Medical Forum WA Public Edn October 2019 by Medical Forum WA

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October 2019

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EDITORIAL Jan Hallam, Managing Editor

Doctors Play a Trump Negotiations around the seventh Community Pharmacy Agreement (CPA) have produced some dazzling moves by various groups, the best must be attributed to the AMA Federal Council. In a hard, low and perfectly flat backhand at the feet of the Pharmacy Guild, with absolutely no spin, the council resolved to develop a blueprint on drug dispensing models that would see GP ownership of pharmacies and dispensing of medications from general practice. The statement said this would offer patients “enhanced convenience, safety, and quality care in their access to medications.” The national AMA president, GP Dr Tony Bartone, said “incorporating pharmacy services into general practice, under the ownership of a medical practitioner, would improve patient care by allowing GPs to lead a team of co-located health professionals in providing multidisciplinary health care to patients at the local community level.” “Many general practices already provide co-located services with pathology collection centres, and in-house psychologists, physiotherapists, dietitians, and podiatrists. Adding pharmacy to the mix would have benefits for patients, pharmacists, and GPs.” It’s worth just sitting on that thought a moment, rolling it around, assessing its success in the revitalised propaganda trope of the ‘pub test’. There would be a number of GPs in WA who would be nodding their head vigorously about now. One GP who rang us recently said he had a rations kit bag packed and was ready for a protracted campaign. And the RACGP appears to be standing shoulder-to-shoulder with its AMA comrades.

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What needs to change to see this scenario unfold is a change of the ownership regulations in the new CPA. The current agreement insists on only pharmacists owning pharmacies. The charge is being led by the coalition group United General Practice Australia, of which Dr Bartone is Chair. While the RACGP is not a member of that group, its president, Dr Harry Nespolon, has been outspoken on the issue, saying the current pharmacy ownership regulations were anticompetitive. By allowing ownership beyond pharmacists, it would be good for the sector and for the community at large. Dr Bartone told a Melbourne radio station that this change would simply be Australia following world’s best practice and would help maintain continuity of care. So, it can be said with certainty, and perhaps with satisfaction in some quarters, that doctor rhetoric has moved beyond its initial bubble-blowing salvos of “if pharmacists want to practise medicine, they should get a medical degree” or “pharmacists should stick to their perfumes and probiotics”, to much harder ball. But with hard ball, the stakes get higher. GPs would say, and with some justification, that the Pharmacy Guild’s drift into medical practice has already changed the rules of engagement. However, the sticking point is the love affair both federal and state governments have with the simple solutions offered by community pharmacies. Hence the greenlight for the delivery of vaccination schedules and even patient consults in some areas. The Pharmacy Guild has been described in some media reports as one of the most powerful lobby groups in Australia. The former ACCC chair Prof Graeme Samuel is reported as saying the guild had engaged in “straight political blackmail” and “unashamed” lobbying in the past “to maintain an anticompetitive regime.” Docs will need to be on their mettle.

Journalist James Knox (08 9203 5599) james@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

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OCTOBER 2019 | 1

CONTENTS OCTOBER 2019

INSIDE 12 Registars – Flogging the Willing Horse? 16 IMGs and the Rural Workforce 22 Gambling’s New Generation 26 Life Without Breath

NEWS & VIEWS 1 Editorial: Doctors Play a Trump – Jan Hallam 4 Letters to the Editor:

8 9 21 31 43

AMA and Climate Change – Dr Kinglsey Faulkner Rainfall: How Different Is It? – Dr Colin Smyth Change Behaviour – Dr Colin Blair Health Service Delivery – Dr Mick Adams WA is Not Victoria – Drs Peter Beahan & Dr Richard Lugg Have You Heard? Beneath the Drapes Medical Forum Readership Survey 30 Years of Breast Screen Facing Off to Sleep Apnoea

LIFESTYLE 50 Travel: A Wild Beauty 52 Theatre: Fully Sikh 53 Wine Review: Howard Park – Dr Louis Papaelias 54 Music: WASO’s New World 55 Competitions 55 Wine Winner: Dr Ashley Irish medicalhub.com.au

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CONTENTS OCTOBER 2019 CLINICALS

41 This Foul Rheumatic Breed’ Dr John Quintner

43 The fabella – It’s role and Problems Prof Piers Yates

44 Managing Ankylosing Spondylitis Dr Ai Tran

47 Over treating Sports Injuries? Dr JP Canerio

44 Low FODMAP Diet Charlyn Ooi

45 Sports injuries in Female & Male Athletes Dr Carmel Goodman

49 EOS Imaging Dr Nicholas Wambeek

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15 What Makes a Better Doctor? Dr David Oldham

35 A Spoonful of Walking… Gael Myers

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37 GST Anomaly Hurts Vulnerable David Beard

39 Medevac: Clear Case for Doctors Dr Barri Phatarfod

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Mark Hands (Cardiologist), Stephan Millett (Ethicist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon)

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AMA and climate change Dear Editor, On 3 September 2019, to its great credit, the AMA formally recognised climate change as a health emergency. Their media release stated: “AMA has joined other health organisations around the world including the American Medical Association, the British Medical Association and Doctors for the Environment Australia in recognising climate change as a health emergency. “The Federal Council recognises climate change as a health emergency with clear scientific evidence indicating severe impacts for our patients and communities now and into the future.” Doctors for the Environment Australia (DEA) was founded by the late Prof Anthony McMichael of ANU and Prof David Shearman of Adelaide University and other colleagues in 2001. In 2002, DEA set the agenda on climate and health with its first position paper. It was well ahead of the first major Lancet Commission report of 2009. Since then it has made multiple submissions and published many position papers and fact sheets on various environmental hazards to health with climate change remaining the major threat. DEA assisted in the drafting of the first AMA Position Statement on Climate Change and Health in 2005 and has been involved in updates since then including their 2015 version. The scientific evidence has continued to expand but so has the urgency of dealing with increasing global carbon emissions causing global warming and the increased likelihood of severe weather events. These events have caused great devastation and loss of life overseas and Australia is not immune. The images of prolonged droughts, episodic floods, raging bushfires spreading across wide landscapes and over more months each year, heat waves resulting in silent deaths mainly among the most vulnerable, and

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4 | OCTOBER 2019

mental health challenges including suicide caused by these stresses, cannot be ignored. Unless there is a profound awakening of the leaders of our nation and others across the globe, and effective policies to rapidly reduce Australian and global emissions are introduced, these problems are confidently predicted to become worse, much worse.

The full article is found at http://www. technocracy.news/greenpeace-co-founderglobal-warming-is-a-complete-hoax-andscam/ Sure, there are changes taking place in our world, but are they significantly different to what has happened throughout history, especially since reliable records have only been kept for the last 200 years or so?

The medical profession is scientifically trained and highly respected. It is becoming better informed about the nexus between climate change and health and must use its influence to help drive policy change on behalf of the communities it serves.

Dr Colin Smyth, GP, Northam

Dr Kingsley Faulkner, Co-Chair, Doctors for the Environment Australia.

Re: WA Climate Health Inquiry, Dr Yin (September 2019 edition) is right to say that climate change is a health issue.

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How different is it? Dear Editor, I refer to the letter, Climate is a health issue (September, 2019) regarding the effects on climate change and health. Dr Yin states that “from heatwaves, increased frequency of bushfires, droughts and it impact on food production and the mental health of farmers, there will be profound and widespread local effects”. It was interesting to see a chart produced by the Bureau of Meteorology in January 2019 (http://www.bom.gov.au/climate/ history/rainfall/) It shows that over the last 119 years how rainfall has varied from year to year and despite what the climate change proponents say, recent rainfall levels have not varied any different to what has happened from time to time over the past 119 years. A recent interview (March 2019) with Greenpeace co-founder and former president of Greenpeace Canada Patrick Moore described the cynical and corrupt machinations fuelling the narrative of anthropocentric global warming and “climate change” in a Wednesday interview on SiriusXM’s Breitbart News Tonight with hosts Rebecca Mansour and Joel Pollak.

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Change behaviour Dear Editor,

However, a zero C02 emissions target for Australia will have zero measureable impact in 100 years and well within statistical variation and unable to be differentiated from random variation in the climate. [Danish author and President of the think tank, Copenhagen Consensus Center] Bjorn Lomborg has detailed a plan that suggests a more practical and beneficial approach to climate change is to focus on strategies to reduce the burden of population on the planet such as the education of women, contraception, clean water and adequate nutrition. These strategies would avoid leaving hundreds of millions of people in poverty. Dr Colin Blair, Obstetrician, Murdoch ....................................................................

Health service delivery Dear Editor, Following on from Dr Coffin’s letter (July 2019), in which she raises the issue of the length of time it has taken the medical profession to come to terms working with Aboriginal and Torres Strait Islander people. The establishment of the Aboriginal community controlled health sector and the development of the National

continued on Page 6

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LETTERS TO THE EDITOR

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continued from Page 4 Aboriginal Health Strategy has been vital in the negotiating and education process.

they feel comfortable, of not being judged, put down or racially vilified (Coffin), where the intervention is based on positive health care.

Presently there are about 140 local and regional Aboriginal Community Controlled Health Services (ACCHSs). They are primary health care services initiated, planned and managed by local Aboriginal communities, aiming to deliver high quality, holistic, and culturally appropriate health care.

A safe and culturally responsive environment is one that acknowledges, respects, and accommodates differences. Cross cultural strategies and training programs have slowly gained traction in the private and public healthcare domain. Each, in their own way, have attempted to create a better understanding and awareness of respecting and accommodating cultural difference and diversity.

In addition to ACCHS we have seen the development of the Australian Indigenous Doctors Association (AIDA), the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM), National Aboriginal and Torres Strait Islander Health Workers Association (NATSIHWA) and Indigenous Allied Health Association (IAHA).

Changes occur through strong strategic executive leadership across the health system. In particular, more needs to be done nationally to embed cultural safety and respect across all health services, and creating culturally safe and responsive healthcare for Aboriginal and Torres Strait Islander people requires a coordinated cross-sectoral approach to achieve this goal.

These groups provide a representative voice for Aboriginal communities in health-related issues. In doing so they assist in overcoming the barriers for Aboriginal and Torres Strait Islander people in accessing health care and adhering to recommended treatments as Thompson and Thackrah eluded to in their article Cultural Competence in Health Care (June 2019).

Dr Mick Adams, Australian Indigenous HealthInfoNet, ECU

These peak health organisations have increased the capability within the healthcare systems to deliver culturally safe and responsive health and wellbeing services for Aboriginal and Torres Strait Islander people. Further to Thompson and Thackrah, opportunities to work alongside Aboriginal and Torres Strait Islander people, who are committed to partnerships and willing to impart understanding of community knowledge, culture and sensitivities, is known to support change in these areas. For many Aboriginal and Torres Strait Islander people do not trust the medical profession (hospitals and private clinics). Aboriginal Community Controlled Health Services provide a practice where

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WA is not Victoria Dear Editor, Media coverage of the WA Voluntary Assisted Dying Bill must have reached its lowest level of doom and gloom in The Weekend Australian (August 31-September 1). A report quoting a Catholic Bishop who described VAD as “death creep” included reference to “expansion" and “slippage". But does it bear any resemblance to truth and reason? Firstly, the Victorian Voluntary Assisted Dying Act 2017 was never meant to be a benchmark. It was greeted with both praise and criticism. Other states have a right to make their own laws, and if they don’t copy them directly from the Victorian pages that is because they are, and deserve to be, independent. Comparisons will show differences, but they are not automatically better or worse. Take, for example, the Victorian prohibition on the doctor raising the subject of VAD with the patient. That should be seen as an unparalleled interference in the doctor-patient relationship. But, more than that, the MEP Final Report provides evidence of the low level of individual health literacy in up to 60% of Australians. Many of them need "permission" from their doctor to open up the subject of VAD. The MEP also documents the very strong opinion in the public consultations that there should be no such prohibition. Take, for example, the slight difference in the WA Bill with respect to the degree of favour given to oral self-administration. There are good reasons why intravenous administration may be a better option. That is not creep. And, so, it goes on. Why is a government permit better than surveillance by a VAD Board? What is wrong with timely disclosure of conscientious objection? Criticism is levelled at WA for not insisting that one of the two authorising doctors should be a specialist in the field of the patient’s illness. Yet, this is not the case in any jurisdiction in the world, including Victoria! In summary, other states are not changing the Victorian law. They are making their own law, guided by independent advisers. The processes do not warrant such a hostile response. Dr Peter Beahan and Dr Richard Lugg, Doctors for Assisted Dying Choice

www.healthnews.net.au/trial-offer T: (08) 9203 5599 E: info@healthnews.net.au

6 | OCTOBER 2019

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LETTERS TO THE EDITOR

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Modern day PSA screening

By Dr Linda Calabresi GP and Healthed Medical Editor

The concept of age-related PSA levels is actually out of date, says Brisbane urologic oncologist, Dr Ian Vela, at least when it comes to suspecting prostate cancer. Whereas in the past clinicians would be reassured by levels that remained in the age-related reference range, these days it is considered more important to note the trend of the PSA levels over time as well as the absolute value.

authoritative bodies including the RACGP, all men should be offered PSA testing every two years from the age of 50 through to age 69, and further investigation should be done if the total PSA is greater than 3.0 ng/mL, regardless of age.

While it is true that the PSA level does tend to increase with age, largely due to benign conditions such as BPH, a trend of increasing PSA levels over time can be evidence of prostate cancer even if levels remain in the reported age-related reference range, says Dr Vela, who will be speaking at the Healthed’s upcoming General Practice Education Day in Perth on 2 November.

In investigating such patients, checking the free to total PSA ratio can be very useful. A free to total ratio less than 15% is highly suspicious for malignancy, whereas ratios greater than 25% tend to suggest a benign cause for the elevated PSA level. In between is what Dr Vela calls the ‘grey zone’ where the result isn’t all that helpful.

According to our national PSA guidelines, endorsed by the majority of Australian

Also important in considering which patients to further investigate is family history. A man who has a first degree

relative who has had prostate cancer has double to triple the risk of developing the disease. Consequently, all male patients need to be asked about family history. Men who are found to have an acutely elevated PSA after previously having low PSA levels, that is a rapid PSA velocity, need to have an infective cause ruled out first, as this is the most likely cause. Current PSA guidelines can be found on the Cancer Council website at https://wiki.cancer.org.au/australia/ Guidelines:PSA_Testing. Further online and print resources can be at www.healthymale.org.au (formerly known as Andrology Australia).

Managing depression in the busy professional The cognitive dysfunction commonly associated with major depression is one of the condition’s most disabling symptoms, especially for the highperforming professional, says psychiatrist Dr Jon Paul Khoo. Impairment of cognitive function is the symptom most associated with an incapacity to work and it is well-accepted that the benefits of work go beyond the financial rewards. Work offers a person the rewards of constructive endeavour, provides routine and structure, informs their sense of identity, often enables social interaction and community connection and enhances physical, emotional and cognitive health. But for many patients, cognitive symptoms of depression such as an inability to concentrate, difficulty with problem-solving and decision-making, poor memory and

The

GENERAL

feeling overwhelmed mean their performance at work is severely compromised. “Cognitive symptoms of depression are the most common reason people can’t work,” said Dr Khoo, who will also be presenting at the upcoming Perth General Practice Education Day. Often the person will not recognise that depression is the cause of these symptoms. People in jobs where there is high demand but little control over the work environment, will often attribute the symptoms to stress or burnout, or blame the situation on management. And this can be a significant contributing factor. But unless the major depression is recognised and the patient develops insight into the nature of their condition, it is unlikely they will improve, said Dr Khoo. Once a patient has overcome the barriers of insight and stigma, and managed to access

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correct diagnosis and accept treatment, it is important that therapy addressed the cognitive dysfunction as a priority. Evidence shows aerobic exercise is of considerable benefit for improving this symptom. And while there are no studies that point to any particular medication being better than others, it has been shown that antidepressants that cause significant sedation or have anti-cholinergic sideeffects can cause a worsening of cognitive function. Therefore, mirtazapine and tricyclic antidepressants are best avoided. Hear more form Dr Ian Vela and Dr Jon Paul Khoo on these topics at the upcoming Perth General Practice Education Day seminar, which is being held at The Perth Convention & Exhibition Centre on 2 November. See below for details.

Coming soon to Perth: highly rated, one day seminar featuring leading experts from across Australia Register now at healthed.com.au

OCTOBER 2019 | 7

allergies, especially antibiotics. At the recent conference of the Australasian Society of Clinical Immunology and Allergy (ASCIA) in Perth, Dr Lucas reported that 90% of people who self-reported an allergy avoided taking certain antibiotics, which restricted prescription choices for doctors when treating infections and led to the emergence of super bugs. While the process of reporting and creating an antibiotic allergy label was important to protect patients from serious adverse reactions, if the reported reaction was not further investigated and confirmed, the label could be incorrect. “It is estimated less than 10% of adult and paediatric patients carrying an ‘antibiotic allergy’ label are truly at risk of a significant allergic or adverse reaction,” Dr Lucas said. “We also urgently need to increase resources to enable patients to seek specialist advice to allow for a medical assessment of their drug allergy status.”

Tatts all, folks Love them or hate them, tattoos might be a doctor’s best friend. Scientists in Germany have reportly developed three tattoo dyes that change colour based on the levels of certain health markers in the blood. One of the dyes responds to pH, and gradually changes between yellow and blue depending on whether the blood is more or less acidic. In a healthy scenario, the pH-measuring tattoo ink would always look dark green. Another dye reacts to changing glucose levels by changing from light green to dark green and could help people manage their diabetes. The third dye moves between shades of light blue based on the level of albumin in the blood, which is of particular interest to people who are at risk of liver failure or kidney failure. Don’t prescribe tatts to your patients just yet. The researchers are yet to determine if the colour changes are reversible. So far only the pH marker turns back to its original colour. And questions hang over people with different skin tones, the safety of the dyes and if they colourfast. The small stuff!

Killer asbestos Last month we began our exploration of the re-emergence of silicosis as an industrial hazard and we continue this month with an interview with a stonemason who contracted the disease during his 33 year career. Links are also being made to the asbestos campaign when mesothelioma raised its ugly head. Australians continue to bear the burden of asbestos-related disease. The AIHW released its latest report which showed that 699 people died in 2018 from mesothelioma. There were also 662 new diagnoses last year in people aged between 22 and 101 years.

Last orders on Daybreak The national Drug Research Institute (NDRI) based at Curtin University has just published an evaluation of the Daybreak digital app, which has been developed as an intervention to support high-risk drinking individuals looking to change their relationship with alcohol. The study, which was published in the Journal of Medical Internet Research, found that with three months consistent use it helped both “risky/ harmful” and “probably dependent” drinkers – the most complex cases to treat. The evaluation involved 793 Australian adults and found that the 70% of participants classed as “probably dependent” more than halved their alcohol consumption while using Daybreak, from 40.8 standard drinks a week to 20.1 standard drinks. Alcohol consumption among “risky/harmful” drinkers dropped from 22.9 standard drinks a week to 11.9 standard drinks, which is below NHMRC

8 | OCTOBER 2019

The fat gene switch

This is despite asbestos, in all its forms, being banned in Australia since 2004. “The ‘average’ Australian with mesothelioma was male, diagnosed at around 75 years of age, exposed to asbestos in occupational and non-occupational settings and lived for around 11 months after diagnosis,” the report said. WA had the highest standardised rate between 2015 and 2018 with 4.4 cases per 100,000 people.

Black hole of self-reporting In the September issue we spoke to immunologist and allergist Dr Michaela Lucas. Her particular interest is around drug

The WA Raine Study treasure trove is the backbone of a UK/Finland study which has found that the body mass index (BMI) in babies, children and adults is influenced by different genetic factors that change as we age. Researchers found that BMI in babies was influenced by a distinct set of genetic variations that played little role in determining weight in later life. However, some genetic variants associated with adult BMI started playing a role during childhood from around the age of four to seven years old, suggesting that the origins of obesity in adults might lie in this critical stage of childhood. Senior author Prof Marjo-Riitta Jarvelin, from Imperial College London, said the study showed that nearly 100 genetic variations, which increased a person’s risk of obesity in adulthood, seemed to start taking effect from around the age of four.

guidelines that recommend no more than 14 drinks a week. NDRI’s Dr Robert Tait said that those who stayed engaged with the Daybreak program showed remarkable reductions in their alcohol consumption. “While our evaluation only focused on a small group of people over three months, the reductions in alcohol consumption achieved indicate the potential for online interventions to help people with more entrenched alcohol problems, which is particularly significant given the wide potential reach of online interventions.” Since 2016, Daybreak has been available across the PHN network, and since 2018 it has been funded by the Federal Government with an initial $3m investment. More than 5000 app users remain active in the program each month. https://www.jmir.org/2019/9/e14967/J Med Internet Res 2019;21(8):e14967 doi:10.2196/14967

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“Environmental factors like the food we eat and our lifestyle have an increasing impact on obesity development as we age,” she said. “These external factors seem to unmask, gradually, the genetic contributors to obesity that we have from early life, programming development towards an unhealthy direction.”

Susan Hunt has been appointed CEO of both Lotterywest and Healthway on a five-year contract. Ms Hunt has been acting in both positions since January 2018. From 2004 to 2017, she led Perth Zoo, where she spearheaded the development of the first World Zoo Animal Welfare Strategy.

Needing clear air Former Curtin University professor Dr Linda Selvey, who is president of the Australasian Faculty of Public Health within the Royal Australasian College of Physicians, has joined the chorus urging the government to revise air pollution limits. She says air pollution contributes to asthma, heart disease, lung disease and cancer. “Australia’s air pollution limits haven’t changed in 21 years. Our current air pollution restrictions far exceed the recommendations set by the World Health Organisation, so we must take urgent action to protect our community,” she said. She pointed to data that suggested over 3000 premature deaths a year are caused by ambient air pollution in Australia. Nitrogen dioxide and sulphur dioxide are largely released from vehicle emissions and coalfired power generation respectively.

Cancer perceptions What role does fate play when it comes to the perceptions of 145,000 people diagnosed with cancer each year in Australia? Quite a lot it seems. Despite the multitude of warnings on the cancer-related dangers of smoking, sun exposure, poor diet, alcohol consumption and inadequate exercise going by research from the University of Newcastle and the Vietnam Cancer Institute, the message isn’t getting through. A study of Australian cancer patients identified ‘bad luck’ or fate as the third most commonly perceived cause of their cancer, behind age and family history. It compared the perceptions between 585 cancer patients in Australia and Vietnam, analysing differences across 25 possible beliefs about what may have caused their cancer. Almost half of the Australian cancer patients believed “getting older” was the main cause of their cancer, while most Vietnamese patients cited “poor diet” as the main contributing factor for their cancer. Overall, smoking was ranked fifth most likely cause and alcohol the ninth most likely cause.

ACCC hip and shoulder To add to the complex concoction that is Australian private health insurance, the ACCC is chasing down Medibank Private in the Federal Court for alleged false representations about benefits covered by its health insurance policies. And not for minor procedures but for joint replacement. The ACCC alleges that Medibank falsely represented to over 800 AHM members holding “lite” or “boost” policies, who were making claims or enquiries, that they were not entitled to cover for joint investigations

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Melanoma GP night The WA Kirkbride Melanoma Advisory Service (WAKMAS, formerly WAMAS), is holding its second annual GP education evening at the Harry Perkins Institute for Medical Research in November. The service’s director Dr Mark Hanikeri will give an overview of the service before a program of topics – from WAKMAS referral pathways to clinical topics such as advances in treatment of stage 3 melanoma, surgical management, and future developments for diagnosis and treatment. There will be plenty of time for questions. The evening will be held on Tuesday, November 12, 2019, commencing at 7pm concluding around 9pm. Entry is free. This sponsored event is usually over-subscribed and seats are limited so please save the date and confirm attendance early. or reconstruction procedures, when in fact they were. “As part of our case, we estimate about 60 members needlessly upgraded their policies so they could access the joint investigation and reconstruction procedures they were already entitled to under their existing, cheaper insurance policies,” the Commissioner Rod Sims said. “In some cases, it is alleged that members who upgraded their policies were also required to serve a further waiting period to access these procedures,” Mr Sims said. He said the alleged misrepresentations had serious consequences for those members requiring procedures including spinal surgery, pelvic surgery, hip surgery and knee reconstructions. “Some members were forced to delay surgery due to high out-of-pocket costs…and to seek alternative remedies to manage pain, when they were in fact entitled to insurance cover,” he said. Medibank self-reported this conduct to the ACCC and has begun compensating affected members.

Women stand up A new AIHW report that looks at the prevalence of and hospitalisations associated with endometriosis reveals that almost 7% of women aged 25-29 and 11% of women aged 40-44 have the condition. Researchers at the University of Queensland used data from the Australian Longitudinal Study on Women’s Health,

Dr Marcel Bonn-Miller, the clinical scientific director of Spectrum Therapeutics, the medical division of Canopy Growth Corporation, has been appointed to the board of the Perthbased AusCann as a Non-Executive Director. A research team led by the Perkins Institute’s Prof Nigel Laing has been awarded $9m from the state government research fund for work on identifying four – possibly five – new genetic diseases. Curtin University’s Prof Judith Finn from the School of Nursing Midwifery and Paramedicine has been awarded an NHMRC grant for her work on improving survival outcomes for the 25,000 Australians who have out-ofhospital cardiac arrest. A/Prof Gavin Pereira has been awarded $1.45m to continue his work on preterm births and stillbirths. Prof Peter Gething, from the Big Data Institute at the University of Oxford, will take up an appointment at Telethon Kids Institute as The Kerry M Stokes Chair of Child Health. UWA grinners from the latest NHMRC funding round include Telethon Kids Director Prof Jonathan Carapetis who was awarded $1.7m for his rheumatic heart disease research. Nobel Prize-winning researcher Prof Barry Marshall was awarded $276,863 for his Noisy Guts Project. Paediatrician and Telethon Kids research Dr Andre Schultz will receive $1.4 million for research into children with chronic wet cough. Prof Andrew Whitehouse, senior principal research fellow at Telethon Kids Institute, will receive $3.1 million to improve outcomes for children with autism.

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continued from Page 9 along with health service data, to estimate the prevalence of endometriosis in two groups of women — those born in 1973-78 (with data available up until age 40–44) and those born in 1989-95 (data available up until age 25-29). Around one in 15 (6.6%) women born in 1989-95 were diagnosed

with endometriosis by age 25-29 — a figure that is 1.7 times as high as that of women born in 1973-78 at the same age (4%). This increase may reflect increased awareness of endometriosis among women and doctors, leading to increased diagnosis and/or reporting of diagnosis among women born more recently. In 2016-17, there were about 34,000 endometriosisrelated hospitalisations, 95% of which

involved at least one procedure. The most common procedures included diagnostic hysteroscopy, and dilation and curettage. Endometriosis-related hospitalisations were more likely to be partly or fully funded by private health insurance than all hospitalisations for females (57% compared with 43%), and around twice as likely to be self-funded as all hospitalisations for females (7.9% compared with 3.6%).

Urgencies not emergencies The 18-month state-based GP Urgent Care pilot kicked off in September with 125 practices participating, which Health Minister Roger Cook says will give 70 postcodes access to urgent care with a local GP. In June, we reported the GP pushback to St John Ambulance’s federally funded urgent care centres. While there has been no announcement by either the federal government or St John Ambulance as to whether they were successful in securing the election commitment of $28 million, it hasn’t deterred the State Government, in collaboration with WAPHA (and the support of the RACGP and the AMA), to set the course for this more modestly priced pilot using the resources of private general practices. We’ve heard that Brecken Health will lead the charge in the Bunbury region, so the pilot is also hitting the regions. It is, of course, the state government’s desire to take pressure off emergency departments by having urgent

WA Premier Mark McGowan; MLA Simon Millman, GP Urgent Care participating GP Dr Mike Civil and Minister for Health Roger Cook care (simple fractures and wound care) delivered in the community. The pilot will be evaluated by UWA and Curtin academics. The government says that in 2017-18, 190,000 attendances to hospital EDs could have been treated by GPs. Participating GP practices in the state pilot will have access to pathology and radiology services and have fully equipped treatment rooms. GP Urgent Care appointments can be accessed between 8am to 8pm, seven days a week. These hours were determined

using records of ED presentations for these non-life-threatening conditions – most of which occur during the day. A sample of the day in the life of an Urgent Care GP could be seeing patients with gastrointestinal illnesses, musculoskeletal and orthopaedic injuries, ENT conditions, stings, rashes and wound infections and abrasions and minor lacerations. Appointments can be made online at http://gpurgentcare.com.au or by calling HealthDirect on 1800 022 222.

Be a breast cancer mythbuster

here is a lot of information on the internet and in the media that is simply false about breast cancer. These myths receive a lot of attention which can cause anxiety and harm for women. The following is a short list of myths about breast cancer women have asked BreastScreen WA.

FAKE NEWS

You can help dispel these myths! • Women need a thyroid shield / guard when having a mammogram False, because the X-ray beam is focussed at the breast and the scattered radiation dose is extremely low • Using antiperspirant deodorants causes breast cancer False • Stress causes breast cancer False

• A bump or knock to the breast causes breast cancer False • Breast compression during a mammogram spreads breast cancer False • Thermography detects early stage breast cancer False

Women may book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50

10 | OCTOBER 2019

Mar ‘18

More myths, visit: www.breastscreen.health.wa.gov.au/Breast-health/Myths

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Flogging the Willing Horse? Service registrars are being identified as the most vulnerable of hospital doctors and yet the problem is often overlooked until they burnout.

n November, the Doctors Health Advisory Service WA will convene the biennial Australasian Health Doctors’ Conference in Fremantle. It is its first international event since it became part of the national network of doctors' health services funded by the Medical Board of Australia late in 2016.

The priority of DHASWA has been to establish a register of doctors for doctors. As the literature attests, the first big hurdle for medical practitioners to look after their health is getting their own doctor. Its other focus is the theme of the conference – Creating Healthy Workplaces. This year’s AMA WA Hospital Health Check is a window into just how well the state-run health services are doing that. This year 750 doctors-in-training (DiTs) at the major tertiary teaching hospitals were surveyed on a wide range of criteria from morale and culture to rosters, bullying and accessibility of annual and parental leave. The 2017 and 2018 surveys were horrors, reflecting an erosion in confidence in the health service providers, particular those which oversaw PMH and SCGH, with FSH nipping at the heels. A new children’s hospital and new wellbeing initiatives (with RPH leading the way) seem to have turned the tide as evidenced in the 2019 survey. However, there is a long way to go. Morale among DiTs at SCGH is just 53% positive with KEMH peaking at 57%. Bullying seems highest at KEMH with 45% of DiTs reporting some form or other. When it comes to workplace culture, Charlies could muster only 54% approval. When you factor in unexpected overtime (SCGH hit the heights with an average of 12.3 hours a fortnight), expectations of less than 2½ weeks annual leave (1.8 weeks at FSH), and about a quarter of DiTs fearing job security if they asked for parental leave, it would suggest systemic issues are still causing anxiety. Medical Forum spoke to Dr Sarah Newman, secretary and assistant director

12 | OCTOBER 2019

of DHASWA and, since 2017, a GP in Lockridge. She is an energetic advocate for doctors’ health and wellbeing and has been acknowledged by both the RACGP and the AMA WA for her services to doctor welfare. We asked her specifically about the lot of service registrars, who have, anecdotally, been the group of doctors most disillusioned by being stuck in something of a no-man’s land between internship and traineeship. “These non-training registrars don’t really have any identifiable person who is looking out for them whereas most registrars with problems can consult their training mentors to help them sort out work issues,” she said. Sarah added that compounding this was the difficulty in determining how many people fell into this category. “Until recently we do not know how many service registrars there are in WA because we don’t count them yet they play an integral role in keeping our public health system afloat. This leaves them open to industrial manipulation with no one necessarily knowing or caring about it.” “The hospital, I don’t think, is the ideal organisation to be looking after their welfare because the needs of the hospital are often opposed to the needs of registrars. It is a tricky situation for registrars because even though they may not be on a training program, it could well be they are hoping to be, so they accept working hours outside of industrial contracts to be more visible to consultants.” “I have not been a service registrar myself but seeing it from the outside, you could feel very conflicted approaching a consultant to say, ‘hey, this workload is excessive, I can’t sustain this amount of on-call’. A registrar in training program

would feel a lot more confident to put their hand up if there were a problem.” Sarah said the first line of help for service registrars around working conditions would be the AMA but they do need to firstly want to speak up. Getting time off is one of the hardest issues of all. “Leave is an incredibly difficult issue in our hospitals and that is not just for service registrars, it’s all round. However, service registrars are probably going to be covering jobs of those who do get leave, the preference to which is mostly likely training registrars. The service registrars have no one fighting in their corner, so it’s a very easy position to be used and abused,” Sarah said. “Like everything in the sphere of doctor health and welfare, systemic industrial changes are required with health services having visible people whose job it is to look after staff’s wellbeing. Hospitals also need to be more aware how vulnerable the position of service registrar is to abuse and have it come under regulation that is overseen, perhaps by the Post-graduate Medical Council (PMC).” “The PMC oversees the education of interns and RMOs within the hospitals, and if they were to include service registrars in their remit, who may be doing all of the shift work and receive none of the professional development, it may shed more light on what’s happening.” “It would be a lot of work to accredit all of the service registrar positions, but it would be worth it.” “These registrars are at a high risk of burnout, and burnout leads to higher patient risk. At the end of the day we want to make everyone safe – our patients, our doctors and our hospitals as well.”

By Jan Hallam

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What the Health Services Say We asked the health services to respond to the concerns for the health and welfare of those registrars who are not college trainees at their tertiary hospitals. Here are the responses from their spokespeople. North Metropolitan Health Service (SCGH, KEMH) “There has not been an identified spike in the exit rates of junior doctors in the past 18 months. Our exit rate is consistent with previous years. “Acknowledging that there is always room for improvement, NMHS continues to review and explore ways to further progress the educational experiences of our service registrars and all junior doctors. “In addition to encouraging feedback and listening to our medical staff, we also

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proactively develop programs and action plans to ensure their needs are met. Examples include the following initiatives: • The establishment of the Medical Culture and Wellbeing Working Group to better engage with Junior Medical Officer (JMO) to improve communication and decision-making relating to JMO matters. • Establishing monthly open forums for discussion following term evaluations and feedback received via the Medical Executive Group. • Reviewing the current leave management and rostering processes and developing contemporary models of after-hours service provision.”

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What the Health Services Say South Metropolitan Health Service (FHS) – Dr Paul Mark, Area Director Clinical Services “All registrars treating patients are allocated to a clinical team which usually consists of a combination of consultants, fellows/ senior registrars, registrars, RMOs and interns. “When registrars are assigned to a clinical team they are supervised by the consultants in the team, which is overseen by the head of the specialty. This includes participation in multidisciplinary and other specialty meetings. “Within the registrar group there are advanced trainees in a specialty and service registrars: • Advanced trainees are in the training program of one of the Learned Colleges who prescribe the educational syllabus and conduct work-based assessments (completed by supervising consultants), examinations and assess other tasks such as research. • Service registrars are in a variety of specialties including emergency medicine and are recruited by the specialty and partake in their educational activities and performance management. “Surgical service registrars are recruited via a centralised process and rotate every six months, often between Health Service Providers (HSPs). “Service medical registrars are recruited through a state-wide process and are allocated to a HSP for a full year. They

rotate teams every three months to positions not accredited for training. If a training position is vacant, they fill the position for up to 12 months.

• Raising awareness about mental health and wellbeing of doctors;

“The largest group of medical service registrars are Basic Physician Trainees who have a designated Director of Training and Education Registrar to provide support and a structured training program. Following success at the college exams they usually progress to advanced trainee status.

• Fostering an anti-bullying and antiharassment culture.”

Medical Education Unit;

“Service medical registrars who are not a part of the Basic Physician Training program do not have a structured educational program, recruitment is difficult and attrition is high. Currently there are 15.4 FTE in this group. Fiona Stanley Fremantle Hospitals Group (FSFHG) has used the recruitment of international medical graduates as a short-term solution. Consideration is being given to recruiting a small number of supervised medical officers on longer contracts to fill some of these non-training positions. “There are a range of educational opportunities for all medical staff at FSFHG. All registered medical practitioners are required to meet the continuing medical education requirements of the Medical Board of Australia. “FSFHG has a number of initiatives in place to support Doctors in Training: • Engagement of DiTs via Regular Medical Liaison Group meeting between representatives of Fiona Stanley Medical Officers’ Society, Executive, Medical Workforce, and the

Join your colleagues to be engaged by speakers, clinical and practical learning sessions, and social events.

East Metropolitan Health Service (RPH, SJG Midland Public) – Liz MacLeod, EMHS Chief Executive “At EMHS, we have actively sought feedback from our service registrars to help develop their skills to gain entry into a vocational training programme. This includes access to a high-quality wellbeing program, mentoring, careers advice and interview skills training. Significantly, we also continually review what we are doing to assess if there is any way to further improve the educational experiences of our service registrars and indeed all junior doctors. “We understand that there is a national review of training and the medical workforce, being led by the Federal government and commend that action. We have actively contributed to the discussions regarding the need to address service registrar/unaccredited registrar positions and training pipelines. In the interim, we will continue to listen to our service registrars, and continue to develop programs that help address their needs, in addition to that of all our junior doctors.”

ADHC

2019

DO YOU HAVE A PASSION FOR DOCTORS’ HEALTH?

• Addressing high risk groups from a welfare perspective such as IMGs, interns, and doctors sitting exams;

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ruralhealthwest.eventsair.com/2019-adhc 14 | OCTOBER 2019

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FEATURE

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INCISIONS

What Makes a Better Doctor? Is it sacrificing mental and physical health? Destroying relationships? Dr David Oldham suggests it’s time to find a better way to train our doctors. There is something wrong with our selection and assessment processes. I was talking with a service surgical registrar the other day and he was giving me some insight into his life. For the past two years he had been working at least six 12-hour days each week (and only getting paid for eight). His life revolved entirely around pleasing his bosses and doing whatever it took to get into the hallowed training program. His family life was a wreck – he rarely saw his wife and children, and when he did, he was too tired to do anything enjoyable. His personal health was a mess. He had stopped his regular exercise and social activities with friends, had put on 15kg in weight, and probably ticked every box of the latest DSM criteria for major depression. He was severely burnt out and a danger not only to himself but also to his patients. He readily acknowledged the sacrifices he was making and the toll it was taking on him. However, he said it would all be worth it once he got on the program. I suspect he would sell his grandmother if it helped him get a training place. The psychological term for this self-sacrifice is “delayed gratification”. It is something that doctors are very good at. When used judiciously it results in high achievement without taking too great a personal cost.

Unfortunately, some specialties regard extreme self-sacrifice as a badge of honour.

constructively with managers are regarded as unimportant, or even as a weakness. The time has come to rethink our selection and assessment processes.

When I speak with surgical colleagues (and some non-surgical colleagues) about this, they all nod – it was something they endured and now that they are out the other end they regard it as a rite of passage – “if I had to do it, then so do my successors”.

It is justified by statements such as “it will toughen them up and make them a better doctor”, and “if they can’t handle it, then they shouldn’t be doing it”. Consequently, those who get into and through some training programs are those who are prepared to sacrifice themselves the most, and not necessarily those who would be the best doctor for their patients, co-workers and the health system.

Service (and training) Registrars should not be selected and judged on their ability to flog themselves, but on their clinical skills and ability to be kind to patients, to communicate with co-workers, and cooperate with managers to solve workplace problems. They should have a balanced work and home life, so they come to work each day feeling refreshed and leave work each day feeling like they have made a positive contribution to their patients and workplace. Critical issues such as this will be discussed at the Australasian Doctors Health Conference in Fremantle on 22 and 23 November https://ruralhealthwest.eventsair. com/2019-adhc ED: Dr David Oldham is Medical Director and Chair of the Doctors Health Advisory Service WA.

This cycle tends to be self-perpetuating. Those selecting trainees tend to choose (consciously or subconsciously) those they perceive as being most like themselves. Willingness to sacrifice their life for their specialty is often the main, if not only, criteria. Non-technical skills such as empathy for patients, concern for co-workers, and wanting to work

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FEATURE

IMGs and the Rural Workforce With the GP colleges assuming training responsibilities, will we need so many overseas trained doctors? Not any time soon.

16 | OCTOBER 2019

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FEATURE

he corollary of every GP training story, is, of course, Australia’s and, especially, WA’s continued reliance on the services of international medical graduates, particularly in rural areas, and the general medical workforce questions this engenders.

Despite the increase in the number of medical students and GP registrars over the last decade, providingenough Australian trained doctors for all rural areas, and especially remote ones, has not been easy. In January, the public health journal, Human Resources for Health published an article using data from Medicine in Australia: Balancing Employment and Life (MABEL) surveys. It concluded: “Rural self-sufficiency will be enhanced with policies of selecting rural-origin students, increasing the balance of generalist doctors, enhancing opportunities for remaining in rural areas for training, ensuring sustainable rural working conditions and using innovative service models. However, these policies need to be strongly integrated across the long medical workforce training pathway for successful rural workforce supply and distribution outcomes by locally trained doctors. Meanwhile, OTDs [overseas trained doctors] substantially continue to underpin Australia’s rural medical service capacity. The training pathways and social support for OTDs in rural areas is critical given their ongoing contribution to Australia’s rural medical workforce.” In the 2018 Australia’s Health report from the Australian Institute of Health and Welfare (AIHW) it found: “Migrant/overseas-trained health workers form a substantial part of the health workforce in Australia…in 2016, 33%

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of medical practitioners employed in Australia received their initial qualification overseas. They make up 31% of employed medical practitioners in Major cities and 41% of employed medical practitioners in rural and remote areas of Australia.” WAGPET CEO Dr Janice Bell is concerned about the drop off in the number of suitable doctors wanting to be GPs over the past two years. “No one knows exactly what all the factors might be contributing to the dropoff, which has affected WAa bit less than some other, particularly rural, places in Australia. There is a lot of speculation at present. We know over this time, for instance, we lost the Prevocational Graduate Placement Program (PGPPP), so now doctors are having to choose a career that they've never even tried. This is not the case for any other major medical specialty,” she said. “Doctors tend to be risk averse people. Even if you're really sure you know what you want to do, choosing general practice is a pretty brave move if you’ve never even tried it. Our career intentions research in WA proved the prevocational experience is pivotal in career decision making, yet GP is missing from it.” We miss PGPPP In Medical Forum back in April 2017, Janice lamented the government’s shortsightedness in giving up on PGPPP. “It was a real shame for WA, junior doctors and the profession because it really did create a pathway for doctors in an experiential way,” she said then. As a result, WA is likely to rely on overseas trained doctors for some rural areas for at least the next decade, she thinks. “I'm very nervous about turning off the tap of doctors coming from overseas. That might work for some areas of

Australia now, including larger rural towns and centres in WA, but it couldbe tragic for many parts of WA.” But while critical at least into the medium term, importing doctors was not proving to be the best long term strategy. Evidence showed that the majority of OTDs who started practice in rural and remote areas did not stay but moved to the city when their moratorium expired. On the other hand, Janice says “We now have evidence from across Australia that suggests if we get GP registrars out rurally during training, they tend to stay on afterwards. More so, wherever GP registrarstrained last that's where they tend to stay. So, we have worked really hard to have people working in some of the more challenging rural areas for their last term in training. The results are even better if the registrars have acquired rural generalist skills, procedural or in a special interest area like Indigenous health and are Australian trained medical graduates (AMGs). “Of course, that stickiness doesn’t apply to everyone, but it’s more powerful than any other variable we have relied upon traditionally – where a doctors trains seems more powerful than rural origin, or RCSattendance, or gender, or fellowship pathway.” It's a MDRAP To support these endeavours, in July this year the federal government released guidelines for a comprehensive rural placement program called More Doctors for Rural Australia Program (MDRAP),much of which will commence in 2020. There are several different programs that come under the MDRAP banner, some new and some reshaped.

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IMGs and the Rural Workforce With this new funding, the RACGP has engaged the RTOs, like WAGPET, to run an education support program for OTDs working in rural and remote areas. The Practice Experience Program (PEP) will help them get their fellowship and develop additional skills as a GP. With the same funding ACRRM have provided subsidies for doctors on its independent pathway. “Providing non-VR overseas trained doctors with educational support towards fellowship is warmly welcomed,” said Janice. Under MDRAP, there are also additional places in the AGPT for GP registrars choosing to become rural generalists. “We are very pleased with the positive uptake into our WA rural generalist program(WARG),” Janice said. “It’s early days, but there’s been huge support from the health care sector – the department, private hospitals, and WA Country Health Service especially – and a new cohort of more experienced prevocational doctors, often with some other specialty training under their belt, are applying to join the AGPT as a result.” Try before you buy There is also a PGPPP-like program for doctors wanting to experience general practice, perhaps before applying for a position on the AGPT. This is said to be a well supported program with limited places, although the details are yet to be announced. But there is another ‘MDRAP’ also for AMGs who have had no experience in

general practice, and this one is not so well supported. “This MDRAP 2 is currently designed as a workforce program administered by workforce agencies, and not a training program led by the RACGP or by ACRRM. It replaces the Rural Locum Relief Program, which was specifically designed to provide relief for doctors to go on holiday or study leave, and now it’s become a full-on 3GA program open to AMGs and IMGs without the usual rigour around learner-appropriate education or supervision, especially for those who have never worked in general practice.” More support needed The idea of vulnerable doctors being made to sink or swim in vulnerable towns has caused ripples with the colleges, with a number of meetings being held with the minister for clarification and reassurance that safety and quality will be protected. The head of ACRRM, Dr Ewen McPhee, met with the Health Minister Greg Hunt and the Minister for Regional services, Mark Coulton to secure a commitment to further review the MDRAP supervision and training model.

“It is vital there is robust and appropriate training and supervision of junior doctors, especially in rural and remote areas. Having this training will positively impact the quality of education and the safety of the patient and doctor.” Junior doc warning While ACRRM seems to offer qualified support, concern lingers that junior doctors are being thrown into the deep end without a safety net, for them or for their community who won’t know what is the qualification of doctor to provide their health care. Janice added, “I do feel this very real concern has been heard and understood, at this time. All doctors working on general practice should have oversight from either or both GP college, and the education and supervision appropriate to their needs and context to ensure basic safety and quality underpins all that we do in the name of our profession.”

By Jan Hallam

In a statement Dr McPhee said: “With review and consideration, the MDRAP will provide junior doctors with safe and supervised learning environments before making career decisions. It will also provide Australians with the confidence their GP has attained or is undertaking training towards Fellowship.

Read this story on our website mforum.com.au

Canberra Rewards Translation The Western Australian Health Translation Network was one of eight centres nationally to pick up a grant worth more than $4.1m as part of the commonwealth Medical Research Future Fund’s (MRFF) Rapid Applied Research Translation (RART) initiative. Just as Medical Forum was going to press, Health Minister Hunt announced the $33m in total was being allocated for research into interventions that focus on people with or at risk of developing chronic conditions. The most recent grant builds on $1.97 million previously awarded to WAHTN in 2018, totalling $6.1 million provided by the Australian Government over three years. The grant will provide funding for 12 research projects from WAHTNs Health

18 | OCTOBER 2019

Service Translational Research Projects (HSTRP) initiative The HSTRP program attracted 68 applications from the public and private health sector, PathWest and the WA Primary Health Alliance. The large number of quality applications made the process highly competitive. It also provided an encouraging snapshot of the strength and breadth of translational health research occurring in WA hospital and primary health settings. The successful projects, listed in the table below, will be supported by $2.84 million in MRFF funding, with matched funding from the health services.

Saunders, A/Prof Paul Cohen, Prof Michael Millward, Prof Girish Dwivedi, A/Prof Andrew Maiorana, Dr Wei-Sen Lam, Ms Jo Moore, Prof Desiree Silva an Mr Richard Varhol. Executive Director of WAHTN, Prof Gary Geelhoed, said the grants to WAHTN and similar groups which comprise the Australian Health Research Alliance (AHRA), confirmed the ongoing commitment of the NHMRC and MRFF to the importance of these entities in promoting medical research and its timely application.”

The successful HSTRP recipients are: Dr Christopher Brennan-Jones, Dr Andre Schultz, Prof Graham Hillis, Prof Christobel

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s valued readers of Medical Forum, we are asking you to help us make the magazine an even better reading experience.

At Medical Forum, the state's leading independent health magazine, we want to grow and develop in ways that inform and entertain you. So, in early October we will be sending out an email survey and hope that you can spare 10 minutes to help us improve our delivery and provide you with the best possible and relevant content. All information submitted is anonymous and completely confidential because we not only value your feedback but we also value your privacy. The information you provide will help us improve the content, look and feel of Medical Forum and its companion website medicalhub.com.au. As a way of thanking you for your support and your time, all respondents of the survey will go into the draw for a $500 voucher for use at the hospitality facilities at the State Buildings such as

WildFlower restaurant, Long Chim, Petition, Treasury Lounge and Bar or the luxury boutique hotel, Como. Look out for the survey email which will be delivered to your inbox on October 3.

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Gambling’s New Generation Gambling products are reaching deep into the heart of a country that is already in love with a punt. Children are their new frontier.

ambling in Australia is everywhere – be it in multiplatform marketing, during live sporting broadcasts, or within apps and games designed for children.

Medical Forum spoke with experimental psychologist and gambling researcher Dr Alex Russell, from Central Queensland University. He says the delivery mechanisms for gambling are changing with each new generation of gamblers.

This pervasive marketing has normalised gambling in every corner of Australia and underregulated apps and games have conditioned a new generation of gamblers, leaving in their wake serious health and social problems.

“Young people are not taking up the pokies as much these days. A lot of them are, instead, using apps on their mobile phones. With sports betting, in particular, moving to a mobile phone platform through apps and mobile web browsing, it's really targeting people who spend a

A recurring theme in our research was how young males from late teens to mid-30s were the most susceptible to the lure of gambling, but why and how were questions harder to find answers for.

22 | OCTOBER 2019

lot of time on their phones – and that’s young people.” “Young men are most at risk of problems related to sports betting because they tend to do it together. It becomes part of hanging out and being part of that group. And it also has a degree of skill and prestige involved. These young guys are always looking to outperform each other.” “Australia has always had a unique relationship with gambling compared to the rest of the world – we are a nation of gamblers. There's a weight of evidence to show that we lose the most money on gambling per capita worldwide, by a long way.”

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WA isolates pokies “The figure is put at about $1300 per head each year – it's a big deal to lose that much money. We also have a less than healthy relationship with the pokies as well, apart from WA, which only allows gaming machines in licensed casinos. Pokies are in pubs and clubs and places that aren't primarily designed for gambling. WA’s policy reflects how most other countries treat these machines – in places built for gambling.” When it comes to gambling and sport, the Melbourne Cup is a prime example of how deeply rooted gambling is in Australian culture, “The nation stops for the Melbourne Cup. Racing wouldn't exist without gambling and we're seeing other sport going the same way, particularly televised sport which is targeted by gambling ads. This trend has really taken off over the past 10 years,” he said. For children who are watching adults, gambling becomes a normal thing. Pushing this normalisation along is the conditioning that goes along with subtle gambling marketing on devices children and young people use on a daily basis. Essentially, this is gamifying gambling. “A lot of apps these days have gamblinglike elements in them. Some of them are explicit, such as content on Grand Theft Auto, which has casino levels where gamers can play a type of simulated form of gambling in the game,” Alex said. Another trick of the gambling trade is the obfuscation of what is a gambling product and what is a game. “When we think of what gambling actually is, it's putting money at risk on the outcome of an action, such as spin on a pokie, or on the results of a game – to bet on an uncertain outcome for the chance to grow your money,” he said. Touch-screen bets “There's a lot of games on your phone or device where you can pay a micro transaction during a game of bingo or poker, for example, which will unlock certain features, but you can’t ever win money from it. So, it's not technically gambling and therefore falls under different laws and the restrictions are

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different. But it's an action close to gambling and the behaviour is similar.” Within some games, there are loot boxes which are, in essence, a habitual chain of activities that are repeated to gain a neurochemical reward. And it is these elements that are conditioning young children to gamble. “That's a real concern. Young children can buy entries into a loot box and have a chance of winning something really good. And some games are being sold on the basis of what you win, which technically puts it into the realm of gambling.” Author and academic Joshua Krook studies gambling design in these games. He explained that some games might not be gambling but they use the same mechanics. “I would put something like Candy Crush into that category. This is an extremely popular mobile app that you can download for free. The mechanics are exactly the same as a slot machine.” Within some games and apps are features called progress gates. When a user loses, they can either pay to continue playing or wait for the game to begin again in which time, paid advertisers get their pound of flesh. Joshua considers these progress gates as a form of gambling. “As the difficulty ramps up, you lose more often, so the temptation is to pay to play. These never-ending levels, where you pay to continue, are soft gates, similar to that used in casinos, unlike the old arcade games of the 1980s and ‘90s where it was game over.” Joshua said game developers were hiring psychologists and neuroscientists and former employees of casinos to help them design games to entice people to play their products. “Their intention is to get people addicted. The randomised nature of rewards you find in certain video games parallels slot machines. You haven’t done anything special to get a reward but that unexpected gratification is an addictive feature of the game. In the same way that the randomised reward system of slot machines is addictive – you can win a lot, you can win a little, or you can win nothing at all.”

Gaming to gambling The transition from ‘gambling-esque’ type games to actual gambling can be seamless, according to Joshua. “It’s almost as if the earlier games are priming young people for gambling. They play these games as a child and as they get older and can legally go to casinos, they transition – from spending fake currency in games to gambling real money when they're older. They are addicted in the same way because the same mechanisms are used.” Joshua sees children in the firing line of these developers. “Games like Candy Crush and the major games in any app store, use bright colours and cute animation that makes it very appealing to children. These games act as that first step to get people hooked on that kind of technology. And it's really a question of what we can do to protect people.” The Weighing up the Odds study by the Australian Gambling Research Centre surveyed young men between 18 and 35 who watch or play sports. The authors found 23% of the respondents placed their first bets before they were 18; 64% of the respondents said alcohol was a factor in their betting behaviour; 70% of the respondents were found to be “at risk of, or already experiencing, gambling harm”. The Victorian Responsible Gambling Foundation’s report, Gen Bet: Has gambling gatecrashed our teens, found 50% of adolescents have high levels of exposure to sports betting marketing; up to 25% of young people bet on sport; teenagers are four time more likely to develop gambling problems than adults. To understand young people and gambling from a public health perspective Medical Forum spoke with Dr Melissa Stoneham from the Public Health Advocacy Institute of WA. While she acknowledges that the most at-risk of problematic gambling are young males between the age of 18 and 34, PHAIWA is most concerned about the industry tactics used on younger people, which almost grooms them to gamble as soon as they come of age, which is 18.

continued on Page 25

OCTOBER 2019 | 23

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Gambling’s New Generation Life starts crumbling “Younger men are getting into all sorts of trouble in relation to gambling, mostly around loss of money, which can also upset social relationships. What can we do about it? I think people need to start talking about the risks associated with gambling, and that it's not just fun, there's some real public health and social and emotional risks associated with gambling,” she said. “Gambling counsellors are also telling us that they're seeing an increasing number of young men, most of whom started gambling on sports on their mobile phones.” The marketing of gambling is no more apparent than when a sporting event is televised. “When a child is watching sport, either live sport or on television, they're bombarded with messages – from a logo on the uniform, betting odds running along the screen, advertisements during breaks in the game, it's on the balls, on the posts. Kids are constantly getting these messages about gambling and about betting odds. And they start to think that this is a pretty cool thing to do.” Melissa said the gambling industry uses techniques that they know young kids can relate to, such as humour or cartoons. “When you look at the betting ads, especially on YouTube, which everyone can access, the industry uses a lot of those tactics that young kids actually get hooked on.” Inducement strategies are another way for gambling companies to indoctrinate users into thinking that gambling is innocuous, such as cash back offers if you add $50 to your account, or a $100 starter kitty when you sign up. “These inducement strategies actually reduce the child’s awareness to a point where they think gambling has no risks.” “To a child, this just sounds like, ‘Wow, this is great. When I get older, when I'm allowed to bet, that's what I'm going to do,’ because it's clearly an easy way to make money and they are also probably starting to think that betting is a normal thing to do. So, we're really concerned that when they get to 18, they're going to start to bet.” To counter the overabundance of gambling advertising, Melissa suggests that parents of young children need to talk about the real risks associated with gambling when these advertisements come up on their television screen.

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It’s a health issue Gambling, she said, should be viewed through the prism of the negative health outcomes it generates. “A lot of people have been hurt by problem gambling. Lost money, lost jobs, lost homes. Relationships have broken up,” she said. She added that gambling, while normalised in our culture, much like anti-social behaviour around alcohol, can still have a stigma attached if problematic gambling behaviour seeps into a person’s life. Then they may not be completely forthcoming about the magnitude of their addiction, which is why Melissa sees gambling education to be something talked about in schools and for doctors to discuss with their patients. “Gambling is something that schools should be talking about during health subjects or sports subjects. Doctors could also be asking their patients if they have issues with gambling if they feel that it may be contributing to their emotional issues.” Dr Alex Russell said there were often co-morbid behaviours to look out for in problem gamblers. “We find people who have problems with gambling tend to have other problems – it’s often alcohol, sometimes drugs, often smoking and mental health issues.”

behavioural addiction versus a substance addiction. People understand why people get addicted to alcohol because it makes people feel good. It makes sense and they think the solution is to just stop the alcohol. However, with a behavioural addiction like gambling, there is nothing going into your body.” “People don't tend to understand it so much nor that it can lead to the condition being highly stigmatised. There's this idea of, ‘look, why don't you just stop?’ That's a major difference between the two in terms of how people understand them.” “But it seems, internally, there's the same dopamine reward pathways being activated for both problem gambling and alcohol use.” An awareness of how these games and gambling applications can morph from entertainment and enjoyment to compulsive behaviour will ultimately come down to the user, according to Joshua. “If at any time you feel like you're playing something, but you don't really want to, yet you feel compelled to, that's when you’ve got to ask yourself questions like ‘what's driving me to do this?’ ‘Is it something within the game itself that is causing this problem behaviour?’.

By James Knox

“Gambling is a bit different as it is a

OCTOBER 2019 | 25

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Life Without Breath In this follow-up to the re-emergence of silicosis, we speak to those with whom it affects most dearly – the workers in stone.

n the September edition of Medical Forum, we delved into the issue of silicosis, the deadly group of lung diseases that has recently re-emerged and have the potential to be a major public health concern. As a result of that report, we have had the opportunity to speak to someone who has been diagnosed with the disease and speak to regulators in more depth about the threats posed to public health through exposure to silica-based products, such as engineered stone. Garry Moratti is a 51-year-old stonemason who worked in the sector for over 33 years, starting at the age of 15 years. Garry recalled the day of his diagnosis. “It was about three years ago and just a day before my birthday, on 22 May, 2017. I started to feel funny and I collapsed at work and they took me to the hospital and that’s when I learnt I had silicosis.” The diagnosis has drastically changed Garry’s life. “I haven't been back to work since because I just can't do anything. It's affected my family. It's affected me, I suffer from depression and anxiety and, for me,

26 | OCTOBER 2019

there's only one cure – a lung transplant.” “I've got about 30% of my lung covered in silicosis – I am actually one of the lucky ones. I don't know how I got out of it so easy, to be honest.” Garry blames the engineered stone, which entered the industry around 20 years ago. He wants to raise awareness of the dangers of working with these high-silica compound products. “I've got silicosis and there's not much I can do about it, but I want to get a point across to those people working in the industry how dangerous working with engineered stone can be.” The cruellest cut Silica dust is created by the cutting of engineered stone and Garry says there was no awareness of its dangers when it began being imported into Australia. Workers were using the same dust masks as for marble and granite when special dust masks were apparently required. Engineered stone has become prolific in the Australian marketplace because it is cheaper than actual stone products such as marble and granite, which have a much lower silica content (marble ~ 2%, granite ~ 30%, engineered stone ~ 90%).

Garry believes the real cost is being paid by the workers exposed to the respirable silica dust. “You shouldn't really even get this stuff on your skin. Even if you're cutting wet, you get wet all day with the dust. Soon as you dry out a bit, the dust is flying around. It's ridiculous.” In Garry’s most recent job, his workplace attempted to minimise the risk to their employees by implementing dust control protocols, yet these were insufficient for just the types of circumstances described by Garry. “The owner of the company didn't like dust, which is good, but we weren't aware that it was so fine you had to have a special dust mask for engineered stone. About 90% of the work is with this stone,” he said. “The owner bought the best dust masks for working with marble and granite but we were unaware that we should also be suited up to prevent it getting on our skin.” “And this employer was the type of person who would say to you every afternoon if he knew you’d been working with the stone, he'd say, ‘you have a shower before you go home, before you leave the place.’” “But we still weren't aware of the dangers.”

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Know the risks Garry has a message for those working with engineered stone: “Do your own research and find out what sort of dust mask you really need. And if the boss has a problem with it, it's not worth working. People have got silicosis and no one knows about it yet, especially young people in the industry.” Medical Forum also spoke with Robert Vojakovic of the Asbestos Diseases Society of Australia. Robert has been a passionate campaigner for victims of exposure to occupational carcinogens, and most prominently led the awareness campaign of the dangers of asbestos. As there are emerging parallels between engineered stone and asbestos, Robert’s perspective on the two provides some interesting historical context. His opinion on occupational exposure to crystalline silica dust is unwavering.

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“It’s worse than asbestos. You don’t get tuberculosis from asbestos. We have to worry because someone can live with silicosis for a number of years without symptoms. Silica is most likely to give you tuberculosis at some stage in your life and that's what I'm worried to see.”

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In July this year, Safe Work Australia recommended a new dust exposure limit of 0.05 milligrams per cubic metre (the current standard is 0.1) to be implemented in three years’ time. This isn’t sufficient in Robert’s view and he believes the standard of exposure should be zero.

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Asbestos and engineered stone with high silica content are similar in so much as they are benign until agitated or worked with, such as stonemasons cutting stone.

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Robert says it’s the cutting that is problematic and the controls in place in workshops and on-sites are inadequate. Strict protocols needed

ACAT referral.

Step 4.

“No longer can P2 masks (the current recommended particulated respirator) can no longer be relied upon. Complete hermetic isolation is required. Workers who cut engineered stone should then go into a contamination unit when they finish,” he said.

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When asked what action he thought should be taken to control the incidence of silicosis in Western Australia, Robert urged WorkSafe, to immediately decree that all employers must have their staff scanned on a six-monthly basis.

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Robert believes there is a strong case to ban engineered stone, similar to that of asbestos.

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However, while Robert holds these strong personal views on engineered stone with high silica content, he believes the wider population needs to take note and to pressure politicians, similar to how he campaigned for asbestosis victims. Robert urges GPs with patients working in industries that may produce occupational crystalline silica dust to, “immediately ask workers, even their bosses, to have a check-up, and to ask questions such as how many years have they worked in the industry” to identify if these people at in the at-risk cohort. We asked WorkSafe Commissioner Darren Kavanagh if the recommended standard of 0.05mg/m3 would be sufficient. “Halving of an exposure standard might be interpreted as a reflection of the importance of the risks around silica,” he said. “There also has been a range of new equipment, new technologies, new sampling equipment that measure the concentrations of silica. So that's provided information, new information, to form a view about the recommended level.”

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Life Without Breath In regards to the current standard and the compliance of WA workplaces he said:

risks we see in the workshop are the same as the ones we see out in the work sites”.

stone, he stops short of a comparison with asbestos.

Workplaces responding

Darren has found a genuine concern about the risks of engineered stone from the industry stakeholders whom he sees are “genuinely interested in trying to make sure that people aren't being exposed.”

“I understand why people are making that comparison as there are some similarities between the two materials. But based on the volume of material that has been produced in the past, and I'm referring to a comparison to the engineered stone bench tops, I'm not sure we can get to those same levels as asbestos,” he said.

“We've found through some proactive campaigns with the agency is that there are controls in some places. So, some places are striving to work to appropriate controls. But there is definitely a number of workplaces that aren't applying proper practices, proper safety controls. So, there's still a bit of work to do there.” Although measuring crystalline silica dust exposure is a relatively easy task in workshops, it’s the installation aspect that is difficult to measure, simply because engineered stone products are being installed in houses, apartments and workplaces on a daily basis. This means the number of workplaces with crystalline silica dust exposure is changing on a day-to-day basis. With regards to the risks faced by workers installing engineered stone products, Darren holds a balanced view. “I think there's an anecdotal view about the risks associated with the installation side of it, but I don't think we've got enough information yet to prove categorically that the

With regards to the potential for WA to see the increase in the number of silicosis diagnoses in-line with the eastern states, Darren says WA has not experienced the same increase in cases. “But that's not to suggest that we've got the perfect working environment. I think there's enough evidence to suggest that we've got lots of improvement to do.” So far, WorkCover has accepted two silicosis claims and 141 workers have gone through health surveillance programs, with 36 workplace audits taking place since July 2018 and all of the audited workplaces receiving at least one non-compliance notice. Of the 36 workplaces audited, 292 improvement notices and two prohibition notices have been issued.

“We’re talking about thousands and thousands of people having been exposed to asbestos over the years and we're not near those numbers for engineered stone. I don't say that to be dismissive or challenge the concerns that people have. I think a bit of balance is required.” Whatever regulations may do to shape the future exposure to silicosis, it doesn’t change the grim outlook for Garry Moratti and workers like him. It is these personal stories that will eventually write the narrative of engineered stone and silicosis in Australia.

By James Knox

While Darren doesn’t underplay the potential harm of working with engineered

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The Dream BreastScreen Team

Jan Pickering, left, Andrew Waddell, Angela Hellewell, Dr Liz Wylie, Helen Lund, and Katy Grace. Seated: Cynthia Leal, and Dr Eric Khong

reastScreen WA celebrated its 30th anniversary recently and its current director Dr Liz Wylie has seen all but a few of those early months. The program started in 1989 after a successful national pilot that saw breast cancer screening become a way of life for every woman over 50 and until the age of 75. Liz was a radiology registrar in the UK when the doors flung open in a little old house in Hamersley Rd, Subiaco. “Dr Mike Gibson was the first senior radiologist, who started the program with Val Gardner, and the first clinic was in Cannington. By 1995, we were statewide,” Liz told Medical Forum. “I came back to WA in 1990 and started at BreastScreen. My reading number is six. Next year I will celebrate my 30th anniversary with the service and on February 5 I will have notched up 20 years

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as Medical Director. I feel really privileged that I've had this opportunity to make a career at BreastScreen.” Liz has seen great changes in her three decades.

treatment so successful. But it is a belt and braces situation – treatment is successful when you have early diagnosis. If you can have both, why would you choose just one?”

The first is, of course, breast cancer itself. When Liz started screening women in 1989, the incidence of breast cancer was one in 14 women, today it is one in eight, in some studies it’s one in seven.

Then there’s access. There are 11 BreastScreen sites in the metropolitan area and four screening buses that are on the road most of the year. Liz said a lot of work goes into the regional and remote screening, particularly for Aboriginal women in remote communities.

“The incidence of the disease has doubled in that period, whereas the mortality has reduced. We would like to think that screening has been a major contributor to the reduction in breast cancer mortality, despite the increased incidence,” she said.

“With the digital equipment on the buses, we don’t go off-road but we bring women to the buses from all over. We're heading to Laverton soon and we'll be bussing people from all the lands. Some women will have 2000km round trips,” Liz said.

“Early detection has made better treatments more effective.”

“So, we organise the bus and provide all the food and camping accommodation, and the communities respond very well.

“One of the problems of such success, I think, is people start thinking we don't need to do all the things that made cancer

continued on Page 32

OCTOBER 2019 | 31

continued from Page 31

The Dream BreastScreen Team We've got a great Aboriginal health promotion officer in Kelly Cameron who arranges these trips with fantastic assistance from Aboriginal health workers on the ground.” “We have better participation, generally, on those country visits than we do in the metropolitan area because people are more incentivised. If the van is there only once every two years, you go get a mammogram. When the service is around the corner and available at any time, it's hard for people to get motivated.” The other area of great change is technology. Gone are the days where x-ray film was developed, dried then hung on multi-viewers. Gone are the bits of paper. And gone is the vacuum of information. “Digital imaging and the ability to transmit images so quickly has made the service remarkably efficient. And now we're getting all the advantages of being able to communicate with women electronically, sending them SMS invitations and reminders. And from August 23, which was Daffodil Day, we launched a service where women would be able to access their results via SMS,” she said.

“Since the launch, about 70% of women are taking up the offer to receive their results electronically.” The changes ahead, Liz said, include automated breast density reporting. “We've been doing empirical breast density reporting in WA for a long time. Automated breast density reporting would certainly make it more consistent but that’s not on the horizon until there has been an agreed funding model.”

which has made such a difference to obstetrics, will change the breast cancer detection paradigm. So few women are now having amniocentesis because all those genetic determinations are made from an early period in pregnancy from a simple blood test.” “In the ideal world, you would go once a year to your GP to have your cholesterol, blood sugar and tumour panel taken and only if have you returned a positive tumour panel, would the investigation begin.”

BreastScreen enjoys the backing of both federal and state governments and it’s hard to conceive of a time without it, but Liz can, in fact wishes it.

“I think that would be wonderful and it would make such a difference to diseases like ovarian and lung cancers that are so difficult to screen for.”

“My hope is that within the next 10 to 15 years we don't have a population screening program like this. Currently, we screen every woman over 50 to the age of 75 to find the one person in seven who has breast cancer,” she said.

In the meantime, BreastScreen continues its vigilant care of women all over the state and sharing its rich data to make breast cancer treatment the best it can be.

“For the majority of women that’s 13 or 14 mammograms in that period, with the prospect of being recalled with a false positive diagnosis at least once in that time.”

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A Spoonful of Walking… Exercise is showing its clinical chops as an effective part of treatment for all manner of chronic diseases, says Cancer Council WA’s Gael Myers. What if I told you there was a single prescription you could write for your patients to help them reduce their risk of cancer, type 2 diabetes, cardiovascular disease, falls and joint pain, while also helping them to manage their weight, blood pressure, blood glucose control, mood and response to cancer treatment? It doesn’t come in a bottle, it’s exercise.

While the national guidelines recommend a minimum of 30 minutes of ‘moderate’, or 15 minutes of ‘vigorous’, cardio on most days and strength building twice a week, the key message is that doing some exercise is better than none, and more is better.

Moving a patient from being completely sedentary to them taking a 15-minute walk twice a week is an absolute win. Developing an exercise prescription in collaboration with patients has three essential components: • Move more – this includes activities that make the cardiovascular system work harder such as walking, jogging, swimming, playing sport, gardening,

active housework, riding to work or lawn bowls. Enjoyment is the key. o Half-hour walk after work on Tuesdays. Park the car 100m further away from work every day • Move stronger – strength building activities such as calf raises, squats, push-ups, yoga and pilates are important, particularly for older adults. Free, downloadable strength workout programs are available from the LiveLighter website. Specify the activity, frequency and time. o Community yoga class on Saturday mornings Gentle squats during TV ad breaks • Move often – strategies to reduce and break-up sitting time. This could include restricting daily screen time, doing stretches in front of the TV, using a standing desk at work or setting a reminder to stand up from the desk and stretch regularly. o Reminder alarm on phone to stand up and stretch every hour at work Take all phone calls standing up Moving Medicine, an initiative from the UK, has developed step-by-step guides for having one-minute, five-minute or longer conversations with patients about physical activity in relation to a number of health conditions, including cancer.

ED: Gael Myers is an accredited practising dietitian and LiveLighter coordinator.

Partner with PHYSIO + PILATES

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He also conducts research into the benefits of exercise for cancer patients at all stages of disease, with a specific focus on advanced cancer patients.

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Cancer Council WA offer exercise classes suitable for people diagnosed with cancer within the last two years, are currently undergoing cancer treatment or who have completed cancer treatment in the last two years and there are also private practitioners.

Cancer Council WA Senior Research Fellow Dr Nicolas Hart works with cancer patients daily across the disease spectrum in the exercise clinic.

“In particular, numerous studies are currently underway to explore whether exercise can delay disease progression and improve progression-free and overall survival,” he said. “It’s important that people living with cancer engage in structured resistance

There is also evidence to suggest that regular exercise before, during or following cancer treatment can reduce the risk of cancer recurrence and mortality (all-cause and cancer-specific).

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He said exercise can reduce fat mass, improve muscle mass and strength and preserve bone density and structure, all of which link directly to patient outcomes, including toxicities to cancer treatments, and patient survival.

The recently released position state by Clinical Oncology Society of Australia (COSA) on exercise in cancer care recommends that exercise is included as part of standard cancer treatment. Exercise has been established as a safe and effective strategy for: • Improving physical function • Reducing cancer-related fatigue • Reducing psychological distress • Improving quality of life

training to build muscle and build strength, as well as some form of aerobic exercise.” “Patients with bone metastases should consider modified programs tailored by an accredited exercise physiologist.” Nicolas suggests GPs use the Chronic Disease Management Plan to provide five annual Medicare rebated referrals to an AEP to enable high fidelity, clinically supervised exercise medicine programs.

• Physiotherapy • Clinical Pilates • Hydrotherapy • Falls Prevention • Pre & Post Operative Rehabilitation Learn more lifereadyphysio.com.au To start a conversation, email jarrad@lifereadyphysio.com.au

OCTOBER 2019 | 35

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We get spines working. Workspine is dedicated specialist team committed to occupational spine rehabilitation. This multi-disciplinary service includes neurosurgeons and spine surgeons, interventional pain specialists as well as psychologists and specialist exercise rehabilitation staff. The Workspine team has extensive understanding and expertise in the workers compensation system, has a transparent and proactive approach to occupational spinal injury management. Workspine has three convenient locations listed below. Contact us now and let your patients be managed by our expert team. Dr. Andrew Miles FRACS

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GUEST COLUMN

GST Anomaly Hurting the Vulnerable Exercise Physiologist David Beard laments the barriers government puts up for people in need of exercise for their medial conditions. Thousands of Australians are suffering with chronic and life-threatening conditions such as cancer and diabetes, yet they’re missing out on critical health care because Canberra, for over a decade, has failed to sort out a GST anomaly. Exercise physiology remains the only Medicare recognised allied health service that has GST applied, and that charge is hurting vulnerable patients in need of care. I see firsthand the impacts. My patients are fighting cancer, diabetes and mental health issues and exercise physiology is helping them to manage their conditions but the added cost for some is too much to bear. They are having to terminate their care early, seeing the added financial burden as unsustainable. Exercise & Sports Science Australia (ESSA) have been calling on the government to take action for several years now. It has been a frustrating battle.

We have spoken to several different governments. We have discussed it with Prime Ministers, State Ministers and Government officials. They have one by one handballed it to someone else. Instead of saying ‘this is someone else’s problem’, someone in government needs to take ownership and fix this issue. All the politicians we’ve lobbied say our case has merit, but no one in a position to address the anomaly is prepared to do something about it.

physiology helps manage are associated with high use of health care services. Cancers, cardiovascular diseases and mental disorders will contribute to almost half of the projected disease burden on the health system by 2023. Patients who are stopping care early due to financial constraints, go on to become a burden on the health system, often needing expensive drugs or surgery, which they could have avoided if they’d continued to receive treatment.

The Federal Government says it is on a mission to clean up unnecessary bureaucracy but leaving this tax anomaly unresolved is increasing suffering and costing the taxpayer longer-term.

Exercise is a medicine – it is increasingly being prescribed to patients by GPs and specialists. Studies show it helps fight diseases such as cancer and diabetes, but it seems that if it’s not in the form of a pill, politicians aren’t interested.

The GST charge nets the government less than $20 million a year nationwide, but the wider implications of this tax revenue, is damaging.

The government doesn’t want to lose GST revenue, but is willing to pay more for care for these people once they are in real crisis – it just doesn’t make sense.

Already, the chronic diseases that exercise

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GUEST COLUMN

Medevac: a Clear Case for Doctors The Medevac Bill goes to the heart of a doctor's pledge and should be preserved to save lives, says Dr Barri Phatarfod Doctors may be unclear as to where they stand on the issue of refugee treatment and offshore detention. With seemingly compelling arguments on both sides, it can be tempting to just trust the government to decide policies, however distasteful they appear. The Medevac Bill forces us to confront this. This Bill permits doctors to decide if a person requires transfer to Australia for urgent medical treatment unavailable on Manus Island or Nauru – the type of decision Australian doctors make every day. It also provides clear timeframes to transfer critically ill people while maintaining multiple opportunities for ministerial refusal. It does not allow doctors to decide visa categories, challenge refugee determinations, or advise permanent resettlement. Until now, recommended transfers could take several years resulting in irreversible deterioration from head injuries, heart conditions, diabetic renal complications and, tragically, multiple deaths in offshore centres. The doctors who made these recommendations were contracted by the Immigration Department itself to provide advice. Yet successful medical transfers to Australia have overwhelmingly been as a result of costly court cases. Of the 500 cases we have reviewed, the majority involve inappropriate delays to adequate medical care. One man waited three weeks after an MVA before he had a CT scan confirming multiple visceral rupture. A woman has had PV bleeding daily for two years after a gang rape in Nauru, and another man had a depressed skull fracture from a machete attack, both waiting dangerously long times for any investigations. And, of course, Hamid Khazaei, whose agonising death in 2014 was found by the Coroner to be avoidable if the doctors’ urgent and increasingly desperate recommendations had not been overruled. In the face of such an eminently sensible proposal, it is hard to understand the opposition to it, especially from the four government MPs who are themselves medical practitioners. For some time now, asylum seekers in Australia have been deemed to be outside our health system, so their medical needs

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fall within the remit of the Immigration portfolio, rather than Health. In doing so, Australia has effectively negated the humanity of these individuals – those with epilepsy, blindness, pregnancy – and defined them solely by their visa category.

Doctors, including successive AMA and College heads, who object are told to ‘stick to medicine’. The government narrative is that doctors are straying out of their lane and into the political arena.

So, what does it mean to ‘stick to medicine’? The Australian doctors’ Medical Code of Conduct outlines this for us. Like counterpart Codes globally, ours comes directly from the World Medical Association, the international physician body formed in 1947 to address the grotesque human rights violations perpetrated by medical practitioners. These Codes enshrine that a physician’s primary duty is to the patient, irrespective of the politics of the day. When you ascribe to this code, you don’t get to pick to which category you will apply it. So, it is absurd that refugees could fall outside the reach of this Code. It’s not because they’re not citizens, as we would never deny care to a tourist, or another temporary visa holder. It is solely because the department has decreed their mode of arrival as ‘illegal’.

But what is this, if not politics intruding into medicine – the very scenario our Code was designed to prohibit? The UN states that seeking asylum by boat is lawful under the refugee convention, so even the rationale is fallacious. So, too, is the suggestion that they may have traversed several countries before arriving in Australia, as none are signatories to the Refugee Convention. But these are not the arguments doctors should be making. We should treat these individuals appropriately because our oath requires us to, and our own personal view of immigration, boat arrivals or people’s life decisions is irrelevant. There are many groups in Australia who suffer systemic unmet health needs due to appalling neglect, political apathy and lack of funds. These same politicians have spent some $9.5 billion to make life as traumatic as possible for refugees; steadily dehumanising them to the point where the Australian public could accept that denying them urgent medical care is an acceptable response to people fleeing persecution. Over the decades since the WMA was ratified, various groups have been marginalised worldwide, and it can often be hard to cut through the rhetoric. However, there is one overriding and constant truth that doctors know because we all signed up to it: patient care must always come before political ideology. ED: Dr Barri Phatarfod is a GP and founder of Doctors for Refugees

OCTOBER 2019 | 39

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CLINICAL OPINION

‘This Foul Rheumatic Breed’ By Dr John Quintner, Consultant Physician in Rheumatology & Pain Medicine (ret.) Once known as ‘fibrositis’ or ‘soft tissue rheumatism’, Shakespeare’s “foul rheumatic breed” lives on. In 1904, British neurologist William Gowers speculated that the pain of such conditions was caused by a mysterious inflammation of the fibrous tissues of muscles and nerves. Although inflammation was never demonstrated, ‘fibrositis’ remained a popular diagnosis for the next 50 years. During the 1953 Test Match, England captain Len Hutton was laid up temporarily with ‘fibrositis’, and the radio doctor summed up the matter in his usual pithy style:

With the fate of England hanging in the balance, the problem of fibrositis has surely now become a matter of national importance. “And to complicate matters, at the very time that England’s Captain is reported to be suffering with this distressing but fortunately never dangerous malady, experts at the BMA are heard to declare that no such thing exists. How can our fate as a cricketing nation depend upon the outcome of an illness that doesn’t exist? It’s all very difficult.” Expert opinion was that “much rheumatic pain occurs without demonstrable pathology in persons emotionally disturbed and can often be modified by adjustment to the current problems”. During the late 20th century, two distinct offspring of ‘fibrositis’ appeared – myofascial pain syndrome (MPS) and fibromyalgia syndrome (FMS). Proponents attempted to dispel the belief that they could both be attributed to emotional disturbance. In the 1980s, Drs Janet Travell and David Simons invented a lesion – the ‘trigger point’ – as a presumed site of tissue damage or subtle dysfunction within muscle and the cause of both local and distantly felt pain. This ‘discovery’ resulted in irrational and ineffective treatment designed to ‘inactivate’ the trigger points (e.g. spray and stretch, myofascial release, and dry needling). Some authorities even believed that multiple trigger points in muscles could be responsible for FMS.

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But clinicians have been unable to reliably locate them by palpation and imaging studies have been confusing.

Dr David Sofield

Dr Mikhail Lozinsky

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The MPS theorists ignored the possibility of other more scientifically credible explanations for the local tender spots in muscles, and for the pain produced on palpation. Firstly, pain arising from deep body structures can be referred to distant tissues, and such tissues can be tender. Secondly, palpation over inflamed nerve trunks can also produce deep pain that radiates widely. The failure to consider these other explanations for the phenomena attributed to myofascial trigger points has had major ramifications around the world. The amount of useless treatment carried out, and the cost thereof, is inestimable. References on request

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MBBS (WA), FRACS, FRCSE MBBS FECSM

BSc. (Physiotherapy) PhD

FRACS, FEBU MBBS

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Denielle Rankin Practice Manager Urgent referrals will be seen within 48 hours and we welcome calls for advice anytime on 0419151050 (David Sofield) Or 0426255629 ( Mikhail Lozinsky)

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HOT TOPIC

The fabella – role and problems By Prof Piers Yates, Orthopaedic Surgeon, Murdoch The fabella (Latin: little bean) is a sesamoid bone found in the head of the lateral gastrocnemius muscle. It is present in about 12-15% of the population, although there have been studies suggesting much higher rates, probably because they are frequently cartilaginous and therefore missed on plain X-rays. Some 85% are bilateral. Its point of articulation is on the posterolateral femoral condyle and can be ossified or fibrocartilaginous. It is often mistaken for a lose body in the knee or and osteophyte.

of primary osteoarthritis (OA) of the knee has been postulated, with approximately 35% of patients with primary knee OA having at least a single fabella, whilst they are present in only 15% of individuals without OA. Symptomatic osteoarthritis of the fabella itself is exceedingly rare, with very few cases ever documented or confirmed. One such case was documented but lacked confirmation via a histological diagnosis. We confirmed a case ourselves in 2011. References available on request

The fabellofibular ligament attaches to it, which can be present instead of, or alongside, the arcuate ligament, aiding the stabilisation and reinforcement of the posterior knee capsule. The development of the fabella and this ligament relate to the evolutional transition to bipedal posture about 5 million years ago.

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The fabella has been associated with a number of clinical problems, including common peroneal nerve compression, vascular insufficiency, osteoarthritis, and stress fracture. A link between the presence of a fabella and the development

Facing Off to Sleep Apnoea UWA researchers from the Centre for Sleep Science and the Computer Science and Software Engineering faculty have joined forces to develop 3D imaging to help predict the severity of obstructive sleep apnoea (OSA).

The journal paper reported 100 participants did not have OSA (apnea-hypopnea index, AHI <5 events/hr), 100 had mild OSA (5≤AHI<15 events/hr), 100 had moderate OSA (15≤AHI<30 events/hr) and 100 had severe OSA (AHI≥ 30 events/hr).

The research, published in the Journal of Clinical Sleep Medicine, builds on previous work identifying how the structure of the face, head and neck play a key role in diagnosis.

“Measurements of linear distances and angles, and geodesic distances were obtained between anatomical landmarks from the 3D photographs and their relationship to the presence and severity of OSA determined. A maximum classification accuracy of 91% was achieved when linear and geodesic craniofacial measurements were combined into a single predictive algorithm.”

Prof Peter Eastwood, director of the Centre for Sleep Science, and his research team ran overnight sleep studies while Dr Syed Zulqarnain Gilani, from UWA’s School of Computer Science and Software Engineering, analysed the 3D faces. “What we found was that we could predict the presence of obstructive sleep apnoea with 91% accuracy when craniofacial measurements from 3D photography were combined into a single predictive algorithm,” Dr Gilani said.

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The technique may help the estimated 75% of undiagnosed individuals who because access and cost of current diagnostics remain unrecorded. The study recruited 400 middle-aged men and women whose faces were analysed from 3D photographs.

“This breakthrough has the potential to reduce the burden on hospitals and sleep clinics that currently run sleep studies for everyone,” Dr Gilani said. “It can flag people at risk of sleep apnoea who can then be referred for diagnosis and treatment.”

OCTOBER 2019 | 43

Managing ankylosing spondylitis By Dr Ai Tran, Rheumatologist, Murdoch There have been major advances in the diagnosis and treatment of axial spondyloarthritis (axial SpA) which includes ankylosing spondylitis (AS) and non-radiographic axial SpA (nraxSpA). In AS, sacroiliac joint abnormalities are observed by conventional x-rays but not in nr-axSpA. Ossification in the spine is the primary pathology in AS resulting in progressive irreversible structural damage. Until recently no treatments halted disease progression or led to disease remission. This is changing, increasing the emphasis on early detection. First line therapies for AS are physiotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs). Regular physical exercise and patient education form the cornerstone of treatment. A Cochrane review highlighted that any exercise, whether supervised or home-based, was better than no exercise for improving movement and physical function. NSAIDS can relieve symptoms including back pain and stiffness in up to 7080% of patients, however, the potential cardiovascular and gastrointestinal toxicities should be taken into consideration. Its role in preventing radiographic progression in AS is yet to be established.

KEY MESSAGES Physiotherapy and NSAIDs are first line therapies for ankylosing spondylitis Up to 40% of patients do not respond or are intolerant to TNF inhibitor therapy Interleukin 17 inhibitor therapy is an approved treatment for patients with ankylosing spondylitis. The biological era has transformed AS management. Tumour necrosis factor inhibitor (TNFi) therapy is currently available for patients who have persistently high disease activity despite conventional treatments. In Australia the currently available TNFi therapies include adalimumab, certolizumab, etanercept, golimumab and infliximab. Biosimilar TNFi therapies have also become available slightly lowering the prices of biologics. This year, golimumab was the first TNFi to be approved for the use in nr-axSpA for patients with raised inflammation markers and MRI evidence of sacroiliitis. Pooled data from 12 European registries including more than 24,000 patients with a baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of 59mm,

show six months into treatment, 72% of patients scored less than 40mm. At one and two years into treatment, 75% and 77% achieved BASDAI scores below 40mm respectively. Importantly, the ability of TNFi therapy to reduce spinal radiographic progression in patients with axial SpA have also been demonstrated if used long term (over four years). Up to 40% of patients do not respond to or are intolerant to TNFi therapy. Antagonism of the IL-17 cytokine made by Th17 cells is an alternative approach to the abrogation of inflammation. Secukinumab (a fully humanised IL-17A inhibitor) is the latest biological drug available for use in axial SpA. Studies show that Secukinumab can reduce spinal inflammation on MRI as early as week six in patients with AS with a low overall rate of spinal radiographic change over two years regardless of previous TNFi exposure The overall safety profiles of biological drugs are acceptable and the benefits outweigh the risks enabling patients with axial SpA an enhanced quality of life and reduced disability. References available on request

Author competing interests â&#x20AC;&#x201C; nil

Low FODMAP diet isnâ&#x20AC;&#x2122;t one size fits all By Charlyn Ooi, Dietitian, Ardross IBS is a chronic functional gastrointestinal disorder affecting one in five Australians. It can be debilitating and significantly impact quality of life. It is far more common in females. Symptoms include bloating, abdominal cramps, flatulence, diarrhoea and/or constipation. The exact cause of IBS remains unknown. Common triggers such as food intolerances, inadequate fibre intake, visceral

44 | OCTOBER 2019

hypersensitivity, alterations in gut motility and microbiome, infection and certain medications may exacerbate symptoms in genetically predisposed individuals. Although the low Fermentable Oligo-, Di-, Mono-saccharides and Polyols (FODMAP) diet has been widely accepted as an effective first-line dietary treatment strategy for the management of IBS, it is certainly not a diet for life. An individualised dietary approach is imperative for optimal patient outcomes.

FODMAPs are short-chain carbohydrate sugars poorly absorbed and subsequently fermented in the large intestines, resulting in luminal distension, diarrhoea, excess wind, cramping or constipation. Common high FODMAP foods include garlic, onion, wheat, mushrooms, apples, watermelon, lentils and milk. Data from Monash University revealed that a temporary reduction of FODMAPs in the diet improved overall gastrointestinal symptoms by 86%. Following the initial

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CLINICAL UPDATE

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CLINICAL UPDATE

Sports injuries in female versus male athletes By Dr Carmel Goodman, Sports Physician, Mt Claremont Female participation in Australian Rules Football (AFL) grew from 200,000 in 2014 to 530,000 in 2018 while female participation in cricket grew over 10% from 2016/17 to 2017/18. International research reveals that women playing various sports are more susceptible to concussion and ACL injuries than men. The inaugural AFL Women's (AFLW) Injury Report, (covering 2017 and 2018) identified ruptured ACLs and concussion as the major injury concerns, with women in the AFLW nine times more likely than men to rupture their ACL. Worldwide reported literature shows four to six times higher risk. The commonest ACL injury in female athletes occurs in a non-contact position such as jumping and landing on one leg or decelerating to stop and changing direction. Current evidence suggests the main reason females are at greater risk for non-contact ACL injuries is that they tend to have less neuromuscular control of knee motion during athletic manoeuvres. When jump landing or quickly changing direction, females have reduced knee flexion, increased quadriceps activity and decreased hamstring activity compared with males. Fortunately, unlike anatomic risk factors (largely non modifiable), neuromuscular risk factors can be modified through training.

two to six weeks ‘Elimination Phase’, the individual undertakes a structured challenge protocol in the ‘Challenge Phase’ to identify their personal triggers. The final step is the ‘Personalisation Phase’, where tolerated FODMAP groups are reintroduced. Challenges of the low FODMAP diet The low FODMAP is not a ‘No FODMAP’ diet. The concept of this diet involves a reduction of FODMAP load to alleviate symptoms. An internet search will reveal a range of often outdated and conflicting FODMAP food lists. Caution needs to be applied when interpreting these food lists as they can create more confusion, lead to unnecessary food restrictions and nutritional gaps. The low FODMAP diet is a specialised area of nutrition best undertaken with the guidance and support of a dietitian

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KEY MESSAGES Female athletes are at greater risk of concussion and ACL injury Correct training can reduce ACL injuries Concussion symptoms and sequelae are worse in females

Neuromuscular training programs are designed to strengthen hamstring and core muscles, improve balance, and teach athletes how to avoid dynamic knee valgus by correct landing techniques. Pooled results from various neuromuscular training programs show a 70% reduction in ACL injury rates in female athletes, particularly in the 15-18-year age group. The optimal time to begin NMT is early adolescence. Concussion Recent international research suggests that there has been a threefold increase in sports-related concussion (SRC) in men and a sixfold increase in women, competing in comparable sports (i.e. soccer and basketball).

An analysis of head impacts and concussions in elite-level male and female Australian cricketers over the 2015/16 and 2016/17 seasons revealed that 53% of head impacts in females were diagnosed as concussions compared with 32% in males. There has been a reported surge in female athletes presenting to ED departments around Australia with suspected SRC in the past two years. Various studies have demonstrated that female athletes report more total symptoms and experience slower resolution of these symptoms than males, experience more severe post-concussion symptoms than males, are more than twice as likely as males to experience neurocognitive impairment in the acute phase following a SRC (57% compared to 28%) and can suffer from prolonged cognitive impairment. Players, parents and coaches need to be very aware of the risk of concussion with immediate removal from the field of play for appropriate medical assessment paramount.

Author competing interests – nil

Research reports that the incidence of concussion causing missed matches was twice as high in AFLW compared to the AFL in the 2017 and 2018 seasons.

specialising in IBS, who plays an important role in supporting the patient to implement the diet successfully, identify their individual triggers and evaluate tolerance thresholds. Patients with complex medical issues including multiple allergies or intolerances, diabetes or children will require comprehensive support. Despite being a highly effective treatment strategy for IBS, a low FODMAP diet is not recommended long-term. The effects of long-term FODMAP restriction remains unclear but recent studies have observed negative changes in gut microbiome diversity. A probable cause is the reduction in high fibre foods that also contain prebiotics and resistant starch, limiting fuel for the gut bacteria. Moreover, it is uncommon for someone to react to all the high FODMAP groups. Ideally, we are looking for the least

KEY MESSAGES The low FODMAP diet is highly effective for IBS Individualised dietary and lifestyle modification advice is imperative A low FODMAP diet is not for life restrictive diet possible while maintaining good symptom control. References available on request.

Author competing interests – nil relevant disclosures.

OCTOBER 2019 | 45

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CLINICAL UPDATE

Sports injuries – are they over treated? By Dr JP Caneiro PhD, Specialist Sports Physiotherapist, Shenton Park Most people would be familiar with the story of Tiger Woods having years of intense therapy, ‘core’ exercises, back taping, medications, spine injections and four back surgeries for his back pain. Despite some symptom reduction, his back pain remains ongoing and limiting. According to the International Olympic Committee, athletes are commonly managed by rest, limited training and competition, early referral for diagnostic imaging, and treatments targeting symptom reduction, correction of faulty structures and ‘fixing’ damaged tissue. This approach is not aligned to current best practice guidelines for the management of musculoskeletal (MSK) pain. The assumption that MSK pain associated with sport is a sign of tissue damage, makes sense in traumatic injury with clear identifiable symptoms. Temporary protection and rest of the injured area is needed for healing to occur, before rehabilitation and return to sport. However, MSK pain, in the absence of trauma, is commonly managed with early scanning, over-treatment and advice to limit activities presumed to be dangerous. This can lead to reduced confidence and fear of injury, vigilance, and deconditioning, which increase the risk of pain and chronicity. Modern understanding of pain goes beyond structural considerations. The degree of tissue damage on imaging is a poor measure of a person’s pain, distress and disability. Imaging findings such as disc degeneration, disc bulges, hip labral tears, rotator cuff tears, meniscal tears, and tendinopathy are prevalent in painfree athletic populations, and are a poor predictor of a person’s risk of future pain and activity limitation. The development of non-trauma MSK pain in athletic populations is better predicted by factors such as sudden increases in training volume, poor sleep, fatigue, and depressed mood than structural factors. The strongest predictors of MSK pain chronicity and

KEY MESSAGES Musculoskeltal pain in the absence of trauma does not equal tissue damage Address any underlying physical and mental health contributors Encourage self-management

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disability are avoidance of movement and activity, pain-related distress, and low selfefficacy. A new approach is needed Over-treatment of sport-related pain complaints can be reduced. In the absence of trauma, do not assume that pain indicates tissue injury. Do not misinterpret age-related changes on imaging for pathology. Consider, screen for, and manage the athlete’s overall physical and mental health as well as training-related factors to improve function, pain and sports participation. Physical activity is safe and protective so keep athletes training as tolerated. Use symptom palliation (passive therapies, medication, injections) only as an adjunct to active management (education, physical activation, lifestyle changes). For non-traumatic MSK pain, only use evidence-based surgical interventions that are supported and when evidencebased non-surgical interventions have been trialled. Use shared decision making

to devise an individualised treatment plan. Empower athletes to develop skills to selfmanage possible flare ups. Implementing best care practice principles is likely to reduce over-treatment in sports. References available on request. ED: The author acknowledges the input of Prof Peter O’Sullivan Author competing interests – nil

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CLINICAL UPDATE

EOS Imaging By Dr Nicholas Wambeek Radiologist In 1992 Georges Charpak won a Nobel Prize for the development of the Xenon Multiwire Proportional Chamber whilst working as a physicist at the European Organization for Nuclear Research in Geneva (CERN). This technology was then developed for clinical use as highly sensitive x-ray detector by French company EOS. It was introduced for imaging in clinical care in Europe in 2007 and has subsequently gained widespread acceptance in other parts of the world including Australia. EOS imaging offers very low dose image acquisition (up to 85% less radiation) and produces minimal magnification error, when compared to conventional x-rays. EOS takes simultaneous AP and Lateral images of the whole body and can be used to create 3D reconstructions where clinically applicable. Low radiation dose is of particular value in children and adolescents who may require multiple spinal x-rays for diagnosis and follow up of scoliosis, as this can result in significant radiation exposure over time. The open unit design increases patient comfort for adults and children. The patient stands in unit and is in direct visual and verbal contact with the radiographer. Generally, less than two minutes is required to obtain whole spine and lower limb imaging at high resolution The technology is validated for the study of spinal, pelvic and lower limb deformity in children and adults

KEY MESSAGES EOS allows simultaneous AP and Lateral image acquisition of the spine and lower limbs in the standing position. Its key applications relate to spine, pelvis and lower limb imaging, including sagittal and coronal balance assessment, and accurate lower limb alignment and leg length measurements. It is not a substitute for conventional joint radiography. Principal Applications These commonly include spine imaging for the diagnosis and follow up of scoliosis in children and young adults and pre and post-operative assessment of sagittal and coronal balance to optimise outcomes in spinal surgery. In the lower limb setting, EOS is the most accurate modality for leg length and alignment measurements pre and post operatively as well as spinopelvic mobility assessment prior to primary hip and knee arthroplasty and revision arthroplasty. In the general practice and allied health setting its primary utility is for assessment and follow up of suspected spinal deformities and limb length discrepancies in children and adults. It is not a substitute for standard radiographs of joints. Author competing interests â&#x20AC;&#x201C; the author works in a practice using EOS technology

Above: Simultaneous AP and Lateral Spine and lower limbs for evaluation of spinal balance and lower limb alignment in an adult female prior to hip surgery. Below: 42 yo male with old tibial mal-union. Low dose 3D EOS demonstrates fracture morphology and accurate femoral and tibial lengths, as well as lower limb alignment for pre-operative planning.

Open unit design increases patient comfort for adults and children. Patient stands in unit and is in direct visual and verbal contact with the radiographer.

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OCTOBER 2019 | 49

TRAVEL

A Wild Beauty

’m back to the Russian Far East, this time heading north from Anadyr in search of Russia’s equivalent of Africa’s big five – polar bears, Pacific walrus, wolverine plus various species of whales and seals. The other mammals on the checklist include Musk ox and reindeer, which were introduced into the region the 1900s, lemmings, Arctic fox and the abundant ground squirrel.

Waiting for us in the bay of Anadyr was the Kapitan Khlebnikov, a Russian icebreaker capable of carrying 110 passengers plus expedition staff, Russian crew and officers.

Culturally, there is also much to see and learn about the traditional coastal Chukchi and Yupik people, many of whom continue their reliance on fishing and hunting, just as their ancestors did.

The wildlife spotting started on the first day. Small groups of white Beluga whales, some with calves, plus the frisky spotted seals were swimming close to the ship in search of the abundant salmon which have come upstream to spawn.

As home for the next two weeks, it would weather open sea and crash through sea ice during our journey north along the Chukotka coastline, through the Bering Strait, across the Arctic Circle to Wrangel and Herald islands, two conservation areas rich with unique geology and biodiversity.

Kittiwakes, Guillemonts and gulls were wing by wing, scrabbling and nesting on the cliffs, looking every bit like high-rise apartment dwellers in tiny units. What a sight, and what noise! Geography buffs will know Cape Dezhnev as the north-eastern most point of the Eurasian continent. It is named after Russian Semyon Dezhnev who was first to sail through the Bering Strait in 1648, 80 years before Bering did in 1728. It is a lonely place. We landed and explored the snow banks and cliffs, and an abandoned Yupik village on the hillside above the small beach. The inhabitants were forced to leave by the Russian authorities in 1958. The Yupik,

First stop is Preobrazhnaya Bay for a zodiac cruise along the bird-studded cliffs.

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When you are invited to be ship doctor on a boat cruising the Russian Far East and Arctic Circle, there’s nothing for it but to pack the parka and stethoscope. GP Dr Lin Arias reports back.

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TRAVEL

who are often called Eskimos, also live in south-western Alaska.

food – whale meat and blubber, walrus meat, salmon, cakes and various berries and greens – are free to all. Lovely beaded handicrafts and carvings are on display, and there’s plenty of information for youngsters about preserving their environment.

In the coastal village of Lavrentiya we lost ourselves in the fascinating museum there and were treated to an exhibition of local dancing and food. The indigenous people are allowed to hunt walrus and whales on a quota system. Marinated whale meat, anyone? It’s not for me, though I can vouch for the delicious cloudberries! Waking up to the sound of thick sea ice scrapping the hull gets everyone up and on deck. We have 20 hours of light and as we head north, darkness never really settles. Through breaks in the sea ice, we were treated to great views of humpback and bowhead whales. And then we heard the call: “Polar bear on the ice at 3 o’clock” which turned out to be the first of many sightings of these marvellous animals. We had a bonanza viewing experience when the ship sailed to within meters of a floating whale carcass. Six polar bears, including a mother and cub, were taking turns to feed. Usually the animals are solitary, each to its own area of ice, so having a group together is unusual. Sadly, we finally had to restart the engines and move on. Over the course of the trip we saw 40 bears, including several on land. Most of the time we spotted bears on the sea ice, either from the ship or when we went zodiac cruising. Small groups of Pacific walrus, with their long white tusks, were also numerous on the ice.

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The most watched event is the rowboat racing. Teams of six rowers per boat, with about four boats to a race, pull against the stiff wind and into the fog for 5km and back, watched and cheered on by those of us on shore.

We had two days of landings on Wrangel island, hiking with the rangers who live there all year round. Both Wrangel and Herald islands were untouched by glaciers during the Pleistocene era. It is thought they are the location of the last of the woolly mammoths to roam Earth. Now the islands are referred to as polar bear maternity wards, with over 300 dens on each island. Perfect for viewing and, as we discovered, close encounters. Good weather continues to prevail and we arrive at Lorina for the annual Beringian Arctic Games. Coastal communities along the Russian far east and Alaska’s coastline come together to celebrate their traditional customs and engage in some friendly competition.

As we head back to Anadyr, we cruise by grey whales feeding, gorgeous glaciated valleys with green hills dotted with colourful summer flowers, and visit ancient deserted occupation sites, such as Whalebone Alley on Yttygran Island. All along the trip naturalists give talks on subjects ranging from the history of Russian exploration and seafaring (keen readers may know of the unlucky Karluk) to sea ice dynamics, marine mammals, botany, ocean currents, and arctic ecology. There are reference books and plenty of fiction in the library, plus a gym, pool and sauna to while away time between sightings, chatting, meals and the next great day. Medically speaking, there were only viral illnesses and minor injuries to attend to on board this time. I hope for the same good fortune when I join the Heritage Expeditions’ cruise traversing the great North East passage.

Traditional dancers in beaded costumes sing and dance most of the day. Traditional

OCTOBER 2019 | 51

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THEATRE

No Freak, Fully Sikh

ukhjit Kaur Khalsa slammed her way into the national arts scene through performance poetry, representing WA at the Australian Poetry Slam in 2014 and a standout appearance on TV’s Australia’s Got Talent, in 2016, where her work brought racism starkly into the nation’s living rooms. Her energy is infectious and her talent inspiring. So, what’s next for poetry’s poster girl? The theatre, of course. Sukhjit hits the boards of the Heath Ledger Theatre in October in a one-woman poetry show that takes audiences on her own journey of growing up Sikh in the Perth suburb of Leeming. Fully Sikh is, as Black Swan State Theatre Company says, “a celebration of family and Sikh culture…It is the story of growing up as a brown, hairy Sikh girl in the Perth suburbs and features a Punjabi meal cooked live on stage.” How does a poetry artist with a suitcase full of three-minute poems go about stringing together a theatrical narrative to keep an audience transfixed for 75 minutes? With a lot of talent and some help from equally talented collaborators, namely director Matt Edgerton and musician Pavan Kumar Hari, who will be playing a range of Indian instruments in the course of the show. Over the past two years, Sukhjit and Matt have been working on the concept. While Shakespeare and his cohort made verse the lingua franca of the theatre in the 15th and 16th centuries, it’s not the usual medium for the contemporary stage but Sukhjit gives those bars a good rattle.

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Medical Forum spoke to Matt on the eve of the premiere of this unique coming-ofage story. “It's a really unique story from a performer with such an extraordinary story who tells it in such an extraordinary form,” he said. “I’ve worked extensively with Shakespeare plays and also with other contemporary companies such as the Sydney based Poetry in Action. But, it’s true, it is still unusual to have a full theatre show as a contemporary spoken word performance.” Fully Sikh is a co-production between BSSTC and Barking Gecko companies, so its content has wide appeal – for the Sikh community, the regular theatre crowd and young people. “It’s going to be a pretty exciting window into a culture many people don’t know much about in such an extraordinary form,” he said. “Sukhjit explores her years from late primary school through the high school years where she grapples with her identity as a member of a Sikh family and a high school community, with all the social pressures of tradition, faith and how to fit in. For young people from strong faith communities, there's some big challenges in growing up in Australia.” “It's pretty massive threshold to pass through growing up, working out who you are, working out what group of people you fit in with, and what identity you want to choose.” “Sukhjit is extraordinary in front of an audience but this is her first full length work of theatre,” Matt said. “My experience is developing new work – it’s something I've been doing for 20 years across various companies. My role is to work with an artist to help them articulate

Pavan Kumar Hari and Sukhjit Kaur Khalsa

the story they want to tell and help them find a form and a structure in which to do that.” “I’m a sounding board. We’ve had four creative developments now where we've had our designer, Isla Shaw, a wonderful Melbourne based designer, offer her input on set and costume design. Then musician/composer Pavan Hari, who works musical motifs to underscore the poetry, or in some instances his music is the only thing that we're hearing. So, it’s been working out how all of these different languages of theatre fit together.” Sukjhit is a seasoned performer, not just as a performance poet but she has done her time as intern at the Barking Gecko theatre company. She is instinctive about performance and Matt says she has a knowledgeable theatre head on her shoulders. “She's very articulate about theatre, she just hasn't made her own professional play before. She’s by no means a novice and as a performer she is a knockout. Some people just have that ability to step in front of the crowd and have people in the palm of their hands. She's certainly got that great skill.”

By Jan Hallam

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WINE REVIEW

Howard Park Builds on Strengths Howard Park began in 1986 as a micro boutique producer when John Wade, formerly from Wynns Coonawarra, crafted excellent riesling and cabernet from purchased grapes. Seven years later Jeff and Amy Burch took over the reins and the operation expanded significantly with the much-needed injection of capital. Vineyard land was purchased, wineries were built and production increased significantly.

By Dr Louis Papaelias

Today, after 30 years, Howard Park owns premium plantings in both the Margaret River and Great Southern wine districts. Much effort has gone into improvements in viticulture with clonal selection, soil management and identification of important blocks within each vineyard. Importantly champion winemaker Janice McDonald heads the wine making team. I had the good fortune of getting a glimpse into her wine making and selection expertise at a tasting at the Margaret River winery. A number of newly vintaged samples of the various vineyard blocks were arrayed on the tasting table and the exercise was to identify the differences between samples and then come up with a blend that was the best expression of the particular variety, in this instance cabernet and chardonnay. My own final mix shall not be talked about but I can say that I learnt a lot from Janiceâ&#x20AC;&#x2122;s conclusions, based on the wealth of experience that she brought to the tasting.

Jete Brut Blanc ($36)

2016 Flint Rock Shiraz ($32)

With 94% Chardonnay, 6% Pinot Noir, this cool climate Mount Barrow vineyard fruit gives this wine a delicate flavour and fine cleansing acidity. Partial fermentation in oak and partial malolactic fermentation add to the complexity brought on by 30 months of lees maturation. Very fine bead, tight structure with flavour and a persistent aftertaste. Named Australiaâ&#x20AC;&#x2122;s Best Sparkling Wine at the Champagne and Sparkling Wine World Championship 2017.

Made from Great Southern fruit which encompasses Mount Barker, Frankland and the Porongurups. A ripe plummy shiraz with overtones of spice and liquorice. Well rounded, supple palate and a pleasing, clean sumptuous finish. (14.5% alcohol)

2018 Riesling Mount Barker ($34) Vintaged from Mount Barrow vineyard at up to 370m elevation. Lifted citrus honeysuckle and lychee aromas. Full fruited with a whiff of lemon curd and a fine steely structure that finishes long. A classic Mount Barker Riesling drinking beautifully now as aperitif or accompanying seafood. Will handle spicy Asian dishes. Can be cellared for 10 years, easily. (12% alcohol)

2016 Leston Cabernet Sauvignon ($50) Made exclusively from selected parcels of the Leston Vineyard in Wilyabrup. The wine opened up with time in the glass. Classic cabernet cassis emerges with added touches of earth, black olive and dark chocolate. Lots of fine-grained tannin which matches and balances the intensity of the fruit. A good example of fine Margaret River Cabernet. Will age 10 years easily. (14.5% alcohol)

2018 Miamup Rose ($28) Made from Shiraz grapes grown on the Leston vineyard at Wilyabrup. Lightly pressed and partially oak fermented. Pale salmon in colour. Rose petals and red fruits with a touch of tannin make for a refreshing summer drink. Finishes dry. (13% alcohol)

REVIEWER'S

2018 Allingham Chardonnay ($89)

PICK

This is the flagship white named in honour of the late Muriel Allingham, mother and grandmother to the Burch family. Produced from the best blocks of the Allingham vineyard, situated in the cool Karridale subdistrict, the most southerly part of the Margaret River appellation. Initially reserved, then opens out in the glass to reveal ripe white peach and honeysuckle held together by energising acidity and restrained sophisticated French oak. A very long finish gives it the stamp of high quality. Good now but better in a year or two. (13% alcohol)

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OCTOBER 2019 | 53

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MUSIC

Discovery with WASO

ith WASO’s stellar 2019 season moving towards the pointy end of the year, it has just released its 2020 offerings and the future looks good from here. Principal Conductor Asher Fisch, who is a year into his second tenure with WASO, has continued to reinvigorate and inspire the orchestra as Medical Forum discovered when we spoke with the orchestra’s Executive Manager of Artistic Planning, Evan Kennea. “Asher is really thrilled with the orchestra and excited to create programs they love to play and that audiences find exciting, and maybe a little different sometimes, to listen to. We are five and a half years in with Asher and the orchestra still absolutely love him and he loves coming to Perth. And long may that continue.” In 2020 Asher will continue with his Discovery Concerts series, where he presents a keynote discussion exploring the nuances and origins of some of the great works of the repertoire, This could mean he jumps on a piano stool and plays piano with the orchestra as was the case in the first Discovery Concert. The first was held in 2017 and was received with much acclaim. “The audience loved the way Asher presented the music and discussed it and demonstrated at the piano, then highlighted sections of the orchestra. They took people on a journey of musical understanding. The feedback from the

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audience was just amazing,” he said. “Asher is such a great communicator. The way he talks about music and demonstrates various aspects of it. Even musicians in the orchestra, who spend their lives playing orchestral music, find Asha has new revelations for them.” Concerts in the Discovery Series are not just for lovers of classical music but for those looking to explore the genre. “Everybody is brought in and it wasn't only the experts who felt included, it was every audience member in the hall. It's really exciting and welcoming and engaging”. The next Discovery Concert is in November with the theme, ‘The Art of Orchestration’, which opens up the magical world of those single-instrument unforgettable motifs given the symphonic makeover. St Georges Cathedral Master of Music Joseph Nolan will demonstrate how Bach’s Toccata and Fugue sounds like on the organ, then Asher and the crew will put a Stokowski firecracker underneath it. Same too with Mussorgsky’s piano-to-orchestra Pictures at and Exhibition and sublime soprano Siobhan Stagg takes on Strauss.

plunge into the deep end of a big symphonic concept, but would love to be involved,” Evan said. The orchestra is hoping by loosening the bow tie a little, a world will be opened up to a whole new audience. “Once people are inside the hall and they hear the orchestra in full flight with a great conductor like Asher, it's a sonically powerful experience. People are often surprised by the emotional impact of the music as well. I think people have an idea of classical music that it is sort of light, fluffy. When in reality it can kind of grab you by the scruff of the neck,” Evan said. One of the highlights of the new season is the Beethoven festival, celebrating the composers 250th anniversary. WASO with dazzling pianist Behzod Abduraimov will present all five of Beethoven's piano concertos with Symphony No. 5 for good measure over three nights in November. Not to be missed.

In 2020, WASO will perform full orchestral concerts on Thursday afternoons called the Afternoon Symphony Series, which is a boon for those keen to see a full program without having to head out on a Friday or Saturday night. Another initiative is Naked Classics which isn’t has daring as it sounds – patrons will be invited to bring their drinks into the concert hall and enjoy a more relaxed social vibe, with conductors and presenters engaging with the audience and explaining the works they are performing. The target audience for Naked Classics is a younger set, those who have finished work and want to experience the concert hall and the orchestra in a more relaxed setting. “It’s an audience that isn't fully ready to

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COMPETITIONS BACK TO CONTENTS

Enter Medical Forum's competitions! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link. Movie: After the Wedding (Michelle Williams) has devoted her life to running an orphanage in a Calcutta slum. With funds running dry, a potential donor (Julieanne Moore), requires she travel from India to New York to deliver a presentation. Not everything is as perfect as it seems. In cinemas, October 24

Movie: Pavarotti Former actor turned director Ron Howard has jumped into the deep well that is tenor Luciano Pavarotti for his next bio-pic following from his hit documentary on The Beatles. In Pavarotti, Howard has much to work with. Pavarotti had a long career of enormous standing and his personal life was complex and intriguing.

Movie: Charlie’s Angels Director Elizabeth Banks takes the helm as the next generation of fearless Charlie’s Angels take flight. The new angels – starring Kristen Stewart, Naomi Scott, and Ella Balinska – are ready to fight evil wherever the mysterious Charles Townsend sends them.

While stories of leaving his first wife, Adua Veroni, with whom he shared 39 years of married life and three daughters, and subsequent marriage to his personal assistant Nicoletta Mantovani (with whom he had another daughter), it’s his music and magnificent voice that will live on down the ages.

In cinemas, November 14

He died in 2007 with an extraordinary catalogue of work including opera roles and recordings. His professional association with Australian soprano Dame Joan Sutherland was one of the opera world’s legendary partnerships.

Movies: British Film Festival

Pavarotti became ‘the people’s tenor’ after the concert to mark the 1990 FIFA World Cup in Italy where he was joined on stage with Placido Domingo and Jose Carreras before a live audience at the Baths of Carracalla in Rome. It was televised across the world and the CD and DVD sales kept the legend of The Three Tenors alive for decades. The rendition of Puccini’s aria Nessun Dorma became the anthem of the tournament and synonymous with Pavarotti.

Windsor and Luna On SX, October 30 to November 24

In cinemas, October 24

Maestro Asher Fisch takes the audience on a magic carpet ride through the intricacies of orchestration – composers who take popular single instrument pieces and gives it the lavish treatment for full symphonic flourish.

August Winners

Perth Concert Hall, November 22, 23 Pill Testing Law vs Harm

Theatre: Black is the New White – Dr James Flynn

Child & Adolescent Health Preterm Births Childhood Obesity T2DM in Kids, Myopia, Hearing Loss & Growing Pains

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.

Musical: Hair – Dr Michael Parola & Dr Nai Lai

Music: WASO Discovery Concert

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Like you, when the day comes to an end, we’re still on call

The best of British cinema heads to the Windsor Cinema and Luna on SX with a standout selection of arthouse and box office hits.

Day in, day out. We’re here to help.

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Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.

Movie: The Nightingale – Dr Tracey Muir, Dr Andrew Toffoli, Dr Michael Bray MAJOR PARTNER

August 2019

www.mforum.com.au

Movie: Amazing Grace – Dr Sue Bant, Dr Katherine Shelley, Dr Michael Armstrong Movie: Dora & The Lost City – Dr Angelo Carbone, Dr Germaine Wilkinson, Dr Andrew Leech Movie: The Angry Birds 2 – Dr Glenn Liew, Dr Annlyn Kuok, Dr Esther Moses, Dr Michael Light

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Wine winner

Fiona Stanley Hospital renal physician Dr Ashley Irish is the winner of the Castelli Wines from Denmark in the Great Southern. Among the gems is Dr Martin Buck’s pick, the Empirica 2016 Uvaggio – described as close to Rhone Valley perfection.

OCTOBER 2019 | 55

You don’t buy a practice every week, but we do

It’s a big decision, Huge. For most, it’s a once in a lifetime proposition. We take this very seriously too. So much so, that over the last 25 years we’ve developed a process for medical professionals looking to go out on their own. But we don’t just look at you, we look at the business as a whole. We act as your partners in ensuring that it is a viable and profitable opportunity. We assess everything - location, competition, client-base and growth potential. Then, and only then, we tailor a loan to meet your needs. Forgive the pun, but we have a lot of practice when it comes to buying a practice. Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.