Medical Forum WA 0718 Public Edn

Life Challenges Men & Boys Doctors’ Wellbeing Prostate MRI; Hyperbaric Medicine; PrEP

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2258.6 03/18 (0811)

EDITORIAL Jan Hallam, Managing Editor

Finding the Us in #metoo Sexual harassment and assault; bullying; rage; resentment; envy – let’s get it all out there in the open because it seems as if it is all around us; in our homes; in our workplaces; in our society.

There have been opinion pieces in the medical press published recently which suggest we are approaching a #metoo moment in medicine. The Australian Medical Students Association is rightly concerned about results published by the Medical Board of Australia and a research paper produced by the Medical School at the University of Newcastle, which paint a pretty grim picture of the bullying and harassment of junior doctors. We have looked at these in more depth on p12.

A young woman is raped and murdered in a park.

A gay man is bashed and killed. A husband kills his wife and children.

A wife kills her husband and children.

This is the endgame that the vast majority of people with destructive natures or poorly regulated emotions never reach. For most it’s enough to make another’s life miserable for reasons that range from “because my life is miserable” to “I’m superior and you will bend the knee to me”.

This kind of violence is rife and it has no socio-economic, political, racial, cultural or religious boundaries. It has been a part of our culture since we decided to stand on two legs but it doesn’t mean it is right and it certainly doesn’t mean that it can’t be changed.

The tide is turning, perhaps. After 100 years of the women’s movement – Great Britain just this year marked the centenary of women’s franchise (staggeringly only for women over the age of 30) – some penny, somewhere, surely has dropped.

We can argue socialism versus libertarianism until the cows lose interest – the should-do, must-do, can’t-do, never-do – and while that is being played out in its parallel universe, something far more important is taking place. People are speaking up – often it’s a mere whisper against the roar of power, but the stories are coming and they will be eventually swept in on that tide. And, a bit like the Busselton beachfront after a storm, there will be the need for a big clean-up.

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MEDICAL FORUM

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au

The MBA survey is particularly sobering because it starts from the premise “what my medical school didn’t teach me” in this instance about harassment and bullying, normalising it as behaviour to endure. If we were to apply that principle to the perpetrator, surely we should be asking “what medical school taught you to behave like that”?

The Doctors in Training Committee of the AMA WA released their 2018 Hospital Health Check surveying 700 juniors and that’s not pretty reading either.

Approaching the WA Department of Health for comment on these sorts of issues is a hollow exercise. Yes, they have the overtime agreements signed and in place; yes, there are pastoral care programs; and check the boxes for peer review and wellbeing education as well.

They can’t make people use these services but perhaps they can ‘encourage’ their hospital service executives to allow genuine complaints to be made without fear of repercussion and then act forthrightly to counsel the perpetrators.

Senior doctors play a role too. Call out colleagues. You know who they are. Talk to them.

People come to work to work, not to wage war for their safety and sanity.

Administration Jasmine Heyden (0425 124 576) jasmine@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

Journalist Mr Peter McClelland journalist@mforum.com.au Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

JULY 2018 | 1

CONTENTS JULY 2018

INSIDE 10 12 16 36

Spotlight: Peter Lyndon-James Doctors Wellbeing Raising Men Mountain Man

36

10

NEWS & VIEWS 1 Editorial: Finding the Us in #metoo - Jan Hallam 4 Letters to the Editor

WAPHA & HealthPathways - Dr Richa Tayal No Trust in Euthanasia Lobby - Dr John Hayes Have You Heard?

Beneath the Drapes Doctors Retreat Guthrie Test Widens Help for Tinnitus

16

6 7 15 29 34

12

LIFESTYLE 38 My Local: My Vicino 38 Recipe: Spicy Beetroot Soup 38 Wine Winner: Dr Maria O’Shea 39 Wine Review: Singlefile - Dr Louis Papaelias 40 Funny Side 40 WA Doctors Orchestra 41 The Happy Bowel - Dr Michael Levitt 42 Music: Tristan und Isolde 43 Theatre: Curious Incident of the Dog in the Night-Time 44 Competitions

Cover: Dr Neville Knuckey on Mt Blanc, France

MAJOR PARTNER 2 | JULY 2018

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MEDICAL FORUM

CONTENTS JULY 2018 CLINICALS

5

23

Prostate Specific Antigen Dr Chanika Ariyawansa

Men & Methamphetamine Dr Michael Christmass

Male Suicide in Australia Dr Stephen Proud

27

29

31

Management of Ureteric Calculi Dr Shane La Bianca

MBS and Prostate MRI Dr Tom Shannon

25

SBRT In Lung Radiotherapy Dr Sean Bydder

26 Bariatric Medicine Dr Neil Banham

33 Being PrEPared Dr Yin Min Hew

Workplace Culture The Good, The Bad & The Ugly

Thursday September 6 7:15 - 8:50am

for a Free Breakfast Royal Perth Yacht Club

Medicine is a hard gig and doctors have to shoulder heavy decisions with enormous consequences. But is there any place for behaviour that belittles and harasses co-workers?

Virtual attendance for rural doctors.

To attend or register for live steaming go to: www.doctorsdrum.com.au

34 Veterans’ Mental Health Dr Michael Woodall

35 Current approaches to PTSD Dr Rebecca Gannon

GUEST COLUMNS

8 Collegial Respect Works Wonders Dr Michael Lucas

19 From Boy to Young Man Mr Jarrod Kayler-Thomson

20 Diversification – the Super Option Mr Chris West

21 Personalised Therapies Mr David Beard

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

MEDICAL FORUM

JULY 2018 | 3

LETTERS TO THE EDITOR WAPHA & HealthPathways

of ENT pathways and use this model for further streams.

Dear Editor,

The most viewed pathways vary month to month but those most recently seen have been low back pain in adults, hypertension, tonsillitis and sore throat, cervical screening, codeine use and deprescribing, and mental health (anxiety, depression and suicide risk).

HealthPathways WA is part of a knowledge sharing community supporting primary care clinicians to plan optimal patient care with benefits resulting from networking with other sites to ensure continuous improvement.

Since its inception in 2015, take-up of HealthPathways has been positive. From January 2016 to April 2018, the number of monthly users has risen by about 273% (238 to 888) with monthly sessions up 315% (751 to 3003).

Both area health services and GP groups have acknowledged the system as a key enabler to achieve integrated care, particularly the communication between hospitals and GPs on patient referrals.

This reaffirms the important secondary role HealthPathways plays in reducing and managing hospital wait lists and potentially preventable hospitalisations.

Each month, there is a steady stream of return visitors and new visitors, a sign that users see value in the system. We expect this trend will continue.

Dr Richa Tayal, GP and HealthPathways WA Clinical Editor ....................................................................

No trust in euthanasia lobby

Australia has 30 HealthPathways sites, with pathways usually localised from existing pathways to reflect local practice.

For example, WA Primary Health Alliance recently authored a pathway to reflect new national cervical screening guidelines, which was subsequently replicated across Australia.

Dear Editor,

WA has localised 387 of 550 pathways, each reviewed by a GP clinical editor who collaborates with experts to include best practice referral and clinical guidelines, which in turn helps GPs access criteria for referrals.

Euthanasia “for the elderly, mentally ill and anyone who is suffering” declared euthanasia leader Andrew Denton in the Richard Fidler interview ( ABC Conversations) and in newspapers around the country.

As we localise new pathways and review current localised pathways, there will be opportunities for system improvement.

For example, we would expect to replicate the success of the recently updated suite

Dr David Goodall’s ‘rational suicide’ for being “tired of living” had the full support of the euthanasia lobby, even though he was not terminally ill. The WA Chief Psychiatrist supports euthanasia for the mentally ill,

while columnist Nikki Gemmell in the ABC Australian Story program supports euthanasia for people like her mother ,a closet Exit member, who suicided because of chronic foot pain. Speaking on ABC Radio, Dr Scott Blackwell supported euthanasing the frail-aged advanced dementia patients in nursing homes.

Even Blind Freddy can see that the euthanasia lobby has no intention of limiting euthanasia to the “terminally ill”. Why then do they continue to mislead the Australian People? The media should be demanding answers to these questions, but instead have fallen for the spin.

Readers may recall the notorious case of Mrs Nancy Crick, whom the euthanasia lobby claimed was “terminally ill” with bowel cancer, even though her doctors had stated that she was free of cancer. Mrs Crick ended her life surrounded by Exit members.

No one was charged for her unlawful death and there was no apology from the euthanasia lobby for misleading the public.

We know 98% of patients die peacefully with palliative care, yet 26% of patients die without access to that care (PallCareVic).

Service “depends on your postcode”. In an Open Letter to Politicians, the key message from 101 Palliative Care Professionals was to improve palliative care services rather than legalising euthanasia.

Veteran journalist and commentator Paul Kelly remarked that “Once euthanasia is legalised, the only discussion is how to further liberalise the law”. (The Australian) In Canada, six months after legalising euthanasia, the process has begun to extend it to the mentally ill, competent minors and to legalise advance requests for euthanasia.

Dr John Hayes, Woodlands

We welcome your letters and leads for stories.

Please keep them short.

"The true measure of a man is how he treats someone who can do him absolutely no good."

Samuel Johnson (1709-1784)

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4 | JULY 2018

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The biochemistry department at Western Diagnostic Pathology has expertise across multiple disciplines including clinical biochemistry, toxicology and clinical endocrinology. We also have an accredited registrar position with a wide variety of teaching opportunities.

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Prostate Specific Antigen Prostate cancer is one of the most common cancers diagnosed in Australia.

It is estimated that just over 16,000 new cases will be diagnosed this year (23% of all new cancers).

Even though the five-year survival rate is greater than 95%, prostate cancer mortality (12.7 % of all cancer deaths) is expected to be the third highest after lung and colorectal cancer this year. (Prostate cancer statistics | Prostate Cancer, 2017) Serum prostate-specific antigen (PSA) is an effective marker of prostate cancer; its value as a screening tool is less certain. (Prcic, Begic, and Hiros, 2016).

Table 1: Sensitivity & Specificity of PSA (Total) Range Sensitivity Specificity Positive Negative (ug/L) Predictive Predictive Value Value

prostate-specific antigen detection with well-documented variability in measurement.

Despite international efforts to standardise the assays across manufacturers, mainly through creating a common reference material, this has not eliminated betweenassay differences. Whilst there have been improvements, results from various assays remain non-comparable primarily due to use of different antibodies and calibrators. This applies to many other analytes and underpins why serial testing should always be done using the same assay to minimise the effect of result differences on patient monitoring.

Notwithstanding the variability seen between manufacturers, random variation will always form part of serial testing results. Both biological and analytical variability play a significant role when interpreting serial results.

Attempts to improve specificity that may be helpful include:

<2

25%

61.3%

4.8%

91.2%

2-4

29.1%

59.4%

19.3%

71.5%

• Age-specific reference range intervals and

4-10

62.7%

45.3%

40.9%

66.7%

• free PSA to total PSA ratio

2-10

81.9%

16.8%

37.4%

60.5%

10-20

8.4%

94.2%

46.7%

62.9%

>20

4.8%

97.8%

57.1%

62.9%

Various factors other than prostate cancer may cause abnormal levels of PSA, which may impact on patient care and should be considered when interpreting PSA results (see Table 2).

One of the most important factors seldom considered is the differences seen among PSA methods performed on different analysers.

A major reason is the lack of standardisation amongst the various manufacturers of PSA reagents. There are numerous assays for

A less used marker that seems to hold some promise of improved accuracy in predicting prostate cancer risk, compared to other markers is known as phi (Prostate Health Index). phi combines free-PSA, total PSA and truncated proPSA (p2PSA) into one index.

Truncated proPSA (p2PSA) forms part of the free PSA fraction found in the circulation, p2PSA is found in a higher proportion of free PSA in patients with prostate cancer.

The utility of this marker has not been fully characterised.

Table 2: Factors affecting PSA levels Causes of an elevated serum PSA

Dr Johan Conradie MBCHB, FCPath(Chem), FRCPA Head of Department – Biochemistry and Toxicology Consultant Chemical Pathologist

Dr Chanika Ariyawansa MBBS Registrar- Chemical Pathology

Dr Kalani Kahapola Arachchige FRACP, FRCPA, MAACB Consultant Chemical Endocrinologist

Phone 9317 0999 and ask for the Chemical Pathologist.

Table 3: Medicare Benefits Schedule (www9.health.gov.au, 2017) Prostate Specific Antigen (PSA): Total Medicare rebate is available under the following conditions: Monitoring of previously diagnosed prostatic disease (66656) One PSA test per 12 month period in men (66655).

Age

TAKE HOME POINTS

Benign prostatic hyperplasia (BPH)

• Prostate cancer is one of the most common cancers diagnosed today.

Prostate cancer

• Serial PSA testing should be performed using the same analysing platform.

Dr Melissa Gillett FRACP, FRCPA, MAACB Consultant Chemical Pathologist/ Endocrinologist

Prostatic inflammation/ infection Perineal trauma

• Always consider secondary causes of elevated PSA level.

Causes of a decreased serum PSA

• Interpret using age specific ranges

Medications:

• Appropriate use of free to total-PSA ratio are indicated for PSA levels above agerelated- median to <10 ug/L

• The usefulness of PHI is still to be confirmed.

Statins

Weight (Increased BMI) 5-alpha-reductase Inhibitors

NSAIDS Thiazides

Prostate Specific Antigen (PSA): Free/Total Ratio Medicare rebate is available under the following conditions: Follow-up of a PSA result that: 1) lies at or above the age-related median, but below the age-related, method-specific 97.5% reference limit – 1 test per 12 month period (66659), or 2) lies at or above the age-related, methodspecific 97.5% reference limit, but below a value of 10 μg/L – limited to 4 tests per 12 months (66660).

References available on request.

General Enquiries: Ph (08) 9317 0999 Email: admin@wdp.com.au Website: www.wdp.com.au Results Enquiries: Ph 136 199 For a list of Collection Centres and Laboratories go to www.wdp.com.au

MEDICAL FORUM

JULY 2018 | 5

HAVE YOU HEARD?

In the process of exploring our feature on doctor wellbeing (see p12), we spoke to the chair of the Doctors Health Advisory Service WA Dr David Oldham who gave us an update of the services now being provided here. The committee representing senior and junior doctors has been established and as per the DHAS WA’s contractual agreement with the Medical Board of Australia, the 24/7 doctors' helpline is taking calls on 9321 3098. The big project for 2018 is compiling a ‘doctors for doctors’ list which will be available on the DHAS WA website. The committee is also finalising doctor welfare guidelines, which will mainly target public hospitals employing doctors but David said they would be also relevant for private hospitals and larger group practices. “We're hoping to see the same sorts of supports available for doctors as there are for non-doctors.”

Youth mental health Australian Rotary Health is encouraging a conversation about mental health and young people at their forum and networking event for researchers and clinicians. Lift the Lid on Mental Illness: Young Minds Matter will explore youth mental health with keynote speaker A/Prof David Lawrence from UWA’s Graduate School of Education. He said mental disorders were among the most common and disabling health conditions affecting children and adolescents today.

“Young Minds Matter surveyed over 6000 families with children aged 4-17 years around Australia. We examine how mental disorders impact children’s development and learning, and what types of help

children need, and receive,” he said.

Information regarding ARH research grants will also be discussed at the event. It is hoped that through research ARH may have a positive impact on those figures.

The event is being held at the University Club, UWA, on Wednesday 25 July, 2018 starting at 6.15pm. Tickets at www. trybooking.com/VUTX

National men’s strategy Health Minister Greg Hunt announced a national men’s and boys’ health strategy 2020-2030 during National Men’s Health Week last month which will focus on mental and physical health. We are all for more support but we’re also wary of a politician’s nose for a good headline, so the proof of this pudding is in the eating. There was little information about anything – no who, what, when or why but there is to be an online public consultation later this year to help set the priorities. The minister was not clear as to which organisations would take the lead. Simply saying the government funded organisations such as the Men’s Health Information Resource Centre at Western Sydney University, Andrology Australia and the Australian Men’s Health Forum. Hopefully they will have some idea of what to do.

Money in sheds In the same media release, Health Minister Hunt reminded us that in the May budget the government was topping up the Australian Men’s Shed Association to the tune of $395,000 to make a total of $5.1m over three years to June 2019. But something appears to be rotten in the state of Denmark, more specifically Bridgetown.

Telehealth Awareness Week Regional GP Dr Damien Zilm was in Laverton when Medical Forum spoke to him about Telehealth Awareness week, which took place June 25-29. He put his hand up happily to be a spokesperson for the week, which was organised by WACHS, because he sees what a huge difference it has made to the outcomes of his patients particularly in remote locations such as Laverton. As the acceptance of telehealth grows among GPs and specialists, he also sees greater communication and collaboration between primary and specialist clinicians, which can only serve the patient well. Damien is both a provider and a user of telehealth as he goes on his rounds between Leonora and Laverton in the remote Goldfields, and also at the Northam Emergency Department and the Emergency Telehealth Service (ETS).

He said telehealth enabled him to give more integrated care to remote patients who are seeing a specialist. “Telehealth helps people

6 | JULY 2018

While the money is flowing in, it doesn’t seem to be flowing west. A spokesperson at the perhaps aptly named Grumpy Old Men’s Shed said that while any increase in funding to a service that has men’s mental health at its very core is most welcome the purse strings are tightly drawn at the national level. This ongoing imbroglio has led to a degree of tension between Men’s Sheds WA and the Australian Men’s Shed Association. Claw-hammers at 30 paces, it would seem?

Consumers want their data Australians overwhelmingly want ownership and control of their own health data (96%) and want to be asked for consent when their data is used by government, private companies or researchers (90%). These were the stand-out findings of a national survey conducted by Consumers Health Forum and NPS MedicineWise released last month. However, consumers were generally receptive to their data being shared for public or individual good (62.5%), and are significantly less likely to share it if the use is for commercial gain.

Over two thirds (64.5%) were comfortable sharing their de-identified data but only 21.8% were agreeable to identified data.

The release of the survey coincided with the release of the My Health Record System framework which outlines how data can be used and protected for public health and research purposes.

Apparently My Health Record data will be available on a de-identified basis to policy makers and researchers. But as the CEO of the Consumers Health Forum Leanne Wells said eloquently: “Without that trust and confidence we know from this research, this will negatively influence

to stay in their own community, helps them stay connected to their own GP, and allows the GP to incorporate the specialist’s care plan into their own management, so all of us are on the same page.”

Fast Facts In 2017: • More than 18,000 country outpatient appointments were conducted via the WA telehealth network as well as more than 7000 mental health services.

• Rural and remote patients use telehealth for more than 30 specialties including oncology, surgical follow-up, respiratory medicine, haematology, orthopaedics as well as education for chronic conditions such as diabetes and asthma.

• The Emergency Telehealth Service conducted more than 17,000 consultations.

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Doctors helping doctors

drapes beneath the

Overtime and over time It was suggested to us anonymously that some junior doctors working in the public system were doing too much unpaid overtime. The correspondent wrote: “It feels that the Health Department has a false indication of our working hours and everything looks great on paper but we are advised that we can't claim overtime.

I know from my own experience that I have worked for free at least 15-20 hours a week because I didn't want to jeopardise my chances to get into training. But now, I see junior doctors struggling at work and not feeling respected and it’s not fair.” It was tricky investigating the issue because there was no specific work site mentioned.

When we approached the Department of Health WA, they sent us the 2016 industrial agreement in which paid overtime (or time in lieu) looked to be locked up good and tight. But is there a disconnect between policy and procedure? The 2018 Hospital Health Check survey run by the AMA WA’s Doctors in Training Committee suggests there could be. Rosters reflecting hours worked was endorsed by respondents at only Joondalup Health Campus and PMH (94% and 80% respectively) – RPH sitting at 70%.

Not so good at KEMH (53%), SCGH (56%) and FSH (60%). When it came to seniors being receptive to approving overtime, only 21% of juniors at KEMH agreed with the statement and only 32% at SCGH. Clearly, there is a case for more transparency.

Vaccine mania Is it us, or is the whole town talking vaccines? Hard on the heels of research offering support for those living in anti vax postcodes comes the news that a vaccine research hub will open in Perth.

The global Human Vaccines Project based in New York, which aims to decode the human immune system, is opening its only international hub at Telethon Kids Institute.

It aims to accelerate the development of vaccines and immunotherapies against a range of major infectious diseases and cancers. Telethon Kids joins the vaccines project as the only site dedicated to children’s health and will lead the paediatric component. Canadian research Prof Tobi Kollmann will move to Perth to establish the WA hub. He will also be working as a clinician at the new Perth Children’s Hospital two days a week.

Prostate Cancer • Hesitancy

• Nocturia

• Frequency or urgency

• Haematuria

• Weight loss.

1.6* 2.1*

Benign rectal exam

2.8

12

1.9

3.3

3.9

12

9.4

3.3* 2.8

3.9

15

2.0* 3.3

10

Frequency or urgency

3.0

Malignant rectal exam

Nocturia

1.0 0.75 2.2

Hesitancy

Weight loss

Figure 4: Probability of cancer if clinical features present1

PPV= Positive predictive value (%) or probability of cancer

2.2

PPV as a single clinical feature

1.8

Haematuria

1.8

Loss of weight

3.2

Nocturia

4.7

Hesitancy

3.1*

Frequency or urgency

4.0

Benign rectal exam

13

Rectal exam malignant

Risk factors • Increasing age8 • Family history of prostate, breast or ovarian cancer (see RACGP Red Book for risk criteria).

2

For example, the probability of prostate cancer for nocturia alone is 2.2%, but nocturia combined with weight loss increases the probability to 12%.

Two separate presentations of nocturia have a probability of 3.3%.

Probabilities highlighted in red are >5%, and urgent referral should be considered.

>5% probability of cancer 2-5% probability of cancer 1-2% probability of cancer <1% probability of cancer

*

Second presentation denotes data unknown

Diagnostic option to One-Stop Prostate Clinic Criteria for referral

• Hard, irregular prostate on DRE, regardless of PSA result

• Rising/raised age-specific PSA with symptoms.

Implications for practice • Severity of symptoms does not predict prostate cancer.

• Men age >40 years with lower urinary tract symptoms should have a Digital Rectal Exam (DRE) and PSA blood test.

Fax referral to One-Stop Prostate Clinic at Fiona Stanley Hospital f: (08) 6152 8069

Figure 4 shows the probability of prostate cancer for individual and pairs of clinical features, including second* presentation.

Note: PSA should be taken at least 2 weeks after treatment for UTI. Two PSA measures should accompany referral.

For further information contact One-Stop Prostate Clinic

Same-day assessment and TRUS biopsy at Fiona Stanley Hospital

p: (08) 6152 6916

Follow-up of results by One-Stop Prostate Clinic

Refer all suspected prostate cancer to a Urologist affiliated with a multidisciplinary team (MDT).

Public health advocate and former DG of Health Prof Mike Daube was named 2018 Western Australian of the Year.

Mr Glen Power is the new CEO of Perth Clinic. He was most recently leading the Pathwest Transformation project.

Prof Bryant Stokes has stepped down as Chair of the North Metropolitan Health Service to take on a review of the public mental health services. Mr Jim McGinty is the new NMHS chair.

Former CEO of Optometry WA Mr Tony Martella is the new Executive Officer for operations at the AMA (WA).

Dr Michael Quinlan and Prof Christobel Saunders were made officers of the Order of Australia in the recent Queen’s Birthday honours while Telethon Kids Institute director Prof Jonathon Carapetis, Bridgetown GP Dr Thomas Jones, pain specialist Dr Roger Goucke, physician Dr David Hillman, pathologist Dr Domenico (Dominic) Spagnolo, urologist Dr John Taylor and A/Clin Prof John Rosenthal were also recognised with awards in the general division.

Former national president of the AMA Dr Michael Gannon has been appointed to MDA National’s Mutual Board.

Dr Richard Hopkins is the new Managing Director of Perth-Based bio-pharmaceutical company, Zelda Therapeutics. He was previously CEO of PharmAust Ltd and MD and cofounder of Phylogica.

Finding Cancer Early

Symptoms that best predict prostate cancer1

Haematuria

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consumers’ willingness to consent to the use their data. It is heartening to see that the findings of the research are reflected in the framework, particularly that My Health Record data should not be used for commercial or non-health related purposes such as determining eligibility for welfare benefits, insurance assessments and direct marketing to consumers.”

A number of WA GPs have lent their support to the Cancer Council WA’s campaign to encourage particularly rural GPs to find cancer early using the specially devised tools developed by CCWA. The campaign kicked off in April and a second round of advertisements will kick off on July 7. The program targets people over 40 years of age living in regional WA with a focus on early detection of the five most common cancers: bowel, breast, lung, prostate and skin. Ds Rob Whitehead, Colin Smyth, Marie Fox, Tonya Constatine and Prof Max Kamien revealed quite a bit of themselves in the television campaign in 2014-16 to encourage people to seek help. The campaign will run until December 2020.

Prof Elaine Holmes has been awarded the Premier's Science Fellowship ($1m) and Dr Ruey Leng Loo an Early to Mid-Career Fellowship ($500,000) for their work in phenomics research and data analysis.

Nearly $4m of partnership grants committed by the State government and NHMRC have been awarded to: Prof Elizabeth Armstrong (Rehabilitation services for Aboriginal Australians after brain injury, ECU); Prof David Atkinson (Improving mental health screening for ATSI pregnant women and mothers of young children, UWA); Prof David Mackey (Targeting at-risk relatives of glaucoma patients for early diagnosis and treatment UWA); Prof Tom Brett (Improve detection and management of Familial Hypercholesterolaemia in primary care, UNDA); Prof John Newnham (Multi-state partnership to prevent preterm birth, UWA); and A/Prof Rae-Chi Huang (Early-life stressors and LifeCycle health, TKI).

Epidemiologist Prof Rosa Alati is the new head of Curtin University’s School of Public Health.

View referral contact details for metropolitan and regional WA.

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JULY 2018 | 7

INCISIONS BACK TO CONTENTS

Collegial Respect Can Work Wonders Communication between colleagues is much in the news. While consensus can’t be guaranteed, surely respect can, suggests Dr Michael Lucas.

Following a recent Independent Medical Examiner (IME) review of a motor vehicle injury claimant, on my desk this month a written communication from a fellow Consultant Physician arrived.

The letter commenced: Dear Dr, I gather you are in the minority of flat earth society doctors who still believe (specified condition) does not exist…

Thereafter followed a collection of justifying comments and derogatory insinuations supporting the author’s opinion, concluding with the statement Enjoy your Homework.

Clearly the author was of the opinion that I had much to learn.

While certainly capturing my attention, I did wonder if the content and tone of such a physician-to-physician communication was truly reflective of the expected benchmark for this day and age, or whether there perhaps remains room for us to remind ourselves of the importance of our intercolleague interaction skills.

The importance of communication skills for doctors is well established, and considerable efforts have been made to improve such skills. Poor communication between doctors has been cited as being at the heart of many complaints, claims, and disciplinary actions.

A recent British Medical Journal article (Davies, 2015) explained the importance of maintaining good relationships with colleagues and communicating effectively with other health professionals.

highlighting issues in relation to effective communication among health care providers. Limitations in training in medical school and residency to communicate well with people were noted and insufficient emphasis in our training on taking the time to write a really good letter was suggested.

A comment in Physicians Practice (Jacques, 2015) suggests, perhaps wisely: “No matter how we choose to communicate – whether it's on the phone, in an email, or via text – view every single message delivered as a piece of formal correspondence that will live on in perpetuity.”

The author suggested in our role as key decision-makers and influencers of organisational culture, senior physicians play a critical role in fostering greater care coordination by improving physician-tophysician communications.

The last thing we should want is for a casual, off-the-cuff comment to resurface in the wrong place with the wrong people at the wrong time.

When clinical opinions differ, it is perhaps even more important to bear in mind we should treat colleagues with respect and dignity.

I recall an article in the Physician Executive Journal (Shannon, 2012) some time back

A commitment to preserve the integrity of our professional relationships should underlie the tone of every digital and personal conversation we have and sets us apart as respected professionals.

References available on request.

ED: Dr Lucas is an Occupational Physician, Interim RACP Western Australian Committee Chair and State Representative on the RACP College Council.

CURIOUS CONVERSATIONS Running, Reading and Politics

Dr Peter Burke is very happy with his first career choice.

My second career choice would have been… journalism. But they’re a hard-drinking lot and no one pays them much anymore so I’d be a penniless dypso by now.

If I could win an Olympic Gold medal in any sport I’d choose… the 10,000 metres with a big surge past the struggling East Africans in the last 200 metres.

The best thing about being a doctor is… everything, if you’re

8 | JULY 2018

interested in human beings. What a job, an endless source of humour, pathos, sadness and drama.

One person I really admire is… Jimmy Dore, a comedian who analyses the media spin of world politics. YouTube him!

One book I’d love to have written myself is… sorry, just can't separate the holy trilogy of Brave New World, 1984 and Farenheit 451.

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FEATURE

An epiphany turned around the life of drug user and dealer Peter Lyndon-James. Now he’s helping others to go straight.

B

ouncing back from a troubled and highly dysfunctional background is a tough task but the founder of Shalom House, Peter Lyndon-James, has done just that… and a lot more besides! After spending nearly 30 years in institutions, Peter is now helping other men to live better and more fulfilling lives.

“I was nine years old when my dad walked out leaving my mother with five kids and she just couldn’t cope. So it wasn’t all that surprising when I ended up living on the streets, being physically and sexually abused before being made a ward of the state at a very young age.”

“I’d never done anything wrong but I kept running away from foster homes so they locked me up in Longmore and Riverbank.

Imagine, a nine year-old being stripped naked, given a pair of pyjamas and six comic books and locked in a prison cell? I just lay there hugging my pillow and crying.

All I wanted was my mum and dad.”

“In 1991 I graduated to the ‘Big House’ at Canning Vale and since then I’ve sampled the delights of almost every institution in WA.” “I felt comfortable in prison, those people became my family and many of them had stories just like mine. It was a terrible culture but it’s something I adapted to, you have to project an image of toughness otherwise you get bullied and bashed. The only problem was that all these people were doing things I really didn’t want to do.”

“I wanted to be a ‘geek’, a normal person doing good things with my family.”

But that was easier said than done and Peter soon stepped back into some pretty extreme behaviour.

Hard on the outside “After I got out I was soon back selling 2.5kg of methamphetamine a day, and dealing in guns and explosives. I didn’t look great, either. I had a long beard, tattoos, gold chains and big rings on my fingers.

Early one morning our house was raided by the Organised Crime squad, they came through the front door with shotguns, there was a chopper over the roof and my wife and young son were cowering on the floor.”

10 | JULY 2018

“I snapped, I’d had enough and I hated who I was.”

After a lot of soul searching and, what he describes as ‘divine intervention, Peter’s life went in a vastly different direction.

“I went back to study and became a volunteer prison chaplain. The first day I walked back into Acacia one of my old friends saw me and asked me what I was doing. I told him, and added ‘I’ve got the keys this time, mate’. He laughed.”

Reuniting families “It’s not easy to get to the final stage and graduate from Shalom, and many don’t make it but many don’t go back to drugs, either. A big part of what we’re doing is putting families back together. That’s what I wanted in my own life, a normal family life.”

Shalom House is run as a business.

Residents pay $300 a week to stay in the facility, they work five days a week and doctors are an important part of the equation.

“In 2012 we opened Shalom House in the Swan Valley, a place that’s regarded as the strictest rehabilitation centre for substance abuse in Australia. We’ve got about 130 men there now, they get up at 5.30 in the morning and then it’s off to breakfast and work.”

“We’ve had psychiatrist Dr Willem Van Wyk from the Marian Centre with us from the beginning and Dr Graeme Hammond does the medicals for everyone who comes through the door. It’d be great if a few more doctors visited and had a look at how we run things here.”

“There’s no smoking, no swearing and if I see that two guys don’t like each other, I put them in the same room.”

“We’re an entirely self-funded, not-for-profit organisation and we plan to roll out this model across Australia. Everyone here is on the same page, you won’t find any big salaries, it’s just good people trying to make a difference.”

“Shalom is a ‘cold turkey’ facility. Even a person coming down off alcohol will get, at most, a couple of Valium. We had one guy who was on 140mg of methadone a day and he made it through OK. He’s doing well now and is a completely changed young man.”

“Shalom is all about telling people they can change their lives and that they’re worth something.”

By Peter McClelland

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Finding Drug Solutions, Inside Out

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FEATURE

Doctors are standing up to defend themselves and their colleagues from bullying and harassment but much more needs to be done.

S

ince 2015, when spikes of doctor suicide, sexual harassment and bullying became national headlines, there has been an outpouring of reflection, from both inside and outside the profession, on a culture in which such behaviour can be passed over as normal, or an unfortunate by-product of the pressure-cooker nature of medicine.

The positive to come from all the soul searching is that this way of thinking is no longer acceptable by the vast majority of doctors, regardless of their seniority.

However, if affected parties and the community at large expected immediate reform, they would be severely disappointed. Complaints, as illustrated below, continue to pour out of the system, but conversely, poor behaviour continues to draw the attention of researchers, regulators and the media.

In May this year, the Australian Medical Council and the Medical Board of Australia released the results of their Preparedness for Internship Survey which was designed to assess how well medical school prepares students for the workplace. Of the 658 interns who responded, 82% were in their 20s, 15% in their 30s and 3% were 40 years or older.

Gaps in education While high ratings were ascribed to their core clinical training (history taking, examining patients, communication with patients) and other skills such as informatics, preventing cross infection, IV cannulation and teamwork, most respondents did not think medical school had prepared them well for issues “such as seeking support for psychological distress, bullying and harassment, or raising concerns about colleagues who were distressed or not performing.”

The AMC and MBA acknowledged that a sample bias may have arisen because not all of the intern population took part in the survey. Even so, the survey overall indicated the vast majority (75%) were satisfied that medical school had prepared them well enough, despite significant variance in responses.

While 42% found patient care and interaction the most satisfying part of their

12 | JULY 2018

internship, 25% found that workplace personalities and politics to be the most challenging aspect.

year’s survey reflects slight improvement in culture but there are still some worrying figures.

When questioned on their preparedness for situations requiring support, nearly 35% thought they were not prepared or poorly prepared to raise concerns about bullying and harassment; 40% only felt somewhat prepared. The figures were similar for raising concerns about colleagues, and seeking support for psychological distress.

Medical Forum spoke to Dr David Oldham, the chair of the Doctors Health Advisory Service WA, who said over the past 12 months, some hospitals had taken strides in improving communication channels. Royal Perth Hospital for instance has appointed a dedicated wellbeing officer.

Culture holds them back Tellingly, when asked what would have helped them be more prepared for the workforce, respondents put raising mental health issues and issues around patient care in the too-hard-basket “because of medical professional culture” and fear that asking for help would reflect poorly on their capabilities.

Surveys of PGY1 and PGY2 doctors in NSW and the ACT conducted in 2015 and 2016 (n = 374 and 440 respectively) by researchers at the University of Newcastle, was published in February this year in the Australian Health Review. They describe rates of exposure to bullying and sexual harassment and what actions, if any, were taken in response to complaints.

“DHAS has been assisting peer support groups and we recently went to a practice session at RPH and it is a really good model, which is reflected in the DiT survey, I think,” David said.

The DiT survey indicated that 5% of respondents had reported sexual harassment in the past 12 months and 65% felt confident their hospital would act and maintain their confidentiality. Up to 40% of respondents reported bullying, with 50% confident their complaint would be acted upon in confidence.

The estimated response rate was 17-20% and results from both surveys followed almost identical trends. Most respondents in both surveys reported being bullied (n = 203 (54.3%) and 253 (57.5%) respectively), 1619% reported sexual harassment (n = 58 and 82 respectively) and 29% of females reported sexual harassment.

However, at individual hospital sites, this confidence fluctuated widely. At KEMH and PMH, only 26% and 29% respectively had confidence that bullying would be acted upon. At Fiona Stanley Hospital it was 50%; SCGH, 43%; RPH, 54%; and Joondalup, 75%.

The authors concluded that the reasons junior doctors did not take action in response to these incidents included workplace normalisation of these behaviours, fear of reprisal, and lack of knowledge or confidence in the reporting process.

A spokesperson for the WA Department of Health said health services had “a variety of health and wellbeing initiatives, practices and programs” for DiTs including “pastoral care for staff experiencing challenges with respect to work or their personal lives; organised peer review group sessions; induction and wellness training in communication and resilience; mental health training and onsite welfare advocates who are available to provide independent and confidential support to DiTs”.

The Blame Game For those who did take action, most reported ineffective or personally harmful outcomes when reporting to senior colleagues, including being dismissed or blamed, and an intention not to trust the process in the future.

In May, AMA WA released its Doctors in Training 2018 Hospital Health Check.

Coming off an explosive 2017 report, this

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The hopeful signs are that both morale and culture have improved, though KEMH

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The Good, The Bad & The Ugly

FEATURE

remains lowest at 35% on both scores.

Let the light in

“Hopefully we have reached the bottom of morale and there are signs of a turnaround, but it will take time,” David said.

However, what seems to be seriously lacking is transparency – which goes handin-hand with a culture that turns a blind eye, if not positively encourages, silence.

“The key will be engagement by hospital executives. Unless the executives are willing to commit to initiatives and attend meetings with junior doctors, and senior doctors pay more than lip service, nothing will change. But I think the signs are good.

There are people in most of the health services who are committed to taking those steps.”

MEDICAL FORUM

Medical Forum has spoken to many doctors about this cone of silence, and more and more are telling us bad behaviour needs to be called out. One senior doctor said we must stop “eating our young” while another has suggested that an individual doctor could be a change agent. “If individual senior doctors did more

to counsel errant colleagues on the spot, the culture of the workplace would improve immeasurably,” they said.

By Jan Hallam

At the next Doctors Drum on September 6, the panel will take on the challenge of Workplace Culture: The Good, The Bad & The Ugly.

JULY 2018 | 13

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FEATURE

Getting Away From It All – Briefly A trial for a junior doctor wellness retreat has produced such positive reactions, it will be rolled out across the country.

G

iven that private health insurers commit time and money supporting consumer wellness programs to keep their members healthy and out of hospital, it begged the question what do medical defence organisations offered its members.

As it turned out, doctor wellness, especially for junior doctors, has become a particular focus.

There is, of course, an emphasis from MDA National, Avant and MIGA to support doctors going through the stressful AHPRA complaints process largely around access to confidential peer and professional support. There are also sponsored health assessments. At MIGA there is a Caring for Our Colleagues workshop as part of its risk management program.

And, of course, all MDOs are active participants in the national independently run doctor health services, which have been established by funds from the Medical Board of Australia with support from the state branches of the AMA. A new initiative from MDA is its fully subsidised Live Well Work Well Junior Doctor Retreat, which was been trialled recently for junior doctors in Queensland in conjunction with AMA (Qld) and Beyond Blue. Participants attended workshops led by senior doctors, did mindfulness and yoga sessions with trained practitioners and generally ate healthy food and shared stories with their peers.

MDA’s national event manager Kylie Philippzig said the success of the retreat has made a national rollout among its junior members a sure thing.

Knowing then and now One of the workshop leaders, psychiatrist Dr Catherine Llewellyn, told Medical Forum that she shaped her session around the topics she would have liked to have discussed with someone at the beginning of her career.

“Things such as setting boundaries, pacing yourself, looking after yourself, knowing how to switch off – these are important strategies that are beneficial to address,” she said.

“There is a lot to juggle in those early years.

Hospitals are enormously complicated systems that have complex politics and

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junior doctors have to learn how to navigate those systems and make serious decisions in what are often difficult and distressing scenarios.”

While there are still lingering elements of the ‘I did it tough, so you should too’ culture, Catherine believes it is far less prevalent now.

“But that doesn’t stop a junior doctor’s anxiety over how their seniors might perceive an acknowledgement they are struggling, especially if they are choosing their sub-specialties,” she said.

Cultural change needed “The different branches of medicine and surgery have their own internal cultures which have, in the past, dissuaded trainees to speak up. That still exists to a certain degree, despite the presence of collegially concerned and supportive bosses.”

“Programs supporting junior doctors all stress the importance of finding a mentor.

That person may not be in your specialty or your team, but it makes an enormous difference to have someone you can connect with for that collegial support.”

Another important message Catherine conveyed was about the impossibility of knowing everything.

“To begin your career feeling pressured to know everything is too much. I subscribe to the ‘more you know the less you know’ school and I’m sure that comes with experience. You must become selective about what information you need to know and what you don’t and those decisions are made in reference to your own special practice. If changes occur that affect my practice, I upskill. I think the attendees were reassured that we are all at times vulnerable and stressed and can’t possibly know everything.”

“We senior doctors need to remember what it felt like when things didn’t go right for us during our training, and, let’s face it, I don’t think you ever forget, and to take steps to protect our own juniors. That’s how cultural change happens.”

Lived experience Medical Forum also spoke to intern Dr Declan Scragg who was one of the ‘guinea pigs’ at the retreat and from his perspective it was a “fantastic weekend”.

“We did a lot of mindfulness stuff in medical school but once we started as interns, it has been a big change. It is now a much more conscious process.”

Declan is 37 with a wife and children and a ton of work and life experience before he began his medical studies at the age of 32, but he admits that medicine is a great leveller and found all the sessions at the retreat useful.

“I got a lot out of them. The skill of being present and non-judgemental of your thoughts, trying to control reactions to situations in a more productive way, group work – these were useful reminders now we’re working.”

“I still have a long way to go and still have my medical and surgical terms to come but I think everyone recognises, from the administration down, that it is not a good situation to have doctors work massive hours. It’s not safe, not good for the patient nor the doctor.”

For him the retreat was an outlet to be with his peers, sharing the good and bad of the first few months and hearing from senior doctors how they got through.

By Jan Hallam

JULY 2018 | 15

FEATURE

The ancient wisdom of initiating boys to manhood is nourishing a supportive process being played out in Perth with the help of a local GP.

M

Tapping emotions

ale adolescence has been described as a ‘descent into hell’. GP Dr Gavin Marsh is passionate about making the journey from boy to young man something a great deal easier than that. It’s all about confronting challenges and developing resilience with lots of support from role models who’ve done gone through the same thing in their own lives.)

“We think the word ‘ritual’ is so important for young men because it’s closely tied to forging a strong identity, a sense of self about just what it means to be a man.

People such as Tim Winton and Jordan Peterson have been talking about this for a while, and it goes back aeons, of course.”

“We’ve got an entire generation of young men with no idea of their place in the world. And sometimes that doesn’t end well for anyone. There’s an old African proverb that says, ‘a young man will burn down the village just to feel the heat of a fire’ and one way of preventing that is to build a community that facilitates a positive transition to becoming a man.”

“Most young men will model the behaviours they see around them. It’s like clothing, they’ll try on bits and pieces. If they’re relying on their peers, sometimes really good role models can be thin on the ground.”

Building values “Rites Together tries to build a strong sense of self in young people and give them the tools to build appropriate boundaries, to be able to say ‘no’ to things they really don’t want to be part of.”

Gavin acknowledges both the good work that’s been done in the past and the importance of a community-based approach in the future.

“A lot of organisations have tried to fill this space and I say, ‘good on them for that!’

Scouts, Guides and many religious groups, despite their current bad press, have been offering programs fostering self-reliance and strong values for years. But one of the founders of the Rites of Passage movement, Dr Arne Rubinstein, is adamant that it’s the broader community which needs to take up the sort of work that gives young people a sense of mission in life.”

16 | JULY 2018

“The day the boys return to their families is celebratory and we have a reunion a few weeks later. We give the men an opportunity to do some further selfdevelopment work, if they wish. The Rites Together camp often taps into a lot of unexplored emotions.”

“I never come away from a camp without learning something about myself. When you do this sort of work you have to continually think about your own journey and think deeply about your own life.”

“It’s interesting to see the new Australian cricket coach, Justin Langer, is seeking to develop the same ethos within the new crop of players. He wants them to be seen as good role models with a strong conviction regarding the appropriate way to behave on the field.”

Gavin paints a ‘word picture’ of just what happens on a Rites Together camp.

Mothers play a role “One of the first things we do is to redefine the relationship between mother and son.

It’s absolutely critical that the former steps back and releases her son, and there’s a ceremony that marks just that. That happens on the first day when the boys and their fathers are heading off to camp.

It can be a highly emotional time.”

“There are challenges involved, some of them physical. But what we’re really asking from a young man is to step out in different ways and find his own voice. There’s a lot of group story-telling, some of the fathers will talk about their relationship with their mothers and others may speak about sadness and issues surrounding sexuality.”

“The boys are hungry to hear what it’s like to be a man, what that actually looks like and how it feels to fail. Some of these sessions last for three hours and you can hear a pin drop.”

“It’s also a place of honouring a young man, of speaking about his skills and attributes not what might have happened in the past or what he might become in the future. Many of these concepts go back a long way in human history and we’re just doing it in a more contemporary way.”

There’s no shortage of amazing transformations on a Rites Together camp, says Gavin.

“The program runs for four days and the ideal age for the boys is between 15 and 16 years of age. It’s a place of change, we call it a ‘ritual space’ and it’s often very different from the outside world. We have men turning up with their own lives in total disarray so it can be big wake-up call for them, too.”

“Many of the boys arrive with hoodies over their heads, you can’t see their faces and there’s absolutely no eye contact. They’re so closed down and then we see it change, the smiles and the engagement with the group. Sometimes one of those young men will come back and join our leadership team, which is very satisfying.”

Inclusive process “Often a mother raising boys on her own is desperate for something like this and will ask us to find a male mentor to attend the camp with her son. We do that, and we also organise different payment plans to make it possible for anyone and everyone to attend.”

“Many aspects of modern life can be pretty dysfunctional. We need to seek out ways of marking and celebrating the achievements and the transitions in the lives of young people.”

“I’d encourage my medical colleagues to get involved. It’s an opportunity to understand yourself better and to be able to look at some issues in your own life within a supportive environment can be immensely rewarding.” www.ritestogether.org.au

By Peter McClelland

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Steps to Manhood – Together

Dr Gavin Marsh on a Rites Together camp.

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JULY 2018 | 17

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GUEST COLUMN BACK TO CONTENTS

From Boy to Young Man It’s important to mark the transition from boyhood to adulthood, suggests teacher Jarrod Kayler-Thomson who helps young men to do just that.

As parents we all want our children to grow up to be happy, healthy and successful. Our school launched an extraordinary program this year called The Making of Men, which runs the entire school-year and requires every Year 9 boy to live on campus for three weeks.

While they’re there, they engage in some interesting conversations, ones that wouldn’t normally take place in a classroom.

The journey begins with a boy packing his belongings in preparation for the immersion.

When he arrives he is shown to his bunkbed where he will sleep for the next 19 nights. Every boy must relinquish his mobile phone for the three weeks, and that’s a gutwrenching exercise for Gen Z boys.

The first two days, they participate in conversations and exercises designed to consolidate a particular set of values, both collectively and individually, and establish a psychology of trust.

With a single candle flickering, boys are asked to form a circle and the ‘talking stick’ is passed around. Each boy nominates a moment in time he believes has been significant in shaping who he is today.

They share their personal stories, which is challenging for 14-year-olds, yet the room is filled with understanding, gratitude and empathy. They’re on their way!

Seven days pass and the boys are reunited with their mothers (or a significant female).

The conversations shared over the next 24 hours explore this bond and they arrive at a shared understanding that this relationship must adapt to the fact that there are important differences between being a mother of a boy and fulfilling the same role in support of a young man.

It’s been 12 days since they last saw each other and they come together with some nervousness but also a willingness to see what this relationship has been, and what it can be.

The second week explores relationships with the boy’s mother, peers, girls and father (or significant male). This comes to a close with a weekend shared between the boys and their fathers.

Over the next 40 hours, boys and their fathers explore their relationship and learn from other men in this newly created community. There’s a critical moment at this juncture when the boy commits to being the very best young man he can be.

From that moment on, all the ‘boys’ are referred to as ‘young men’.

The latter are now on the final stretch of their journey. They take time to reflect on their life’s purpose, identifying both their strengths and areas that need refining.

The final night arrives and as a united group they leave their campus accommodation to attend a celebration.

One by one the young men are asked to stand alone to be honoured by their peers.

It’s beautiful, it’s brave and it’s confronting.

It’s a Rite of Passage.

ED: Jarrod Kayler-Thomson is head of Year 9 at Christ Church Grammar School

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Just as you need a balanced diet for healthy eating, you also need a balanced superannuation portfolio for healthy investing. The common denominator is the critical importance of diversity. We’re all well aware of the Five Food Groups: protein, grain, dairy, vegetables and fruit. And when it comes to Super it’s all about five different Asset Classes: Equities, Real Assets, Alternatives, Fixed Income and Cash.

Equities – The Investment Proteins Equities, or shares, are important for healthy growth. A diverse allocation to both Australian and global equities is a core ingredient of a healthy investment portfolio.

It’s really important to have a wide variety of different local and imported equities.

Yes, Texan steak, Japanese sashimi and a British Sunday roast!

Real Assets – The Investment Grains Real assets, property, infrastructure and

agriculture, are staples of an investment portfolio. One of the advantages of investing in Real Assets is that returns are correlated with inflation. A Real Assets portfolio is much more than just an investment property in Mandurah. Ideally, it should include commercial, retail and industrial property along with several types of infrastructure assets.

Regular wholegrains…then throw in some quinoa.

Alternatives – Investment’s Dairy A well-constructed allocation to Alternatives – hedge funds, private equity and other exotic investment strategies – will help to build strong, resilient bones in the face of market downturns. They should be taken in moderation and there’s plenty of room for substitution – but don’t fill up on ice cream!

Fixed Income – Time for Vegetables!

As boring as peas and brussels sprouts may seem, Fixed Income – Bonds primarily – is the often overlooked hero of a healthy investment portfolio. They provide stable

income and protection against inflation and keep your portfolio ticking along.

Cash – Here’s the Fruit Generally, you need less Cash than Fixed Income just as you need less fruit compared with vegetables. But it’s still important to have Cash on hand to take advantage of cheap assets and/or or to fund unexpected expenses.

A healthy investment plan should include all five of the above Asset Classes whereas speculative investments, such as soft drinks and salty snacks, should be kept to a minimum.

Eating healthily can be tricky, especially if you’re trying to keep track of everything yourself. The same is true of healthy investing. Seek help when you need it.

Disclaimer: This information is of a general nature only and has been provided without taking account of individual objectives, financial situation or needs.

ED: Chris West works for WA Super, GM Investments

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20 | JULY 2018

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BACK TO CONTENTS

Diversification – the Super Option

GUEST COLUMN BACK TO CONTENTS

Personalised Therapies There’s a lot to be gained in applying an individually focused approach to metabolic syndrome suggests Exercise Physiologist, David Beard.

When you’re talking about long-term improvements in weight control and better management of chronic conditions such as diabetes and metabolic syndrome, a relatively ‘new kid’ on the block involves the clinical use of an Indirect Calorimeter (ECAL).

It’s been around for while up in the stratosphere of the elite athlete but is now more widely available for the average punter.

ECAL measures O2 consumption and CO2 production and is a research standard for analysing whole-body energy expenditure.

It also provides an index of the nature of macronutrient substrate oxidation, namely carbohydrate (CHO) versus fat oxidation.

ECAL determines three key pieces of information relating to metabolic profile: • Resting Metabolic Rate (RMR): the calories an individual requires at rest.

• Substrate Utilisation: the proportional use of fat or glucose to produce energy.

• Mitochondrial Efficiency: the optimisation

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of an individual’s mitochondria to extract and utilise oxygen to produce energy.

The real value in measuring individual metabolism is that it facilitates the implementation of change and, with retesting, the ability to gauge if that desired metabolic change is actually taking effect.

So, how does this approach differ from standard diet and exercise advice?

Most current dietary strategies focus on creating a negative energy balance. While this is important for weight loss, a majority of studies has shown poor long-term compliance and consistent reports of persistent hunger. Without the use of ECAL you’re just guessing at energy balance, and that’s less than ideal. An ability to measure Substrate Utilisation also allows improved optimisation of fat use and takes the guesswork out of weight management.

An ECAL approach involves personalised exercise and diet strategies, refined with regular testing, that aims to optimise an individual’s metabolism. For example, we

may suggest dietary changes to increase fat utilisation thus decreasing the reliance on glucose to provide energy. We may also suggest exercise strategies to improve the cells’ ability to use oxygen, which might involve a program of less strenuous exercise.

The patient cohort that’s most likely to benefit from ECAL is one with a BMI of 30+, those with fatty liver disease and Type 2 Diabetes, women with PCOS and anyone considering bariatric surgery. Practitioners offering the ECAL program generally work with a patient for 12 weeks and the ultimate aim is a 5% weight loss (at least) over 12 months, which is clinically significant in terms of diabetes management, improved fertility and sleep apnoea.

Every patient has a unique metabolic profile and a personalised clinical intervention such as ECAL aims to normalise A1c levels and, in returning them to a pre-diabetic range, allow an individual to be medication-free.

References available on request.

JULY 2018 | 21

Every day, Silver Chain’s ‘Hospital at the Home’ (HATH) services the equivalent of 200 hospital beds in WA alone.

Referring your patients to our service this winter (for conditions such as respiratory infections and cellulitis) goes a long way to helping them avoid long Emergency Department queues and get the additional health benefits of staying at home.

Our service includes home hospital doctor and nurse visits, 24/7 contact centre and detailed reporting back to each patient’s GP. Referral of your patient to Silver Chain is simple, call 1300 466 346 to speak to our Ambulatory Liaison Nurses. silverchain.org.au/hath

22 | JULY 2018

MEDICAL FORUM

CLINICAL UPDATE BACK TO CONTENTS

Men and methamphetamine – What can the GP do?

By Dr Michael Christmass, Consultant in Addiction Medicine, East Perth Methamphetamine is synthetic and derives from phenethylamines, endogenous trace amines with structural similarity to the monoamines (dopamine, norepinephrine, serotonin). Adding a methyl group to phenethylamine gives a-methylphenethylamine AKA amphetamine. Adding a second methyl group gives a-dimethylphenethylamine AKA methylamphetamine.

Methamphetamine use declines with almost any form of constructive engagement in a treatment service (e.g. both placebo and treatment groups improve in multiple studies of various treatment modalities). But, poor treatment uptake (10%) and retention (<50%) is well documented.

Methamphetamine exists in three main forms of differing purity. The powder (street name “speed” 10% pure), the oily sticky base (street name “base” 20% pure) and the crystalline form (street name “crystal “or “ice” 80% pure).

Treatment, in the short-term, should exclude emergent problems including CVD (e.g. ischemia, dissection, arrhythmia), renal, and psychiatric. There is inadequate evidence to support any medication or psychotherapeutic intervention for withdrawal. Limited and brief (3-5 day) use of benzodiazepines may assist with anxiety and agitation.

Methamphetamine use has declined since 2001. But, since 2010, there has been a marked and continued increase in the number of methamphetamine users that prefer the crystal form (ice). Ice is more potent and can be smoked or injected producing rapid onset of intense effects.

Higher rates of dependence result and, in turn, individual and societal harms increase. WA has more methamphetamine users (2.7%) than anywhere in Australia (1.4% national average). The proportion of methamphetamine users preferring ice nearly doubled in WA between 2010 (43.9%) and 2013 (78%). This was far higher than the national average (50%). Australian men use more methamphetamine than women.

The good news, however, is 53% of users visit a GP compared with 10% for specialist services. GPs are in a position to establish perhaps the most important treatment tool for methamphetamine users: rapport.

In the long-term, develop a therapeutic alliance. Treat common medical (e.g. skin and dental infections) and psychiatric (e.g. depression) problems. Educate on harms and harm minimisation (e.g. safe injecting).

Encourage renormalisation (community involvement, relationships).

Consider clinical psychology. There is some evidence for CBT. Off-label naltrexone and bupropion (in less frequent users) have some evidence for effect in relapse prevention. Baclofen is not recommended.

Direct users and loved ones to the Meth Helpline (1800 874 878) or the Parent and

What is meth? Ice? Crystal?

Speed? Is there really an epidemic in WA? Do men use more than women? Isn’t meth a problem for specialists? Actually, GPs are especially well placed to help.

Family Drug Support Line (94425050, metro; 1800653203, rural).

When you need advice, contact the Clinical Advisory Service at Next Step. Finally, expect sporadic engagement, it’s not personal.

References available on request

Author competing interests: nil relevant disclosures. Questions? Contact the editor.

KEY MESSAGES Treat medical and psychiatric complications of methamphetamine use Withdrawal management is ineffective without sustained followup engagement (e.g. counselling) Rapport and long-term support to redevelop positive community engagement is important

Wastewater Reveals Drug Use in WA The Australian Criminal Intelligence Commission (ACIC) released its fourth report in April from the National Wastewater Drug Monitoring Program which showed that WA still reported some of the highest levels of methylamphetamine consumption in the country.

The report found that of the substances tested in Western Australia in December 2017: • Nicotine and alcohol remain the highest consumed substances.

• Average methylamphetamine consumption increased in capital city and regional sites.

• WA had the highest average regional

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consumption of methylamphetamine in the country.

• Average cocaine consumption increased in capital city sites and remained relatively stable in regional sites.

• Average MDMA consumption increased in capital city sites and remained relatively stable in regional sites.

• Average heroin consumption decreased in capital city and regional sites.

Samples were collected during October and December 2017, covering 12 substances. Forty-five wastewater sites were monitored nationally in December 2017, covering 54.3 per cent of Australia’s population—around 12.7 million people.

It was estimated from testing that over 8.3 tonnes of methylamphetamine is consumed in Australia each year, 3 tonnes of cocaine, 1.2 tonnes of MDMA and 700kg of heroin.

“Such estimates can then be compared with other data, such as the weight of drugs seized by law enforcement, to further enrich our collective understanding of these drug markets and identify the most effective supply, demand and harm reduction measures,” the ACIC said.

Methylamphetamine was by far the state’s most consumed illicit drug, however, rates of use for cocaine, MDMA, oxycodone, fentanyl and heroin were all below the national average.

JULY 2018 | 23

we've got you covered

Working together to provide comprehensive urological care Dr. Jeff Thavaseelan Dr. Shane La Bianca Dr. Andrew Tan Dr. Akhlil Hamid Dr. Trenton Barrett Dr. Matt Brown

Hollywood Clinic Suite 15 / Ground, Hollywood Medical Centre 85 Monash Avenue, Nedlands WA 6009 Phone (08) 9322 2435 / Fax (08) 9322 5358

www.perthurologyclinic.com.au refer@perthurologyclinic.com.au 1800 4 UROLOGY (1800 487 656) Healthlink: jthavase

Wexford Clinic Suite 23 / Level 1, Wexford Medical Centre 3 Barry Marshall Parade, Murdoch WA 6015 Phone (08) 6189 2970 / Fax (08) 6225 2105

Also consulting at Joondalup, Mandurah, Geraldton and Albany

24 | JULY 2018

MEDICAL FORUM

CLINICAL UPDATE BACK TO CONTENTS

Male suicide in Australia

CHOLESTEATOMA: A SERIOUS COMPLICATION OF CHRONIC OTITIS MEDIA Anne Gardner

Post Dip. Aud., BSc

By Dr Stephen Proud, Psychiatrist, Bunbury “Suicide is an event of human nature, which, whatever may be said and done with respect to it, demands the sympathy of every man, and in every epoch must be discussed anew”.

[Johan Wolfgang Von Goethe] Humans have attempted to explain it in the currency of each era, invoking gods, magic, sin, valour, philosophy, saving face, anomie and more recently, mental illness.

Different groups have variably been more prone to suicide. Women in eras and cultures where they had little power or voice suicided more than men. For the past 100 years in the developed world male suicide rates have significantly exceeded those of women.

Annually in Australia about 3000 people die by suicide with 65,000 attempts – 75% of those suicides are men. In middle age and above, about 84% are men.

Most suicides occur in men aged between 20 and 55 although the highest age specific rates occur in the young and the elderly. It is the leading cause of death in males under age 44 and the second leading cause in ages 45-54.

Suicide is also higher in some specific groups, such as indigenous Australians and returned veterans. More returned soldiers from conflicts after Vietnam have perished from suicide than from direct conflict wounds; last year 85 Australian veterans took their own life.

Why do men suicide?

Partly the answer lies in higher use of drugs and alcohol, partly in higher direct trauma roles, (e.g. defence force, fire fighters and prison service; women are more represented in police and ambulance services) but part of the answer lies in the lethalness of an obsolete notion of maleness that hasn’t evolved with society’s changing nature.

Men seek help less, seeing illness as ‘weakness’. They have less intimate confidants than women, are more likely to become angry than feel despair and sadness, and are less likely to talk and share their awkward feelings. Men are more likely to be divorced than to initiate the divorce and less likely to be the prime carer of children (either by choice or by coercion).

Depression, a common precursor to suicide, is equally prevalent in men and women, and both sexes preferred method is hanging; yet men suicide more.

What can be done?

Society should invest in the treatment of trauma, drug and alcohol abuse, emerging risks such as cyber bullying and mental health treatment and access. However, we need new ways of experiencing and understanding maleness. This requires fraternity, leadership (where are the male movement equivalents of Gloria Steinem) and progression of the men’s movement beyond the first wave of Robert Bly and Steve Biddulph.

Author competing interests: nil relevant disclosures. Questions?

Contact the editor.

KEY MESSAGES Suicide has always been with us.

Rates vary in differing populations.

More male leadership is required.

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Andre Wedekind M.Clin.Aud., BHSc (Physiotherapy)

Dr Vesna Maric AUD., M.Clin.Aud., BSc (Hons)

What is a Cholesteatoma?

Cholesteatomas are benign keratinising squamous epithelium, that grow throughout the middle ear cavity and mastoid process. The abnormal growth of skin forms from severe bouts of chronic otitis media or perforated tympanic membranes.

Prevalence of Cholesteatomas • Infants and children who experience Otitis Media, Chronic or Acute, are more at risk.

• Adults who have had recurrent ear infections are at greater risk too.

• Cholesteatomas are rare, children who experience OME and AOM that cause their tympanic membrane to burst are more at risk as skins cells are more likely to invade the middle ear cavity.

Course of progress There are two types of cholesteatoma growths; 1. Congenital Occurs during fetal development when the squamous epithelium gets trapped within the temporal bone.

Congenital cholesteatomas may grow throughout the middle ear cavity, eventually becoming large enough to erode the ossicles and temporal bone.

2. Acquired • Primary Acquired Cholesteatomas may follow retraction or perforation of the tympanic membrane which may cause infection and minimise the healing of the tympanic membrane allowing the epithelium to enter the middle ear and grow.

• Secondary Acquired Cholesteatomas may follow acute or chronic otitis media, eustachian tube dysfunction and otitis media with effusion. Secondary acquired cholesteatomas may also arise due to tympanic membrane scarring, for example from tympanostomy tube insertion.

SIGNS OF A CHOLESTEATOMA Foul smelling discharge

Hearing loss

Facial weakness

Tinnitus

Full feeling in the affected ear

Erosion of bones

Pain/discomfort, especially Dizziness behind the pinna

Servere cases, Meningitis

Cholesteatomas are locally destructive and independently grow due to active enzymes and acid produced by the epithelium itself, depending on the duration of the growth this may lead to ossicular erosion. Unless identified and treated in the early stages with medication, cholesteatomas need to be surgically removed to stop further damage from occurring.

A cholesteatoma which invades the inner ear can cause balance and sensorineural hearing damage.

Treatment Investigation by an ENT is needed to diagnose a cholesteatoma. Should the cholesteatoma be small enough to avoid surgery, cleaning of the external ear canal, antibiotics and the use of ear drops will be the initial steps to help reduce the growth and clean the affected ear.

A hearing aid or a bone conduction aid can be used to address any hearing loss resulting from the cholesteatoma and generally the outcome is very successful.

51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au

JULY 2018 | 25

CLINICAL UPDATE

By Dr Neil Banham, Medical Director, FSH Hyperbaric Medicine Unit For clinical purposes, the pressure must equal or exceed 1.4 atmospheres absolute (ATA). Most HBOT in Australasia is performed at 2.4 ATA.

Hyperbaric Oxygen Treatment (HBOT) exposes an individual to near 100% oxygen while inside a treatment chamber at a pressure higher than sea level pressure. What is its role?

Fiona Stanley Hospital Hyperbaric Medicine Unit (HMU) is the state referral service for Diving and Hyperbaric Medicine providing a 24/7 on-call service. It is the only facility able to provide HBOT at pressure equal or greater than 1.4 ATA in Western Australia.

FSH HMU has a new three compartment ‘multiplace’ chamber with the capability of treating intubated patients and two single occupant ‘monoplace’ chambers.

The Medicare Benefit Schedule has specific item numbers for HBOT. Accepted indications include decompression sickness and gas embolism, radiation tissue damage (including radiation cystitis and proctitis), problem wounds (especially diabetic foot wounds where the major vascular supply is present), necrotising infections (necrotising fasciitis and gas gangrene), acute ischaemia (retinal artery occlusion, failing flaps) and carbon monoxide poisoning.

These indications have a good evidence base. Often, HBOT is an adjunct to other therapies (good wound care for diabetic foot wounds, surgical debridement and antibiotics for necrotising fasciitis).

patients on medications which may lower the seizure threshold.

Refer patients via phone (6152 5222), fax (6152 4943) or email (FSH.Hyperbaric@ health.wa.gov.au). A list of accepted indications is on the FSH website.

Discussion or referral of difficult ‘fitness to dive’ cases is welcomed.

References available on request Author competing interests, nil relevant disclosures. Questions? Contact the editor

Significant complications are unusual. Mild middle ear barotrauma is not uncommon but easily managed. Transient worsening of myopia may occur during a course of treatment and is usually reversible over 6-8 weeks. Oxygen toxicity seizures are rare and self-limiting, being more common in

KEY MESSAGES HBOT has an evidence base in certain conditions.

It is generally well tolerated.

FSH HMU is contactable 24/7.

HBOT for radiation cystitis has shown to be effective in over 80% of cases – both in our experience and in the published literature.

The usual course of HBOT for this is 30 sessions (2.5 hours per day, five days per week for six weeks) – not an insignificant time commitment.

Newer emerging indications with a developing evidence base include refractory fistulating Crohn’s disease and idiopathic sudden sensorineural hearing loss.

A quick internet search will reveal a multitude of other purported conditions which ‘hyperbaric therapy’ will cure including autism, cerebral palsy, Lyme disease, chronic fatigue syndrome and Alzheimer’s. Such providers administer ‘mild’ hyperbaric therapy (air compressed to 1.3 ATA) in inflatable chambers, for which there is no published evidence of benefit.

FSH HMU does not treat such referrals.

There are few contraindications to HBOT—the main being inability to equalise middle ear or sinus pressures and severe claustrophobia.

26 | JULY 2018

MEDICAL FORUM

BACK TO CONTENTS

Hyperbaric Oxygen Treatment – what, when, how?

CLINICAL UPDATE BACK TO CONTENTS

Management of ureteric calculi

By Shane La Bianca, Urologist, Murdoch

Records of human kidney stones go back as far as ancient Egypt, over 7,000 years ago. Today, ureteric colic is one of the most common disorders of the urinary tract, with an increasing incidence thanks to changes in dietary and lifestyle habits over the last 50 years; one major factor is increasing Western society caloric intake, obesity and a tendency (in the heat of Australia especially) to dehydration due to inadequate fluid intake. Symptomatic stone disease often presents to ED’s.

Most kidney stones pass out of the body without any intervention.

Stones that cause ongoing symptoms or complications are often treated, usually without major surgery.

Treatment is divided into two phases, initial management and definitive (surgical) treatment.

The algorithm below is a useful initial management protocol. The colic sufferer is easily recognised - pacing in the waiting room, moving restlessly from seat to water fountain and toilet, sweating, green with nausea, asking, “How much longer until the doctor’s free?”

Stone Composition Straining the urine to obtain a stone for analysis is useful to ascertain if specific medical therapy is indicated e.g. treating hyperuricosuria with allopurinol to reduce serum urate levels.

Conditions like hypercalcaemia or renal tubular acidosis (RTA) are quite uncommon. Cystine stones are rare.

In recurrent stone formers, metabolic stone studies measuring serum levels and 24 hour urine production and solute excretion can be helpful but need to be done after initial episode has passed.

Radio-opaque stones are generally calcium-based and do not respond to dissolution therapies. CT is quite good at determining the calcium content of stones (Hounsfield Units).

Stones seen clearly on plain x-ray may be suitable for Extracorporeal Shock Wave Lithotripsy (ESWL). This is still available in WA as a mobile service with a transportable lithotripter that can be brought

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Ureteric calculi are painful, more common in our hot climate, and mostly idiopathic. Some calculi require referral, most require analgesia and time. into operating theatres as required. It is generally more useful for renal rather than ureteric stones (with higher clearance rates).

Common pitfalls Over-investigation is common. That is, most causes are idiopathic.

Markers of inflammatory response, an MSU to exclude ureaseproducing species such as Proteus, Brucella, Klebsiella) and assessment of renal function are usually all that is required. If clinical history is suggestive then biochemical assessment of Ca and s.Urate levels can be considered but is not critical in the initial phase unless suspecting hypercalcaemia due to malignancy or hyperparathyroidism (stones, bones, groans and moans).

One common myth is that increasing fluid intake will result in more rapid passage of a ureteric stone. Once a stone is impacted in the ureter, renal blood flow and filtration/urine production falls and peristalsis diminishes. Increasing water intake simply induces a diuresis via the unobstructed contralateral kidney - resulting in a very full bladder!

Another pitfall is persisting with analgesia for ureteric colic, that is ineffective. Initially, with severe pain, the use of opioid-based medication is reasonable, in conjunction with Tramadol™ and NSAIDs. Beyond the initial presentation, opioids become less effective and increasing doses of paracetamol/codeine may simply lead to constipation without adequate pain relief.

Stones greater than 5mm diameter, more than 5cm from the bladder and symptoms persisting for more than 5 days, usually mandate intervention. Renal damage is unusual in the absence of infection even with persistent obstruction.

Author competing interests: nil relevant disclosures. Questions? Contact the editor.

JULY 2018 | 27

28 | JULY 2018

MEDICAL FORUM

CLINICAL UPDATE

By Dr Tom Shannon, Urologist, Nedlands

Impact for primary care physicians?

Author competing interests: nil relevant disclosures. Questions? Contact the editor.

When combined with the previously released consensus guidelines, the early detection of prostate cancer has never been more straightforward. The guidelines recommend: • Men of average risk are tested every two years from the age of 50 with a PSA test R CER lue (%) a NCEECO CANNC ve v cer icti ER CA NG CALO TAT canCTAL CA red RE LU NCER PSRTOS = Positivbeapbility of A E pro PV BR

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• Men who are concerned about prostate cancer are tested from age 45

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• Two PSA tests more than one month apart with reading above 3ng/ml and FTR<25%, or a repeat PSA over 5.5 in a man less than 70

Only specialists can order the scans.

ria Noctu Fatigue

• DRE suspicious for cancer, or

Scans can be repeated at one year and every third year after, or if there is clinical concern.

We have previously published data showing much higher rates of significant prostate cancer in WA. We now have good tools to tackle this problem.

ple ancy oea Nip rgDyspn e Hesit Diarrhoea cha dis

A. Suspected of having prostate cancer:

• The patient is not planning or having treatment

• Refer for urological assessment if the DRE is abnormal OR the PSA is above 3 for average-risk men, above 2 for highrisk men and above 5.5 if over 70 years

1.0

a

To be eligible for a funded scan, a patient must be:

• The patient has been diagnosed with prostate cancer and is on active surveillance

• Repeat a PSA test after one month with a FTR

Bre

When done well, MRI reduces the need to biopsy by 50% while improving cancer detection rates and reducing the detection of insignificant disease. MRI is an excellent staging tool, which improves surgical outcomes, both oncological and functional.

B. Known prostate cancer on surveillance:

• Men at higher risk are tested from the age of 40

aturia

Early detection is critical due to small anatomical margins for curative resection and significant potential morbidity with advanced disease. From July 1 Medicare will pay up to $450 for multi-parametric prostate MRI, removing a significant barrier to access for many men.

• Two PSA tests over 5.5ng/ml and FTR<25% at least one month apart in a man over 70

Prostate MRI has been a major advance in the management of prostate cancer.

t loss Weigh Cough

Prostate cancer remains more common than breast cancer, with more deaths and more morbidity.

• At least double increased risk of prostate cancer with two PSA tests over 2ng/ml and FTR<25%, one month apart in a man less than 70. (One or more first degree relative positive)

ain st p

The early detection of significant prostate cancer in Australia has never been easier with the MBS now supporting prostate MRI and consensus PSA testing guidelines giving clear guidance to primary care.

Age

BACK TO CONTENTS

MBS and prostate MRI – what does it all mean?

Newborn Bloodspot Screening

9

50-5

-69

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The Guthrie ‘heel prick’ test has been an integral component of newborn care for 50 years. The screening procedure runs its ruler over approximately 25 different conditions and is estimated to save the lives of 35 babies in WA every year.

Health Minister Roger Cook is singing the praises of the WA Department of Health for its instrumental role in the development of a national Newborn Bloodspot Screening (NBS) framework.

“The creation of this framework will ensure NBS programs continue to be regarded as one of the most successful population health initiatives of our time,” said Mr Cook.

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WE HAVE TOOLS TO HELP GPs FIND CANCER EARLIER Download our new cancer risk assessment guides today.

Find out more at cancerwa.asn.au/gp/fce

In a further feather-in-the-cap for WA the policy framework has been endorsed by the Australian Health Ministers' Advisory Council.

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JULY 2018 | 29 CCW1042_GP Press_61x125.indd 1

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CLINICAL UPDATE BACK TO CONTENTS

SBRT revolution in lung radiotherapy

By Dr Sean Bydder, Radiation Oncologist, Nedlands

Stereotactic Body Radiation Therapy (SBRT) is a major advance in radiation treatment. For some patients, this allows shorter treatment courses, fewer side effects, and better treatment outcomes.

Traditionally lung cancers unsuitable for surgery were treated with six to seven week courses of radiotherapy, while metastases to the lung unsuitable for surgery were often not treated.

As SBRT is highly accurate, it allows larger doses of radiotherapy to be given with each treatment (fraction). It can avoid normal tissues better than previously possible. Entire radiation courses can be given in three to four fractions. These courses are biologically equivalent to several times the previous treatment.

CyberKnife Stereotactic Robotic Radiosurgery System SBRT can be given with the modern radiotherapy machines or purpose-built systems such as the CyberKnife. The CyberKnife system uses a linear accelerator mounted onto a robotic arm to deliver 100-200 separate precisely targeted radiation beams.

CyberKnife is ideally suited to treating lung tumours as it tracks and automatically adjusts for respiratory movement (using a combination of infrared monitoring and x-rays). A gold marker seed may need to be inserted near the tumour a few weeks prior to treatment to allow X-ray tracking. SBRT is non-invasive and generally well tolerated.

adrenal metastases, kidney cancer, prostate cancer, nodal metastases, and vertebral metastases. The CyberKnife system is also ideal for giving intra-cranial Stereotactic Radiotherapy (e.g. to brain metastases). The only two CyberKnife units in Australia are both in Perth.

Author competing interests, Dr Bydder declares a financial benefit from patients treated with Cyberknife stereotactic radiation.

Questions? Contact the editor

KEY MESSAGES SBRT using larger yet fewer, more accurate radiotherapy fractions is producing good results against cancer It is now the gold standard treatment for suitable inoperable early lung cancer Robotic radiosurgery systems can track lung tumour movement through respiration

Bev Eintracht and Tennille Crooks

A recent Australasian randomised trial compared SBRT with conventional radiation treatment for early but inoperable NSCLC. Patients treated with SBRT were less than one-third as likely to have local failure and half as likely to have died. Overseas, two randomised trials compared SBRT to surgery for operable NSCLC, but both failed to accrue enough patients. Overall there was a 95% three-year overall survival with radiotherapy – however with so few patients, it is wise to remain cautious.

SBRT might be especially beneficial to treat lung metastases (from lung or other cancers) where there are only a few metastases. Many non-randomised studies show local control rates of about 80%, with low toxicity.

Ideal patients for lung SBRT Surgery is preferred but many cancer patients have COPD or other medical conditions. SBRT is the next best choice. The ideal SBRT patient has a small peripheral tumour. Central lung lesions may be treated but this requires a dose reduction and longer treatment courses.

SBRT is also indicated for carefully selected patients with medically inoperable liver cancer or liver metastases, pancreas cancer,

MEDICAL FORUM

At the new, fully independent Perth Hearing & Tinnitus clinic we are helping patients to learn to habituate their tinnitus with a multidisciplinary approach.

We provide: • • •

Comprehensive testing Counselling and fitting of devices if appropriate Liaison with psychologists, physiotherapists, TMJ specialists & others

Experienced clinical audiologists and tinnitus specialists Bev Eintracht and Tennille Crooks also provide support in hearing and communication difficulties.

We are accredited for the Office of Hearing Services voucher program serving pensioners and card-holding veterans.

A Hearing Services Medical Certificate, signed by a GP, is required to join this program.

3/134 Main St, Osborne Park, 6017 Contact us 9242 2208, or admin@perthhearing.com.au for further information

JULY 2018 | 31

Specialists in Prostate and Robotic Surgery

Mr Tom Shannon FRACS Over 1700 radical prostatectomies

Member Urological Society Australia and New Zealand

Member Endourological Society

Board member Prostate Cancer Foundation of Australia (WA board)

Board member WA Urological Research Organisation

Advisory board member Exercise Medicine Research Institute (Curtin University Joondalup)

World Class Results

Surgical results in 2017 In organ conďŹ ned disease 100% primary resection success (Literature averages 60 - 85%)

In extra prostatic disease 90.1% complete resection (Literature average 40 - 65%)

Cancer control - (PSA over 0.2 after surgery)

ConďŹ ned disease - 3% (One third of published average PSA failure rates)

Extraprostatic disease - 16% (Half the rate of published average PSA failure rates)

Source Uropath WA Radical Prostatectomy Database

Patient support and multidisciplinary team

Extensive website

Prostate cancer specialist nurse - education and support

Sexual health nurse practitioner - rehabilitation programs

Dietician - rapid weight loss programs

Exercise physiologist - weight loss programs, exercise in cancer programs

Nedlands and Midland - Phone 93897696 Fax - 93861799

www.theprostateclinic.com.au 32 | JULY 2018

drtomshannon@theprostateclinic.com.au MEDICAL FORUM

CLINICAL UPDATE

Claremont Pain Clinic

BACK TO CONTENTS

Being PrEPared

By Dr Yin Min Hew Sexual Health Physician, Nedlands The fight against HIV has taken a new direction with PrEP, which alongside other measures intends to reduce HIV incidence, transmission, mortality and morbidity.

Dr David Holthouse Neurosurgeon/Pain Specialist FRACS FRACGP FPMFANZCA

Since the disease spectrum began to emerge in the 1980s in America where cases of cancers and opportunistic infections were spreading, HIV remains a serious infectious disease threat, years after the virus was discovered in 1983.

According to UNAIDS statistics, it is estimated that, from the beginning of the epidemic, about 76 million people have been infected with HIV and about 35 million people have died from AIDS-related illnesses. In 2016, there were 36 million people living with HIV and statistics reveal that about 1.8 million people are being newly infected with HIV. In Australia, there were 26,444 people living with HIV at the end of 2016. About 11% are unaware of their HIV status which can result in late diagnoses. High risk groups such as men who have sex with men (MSM) account for 70% of the diagnosis. Heterosexual sex accounts for about 20% with people from high-risk areas such as Sub-Saharan Africa accounting for half of these cases. Other at-risk populations such as transgender and injecting drug users account for the rest.

Roughly 1000 cases of newly diagnosed HIV are reported every year in Australia.

Safe sex practices such as condom usage, clean needle exchange, post-exposure prophylaxis, education about HIV and encouraging more testing for HIV has not yielded the effect needed to decrease transmission worldwide. New approaches are needed to tackle the epidemic. In the past decade, HIV prevention has focused on Treatment as Prevention (TasP) and also Pre-exposure Prophylaxis(PrEP) In the case of PrEP, initial trials were promising showing a reduction of HIV transmission around 40-60% in both MSM and heterosexuals.

However, the outcome of two major MSM trials was able to show 86% reduction in HIV transmission. This changed the landscape for PrEP and also HIV prevention. For the first time, un-infected people have a choice to take a medication that will be highly effective in preventing them from acquiring HIV before an exposure, especially in high-risk populations.

Adherence to taking PrEP is the key to success. The fixed dose combination of Tenofovir Disoproxil/Emtricitabine (TDF/FTC) is currently licensed for use as PrEP and it is recommended that it is taken daily. PrEP is not envisioned to be a lifelong prophylaxis and a person’s lifestyle will greatly determine its usage.

With PBS listing approved (1 April 2018), more people can readily access PrEP by prescription and obtain the medication at their local pharmacy.

Author competing interests: nil relevant. Questions? Contact the editor.

KEY MESSAGES Each year about 1000 new HIV cases are reported in Australia PrEP trials show 86% reduction in HIV transmission PrEP is PBS listed

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Dr Pat Coleman Anaesthetist/Pain Specialist

FANZCA FPMFANZCA FRACGP DRCOG

Providing a Comprehensive Service for Chronic Pain Patients Dr David Holthouse has a neurosurgical background and is a qualified GP. He remains open to seeing neurosurgical cases although the major focus of the clinic is procedural pain management. He also has a keen interest in neurostimulation.

Dr Pat Coleman is an anaesthetist as well as qualified GP, who has a FPMANZCA and is experienced in pain interventions such as spinal injections, rhizotomies and stimulators. He is also able to see cases with pain issues such as CRPS and post-surgical pain in any region of the body or other pain states.

About Claremont Pain Clinic • On-site clinical educator and a registered nurse experienced in pain • Focus on neurostimulation as a potential treatment and a comprehensive education program for stimulator candidates to attend • An affiliation with Pain Options – Specialist Physiotherapy • On-site pain/spinal physiotherapist who assists in the rehabilitation of pain patients and workers compensation patients • Close working relationship with a number of other spinal surgeons who are sub-specialists in fusion surgery and often assist in the workup and selection of patients for this surgery • Work closely with a clinical psychologist and psychiatrists with experience in pain management and pain conditions • We do not see patients with active MVIT claims, public liability cases or non-insured patients • We are unable to cater for drug addicted patients who should be referred to a public pain clinic

Workers Compensation • David is part of the Workspine group and both practitioners have a keen interest in workers compensation cases • Workers compensation cases can be referred directly and will be dealt with quickly • Workers compensation consult and procedure slots set aside for cases to be seen urgently

Claremont Pain Clinic Phone: 9385 1323 Fax: 9463 6333 Email: glsfax@jazi.net Address: 12/237 Stirling Highway, Claremont WA 6010 PO Box (please send all mail here): PO Box 563, Claremont WA 6910

JULY 2018 | 33

CLINICAL UPDATE

By Dr Michael Woodall, Psychiatrist, Alfred Cove

Suicide rates are higher compared to the general population in military veterans. In US combat veterans, suicidal behaviour is higher in those who are younger, suffer from Post Traumatic Stress Disorder, depression and anxiety and score lower on measures of general health.

Identification and effective treatment of mental health disorders in the veteran population is essential in reducing suicide rates.

Veterans maybe of any age or gender with the number of women in the ADF increasing from 4% in 1973 to 15% in 2015.

Women’s roles have expanded significantly including deployment of mothers. There are many traumatic stressors in the military environment that may lead to mental health disorders. These can occur in Australia and on deployment overseas (peacetime and combat).

GPs have a key role to play in the diagnosis and treatment of mental health issues in the veteran population. These issues can occur across a lifespan with increased suicide rates in those under 30. There can be a significant transgenerational impact on a veteran’s family and GPs can assist in breaking down barriers such as stigma and accessing the range of available support.

The Transition and Wellbeing Research Program has been established to

investigate these issues. The Mental Health Prevalence and Pathways to Care reports have been released. The study populations are ADF members who transitioned from regular ADF between 2010 and 2014, a random sample of regular ADF members serving in 2015 and those who participated in the 2010 Military Health Outcomes Program (MILHOP).

The estimated prevalence of lifetime mental disorders in transitioned ADF showed anxiety (46.1%) and alcohol disorders (47.5%) as the most common classes of lifetime disorder; 25% are estimated to have met criteria for PTSD. GPs can address maladaptive strategies that may be used to avoid acceptance of mental health issues, such as alcohol and substance misuse. On diagnosis by a GP, the DVA will fund treatment of PTSD, anxiety, depression, and alcohol or substance misuse disorders for veterans with operational service. These arrangements are known as “non-liability health care” and aim to allow prompt intervention.

The DVA At Ease website provides online mental health information. It includes self-help tools, information, and free mobile apps to help with stress, PTSD, alcohol, resilience and suicide prevention.

DVA provides group treatment programs for PTSD in hospitals across Australia.

The Veterans and Veterans’ Families

While the number of veterans presenting with mental health issues is increasing, so too are the treatments and support.

Counselling Service (VVCS) provides free confidential mental health services for veterans and their immediate family members. No referral is required, though veterans may need encouragement to check their eligibility and be reassured about the confidentiality of these services.

Treating veterans can be very satisfying with a comprehensive service and support available to assist GPs in providing effective care.

KEY MESSAGES Veterans have complex mental health needs DVA fund treatment on diagnosis by a GP VVCS provides psychological treatment DVA “At Ease” is a useful online resource Author competing interests - nil relevant disclosures. Questions? Contact the editor

GUEST COLUMN

Tinnitus can be managed

By Ms Bev Eintracht and Ms Tennille Crooks, clinical audiologists, Osborne Park To varying degrees, about 17-20% of us suffer from aggravating 'head noises' or tinnitus. The 1953 Heller and Bergman study demonstrated that everyone has noise in their auditory system, so it is not the tinnitus per se that causes the problem, but our learnt associations with it.

Although most people (over 94% according to some studies) who become aware of their tinnitus habituate to it without much effort, there are authors who suggest that 30-40% of people experience impaired

34 | JULY 2018

social and occupational performance, and reduced life enjoyment. Certainly, in the worst cases, avoidance of situations can increase stress. Negative thoughts and emotions can accentuate tinnitus symptoms, creating a vicious cycle that requires psychological intervention.

At an initial interview with a tinnitus sufferer, it is valuable to determine if the patient is curious, concerned or distressed about their tinnitus.

• Curious patients may need only general information about possible causes,

For many health professionals, tinnitus is one of those conditions that fall into the too-hard basket but treatments are available. mechanisms, prevalence, and likely outcomes.

• Concerned patients may need more detailed information, including selfdirected treatment options. They may also need a more formal approach that includes tinnitus questionnaires and psychoacoustic testing.

MEDICAL FORUM

BACK TO CONTENTS

Veterans’ Mental Health

CLINICAL UPDATE BACK TO CONTENTS

Current approaches to PTSD

By Dr Rebecca Gannon, Psychiatry Registrar, Hollywood

It is estimated that 5-10% of general population will suffer from PTSD at some point in their lives. Patients will often present to health services with a variety of physical and psychological complaints. Stigma towards mental health conditions can preclude patients being forthcoming with their trauma history.

If a patient presents with non-specific physical health problems this should prompt the practitioner to routinely ask about stressful or traumatic experiences.

Organisations such as Phoenix Australia provide free useful resources for health professionals.

To diagnose PTSD symptoms must be present for at least a month and led to significant distress or impairment in important areas of functioning: • Re-experiencing – intrusive distressing recollections of the traumatic event; flashbacks; nightmares; intense psychological distress; or physical reactions, such as sweating, heart palpitations or panic when faced with reminders of the event.

• Avoidance and emotional numbing – avoidance of activities, places, thoughts, feelings, or conversations related to the event; restricted emotions; loss of interest in normal activities; feeling detached from others.

• Hyperarousal – difficulty sleeping; irritability; difficulty concentrating;

• Distressed patients commonly need more specific tinnitus treatment with the help of multidisciplinary clinicians, especially if comorbid conditions are present.

People who seek medical attention are often concerned that their tinnitus may be a sign of a severe disease, such as a brain tumour. If a tinnitus sufferer does seek medical attention but feels that the attention is inadequate, they may be left with a sense of helplessness, and their coping resources may become even more strained. If so, their tinnitus or its associated symptoms may become worse leading to an increased level of distress.

Generally, current treatments aim to reduce the impact of tinnitus on a person's life (the psychosocial consequences) including

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hypervigilance; exaggerated startle response.

Management is a multi-pronged approach.

Assessment is the first and most crucial component – patients must be urgently and thoroughly assessed from both a medical and psychiatric perspective.

Medications are essential in managing symptoms that interfere with daily functioning, correcting sleep patterns and managing anxieties or flashbacks.

Continuing to work and function on a daily basis aids long-term recovery. Individual therapy with a trained psychologist is important and group therapy provides essential support, providing patients the opportunity to see they are not alone and that others face similar challenges.

Traps • Not asking about trauma exposure.

Many patients present with a variety of symptoms and often won’t reveal a trauma history unless prompted. It is easy to miss if you don’t ask.

• Ensure treating therapists have experience in trauma.

• Beware comorbid conditions – in PTSD, 86% of men and 77% of women may have another disorder (e.g. depression, substance misuse or anxiety).

Assessments should always go beyond PTSD symptomatology.

• Don’t forget the families – those supporting patients with a traumatic experience are often burnt-out,

strategies designed to reduce the patient’s perception of the condition as well as those that simply change the patient's reaction to it.

Effective treatment and interventions need an interdisciplinary approach, which in a clinical setting draw in the perspectives of otology, audiology, psychology, pharmacology, and neuroscience. There should also be clear referral paths for patients whose needs fall outside of the expertise of any particular team member.

Many treatments for tinnitus involve educational and/or psychological components, which is typically delivered by a tinnitus specialist audiologist and/or clinical psychologist.

It is important to enhance a person's

Post traumatic stress disorder (PTSD) significantly affects daily life. Symptoms can be managed with medications to restore functionality and therapy which can result in positive outcomes for all. depressed or anxious themselves from being a carer. Interview the main supports individually to obtain collateral history and ensure they have their own support in place (own GP/therapist) so they can continue to care for your patient.

ED: The author acknowledges the contribution of consultant Psychiatrist Dr Mathew Samuel in the writing of this update.

KEY MESSAGES PTSD is under recognised and patients present to any doctor with comorbidities such as alcohol abuse and anxiety disorders Always ask your patient about history of trauma from childhood until now PTSD can be treated with good combination of medications and therapy such as Eye Movement Desensitisation and Reprocessing (EMDR) Author competing interests - nil relevant disclosures. Questions? Contact the editor

understanding of their condition but encourage them to pay less attention to it.

That can sometimes be a difficult balance, but it is critical for the clinician to explain why paying less attention can produce a benefit; that it is not just ignoring it but acting to reduce it neurologically via the limbic system interactions.

It is also sound to assess someone suffering from chronic tinnitus for anxiety, depression and sleep problems.

Many tinnitus sufferers are told that 'there is nothing that can be done' or that 'you will have to learn to live with it' and this is not the case. While there is no cure, there are treatment options available and patients can successfully manage their tinnitus to the point where it is no longer a concern.

References on request

JULY 2018 | 35

ADVENTURE

Climbing mountains is a family affair for neurosurgeon Dr Neville Knuckey. It was Neville’s wife, Jacquelene, who first suggested pulling on the crampons and he’s been following in her footsteps ever since.

Travelling to exotic locations is one of the fringe benefits of mountaineering.

“In 2010 Jacquelene heard about a bunch of kids climbing Mt Kilimanjaro on a cancer fundraising climb and she said to me, ‘why don’t we do that?’ Frankly, I couldn’t see the point but I’d been doing a lot of marathon running and hadn’t done one in Africa so we climbed it and enjoyed the whole business. Since then we’ve done two climbs every year.”

Mountains are the boss

“Jacquelene’s actually a better climber than me. She must have some Sherpa blood because she’s less sensitive to altitude sickness, is quite strong when the mountain becomes steeper, and gets to the top before I do!”

“But the rest of our family’s not so keen.

Our eldest daughter, Sarah, came with us on the first climb and hasn’t been tempted to do it again, and Samantha climbed Mt Blanc with us about four years ago and collapsed on the final ascent.

She now thinks ‘four stars’ is roughing it and believes that parents who love their children shouldn’t try to kill them.”

Neville’s own background could best be described as ‘rough and tumble’.

“We’ve climbed a mountain range on every continent and completed four of the Seven Summits. One of those was Mt Kosciuszko, which some people scoff at because it’s only a bit over 2000m.”

“For something completely different it’s hard to beat Antarctica. We sailed in a 60 foot boat to the peninsula, trekked and climbed for about a month and it was a stand-out trip. But I guess for the sheer beauty of the mountains, it would have to be the Himalayas. It really is high-altitude trekking and you soon realise that the mountain is the boss and you’re actually pretty insignificant.”

“You need to have a lot of respect for the mountain.”

One climb that Neville and Jacquelene won’t be attempting is Everest or, as the Tibetan’s call it, Chomolungma. It’s not for the faint-hearted and the last year where there were zero fatalities was 1977.

“We’re both fit enough, I think. But at 8848m it’s an extremely challenging climb and I’m not entirely comfortable with the rather mercenary philosophy underpinning many of the attempts on the summit.

Some people haven’t had much climbing

experience at all, they plonk down $100,000 and it’s the Sherpas who take all the risks and put their lives on the line.”

“Most of the time they don’t mind too much because they need the money but it doesn’t sit well with me at all.”

“Most people who get to the summit are in their 30s or 40s and there’s a pretty high carnage rate if you’re older than that. Put it this way, there are nearly 300 unrecovered bodies currently lying on the mountain.”

All in planning Neville acknowledges the parallels between planning an ascent and preparing for a surgical operation.

“There’s a strong fit between the practice of neurosurgery and climbing a mountain.

In both cases you have to plan very carefully beforehand and there’s also a match between one of the biggest risk factors in both endeavours, and that’s cerebral oedema. A swelling of the brain is often something we have to deal with in neurosurgery and there’s always the risk of hypoxia on a high altitude climb.”

“I’m actually giving a talk to the Neurological Society that embraces both mountaineering and neuroprotection later this year.”

“I’ve always been very physically oriented and loved the outdoors from a young age. I’ve run marathons, done the solo Rottnest Swim and a bundle of triathlons.

I enjoy it and don’t see it as a chore because it’s all part of keeping fit and healthy,” he said.

“I’m 65 years old now so both my wife and I have what we call ‘rotating pain syndrome’. My left knee is a bit tricky so I can’t run anymore, I ruptured a lumbar disc while sailing and I fractured my pelvis when I fell off my bike. Cyclists and motorcars aren’t a good combination!”

Jacquelene and Neville Knuckey on Mt Elbrus in the Caucasus Mountains -- the highest peak in Europe

36 | JULY 2018

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BACK TO CONTENTS

On the Mountain

ADVENTURE

Dongo Zho in the Indian Himalayan region

The climb to Mt Mera, Nepal

Alphamayo Mountain Andes, Peru Neville elaborates on his own trek towards neurosurgery.

“I was always interested in science at high school and a family friend suggested I think about doing medicine. When I was doing the usual registrar rotations in the mid-70s there was very little known about how the brain functioned and that fascinated me.

I enjoyed the technical challenge, too.”

“We’ve got a busy research lab at the Perron Institute that focuses on neuroprotection, which I enjoy. If I had to go back in time and choose my specialty again I’d make the same choice, but I wouldn’t mind a bit less ‘on-call’ work!”

“I think about retirement occasionally and then I promptly forget about it. I tried

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working four days a week but it just didn’t suit me so now I take two longer holidays twice a year, which works really well.”

Treks continue “We’re just about to leave on a trip to walk the Larapinta Trail in Central Australia, which runs along the spine of the McDonnell Ranges. And then in August we’re going to Pakistan to trek to the Base Camp at K2. It’s the second-highest mountain in the world, by far the most dangerous and we won’t be climbing it!”

Neville has some pointers for anyone thinking about pulling on the crampons.

“A simple 10-day trek is a good way to start to see if you actually enjoy walking every single day one after another. We’ve actually

Neville and Jacquelene in the Antarctic taken people on treks to Peru and Nepal, some people do it once and that’s enough for them. Not everyone likes a sleepingbag, all your modern comforts are gone and altitude sickness is both unpredictable and unpleasant.”

“It’s a very basic lifestyle on the mountain.

All you’re really concerned about is getting enough food and water and avoiding injury. When you return to modern life you suddenly realise that a lot of the things you’ve been worrying about aren’t all that important.”

Neville recommends two books on mountain climbing: Into Thin Air and Touching the Void.

By Peter McClelland

JULY 2018 | 37

FOOD My Vicino

MY LOCAL

224 Cambridge Street, Wembley 9380 4084 The food scene in the city seems to come and go on the tide of fortunes of St Georges Tce but out in the ‘burbs there is a growing desire for a true local where the food is real, the prices are realistic and you don’t have to get into your car, well, at least not for more than five minutes. Joe T (himself a Wembley local) is owner and sometime chef of Italian trattoria My Vicino (My Local) in uptown Wembley where his main role is to create a friendly warm atmosphere, which he does to perfection. It’s open for 7am to 2.30pm for breakfast and lunch (Tuesday to Sunday) then re-opens at 6pm for dinner (Tuesday to Saturday).

In the evening the signature share plate is the bruschetta board which ranges in size from eight pieces to serve two people to a whopping two metre board with 24 pieces.

Delicious toppings of roast tomatoes (sublime), roasted Mediterranean veg, mushroom; white anchovy (don’t stop), prosciutto and mozzarella, and roasted pumpkin populate the boards.

Other dishes come direct from the Italian cuccina – polpette, gnocchi, pastas of all shapes, lamb, chicken, bistecca … and are all designed to share.

My Vicino is licensed with only a modest imported wine list, all by the glass as well as bottle, just as if you were in Rome but you don’t have to leave the neighbourhood.

BEETROOT SOUP/DIP This spicy beetroot paste can be used as a dip, a base for a soup or a wild topping for a bruschetta.

INGREDIENTS 5 beets peeled and quartered Handful of fresh coriander 1 red onion 2 cloves garlic ½ cup walnuts Olive oil Juice of 2 lemons SPICES 1 tspn salt 1 fresh chilli 1 tspn ras al hnout 1 tsp sumac ½ tspn black pepper

METHOD Preheat oven to 220C. Drizzle beets with olive oil and season with salt. Place flat on a tray lined with baking paper and roast for 40 mins. Cool slightly.

Finely chop herbs, onion and chilli.

In a food processor add beets, onion chilli, garlic and herbs and pulse for a few seconds. Add the dry spices and walnuts and pulse for a few seconds.

Add about 1 tblspn olive oil and lemon juice and pulse to combine.

For soup, put beetroot base into a pot and add 4 cups of stock – chicken or vegetable. A commercial stock is fine. Bring gently to the simmer. You can add a dollop of sour cream if you want a creamier soup but it is has a clean finish as it is.

For dip, spoon beetroot base into a serving dish, sprinkle with a little more olive oil and crumbled fetta.

Wine winner

There’s nothing quite like a good Pinot Grigio and a sundowner on the Busselton Jetty, says Doctor’s Dozen Wine winner GP Maria O’Shea. A wine trip to Sancerre in France’s Loire Valley is pretty appealing, too. But it’s hard to beat a glass of wine on the terrace at home and playing in the garden with the kids.

Dr Maria O’Shea, right, with her sister Lise

38 | JULY 2018

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WINE REVIEW

Singlefile’s Mark of Greatness

By Dr Louis Papaelias

After a successful career in academia and then in international consulting, South African-born Philip and Vivienne Snowden realised their dream child. In 2007 they purchased a picturesque property in Denmark, Western Australia. Grapes had been planted on the property since 1989 giving them immediate access to the fruit of mature vines. Their vision was to make top flight wine, not only from their Denmark property but also from the best grapes that the Great Southern wine district could offer. With daughter Pam and son-in-law Patrick Corbett, the Singlefile team quickly burst onto the Australian wine scene. Named to reflect the daily waddle to the vineyard lake by the family’s flock of geese, Singlefile, in 2014, won James Halliday’s inaugural award for Australia’s Dark Horse Winery of the Year. This was followed in 2015

when their premium ‘Vivienne’ chardonnay scored equal top points with the Vasse Felix Heytesbury chardonnay in Gourmet Traveller Wine magazine review of Australian premium chardonnay.

Singlefile’s Denmark vineyard produces what Denmark is best at, and that is chardonnay. Premium reds, namely Cabernet Sauvignon and Shiraz, are products of the premium Riversdale vineyard in Frankland River. All the wines reviewed below are of gold or silver medal standard and are up there with the best Australia can offer.

1

2

3

4

2015 Singlefile ‘The Philip Adrian’ Cabernet Sauvignon ($80) Singlefile’s flagship red is made from the pick of the Riversdale crop. As is typical of the classed growths of Bordeaux, it is given the best treatment with the best barrels selected. This is a true “vin de garde” in other words a wine that will keep and show its best with further maturation in the bottle. The wine has typical blackcurrant with hints of chocolate and black olive packed tightly into a firm but fine tannin framework. It is yet to open up but the exceptionally long lingering finish gives an indication of its future greatness.

1. 2017 Singlefile ‘Family Reserve’ Chardonnay ($50)

3. 2016 Singlefile Frankland River Shiraz ($37)

Sourced from the home vineyard, this chardonnay displays aromas of crisp stone fruit with a touch of citrus and a subtle whiff of oak. It has been picked a little later than the other Singlefile chardonnays and shows a generosity that makes it accessible at a younger age. Lovely mouthfeel and crisp clean long finish make for very attractive drinking now and even better in 2022.

Less forward than the Clement V, this Shiraz from the Riversdale vineyard has a deep colour and a nose of lifted spice and chocolate. Good clean dark fruits with firm tannins and a generous mouth feel. This wine will show more in 2-10 years.

2. 2016 Singlefile Great Southern Clement V ($30)

As is it is in Margaret River, so it is in Frankland. Cabernet is king and this one exudes class. Packed with plum and cassis there is a lovely depth of flavour and a juicy mouthfeel overlaying fine soft tannins and a lingering finish. The wine spent 16 months in new and one-year-old casks yet oak is far from dominating. A serious wine that will go on improving for 10 years but has enough delicious fruit flavours to be enjoyed now.

The name is an oblique reference to the Avignon pope in Chateauneuf du Pape. It makes a nice change from the bland GSM name that many other wineries use to describe their blend of Shiraz, Grenache and Mataro (Mourvedre). The wine does not disappoint. It has immensely appealing red berry and spice aromas leading to a supple and crisp, savoury taste with soft tannins. Lovely and approachable as it is now but built to keep for five years at least.

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4. 2016 Singlefile Riversdale Frankland River Cabernet Sauvignon ($37)

JULY 2018 | 39

"Posh hotels have a turn-down service. I had never heard of this and there was a knock at the door and a woman said, 'I've come to turn down your bed.' To which I said, 'Well many women have in the past.

Why should you be any different?'"

- Tom McIntyre

COMEDY TRAILBLAZERS “If you arrive fashionably late in Crocs, you’re just late.” - Joel Dommett “My wife told me: ‘Sex is better on holiday.’ That wasn’t a nice postcard to receive.” - Joe Bor "My wife wanted a new fridge. And because I like sex, I said yeah." - John Bishop “My friend got a personal trainer a year before his wedding. I thought: ‘Bloody hell, how long’s the aisle going to be’.”

- Paul McCaffrey

"If God had written the Bible, the first line should have been 'It's round.'"

- Eddie Izzard "I was watching the London Marathon and saw one runner dressed as a chicken and another runner dressed as an egg.

I thought, this could be interesting."

- Paddy Lennox

FORECAST: STORMY A man and his wife are sound asleep in bed when the phone rings.

The man picks up, listens for a second

and says, “How the hell would I know, you idiot? I'm not a weatherman,” before slamming down the receiver. “Who was that?” asks his wife. “Wrong number. It was some jerk asking if the coast was clear.”

TURNING THE TABLE A man and a woman are having dinner in a restaurant. Their waitress, taking another order at a table a few paces away, spots that the man is slowly sliding down his chair and under the table, with the woman acting unconcerned. As the waitress watches, the man slides all the way under and out of sight. Still, the woman dining opposite him appears not to notice. Finally, the waitress comes over to the table and whispers discreetly to the woman, "Pardon me, ma'am, but I think your husband just slid under the table." "No, he didn't," the woman calmly replies. "He just walked in the door."

“My therapist says I have a preoccupation with vengeance. We'll see about that."

- Adam Hills "I was in my car driving back from work.

A police officer pulled me over and knocked on my window. I said, 'One minute I'm on the phone’." - Alan Carr "The easiest time to add insult to injury is when you're signing somebody's cast."

- Demetri Martin "I was playing chess with my friend and he said, 'Let's make this interesting.'

So we stopped playing chess." - Matt Kirshen "A man walks into a chemist's and says, 'Can I have a bar of soap, please?' The chemist says, 'Do you want it scented?'

And the man says, 'No, I'll take it with me now.'" - Ronnie Barker "I doubt there's a heaven; I think the people from hell have probably bought it for a timeshare." - Victoria Wood Ronnie Corbett: "Do you think marriage is a lottery?"

Ronnie Barker: "No. With a lottery you do have a slight chance." - The Two Ronnies "I went to the doctor and he said, 'You've got hypochondria.' I said, 'Not that as well.'" - Tom Vine

"The covers of this book are too far apart."

- Ambrose Bierce (1842-1914)

Doctors Making Music The West Australian Doctors Orchestra is set to stage its eighth biennial concert next month and what a testament it is to the participants and organisers over those 16 years.

This event, on August 26 at 2pm, will feature dermatologist Dr Roland Brand on the piano for the much loved Grieg Piano Concerto in A minor. Roland is no stranger to the concert platform nor the solo spot at WADA’s concerts.

The concert opens with the overture to the sparkling Orpheus in

40 | JULY 2018

the Underworld by Offenbach and the symphony is Beethoven’s magnificent No.5.

UWA’s Mark Coughlin will conduct proceedings at the Joy Shepherd Performing Art Centres at St Hilda’s Anglican School for Girls in Mosman Park.

Tickets are available at trybooking and proceeds will go to the work of Australian Doctors for Africa. Afternoon tea is available for a gold coin donation.

MEDICAL FORUM

FEATURE

Knowing the Evacuation Drill Colorectal surgeon Dr Michael Levitt has shared some of his acquired wisdom to aid people in one of the body’s most problematic functions.

L

ike every other function of the human body, bowels are intriguing and pretty clever … when they’re working well, that is.

When they’re not, they can not only dominate conversation (even in polite circles) but they can make life difficult for the suffering and for all those around them, including their doctors.

Everyone has a bowel story and there’s a fair chance that colorectal surgeon Dr Michael Levitt has heard most of them.

When Michael is not at Osborne Park Hospital juggling surgical lists as OPH’s comedical director or in his private rooms, he likes to write and, just to prove a point, his third book, The Happy Bowel, has just been published by Fremantle Press.

When Medical Forum caught up with him at OPH, he was reviewing the waiting list for colonoscopies. It was unsurprisingly long but getting shorter, he assured us. The irony did not escape him that a book which aims to empower people to understand and direct their bowel function better (rather than their bowels controlling them) might also have a positive impact on that long list.

“All three books have been about bowels, largely because I have too many stories to contain in just one,” he said. “And also because I see so many people in various states of desperation who think surgery is the only solution to their constipation/ irritable bowel.”

“It’s not, for many of them.”

Knowledge is power

produced, any human bowel action that has possessed all four of these characteristics will have represented a genuinely positive life experience for that person. And any individual who can say that they achieve such agreeable bowel actions on a majority of their visits to the bathroom can rightly claim to have a good bowel habit.”

“You need only ask yourself: ‘Do I regularly commence rectal evacuation with a minimum of delay? Does it involve a minimum of effort? Am I regularly able to leave the bathroom after just a short period of time? And do I leave feeling satisfyingly empty?’ If the answer to all of these questions is ‘Yes’, then you have an excellent bowel habit. If it’s not, then you are likely to be struggling.”

“Notice that what does not count here – or, at least, not to anywhere near the same extent – is stool frequency, or how many times a day or a week you empty your bowel. This is an extremely important point: How often you go is simply not as important as how easily and how completely you empty your bowel.”

“People who are having difficulty with their bowels – those who are not able to experience the simple but significant pleasure of having regularly satisfactory bowel actions – can almost always describe their difficulty with reference to one or more of these four characteristics…

While many different factors and conditions can cause trouble with our bowels, they virtually all manifest as problems in one or more of these four key areas.”

Knowing the rules And with this happy introduction, Michael continues to encourage readers to reevaluate their perceptions, habits and behaviour when it comes to one of the

body’s most whispered about functions.

He has three Golden Rules for happy, healthy rectal evacuation: • Golden Rule Number One: Never attempt to empty your bowel until the urge to do so is strong and true.

• Golden Rule Number Two: Never, ever, take any distracting influences – newspapers, books, magazines, mobile devices – with you to the bathroom.

• Golden Rule Number Three: The ideal consistency for a human stool is solid.

These rules have a companion set of ‘Three Ds’, which Michael says in a “simple behavioural approach to correct the faulty toileting behaviour associated with ‘speculative’ defecation: • Defer visiting the bathroom until the urge to go is strong and true.

• Desist if rectal evacuation does not commence both promptly and effortlessly, rather than sit and strain get up and leave the bathroom immediately.

• Distinguish between real urges and false alarms. It is the essence of correcting speculative defecation and its associated problems of straining, haemorrhoids and pelvic floor pain.

The Happy Bowel also looks at the use of laxatives (in Michael’s words, “I need statins to control lifestyle-resistant cholesterol, why wouldn’t someone with slow colonic transit need laxatives?”), medications that affect bowel function, alternative treatments (enemas, colonic irrigation, probiotics) and bowel problems in children, along with case studies and FAQs. Take Home Message? When you’ve got to go … it’s good to go.

By Jan Hallam

Bowel function is steeped in social and behavioural mythology which has been passed down the generations to arrive at a rather uncomfortable endpoint that proscribes what’s normal. The problem is, ‘normal’ is not normal at all.

Michael writes: “In all of recorded human history, every truly satisfactory bowel action has had four things in common: it has been prompt, effortless, brief and complete. Wherever and by whomever it might have been

MEDICAL FORUM

Illustrations: The Happy Bowel © Fremantle Press

JULY 2018 | 41

MUSICAL GALA

The Power of Wagner The centrepiece of the Western Australian Symphony Orchestra’s 90th anniversary celebrations is a concert presentation of Richard Wagner’s Tristan und Isolde – a fourhour philosophical devotion to love, sex and death.

Many Wagnerites regard Tristan und Isolde the ‘ultimate opera’ taking the audience on a dramatic journey of life, passion, death, rebirth only to die in the arms of love. It also requires extraordinary stamina by everyone taking part – singers, chorus, orchestra, conductor, and, not least of all, the audience.

WASO has been building up to this moment for the past 18 months with principal conductor Asher Fisch, one of the world’s great Wagner exponents, last year delivering a well-received introduction to the maestro’s music in Wagner and Beyond – a tasting plate of sorts.

Now Perth can experience the full immersive experience with this ancient story set to Wagner’s radical musical ideas.

Wagner is a divisive character in music circles – those who love his music walk over hot coals and fly thousands of kilometres to see one of the gems. For others, fear, holds people back. A full opera is rarely seen in Perth because of the massive resources required – the orchestra has been supersized, as has the WASO chorus with the help of St Georges Cathedral Consort for this twoperformance season.

And not every singer has the vocal capacity and stamina to belt out four hours of the most challenging singing.

One of the world’s most acclaimed Wagnerian tenors, Australian Stuart Skelton, is returning to Perth to sing the role of Tristan and Dutch soprano EvaMaria Westbroek, who similarly has a fine Wagnerian pedigree, will sing Isolde.

Perth tenor Paul O’Neill is also in the concert cast and reacquaints himself with Fisch, Skelton and Westbroek from his days at

the Staatsoper Berlin where he was a member of the ensemble of that esteemed opera company.

Paul, who initially trained at WAAPA before winning a scholarship to study with the National Opera in Covent Garden, told Medical Forum he was thrilled to be lining up with such a stellar cast.

“Perth hasn’t seen anything quite like this – it will be a thrilling experience.”

Paul said his voice was not quite ready to take on the role of Tristan, “but it’s nice to be part of it”.

Everything about Tristan is big and Paul gave some insight into what that means for a singer.

“The music produced by people such as Asher, Stuart and Eva-Marie is at such a professional level. They fly around the world doing this. And they’re singing sometimes for six hours. That’s a lot of singing!”

“I sang in a production of the Die Meistersinger von Nūrnberg at Staastoper and I had one line where I was front and centre and I was belting it out over the force of 90 musicians in the pit.

I have never felt such power my entire life.

I realised then how I would need to sing to perform those big Wagner roles and it wasn’t going to happen overnight; my voice would need developing.”

So how does that happen?

“Practice and wait for the voice to get bigger. It is a body building experience and not something you can rush into. It’s like making a fine wine. You start with the right grapes, put it in the bottle and then wait – there’s no speeding it up. It is also about experience because as you keep singing, you learn more and more about your own voice.”

There are just two performances of Tristan und Isolde at the Perth Concert Hall – on the evening of Thursday, August 16, from 6pm to 11pm, and the afternoon of Sunday August 19, from 2pm until 7pm. The interval is long enough for the entire auditorium to refuel!

For the Wagner uninitiated, this is a performance not to be missed; for Wagnerites, the cream of the crop is coming to town. Time for everyone to get into training!

By Jan Hallam

MEDICAL FORUM

THEATRE

Being Brave…Being Curious One of the year’s most anticipated productions hits the stage in Perth next month and literally steps into a box of magic.

Mark Haddon’s book, The Curious Incident of the Dog in the Night-Time took the world by storm in 2003 and now the stage-play is doing the same thing. It’s had an extended, sell-out season in the UK, a critically acclaimed run on Broadway and a world tour taking in the Netherlands, Canada, Singapore, China and Australia.

The Curious Incident, with Joshua Jenkins in the lead role, will begin its Perth shows at His Majesty’s from August 8.

Joshua agrees that, with the phenomenal success of the book, it made perfect sense to ensure that the onstage drama closely follows Haddon’s original storyline.

“The show is very loyal to the book and all of us felt it was important to maintain that level of integrity. We might have to tweak a word or two for an overseas audience but it’s pretty much the same show you’d see in London. It’s interesting to see the different theatre etiquette in other countries. In China it’s not unusual to hear mobile phones ringing and people often pop out to go the loo, presumably.”

“But the show crosses national and cultural boundaries very easily because it’s dealing with universal themes, essentially.”

“When Christopher, the main character, puts on his detective hat and steps out

into the world he really dives in the deep end. Although it’s not stated explicitly, Christopher is obviously on the autism spectrum. He doesn’t like being touched, he’s uncomfortable in many social situations and loud noises frighten him.”

“But he’s so courageous in, quite literally, stepping outside his comfort zone. It turns his world upside down. And there’s even a line in the play where Christopher says, ‘I was brave!’ And he was, as are we all at different times.”

“Most of us aren’t good at some things – at times, most things – and often it takes courage to step out the front door and hold down a job or maintain a relationship.

That’s what life’s about, and we can all identify with that.”

Joshua was one of those lucky people who, from a young age, had a pretty clear idea of his chosen career. When he was seven years-old a bunch of bright, colourful characters caught his eye.

“I can’t remember a time when I wanted to be anything else but an actor, although I did have brief fling with the Teenage Mutant Ninja Turtles because my Mum told me I could be anything I wanted!”

“My sister went along to dance classes and I’d go and watch the shows. I loved it! One Christmas my Nan gave me some tap shoes and the rest is history.”

“Coming to Australia has been really exciting because most of the cast, including me, have never been here. We came to Brisbane, then Asia and now we’re back again. It’s just amazing, we’re so lucky. We get to do what we love and travel the world at the same time.”

“We’ve been to 15 major cities on four continents with this show. It’s lovely because we get a week off here and there.

I’ve driven down the Great Ocean Road and seen the Grampians in Victoria, and Port Douglas up north. This country is so beautiful.”

So, just what can Perth theatre-goers expect to see when the curtain goes up at the Maj? “There’s certainly a lot going on! A big, black box sits onstage and it really becomes Christopher’s whole world. We enter Christopher’s mind, and he is definitely someone who sees the world differently.

The audience is bombarded by strobe lights and images making it a totally immersive experience.”

“Curious Incident is, I think, all about a celebration of difference. It’s a window into how we treat people who are seen as strange and difficult. I’d like to see more stories like this. It would be lovely if all of us were a little more open-minded.”

By Peter McClelland

JULY 2018 | 43

COMPETITIONS

Entering Medical Forum's competitions is easy!

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter.

Movie: Mission: Impossible - Fallout Ethan Hunt and members of the Impossible Mission Force are back and in a race against time after a mission goes horribly wrong. Tom Cruise, Henry Cavill, Simon Pegg and Alec Baldwin create another 100 minutes of breathless stunts and derring-do.

In cinemas, August 2

Choral: Swoons So much glorious music has been written for choirs that it’s hard to select just a few pieces for one concert.

But responding to demand, Perth Symphonic Chorus has created an afternoon of favourites such as Fauré’s In paradisium from his Requiem, Lacrimosa from the Mozart Requiem and Schubert’s Heilig, Heilig, Heilig, along with Ešenvalds’ new ethereal work, The New Moon, for unaccompanied 12-part choir and six tuned wineglasses.

Movie: The Breaker Upperers From the producers of Hunt for the Wilderpeople comes this comedy starting NZ comedians Jackie van Beek and Madeleine Sami, who play besties Jen and Mel. They discover they were being two-timed by the same man, so start a business breaking up couples for cash.

In cinemas, July 26

The pace picks up in the second half with best-loved show tunes and songs from the jazz repertoire.

Highlights from Broadway musicals Porgy & Bess, West Side Story and My Fair Lady line up alongside Blue Skies, Mack the Knife, I Got Rhythm, and It Don’t Mean a Thing, to name a few, complete with a small jazz band and soloist.

Christ Church Grammar School, August 12, 2.30pm-5pm

Movie: Book Club Hang on to your hats. Four lifelong friends who read 50 Shades of Grey in their monthly book club find their lives changing as discussion leads to some interesting revelations. Jane Fonda, Mary Steenburgen, Diane Keaton and Candice Bergen lead the fun.

In cinemas, August 9

M E D I C A L F O R U M $ 12 . 5 0

Dance - St Petersburg Ballet Theatre Swan Lake: Dr Nigel Armstrong, Dr Olga Ward

Fertility & Glass Ceilings TV Mesh; Contraception; C-Section Future Medicine

MAJOR PARTNER

Movie - Tea with the Dames: Dr Kate Concanen, Dr Sally Freight, Dr Suzette Finch, Dr Michael Hart, Dr Gavin Leong, Dr Greg Glazov, Dr Paul Kwei, Dr James Flynn, Dr Monica Keel, Dr Linda Haines Movie - The Leisure Seeker: Dr Robert Weedon, Dr Simon Machlin, Dr Ian Walpole, Tammy Ryan, Jennifer Muir, Dr Simon Turner, Dr Michael Bray, Alarna Thomas, Karen Fairhead, Tracy Monahan Theatre - Assassins: Dr Lynn Graham

44 | JULY 2018

Wagner’s epic is the centrepiece of the WA Symphony Orchestra’s 90th anniversary, and this concert production of Tristan features a dream cast of Stuart Skelton and Eva-Maria Westbroek in the title roles with Asher Fisch at the helm of WASO, the WASO Chorus and the St George’s Cathedral Consort

Being a Woman

M AY 2 0 18

Movie - Hotel Transylvania 3: A Monster Vacation: Dr David Jameson, Dr Mojdeh Bassiri, Lee Jackson, Dr Nicole Cole, Dr Katherine Shelley, Dr Harjit Kaur

Music: Tristan und Isolde

May 2018

www.mforum.com.au

Perth Concert Hall: Thursday August 16, 6pm-11pm

Theatre: Curious Incident of the Dog in the Night-Time This extraordinarily conceived stage production of Mark Haddon’s bestselling book has broken records on the West End and Broadway and now arrives in Perth with some of the London cast, including lead Joshua Jenkins, who plays the young boy Christopher Boone.

His Majesty’s Theatre, August 8-19

MEDICAL FORUM

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