Medical Forum WA 04/16 Public Edition

Crash Course t Revalidation t Bike Helmets Off or On? t Docs – A Price on Your Head? t Clinicals: Infective Carditis; Hepatitis C; Melanoma; Anticoagulants & more‌

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April 2016

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Editorial

Health Consumers Are Anxious – Are You? I call it my “light globe moment”, a realisation at the last Doctors Drum (Doctors – a Price on Your Head?) that doctors are part of the health industry and therefore part of the problem, not necessarily the solution. ‘Reforms’ that divide up the health cake more effectively will benefit consumers, even though we squabble over the size of our slice. The community realises that doctors have not been good gatekeepers – governments and private health funds will step in to regulate prices because health is funded by consumers through taxes or premiums.

Medicare values doctors who do better in the health system than them. Most don’t appreciate that government gives an incentive payment to GPs to bulk bill.

It is no secret that the minority consume most of the health resources. Those with private health insurance want the best and there are plenty of specialists and vendors of the latest and greatest to keep that dream alive, so that 10% go on consuming 60% of resources. Public health differs little – some say there is less value placed on health, less health literacy and more risk taking but still 3% consume 40% of public health resources.

Meanwhile, consumers are confused. Where does Medicare finish and private health care start? What of the teamwork, new technology, selfcare and out-of-pocket expenses? Educating the public on these things and the better lifestyle choices is important, if not critical to the longer term.

Such health demands are outstripping taxes as the population demographics change and governments grapple with huge deficits. Those who afford private health insurance are bucking against rising premiums and co-payments, despite a government top-up.

It has got to the point that self-preservation now drives governments and insurers.

Yet election cycles are far shorter than the preventive health cycles needed for lifestyle changes. That’s why the reforms, whether the electronic health record or the regulation of primary care, are geared to the short term and driven by people who don’t mind if their slice of the cake is large.

This doesn’t mean reforms are not needed. It just means your perspective on them changes when you realise that how we pay doctors largely dictates their behaviours, whether in the public hospital system or community medicine. Change can be either facilitated or impeded.

One thing is for sure, the community believes government should fund health. Medicare has not encouraged a user pays attitude, resulting in a lack of accountability for lifestyle choices. Health consumers value Medicare. They care little about whether

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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

As more consumers abandon private health care, the temptation will be for insurers to control primary care, an early step in the cost chain. Anything that gets GPs to take a holistic view of patients to keep them out of hospital will attract the attention of government and private health insurers. Managed care, where insurers tell doctors what to do, may be the cost containment measure we all wear.

Information technology (IT) seems wasteful in the public system, or as one Doctors Drum panellist put it, bureaucrats are “captured by a culture of caution” that Dr Rob McEvoy delivers bad outcomes. IT can improve communication and reduce duplication and a resurrected e-health record may help chronic disease management.

Provided IT people are allowed to take a few risks, are transparent in what they do and are not self-absorbed, good should come of it. Otherwise, we will end up with ‘etherware’ and health will be shaped by public opinion and anxiety.

To make all this work, improved health literacy among the high health users must translate into changed behaviours. It is this change of behaviour, with better self-care, that will give us a better health system, not necessarily what the doctors do to them.

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

APRIL 2016 | 1

April 2016

Contents

14

16

18

24

FEATURES 14 Spotlight: Mr Graham Edwards 16 Profile: Dr Tony Robins, WACHS 18 Doctors Drum: Doctors – 20 24

A Price On Your Head?

Bike Helmets – the Pros and Cons Revalidation Out of the Shadows

NEWS & VIEWS 1 Editorial: Health Consumers Are 4

Anxious – Are You? Dr Rob McEvoy Letters to the Editor: Poor Hospital Communication Dr Geoff Kirkman Mental Health: Fund and Act Ms Margaret Doherty Mental Health: Tipping Point for Reform Mr Geoff Diver GP Training Squeeze Dr Janice Bell Donor Families Vital to Conversation Mr Bruce McDowell Family Court: Documentation Critical Dr Jane Deacon Lyme Disease Inquiry Senator Dio Wang

6 10 12 17 23 28

Curious Conversations: Dr Sarah Pickford Sights on AMA National Presidency Have You Heard?

Meet the CEO: Mr Tim Shackleton, Rural Health West Recognising Rural Service Charity to Enterprise

LIFESTYLE 40 Laps to Beat Diabetes 42 Wine Review: Knee Deep Wines 43 44 45 46

Dr Louis Papaelias Competitions Funny Side Ghost the Musical Katie Noonan & Brodsky Quartet

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MEDICAL FORUM

Clinical Contributors

5

Dr Chris Finn Infective Endocarditis

7

Dr Colleen May Direct Oral Anticoagulants

31

Dr Gerry McQuillan Hepatitis C Game Changer

33

Dr Reza Salleh Non-surgical Foot & Ankle

33

Dr Rick Bond Carotid Endarterectomy

34

Dr Samantha Bowyer Metastatic Melanoma

37

Dr Astrid Arellano Q&A: Rickettsial Infection

39

Dr Kate Borchard Non-Scarring Alopecia

Guest Columnists

10

Ms Melissa Parke Refugee Policy a Shame

27

Ms Sheree Yorke Battles Blaze After Fires

28

Dr Steve Monterosso Drs Reporting for ‘Duty’

29

Mr Brad Pettit Building a Healthier Perth

Bike Helmets – Pros and Cons Page 20

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), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM APRIL 2016 | 3

Letters to the Editor

community safety, not a ‘lock ‘em up and throw away the key’ approach. We’re better than that.

In the Interest of Clear Communication Dear EDCs and JHDs,* Could you please stop sending me notes replete with TLAs and FLAs** . I have just received a note stating the patient presented with CP and also states C: HSDNA, vitals and U NAD and was discharged with a diagnosis of MSP. As an OF I know SFA about many things medical but your PPCs *** are risking major penile elevations such as when Oroxine and Lanoxin 125 were confused in a patient script request I wrote out years ago.

Does the note from the antenatal clinic mentioning BPD at 32 weeks refer to the patient’s foetus or to her difficult persona or indeed her unstable effect. Or does the elderly corpulent gent who snores badly with PND suffer from a dicky ticker or from excessive mucus?

Continue these PPCs and I will be forced to present to ED and remove your NADs without LA! Capiche!!

Yours in bruxism, steam, flatulence, borborygmi and sphincteric spasm Dr Geoff Kirkman, Stirk Medical Group *Emergency Department Consultants and Junior Hospital Doctors. ** Three Letter Acronyms and Four/Five Letter Acronyms. *** Piss Poor Communications. .....................................................................................................................................................

Fund and act!

we treated cancer, coronary care or any other physical illness using a Victorian era model!

Dear Editor,

The Plan will only realise its goals if the underlying principles of working in partnership with individuals and family members are actualised. This is a significant cultural shift which must not be underestimated.

Re: Time for Action in Mental Health, (February edition), it is positive that there is now a 10-year plan before government for funding. For the one in five individuals and families affected by mental distress in our community, securing sufficient funding to realise this Plan needs to be a priority and implementing it needs to be a matter of urgency.

With just less than a year to go before a State election, I’d encourage readers to contact their local Member of Parliament or political aspirants, ask them where they stand on this issue and tell them why this Plan needs action within a tight fiscal environment.

Mental health has been under-funded for too many years. Now there’s a real opportunity to change this. Individuals who experience mental distress deserve to have a progressive and effective community and inpatient treatment and support system, not one in which its main hospital (Graylands) is described as “one of the last stand-alone psychiatric institutions in Australia…based on a Victorian era asylum model”. Imagine if

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DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

Lastly, let’s not forget about the heinous piece of legislation – The Criminal Law (Mentally Impaired Accused) Act 1996 which continues to be a blot on our human rights landscape.

The government is still reviewing it – I’m not sure what the record is for the longest legislative review in history, but it must be coming close.

It’s time to bite the bullet and create modern legislation which treats the unwell people who come under this Act with dignity and respect and in a way that makes it most likely to secure

Margaret Doherty, Mental Health Matters 2 ........................................................................

Best Practice and Individual Experiences Dear Editor, I read the various contributions in the Mental Health Reform feature (March edition), having lived through the past five years since my daughter Ruby died after being discharged from Fremantle Hospital, I have formed a few opinions of the system.

In January the Coroner handed down the long-awaited decision into the inquest into five deaths of people discharged from public hospitals in the SMHS catchment.

In a way the victory for the families of those five was won years ago when the Coroner decided to hold the inquest for all five cases.

The counsel assisting the Coroner ran an astute strategy where the five deaths were the hub of the wheel but the individual circumstances the different spokes.

For three weeks of hearings the commonality of the SMHS stayed in focus.

There were other victories such as finally seeing people cross examined in ‘open court’ and seeing which bits of the case the counsel for SMHS chose to contest and which they accepted. All but one witness gave what appeared to be an honest an open account of their case in the Coronial spirit of not attributing blame, but looking for options to prevent a re-occurrence. continued on Page 6

Always remember that you are absolutely unique. Just like everyone else.

Margaret Mead

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4 | APRIL 2016

MEDICAL FORUM

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Infective Endocarditis

"CPVU UIF BVUIPS Case Vignette A 39yo woman presents with fever and right–sided paraesthesia, weeks after laparoscopy. Oral antibiotics provide temporary relief, however fever recurs and she presents for a second time.

A murmur is noted but not considered relevant given her history of known mitral valve prolapse and mitral regurgitation. It is a couple of months before a unifying diagnosis of a stroke on account of severe infective endocarditis affecting her already abnormal mitral valve is made. She has a long complicated illness including further embolic events, and extensive surgery is required including mechanical valve replacement.

Infective endocarditis (IE) describes intracardiac infection that usually includes heart valve infection. An uncommon condition, importance stems from the associated morbidity and mortality, and the difďŹ culty with initial diagnosis. About 50% of cases will require cardiac surgery.

Diagnosis

IE affects a broad demographic but is more common in those with poor dentition, IV drug users, or those with pre-existing valvular or congenital heart disease.

Secondly, transthoracic echocardiography (TTE) – sensitivity for detecting IE is somewhat limited but cases requiring urgent treatment will usually be detected – sensitivity depends on image quality, which varies signiďŹ cantly between patients.

Clinical presentation varies and includes both acute and subacute illness. Fever is usual but may be mild and inconsistent.

Other non-speciďŹ c symptoms are common such as sweats, malaise, headache, cough, dyspnoea and weight loss. A cardiac murmur is common, and there may be associated cutaneous petechiae or nail bed splinter haemorrhages.

Patients may present with embolic phenomena including stroke, organ infarction (e.g. spleen or kidney) or metastatic infection (e.g. osteomyelitis or septic arthritis).

The diagnosis of IE may rely on clinical, microbiological and echocardiographic ďŹ ndings.

Most cases involve one or both major modiďŹ ed Duke criteria: 1. Positive blood culture with an organism consistent with IE (see Table 1) 2. Echocardiographic features of IE (e.g. valvular vegetation or abscess) The most common bacterial causes are Staphylococcus aureus and some species of Streptococci found in the oral ora.

Cases due to Streptococcus gallolyticus (formerly S. bovis) have a high incidence of underlying bowel pathology (including bowel cancer) and colonoscopy is mandatory.

Two important steps should follow suspicion of IE. Firstly, three separate blood cultures before antibiotic therapy is commenced.

Even a single dose of antibiotics may render blood cultures negative, potentially delaying the diagnosis and targeted antibiotic therapy.

Chris Finn is a consultant cardiologist with Western Cardiology who consults in Applecross and Subiaco, and practises at Sir Charles Gairdner Hospital and St John of God Hospital Subiaco. Chris graduated from UWA, and completed fellowships in Brisbane and Singapore.

Chris practices general cardiology, performs coronary angiography and has special interests in valvular heart disease, and transoesophageal and stress echocardiography.

The case vignette is a reminder of the importance of a high index of suspicion for this diagnosis, which if missed often results in a poor outcome.

References available on request.

Table 1 – IE Organisms Staphylococcus aureus Viridans Streptococci (eg. S. sanguis, S. milleri) Streptococcus gallolyticus (formerly S. bovis) Enterococcus species

When there is a high suspicion of IE (particularly when TTE imaging is suboptimal), transoesophageal echocardiography (TOE) should be considered. TOE provides more detailed imaging (see Image), particularly of the aortic and mitral valves, and allows more deďŹ nitive diagnosis or exclusion of infective endocarditis.

HACEK organisms* Coxiella burnetti (‘Q fever’) Bartonella species *HACEK organisms are fastidious bacteria including Aggregatibacter species, Cardiobacterium hominis; Eikenella corrodens; and Kingella kingae.

Treatment decisions Treatment is most effective if the culprit organism is identiďŹ ed. Blood cultures prior to antibiotic therapy are often critical. Prolonged intravenous antibiotic therapy is commenced in hospital, and continued from home in some cases.

The decision to proceed with cardiac surgery for infective endocarditis can be a difďŹ cult one involving multiple specialties. Potential indications for surgery include recurrent septic embolism, large aortic or mitral valve vegetations or abscess formation.

TOE showing large mitral valve vegetation (>4cm) within the left atrium

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Letters continued from Page 4 I can now get a completed death certificate for Ruby.

But reform was also unavoidable. The SMHS’s reluctance to deal with me drew other families into the fray. Their reluctance to investigate anything openly brought in the Minster, the Chief Psychiatrist, the DirectorGeneral, the media and all the other families into the fray as well. At every turn the SMHS tried to put out the fire with petrol.

This perfect storm also coincided with the government initiative to set up the Mental Health Commission, Mental Health Advisory Council and formulate the Plan and a new Act. The media then started to explore how to report these things, families, carers and consumers all felt a growing voice and mental health now had human faces. Families wanted individual answers but also wanted reform.

A lot has changed in five years.

Geoff Diver, parent and advocate ........................................................................

GP training squeeze Dear Editor, It was pleasing to read about WAGPET registrars training and working where they are most needed in Rural Training Improves Care in Broome (March edition). These stories are the result of the Rural Clinical School of WA, WA Country Health Service and WAGPET working collaboratively to build and deliver a comprehensive map of rural opportunities for our increasing numbers of doctors.

In 2015, the HealthFix review into the GP training program in WA, containing within it a report specifically on the Kimberley, demonstrated a gradual but deliberate impact that has been felt across most of rural WA. Now where there are students, there are doctors-in-training, and where there are registrars and new GPs, there are other specialists, Aboriginal health workers, pharmacists, physiotherapists, receptionists, drivers.

The result is inevitably improved health outcomes through better access to more of the right care locally, where it is needed. A decade ago, there was just one registrar in the whole of the Kimberley, now there are 30 or more.

There is still work to do, of course, so WAGPET has again contracted HealthFix, this time to focus on understanding the rural procedural workforce story 2007-2017.

HealthFix will reprise their Maintaining an Effective Rural Procedural Workforce Review of 2007 and address new and old challenges in rural health procedural services provision.

While much has happened in a decade to turn the procedural training and workforce story around, there are new pressures coming our way that will likely impact on the positive trend and which need to be explored.

These include likely reductions in RMO training positions from 2017, no dedicated prevocational GP training program since 2015, risks around the registrar salary support scheme in Aboriginal health settings and changes to policy drivers and college thinking in fiscally frugal times.

Hopefully the updated report later this year will tell us what has changed so we can navigate these and other challenges collaboratively to provide a safe and quality medical workforce.

Families vital to conversation Dear Editor, In 2008, my wife and I lost our 19-year-old daughter in tragic and unexpected circumstances.

Because we made the decision to donate on behalf of our daughter, I became a donor father and I am now the Chairman of Donor Families Australia (DFA). Dr Bruce Powell, in Breaking Down the Barriers (March), referred to the tragic death of a young man, only 19, in similar circumstances to our own. I wish to respond how organ and tissue donation impacts on families.

DFA, a grassroots organisation made up of families of organ and tissue donors including living donors, has been operating for just over three years. In that time we have formed a national committee and a national membership base. For the first time the National Organ and Tissue Donation program has been able to seek donor family advice from an organisation that knows what it is like to be in this unique situation and that has important views about how donation can be supported, recognised and increased.

The National Reform Agenda initiatives that started from Kevin Rudd’s push to increase Australia’s Organ and Tissue Donation in 2008 lacked the critical input of donor families. The initial organisational response was to form a large group of foundation members to formulate the aims and objectives of OTA. Of the 60 or so people sitting around the table one was a donor family member.

Adj/Prof Janice Bell, CEO, WAGPET

It has taken all this time for the authorities to include collective donor family representation

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

continued on Page 8

Curious Conversations

A Passion for Life Her dog, close friends, a vintage champagne and a tree in King’s Park is enough to make Dr Sarah Pickford happy.

I think I'm a pretty good… dog owner. Our much-loved hound gets two walks every day, cuddles on the sofa and plenty of treats. In return, he is a fabulous listener, a true friend and his happy greeting always makes me smile.

Three things I'd like to do before I die are… walk the Inca trail, go to Antarctica and take my niece and nephew on a tour around Australia.

They’re nine and 11, live in Switzerland and almost old enough to visit ‘Auntie Sarah’ minus their parents.

6 | APRIL 2016

One thing that really upsets me is… a lack of commitment to the task at hand. Life is short, we have so many opportunities and it concerns me when people don't give 100%. It doesn't matter if it's work or relaxation – let’s be passionate about everything we do!

The meal I'd like to have for a big celebration would be… oysters, sushi and rare beef served with vintage champagne and a great Margaret River Cabernet. Most important of all would be the people around me – my partner, my sister and close friends preferably sitting in the shade of a fabulous tree in Kings Park.

MEDICAL FORUM

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By Dr Colleen May Haematologist Clinipath Pathology

The Direct Oral Anticoagulants In the management and prevention of thrombotic conditions such as PE, DVT, AF and post-surgery, the current choices for long term oral anticoagulants include warfarin and the direct oral anticoagulants (DOACs).

DOACs promise equivalent benefit to warfarin without the need for constant monitoring, dose alterations or dietary restriction. The three currently on the Australian market are: rivaroxaban (Xarelto® Bayer), dabigatran (Pradaxa® Boehringer Ingelheim), and apixaban (Eliquis® Bristol-Myers Squibb/ Pfizer®).

Efficacy DOACs are non-inferior to warfarin in the settings of VTE prevention in non-valvular AF and therapy of PE and DVT. Bleeding rates were shown to be equivalent, with intracranial bleeding on warfarin balanced by gastrointestinal bleeding with DOACs. Pharmacology

Perioperative management

Renal impairment can lead to accumulation and overdosage of DOACs. Accurate estimation of renal function is imperative and the eGFR should not be relied upon. Apixaban and rivaroxaban are also metabolised by the liver and are contraindicated in Child-Pugh Class C cirrhosis, acute hepatitis and liver disease with an associated coagulopathy.

The half-lives of the DOACs in patients with a CrCl>50mL/min means that withholding the drug for 24 hrs prior to low risk, or 48-72 hrs for high bleeding risk, procedures is usually sufficient. In impaired renal function (CrCl 30-49mL/min) these extend to 48-72 hrs and 72-96 hrs, respectively.

Contraindications to DOACs include active bleeding, planned surgery, lesions at risk of bleeding (recent CVA, active PUD), CrCl <30ml/min, concomitant treatment with strong inhibitors of CYP34A and P-glycoprotein (Clarithromycin, azoles, HIV PIs), pregnancy and lactation.

Although designed not to require any therapeutic monitoring, certain situations may demand an assessment of coagulation or drug level: patients with low body weight or obesity; children; those with renal or hepatic impairment; accidental or deliberate overdoses; to measure adherence; to evaluate patients with haemorrhagic or thrombotic complications; and to assess levels prior to surgery.

Other drug interactions include SSRIs and PPIs with dabigatran. Inducers of CYP3A4 and P-gp (phenytoin, carbamazepine, St John’s Wort) have been shown to increase bleeding risk when combined with apixaban and are expected to reduce dabigatran concentrations, raising concerns of underanticoagulation. P-gp inhibitors (amiodarone, clarithromycin, verapamil) should be used with caution and patients kept under close surveillance due to their potential to increase dabigatran levels and potentiate its anticoagulant effect. NSAIDs and anti-platelet agents should be used with caution and only for short periods with any anticoagulant.

Pitfalls

The standard assays of coagulation used to monitor heparin and warfarin are unsuitable for the DOACs because the assays are either insensitive or too sensitive to the drugs. Clinically important anticoagulation may be predicted. Prolonged APTT and TCT suggest clinically significant dabigatran and an APTT >80sec predicts increased bleeding risk. A prolonged INR (>1.2) indicates

Uses PBS listings for the current drugs are not uniform and may be a potential cause for confusion.

Current approved Australian indications for oral anticoagulants are listed here (see table).

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

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clinically significant rivaroxaban levels. Assays developed to determine blood levels have no ratified reference ranges, and analysis is dependent on the timing of the last dose and the strength of the tablets.

Common adverse events for all NOACs include increased liver transaminases and GI upset.

Caution: assays for thrombophilia such as Protein C and S, Lupus anticoagulant and activated protein C resistance, are interfered with by DOACs. Management of bleeding complications Minor bleeding: withhold drug for a dose, discontinue if appropriate; apply local measures; assess for aggravating factors; determine renal and liver function.

Moderate bleeding: above, plus hydration to maximise urine output; charcoal if ingestion within 2 hours; platelet transfusion if concomitant thrombocytopenia or antiplatelet agents; administer tranexamic acid.

Severe or ongoing bleeding: dialysis can be used in dabigatran-treated patient; prothrombin complex concentrate (Prothrombinex®-VF) and recombinant factor VII (Novoseven®) for rivaroxaban. Idarucizumab (Praxbind®) is a monoclonal antibody fragment developed to reverse the anticoagulant effects of dabigatran (limited availability).

Letters continued from Page 6 as part of this “complex ecosystem”. We can’t stress enough that donor families and, of course, more importantly, donors are crucial, if not the most important part of this ecosystem. Without donors and support for organ and tissue donation family decision makers there is no transplantation.

When I became a donor father eight years ago there was very little to no support available for donor families, especially in the regional centres where my wife and I live.

There certainly was no means of linking with other families experiencing a similar situation.

Since establishing DFA we now have a network of hundreds of families who participate on our Facebook page and find support as members. DFA also advocates for families to ensure donor families receive trust, respect and a voice in decision making circles.

This principle is crucial to the success of our organ and tissue donation and transplantation system. When families encounter the devastating experience of losing a loved one they want to be helped, advised and nurtured through the numbing experience.

Health professionals who provide that care need the benefit of that experience to provide care which will neither push the family to a decision, nor provide too little information for an uninformed decision. The key for families is that the initial approach must be done by well-trained and caring staff. There must always be total respect for the families’ decision whatever that may be.

The DFA was present when Minister Nash announced the findings of the Ernst & Young review and I am pleased to say that the review contained many recommendations put forward by donor families.

With improved donor numbers in 2015 comes more donor families. We hope that the states have the ability to ensure that the families who make those donation decisions are satisfied by their short and long-term experience. Let’s hope more potential recipients get to benefit from a system that relies on the donor and their family, and their contribution to society.

Mr Bruce McDowell, Chair, Donor Families Australia ........................................................................

Documentation critical Dear Editor, It’s not unusual for doctors to find themselves dealing with patients who are in the midst of an acrimonious divorce. Doctors Caught in the Crossfire (March edition). Doctors can be drawn into the mix in a variety of ways.

Allegations of child sexual abuse may be raised in this context. The allegations are often raised by the child’s mother against the father, and sometimes by the father against the mother’s new partner. One of the parents may present with the child alleging sexual abuse.

8 | APRIL 2016

Our advice would be to clearly document the history given by the parent, or the child if they are able to provide a history. Physical examination for sexual abuse can be intrusive and traumatic for a young child, so it is probably best handled by the specialist unit at PMH, or with advice from PMH if outside the metropolitan area.

Requirements for mandatory reporting of child abuse are different in each state of Australia.

In WA, the only requirement for mandatory reporting is child sexual abuse. The wording of the legislation is that if a doctor believes “on reasonable grounds” that a child has experienced or is experiencing sexual abuse, then it must be reported to the Department of Child Protection (DCP).

If a doctor forms a reasonable belief, based on the history given, that the child has suffered or is suffering from sexual abuse, a report should be made. If the doctor does not believe that sexual abuse has occurred, then the child can be referred to another doctor with more expertise in the area for another opinion. For example, a mother’s complaint that the child’s father was applying nappy cream to his infant daughter would not be considered sexual abuse.

Doctors can make a voluntary report to the DCP if they have other concerns about a child.

In WA, there is legislative protection for the notifier with regards to civil or criminal liability, and a mandatory report overrides the usual duty of confidentiality and privacy. As the mandatory reporter’s identity is generally protected, it is not necessary to advise the parent(s) that a mandatory report has been made, but doctors may choose to inform the family.

Dr Jane Deacon, Medico-legal Adviser, MDA National ........................................................................

Inquiry into tickborne disease Dear Editor, I read with interest, Lyme Disease in Australia (February edition). As part of a Senate inquiry into Lyme-like illness, I convened a roundtable in Perth to hear evidence from experts and patients who present with debilitating symptoms of this tick-borne disease, which has divided medical opinion.

For a variety of reasons, there is little publiclyaccessible reliable data on the extent of suffering attributed to Lyme-like disease in WA – for example, there is scant detail of patient demographics, the impacts on carers, or treatment capabilities. One as-yet unsubstantiated claim received is that the number of patients diagnosed with ‘Lyme disease’ in WA has risen from about 150 in 2012 to over 1000 in 2015.

credible perspective on the incidence of Lymelike illness and whether demand for treatment is growing in WA. One WA GP stated that he was treating about 900 people, 700 of whom had definitive positive test results for Borrelia via nongovernment laboratories. Some of these people had never left WA. Other key issues to emerge from the roundtable included: så 1UESTIONSåOFåAåPOTENTIALåNATIONALåPUBLICå health risk (for instance, from blood transfusions), and the associated legal liability and consequential need for widespread clinical testing. så 4HEåEXISTENCEåOFåCASEåCLUSTERSåINå7!åTHATå had limited public awareness. så 4HEåGROWINGåNEEDåFORåAåPUBLICåAWARENESSå campaign on the risk of exposure to ticks. så 4HEåNEEDåFORåSPECIALISEDåTRAININGåANDå clinics så 4HEåNEEDåFORåLEGISLATIONåTOåSTOPåTHEå reported practice of primary care doctors being persecuted for treating patients presenting with Lyme-like disease.

While the need for further research into the links between native tick-borne pathogens and Lyme- like illness has already been identified, it is crucial for existing sufferers to move from divisive debate to national agreement on diagnosis and treatment.

At the very least, our Health Department should establish a data repository and conduct ongoing analytics for patient-generated data.

This should obviate interference from biased sources so that on a national scale, as well as in individual patient profiles, we have a more dependable benchmark on emerging trends in Lyme-like illness.

Zhenya ‘Dio’ Wang, Senator for WA ........................................................................

Clarification In last month’s magazine we incorrectly referred to lawyer Sharon Auburn with the post-nomial SC, which is strictly reserved for Senior Counsel appointed by the government. Sharon is "special counsel". We apologise for any embarrassment caused.

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, especially those over 300 words, 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.

In acknowledging divisions of opinion within the medical fraternity, it is important to gain some

MEDICAL FORUM

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APRIL 2016 | 9

Incisions

Refugee Policy a Shame On Us Retiring Labor MHR for Fremantle and former UN lawyer Melissa Parke speaks out against Australia’s refugee policies.

It seems that in the last 15 years, Australia has forgotten the lessons of World War II—the direct connection with suffering that led Australia to be the sixth signatory to The Refugee Convention that brought it into force.

What a mockery it makes of our commitment to the international rule of law, which we are fond of quoting at the Chinese when it comes to their island-building activities in the South China Sea. What a mockery it makes of our claim to be a respecter of human rights.

Most of the world's 60m refugees are being hosted in poor neighbouring countries in Africa, Asia and the Middle East, and increasingly in Europe.

In the nine years I have been in Parliament, Australia's position has become demonstrably worse and far more hypocritical. Whereas the Howard government made little attempt to hide the cruel nature of its policies, seeking to demonise asylum seekers as queue jumpers, people who would throw their own children overboard and potential terrorists, the present generation of politicians on both sides use the cloak of humanitarian language to justify the policies.

Lebanon, a small country of 4m people, is hosting more than 2m Syrian refugees – half of its population again. It would be the equivalent of 12m people turning up on Australia's doorstep. Against such numbers, our commitment of 13,000 humanitarian places is not nearly as generous as our political leaders would have the community believe. Of the additional 12,000 Syrian refugees Australia has committed to, only 26 have arrived so far. This is pitiful.

Even worse is the deliberate policy of cruelty that defines our offshore detention system, together with the mantra that no-one who arrives by boat will ever be resettled in Australia. What a mockery this makes of our commitments to the UN refugee convention.

Last year, the government made amendments to the Migration Act that were, unfortunately, supported by the Labor opposition, in which it retrospectively absolved itself of responsibility for everything that has happened on Manus and Nauru since August 2012.

The High Court recently upheld that law as constitutional. Why? Because there are virtually no human rights protections in the Australian

Constitution and the parliament has the power to make laws on any matter, no matter how draconian. This is why many people have been calling for a bill of rights or a human rights act.

Of course, regardless of the domestic legal position, under international law Australia cannot contract out its legal responsibilities and remains responsible for the plight of people it sends to Manus and Nauru.

AUTHOR’S NOTE: This is an edited version of a speech I gave to Parliament on February 29. It reflects the deep disappointment I feel in relation to current policy concerning the treatment of asylumseekers and refugees. However, there are glimmers of hope. Last year the mass demonstrations following the death of Aylan Kurdi resulted in the Government expanding the humanitarian program and this year the High Court’s decision regarding offshore processing led to the ‘Let Them Stay’ campaign. The involvement of medical staff at Lady Cilento Hospital in this campaign was crucial. I applaud the courage of doctors and other medical staff in refusing to discharge baby Asha and her mother until assurances were given that they would not be returned to Nauru. I also commend the powerful speech given by AMA President Prof Brian Fowler in February this year. Civil society, including the medical profession, is leading the way towards the just treatment of asylum-seekers in Australia.

President Hopeful Takes a Swipe at Pot Shots WA AMA President Michael Gannon, left, has announced his intention to stand for national AMA president next month. He has told media he will focus on mainstream health policy and be less confrontational than Prof Brian Owler over controversial issues such as asylum seeker policy.

Dr Gannon told Medical Observer that “if you step into the minefield of asylum seeker policy, you risk alienating the Government.”

“I don’t think you should ever have cheap shots – but you must also be constructive in the criticism, provide workable solutions and work in partnership where appropriate.”

Despite being on the federal executive that was responsible for drafting policy on issues such as asylum seekers and Ebola response, Dr Gannon was reported as saying the attacking stance may have detracted from its effectiveness in other areas such as the primary healthcare review, the private health insurance review and the MBS review.

10 | APRIL 2016

“Although my colleague Prof Owler was very careful in his recent comments on asylum seeker policy and he was reading from our book of policies, I think obviously there is the risk when you criticise a really complex and clear area of government policy, that you then get a bloodied nose in what is core business,” he said.

The West Australian reported that Dr Gannon was uncomfortable with Prof Owler’s intervention in the asylum seeker debate and “fervent” criticism of the Abbott government’s response to the African Ebola epidemic.

Prof Owler hit back saying his public comments had always reflected AMA policy and been supported by members, while Dr Gannon’s comments in favour of the GP co-payment had not been supported by the wider membership.

Federal vice-president and Victorian emergency doctor Stephen Parnis is also running for the top job.

Children in crisis here While the AMA WA President Dr Michael Gannon may feel uneasy about the national AMA’s support of doctors standing firm in the face of government pressure over asylum seekers, a number of WA doctors have told us they were deeply concerned about the welfare of local asylum-seeker children.

One doc, who did not want to be named for fear of a backlash, said one of the key issues doctors faced here was the haphazard access these children had to state-funded public schools.

“These families (who do not receive full Centrelink payments and do not always have work rights), need to pay international fees to attend state schools. Thus most are placed within the Catholic education system which is now overstretched. When they are released from Community Detention and move to Bridging Visa Es, families must negotiate with the school regarding fee subsidies or waiving.”

Medical Forum has been told that WA is the only state in Australia that doesn’t allow asylum children access to state schools. We took this up with the WA Education Department who flicked it like a hot spud to the Department of Immigration and Border Protection who responded with: “The Department has funding arrangements in place in all states and territories to ensure children of school age in community detention have access to education.”

It addressed none of our doctor’s concerns nor did it answer any question we raised.

MEDICAL FORUM

Have You Heard?

Zika questions unanswered The Rio Olympic Games organisers have Brazil’s economic crisis to worry about beyond the Zika virus outbreak predicted to spread into Africa and Southern Europe. Questions to be answered are: how the Zika virus affects the body; why it is spreading rapidly in the Americas; how else it can be transmitted apart from mosquito bites; whether vector spread will see southern Europe as a target (e.g. dengue and chikungunya); and does the link with congenital defects in babies extend beyond anencephaly? The virus was first isolated in the Zika Forest in Uganda in 1947. The Ebola outbreak demonstrated that with global travel, other countries are potential targets. Unlike Ebola, one quarter of Zika infections are asymptomatic. The importance of public health measures, proper surveillance (e.g. Guillain-Barré syndrome in adults), detecting viral mutations, and rapid diagnostics and vaccination have been spurred along by Olympic gamers from around the world, without which the Brazilians may have been left to their own devices. Unprotected sexual contact has some worried, including asymptomatic returned travellers (see www.cdc.gov/zika/).

Why are we waiting?

Volatile times ahead

The world would not be spinning if we didn’t hear of yet another complaint about the PBS authority line. Apart from the wait (“15 minutes for five patients”) one doc rang in to let off some steam not just about the wait time but the charade that the operator goes through, every single time. Once the credentials of the practitioner are established wouldn’t a simple code suffice? “Instead it's, "Well Dr X (I know I'm Dr X), for John Doe (I know it's for John Doe), MS Contin 80mg slow release (I know it's MS Contin 80mg slow release), two a day (I know that too), 56 tablets (that's how many I requested), Z for zulu (it's ALWAYS Z for zulu why repeat that every time!)…It's maddening!

Especially when you’re hanging on knowing you have a roomful of patients waiting and some other doctor is hanging on the line waiting for you to finish.”

There’s action aplenty at Primary Health Care Ltd. The national corporate, which runs eight medical centres, four imaging sites and Western Diagnostic pathology here in the West, announced mid-February that it was going it alone and trialling a copayment for some of its services (believed to be pathology and imaging) as a response to the rebate freeze. The edging away from its traditional bulk-billing business model came after the mid-year financials revealed a 28.5% rise in interim profit to $68.6m although its underlying profit had slumped $5m to $50.1m. Share prices have been going south all year. It looks like it was too much for Henry Bateman, son of Primary founder the late Dr Ed Bateman who had pioneered the bulk-billing model. Henry, who was GM of medical centres, has left the company and

Sydney GP Dr John Houston is leading the BB centres while Maxine Jaquet is now GM of the new private billing division. Meanwhile investors have been circling, fuelling takeover rumours. NAB has increased its stake in the company early in March and by March 18 China's Jangho Group had seized an 11% haul. (Last year Jangho – a construction company – moved in the Australian health market with a $198m buy-in of Vision Eye Institute.) CEO Peter Gregg has told staff: “What this recent development indicates is the strength of the business, our healthcare practitioners who contribute every day to the company's success, and the supportive industry dynamics in healthcare." Everyone can rest easy!

Traffic jam for home visits Mobile After-Hour GP services must feel the bulk-billing business model is still a

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MEDICAL FORUM

healthy option with another provider hitting the highways and byways of the Perth metropolitan area. National Home Doctor Service (NHDS) launched in time for the festive season, joining Dial A Doctor, Perth After Hours Medical Service, Doctor Home Visits and GP2Home creating something of a Mobile GP traffic jam. But some surgerybased GPs are not convinced by NHDS’s national TV ad campaign with asserts that demand for after-hours home visits go unmet.

Rather it’s a pitch for new business taking patients away from regular GPs and a drain on Medicare. RACGP’s Dr Evan Ackermann acknowledged their concerns but there is no action foreshadowed by the College.

Book anywhere anytime HealthEngine continues to emphasise consumer convenience for booking appointments with 39% booked after hours and 47% of their traffic from mobile devices.

The latest development is the Apple Watch so patients can search for a nearby appointment while out and about. If it is after hours, you will be among the 40% who make bookings between 9pm and 2am. In fact Dial a Doctor is listed if you want a doctor to come to you, or one that bulk bills can be found too. Price and convenience!

Patient heal thyself Amongst the emails announcing the demise of Dick Smith Electronics and the person who invented email, was the news this month that poor management of chronic disease costs Australia more than $320m a year in avoidable hospital admissions –

heart disease, asthma, diabetes and others – according to the Grattan Institute. The failure of primary care was singled out. Our Doctors Drum discussion early March agreed that primary care’s ability to gate-keep was being hamstrung by a need for greater health literacy and, with this, more responsibility for self-care. The Institute estimates that government spends over $1b a year on planning, coordinating and reviewing chronic disease management and encouraging good practice in primary care, saying social and environmental changes are the best way to prevent these diseases. A move away from fee-for-service payments for one-off visits was suggested, along with team care, more responsibility for Primary Health Networks, and well-designed incentives for disease prevention. Stephen Duckett was the Health Program Director.

College asks its members The RACGP has reviewed how it will govern itself, after it raised it with members at the 2013 conference. The college says members want a peer-led professional organisation with dedicated groups that deal with relevant matters. New is the RACGP Senate responsible for RACGP member engagement and general consultation. The Council and Board remain. Member comment is still being sought from members, which will be required if the college lives up to its own expectations “as the peak representative body for general practice in Australia” and throws off the slowto-move fuddy-duddy image.

NDIS battle lines drawn Well the collegiate harmony was too good to last. Last month, Disability Services Minister Helen Morton was trumpeting the sixth quarter results of the NDIS My Way trial – where it reported that 90% of its goals were being achieved – at the same time Federal Social Services Minister Christian Porter told a meeting of state ministers that the NDIS purse strings would only be open if states agreed to cede control of the program to the Feds. Minister Morton said that the Barnett Government from the top down would not allow “WA disability services to be run… from a regional Victorian city”. As readers will be aware, not-for-profits and academics are concerned that the NDIS will be unsustainable and the last thing they need is a turf war. The State-run My Way’s latest report shows 2058 people are eligible to access services through the My Way trial with no waitlist.

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MEDICAL FORUM

APRIL 2016 | 13

Spotlight

A Fortunate Life Former politician Graham Edwards measures his life by the things he does rather than those he can’t...and the list is exhaustive.

It’s been a life well-lived for Graham Edwards AM. The former State and Federal Labor Member of Parliament and current President of the WA RSL has an ongoing passion to serve his community. It’s an impressive track record for someone who left school at the age of 15 and lost both legs to a landmine in Vietnam.

“I was very fortunate because a lot of blokes in those circumstances didn’t survive. I was in a world of pain when the mine exploded and there was the added danger of the downdraft from the rescue chopper setting off a stickmine.”

“The emergency medical treatment I received was first-class and gave me the gift of life, a second chance. I came back from Vietnam with a new outlook, every day was a bonus and I was determined not to waste that opportunity. It gives me a lot of satisfaction to confront challenges. I don’t think anyone should be measured by their disability.”

Primitive rehab of the past There were plenty of challenges during Graham’s rehabilitation, none more so than when he was admitted to a repatriation hospital in Heidelberg, Victoria.

“It was probably the most demeaning time of my life. They fitted me with artificial legs and every morning I was picked up and taken to what was allegedly a rehabilitation centre. I soon discovered it was actually a place for people with learning difficulties. I was very pleased to leave and come back to Perth.”

“I wore artificial limbs for about seven years but they were heavy and cumbersome. I couldn’t walk down a steep slope and when I swung a golf club I’d fall over. They were held on by suction and very painful where they rubbed on the stumps so I decided to ditch them, despite one doctor telling me I’d be ‘socially incomplete’.”

“I remember one day my wife said that the gutters needed cleaning so I climbed up the ladder, slid along on my bum and removed all the leaves. I couldn’t have done that wearing the legs so I decided to give life in a wheelchair a crack. It was the best decision, in terms of my rehabilitation, that I ever made.”

“In 2005 I was asked to speak with a young bloke who’d lost his legs in Afghanistan and I was amazed by the changes in artificial limbs.

They’re lighter, more manageable and much more sophisticated. Perhaps I’d do things differently now, although my amputations were above the knee and that’s a significant factor.”

As Graham points out, there’s been a distinct improvement in the treatment of returned service personnel.

“Some of the blokes who came home from WWI spent the rest of their lives in psychiatric institutions and their problems with loneliness, alcoholism and suicide are well documented.

It was a horrific time for them, and their families.”

“One of the positives that came out of the Vietnam era was the fact that it gave mental health issues a higher profile and forced both the government and the ADF to recognise PTSD and do something about it. The Defence Department and Veterans’ Affairs are working much better as a team but there’s a long way to go. A lot of people are still falling through the cracks.”

“The redeployment rate is decreasing for Special Forces soldiers in Iraq and Afghanistan and, I think, when the lid comes off some of the psychological issues, we’ll see more people coming forward and asking for help.”

Australia does its share Australia as a country, suggests Graham, has punched well above its weight in armed conflicts a long way from home.

“For a relatively young nation we’ve lost a large number of young men and women in foreign countries fighting other people’s wars.

The current total stands in excess of 100,000 lives with many thousands more injured and maimed.”

“That record notwithstanding, I’m no fan of rampant nationalism. It scares me, particularly when you see people wrapping themselves in the Australian flag and shouting slogans. It makes me think of Germany in the 1930s.”

Improving pain control

Graham has some interesting insights into both overt and more subtle issues surrounding disability.

“The artificial limbs seemed to make my phantom pains worse, too. I found that some doctors were highly sceptical about that, despite the fact that I was having incredible pain in my right stump and could actually ‘feel my toes’ cramping. I saw a specialist who knew exactly what the problem was, he operated and the relief was immense.”

“Perth, as a modern city, is not too bad when it comes to being ‘disability friendly’.

The biggest barriers are attitudinal and some years ago I experienced that myself. I applied for a promotion, I knew that my skills were well-suited to the position but I was unsuccessful. After a few discreet enquiries I learned that the panel felt I might struggle

14 | MARCH 2016

Graham Edwards AM

negotiating stairs and corridors. I felt that was a pathetic reason to exclude me so I appealed and got the position.”

Modernising the RSL Graham turns 70 this year and the WA RSL is a work-in-progress.

“I’d like to ensure that the RSL fulfils its potential. Membership is increasing, we’re working hard through the sub-branches and we’re using social media to tell the story of what we do.”

“The modern RSL isn’t just a bunch of old blokes sitting in a bar embellishing war stories. We’re vitally interested in the welfare of veterans.”

By Peter McClelland

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15

Close-Up

Think Global, Act Local Rural and remote communities deserve to be happy and healthy but Dr Tony Robins sees there are different ways of achieving those outcomes.

In 1993, the ED of Medical Services at the WA Country Health Service, Dr Tony Robins, was a young flight doctor with Dr Tony Robins the Australian Defence Force on active duty in Somalia. Part of that operation was humanitarian – to get food and medical supplies to a starving population, but what he saw there and what part he played has shaped his life and work ever since.

“I was taken to an orphanage as part of an advanced party with the army to see what support we could give. They had converted an empty generator shed, a concrete bunker really, into a makeshift health facility and it was full of children lying on straw contaminated with human and vermin waste.

All the children had malaria whether it was their primary diagnosis or they had contracted it at the facility. There were three local nurses caring for these many children with no doctor,” Tony recalled.

“It was the middle of the day and it was hot, over 40C, and the nurses were trying to keep kids cool. I went to the senior nurse and suggested we could supply a mobile generator, fans and a fridge; we could supply liquid paracetamol and vaccines to help the children. Thankfully one of the nurses was bold enough to speak up because there is a cultural shyness for many when confronted with the ‘big western doctor’. However this nurse plucked up the courage to give me a dose of reality.”

“She thanked me but said a generator would

16 | APRIL 2016

be stolen within hours of us leaving. In any event they couldn’t get fuel to run it and same with the fridge. And as for the fans, they were desert people and the heat was not as big a problem as the sub-zero temperatures at night. Keeping the children warm especially with the rigours and tremors from the malaria was difficult.”

“What she asked us for was some secondhand army blankets, old army stretchers to get the children off the floor to stop infection spreading and paracetamol tablets that they could crush up and added to bottled water. Those things, she said, would do more for those children than any of our technology. I felt very humble. That person knew exactly what was needed to improve health outcomes in her community and it was not necessarily high-cost western solutions, but low-cost, easy to obtain and maintain practical solutions.”

“Listening is the key.”

Budgets and balance As medical director of an organisation that is responsible for improving health outcomes over a vast area with vastly different demographics, listening, says Tony, is crucial to WACHS’ success. He believes his role is to represent the country in metropolitan board rooms and bring metro support and infrastructure to the bush – all balanced delicately within a constrained budget.

That budget, which for years had been underserviced, received a mighty kick from the Royalties for Regions program which has seen the refurbishment and rebuilding of country hospitals over the past decade.

A showcase model is the Southern Inland Health Initiative (SIHI) which brought $500m to the table to “transform the health infrastructure” in the Great Southern,

Wheatbelt, parts of the Mid-West and the Goldfields.

But it wasn’t just a bricks and mortar revolution. Crucial to the equation was a sustainable health workforce to use the facilities and keep communities healthy.

This traditional hot potato has responded to extra cash but, perhaps, more importantly a blossoming culture of collaboration with other organisations such as Rural Health West, WAGPET and now the newly formed WAPHA. WACHS employs 9500 people, 300 of whom are salaried doctors with a further 1000 on contract. Unlike the metropolitan health services, the system revolves around highly skilled GPs, either salaried to the hospital or contracted from private practices to provide services to local hospitals, which makes it doubly important to retain their services.

Miracle of SIHI SIHI has delivered about 36 extra doctors to the region in the past five years – a feat which couldn’t have been achieved without the partnership with Rural Health West. Attracting and retaining GPs into those regions has required a concentrated effort.

“The better facilities have certainly made practice more attractive for GPs but research

by Rural Health West has shown that doctors and their families need broad support – for practice, professional development, work-life balance, financial – to move, work and stay in the bush,” Tony said.

All this effort is to ensure as many people in rural and remote areas have the opportunity to see a doctor face-to-face, whether that it be in private practice or a hospital.

“Country people deserve to have that knowledge, experience and training; they need a doctor to see them, touch them and

MEDICAL FORUM

Meet the CEO

empathise and support them. This is WACHS’ preferred model of care that we aim to deliver to any community.”

“GPs in rural and remote areas have a long-standing reputation of service to their communities. They drop everything, day or night when needed so it’s vital not to let them burnout. That’s why we place such importance on providing locums and the Emergency Teleheath Service (ETS) also plays a part as a back-up when GPs are in or out of town.”

ETS is an adjunct The ETS is now offered at 74 WACHS sites between 8am and 11pm.

“ETS is not a replacement for the local doctor, it’s a back-up and operates when the local doctor is not available and mostly used by nursing staff in hospitals. When the GP is in town, it is not called generally as a first-line response but it is a support and an extra hand in emergency situations, albeit virtual.

No doctor is obliged to use it, nor is there any charge when it is used.”

Demand for ETS has been so great that a request to increase it to a 24/7 service, statewide, is being explored.

The need for a constant supply of doctors is an ongoing reality of Tony’s job. WA has moved on from its critical shortage of a decade ago eased by an influx of IMGs and an increased supply of local medical graduates. However, he believes we are far from being self-reliant in the health workforce.

A place for IMGs

Keeping the Bush Healthy Tim Shackleton took up the reins at Rural Health West last month ready to take the organisation into a new era of bush medicine.

Rural HW CEO Tim Shackleton

WA is a big state, but it’s not overstating it to say Tim Shackleton knows just about every square kilometre of it. The new CEO of Rural Health West has lived and worked in our rural and remote areas all his life and it’s this intimacy with the bush that will be put to good use in his new role.

Tim was raised in Katanning before heading to UWA in the mid-1980s to study for a human movement degree. A solid nine years at the Asthma Foundation (three years as Executive Director) introduced him to health management which has seen him take up myriad opportunities since.

Tim is perhaps best known for his management of the RFDS between 2006 and 2011 where, as CEO, he led a team that expanded the reach and viability of the service and embedded it as a vital part of the Western Australian health landscape.

But his first contact with the operation was in 1996 when he headed to the Kalgoorlie branch, accompanied by wife Catherine and babe-in-arms.

After three years with RFDS, the couple embarked on a decade-long adventure across the state that led them first to Meekatharra, then Port Hedland, where Tim became Pilbara-Gascoyne regional director for the newly founded WACHS, and then to the same position in the Wheatbelt.

“This was such a formative decade for my life and the lives of my wife, Catherine, and our four children. The people we met and the things we were able to do were amazing,” Tim said.

For the past five years, he has been at the helm of his own consultancy, working with health organisations in the rural and remote space. The business is being mothballed so he can devote his energies to Rural Health West.

“We still have a requirement for IMGs and like most people who work in remote Australia we recognise that we probably always will but our reliance has fallen.”

“As a consultant I was able to immerse myself in issues, which CEOs and boards can find hard to do due to time constraints. I learnt more about the health system in the past five years than I had during the previous 10 years.”

He said there were stereotypes in the past that IMGs were less qualified and too junior for solo roles but they were wrong.

“I had first-hand experience of the complexities of GP recruitment – how to attract, retain, train and support doctors in often difficult situations. These are complex issues that take a lot of effort to get right.”

“IMGs are highly trained, skilled doctors from medically competent countries and many, such as those from South Africa, are very experienced in remote and rural medicine.

IMGs when they are well selected don’t just bring a doctor to a community but they add value to the health system and that fact is sometimes lost.”

“Being on the board of WAGPET for the past three years and acting chair for several months opened my eyes to just how essential a good GP is to the health and livelihood of a rural/remote community. It’s been emblazoned on my brain.”

The selection process has been refined and Tony said there was robust credentialing and monitoring systems in place so it was easier to pick the right people and keep them safe.

While the challenges remain, Tony is confident that two significant changes have sown seeds for a successful future.

“The investment into rural and remote medicine is significant in anybody’s language.

The second is our inter-agency collaborations.

We are able to keep patients closer to home and we can’t do that alone.”

By Ms Jan Hallam

MEDICAL FORUM

Filling the Rural Health West seat vacated by the retiring Belinda Bailey was a natural step.

“I was attracted to it because of its commitment through sound health workforce strategies to improve the health and sustainability of disadvantaged rural and remote communities.”

While the future rural workforce will be bolstered by the increased number of medical graduates, Tim said there was still a current shortfall of between 90 and 95 doctors in the bush. Small communities that rely on solo GPs are often the worst hit and it’s this shortfall that will continue to fuel demand (if at a reduced rate) for overseas trained doctors.

After the critical years of getting bums on seats, Tim says it’s time to look at refining the workforce strategy.

“The promise of more local graduates means the future focus for Rural Health West can shift to finding the right doctors for the right job and to play a role in facilitating better planning and coordination of health service delivery in rural and remote areas.

“There are many players in the market who need to be brought together through an independent and constructive approach. An excellent example of this is the Rural Health Agency Reference Group which is collaborating to tackle the challenges and opportunities identified by rural doctors in the Finding My Place report. This collegiate approach will provide greater benefit to the country doctors and communities we are all working to support.”

APRIL 2016 | 17

‘Doctors – A Price On Your Head?’

With such a provocative subject and the current cost-sensitive environment, the first Q&A Doctors Drum breakfast for 2016 was a sellout.

The power of the Doctors Drum breakfast is the two-way flow of ideas. The first event of the year was no exception with the panel offering their individuals insights but in turn the entire forum delivering some useful feedback so that the wheels of change could be oiled.

The talk inevitably revolved around price and value of health and how they were determined; how doctors were valued by the government, the consumers and even within the profession itself; and who should foot the bill drove much of the discussion. As one of the panellists suggested – “The relationship between payer and payee in the medical transaction will shape how we will be doing health in the future.”

Role of Private Health Insurance With the head of one of the state’s biggest health insurer on the panel, there was no surprise that the role of PHI in the health picture was examined at length. The burning question was raised quickly – would PHI become involved in primary care and it seemed an inevitable conclusion that it would, especially if the cost and volume of hospital admissions weren’t curtailed. The health system could not afford to continue to do top-heavy tertiary care.

The cornerstone of a robust health system was the GP and primary care. It was stated that “We end up funding the consequences of poorly funded primary care in the hospital/ private sector.” The insurers want a role and it looks like the government wants them to have such a role and the point was made that we can’t expect different outcomes by doing the same thing.

Accompanying this need for increased investment in primary care was the hotly debated need for greater individual accountability and responsibility for personal health outcomes. It is also a business imperative and the reason the current federal government is focusing so acutely on chronic illness. Nationally 2.5% of the population claim 40% of the health costs; the breakfast was told that 10% of one fund's members claim 60% of the total payout. There’s little wonder the government is tackling these high-cost areas first.

The expert panel listens to comment from the floor.

Focus on Medicare For the GPs in the room, Medicare was their first thought and their disappointment in the current freeze was palpable. It went to the heart of community value of GPs and their sense of entitlement to have their health serviced and paid for by the government. Two doctors referred to the 2008 relative value study which put the value of GPs at $300 an hour. It was suggested at the meeting that figure now was more like $150.

However, for another a co-payment would push people out of the primary system and expose the tertiary system to chronic health problems five, 10 years down the track because people had done nothing about because of the deterrent of a co-payment.”

But perhaps the last word on this should be from one doctor who said that GPs understand what their patients can afford to pay and everyday there was a Robin Hood scenario – taking from the rich to give to the poor.

The floor price for a general consultation had to be raised and Medicare had to stop rewarding six-minute medicine, said one. However, another doctor said a lot of good medicine could be done in six-minutes but general practice had to get better at being part of a health care team. “We pay lip service to the team care approach but we don’t know how to use it properly and if we did there would be some health costs that could be shared and we’d still have good outcomes.”

Bureaucracy & technology

The view that health was a commodity like any other in the market was disputed.

Some thought that without some financial contribution, consumers would not value the high quality health service they received.

The growth of the health bureaucracy was another focus. A figure was produced that since the 1970s the clinical staff growth rate compared to the health bureaucracy was something in the order of 30:3000. The future

With the recent Auditor General’s scathing report into WA Health’s wasteful IT program, both bureaucracy and technology came in for some stick. One doctor didn’t think that health costs were down to doctors’ salaries but rather bureaucratic ineptitude. Doctors would be less than impressed if their pay suffered to rectify the $41m shortfall. Another said that the Health Department “did IT really, really badly”.

Supported by:

See www.doctorsdrum.com.au

18 | APRIL 2016

MEDICAL FORUM

must be dedicated to innovation novation and use of efficient technology to rein in these sorts t off costs. t Wastage and inefficiency were rife in the system and there were those who believed the electronic health record would be a saviour. The room was told that My Health Record was imminent with government setting its sights on a July 1 national rollout.

Medical devices and pharmaceuticals also came under the spotlight. Publicity around robotics and wonder drugs raised expectations in the community that their use was part of standard care. There was little understanding by consumers of the size of the gap payments these high-tech procedures incurred.

This raised an interesting discussion about relative values versus outcomes. Was a $50,000 gap worth a $1000 gap if the broad outcomes were comparable?

Is it a reasonable expectation that the taxpayer/health insurer should pick up that tab?

The breakfast concluded with what was described as the linchpin of the discussion – education and communication. Consumers of the future must be literate and accountable for their own health and have a deeper understanding of relative values of treatments if the system were to flourish.

The Panellists Rob Bransby, CEO of HBF Dr Jill Orford, paediatric surgeon Dr Hilary Fine, GP, representing IPN Ms Sarah Wells, medical finance specialist Mr Roger Cook, WA Opposition spokesman for health Dr Colin Hughes, retired GP

See www.doctorsdrum.com.au

Feature

Bike Helmets’ Hard-Hat Diplomacy Community complaints on wearing bicycle helmets is being heard in high places but road safety experts are in no mood to budge.

There are lots of good reasons to ride a bicycle, everything from cardiovascular health to easing Perth’s traffic congestion.

In 1990 Australia introduced all-age mandatory bicycle helmet legislation and was the first country to do so.

The decision would appear to be a ‘no brainer’ but perhaps it’s not quite as simple as that.

Speaking Out RPH intensive care nurse Marianne Holzherr feels so strongly about the issue that she made a submission to a recent Senate Inquiry into Personal Choice and Community Impacts.

“I’ve been quite vocal in challenging compulsory bike helmets because I don’t like anything remotely resembling a ‘nanny state’.

I didn’t make a fuss when the legislation went through, there didn’t seem to be much an individual could do. It was a time when everything was being banned!” said Marianne.

“We travel a lot and this sort of thing isn’t happening overseas. When I saw some recent data that suggested bike helmets made very little impact in the reduction of serious head injuries I decided to put pen to paper and make a written submission to the Parliamentary Inquiry.”

Marianne points out that she has a far from blinkered view on the issue.

“It’s quite sensible for cyclists riding fast in busy traffic to wear a helmet, but if you’re not in that category and a safer route on a cycleway is an option then there’s little need for a helmet. It’s very common to see adults and children tootling along slowly, which shows that there are two quite distinct forms of cycling.”

“And if you are cleaned up by a car a helmet will make very little difference.”

20 | APRIL 2016

“There was actually a spike in hospital admissions across Australia after the helmet legislation was passed and some experts felt that a coterie of cyclists was riding more recklessly. It does seem that people will take more risks because they’re wearing a helmet, and I’ve seen that on the snowfields.”

“I felt so strongly about all this that I stopped cycling for a while but, after an informal conversation with a policeman, I’m back on the bike again. He told me they’re not stopping people anymore and I have noticed a lot more cyclists riding without a helmet.”

“My oldest daughter rides more than me, minus headgear. We put helmets on them when they were little but now they make up their own minds.”

“Despite the fact that the police don’t appear to be prosecuting it will still be interesting to wait for the outcome of the Senate inquiry.

Hopefully it might lead to a change in the legislation, but I concede it’s a tricky one.

There’s all that stuff about being ‘worth it to save one life’ but you could say that about almost anything!”

Medical Opinion The view from the ‘sharp-end’ is unlikely to support the repeal of mandatory helmet legislation. The Director of Trauma Services at RPH, which receives about 85% of all major trauma in WA, is uniquely placed to see the effects of cycling minus a helmet.

“There’s clear evidence from both our own data and internationally that wearing a helmet reduces head injuries. I conducted a study, some years ago now, that showed an increased likelihood of intracranial injury if a helmet wasn’t being worn. Furthermore, the degree of injury and the number of trauma lesions in the brain are much less for those who wear a helmet,” says Dr Sundhakar Rao. “The numbers represented were those

who were in-patients for at least 24 hours, and those who died within a 24-hour period. Hundreds more attend EDs who are treated and discharged.”

Dr Conrad Ng, an ED specialist from RPH, says there’s no doubt helmets minimise the severity of head injuries.

“And that’s a good thing because it seems to me that there a lot of people out there on bikes, particularly on the weekend. A law such as this is only as effective as its level of enforcement and if police are turning a blind eye, or are just too busy, that’s less than ideal,” he said.

“We see these injuries every day and the Head Injured Unit at Shenton Park is a sobering place. It’s confronting to watch families trying to cope and it’s a long, hard slog through rehabilitation and, at times, with little overall improvement.”

Facts and Figures If too much information about mandatory bike helmets is never enough then Chris Gillham is your ‘go-to’ guy. He’s a print and radio journalist with a passionate interest in helmetlaw research and his website has extensive links to academic and government reports.

“I’ve been online for almost 20 years on this issue and it has become a well-used data resource for cyclists in other countries who are trying to prevent the implementation of similar laws.

Statistics clearly show an enormous decline in cycling participation in Australia since 1990 and that has ramifications for public health and Mr Chris Gillham traffic congestion.”

MEDICAL FORUM

Feature

“The spike in hospitalised cyclist injuries, despite decreasing numbers hopping on a bike, suggests that there has been an increase in the crash rate. And yes, the proportion of head injuries has dropped postlegislation although nowhere near the figures claimed by the pro-law camp.”

Cycling without one doesn’t hold much appeal because I rode for enjoyment, not to keep a constant eye out for a police car.”

“But the important thing is that those head injuries sit within a much larger pool of broken limbs and spinal damage.”

The positive spin-offs from hopping on a bike are enormous suggests the WA Road Safety Commissioner, Kim Papalia. He’s one voice suggesting that mandatory helmet legislation doesn’t appear to be denting the popularity of life on two wheels.

“Both sides of the argument acknowledge the fact that civil liberties are sacrificed in the passing of this legislation, it’s just that the pro-law lobby believe that the sacrifice is worth it.”

Chris points out that there’s a demographic component to declining cycling numbers.

“The baby-boomers, who grew up in a helmet-free era, inflated participation figures over the past 20 years and many are putting their bikes and themselves into retirement.

They’re not being replaced by the younger generation, many of whom have been discouraged by the mandatory helmet law.”

“Since 2011 every National Cycling Participation survey has shown a distinct drop in cycling numbers.”

And Chris, as he freely points out, includes himself in that group.

“I pedalled everywhere until my mid-teens and through my 20s rode a 12-speed racing bike. The helmet law came in when I was 32-years-old and I saw no point buying an uncomfortable and inconvenient helmet.

“My bike rusted away and I put it out for a council pickup about a decade ago.”

Official View

“Statistics indicate that cycling numbers are increasing across WA and that the benefits are palpable, everything from economic to environmental to health and fitness levels. In the last five years more people are riding a bike once a week or more. That number stands at around 600,000 individuals and, in fact, we have one of the highest rates of cycling in Australia.”

“I spent over 32 Mr Kim Papalia years in the WA Police and I’ve seen the aftermath of injury on our roads at places such as Shenton Park Rehabilitation Hospital.

So based on my personal experience and on research we’ve harnessed at the Commission, mandatory helmet legislation is absolutely the right direction to head and

RPH intensive care nurse Marianne Holzherr cycling with her daughters

there are no plans by the current government to alter that. The figures show a 74% reduction in the likelihood of a severe brain injury if you’re wearing a helmet and there’s an economic dimension to that.”

“Our position at the Commission is that a combination of education and enforcement is the best way of responding to this issue.”

By Peter McClelland

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MEDICAL FORUM

APRIL 2016 | 21

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22 | APRIL 2016

MEDICAL FORUM

News & Views

Recognising the Service of Rural Docs Rural Health West’s annual service awards took place at its annual conference last month recognising the long-standing contributions by doctors in rural and remote medical ppractice.

Special Awards Kalgoorlie Obstetrician and gynaecologist Dr Barney McCallum took off the award for Outstanding Service to Rural and Remote Health for his 25-year commitment to the health of women and infants of the Goldfields from Leonora to Esperance. His work delivering about 300 babies a year has been widely recognised within the profession and the community. He also has a commitment to doctor training and is well-loved and respected by his students.

Cardiologist Dr Johan Janssen was recognised for his many years’ work in the Goldfields and Midwest, primarily in cardiology but also in renal medicine with the Extraordinary Contribution to Outreach Services award. He teaches at the Rural Clinical School and supported, in a supervisory capacity, a tele-nuclear medicine operation in Geraldton and Kalgoorlie.

Bunbury GP Dr Michael Camparti’s commitment to the community, his patients and his students for more than 30 years has been recognised with the award for Above and Beyond – Community First. His enthusiasm for education makes him a beloved supervisor and teacher; he is always on-call and he finds time to participate in community groups including the Army Reserve and regional public health campaigns.

Dr Barney McCallum

From left: Dr Johan Janssen, Dr Suzanne Phillips, Dr Michael Comparti and Prof Geoff Riley

Dr Suzanne Phillips has won the Award for Outstanding Hospital Doctor for her work across the country including Brisbane, Alice Springs, Dalby (Qld) and most recently the Kimberley region. She manages the Broome Health Campus and always leads by example, covering multiple night shifts, monitoring workflow and physically attends and sees patients when there is significant build-up or delays.

Prof Geoffrey Riley has been awarded a Lifetime Membership for his tireless work over four decades improving the health options and outcomes of people living in rural and remote WA. Geoff is a passionate believer that rural organisations needed to be rurally administered and run by rural people. He was head of the RCS for seven years until 2014 and acting dean of the UWA Faculty of Medicine for 12 months. He is back working in rural and remote Western Australia in several roles, but also spending more well deserved hours in the shed.

MEDICAL FORUM

Kimberley GP Dr Chistina Herceg’s work with indigenous communities over the past 17 years in some of the state’s most remote areas has been recognised with the Award for Remote and Clinically Challenging Medicine. She is actively involved with WAGPET as a Supervisor Liaison Officer and GP supervisor.

20 Years’ Service

30 Years’ Service

Dr Stephen Bailey, Dr Tonya Constantine, Dr Donald Howarth, Dr Christine McConnell, Dr Michael Mears, Dr Alice Tippetts and Dr Lorin Monck

Dr Michael Comparti, Dr Ross Henderson and Dr Clyde Jumeaux.

APRIL 2016 | 23

Feature

Revalidation Emerges from the Shadows The Medical Board has signalled its intention to make revalidation a priority for 2016 but it may not get the smooth ride it is hoping for.

Revalidation has been lurking in corners and corridors of hospitals and GP surgeries for years now with little but anxiety and antipathy resulting. Now the Medical Board has solidified its intentions with the release of a commissioned report on potential revalidation models and the establishment of an Expert Advisory Group, which has been directed to report its recommendations by the end of the year.

A spokesperson for the Medical Board confirmed that the advisory group held its first meeting in January so the clock is officially ticking.

The group is chaired by Prof Liz Farmer, who has her own consultancy as well as academic roles at the University of Wollongong and Flinders University. WA is not represented.

Medical Forum was told the advisory group’s role was to develop one or more revalidation models for Australia and advise how these models could be trialled and evaluated for “effectiveness, feasibility and acceptability”.

five years and/or older physicians (70+) to undergo peer assessment. The US uses a high-stakes examination, while Belgium offers a financial incentive.

Positives – Model B would assess 16 components of the Good Medical Practice framework (Model A, only seven) and provide enhanced MSF opportunities.

Forum for doctor feedback

While CAMERA offered three models, it’s apparent it sees only one as feasible.

Downsides – limited opportunity for reflective practice, a lack of regular appraisal for all Australian doctors and potential hostility towards exclusively directed CME.

While they nut out the details, the board has signalled its intention to appoint a consultative committee to provide a forum for medical practitioners to comment on any proposed models. This committee will be chaired by Medical Board head Dr Joanna Flynn and we’re told it will include representatives of the Medical Council of NSW, the AMC, specialist colleges, medical schools, the AMA, consumers and government.

Last year's report compiled by Plymouth University Peninsula’s Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA) is the starting point. It studied and assessed the history and literature of the international experience to inform the local discussion on structures, design and role of revalidation here and to put forward three models.

The report (available from the Medical Board website) makes interesting reading.

International case studies A survey of medical regulation in countries equivalent to Australia showed that the majority of reviewed case studies (UK, Canada, New Zealand, USA, Germany, the Netherlands, Belgium) use peer review and/or clinical audit as an additional form of medical regulation. All recognise eLearning/distance learning as valid exercise. New Zealand, the Netherlands and Belgium stipulate a minimum number of consultation/practice hours as part of their revalidation criteria.

Only the UK and Canada review patient complaints, while Canada also randomly selects doctors who have been in independent (private) practice for more than

24 | APRIL 2016

Model A We could rename this “Revalidation Lite”. Its operates entirely online over a five-year period in which time doctors produce an annual online portfolio evidencing their participation in mandatory self-directed Continuing Medical Education (CME) and Multi-Sourced Feedback (MSF). It would need to be signed off by a line manager, or equivalent, or a professional body annually as well as a fifth signature needed to finalise revalidation.

The positives are its cost effectiveness, accessibility (provided adequate internet), easy to administer and relatively easy to assimilate into daily workloads.

Downsides – it might demonstrate that doctors are up to date but not necessarily fit to practise; with the NBN still problematic internet is a real problem for some; and the report writers identified limited opportunities for “reflective and collaborative learning and missed opportunities to target ‘at risk’ physicians” which it identifies as 60+ or in independent practice for five years or more.

Model B This would also operate over a fiveyear period though it tries to resolve the deficiencies of Model A. Doctors would be required to present an online portfolio detailing engagement in directed CME (no self-directed option), facilitated online learning, bi-annual appraisals for targeted groups (see above) and participation in MSF from a specified number of patients and colleagues. A revalidation appraisal would be undertaken for all doctors every fifth year.

Model C This comprises both formative and summative components ensuring doctors are both up-to-date and fit to practise. Doctors would be required to prove their involvement in self-directed and directed interactive (minimum level of 25%) CME, facilitated online learning, blended learning, annual appraisals, participation in MSF and a review of patient complaints. It, too, would operate over a fiveyear cycle with every fifth appraisal acting as a revalidation recommendation.

“Doctors would…be required to attend a core of similar CME events providing continuity but would maintain freedom amongst their CME choices beyond this. Blended learning [traditional + electronic] will help incorporate [most] learning preferences identified in the Australian context and close the current gap between evidence and practice given its demonstrated ability to improve knowledge retention and physician performance,” the report said.

“All physicians would engage in annual appraisals…A review of patient complaints would provide an additional layer of reflective practice.”

It concludes: “Although difficulties in fully implementing Model C in the Australian context are acknowledged given the high percentage of private physicians, Model C offers the best model of revalidation informed by the current evidence base and is most continued on Page 27 MEDICAL FORUM

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Guest Column

Battles Blaze After Fires Go Out Physical and emotional injury are ever present threats for firefighters.

Ms Sheree Yorke from the WA fire and emergency service explains the help at hand.

In the middle of yet another catastrophic bush fire season, career and volunteer firefighters have been put to the test both physically and psychologically. The recent Harvey and Waroona bushfires which destroyed homes and took lives, saw hundreds of firefighters working in extreme conditions to overcome and control the devastating fire. As the community rallies to support those affected, paid and unpaid firefighters are also recovering as they prepare to face the next major emergency.

Given the nature of a career or volunteer firefighter’s role, the risk of injury is high.

On average, 150 career firefighters and 30 volunteers (excluding Bush Fire Brigade) are injured while on duty each year. Body stressing injuries (strains and sprains) account for two-thirds of all injuries and commonly involve the lower back, shoulders and knees.

Approximately 9% of reported injuries are psychological, such as post-traumatic stress disorder.

Career firefighters are covered under the Workers’ Compensation and Injury Management Act 1981 and should their injury be deemed compensable, are financially covered for lost time, medical treatment and rehabilitation expenses. Volunteers, excluding the Bush Fire Brigade, are covered under a personal accident insurance scheme which predominantly mirrors the benefits of workers’ compensation. Bush Fire Brigade members are covered under their local government insurance schemes.

Firefighters working temporarily in a nonoperational capacity undertake projects and tasks within the medical restrictions outlined by their treating doctor. The firefighter’s recovery and rehabilitation remain the priority. The firefighter is able to perform meaningful work, upskill, and feel supported by colleagues while they recover from their physical or psychological injuries.

It is not uncommon that mental health issues can co-occur with physical injuries and that emergency service workers suffer from a higher rate of mental health issues than the general public possibly as a result of the repeated trauma exposure they can be subjected to in the course of their work.

Early intervention, effective communication and timely and supported return-to-work processes are essential for achieving positive outcomes for injured firefighters. Information packages, including fact sheets outlining the physical and psychological requirements of a firefighter, are available on the Department of Fire and Emergency Services (DFES) website for GPs and specialists.

The DFES Workers Compensation and Injury Management team assist with providing informed return to work recommendations and options for accommodating firefighters in a non-operational capacity before returning to full firefighting duties. The role extends to providing current evidence-based rehabilitation education to injured workers and working closely with the treating medical team.

DFES has a dedicated Wellness Branch to support all personnel (paid and volunteers).

Services include chaplaincy, peer support, confidential counselling (Employee Assistance Program, EAP) and wellness officers.

Both career and volunteer firefighters risk their lives to protect the community and have the potential to sustain significant physical and psychological injuries in the process. Medical practitioners are encouraged to understand the demands of an operational firefighter and what support services are available to firefighters and their families through DFES. ED: Sheree Yorke is physiotherapist and A/Manager Workers’ Compensation & Injury Management at the Department of Fire and Emergency Services.

Revalidation Emerges from the Shadows

Feature

continued from Page 24 likely to assure both safe, and over time, better practice to the betterment of patients.”

Devil in the detail The advisory group has its work cut out as the detail is missing and the devil is sure to lurk there. The UK has yet to complete a full five-year cycle so we are yet to see a full evaluation of its processes and it is premature to start raising questions about cost, education providers, delivery methods, auditors etc here.

One thing is for sure, the Medical Board’s significant investment into the revalidation process is the best pointer to its inevitability.

However, that doesn’t guarantee that doctors will go gently into that good night.

Those who have worked in the UK since December 2012 or have friends who do, sound a warning. In 2013 Hills GP Dr Will Thornton wrote in Medical Forum that revalidation was a blunt instrument to

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demonstrate to the public that doctors were up-to-date and safe to practise – two different endpoints requiring different processes.

He was concerned that the cost of establishing a suitable and robust process for Australia’s 102,000 doctors would be vastly expensive and anything less than robust would be a waste of time.

He is joined by outspoken critic, retired Victorian physician Dr Kerry Breen, who, by the by, last month called for AHPRA’s investigative powers to be stripped and returned the states. In the February 2014 MJA he wrote that “The MBA would be wiser to start afresh by asking and answering two questions – namely, is there a problem with medical registration in Australia that needs attention, and, if so, what should be done to fix the problem?”

community expects that registration ensures that all doctors are competent and practise medicine safely, that current registration processes cannot provide such assurance, and that revalidation will provide it.”

“It seems illogical and unnecessarily costly to introduce an additional layer of assessment of all doctors when there is general agreement that most doctors strive to maintain and enhance their knowledge and skills and are rarely the subject of complaint.” He adds that this is even more problematic without an evidence base to indicate that revalidation will achieve its stated aim.

This prevailing mood of disquiet will make it a long hard year for the Medical Board and its advisory group, but it will be even longer for the medical profession awaiting the outcome.

By Ms Jan Hallam

No magic bullet “It is not sufficient to simply assert that the

APRIL 2016 | 27

Guest Column

Doctors reporting for â&#x20AC;&#x2DC;Dutyâ&#x20AC;&#x2122; A doctorâ&#x20AC;&#x2122;s â&#x20AC;&#x2DC;Duty to Warnâ&#x20AC;&#x2122; is highly problematic, says Dr Stephen Monterosso PhD from Curtin University Law School.

In 1992, somewhat jaded by doctors and their traditional reliance on collegial support in matters of medical negligence, the High Court of Australia brought down a signiďŹ cant tort law decision in Rogers v Whittaker. A 40-year-old woman was left almost blind after an operation on her right eye by an ophthalmic surgeon.

The patient developed a rare condition in her left eye and, as there was no restoration of sight in the right, she was consigned to virtually complete blindness. Consequently, she ďŹ led a suit against the surgeon alleging a failure to warn of the risk (1:14,000) of â&#x20AC;&#x2DC;sympathetic ophthalmiaâ&#x20AC;&#x2122;. In court, the woman claimed that she had strenuously questioned the surgeon regarding possible complications. The surgeon relied on the so-called â&#x20AC;&#x2DC;Bolanâ&#x20AC;&#x2122; principle, which deďŹ&#x201A;ects liability in circumstances in which a particular procedure is deemed to be common practice and collegiately acceptable.

Essentially, the â&#x20AC;&#x2DC;Bolanâ&#x20AC;&#x2122; principle allows the court to impose a duty of care but any question regarding a breach of standard of care remains a decision for the medical profession.

The High Court found the surgeon negligent and rejected what it deemed to be the

News & Views

paternalistic â&#x20AC;&#x2DC;doctor knows bestâ&#x20AC;&#x2122; attitude imbued in the Bolan test. Crucially, the six judges found that â&#x20AC;&#x2DC;collegial common practiceâ&#x20AC;&#x2122; is merely one item to be considered in assessing medical negligence. In addition, the court deemed that the duty of a doctor to a patient is expansive and includes examination, diagnosis, treatment and providing information.

A number of legal cases post Rogers v Whittaker have also had some ramiďŹ cations, particularly in the area of duty to warn.

In Chappel v Hart an ENT surgeon was deemed negligent for failing to warn, despite inquisitive and persistent questioning by the patient, of the risks regarding perforation of the oesophagus during a procedure to remove a pharyngeal pouch. So doctors should consider a patientâ&#x20AC;&#x2122;s individual understanding of medical procedures, particularly in relation to material risk, during pre-treatment consultation.

In Rosenberg v Percival, however, the patient held a PhD, had 20 yearsâ&#x20AC;&#x2122; nursing experience and was an academic. The court rejected the patientâ&#x20AC;&#x2122;s assertions that she would not have proceeded with the surgery had she been aware of the material risks, largely due to her high level of understanding and experience in

the medical area. Itâ&#x20AC;&#x2122;s important to know your patient.

There is no doubt that legislative activism in the area of tort law has had some impact on common law principles relating to medical negligence. Much still remains unsettled in this rather difďŹ cult legal area, although a greater degree of certainty has emerged due to the restatement of the Bolan test within civil liability statutory law.

Where the duty to warn a patient of inherent material risk is concerned, the common law Rogers v Whittaker principle remains relevant.

The following guidelines may prove helpful. sĂĽ 4HEREĂĽISĂĽAĂĽGENERALĂĽDUTYĂĽOFĂĽCAREĂĽFORĂĽDOCTORSĂĽ to warn patients of potential material risk. sĂĽ -ATERIALĂĽRISKĂĽWILLĂĽBEĂĽASSESSEDĂĽWITHĂĽ reference to a particular patient and a particular doctor, and the probability of complications with reference to the actual medical procedure itself. sĂĽ 4HEĂĽPLAINTIFF PATIENTĂĽMUSTĂĽSATISFYĂĽTHEĂĽCOURTĂĽ that any failure to warn by the doctors caused demonstrable loss. sĂĽ 4HEĂĽDUTYĂĽTOĂĽWARNĂĽISĂĽNOTĂĽUNEQUIVOCAL ĂĽ.OTĂĽ every patient must be warned of every possible risk.

ED: References on request

Charity to Enterprise

Governments are looking to Not-for-ProďŹ ts for delivery of community-based healthcare services which means juggling limited budgets.

Thereâ&#x20AC;&#x2122;s an increasing demand for the alcohol and drug counselling programs provided by Holyoake. Their efforts in helping individuals and families through challenging times, and the transformation of the organisation itself, was recognised with the award of the 2015 Telstra Western Australia Business Woman of the Year to its CEO, Ms Angie Paskevicius, below.

â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s been a broad take-up of these because, unfortunately, stress is all too common in the workplace.â&#x20AC;?

â&#x20AC;&#x153;It really is a reďŹ&#x201A;ection of the dedicated group of people who work here at Holyoake. We provide strong outreach services in schools, local government and the workplace. In the latter case, we have a â&#x20AC;&#x2DC;WellBeing at Workâ&#x20AC;&#x2122; social enterprise programs focusing on substance abuse issues linked with unhealthy coping strategies.â&#x20AC;?

â&#x20AC;&#x153;When I ďŹ rst came to Holyoake we were totally reliant on government funding. It was clear that we needed to diversify our revenue stream and become more self-determining regarding our future direction. Weâ&#x20AC;&#x2122;ve done that and weâ&#x20AC;&#x2122;re now able to focus much more on prevention, an area thatâ&#x20AC;&#x2122;s rarely funded by government.â&#x20AC;?

28 | APRIL 2016

Holyoake provides assistance to more than 6500 people annually in WA with a particular emphasis on practical programs. This has been facilitated, says Angie, by the shift from a charity model to an enterprise structure.

â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve developed a number of successful evidence-based services, not just here in WA but across Australia and internationally.â&#x20AC;?

facilitators who lead groups in handdrumming exercises both online and in the corporate sector. Thereâ&#x20AC;&#x2122;s a strong emphasis on social and emotional learning and we even have a computer-game version!â&#x20AC;?

Angie recognises that itâ&#x20AC;&#x2122;s absolutely critical to have an ongoing relationship with GPs. â&#x20AC;&#x153;Only about 7% of our referrals come from GPs, in fact most people we see self-refer.

Weâ&#x20AC;&#x2122;d like to raise awareness of the services we provide because we know that GPs are at the front-line for people struggling with alcohol and drug issues. We offer hope and support to individuals and families in a very challenging environment. People can change and lasting change is possible.â&#x20AC;?

By Mr Peter McClelland

â&#x20AC;&#x153;One of our most successful initiatives is the Drumbeat program. It involves training MEDICAL FORUM

Guest Column

Building a Healthier Perth There is a growing mood for change suggests Fremantle Lord Mayor Brad Pettitt regarding healthier and more sustainable urban design.

A sustainable city is a healthy city. The links between environmental sustainability and public health are no longer confined to well-known issues such as air quality and traffic congestion but are inextricably entwined with the way we design our cities. There are surprisingly strong synergies between creative, intelligent urban planning and broader societal health benefits.

There are many elements to creating a healthy city. Increasing urban forest cover to reduce the heat island effect, constructing healthy buildings that use less energy and, perhaps the most fundamental factor, redesigning our city away from the model of ‘automobile dependent’ suburbs to centres that offer a range of mobility choices.

For Perth, this is now a critical issue. Traffic congestion is getting worse, commute times are getting longer. Perth is now the second most congested city in Australia and the Committee for Perth estimates there is a 31-minute delay for every one hour spent travelling during peak periods.

To make matters worse, the 2015 Australian

Infrastructure Audit predicted that the greater Perth region will have the nation’s most congested roads by 2031.

Traffic congestion is not just hitting the hip-pockets of West Australians, it’s also impacting on our health. International evidence suggests that increased travel times are linked with long-term, serious health and social problems including premature death, obesity, heart disease, increased blood pressure, cancer, type 2 diabetes, high cholesterol, mental health issues, sleep apnoea and higher divorce rates.

average and more than four times the world average with around 25 tonnes per person, WA is even higher. So a sprawling, carfocused city design that’s bad for our health is even worse for the environment.

The good news is there’s a mood for change.

Research carried out by the Committee for Perth in late-2015 revealed that 89% of residents want an efficient public transport system for Perth, while only 17% of the community believe that this requirement is currently being met.

Extended travel times and flow-on health issues are adversely affecting a growing number of people in Perth. More than 70% of all new housing is located on the urban fringe, well away from public transport and mixed-use, walk-friendly centres. Our largest growing suburbs are more than 33km away from the CBD.

So the challenge is to design the future of Perth as an active transit city in which walking, riding and catching public transport are the fastest growing forms of moving people around the metropolitan area. To achieve this, Perth will need to be more dense and compact with development focused on mixed-use centres where people can live, work and enjoy their leisure time within one space.

Linked with this is the unenviable fact that Perth has one of the highest per capita CO2 emissions on the planet. While Australia’s per capita emissions are nearly twice the OECD

This is a wonderful opportunity to create a more liveable Perth. A modern city that is substantially healthier for its residents and the planet.

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Clinical Opinion

Hepatitis C game changer You may have already heard that new direct acting antivirals (DAAs) have arrived for hepatitis C (HCV) infected patients.

The PBS has listed DAAs prescribable by hepatologists, gastroenterologists and infectious disease physicians experienced in the treatment of chronic HCV infection.

For GPs with an interest in this area DAAs may be prescribed through the PBS General Schedule (Section 85, authority required) “in consultation with” the above specialists. The Section 85 listing means that community pharmacists can dispense DAAs. No specific S100 prescribing courses are required (unlike previous interferon prescribing).

Many GPs reading this may be concerned that their clinical skills are being challenged.

The loosely defined term “in consultation with” means a GP needs to consult with one of the above specialists by phone, mail, email or video–conference in order to meet prescriber eligibility requirements. How this works on a practical basis will vary depending on previously established referral patterns.

By Prof Gerry MacQuillan Gastroenterologist Nedlands

For HCV patients in tertiary viral hepatitis clinics, correspondence from the hospital (“in consultation with”) might satisfy PBS requirements when telephoning for an authority script: HCV genotype (1, 2, 3, 4, 5, 6); cirrhosis status (yes/no) will need to be provided. There will be teething issues (given the magnitude of change in HCV drug prescribing and the simultaneous S100 and S85 listing). Community dispensing problems of section 85 scripts may arise with the upfront pharmacy costs of the DAAs and new wholesaler agreements.

(for HCV genotypes 1, 2, 3) these new “all oral” regimes are well tolerated. Monitoring compliance whilst on therapy remains important.

What are the new HCV DAAs?

Treating HCV patients now will prevent HCV related liver transplants in the future. The dawn of an exciting new era has begun for HCV patients.

Those listed on March first are daclatasvir (Daklinza®); ledipasvir with sofosbuvir (a coformulated once daily single pill Harvoni®); sofosbuvir (Sovaldi®) and ribavirin (Ibavyr®).

More drug regimens will follow. Potential drug-drug interactions can be worked out on the Liverpool “HEP iChart” app or online.

Cure rates are in excess of 90% with shortened treatment courses (generally 12 weeks). With no interferon related side effects

by Medical Director PROF JOHN YOVICH

HCV related cirrhosis (alcohol avoidance is very important) and treatment failures should be referred to tertiary care for long-term follow-up or resistance testing. For further information the Australian Recommendations for the Management of HCV infection: A Consensus Statement will be published in the MJA and online.

Unfortunately, the incidence of diabetes and obesity related non-alcoholic fatty liver disease is rising, and will replace HCV as the leading indication for liver transplantation in the future.

Author competing interests: the author has consulted to BMS and Gilead. Questions? Contact the author on 9386 1004

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PIVET MEDICAL CENTRE

Lifestyle influences on fertility and IVF outcomes #3 … focus on nutrition Last month I reported on work arising from the PIVET-Curtin collaboration and introduced discussion about our published work on the benefits of a high fruit and vegetable (F&V) intake, euphemistically entitled the “broccoli index”. We surmised that F&V provides the anti-oxidant requirements to counter the oxidative stresses associated with both normal and abnormal metabolic events, and known to cause DNA fragmentation. This can readily be measured by a variety of tests on sperm (SCSA, HALO, Tunel and Comet assays) and also presumed to underpin the tendency for aneuploidies in ageing oocytes.

PIVET’s collaboration with Curtin is via the School of Biomedical Sciences where the main research lines are focussed on impaired metabolic responses from insulin resistance (Metabolic Syndrome) as well as elucidating the intracellular signalling mechanisms associated with cancers. These two distinct areas actually have commonality involving signalling pathways which are disrupted and become the focus for new therapeutics.

Mammals, including humans, evolved successfully by developing NOW AT 2 LOCATIONS PERTH & BUNBURY

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mechanisms to reproduce when nutriments were available but to inhibit the processes at times of food scarcity. In modern affluent settings, these inhibitory mechanisms may be evoked from personal lifestyle influences including periods of anorexia or bulimia during teenage years, long-term quirky diets, extreme exercise mismatched to nutritional intake, excessive nutriment intake (balanced and unbalanced), sometimes isolated nutrient deficiency, and sometimes by following inappropriate health advice such as avoidance of dairy products or extreme low-fat dietary intake.

Hippocrates suggested “the right amount of nourishment and exercise, not too little and not too much, provides the safest way to health”. However, despite a plethora of nutrition-based publications (see the recent review: Fontana & Torre, Nutrients, 2016) very little clear knowledge has so far been presented that can define an appropriate “fertility diet”. With our Curtin PhD, Masters and Honours students we plan to correct this knowledge void.

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APRIL 2016 | 31

Guest Columns

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MEDICAL FORUM

Clinical Updates

Non-surgical foot and ankle pathology The majority of foot and ankle conditions have established surgical treatments but a sub-group remains difficult to treat.

Non-surgical treatment options are being investigated for Achilles tendinopathy, plantar fasciitis and Morton’s neuromas.

Extracorporeal Shockwave Therapy As a generalisation, both Achilles tendinopathy and plantar fasciitis are caused by overuse and repetitive trauma resulting in degeneration, inflammation and weakening of the tissues, which can eventually cause rupture. Standard non-operative treatment options (orthotics, eccentric exercises and corticosteroid injections) often have poor success rates.

Initially used to disintegrate renal stones, ESWT has expanded to treat pathological dystrophic calcification in musculo-skeletal disorders and now to Achilles tendinopathy and plantar fasciitis.

How ESWT produces a regenerative and tissue repairing effect in musculoskeletal tissues is not completely understood.

Interstitial and extracellular responses and tissue regeneration are seen with increased numbers of blood vessels, local release of angiogenetic factors, differentiation of mesenchymal stem cells, decreased inflammatory mediators and increased levels of growth factors. Shock waves can stimulate tenocyte and fibroblast proliferation and collagen synthesis.

Treatment efficacy of plantar fasciitis and Achilles tendinopathy is generally around 80%.

autologous blood concentrates means further research is required.

Chronic Achilles tendinopathy or plantar fasciitis of at least six months duration is generally felt suitable for ESWT. Relative contraindications include pregnancy, anticoagulant therapy and a partial thickness tear (>20% of the cross sectional area) of the Achilles tendon or plantar fascia.

Radiofrequency ablation of Morton’s Neuroma

Autologous platelet rich plasma (PRP) injections Autologous blood with a concentration of platelets above baseline values should in theory provide various growth factors that participate in tissue repair processes. Despite two decades of use, there remains extensive debate about this treatment option for orthopaedic injuries.

Easily performed in an outpatient setting with minimal risk, PRP injections show most promise in treating Achilles tendinopathy with areas of cavitation due to mucoid degeneration.

Occasionally, atheromatous plaque rupture may result in an ulcer of the inner arterial lining. A platelet plug that is unstable for up to six months fills the ulcer. Pieces can embolise to the brain to cause a stroke, TIA or retinal artery ischaemia. The presence of one of these events defines carotid stenosis as symptomatic.

Carotid endarterectomy is open surgical removal of the atheromatous plaque, done to reduce the future risk of stroke. Paradoxically, surgery has a risk of causing a stroke of between 1 and 10%.

MEDICAL FORUM

Usually a degenerative process resulting in fibrosis of the inter-digital nerve, Morton’s Neuroma is one of the commonest causes of debilitating foot pain. Classical treatment options include alteration of shoes, orthotics and metatarsal domes, and ethanol ablation.

With an up to 20% persisting pain rate, surgery is seen as a last resort.

Generally performed as an outpatient procedure (under local anaesthetic or ankle block), radiofrequency thermal ablation is a minimally invasive option for patients resistant to conservative treatment. A probe is inserted (under ultrasound guidance) into the region of the nerve and high frequency sound waves are used to heat the tip to up to 90° Celsius.

It is thought that the heat causes protein breakdown and destroys the peripheral nerve endings and myelin sheath, blocking only nociceptive input.

Most studies on PRP injections concentrate on elbow lateral epicondylitis and knee arthropathy but some examined the efficacy in tendons around the foot and ankle.

Studies suggest over 85% of patients have significant pain resolution with less than 10% needing a surgical neurectomy.

The current literature lacks standardisation of study protocols, platelet separation techniques and outcomes. The uncertainty about clinical use of platelet rich plasma and

Author competing interest – nil relevant disclosures.

Questions? Contact the author on 9382 9102

Carotid endarterectomy Atheroma is common at the point of division of the common carotid artery into its internal and external branches and results in progressive narrowing of the carotid artery. Cerebral autoregulation and collateral flow means that symptoms from decreased cerebral perfusion are rare, even with severe narrowing. Nonspecific symptoms of dizziness, blurred vision, vertigo, headaches, nausea or impaired cognition are almost always due to non-carotid pathology and should rarely prompt carotid imaging.

By A/Prof Reza Salleh Orthopaedic Surgeon Subiaco

The risk of stroke from surgery versus the risks without surgery must be calculated for all patients based upon symptoms, degree of stenosis, age, sex and co-morbidities.

Historical studies have provided data, which is still applicable, to facilitate this assessment.

Symptomatic is important The risk of subsequent strokes in a recently symptomatic patient is around 25% in two years. Carotid endarterectomy is indicated in patients with symptomatic stenosis of over 70% and some with less than 70%.

As risk of stroke decreases with time after the symptomatic event, surgery should be performed as soon as possible, ideally, during the same admission as for the primary event.

In asymptomatic patients, stroke risk is low at around 2% per year (1% in patients without carotid disease). Historical studies show benefit for surgery compared to Best Medical Therapy (BMT) but BMT is delivered more aggressively today. Less surgical benefit has been demonstrated in women.

In asymptomatic patients the degree of stenosis is not related to the stroke risk and

By Dr Rick Bond State Director of Vascular Surgery

consequently, there is no consensus over when to operate. Routine screening of this group is not recommended due to the low benefit from surgery.

Weighing up the odds A general approach used by many Australian surgeons is to operate in fit male patients with over 80% and females with over 90% stenosis since there is a 10-20% risk of stroke when the artery finally occludes. Carotid surgery should definitely be considered in fit, older (even over 80) patients as surgical risk is only minimally increased with age but stroke morbidity is greater in older patients.

Carotid surgery is not indicated for completely occluded arteries, as embolization can’t occur without forward flow through the artery.

Author competing interests: no relevant disclosures.

Questions? Contact the author on 6397 5120

APRIL 2016 | 33

Clinical Update

Metastatic melanoma: beyond chemotherapy

Dr Samantha Bowyer Rockingham General Hospital Cooloongup

Fig.1: The MAP Kinase Pathway.

Constitutive activation of the mitogen-activated protein (MAP) kinase pathway occurs in serinethreonine protein kinase B-RAF (BRAF) mutated melanoma cells, which is independent of extracellular signals. Selective binding of oncogenic BRAF by a BRAF inhibitor blocks downstream activity and reduces cell proliferation and survival. MEK, a substrate of BRAF, can also be inhibited to block this pathway at a second place.

Metastatic melanoma historically has been difficult to treat, being relatively chemo-resistant, with patients rarely living beyond a year from diagnosis.

In recent years, the evolving treatment of advanced melanoma has seen the development of targeted agents, notably BRAF and MEK inhibitors that offer high response rates in the subset of patient harbouring a BRAF activating mutation.

However, emerging drug resistance limits responses over time. Immunotherapy with checkpoint inhibitors, such as CTLA-4 and PD-1 inhibitors, represent another major advance and have the potential to achieve long term tumour control in melanoma and other cancers. Ongoing research aims to maximise long term survival in advanced disease as well as improve outcomes in the adjuvant setting.

Immuno-oncology is one of the main treatment advances of the decade, and the dynamic field of melanoma treatment is now at the forefront of evolving approaches to cancer therapy. It is likely treatment of the future will become highly personalised based on tumour and patient characteristics.

Targeted therapy MAP Kinase pathway (see Fig.1) Activating mutations in serine-threonine protein kinase B-RAF (BRAF) occur in 40-60% of patients with melanoma. DNA sequencing on fresh or archival tumour tissue confirms the presence or absence of the mutation and is done at the time of diagnosis of advanced disease to plan future treatment options. Targeted therapies blocking the mutated protein to inhibit cell proliferation and survival have become a new standard of care for patients with this mutation. Compared to

34 | APRIL 2016

monotherapy, combining with a MEK inhibitor to block this cancer growth pathway in two places has demonstrated higher response rates (70% vs 50%, demonstrating >30% tumour shrinkage) and longer responses (median progression free survival 9-11 months vs 6 months). This can produce rapid symptomatic benefit for patients and improvement in performance status in those with high burdens of disease.

Dabrafenib is an oral selective inhibitor of BRAF currently reimbursed on the PBS in the first line setting, as monotherapy or in combination with trametinib, a MEK inhibitor.

Common adverse events of monotherapy included squamoproliferative lesions of the skin, arthralgia, headache and pyrexia.

Combination therapy increases pyrexia incidence (51% vs 28%); but the risk of squamoproliferative lesions, including cutaneous squamous cell carcinoma, is reduced. In clinical practice these agents are very well tolerated.

The benefits of targeted therapies are limited by the emergence of genetic changes in the tumour and reactivation of the MAPK pathway leading to complex drug resistance. Tackling resistance mechanisms is a future challenge and multiple targeted therapy combinations are currently under evaluation.

Immunotherapy The immune system can adapt to diverse tumour specific antigens as well as develop memory (see Fig.2). Improved understanding of immune tolerance in cancer and the role of blocking negative regulatory signals to potentiated anti-tumour immunity have been another key area of advancement. The immune check point inhibitors, T-lymphocyteassociated antigen 4 (CTLA-4) blockade and

programmed cell death 1 (PD-1) receptor inhibitors, act to release the brakes on the anti-tumour cytotoxic function of T-cells.

CTLA-4 Blockade The CTLA-4 inhibitor, ipilimumab, was the first immunotherapy introduced onto the PBS after it prolonged median survival (with a proportion of patients becoming long term survivors). Pooled survival data demonstrates a 22% survival rate at 3 years indicating longevity to response after initial induction therapy over 12 weeks. The main toxicities relate to activation of the immune system against autoantigens, primarily causing diarrhoea or colitis, skin rash, hepatitis and endocrinopathies; usually settling with the use of corticosteroids although more severe toxicity require escalating levels of immunosuppressants. As such, severe autoimmune disease or a history of organ transplantation are relative contraindications.

Anti-PD-1 Antibodies Pembrolizumab is a humanised monoclonal antibody that blocks the inhibitory programmed cell death 1 (PD-1) receptor expressed by T-cells. In 2015, Australia was the first country in the world to reimburse pembrolizumab for the first line treatment of advanced melanoma in patients with BRAF wildtype melanoma or after failure of a BRAF inhibitor in those harbouring an activating BRAF mutation. Objective responses are seen in up to 45% of patients and are usually durable. Compared with ipilimumab the safety profile is more favourable with only 3% of patients experiencing moderate or severe adverse events. In practice, pembrolizumab is tolerated extremely well by most patients, continued on Page 37

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APRIL 2016 | 35

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Clinical Q&A

Rickettsial infection?

By Dr Astrid Arellano Infectious Diseases Physician Palmyra

A 55 year-old man presents with four days of arthralgia, a rash, intermittent fevers, headache and fatigue. He had spent five days in the bush near Dwellingup two weeks prior, and his wife removed a skin tick upon his return. There is a maculopapular rash, groin adenopathy, an eschar on his leg, and he is febrile (38.2C). Your diagnosis?

Q A

In the presence of an eschar, a maculopapular rash and a tick bite, rickettsial infection is highly likely.

Bloods show lymphopaenia (0.47), thrombocytopaenia (120), raised ALT (320) and CRP (120).

The spotted fever group IFA is 128 rising to 1028 after four weeks. A blood rickettsia PCR yields a sequencing product that is identified as R. honei.

Eschar and swelling on lower limb as a result of a tick bite

Treated with doxycycline 100mg BD for one week, his fever and clinical symptoms improve within a few days.

Discussion Rickettsiae cause a systemic illness characterised by fever, rash, headache, and a cutaneous eschar in some (see right). Scrub typhus (O. tsutsugamushi) is found in northern WA’s native rodents, Murine typhus (R. typhi) in urban rats, and the Spotted Fever Group (R. honei, R. gravesii and R. felis) is common in the ectoparasites of southwest feral pigs, reptiles, and kangaroos but rarely reported in humans. This is probably because the majority cause mild illnesses and the more severe cases are not recognised.

It is an under-diagnosed illness. Rickettsial infections need to be considered in individuals with a compatible clinical picture. Detection in blood by PCR and sequencing of Rickettsiae spp. is available. Serology is the mainstay of diagnosis albeit delayed. Treatment with doxycycline reduces the length of the illness and fever from around 30 to a few days.

Maculopapular rash due to rickettsia infection

Photos courtesy of Dr John Dyer and Dr Ed Raby, Fiona Stanley Hospital.

Author competing interests- no relevant disclosures. Questions? Contact the author on 9319 3811

Metastatic melanoma: beyond chemotherapy continued from Page 34

Fig.2: Mode of Action of Checkpoint Inhibitors.

T-cells recognise antigens presented by major histocompatibility complex (MHC) through their T-cell receptor (TCR). A co-stimulatory signal, delivered

by B7, is required to turn on the T-cell. Following T-cell activation, cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4) is upregulated to initiate inhibitory signalling in the priming phase of T-cell response.

Monoclonal antibodies blocking CTLA-4 thereby prevent down regulation of cytotoxic T-cell activity and potentiate anti-tumour activity. The programmed cell death 1 (PD-1) receptor negatively regulates the effector phase of T-cell responses after binding with its ligand PD-L1, which is frequently expressed in the tumour microenvironment. Antibodies blocking the interaction release the cytotoxic function of more tumour specific T-cells allowing tumour cells to be destroyed by the immune system.

even the elderly. Nivolumab, another PD-1 inhibitor, has recently received TGA approval as monotherapy and in combination with ipilimumab.

Although immunotherapy has been a major advance several hurdles still exist related to appropriate patient selection, understanding the immune system’s response to cancer, and the high cost of these drugs. Several new therapies as well as combinations are under

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investigation aiming to more effectively harness the cytotoxic potential of the immune system.

References available on request.

Conflicts of interest: nil relevant. Questions? Contact the author on 9599 4442 or Samantha.bowyer@health.wa.gov.au

APRIL 2016 | 37

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MEDICAL FORUM Excellence in Molecular Imaging

Clinical Update

Non-scarring alopecia in women

By Dr Kate Borchard Dermatologist Mt Hawthorn

Non-scarring alopecia may be due to systemic or local causes, or disorders of the hair shaft (congenital or acquired). As the follicles remain, recovery is possible.

Systemic causes of alopecia include nutritional deficiencies (e.g. protein, iron) hormonal derangements (e.g. hyperandrogenism, hypothyroidism), stress, multi–organ diseases (e.g. SLE, sarcoid) and some medications (e.g. ACE inhibitors, NSAIDS). An effluvium develops (increased shedding >50 hairs/day). Specific causes may lead to a patterned or patchy alopecia. The hair may also be of poor quality.

Androgenic alopecia, mediated by the androgen dihydrotestosterone, is the commonest type in women. Genes that shorten the anagen (growth) phase are activated by androgens, and hair follicles shrink. With successive anagen cycles, the follicles become smaller, leading to shorter and finer hair. Nonpigmented vellus hairs replace pigmented terminal hairs. The thinning is diffuse, but more marked in the frontal and parietal regions with sparing of the frontal hairline. Most women with androgenic alopecia have normal menses, fertility and endocrine function including circulating

androgens. If a woman has irregular menses, abrupt hair loss, hirsutism or acne recurrence, an endocrine evaluation is appropriate as this may indicate polycystic ovarian syndrome.

In telogen effluvium there may be no recognisable cause, and the shortened hair cycle can continue for years (chronic telogen effluvium). This is more common in women who have had long hair. It is characterised by bitemporal recession and may coexist with androgenic alopecia.

Local causes

Early androgenic alopecia

Alopecia areata is patchy hair loss of autoimmune origin. It usually presents suddenly with a single oval patch or multiple confluent patches of asymptomatic, wellcircumscribed, non-scarring alopecia. Less commonly there is diffuse or total alopecia of the scalp or all hair of the body. Exclamation point hairs are a hallmark of the disorder. It affects men and women equally, and is more common in children and young adults. The course is one of spontaneous remissions and recurrences.

Hair shaft abnormalities Hair shaft abnormality can be congenital (diagnosed by microscopic hair examination), traumatic (heat or traction from styling or chemicals in hair treatments) or due to trichotillomania.

Exclamation mark (tapered) hairs in alopecia areata

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Trichotillomania is a compulsive behavior involving repeated hair plucking, and is frequently associated with psychiatric illness.

It is more common in women and children.

Though difficult to treat, antidepressants, and cognitive behavioural therapy may help. Appropriate investigations are guided by clinical suspicion but may range from nutritional and hormone screens through to scalp biopsy and hair microscopy.

Treatment Treatment options are dependent on the cause. For systemic causes, treatment is directed at the underlying disorder.

For hair shaft abnormalities, treatment is education and cessation of damaging hair care practices, and psychiatric assessment for trichotillomania. For the local causes, set realistic expectations at the outset; for androgenic alopecia, for example, the treatment aim is to retain the current hair, and any regrowth is a bonus. Some forms of alopecia areata, such as the ophiasis pattern and total alopecia are more treatmentresistant.

Topical or intralesional steroids, calcineurin inhibitors, antiandrogenic medications, immunosuppressants or immunotherapy may be useful in local causes.

Agents to stimulate hair growth, such as minoxidil, and cosmetic camouflage may be added to any treatment regimen.

Author competing interests: no relevant disclosures.

Questions? Contact the author kate@oxforddaysurgery.com.au

APRIL 2016 | 39

Lifestyle

Swimming 365 They can’t wait to leap off the blocks, their HbA1c levels are under control and they keep coming back. Here is chronic disease management in action.

Swimming 365 is a program run by Diabetes WA, Swimming WA, UniSwim and UWA Exercise & Performance aiming to put the brakes on Metabolic Syndrome.

If you’re a professional working in the mental health sector then you know all about the difficulty of sustaining enthusiasm and attendance rates in a group setting. Jenny (who did not want to be identified) is 62-years-old and has had type 2 Diabetes since 2002.

“A diagnosis can feel a bit like a sentence, suddenly you’ve got all these restrictions and things you should and shouldn’t do.

But Swimming 365 is very empowering and it’s done in manageable chunks with lots of positive feedback. It actually makes me feel quite heroic.”

“We all have fairly large girths associated with metabolic syndrome and, to be honest, most of us would never have been seen dead in our swimming costumes. But we feel very comfortable now as we tackle this problem together. There’s the added bonus that the program is individually designed for us, it’s a privilege to receive all this training and professional expertise.”

The participants are all registered with Diabetes WA, which is where they heard about Swimming 365, and they are then required to talk about the program with their own GP. First-term fees are covered by Medicare and negotiations are taking place with private health funds to cover some of the ongoing charges.

“The ‘365’ is there for a reason because we’re encouraged to continue right through winter.

It burns more fat swimming during the colder

40 | APRIL 2016

months, apparently. I was in the inaugural group that started in February 2015 with Aqua Aerobics and low-impact cardio workouts run by exercise physiologists,” Jenny said.

“My HbA1C levels are under 6.6, I’m not taking any medication and managing nicely with a combination of diet and exercise.

Swimming 365 makes me feel wonderful, we’re all swimming nearly 6km a week and I certainly feel slimmer.”

The man behind the wheel of Swimming 365 is Tom Picton-Warlow and to say he’s enthusiastic about the program would be an understatement.

“We’ve had a highly successful first year of operation with strong participation and retention rates. Our focus is always to provide e value for the participants with a holistic approach incorporating exercise and diet.”

Dr Bonnie Furzer

“Diabetes WA provides an accredited dietitian to give nutritional advice, UWA Exercise and Performance have an accredited exercise physiologist and the coaches from Swimming UWA and UniSwim have expertise and links right through to FINA.”

“I was a director on the boards of Swimming Australia and Swimming WA from 2010-15 and it was obvious that getting into the pool and exercising could play a significant role in people’s health. We’re blessed to have so many great places here from the Swan River, to public pools and the Indian Ocean.

Swimming is part of our cultural DNA.”

“The nutritional component is extremely important and regular exercise gets the participants thinking about food in a different way. Australians are carrying more excess weight than ever before and a combination of professional instruction, exercise and increased knowledge will, hopefully, go some way to address the rising incidence of Metabolic Syndrome.”

Tom is ideally placed to head-up Swimming 365.

“We’re so pleased with the outcomes. We’ve got four people from the group with Type 2 who are competing as a team in the 20km Port-to-Pub Swim [Fremantle to Rottnest], which will be a fabulous achievement.”

The ‘science’ behind the program is provided

by UWA Exercise Physiologist Dr Bonnie Furzer who has a research interest in the

MEDICAL FORUM

pairing of exercise and chronic disease.

“My PhD thesis focused on cancer patients.

I’m interested in the design of exercise programs that help with healthy function, whether it’s a patient presenting with the side-effects of treatment or a chronic disease.

Swimming 365 is a unique program, the combination of structured exercise and hydrotherapy in this context is a novel one and the results have been pleasing.”

“It’s often quite difficult to encourage people who may not have been all that active in the past. We weren’t sure how an older group would cope with that. We’ve had great compliance and a retention rate in excess of

80%, they keep coming to the sessions and they re-enrol for the next semester. They’re obviously seeing sufficient benefits to keep jumping into the pool and that’s heartening from a health perspective.”

Bonnie was involved at the planning stage of the program.

“About 18 months ago UWA academic staff involved with swimming partnered with us here at Exercise and Performance and the aim was to design a structured program that had an emphasis on progression and was able to be medically assessed. It was also important to have a strong liaison with a participant’s GP.”

Mr Tom Picton-Wa rlow “There are many complex factors linked with Metabolic Syndrome, it’s far too simplistic to say it is one thing or another. The critical factor is that an individual can learn how to make a difference in managing their health and see where they fit within the spectrum of their disease.”

“There are just so many potential benefits from structured exercise.”

By Mr Peter McClelland

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MEDICAL FORUM

APRIL 2016 | 41

Wine Review

Knee Deep

Develops its Portfolio

By Dr Louis Papaelias

In 2000 Dr Phillip Childs and his wife Sue gave birth to Knee Deep Wines – a 34ha estate of established farmland that they transformed into vineyards, winery, and restaurant with winemaker Bob Cartwright responsible for the wines up until 2012. Bob has had an illustrious winemaking career, firstly with Houghton and then with Leeuwin Estate. Bruce Dukes has been in charge of the winemaking at Knee Deep since 2012.

The estate is located in the Wilyabrup sub-district of Margaret River, home to Moss Wood, Woodlands, Sandalford, Evans and Tate and Fermoy Estate. The area is primarily renowned for its Cabernet Sauvignon wines, closely followed by its Chardonnay and Semillon Sauvignon Blanc blends. Having reviewed these wine in 2014, I was interested to see the latest line-up.

1. 2015 Semillon Sauvignon, 2015 Sauvignon Blanc Two attractive aromatic wines perfect for summer drinking. The Semillon Sauvignon Blanc has a high-toned citrus grassy aroma with a crisp refreshing finish. The Sauvignon Blanc is more pungent with an asparagus, grassy bouquet and a generous mouth-filling palate structure.

2

3

2. 2012 Kim’s Chardonnay Looking back on my notes for the 2011 Kim’s Chardonnay, I commented “the oak is not at all apparent”. On retasting this alongside the 2012, I found the oak in the 2011 is, in fact, much more apparent compared to the 2012. The 2012 has a richer fruit character with more of the desirable minerality that gives a good chardonnay its appeal. A classy wine made to accompany white meats. It will certainly take further bottle age.

4

3. 2013 Cabernet Merlot An attractive nose of berries and black olives leads to a generous mouthfeel which has agreeable clean fruit tannins and a soft finish. Hard to fault and a wine that I imagine would sell well in the restaurant.

4. 2011 Kelsea’s Cabernet Sauvignon My comments for the 2010 wine were “Rich, ripe, cassis, hints of black olive.

Real depth of flavour with a long persistent finish. Shows very fine oak treatment.”

For the 2011 I would add that a touch of green grass freshness gives the wine an appealing drinkability at the moment. A worthy addition to the great cabernet heritage of the Wilyabrup area.

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In cinemas, April 28

Musical: Ghost Ghost was one of the all-time favourite date-night movies with Patrick Swayze and Demi Moore keeping all the punters happy. Now it is a musical with the talented Rob Mills (Grease) and Jemma Rix (Wicked) in the lead roles of Sam (the â&#x20AC;&#x2DC;Ghost) and Molly. Their performances and the special effects are the talk in theatrical circles.

Crown Theatre, from May 21

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by Australian composers including Carl Vine, Elena KatsChernin, Richard Tognetti, Iain Grandage, Andrew Ford, David Hirschfelder, Paul Grabowsky, Paul Dean and John Rodgers.

The Brodsky will also perform some of their own repertoire.

Perth Concert Hall, May 5

Movie: X-Men Apocalypse 3D James McAvoy (Professor X), Michael Fassbender (Magneto) and Jennifer Lawrence (Mystique) line up for the next X-Men instalment which turns its attention on the Apocalypse, the ďŹ rst and most powerful mutant of the X-Men universe, who re-awakens after thousands of years. Heâ&#x20AC;&#x2122;s hungry for power and breakfast after hibernation for so long â&#x20AC;&#x201C; so expect plenty of biff and kapow.

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APRIL 2016 | 43

SHORT STUFF

WISDOM OF THE AGE

I asked the librarian about a book on Pavlov's Dog & Schroedinger’s Cat.

The 90-year-old man was in for his checkup when the nurse learned he was about to marry an 18-year-old girl.

She said it rang a bell, but she could not be sure if it was there or not.

Just had a terrible doctor’s visit. He’s diagnosed me with something called Viagraphobia. I haven’t had a chance to look it up yet, but I'm scared stiff!

"Now, Mr. Jenkins," the nurse warned, "you should know that when a man your age marries an 18-year-old girl, somebody could get hurt."

to take your efore I refuse Be ve an opening questions, I ha statement..

- Ronald Reaga

n

The old man shrugged, "If she dies, she dies."

DREAMING BIG

How many physiotherapists does it take to change a light bulb?

CLEAR THE FAIRWAY

None. They just give the dead bulb some exercises to do and hope it will be working a bit better the next time they see it.

A pastor, a doctor and an engineer were waiting one morning for a particularly slow group of golfers.

The young accounting graduate, fresh out of uni and knowing everything, applied for his first job. The prospective employer asked him what starting salary he was looking for.

What is a double-blind study?

Engineer: What's with these guys?

We must have been waiting for 15 minutes!

Two orthopaedists reading an electrocardiogram.

A man walks into a doctor's office. He has a cucumber up his nose, a carrot in his left ear and a banana in his right ear.

"What's the matter with me?" he asks the doctor.

The doctor replies, "You're not eating properly."

"How can I ever thank you?" gushed a woman to her lawyer, after he had solved her legal troubles.

"My dear woman," lawyer replied, "Ever since the Phoenicians invented money there has been only one answer to that easy question."

WHO’S DA BOSS When a car skidded on wet pavement and struck a telephone pole, several bystanders ran over to help the driver.

Doctor: I don't know, but I've never seen such ineptitude!

Pastor: Hey, here comes the greens keeper.

Hi George, what's with that group ahead of us? They're rather slow, aren't they?

George: Oh, yes, that's a group of blind fire fighters. They lost their sight saving our clubhouse from a fire last year, so we always let them play for free anytime.

The group was silent for a moment.

Pastor: That's so sad. I will say a special prayer for them.

Doctor: Good idea. And I'm going to contact my ophthalmologist buddy and see if there's anything he can do for them.

Engineer: Why can't these guys play at night?

"Oh, around $100,000 a year, depending on the benefits package."

"Well, how does this sound? Five weeks annual leave, 22.5% superannuation, paid expenses to overseas conferences every year, home telephone reimbursed and a company car replaced every 20,000km, say a Mercedes convertible."

The graduate sat up straight and tried not to look excited. "Wow. Are you kidding?"

"Yeah. But you started it."

TAKING CARE OF BUSINESS A doctor and a nurse were called to the scene of an accident.

Doctor: We need to get these people to a hospital now!

Nurse: What is it?

Doctor: It's a big building with a lot of doctors, but that's not important now!

A woman was the first to reach the victim, but a man rushed in and pushed her back.

"Step aside, lady," he barked. "I've taken a course in first aid."

The woman watched him for a few minutes, then tapped his shoulder.

"Pardon me," she said. "But when you get to the part about calling a doctor, I'm right here."

quickmeme.com

44 | APRIL 2016

MEDICAL FORUM

Musical Theatre

THE SPIRIT OF INNOVATION It took the theatre 20 years to get around the special effects dilemma of staging the 1990 romantic thriller Ghost – the film that became the instant date-night favourite starring Patrick Swayze and Demi Moore.

But finally, in 2011, a collaboration between the original screenwriter Bruce Joel Rubin and musicians Dave Stewart (of Eurythmics fame) and Glenn Ballard came up with the music, lyrics and book for a musical that has since swept the world.

Ghost the Musical has finally hit Australian shores with the Perth season opening at Crown Theatre from May 21, the last stop in a national tour and starring local heroes Rob Mills (Grease) and Jemma Rix (Wicked) in the roles of lovers Sam and Molly.

You probably know the story – Sam discovers a money scam and is murdered leaving Molly alone and bereft.The tricky bit is that Sam’s ghost continues to play the role of leading man – enter some hi-tech lighting and a surreal narrative that musical theatre does so well.

The duo are joined by the comic heart of the show, ‘spiritualist and psychic’ Oda Mae Brown (played by renowned UK musical theatre doyenne Wendy Mae Brown).

Wendy spoke to Medical Forum just after an exhausting rehearsal in Melbourne recounting how she ended up 12,000km from her London base.

“I was in rehearsals for Kiss Me Kate at the Old Vic in London when I got the call to join the Australian cast of Ghost. It’s a really great role for me requiring singing, dancing and acting; the lot,” she said.

It required an early exit from Kiss Me Kate that baffled her director, the great Trevor Nunn, who was just a little amazed that one of his stars was begging him to let her go 12,000km for a show that had not been performed there before.

talent and offered me a place at their full-time school.”

Performing was a way of life in the Brown household. Wendy’s father was a well-known n ska trumpeter Dave Augustus Brown and while her mother had a solid ‘day job’ as a nurse, Wendy said she had a great voice.”

“We were not able to listen to ‘nonsense’ as Dad described popular music. Ours was a diet of Ella Fitzgerald, Ray Charles and Miles Davis. We were surrounded by good music.”

Her first gig after graduating was touring the UK with Little Shop of Horrors and her big break came when she was cast in the original al 9.

West End production of Mamma Mia in 1999.

“Like every performer, the early years of my career lent me plenty of time to ask myself whether I’d done the right thing.

I’d watch people going off to work at 8am every morning and I envied them … just to be ordinary. But those are just the years you have to go through as a performer – to be unemployed, to work out how to be resourceful and what to do next. Now I tend to go from one job to another and my main gripe is being tired! Every show is a different beast and you have to give each show your 100%.”

This is Wendy’s first time in Australia and g she’s loving the light and warmth and making her sisters back in England jealous. She’s also happy to be taking the show around the e country. But it’s no cake walk.

“It’s a physically tough show. You have to be on the top of your game.”

By Ms Jan Hallam

R Je mma Rix a nd

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“I knew Ghost was a great film and that the West End musical ran for a year. I didn’t have much time to think beyond that and the fact that the Australian production has a talented management team behind it, so I was confident it would work here.”

“I think it’s a great, high-energy show and Rob and Jemma are both stunning singers.

This role for Rob has changed people’s minds about what he can do. He’s a really, really good Sam and Jemma is breathtaking as Molly.”

As for the all-Australian ensemble cast, Wendy says they are world class.

“It’s a physically punishing show and everyone has to be fit and healthy to get through a performance but we’re blessed to have some great dancers in the show.”

The stage has been Wendy’s life since starting theatre school as a youngster.

“I was a hyperactive child so my parents put me into dance school every Saturday for a break! The teachers told my parents that I had

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Music

Brodsky Quartet

Andrew Bolt may not be a name on people’s lips when they go to a concert but he has been the architect of some of the most momentous moments in the cultural life of Perth in the past three decades.

Think the 2009 visit by the London Philharmonic, the history-making tour of Berlin Philharmonic in 2010 and the third concert in the triumphant triumvirate, the 2011 Vienna Philharmonic tour, all have Andrew Bolt somewhere in the vortex.

As general manager of the Perth Concert Hall for the 21 years, he was the linchpin for shows and companies coming in and out of our premier concert hall and along the way he became an effective cultural lobbyist for the state.

When the Perth Theatre Trust took over the management of the state’s theatrical venues from AEG when its contract expired, Andrew decided, after talking to his formidable list of contacts, to become an independent producer and his first show next month hits the stage and it’s a cracker.

K atie Nooonnaann at times but I have a pretty good lay of the land through years of working in the Perth market and travelling extensively throughout Australian and overseas. I know it as well as anyone can.”

Just hours after hanging up the phone from Andrew, Medical Forum learnt that as well as this promising new producing career, Andrew would also be packing his bags to become general manager of the famous Bridgewater Hall in Manchester.

The SMG-managed Bridgewater has a 2300seat capacity and is home to three resident orchestras – the Hallé, the BBC Philharmonic and Manchester Camerata. The Hall also programs its own classical music season, the International Concert Series.

Versatile songstress Katie Noonan and the acclaimed Brodsky string quartet have collaborated on a unique album of songs written by Katie based on the poetry of Judith Wright that have a classical and jazz vibe. The CD was made in London last year and Katie and the Brodsky will premiere the material for a live audience in a national tour, taking in Perth and Albany, which Andrew will oversee.

Andrew is not fazed by the balancing act between this amazing opportunity in the UK and the shows he has in the pipeline for Perth and nationally. But no doubt the frequent flier points will rack up with his Bridgewater role starting March 15 and his first show opening May 5 at the Perth Concert Hall (May 4 at the Albany Entertainment Centre).

Andrew is understandably excited at the prospect but not daunted.

“The rigours of business are the same wherever you are. You just have to be organised,” he said.

“This will be a good first cab off the rank. I feel confident about this next chapter because I know the industry and its players so well. But I also know that promoting shows is a science and alchemy in one – with perhaps a bit of voodoo thrown in for good measure,” he said.

“It really does help to know your industry but the reality is that the market can be fickle

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There will also be some synergy being based in the cultural hub of the UK and planning shows for the Australian market. Already in the works for Andrew are the Punch Brothers from New York, whose style is described as "bluegrass instrumentation and spontaneity in the strictures of modern classical". Andrew is excited to see the local market reaction.

Andrew Bolt

“These guys are not terribly well known but they had a hit show in Adelaide in 2013 and generated a lot of interest. I’ve joined a consortium of my colleagues around the country to bring them out to Australia again.

I’m presenting them in Perth in August.”

Then Andrew takes the bull by the horns to mount his first national tour and he seems to have a backed a winner here as well. Not too many classical music fans can resist the temptation to hear the Tallis Scholars and they will have their chance in November.

“This is a guerrilla approach, in a sense, and I quite like working this way. I join forces with some wonderful colleagues who are out and about, pick a venue and put on a show.”

Simple – if you have 35 years’ experience and know everyone there is to know in show business!

By Ms Jan Hallam

MEDICAL FORUM