accepted recommendations absolute pearlers? We are not convinced. The accepted recommendations appear to improve how National Law works for health consumers but without anyone to take on implementation (it was one of the rejected recommendations) should we be worried? Doctors might be pleased to learn that the recommendations adopted include: så !(02!åTALKSåTOå7! Så(EALTHå å$ISABILITYå Services Complaints Office (HaDSCO) to work out who does what, and interviews complainants to work out their expectations, så )NVESTIGATIONSåANDåREPORTSåAREåSHAREDå across National Boards, AHPRA and HaDSCO.
The Review admonishes the communication style of AHPRA, a process that fails to give both complainants and those complained against confidence, due in part to poor administration and partly due to constraints under National Law. Timeliness, communication, transparency and consistent outcomes were of most concern. If you want to read any of this report, pages 2437 are worthwhile (see www.coaghealthcouncil. gov.au/Publications/Reports). As the Avant media release said, the changes are welcomed when it comes to the welfare of its members but there is “more work to be done”. If you look at the rejected recommendations you can better understand why: 1. No short term body established to: så 3EEåTHATå2EVIEWåRECOMMENDATIONSåAREå implemented, så %STABLISHåPERFORMANCEåSTANDARDSåFORå National Boards, Accrediting Authorities, and AHPRA regarding National Law objectives,
så .ATIONALå"OARDSåTOåBEåAUTHORISEDåTOåREFERå complaints to HaDSCO.
så 2EPORTåTOåTHESEåBODIESåHEALTHåWORKFORCEå reform and service access gaps, as needed,
så "ENCHMARKåTIMEFRAMESåWILLåBEåSETåFORå handling complaints.
så !DVISEåONåANYåCROSS PROFESSIONALåISSUESå that arise, and
så 1UARTERLYåPROGRESSåREPORTSåTOåCOMPLAINANTSå are written in plain language.
så !UDITåTHEå-INISTERIALå#OUNCILåWHENåSAFETYåISå questioned.
så #OMMUNICATIONåSTYLEåWITHåCOMPLAINANTSåTOå be improved.
2. No national adoption of WA’s exemption of mandatory reporting for doctors undergoing treatment.
så !(02!åANDå.ATIONALå"OARDSåTOåREVIEWå within 12 months how the 60 committees for the National Boards, and 78 committees for the 20 State or Territory Boards can be changed to remove duplication. så 4HEåPERFORMANCEåOFå!(02!åANDå.ATIONALå Boards are benchmarked for handling IMG applications and similarly specialist colleges. så 4HEåTRAININGåOFåINVESTIGATORSåTOWARDSåMOREå appropriate investigative standards and approaches.
3. No banning of promotional testimonials. 4. No national protection of birthing services as a standalone. 5. No ATSI committee to improve responses to ATSI health and cultural issues. After more than a five-month delay to release this Review publicly, recommendations still deferred pending further advice include: så 2EDUCEDåBUREAUCRACYåTHROUGHå amalgamation of National Boards,
National Registration Review Cover
så #ONSOLIDATIONåFORåNINEåLOW REGULATORY workload professions to reduce costs and paperwork, så 0EGGINGåOFåFEESåFORåACCREDITATIONåTOå#0)
så 3TANDARDISEDåACCREDITATIONåPROTOCOLSå and fee structures across all regulated professions, så 2EDUCTIONåINåDUPLICATIONåAMONGSTå accreditation providers, så 'IVEåTHEå.ATIONALå(EALTHå0RACTITIONERå Ombudsman jurisdiction over accreditation functions, så ,OOKåATåADOPTINGåTHEåCHEAPERå5+åSYSTEMå of accreditation if it offers similar or better results, så 2EQUIREå.ATIONALå"OARDSåTOåSEEKåAPPROVALå for changes to qualifications for registration, or codes or guidelines if they increase paperwork or adversely impact on the health workforce. In a rapidly moving world, this Review is likely to lose momentum, and with that perhaps the opportunity for changing things for the better.
By Dr Rob McEvoy
Sharing the Care A RACF place is dependent on an ACAT assessment and availability of beds, so as couples get older, if one is fit the other may end up in care. Amana Living said they have never received a request from an independent spouse to move into residential care in order to be with their partner. This doesn’t mean loving couples don’t sometimes end up together in aged care, when independent living is no longer possible after many years together. If one has dementia they may be in a secure dementia wing while the other is in separate accommodation. Older people are allowed to keep their pets with them, under clear guidelines. Joan and Ron Wellington, married for 74 years, are living in Amana Living’s Lesmurdie care facility.
10 | SEPTEMBER 2015
MEDICAL FORUM
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SEPTEMBER 2015 | 11
Have You Heard?
Inspiring good deeds Not-for-profit MercyCare is forging new trails WITHåAåNEWå(1åINå7ESTå0ERTHåANDåMOVESåINTOå self-directed care along with others in the aged care sector. As part of its community outreach it holds an annual oration to inspire and encourage. This year’s oration on September 24 at Hyatt Regency is to be delivered by the courageous Dr Gill Hicks, an Australian who was caught up in the London bombings in July 2005. She was seriously injured in one of the
blasts in the Kings Cross Underground station and lost both her legs. She is now a committed peace activist who has travelled the world encouraging people to live life to their fullest potential. She was South Australia’s nomination for Australian of the Year in 2014. Tickets for the oration have been made available to Medical Forum readers. Email your name, practice address, email and phone number to oration@mercycare.com.au if you’re interested in attending.
Online bookings hot up
Dr Gill Hicks
HealthEngine has some competition. Medical Director has recently released its web-based scheduling upgrade. Similar to HealthEngine, under its Terms and Conditions, anyone providing personal information to make a doctor appointment, consents to a third party (Health Communication Network) offering them products and services that the third party believes may be of interest to them. 1st Available is another online and mobile healthcare search and appointment booking service and because the development team’s background is with seek.com, carsales.com. au, realestate.com.au, this is very much about consumer convenience. 1st Available is using consumers to ‘incentivise’ providers to sign up, is ASX listed, and is a joint venture partner with health insurer Nib. It has also teamed up with whitecoat.com.au to accelerate growth by linking consumers to ancillary providers including dentists, optometrists, physiotherapists and chiropractors (about 20 in all, including naturopaths and western herbalists).
Taxing times Just before the end of financial year we, and probably you, were bombarded with requests for donations. Under the heading “Finding better ways to save lives in rural and remote Australia” we got one such request from the Emergency Medicine Foundation which said it had funding requests for $11.7m for 160 research projects from some of Australia’s leading researchers who have identified opportunities to address these challenges in rural and remote regions. While we are talking tax, Dr Margot Cunich from Uncoventional Conventions warns that accreditation of a conference does not imply tax deductibility. For example, six hours of learning activities (even if accredited) spread across a 13-day tour would not satisfy the ATO. Seek tax advice before you claim.
Stop insulting General Practice In July we were contacted via our website by a Hills GP who said he and his colleagues were insulted by a Tweet published in The West Australian that linked a poor performing cricketer with being a GP. The tweet read: “Now his test career is over, Watto (Shane Watson) can fulfil his dream of becoming a GP. He’s the go-to guy if you need a pointless referral.” Our doc told us the Abbott rebate freeze was insult enough but this was beyond the pale. When will the Government stand up for general practice? As the financial squeeze in health tightens, the value of GP services is being put on trial it seems. This issue and others are expected to come up at the September 10 Doctors Drum meeting organised by Medical Forum – ‘Money for Medicine – Slicing the Cake’ (see P18).
smithcoffey
12 | SEPTEMBER 2015
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Faces in pain
Community sector strengthens The state investment into the mental health sector continues with the opening of the Richmond Wellbeing Centre in Cannington at the end of July. A Lotterywest grant funded the centre which houses Richmond Wellbeing, formerly Richmond Fellowship WA, the Hearing Voices Network WA, outreach services and a training centre. The emphasis here is on recovery and the centre is a prime example of future directions arising from the new strategic plan for mental health (due to be released early October) where consumers and their families have access to personalised services close to their home. The official opening featured an art exhibition created by artists who had received help from Richmond Wellbeing including work by artist Donna Murray (pictured).
New centre brings hope Back in 2013, Medical Forum took up the campaign for those with intellectual or cognitive disability who found themselves in the justice system, often jailed without trial (some for years) because they were deemed unfit to plead. Jail was the only alternative until last month when the Bennett Brook Disability Justice
Centre in Caversham opened. The move has been welcomed by all those in the disability sector who have campaigned long and hard for such a facility. However, ED of People with Disabilities WA Samantha Jenkinson and CEO of Developmental Disability WA Taryn Harvey said legislative reform was needed so that Bennett Brook did not become another form of indefinite custody.
A facial recognition app which aims to detect pain in the elderly with dementia has been brewing in the backlots of Curtin’s Bentley campus for more than two years. The research team now hopes to refine the software to create a second app that would detect pain in preverbal children. The Electronic Pain Assessment Tool, or ePAT, is the brainchild of a Curtin School of Pharmacy research team being led by Prof Jeff Hughes. The tool, using 3D facial recognition software, maps the objective facial features of pain and combines that with other non-facial features to determine the presence and severity of pain through a 10-second video. Local investors have backed the project, which is hoped to pass the registration hurdles within 18 months.
Overdose awareness The inaugural International Overdose Awareness Day forum was held on September 1 to raise awareness of prescription medication misuse and addiction. The patron is Kim Ledger whose actor son Heath died from such an overdose. Scriptwise, a not-for-profit organisation, has organised the event to advance the voices and concerns of families and individuals who have been personally affected by prescription medication addiction and overdose. Spokesperson Vicki Weston said that in 2013 prescription medications contributed to 75% of the 116-recorded fatal overdoses in WA, while illicit drugs contributed to 46.6%. See www.scriptwise.org.au
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SEPTEMBER 2015 | 13
Spotlight
Helping Hand to Kids in Need Spending your formative years in an orphanage isn’t the greatest start in life. But mining entrepreneur and philanthropist George Jones is an impressive exception to the rule. George Jones is a distinguished name in business and in health. He has been generous with his hard-earned money and he is committed to making other people’s hard lives easier. But his own start in life was anything but easy. “My mother and stepfather were chronic alcoholics, we weren’t fed and clothed properly and school wasn’t great. In fact, we were pretty close to street urchins. My parents would rent a house, pay the fee a couple of times and then stop until we were all kicked out. I ended up going to 12 different schools in nine years,” George said. George is patron of Parkerville Children and Youth Cares, a place he knows intimately. He, his brother and two sisters were all residents there in the 1950s. However, Parkerville wasn’t the first orphanage for the Jones kids. The Salvation Army came to the rescue when he was five years old as his situation at home became untenable. Getting back on track “First stop was the Salvos and then Parkerville. We got decent food and, just as importantly, emotional support from our Cottage Parents who actually had their own children living there, too.” “It was something like a normal life. Sure, there were rules and we had to apply ourselves but that’s where I developed a strong work ethic. I copped a caning on a regular basis, but we are talking about the 1950s after all.” George acknowledges that while Parkerville was a positive experience for him, others may hold a different view. “I’ve spoken with many people who said they had difficulties but it seemed to me that the real problem was their underlying circumstances. Even in my own family there were different outcomes. My two sisters really enjoyed Parkerville but my brother didn’t emerge very well at all. He turned into a bit of a no-hoper and has spent time in gaol. There’ll always be some people who will rise above adversity and others who won’t.” “I’d just turned 15 when I left Parkerville. They gave me £20, which was enough to live on for a month in the 1960s, put me on a train to Perth with an address where I could stay as a boarder. I knew I was responsible for what came next and I also realised that I couldn’t just sit around hoping things would get better.”
school but I went into the army, learnt a trade and served in Vietnam. That gave me enough money to buy a block and build a house and I finished a business degree at Curtin.” “Nonetheless, I wouldn’t have described myself as a particularly confident young man when I left the army. I kept to myself and was pretty quiet, and I had a lot of skin problems in my teenage years. These days those problems are cleared up quickly with the new medications.” Most people don’t get to the age of 70 without some sort of interaction with the medical fraternity, and George is no exception. “I’ve had an over-active thyroid removed and I’ve also suffered from Meniere’s disease. In fact, that was the catalyst for my ongoing association with the Ear Science Institute because it was Professor Marcus Atlas who did the operation to disconnect the nerve.”
in WA there aren’t too many who give much of their wealth away. There are some notable exceptions such as Andrew Forrest and Malcolm McCusker, in fact the latter is a shining example.” “I used to keep my philanthropy very quiet and I’ve discussed this aspect with Malcolm. He’s of the opinion that we need to take a higher profile because it’s one way to make people think more deeply about their own contributions.” “I don’t particularly like having my name on a building but people do recognise the connection and, for places such as Parkerville and the Cystic Fibrosis Foundation, it’s part of my job to get people to part with their money.
By Mr Peter McClelland
“I went to see him afterwards and made the mistake of asking if there was anything I could do! We’ve raised $20m for the Institute and he’s got a funding model for the future so Marcus is pretty happy.” Giving kids hope One of his great achievements has been the opening of the George Jones Child Advocacy Centre, which has brought a new dimension to Parkerville and has wider ramifications for young people who find themselves involved with the juvenile justice system. “Since Basil Hanna has been Parkerville CEO, the place has been transformed. I’m proud to be associated with it. The WA Police are right behind our new initiative at the Child Advocacy Centre, which allows children who’ve been abused to be examined and interviewed in a child-friendly environment.” “Any evidence gathered is permissible in court and and they can even appear via a video-link so they don’t have to confront the person who abused them.” Corporate philanthropy in WA has a long way to go before we come close to the US model. George reaffirms this state of affairs and outlines his own approach to raising funds for worthwhile causes. “Australians generally are pretty generous but if you look at the list of the 150 richest people
Making the most of life “I’ve never regarded myself as being particularly talented and I only finished Third Year high
14 | SEPTEMBER 2015
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SEPTEMBER 2015 | 15
Feature
Surrogacy: Altruism or Commercialism? The rights of the child should be at the heart of all our discussions on the future path of surrogacy in Australia. In the latest annual report of the Reproductive Technology Council of WA (RTC), just four surrogacy applications were made and approved in 2013-14. Since legislation was introduced in 2008, 19 surrogacies have been approved and 18 have gone ahead. The story nationally is similar. In 2011 there were 177 gestational surrogacy cycles registered and just 23 babies born. On the other side of the coin, a retrospective audit of overseas surrogacy agencies carried out by Surrogacy Australia in 2011 using Freedom of Information, showed a 277% increase in the number of babies born to Australians via commercial surrogacy, with numbers rising from 97 in 2009 to 269 in 2011. The chief surrogacy ‘market’ in our region is India though there is a watching brief on the development of Mexico and Nepal as the next big surrogacy centres. Thailand was in the mix until the Thai military government shut down the industry in response to the Baby Gammy case. The relatively small number of local altruistic surrogacies and this apparent blow-out in numbers of overseas commercial surrogacies has the community talking but, for a considerable time, Australian health policy makers and governments have been reviewing the surrogacy situation here and abroad. In WA, the RTC undertook review of the 2008 Surrogacy Act last year and there have been two House of Representatives roundtable meetings this year. The consistent message from these reviews is the need to have a national approach to surrogacy laws so those wishing to go down that path can navigate more easily through the various state jurisdictions.
Who the law protects The local laws are rigorous but are they too restrictive? The Executive Officer of the RTC, Ms Mo Harris, said surrogacy laws in Australia protected and supported all parties through the process so that the pregnancy, birth and ultimately the transfer of parentage could proceed in a safe, ethical and transparent way. She thought if commercial surrogacy was to be considered in Australia then this should be a matter for considered and considerable national debate. “It’s a big step for the country to take. We’ve only just introduced surrogacy in the past few years and I don’t think we need to rush to join a race to the bottom. There are many models that should be examined before commercial surrogacy,” she said. “A lot of work is being done nationally around gamete donation and surrogacy – looking at the model for blood and organ donation and promoting surrogacy and gamete donation in a similarly altruistic way. The next step is to acknowledge people for what they’ve done; to share their story and information.” One of the reasons people are heading overseas to enter commercial surrogacy arrangements is the cost. According to Surrogacy Australia outof-pocket costs for women undergoing IVF is between $2000 and $5000. It says only 0.1% of those seeking IVF treatment require surrogacy, yet Medicare provides no rebate for surrogacy IVF which could end up costing between $12,000 and $18,000. “If people are using commercial surrogacy because of cost, there is a lot more that can be done with Medicare,” Mo said.
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“Infertility is an incredibly emotional subject but the closer we approach the commercial end of the spectrum, the more ethically complex it becomes. A Danish Council of Ethics report makes the case that once you commercialise something, altruism goes out the window and many think that will impact on our national identity.” Human rights alert It’s not just Australian governments scrutinising commercial surrogacy. The United Nations has been on alert since 2008 when India started promoting itself as the ‘womb of the world’. The human rights council in The Hague is particularly concerned about current arrangements and recent controversies which appear to put infants at risk of trafficking, which is leading to a multinational approach along the lines of international adoption protocols. The rights of the child in commercial surrogacy are not necessarily secured with Australian citizenship by descent. According to Mo, while they might have citizenship, these babies don’t have transfer of parentage, which is a matter of law for altruistic surrogacy in Australia. This uncertainty can have profound implications for the child who could be rendered stateless if things went awry. The potential risks of baby trafficking came to light recently when an Australian couple from NSW had twins by a surrogate in India. They brought the baby girl home to Australia but left the baby boy behind. While the issue was not dissimilar to the Baby Gammy case in Thailand, the publicity surrounding Gammy’s abandonment meant the Australian public were aware of the child’s fate. Unfortunately that’s not the case for the baby boy in India, whose whereabouts is unknown. There are concerns the baby was trafficked. There are other equally horrifying accounts of commissioned multi-surrogacies for the purposes of human trafficking.
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It’s no more edifying when the spotlight is turned on the potential exploitation of the birth mothers in these arrangements. Cases of multiple surrogates implanted to increase the chance of a take-home baby; and poor women whose base-line health is marginal giving birth to premature
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babies who are at greater risk of being born with cerebral palsy and other disorders. There are serious human rights questions surrounding elements of the trade. While this type of exploitation would be inconceivable in Australia, when cash is made king, it can play havoc on a society’s ethical baseline, which returns us to the need for genuine discussion and transparency. Those desperate for a family need to be protected as do all the people in the chain. But once a baby is born, it is up to all of society to ensure that it is safe, nurtured and its rights protected.
By Ms Jan Hallam
The Law in WA By Morag Smith, Senior Solicitor, tor, Avant Mutual Group my’ case, which In the wake of the ‘Baby Gammy’ created disquiet in relation to the ethical issues surrounding international surrogacy, Thailand’s parliament passed legislation banning foreign nationals from entering into surrogacy agreements with Thai women. In Australia, the Standing Committee on Social Policy and Legal Affairs has held two roundtables to examine Australia’s role in surrogacy issues. In March, the committee noted that domestic legislation on surrogacy was inadequate and recommended an inquiry into the regulatory and legislative framework for surrogacy.1 Morag Smith
Following a review bv the Western Australia Department of Health on the effectiveness of the Surrogacy Act 2008 (WA), the Minister for Health agreed that work was required at a national level to regulate national and international surrogacy arrangements.2 What the WA legislation says Current West Australian surrogacy arrangements are governed by the Surrogacy Act (WA) and the Human Reproductive Technology Act 1991 (WA) (HRT Act). Women are only eligible for a surrogacy arrangement under the HRT Act, if they are unable to conceive or deliver a child due to medical reasons or risk conceiving a child affected by a genetic disorder. Women unable to conceive due to age are not eligible to enter into a surrogacy arrangement. The Surrogacy Act outlines the strict requirements for the prospective parents to become the legal parents of the child as follows:
reasonable expenses arising from the pregnancy and the birth. Future considerations To become the legal parents of a child born as a result of a surrogacy agreement, the prospective parents need to obtain a parenting order from the Family Court. The Court order can also include a plan that outlines the level of contact (if any) the birth mother has with the child and the information (including medical history) that any of the parties can provide to a third party. However, right up until the Parenting Order is made, both the birth mother and prospective parents can change their minds. If any party to the agreement changes their mind, the surrogacy agreement, while legal, is not enforceable. The only aspect enforceable under contract law is the agreement to meet the expenses of the birth mother. The lack of enforceability of surrogacy agreements means there is always a risk the intended parents may decide they do not want to assume responsibility for the child. Hopefully, the slated Commonwealth Inquiry will result in a national response to this issue. References 1. Parliament of the Commonwealth of Australia Roundtable on Surrogacy: March 2015. 2. Extract from Hansard p8829e-8830a 26.11.2014.
Ethical Issues in WA
så 4HEåBIRTHåMOTHERåMUSTåBEåOVERå åANDåHAVEåPREFERABLYåGIVENåBIRTHå to a child previously;
By Cailin Jordan, Counsellor, Hollywood Fertility Centre
så THEåSURROGACYåARRANGEMENTåMUSTåBEåINåWRITINGåANDåSIGNEDåBYåALLå affected parties, including the defacto partner or husband of the birth mother; så EACHåPERSONåMUSTåUNDERGOåCOUNSELLINGåANDåBEåDEEMEDå psychologically suitable to be involved in the surrogacy arrangement; and så THEåPARTIESåMUSTåRECEIVEåLEGALåADVICEåABOUTåTHEåEFFECTåOFåTHEå surrogacy arrangement. The written agreement must be approved by the Reproductive Technology Council before the birth mother becomes pregnant. If the birth mother is already pregnant, the agreement is not deemed valid. Tough penalties for commercial surrogacy arrangements Commercial surrogacy arrangements are illegal and anyone found entering into a commercial agreement is subject to a substantial fine or imprisonment. However, a birth mother is entitled to reimbursement of
MEDICAL FORUM
Cailin Jordan
Surrogacy has been described as one of the greatest gifts one woman can offer another. Current Australian practice is respected as ethical and world class. However, it is complex. Careful consideration and guidance ensures all parties explore the legal and ethical issues around their personal circumstances to optimise long-term outcomes and support the child born of a surrogate arrangement.
The few high profile cases that go wrong make the media. It is important to inform patients that surrogacy is legal in WA. However, they need to benefit from the comprehensive medical, legal and psychosocial preparation that accompanies surrogacy. The aim is to facilitate informed consent. continued on Page 21
SEPTEMBER 2015 | 17
Trailblazer
Doctoring to a Different Beat Chevron Australia’s CMO and Oxford MBA Dr Carlo Bellini has brought the worlds of medicine and business together in a fascinating career that spans continents. Doctor, Dancer, Doer. So reads the tagline on one of Dr Carlo Bellini’s online profiles. It is a short, yet accurate description of the Chevron Australia Chief Medical Officer. Carlo’s role for the multinational corporation is a bespoke position that hands him responsibility for the health and wellbeing of thousands of Chevron employees and contractors. The remit is a broad one; overseeing the operation of remote field medical centres, planning and ensuring remote medical emergency capabilities, managing the Fitness For Work program and overseeing the wellness program. Lastly, as subject matter expert on all things medical, Carlo has heavy involvement in developing Chevron’s health policies and procedures. It is a position he describes as “all-consuming”
Dr Carlo Bellini at Zero Gravity
but it is one he relishes, primarily because it allows him to marry his love of medicine with his second love, business and innovation.
business and the way that it connects people and enables or doesn’t enable things to happen in the world.”
His route to Chevron CMO is almost as unique as the role itself, and somewhat ironically involved stepping away from medicine at crucial points in his career.
His desire to become a doctor was further cemented in his teens with a trip to India where he spent time volunteering at Mother Teresa’s House of the Dying and Destitute, essentially a palliative care setting.
Like many of his peers, Carlo wanted to be a doctor from a young age. Unlike many of his peers, he was also working in a small business – his parent’s pharmacy – from a young age and gaining valuable exposure to this world. Early inspirations “I have a very close family, I am part of a close community and part of my desire to be a doctor was about doing something for the greater good of the community,” he explained. “At the same time, I always had an interest in
A medical degree followed, but only after Carlo applied for – and was refused – the chance to do a double degree in medicine and business. The traditional hospital internship came next, and it seemed a career in cardiology beckoned. But when it came time to commit to physician training, Carlo took a step back. “While I loved working in the public health system, I found it was also a system where people did things because that was the way things were always done,” he said.
Where’s the Money Going? ‘Money for Medicine -- Slicing the Cake’ Thursday 10 September 7.15-8.50am Go online or phone 9203 5222 to reserve your place! A Free Breakfast at Rendezvous Scarborough Moderator is Russell Woolf
A serious moment during the last Doctors Drum “I thought the discussion was excellent. Great to get some insight from the politicians. Well done.” Dr Cliff Neppe, Duncraig “A very enjoyable breakfast and a welcome break from work. I enjoyed meeting new people and specialists I have referred to but never met. The panel were very impressive and Russell Woolf was great. It was very useful for the GPs to vent their frustrations.” Dr Rimi Roper, Mt Lawley
Limited numbers, reserve your place now at www.doctorsdrum.com.au 18 | SEPTEMBER 2015
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Thinking outside the box “There were only a small number, or in some cases an absence of, people with a clinical background who had also upskilled in management. I saw a real opportunity there. I decided I wanted to work at a systems and population level to improve healthcare in Australia.” This thinking prompted the decision to undertake an MBA at Oxford University, where he “stepped out of the medical paradigm”. He spent a year gaining exposure to a wide variety of industries and disciplines, and emerged even more convinced that medicine and business was a rational pairing. “A lot of people would probably challenge that,” he said. “Obviously the product is different but in terms of running a hospital for example, utilisation of the hospital, operationalisation of the hospital, efficiencies, waste, the problems that a hospital faces to perform at the highest level – these are very similar problems faced by other industries. I don’t think that is often recognised.” His next stop was perhaps even more unconventional – the graduate study program at the NASA and Google sponsored Singularity University at NASA Ames
While I loved working in the public health system, I found it was also a system where people did things because that was the way things were always done,” in California. Here he spent 10 weeks considering some of the “grand challenges and biggest problems” facing modern society. Health care, artificial intelligence, energy and robotics were all on the agenda.
Afterwards he worked with Boston Consulting Group where he took on a role as a strategy consultant, still primarily outside health care. “Even though health care was my passion, I felt I needed to work in other areas first so I could bring that back to health care. A lot happens in other industries but because doctors are so invested in health and because medical education is quite singular and in some ways isolated, they are not as exposed to broader business ideas,” he explained. Two years ago, he received the phone call from Chevron. It was the opportunity he was looking for – a chance to combine his medical knowledge with his business nous. Workforce health management As CMO, much of his time is spent working at the strategy and management level, though he engages with patients more directly through the Fitness for Work program. As part of the program he is involved in individual patient consultations to ensure recruits are fit for their role or to help existing employees remain in or get back to their jobs following a health concern. But he isn’t just there for Australian employees. Chevron has several hundred expatriates and their families based in Australia and he facilitates their health care as well. He describes this element of his role as “particularly rewarding”. Does he ever consider what might have been, had he kept up with cardiology? “I didn’t leave clinical practice because I didn’t enjoy it. I loved it, I really loved working with people. Working in cardiology was great and for me it was always about the patient. I feel that what I’m doing now is still about that, but in a different way,” he said. “I really enjoy my role because it is a combination of health care, business, management, strategy and there’s innovation in there as well.”
Dr Carlo Bellini
His unconventional choices have resulted in a unique skill set that has seen him work in very different environments. He was recently named in this year’s 40under40 awards which recognise Western Australia’s young business talent. Generational shift Carlo notes an increasing number of health professionals are recognising the growing sway that business and politics has over the health sector. “I’ve seen a shift in the past decade. Initially medical colleagues didn’t really understand why I was pursuing business and now business is at the forefront of many health care decisions. People recognise the importance of business and management in health care and how they will largely influence the type of care we can provide,” he said With a return to clinical practice “very unlikely”, there’s just one question that remains. What sort of dancing does he enjoy? “All kinds,” he laughed. “While I was at Oxford I joined a salsa dancing group and we competed at an international salsa tournament in Paris. Dancing is something I have always enjoyed.”
By Ms Shannon McKenzie
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Feature continued from Page 17
Surrogacy Ethics The Surrogacy Act (WA) was passed in 2008 followed by Regulations, Directions and Rules in 2009, allowing non-commercial surrogacy arrangements to be made between eligible people in Western Australia. Surrogacy involves a woman (the birth mother) agreeing to carry a child for another person or couple (the arranged parents) with the intention that the arranged parents will raise the child. All surrogacy arrangements in WA must comply with the Surrogacy Act 2008 and be approved by the Reproductive Technology Council, (part of the Department for Health) before the birth mother becomes pregnant. This is intended to protect the interests of any child born in this way. The WA Act allows for: så !NåELIGIBLEåWOMANåORåCOUPLEåTOåARRANGEåANåALTRUISTICåSURROGACYåAFTERå a comprehensive assessment and approval has been undertaken. så !NYåWOMANåWHOåHASåAGREEDåTOåCARRYåAåCHILDåFORåAåWOMANåORåCOUPLEå eligible for IVF, can access IVF also. så 4HEåTRANSFERåOFåLEGALåPARENTAGE å THROUGHåAå&AMILYå#OURTåORDER åTOå the arranged parents. Where is surrogacy information? Eligibility is regulated under the Human Reproductive Technology Act (WA) 1991 (see other article). There are grey areas. A postmenopausal woman will not be eligible, however a woman experiencing premature menopause, may be. If there is any uncertainty about your patient’s eligibility, refer to a fertility specialist – the clinics in Perth offering surrogacy assistance are Hollywood Fertility Centre, Concept Fertility Centre and Pivet Medical Centre (ref. Reproductive Technology Council website). The surrogacy coordinator is usually the first contact. Alternatively, prospective parents can visit www.rtc.org.au and view Section 23 of the Human Reproductive Technology Act 1991(WA) or Section 19(2) of the Surrogacy Act (WA) 2008.
Legislation also defines who is eligible to be a surrogate (birth mother). Ask a surrogacy coordinator or view Section 17 of the Surrogacy Act 2008 on the RTC website. Surrogacy arrangements A couple may require gestational surrogacy (arranged parent provides their own egg and sperm and or donor egg or donor sperm) or traditional/partial surrogacy (birth mother provides the egg and the arranged father or a known sperm donor provides sperm). Many surrogates are well known to the intended parent(s). Only altruistic surrogacy is legal in WA, although it is legal for prospective arranged and birth parents to advertise for an altruistic surrogacy arrangement. Those involved in a surrogacy arrangement undergo: a medical assessment; counselling; clinical psychology assessment for the intended parent(s), the surrogate, surrogates partner and sometimes the surrogate’s children; and the seeking of independent legal advice. The rights of all involved are protected through informed consent. Questions? Contact the author on 9389 4200.
Med Students Kimberley Dreaming
Medical students’ cultural and linguistic orientation provided by the Kimberley Interpreting Service.
Notre Dame Medical School’s Kimberley remote area health placement fittingly celebrated its 10th anniversary last month at the Derby Civic Centre where a video made by students ‘premiered’ to local residents. The program’s academic coordinator Dr Donna Mak told Medical Forum that the success of the program lay in the participation of rural communities and individuals who generously shared their lives and homes with medical students.
sometimes other health professionals and educators,” she said. The Kimberley placement program is conducted in a student’s second year where they are hosted by a family or community for a week to give students a perception of the challenges and joys of living remotely. It has inspired a number of students to choose to ‘go bush’ after graduation. The video can be viewed at https://vimeo.com/134960862
“The involvement of lay people is a very different approach to traditional med student teaching which is done by doctors,
MEDICAL FORUM
SEPTEMBER 2015 | 21
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Guest Column
Holding on to Empathy in Medicine Without empathy and kindness, doctors expose themselves to patient dissatisfaction and open the door to legal action, says retired gynaecologist Dr Margaret Smith. The world has become so litigious that many people are afraid of being sued often for trivial offences. I was fortunate to be taught and practise medicine in a kinder age when mistakes happened but it was understood that, with the best will and competence, some were unavoidable – doctors were not perfect. But nowadays, the cost of medical insurance, particularly for obstetricians and surgeons, has gone up tenfold. I feel that much of this is not because more mistakes are made but that doctors are no longer treated like gods – and don’t deserve to be! Of course our system of medical defence is necessary and helpful. I also believe high fees have come about because of lack of adequate communication between doctor and patient. Doctors do explain the risks of any procedure, often at great length but with little compassion. Some patients at this stage simply refuse to have the operation, which would have been of real benefit. But apart from this necessary information, another problem is becoming increasingly obvious, at least to me – defensive medicine.
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Some doctors simply lack empathy and don’t reassure patients adequately about a diagnosis. There seems a fear that to reassure a patient that cancer is very unlikely exposes them to the remote possibility of a wrong diagnosis. So the patient is left unnecessarily worried and fearful.
I fear that empathy has been lost in the waves of magnificent medical advances
Patients need reassurance at every step of diagnosis – they usually fear the worst even if all initial tests have ruled out the big C! They need information about their condition from the doctors treating them, not from websites or friends. In my early practice 55 years ago, we had a few blood tests and X-rays, none of today’s sophisticated imaging and no chemotherapy or sophisticated antibiotics.
But we gave patients comfort and reassurance. They felt cared for even if we could offer no amelioration or cure. Alas, this has changed. I am now, thankfully, retired but am sought by people wanting advice because they feel their doctor hasn’t listened to them. It is not about competence but lack of caring! Sir William Ostler has been called the Father of Modern Medicine. In his magnum opus Principles and Practice of Medicine, he established the methodology for bedside teaching for students and the system of medical residency for post-graduates. He pleaded for empathy as well as calmness amid a storm. I fear that empathy has been lost in the waves of magnificent medical advances that have made diagnosis and treatment so much easier and certain. But our patients are humans who need emotional support, not just having their physical problems fixed.
SEPTEMBER 2015 | 23
Genea’s GeneSyte prenatal test provides reliable, comprehensive answers about the health of a developing foetus. The test represents a major advancement in prenatal testing, providing accurate answers about foetal chromosomal health—without the risks associated with invasive procedures, such as amniocentesis or chorionic villus sampling (CVS). Performed as early as 10 weeks gestation, [OL [LZ[ KLTVUZ[YH[LZ Z\WLYI ZLUZP[P]P[` HUK ZWLJPÄJP[` MVY [OL TVZ[ WYL]HSLU[ [YPZVTPLZ GeneSyte can also detect sex chromosome aneuploidies in singleton pregnancies—at no extra charge. I !:9:>:8D * '@=91= >D90=:81
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Source: Verinata Health Inc. (2012). MX – Monosomy X (Turner syndrome) – XXX, XXY, XYY: Limited data of these more rare aneuploides preclude performance calculations.
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Expansion into twin pregnancies.
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An easy, non-invasive blood test delivering the answers you seek in just days. 191&D?1 5> 1->D ?: :=01= -90 9110> :97D - >58;71 .7::0 >-8;71 &58;7D /:8;71?1 191- > $=19-?-7 %1<@1>? :=8 -90 -0A5>1 D:@= ;-?519? ?: -??190 - 191- /:771/?5:9 /19?=1K59 )1>?1=9 @>?=-75- ?41 /:771/?5:9 /19?=1 5> :77DB::0 1=?575?D 19?=1K2:= ?415= .7::0 ?1>? ->D ?: =1-0 =1;:=?> -=1 -A-57-.71 B5?459 B:=6593 0-D> 2=:8 >-8;71 =1/15;?
A Genea Prenatal Request Form is available from www.hollywoodivf.com/doctorsinformation/useful-forms.aspx
Hollywood Fertility Centre 81-9> 4534 >@//1>> =-?1> @901=>?-90593 >?-22 -90 5905A50@-7 /-=1 (5>5? www.hollywoodivf.com 2:= =121==-7 2:=8> -90 01?-57> :2 :@= ?=1-?819?> ? -7>: 59/7@01> 592:=8-?5:9 2:= D:@= ;-?519?> 24 | SEPTEMBER 2015
MEDICAL FORUM
Guest Columns
Relationships: the heArt of medicine Public health physician Dr Donna Mak reflects on the qualities that make a great doctor in the 21st century. KPIs and systems approaches to health care could improve quality of care. But quality in the healing professions is more than compliance with measurable standards. It is about relationships – those we have with our patients, their families, our colleagues and the communities we serve. Given the increasing complexity of health care and the organisational demands to justify decisions with quantifiable data, metrification is probably here to stay. So how do we make it work for us, not against us? First, if we are going to use a measurement approach to accountability and reward, we need to measure the right things using the right methods. If we don’t we will incentivise the wrong behaviours. We must think critically about the validity and reliability of KPIs and recognise what they are – indicators, that is, proxy measures of the real thing – and continually strive to develop better indicators. Unfortunately, these pursuits tend to be regarded as outside the scope of mainstream clinical medicine, perhaps because clinical epidemiology and quality improvement are
not fully integrated into our teaching curricula as crucial aspects of clinical competence. These areas of competency will grow in importance as increasingly CanMEDS or similar frameworks use terms like medical expert, communicator, collaborator, manager, health advocate, scholar, and professional to define what it means to be a doctor in the 21st century. Our ability to heal comes not from meeting Pindan Don’t pack anything white. Unless you want it to be forever tinged with Pindan. The red dirt of the Kimberley. So fine it seeps into every fibre of your clothes, crease of your shoe, pore of your skin. And, if you’re lucky, the recesses of your heart, imbuing you with the spirit of this ancient, timeless land to guide and strengthen you wherever you travel in this or any other world.
KPIs but from relationships built on and sustained by trust, respect and reciprocity – relationships that lie at the heArt of medicine. These relationships help us achieve enormous health gains if we as individuals, and a profession, open our ears, minds and hearts to community voices to advocate with and for the community. For example, the advances in HIV management over the last 30 years would not have occurred without active participation of HIV-affected communities. Much closer to home, government funded antenatal pertussis vaccination would probably have taken much longer to be introduced in Australia if baby Riley’s parents, Cath and Greg Hughes, had not joined with immunisation professionals to lobby for this program. I was privileged to learn the value of relationships at a very early stage of my career from Kimberley people generous enough to take a young, naive doctor under their wing and teach her how to work with them. More than 25 years later, their descendants have welcomed nearly 1000 second year Notre Dame medical students into their homes and hearts and communities whom they will serve after graduation.
Understanding the Problem An eating disorder is complex and Frances Cook, the Butterfly Foundation’s National Manager of Programs and Practice, talks of clear and simple guidelines. Any doctor, particularly a GP, is likely to be one of the first health professionals a person with an Eating Disorder (ED) will see. EDs affect about 9% of the population, leaving little doubt that over the course of your career you will treat a number of these patients. This is particularly so if your practice focuses on a high-risk group such as adolescents, women, athletes or those struggling with issues surrounding weight and/or body shape. EDs continue to be misunderstood in both the general community and among health professionals. The first step in taking an effective approach to eating disorders is to understand them. Eating Disorders are complex – they defy classification solely as mental illnesses. They involve considerable psychological impairment and distress and are also associated with potentially serious medical complications – a complex interplay of genetic, psychological and environmental factors. Eating disorders are characterised by feelings of hopelessness,
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anxiety and depression, intense feelings of self-hatred or shame often sustained by the tormenting voice of a harsh inner-critic. Eating Disorders are serious – they have the highest mortality rate of any psychiatric illness. Medical complications, chronic physical conditions, and increased risk of suicide are all involved. While most research has focused on anorexia nervosa, people with other presentations (such as binge-eating) also have an elevated mortality risk. Eating Disorders are difficult to identify – patients often deny or fail to realise they have a problem; reluctance to seek help may be because they believe some behaviours are actually helping them. We know that people with EDs consult their GP in the five years prior to an ED diagnosis much more frequently – diverse and quite separate complaints such as amenorrhoea, gastro-intestinal problems, anxiety and/or depression, substance abuse, sleeping difficulties and physical injuries caused by over-exercising.
Eating Disorders are treatable – with early and effective treatment an ED is something people can recover from. The key to successful recovery is early intervention. There is often a significant delay between the commencement of disordered eating symptoms and the initiation of treatment. Reducing this delay can improve health and quality of life. It is crucial that patients are carefully screened. A psychosocial assessment (HEADSS) is a simple way to gather useful and relevant information. Established treatment guidelines and screening programs are available (see below). There’s a lot of support out there to identify and manage an ED in a patient you’re concerned about. The Butterfly Foundation operates a National Helpline that medical professionals can use to improve their doctor/ patient interaction and locate local support. Ed: Butterfly Foundation 1800 33 4673 (8am-9pm AEST) www.thebutterflyfoundation.org.au National ED Collaboration www.nedc.com.au
SEPTEMBER 2015 | 25
Clinical Update Feature
Medical Admin on Parade The modern-day medical administrators must be accountable, decisive and equipped to handle multi-million dollar budgets and lots of staff. The rebirth of medical administration is driven by a desire to attract people with expertise and know-how so consumers get value for money. In WA, arguably the top administrators gravitate to the private sector, where big budgets and cost containment are behind more acute innovation. RACMA The Royal Australasian College of Medical Administrators recently had its annual WA get-together at Hollywood Private Hospital. RACMA has 35 fellows, 15 trainees, and 20 associate fellows in WA and believes that a clinical background, clinical experience especially, creates effective management of patient care. That’s why medical students and doctorsin-training were among the 20 or so at the meeting, rubbing shoulders with experienced College fellows and senior medical administrators. They heard South Metro Health Services’ Dr Tim Smart relate his experiences postPatell controversies at Bundaberg Hospital, 1UEENSLANDånåHEåLEARNTåTHATåHAVINGåPEOPLEå with both financial and clinical understanding of patient care was important. He said administrators who put patients first and knew their stuff were in the best position to respond decisively, which is where things
are heading. Why? Growing cost pressures, which Tim feels could get ugly in public health, as deficits grow. Clinicians are best placed to make decisions on behalf of patients – those who have clarity of vision, a population health viewpoint, and flexibility. Dr Sayanta Jana promoted the WA RACMA Observership Program, a ‘work experience’ for those considering a career in medical administration – an area of growing interest; placements are in major public or private hospitals, within the Health Department. “While some leaders are born, some are ‘made’. The Fellowship provides an upcoming leader with the bare minimum skill-sets required to run health services and Dr Sayanta Jana the greater health system. The intent of the College is not to churn out a high number of Fellows, but to empower clinicians, medical leaders and those with an interest in medical administration,” he said. Several pathways and qualifications are offered by RACMA. Medical Services Director at Armadale Hospital, Dr Alison MacLean, looks after
Media people (l to r): Paul Murray, John McGlue and Gareth Parker
RACMA’s educational activities. She said medical administration is not a 9-to-5 job, and recalled being rung at 3am by an irate surgeon who could not find biscuits Dr Alison MacLean in the fridge after late night surgery! Such incidents were an eye opener on some doctors’ perceptions of medical administration, she said. She outlined that the rigor of the threeyear RACMA fellowship included an entry requirement of three years’ minimum direct clinical care, and graduation from an Australasian university. Work load included prescribed reading, full-time work, webinars, reflective writing, and a final exam (in Sydney) after completing a Masters. In contrast, the one-year Associate degree was more for specialists at the end of their clinical careers. She said new graduates would be in good company as RACMA fellows within the public hospital sector included the DG Dr David Russell-Weisz, and SMHS ED Dr Robyn Lawrence.
Panellists (l to r): Kempton Cowan (JHC CEO), Robyn Lawrence (FSH), Sue Murphy (CEO Water Corp), Andrew Harding (CEO Rio Tinto)
ACHSM Conference Around the same time, the Australian College of Health Service Management (ACHSM) held its one-day Leadership Conference at the Hyatt Regency. Of the 275 attendees, about 75% were non-clinicians. As only one fifth were ACHSM members (there are 200 in WA), this event was a chance to recruit while lifting the profile of health management. The program was clearly influenced by ACHSM president Dr Neale Fong. Speakers included the Premier Colin Barnett, former AFL coach John Worsfold, media
26 | SEPTEMBER 2015
people Paul Murray, Gareth Parker and John McGlue and SMHS ED Dr Robyn Lawrence, Water Corp CEO Sue Murphy, CEO Joondalup Health Campus Mr Kempton Cowan and Andrew Harding, CEO of Rio Tinto. Attendees came from private, public and NFP sectors – there are 50 ACHSM fellows in WA with six sitting this year. At one session, Kempton Cowan said the mix of public and private patients at Joondalup Health Campus had underscored the different
approaches necessary to engage clinicians and get them involved in a common vision. The panel were asked about personal resilience. Kempton said young people today faced the biggest challenges. Andrew said his attitude was never to give in and try to make a difference – he meditated for 30 minutes each day. Robyn said having outlets such as morning walks and chats with people she trusts were important.
By Dr Rob McEvoy
MEDICAL FORUM
Clinical Update
Update: aspirin in cardiology
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
By Dr Andre Kozlowski, Cardiologist, Subiaco.
Since the discovery of its protective property aspirin (ASA) became the cheapest and most widely-used agent in cardiovascular medicine but its popularity often comes with misconception regarding clinical application and potential side effects. Coronary Artery Disease Acute Coronary Syndrome ASAâ&#x20AC;&#x2122;s role in acute coronary syndrome (ACS) is undisputed: a loading of 300 mg in addition to ticagrelor, prasugrel or clopidogrel is mandatory regardless of the way of initial treatment: thrombolysis or PCI. Secondary prevention After coronary intervention dual antiplatelet protection is usually recommended for at least 12 months for drug eluting stents and 1 month for bare metal stents followed by life-long treatment with one antiplatelet agent. The development of a new generation stents, bioabsorbable scaffolds and â&#x20AC;&#x153;hybridsâ&#x20AC;? potentially allow shorter period of dual antiplatelet treatment but the recommendations are individualised depending on the type of stent, the complexity of the disease and other co-morbidities. Shorter duration of dual protection is particularly important in patients requiring anticoagulation. A recent study suggests that patients with stable coronary disease who are on NOAC and additional ASA are at higher risk of bleeding without clear beneďŹ t of cardiovascular protection. Primary prevention The role of ASA in primary prevention remains less clear. The decision to use it is usually a matter of preference indicating substantial degree of misperception regarding both efďŹ cacy and safety. Aspirin is an antiplatelet not an â&#x20AC;&#x153;antiatherogenicâ&#x20AC;? agent and the risk of cardiovascular disease should be reduced by the well-established preventive measures, including lifestyle modiďŹ cation, antihypertensive and lipid-lowering agents. It is an active agent and a beneďŹ cial property may be offset by its side effect According to BAFTA trial ASA has similar risk of major bleeding to Warfarin. Itis not recommended for â&#x20AC;&#x153;preventiveâ&#x20AC;? use in general population however it may be more beneďŹ cial than harmful in asymptomatic but high-risk patients and with high CT calcium score and in the absence of contraindications. Atrial Fibrillation There is an ongoing misperception about the protective role of ASA in atrial ďŹ brillation. It has traditionally been used as a â&#x20AC;&#x153;soft alternativeâ&#x20AC;? in non-valvular AF with low CHA2DS2-VASc score or in patients unable or unwilling to take anticoagulants. Despite the fact that AF is responsible for 30% of all strokes almost half of the patients with high score were unaware or deny their knowledge of the risk. Recent study suggests that only 27% of the patients with known AF and high risk score prior to stroke were taking Warfarin, the majority were on ASA. Current guidelines discourage use of ASA for thromboprophylaxis, as it is neither an effective or safe agent in truly low risk patients with zero risk score, and in the absence of other indications. Dual antiplatelet rather than ASA alone may be considered in patient refusing oral anticoagulant. Competing interests author: Western Cardiology contribute to production costs for this article. Questions? Contact the author on 9346 9300.
FERTILITY NEWS
by Medical Director Prof John Yovich
Antacid Medications â&#x20AC;Ś detrimental to total motile sperm count As a reviewer for several, and sectional editor for a few medical journals, I am Clinical privileged to view the latest work being Professor UHVHDUFKHG LQ WKH Ă&#x20AC;HOG RI 5HSURGXFWLYH John Yovich Medicine. I recently approved a study from 5RWWHUGDP WKDW LV QRZ XQGHU FRQVLGHUDWLRQ ZLWK WKH MRXUQDO +XPDQ 5HSURGXFWLRQ EXW KDV ZLGHU LPSOLFDWLRQV that should interest readers of Medical Forum WA. The study shows that medication used for gastric acid-related symptoms detrimentally affects total motile sperm count (TMC) and concentration in men in subfertile settings. They studied the effects of antacids, particularly proton-pump inhibitors and H2-receptor antagonists, which were being used by 4.5% of the men attending infertility clinics (without other obvious medical conditions). Whilst we have learnt that semen parameters, other than azoospermia and very severe oligospermia have poor predictive value for fertility and IVF outcomes, TMC has recently been validated. Serum screening of these men indicated folic acid (B9) and cyanocobalamin (B12) levels were reduced whilst homocysteine (Hcy) levels were elevated. This motivated me to review my understanding of the 1-Carbon metabolic pathway, which centres around folate (pteroyl-glutamate). Its active form tetrahydrofolic acid (THFA) assists transfer of methyl, methylene DQG IRUP\O FDUERQ JURXSV WR HVVHQWLDO VXEVWUDWHV IRU '1$ 51$ and protein synthesis e.g.: THFA+ B12 + B6 deliver single carbon units for Hcy ° Methionine $OWKRXJK 5DQLWLGLQH DQG &LPHWLGLQH DUH NQRZQ WR DFW DV DQWL androgens, and the latter can affect the H-P-G axis, the general effects of gastric acidity suppression are thought to be more relevant as PPIâ&#x20AC;&#x2122;s (such as Nexium, Losec and Somac) were the most used, affecting Folate and B12 absorption and thereby causing Hcy elevation. The implications arising from the study are to avoid continuous use of antacids if possible, and to promote supplementation of B group vitamins especially Folate (B9), B12 and probably B6 (pyridoxine) and B3 (NADPH). B12 of course is an important co-factor for conversion of essential amino acid methionine to S-Adenosyl M (SAM) which enhances methylation and Hcy binding.
NOW AT 2 LOCATIONS PERTH & BUNBURY
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MEDICAL FORUM
SEPTEMBER 2015 | 27
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Clinical Update
The low allergy pet myth Inevitably, patients say their pet was selected because it is â&#x20AC;&#x153;low allergyâ&#x20AC;? or â&#x20AC;&#x153;doesnâ&#x20AC;&#x2122;t shedâ&#x20AC;?, so obviously it is not contributing to their allergy. Or is it? Diseases that can worsen from pet exposure include atopic dermatitis, allergic rhino conjunctivitis and allergic asthma. Pet allergy prevalence has paralleled increased pet ownership in Australia â&#x20AC;&#x201C; one of the worldâ&#x20AC;&#x2122;s highest, with 25 million pets (63% of households); dogs (19 per 100 people) more than cats (15 per 100 people). However, some 17% of cat owners are allergic to them compared to 5% of dog owners. Allergens everywhere The major cat allergen Fel d 1 is a low molecular weight globulin secreted from the salivary, sebaceous and perianal glands and transferred to the skin by grooming and licking. Can f 1 is similar, produced in the tongues of dogs. There are multiple other minor allergens including serum albumin, immunoglobulins, and prostatic antigens. Airborne pet allergen, carried on particles under ďŹ ve microns in diameter remain suspended in the air for hours, whereas dust mite is carried on particles over 20 microns,
that fall rapidly to the ground. Exposure to cat or dog allergen in homes can be 100 times greater than dust mite, and allergens persist in homes for up to six months after pet removal.
appointments. Most classrooms have allergen levels approaching that found in houses with one pet and can trigger asthma symptoms.
Access to airways and spread are facilitated in a variety of ways. Allergens are present in homes without pets in sufďŹ cient quantities to sensitise patients. They are also found in many public places e.g. upholstered chairs in hospitals such that allergen inhalation can exacerbate asthma in patients attending
There are misconceptions amongst health professionals and the public regarding low allergy pets.
The â&#x20AC;&#x2DC;smooth-roadâ&#x20AC;&#x2122; analogy illustrates the dangers of over-management. Every day is a journey. Bumps in the road are integral to the experience of lifeâ&#x20AC;&#x2122;s journey. In overcoming everyday obstacles, as children, we learn our capabilities and we learn resilience; lessons worthy of a skinned knee. When over-management smooths the road of life too much, we are left equipped to travel only on smooth roads. The journeys might be easier, but the destinations are crowded and predictable. Fun places in life are at the end of bumpy roads. Over-managed children develop learned helplessness, relying upon support to overcome lifeâ&#x20AC;&#x2122;s daily obstacles. This
30 | SEPTEMBER 2015
There are no hypoallergenic pets
Key Messages sĂĽ ,OWĂĽALLERGYĂĽCATSĂĽORĂĽDOGSĂĽDOĂĽNOTĂĽEXIST sĂĽ #AT DOGĂĽALLERGENSĂĽAREĂĽUBIQUITOUSĂĽ ĂĽCOMPLETEĂĽ avoidance is impossible. sĂĽ /CCUPATIONSĂĽLIKEĂĽTEACHERS ĂĽCLEANERSĂĽANDĂĽ veterinarians have greater exposure. sĂĽ 2EGULARĂĽPETĂĽEXPOSUREĂĽANDĂĽDOESĂĽNOTĂĽLEADĂĽTOĂĽ natural desensitisation; allergy risk increases with the duration of exposure. sĂĽ -OSTĂĽATOPICSĂĽWHOĂĽACQUIREĂĽAĂĽNEWĂĽPETĂĽBECOMEĂĽ allergic to it whether it stays outside or inside. sĂĽ 7ASHINGĂĽPETSĂĽFREQUENTLY ĂĽSTEAMĂĽCLEANINGĂĽ furniture and ďŹ&#x201A;oors, and HEPA or electrostatic ďŹ lters to remove airborne allergen are helpful but desensitisation may be more effective.
Effects of attachment parenting According to Attachment Theory, threats to the security of mother-infant attachment are the cause of many psychological and behavioural problems. Hence, where possible, children should be shielded from distress and comforted when attachment is threatened. However, when this doctrine is taken to the extreme it leads to overmanagement and over-nurturing.
By Dr Colin Somerville, Allergist, Leeming
Many believe poodles and labradoodles cause fewer allergies due to a more compact coat or less hair shedding. Studies show no difference in these petâ&#x20AC;&#x2122;s allergen production in homes where these reside. Some even produced more allergen than other â&#x20AC;&#x2DC;allergenicâ&#x20AC;&#x2122; dogs. In short, no evidence supports the concept of hypoallergenic pets. Bathing a pet can help reduce allergen if done at least twice weekly The only truly effective way to treat a pet allergy is to remove it from the home and then clean extensively to remove residual allergen. Many patients are reluctant to do this. Even if they do, reactions in other environments can make desensitisation the only alternative.
Author competing interests: no relevant disclosures. Questions? Contact the author 9313 5171
Clinical Opinion
By Dr David Roberts, Paediatrician Joondalup
undermines development of a robust sense of self-worth. The sense of capability is integral to self-esteem. Over-nurturing This is excessive attention to a childâ&#x20AC;&#x2122;s wants and needs, including comforting in distress. Whilst many children delight in being comforted (generally wanting more) it does not follow that they donâ&#x20AC;&#x2122;t get enough or are deprived of love. Distress is not always the result of a threat to attachment. Over-nurturing entrenches immature or regressed behaviour, rendering children underprepared for the rigours of the next stage of childhood, setting them up to stumble at the next hurdle. This is stigmatising, because children notice the strengths and weaknesses of their social peers, and some ruthlessly exploit the weaknesses of others. A childâ&#x20AC;&#x2122;s self-esteem is also founded on competence in the social world and sense of likability. A failure to impose boundaries is a third consequence of attachment parenting, which proposes instead the technique of disciplinary
reasoning. There are three problems with this. First, disciplinary reasoning doesnâ&#x20AC;&#x2122;t work in the young because it is simply age inappropriate. Secondly, without boundaries children fail to acquire self-regulation, and an ADHD like picture often emerges as a result. Finally, without authority ďŹ gures children fail to learn about social hierarchies, and present themselves as precocious and disrespectful to unfamiliar adults (e.g. teachers). Not all the ills of modern children are traceable to Attachment Parenting, and many of the consequences outlined above are multifactorial. Neither should we stigmatise Attachment Theory for the ills of Attachment Parenting. Nonetheless, it is a fashion â&#x20AC;Ś the sooner passed the better. Author competing interests, no relevant disclosures. Questions? Contact the author 9300 3002.
MEDICAL FORUM
Clinical Update
Tuberculosis (TB) in Western Australia Bacterial (streptococcal pharyngitis, bartonella infection) or viral lymphadenitis (infectious mononucleosis, rubella) are the most likely aetiologies with lymphoma or thyroid malignancy the most common non-infective causes. Active tuberculosis is the commonest cause for neck swellings in countries where TB is endemic, like Myanmar, where this man is from. Epidemiologically, his presentation warrants a changed differential diagnosis, with active tuberculosis topping the list.
By Dr Astrid Arellano Infectious Diseases Physician, Palmyra
Active tuberculosis cases in WA mirror the wider Australian prevalence of 5.0/100,000 cases each year. WA had 142 cases of active TB in 2014 (table 1). Certain groups (overseas born, indigenous Australians) have much higher rates. TB is an important differential diagnosis in an unexplained cough for three weeks, especially with sweats and fevers. Think active TB Most cases (75%) are pulmonary and can present with a cough, haemoptysis and
CASE REPORT A 22-year-old from Myanmar presents with bilateral neck swellings increasing in size over three months. He denies fevers, sore throat, a cough, haemoptysis, weight loss or a recent URTI. He feels tired. On examination, there is a 5x7 cm warm, tender right sided cervical swelling. Smaller enlarged lymph nodes are present on the left posterior to the sternomastoid. The oropharynx is normal and chest is clear. What is the differential diagnosis and the most relevant investigations?
Table 1. Western Australia Tuberculosis 2014*
cachexia but often are asymptomatic. A high index of suspicion is required to make the diagnosis (e.g. screening CXR for VISA application). The second most common presentation is TB lymphadenitis often with a painless, firm swelling that increases in size over time with or without systemic symptoms. Tuberculosis is a microbiological diagnosis and sputum AFB (acid fast bacilli) examination is highly sensitive. In this case, cervical lymph node FNA showed AFB. A positive Mycobacterium tuberculosis (MTB) PCR without rifampicin resistance was found on GeneXpert (an automated test identifying MTB and rifampicin resistance) testing Subsequent cultures grew a fully susceptible MTB isolate. The patient had a CXR (fig. 1) and sputum AFBs were smear negative but culture positive. (CT scan does not add sensitivity to the diagnosis and is not required, except in miliary TB cases.) Treatment is effective and curative in over 95% of cases. It is important that experienced TB physicians manage cases. ED. The WA TB Control Program at the Anita Clayton Centre is free and manages active TB cases in WA. TB physicians can advise on 9222 8500. References available on request
0-49 yrs
50-64yrs
65+yrs
Total
Total %
Male
45
12
Female
53
8
17
74
52%
7
68
48%
Country of birth/ Indigenous status Australia born - non Indigenous
7
3
4
14
10%
Australian born - Indigenous
0
1
0
1
1%
Overseas born
90
15
20
125
88%
Unknown
1
1
0
2
1%
New
93
18
22
133
94%
Relapse following full or partial treatment
4
1
1
6
4%
Treatment after failure
0
0
0
0
0%
Unknown
1
1
1
3
2%
43
12
12
67
47%
Case classification
Clinical presentation Pulmonary only Pulmonary plus other sites
11
2
4
17
12%
Extrapulmonary
44
5
7
56
39%
Unknown
0
1
1
2
1%
Laboratory results Sputum smear and culture positive
13
5
9
27
19%
Sputum culture positive (smear negative)
18
4
2
24
17%
Other culture positive
40
6
5
51
38%
Nucleic acid testing(a)
4
1
1
6
4%
Unproven(b)
20
4
7
31
22%
Figure 1. CXR showing right upper zone infiltrates with cavitation in man with bilateral neck swellings and no chest symptoms
Author competing interests – no relevant disclosures. Questions? Contact the author on 9319 3811.
Data provided by the WA TB Control Program. *Nine cases from age 0-14 are included. (a) Positive nucleic acid test without a positive culture. (b) Cases with no positive culture or nucleic acid test.
MEDICAL FORUM
SEPTEMBER 2015 | 31
Fertility, Gynaecology and Endometriosis Treatment Clinic
When your patient’s family plan isn’t going to plan... Fertility North can help. z Cycle Tracking z Timed Intercourse z Artificial Insemination z Ovulation Induction z In-vitro Fertilisation (IVF) z Intra-cytoplasmic Sperm Injection (ICSO) z Pregnancy Monitoring z Donor Services z Sperm / Egg Freezing z Oncology Fertility Preservation z Egg Freezing for Social Reasons z Semen Analysis
Dr Vince Chapple
Dr Jay Natalwala
Dr Santanu Baruah
Dr Gian Urbani
Dr Megan Byrnes
Medical Director
Clinical Director
Fertility Specialist
Fertility Specialist
Fertility GP
Qualifications
Qualifications
Fertility Specialist Qualifications
Qualifications
Qualifications
Qualifications
MB, BS (London) FRANZCOG MRepMed
MB, BCh (UK) DRCOG FRANZCOG MRepMed
MBBS, MRCOG (UK) CCT (UK), CGES FRANZCOG
MBCHB, MMEd(O&G) FRANZCOG MRepMed
BMedSci, MBBS FRANZCOG MRepMed
MBBS, DRACOG FRACGP
Dr Jane Chapple
Suite 30, Level 2, Joondalup Private Hospital, 60 Shenton Avenue, Joondalup WA 6027 Phone: (08) 9301 1075 Fax: (08) 9400 9962 Email: admin@fertilitynorth.com.au
www.fertilitynorth.com.au
Fertility, Gynaecology and Endometriosis Treatment Clinic 32 | SEPTEMBER 2015
MEDICAL FORUM
Clinical Update
What masquerades as sinusitis Patients presenting with “sinusitis” often get a diagnosis of migraine or nonmigranous headache, temporomandibular joint (TMJ) problems or allergic rhinitis, all of which can coexist with sinusitis. Because the differential diagnosis is long, diagnosis of sinusitis can be very difficult (see box). Clinical evaluation, endoscopic examination, or further investigations are frequently required. A closer look at the main presenting symptoms can be used as a starting point. Nasal symptoms Most patients present with nasal congestion or obstruction. When congestion is predominant think of: allergic rhinitis, especially with seasonal variation; and overuse of nasal decongestant sprays (rhinitis medicamentosa). For obstruction: if persistent think of a septal deviation; or unilateral obstruction may mean a tumour (weeks or months) or a nasal foreign body (days). Nasal discharge, often a main symptom, presents some diagnostic dilemmas: it may be minimal in some forms of sinusitis; some patients are not aware of a postnasal drip; and patients with mucous in the throat or hoarseness may have laryngitis or acid reflux. When nasal discharge is clear, the diagnosis is more likely allergic or nonallergic rhinitis, rhinitis medicamentosa or “vasomotor” rhinitis. Usually an altered sense of smell and taste is secondary to the inflammatory process. If these exist without symptoms of inflammation,
s Ms Vicky Moriarty is the new RACGP WA State Manager after long-serving manager Malvina Nordstrum left to join the WA Primary Health Alliance. Ms Leah Williams is moving to the College head office in Melbourne to take up a post as communications and media adviser. s The Chief Medical Officer, Prof Gary Geelhoed, and Prof Jonathan Carapetis, head of Telethon Kids Institute, have been appointed to the National Health and Medical Research Council. Also appointed is Mt Barker raised Prof Sandra Eades, currently working in Aboriginal Health at Baker IDI Heart and Diabetes Institute. s Ophthalmologist Dr Fred Chen, Dr Tom Snelling from Telethon Kids Institute and Prof Willem Joost Lesterhuis from UWA Medical School are three of seven people sharing grants from the New Independent Research Infrastructure Support fund.
MEDICAL FORUM
By Dr Chris Dhepnorrarat, Adult & Paediatric Otolaryngologist, Subiaco
nasal endoscopy, sinus and head imaging will usually rule out a skull base tumour. Headache and facial pain A detailed history is required to distinguish the different types of headache. Lethargy is common in sinusitis but think of sleep apnoea with morning headaches, especially if there is sleep disordered breathing. Patients with midface pain or upper jaw pain require evaluation for dental and periodontal disease as well as disorders of the TMJ. With severe pain, acute infection in an obstructed sinus will need to be considered. Patients with only facial pressure or fullness may have sinusitis with little or no infection (e.g. polypoidal sinusitis). Consider a sinonasal tumour if: progressive unilateral obstruction and epistaxis over weeks or months, especially when there is no bleeding site visible on the anterior septum; or changes to facial appearance and visual disturbances. Symptoms, age of onset, duration and family history are important for recognising sinonasal symptoms of systemic diseases like cystic fibrosis and granulomatosis with polyangiitis (formerly Wegener’s granulomatosis). References available on request
DD of Sinusitis Symptoms Nasal and sinus obstruction Septal deviation Antro-choanal polyp Benign or malignant sinonasal tumour Nasal foreign body Headache and facial pain Migraine Tension and Cluster headaches Trigeminal neuralgia Other headache syndromes Dental and periodontal disease Rhinorrhoea and postanasal drip Allergic and nonallergic rhinitis Laryngitis Gastro-oesophageal reflux Rhinitis medicamentosa Rhinitis of pregnancy Adenoiditis and adenotonsillitis Systemic conditions Sleep apnoea Cystic fibrosis Granulomatosis with polyangiitis
Author competing interests – no relevant disclosures. Questions? Contact the author on 6380 4955
s Australia’s first listed medical marijuana company PhytoTech Medical Limited has been given the nod by shareholders and merged with MMJ Bioscience Inc. to rebrand as MMJ PhytoTech Limited (ASX=MMJ). Phytotech researches in Israel and will loan the Canadian based MMJ CAN$1.35m, with board mergers aimed to grow the international medical cannabis market, especially its European operations focused on sales of its dietary supplement Cannabidiol (CBD). s Resonance Health’s Chief Scientific Officer Prof Tim St Pierre has won the Commonwealth Bank sponsored Western Region EY Entrepreneur of the Year™ in the technology category (see www.ey.com/au/ eoy). He competes for the national award in Sydney in October. He and UWA have developed FerriScan® (an MRI-based technology to measure liver iron) and now the HepaFat-Scan that measures fat in the
liver (for Non-Alcoholic Fatty Liver Disease linked to obesity). s Curtin University has appointed Prof Rachel Huxley as its new Head of School of Public Health. She comes from University OFå1UEENSLANDåANDåHASåWORKEDåATå/XFORDå UK, Sydney Uni, and Minnesota Uni. Her research focus is on major and modifiable risk factors for chronic disease, and any sex and ethnic disparities. She replaces Prof Bruce Maycock. s Dr Maria Garefalakis is no longer medical director at Sexual and Reproductive Health WA (formerly Family Planning WA). A replacement has not been announced. s Fiona Stanley Hospital has won the top prize at this year’s WA Architecture Awards, with Hassell, Hames Sharley and Silver Thomas Hanley commended for their design efforts.
SEPTEMBER 2015 | 33
Medical Audiology Services
Hear the best you can!
Funding Options for Audiological Services
Andre Wedekind M.Aud.,M.Clin.Aud., BHSc (Physio)
Dr Vesna Maric AuD.,M.Aud.S.A.,M.Clin. Aud.,BSc.(Hons)
Audiological diagnostic and rehabilitation services can attract high fees. Below is a summary of funding options to assist referring doctors and patients. For more complete information about funding, services and online referrals, visit medicalaudiology.com.au. OfďŹ ce of Hearing Services: Eligible clients can receive services from a wide network of acredited providers. Included are free hearing tests, fully or partially subsidised hearing aids, other hearing technologies and rehabiliation support. The main eligibile groups include Australian pension card holders, Department of Veteransâ&#x20AC;&#x2122; Affairs clients, children and young adults aged under 26 years and Aboriginal and Torres Strait Islanders aged over 50 years. Other smaller groups are also eligible.
Public Services Vestibular and auditory function tests are available through public hospital ENT departments, which may also have limited funding for cochlear implant and bone conduction devices. Routine paediatric hearing tests are available through Child Development Service centres. Medicare in the Private Sector Rebates are available when referrals for auditory or vestibular function tests are made by ENT specialists or Neurologists. A small number of authorised audiologists can also offer rebates for vestibular and hearing tests with a GP referral. In addition, accredicted audiologists can provide services under a Chronic Disease Management Plan. Gap payments may apply. Private Health Funds Selected policies provide rebates for hearing aids and other devices, although amounts vary substantially. Implantable options (e.g. cochlear implants) are covered by all private health funds. Very few funds offer rebates for diagnostic services or consultations. Patients are advised to contact their private health fund prior to an audiology appointment. Insurance Claims The cost of assessments, consultations, devices and rehabilitation programs can be covered by insurance companies on a case-by-case basis. Main areas are workplace injuries and motor vehicle accident claims.
Medical Audiology Services is accredited to operate under the OfďŹ ce of Hearing Services program and provide all Medicare private sector rebate options, as well as services funded by private health funds and insurance companies.
51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917
Clinical Update
Psychosis in the elderly
By Prof Sergio Starkstein, School of Psychiatry, UWA, and Fremantle Hospital
Psychosis is the presence of delusions, hallucinations, disorganised speech, bizarre behaviour, and negative symptoms such as mutism and apathy (DSM-5 deďŹ nition). Primary psychosis is caused by a psychiatric disorder; secondary is due to a medical disorder. Around 23% of the older population may present with psychotic symptoms with delusions and visual hallucinations the most common psychotic symptoms. Underlying medical conditions common Careful clinical evaluation is required, as about 60% show an underlying medical condition. The most frequent are the â&#x20AC;&#x153;six Dâ&#x20AC;&#x2122;sâ&#x20AC;?, delirium, drugs (e.g. alcohol and medications), disease (infectious, neurological, metabolic or endocrine), depression and other affective disorders, dementia, and delusional disorder/schizophrenia. Dementia is the commonest cause of psychosis in the elderly. Medical comorbidities, especially delirium, should be ruled out before treating psychosis. Use non-pharmacological approaches, psychosocial interventions, behavioural management techniques, and music therapy ďŹ rst. Acetylcholinesterase inhibitors have demonstrated modest efďŹ cacy to reduce agitation and psychosis in dementia. Recent studies suggest antidepressants such as sertraline and citalopram may be useful for agitated behaviour. Atypical antipsychotic use is associated with increased mortality and stroke risk and is not recommended; risperidone is the only such drug approved in Australia for behavioural disturbances and psychosis in dementia. Delirium is highly prevalent among elderly inpatients, and may be the ďŹ rst sign of dementia. Delirium is associated with visual and hearing impairment, depression, alcohol abuse, and being over 75. Excess morbidity and mortality, functional decline, falls, and a high rate of institutionalisation can result. Most present with visual hallucinations and delusions. It is divided into hyperactive and hypoactive types. An EEG may be indicated to rule out nonconvulsive status epilepticus or atypical partial complex seizures. Diseases commonly include metabolic disorders, infections, neurological disorders such as Parkinsonâ&#x20AC;&#x2122;s disease, stroke, and subdural hematoma, and endocrine disorders such as hypo/hyperthyroidism, hyper/hypoglycaemia, and hypo/hyperparathyroidism. Treating delirium relates to the underlying medical condition although short-term antipsychotic medication may be indicated for severe psychosis; however, judicious use is necessary as these may increase Parkinsonism, produce a metabolic syndrome, and prolong THEĂĽ14CĂĽINTERVAL ĂĽ Drugs (especially alcohol) should always be considered, with psychosis from either drug intoxication or withdrawal. Most common substances of abuse producing psychosis are alcohol, cannabis, phencyclidine, and stimulants. Medications most commonly associated with psychosis are antiParkinsonian and anticholinergic drugs, cimetidine, digoxin, antiarrhythmic drugs, corticosteroids and interferon. Primary psychosis is rare among the elderly, and is usually associated with a history of schizophrenia of schizoaffective disorder. Most guidelines for antipsychotic use in late-life schizophrenia recommend starting dosages of 25% of the recommended adult dose, and maintenance at 25%-50% of the adult dose. Side effects should be closely monitored, the most frequent being cardiovascular, sedation, metabolic changes, anticholinergic, Parkinsonism, tardive dyskinesia, falls, and agranulocytosis.t
Author competing interests: no relevant disclosures. Questions? Contact the author on 9431 3333
W: www.medicalaudiology.com.au
34 | SEPTEMBER 2015
MEDICAL FORUM
ROTATOR CUFF REGENERATION FirstPERCUTANEOUS & Exclusive PRP Stem NON Cell Specialist Centre in WA SURGICAL REPAIR MRI Before Rx: Rest Pain Unable to lift 10 kg
65 M failed cortisone injection
MRI 4/12 Post Rx: Improved Pressing 80 kg
Supraspinatus Tear Pre Rx: Broken red arrows show very poor & ' torn supraspinatus. Post Rx: Broken yellow arrows show restora & & ! % Yellow long arrows # ! !
Mid Supraspinatus Tear, Pre Rx: Broken red arrows show in ! ! " ed arrows # ' supraspinatus. Post Rx: Broken curved yellow arrows show & & ! %
Cu ' $ Red arrows # ! ! " red arrows # ' ! ! red arrow shows ' Post Rx: Yellow arrows # ! ' " &
First & Exclusive PRP Stem Cell Specialist Centre in WA Dr Arockia Doss MBBS (Ind) MRCP (UK) FRCR (Lon) FRANZCR Interventional Radiologist
Suite 3, 55 Hampden Road Nedlands WA 6009 P 6389 2776 F 6389 2778
bookings@igtc.com.au
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IGTC is a trademark owned by Shashi Pty Ltd. Any unauthorised use is strictly prohibited.
www.igtc.com.au
SEPTEMBER 2015 | 35
Conference
GPCE, Perth 2015 About 250 delegates, including some day attendees, were there to soak up the information and gather some category 1 & 2 CPD points. Some, both GPs and nurses, came from interstate. The varied educational program – from hearing health and chronic kidney disease to dementia and CPR – offered those attending the chance to hone their skills. With software, finance, medical supplies, employment, and help with specific health problems offered at the exhibition, delegates were often caught out and had trouble running on time for sessions. Even “IT-challenged” people handled the conference App, set up for delegates to provide CPD assessments online. With so many CPD meetings available to GPs these days, the Perth GPCE is positioning itself as indispensable. Medical Forum was there to capture the action.
Delegates Dr Sarah Hawkins and Dr Cp Lim enjoy their tea break
Venosan was one of many exhibitors at GPCE Dr Ali Kutlu goes through his CPR paces on the simulator.
Conference Corner SEPTEMBER 17-21 Asian Pacific Conference of Nephrology (APCN) & ANZSN ASM 2016 0ERTHå#ONVENTIONå å%XHIBITIONå Centre www.apcn2016.com.au
20-22 Oceania Tobacco Control Conference 0ERTHå#ONVENTIONå å%XHIBITIONå Centre www.otcc2015.org.au
Allergist Dr Richard Lowe explains some details of his talk on anaphylaxis to Dr Laura Dotto.
NOVEMBER
13-15 State Conference of AMSA Global Health Conference Science and Medicine in Sport and Exercise http://ghc2015.amsa.org.au Bayview Geographe Resort, Busselton OCTOBER www.sma.org.au/conferencesevents 15-16 Indian Ocean Rim Laboratory Haematology Conference Esplanade Hotel Fremantle www.labhaem2015.org
36 | SEPTEMBER 2015
Endocrinologist Dr David Hurley gives a talk on pituitary problems
MEDICAL FORUM
Clinical Update
Iron overload assessment tips Haemochromatosis, 20-30 years ago, was deďŹ ned by elderly men with all the complications of longstanding iron deposition in organs (cirrhosis, endocrine deďŹ ciencies, heart failure, arthritis). It was rare. With both iron studies and HFE gene tests now commonly performed, we detect early phases of haemochromatosis but also people with elevated ferritin for other reasons.
lesser degree double heterozygous for C282Y and H63D mutations (slower and milder iron deposition). The genotype confers the potential for iron loading but the ferritin determines if this has occurred. Mutations of H63D alone (even homozygous) without C282Y mutations have not been associated with iron overload. The S53C mutation is much less studied, and may not play a role.
Interpretation of clinical importance
In 5% of cases, iron overload is not related to HFE-mutations.
Many with haemochromatosis will probably not have a severe phenotype and not develop the full-blown end-stage features. In early diagnosis we lack the technology to determine this so we venesect everyone.
Venesection or not? End-organ assessment is important to determine in difďŹ cult cases if a trial of venesection is warranted.
Iron deposition takes years before causing problems. A 70 year old with a ferritin of 700 is unlikely to have signiďŹ cant iron loading, but a 25 year old may run into problems soon. Iron loading leads to raised ferritin to store the excess iron and it rises as iron loading progresses. Thus raised ferritin is the key diagnostic ďŹ nding. Ferritin can also be elevated by liver disease, metabolic syndrome, infection and inďŹ&#x201A;ammation (acute phase response) but in these situations is â&#x20AC;&#x153;emptyâ&#x20AC;? of iron. Ferritin itself is harmless; the iron bound to it causes organ damage. Sometimes elevated transferrin saturation with normal ferritin is detected. Transferrin saturationâ&#x20AC;&#x2122;s usefulness is limited in my opinion by it being calculated from serum iron and transferrin values. Small changes in either can skew the result leading to misinterpretation.
By Dr Steve Ward Clinical Haematologist, Nedlands.
Genotypes highly relevant With two or more elevated ferritin levels and no obvious alternate reason, test for the Haemochromatosis gene (HFE). Genetic Haemochromatosis is due to homozygous HFE C282Y mutation, and to a
Key Points: Iron Overload sĂĽ 2AISEDĂĽFERRITINĂĽHASĂĽCAUSESĂĽOTHERĂĽ than haemochromatosis.
The liver takes the brunt of iron deposition and is the ďŹ rst organ affected. ALT is the most sensitive liver marker but can be raised for other reasons. Hepatic ultrasound can help. It can be hard to determine which came ďŹ rst: too much iron leading to liver inďŹ&#x201A;ammation, or inďŹ&#x201A;ammation causing raised ferritin (without iron binding). A normal ALT, glucose and TSH make signiďŹ cant iron loading less likely. In these situations, monitor annually. A therapeutic venesection trial can determine the rate of fall in ferritin with venesection and in turn how much iron the individual stores. References available on request
sĂĽ 4RANSFERRINĂĽSATURATIONĂĽMAYĂĽNOTĂĽBEĂĽHELPFUL sĂĽ 6ENESECTIONĂĽTRIALĂĽIFĂĽPERSISTENTĂĽELEVATIONĂĽ of ferritin plus end organ effects.
A normal ferritin makes current iron overload unlikely.
Author competing interests: no relevant disclosures. Questions? Contact the author 6142 0970.
App: Diagnostic Imaging Pathways Details. For doctors as a mobile aid to ordering imaging. Free (no in-App purchases). Only for Apple mobile devices, that is iPad, iPod Touch or iPhone (iPhones 5, 6 and 6plus) â&#x20AC;&#x201C; android version to be released very soon for the 30% of docs with androids. Can be downloaded from Apple App Store or from companion website www.imagingpathways. health.wa.gov.au . On ďŹ rst execution, the App checks for the latest images and pathway information from the web server (about 150 MB to download), thereafter it is designed to be functional without an internet connection (but requires this to receive updates). No password protection. Recommended. Via press release, as an addition to website www.imagingpathways. health.wa.gov.au Purpose and developers. Most clinicians are grateful for any assistance in ordering the most appropriate radiological examinations for their patients, and those that best achieve
MEDICAL FORUM
a diagnosis â&#x20AC;&#x201C; released as a smartphone version of DIP in response to a growing need for portable and convenient tools. This App offers 200 pathways from a variety of clinical categories. There is a clear representation of radiation levels throughout the step-by-step process; patient beneďŹ ts from less radiation exposure and unnecessary examinations; and system beneďŹ ts from a more costeffective diagnosis. The program is originally produced by Royal Perth Hospital, as part of an evidence-based education and decisionmaking support tool. Look and feel. Front page shows 12 tiled medical specialties. Each one has a number of medical submenu disease states. Simplicity. Menus is easy to navigate Liaison between doctor and patient. Nil, both can independently access. Accuracy of information. An unbiased tool offering detailed explanatory notes in pop-
Review by Dr James Salvaris GP, Victoria Park
up boxes about why investigations should or should not be carried out. It is regularly reviewed and up-dated. Minuses. Program does not rotate into â&#x20AC;&#x2DC;Landscapeâ&#x20AC;&#x2122; view and it cannot be printed. However, a screen shot of the pathway will capture into â&#x20AC;&#x2DC;Photosâ&#x20AC;&#x2122; folder, which you can then be emailed to yourself and if you wish, print or save! The inclusion of the trauma pathways and a â&#x20AC;&#x153;favouritesâ&#x20AC;? section are features to be implemented in the next release soon. There is no facility to make freehand notes and attach these to a particular pathway. ED. Thanks to the assistance of Em.Radiologist Richard Mendelson, RPH, and IT Manager Robert Long, ImagingWest.
SEPTEMBER 2015 | 37
Travel
THE
GOOD LIFE OF BOLOGNA From its 3000-year heritage, Bologna is a city bursting with history, culture and some of the best food in Italy.
nive Bologna U
eetscape Bologna Str
rsity
38 | SEPTEMBER 2015
Bologna music museum
MEDICAL FORUM
Bologna is known as “la grassa” or “the fat one” because of its reputation as the home of fine produce such as parma ham and parmesan cheese and the origin of classic Italian dishes such as “ragu” (bolognaise sauce) and “tortellini in brodo”, basically tortellini pasta in a rich beef broth. It is certainly less-frequented by tourists than Florence or Venice and perhaps this is why it feels more like “real Italy”. It has all the essential elements of an Italian city with Neptune’s fountain in its central piazza, bordered by renaissance buildings and outdoor cafes. The Duomo could have been as beautiful as the Duomo in Sienna, except that the money ran out and the lovely pink and cream marble clads only the lower half of the building. When we visited in July last year there were free screenings after sunset at the outdoor cinema in the piazza.
The theatre was commenced in 1636 and took a hundred years to complete. Particularly interesting are the sculptures of physicians which stand in niches around the room, including one examining a dissected nose. Some of the university’s famous alumni include Dante, Petrarch, Thomas Becket, Erasmus and Copernicus. In more recent history, Luigi Galvani, the who discovered biological electricity, and Guglielmo Marconi, the pioneer of radio technology, also worked at the University If you are interested in classical music and the origins of modern musical instruments, Bologna is a hub having been proclaimed in 2006 a UNESCO City of Music. I recommend a visit to the International Museum and Library of Music. The displays are thoughtfully arranged and the audio guide is excellent, featuring biographical information on composers and excerpts of their music.
Medical Museu m Bologna
The Bologna streetscape is visually appealing because of the warm colours of the buildings – terracotta, red and yellow – as well as the covered colonnades, which shelter pedestrians in inclement weather. The University of Bologna is the oldest university in Europe, having been founded in 1088 and the university district is still one of the liveliest parts of the city. We wandered through the university precinct and enjoyed reading
street names such as Piazza Giuseppe Verdi, before stopping for an open air lunch of pizza and Italian beer. The anatomical theatre in the former school of medicine near the Duomo is a must-see for medicos. It features carved spruce panels on the walls and ceiling, seating for students in galleries on three sides and a rostrum for the professor on the fourth. In the centre is the marble autopsy table.
Bologna is small enough to stroll around in a day or two, but take three and enjoy a long lunch.
Words and Pictures by Dr Amanda Wilkins
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MEDICAL FORUM
SEPTEMBER 2015 | 39
B allll means By m lletâ&#x20AC;&#x2122;s tâ&#x20AC;&#x2122; b be openminded, minded but b not so open-minded that our brains drop out.
- Richard Dawkins
ROCKINâ&#x20AC;&#x2122; RELIGION I went into the confessional box after years of being away from the Church. Inside I found a fully equipped bar with Guinness on tap. On one wall, there was a row of decanters with ďŹ ne Irish whiskey. On the other wall was a dazzling array of the ďŹ nest cigars and chocolates. Then the priest came in. I said to him, â&#x20AC;&#x153;Father, forgive me, for itâ&#x20AC;&#x2122;s been a very long time since Iâ&#x20AC;&#x2122;ve been to confession, but I must ďŹ rst admit that the confessional box is much more inviting than it used to be.â&#x20AC;? The priest replied, â&#x20AC;&#x153;Get out, you moron, youâ&#x20AC;&#x2122;re on my side.â&#x20AC;?
A LIFE LESSON In a School science class four worms were placed into four separate jars. The ďŹ rst worm was put into a jar of alcohol. The second worm was put into a jar of cigarette smoke. The third worm was put into a jar of sperm. The fourth worm was put into a jar of soil. After the ďŹ rst day: sĂĽ 4HEĂĽlRSTĂĽWORMĂĽINĂĽALCOHOLĂĽnĂĽDEAD sĂĽ 4HEĂĽSECONDĂĽWORMĂĽINĂĽCIGARETTEĂĽSMOKEĂĽnĂĽDEAD sĂĽ 4HEĂĽTHIRDĂĽWORMĂĽINĂĽSPERMĂĽnĂĽDEAD sĂĽ 4HEĂĽFOURTHĂĽWORMĂĽINĂĽSOILĂĽnĂĽALIVE So the science teacher asked the class â&#x20AC;&#x201C; â&#x20AC;&#x153;What can you learn from this experiment.â&#x20AC;? Little Johnny quickly raised his hand and said. â&#x20AC;&#x153;As long as you drink, smoke and have sex, you wonâ&#x20AC;&#x2122;t have worms.â&#x20AC;?
HEALING WORDS The worst place to have a heart attack is during a game of charades. Especially if the people you are playing with are really bad guessers. A fellow was sitting in the doctorâ&#x20AC;&#x2122;s waiting room, and said to himself every so often, â&#x20AC;&#x153;Lord I hope Iâ&#x20AC;&#x2122;m sick!â&#x20AC;? After about the ďŹ fth or sixth time, the receptionist couldnâ&#x20AC;&#x2122;t stand it any longer and asked, â&#x20AC;&#x153;Why in the world would you want to be sick Mr. Adams?â&#x20AC;? The man replied, â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;d hate to be well and feel like this.â&#x20AC;?
Mummy Bear who swept the ďŹ&#x201A;oor in the kitchen. It was Mummy Bear who went out in the cold early morning air to fetch the newspaper and croissants. It was Mummy Bear who set the damn table. It was Mummy Bear who walked the bloody dog, cleaned the catâ&#x20AC;&#x2122;s litter tray, gave them their food, and reďŹ lled their water. And now that youâ&#x20AC;&#x2122;ve decided to drag your sorry bear-arses downstairs and grace Mummy Bear with your grumpy presence, listen carefully, because Iâ&#x20AC;&#x2122;m only going to say this once...I Havenâ&#x20AC;&#x2122;t Made The Porridge Yet.â&#x20AC;?
I DO...I THINK He was a widower and she a widow. They had known each other for years being high school classmates and having attended class reunions in the past without fail. At the 60th anniversary of their class, they had a wonderful evening, their spirits high. The widower was throwing admiring glances across the table, the widow smiling coyly back at him. Finally, he picked up courage to ask her, â&#x20AC;&#x153;Will you marry me?â&#x20AC;? After about six seconds of careful consideration, she answered, â&#x20AC;&#x153;Yes, yes I will!â&#x20AC;? The evening ended on a happy note for the pair but the next morning the widower was troubled. Did she say Yes or did she say No? He couldnâ&#x20AC;&#x2122;t remember. Try as he might, he just could not recall. With fear and trepidation he picked up the phone and called her. First, he explained that he couldnâ&#x20AC;&#x2122;t remember as well as he used to. Then he reviewed the past evening. As he gained a little more courage he then inquired of her, â&#x20AC;&#x153;When I asked if you would marry me, did you say â&#x20AC;&#x2DC;Yesâ&#x20AC;&#x2122; or did you say â&#x20AC;&#x2DC;No?â&#x20AC;&#x2122; â&#x20AC;&#x153;Why you silly man, I said â&#x20AC;&#x2DC;Yes. Yes I will.â&#x20AC;&#x2122; And I meant it with all my heart.â&#x20AC;? The widower was delighted. He felt his heart skip a beat. Then she continued. â&#x20AC;&#x153;And I am so glad you called because I couldnâ&#x20AC;&#x2122;t remember who asked me!â&#x20AC;?
THE TRUTH ABOUT THOSE BEARS Baby bear goes downstairs, sits in his small chair at the table. He looks into his small bowl. It is empty. â&#x20AC;&#x153;Whoâ&#x20AC;&#x2122;s been eating my porridge?â&#x20AC;? he squeaks. Daddy Bear arrives at the big table and sits in his big chair. He looks into his big bowl and it is also empty. â&#x20AC;&#x153;Whoâ&#x20AC;&#x2122;s been eating my porridge?!â&#x20AC;? he roars. Mummy Bear puts her head through the serving hatch from the kitchen and yells, â&#x20AC;&#x153;For Godâ&#x20AC;&#x2122;s sake, how many times do I have to go through this with you idiots? It was Mummy Bear who got up ďŹ rst. It was Mummy Bear who woke everyone in the house. It was Mummy Bear who made the coffee. It was Mummy Bear who unloaded the dishwasher from last night and put everything away. It was
40 | SEPTEMBER 2015
MEDICAL FORUM
By Dr Craig Drummond Master of Wine
Eclectic is the only way I can summarise the six wines for this month’s review, as they have little or nothing in common. However, they do reflect changing times. One wine is from Greece, one of the countries embracing modern winemaking practices and now competing for their share of the international market. The other five wines are from Australia but showing unusual varieties or production methods. Australian consumers have been raised on varieties from France (Chardonnay, Sav. Blanc, Shiraz, Cab. Sav) and Germany (Riesling). But more recently it has been recognised that with our broad range of viticultural climates many of the vast number of European ‘native’ varieties, especially from Italy and Spain, may be better suited, hence the emergence of ‘natives’ such as Sangiovese (Italy) and Tempranillo (Spain) and now a plethora of other less known grapes. Have you tried Vermentino, Negroamaro or Furmint?
Wine Review
New Kids on the Block
Akakies 2014 Sparkling Kir. Yianni Amyndeon, Greece A confession – my experience of Greek sparklies is, to say the least, limited. Of my more than 17,000 tasting notes, there are only about 30 from Greece and only two of those were sparkling. My notes reveal why I did not pursue more! However, this wine is different. This is newage Greece with clean, faultless winemaking. A rose style, the colour is a vibrant cherry red, the mousse very active. A clean, modern wine made from the Xinomavro grape, displaying a fruity nose, and on the palate simple fresh flavours of strawberry and red cherry. The sweet finish (residual sugar of 18g/litre) makes it widely appealing. Hahndorf Hill 2014 Gruner Veltliner, Adelaide Hills This grape is from Austria and, with Riesling, is the backbone of that wine industry. This wine is the first Aussie example I have tried so I can only judge it on Austrian standards and it certainly stands up on varietal character. The colour shows the typical light gold with the definite green hue. Aromas are restrained with green herbal tones; the palate complex and full bodied with the typical green pea and white pepper characters with some bay leaf and capsicum. Firm, lively acidity gives a clean finish. La Bratta 2013 Bianco, Margaret River Arlewood Estate makes white and red wines under this label in limited quantities. The website mentions ‘Chardonnay blends’ which confuses me as I can only find Semillon/ Sauvignon Blanc characters modified by fermentation in oak. This style is big and complex, with rich aromas of green fruits and oak. The flavours are powerful with lemon citrus, green herbs and a distinctive lanolin background nd and there’s plenty of oak. A wine made to last but needs more time me to integrate. An ‘enthusiast’s wine’ and not for the fainthearted. Alpha Box & Dice 2014 Rebel Rebel Montepulciano, Langhorne Creek Montepulciano is a red variety of central Italy and not to be confused with the Tuscan village of the same name. This wine is my favourite of the tasting. A pleasant surprise for a grape I have always considered average. The wine is vibrant, showing real personality. The nose is beautifully enticing with perfumed fresh sweet berries and red fruits; flavours of confectioned red cherries, cranberry, a touch of cinnamon; acid is fine, clean and penetrating and tannins are fine grained and soft. Highly recommended. Hither Yon 2013 Tannat, McLaren Vale Tannat (meaning ‘tough, little one’) is a variety originating in Madiran in southern France. This is the first Aussie example I have seen. It’s a
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deeply coloured wine – brick red with purple edges. The nose is enticing with spicy dark plum, c cloves and eucalyptus; the palate has dark fruits, liquorice with a leather touch. It has the expected firm gripping tannins. It’s very complex for its youthfulness and drinks well but will benefit from a couple of years in bottle. La Prova 2013 Sangiovese, Adelaide Hills/Barossa Valley Central Italy’s flagship grape needs little introduction now – Sangiovese is probably the most established of the European ‘natives’ in Australia. This wine shows the typical garnet colour with a savoury nose, evident acid, cherry kernel and ripe plum flavours, and fine grained tannins. It’s a sound wine for current consumption. All these fascinating wines have been made available for this review and for this month’s Doctors Dozen from The Wine Thief, 69 McCourt St, West Leederville, phone 0414 836 439.
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Wine Question: What was the grape variety of Craig’s favourite wine of the tasting? Answer: ...................................................
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MEDICAL FORUM
SEPTEMBER 2015 | 41
Comedy
Laughter THE BEST MEDICINE!
Getting people to talk about mental illness might be as easy as making them laugh. Consult a comedian! The Stand Up! for Comedy night promises to be a barrel of laughs with some healthy self-reflection on the demons ticking away inside our skulls. Andrew Horabin is among the comedians who’ll be strutting the stage at His Majesty’s Theatre in a curtain-raising show for Mental Health Week on October 2.
confident, robust, honest and authentic at work then surely that’s a good thing. So that’s my number one hat and stand-up is just for fun.” “I use a lot of comedy in my workshops. If you can make people laugh you can also make them think. Amongst all the humour, we talk about other important things in life such as individual ego, self-discovery, teamwork and maturity. All of this happens tea while we’re laughing our heads off, so it’s whi the best job ever!” In a ‘blurb’ for Stand Up! Andrew writes, ‘I’m no doctor, but I reckon all of us suffer from illness, are recovering from one or a mental m will be the next in line.’ “I’m trying to draw attention to the fact that we’re either all crazy or we’re just not paywe’ ing attention. The modern way of life is just nuts! But I have to be careful in the show, nut too. You have to do this in a sensitive way too be because it’s tough for anyone suffering from a mental illness. But we do need to fro ta talk about all the things that are driving us cr crazy.”
Co media n Andrew
Horabin
“M “Most comedians are pretty self-deprecating and audiences love that. Watching ca so someone on stage flaunting their flaws, d dumb ideas and wet patches is catharttic. There’s a person up there on stage s saying, ‘Look at me, I’m a fool!’ Now and tthen it’s good for everyone to have a ‘Hey, I’m that kind of fool, too’ moment.”
Andrew’s main gig is a professional speak speaker and facilitator with a strong focus on the workplace.
“Sta Up! for Comedy is a good way of let“Stand ting people know they’re not alone in struggling with these issues. In fact, they’re in the majority!”
“Most of us spend a lot of time at work so if I can help someone to be happier, more
Andrew outlines just what the audience at His Majesty’s can expect.
42 | SEPTEMBER 2015
“I’ll play a couple of songs. I always like to have a look at the crowd on the night and see what feels right. But I’ll definitely be having a crack at all those everyday things that send us crazy and hinting, strongly at times, that all of us are suffering from some kind of spiritual or mental sickness.” “It’s just a matter of whether we know it or not. I mean how many people do you know who are normal? I actually ask for a show of hands from all the ‘normal’ people in the audience so that we know who the deluded ones really are.” It’s a special sort of person who loves the spotlight and Andrew is one of them. “I’ve always liked being on stage and making people laugh. My mum encouraged me to get involved in debating and dad helped me to get motivated to set this up as a business enterprise. I love performers such as Ben Elton, Billy Bragg, Billy Connolly and the D-Generation. They inspire me!” Andrew reckons that any doctor in the house at His Majesty’s will be inspired, too! “We expect our GP to be able to fix everything. Medicine is a high-stress profession and patient expectations must put enormous pressure on them. It’s all too easy to forget that the doctor you’re talking to is a human being and not some agent of God with perfect powers of perception and a magic wand.”
By Mr Peter McClelland
MEDICAL FORUM
Music
Song in her Heart A late-blossoming singing career has been all the more sweeter for one of the country’s latest great voices. Greta Bradman’s website describes the award-winning Australian soprano as “recitalist, concert and stage performer”. She is also a clinical psychologist, a wife and mother of two young boys and, something that never escapes a news report, the granddaughter of cricketer Don Bradman. Just as for her father before her, that is both a blessing and a burden. As a performer with a glorious voice and who can match it with any on the national stage, it is understandably important to have her talent recognised for what it is. And yet, when Medical Forum snatches a brief moment late in her day to talk about her career and upcoming performance with WASO, From Broadway to La Scala, on September 26, she has just run through the door from one of her young son’s sporting commitments. Family is very much on her mind. Despite the polite requests from her record company not to talk about cricket (what Australian would at present) or the Bradman connection, Greta introduces it to the discussion. This talent that has blossomed over the past 33 years has been born and nurtured by her family; it’s a fact she embraces. “My grandparents on both sides all loved music. My mum’s dad had a pianola with such an amazing collection of rolls. Endless fun. My dad’s dad adored opera. My memories are of listening to Victoria de los Angeles, Maria Callas and Elizabeth Schwarzkopf on his amazing collection of vinyls. Music has always been a part of my life,” she tells us. “I learnt the piano from the ages of six to 18, I played flute, guitar, clarinette and I participated in a youth theatre and, of course, I sang – in the school choir, at the Elder Conservatory in Adelaide.” There were awards and accolades at this young age, yet her destiny as a musician is much more adventurous than a straight road. There was her love of science and bio-chemistry to acknowledge, which led to a masters degree of clinical psychology. Music and singing was ever present but, as she described, “just a pipedream until the penny dropped”. “In 2009 I had a placement in a child psychology setting in the public sector and that was really confronting. It put things in perspective. I continued to work with children through my 20s but I also found my voice.” “I wanted to sing professionally but I needed a lot of technical training and I thrived on it.” The stars aligned in 2013 when she was awarded an Australian National Academy MEDICAL FORUM
Clockwise from left: Lisa McCune, David Hobson, Teddy Tahu Rhodes and Greta Bradman
of Music fellowship and won the Australian International Opera Award and the rest, as her talent spread across the globe, is history. One of the musical world’s most respected musical maestros, Sir Richard Bonynge, has taken Greta under his wing and recording contracts and concert dates are lining up. This month she joins bass baritone Teddy Tahu Rhodes and tenor David Hobson, opera stars of note, and musical theatre queen
Lisa McCune in a night of ‘anything goes’ from Cole Porter to Puccini. While Greta is moving in the Bel Canto circles of Donizetti, Bellini and Verdi, her upbringing gives her a love of a good show tune and she can’t wait to get on Perth Concert Hall stage with the crew. “I’m learning so much from these singers, they have amazing experience and it’s really exciting to be a part of it.”
By Ms Jan Hallam SEPTEMBER 2015 | 43
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GP Addiction Medicine #VTZ (1 "EEJDUJPO .FEJDJOF DMJOJD needs medical staff. The clinic is closely affiliated with BO FYDFMMFOU UFBN PG QTZDIPMPHJTUT QTZDIJBUSJTUT DPNNVOJUZ IFBMUI TUBGG and a private psychiatric hospital. Close contact with government agencies with excellent support. Good remuneration as all billing is mental health item numbers. %FEJDBUFE BOE FYQFSJFODFE TUBGG B devoted patient population. Rewarding work in a stimulating environment. Flexible sessions to suit. Cambridge Clinic - Phone after BN 9388 2005
CURRAMBINE GP Clinic is looking for Full time or Part time GP for after-hours clinic /FX 1VSQPTF CVJMU NFEJDBM DFOUSF (SFBU GBDJMJUJFT /03 /PO $PSQPSBUF 0OTJUF /VSTF - Rates Negotiable 4PGUXBSF #FTU 1SBDUJDF "DDSFEJUFE QSBDUJDF Email resume to shentonavenuemedical@outlook.com
"SF ZPV MPPLJOH GPS EPDUPST GPS ZPVS medical practice? "VTUSBMJBO .FEJDBM 7JTBT JT PXOFE BOE SVO CZ 1SBDUJDF .BOBHFST CBTFE JO 8" XIP IBWF PWFS ZFBST FYQFSJFODF PG UIF 6, BOE "VTUSBMJBO IFBMUIDBSF TZTUFNT We currently have a number of doctors XIP BSF MPPLJOH GPS QPTJUJPOT JO "VTUSBMJB We are able to assist practices with all paperwork involved including the NJHSBUJPO QSPDFTT JG SFRVJSFE Please visit our website www.australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or "OESFB PO 0401 371 341. CURRAMBINE Mole and Skin Cancer Clinic is looking for an experienced FT or PT VR doctor New Purpose built clinic with (SFBU GBDJMJUJFT /PO $PSQPSBUF /03 "DDSFEJUFE 1SBDUJDF 0OTJUF /VSTF - Rates Negotiable #FTU 1SBDUJDF TPGUXBSF Email your resume to shentonavenuemedical@outlook.com
YANCHEP CLAREMONT The Walk-in GP practice located in the trendy suburb of Claremont. PG CJMMJOHT Looking for GPs for Saturdays and 4VOEBZT %84
Fully computerised with on-site pathology and RN support. Located in a modern complex with access to the gym and pool. For further information please contact Dr "OH PO 9472 9306 or Email: info@thewalkingp.com.au (vacancies may be available for VR GPs on XFFLEBZ 1. TFTTJPOT
DUNCRAIG & OSBORNE CITY Duncraig Medical Centre Osborne City Medical Centre Require a female GP â&#x20AC;&#x201C; would CF GVMMZ CPPLFE EBZ Flexible Mon to Fri hours. BGUFS IPVST PQUJPOBM
Excellent remuneration. .PEFSO QSFEPNJOBOUMZ QSJWBUF billing practice. Fully computerised. Please contact Michael on 0403 927 934
BULLCREEK/WANNEROO/ FORRESTFIELD 3FRVJSFE 73 OPO 73 (1 GPS #VMM$SFFL Wanneroo/Forrestfield Normal and after hours available. DWS location available and good QFSDFOUBHF PGGFSFE /VSTJOH 1BUIPMPHZ BOE "MMJFE )FBMUI BWBJMBCMF Contact 0401 625 712 or Email Waliadr@hotmail.com
79
/PSUI PG 3JWFS %84 "SFB
Experienced FT GP required #VTZ DPNQVUFSJTFE QSBDUJDF /VSTF BOE "ENJO TVQQPSU &BSO VQ UP PG CJMMJOHT Flexible hours Non VR welcome to apply Enquiries to Phil: phil27bc@gmail.com
4U -VLF ,BSSJOZVQ .FEJDBM $FOUSF Great opportunity in a State of art DMJOJD JOOFS NFUSP /PSNBM BGUFS IPVST /VSTJOH TVQQPSU 1BUIPMPHZ BOE "MMJFE services on site. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979 CHURCHLANDS Herdsman Medical Centre in Churchlands SFRVJSFT B 1BSU UJNF 73 BOE '3"$(1 qualified GP. We are a friendly western suburbs practice. o TFTTJPOT QFS XFFL SFRVJSFE Saturday morning per month. Practice culture is quality care and we QSJWBUF CJMM BMM QBUJFOUT FYDFQU BU %PDUPS T discretion. $PNQVUFSJTFE XFMM TUBGGFE practice nurse. Please forward CV with references to Ms Dianne Swift by email practicemanager@herdsmanmedical.com.au
BUTLER Connolly Drive Medical Centre 73 (1 SFRVJSFE GPS UIJT WFSZ OFX TUBUF PG UIF BSU GVMMZ DPNQVUFSJTFE BCTPMVUFMZ QBQFSMFTT TQBDJPVT NFEJDBM DFOUSF Fully equipped procedure rooms and DBTVBMUZ XFMM GVSOJTIFE DPOTVMU SPPNT QBUIPMPHZ BMMJFE IFBMUI 3/ TVQQPSU "CVOEBOU QBUJFOUT %84 OPO DPSQPSBUF Generous remuneration. Confidential enquiries %S ,FO +POFT PO 9562 2599 5JOB NBOBHFS PO 9562 2500 Email: ken@cdmedical.com.au
SHOALWATER F/T VR GP required for our brand new medical centre located in Shoalwater %84 0GGFSJOH NPEFSO TVSSPVOET BOE GVMMZ computerised clinical software. We are a GSJFOEMZ QSJWBUFMZ PXOFE BOE SVO DFOUSF " GVMM DPNQMFNFOU PG OVSTJOH TUBGG admin team as well as onsite allied health/specialists and pathology. Generous remuneration offered. Please phone Rebecca on 08 9498 1099 or Email CV to manager@sevilledrivemedical.com
HAMILTON HILL " GFNBMF (1 SFRVJSFE GPS B DMJOJD JO B %84 BOE "0/ BSFB NJOVUFT ESJWF GSPN Fremantle. 3 Doctor GP Practice. Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or Send CV to eric@hamiltonhillfamilypractice.com.au
Myaree Medical Centre seeks a full-time 73 (1 GPS PVS NPEFSO FYQBOEJOH TPVUI PG the river practice. 8F BSF B QSJWBUF CJMMJOH OPO DPSQPSBUF practice servicing a predominantly younger EFNPHSBQIJD 0VS TVSHFZ JT B NPEFSO XFMM FRVJQQFE QVSQPTF CVJMU GBDJMJUZ 0VS EPDUPST IBWF B TQFDJBM JOUFSFTU JO TLJO cancer medicine as well as mainstream general practice. &YDFMMFOU SFNVOFSBUJPO 8FFLEBZT POMZ no after hours. 'VMMZ DPNQVUFSJTFE POTJUF QBUIPMPHZ "MM BQQMJDBUJPOT DPOTJEFSFE Confidential enquiries to Julia SFDFQUJPO !NZBSFFNFEJDBMDFOUSF DPN BV or 9317 8882 GOSNELLS "TICVSUPO 4VSHFSZ &TUBCMJTIFE VR GP needed part time. Ethical patient oriented practice 'VMMZ "DDSFEJUFE 1SJWBUF CJMMJOH PG billings. Fully equipped with nurse support. Email: angiesurgery@gmail.com or call "OHJF 0422 496 594
OCTOBER 2015 - next deadline 12md Tuesday 15th September â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au
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medical forum
CANNING VALE $BOOJOH 7BMF %84 SFRVJSFT GVMM QBSU time or locum VR GP urgently. Rates negotiable. Privately owned practice - fully DPNQVUFSJTFE IVHF DPOTVMUJOH SPPNT TQBDJPVT USFBUNFOU SPPN XJUI 3/ BOE PO site pathology with other health alliances in the complex. Phone: Julie 9456 1900 Email: jphyo@nicholsonmedical.com.au MANDURAH Modern Medical Clinics team is looking for new doctors to assist with our expansion plans. Mandurah is currently recognised as an area of need and district work shortage but this will not last for long. If you would be interested in moving to the paradise of Mandurah in the next few ZFBST UP KPJO PVS UFBN QMFBTF DPOUBDU Steve or Carol for a confidential discussion mail@modernmedicalclinics.com.au
GREENWOOD (SFFOXPPE ,JOHTMFZ 'BNJMZ 1SBDUJDF The landscape of general practice is DIBOHJOH BOE JU JT DIBOHJOH GPSFWFS "SF you feeling demoralised by the recent Federal government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? *U EPFTO U IBWF UP CF UIJT XBZ Come and speak to us and see the different ways in which we operate our HFOFSBM QSBDUJDF #F QBSU PG UIF HBNF changer! 0VS QSBDUJDF JT MPDBUFE OPSUI PG UIF SJWFS Sorry we are not DWS. Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion.
Contact jasmine@mforum.com.au to place your classified advert
ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? As WAâ&#x20AC;&#x2122;s only specialised medical business broker we have helped many buyers ďŹ nd medical practices that match their experience. You wonâ&#x20AC;&#x2122;t have to go through the onerous process of trying to ďŹ nd someone interested in selling. Youâ&#x20AC;&#x2122;ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision. Weâ&#x20AC;&#x2122;ll take care of all the bits and pieces and youâ&#x20AC;&#x2122;ll beneďŹ t from our experience to ensure a smooth transition.
COMO Como Medical Clinic requires a full time or part time VR GP to join our friendly team. 8F BSF B TNBMM OPO DPSQPSBUF XFMM FRVJQQFE "(1"- BDDSFEJUFE BOE mainly private billing practice. You will be well supported by the owner-doctor and two practice nurses. Flexible working hours and holidays TDIPPM IPMJEBZT BWBJMBCMF 0GGFSJOH SFDFJQUT Please contact Linley Gray on 0417 978 574 for confidential enquiries.
BEECHBORO P/T or F/T GP required to join long established busy medical practice in #FFDICPSP 1SJWBUFMZ PXOFE EPDUPS QSBDUJDF XJUI GVMM nursing support. %84 BOE FBHFS UP SFQMBDF SFDFOU (1 T departure back to Europe. Mixed billing. Generous terms. Confidential enquiries to manager@altonemed.com.au JOONDANNA We are seeking a VR GP to join our friendly team on a part-time or full-time basis. /FX TUBUF PG UIF BSU NFEJDBM DFOUSF Flexible hours and billing. Percentage negotiable. Fully-computerised. Nursing support for CDMP. Please call Wesley on 0414 287 537 for further details.
To ďŹ nd a practice that meets your needs, call:
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 non DPSQPSBUF QSBDUJDF XJUI GFNBMF NBMF General Practitioners. 4FTTJPOT BOE MFBWF OFHPUJBCMF TBMBSZ JT compiled from billings rather than takings. 6Q UP PG CJMMJOHT QBJE EFQFOEBOU PO FYQFSJFODF Please contact Jacky on 0488 500 153 or E-mail to jacky-steven@live.co.uk WEMBLEY DOWNS 0QQPSUVOJUZ UP KPJO PVS privately owned practice. 1SJWBUF #JMMJOH 'MFYJCMF IPVST 0O TJUF QBUIPMPHZ Fully computerised "MM $PSSFTQPOEFODF JO DPOGJEFODF Email: Diane pmgr@ovmc.com.au WILLETTON )FSBME "WF 'BNJMZ 1SBDUJDF We are looking for a suitable full time PS QBSU UJNF 73 (1 UP KPJO PVS GSJFOEMZ team. 8F BSF B TNBMM OPO DPSQPSBUF QSBDUJDF GVMMZ DPNQVUFSJTFE BOE BDDSFEJUFE XJUI registered nurse support. If you would like to join us: Email: hafp@eftel.net.au or call 9259 5559 www.heraldavefamprac.com.au
Reach every known practising EPDUPS JO 8" UISPVHI .FEJDBM Forum Classifieds...
Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au
GP Opportunities - WA Concerned with the rising practice costs? Worried about the Medicare schedule freeze? As a result of IPNâ&#x20AC;&#x2122;s expanding network, there are currently a number of exciting opportunities for Doctors and practices looking at their future prospects. IPNâ&#x20AC;&#x2122;s Business Development Manager, Craig Coombs will be in Perth from the 2 - 9 September.
Apollo Health is seeking local Drâ&#x20AC;&#x2122;s with an interest in : - Skin cancer - General family medicine - Walk in /Urgent care For our practices in Armadale, Cockburn and Joondalup FRACGP required, Relocation incentives available
Call today to schedule a discussion to discover how IPN can look after you. For all conďŹ dential enquiries, please contact Craig Coombs: 0427 744 097 craig.coombs@ipn.com.au With IPN, weâ&#x20AC;&#x2122;re looking after you.
If you would like to join our dynamic team please contact ofďŹ ce@apollohealth.biz OCTOBER 2015 - next deadline 12md Tuesday 15th September â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au
medical forum
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56 Almadine Drive, Carine p 08 9448 7799 m 0401 815 587
www.gpwest.com.au
VR GP full time or part time required for busy practice in Baldivis
VR GPs wanted to join a friendly team
Established in 2011, this purpose built, non-corporate practice is RSHQ GD\V D ZHHN DQG RIIHUV *3ÂśV Ă&#x20AC;H[LEOH KRXUV WAGPET and GPA accredited practice with a rapidly growing SDWLHQW EDVH ORFDWHG DSSUR[LPDWHO\ NPV VRXWK RI 3HUWK ZLWK ':6 LI QHHGHG
Okely Woodlake Village Newpark Medical Centre Medical Centre Medical Centre CARINE
ELLENBROOK
GIRRAWHEEN
New Gumnut Medical Centre WANNEROO
contact Dr Kiran Puttappa 0401 815 587
Pathology and psychology on site, with a busy pharmacy QH[W GRRU :HOO HVWDEOLVKHG &'0 FOLQLF *3 2EVWHWULFV DQG LQGHSHQGHQW PLGZLYHV 6SHFLDO LQWHUHVWV VXSSRUWHG PLQRU WKHDWUH WUHDWPHQW URRP DPSOH SDUNLQJ If you would like to join our friendly supportive team of doctors, nurses and admin staff please contact Sue Fegebank on 08 9523 6829 RU HPDLO \RXU &9 WR ULGJHPHGLFDO#JPDLO FRP
kiranpkumar@hotmail.com
GPs Wanted â&#x20AC;&#x201C; Belvidere Health Centre (Belmont, 39 Belvidere Street) Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D;
(FOFSPVT IPVSMZ SBUFT 'MFYJCMF XPSLJOH IPVST $MJOJDBM BOE OVSTJOH TUBŢ TVQQPSU .PEFSO XFMM FRVJQQFE GBDJMJUJFT 'VMMZ DPNQVUFSJTFE
GPs Wanted â&#x20AC;&#x201C; GP After Hours Clinics in Belmont, Armadale and Rockingham Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D;
(FOFSPVT IPVSMZ SBUFT .PEFSO XFMM FRVJQQFE GBDJMJUJFT 'VMMZ DPNQVUFSJ[FE BOE BDDSFEJUFE DMJOJDT 1SJWBUF BOE #VML #JMMJOH PQUJPOT $MFSJDBM BOE OVSTJOH TUBŢ TVQQPSU For more information contact Rod Redmond at 08 9458 0505 or r.redmond@archehealth.com.au
Metro Area GP positions available VR & Non â&#x20AC;&#x201C; VR Drâ&#x20AC;&#x2122;s are welcome to apply. Send applications to hr@betterhealthcare.com.au
Do you need a website or a refresh? Contact Thinking Hats today and we can help! hats@thinkinghats.net.au
OCTOBER 2015 - next deadline 12md Tuesday 15th September â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au