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EDITORIAL Dr Rob McEvoy, Medical Editor
Even Santa Needs a Break! The business of medicine requires that everyone does some navel-gazing over Christmas. Across the medical scene we’ve noticed that the older generation are getting wiser and older (and less tolerant of bulldust from any quarter) and the younger generations are endeavouring to run the show, their way. Resistance to change is inevitable. This aside, you may have been part of a planning meeting this year.
is but one interest and its trackability can be a two-edged sword. The rules of meaningful engagement are ever changing. Moreover, the pace of change is much higher, the focus for doctors at ‘Doctors vs the Pace of Change’ at Doctors Drum. Certainly, change is more immediate – you may have noticed SMS reminders about appointments, with just 24 hours to go, with the opportunity to cancel without penalty?! And in medicine, with technology moving so fast, the latest equipment seems out-of-date soon after installation. For us, working in the medical system, it seems sponsors of medical events or those with technology want more “bang for their buck” and rightly so. With no surplus in the medical system (has anyone told the pollies?) there are cries for efficiencies all the way down the line. All this means we have to be more protective of our editorial independence.
• Revised targets (up or down). • Revamping your website to make it more engaging. • Packaging things for health consumers. • Making what you do more about them and less about you.
During your discussions some home truths may have come out. Such as, private medicine is subject to similar market forces as those in other industries but often seems recession-proof; and personal connections have grown weaker and so have referral networks.
Which brings us to our Clinical Updates because bias may be perceived. We try to keep them short – grab information on an aspect of care. We take names from any source and topics we decide will interest our wide readership. We then contact potential authors and ask the big questions. Finally, author competing interest statements keep readers better informed.
There is a growing consumerism driving things and more interests that compete for everyone’s attention. Social media
We at Medical Forum wish you and yours a happy and safe festive season.
• Growing your audience with new equipment or expertise.
Clinical Updates this edition… I always thought a medical report was a report, so thanks to Dr Katie Thorne for pointing out how inaccuracies arise with Bone Mineral Density reports (P39). Ripped muscles might mean fried HPG axes, according to Dr Peter Burke (P47). Cunning mozzies are all overseas or in Rockhampton, as revealed by Dr Chris Rynn (P41). Dr Aidan Perse points out how to vaccinate more cheaply against rabies before you go to Bali etc – no more holidays cut short by monkey bites (P43)! Dr Arun explains why altering vulval appearance is sometimes important (P49). And Dr Kalani Kahapola says a more serious look at thyroid function in pregnancy is warranted (P5). There, a more varied bunch of Clinical Updates and other content you couldn’t wish for. This includes the Close-up of Deborah Lehmann who looks after ear health in WA and plays the harpsichord (not at the same time).
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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
Administration Jasmine Heyden (0425 124 576) jasmine@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au
Journalist Mr Peter McClelland journalist@mforum.com.au Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au
DECEMBER 2018 | 1
CONTENTS DECEMBER 2018
INSIDE 12 14 16 25
Dr John Stace’s Peace Ride Close-Up: A/Prof Deborah Lehmann Urgent Care in the Community Christmas Greetings
12
14
NEWS & VIEWS 1 4
16
7 8 9 19 24 39 49
Editorial: Even Santa Needs a Break! - Dr Rob McEvoy Letters to the Editor Can you blow out a candle? - Dr Tim Welborn Comment - Prof Fiona Lake Careful with Words - Dr Peter Burke Assisted Dying Options - Dr Peter Beahan Paramedics Prepare for National Registration - Ms Deborah Walley Claims Inquiry Led Astray - Dr John Hayes Comment on COSA - Prof Robert Newton Wider Car Bays Needed - Mr G. Powell, Perth Curious Conversation - Dr David Oliver Have You Heard? Beneath the Drapes Senior Docs in AHPRA’s Sights? Medicolegal: Are You a Flight Risk? Ms Kate Reynolds Aged Care Commissioner Asthma study focuses on young children
LIFESTYLE
25 MAJOR PARTNER 2 | DECEMBER 2018
50 52 53 54
Travel USA Why You Need to Self-Care - Dr Jenny Brockis Wine Review: Windows Estate - Dr Craig Drummond MW The Funny Side
55 Social Pulse: Bethesda OSH Award; Curtin Alumni Awards 56 Competitions 57 Theatre: Madiba The Musical
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CONTENTS DECEMBER 2018 CLINICALS
5 Subclinical Hypothyroidism in Pregnancy Dr Kalani Kahapola Arachchige
39 What I Want from a Bone Density Report Dr Catie Thorne
40 Mosquito-Borne Diseases: Targeting the Vector. Dr Christopher Rynn
45
The Doctors Health Advisory service of WA provides Medical Practitioners with a confidential health service around the clock.
Rabies Vaccination – New Regime Dr Aidan Perse
43 Travel Tips for ‘Hard-ofHearing’ Ms Bev Eintracht
47 The harms of SARMs Dr Peter Burke
How to contact: For doctors in crisis or for those wanting to speak with a DHASWA doctor:
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Drs For Drs list is now live at
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Female Genital Cosmetic Procedures Dr Angamuthu Arun
GUEST COLUMNS
10 Doctors Are Human Too Dr Jenny Brockis
21 Health Revalued Dr Michael Watson
23 Blockchain – the Estonian Example Dr Jill Orford
37 Teachers Key to Longer Healthier Life Dr Bret Hart
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), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician)
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LETTERS TO THE EDITOR Can you blow out a candle? Dear Editor,
Fifty years ago, a rapid simple sign of diffuse airways obstruction was described by Dr Moran Campbell that would supplement clinical assessment. The test known as FETC (forced expiratory time – clinical), could be added to conventional chest auscultation for wheeze and/or expiratory rhonchi. In prior decades, a patient would be asked to blow out a lighted candle or match, failure to do so reflecting severe pulmonary disease. FETC provides a much more useful semi-quantitative measure of the extent of airways obstruction, and correlates surprisingly well with forced expiration time on spirometry, and with FEV1/VC (%). It allows an immediate assessment of the efficacy of bronchodilators. The original reference (BMJ 28 March 1964) is easily accessed online. Briefly the patient is instructed to “take a deep breath and blow it all out as quickly as possible”, while the clinician times the audible expiration to the nearest half second. Listening over the larynx to identify accurately the cessation of audible expiration is recommended (but optional). The mean value of three consistent measurements is required. A confident diagnosis (or exclusion) of airways obstruction can be made. As a rough guide, FETC <5.0 seconds is equivalent to an FEV1/VC of >60% (almost normal); and FETC >10.0 seconds indicates FEV1/VC of <40%. Some patients with severe COPD or emphysema can take >30-60 seconds to complete their expiration. Perhaps FETC, like blowing out candles, is now a mere historical artefact, and reflects
SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.
4 | DECEMBER 2018
Dr Tim Welborn, Endocrinologist, Nedlands References on request
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COMMENT Dear Editor, Forced Expiratory Time has a long history, as noted by Prof Welborn. It is simple, requires no equipment and therefore is attractive as a tool for clinical use and in population studies. It perhaps is one of the best studied clinical signs in terms of defining its sensitivity and specificity for the detection of airflow obstruction. Researchers from McMaster (including David Sackett) in 2002, showed the presence of a prolonged FET (>9 sec) along with self-reported COPD and wheezing were the only three of many clinical features that were associated with COPD (3). Studies against the gold standard of spirometry demonstrated sensitivity/specificity ranging from 77.3%/70.2% (1) to 92%/43% (2) (if patients could do the test properly and a significant number could not). How it tracks over time is not clear. Do I use it as a respiratory physician? No. Spirometry is easily available and better for monitoring. Do I teach it? Yes (but with a proviso), because it is great getting students to understand what is happening in airflow obstruction and how the clinical relates to the physiology. PS: An addition to the instructions should be to blow out TILL ALL THE AIR is OUT, as the
focus is on emptying the lung, not trying to get the first bit out quickly, which of course is the ‘peak flow’ Dr Fiona Lake, Respiratory Physician, UWA References 1. Straus S et al on behalf of the CARE-COAD2 Group. Accuracy of History, Wheezing and Forced Expiratory Time in the diagnosis of Chronic Obstructive Pulmonary Disease. J Gen Int Med 2002;17:684-688. 2. Glover R, Cooper B, Lloyd J. Forced expiratory time (FET) as an indicator for airways obstruction. European Respiratory Journal 2014 44: 1819. 3. Kern D, Patel S. Auscultated Forced Expiratory Time as a Clinical and Epidemiologic Test of Airway Obstruction. Chest 1991;100:636-639.
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Careful with words Dear Editor, "No one wants an abnormal baby" was the ED's take home point on this article on P28 (November 2018). Really? No one? I'm sure it was just poor phrasing, but it seems a pretty horrible sentence to appear in a magazine intended for the caring profession. If I were a parent who had raised and loved a Down’s syndrome child, I would be pretty offended. It's not true. If it were true, there would be no need for the 'informed consent' and 'appropriate post-test counselling' that the writer advises, for every parent would immediately want termination of any abnormality. This is patently not the case. I would say the opposite in fact. We are mammals. On some level, we all want all our babies, normal or abnormal. That is the awful quandary that genetic testing may present. And alas the definition of 'abnormal'
continued on Page 6
I have often regretted my speech, never my silence Xenocrates (396-314 BC)
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Re: Articles (September edition) highlighting the importance of spirometry in general practice for the diagnosis of asthma and COPD, and assessing response to treatment. Also its usefulness in identifying misdiagnosis and avoiding unnecessary long-term treatment is also emphasised. An expert comments on the need for standardising the technique, and allowing sufficient time (20-30 minutes) and office space.
the general trends to move from formal ‘hands on’ clinical examination to more attractive (and income generating) modern technologies. But I would like to think that this simple screening test will still be helpful.
Major Partner: Clinipath Pathology
By Dr Kalani Kahapola Arachchige
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Management of Subclinical Hypothyroidism in Pregnancy Universal screening for thyroid dysfunction is not recommended (except in high risk women) – it aims to detect rare cases of overt hypothyroidism that require treatment. However, more common mildly elevated TSH levels, especially in early pregnancy, can cause uncertainty. Normal thyroid function is important in conception, pregnancy progression and foetal neuronal development. There are well-established recommendations for treatment of overt hypothyroidism. However, consensus is lacking on how to define or manage subclinical hypothyroidism (SCH). PRACTICE POINTS: TREATMENT OF SCH DETECTED DURING PREGNANCY • The definition and management of subclinical hypothyroidism in pregnancy are controversial. • For elevated TSH, treat according to recommendations above (see three bullet points). • For women treated with thyroxine during pregnancy, aim for TSH between 0.1- 2.5 mU/L. • TSH should be re-checked every six weeks after commencing levothyroxine, until 20 weeks gestation, and once in the 3rd trimester - to guide levothyroxine dose adjustment. • Levothyroxine can be ceased after delivery in all women except those: • contemplating a repeat pregnancy within 12 months of giving birth • attempting to conceive again with a history of unexplained spontaneous abortion • who had a TSH > 10 mU/L prior to commencing thyroxine therapy • who have strongly positive Anti-TPO antibodies
All women should be advised to have Free T4 and TSH tested six weeks post-partum.
Definition of SCH: What is the appropriate upper limit for TSH in pregnancy? Subclinical hypothyroidism (SCH) is a biochemical diagnosis - a raised TSH with normal fT4. Changing the definition of ‘a raised TSH’ has altered the prevalence of SCH. In the 2011 American Thyroid Association (ATA) guidelines, 2.5mU/L was suggested as the upper limit for TSH in the 1st trimester – this was too low resulting in over diagnosis of SCH, unnecessary treatment of pregnant women, and unwarranted anxiety amongst women and health care professionals. Reference range studies have generated inconsistent results, but a TSH cut-off of 4 mU/L is now regarded as more reasonable upper limit in the first trimester (except where a local trimester-specific TSH reference intervals are available). The use of an upper TSH limit of 4 mU/L or trimester specific reference intervals have been endorsed by the 2017 ATA guidelines. Several studies have shown adverse obstetric and foetal outcomes when maternal TSH is above 4 mU/L (but in randomised controlled trials to date, thyroxine treatment has not improved outcomes). Treatment of subclinical hypothyroidism in pregnancy guidelines are changing. Women with previously diagnosed hypothyroidism should have their thyroxine dose adjusted preconception to achieve a TSH in the lower part of the reference range (0.1-2.5 mU/L). When pregnancy is confirmed, women should increase their thyroxine dose by about 30%, which can be done by taking a double dose, 2 days per week. In women without previous hypothyroidism, a balanced approach to an elevated TSH during pregnancy is as follows: • If TSH is above 10 mU/L, free T4 and TPO Antibodies (Ab) should be measured on the same sample, and thyroxine treatment started immediately at a dose of approximately 100 ug/day. • If TSH is mildly elevated (4 to 10 mU/L), TSH should be confirmed on a second
About the Author Kalani is an Endocrinologist and Chemical Pathologist who completed her training in Perth and has special interests in female reproductive endocrinology. She also has an interest in adult general endocrinology, adrenal, pituitary, thyroid disorders, osteoporosis, and type 2 diabetes mellitus. Kalani maintains an endocrinology practice at the Keogh Institute and joined Clinipath Pathology in 2018 as Chemical Pathologist in the laboratory and sessional Endocrinologist at the WA Specialist Clinic.
sample together with free T4 and TPO Ab, and treatment instituted at a dose of 50 to 75 ug/day, provided TSH remains above 4 mU/L. • Women with borderline TSH of 2.5 to 4.0 mU/L do not require immediate treatment; measurement of TPO Ab levels may be appropriate, and thyroxine treatment can be considered if TPO Ab are positive (to prevent progression to mild hypothyroidism during pregnancy). These guidelines apply to low risk women with SCH detected incidentally during pregnancy. They do not necessarily apply to women treated with assisted reproduction technology or with adverse obstetric histories (for example multiple previous miscarriages). For these women, many authorities recommend thyroxine treatment of even borderline high TSH levels (although the evidence supporting this approach is weak). Dr Kahapola Arachchige would like to acknowledge the close assistance of Prof John Walsh (Endocrinologist) in preparing this article. References 1 2017 Guidelines of the American Thyroid Association for the diagnosis and management of Thyroid Disease during pregnancy and the postpartum. Thyroid 2017 Mar; 27(3):315-389. 2. Subclinical hypothyroidism in women planning conception and during pregnancy: who should be treated and how? S. Maraka et al J Endocr Soc 2018 Jun;2(6):533-546 3. Regulation of Maternal Thyroid during Pregnancy. Glinoer et al JCEM 1990; 71(2) : 276-287 4. Treatment of subclinical hypothyroidism or hypothyroxinemia in pregnancy. NEJM 2017;376(9):815-825
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LETTERS TO THE EDITOR continued from Page 4
Dr Peter Burke, GP, Nedlands ED. This letter makes some important points about our ED note. Not least is how we define ‘abnormal’ these days. We will be more careful next time!
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Assisted Dying Options Dear Editor, Self-administration of a lethal medication provided by a physician has been referred to as physician-assisted suicide (PAS). Some jurisdictions such as the State of Oregon permit PAS only. Other jurisdictions such as Holland permit PAS and intravenous injection. Support groups for assisted dying do not favour the word suicide as it is seen as stigmatising and inappropriate to a person who is already dying. The terminology currently adopted by governments in Australia is that of Voluntary Assisted Dying. The Victorian Voluntary Assisted Dying Act 2017 provides for lethal medication to end life in defined circumstances. However, it states that: “the person must administer the substance themselves, unless they are physically unable to do so, in which case the doctor may assist.” The WA Joint Select Committee on End of Life Choices has made recommendations of a similar kind. In both cases, there is no reference to the route of administration. Selection of self-administration as the required option broadly follows Oregon’s Death with Dignity Act (1997). It follows the notion that self-administration demonstrates patient autonomy and responsibility. Self-administration is often thought of as oral self-administration and contrasted with intravenous administration by a physician. However, this is a false dichotomy. Selfadministration can be intravenous selfadministration (see below) or oral selfadministration. In either case, it meets the same criterion – that of the patient exercising autonomy and responsibility. In both cases it is provision of the means. Oral self-administration relies on a single medication that is lethal because it is given in overdose. It involves swallowing a volume (50-100ml) of water into which is dissolved a large quantity of pentobarbitone (Nembutal). Painless loss of consciousness and death
6 | DECEMBER 2018
For the public the establishment of paramedic registration will improve safety by providing assurance that registration standards are met and maintained by those registered as paramedics.
It can have some technical difficulties with swallowing and some side effects, not noticeable to the patient, such as muscle twitching and gasping. In experienced hands it is reported to be reliably satisfactory, though time from ingestion to death can range from 15 minutes to several hours.
With the recent announcements of Participation Day being December 1, 2018, the day that it becomes National Law, St John has been working closely with the Department of Health, AHPRA and the board to accommodate the changes for paramedics to be registered and included in the National Scheme.
Intravenous self-administration requires a physician to place a cannula in a large vein and to attach it to a simple delivery system (detailed on request) that can be operated by the patient with minimal effort. Medication used to prime the device is most effectively and conveniently derived from agents used in anaesthetic practice. Such drugs are precisely targeted and effective within seconds or a few minutes. Dr Peter G. Beahan, in collaboration with Doctors for Assisted Dying Choice (WA) – Dr Alida Lancée, Prof Max Kamien, Dr Richard Lugg, Dr Roger Paterson, Dr Johan Rosman and Dr Ian Catto References on request
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Paramedics prepare for national registration Dear Editor, RE: Have you heard? Paramedic a protected species, October edition. Paramedics are an important part of the health system and national registration is a big change for the profession and one that St John Ambulance Western Australia fully supports and embraces. This is more than protecting the title Paramedic. Registering under the national scheme means all paramedics will meet national standards and are suitably trained and qualified. Six registration standards define the requirements all applicants need to meet to be registered which cover: • Continuing professional development • Criminal history • English language skills • Professional indemnity insurance arrangements • Recency of practice and • Grandparenting In the prehospital environment, registration will assist in strengthening accountability and providing transparency among health care practitioners and prescribed standards of education.
Ms Deborah Walley, Executive Manager Education Services, St John Ambulance ......................................................................
Inquiry led astray Dear Editor, The WA end-of-life choices inquiry was told and believed the outrageous claim that “closer to 30%” of patients die in pain, despite palliative care. The inquiry Chair, Ms Sanderson, spoke publicly at the WA Palliative Care Special Forum on August 28 and specifically referred to the expert opinion of Dr Brien Hennessy, Head of Anaesthetics at SCGH. There is not one palliative medicine specialist in Australia who would agree with Dr Hennessy’s opinion. The inquiry is condemned for not disclosing that Dr Hennessy is the brother of Ms Jill Hennessy, the Victorian Health Minister, who sponsored the Victorian Assisted Dying legislation. The inquiry has not been open and honest with the WA public. The first sign that the inquiry had been misinformed was apparent at the public hearings when Mr Robin Chappell MLC stated that they were of the understanding that nearly one-third of patients die in pain, despite palliative care. The Oopen letter to legislators from 101 palliative care professionals, stating that only 2% die in pain, was tabled to the inquiry. Clearly this was ignored along with the findings of the 2017 annual report of the Palliative Care Outcomes Collaboration (PCOC), which found that only 2% die in pain. The PCOC concluded that “Palliative care is highly effective”. Submissions to the inquiry opposed euthanasia 55.5% to 35%, with many expressing concern with the progressive liberalisation that occurs once euthanasia is legalised. Their concerns were summarily rejected, even though there is a draft Bill before the Dutch Parliament to allow euthanasia for healthy 70-year-olds “tired of living”!
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is ever-expanding, which should make doctors more and more cautious in our advice, including advice about doing genetic testing in the first place.
usually occur within 15-45 minutes. It has the advantage that the patient has complete control over timing leading to a reduction in anxiety and in many cases a complete abstinence from its use.
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Has the inquiry been living on another planet? With seven of the eight members supporting euthanasia, it is no surprise that the inquiry supported euthanasia. It is disturbing that decisions have been made with such gross misinformation about palliative care. The inquiry has found that there are major deficiencies in the service and provision of palliative care and its recommendations are commendable. This problem however is not solved by legalising euthanasia. Dr John Hayes, Physician, Woodlands ...................................................................... Dear Editor, RE: Comment on the Clinical Oncology Society of Australia position statement on exercise in cancer care (published online May 7, 2018: MJA 2018; 209 (4): 184-187. || doi: 10.5694/mja18.00199) The outdated “rest strategy” is now accepted as contraindicated for cancer patients and it is recommended that patients perform specific exercise regardless of cancer type, stage or even when undergoing difficult treatments. Unfortunately, the COSA position statement on exercise in cancer care has been extensively criticised both within Australia and internationally including an editorial in The Lancet Oncology1 raising numerous serious concerns. The recommendation that “exercise to be embedded as part of standard practice in cancer care” is unrealistic and not feasible in the Australian health system. The authors’ recommendation that cancer patients aim for 150 minutes aerobic and two or more resistance training sessions per week were originally proposed some 10 years ago2 and are identical to that
recommended internationally for all healthy older adults. The field of exercise oncology has progressed substantially since this time and it is now evident that exercise prescription must be highly tailored to individual patient needs and access, and address morbidity and mortality risk on a strict priority basis. For many patients with cancer the COSA recommendation is unachievable, contraindicated and could place them at risk. Further, the authors state that best practice cancer care should include referral to an exercise professional, however facilities, clinicians, pathways and financial support for this are very limited in Australia. Exercise medicine in the cancer setting has been demonstrated to facilitate other therapies, reduce treatment side effects and potentially enhance survival. However, like any other cancer treatment it must be prioritised within overall patient management. Without accredited exercise physiologist support, cancer patients will not be able to access this important synergistic treatment appropriately. If patients follow the COSA recommendations, they risk experiencing sub-optimal and potentially harmful consequences as well as feelings of failure and disappointment at not being able to meet the targets. Prof Robert Newton, Associate Dean, Medical and Exercise Sciences, ECU ED. The COSA statement did not have any WA people in the authors’ list. References 1. Editorial. Exercise and cancer treatment: balancing patient needs. The Lancet Oncology, Volume 19, ISSUE 6, P715, June 01, 2018. Published:June, 2018DOI:https://doi.org/10.1016/ S1470-2045(18)30376-0 2. Hayes, S.C., R.R. Spence, D.A. Galvão and R.U. Newton. Australian Association for Exercise and Sport Science position stand: Optimising cancer outcomes through exercise. Journal of Science and Medicine in Sport, 12(4): 428-434
Wider car bays needed Dear Editor, The size of car parking bays in all shopping centres and car parks need to be addressed by local government and the health profession across the country. The width of a car parking bay was determined decades ago on the average family car – sedans, stations wagons panel vans. Today we have large 4x4 onroad/offroad vehicles which can be 300mm-400mm wider parking in these small bays. For other drivers and passengers trying to enter or exit their car that’s parked next to one of these vehicles it means having to twist and turn to get into their seat because their car door cannot be opened wide enough. For the older person this, over time, can cause serious problems with back, hips, knees and ankles requiring medical attention. Councils need to widen parking bays by one metre for the sake of our health. G. Powell, Perth ED: This correspondent is not a doctor but he/she has an interesting point.
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Correction On P13 November edition, we published an error that indicated that the drug available for schizophrenia was lorazepam (AtivanTM), when this is used for agitation. The correct antipsychotic is olanzapine (ZyprexaTM). Neither are available on the PBS. Olanzapine is available if the patient has a specific diagnosis of schizophrenia, having been made by a specialist geriatrician or psychiatrist. We thank Dr Carthew, the interviewee, for bringing this to our attention.
CURIOUS CONVERSATIONS One thing general surgeon Dr David Oliver doesn’t like doing is spinning in the rain. Luckily for him, he’s in the right job in the right place.
One of my best moments in medicine was... a dead heat between my first unsupervised appendectomy and, much more recently, diagnosing unexpected ovarian cancer in a colleague's mother who’d been sent to me with an inguinal hernia.
If I hadn't done medicine my second career choice would've been... I was always fascinated with flying, so maybe a pilot? Although given how easily I get dizzy with spinning motions I think I made the right choice.
If I could take a year off I would... learn to play the saxophone. I already know how to play the piano, rather ordinarily.
The book I'm reading now is... Empire: How Britain Made the Modern World. A fascinating read on the abolition of slavery, significant increases in military spending and a glimpse into colonial life in India. Fiction preference? Fantasy!
The best thing about living in Perth is... how seldom I actually use an umbrella in winter or get wet playing golf.
MEDICAL FORUM
DECEMBER 2018 | 7
HAVE YOU HEARD? The HBF big spend
Panel to develop dying laws In the letters pages this issue the news of the WA Government’s decision to bring a Bill on Voluntary Assisted Dying to the Parliament next year has sparked reactions from various sides of the debate. The government announced the make-up of an expert panel to guide the development of legislation. The panel is: Chair, Malcolm McCusker QC (former Governor of WA); Dr Penny Flett (Retired doctor and former CEO of Brightwater and chair of WA Aged Care Advisory Council); Dr Scott Blackwell (GP and palliative care expert and former president of the AMA); Dr Roger Hunt (academic and senior consultant, Central Adelaide Palliative Care); A/Prof Kirsten Auret (Rural Clinical School of WA and palliative care specialist); Dr Elissa
Albany steps up – and down Last month the Health Minister opened a new six-bed step up/step down service in Albany – the first of its kind in regional WA. The Albany service is operated by Neami National and Mr Cook said the Government would invest $28 million in capital funding over the next three years to progress the establishment of community mental health step up/step down services in Broome, Bunbury, Geraldton, Kalgoorlie and Karratha. It's known people recover from mental health issues when they can receive care, support and treatment within their own community, close to where they live and their family and friends.
Targeting youth mental health The WA Government this month also announced a 12-bed specialist inpatient care for youths aged 16-24 based at the Bentley Hospital site. The new unit will treat vulnerable young people experiencing acute mental health problems and is open 24/7 all week offering assessment and treatment. The new East Metropolitan Youth Unit (EMyU) will include three beds for secure care. "Seventy-five per cent of mental health problems start before the age of 25 so if we can get in early and help young people by providing appropriate care, we have an opportunity to dramatically improve their mental health outcomes,” the minister said.
Headwest merges It’s the sign of the times. Headwest, which was started by four families each with a child with an acquired brain injury
back in 1980, is merging with the national NFP organisation, Synapse, as demand stretched the local group’s resources to breaking. Headwest chair Nick Lonie told Medical Forum that the merger would ensure WA families would continue to be served with some expansion of services. For West Australians impacted by brain injury. Synapse Acting CEO Adam Schickerling said the organisation had staff and services in place to provide locals immediate support.
Air pollution and autism One Monash Uni study has linked exposure to air pollutants and increased autism among infant Chinese children. They found that Shanghai children, from birth to three years, had up to a 78% increased risk of developing autism spectrum disorder (ASD) from exposure to fine particles (PM2.5) from vehicle exhausts, industrial emissions and other sources of outdoor pollution. The study watched 124 ASD children along with 1240 unaffected children over nine years. Previous studies had made the prenatal-air-pollution and ASD connection in children; the authors surmised this was one environmental factor linked to genetic and other factors. In Australia, where there is no safe level of exposure, air pollution is calculated to cause about 3000 premature deaths a year.
Docs slammed for opioid stats The Australian Accident Helpline said that despite a ban on over-the-counter sales of codeine in Australia (after February 2018), the abuse of opiate-derived drugs was not slowing down, with most fatalities coming from easily obtained pharmaceutical products. The helpline media release said there had been an upsurge in enquiries from callers critical of physicians turning a blind eye to the plight of relatives, who had either died or become dysfunctional due to the dependency and abuse of pharmaceutical products. How they initially became addicted is not mentioned. “These physicians are little better than drug pushers operating under the cloak of professional respectability to make a fast buck out of vulnerable people. It's only a case of when, not if, a doctor in Australia gets hit with a
Win for Grumble Guts A UWA research project that uses acoustic sensing technology to detect gut disorders, and could replace the usual invasive colonoscopy method, has taken out a top honour in the state Innovator of the Year Awards. Irritable Bowel Syndrome affects 11% of the world’s population and the current method to diagnose it through a colonoscopy is time-consuming, invasive and costly. Nobel Laureate Barry Marshall and his team have developed an acoustic belt that listens, records and analyses gut noises linked to gut disorders for faster and more effective diagnosis. The award will allow the team to learn how to commercialise the invention as well as offer mentoring and advice on business development and finance.
8 | DECEMBER 2018
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HBF recently announced that changes to Extras Cover were coming on January 1, 2019. It’s mostly removal of some services (e.g. dental) and reduction in annual limits (e.g. physiotherapy). Last financial year HBF paid $249m to members for dental treatment (its optical bill came in at $53m). Cost was the single biggest factor preventing visits to the dentist. We asked HBF to comment on the Australian Dental Association President’s statement that HBF's withdrawal from the agreement would put “an end to preferred provider arrangements” and HBF sent these inpatient figures. Maybe they feel rising inpatient costs are eating into what they can pay out in Extras Cover? The spend on “Endocrine, Nutritional and Metabolic diseases” was $47,508,479.76 in FY2017, the highest increase of any category (19.89% increase on 2016). The biggest HBF payout was for “Musculoskeletal system and connective tissue” problems at $288,778,612.49 for 2017 (a 6.16% increase on the previous year. We presume this included various joint prostheses as orthopaedics was not separately listed). For the record, expenditure on “Pregnancy, Childbirth and Puerperium” for 2017 was $59,676,682.13 (6.74% increase on 2016) and on “Neoplastic disorders” for 2017 was $28,291,322.21 (6.16% increase).
Campbell (Geriatrician and President of Palliative Care WA); Dr Simon Towler (Clinical lead SMHS Futures program, Specialist Intensive Care); Kate George (senior lawyer specialising in human rights); Fiona Seaward (Commissioner of the Law Reform Commission of WA); Noreen Fynn (Consumer representative with experience in the carer, disability, aged care and mental health sectors); Samantha Jenkinson (Executive Director of peopleWithdisabilities (pWd) WA). The Premier announced that Labor MPs would be offered a conscience vote on the government-introduced Bill.
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Neurologist and stroke physician at SCGH, Clinical Professor of Neurology at UWA and Medical Director of the Perron Institute for neurological and translational science, Prof David Blacker, has won the 2018 Award for Excellence in Stroke Care Delivery. Dr Joanne Flynn has retired from the Medical Board of Australia and Prof Anne Tonkin, from South Australia, is the new chair. Prof Con Michael continues to be WA’s representative on the national board.
Item 42652 processed between May 2018 – September 2018, by State Demographics figures show most people receiving this treatment are males (up to 3:1 more than females) and aged 15-35 years, Bottom image; Keratoconus can be diagnosed promptly by both either optometrists and ophthalmologists - the earlier the better. See www.keratoconus.org.au/
MBS Coverage of Keratoconus On May 1, the College of Ophthalmologists sent a press release saying the listing of Corneal Collagen Cross Linking (CCXL) on the Medicare Benefits Schedule (MBS) would deliver “hundreds of Australian patients easier access to a sight saving procedure”. CCXL is the only effective treatment for keratoconus (progressive thinning of the cornea). Conservative profiling puts the incidence of keratoconus at one in 2000 people, but new diagnostic techniques suggest 1 in 600. Keratoconus symptoms include blurred vision, short sightedness, light sensitivity, ghosting and halos around light sources (peaking aged 15-35 years of age). The CCXL procedure halts the progression of keratoconus. The cornea is soaked in a solution of Riboflavin and then exposed to ultraviolet light. This process increases the intermolecular bonds between collagen fibres, making the cornea more robust. The item number is 42652 and the Medicare rebate is $1020. CCXL is used in the treatment of estasia (a group of corneal diseases of which keratoconus is the most common). Anyone wishing to review statistics around a certain MBS item number can visit http://medicarestatistics. humanservices.gov.au/statistics/mbs_item.jsp
huge personal injury claim,” it said. There were 2177 drug-related deaths in Australia in 2016, with those at highest risk males aged 35-39, then females 45-49 years.
Big business of research The Association of Medical Research Institutes (AAMRI has 50 members with 19,000 employees) was involved with three consecutive media releases recently. The first on 8.5.18, soon after the federal budget, announced that the $2 billion set aside for the Medical Research Future Fund “secures Australia’s future as medical research leader.” It went on to outline the social, health, and economic benefits of researchers having access to these funds so they could innovate, become world leaders, and turn “new discoveries into the next generation of advanced patient treatments”. “Australian researchers are delivering excellent results,” said Prof
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Cunningham President of AAMRI and “ we need to be capitalising on our research and commercialisation successes.” The second media release came nearly two weeks later, announcing that “Medical research held back by inefficient funding system”, and saying research grants only cover part of the full cost of doing research as “for every $1 spent on research, a further 54 cents of funds are needed for these indirect costs” (government currently provides 23 cents). The short-fall of 31 cents for every dollar spent on research was needed for things like IT services, data analysis and storage, running business development units, building services and utilities. The third release, on October 16, showed how “medical research has significantly boosted our country’s welfare, economy and future potential.” It said that for every dollar invested in medical research, we gain a $3.90 return to the economy.
Former WA Chief Health Officer Prof Tarun Weeramanthri has won the Minister for Health award. He stepped down from his post earlier this year. He was instrumental in addressing water contamination issues to ensure the safe opening of the Perth Children's Hospital, and was the driving force behind many achievements in public health including the passing of the Public Health Act 2016. Prof Hugh Dawkins, Director of the Office of Population Health Genomics, Public and Aboriginal Health, will become HBF’s first Chief Health Adviser at the end of 2018. Chief Scientist Prof Peter Klinken will chair both the Lotterywest and Healthway boards, which already have some common directors. A new four-chair renal facility at the Mawarnkarra Health Service in Roebourne has opened. A new chair of child health, known as The Kerry M Stokes Chair of Child Health, will be established at Curtin University with the support of the Telethon Trust and the Telethon Kids Institute.
The Eyes Have It The Australian Government will list $80m in eye medications through the PBS. These include (since November 1) steroids for retinal vein occlusion (3300 patients per year), eyeball injections of Lucentis® for choroidal neovascularization beyond wet AMD (1200 patients a year). The Government subsides close to $10 billion worth of new medicines – one new PBS listing every day after recommendation by the independent Pharmaceutical Benefits Advisory Committee (PBAC).
Don’t PLAN on it According to a press release from another CPD provider, “Planning, Learning And Need (PLAN) is no longer compulsory for GPs. RACGP found PLAN to be highly unpopular among GPs!” It went on to say how people could keep their PLAN CPD points and replace with Category 1 programs.
DECEMBER 2018 | 9
INCISIONS
Self-care in the caring professions is the important first step to a fulfilling life and career, says former GP Dr Jenny Brockis. The well-known risk factors contributing to our mental distress include working long hours, working shifts, feeling isolated or unsupported, experiencing bullying, dealing with patients who are distressed, angry or aggressive, and the sense of being overwhelmed by the rapidly growing workload of those needing long-term health care to manage their multiple, chronic medical problems.
It was the whispered conversations in the waiting room that finally woke me up to the reality that I was dealing with something beyond my immediate control. “Is Dr Jenny all right?” “Does she have cancer?” My gaunt appearance, an 8kg drop on a 55kg frame, was hard to hide. I didn’t have cancer, but I did have something else.
The cost of presenteeism (turning up sick to work) costs the Australian economy around $34 billion a year. The human costs are far greater.
I had been struggling with stress for months and was physically and mentally exhausted. As the principal of a group medical practice with two small children and a husband away a lot on business, I didn’t know who to talk to or what to do about it. I couldn’t bear the thought of being judged a lesser person, or worse still deemed incompetent as a doctor.
Continuing to ignore the ‘bleeding obvious’ where the headlines report on the tragic death of a colleague or medical student due to suicide is simply unacceptable. Do we not care about the mental wellbeing of our own tribe? Are we in denial that it’s a major problem requiring urgent attention? Or is it that we’re just too caught up in our own bubble of busyness and stress?
It’s a ridiculous state of affairs that so many of us as health professionals, who love what we do, who care so deeply for others, and want to always be of service, fail so miserably in the self-care department.
Perhaps, to overcome our delusional state, we need to tattoo across our foreheads #Humantoo, because none of us are immune to the impact of severe, chronic stress.
The state of mental wellbeing in the health profession is looking decidedly peaky and it starts well before graduation. More worryingly still, the prevalence and severity of anxiety and depression in health care students is increasing.
We can all take individual and collective responsibility to ensure our workplace environment supports and nurtures everyone at work. ED: Dr Jenny Brockis works as a corporate wellness consultant specialising in brain health and lifestyle medicine.
See Page 52
The state of mental wellbeing in the health profession is looking decidedly peaky and it starts well before graduation. More worryingly still, the prevalence and severity of anxiety and depression in health care students is increasing.
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SPOTLIGHT
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ICAN Pedalling for Peace Retired WA medical officer Dr John Stace writes here about his peace ride to raise awareness of the dangers of nuclear weapons.
L
ast month, at the age of 74, I participated in the longest bike ride of my life. It started in Melbourne, traversed the hills of the Snowy region and ended at Parliament House in Canberra. It was a journey of 900km with a cumulative climb of 9000m and a similar descent.
I walked up the steep ascents at 5km/h while my younger colleagues pedalled past me and shouted encouragement. I cautiously rode down the descents, especially when on winding gravel roads. However, on one long straight steep hill I abandoned caution to the wind and flew down at 65km/h. My personal best! I took part in the Nobel Peace Ride to show my support for ICAN (International Campaign to Abolish Nuclear Weapons), which was awarded the 2017 Nobel Peace Prize for the reasons described in the following citation: "[ICAN] is receiving the award for its work to draw attention to the catastrophic humanitarian consequences of any use of nuclear weapons and for its groundbreaking efforts to achieve a treaty-based prohibition of such weapons. "We live in a world where the risk of nuclear weapons being used is greater
From left John Stace at the start of the peace ride; and on the road. than it has been for a long time. Some states are modernizing their nuclear arsenals, and there is a real danger that more countries will try to procure nuclear weapons, as exemplified by North Korea. Nuclear weapons pose a constant threat to humanity and all life on earth. Through binding international agreements, the international community has previously adopted prohibitions against land mines, cluster munitions and biological and chemical weapons. Nuclear weapons are even more destructive, but have not yet been made the object of a similar international legal prohibition. “ICAN has been the leading civil society actor in the endeavour to achieve a prohibition of nuclear weapons under international law. On 7 July 2017, 122 of the UN member states adopted the Treaty on the Prohibition of Nuclear Weapons.” Our little group of cyclists were carrying the Nobel Peace Prize medallion from Melbourne (where ICAN started some 10 years previously) to Canberra where we hope a decision will be made for Australia to endorse the Treaty.
Dr John Stace with Nobel prize
12 | DECEMBER 2018
I have 10 grandchildren and I want them to have long, happy and productive lives. I don’t want them to live in the shadow of ‘The Bomb’ because the risk of a nuclear
war is as close now as it was at the height of the Cold War between The West and the Soviet Union. This risk was clearly shown in January 2018 when the Bulletin of Atomic Scientists moved the hands of the Doomsday Clock to two minutes to midnight…the same as in 1954. If you want to donate to ICAN, do so via the ICAN website. www.icanw.org/au.
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Working to give health care access to the world’s most disadvantage has been the driving force behind A/Prof Deborah Lehmann’s long career. “I arrived in 1981 and was asked to do a pneumococcal vaccine trial and an evaluation of oral rehydration for diarrhoea and stayed in Tari until 1984 doing population–based studies, before taking up the position of head of the pneumonia research program at the PNG Institute of Medical Research (PNGIMR) in Goroka in the Eastern Highlands,” she said. “Pneumonia is the most common cause of death in children worldwide and by far the most common in PNG. Diarrhoea and malaria continue to be a problem and there are also health issues around climate change.”
A/Prof Deborah Lehmann with past Huli staff of the PNG Institute of Medical Research at a celebration of 40 years of pneumonia research in PNG in 2010. Photo courtesy of Lea-Ann Kirkham
D
eborah Lehmann AO learnt from an early age about different life opportunities. Whether her experiences of growing up in New York and Geneva as a daughter of a United Nations translator, or working from Nepal and PNG to the Goldfields of Western Australia and among disadvantaged in the Perth metropolitan area, the head of ear health at Telethon Kids Institute has a deep understanding how social determinants can brutally affect health outcomes.
For my 70th birthday we put on a concert at home. I haven’t had much time to practise but I’m planning on more concerts in retirement.”
It has formed the basis her four-decade career which has sought to alleviate that disadvantage through early detection and treatment of infectious disease and prevention by way of vaccination.
“I’m not sure I was very good at the science but I did want to help people. There are high rates of infectious diseases in Nepal and I began looking at its relationship to people’s nutrition.”
However, It may have been very different if Deborah had pursued her passion for music and her considerable talent as a harpsichordist. “I did my final music exams in Geneva and went off to London thinking there wasn’t much scope for harpsichordists in Geneva and planned to do medicine but continue playing and perhaps do general practice on the side,” she told Medical Forum. “Somehow, I moved on from music and focused on medicine. I think I took the easy option. There’s not much work around for a harpsichordist, though I still love to play.
14 | DECEMBER 2018
After graduation, Deborah went off to Nepal where she ended up staying 2½ years working on TB control. “It entailed walking around the hills and checking people and their sputum slides and training locals. I became very interested in infectious diseases so returned to the London School of Hygiene and Tropical Medicine to do a Masters,” she said.
“Then I was drawn to an advertisement for a job in PNG because I was unsure whether to stay in England. I dropped my application into a letterbox in Oxford and almost immediately returned to Nepal to a remote part of the country. It took so long for the message to get through, I learnt only several months later that I had scored an interview … and then the job.” Deborah was bound for Tari in the Southern Highlands of PNG, which has recently been in the news for a devastating earthquake and social problems related to mining.
“I met my partner, Michael Alpers, who was director of (PNGIMR) for 22 years. He has studied kuru, a very rare disease for more than 50 years. Meeting Michael gave me another reason for staying.” Help from the ground up “We looked at the burden of disease, causes, risk factors and evaluations of interventions, then made policy recommendations. We were very multidisciplinary and that as continued to the present day. I transferred these PNG teachings to my work here with Otitis Media (OM) in Aboriginal populations.” A meeting with Fiona Stanley precipitated Deborah’s and Michael’s move to Perth in 1998 when she was awarded a Healthway grant to study OM using similar designs as in PNG. “I started a cohort study in Kalgoorlie looking at risk factors for OM in Aboriginal and non-Aboriginal children including carriage of bacteria in the nose,” she said. “Aboriginal children have a high carriage rate and it can start within days of birth which put them at higher risk of both OM and pneumonia. We have also looked at the epidemiology of these diseases through data linkage.” “After the Kalgoorlie study we had a health promotion program for hand washing, avoiding smoke and regular ear checks. The implementation of the program has caught up recently with the involvement of WACHS, Bega Garnbirringu Aboriginal Health Services and Telethon Kids. Children’s ears are checked routinely when they come for immunisation.” Deborah says there is more awareness
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Help for Those in Greatest Need
CLOSE-UP of the dangers of runny ears now at the community level and more action at the national level.
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Political will “We currently have a Centre of Excellence with all the key players across Australia and the Minister Ken Wyatt is committed to addressing ear disease. We’ve had a roundtable and a road map has been laid out and we now need funding for research. Certainly, there is more money going into ear disease now,” she said. “Those things are positive but it’s still actually hard to assess. I am involved in the WA Ear Health Strategy and we have working groups looking at workforce development, health promotion and determining minimum data sets to evaluate programs. That’s quite tricky to do.” “The Pilbara and Kimberley both have their strategic plans but there are a lot of players in the field in WA, so coordination is difficult. But I think there is real impetus now and that is encouraging.” Deborah stressed the importance of community involvement in the design and implementation of health strategies. “There are certainly more ear surgeons going to communities but for sustainable progress you need buy-in from the communities. There is no point detecting disease unless there is a program behind it. Linked data suggests that there is more
surgery in the remote areas. There is also evidence that the most underprivileged are the most unlikely to get the ear surgery. We need to work on that.” Most recently, Deborah has been working in metropolitan areas where she says access is as bad if not worse than in regional areas. Disadvantage in the city “The urban ear health project is following children from birth and training Aboriginal health workers to examine children’s ears. They will soon be able to refer children through a new telehealth program. It’s a tricky business to diagnose and manage ear disease but it’s crucial for individuals and their families because chronic ear disease is damaging. Families need to be able to treat the disease.” Training the next generation of researchers is never far from Deborah’s thoughts. She has mentored a number of Indigenous students and students from PNG who are working on ear health and vaccine projects. In September, Wesfarmers Centre announced it would support a Deborah Lehmann Research Award in Paediatric Infectious Disease Research to support the training and development of early career researchers from the Western Pacific region. The announcement coincided with the 50th anniversary of PNG’s Institute of Medical Research, which had been
so seminal in developing Deborah’s own career. Deborah says she plans to step down from her position at Telethon Kids in April but adds that not many people are taking that seriously. While she may be stepping away from active research she intends to continue mentoring researchers both here and in PNG. Future postive She is excited about the work being developed by colleagues at TKI – a new study on OM’s impact on language development and, work on biofilm and probiotics and a rethinking of vaccine schedules at maternal and neonatal stages of development. “Technology and microbiology have dramatically changed so much in our understanding of bugs and the relationship between bugs. But on the other hand we have to acknowledge and deal with the social determinants. OM is a disease of poverty and we have to face that as well,” she said. “Sadly, one of the key barriers for Aboriginal people is racism, which is so entrenched. We have to improve opportunities for education, ensure appropriate food and housing in remote areas and involve people in improving their own lives.”
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DECEMBER 2018 | 15
FEATURE
St John Ambulance hopes that bringing non-life threatening urgent care into the community will be good for patients and for ED overcrowding
I
n July 2016, St John Ambulance acquired four medical sites and while the GP services were retained, St John set about establishing urgent care sites in Joondalup, Cockburn and Armadale.
The idea was to move into primary care to alleviate the ambulance ramping issues at metropolitan EDs, but they have since evolved to be much more. During the research phase it became apparent to St John that ramping was not so much the issue as the number of urgent but non-life-threatening problems that were ending up in ED because there was no other treatment option available. The idea of a walk-in service for these cases evolved and the seeds were sown for a new model of urgent care based in the community. The two larger St John Medical sites (Joondalup and Cockburn) are seeing about 7000 urgent care patients a month, with a growth rate of 40% year on year. Armadale is the most recent site to open and it is expected to show similar growth.
16 | SEPTEMBER 2018
Medical Forum did a tour of the urgent care centre at Joondalup and spoke to St John’s Urgent Care Medical Director Dr John O’Toole (pictured below) and Dr Tim Lipscombe St John Medical’s head of general practice about the reasons behind the group’s move into primary care. Serving the need “Research shows us that 430,000 people a year walk into a WA ED with a Category 4 (semi) or Category 5 (non-urgent) problem. These low acuity presentations account for more than 50% of all ED activity in WA. The mortality rate for this group is extremely low. They are not admitted in 85% of cases and less than 10% of this group are brought in by ambulance – the majority walk in,” John said. “So, you don’t need to reinvent the ambulance service but rather create a new service to care for that 430,000 who don’t necessarily need an ED. St John concluded that urgent care centres were an important piece of the puzzle to manage this cohort,” he said. The urgent care centres are resourced to manage:
• Musculoskeletal injuries such as sprains and broken bones (with x-ray, plastering and splinting facilities on site) • Wounds that may require stitches, glue or dressings • Acute but non-life-threatening infections such as tonsillitis, urinary infections, gastroenteritis, colds and flu etc. • Minor burns • Minor eye injuries “By-and-large, patients understand the concept of urgent care and this is increasingly the case as public awareness spreads, though we never turn any patients away. At the very least we have a duty of care to ensure that all patients who attend are safe to leave and we will only know this if we assess them,” John said. “We can rapidly identify any acutely unwell patients and expedite their transfer to the emergency department, which remains the best location for their care.” Urgent care elsewhere Before opening the three centres, St John studied the operations of urgent care centres in New Zealand and Ireland. “NZ has been doing urgent care for 30 years. We looked at Auckland, a city of
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Urgent Care in the Community
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1.6 million people, so slightly smaller than Perth, and it has 18 urgent care centres. In the beginning, they were viewed with frank contempt by GPs because it wasn’t clear what they were trying to do. After 10 years there was polite indifference. Now, they are a part of the fabric of the city’s healthcare,” John said.
appointment with their regular GP, we will advise them as such. Urgent care does not perform health assessments, management plans, preventative medicine, referrals to specialists (other than acute specialties such as plastics and orthopaedics). This is the remit of the GP and we are careful to reinforce this.”
“The reason it took so long for them to be accepted, I think, was because the system evolved organically without a clearly articulated purpose, in the early days. St John is explicit about what we’re doing here in Perth. We want to provide a service for patients with urgent but non-life threatening problems, and to get those patients back to the care of their regular GP as efficiently as possible. I think GPs will see the value of it.”
However, it can help community GPs keep control of their busy day.
“Depending on which centre, 40-50% is an injury and the rest is sudden, acute infection. So, we know it’s not just another GP service. Certainly, the people with injuries would have been in an ED if they hadn’t come here.”
Help for busy GPs
Medicare billings
“In modern urban general practice, it doesn’t make sense to set yourself up to see a lot of walk-in urgent fractures or lacerations because you also have a waiting room full of patients. Juggling those things can make a GP’s life untenable,” John said.
The service is billed to Medicare using standard time-based codes. Specific item codes are also used where extra services such as suturing are provided. However the urgent care centres do no use the controversial ‘urgent after-hours’ item numbers.
Tim Lipscombe (pictured left) said the model was making an impact.
“We’re set up here to deal with this stuff all day long from 8am to 10pm and we’re efficient at it.”
“In the past six months we have seen about 60,000 patients of which 5% have needed to be escalated to an ED – that’s 95% of patients whom we managed, resolved their problems, and sent home,” he said.
John said that patient activity was largely a predictable measure and “we staff prospectively according to the expected volume of patients”.
“St John analysis shows about 30% of patients attending an urgent care centre would have otherwise gone to an ED.” Back in Auckland, that city’s EDs actively refers people to urgent care with the triage nurse given the authority to refer to the most appropriate location. This decluttering EDs of non-urgent patients, according to research, makes EDs safer and more efficient, Tim said. Resources for purpose
“Based on more than two years’ experience and data, we expect that the average GP working in our service will comfortably see four patients an hour at a minimum. They will typically see more during busy periods. This ability to be decisive and efficient is a core skill of GPs.” John said average wait times from arrival to doctor assessment varied according to surges in activity but 30 minutes or less was the typical wait time. There were concerns expressed early in the planning stages, that community acute care centres would create a latent demand; that they would simply be “glorified GP after hours”.
John said the evidence showed the opposite – that only 2% of presentations could be categorised as routine general practice.
Growth is certainly on St John’s mind. A small GP service has opened in Cannington and in November St John began providing a GP service in Kambalda, signalling an interest to develop regional operations to fill voids in access. The hope of the Shire of Coolgardie and St John Medical was the development of an “integrated, coherent, quality primary health service”. For St John’s part, it said it would use telemedicine with a metropolitan-based GP pool to build capacity and each of these doctors would undertake an immersive experience in the Shire. “We think there is room for more St John centres and we think the model works really well and contributes to the primary health system. We can certainly do more,” Tim said.
By Jan Hallam
The Perth centres are staffed by GPs, nurse practitioners radiographers and nurses and equipped with treatment rooms, x-ray and access to specialist opinion from orthopaedic and plastic surgeons. “We employ more than 50 VR GPs. We recognise that GPs are highly trained in pragmatic clinical decision making which is ideal for urgent care. GPs see a large volume of patients over time and understand all the steps of their health care journey. This makes them efficient in the use of resources and time. Most will have worked in an ED or acute care environment at some point,” John said. However, while John espouses the strengths of GPs in the primary urgent care setting, he stresses it is not a replacement for a person’s own GP. “We want to facilitate a patient’s relationship with their GP, not interfere with it. If a patient is appropriate for urgent care, send them in and we will attempt to fix the problem, but we’ll them send back to you,” he said. “If a patient presents with a routine problem that would be better managed in an
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DECEMBER 2018 | 17
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NEWS & VIEWS
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Senior Docs in AHPRA’s Sights? Are we making it harder for retired doctors to contribute, and do they really want to? reasons, apart from retirement” for a medical practitioner to reduce their scope of practice and “even practitioners who have retired might want to continue to undertake activities covered by the definition of practice, such as writing prescriptions and referrals for themselves and their family”, things could not be black or white.
There are two ways doctors can retire legally according to the Medical Board and AHPRA. The first is to forgo registration altogether (and still keep the ‘doctor’ title). The second is to register with AHPRA as a nonpractising doctor, which means you can write repeat scripts and referrals for family and friends with AHPRA and the Medical Board still controlling what you do. You are in effect ‘parked’ ready to fulfil ‘recency of practice’ and ‘CPD requirements’ before becoming fully registered. In both instances, you are prevented from ‘practising medicine’, which means you cannot offer an opinion or intervene electively (in some states it is an offence to not offer assistance in emergencies under Good Samaritan legislation). Lack of step-down inhumane Mr Stephen Milgate, CEO of ASADA (Australian Senior Active Doctors Association), says the absence of any formal step-down in workload in the later stages of a doctor’s career is “unreal, inhumane and archaic”. By that he means limitations on what the doctors can do with limitations also on the Medical Board’s powers. We are not talking big numbers at any one time and, because people reaching retirement have other things on their mind, organising these doctors into a cohesive lobby group has been hard. WA has 10% of the national doctor workforce and for April 1-June 30, 2018, 208 doctors in WA were listed as non-practising (of 40,352 doctors nationally) with no numbers on those fully retired. There are only 1723 non-practising doctors aged over 55 years, nationally. Are senior doctors more dangerous? Should older doctors be considered impaired until proved otherwise? No, according to ASADA. “Australia’s senior doctors, if allowed to continue in limited practice, are an enormously valuable resource” and it points to terrorism or major catastrophies as circumstances in which these doctors would be a valuable resource. Age Discrimination Commissioner Susan Ryan had given the go ahead in 2015 if evidence showed older doctors were higher risk.
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“The Federal Council concluded the AMA could not continue to advocate for a registration category for retired medical practitioners solely on the basis that they would be writing prescriptions and referrals for themselves and their family outside of a formal doctor-patient relationship. Anyone involved in direct patient care, or acting in a capacity that would impact on safe patient care, and who wants to identify themselves as a medical practitioner, should hold full registration and meet full CPD requirements.” It must have been because AHPRA/ MBA are now targeting senior doctors. In November, 2017, it announced a new Professional Performance Framework (validation by another name) that included formal peer review and health check for all doctors aged 70 and three-yearly afterwards. Outcomes of these processes are not reported to the MBA unless there is a serious risk to patients. ASADA says “All doctors (as human beings) are at risk of impairment at any age. Current regulations allow AHPRA to have the health of any doctor assessed at any time. There is no need to keep adding more and more complexity. Authorities have all the laws they need and more to maintain public safety in this area.” Many doctors whether playing golf or at the beach, might be asked for an opinion on a melanoma. Do we allow doctors to respond? Under current guidelines they must not if they are not registered or are registered as a non-practising doctor. Still ready to give ASADA says it is important we make it easy for doctors reaching retirement to contribute something, if they wish, towards patient care. It also says while age brings an increased risk of cognitive decline, it is unwise to consider cognitive impairment simply as a matter of ageing. In 2015, the AMA discussed what to do with doctors heading for retirement. They decided that while there were “many
The same applied to medical practitioners in non-clinical practice roles generally e.g. teaching. Four years ago ASADA called on the Medical Board and AHPRA to provide plain English explanations for what Australia’s registered non-practising and nonregistered (retired) medical practitioners could and could not do in ‘emergency’. They wanted this in the light of the removal of previously held rights. Problems stem from AHPRA’s and the Medical Board’s definition of practice (see the website) which is broad. National Chair of the Medical Board Dr Joanna Flynn around the time of her retirement said: “There are doctors who are not performing well enough out there; complaints mechanisms are not fine-grained enough to pick up everyone who’s underperforming, and we’d rather pick people up before there’s a problem than too late. If [revalidation] doesn’t improve that, we will have failed,” she said. Is this a sledgehammer to crack a nut?
By Dr Rob McEvoy
ED: See http://www.asada.net.au/ https://www.medicalboard.gov.au/News/Statistics. aspx https://www.aihw.gov.au/
DECEMBER 2018 | 19
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genesiscare.com 20 | DECEMBER 2018
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Health Revalued After all the upheaval at the Child and Adolescent Health Services, focus is returning to who matters most – the patient, says Dr Michael Watson. I love writing at Christmas time because it’s an opportunity to tell a good news story! It is almost 18 months since I wrote about the illness afflicting Child and Adolescent Health Services (CAHS). Then I wrote about Bureaumania, a term first coined by French economist Jacques de Gourney. Arguably CAHS had been sliding down this road for the best part of two decades. The hallmark features of this organisational disease are management’s obsession with centralised decision making and its enforcement by coercion to obtain compliance and control. Obsession with rules-based policies which, when blindly followed, breach organisational values and blatant disregard of respect are typical.
This child had been severely traumatised by an event at school and the resultant PTSD has meant she has virtually not left her bedroom for two years despite the best efforts of her devoted parents. Child and Adolescent Mental Health Services (CAMHS) has a reputation among families (as evidenced by social media) of failing to deliver for children with Autism and their families. This is almost certainly due to bureaucratic policy barriers rather than the failing of individual CAMHS staff. None-the-less this child ended up being bounced from a regional CAMHS office back to PMH psychiatry and back to CAMHS, with no one able to help her because she did not fit the bureaucratic case management model.
We’ve seen how this leads to stagnation of innovation, disillusionment and feelings of helplessness and despair in staff and, ultimately, a deterioration of services for children and their families.
I recently road-tested the new CAHS values system when a 15-year-old child with a label of Autism was referred to Valued Voice, a public health advocacy enterprise I have established to help empower children and their families who suffer disadvantage to use their stories to effect systemic change.
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It was the empowerment provided by living these values (no doubt with support of the CEO, the Board and the DG) which allowed the CAMHS clinical triage coordinator and child psychiatrist to break the usual service paradigm that requires a child to come to the clinic.
These parents were incredibly grateful for the insights provided by this consultation. It gave them a way forward in a situation that seemed hopeless. Bureaucratic rules were broken while staff lived their organisational values and I am sure the CEO will now follow up and help CAMHS to rewrite their rules to better fit the values of the CAHS.
The most potent of those values is Respect (Empathy plus Compassion) which results in an organisation’s leadership moving from a desire to ‘rule’ to the desire to ‘serve’ children, their families and the staff who deliver services to them.
This is a redirection of focus from technical excellence to human excellence and they are empowering staff to cut through bureaucratic barriers.
The value of Respect (empathy plus compassion) was the key driver. However, equity (greater resources for greater need) and collaboration (crossing intersectoral barriers to work with the NFP sector and private clinicians) broke down the bureaucratic policy barriers.
A child psychiatrist visited the child at home which is an extremely rare event for children with developmental disability (but hopefully will not be in the future).
A survey of lived values was commissioned by the Director General of Health and followed up by other surveys by organisations such as the AMA WA and what was encouraged was a meaningful return to CAHS’s own organisational values!
It seems clear that the Board’s influence of placing values (particularly those of compassion, respect, equity and collaboration) at the forefront of the organisation’s current and future focus (I suspect the Chair has been instrumental in this). And they are starting to have an impact!
(via the Director General of Health) resulted in a prompt meeting and he was clearly interested in understanding the plight of this child and how his service might help. He was empathetic and thoroughly investigated the issue. He demonstrated a clear commitment to living his organisation’s values of respect, compassion, collaboration and equity.
This child and family were being supported by a simply amazing paediatrician in private practice who was able to innovate and to use telehealth to provide clinical services, and a compassionate local GP who was prepared to do a home visit. The clinical team had also engaged an excellent clinical psychologist and OT from a not-for-profit organisation that has expertise in developmental disability. Despite this, what was missing was the input of a child psychiatrist who could provide specialist psychiatric advice to the team on the management of this child’s PTSD. An approach by Valued Voice to the new CEO of CAHS, Dr Aresh Anwar,
It is the restoration of hope for this family (and also for this organisation) that is the real success story and clearly demonstrates the benefits of living organisational values. The Director General’s and the Minister’s commitment to the promotion of values in our health system is commendable and their idea of ‘whole of health’ surveys, which will regularly measure lived values of all of WA government health care organisations, should be supported. It is the values of empathy (understanding) and compassion (kindness) – i.e. Respect – that are the real drivers of success in health. By measuring these lived values (and these surveys can), we will see a return to a public ‘service’ culture and an end to the bureaucratic behaviours which are doing so much damage to our health system.
DECEMBER 2018 | 21
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22 | DECEMBER 2018
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Blockchain – the Estonian Example As data mushrooms, systems are being devised to make the most of vital information. Paediatric surgeon Dr Jill Orford explores blockchain for health. As Australia’s My Health Record rolls out, with inherent predictable teething problems, it is interesting to look at how other countries tackle the inevitable transition to paperless medical records. Estonia stands out and uses blockchain, technology widely touted as the new wave of digital disruption.
taxation, banking, insurance, education, voting, justice system, education and health care.
Blockchain is a decentralised database built across multiple IP addresses (nodes). It is a synchronised chronological ledger system with each block of information bundled, time-stamped and encrypted. The code (hash) that is produced is linked to the hash of the previous block and used as a base (seed) for building the next block of information.
Each person has a chip enabled card and a private password. One can decide to lock down a medical record and limit availability to nominated clinics or systems. Each time a person’s secure data is viewed online, that event is reported. An unauthorised look is a criminal offence.
In this way, the sequentially linked blocks of information cannot be altered without “breaking the chain”. Each block is copied across the nodes. Changing one block will corrupt all subsequent blocks and visible to all network participants.
The underlying principle is that everyone owns all their individual data. Apart from publicly available information, such as land and company ownership, other information remains private and controlled by the individual.
Blockchain uses a consensus algorithm and does not require a centralised authority (such as government departments or financial institutions) to certify validity and maintain security of records. Estonia has established interconnected blockchain networks to digitise multiple systems, including land ownership,
Data sits locally, for example at a clinic, and is shared to another location (hospital or clinic) when a request is initiated by the individual. Transfer of data occurs via X-Road, a government platform that connects servers with encrypted links.
continued on Page 37
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MEDICOLEGAL
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Are you a Flight Risk? Kate Reynolds, a lawyer from Avant, explains why getting a flight out of Australia may be complicated. It’s Christmas. You’re exhausted. You get on a plane, turn your phone off and relax. You then hear this announcement: “Ladies and gentleman, I apologise for the interruption, if we have a doctor on board, please identify yourself to one of our cabin crew”. Instantaneous mid-air anxiety. You’re already anticipating the problem of providing medical assistance in cramped conditions with limited equipment under the watchful eye of the other passengers. A fleeting thought crosses your mind as to your legal liability in the event of an adverse outcome. You are acutely aware that, having volunteered, you will owe a duty of care to this undiagnosed patient you have never met. According to unpublished in-flight emergency data obtained from Qantas Airways’ Department of Medical Services there are an average of 284 medical events per month. A retrospective study using a single airline over one year found the medical incidents to be 1 per 11,000 passengers.
when he lied and denied that he was a doctor in an emergency scenario. What care are you expected to give? The majority of doctors have received no formal training in relation to in-flight emergencies. The equipment available on planes varies but may include an AED, enhanced emergency medicine kit, reserve emergency medicine kit, a universal precautions kit and 24/7 on-ground medical assistance standby.
Doctors often ask about their responsibility if they act as ‘good Samaritans’ in these circumstances.
The care that you would be expected to provide takes into account the circumstances and your skills. Do not feel compelled to perform interventions which are beyond your clinical scope.
Do you have a duty to assist?
What if something goes wrong?
In Australia there is no common law requirement for doctors to provide assistance as a ‘Good Samaritan’ in an emergency. In 2014 the Supreme Court of Western Australia confirmed that there was no specific professional duty on a medical practitioner to provide medical treatment to someone who is not their patient in the circumstances of an accident. While there is no common law duty, NSW and NT both have legislation that applies in emergency situations and which respectively make it an offence to fail to assist without reasonable cause, or to callously fail to assist a person urgently in need. However, doctors do have a professional obligation to offer assistance in an emergency, taking into account their own safety, skills and the availability of other options. If you begin to assist, you are obliged to continue to provide assistance until your services are no longer required. In WA, there was a case where a doctor was found guilty of professional misconduct
24 | DECEMBER 2018
Firstly, most airlines have insurance policies that protect medical professionals when providing in-flight clinical assistance. Likewise, medical indemnity insurance often extends to ‘good Samaritan’ assistance worldwide, but you should check with your insurer to be certain. The Good Samaritan laws in Australia protect practitioners who offer their skills in good faith to aid a person in need and with no expectation of payment. If you do render assistance mid-air, • Inform the crew and the passenger about the extent (or limits) of your medical experience and qualifications. • Ask the crew if they have access to surface medical support and if they do, request that they immediately contact their dedicated health care support service. • If possible, obtain a history from the patient and their consent before initiating any examination or treatment. • Consider your wellbeing, in particular
the risk of cross-contamination. • If the patient speaks a different language, the airline’s surface health care support service may be able to provide a translator. Alternatively, perhaps a crew member or the patient’s family can help? • If the patient is unable to consent to treatment and there is no family member or ‘responsible person’ on board, you can proceed with treatment if you believe on reasonable grounds that the proposed treatment is in the patient’s best interests. • Document your assessment and interventions using the standard airline medical incident form, or if necessary a blank piece of paper. Always request a copy of the document for your own records. Further reading – https://www.avant.org.au/ news/20141219-what-is-your-legal-duty-as-a-goodsamaritan-on-a-plane/ ; https://www.doctorportal.com.au/ mjainsight/2017/39/what-is-my-duty-to-assist-inemergency/ ED. Case law is limited in this area so the doctor must ask who will be holding his/her hand in court. The doctor wants to know if an MDO will render assistance if things go wrong. Assistance gratefully received makes this a low-risk scenario for any insurer. First, doctors who are not registered or have limited registration should say so before intervening, along with their recent relevant experience. ‘Scope of practice’ for the purposes of an emergency scenario doesn’t necessarily cease when a doctor retires or partially retires. The doctor must ask him/ herself can they safely perform an intervention/ treatment? If a non-practising doctor renders assistance on a plane then as long as they are not outside their scope, the Good Samaritan law (the Civil Liability Act) will assist in protecting them. Should the doctor be caught up in litigation they will want to know if they indemnified under their policy. Check your policy against various scenarios. For example: Is good Samaritan coverage offered by the insurer? and is the ‘scope of practice’ defined retrospectively by the court or is it in the policy?
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2018 FEATURE Seasons greetings from WA Health Professionals
Medical Forum wishes all our readers and supporters a Merry Christmas and a Happy New Year.
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DECEMBER 2018 | 25
Let the light shine on your Christmas And she gave birth to her first born son... and laid him in a manger... as there was no room at the inn. Luke 2:7
To our doctors and all involved in the health care community, we wish you a Christmas filled with hope, peace and joy.
26 | DECEMBER 2018
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Christmas Greetings Feature
Highs of 2018 and Hopes for 2019 This year we’ve seen great progress in health research and innovation across Western Australia – from opening a new state-of-the-art children’s hospital to growing the use of telehealth services to our regional and remote patients. WA is now leading the world in this emerging area of health care delivery with over 30,000 telehealth consults so far this year. Like so many big success stories it stems from a simple idea, that’s been well executed by a dedicated, motivated and professional team. WA is fast becoming a hub for globally renowned health scientists. Strengthening support for research means we can provide better health outcomes for West Australians and create commercial opportunities that will deliver high value jobs, investment and a boost to the WA economy.
Christmas came early for me this year when we finally got to open the magnificent Perth Children’s Hospital (PCH). After so many challenges, the opening of PCH was a testament to the commitment, dedication and resilience of all staff involved. The hospital is a truly world class facility and will carry the legacy of Princess Margaret Hospital as a provider of high quality and safe services for thousands of Western Australian children and their families.
As Health Minister my Christmas wish is to see more growth in the exciting landscape of health research and innovation. For my part, in 2019 I pledge to work to improve the environment surrounding research and innovation to establish a culture that encourages, nurtures and supports new ways of delivering safe, efficient and effective healthcare. I’d like to invite everybody who works in the health to take the journey with us. We have a vision and a strategy to deliver an exciting and sustainable future.
While we now have many new hospital facilities, our focus in 2019 will be to concentrate on improving that balance between delivering more community services versus hospital care, such as telehealth, and embedding a more sustainable health system in WA.
A happy and healthy Christmas to you and your families
Director General of Health Dr David Russell Weisz
Health Minister Roger Cook
Merry Christmas & Best Wishes for a Happy, Healthy & Prosperous 2019. We thank you for your support this year and look forward to continue delivering high quality service to you and your patients in 2019.
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DECEMBER 2018 | 27
We wish all our referring doctors and our patients a happy and safe festive season. Thank you for your support this year and we look forward to working with you again in 2019.
Leaders in Medical Imaging
perthradclinic.com.au 28 | DECEMBER 2018
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Christmas Greetings Feature
Dr Mini Zachariah To all my referring doctors and colleagues, wishing you a Merry Christmas and a safe and Happy New Year. Thank you for your continued support and I look forward to working with you in 2019.
Dr Phil Daborn
Merry Christmas A special thank you to all my referring colleagues for your continued support from Dr Yovich throughout 2018. and the team that Wishing you & your families a joyful festive gives the greatest season, and all the very best for 2019. gift of all.
Warmest wishes Mini
For all appointments & enquiries:T: (08) 9422 5400 | E: info@pivet.com.au Visit www.pivet.com.au for more information
Mr Marek Garbowski
wski
MBBS FRACS (Vascular)
Vascular & Endovascular Surgeon
ar Surgeon
I would like to extend my warmest greetings of the season, best wishes and health for the coming year to all my referring doctors, their families and staff.
s and colleagues.
Thank you kindly for your outstanding continued support. I look forward to working with you in 2019 in mutually caring for the wellbeing of our patients.
Best of health to you2012. all anding and continued support throughout Marek Garbowski & Staff at Perth Vascular Clinic
e and wellbeing is of paramount importance
Perth Vascular Clinic: Suite 218, SJOG, 25 McCourt Street, SUBIACO
ou are provided with the professional yourphone: 9382 9100 All enquiries andassurance appointmentthat bookings a College recognised Vascular & Endovascular Surgeon who www.perthvascularclinic.com.au Australian & New Zealand SUBIACO Society for Vascular CARINE Surgery. JOONDALUP BUNBURY
king with you in 2013 in mutually caring for the wellbeing MEDICAL FORUM
DECEMBER 2018 | 29
Christmas Greetings Feature
The Prostate Clinic
Thank you for your wonderful support in our first year. We look forward to growing our partnership with you and your patients in 2019. Best wishes for a happy and healthy festive season! SAVE THE DATE: Saturday 16th March 2019 Interactive workshop (40 CPD points): Managing Prostate Cancer â&#x20AC;&#x201C; LUTS and Sexual Health in General Practice Register your interest by emailing info@theprostateclinic.com.au
30 | DECEMBER 2018
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Christmas Greetings Feature
Dr Arun and his team wish you a very Happy Holiday season and a peaceful and prosperous New Year. Thank you to all our referring GPs and specialist colleagues for your continued support in 2018 and look forward to providing Gynaecological services to your patients in 2019.
Fertility Specialists of WA and Fertility Specialists South wish all our colleagues and associates a Merry Christmas and a Happy New Year.
Rockingham Womenâ&#x20AC;&#x2122;s Health Centre
Thank you for your support throughout the year and we look forward to working with you again in 2019.
Baldivis Professional Centre Unit 1, 11 Minden Lane, Baldivis 6171 T 9550 0300 F 9592 9830 E reception.drarun@gmail.com www.doctorarun.com.au
The cardiologists, sleep & respiratory physicians and staff would like to wish you and your family
a safe, joyous festive season and a very happy new year
We look forward to continuing to care for your patients throughout 2019 Dr Stefan Buchholz Dr Randall Hendriks Dr Mark Ireland Dr Ben King
Dr Donald Latchem Dr Allison Morton Dr Mark Nidorf Dr Vince Paul
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Dr Peter Purnell Dr Pradyot Saklani Dr Nigel Sinclair Dr Isabel Tan
Dr Angus Thompson Dr Peter Thompson Dr Alan Whelan Dr Xiao-Fang Xu
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DECEMBER 2018 | 31
Like you, when the day comes to an end, we’re still on call
Issues pay no respect to working hours. You might be on the way home, but that doesn’t necessarily mean that your work is over. It’s the same for us. Our client service centre operates 24/7. It doesn’t matter what time of day or night it is. It doesn’t matter where you are. We’ll ensure that your call is handled by a highly trained team member and that local resources are mobilised and monitored to find a solution for you. Day in, day out. We’re here to help. Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.
Car loans | Commercial property | Credit cards | Equipment finance | Fit-out finance | Foreign exchange | Home loans | Personal loans | Practice purchase | Practice set-up | Savings accounts | SMSF | Transaction accounts | Term deposits | Vehicle finance The issuer of these products and services is BOQ Specialist – a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”).
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Christmas Greetings Feature
Professor John Yovich and the team at PIVET wish all our colleagues and friends a very happy festive season.
Were I a philosopher, I should write a philosophy
We thank you sincerely for your continued support and look forward to working together again in 2019.
of toys, showing that nothing else in life need to be taken seriously, and that Christmas Day in the company of
08 9422 5400 | www.pivet.com.au
children is one of the few occasions on which adults become entirely alive.
â&#x20AC;&#x201C; Robert Lynd
Seasons Greetings for 2018 from Perth Urology Clinic
From Shane, Jeff, Andrew, Ak, Trent, Matt and all the staff at Perth Urology Clinic.
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Christmas Greetings Feature
Merry Christmas and hoping this year concludes on a cheerful note and makes way for a fresh and bright New Year! Thank you for a great 2018! Cheers Jen & Jaz
One of the most glorious messes in the world is the mess created in the living room on Christmas day. Don’t clean it up too quickly.
– Andy Rooney
A warm thank you to all of our referrers and colleagues for your support in 2018. We wish you all a very merry Christmas and a very happy New Year. All the best over the holidays and we look forward to working with you in 2019 and beyond.
34 | DECEMBER 2018
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Christmas Greetings Feature
It was the beginning of the greatest Christmas ever. Little food. No presents. But there was a snowman in their basement.
May your holiday be blessed with warmth and the love of friends and family togetherness. Thank you for all the wonderful support during the past year.
â&#x20AC;&#x201C; Markus Zusak,
From the entire team of WBI, wishing you a merry Christmas and merrier holiday season!
The Book Thief
Freecall 1800 632 766 CliniC will be Closed on the 22nd of deCember 2018 and opens on the 2nd of January 2019
The team at Upper GI West would like to wish you all a very happy and safe festive season. We would like to thank our referring doctors, colleagues, clinical and administrative staff for your continued patronage and support over the last 12 months. We look forward to working with you all again in 2019. Wishing you and your loved ones a safe, wonderful Christmas and a Happy New Year! Kind regards, Krishna, Alan, Matt, Mo, Sanj and the team of Upper GI West
Mr Krishna Epari
Mr Alan Thomas
Assoc Prof Mo Ballal
Mr Sanjeeva Kariyawasam
Mr Matt Henderson
Suite 73-74 SJOG Wexford Medical Centre 3 Barry Marshall Parade Murdoch WA 6150 T (08) 6189 2500 F (08) 6189 2505 Healthlink uppergiw info@uppergiwest.com.au www.uppergiwest.com.au
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GUEST COLUMN
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Teachers Key to Longer Healthier Life What do Thomas Edison and Augustinian friar Gregor Johann Mendel have in common? Dr Bret Hart has the answers Edison suggested that “The doctor of the future will give no medicine, but will interest his patient in the care of the human frame, in diet and in the cause and prevention of disease.” This might seem fanciful but so were many of Edison’s inventions which became commonplace.
are, therefore, independent of confounding factors and disease processes.
an IMR of 8.1 and mothers with more than 16 years 4.2 per 1000 live births.
In the US, the Robert Wood Johnson Foundation explored the correlation between education and longer healthier lives (healthspan). They estimate that college graduates can expect to live five years longer than students who don’t
The foundation has devised a calculator (countyhealthcalculator.org) to show the impact of altering a State’s level of graduation on rates of diabetes, associated costs and age of death. This dramatically demonstrates outcomes doctors would find hard to emulate. But all these estimates relate to correlation not causation which would require an unethical trial over several decades to prove. This is where MR is invaluable and was used by Tillman & Vaucher and 15 others across mainly high income countries to clarify the nature of the association between education and coronary heart disease (CHD). The results published in last year’s BMJ, showed that a genetically determined increase of one standard deviation in length of education (3.6 years) was associated with a clinically important decrease in risk of CHD.
Meanwhile Mendel had sown the (pea) seed of a revolution currently unfolding to untangle causality and correlation. It’s called Mendelian Randomisation (MR) and may help establish that Edison’s prediction is not so farfetched. MR is akin to a “genetically randomised trial” by exploiting the fact that genotypes are randomly assigned at conception and
finish school. They also found an additional four years of schooling reduces the risk of diabetes by 1.3%, heart disease by 2.2%, obesity by 5% and smoking by 12% with the benefit crossing generations. Infant mortality rates (IMR) decrease in proportion to the number of years mothers spend in education. For example mothers with less than 11 years of education have
Teachers focus on the section of the population with the greatest potential for return on investment (ROI) so have greater ability to shift the curve than doctors who respond to demand from those who may be at higher risk of disease but are smaller in number than those at risk in the whole population. And the demographic shift is feeding a demand for healthcare interventions at the end of life when the ROI is least. The unsustainable health system could take a leaf out of the education system’s learned book. References available upon request.
continued from Page 23
Blockchain – the Estonian Example Advantages of this system are health care efficiency, security, safety and integration of a multitude of different digital systems.
Cited benefits are E-ambulance, where paramedics can access medical records and register a patient’s imminent arrival to the emergency department.
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People can link their multiple health providers. This enable alerts for risk of drug interaction, avoids duplication and reduces error. There are many other applications including data sharing for clinical trials, supply chain for drugs and prostheses, and workflow efficiency. Conversations around digital health technology invariably lead to privacy concerns. Efficiency, security and privacy are equally important for our medical
records. While no system is tamperproof, paper records, or opting out of electronic medical records, is not viable in an environment of exponential growth in data. Our future medical expertise will rely on accurate, coordinated up-to-date individualised medical information. References available upon request.
DECEMBER 2018 | 37
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What I want from a bone density report Dr Catie Thorne from Bunbury gives us the benefit of her experience over bone density reports. These are my thoughts on the bone mineral density (BMD) report after reading the ISCD Official Position Statement 2015, working in General Practice and at the Keogh Institute for Medical Research, and reading reports from different providers. Some providers issue the BMD report without the scan images. It is worthwhile having them to check quality control, especially if the scan reports a significant change that might change treatment. Inaccurate reports may trigger inappropriate decisions that can be costly and sometimes harmful to patients. A picture is worth a thousand words. It is very annoying trying to get scan images and it is difficult accessing images due to different reporting “portals” and privacy issues. The graphs help the patient understand the discussion of results. The same BMD machine should be used each time; a change should be reported, only if it is based on the precision error, and least significant change. A change of serial number or brand of machine may render a reported percentage change insignificant. Lumbar spine BMD should be measured using L1-L4, or a minimum of two vertebrae, and checking the same vertebrae are included in subsequent scans. Any artefact should be mentioned and excluded from analysis. Proper consistent positioning of the proximal femur is crucial for the accurate interpretation of femoral neck bone density and, in particular, for any change in hip bone density. It is not indicated to routinely perform 1/3 radius, as happens in some practices, unless the hip and lumbar spine are not valid, or if the patient’s weight precludes them lying on the densitometer bed. The diagnosis of osteoporosis or low bone density (osteopaenia) by the T-score is relevant to scans from post menopause or over 50 years, and should be made only
on the lumbar spine, femoral neck or total hip. The diagnosis should not be made on the T-score of an individual vertebra or Ward’s triangle. The Z-score (not the T-score) should be used in premenopausal women and those who are under 50 years of age. Statements like “has the bones of an 80-year-old” should never be made. The online risk calculators (Garvan and FRAX) are developed using the bone density of the femoral neck, not, as some providers do, by choosing the lowest bone density in the scan. To report risk, previous fragility fracture is
important. Bones of the hands and feet or the face are excluded. Some patients incorrectly say they are “minimal trauma facture” for the radiologist, thus erroneously influencing the fracture risk estimate. The ideal report recognises artefacts, takes into account the recorded history, identifies significant changes since the last scan and perhaps suggests further investigation (e.g. a low Z-score prompts for secondary causes of osteoporosis), and be open to a phone call to question the report. Author competing interests: nil relevant. Questions? Ask the editor.
Aged Care Commissioner Starts Her Watch The Federal Government has announced the appointment of the first aged care quality and safety Commissioner. Ms Janet Anderson will oversee establishment of the Commission, as it prepares to start intensified compliance monitoring from 1 January 2019.
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The new Commission will have a budget of almost $300 million over four years, employing dozens of additional senior compliance officers. Ms Anderson has vast health experience in Canberra and for the past two years has held the positions of Deputy Chief
Executive and acting Chief Executive of the Northern Territory Department of Health. The new Commission will immediately integrate and streamline the roles of the current Aged Care Complaints Commissioner and the Australian Aged Care Quality Agency.
DECEMBER 2018 | 39
CLINICAL UPDATE
By Dr Christopher Rynn, Travel Medicine Physician Emerging drug resistance and the altered habits of mosquitos make avoidance more important.
Increasingly, mosquito-borne diseases put Australian travellers at risk of exotic infections. Arboviruses such as dengue, yellow fever, chikungunya, zika, Japanese encephalitis and Ross River are re-emerging and expanding their geographical reach. Despite some inroads there are still 216 million cases of malaria annually. Protection of travellers from these diseases relies upon vaccines, anti-malarial prophylaxis, mosquito-control programs and/or personal preventive measures. Current vaccine options are few. A yellow fever vaccine has been available since 1938 but supply can be limited. Australia has a long-lasting vaccine for Japanese encephalitis but at $250-$300, it may be too costly for many travellers. A dengue fever vaccine, licensed overseas, is potentially hazardous to non-immune travellers. A malaria vaccine will be used in three African nations in 2019, but only for young children. Malaria prophylaxis is recommended for travellers at risk, and drugs have been in widespread use for decades. However, parasite resistance has occurred with all current drugs, and slow development of alternatives means even diligent travellers are at risk of acquiring resistant strains. Strategies for mosquito control have been implemented around the world, focussing on the local vector species for pathogens.
Africa has long-lasting insecticidal nets and indoor residual spraying of insecticides. Communities at risk of dengue have introduced inspections and destruction of mosquito breeding reservoirs. Breeding areas for mosquitoes can be sprayed with insecticide or biological agents. Recently in Townsville, Aedes mosquitoes infected with Wolbachia bacteria were released - this symbiotic bacterium reduces the feeding ability of the mature Aedes mosquitoes (the only ones capable of dengue virus transmission). In light of increasing diseases, better mosquito protection needs to be implemented, particularly personal preventive measures. If individuals take responsibility for avoiding bites and limiting mosquito breeding, the disease risk to
West Papuan village the community can be reduced. To take appropriate PPM, understanding the biting and breeding behaviour of mosquitoes is important, including recognising that mosquitoes are capable of altering their behaviour.
Anopheles. In Africa, the malaria vector An. gambiae, is a nocturnal species that prefers to live outdoors and enter buildings to bite, but is flexible. In a classical example of behavioural resistance, implementation of bed nets and indoor spraying has caused it to bite outdoors and earlier in the evenings, before its human blood source has gone to bed! A dominant American vector, An. albimanus, chooses to rest indoors and bite earlier in the evenings, from 1800hr to 2100hr, around the same time its victim is having a meal. Aedes. Found globally throughout the tropics, it is expanding into temperate regions, including USA and Europe. Their eggs are resistant to dessication, so they can tolerate dry periods. They can also tolerate the cold snow-melt of arctic areas. Ae. aegyptii and Ae. albopictus are efficient vectors of many arboviruses, including dengue, chikungunya, zika and yellow fever. Theyâ&#x20AC;&#x2122;ve adapted to rural and urban environments, can breed in small collections of freshwater, and bite in the daytime and early evening, preferentially outdoors. Culex. These mosquitoes breed in ground collections of water â&#x20AC;&#x201C; puddles, rice fields, plastic containers, blocked drains. Species like C. annulirostris and C.tritaeniorhynchus will breed in saltmarshes and brackish water. C. quinquefasciatus is associated with urbanisation, and bites at night. It can rest outdoors or indoors. They can transmit Japanese encephalitis, Ross River virus, Barmah Forest virus, and several equine encephalitis viruses.
Kokoda Track sign
40 | DECEMBER 2018
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Mosquito-borne diseases: targeting the vector
Apply insect repellent to all exposed skin. Effective insect repellents contain DEET, picaridin, PMD, OLE. Application timing depends on the mosquito vector, viz. daytime and early evening for Aedes, early evening until early morning for Anopheles, and early evening and throughout the night for Culex. Cover as much skin as possible with long sleeves and long trousers. Use loose-fitting clothes that are lightly coloured. Wear clothing that has been treated with an insecticide like permethrin. Minimise human odours that mosquitoes can detect and use to identify you as a food source, such as fragrances and perfumes, excessive carbon dioxide (heavy exercise), sweat (over-heating and exercise) and urine (latrines).
ACCOMMODATION PROTECTION; Sleep under an insecticide-treated bed net, ensuring it is taut and not resting against skin. Close doors and windows to prevent ingress of mosquitoes. Inspect rooms for mosquitoes: pay attention to the corners, under furniture and in bathrooms. Spray a fast-acting insecticide inside rooms and around eaves of buildings during peak times of mosquito breeding (during and following rain). Keep interiors uncomfortable for mosquitoes: air-conditioned rooms as cold as tolerable; and ceiling and floor fans on high speed. Spray long-lasting insecticide around external walls. Burn mosquito coils inside rooms.
Further Internet Reading 1. Centers for Disease Control and Prevention. Prevent Mosquito Bites. Atlanta, Georgia (USA): US Department of Health and Human Services; 2018 Mar [updated 2018 Mar 19]. Available from www.cdc.gov/features/ stopmosquitoes/index.html 2. WHO. Malaria. Entomology and vector control. Geneva (Switzerland): 2018 [cited 2018 Oct 25]. Available from www.who.int/malaria/areas/vector_control/en/ 3. Townsville City Council. Mosquitoes. Townsville, Queensland (Australia); 2018 [cited 2018 Oct 25]. Available from www.townsville.qld.gov.au/community-support/community-safety/mosquitoes
REDUCE MOSQUITO BREEDING; Empty water containers around the home at least once per week (the minimum time for Aedes eggs to mature). Remove rubbish that allows water to pool e.g. plastic containers, car tyres and tarpaulins. Attend to tropical plants that catch water e.g. tops of cut bamboo and the base of palm fronds – drill a hole so water can drain. Produce movement in water catchments to discourage mosquitoes from laying eggs around the water fringe e.g. install a fountain. Spray agents that are mosquito larvicidal in large breeding areas like lakes and swamps. Biological agents such as Bti are safe to mammals.
References available on request Author competing interests: nil relevant. Questions? Ask the editor.
New and improved online booking portal
B
BreastScreen WA first launched online booking in 2014 and was the first WA Health clinical service to allow clients to make their own bookings via a digital platform.
After some simple questions to confirm eligibility there is a follow up email or SMS confirmation. Women needing an interpreter and those with special requirements are still required to contact the call centre on 13 20 50 during business hours.
About a third of all bookings are being made online, with 50% of these from mobile devices. As technology continues to improve BreastScreen WA is keen to enhance the system to improve the overall client experience.
“All WA women aged 40 and above, with no breast symptoms, are eligible for a free mammogram and will be able to book their appointment online or by calling 13 20 50”, said BreastScreen WA’s Medical Director, Dr Liz Wylie.
The new system allows for a quick search for a convenient appointment time at any of the 11 metropolitan clinics, Bunbury or rural mobile units.
BreastScreen WA continues to support GPs and clients with service improvement innovations.
reastScreen WA has upgraded it’s successful online booking platform.
Women may book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50
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Mar ‘18
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PERSONAL PREVENTION;
DECEMBER 2018 | 41
GP Urology Masterclass 2019 Review essential principles . State of the art updates . Specialist Q&A
Prostate
Robotics
Kidney
Female Urology
Bladder
Andrology
Incontinence
Stones
Fertility
Multidisciplinary
This workshop has been accredited with the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) for continuing professional development points. Hosted by Perth Urology Clinic
Dr Dr Dr Dr Dr Dr
Trenton Barrett Matt Brown Ak Hamid Shane La Bianca Andrew Tan Jeff Thavaseelan
Event Details
Topics 1. Functional Urology
• Female Urology • Andrology • Stones • BPH
• Urological Surgeons • Physiotherapy • Exercise Physiology Interactive approach • Q&A after at each session
2. Urological Oncology
Westin Hotel East Perth 16th Feb 2019
• Prostate
Registrations at 8:00am for a 8:30am start Close 4pm followed by post conference drinks 4:00pm to 5:00pm
• Bladder
RSVP angela@perthurologyclinic.com.au
Speakers
• Kidney
• Mock MDT (multidisciplinary team meeting) ∘ Urology ∘ Medical Oncology ∘ Radiation Oncology Genesis Health Care ∘ Cyberknife 5D Clinics ∘ Radiology Perth Radiological Clinic
42 | DECEMBER 2018
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CLINICAL UPDATE
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Travel tips for the ‘hard-of-hearing’ By Bev Eintracht, Audiologist, Osborne Park Holidays can be stressful for people who suffer from hearing loss and/or tinnitus. These tips aim to make any holiday a pleasurable and stress-free experience. For starters, holidays can be used as a ‘lever’ for someone who needs hearing aids i.e. they make the holiday more enjoyable. For some, noisy main roads and crowded restaurants are not their friend. General Tips • Don’t forget extra batteries, wax filters and cleaning tools. • For accessories, such as a recharger or phone clip, don’t forget the chargers and adaptors if travelling overseas. • For the hard-of-hearing, print off all bookings and flight info, or save on your phone. Download the app from the airline that notifies changes to flights. • Going to a foreign country? Download a translator app with voice to text translation.
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• Being organised can reduce stress that worsens tinnitus. • Keep earplugs in your bag for those unexpected loud noise situations. Improve sleeping with tinnitus • Take a portable sound machine and pillow speakers to help to sleep/relax at night. • Maskers, such as BOSE noise masking ear plugs can also help with tinnitus, or stop you hearing a snoring partner, or a noisy party in the hotel next door. • Use lavender oil on your pillow to help you to relax Tips for the plane • Leave hearing aids on whilst flying. Tell security you have hearing aids - they may ask you to remove them when going through security checks. • If possible, sit near the front – it’s quieter. • Those with tinnitus can use entertainment on offer as a distraction. • Do mindfulness exercises to help to stay calm and relaxed.
• Noise reduction headphones make it easier to hear without needing to turn the volume up. • If you suffer from blocked ears, take a decongestant before you fly, and acquire EARPLANES - pressure reducing earplugs that regulate pressure changes (available at the airport). Tips for trains and busses • Trains and busses may have an audio loop system installed that connects directly to your telecoil in your hearing aid – make sure that your telecoil is activated in your hearing aid (if it has one) • Choose a train compartment with fewer people Going on an organised tour? • Tell the tour guide and if you have a mic linked to hearing aids; give it to the guide to use so their commentary isn’t missed.
continued on Page 45
DECEMBER 2018 | 43
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CLINICAL UPDATE
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Rabies vaccination - new regime By Dr Aidan Perse, Travel Medicine Physician, Fremantle and Nedlands Issues that need to be discussed with travellers to developing countries include food and water–borne diseases (e.g. Hep A and typhoid), mosquito–borne infections (dengue, zika Chikungunya, malaria, Japanese encephalitis, yellow fever) and airborne diseases such as flu and measles. And then there is rabies, a virus spread from bites or scratches of infected mammals. If not properly treated and rabies symptoms develop, the disease progresses swiftly and is virtually always fatal. Countries posing most risk to Australian travellers include India, Thailand and Bali. Tens of thousands of deaths occur in the developing world annually. Rabies is vaccine preventable, but traditionally the course has cost over $300 for the three doses in Australia and is given over a period of three to four weeks. High risk travellers include those working with animals (vets and wildlife volunteers), ecotourists, travellers to remote places (treatment difficult to find), long term or frequent travellers, and children, who are more likely to pat animals without alerting parents. For all these people rabies vaccination is recommended. At our clinic, post exposure rabies treatment is needed a couple of times a week - monkey bites from Ubud (Bali) are the commonest reason. Most require full post exposure rabies treatment, involving wound infiltration with 10 ml of human rabies immunoglobulin, and four to five IM vaccine doses over two to four weeks. Treatment is also uncomfortable for the patient as well as expensive and difficult to source. Travellers to rabies affected countries should always avoid close contact with either wild, stray or domestic animals; in particular dogs, cats, monkeys and bats. No tests diagnose rabies infection in humans before the onset of disease, so potential exposure
must always be treated. Ideally, we would vaccinate travellers more often but cost, and sometimes time, are barriers to greater uptake. New options Traditional pre-travel vaccination is three IM injections over 3 to 4 weeks before departure. If exposure occurs, two quick booster vaccine doses are given three days apart. Once vaccinated, the schedule is for life, provided booster doses are given after exposure. There is no need for immunoglobulin. Variations to this schedule have been endorsed by the WHO (Australia is yet to). A
KEY MESSAGES Rabies is a serious life-threatening risk for travellers to developing countries.
Rabies is present in most countries in the world. A new regime may boost uptake of vaccination. cheaper, shorter course of two intradermal doses of rabies vaccine, injected at separate body sites at the same time, and repeated one week later. This requires less time and is substantially cheaper, facilitating potentially wider uptake. Trials show 98–100% effectiveness. Check serology prior to departure, some two weeks after the final doses, to ensure effectiveness. To have enough time to confirm immunity, see travellers 6 to 8 weeks before departure. The vaccine must be given intradermally and subcutaneous administration (i.e. accidentally too deep) will render it ineffective. It is imperative that the nurse giving intradermal vaccinations is trained and experienced in the technique.
Cost and time have been barriers to vaccination. A new regime has the potential to increase vaccination uptake.
Author competing interests - nil relevant disclosures. Questions? Contact the editor.
continued from Page 43
Travel tips for the ‘hard-of-hearing’ Accommodation
Tips for carers
• Accessibility rooms are in some hotels they include special options for people with disabilities, including hearing loss. Enquire if your hotel has these on offer.
• Turn off aids at night to preserve battery life
• Ask hotel staff to turn on captions on the TV
• Keep half the spare batteries in your hand luggage
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• Check for signs of wax blockage and clean if necessary
• Use drying kit each night if in a humid climate ED. The author acknowledges the support of Ms Tennille Crooks, audiologist at Perth Hearing & Tinnitus Clinic in preparing the article. Author competing interests: No relevant disclosures. Questions? Contact the editor.
DECEMBER 2018 | 45
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The harms of SARMs By Dr Peter Burke, Clinical Fellow, Keogh Institute “Don’t ask your GP about steroids. They will know less than you do or they will just try to talk you out of it.” This was a recurrent theme in the SBS Insight programme earlier this year, entitled “Sizing Up Steroids.” It’s probably true. The committed male body builder will know more than you. He will have accessed online forums and commercial websites. There exists a Deep Pharma world of ‘deca’ and ‘tren’ and ‘anavar’ and ‘ostarine’. Drugs that are not TGA approved for this purpose. Drugs for veterinary use only, not trialled in humans. How are doctors meant to keep up with it?
And talk them out of it? Yes, indeed. That is what most of us will attempt to do, unless we have abandoned all hope. Charles Atlas, the male ‘body beautiful’ of the twentieth century, was 177cm and just 85 kg. He eschewed drugs and gyms. Nowadays he would be the ‘before’ shot, not the ‘after.’ Some competition body builders of his height reach 160kg. Such cases are a lost cause. Dialysis beckons. I am not so concerned here with older men who have used drugs for years and whose fate is sealed. I am concerned with younger men, who might escape that fate. We see a proliferation of websites fostering
CASE REPORT A 22-year-old male student presented with fatigue and lowered libido. Total testosterone was extremely low at 1.2, with LH of 1, indicating secondary hypogonadism. An undeclared drug was suspected. At the next visit he brought in two little dropper bottles which he had bought online for $500 for homeopathic steriods. One labelled ‘MYO’ and the other ‘GAIN.’ He had only been using them for two weeks. Happily, on cessation, his hypothalamic-pituitary-gonadal (HPG) axis fully recovered within two months. The drug was not a steroid but a SARM, a selective androgen receptor modulator, promoted online as a safe non-steroid alternative. But their capacity to suppress the HPG axis is profound. Gonadotrophin production turns off, so the testes will start to shrink. The
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Young men in WA are frying their HPG axes using drugs mailed from overseas and not controlled by Australia’s TGA. body dysmorphia in young men, and selling them steroids. Half-truths are artfully stitched together. They deliver next day, anywhere in Australia. They proclaim ‘zero risk.’ But that is a lie. See case report for the reality. Author competing interests: nil relevant disclosures. Questions? Contact the editor.
longer this suppression continues, the less reversible the effects. At the Keogh Institute we are seeing more cases of young men with adverse consequences from using anabolic steroids, and newer agents such as SARMs. Often the ingredients are unknowable. GPs and physicians may also see young men who have recently started such drugs, or plan to. In counselling them, one must compete with the alluring websites, which inform your patient that, when it comes to body-building drugs, doctors are mostly ignorant, old-fashioned and censorious. It is not easy for an ageing GP to compete. One’s own muscles might not quite ripple and gleam like those of the website’s well-oiled male model. But we must try to articulate the case against, for no one else will.
DECEMBER 2018 | 47
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CLINICAL UPDATE
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Female genital cosmetic procedures By Dr Angamuthu Arun, Gynaecologist, Waikiki Female genital cosmetic surgery (GCS) is no longer the exclusive domain of the rich and famous. Surgeries designed to help the more debilitating side effects of childbirth have been modified by an industry to convince women they're imperfect. Despite recent reviews suggesting a lack of scientific evidence, requests for GCS continue to rise, both in the public and private sectors. Patient choice, increased awareness, accessibility, affordability, and aggressive marketing have increased the demand for these procedures. What is genital cosmetic surgery? Labiaplasty (Labial Reduction Surgery) is the most established cosmetic genital procedure; trimming and over-sewing the edges is probably most widely practiced. The most common reasons women request this operation is because the labia are too large (seen in tight clothing, swimsuit or make sports uncomfortable e.g. cycling), aesthetically un-pleasing, or complaints of sexual problems. Labia are reduced by wedge or trim labiaplasty. Women with an active gynecological problem (e.g. infection) or unrealistic expectations should not have the surgery.
Female genital cosmetic surgery is fuelled by increased awareness of vulval appearance, heightened by a host of factors.
Vaginal tightening (vaginoplasty). Women undergo this to enhance the sexual experience for themselves and their partners. Childbirth and age can reduce vaginal tone and strength, reducing friction and sensation during sex for both partners. Some women also have trouble keeping tampons in place and may encounter air-like noises during intercourse.
theoretically also a woman's sexual pleasure (repeated after about every 3-4 months).
Perineoplasty. This procedure aims to restore malformed tissues of the perineal region e.g. tighten the area, remove excess of relaxed or folded skin, and strengthen the perineum. Quite often perineoplasty is done together with vaginal tightening.
Clitoral hood reduction. Reducing the hood of skin that surrounds the clitoris, exposing the glans (or head) of the clitoris, aimed at providing more stimulation, therefore, heightening a woman's sexual pleasure. Also known as ‘hoodectomy’.
Hymenoplasty. A reconstruction of the hymen predominantly performed for religious or cultural reasons, and is also promoted as 're-virgination' for women who want to give their partner the 'gift' of their virginity.
Note: Laser or radiofrequency vaginal rejuvenation may be offered to women with fibrosis or scarring of the vaginal mucosal wall as a result of episiotomy or tear following childbirth or previous vaginal surgery, without altering the appearance of the vulva or vagina externally.
Labia majora augmentation. This procedure seeks to plump up the outer lips by injecting them with fatty tissue taken from another part of the woman's body. Vulval lipoplasty. Seeks to make the mons pubis less prominent by liposuction of fat deposits. G-spot augmentation. Injection of a substance such as collagen into the G-spot in order to enhance its size and, therefore,
The risks and complications of GCS GCS carries all the associated risks of surgery and these particular risks: nerve damage and loss of sensation; labia asymmetry; permanent colour change; scalloping of the labia edge; tissue death along the wound; pain during sex; change in sexual arousal; dissatisfaction with the results; and damage to other genital areas.
Asthma study focuses on young children How to diagnose children with asthma when there is no standard test? That’s the question Dr Robert Lethbridge from Telethon Kids Institute is seeking to answer in his Metabolomic Asthma Profile study (MAP) currently underway.
this testing has been done. Their age is salient due to the difficulty in differentiating asthma from wheezing, especially given the specific tests necessary for diagnosis.”
It has had the clinician/researcher focusing on urine as the possible marker.
“Children just can’t do spirometry and lung function testing even at six or so, let alone younger.”
“We can work out differences in chemical composition of the urine from kids that we see with asthma verses kids that don’t have asthma or who never wheezed,” he said. Currently, there is no clinically viable methods to identify if a child under six has asthma, or is wheezing. Earlier studies have found differences between asthma and non-asthma but looked at adults and older children, so MAP is the first time young children (2-4 years old and 6-10 years) have been studied. “It’s probably the youngest cohort on which
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The accuracy of asthma diagnosis in children is problematic, Robert says.
“It’s a lot of educated guessing when it comes to deciding on what child will benefit from medication, and with asthma it’s mostly inhaled steroids. That means there is probably a group of kids who are on therapy without any real benefit and being unnecessarily exposed to medication with potential side effects.” “There might also be children experiencing wheezing who are not on medication and might genuinely benefit from it.”
doctors rely on self-report data from patients’ parents and medical history. “There’s not much more GPs can do and they do it amazingly, that is, take a good history, investigate family history and put all of these presentations and clinical findings together to come up with a picture about how this child’s respiratory health is. There is nothing fancier that you can really do,” Robert said. If this study can identify asthma in urine, it will lead to a paradigm shift in how GPs diagnose the condition. “Often by the time patients have hit a GP or hospital, they are actually better, or at least they are not in that flare-up, which makes things more difficult to diagnose. Hopefully a more objective test will be useful for making those calls.”
By James Knox
The potential of a diagnostic urine test for asthma diagnosis is significant. Currently,
DECEMBER 2018 | 49
LIFESTYLE
USA, Here We Come! Rediscovering the curiosity of childhood can make a whole batch of new memories.
H
aving experienced USA cities in the 1980s it was good to go back and see what impressed. The first thing is the people – these days many are overweight (they eat large meals and seem hooked on sweetness), and are confidently patriotic but don’t confront misfits in public (for fear of being blown away, I guess). US citizens are very much like Australians, but with such a big population with a ‘what’s next’ attitude, they seem more diverse. This is a story about a USA eastern seaboard holiday.
In Florida, you have Disneyworld, Universal Studios and the Kennedy Space Centre in close proximity.
Disney world is a world of fantasy for the young and young at heart. Characters are bought to life with huge puppets or everything rescaled to lifelike proportions to fit your imagination, down to the finest detail. So you can let your imagination take wings, whether waiting in line for a 3D simulated Avatar experience (well worth any wait) or bouncing off the many stories and parades. Animal Kingdom, Magic Kingdom, Hollywood Studies, and EPCOT (Experimental Prototype Community of Tomorrow) are the 4 themes – adults may be worn out before the children but what the heck, plan a full day at each and use the park’s fast track booking system to reduce the queuing which can be huge in peak season.
Things are much bigger at Kennedy Space Centre than you imagine, both in terms of the human effort that goes into NASA and the size of things. The way space station and moon mission exhibits are very interactive is just amazing. So is the rapid progression of technology since the Apollo missions.
Whether you grew up with Goofy, Snow White, the Muppets, Dr Seuss, Transformers, Harry Potter, Indiana Jones, Shrek etc. there will be a Disney or Universal Studios character that most adults and their kids can identify with. This is a great opportunity to revisit those childhood experiences and to get the kids immersed in their stuff. The North Americans are great at reliving childhood experiences, whatever your age or inkling,
Daphne Duck gives us a wave while Donald is befixed by the passing parade
The town square dancers entertain the onlooking crowd, on queue and on time
50 | DECEMBER 2018
Shrek talks to his fiancée over the little girls hat, which he would like to eat because it looks like a strawberry
The recognisable props for Avatar dwarf the people below
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LIFESTYLE
Many famous Disney characters appear during the lunchtime parade. and doing it with a capital ‘F’ for Fantasy. They do this by updating displays with new 3D and other interactive experiences which the younger generation often take for granted these days. If you get accommodation away from the
The older brother shouldn’t look so smug because the younger brother just saw the transformer move!
main drag and hire a car, the roads will take you where the GPS says. Plan to get at the venues early. Sure, there is the Aussie Disney World but this one is bigger and better. As a fully grown adult I was thrilled by the Blues Brothers street concert and admitted to getting the shirt wet in the
Rip Saw Falls water park amongst other things! There is so much to do and experience, everyone will have their own story. This is one for the whole family.
By Dr Rob McEvoy
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DECEMBER 2018 | 51
Why You Need to Self-Care Working beyond 40 hours a week has been shown to not only diminish productivity and performance, it takes us away from our families and friends. Doing something other than work stimulates creativity, happiness, makes us more interesting and more appealing as people. If this seems an impossible goal, start to work fewer hours each week? Be mindful Taking time out on a regular basis to simply be and think, serves as a checking-in process to ask the questions ‘Am I OK and on track?’, ‘What’s going well, or what isn’t?’ ‘What needs to stop or change?’
Dr Jenny Brockis offers some reasons why caring for yourself is good for you and patients and some practical tips to help achieve it. Looking after yourself has some very real benefits. For starters, it helps you to: • Retain that sense of purpose and joy, the why we became a doctor in the first place. • Enjoy being on the job – feeling more energised, confident and resilient to those curveballs we deal with on a daily basis. • Gives you better cognition and memory, more empathy, being easier to work with and making fewer mistakes. Our patients benefit too – feeling they’re heard, included and related to. Naturally inspiring others to make those behavioural changes to benefit their longterm health starts with you leading by example.
Renewable energy resources
Identify who is in your support team. Whether this is your partner, a trusted colleague or your GP (You do have a GP don’t you?), know who these people are and ask them to speak up if they notice things are not going so well for you.
Planning your work day includes scheduling time for fulfilling those basic physiological and psychological needs without the guilt. Starting with taking a proper lunch break, which includes eating real food and not eating ‘al desko’. Scheduling time for regular exercise, even if it’s just a walk around the block, to decrease stress, clear the mind and boost your mood enhancing hormones. Placing a high value on enough sleep. Our propensity for voluntary sleep restriction – justified as work or study doesn’t hold water when it comes to maintaining mental flexibility, emotional regulation and a positive outlook.
Schedule your own wellness program with your doctor that includes a physical, mental and cognitive check-up. This helps to normalise the event and reduce any associated stigma and practice relaxation techniques regularly.
Step away from the desk!
Stay real
We’re not designed for long-term focus, so take 5-10-minute breaks several times a day. They restore energy and provide time for the subconscious to start to work through the day’s events. This helps keep things in perspective and facilitates problem-solving and decision-making so you’re not kept up at night worrying about them.
If despite your best efforts, things are getting on top of you it’s time to acknowledge what’s happening and give yourself permission to speak up. It might feel uncomfortable, scary even, but we are human and as such we are all fallible, vulnerable and imperfect. It’s always OK to ask for help.
Build social cohesion Happiness at work doesn’t occur in isolation. This is a team effort where everyone looks out for each other, where to boost positivity. Employ random acts of kindness, be generous with your attention, be an active listener and always start with a smile.
Wine winner
RFDS’s Dr Diane Comley has won the Giant Steps doctors dozen and it came at a perfect time – just after her family celebrated her son’s wedding at Millbrook Estate. Diane says she’s still loving the patients and the work with RFDS after nearly a decade doctoring on the wing.
52 | DECEMBER 2018
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WINE REVIEW
Windows on to Quality Windows Estate is a family owned and operated vineyard and winery belonging to Chris and Joanne David situated on the border of the Yallingup and Wilyabrup sub-regions of Margaret River. Chris is both farmer and viticulturist/winemaker. He began his wine pursuit at the tender age of 19, planting vines in 1996 and making his own wines from 2006. He has 7ha under vine. Chris is trained in viticulture but is a self-taught winemaker and his amazing achievements typify 'the great Aussie spirit’. I could say more but I think their wines do the talking.
2016 Windows Margaret River Petit Lot Chardonnay Wow! The wine of this tasting. This Chardonnay exudes class. Delectable, refined, intense, elegant and fragrant. I have never used frangipani as an aroma descriptor before but it is certainly there with flavours of white peach and nectarine. Wonderful characters of cashew and a nuttiness from oak. Beautiful acid backbone gives power and purity, and long, clean, refreshing, lingering flavours. Compared to famous White Burgundies, this price is amazing value. (RRP $60) 2017 Windows Margaret River Estate Grown Semillon Sauvignon Blanc The inviting 'fresh cut grass' aromas signify Semillon dominance and typify Margaret River’s Semillon. Light-tomedium bodied; palate profile simple, linear and intense. Herbal characters, gooseberry and white peach. Racy, 'crunchy' acidity gives a clean finish. Enjoyable short-tomedium term. Good with seafood. (RRP $27) 2017 Windows Margaret River Petit Lot Fume Blanc The 'Fume' on the label implies oak treatment. Chris was inspired by the wines of Sancerre in France. The complexity of this wine reminds me more of Pouilly Fume (opposite bank of the Loire River to Sancerre) where the soils are more loamy and the wines more full bodied. Exhibits aromas of citrus, grass, complex nettle characters and a funky element from natural yeast fermentation. Palate shows lemon citrus, green skins, a touch of lanolin with flinty minerality, crisp acid and a
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By Dr Craig Drummond Master of Wine
clean finish. Shows strong wine making influence with fermentation on skins adding texture, and 11 months in three-year-old French oak and a year in the bottle before release giving it body and definition. (RRP $35) 2017 Windows Margaret River Estate Chardonnay A very 'Margaret River style' Chardonnay for which the region has become famous. Fruit driven with rich, ripe flavours and succulent textural mouth feel. Stone fruits, grapefruit, dominate the palate. A fine acid core and added creaminess from malolactic fermentation. It is difficult to find the oak in this wine, which if present is well integrated. Shows good balance and evolving complexity. (RRP $45) 2016 Windows Margaret River Basket Pressed Syrah Syrah is how most of the world know what Australians call Shiraz but Syrah is becoming a popular term for some local producers. Nose is restrained, with cinnamon, blackberry and a savoury edge. Palate is full bodied with gripping firm tannins, defined flavours of Satsuma plum and black cherry, some background spice and black pepper. Oak is not a dominant feature. It is a young wine that needs time to mellow but very pleasing and, with cellaring, will open up. (RRP $36) 2016 Windows Margaret River Basket Pressed Cabernet Sauvignon A well-crafted Margaret River Cabernet never disappoints and this wine certainly lives up to the region’s big reputation. The nose is restrained at first but then opens up in the glass. Black cherry initially, then comes the blackcurrant and cedary oak. Palate is elegant and refined; smooth and silky, linear, but with a 'bite' at the end palate perhaps from the addition of 3% Petit Verdot (often called 'the winemakers spice') prior to bottling. Dominant flavours of blackcurrant/cassis. The tannins are fine grained and drying, the acid, perfectly balanced, the quality French oak integral. A great wine for long-term cellaring. (RRP $45)
DECEMBER 2018 | 53
"A lovely thing about Christmas is that it's compulsory, like a thunderstorm, and we all go through it together."
REVISED CHRISTMAS DAYS Effective immediately, the following economising measures are being implemented in the "Twelve Days of Christmas" subsidiary: 1) The partridge will be retained, but the pear tree, which never produced the cash crop forecasted, will be replaced by a plastic hanging plant, providing considerable savings in maintenance 2) Two turtle doves represent a redundancy that is simply not cost effective. In addition, their romance during working hours could not be condoned. The positions are, therefore, eliminated
- Garrison Keillor
7) The seven swans-a-swimming is obviously a number chosen in better times. The function is primarily decorative. Mechanical swans are on order. The current swans will be retrained to learn some new strokes, thereby enhancing their outplacement
11) Eleven pipers piping and twelve drummers drumming is a simple case of the band getting too big. A substitution with a string quartet, a cutback on new music, and no uniforms, will produce savings which will drop right to the bottom line
3) The three French hens will remain intact. After all, everyone loves the French 4) The four calling birds will be replaced by an automated voice mail system, with a call waiting option. An analysis is underway to determine who the birds have been calling, how often and how long they talked. 5) The five golden rings have been put on hold by the Board of Directors. Maintaining a portfolio based on one commodity could have negative implications for institutional investors. Diversification into other precious metals, as well as a mix of T-Bills and high technology stocks, appear to be in order 6) The six geese-a-laying constitutes a luxury which can no longer be afforded. It has long been felt that the production rate of one egg per goose per day was an example of the general decline in productivity. Three geese will be let go, and an upgrading in the selection procedure by personnel will assure management that, from now on, every goose it gets will be a good one
10) Ten Lords-a-leaping is overkill. The high cost of Lords, plus the expense of international air travel, prompted the Compensation Committee to suggest replacing this group with ten out-of-work congressmen. While leaping ability may be somewhat sacrificed, the savings are significant as we expect an oversupply of unemployed congressmen this year
Overall we can expect a substantial reduction in assorted people, fowl, animals and related expenses. Though incomplete, studies indicate that stretching deliveries over twelve days is inefficient. If we can drop ship in one day, service levels will be improved. 8) As you know, the eight maids-a-milking concept has been under heavy scrutiny by the EEOC. A male/female balance in the workforce is being sought. The more militant maids consider this a dead-end job with no upward mobility. Automation of the process may permit the maids to try a-mending, a-mentoring or a-mulching 9) Nine ladies dancing has always been an odd number. This function will be phased out as these individuals grow older and can no longer do the steps
Regarding the lawsuit filed by the law society seeking expansion to include the legal profession ("thirteen lawyers-a-suing"), a decision is pending. Deeper cuts may be necessary in the future to remain competitive. Should that happen, the Board will request management to scrutinize the Snow White Division to see if seven dwarfs is the right number.
Spirit of Christmas
54 | DECEMBER 2018
Lovers of musical theatre and Carols by Candlelight will need no introduction to the voice of Marina Prior.
She brings some Christmas cheer to Perth for the first time on December 14 at the Astor Theatre in Mt Lawley.
She has starred in huge musical hits such as The Phantom of The Opera, Les Miserables, Cats, The Pirates of Penzance, West Side Story and Guys & Dolls among many others, and has been front and centre of the annual Carols by Candlelight in the Domain for nigh on a decade.
Joining her onstage is renowned pianist David Cameron to share carols such as Angels We Have Heard On High, Maryâ&#x20AC;&#x2122;s Boy Child and When A Child Is Born as well as some of her signature showstoppers.
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SOCIAL PULSE 2
1
1. Acting Bethesda CEO Deborah Bell and Melody Miles.
Worksafe Gong for Bethesda Curtin Acknowledges Alumni A global humanitarian, Indonesian-based innovators and an Indigenous psychologist are among those recognised at Curtin University’s 2018 Alumni Achievement Awards. Curtin Vice-Chancellor Professor Deborah Terry presented the Lifetime Achievement Award was presented to Dr Tracy Westerman – a Njamal woman from the Pilbara, who was the first Aboriginal person to complete a combined Master/PhD in Clinical Psychology, and who has dedicated the past two decades to to reducing the high rates of mental illness among Indigenous people. Centre for Humanitarian Leadership Founding Co-Director Associate Professor Phil Connors was awarded the Global Impact Award in recognition of his work that has assisted international communities affected by crises. Gloria Sutherland was recognised for her advocacy for equity in health services for those in the Kimberley. The Young Alumni Award was presented to medical journalist Melissa Davey and entrepreneurial pharmacist Travis Bailey, who established the South-West Hospital Pharmacy and Shenton Park pharmaceutical manufacturing facility PureIV.
Bethesda Health Care won the Best Workplace Safety and Health Management System at the 2018 Work Safety Awards, hosted by Department of Mines Industry Regulation and Safety as part of Safe Work Month. Acting Bethesda CEO Deborah Bell and Melody Miles, Manager Occupational Safety and Health attended the awards ceremony. Melody received the award on the hospital’s behalf from The Minister for Commerce and Industrial Relations Bill Johnston. This external recognition follows Bethesda retaining their WorkSafe Platinum status for a further two years. It was the third time it had received this award.
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DECEMBER 2018 | 55
COMPETITIONS
Enter Medical Forum's competitions! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link. Movie: The Front Runner Hugh Jackman stars as the charismatic politician Gary Hart who captures the imagination of young voters and was considered front runner for the 1988 Democratic presidential nomination. That was until his campaign was derailed by his extramarital relationship with Donna Rice. It’s based on the book All the Truth is Out by Matt Bai.
Movie: Storm Boy There are some classic Australian stories that deserve retelling and Colin Thiele’s Storm Boy is one of them. It was first published as a novel in 1977 and has since had an iconic film outing in 1976 with David Gulpilil as Fingerbone Bill and Greg Rowe as Storm Boy and of course Mr Percival the pelican. There has also been a stage adaptation. This 2018 rendering reimagines it. ‘Storm Boy’ has grown up to be Michael Kingley, a successful retired businessman and grandfather. When Kingley starts to see images from his past that he can’t explain, he is forced to remember his long-forgotten childhood, growing up on an isolated coastline with his father. He recounts to his grand-daughter the story of how, as a boy, he rescued and raised an extraordinary orphaned pelican, Mr Percival. Their remarkable adventures and very special bond had a profound effect on all their lives. It stars Geoffrey Rush, Jai Courtney, Trevor Jamieson, Morgana Davies and Finn Little as ‘Storm Boy’. While there have been some liberties it remains a timeless story of an unusual and unconditional friendship. In cinemas, January 17
Choral: Remembrance Day Concert – Dr David Storer
In cinemas, February 7
Music: Christmas With Marina Prior Star of stage and screen Marina Prior brings her Christmas special to the Astor Theatre with a mix of traditional Christmas classics and family favourites and showstoppers from her musical theatre life including Les Mis, Phantom and Cats. Marina is joined by pianist David Cameron. Astor Theatre, December 14, 7pm
Crown Theatre, January 2-12, MF performance January 2, 7pm
Keep on Moving Knees & Shoulders NIPT & Ultrasound; Psychosis; & Paget’s O C T O B E R 2 0 18
MAJOR PARTNER
Movie: Westwood: Punk, Icon, Activist – Dr Monica Keel, Dr Mair Tavasoli, Dr Claire Amanasco, Dr Jim Gherardi, Dr Dian H Hurun Movies: British Film Festival – Dr Daphne Tsoi, Dr Michael Leung, Mrs Sarah Longhorn, Dr Jenny Philip, Dr David Bucens
October 2018
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Movie: The Girl in the Spider’s Web – Dr Tanya Subramaniam, Dr Melanie Chen, Dr David Jameson, Dr Jenny Elson, Dr Julia Charkey-Papp, Dr Peter Louie, Dr James Flynn, Dr Simon Machlin,
56 | DECEMBER 2018
US Supreme Court Justice Ruth Bader Ginsburg has been something of a movie celebrity with a documentary on her life released earlier this year, now this feature film with Felicity Jones (The Theory of Everything) taking on the role of this feisty inspiring woman.
This pulsating and vibrant show celebrates the life of the late South African leader Nelson Mandela, who would have turned 100 in July this year. His fight against apartheid is interwoven with the story of a young activist who is arrested and thrown into jail. Powerful and intoxicating. LEARNING OUT BUSH
Music: Katie Noonan’s Elixir with Michael Leunig – Dr Marina Dunne Kids Theatre: Gruffalo’s Child – Dr Annlynn Kuok
Movie: On the Basis of Sex
Musical Theatre: Madiba – The Musical M E D I C A L F O R U M $ 12 . 5 0
Winners from October
In cinemas, January 24
"Wit is educated insolence." - Aristotle (384-322 B.C.)
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MUSICAL
Only Impossible Until Done
F
or 29-year-old South African performer Perci Moeketsi, taking on the role of Nelson Mandela in Madiba The Musical is a joy, but it is also a responsibility that carries some weight. The young actor was chosen from hundreds to lead the world’s first English speaking production of a show that originated in Paris. Ironically, it hasn’t been seen in South Africa, but Perci hopes that’s just a matter of time. The show had its world premiere in Melbourne in September and heads to Perth in the New Year (January 2-12). “This is such a dynamic show. It has light and dark shades, weighty songs matched with light-hearted songs, dance and, of course, the story of the man is just phenomenal,” he said. “I heard interviewer ask a producer why Jesus Christ Superstar was a hit and his answer was ‘well, it’s about Jesus and no one gets tired of telling it’. Madiba is about Nelson – the story a great human being.” “The closing line before the anthem is: ‘The sun shall never set on such a glorious occasion’. And that’s so true – this story will continue to be told and inspire. It touches everyone.” As the show plays on around the country, the mantle of this part is feeling lighter for
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Perci but he’s taken on Mandela’s saying ‘It is impossible until it is done’ to heart.
and they have been so ingenious and creative,” Perci said.
“I felt the pressure early on. I still feel a great responsibility but now, you know, when things come together, I have realised that the best way to say thank you is to do what you have been entrusted to do.”
“It hasn’t been seen in South Africa yet but I’m hoping that it will. I would feel very blessed if we could take this home, which is already feeling the buzz about this show.”
“The more I get into this character, the more I feel the spirit of the man inspiring me. He was a global phenomenon and to portray him in such a way, to be picked from god knows how many people, to come to Australia, it’s amazing.” “In my home language we have a saying “work is afraid of work”. There is a lot of work to do, but the only way to get rid of it is to do. The pressure is work but because I am working, I suddenly have the muscle to do the work and the work becomes less. The more I research the man, work with the cast, talk to producers and directors, the less scary and daunting the task becomes. The more the spirit of the man comes out but the ball can never be dropped.” Madiba began life as a French production and was adapted for English audiences by Dylan Hadida and Dennis Watkins with producer Neil Croker at the helm. “You would think a producer from South Africa would have been well placed to tell this story but sometimes it does take someone outside to capture the vision
This year Nelson Mandela would have celebrated his 100th birthday and Perci thinks that his legacy will live on forever regardless of politics “It is very important to remind ourselves of revolutionaries. Mandela inspired our constitution, our laws and our ideas. But art can keep that flame alive,” he said. “Humans are stupid. We tend to forget our history but that’s the beauty of history books, which in turn can be transformed into songs and dance. The arts have a responsibility to contribute to that revolutionary spirit which helped change the shape of the modern era.” “There should be even more dance after his passing. The essence of his ideas is still with us. Whatever form the future takes, he will be with us. If technology occupies us, he will be in that technology. His spirit will never die and he will always be a part of our future. This musical is a part of those things through theatre, song and dance.”
By Jan Hallam
DECEMBER 2018 | 57
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