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Editorial
Dissecting the Health Journey It’s all about convenience these days – because of the time pressures people find themselves under and because convenience is how new business can gain a foothold. In medicine, is convenience shaping how and what we do in a way that is good for people’s health? Patients (or their parents – this is the Child Health edition!) will say that anything that gives us improved access to good advice is a bonus because access is harder to get. Fair enough. But if the patient lobs on the caregiver without all relevant information, how can the caregiver give a considered elective decision or even a snap judgement? My contention is that convenience is turning some ‘elective decisions’ into ‘snap judgements’ and this may not be healthy. Those patients familiar with using the internet will source information and try to access their doctor 24-48 hours before their script runs out. A considered opinion about their contraceptive use or diabetes management is not entered into because they could only book six minutes with their doctor. Or they arrive on the specialist’s doorstep with a rushed referral and incomplete information. Costly investigations may be repeated (no pathology coning rules for specialists). In the hands of some doctors and patients, My Health Record (the rebadged PCEHR) and other things may simply patch over the cracks by replacing careful consideration with convenience. It needs to be watched. One lesson we have all learnt in recent years is there is more to health than the time spent with doctors. The health journey involves the patient (more self-help is coming) those around them (the doctor is part of a ‘team’) and advice from family/ friends/fellow sufferers (the internet). One analogy is the convenience of the new Mobile Travel Agents (“we come to you”). Is something of substance being replaced by convenience – such as the conversation travel companions had during their drive to the Travel Agent, the private conversation that no longer occurs? It is a hard one to pick. Doctors are learning they are a small slice of their
patient’s health journey – the whole journey needs to be carefully considered before changing one slice. And then you have the innate talents of the doctor. Doctors self-select into different streams in medicine, maybe not for the right reasons. The RACS clearly has a problem with sex discrimination and bullying and is changing its spots. General practice, rural and urban, is incredibly diverse with myriad market forces at play. Feet-of-clay doctors, both specialists and GPs, can train as underperforming doctors, whether just a square peg in a round hole or poor achievers at most things. Who judges their performance? The profession cannot leave it to the Medical Board or AHPRA or those influenced by commercial interests. Training of doctors has a low attrition rate, compared to say, pilots. Why? Both must perform well in life or death situations. Yet we hear of university trainers restrained by appeals of various types and living in fear of litigation; the same for specialist colleges. The end result may be that misfits get passed. Money comes into it too. But before we launch into a class war we have to ask, ‘Are these people not fitting in for good reasons?’ It all goes to show how complex medical training is but it is in need of some serious navel gazing. Unless the profession has an open conversation on the issue of ‘dud’ doctors, like child abuse, it will never come into the open. The profession has nothing to hide, just some things it prefers not out in the open! The September 22 Doctors Drum, “Training and ‘Dud’ Doctors?” we hope, is a good start.
This is our Child Health edition. Kids don’t come before the Courts because they want to – someone is reaching out to them perhaps for the first time (p20). Are male doctors unfairly scrutinised over others’ sins when it comes to child abuse (p27). While beer, negative gearing, and musicals may not be for the younger set, we have kept the Clinical Updates mainly around kid’s health. The ninth Doctors Drum event has not disappointed anyone (p22). Enjoy the child-like distraction of variety in this magazine!
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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
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
AUGUST 2016 | 1
August 2016
Contents
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FEATURES 14 Profile: Epidemiologist Prof Fiona Stanley 16 Spotlight: Janet Holmes a Court 20 Mental Health Court Success 24 Kids and Internet Dangers NEWS & VIEWS 1 Editorial: Dissecting the Health Journey
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4 6 10 12 12 15 18 22
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Dr Rob McEvoy Letters to the Editor Patients have Right of Choice Dr Jayson Oates RACGP Sounds Prostate Caution Dr Frank Jones Prostate Fine Print Worth Noting Dr Gerry Cartmel Community Engagement Key Challenge Ms Pip Brennan Low Can They Go? Curious Conversations Dr Ben Wood Have You Heard? After Hours Crowded House Beneath the Drapes Banksia Hill FASD Project Obituary: Dr Patrick McGonigle Doctors Drum: ‘It’s Always the Doctor’s Fault?’ LARCS a Remote Success
24 Lifestyle 42 Negative Gearing: Accentuate the Positve 44 Funny Side 45 Beer Review: Little Creatures
Dr Sergio Starkstein & Dr Bradleigh Hayhow 46 Towards Veteran Healing 47 Sound of Music 48 Clinton the Musical 49 Competitions
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Augus e-Poll t
Doctors Wary of Young Children
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Clinical Contributors
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Dr Mina John Allergen-Specific IgE
33
Dr Leon Levitt ‘Tongue Tie’ Controversies
39
Dr Amanda Wilkins Developmental Delay
40
Dr Colin Whitewood Growth Plate Injuries
35
Dr Alan Donnelly Pitfalls in Dermatology: II
37
Dr AS Arun Endometriosis & bladder pain
31
A/Prof Donald Payne Teens Fall in the Gaps
Guest Columnists
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Dr Kajal Hirani & Dr Sarah Cherian Refugee Adolescent Health
29
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INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM AUGUST 2016 | 3
Letters to the Editor Patients have the right of choice Dear Editor, My response to the editorial Can Venus Stop Revalidation and feature Living in a Barbie World (May edition) was that they are quite reasonable, except I don’t agree. Absolutely, Female Genital Cosmetic Surgery (FGCS) is getting more common. Let’s first accept patients getting FGCS because of physical discomfort (even if the choice to remove pubic hair contributes to the problem) as a sufficient medical condition and accept the rest as ‘cosmetic’. Why do these (predominantly young) women do this? The most comprehensive paper on this was published by Sharp et al, Psychology of Women 2014. A Tripartite model has been used to understand eating disorders and other forms of consideration of cosmetic surgery. The three influences being relationship quality (including here sexual confidence), media exposure (including the internet and pornography) and peer influences. Interestingly hair removal was not found to be a separate influencer but was secondary to media exposure. None of my cosmetic patients have anything distasteful/unnatural or needing fixing. In fact I go to great pains, as do most of my colleagues, pointing out that the patient does not need cosmetic surgery. In FGCS I refer them (on the website and handouts) to see http://www.greatwallofvagina.co.uk and http://www.labialibrary.org.au. Reassurance that what they have is normal and natural does not (in the majority) dissuade them from wanting surgery. Now, would the world be a better place if no one felt the need for cosmetic surgery? Absolutely. But we live in a society that allows all kinds of body modification. I see a lot of young people with piercings or outrageous tattoos that I think are a very bad choice. But I allow them the choice without publicly demeaning the choice. The RACGP has a tremendous publication Female genital cosmetic surgery: A resource for general practitioners and other health professionals. Its first recommendation is to listen to the patients. Our patients are invited to participate in the follow-up study by Sharp
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in satisfaction post FGCS. Anecdotally they report feeling much more confident. The ‘Barbie Doll’ look is a marketing term (apparently very successful) of one surgeon in Beverly Hills. It is not what my patients are looking for, nor what I offer. Like all of my cosmetic patients, the FGCS patient wants to feel comfortable and confident in her appearance. Maybe they should just go for counselling. But maybe they are reasonable and intelligent women, who do have some insight into peers/media/relationships that influence their choices and are able to come to a rational decision about what they want to do with their fingernails, hair and even their vulva. Dr Jayson Oates, Plastic Surgeon, Subiaco ........................................................................
The new NHMRC guidelines are clear: “this guideline does not recommend a population screening program for prostate cancer (a program that offers testing to all men in a certain age group who do not have prostate cancer or symptoms that suggest prostate cancer). Current evidence does not support such a program.” Men with no signs or symptoms should only be offered prostate cancer testing after they have been fully informed about the harms and benefits and make an informed decision and request PSA testing based on their personal values and priorities. For example, they may have a strong family history of prostate cancer. The RACGP has produced a patient information sheet to help men make an informed decision: Should I have prostate cancer screening? Dr Frank Jones, RACGP President, Mandurah
RACGP sounds prostate caution Dear Editor, RE: New guidelines for PSA testing (July edition), it is true that the RACGP recently endorsed the new National Health and Medical Research Council (NHMRC) approved guidelines for early management of prostate cancer. The new guidelines align with the RACGP’s view that prostate cancer screening using either the prostate-specific antigen (PSA) test or digital rectal examination is highly unreliable and not recommended. This is because the harms of screening outweigh the potential gains. Dr Tom Shannon’s recent letter could be interpreted as suggesting that regular screening of men is actually recommended by the new guidelines. This is not the case.
ED: Melbourne’s Prof Jon Emery will speak on the guidelines in Perth on August 6 at the invitation of the RACGP, Prostate Cancer Foundation and Cancer Council WA.
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Letters to the Editor continued from Page 4
Prostate fine print worth noting
Community engagement a key challenge
Dear Editor,
Dear Editor,
Dr Shannon (Letters, July edition) along with Perth Pathology (page 5) pick up on the difficulties with the diagnosis and treatment of cancer of the prostate and present current recommendations for screening (does an unscreened cohort exist?).
The clock has ticked over and the power has devolved from WA Health’s Royal Street premises back out to the Area Health Services. It is instructive to note in the e-Poll (Consumers and Public Hospitals, July) that 58% of doctors (or 63% of the specialists who responded to this poll) believe that the public hospital system will perform below expectations in the months to come.
The Prostate Cancer Foundation website to which Dr Shannon refers states: “Recent studies of screening in large U.S. and European populations have suggested that the benefits of screening may not occur for 10 or more years after screening, given the long natural history of prostate cancer. These studies also suggest that many men will need to be screened (over 1000) and treated (nearly 50) to save one life from prostate cancer.” So, can we assume these recommendations will not be validated for a further 10 years? Originally I queried the net value of this approach of early diagnosis and treatment in terms of emotional, physical and financial cost compared with an unscreened cohort where diagnosis and therefore treatment is dependent upon symptomatic presentation. Without this we are merely saying “OMO washes whiter” without asking why the clothes need washing in the first place. Dr Gerry Cartmel, Retired Doctor ........................................................................
easily warm to, despite its importance to them.
Aside from the consumer representative circles such as the Consumer Advisory Councils of each of the hospitals, and organisations such as the Health Consumers’ Council, the general public will be blissfully unaware that anything has changed. Area Health Services are irrelevant to most people. Even the distinction between primary and secondary health services eludes most people. It’s not a topic the public at large can
So the level of community engagement in one of the most far-reaching reforms in our state’s health, beyond a small and dedicated group of consumer representatives, has been minimal. Admittedly, it can certainly be difficult to engage with people who have no interest in health. But the opportunity for our state to hear from the people that use the services and factor in how the changes will affect them, rather than how it will affect the hospitals and bureaucracies, has largely been lost. True community engagement is a key challenge and opportunity for our health system. A genuine partnership approach to health service planning is going to be the game changer in how we deliver peoplecentred, affordable health services in the future. But for now, the general public will have almost no realisation of what they might be up against when next they turn up to a hospital for assistance. Ms Pip Brennan, ED, Health Consumers Council WA
How Low Can They Go? It’s been a bad month for tobacco company Philip Morris. Anti-tobacco warrior Prof Mike Daube let us know about the Uruguay Government’s landmark legal win at the World Bank’s arbitration tribunal, which will give the green light to the intended graphic warnings on cigarette packaging. It will no doubt be talked about when the Uruguayan president and oncologist, Dr Tabare Vasquez, heads to Melbourne in April where he will be keynote speaker at the World Congress on Public Health. Mike said tobacco companies were using trade and investment treaties to challenge tobacco control legislation and the World
Bank’s signal would give heart to all governments, especially the smaller ones, to push ahead with tobacco controls. Then there was Philip Morris’s cringeworthy outing in The Conversation by Sydney University’s E/Prof Simon Chapman revealing its involvement in an international conference on chronic obstructive pulmonary disease (COPD) in Brisbane last month. With smoking one of the major causes of the illness, the tobacco company may have had a unique perspective to offer but to have a Philip Morris staffer on the program (and on the organising committee according to Chapman) seems truly bizarre.
Curious Conversations
If You Can Spell It, You Can Do It PathWest pathologist Dr Ben Wood has eaten his last meal but rumours of his demise are much exaggerated. If I could live in another country for 12 months it would be… the United States of America. I’m endlessly fascinated how one country can be at the forefront of education, art and science and yet be so systemically incapable of addressing inequality, anti-scientific religiosity and rational gun control. The most disturbing film I’ve ever seen is… Once Were Warriors leaps to mind but The Boys would probably get my vote. The sustained sense of menace and tragic inevitability makes it difficult to watch. I was drawn to a career in pathology because… I couldn’t spell otorhinolaryngology! I enjoyed histology from my first year at university,
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was amazed to find someone would pay me to do it and always wanted a career with a research interest. If I could win an Olympic gold medal in any sport I’d choose… weightlifting. Anyone who thinks it’s about fat men picking up heavy things needs to watch Dmitry Klokov in action. The flexibility, balance and strength of the elite lifter are mind-boggling. My last meal would be… about half way through my jejunum by now.
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Incisions
Health Effects of Trauma on Young Lives Unique health needs of adolescent refugees make them vulnerable – say PMH’s Dr Kajal Hirani and Dr Sarah Cherian. Refugees in Australia are increasing and they remain ethnically diverse. Approximately half of all refugees worldwide are estimated to be under the age of 18. The proportion of adolescents is unknown, however, as this data is not collected separately. Adolescent refugees have physical and psychosocial healthcare needs that are different to younger children or adults.1 However, healthcare professionals have limited awareness of the issues they face.
Unaccompanied adolescents are more likely to have been traumatised and have mental health problems than those accompanied by parents and, therefore, require intense social support. There continues to be ongoing concerns regarding the adverse effects of closed detention on the physical, mental and behavioural health of adolescent refugees.
Why adolescent refugee health is important Exposure to traumatic experiences during childhood and adolescence can lead to poor physical, mental and behavioural health in later life. Adolescent refugees may have had multiple and repeated traumatic experiences. This includes poverty, social upheaval with loss of homes, death of family members, political persecution, violence and sexual abuse. Accommodation during flight may include refugee camps and/or detention centres. During resettlement, they are challenged by different cultural values, unfamiliar educational programs and new peer relationships.
Adolescent refugees tend to develop maladaptive behaviours, such as violence, aggression and substance abuse, particularly in those who have experienced war trauma. Screening for health risk behaviours with timely intervention can enhance their psychosocial health.
Physical health problems
Education and community integration
Adolescents can have untreated physical health problems. Communicable diseases such as tuberculosis, malaria and soil-transmitted helminth infections are commonly diagnosed. Nutritional deficiencies, neurodevelopmental disorders and chronic diseases have been described too. All this makes comprehensive health assessment essential.2,3 Poor contraceptive knowledge and risky sexual behaviours can result in STIs and pregnancy in young refugees. Many may come from countries where female genital mutilation/cutting (FGM) is practised. Assessing completed FGM is an essential part of a culturally sensitive gynaecological review. Furthermore, adolescents at risk of FGM for cultural reasons should be counselled about health risks associated with the procedure as well as the legal consequences in Australia and if taken overseas. Mental and behavioural health problems Mental health disorders are now well recognised. Post Traumatic Stress Disorder (PTSD) has been widely reported in common with anxiety and depression. Those who have experienced immigration detention are significantly more likely to present with PTSD and have a heightened suicide risk than those from humanitarian refugee backgrounds. Furthermore, poor mental health literacy and cultural stigma can be barriers to seeking support.
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Many adolescent refugees have interrupted education before arrival in Australia and are more likely to have learning problems.4 Attaining English language proficiency, both conversational and academic, can take several years. Pursuing higher education and employment can be difficult in those who have had interrupted schooling. Medical and psychological problems can hinder education so academic progress in school-aged refugees is an important part of healthcare assessment. Any social isolation and perceived loss of friends and relatives in their host country can interfere with strong peer relationships that positively impact on wellbeing. During assimilation, many are torn between their own and host cultures, resulting in family conflict as parents attempt to preserve their own culture. Bullying and discrimination at school and in the wider community can affect mental health adversely. High-risk groups Adolescent refugees who are unaccompanied minors or have experienced immigration detention are particularly vulnerable.2 Unaccompanied adolescents are more likely to have been traumatised and have mental health problems than those accompanied by parents and, therefore, require intense social support. There continues to be ongoing concerns regarding the adverse effects of
closed detention on the physical, mental and behavioural health of adolescent refugees. Furthermore, reports of physical, emotional and sexual abuse of children and adolescents in immigration detention have raised significant child protection concerns, highlighted by the national inquiry into children in immigration detention by the Australian Human Rights Commission (2014).5 In conclusion Adolescent refugees are likely to have complex physical and psychosocial health issues with legal and ethical issues further complicating their management. Many of these young people, with adequate support, have the potential to positively contribute to society. Increased awareness and holistic health assessments are essential to aid successful resettlement and improve their long-term health outcomes. Referral to specialist refugee health services in early resettlement can facilitate multidisciplinary assessment and management. References 1. Hirani K, Payne D, Mutch R, Cherian S. Health of adolescent refugees resettling in high-income countries. Archives of Disease in Childhood. 2016;101:670-676. 2. The Royal Australasian College of Physicians. Policy on Refugee and Asylum Seeker Health, 2015. https://members.racp.edu.au/page/asylum-seekers 3. The Australasian Society for Infectious Diseases. Clinical guidelines. Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016 edition). https://www.asid.net.au/resources/clinical-guidelines 4. Graham HR, Minhas RS, Paxton G. Learning Problems in Children of Refugee Background: A Systematic Review. Pediatrics. 2016;137(6):e20153994 5. Australian Human Rights Commission Publication. The Forgotten Children: National Inquiry into Children in Immigration Detention (2014), 2015. https://www. humanrights.gov.au/our-work/asylum-seekers-andrefugees/publications/forgotten-children-nationalinquiry-children
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By Dr Mina John, FRACP, FRCPA, Clinipath Pathology
Guidance on Allergen-specific IgE potential allergens in food, underscoring the need to rely on the history to direct the testing.
Doctors are creatures of habit; over a decade ago the Radio-AllergoSorbent Test (RAST) was superseded by superior technologies for detecting immunoglobulin E (IgE), but “RAST” is still used most often in laboratory requests for allergy testing. “Allergen-specific IgE” is the correct term for allergy blood testing now and into the future.
• In rare cases, an allergen-specific IgE may not be detectable because of biological factors such as IgE directed to novel molecular targets in the allergen. Once again, this underscores the importance of the clinical history. If there is a very strong clinical probability of IgE-mediated allergy triggered by a specific exposure, Skin prick testing and supervised challenge in a specialised allergy clinic may be appropriate.
IgE-mediated reactions manifest differently, depending on the nature of the allergen exposure. Airborne allergens (grass, weed, tree pollens, moulds and house dust mite) cause allergic rhinitis and asthma. Allergens delivered directly into the circulation (e.g. bee venom, IV medications) or those absorbed through the gut in food or oral medications, mediate acute urticaria, systemic symptoms and anaphylaxis.
As a rough guide to selection of allergenspecific IgE: For rhinitis/allergic asthma – if highly seasonal symptoms request grasses and trees. If perennial symptoms, consider house dust mite, molds and animal exposures as appropriate for pattern of symptoms. A standard aeroallergen panel including a mix of local grasses is not unreasonable for screening based on the high analytical sensitivity of current assays.
Knowing the type of reaction usually narrows down the candidate allergens to be pursued specifically. Modern testing is highly sensitive and specific, however a number of factors influence test performance. Clinically “false” positives. That is, the test is not incorrect, but rather the positive test indicates sensitisation but this is not the cause of the clinical allergy. This is particularly seen in the case of food allergens because: • Cross reactivity occurs between antigenically related proteins in foods. • Cross reactivity occurs due to common carbohydrate determinants in many foods. • Some antigens are chemically altered by cooking and are therefore tolerated, but the specific IgE remains positive to the uncooked food antigen. • An extremely high total IgE>1000kU/L may associate with low levels of allergenspecific IgE, and should be interpreted with caution. Using large screening panels of allergens without a clear history of verified immediate reactions associated with specific exposures are usually not helpful. In the case of food allergens, false positives can lead to unnecessary and potentially harmful dietary restrictions. Clinically false negatives. Allergen-specific IgE’s may test negative even when true sensitisation is present. • Levels of circulating IgE vary with time after sensitisation and allergen exposures.
Allergen-specific IgE testing may be mechanised but interpretation isn't!
Allergen-specific IgE levels to medications and insects, for example, may decline if tested many years after a reaction. Or testing too soon after a severe reaction (e.g. bee anaphylaxis) may miss the appearance of specific IgE, the reason why such testing is typically arranged a few weeks after reactions. • Allergen mixes contain a limited number of component single allergens that may be irrelevant to the clinical reactions, leading to false negatives. This is again mostly applicable to food allergens. A detailed history of food ingredients preceding symptoms along with a history of ingredients known to be tolerated can help determine which likely culprit(s) should be tested as single allergen-specific IgE. The most common causes of serious food allergy are peanuts, tree nuts, fish and shellfish in adults and peanuts, milk and egg in children but there is a vast array of
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For anaphylaxis – testing must be directed by the history. Enquire about food, stinging insects and latex exposures. Medication IgE testing is limited due to the nature of drug epitopes mediating allergy. The entity of food-dependent exercise induced allergy is associated with omega-5 gliadin IgE which can be requested if clinically suggestive. For acute urticaria – testing without clues in the history as to possible allergen is not useful. Enquire about food and medication exposures. Finally, many common adverse reactions are not due to IgE-mediated allergy, including delayed skin rash on medications, local skin rash from topical creams, or headaches after takeaway meals. These entities are usually discernable from the clinical presentation (while a negative allergen-specific IgE helps exclude IgE-mediated allergy if needed). When used selectively in conjunction with clinical information, the allergen-specific IgE test is of enormous value in management of allergy (regardless of what we call it!).
Have You Heard? GPs front and centre After two years as national president of the RACGP, Mandurah GP Dr Frank Jones prepares to vacate the role in September for Tasmanian GP Dr Ben Seidel. Frank spoke to Medical Forum after the Federal Election where Medicare and General Practice were central to the campaigns of both sides of politics. He saw that as a measure of success of the College’s advocacy role which focused on putting patients and their GPs at the heart of debate. The rebate freeze was a difficult issue for the coalition, made even trickier when individual GPs and doctor groups began actively lobbying patients. “It’s noteworthy that the Health Minister was not seen or heard after she mentioned on the radio that she was sympathetic to our cause but had to be mindful of her fiscal responsibilities,” Frank told us. The freeze galvanised the membership and he believed
the Good GP advertising campaign laid solid foundations for the public awareness campaign that followed. “People are now more aware of GPs and their role in the health system. Most importantly politicians know we speak on behalf of our patients, especially the vulnerable. If policies affect the quality of care I can deliver to my patients I will advocate to change them. That’s my personal view and I think that’s now the College point of view,” he said.
Headspace ructions and WA Last month the CEO and five board members of the national youth mental health foundation Headspace resigned leaving turmoil and speculation in their wake. It comes after growing disquiet about the drop-in model’s effectiveness. It has a band of critics including John Mendoza, former CEO of the Mental Health Council of Australia, who told the SMH the original intent of the service had been "perverted" and the national head office had become "obsessed with brand and marketing". We asked WAPHA, whose role it is to fund youth mental youth services here, what effect these ructions would have on WA. CEO Learne Durrington said local Headspace centres had guaranteed funding, with lead agency contracts for the 11 centres across the state renewed for between one and two years. The role of ‘funder’ for these centres had been successfully transferred to the Primary Health Networks, having transitioned from the headspace National Youth Mental Health Foundation on July 1.
Avita’s nuclear preparations Spray-on skin developer Avita Medical’s regular media update on its US contract negotiations sent down a scorcher recently with news that it had won a contract extension to help Biomedical Advanced Research and Development Authority (BARDA) – part of the US health department’s disaster response network – prepare for treating burns from a nuclear explosion. We all know disaster preparedness is all in the planning but given the heightened geopolitical tensions currently it's too easy to add 2 + 2 to get 5. However, the deal means BARDA is supporting Avita Medical’s plans to get its regenerative medicine technology approved and launched in the US. In dollar terms Avita will receive an extra $US7.96m ($A10.71m), on top of a contract worth up to $US54m agreed last year.
Less hatches in despatches Data linkage has revealed that almost one in five Aboriginal children in WA under the age of 16 had unregistered births leaving thousands with no official identity. The finding published in The Australian and New Zealand Journal of Public Health linked birth records from the WA Registry of Births, Deaths and Marriages to births recorded in the state’s Midwives Notification System and it showed that 4628 births to Aboriginal mothers between 1996 and 2012 weren’t recorded. PhD student Alison Gibberd’s research has wide-ranging implications as a birth certificate is fundamental for proof of identity
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Have You Heard? and accessing rights such as obtaining a passport, a driver’s licence and opening bank accounts. CEO of Derbarl Yerrigan Health Service Ms Barbara Henry said there were a number of simple changes that would make it easier for new parents to register the birth of their child before they left hospital.
Sneaky snacks slammed The ACCC has come down heavily on food conglomerates Unilever and Smith's for
misleading healthy food representations. Each was fined $10,800 for labelling of popular products which indicated they had been approved or suitable as healthy options for school canteens. As Megan Neeson from the WA School Canteens Association explains on P29, there is a strict code for food for sale at schools so when you see a label with a tick and “School Canteen Approved” it is reasonable to expect that’s what it is – and what Unilever’s Paddle Pop promised. On
Smith’s Sakata Paws Pizza Supreme Rice Snacks it was a logo with the words “Meets School Canteen Guidelines” and an image of a sandwich and apple. In the small print were the disclaimers that the products met the ‘Amber’ criteria of the National Healthy School Canteens Guidelines. It wasn’t good enough for the ACCC.
Promo ban for formula Still of healthy food for children, the ACCC has re-authorised an agreement between manufacturers and importers of infant formula that prohibits them from advertising and promoting formula for babies under 12 months directly to the public. This five-year agreement is designed to promote breastfeeding in Australia. Submissions ranged from limiting the life of the agreement to two years and another urged a 10-year ban.
WA overlooked
The Specialists’ random trial Who said it was all work and no play over at the Perkins Institute? On September 3 at Royal Freshwater Bay Yacht Club rock legends The Specialists will be going off to raise funds for Team Perkins and its MACA Ride to Conquer Cancer. For $125 a head (no item number), you get the dance to the music of (pictured from left) Prof Graeme Hankey (bass, vocals), Prof Peter Leedman (drums), Dr Peter England (keyboard), Dr David Borshoff (vocals, guitar), Richard Dall (vocals, sax) and Dr Steve Gordon (guitar). Book perkins.org.au/events. The serious white coat stuff happens at the Open Day on August 27.
The National Health and Medical Research Council announced its Research Excellence Awards last month and no WA researcher was on the list. It can hardly be a reflection of the state’s talent pool – we know there is great work being done here. However, the research space is crowded and the funds meagre by international standards. It will no doubt cause some soul-searching in the local community and a spur for some innovative thinking.
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Have You Heard?
Crowded House Concerns have been raised from the RACGP and GPs as to whether all of the players in the crowded after-hours market are true deputising services for daytime GPs or they’re simply running their own race. Medical Forum spoke to Ben Keneally, the CEO of National Home Doctors Service, a newish player in the WA market, and president of the peak body, National Association Dr Ben Keneally for Medical Deputising (NAMDS), who was visiting Perth last month, about some of these concerns. The message was clear. After 20 years of a poor performing and in some instances non-existent after hours’ service, which saw a flood of non-acute presentations at hospital EDs, there was traction at last for these consumers to return to where they belonged – the primary care sector. Medicare stats Ben said the Medicare statistics showed the greatest growth (in numerical terms) in afterhours’ services were in consulting rooms (items 5020, 5040) than home visits (items
597, 599) though there had been increases in those as well. “What we’re seeing is the success of government policy,” he said. “But to speak to those GP concerns, the total number of afterhours home visits represents less than two visits per GP per week. In the 1950s when GPs were responsible for their own homes visits, they would have done at least that number of home visits. Yes, there has been growth, but it’s been off an extremely low base.” “However, there is a distinction between those organisations that genuinely behave in support of general practice and those that have set up with no connection to general practice at all.” “At National Home Doctor Service, and for NAMDS members generally, we are very strict about collecting GP details from 90% of callers, which reflects the proportion of people who don’t have a regular GP. So we report back to the GP; we don’t provide referrals; and we don’t get involved in checkups. There is a clear and detailed triage protocol to preclude routine work. Though there are websites that promote referrals after hours and that is clearly inappropriate and shouldn’t be happening.” The RACGP is waiting and watching.
• St John of God Health Care, plans to sell its pathology division to Clinical Labs. Part consideration for the sale includes SJGHC acquiring a minority shareholding in Clinical Labs. Clinical Labs will also have a long-term contract to provide pathology services to SJGHC hospitals. • Tasmanian GP Dr Bastian Seidel will replace Mandurah GP Dr Frank Jones as President of the RACGP. He takes up the role in September. Canning Vale GP Dr Mary-Therese Wyatt has been elected Registrar Representative on Council. • As reported last issue, Dr Andrew Miller is the new AMA WA president. The vicepresident is Dr Mark Duncan-Smith. Also new to the AMA WA council are Dr Gordon Harloe in the division of Specialty Practice and Prof Leon Flicker as an ordinary member. Former branch president Dr Richard Choong has stepped down from the council. • Dr Stuart Prosser has been appointed Director of Medical Services at St John of God Mt Lawley Hospital and Ms Vanessa Unwin the Director of Nursing and Midwifery. • The Housing Authority has awarded contracts for construction of two renal hostels – a 20-bed facility in Derby ($5.2m) and a five-bed unit on the Carnarvon Hospital site ($2.3m). The Health Department has awarded a $2.9m contract for construction working relating to the Fitzroy Crossing Renal Health Service.
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AUGUST 2016 | 13
Close-Up
Class Stayer Celebrates 70 Years Just as retirement is an alien concept to Prof Fiona Stanley, so is ageing. The tireless worker for child health looks at the achievements and challenges to come.
prevention of spina bifida. As a result of their research and their hard lobbying, commercial flour was fortified with folate.
If energy and enthusiasm, rather than years, were markers of age, Prof Fiona Stanley is a 25-year-old epidemiologist hard on the trail of yet another breakthrough to make lives of children healthier and happier. The energy and enthusiasm are still there, housed in a body that celebrates 70 years on August 1. She laughs when she tells Medical Forum that she shares her birthday with thoroughbred horses across the globe and in racing parlance she, herself, has proven to be a Class One stayer. Fiona was in Melbourne when we caught up with her, spending precious time with her three grandchildren. This morning it was with young Lulu who was chomping at the bit to get going to the promised matinee of The Sound of Music. But Fiona deftly juggles the need to campaign for the health of all children while giving herself to the needs of her own. Her story is a well told one and the evidence of a big life is all around. From registrar at PMH to a respected and potent advocate for children, there have been some big highs and some lows on her watch. Generosity the key The jewel is the Telethon Kids Institute of which she was founding director in 1990. Prof Gus Nossel told Prof Lou Landau, tasked with the job of finding a leader for this bold local leap into health research, to forget those with scientific reputations and instead look for someone with generosity. When asked what were among her favourite personal achievements she nominates being able to set up “organisations, environments and cultures which allow people to shine”. Prof Landau had found the right person. However, Fiona says at the heart of those organisations and environments were WA’s record-linked population databases. “WA is so lucky to have them. We have access
14 | AUGUST 2016
Just the day before we spoke, the AIHW had released its second report of three for the Australian and New Zealand Food Regulation Ministerial Council which evaluated the population health effects of mandatory folic acid fortification in flour.
Prof Fiona Stanley
to the midwives registers and population data such as the Raine cohort study, which have given us such vital information about birth defects, cerebral palsy, autism, intellectual disability and so on. This information is incredibly enabling and has put WA on the international map of research capacity. Hundreds of people, mentored by me and others, have done their PhDs off them.” “The reason I put this as one of my top achievements is that I don’t think I’m all that bright but have a great passion to do very good work. So the best thing to do when you’re in that position is to surround yourself with very bright people and enable them to do the work that absolutely needs to be done to make a difference.” Making an organisation great “It means you don’t have to be first on papers. You push your young people forward, you share your ideas and networks with them. What does that do? It makes the organisation truly great and everyone wants to work there and make it grow.” Her second nomination is the work she and Prof Carol Bower did in linking folate to the
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Since 2009, when these regulations came in, there has been a 14.4% decrease in the rate of Neural Tube Defects (NTDs) in the total study population (which included NSW, Queensland, WA, SA and the NT). Among ATSI women there was a 74.2% decrease (from 19.6 to 5.1 per 10,000 conceptions that resulted in a birth) and 54.8% among ATSI teenagers. “I get goosebumps thinking about it,” Fiona said. “We did it.” Finding obvious solutions It is one of a number of relatively simple solutions for complex conditions that she has steered through to translatable outcomes. Meningitis vaccines for infants; evidence which led to a reduction of the number of implanted embryos to prevent cerebral palsy are just two of the projects she has worked on. The institute was also at the centre of identifying the now famous gap between Aboriginal health outcomes and those of the wider Australian population using statistics from the midwives database showing the infant mortality rate was race specific. “My work at PMH in the 1970s running the Aboriginal clinic was an eye-opener for a little Cottesloe white girl. It was travelling to remote clinics and looking at the squalid conditions Aboriginal children were living in made me decide that I had to do a different kind of medicine; one based on prevention.” “I have a life of extraordinary richness and I’ve learnt so much from indigenous people across Australia. I have discovered
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News & Views
FASD Project Looks for Solutions Young people in detention at Banksia Hill are taking part in an important study that will hopefully lead to management strategies for those with FASD. Research in WA over the past decade has made a diagnosis of Fetal Alcohol Spectrum Disorders (FASD) a reality and now comes the growing need to identify and manage the condition in the community. Telethon Kids Prof Carol Bower and a team of clinicians and researchers are putting the theory into practice with an 18-month project at the Banksia Hill Detention Centre. Concerns expressed by Aboriginal communities and those in the justice system from the Chief Justice down, not to mention several parliamentary inquiries have raised the likelihood of high rates of FASD in young people in detention. “The evidence from overseas suggests this and it’s not thought to be any different here but it is important for us to find out so we can diagnose people and find better alternatives to sentencing and better management strategies to stop the revolving door,” Carol said. A grant from the NHMRC has allowed the team to conduct a comprehensive screening program and to determine who among the young inmates at Banksia Hill has FASD. The project also involves developing and evaluating workforce strategies for staff at the facility. “We have been screening and diagnosing just over 12 months and we’ve just had an extension of time to end of this year. We overestimated the numbers we would get in 12
months, which is good because that means there are fewer kids in detention but it means we won’t have any results until early next year.” Carol said the project was being positively received by both young people and staff alike. “The kids themselves are keen to take part though there have been some difficulties in getting consent from parents or carers. It’s not so much parents/carers are declining consent, more that it’s hard to contact them. It’s a challenging project in many ways but we’ve had fantastic support from the staff and the kids and their families.” Those young people who are on the project are comprehensively examined by a paediatrician, a speech pathologist, an OT and a neuro-psychologist who discuss their findings and come up with a diagnosis of FASD or not. “Not surprisingly a very high proportion of these young people have some condition to report, so the clinicians write a detailed report and summary of the young person’s strengths and difficulties which is fed back appropriately to the parents/carers and the young person themselves and with their permission it’s made available to staff at Banksia Hill,” Carol said. “It includes some management strategies, which can be put in place while the young person is still in detention. The report is then available for them to take when they leave. So it’s also a useful document when they return
How to Diagnose FASD Telethon Kids Institute has published comprehensive guidelines for the diagnosis of FASD on its website. It is designed to help clinicians who are likely to come across patients they suspect as having FASD. While free, it requires registration. There is also a set of e-learning modules, which are due to be activated by August. All the information is available at http://alcoholpregnancy.telethonkids.org.au/australian-fasd-diagnostic-instrument/
the significance of Aboriginal culture; the relationship to land; the real family love and support that exists in communities and I have forged amazing friendships that I will treasure until I die.” Success based on trust
suicide rates we are seeing today. Even the most so-called dysfunctional of communities know what it needs and the kinds of things that come out of Canberra or Perth that are developed by white bureaucrats who don’t understand the context in which Aboriginal people are living will fail again and again.”
“The trust that has grown has been a huge lesson. We are all a bit racist and paternalistic. We don’t trust that Aboriginal people can work out their solutions – but, of course, they can. There have been so many royal commissions and reports and time and again their recommendations are not implemented or they are ignored. If they had been implemented we wouldn’t be seeing the
“We have wasted billions and billions of dollars … and who gets blamed? We must start listening to people like June Oscar whose program in the Fitzroy Valley is making young people proud to be Aboriginal and will turn things around. It’s not rocket science. No one would want things they didn’t understand imposed on them and yet we fail Aboriginal people like that all the time.”
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to the community and will help their school, their doctor, or their lawyer manage their difficulties regardless of whether they get a diagnosis of FASD or not.”
Prof Carol Bower
“The dream is that they will be less likely to go back into prison and more likely to have a good life.” The project is also a positive development for corrective services staff. “They think this is a really useful project because it is providing helpful information to deal with these young people. For example, the project assesses language and one young person who was fluent in expressive language was shown to have trouble with receptive language. And that rang bells with the staff – even though the young person could express themselves, he had difficulty following verbal instructions.” “So it helps grow understanding and to develop strategies. Some of the assessments are individualised but there will be some general strategies that come out of it so we can develop some sort of training package for the staff. It could then flow on to the academy and other parts of corrective services.” The more researchers find out, the sooner intervention can take place, particularly in pre-sentencing environments. “We hope to develop a simple screening tool at the end of the study that could be useful when kids first offend, perhaps, and if they were assessed with FASD then alternative pathways could be put in place.”
“So while I feel Aboriginal health is a strong part of my achievement, in a way I also think that we have failed to convince governments that Aboriginal control, with strong, competent, ethical partnerships is the way to go. Not partnerships that demoralise, or are paternalistic or that shatter self-esteem, that’s why kids suicide.” “We’ve never really healed the stolen generation, but I’m optimistic and always will be. I believe Aboriginal people have got the solutions and it will only take a few of us to help them make gains.”
By Jan Hallam
AUGUST 2016 | 15
Spotlight
Home Is Where the Art Is Janet Holmes a Court has her roots firmly in the soil of WA but can also see when we don’t do things as well as we should. Janet Holmes a Court with one of her art works by Indigenous artists. Picture: Frances Andrijich
It may surprise you to know that one of WA’s best-known business women was once described as a left-wing activist! Does Janet Holmes à Court AC – arts lover and philanthropist – still maintain the rage? “Yes, most definitely! I believe Australia’s treatment of refugees and asylum seekers is disgraceful. It’s inhumane in every sense and seriously damages our international reputation. I’m also very upset by the decline in funding for education and the arts, and even more so by the statistics relating to Indigenous incarceration and suicide.” “And the increasing divide between rich and poor is a real concern.” Mrs Holmes à Court is a quintessential Sandgroper, born in Perth and educated at Perth Modern and UWA but a few aspects of life in the world’s most isolated capital city continue to rankle. Where’s the pizzazz “We don’t do ‘spectacular’ very well here. It’s absolutely fundamental to think about the aesthetics of public space. For example, the Bell Tower is rather diminutive and I’m a little surprised that, given all the fuss and disruption, Elizabeth Quay actually looks out on a relatively small body of water.” “There’s a recurring tendency for knee-jerk planning that sometimes translates into serious, albeit unintended, consequences.” “The new Football Stadium may well end up encouraging gambling because there’s not much to do after the final siren except head for the Burswood Casino. In the same vein, the construction of the Graham Farmer Tunnel was an excellent addition to public infrastructure but did anyone think about the congestion it would cause on Thomas Street?” However, it’s not all doom and gloom for a high-profile woman whose own family name [Ranford] goes all the way back to the early foundation years of the 1840s. Local knowledge “I’m truly local by birth, though I do actually see myself as an Australian. I have a great love for this country. It feels like my place when I look up at that big, brilliant sky and the amazing colours of the land and ocean. The Pilbara, Kimberley, Wheatbelt and the South West are such wonderful places.”
Another luxury that all West Australians have the opportunity to share is an increasingly sophisticated artistic and cultural life. The ongoing generosity of wealthy individuals such as Janet Holmes à Court plays an important part. She has long been a collector of Australian art and she fosters local talent at the Holmes a Court gallery at Vasse Felix winery in Margaret River. She is also chair of the WASO. “Most of my philanthropy involves the Arts. I’m involved with the West Australian Symphony Orchestra, Black Swan State Theatre Company and the Australian Children’s Television Foundation, among others. It goes without saying that the Arts need philanthropic and corporate support.” “I reckon it’s possible to hear fine music 365 days a year in Perth. And our Concert Hall has one of the best acoustics in Australia.” The woman who went on to head-up one of Australia’s signature companies began her own career as a science teacher. “I learnt to work hard and put a lot of time into preparation. It usually pays off if you do the simple things well. I’m also a great believer that nothing can be achieved on your own and being awarded the UK Business Woman of the Year in 1995 was a classic example of that.” “It was for my work with London’s West End theatres and, naturally enough, a large team of people contributed to the end result.” Medical concerns It’s a well-known fact that the ‘baby boomers’ are ageing fast and the health sector, particularly aged care, is struggling to cope. “I’m a supporter of voluntary euthanasia, with the emphasis on voluntary! In fact, I’ve been a member of WAVE [WA Voluntary Euthanasia] for many years.” “More broadly, I’m a little concerned at the high fees charged by some specialists and I’d like to see a lot more attention given to health education, focusing on illness prevention.” “I’m so lucky to be in such good health. Our family has had the same GP, Dr Rex Hughes, for four generations. That’s such a luxury!”
By Peter McClelland
“And of course there are the people! I’ve got friends that go back 70 years and one of my sons lives here with his wife and five children.”
16 | AUGUST 2016
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AUGUST 2016 | 17
Obituary
His Care (and Jokes) Live Forever Gwelup GP Dr Patrick McGonigle’s sudden death has left all who knew him in shock but the happy memories are irrepressible, much like the man himself.
Much-loved Gwelup GP Dr Patrick (Pat) McGonigle, aged 63, collapsed and died on the Hamersley golf course in June with his wife Yvonne by his side. The death of the popular GP, who featured in Medical Forum in March last year, has shocked his family, friends, colleagues and patients. At Patrick’s funeral, his boyhood friend, gastroenterologist Dr Brendan Collins, shared some of his memories of Pat garnered over 52 years, beginning with the first day of high school at St Malachy’s College in Belfast, Northern Island.
boys were accepted into medical school at Queens University in Belfast, with Pat going on to physician’s training and appointments at Royal Victoria Hospital, Belfast City Hospital and Craigavon Area Hospital. Pat met his wife Yvonne at university where she was studying physics. They married when Pat still had two years of studies to complete. Northern Ireland was in the grip of the ‘Troubles’ which spurred Pat and Yvonne with baby son Michael to look south and they set off for Perth in 1983. Brendan and his wife Deirdre followed seven years later.
Medicine beckons
“I remember phoning Pat from Belfast when I was offered a job at RPH and asked him what Perth was like. I will never forget his reply. He said, ‘Perth is the best kept secret in the world. From October to April the sky is brilliant blue and you will struggle to see a cloud’. Pat and Yvonne loved their life in Perth and Pat’s comments sealed the deal for us emigrating also.”
Brendan encouraged his friend to try for medicine but Pat was undecided until the last minute when medicine won out and both
Pat was a keen runner competing in marathons and triathlons and he climbed Kilimanjaro at the age of 60.
“My first impressions of Pat were of a ‘wee hard man’, as they say in Belfast. He looked tough but the impish grin was there as a permanent feature. He was wearing a school jumper his granny had knitted for him and was the only boy in the class who didn’t have a blazer.”
From Pat’s Patients
“He was such a warm and caring doctor and who can ever forget his many jokes. Ken and I attended his funeral and felt humbled to have known Patrick as his patients for over 30 years. He was such an inspirational man.” “A truly remarkable doctor who has (left) a lot of wonderful memories in each and every person he met. His endearing ways and impish jokes will never be forgotten.” “What a giant of a man and doctor he has left huge shoes to try and fill.”
18 | AUGUST 2016
I haven't worked a day in general practice without him. I have lost a mentor, a colleague, a friend, a confidante. What will I do without him?" – Dr Alistair Vickery Laughter the best medicine “Pat loved his work and loved working with his colleagues in Gwelup Medical Centre and I feel he would never have fully retired. No matter how ill, his patients always left the surgery with a smile as Pat’s terrible jokes were legendary. Of course his jokes and high spirits were part of the art of medicine that he practised. Alongside this, however, he was exceptionally thorough and an excellent diagnostician,” Brendan said. Pat’s Gwelup colleagues write that Pat started work as a respiratory registrar at SCGH and quickly moved into general practice at Seacrest. He worked as a GP in Sorrento, Kingsley and Gwelup and cared for many nursing home patients across the northern suburbs. His patients loyally followed him to successive practices over 32 years, a testament to his care and knowledge. “Not many of us can equal his diagnostic acumen and knowledge of complex medical care or his ability to provide that care compassionately and completely for so many, many patients. “Pat, you were a great doctor, a wonderful family man, a teacher and mentor to students and registrars, to your colleagues. You were a modest man with that wonderful Irish gift for story-telling and a man of great intellect. We will miss your jokes, your cheeky grin, your generosity and your wisdom. We will miss you.”
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AUGUST 2016 | 19
Feature
Giving the Chance to Start Over Mental health courts for adults and children are directing services to these vulnerable people while reducing reoffending. It’s a good mental health story! In the State budget this year, $13.1m was committed to the Mental Health Court Diversion programs running in the Perth Magistrate’s Court and the Children’s Court. In a tight fiscal climate that was a big tick of approval for programs that are giving everyone involved – from the accused, their families, the police, the justice system and clinicians – a lot of hope. Since the programs began in 2013, the adult Start program and the children’s Link program have received 934 and 898 referrals, respectively, Dr Adam Brett and have had promising results in improving the mental health of participants as well as reducing recidivism. That translates to a safer community.
Medical Forum spoke to psychiatrist Dr Adam Brett, who is the clinical lead of the adult Start program. His team includes a full-time team leader, three nurses (one full-time, two halftime) and a social worker. His team dovetails with the Magistrate, the police prosecutor, the duty lawyers, community corrections staff and NGO community coordinators to provide an integrated service. “Start is an interagency operation. We deal closely with the NGO Outcare and do joint assessments with them. We look at the clinical issues and Outcare looks at the psycho-social issues such as accommodation, employment, training, budgeting. Issues like that. People are given holistic management,” he said. Working as a team “People on the program see the same magistrate (Mr Kevin Tavener) and usually the same police prosecutor and duty lawyers. The entire court staff is trained in mental health first aid so everyone has a good understanding of the issues when people come to court. Our security person is a key
Ice and the Court
person in the court. She helps talk a lot of people down.” “It is quite noticeable how anxious people are when they first attend court and later they enjoy meeting up with staff and talking through things. That’s very different to a normal court process. We have the time to address people’s problems and treat people more humanely.” “From a clinical perspective, Start has exceeded our expectations. We can do a lot of things other services can’t. People have to volunteer to be part of the program and that’s usually based on their personal insight. They recognise that if they don’t sort out their mental health issues they will go to jail. So we can use that as pivot.” The court doesn’t turn anyone away and will address anything from schizophrenia to druginduced psychosis, matching services to the needs of the client. “A case will come to us and a nurse and a social worker will do an initial assessment and then it will go to the team to discuss how we can help. Anyone who is complex or has significant difficulties, I’ll do a second opinion. If they are already linked in with mental health services, I’m less involved.” Timely assessments
Dr Adam Brett in his role as clinical lead at the Start Court sees close-up the ravages of methamphetamine use but he is confident that programs like his can be useful. “In our experience, we see a lot of ice users fall through the gaps in the system. Mental health services say drug-induced psychosis is not their problem, it’s a drug problem, and drug services say they can’t deal with the drug problem because of the psychosis.” “We have a great opportunity to address those issues and have had tremendous success with these clients. The treatment is straightforward – people stop using drugs and take antipsychotics for 6-12 months – we’ve had a lot of people come through our service who have turned their lives around. That’s what keeps the clinical team ticking is when we see clinical change.” “Unlike the drug court we don’t have ready access to rehab beds but we can get people into rehab. We work closely with community services. At the end of a person’s stay, they return to court and the magistrate at sentencing hands the client a recovery plan which lays out what they have achieved during the term with the court and what they have to do to remain well.” “All our plans need to be cohesive and with community services engaged so we are able to take a back seat. Outcare can follow people up after sentencing so people don’t fall between the gaps, but most times it’s unnecessary because the recovery plans have been well thought through and have worked. Those people are now supported by their GPs and community and mental health services.”
“I have some specialist roles in the program. I do the fit-to-stand trial assessments to ensure a fair trial. In other courts, there is an 8-12 week waiting list for that assessment and is quite expensive. In our court, I can see people straight away and give a verbal report immediately.” “If they need treatment, I can tell the court that they will commence treatment to return in a month’s time with a report. That process saves the court a lot of time and money and saves the patient a lot of difficulties because there’s no delay in getting treatment and to get a report.” “My other role is doing causal link assessments, which give the court an understanding how a person’s mental health issue affects their behaviour. In the open court system, these assessments are given to a private psychiatrist. Although we haven’t demonstrated it yet, US mental health courts have shown to save the government a lot of money and reduces both the prison rate and the risk to the community.” What you won’t see in the figures are the people the Start team can help without them being processed into the justice system at all. “We can advocate for people who have committed a fairly minor offence and are clearly unwell. We link these people into the mental health services and write to the prosecutor asking them to consider dropping
20 | AUGUST 2016
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Feature
Adult Start Court Participants • March 2013 and 30 September 2015, the Start Court received 788 referrals, of which 412 received support from the clinical team. • 191 entered a formal support program; 99 completed the program; 43 were current as of September 30, 2015. Health Outcomes (from a sample review, July-September, 2015) • 92% assessed as demonstrating clinical improvement; • 67% assessed as being at lower risk of self-harm or suicide; • 53% reduced or ceased problematic use of alcohol or other drugs; and • 73% experienced overall improvement in wellbeing. Community safety outcomes • 80% who completed the Start Court program either ceased offending or committed less serious offences. • 62% who were assessed for, but did not enter, the Start Court program reoffended compared with 49% of participants who completed the program. • 58% assessed as posing a lower risk of violence after engaging with the program. Source: Court Diversion Program Evaluation 2015
Children's Link Program
the charges. Many times the prosecution does because they trust our judgement and something worthwhile comes from it. That person gets the help they need and avoids contact with the justice system.”
Participants • Between April 2013 and September 30 2015, Link received 655 referrals relating to 431 young people.
Trust is the key “We work as a team and that’s the special thing. We all did the training together and while there has been staff turnover, there are regular team building meetings. The more we’ve grown as a service together, the more trusting we are of each other.” “The power of this court has impressed us all. Most of our clients haven’t succeeded much in life so when they do get through the program and the magistrate and clinical team are full of praise, it is quite special. It works the other way too, if someone plays up while on the course, the magistrate directs some stern words that have an effect not just on that person but those at the back of the court listening. It’s a powerful and motivating thing.”
• 84.6% referrals resulted in a formal mental health assessment. • 72.6% had no prior history with public mental health services • 94.2% were not currently receiving support from a mental health service Health outcomes (July-September 2015) • 88.5% demonstrated clinical improvement; and • 86.4% had reduced risk of causing harm to themselves or others. Community safety and diversionary outcomes Children’s Court Magistrates identified numerous cases in which the support provided by Link contributed to a decision not to remand or sentence a young person to detention. Source: Court Diversion Program Evaluation 2015
“We believe that people leave the court in a better state than when they arrived and have learnt skills that reduce their risk of reoffending.” The success of the Start Court has attracted the attention of the higher courts and now the clinical team is being asked to supervise mental health pre-sentence orders for more serious offenders. “Three years ago the program was aimed at the lower end of the offending and mental health spectrum but we are now managing more serious offenders. We have expanded to fill the demand – it’s a big niche but it is working. We don’t get many good stories in mental health but this is one of them.”
By Jan Hallam
MEDICAL FORUM
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AUGUST 2016 | 21
‘It’s Always the Doctors Fault?’ If you feel at times like a sitting duck and the system is out to get you, the message from the last Doctors Drum meeting will make you feel a lot better. So what did we learn? Firstly, you are not alone and, most importantly the system leaves a lot of doctors vulnerable. How it lets docs down One of the panellists came armed with some bullet points. If blame needed to be apportioned, he said, try these for size: • Politicised health system with constant funding shortages • A administration-heavy institution unresponsive to staff concerns
The Panellists Dr David Russell-Weisz - DG of Health WA Ms Cheryl McDonald - MIGA Claims Manager Dr David Borshoff - Specialist Anaesthetist Dr Cynthia Innes - Experienced GP Dr David Sofield - Specialist Urologist Ms Pip Brennan - Consumer Advocate of factors, and protocols needed to be user friendly and not bureaucratic. There was also a call to bring the consumer into that safety conversation to make health a truly personcentred culture.
• Empire-building and fund-dependent institutions churning out poorly trained doctors • Obsession with process rather than outcomes
An MDO lawyer at the forum said that there was a growing (but small) number of trainees who contacted her organisation looking for support, claiming they were being harassed or bullied out of a training program. Another doctor said that all doctors had to be responsible and accountable and as senior members of the medical community there was a responsibility to help colleagues.” Consumers expectations The high expectations on doctors by consumers also contributed to this perfect storm. People think doctors had a magic wand and if they couldn’t deliver
Training the wrong people
• A legal system that needs to point the finger at somebody to compensate for those unfortunates who might need ongoing care. But there was a fine line between productivity and risk management. “While I am a believer in good systems and protocols, if they’re thoughtful and been devised in consultation with those on the frontline, those systems can be very helpful but others need to be reviewed,” one doctor said. It was pointed out that it’s rare that just one error causes catastrophe but rather a number
One doctor raised his sobering experience as a former trainer where in some specialties training had been shortened and diluted resulting in poorer quality specialists. Doctors felt pressured not to fail trainees even if they showed themselves unsuitable for the specialty. “I had three consecutive trainees who failed 80% of the criteria. Their results were put to the training committee which took it to the central committee and these people, who could end up as dangerous and incompetent doctors, proceeded with their training because of the medicolegal threat if they were kicked off the training program.”
A pleasant breakfast, heartfelt discussion and a catch-up with colleagues - Doctors Drum 9 had a waitlist again!
Supported by:
See www.doctorsdrum.com.au 22 | AUGUST 2016
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a miracle, they could become a subject of complaint. This then raised the issue of how poorly AHPRA handled consumer complaints. Many doctors feel aggrieved that frivolous complaints, which should be rejected immediately, were allowed to proceed for months until they were finally found to have no substance. The damage this did to a doctor’s mental and physical wellbeing was appalling. One said this poor triaging process meant the entire workings of AHPRA got bogged down. “Valid complaints should be given appropriate time and investigated and not sidelined, while those frivolous matters should be rejected or resolved differently.” One doctor urged a collaborative approach from consumer advocates and practitioners rather than the current adversarial approach as both parties were working their hardest for the patient. While the consumer advocate on the panel agreed wholeheartedly, she said there must be a space for independent advocacy because while most health professionals were incredibly caring people, there were a few who couldn’t care less about their patients. This discussion led to the old chestnut about the poor communication between hospitals and the patient's GP. One doctor lamented that some patients simply could not navigate the tertiary system without help. Their GPs were the most likely people to help them but had their hands tied because they didn’t know what had happened in hospital. When things go wrong, patients don’t seem to have any recourse at the hospital level.
Open Disclosure was cited as a solution even though it was admitted it fell far short of being perfect. However, timely actions by responsive patient liaison services in hospitals could lessen problems. It was pointed out that consumers have never had so many avenues of help as now, but hospitals did have to know of the problems before they could help fix them. Culture and communication
In reply one veteran added: “Over the centuries when there are a group of people terrified by something there’s always a scapegoat – the gods, women burnt at the stake because of the plague, now what’s left … us probably. To deal with that, we need really good communication with our patients; to share their feelings and fears. It’s the best antidote to blame.”
This is where clear communication was essential. Doctors were becoming more confident to have forthright conversations with patients in circumstances where things hadn’t worked out the way they were anticipated, but more education was needed so that doctors could explain without admitting liability. While talk was about doctor responsibilities, it was acknowledged that consumers had to take responsibility for their own health outcomes. The idea of consumer as victim was the wrong language. For one doctor there was an impassioned plea: “There is a societal need to blame someone. We call a smoker who develops lung cancer a victim, an obese person who develops diabetes a victim. The whole system gangs up on the doctor.”
See www.doctorsdrum.com.au
MEDICAL FORUM
AUGUST 2016 | 23
Feature
The Dark Side of the Web The internet poses real risks to the safety of children and the entire community has a role in fighting online child exploitation and abuse. Charles Dickens was right – it is both the best of times and the worst of times, particularly when it comes to the enabling power of the internet. With several highprofile child exploitation and child sex abuse cases hitting the headlines and before the courts, the role of the internet in facilitating such attacks on minors is evident. It is the frontier on which child protection services work tirelessly. The Joint Anti Child Exploitation Team (JACET) is a national taskforce with teams in each state and it is behind those high-profile charges we have A/Prof Peter Winterton been hearing about. It is led by the Australian Federal Police and local police forces and draws on the experience and expertise of agencies such as Child Protection Unit (CPU) based at PMH and ChildFirst, at the WA Department of Child Protection.
CPU physician A/Prof Peter Winterton has seen just about everything in his 37 years working in the area and knows better than anyone how real the threat the internet poses to child safety. Attacks on many fronts “We’re not only talking about child sexual abuse but stalking, texting, sexting, dodgy friendships, drugs, cyber revenge and bullying and the threat is very real,” Peter said. “Like everything in life, the internet is a two-edged sword – it is both a blessing and curse. The very means of exploitation is often the offenders’ undoing as they compile the evidence against themselves on their own devices. That’s the blessing side in the sense of collecting evidence.” The speed by which things can change, is the curse. “A key message, which is so often not understood, is that once you put something on the internet it is there for eternity. And that’s very difficult for small children to understand. Eternity is tomorrow for them,” he said.
JACET has produced a comprehensive online resource called ThinkUKnow, which has been developed in partnership with Microsoft Australia, Datacom and the CBA and delivered by the state and territory police services and Neighbourhood Watch Australasia. And as befits the times and technology it links up with international child protection agencies. Info for families It has a wealth of information for parents, teachers and carers to equip them to manage better their children’s internet useage including fact sheets on popular network games and social media sites, including agerestricted sites such as Tinder. Peter said child abuse is a public health issue: “The only way to combat or at least minimise this is to consider cyber abuse as a public health issue. We have to start educating children at a very early age as to what they are doing. Parents must educate themselves to know what their children can do and are doing, without being punitive.”
Young kids who show psychological distress may turn to the internet, or the internet may turn on them. Test your bias! The headline in the press release read: “Internet and gaming use linked to serious mental health disorders in young people”. Did you think iPads are skewing children’s brains? Did you think the Internet is sending kids crazy? You need to read on. As always, the researchers had a real dilemma between knowing how to dumb down or make socially relevant their results, to attract attention (Rikkers et al. BMC Public Health, 2016, 16:399, DOI 10.1186/s12889-016-3058-1). Yes, some of the Telethon Kids Institute researchers – and there are about 500 of them, half involved in clinical work – had found a strong link between excessive internet use and increased levels of psychological distress in young people. They just didn’t know what was ‘chicken or egg’. Too much Internet distresses young brains or already distressed young brains turn to the Internet. Using the Young Minds Matter survey results, said to provide reliable data on children aged 11-17, most young people in this age group were using the internet or played electronic games, and around 78,000 or 4% of children and adolescents showed problematic internet or games use.
24 | AUGUST 2016
What of the data? During 2013-14, 6310 parents and carers of 4-17 year-olds were interviewed (55 % response rate), together with self-report questionnaires completed by 2967 11-17 year-olds in these households (89 % response rate). Lead author of this research Ms Wavne Rikkers said although some might consider the 4% small, links were sufficient to warrant concern and further research. New technology dominated a young person’s life these days, changing “how young people may deal with issues of social isolation, bullying, depression, behavioural disorders, boredom, or family breakdown,” she said. Amongst the young people surveyed, those with problematic internet use self-reported major depressive disorder about three times those without problem behaviour, 14% had attempted suicide in the previous 12 months, and about one in five had binged on alcohol in the previous 12 months. ‘Problem behaviour’ children were said to be those who showed four of five traits: went without food or sleep, showed an unusual hankering for the Internet or games (including ‘Internet addiction’), had unsuccessfully tried to cut it back, and family, friends and school work missed out because of it.
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Gender differences were evident in how teenagers use the internet or play electronic games. “Girls use IT more for social connection, emotional support and communication. Boys tend to use IT for entertainment and information. This was borne out by our findings that girls with high levels of psychological distress had twice the rate of problem online behaviour than boys. In contrast, boys tended to have higher levels of conduct disorder or hyperactivity coupled with problem online behaviour. This means that treatment regimens for kids presenting with online problem behaviour need to be gender-specific,” Wavne said. Psychological distress, suicidal intent and risky behaviour may be cues to other problems. “We know a third of kids go online to source information about mental health issues, so perhaps that’s a good way of offering treatment solutions.” Wavne recommends www. youngmindsmatter.org.au where a Survey Results Query Tool allows you to make up your own tables and graphs (no statistical skills needed).
MEDICAL FORUM
Doctors as Mandatory Reporters Since January 1, 2009, WA doctors must make a report if they believe a child under the age 16 has been sexually abused. As a CPU physician, A/Prof Peter Winterton has been a sounding board for many doctors in this position. “The level of forming that belief is not belief beyond reasonable doubt, but belief on the basis of probability. It is not the job of the practitioner to conclude absolutely that this has happened only to be significantly concerned based on what information supplied by the child, parent, concerned relative, school, school psych, has helped form that belief.” Peter said such a report went into the mandatory reporting line. That initial report remains anonymous. However, if the matter proceeded to court, then subsequent practitioners, who might include the reporting GP, might be involved.
Bethesda Health Care General Practitioner Education Program (RACGP Accredited Program)
“This frightens the daylights out of many GPs. So what should the GP do in that situation? There are a number of options: • The first is not to report – but that’s not what I’m proposing because that’s not in the best interests of the children of WA; • If they have made a report and feel fearful they are very welcome to contact the Child Protection Unit and get help from people like me and other members of the medical team here; • They can talk to their MDO.” “What confuses and concerns doctors is the report may activate a child protection matter, a criminal matter or a family law matter. These are three separate jurisdictions. The GP may feel the best thing they can do in this situation is to bow out and involve our unit by making a referral. We will then, if need be, become involved as the matter proceeds.” “It may not necessarily let them off the hook. They may have seen the child on a number of occasions and they still may be asked to give evidence in some capacity.” “I’ve been working in this area for a very long time, but it is an area that frightens GPs considerably. GPs do need training in understanding the court process and that they may be involved in legal proceedings.” Always there to help is the CPU. It will move to the new Perth Children’s Hospital on November 20, until then the telephone referral line is 9340 8646 or fax 9340 8822.
Now in its 4th year, the program offers a range of high quality educational sessions including orthopaedics, pain management, prostate cancer, bariatric surgery, breast cancer surgery and palliative care. To join Bethesda Health Care's GP database, please email your details to rsvp@bethesda.org.au or call (08) 9340 6396 www.bethesda.org.au/events
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AUGUST 2016 | 25
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26 | AUGUST 2016
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e-Poll
Male Doctors Wary of Children This edition carries some results for the first time from our straw poll of 109 doctors a couple of months ago. In summary, the results show males are targeted for extra attention when it comes to wariness over child abuse. During work as a doctor, about a quarter of male GPs
Child abuse has been prominent in the media for some time. Has this increased the awkwardness you experience in dealing with younger children, either:
Q
At work as a doctor?
No Yes Uncertain
74% 22% 4%
ED: While most doctors had no problems dealing with younger children, 27% of males did (vs 7% of females). Craft group comparisons showed that awkwardness was experienced by 27% of GPs vs (18% of Specialists).
Q
Or: Anywhere outside work?
No Yes Uncertain
71% 28% 2%
are feeling the heat. Outside work, media coverage of child abuse makes about half male doctors think twice about disciplining another’s child. If the public perception of doctors is changing so that trust is reducing, what does that say about the profession?
[During the short interval open for response, respondents declared themselves as 41% GPs, 45% Specialists and 6% DITs – 75% were male, with the larger preponderance of males partly explained by only 10% of specialists being female (vs. 40% of GPs).]
Augus e-Poll t
WA Doctors Comment Society has changed “Women trust men less with their children in general now. The doctor child-patient relationship is an extension of the greater societal shift.”
taking photos (at my daughter's request) at a grandchild’s first birthday and had a lot of funny looks before I thought it was time to put the camera away. I think kids now miss out on appropriate male affection.”
“The only child abuse perpetrated by male doctors is 'neglect' due to spending too long at work.”
Reservations expressed
The children miss out.
“There has long been the assumption that all males are (potential) rapists and paedophiles.
“It is sad that men in general are painted with the same brush as a child abuser. The vast majority of men are normal, genuine people and should not be made to feel guilty or awkward for displaying affection to children. Children will miss out on a normal, healthy interaction with men as role models. I blame the media!”
“I am extra careful not to even appear to be doing the wrong thing.”
“Have a chaperone in the room always.” “I suspect those who have poor male role models during development pre-puberty and are bullied at school by males. They will have difficulty relating to male children in their handling of paediatric urogenital problems.”
“There is an assumption of guilt with men interacting with kids. I made the mistake of
ED: Males were more likely to experience awkwardness outside work in dealing with young children as a result of child abuse media coverage (35% vs 4% of females).
Has child abuse coverage in the media made you think twice about:
Q
1. Whether you discipline other people’s children?
No Yes Uncertain
51% 42% 6%
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ED: Child abuse media coverage made nearly half of both female and male doctors think twice about disciplining other people’s children.
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2. How you discipline your own child in private?
No Yes Uncertain Doesn't apply
55% 12% 0% 33%
ED: But not their own so much.
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Are you more wary of men (than of women) when they show affection towards children in public?
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ED. There is definite gender bias against men.
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AUGUST 2016 | 27
Vaccine Updates Sign up now Sign up to WA Health’s Vaccine Updates email for regular updates about immunisation programs and vaccines in Western Australia. All immunisation providers are encouraged to register at vaccineupdates@health.wa.gov.au Learn more at health.wa.gov.au Email addresses are stored securely by the Communicable Disease Control Directorate, and are only used to send immunisation information. 28 | AUGUST 2016
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Guest Column
Greening the School Lunch Box Parents and schools wants kids to eat healthy food, kids just want tasty food. Nutritionist Megan Neeson has the job to bring all the parties to the table. In Australia, 25% of our children are overweight or obese and many do not adhere to the Australian Dietary Guidelines. So what if we just told kids to eat more ‘green’ foods? Sounds easy enough, but unfortunately this conjures up images of spinach and brussels sprouts that will have many kids turning away. While these are nutritious choices, ‘green’ foods by our standards are far more interesting. Public and Catholic schools in WA must follow the Department of Education’s Healthy Food and Drink (HFD) policy, underpinned by a ‘traffic light’ system. The policy makes it easy and equitable for all canteens to offer a majority of nutritious foods. ‘Green’ foods are high in nutrients and low in saturated fat and sodium – for example, fruit, vegetables, dairy, wholegrain cereals and lean meat. In comparison, ‘amber’ foods contain some nutritional value but can contribute excess energy and ‘red’ foods are energy dense and nutrient poor, often high in fat, sugar and salt. According to the WA School Canteen Association (WASCA) on average, the menus
As long as it looks good, tastes good and is value for money, students will choose the healthy options. they assess contain 71% ‘green’ items. This includes some pretty tasty fare – chicken and salad wraps, frittata, stuffed spuds, fruit pikelets, sushi and lasagna. When a high school canteen in Victoria Park asked the students what they wanted from the canteen, they requested more homemade items. The menu offers an impressive 90% ‘green’ food including burritos, breakfast muffins, piri piri chicken and stir-fry vegetables with noodles. According to the manager, as long as it looks good, tastes good and is value for money, students will choose the healthy options. The biggest barrier facing school canteens is conflicting messages in the school environment. For example, parents providing
highly processed packaged foods in lunch boxes; teachers rewarding good behaviour with chocolates; and the most frustrating of all, a sausage sizzle at the sports carnival. These are all missed opportunities to promote consistent healthy messages. WASCA supports schools to implement the HFD policy. One strategy is to work with food industry to increase the range of food and beverages available. WASCA produces the Star Choice™ Buyer’s Guide, referred to by many canteen managers as their ‘bible’. The Guide is a register of over 900 manufactured products that are colour coded ‘green’ and ‘amber’. It is also used by community groups, sporting clubs and hospitals to assist in stocking and promoting healthier choices. Some schools are leading the way and embracing a whole school approach to healthy eating. They offer 100% green menus, promote environmental sustainability with ‘wrapper free Wednesdays’, have a ‘water only’ policy and use produce grown in the school kitchen garden. Schools are reaping the rewards. Children who are healthy and eating well, learn better, it’s a win-win.
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AUGUST 2016 | 29
Guest Column
Kids' Sport Specialisation Pressure UWA exercise physiologist Mr Dylan Warner cautions on the physical and emotional effects of streaming young people into specialised sports too early. The main focus for young people participating in physical activity should be on developing healthy, capable and resilient young athletes. Unfortunately, some of these goals become sidelined by the competing priorities of parents, coaches and other vested interests. The focus should always be on the long-term – sustainable, enjoyable development that minimises injury and illness. Ultimately, the overall wellbeing of a young athlete is paramount. In order to achieve this it’s important to consider: • Participation in a wide range of diverse, age-appropriate sport-related activities both structured and unstructured. • A multi-disciplinary team involving GPs, physiotherapists and other allied health professionals to support the athlete and promote realistic goals. There’s an abundance of evidence to suggest that resistance training for young people is a safe and effective form of exercise as long as it’s developmentally appropriate, performed
hip and knee-related problems.
Sport specialisation should be avoided if there is a risk in reducing a young athlete's potential. correctly and well supervised. The benefits of resistance training are particularly effective in reducing muscular imbalance but it’s critically important that the training loads are closely monitored. The general consensus, when you’re talking about young people, is to avoid any training in one sport in excess of eight months within a calendar year. Over-specialisation can lead to a significant reduction in the development of broad technical skills and an increase in repetitive submaximal loading on the musculoskeletal system. This, coupled with inadequate recovery time, leads to a lack of adaptation and increased injury risk. Some of the more common injuries resulting from sport specialisation are patellar tendinopathy, patellofemoral pain, and other
It’s also important to be aware of athlete burnout linked with sport specialisation. Increased pressure placed on a young specialised athlete may increase the risk of depression, overtraining and injury. It’s important to consider the following factors in any discussion regarding the development of well-rounded athletes: • Unstructured activity to develop diverse motor-skills. • Participation in a wide range of activities. • Specialised training should not exceed 16 hours a week. • Scheduled rest periods. There’s no doubt that an appropriate level of physical activity – both structured and unstructured – is crucial in the development of young athletes. It’s also very important to have strong communication lines between parents (carers) and coaches/medical professionals, particularly if there’s a perception that the child is being pushed too hard.
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Guest Column
Falling Through the Gaps A/Prof Donald Payne from UWA’s School of Paediatrics & Child Health, says new training for paediatricians may fill in some of the current gaps. ‘Please see this 16-year-old young woman whose symptoms include headache, loss of appetite and abdominal pain. Paediatric services say she is too old for them and I have been unable to find an adult physician willing to see her’. These sentiments are likely to be familiar to many general practitioners, reflecting the current design of specialist services where a significant gap exists in services for older adolescents and young adults. Common health issues among this group include injuries (intentional and non-intentional), mental health problems, drug and alcohol misuse, sexual health problems and cancer. As well, the number of young adults growing up with chronic childhood diseases, such as cystic fibrosis, diabetes, congenital heart disease and metabolic disease, is increasing as a result of improved treatments. In contrast to the improved health outcomes in other age groups, such as the under-fives and the elderly, health outcomes in a number of priority areas of adolescent and young adult health (e.g. obesity, smoking, sexually transmitted infections, teenage pregnancy, cancer and mental health) have shown little or no improvement in the past few decades. A greater focus on young people will address many health behaviours that determine key outcomes in later life, thus reducing pressure on health service use by older adults. This requires investment.
“A greater focus on young people will address many health behaviours […] This requires investment.”
Developing services for adolescents and young adults requires a willingness among clinicians and managers to adapt. It also requires leadership, which the Royal Australasian College of Physicians (RACP) is providing. From 2017, both adult and paediatric RACP trainees will be able to enrol in specific training in adolescent and young adult medicine (AYAM). This will be part of a dual training program in which AYAM is combined with another recognised specialty, such as General Paediatrics, General Medicine, Endocrinology, Gastroenterology, etc. Physicians with AYAM training will be able to offer expertise in working with this group of patients, many of whom have complex needs. However, rather than attempting to see every young person in this age-group, the primary responsibility of an AYAM-trained physician will lie in leading the development of services for young people. Specific roles may include consultation, support and training for other clinicians, along with the provision of services for specific groups (e.g. those with eating disorders, chronic fatigue and pain syndromes, medically unexplained symptoms, gender identity disorder). Above all, the AYAM specialist’s role is clinical leadership that encompasses teaching, research, advocacy and policy development – to improve health outcomes for young people.
Author competing interests: no relevant disclosures. Questions? Contact the author donald.payne@uwa.edu.au
By Mr Peter Ammon Foot Ankle & Knee Surgery
Surgery for Heel Pain Heel pain is a frequent problem that presents to the general practitioner. Plantar fasciitis is the most common cause of under the heel pain. Most patients will improve with non-operative treatment but not all. Surgery is a very effective form of treatment for this condition in patients with long standing refractory symptoms. Before being considered for surgery patients should undergo at least six months of non-operative treatment that includes the following (in the appropriate order): • Rest, avoidance of activity • NSAIDs, stretching exercise program • Orthotics: off the shelf or custom • Cortisone injection (one only) • Shockwave therapy
Plantar fascia origin
Surgery can be open or endoscopic. The principle part of the procedure is release of the plantar fascia near its origin on the heel. Historically only the medial half was released but recent literature supports more complete release. Open surgery is performed through a 3cm incision in the proximal arch and allows not just plantar fascia release but also decompression of the tarsal tunnel and Baxters nerve which is often implicated in heel pain.
Endoscopic plantar fascia release is indicated for those without nerve compression symptoms and is done through a much smaller incision using a camera assisted cutting device much like a carpal tunnel release. Both open and endoscopic releases are performed as day cases and require approximately two weeks on crutches. Recovery is slightly quicker for endoscopic patients as you would expect. Patients can expect an 80-90% chance of a good result from surgery. Complications are rare.
St John of God Medical Centre Suite 10, 100 Murdoch Drive Murdoch WA 6150 Telephone: (08) 6332 6332 Facsimile: (08) 6332 6308 www.murdochorthopaedic.com.au Murdoch Orthopaedic Clinic Pty Ltd ACN 064 146 774 ABN 23 070 745 210
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AUGUST 2016 | 31
Investing in our future Perth Radiological Clinic is delighted to welcome Doctors Matt Prentice, Kevin Ho, Jolandi van Heerden, Chooi May Lee, Philip Misur, Ziyad Khaleel, Mark Teh, Zeyad Al Ogaili, Peter Counsel and Teck Siew to the practice in 2016. Our success in attracting these talented radiologists lies in the calibre of our existing team, our uncompromising commitment to excellence and the reassurance of independent ownership.
www.perthradclinic.com.au 32 | AUGUST 2016
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Clinical Opinion
‘Tongue tie’ controversies
By Dr Leon Levitt, GP Obstetrician, Wembley
“Tongue tie occurs when… the persistence of the midline sublingual tissue that usually undergoes apoptosis during embryonic development, causes restriction of normal tongue movement”, Knox (2010). This is noted in 2.8-10.7% of newborns (two thirds male). Any reported recent rise in prevalence is more likely due to an increased awareness of the procedure. Controversies abound, including: observations that some babies do well despite obvious tongue tie and some do not respond tongue tie release; the diagnostic criteria for advising release and leaving it alone; age of intervention; release by whom and which method; and what after care to advise? Tongue tie may not cause feeding problems Some babies with the most extreme structural tongue ties feed perfectly well and the mother may be unaware. As well, there are many other reasons for inadequate breastfeeding: structure of the mother’s nipple; maternal supply factors; maternal emotional factors; the health, energy and maturation of the infant; breast feeding technique, positioning and strategy; and issues of sucking, swallowing and the oral cavity. Assessment is relatively subjective and evidence is mostly empirical Assessment requires a full history, an anatomical assessment of the baby, and a functional mobility assessment of the baby’s tongue (and lip). Breast feeding analysis excludes other breastfeeding difficulties. Several assessment tools try to define the anatomical and functional observations: the Hazelbaker Assessment Tool; Martinelli Screening tool; and the Tongue and Lip Tie assessment tool developed by Carole Dobrich from the Goldfarb Breastfeeding Clinic, Montreal. All have value but have not yet fully removed subjectivity. Strong scientific studies are limited so each professional holds onto their pre-existing experience and strategy for release (e.g. laser or scissors) with perhaps misplaced confidence. Professionals often disagree over the significance of Posterior Tongue Tie (restriction at the base of the tongue), and Lip Tie. Health professionals carry inherent bias Lactation Consultants aim to increase breastfeeding rates, and may be too keen to make the diagnosis of tongue tie just in case tongue tie release might help. Understandably, Lactation Consultants are a significant driver of the increasing trend to release of tongue ties.
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Surgeons, paediatricians, dentists and GPs who are financially rewarded for releasing tongue ties, may oblige, especially if they think the mother will go elsewhere if they do not (and some charge $800 for the procedure). Others see it as a fad and denigrate those that are seeking to assist patients. Whichever way, the medical profession leaves itself open to criticism while there is no strong science behind what it does. Pressure from new parents Mothers are the strongest driver of the trend toward more releases, often desperate to reduce their pain and frustration. Only one third of mothers successfully breast feed to six months despite 96% of mothers strongly wishing to at birth – have they been inadequately prepared for the difficulty of breastfeeding? With social media led by other inexperienced mothers on bloggs and Facebook, peer pressure may be greater for current generations. Clinical approach to Tongue Tie Trends eventually adjust with experience and growing knowledge. In the case of Tongue Tie, many forces are at play but there is a way through conflicting attitudes. • First do no harm. If it is not clear a structural problem exists, then no procedure should be done. Only release Tongue Tie where there are breastfeeding problems or severe restriction of mobility. At minimum, a procedure with fewer complications and distress to the baby should be preferred. • Thorough assessment by a Lactation Consultant is first in all breastfeeding problems, providing advice and support on good attachment and posture before any consideration of surgery, even if structural evidence of Tongue Tie exists. • A multidisciplinary team led by the Lactation Consultant or the GP/ Paediatrician using one of the imperfect
assessment tools is better to improve the quality of diagnosis and reduce bias. Others who have a role include Speech Therapist, Child Health Nurse and Psychologist. Notes on Tongue Tie release Release by scissors is the preferred method where there is an anterior restrictive frenulum, because of its low risk profile, reduced distress to baby, much lower cost and availability. Release by laser is preferred for lip tie, and submucosal or Posterior Tongue Tie because it controls bleeding better, can be done at a young age under LA, and both can be done at the same time. However, barriers are the greater expense, more distress to the baby, higher risk of oral aversion, and longer waitlists for qualified practitioners. Surgical release with scissors may be an acceptable alternative. While earliest correction of significant Tongue Tie improves chances for breastfeeding success, time needs to be allowed for the usual settling and feeding strategies and maturation of the baby, rather than rush into the procedure, especially for Lip and Posterior Tongue Tie Release. Release by either method should only be done by health professionals experienced and trained in the use of any equipment (e.g. paediatric dentists for the laser procedure). There are no trials showing that postoperative exercises reduce reattachment but most centres advise the Goldfarb exercises three times-a-day. Review by the Lactation Consultant is highly recommended within a week after the procedure. References available on request
Author competing interests: the author is founder of a health team at Baby Steps Health Centre.
AUGUST 2016 | 33
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MEDICAL FORUM
Clinical Update
Pitfalls in dermatology – Part II
By Dr Alan Donnelly, Dermatologist, West Leederville
due to Group A beta haemolytic Streptococcus – a rapidly spreading erythema forms a tender plaque that is non-fluctuant; there may be associated lymphangitis with palpable lymphadenopathy. The patient is often toxic with an associated high white cell count and there may be associated tinea pedis between the toes as a point of entry for the organisms.
In part two of this series, three more conditions are presented, illustrating pitfalls in diagnosis and treatment of skin diseases. Topical steroid problems Topical steroids are a very effective treatment for many inflammatory skin conditions. Unfortunately their side effects have been exaggerated leaving some patients and their families worried about using topical steroids even when necessary and appropriate. Fear of using steroids is a very common cause for patients to undertreat their eczema. As a general rule, if the inflammatory condition is dry then an ointment has an increased therapeutic effect rather than a cream. Often creams do not have the same therapeutic effect as an ointment base in dry eczema. The most common risk of using topical steroids is atrophy. This is seen most commonly with potent topical steroid use for long periods of time in flexural areas. Another is steroid induced rosacea otherwise known as perioral dermatitis. This often occurs on the face around the mouth with sparing of the vermilion margin. Patients can also get a similar variant in a periocular
distribution. This form of eczema requires cessation of topical steroids with a warning there will be a rebound flare. A tetracycline antibiotic can be used, if tolerated, for an eight-week period. Avoid oral steroids in psoriasis Topical steroids have a role in the treatment of psoriasis but oral steroids are generally unhelpful for psoriasis and can precipitate pustular psoriasis especially upon withdrawal of oral steroids. Lower leg erythema Cellulitis of the lower leg is generally unilateral with infection of the dermis, most commonly
by Medical Director Prof John Yovich
Bilateral lower leg erythema can be treated with systemic antibiotics for a long time with no response with a presumed diagnosis of bilateral cellulitis. However, most bilateral lower leg erythema is due to stasis dermatitis – often bilateral with itchy hot red swollen legs but no associated fever or elevated white cell count or lymphadenopathy. There is also no associated lymphangitis. There may be other signs of venous disease such as oedema and haemosiderin deposition. There may also be superimposed a contact dermatitis due to applications of topical anesthetics or topical antibiotics. With bilateral lower leg erythema think of venous disease with perhaps a contact dermatitis. Author competing interests: no relevant disclosures. Questions? Contact the author on 9380 9690
Specialists in Reproductive Medicine & Gynaecological Services
PIVET MEDICAL CENTRE
Millions of Sperm in the ejaculate … but <5% generate healthy offspring In sub-fertile situations, the main focus for both investigations as well as treatment has always been on the female, although the modern evidence is increasingly towards equivalence between male and female factors. Most males have a 2-3 ml ejaculate with ~50 million sperm per ml but these parameters can fluctuate quite markedly depending upon age, frequency of ejaculation, time, concurrent illness, presence of varicocele and periods of stress. In some parts of the world such as Denmark and other northern European Main: A high rate of sperm with the countries, there HALO effect (normal DNA; low DFI is evidence of DNA fragmentation index); diminishing counts, Left-inset: Spermatozoon with tail swollen and coiling (indicates but this is not normal DNA). shown in Australia. NOW AT 2 LOCATIONS PERTH & BUNBURY
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The WHO updated its semen analysis manual with its 5th Edition in 2010 essentially accepting lower numbers from previous criteria. Following upgraded standardization of the analytic methodology, current normal criteria indicate volume ≥1.5ml, pH ≥7.2, concentration ≥15 million/ml or total concentration >39million with ≥40% motile or ≥32% showing progressive motility; and with ≥4% displaying normal morphology on strict criteria. However the presence of normospermia on these criteria is no guarantee of fertilisation in-vitro hence we have searched for functional tests to select the best sperm, especially for intracytoplasmic injection (ICSI) into the oocyte. One figure shows the Halo test which reflects a low DFI (DNA fragmentation index) and which has taken over from our previous SCSA test. However these tests destroy the sperm hence we are investigating adaptations of HOST (hypo-osmotic swelling test). Tail coiling is a reflection of DNA integrity because of the arrangement of tail filaments from the distal and proximal centrioles; the two, serving separate functions, are uniquely juxtapositioned. The challenge is to unfold the coiling sufficiently to enable preparation of the single spermatozoon for ICSI. Curtin post-grad student Katarina Mitrovic (pictured) has started exploring this process at PIVET for her Honours project.
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Clinical Update
Dilemma: endometriosis and bladder pain If we define chronic pelvic pain (CPP) as pain originating from the pelvic region, pain present much of the past six months, and pain severe enough to cause functional disability and require medical/ surgical intervention, then CPP accounts for more than 40% of all laparoscopies and 12-26% of hysterectomies. Reported prevalence is up to 39% of women of reproductive age, which makes CPP relatively common, comparable to asthma and back pain. Due to the numerous possible causes, the management of CPP is challenging. Women may also have more than one disorder causing their pelvic pain. However, bladder pain syndrome (BPS) and endometriosis are the most common causes (and co-existence was described by Chung et al as the ‘evil twins syndrome’, which conveys the misery of their painful co-existence). Tirlapur et al reviewed 1016 women suffering from CPP who underwent a laparoscopy and cystoscopy to investigate their symptoms: the mean prevalence of BPS was 61% (range 1197%, CI 58-64%, I = 98%); mean prevalence of endometriosis was 70% (range 28-93%, CI 67-73%, I = 93%); and co-existing BPS and endometriosis was 48% (range 16-78%, CI 44-51%, I = 96%). Table 1: Symptoms of BPS • blood in the urine (haematuria)
By Dr A S Arun, Consultant Gynaecologist, Waikiki
Table 2: Differentiation between wendometriosis and BPS
Key Points for CPP While endometriosis is the most common cause of CPP (up to 80%), around 50% of women with CPP have both BPS and endometriosis.
Endometriosis
BPS
Period pain (dysmenorrhoea)
Yes
No
Heavy Periods (menorrhagia)
Yes
No
• Urine analysis is necessary to rule out UTI, which may mimic BPS.
Ovulation Pain
Yes
No
• Ultrasound is useful only in cases with a palpable pelvic mass
Premenstrual Tension Syndrome (PMT)
Yes
No
How does endometriosis cause bladder symptoms?
•
Concurrent cystoscopy and laparoscopy achieves is both diagnostic (when in doubt) and therapeutic (bladder distension; treatment of endometrial deposits)
If endometriosis involves the uterovesical fold (outer surface of the bladder), deposits can react superficially or inside the bladder wall to cause:
etc.), dyspareunia, pain on bladder filling, voiding symptoms, premenstrual and postcoital exacerbations of the pelvic pain are present in both conditions.
• Urgency, increased frequency
Although they are similar in clinical presentation, Table 2 illustrates the difference in the key symptoms pointing to each condition.
• Pain when the bladder is full • Occasional haematuria during a period • In some cases, there is loin pain in the area of the kidneys when ureters are involved. Symptom overlap BPS and endometriosis can be nearly identical in clinical presentation (Table 1). For example, generalised pelvic pain (e.g. lower abdomen, urethra, perineum, upper thigh,
• pain with intercourse (dyspareunia)
Diagnosis The basic assessment includes: • Thorough history – onset of symptoms at least more than 6 weeks’ duration, extent of pain, details on urinary symptoms (eg. frequency, urgency, nocturia, dysuria, haematuria and incomplete voiding) • Pelvic examination – anterior forniceal tenderness (BPS), other forniceal tenderness (endometriosis) • Bladder diary for three consecutive days in women with predominant urinary symptoms.
• pelvic pain • pain with urination (dysuria), • back pain.
• Urinalysis – culture and sensitivity if nitrite positive.
• Incomplete voiding
• Urine cytology on three consecutive days if haematuria or there is smoking history.
Importance of BPS BPS (formerly known as interstitial cystitis or painful bladder syndrome) presents with CPP symptoms but has bladder pressure or discomfort along with at least one other urinary symptom – all in the absence of identifiable pathology or infection. (This definition was proposed by the European Society for the Study of Interstitial Cystitis/ Painful Bladder Syndrome in 2008.)
•
Symptom
• Ultrasound if there is any palpable pelvic mass e.g. ovarian cyst.
Fig 1: Laparoscopy showing endometriotic nodule over the left pelvic side wall.
• Urodynamic evaluation is required only in women with incontinence and the lower urinary tract symptoms. • Further imaging (MRI or CT urogram) if there are abnormalities in the ultrasound scan. Laparoscopy is the gold standard for diagnosing endometriosis (Fig.1) and it is recommended that cystoscopy/ hydrodistension under anaesthesia also (Fig.2) be done to avoid unnecessary delay in making the diagnosis if the co-existence of BPS and endometriosis are suspected.
BPS is being recognised more often, although endometriosis is very common. A missed diagnosis of BPS may result in unnecessary hysterectomy – 80% of women reporting persistent pain or recurrent pelvic pain following hysterectomy for CPP were found to have pain of bladder origin perhaps because gynaecologists traditionally do not focus on bladder syndromes.
Author competing interests: No relevant disclosures. Questions? Please contact the author on 9550 0300.
Fig 2: Cystoscopy showing glomerulations (post distension petechial haemorrhage).
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AUGUST 2016 | 37
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Fertility, Gynaecology and Endometriosis Treatment Clinic 38 | AUGUST 2016
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Clinical Update
Red flags in developmental delay Developmental delay affects up to 15% of children under five years, in at least one area of development. The challenge is to differentiate “late developers” who follow a normal developmental trajectory from those with a developmental disability.
By Dr Amanda Wilkins, Developmental Paediatrician, Mount Lawley
Developmental Status) is time-efficient and improves detection. Any loss of previously acquired skills especially in the motor or language area (regression) is a red flag needing urgent referral.
The other category (e.g. cerebral palsy, progressive neurological disorders, congenital deafness, severe vision impairment, autism and intellectual disability) comprises “low frequency, high severity” disorders. These benefit from early diagnosis.
Motor milestones are: sitting independently at six months; crawling at nine months; and walking independently between 12-18 months. Any child not walking by 18 months should be evaluated for possible neurological disorders. Physical examination may reveal altered muscle tone (either hypotonic/floppy or hypertonic), tremor, abnormal reflexes or abnormal gait (e.g. tip-toe walking). ‘Red flags’ include asymmetry in the use of limbs (e.g. hemiplegic CP) or difficulties moving from one position to another i.e. moving from sitting to standing (e.g. Gower’s sign in muscular dystrophy).
The developmental domains to cover in the history are motor, language, social and adaptive behaviour. A developmental screening tool (e.g. Parents’ Evaluation of
A head circumference below the 3rd or above the 98th percentile in a child who has developmental concerns warrants further investigation. Screening blood tests for
Some developmental delays (e.g. most speech pronunciation difficulties) can be described as “high frequency, low severity”. The exceptions are stuttering and Childhood Apraxia of Speech, both requiring early intervention by a Speech Pathologist.
Red Flags for Developmental Delay • Loss of acquired skills at any age • Asymmetry of limb movement • Hypo or Hypertonia • Head Circumference <3rd or >98th Centile • Lack of babbling at 9 months or less than 10 words at 18 months • Not turning/ responding to sounds by 9 months • Walking later than 18 months • Lack of direct eye gaze, not showing things of interest, not socialising with peers • Not visually fixing and following by 3 months or persistent strabismus • Persisting parent anxiety that “something is not right”
the child with motor delay are nutritional parameters (FBP, iron levels, Vitamin D, Calcium, Phosphate) and muscle Creatine Kinase. Elevated CK is the hallmark of muscular dystrophy. Mild elevations occur in other muscle disorders. Severe disorders with language delay are deafness (either congenital or acquired), autism, verbal dyspraxia and intellectual disability. Red flags for congenital deafness are a quiet baby with a lack of vocalising/ babbling. Acquired deafness is commonly due to middle ear disease. Refer any child not babbling by nine months or using less than ten recognisable words by 18 months, for audiology. Much work has been done on early indicators of autism including language regression (occurs in 30%). Additional key features of autism in toddlers include lack of direct eye gaze with others and lack of pointing to show things of interest. The Modified Checklist for Autism in Toddlers (Revised) increases the detection of autism. It is recommended for use between 18 and 24 months. The initial screening tool is a 20 item parent questionnaire. If first screen is positive, there are follow-up questions. Of those who screen positive at the follow-up, nearly 50% obtain a diagnosis of autism and 95% have developmental delay. Intellectual disability will present as delays in language, play and self-care skills. Generally the child with global delay behaves like a younger child. There can be few clinical signs, so any child with severe language delay requires a formal developmental assessment to diagnose or exclude intellectual disability. References available on request Author competing interests: no relevant disclosures. Questions? Contact the author on 9272 4560.
LARCS Proving a Remote Success Doctors involved in the GP rural outreach program for women, that had been administered by the RFDS and now Rural Health West, will be heartened by research from UWA which shows that there is a high use of long-acting reversible contraceptives (LARCs) among Aboriginal women in WA’s Western Desert region. Despite the good news stories on LARC methods – their reliability and low rate of side effects – Australia’s uptake of LARCs has lagged behind other countries. Dr Emma Griffiths from the Rural Clinical School and Kimberley Aboriginal Medical Services conducted the study between 2014 and 2015, using prescription data from medical MEDICAL FORUM
records and face-to-face interviews with women in the Western Desert communities. Of the 566 Aboriginal women who participated, 34% had used contraception between 1 November 2010 to 1 September 2014, and of those with current contraception at the census date, 77% were using the etonogestrel implant (a form of LARC). Continuation rates for use of the etonogestrel implant were 87% after one year, 72% after two years and 5% after three years. The presence of a dedicated sexual health coordinator to provide counselling and referrals is thought to have made the difference.
“Only one-fifth of women in the participating communities had a current method of contraception documented, compared to the two-thirds of all Australian women aged 18-49 years using contraception in 1998,” Emma said. “This indicates possible ongoing unmet contraceptive needs. The women interviewed identified the need for young people to be healthy and old enough when becoming pregnant. They also said that dealing with partner pressure to cease contraception was an important issue to address.”
But more work needed to be done.
AUGUST 2016 | 39
Clinical Update
The Importance of Two Ears
Anne Gardner
Andre Wedekind
Post Dip. Aud., BSc
M.Clin.Aud., BHSc (Physiotherapy)
Dr Vesna Maric AUD., M.Clin.Aud., BSc (Hons)
Language acquisition occurs within a critical period in the early years of life and requires hearing and practise to develop. Most infants begin producing speech-like sounds (babbling) at around 7 months of age, but congenitally deaf infants show deficits in early vocalisations and fail to develop language if not provided with an early alternative (hearing aids, cochlear implants and/or sign language). If provided with an alternative by approximately 6 months of age and before 12months of age then congenitally deaf infants begin to ‘babble’ and soon catch up to their normal hearing peers. Children who have acquired speech but lose their hearing before puberty suffer a substantial decline in spoken language, which is thought to be due to the absence of an effective auditory feedback loop (the ability to hear, monitor and adjust their own speech). The effects of congenital unilateral deafness cannot be underestimated as studies have shown they demonstrate delays in speech and language comprehension as well as the likelihood of academic difficulty compared to normal hearing peers. Unilateral hearing requires an increased effort to understand speech in noisy environments. Children with unilateral deafness are more likely to demonstrate attention fatigue, behaviour problems and academic weakness compared to bilaterally hearing peers. Neonatal hearing screening is very effective in identifying congenital hearing loss in newborns. Genetics is thought to be responsible for 50-60% of children with a hearing loss, with about 20% of those having a ‘syndrome’ (Down syndrome, Usher’s syndrome). For around 30% of babies with hearing loss, damage is caused by infections during pregnancy or complication at birth. Fourteen per cent of those exposed to CMV develop a sensorineural hearing loss of some degree. For young children and infants under 3 years of age, typical in-office hearing screening methods have poor reliability and may miss children with a unilateral loss, therefore referral to a paediatric audiologist is necessary. All children with an identified risk factor for hearing loss should be monitored closely.
51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au
40 | AUGUST 2016
Traps with growth plate injuries
By Dr Colin Whitewood, Orthopaedic Surgeon, Nedlands
Paediatric fractures are increasing with approximately 50% of children likely to suffer a fracture during childhood, usually boys and 15-30% involve growth plates (with 30-60% of the distal radius). Growth plates are not tolerant of repeated attempts at reduction and any attempts at reducing after about 10 days, significantly increases the risk of growth arrest. For this reason, physeal fractures should be recognised quickly and dealt with within the first few days following injury. The growth plate (the physis) is the weakest portion of the growing skeleton, weaker than the nearby ligaments and tendons. In a young child, a serious injury around a joint is more likely to pull the growth plate apart, than disrupt the ligaments stabilising the joint. A primary school aged patient with a “sprained ankle” is more likely to have suffered a Salter Harris I fracture of the distal fibula physis. Plain radiographs are often inconclusive but simple palpation will reveal maximum tenderness at the level of the growth plate and not over the lateral ankle ligament. Appropriate treatment is immobilising the limb as for any other fracture. In areas like the elbow where multiple secondary ossification centres develop, physeal injuries are sometimes only recognised with comparison views of the uninjured side In 1963, Salter and Harris described a still widely used classification scheme (based on fracture shape) for physeal injuries. Fractures going straight across the growth plate (type I) or include only a metaphyseal fragment (type II) rarely cause any long term problems as they do not usually injure the germinal layer of cells on the epiphyseal side of the growth plate. Fortunately, type II fractures are the most common type (about 75%) of physeal fracture. Types III and IV cross the germinal layer and need to be accurately reduced, otherwise they can lead to a partial growth arrest. This will be seen clinically as a gradual angular deformity at the growth plate (and limb) due to part of the growth plate having closed while the rest continues growing. This is a bit like driving a car and then applying the brakes on only one side. The converse issue (increased growth) can be seen in small fractures in the medial proximal tibial metaphysis in young children. The resultant increase in blood flow to the medial side of the growth plate produces increased growth and over the course of a few months the limb develops significant valgus alignment. Fortunately most of these correct themselves but it can take up to two years.
Coronal MRI slice of the ankle showing a partial growth plate arrest on the medial side of the tibia with resultant varus angulation of the ankle.
Author competing interests: no relevant disclosures. Questions? Contact the author 9389 3800.
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Real Estate
Accentuate Positive It became a murky election issue that ended up by confusing everyone. So what is negative gearing and how will it affect us?
Negative gearing is bandied around with a degree of alacrity that suggests it’s a oneway street to investment success. Two experts in the property market, Rachael Green and Hayden Groves shine a light on the pluses, the pitfalls and the political machinations surrounding a popular wealth accumulation strategy. “There’s no doubt that the property market has been flat for some time and the uncertainty leading up to the recent federal election made some people a bit hesitant about taking the plunge. Negative gearing en Rachael Gre is one way to minimise tax, particularly for higher income earners, and that’s even more so now that some other tax concessions linked with superannuation concessions are being pruned,” says Rachael from Morgan Stanley Wealth Management. “And it shouldn’t be forgotten that property investors do provide much needed rental accommodation so there is the potential for positive social benefit flowing from negative gearing.” The term ‘gearing’, in any context, refers to the borrowing of money for investment. Rachael points out the accent should not fall exclusively on the ‘negative’. Capital growth the aim “Ultimately you do need some sort of capital growth from the investment. It’s not a good strategy to focus entirely on the benefit of a
42 | AUGUST 2016
tax deduction stemming from a loss-making investment because you really should be looking for some capital growth over the longer term.”
“It’s no surprise that individuals in higher tax brackets are well suited to negative gearing, with the added bonus of reaping significant tax benefits.”
“In short, you don’t want the negative side of the equation to continue indefinitely.”
Medical professionals should be casting their investment eye on the long term, suggests Rachael.
In any discussion regarding investment ‘negatives’ the issue of ‘risk’ is always high on the agenda. “If there’s any chance that you might need access to funds at a time when the market is weak you’re faced with the prospect of selling at a loss. We see this quite often in the area of margin lending, a strategy involving borrowing money to invest in shares.”
“Anyone with spare cash flow who’s also a relatively high income earner should consider negative gearing as a form of wealth accumulation. There are significant tax benefits but you need to be mindful that if you’re taking on significant levels of debt it will need to be repaid.” Debt-free retirement
“Volatile markets, in that context, equates to a high degree of risk.” Rachael paints a picture of a typical investor using a negative gearing strategy in the property market. For the long haul “The main characteristics would be someone looking for a long-term investment. A period of between 5-10 years enables an investor to weather the ups and downs of the market and you definitely don’t want to be in a position where you’re forced to sell during tough times.” “It’s not a bad idea to have high levels of personal cash flow either. There are costs associated with borrowing, the potential for interest rate fluctuations and a reasonable level of job security is important.” “It’s ideal to have adequate personal insurance, too. If you end up having a period of illness or protracted convalescence due to injury you’re still going to be required to fund your investment commitments.”
Hayden Groves
“Any strategy leading up to retirement should ensure that any ‘negative’ form of gearing will trend towards the ‘positive’. Ultimately, the intention is to be debt-free.”
One of the strongest points that Hayden Groves, President of the Real Institute of WA (REIWA), would like to make is that negative gearing affects everyone. “The election, and its inevitable political sound bites, reduced these issues to a highly simplistic level. Negative Gearing is just one element of a tax system that’s complex and highly layered. If a political party starts pulling just one lever, such as negative gearing, the overall impact may go well beyond their original intentions.” “A line that’s often peddled is that this form
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of tax minimisation is the preserve of highly wealthy people and from the research we’ve done that’s simply not the case. We found that approximately 80% of investors own just one property, by the time they’ve reached retirement most of them have paid it off and it’s used as a passive income stream.”
Knock-on effects
Hayden reinforces the point made by Rachael, that negative gearing is an integral part of the social housing market.
“In any case, most investors are looking for the best deal and they won’t be inclined to invest their money in established homes.”
Change could hurt
“And we’re not talking about huge sums of money. The average individual negative gearing tax saving is around $2500 per annum and it will cost the state government a lot more than that to supply rental accommodation if investors withdraw from the market.”
“Again drawing from our research, we found that approximately 42% of people who currently invest in property would cease to do so if the Opposition’s proposed changes had gone through.” “Sure, the Perth market is pretty flat right now and it’s very much in favour of the tenant but that could quickly swing the other way. If it does, taxpayers will be footing the bill to create more social housing and some people would be priced out of the market. We’ve seen that happen already as young people are pushed to the outer fringes of suburbia where it’s more affordable.” “The mining boom wasn’t all that long ago. Vacancy rates were low then because there wasn’t enough housing stock.”
By the Numbers • About 1.5m Australians currently use negative gearing (NG) as an investment strategy. • The NG strategy timeline for an investor is between 5-10 years. • The average gross salary for a typical NG investor is under $100,000.
There’s an old adage that for every complex problem there’s a simple answer, and it’s always wrong. That would seem to be the case when political parties are inclined to pull tax levers in isolation from other important variables.
“Restricting negative gearing to new dwellings brings up serious issues, too. If investors are pushed into the new home market there’s a knock-on effect and an adverse one on firsthome buyers who will struggle even more to get a foothold into the market.”
“Altruism only extends so far.”
By Peter McClelland ED: Disclaimer – Rachael is a Financial Planner at Morgan Stanley Wealth Management Australia, a participant of the ASX Group. This communication contains factual information only and is not intended to reflect any recommendations or financial advice, nor is it an offer or solicitation in relation to any particular financial product. Although the information has been obtained from sources believed to be reliable, Morgan Stanley does not guarantee its accuracy, and such information may be incomplete or condensed.
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AUGUST 2016 | 43
Short and Sweet Patient: Doctor, help me please, every time I drink a cup of coffee I get this intense stinging in my eye. Doctor: I suggest you remove the spoon before drinking. Nine out of 10 voices in my head are telling me that I am too fat. The last one is calmly preparing a bowl of chips. Husband brings the child home from kindergarten and asks his wife, "He’s been crying the whole way home. Is he sick or something?" "No," replies the wife, "he was just trying to tell you he isn’t our Frankie." Two police officers crash their car into a tree. After a moment of silence, one of them says, “Wow, that’s got to be the fastest we ever got to the accident site.” Two toothpicks are waiting at the traffic light when an echidna comes by. They look at him silently and then one toothpick says to the other, "Huh, so there's even buses..." A man hired a lawyer when he got sued by his company for embezzlement of many millions. At the beginning of the process, the lawyer kindly reassured him: “Don’t worry, you’ll never go to jail with that amount of money.” And the lawyer was right. When the man did go to jail eventually, he didn’t have a penny to his name. "Please help me doctor, I have a bowel movement every morning at 7!" "But that is a very healthy thing, Mr. Richards!" the doctor said. "It would be, if I didn't usually wake up at 8:30!"
“There are o nly two thin gs a child w communica ill share will ble disease ingly, s and his m other’s age .”
- Benjamin S
pock
Me: “Do you think it’s strange to talk to yourself?” Me: “No.” They say money doesn't bring you happiness. Still, it is better to verify things for yourself. Late one night a robber wearing a mask stopped a well-dressed man and stuck a gun in his ribs. "Give me your money," he demanded. Scandalised, the man replied, "You can’t do this – I’m a politician!" "Oh! In that case," smiled the robber, "Give me MY money!"
I heard a report about a bad outbreak of the tummy bug at a new restaurant, apparently nine out of 10 people there suffered from diarrhoea. I can’t stop thinking about that 10th person who apparently enjoyed it.
An elderly man was on the operating table awaiting surgery to be performed by his son, a renowned surgeon. Just before they would put him under, he asked to speak to his son: "Don’t be nervous, son, do your best and just remember, if it doesn’t go well, if something happens to me… your mother is going to come and live with you and your wife."
There’s that moment when you put your steak on the grill and your mouth waters all over from that amazing smell. Do you vegans feel the same when you mow the grass?
I can’t believe I forgot to go to the gym today. That’s seven years in a row now.
I ate four bowls of delicious alphabet soup. After that I had a massive vowel movement.
Shortest joke a software developer can tell: “I’ll be ready soon.” What's the best place to hide a body? Page two of Google. Women go on a diet on three occasions:
What is the difference between a politician and an actor? An actor gets better scripts with more credible story-lines.
• When they break up with a guy;
A child’s observation: If a mother laughs at dad’s jokes, we have guests.
An optimist sees light at the end of a tunnel and thinks it’s an exit. A pessimist sees light at the end of a tunnel and assumes it is an onrushing train. The train conductor sees two stupid guys staggering on train tracks.
Why were the Stars Wars released in the sequence of 4,5,6,1,2,3? Because they were directed by Yoda.
• When they meet a new guy; • On Mondays.
Meme credit: www.bajiroo.com
44 | JUNE AUGUST 2016 2016
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Beer Review
Delicious Creature Feature Little Creatures burst onto the beer scene in 2000, quickly establishing a reputation as one of Australia’s premier craft breweries and for many of us its American-style Pale Ale has become a faithful modern classic. In recent years the brewery has expanded its range and broadened its scope with a range of occasional seasonal offerings, the latest of which we were delighted to find included in our monthly delivery. Keeping the Belgian Ales as a heavenly standard, we reviewed (several times!) the staples of Little Creatures’ little collection.
By Dr Bradleigh Hayhow and Dr Sergio Starkstein
T he Beers Rogers (3.8% ABV)
Pale Ale (5.2% ABV)
Little Creatures describes the character of this mid-strength amber ale as demonstrating flavours of “roasted caramel and malt” with a “light citrus hop”. We agree. The malt and citrus notes are unusually prominent for a mid-strength beer, and there’s a mild but pleasant bitterness to the aftertaste. The head could be stronger on the pour, but still a standout in its class. Overall score: 7/10
Accurately billed as both “bitter and floral”, this American-style, IPA-leaning Pale Ale is one of Australia’s first and favourite craft beers. Bitter on the palate and floral on the nose, it is both friendly to the novice and faithful to the connoisseur. A true Australian icon! Overall score: 6/10
Bright Ale (4.5% ABV) A filtered ale in which “a touch of wheat keeps things refreshing”, this was our least favourite of the range. While this beer opened well on the palate of a younger collaborator (the inexperience of youth!), it dissipated quickly with only a mild bitterness and shallow hop. We couldn’t help thinking of it as a pilsner in ale’s clothing. Overall score: 4/10 The Hotchkiss Six Domestic Stout (4.5% ABV) Boasting a palate of “smooth, indulgent chocolate”, “roasted barley”, “oats” and “aniseed”, we were definitely into the barley and enjoyed the lingering aftertaste of this winter seasonal brewed with New Zealand Rakau hops. It’s an excellent introduction for those who are new to stouts, and good enough to lure us to the brewery to take a stool by the tap. Our hopes are high for the future of this recent addition. Overall score: 7/10
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IPA (ABV) A true IPA at 6.4%, this is a round and aromatic beer with sound bitterness and a long aftertaste. Very drinkable with minimal dissipation, this is a beer that stays fine in the glass and welcomes an unhurried conversation. Could this be the new Little Creatures flagship? Overall Score: 8/10
The Verdict As some of these beers are now brewed in Geelong, we would have liked to pit the ‘local’ and ‘imported’ products against each other in a taste-off. Alas, the origin of any particular bottle is opaque to the consumer. While we are assured that Little Creatures keeps a close eye on the quality of its products, we couldn’t help wondering if the je ne sais quoi of this Fremantle icon might be in more than just the recipe…
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Beer Question: Which beer did the reviewers have high hopes for?
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AUGUST 2016 | 45
Concert Drama
The Real Thing
After its first national tour when it moved audiences to standing ovations – even those in wheelchairs – Bryce Hallett’s Rolling Thunder Vietnam is on the road again. It is expected to roll into the Crown Theatre from August 17 and when Medical Forum spoke to the show’s creator, he said Perth was a particularly memorable stop the first time with scores of veterans meeting him and the cast to recount their own memories of a war that rent the social fabric of the country. One of the first West Australians Bryce met was former government minister and now RSL president Graham Edwards. He congratulated Bryce on the show’s authenticity and the balance he achieved in the depiction of life for many young men who fought as conscripts or regulars on the Vietnamese peninsula. That authenticity was the product of hundreds of hours of Bryce interviewing and listening to Vietnam vets and it was a revelation to the former Sydney Morning Herald journalist.
Bryce Hallett
“I became a part of the families of some of these veterans. I found it quite challenging but I was very keen to do it. I’d open one door into one vet’s life and another would open, just by them telling their friends about me and what I was after. It took a while to gain that trust but it was paramount to me that any show of this kind was truthful,” Bryce said. “There are four characters – three from Australia and one from the US – and they are amalgams of people I met. In young Johnnie, the conscript from Queensland, it was a thirst for adventure but no one was fully prepared for just how ruthless and brutal the war would become.” These lives are presented on stage as letters to and from soldiers – spoken directly to the audience – between iconic songs of Sixties from stalwarts such as Steppenwolf, Joe Cocker, Russell Morris, Creedence Clearwater Revival and Billy Thorpe. “The music gives searing clarity to the social turmoil the war was creating back home. It combines so powerfully with the storytelling. It feels like an elixir of youth,” Bryce said. The songs reveal the growing momentum of the protest movement, which, in its determination to end the war, wounded the very people it was trying to save. But Bryce said Rolling Thunder was not a history lesson. “It was important to me that this show was not didactic or sermonising, simply truthful and expressing ideas and emotions without judgement. The audience is one step ahead anyway. They see it as more than a nostalgia piece.” But nor could Bryce ignore the feelings of the time.
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“We set the piece in 1968 when the protest movement had become huge. Bobby Kennedy had just been assassinated and Martin Luther King’s murder had fuelled a powerful social conscience but we’re not hammering it with the irony of hindsight. This approach has really resonated with veterans who congratulated us on the balance we struck because their homecoming was bittersweet. They weren’t allowed to join the RSL, they were splattered with red paint. There was a lot of confusion in the country about the war and the homecomings.” “Vets understand now but didn’t understand at the time that this was the first televised war where their parents, their wives, their friends saw and learnt more about what was happening on the ground they did. The news showed Medivac choppers picking up bodies and casualties.” “Soldiers had no idea about the politics. It’s a wonderful thing how Australians and vets have an affinity with modern day Vietnam that Americans simply don’t have, which speaks volumes about Australia and its place in the world and its openness.” The audiences have been a mixture of young and old – vets alongside those who raised placards. The show has become something of a healing and awareness process. “We hear the word ‘healing’ continuously. From the moment we previewed this in Towoomba, a military town, the connections with the audience have been overwhelming. The response to the storytelling and the music is raw and emotional. I think we have made a real connection, which has transcended everything and that’s a reward in itself.”
By Jan Hallam MEDICAL FORUM
Musical Theatre
No Mountain High Enough Lorraine Bayly, doyenne of Australian stage and screen, at 79 is as indefatigable as she is talented.
Lorraine Bayly is one determined woman. The 79-year-old actress, who is forever in our hearts and minds as the ‘Keep Calm and Carry On’ mother Grace Sullivan in the 1970s TV series The Sullivans, is currently doing eight shows a week on stage in the hit-show The Sound of Music. Her age is only numbers and while she gets a kick out of work and work keeps flowing her way, she will keep on keeping on. “I turn 80 in January so I might rethink it, but I’m enjoying this show so much, we’ll see,” she told Medical Forum from Melbourne where The Sound of Music is packing out audiences. “I was playing opposite Sandra Bates in John Misto’s POW story The ShoeHorn Sonata – a very deep and emotional play – when I got a call from John Frost asking me if I was interested in playing Frau Schmidt the housekeeper in Sound of Music.” “It’s a wonderful character role and I’m loving every minute of it.” The Australian production of The Sound of Music is the London Palladium revival to celebrate the 50th anniversary of the Robert Wise film. It also happens to be Lorraine’s
50th stage show. And she’s looking forward to being a part of the show that opens in Perth on September 19. And going by the reviews, audiences and critics alike can’t get enough of Amy Lehpamer’s Maria opposite the beguiling Cameron Daddo as Captain Georg von Trapp. Add Marina Prior as Baroness Schraeder and Opera Australia’s Jacqueline Dark as Mother Abbess, the recipe is right for a perfect night with this classic showcase of musical theatre. Lorraine says she’s having a ball and is torn between her stage time and watching the show. “I have the scene before Jacqueline Dark sings Climb Every Mountain and she has a magnificent voice. So I rush off stage and race into my dressing room so I can watch and listen to her on the closed circuit TV.” While West Australians are most familiar with Lorraine’s TV and film work – The Sullivans, Carson’s Law, Man from Snowy River and Neighbours, music has followed her for her entire career. “My first musical performance was at the age of three after my parents gave me a tambourine for Christmas. I had slipped away from the house entranced by the local Salvation Army band and there I was playing my tambourine alongside the band. Someone found where I lived and delivered me safely home,” she said. “I also learnt the piano from the age of five and would earn a few shillings playing on Saturday afternoon on the radio when I was in my teens.” Her father was a policeman who would turn over the jail (when vacant) in the country town in which they lived to the young Lorraine for
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Lorraine Bayly her theatre productions. Her mother would bake cakes which they sold for a penny at interval and then her father would suggest that perhaps the money should be donated to the local hospital. It gave Lorraine a sense of achievement and a sense of service which hasn’t left her. She is a staunch advocate for organ donation and a supporter of the Australian Kidney Foundation and a life member of the RSPCA. Since the age of 60, Lorraine has dedicated her decades to new pursuits. The 60s were her saxophone years and her 70s have been tennis. The mark of the woman is that these are far from polite amateur hobbies. She ended up playing sax at two concerts at Taronga Zoo Prom nights with the Australian Army band and at 72 she played tennis in the World Masters Games. “I lost all my games but I intend having another crack at it next April when the games are on again.”
By Jan Hallam
AUGUST 2016 | 47
Musical Theatre
Politicians
are People, Too
Actor Matt Dyktynski as Billy Clinton. Image credit: Robert Frith
First it was Keating, now Bill Clinton. Which politician will be next to sing about their human foibles?
Anyone lucky enough to catch Casey Bennetto’s razor-sharp Keating! The Musical when it hit Perth in 2008 will have no doubt how perfectly the genre delivers insightful commentary while entertaining so hilariously in song and dance.
“I don’t believe either of the Clintons have seen it (unless they were very well disguised) but I was told that people from their camp were sent to watch it and they laughed a lot,” Paul said. “I think the Clintons are fascinating people.”
It certainly wasn’t lost on Paul Hodge who as a young man went along to the Brisbane production with his family and came away plotting his own musical.
It is a bold move for an Australian bloke to put on such a cheeky review of US political royalty, especially in a year where Hillary is making her own pitch for the White House but Paul says far from any resentment, American audiences have loved the show.
“As we left the show my dad said, ‘It was good, but I’m not sure politicians make the best subject matter for musicals… except maybe Bill Clinton.” And an idea was born,” Paul told Medical Forum. The trials and tribulations of Bill and Hillary Clinton’s marriage during his term in the Oval Office between 1993 and 2001 have been media fodder for the past 25 years, so why not a musical? Bill Clinton’s own duality – the earnest politician and the charming louche – become Jekyl and Hyke in Paul’s Clinton the Musical – two hilarious characters navigating their respective character’s strengths and weaknesses. The musical has taken the world by storm beginning at the Edinburgh Festival Fringe then moving to London, the New York Musical Festival and Off-Broadway production garnering terrific reviews along the way. From August 27 it gets a Perth showcase by the Black Swan State Theatre Company at the Heath Ledger theatre with Simon Burke and Matt Dyktynksi in the lead roles. While it is certain to be popular with the locals it may not boast the same high-profile visits as the New York show.
48 | AUGUST 2016
“I don’t think there was any resentment at all. From an American audience perspective, it is more important that we were neither Republicans nor Democrats, than insiders or outsiders, which has allowed us to come at it from a fresh perspective.” Republican presumptive Donald Trump makes a cameo appearance in the Perth production as the show undergoes another of its many updates as global politics inexorably rolls along. So is Trump set for a show of his own? “I did think of an idea for a Trump musical, but I hope he will soon be irrelevant to global politics,” Paul quips. But closer to home, Paul and Stephen Carleton have been commissioned to write a musical about Joh Bjelke-Petersen.
Pa ul Hodge with Kerry Butler or Hillary in Off Broadway season.
Ima ge credit: Russ Rowland
Queensland has no shortage of maverick politicians like Katter, Palmer and Hanson. There must be something in the water.” “We’re interested not so much in political commentary as wanting to look at politicians as human beings – and human beings are funny. In the world of the 24-hour news cycle where politicians stick to their talking points, it becomes harder and harder to see their genuine humanity, so I think the idea of showing a bit of your messy humanity in politics is one of the themes of the show. But most of all we just wanted to entertain!”
By Jan Hallam
“It will premiere next July in a co-production with the Brisbane Powerhouse and then tour. Contrary to what my dad said, I think a lot of politicians make great subject matter for musicals. I think Rudd and Gillard would make a fantastic opera. And, of course,
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Movie: David Brent: Life on the Road A documentary crew catches up with David Brent to see how he’s faring post-The Office and finds him on the road selling cleaning products. He reveals to the crew that he hasn’t given up on his dream of becoming a rock star, so a new excruciating venture begins. Ricky Gervais stars, writes and directs! In cinemas, August 25
Movie: Captain Fantastic Matt Ross won the best director at Cannes warmfuzzy tale of a devoted father (Viggo Mortensen) of six living the dream in the deep forests of the Pacific Northwest. When the family is forced to leave their land, the real world comes crashing in.
FEATURE
COMP
In Cinemas September 8
Music: WASO – Schubert and Bartok
Musical: The Sound of Music
Asher Fisch brings the centuries together in this intriguing program featuring Schubert’s ‘Tragic’ symphony, Béla Bartók’s Concerto for Orchestra, a towering classic of 20th century and Mozart’s playful fourth horn concerto featuring WASO’s principal horn player David Evans. Bet you hum along!
Sing along to the evergreen tunes from this successful musical (again), this time with Amy Lehpamer as the nun that was, Maria Rainer, Cameron Daddo as Captain von Trapp and Marina Prior as Baronnes Schraeder, and, of course, the magnificent seven von Trapp family singers.
Perth Concert Hall, August 19 & 20
Crown Theatre, from September 14
Musical Theatre: Clinton the Musical Clinton the Musical, devised by two Queensland brothers, is brought to Perth by Black Swan State Theatre Company from a sell-out season off Broadway. It could have been any number of political figures but Bill Clinton was perhaps an obvious target. The critics loved this show. Heath Ledger Theatre, August 27-September 11
Movie: Italian Film Festival It’s that time again for your slice of the dolce vita with a swag of new-release films from Italy coming our way. This year’s films range from the sharp comedies that the Italians do so well to the big sweeping period dramas. Program details to be released soon.
Doctors Dozen Winner
Medical Educator Dr Alison Creagh is quite partial to a full-bodied Australian Shiraz and is looking forward to popping that particular Cape Grace screw-cap. Alison has followed her taste-buds to both Italy and France enjoying some flinty white wines that were perfect for thirsty cyclists and sampling some very nice reds in the limestone caves of St Emilion.
Cinema Paradiso, from September 15
M E DIC AL FO RU M $10.50
Winners from the June issue Concert – Leo and Lulu: Dr Gregory Hogan Filling the Gaps
Musical – Georgy Girl: Dr Tanya Subramaniam
Can We Afford It? • Prosthetic Pricing Reform
Opera – The Elixir of Love: Dr Daphne Tsoi
• Too Much Testing? • GP Protest on MBS Freeze
Movie – Love and Friendship: Ms Gabriella Tallman, Dr Kate Concanen, Dr Esther Moses, Dr Sarah Harris, Dr Leanne Heredia, Dr Andrew Kam, Dr Sally Price, Dr David Storer, Dr Michael Armstrong, Dr Hilary Clayton
• Clinicals: Liver Injury, Haematuria, Deprescribing, Colon Cancer, Child Reflux, & more
JUN E 2016
Movie – Goldstone: Dr Michael Hart, Dr Trixie Dutton, Dr Len Atlas, Dr James Provan, Dr Sue Martin, Dr Elena Monaco, Dr Fred Faigenbaum, Mr Angelo Carbone, Dr Alem Bajrovic, Dr Paul Kwei
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Movie – Scandinavian Film Festival: Dr Dorothy Graham, Dr Mukti Biyani, Dr Ted Khinsoe, Dr Rimi Roper, Dr Jane Gibson, Dr Colin Stewart, Dr Sue Bant, Dr Farah Ahmed, Ms Vincenza Frisina, Dr Moira Westmore
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MT HAWTHORN Sessional medical/allied health suites with ultrasound, uroflowmetry and secretarial support if required Contact: Elayne 0422 234 540 or email eooi@swanurology.com MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: gcford56@gmail.com NEDLANDS Hollywood Medical Centre 2 Sessional Suites. Secretarial support available. Phone: 0414 780 751
SECRET HARBOUR
SUBIACO 316 CHURCHILL AVE MEDICAL/DENTAL ROOMS FOR LEASE 190 sqm at $390psqm plus 4 car bays each $190pcm 4 consulting rooms, large sterilisation room, office area/ patient discussion area, staff room/kitchen Great location, elegant refurbishment. Email thre3times@gmail.com or call John Hearne 0407 442 660 MURDOCH Wexford Medical Centre consulting rooms available for lease. Modern and well lit. Secretarial support and IT system use available if required. Please contact Ai on 0410 786 007 or email aptran@jointswest.com.au JOONDALUP Serviced Specialist Consulting Rooms Available Within new, purpose built, commercial property in Joondalup CBD, housing other medical tenants. Reception, typing, billing support as required. Please contact Penny Fegan 0420 385 418 for further information PERTH Sessional rooms available at our Travel Doctor TMVC clinic in Perth CBD Fully furnished and fitted out ideal for medical specialists and allied health practitioners. Shared reception, waiting room and facilities. Close to public transport facilities Contact: Rebecca 08 6467 0900 or Rebecca.Hultink@traveldoctor.com.au FREMANTLE Medical practice for lease in Wray Ave, Fremantle. Fully adapted heritage building with four treatment rooms plus reception/ waiting area. 108 m2. Fully renovated with medical grade wiring, new roof, polished boards etc. Great location, exposure, parking and access. Available June. Please call 0411 155 309 or e-mail achieve@iinet.net.au for more details. NEDLANDS Hollywood Specialist Centre. Two large furnished suites available with secretarial support. Available on a sessional basis Monday to Friday. Phone: Leon 0421 455 585 or Gerry 0422 090 355
Contact Jasmine, jasmine@mforum.com.au to place your classified advert
MURDOCH New Wexford Medical Centre – St John of God Hospital Brand new medical consulting room available: t TRN t DBS CBZ For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au
FOR SALE SOUTH of RIVER Great opportunity to own your practice. A unique opportunity now exists for a motivated GP to take over an existing viable practice in an under-serviced community south of the river. Please call 0412 839 977 or 043 998 410 for further information.
URBAN POSITIONS VACANT
Secret Harbour Medical Centre VR GP wanted. 65-70% offered. A generous relocation fee may also be offered Brand new, modern and computerised. Contact: Dr Jagadish Krishnan jags@perthgp.com.au Dr Vishnu Gopalan g_vinu@yahoo.com
BUTLER Butler Boulevard Medical Centre is looking for a Full Time or Part Time GP, 70% gross billing. Full Time or Part Time position also available. DWS welcome. New, state of the art medical centre, Great facilities, Fully-computerised. Flexible hours and billing, NOR, NonCorporate, Onsite nurse. Onsite Pathology, Physiotherapist, Dietitian, Podiatrist and Psychologist. Excellent Remuneration Call Practice Manager on 08 9305 3232 or Email resume to: shentonavenuemedical@outlook.com
SORRENTO F/T or P/T GP for busy Sorrento Medical Centre, Normal/after hours available, we are like family, nurse & allied services on board, remuneration (70%-75%), Please call Dr Sam 0439 952 979
NEDLANDS Fantastic opening for a PT VR GP who seeks work life balance. Looking for GP to do afternoon sessions 5 days a week. Next to UWA and Swan River in a busy shopping centre. Mixed billing. Full accredited. Pathology onsite. FT Registered Nurse Allied health services next door. Call Suzanne on 08 9389 8964 or Email: nedlandsdoctor@yahoo.com.au REDCLIFFE Ascot Medical Group Part-Time VR GP Wanted for friendly General Practice Non-Corporate Practice with Mixed Billings Accredited and Fully Computerised Sessions available: Afternoons and Saturday Morning (Alternate) Please contact Dr Cheng, Dr Hadi or Practice Manager on 9332 5556 ROLEYSTONE Roleystone Family Medical Centre F/T or P/T Female VR Well – Established team, Accredited and fully computerized Please email: practicemanager@roleystonefmc.com.au Phone: (08) 9397 7122
MAIDA VALE We are seeking an enthusiastic VR GP (female) for a PT/ FT position. Our friendly practice is located in the Kalamunda Hills region. Purpose built, fully accredited and private billing. Excellent patient profile with full admin and nursing support. Please contact Peter for a confidential discussion on 08 9454 4500 or email your CV to: office@hillsfamilymedical.com.au and we will contact you within 24 hours.
ROCKINGHAM Read Street Medical and Skin Centre F/ T VR GP. DWS Location. Privately owned, private billing practice. Well established with existing patient base. Special interests encouraged. Fully computerised, excellent support staff. Onsite pathology available. Easy access to major shopping centre and public transportation. Contact us at pracman101@gmail.com Tel 08 9527 4976
SOUTH LAKE Dynamic VR / Non VR GPs required for a new practise in South Lake WA. High percentage offered. DWS available Fully computerised. Registered nurse on site every day. Friendly and supportive team. Allied Health and pathology on site. Great location. Please email latest CV to: admin@starhillmedical.com.au
SEPTEMBER 2016 - next deadline 12md Monday 15th August – Tel 9203 5222 or jasmine@mforum.com.au
medical forum YOKINE Part-Time VR GP required for a small privately owned practice in Yokine. Two male, two female GP’s on site working part time. Family friendly practice with nursing support and a lovely team of receptionists. Our GP’s have full autonomy. Private billing. Fully computerised. Accredited. On-site pathology. Allied health rooms attached next to the practice. Excellent remuneration is offered to the right applicant, but we are not in a DWS area. Please contact Jess jess@swanstsurgery.com.au or Dr Peter Cummins peterc@swanstsurgery.com.au for further information.
SEVILLE GROVE Seville Drive Medical Centre is seeking a hardworking and enthusiastic VR F/T or P/T GP to join our friendly professional team. Our centre see’s 200-250 patients per day; we also have an onsite pharmacy, pathology, allied health and visiting specialists. Full complement of GP’s, clinical staff and administration. Percentage of billings based on experience, with annual percentage increase. Please phone Rebecca or Debbie on 08 9498 1099 or Email CV to manager@sevilledrivemedical.com
HAMILTON HILL A female GP required for a clinic in a DWS and AON area 5 minutes’ drive from Fremantle. 3 Doctor GP Practice. Part time or Full time doctor considered. Fully computerised practice. Rates negotiable. Contact Eric on 0469 177 034 or Send CV to eric@hamiltonhillfamilypractice.com.au MYAREE GP full-time or part-time required For inner south of river practice. Modern, non-corporate, fully accredited training practice. Dr well supported by RN and other Dr’s. 65% remuneration. School holiday cover. Mon- Fri. No after-hours. Ph. – 9317 8882 or email – reception1@myareemedicalcentre.com.au
SHOALWATER F/T or P/T VR GP required for our modern state of the art medical centre located in Shoalwater (DWS). Offering modern surrounds and fully computerised clinical software. We are a friendly, privately owned and run centre. A full complement of nursing staff and administration team as well as onsite allied health, specialists and pathology. Generous remuneration offered. Please phone Rebecca on 08 9527 2236 or Email CV to manager@shoalwatermedicalcentre.com
THORNLIE Thornlie Medical and Skin Cancer Clinic (DWS) are seeking a VR GP to help our friendly growing multicultural practice. Mixed billing, accredited, fully computerised with full-time nursing support. Computerised dermoscopy. Please email: thornliemedicalcentre@hotmail.com or Call 0403 009 838 CURRAMBINE We are seeking a full time or part time VR or non VR GP to join our friendly team at new state of the art premises. We have onsite pathology, physiotherapist and psychologist and pharmacy. Open 7 days with extended week day hours. Please contact Jackie on 9304 1424 or email accounts@sunlandermedical.com.au for more information.
KWINANA General Practitioner with full AHPRA registration required for an immediate start. In the heart of Kwinana is Infinitive Health Wellness Centre, a new modern computerised rapidly growing family owned practice. Excellent location at shopping centre, free parking, plus full support from allied health within centre and diagnostics close by. Flexible hours and 70% of billings. Please contact 6558 0570 or email drk.black@infinitivehealth.com.au
ALL AREAS VRs and NonVRs needed urgently. DWS and area of need. Supervision available if required. Pearsallmedical.com.au Hockingmedical.com.au Alkimosmedical.com.au Good income with initial guarantee. Additional income from Mole Scanner, Aesthetic Clinic & Travel Clinic. Chronic Disease Clinics with excellent admin and nursing support Good doctor/nurse ratio. In house Physio, Podiatry, Psychology, Dietician. Enquiries to Dr Ben Banwait banwaitben@gmail.com or 0416 893 131
JOONDANNA We are seeking a VR GP to join our friendly team on a part-time or full-time basis. New, state of the art medical centre. Flexible hours and billing. Percentage negotiable. Fully-computerised. Nursing support for CDMP. Please call Wesley on 0414 287 537 for further details. WILLETTON VR-GP required part time Hours negotiable Non-corporate 0412-346-146
BATEMAN Seeking VR GP for friendly, accredited, mixed billing, computerised (Medical Director) and long established practice. Contact: 0402 046 166 MORLEY Full-time VR GP required. Centro Medical Centre is a non – corporate mixed Billing Practice situated in the Galleria Shopping Centre Morley. t 8F SFRVJSF B QFSNBOFOU (FOFSBM Practitioner (VR) to start as soon as possible t $POTVMUBUJPO IPVST BSF OFHPUJBCMF t .PSMFZ JT OPU %84 t 5IF QSBDUJDF JT GVMMZ FRVJQQFE BOE computerised with nursing support For further information please contact Margaret Chalk on 08 9375 2266 / 08 9307 0707 Or email cms100@iinet.net.au CANNING VALE Canning Vale (DWS) requires weekend or part-time VR GP urgently. Rates negotiable. Privately owned practice - fully computerised, huge consulting rooms, spacious treatment room with FT RN, and on-site pathology with other health alliances in the complex. Phone: Julie 9456 1900 or Email: jphyo@nicholsonmedical.com.au
BUTLER
85 KARRINYUP St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology and Allied services on site. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979
OSBORNE PARK GP required for Osborne City Medical Centre. Flexible hours Monday to Thursday with optional afterhours. Excellent remuneration / $150 - $200 per hour. Predominantly private billing practice. Modern fully computerised practice with nursing support. Please call Michael on 0403 927 934 DUNCRAIG Duncraig Medical Centre requires a Female GP for immediate start. Fulltime patient load available. However, flexible with Monday to Friday hours. Excellent remuneration / $150 - $200 per hour. Predominantly private billing practice. Modern fully computerised practice with full time nurses. Please call Michael on 0403 927 934 or michael@duncraigmedicalcentre.com.au
Connolly Drive Medical Centre VR GP required for this very new, state of the art, fully computerised, absolutely paperless, spacious medical centre. Fully equipped procedure rooms and casualty, well-furnished consult rooms, pathology, allied health, RN support. Abundant patients, DWS, non-corporate. Generous remuneration. Confidential enquiries Dr Ken Jones on (08) 9562 2599 Tina (manager) on (08) 9562 2500 Email: ken@cdmedical.com.au
BENTLEY Rowethorpe Medical Centre is a nonprofit, friendly practice seeking a part time GP to provide visits to our onsite residential aged care facilities. Practicebased consultations are also available. t 'VMMZ DPNQVUFSJTFE t /FXMZ SFOPWBUFE QSFNJTFT t .PEFSO FRVJQNFOU t 0OTJUF QBUIPMPHZ t )PVST UP TVJU ZPV For enquiries, please contact Jackie on 6363 6315 or 0413 595 676
Seeking expressions of interest from motivated VR GPs wanting to take the next step in your career. Ever dreamed of owning your own practice but don’t want the stress of set up? We are seeking both GPs looking for partnership opportunities and those looking to enjoy work a state of the art, fully supported and modern built for purpose medical centre 10 mins from Perth CBD. Flexible working conditions with excellent remuneration in a private billing and fully privately owned centre. For an entirely confidential discussion please email reception@forummedicalgroup.com
VICTORIA PARK
WEST LEEDERVILLE & KINROSS FT/PT GP required for privately owned these 2 bulk billing practices. Procedures are billed privately. Excellent earning potential at both centres. Onsite pathology, nurse, Psychologist, podiatrist, physio, dietitian, specialist physician & Geriatrician. Contact sanjaykanodia2000@yahoo.com
Dr required for Saturdays at a well-established clinic. DWS status available. Non VR’s with level 3 welcome to apply. Fully computerised and admin support available. Contact: g_vinu@yahoo.com FREMANTLE INTERESTED IN WOMEN’S HEALTH? Fremantle Women’s Health Centre requires a female VR GP one day pw. It’s a computerised, private and bulk-billing practice, with nursing support, scope for spending more time with patients, provides sessional remuneration, superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical, nursing and counselling services, health education and group activities in a relaxed friendly setting. Phone 9431 0500 or email Dawn Needham clinical-manager@fwhc.org.au
SEPTEMBER 2016 - next deadline 12md Monday 15th August – Tel 9203 5222 or jasmine@mforum.com.au
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medical forum Lockridge Medical Centre VR GPs or Subsequent Registrar PT / FT
To work at our modern, independent, accredited, innovative, teaching and award winning practice. A friendly and supportive work environment offering full computerisation, full time practice nursing support from open to close, nurse led chronic disease clinics, onsite pathology, psychology and physiotherapy services available. Offering flexible working hours combined with efficient practice systems in place to support chronic disease which assists the remuneration package. The practice is located in an outer metro suburb on the edge of the Swan Valley, 30 minutes to the hills or 30 minutes to the beach. The practice is not located in an area of district workforce shortage (DWS). With exciting building plans for a purpose built practice on the horizon, before you make up your mind - Our practice is definitely worth a visit. If you are interested we would be keen to speak with you! Please phone Natalie Watts on 08 6278 2555 or Email natalie.watts@lockridgegp.com
Join a growing team of visiting specialists to the south coast. Think Albany, Think Amity Health. We combine experience and efficiency in Albany’s newest purpose built health care facility to deliver: • Full administration, billing and reception support • 12 consulting rooms • Excellent access for clients • Excellent parking • Referral pathways to Amity Health’s team of allied health professionals • Collegial environment • Central location
Metro Area GP positions available VR & Non – VR Dr’s are welcome to apply. Send applications to hr@betterhealthcare.com.au
Amity Health is a not for profit organisation. For more information, call Sian Bushell on 9842 2797
GENERAL PRACTITIONERS REQUIRED DWS positions available in 4 locations! Bunbury: Brecken Health Care - Join a team of 20 GPs Albany: St Clare Family and Occupational Practice – Join a team of 3 GPs Busselton: New site opening soon Eaton: New site opening soon Special interests are encouraged! Skin cancer Antenatal/postnatal care Walk in/urgent and after hours care Occupational Health Travel Medicine Procedural work encouraged Chronic disease management All our sites are fully accredited with AGPAL. Nurses, admin & allied health support as well as pathology on site. FRACGP or equivalent highly regarded but not essential. Flexible hours, Full time or Part time available.
For Further information please contact Dr Brenda Murrison 0418 921 073 or brenda.murrison@breckenhealth.com.au
SEPTEMBER 2016 - next deadline 12md Monday 15th August – Tel 9203 5222 or jasmine@mforum.com.au
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COSMETIC MEDICINE SKIN CANCER CLINIC GENERAL PRACTICE
General Practitioner Registrar Opportunities in Coronary Care and Healthscope General Practitioner Clinics for 2017
This is a rare chance to join a busy medical practice with a very large cosmetic medicine and skin cancer practice. Cosmetic Services provided by GPs Ŕ Wrinkle Relaxers Ŕ Dermal Fillers Ŕ Face Lifts Ŕ Thread Face Lifts Ŕ Skin Treatments Ŕ Hair Transplant Ŕ Blepharoplasty
General Practice Services Provided Ŕ Skin Cancer Clinic Ŕ Skin Cancer Excisions Ŕ Skin Cancer Screening Ŕ Family Medicine Ŕ Womens Health Ŕ Mens Health Ŕ Occupational Health Ŕ Multiple Nurses Ŕ Nurse Practitioner Ŕ On Site admin Ŕ Great and fun team!
Essential Criteria Ŕ Must be an Australian Citizen or Permanent Resident Ŕ Must have Full AHPRA Registration as a Medical Practitioner (Specialist Registration) Ŕ Vocational Registration status AHG Super Clinic Contact Person: Val Reeve Phone: 0415 322 790 Email: val.reeve@australasianhealth.com
A rare and career enhancing opportunity for Registrars on an Approved General Practitioner Trainee Program. Mount Hospital is one of Australia’s leading private providers of tertiary level Coronary Care and Cardiothoracic Surgery located in Perth CBD. Healthscope General Practitioner Clinics are located throughout Western Australia. In partnership both are offering opportunities for Registrars on an Approved Trainee Program to gain experience within the 20 bed Coronary Care Unit at Mount Hospital and within a Healthscope General Practitioner Clinic. During their rotation at Mount Registrars will benefit from the opportunity to learn under the supervision of the Director of Cardiology, Professor David Playford and enjoy excellent facilities with top quality staff and the latest medical technology. To find out more and apply visit Seek.com and search for Mount Hospital.
GP Opportunities Available IPN Medical Centres 2 2 2 2
Baldivis Medical Centre Jindalee Medical Centre Parmelia Medical Centre Port Kennedy General Practice
2 Wanneroo GP Superclinic 2 Wellard Family Practice 2 York General Practice
Could we be the best option for you? If you explore what joining IPN entails, we think you’ll be pleasantly surprised. GPs across Australia choose to partner with IPN for good reason. We offer full practice support, security, autonomy with patient focus, flexibility and work life balance. Investigate for yourself why so many of your colleagues have joined and stayed with IPN. Dr Moayad Al Kaptan- Independent Practitioner - Perth
Contact Luke McLoughlin on 0472 822 745 or email luke.mcloughlin@ipn.com.au
With IPN, you’ll be In Good Company.
SEPTEMBER 2016 - next deadline 12md Monday 15th August – Tel 9203 5222 or jasmine@mforum.com.au
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medical forum WEMBLEY DOWNS
Olympic Medical Centre
VR GPs or Subsequent Registrar Part-Time /Full-Time
Full Time Female VR GP Required Opportunity exists for a Female doctor to take over existing patient base.
An EXCELLENT CAREER opportunity exists for an experienced VR GP to work closely with a family oriented community.
Olympic Medical Centre in Canning Vale is privately owned medical practice with well-equipped treatment rooms.
The practice is accredited by AGPAL and is an accredited teaching practice, which takes registrars in advanced and subsequent terms.
We use Best Practice Software and are as paperless as possible. Many allied health services are housed in the same complex creating a local Health Hub including pathology, physiotherapy, podiatry and psychologist.
We Offer • A modern facility with state-of-the-art equipment for both its Doctors and Staff. • Established patient base • Cosmetic Medicine • Onsite nursing, pathology and allied health services • Private Billing Practice • Great location • Great remuneration
Our Practice is located in the fast growing southern corridor with work hours that are very sociable with plenty of opportunity for work/life balance ensuring you enjoy time with family. ESSENTIAL REQUIREMENTS Vocational Registration Full AHPRA Registration
Essential Criteria • Must have FULL AHPRA Registration • Vocational Registration status
WHY WORK WITH US Owner operated, non-corporate Flexible work hours Long established clinic Stable, friendly and fun work environment Well established systems and processes Computerised Own room Excellent full time nursing support in treatment room Experienced reception and administrative team
This opportunity should not be missed! IF THIS SOUNDS LIKE YOU, please forward your resume to: pmgr@ovmc.com.au
Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. * full-time/part-time/sessional * medical systems and secretarial support * adjacent to Fiona Stanley Hospital
DWS location If you are interested in this Full Time opportunity at Olympic Medical Centre please send your CV to Vishnu - g_vinu@yahoo.com
More information phone: 9366 1802 or email: diane.car@sjog.org.au
GP West Requires VR GP’s to our state of the art medical centers in AON and DWS locations New Gumnut Medical Centre WANNEROO
Wattle Grove Medical Centre WATTLE GROVE
Mundaring GP Super Clinic MUNDARING
GP Owned, 9 Consult rooms, 3 Minor Surgery bays
We also require VR GPs for
All allied health, pathology, pharmacy& Dental
Okely Medical Centre, CARINE Newpark Medical Centre, GIRRAWHEEN Harrisdale Medical Centre, HARRISDALE Woodlake Village Medical, ELLENBROOK
70% of billings for Full-Time VR GP’s Non VR GPs are also welcome
Please contact Dr Kiran Puttappa on 0401815587 or email kiranpkumar@hotmail.com
or visit www.gpwest.com.au
SEPTEMBER 2016 - next deadline 12md Monday 15th August – Tel 9203 5222 or jasmine@mforum.com.au
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WA’s SPECIALIST GP RECRUITMENT AGENCY Current Positions Available Full Time VR GP Male/Female 50% Partnership available, 25 mins East of Perth DWS, Bulk Billing Practice Full Time VR GP Male/Female 50% Partnership available, 15 mins East of Perth Non DWS, Mixed Billing Practice FT/PT VR GP Wanted for busy Practice. 40 mins south East of Perth CBD, See 40+ Patients per day. 65% of Billing, DWS, Bulk Billing FT/PT VR GP Wanted for Well-Established Busy Practice, 25 mins South of Perth CBD, DWS Bulk Billing, 65% of Billings FT/PT VR GP Wanted for Well-Established Practice, 40 mins south of Perth, close to the ocean, DWS Bulk Billing, 65% of Billings For a confidential chat on the above positions or to hear more about other GP opportunities that we have please contact Scott Poole on 0416 524 809 or email your resume to scott@poolemedics.com.au Please Note All Conversations are Strictly Confidential
ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience. You won’t have to go through the onerous process of trying to find someone interested in selling. You’ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision.
St John is seeking experienced doctors to work in our new Urgent Care Centres. Relevant experience in urgent care, rural general practice or similar will be highly regarded. Full or part time. Attractive salary package. If you would like to join our dynamic team please contact office@apollohealth.biz
We’ll take care of all the bits and pieces and you’ll benefit from our experience to ensure a smooth transition.
To find a practice that meets your needs, call:
Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au
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SEPTEMBER 2016 - next deadline 12md Monday 15th August – Tel 9203 5222 or jasmine@mforum.com.au