Medical Forum 11/11 by Medical Forum WA

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Aged Care

Following the success of last year’s event, Best Practice Software is excited to announce that the next Best Practice Summit will be held in Bundaberg in March 2012. We look forward to welcoming you as a delegate, sponsor or exhibitor. Register your interest in attending the conference and receiving further updates by emailing bpsummit@bpsoftware.com.au Workshops will include training sessions on various aspects of Best Practice Clinical and Management as well as future directions for Best Practice, integration with other packages and conversions, etc. Keep watching the Best Practice website: www.bpsummit.com.au in the coming months for further information. And if you haven’t yet tried Best Practice, send or call for the free DVD and experience these and other features for yourself – with your own practice data (from a back-up copy, of course):• We have MIMS – Australia’s most trusted drug database • Support professionals who are truly supportive • Speed and superior stability of 100% SQL performance • Converting your data from MD2, MD3 and MedTech32 virtually automatic • No ads, bolt ons or mixed file formats to compromise performance

• Great value – subscription $907.50 (per full time doctor) for both Clinical and Management • Discounts for practices larger than 4 GPs • Half price for part time practitioners – $453.75 • No downtime for updates or time-consuming maintenance • Unique, fully integrated whole-of-practice software.

CIs for Dementia Dementia Living Tips Enriching Ageing Minds Aged Support Groups The Two-Edged Sword NOVEMBER 2011

PLUS Humour, Guest Columns, Artful Doctors and more …

Clinical Updates Opioid Use Liver Cancer Cervical Cancer Childhood Eczema Cancer Thrombosis Antibiotic Resistance

FreMaNTLe Associate GP or Specialist share rooms with 12 GPs, 4 nurses over two sites. ‘Ellen Street Family Practice’ – in the beautiful federation house 59 Ellen Street – has expanded to second location ‘Ellen Street Central’, near Fremantle town hall. GP owned and managed, fantastic team, computers, nurse support, private billing. Full or part time. Occ health interest welcomed. 60% gross billings. Port, Beach, Cafes, Fremantle friendly! Email: Dr Catherine Douglass at cath@browncowdesign.com.au OR Practice manager at Ellen Street Family Practice: practicemanager@ellenstreet.com Phone: 0421 520 767 Practice Phone 9430 5001 www.ellenstreet.com

WhAT INspIREs YOU? sEE WhAT INspIRED ThEM.

QueeNs ParK GP VR needed for pro-active, friendly, family orientated practice 15 mins from Perth CBD. We are looking for a GP with drive to be part of a growing medical practice Accredited, fully computerised (MD3), private billing, excellent facilities, nurse support, helpful admin staff and on-site physiotherapy, occupational health and pathology. We offer generous percentage of billings and a great opportunity to join our team. Please phone Tim 9356 8993 Email: admin@queensparkmedical.com.au Website: www.queensparkmedical.com.au MosMaN ParK Wanted P/T or F/T GPs seeking to relocate/commence their own practice. We are a friendly, non-corporate, fully computerised practice in Mosman Park. Excellent remuneration. Hours and days flexible. Tel: Dr Merci Kusel 9385 0077 PerTH GP Opportunity Do you enjoy travel? Are you looking for an alternative to General Practice? Travel Medicine may be for you. • Training Provided • Good incentives • Excellent team • Established national network of travel clinics providing excellent support • Sessional hours • Ongoing Education is encouraged • Travel medicine/Tropical Medicine/ Occupational medicine We require: GP – VR an advantage. Team Player Send resume to: tony.gherardin@traveldoctor.com.au or Phone: 6461 7353

PerTH FT/PT GP wanted for an outer metropolitan practice. Fully computerised. Modern facilities. Attractive package. 70%. Contact Kay 0409 887 680 Email: svfp@westnet.com.au. KeLMsCoTT We are seeking additional full-time General Practitioners VR/Non VR who are registered with AHPRA to join our non-corporate Family Medical Practice in Kelmscott & our sister Practice in Bertram. We are an accredited private billing practice in an area of unmet need/district of workplace shortage, with Practice Nursing support and allied Pathology Collection Centre and Podiatrist. Fully computerised with a comprehensive patient data base. Excellent remuneration offered for long term applicants. Please forward enquiries to Dr Justina Taiwo. Email: info@warrinamedicalcentre.com.au

HIGH WYCoMBe FT/PT GP required to join our friendly and busy practice. We are an Accredited practice, fully computerised with full admin support located at High Wycombe. Friendly environment. Attractive remunerations. Please fax interest to Practice Manager at 9454 4587 or call 9454 6987/0423 080 266

KarDINYa Non-corporate General Practice presents opportunity for VR P/T or F/T GP to join exceptional team locating to newly refurbished premises. Well managed long established 6 doctor practice offers a comprehensive CDM program thru 3 RGN support and onsite pathology. Enquiries to Practice Manager on 0419 959 246 or Email: practicemanager@kelsomg.com.au BuLLsBrooK FT/PT GP’s required for computerised accredited practice with RN support. Unmet area of need. Relocation grant may apply. Phone 9571 1478 or Email: nike.ogundipe@bbkfamilypractice.com.au

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LoCKrIDGe VR GPs or Subsequent Registrar PT / FT To work at our recently renovated modern, independent, accredited, innovative, teaching practice. Fully computerised, FT practice nurse onsite support (team of 5), chronic disease nurse support, onsite pathology and a friendly supportive work environment including yum morning teas :) Flexible working hours, great practice systems in place to support chronic disease which assists the remuneration package. Practice is located approximately 16kms from the city centre in an area of district workforce shortage (approx. 35 min drive). 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 Ph: 6278 2555 or Email: natalie.watts@lockridgegp.com

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Contents Prof Geoff Riley, Rural Training Advocate

Aged Care: A Two-Edged Sword

News & Opinion

Perth Pathology

E-poll: Aged Care and Palliative Care

23 Prescribing is Not the Same as Caring.

43 Towards Better Management of Alzheimer’s Disease.

26 The Mind-Body Connection.

44 Managing Opioid-related Side Effects in Cancer-related Pain.

2 Letters. Transplant … Hurry Up, Another Perspective. Dr Kevin Yuen Understanding Pain. Dr John Quintner 3 Dementia Training in India. 8 Have You Heard? 15 Health Reform Comes to Perth.

Beneath the Drapes. 20 Enriching Ageing Minds.

32 Protecting Doctors From Armed Violence.

Dr Rob McEvoy

Mr Peter McClelland

21 A Fix for Older Australians Mr Peter McClelland 25 Imaging Support Tool.

Dr Muntasser Islam

27 Photo Stories. Bethesda Launch and AAPM National Conference. 36 Aged Care Support Groups. 45 Proposed Insurance Schemes.

6 Palliative Care in Aged Care: Not About Numbers.

Dr Scott Blackwell

12 Stop Burying Your Head in the Sand.

Dr Trish Williams PhD

13 What Triggers a Disciplinary Action?

Mr Leslie Buchbinder

Medical Forum Magazine 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

ISSN: 1837–2783

Ms Christine Gee

30 Catch Your Patients When They Fall.

31 It’s Tough to Make a Difference.

Mr Paul Coates

Ms Shelley Harwood

Mr Jeremy England

Dr Michael Armstrong

Mr Jason Burton

35 Using Palliative Medicine Effectively in Advanced Cancer. Dr Ashwini Davray

37 Different Treatment for Cancer Associated Thrombosis.

Dr Ross Baker

39 Antibiotic Resistance Threatens Clinical Effectiveness. 40 Coronary Calcium Scores and CT Coronary Angiography.

Dr Graham Thom

47 Primary Liver Cancer.

Clin A/Prof Gerry MacQuillan

Dr Brendan McQuillan

41 Allergic Eye Disease. Dr Michael Wertheim

Advertising Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Mr Shane Cummings (9203 5222) 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

Editorial Advisory Panel Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Graphic Design Steve Barwick

Lifestyle & Entertainment 27 & 53 The Funny Side. 28 Re-writing the Wrinkly Rulebook.

18 Creating an Enabling Home for Dementia.

Dr Derek Eng

Ms Laurette LeCras

7 Glandular Neoplasia of the Cervix.

Clin A/Prof Roger Clarnette

46 Childhood Atopic Dermatitis and Skin Infections.

Clinical Focus

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Dr Joe Kosterich

29 Palliative Care: Remember the Carers.

Guest Columns

musical medicos in fine voice

Ms Wendy Wardell

48 Plein Air in South West WA. Mr Peter McClelland 49 Poem: Myrtle the Turtle.

Ms Wendy Wardell

50 Competitions and Winners – September edition. 51 On the Grapevine: Moombaki Wines. Dr Louis Papaelias 52 Swan Valley – 175 Years of Winemaking. Mr Peter McClelland 53 Musical Medicos in Fine Voice.

Directories 54 Clinical Services Directory. 78 Classifieds.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reflect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

Letters to the Editor Send your letter to: editor@mforum.com.au

‘Transplant… hurry up’, another perspective Dear Editor, Organ donation is a complex life and death phenomenon. Those on waiting lists are desperate for the call that will herald their life-saving surgery: sometimes with hours to spare, a donor dies, organs are recovered, and a critically ill patient is brought back to life. The celebration of the life saved is in stark juxtaposition to the grief another family is experiencing. The urgency of need is echoed by many organ donor advocates such as the group Sharelife, which had a strong influence in the federal government’s recent organ donation reform. For several years prior, there had also been a movement to improve donation via the National Organ Donor Collaborative. Its performance review, and regular education forums and workshops, assisted in developing donor family support, data systems, and review of best practice. In 2008, the Department of Health and Ageing released the final report of the National Clinical Taskforce on Organ and Tissue Donation, a comprehensive review with recommendations to improve performance. Kevin Rudd announced the formation of the Australian Organ and Tissue Authority with the subsequent establishment of the DonateLife network. While ShareLife contributed to this initiative, a momentum for change had already been established. 2008 was indeed a high organ donation year in WA and nationally. Factors that influence

donation include the size of the donor pool, the cause of death, the variability in life events as a precursor to death, the location of death, the identification of potential donors, the rate of referral to the donation agency, the medical suitability of potential donors, community awareness and support for donation, how families are approached in the ICU, and whether those families consent to donation. To achieve our optimum donation capability we need to analyse and understand all these elements, and avoid the temptation to think there is a singular, simple answer to the dilemma of donor organ shortage. What is the donor pool in Western Australia? Further research needs to be done to fully understand the nature of the donor pool in WA and how best we can optimise our donation rate. The two main causes of death where donation may be possible are cerebrovascular accident (CVA) and motor vehicle accident (MVA). To become a donor, you need to survive the initial event, be admitted to ICU, deteriorate, and die – around 1% of total deaths. Thankfully, fatalities from CVA and MVA are declining in WA, which has the lowest hospital death rate compared to other states. Other potential donors result from mortality associated with suicide, homicide and misadventure – highly unpredictable and often causes medical suitability dilemmas for our transplant physicians (e.g. drug overdose).

ICU beds per 100,000 population compared with South Australia 6.78 and Spain 8.75. In WA the number of ICU beds will increase markedly over coming years. With a static or shrinking donor pool, where can we improve our donation capacity? DonateLife is focusing on how we approach families of potential donors, a key area. The current consent rate in Australia of around 50% varies significantly between states and hospitals and with time. Close to 80% of Australians are willing to be donors when asked. At the bedside however, in the midst of a tragedy, families find it much harder to say ‘yes’. They will more likely say ‘yes’ if their loved one had expressed their wish to be a donor or registered on the Australian Organ Donor Register. The other critical element is how they make their decision. If our intensive care and requesting teams are able to support the family well and sensitively provide them with information about donation, families will be in a much better position to consider the opportunity. DonateLife is currently developing training programs to equip our health professionals to do this better. Changing clinical practise can take time. Public campaigns to raise community awareness are working with families often initiating organ donation discussions with intensive care staff.

WA has a mean population age of 36.3 years; compared with South Australia 39.1 years (one of our highest donating states) and Spain 40.1 years (the international benchmark). With each year of age, mortality from CVA increases markedly. While not trying to overstate it, deceased donation is constrained by the number of people that die in ‘donation favourable’ circumstances.

Another achievement for DonateLife WA has been Donation after Cardiac Death (DCD). In recent history in WA, most organ donation occurred following brain death determination for ventilated patients. From January this year donation is possible for some patients following cardiac death, usually severely head injured patients where ongoing treatment is considered futile. Following discussion with the family and their consent, there is a planned withdrawal of care and organ retrieval may be possible.

Another consideration is the ICU beds available in WA, which influences the capacity for ICU teams to assess potential donors – 3.63

Are we missing potential donors in WA? For many years now our WA donation agency has been auditing all deaths in

Help shape the future of health in WA Call for Expressions of Interest Health Service Governing Councils The Western Australian Government is making our public health system more responsive and accountable to the community by creating ﬁve new Health Services across the State: Q Q Q Q Q

Child and Adolescent Health Service North Metropolitan Health Service South Metropolitan Health Service Northern and Remote Country Health Service Southern Country Health Service.

Each Health Service will have a Governing Council of community members and clinicians with a range of skills and experience, appointed by the Minister for Health. 2

Governing Councils will have a key role in service planning and monitoring; and engagement with community and clinical stakeholders. We’re seeking expressions of interest from suitably qualiﬁed or experienced people to serve as Council Chairs or Members. So if you’d like to help shape the future of health in WA, we’d like to hear from you. Expressions of interest open Saturday 5 November and close Friday 2 December 2011. For more information, including the composition of the Governing Councils, or to submit an expression of interest visit www.health.wa.gov.au/governingcouncils To have an application pack mailed to you, phone 08 9222 2273 during business hours. medicalforum

ICU to check if potential donors have been identified. Upwards of 90% are identified and appropriately managed. A monthly case review with our ICU colleagues from all teaching hospitals ensures a thorough assessment of possible donors. So far for 2011 in WA, there have been 24 organ donors (WA baseline average 20002008, 21 donors/year) and 54 tissue donors. There has been a rise in organ donation in Australia over the last two years with a corresponding rise in transplantation activity. There is more work to be done and we look forward to collaboratively working with the community in building awareness, and saving lives and honouring the donors who make it happen. Dr Kevin Yuen, DonateLife WA Medical Director

Ed. Our previous article (Transplant Performance Hurry-up, October edition) and this response deal with deceased donors. We have not touched on the very healthy living donor program, primarily involving lobeof-liver and kidney organ transplants from matched relatives or unrelated donors, both donor types alive and healthy. This includes the kidney paired donation program where two kidney donor/recipient pairs with incompatible blood types, exchange donors so that each recipient can receive a compatible kidney. Pairs are selected from a national database and if all goes well, the two kidney transplant operations are performed simultaneously. With the media having a field day where donations occur for non-altruistic reasons, such as reports of prisoners in China being cajoled into donating, the ethical framework for this type of donation has to be watertight.

Dementia Training in India

n Dr Janet Farrell sharing a moment with an ARDSI carer in India.

Understanding pain Dear Editor, Diminishing the high level of dissatisfaction with Pain Clinic services evident amongst WA GPs constitutes a major challenge to clinicians responsible for providing these services. Indeed, the very credibility of the newly established specialty of Pain Medicine may be at stake. It has become patently obvious that conventional mono-therapies (whether they be pharmacological or interventional) have by and large failed to provide worthwhile pain relief for many patients. Multimodal approaches badged as “bio-psycho-social” have not fared all that much better. We appear to have underestimated the sheer complexity of such conditions as chronic

spinal pain, chronic widespread pain, and neuropathic pain. They do not conform to our expectations of them having identifiable cause and effect relationships, as can be seen should they develop in the context of compensable injury. Our knowledge gap is reflected by the great difficulty we have in even agreeing upon a scientifically appropriate nomenclature.

Dementia specialist Dr Janet Farrell recently returned from a life-changing experience mentoring and training workers in the dementia care sector in India. Her work overseas followed a request for training assistance from the Alzheimer’s Disease and Related Disorders Support of India (ARDSI) in Calcutta.

Of greater importance is our failure to appreciate, let alone understand, the profound biological changes responsible for our patients’ predicament. Currently we do not have theory sufficiently powerful to take us beyond body/ mind dualistic thinking to help us explain what has happened to them. It is little consolation to clinicians that they share this knowledge gap with their patients.

Janet, who is the manager of High Dependency and Dementia Services at Southern Cross Care, spent two weeks in India providing a practical, hands-on training program for dementia care staff and family carers. The trip was funded by Southern Cross Care, which has supported ARDSI since 2002.

Until better theory emerges to guide our therapeutic endeavours, we must steadfastly resist the temptation to inadvertently contribute to the stigmatisation and marginalisation of our “difficult” patients by allowing negative stereotypes to enter and colour the therapeutic milieu. Blame for our clinical impotence resides neither with our patients nor with ourselves! Dr John Quintner, Pain Medicine Physician

LAST DAYS to Reserve Your Christmas Greeting to all WA Doctors.

“There is a huge cultural difference in India in terms of social welfare systems, hospitals systems, and access to medical treatment; however, I believe one individual can make a difference and provide opportunity for under privileged communities abroad,” Janet said. “The trip was immensely beneficial for my career development and it was inspiring to see care provided under such under resourced conditions by such amazingly positive, passionate carers.” n

Deadline November 10 ! n Acknowledge the support of colleagues and others, n Extend your goodwill to those unfamiliar with your services, and n End the year on a friendly and joyful note.

Medical Forum’s popular

Christmas Messages Supplement

Our Christmas edition comes out the first week in December.

It’s simple. Ring us on 9203 5222 or email jen@mforum.com.au

medicalforum

Medical Pioneer By Dr Rob McEvoy

Prof Geoff Riley – Rural Training Advocate As head of The Rural Clinical School for nearly four years now, Prof Geoff Riley’s journey is a comfortable fit – known and respected in UWA medical training circles but now keen to revisit his rural roots. “I always intended to be a country doctor and was a GP in Pemberton from 1980 to 1990 but had trained in London as a psychiatrist before that. In 1990 I returned to specialist psychiatry, spent the next 18 years in the UWA Department of Psychiatry, and was Associate Dean for students. The Rural Clinical School was going full circle, back into rural practice.” Albany is now his home – the RCS boss has to live in the countryside – and he spends considerable time visiting the 13 rural sites (from Derby and Broome down to Esperance and Kalgoorlie) and talking shop with the 60 academic staff (25 FTE) and 25 professional staff.

reached 60-70 about 4 years ago, it will be 2016 before any surge washes through.

In 2002, federal funding established the Rural Clinical School within UWA’s Faculty of Medicine, Dentistry & Health Sciences, with the explicit purpose of attracting more doctors to rural practice. From just seven students in four towns, the growing popularity of this rural stream has meant that last year they cherry-picked their 76 students from over 100 applicants.

“What really matters are the others, we call ‘the converters’, who have the potential to become very sold on the country. A lot of them say they are ‘coming to see, no promises’, and we know that. They get good exposure, mentoring, free rent for a year and lots of benefits so they are doing it for strategic reasons. We are realistic about this and it’s better that they taste it [rural medicine]. The problem is getting the politicians to acknowledge this.”

Medical students who opt for the RCS stream spend the entire second last academic year in a rural town, studying and gaining a real understanding and enthusiasm for life in a rural practice. Notre Dame’s post-graduate medical students joined the RCS program in 2007 and Geoff said the age differences, of at least a year, make for a good mix of life experiences. Is the scheme working? “It’s too early to say,” he says. “There is no doubt it will produce more country aware doctors. Current figures suggest people who attend the Rural School are three times more likely to go to the bush. But the lag-time is long.” He is talking about the 5-9 years of internship and vocational training that follow the RCS training year and because intake numbers only

These days, medical schools must select 25% of students who have spent at least five years growing up in the bush, that is, those that tend to return to rural practice.

“The younger generations aren’t going to do it the same way – some will spend some years in the bush, some will end up being city-based but do country runs. The shift in awareness of the country, of attitudes, is almost a generational thing, so that while we are scrambling at this stage to prove ourselves with numbers, there is a much more subtle but significant shift where everyone is a lot more aware of country medicine and the quality of what goes on.” The style of rural practice has moved from long-term dedicated rural GPs, to wellequipped practices provided by shires and a higher turnover of doctors with a genuine interest. Reliance on conscripted overseas

trained doctors, who may not be a good cultural fit, is not ideal. Geoff said feminisation is another adaptation. Some groups of child-rearing female doctors cover each other by working part time, which keeps their skills going, and provides essential women’s health services. They also make excellent teachers. He said GPs who seek a better quality of life should not be misinterpreted and the extra training rural doctors often do makes them part of an inspiring elite group. Moreover, altruism, vocation and dedication are not dwindling concepts. “Some generation Y might appear cool, disinterested and selfish. The vast majority of medical students coming through are not like this – they are very smart and incredibly altruistic. This idea that they are not any longer really interested in patients and only interested in prestige etc just doesn’t play out.” By all accounts, the teaching they get through the RCS is uniquely hands on and across the whole medical landscape. “We have horizontal integration. The same topics in the fifth year curriculum are covered – obstetrics, paediatrics, medicine, general practice, cancer, ophthalmology – but instead of being done in 8-week rotations it is all done opportunistically while they are attending the hospitals, AMSs, and general practice clinics. The education is intensive, in small groups from 3 to 10, they have a committed teacher, and with shared learning they teach each other. It is very carefully monitored, much more than in the city, and their progress reviewed. That’s why it works and why even a weak student picks up.” The RCS’s $10m operational yearly budget maintains administrative and teaching facilities at each rural site (as well as a small office at QEII), along with student accommodation (usually houses), and payment to rural GP teachers and professional staff. Support includes four, two-day, face-to-face meetings of academic staff per year. “They get a lot of backup from a medical educator, huge resources from a dedicated librarian, and are paid properly paid, from lead academics on 0.5 FTE who top up knowledge in paediatrics, obstetrics, etc., to preceptors who have students in their practice. It’s all done professionally, not on a shoestring, and people are given the equipment they need. We choose people carefully and we look after them, which is where you get the quality control. ” Geoff said there is no question now that rural GPs can adequately teach the specialties within the fifth year medical curriculum.

We choose people carefully and we look after them, which is where you get the quality control. 4

“The point is country GPs know a hell of a lot, they might upskill to prepare for each teaching session but after a couple of years they have that under their belt. Specialists tend to teach at a level a bit under a registrar but what GPs teach well, apart from the content, is clinical method and reasoning – the universal skills across all specialties – with huge clinical exposure. That’s why it’s so successful.” n

medicalforum

Guest Column

Palliative Care Not About Numbers Palliative Care Australia President Dr Scott Blackwell believes end-of-life care for the elderly should be a dialogue, not a checklist. The Quality of Death Index released by The Economic Intelligence Unit of The Economist rated Australia as the second best place to die in the world. This was the result of a 2010 study on Hospice and Palliative care services across the world. We should be proud of this but only in the context of services whose main work is related to cancer sufferers. In aged care, people are dying increasingly of dementia and other degenerative diseases. Palliative care changes the emphasis of care from curing disease to considering how the person feels. It embraces life and seeks to maximise the life experience of the person despite the inevitable prognosis and the limitations of their condition. It seeks to minimise suffering. In so doing, it respects that suffering may be in body, mind, or spirit. Palliative care also seeks to promote healthy bereavement amongst family and friends.

progressive degenerative neurological disease that leads to death. How often do we help loved ones understand and prepare for loss of mobility, loss of recognition, weight loss with swallowing difficulties, and death? How often do we help relatives understand that their loved one’s body still lives but they have lost them personally (ambiguous loss)? So much is left undone. There are other questions we could raise, but what is important is to seek answers. Within the Productivity Commission Report on Ageing, we

Aged care is not only about problems with numbers, it is also about ticking boxes, which can be worse. How an aged person feels can be impacted by box-ticking exercises.

find hope in the recognition that palliative care is core business for aged care. It also indicates some intent to separate regulation from clinical care, and that is welcome. Urgent attention to a multidisciplinary approach to aged care in the community and RACFs would provide the framework for the implementation of palliative care principles discussed above. More importantly, recognition of the personal needs of the aged is paramount. It is about how they feel, secondly about how their family feels, and not about numbers and boxes to tick. Palliative care in aged care fits naturally as a function of primary care, where care is provided within a relationship, and numbers only used to inform good clinical decision making. Specialist palliative care, expert in the end-of-life care of cancer sufferers, must increase its efforts to become expert in a wide range of degenerative diseases if it is to provide valuable consultative support to primary care in this context. n

Modern palliative care is delivered through the multidisciplinary team. This respects the wide variety of needs of the dying, and the consequent wide variety of skills required to fill those needs. Across health, we have a problem with numbers. Aged care is no different. The aged are more likely to be considered alongside a set of numbers – MMSE, PAS, Cornell, bone density, pain score, etc. – than they are to be asked, “How do you feel?”. Emeritus Professor Eric Cassell, renowned Palliative Care Specialist from the US, recently implored us to recognise that palliative care is personal. Aged care is personal, too, and our failure to talk to the person even if they are demented is a fundamental issue. Aged care is not only about problems with numbers, it is also about ticking boxes, which can be worse. How an aged person feels can be impacted by box-ticking exercises. For example, the recent obsession of aged care regulators with patient weights led to terror in RACF management, which reflected stress onto clinical nursing staff, which resulted in many residents, near terminal, being put on nutritional supplements. The outcome was that people were subjected to unpleasant tasting supplements, perhaps nausea, and bloated abdomens. There is nothing personal in this process. Indeed, the person feels worse. Resources are wasted. Palliative care is also about preparing family and friends for bereavement. Honesty is the pathway to helping them adjust to the realities ahead. The most common example of this is in people suffering from dementia. Dementia is a 6

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By Dr Mike Armstrong

Perth Pathology (Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 Ph 9433 5696 Fax 9433 5472

www.perthpathology.com.au Collection centres throughout the Perth metropolitan area including: Fremantle (Main Lab); Perth CBD, Atwell, Bedford, Belmont, Bentley, East Perth, Ellenbrook, Hilton, Joondalup, Kardinya, Kinross, Maddington, Malaga, Palmyra, South Lake, South Perth, Southern River, Subiaco, West Leederville

Dr Mike Armstrong trained locally at UWA and Perth teaching hospitals. He worked at RPH, Specialist Histopathology and Cytopathology for a time (while it was still an independent service) and later also at Westerns and GPL. Mike has a special interest in GI and skin pathology and cytopathology. In addition to his work at Perth Pathology, Mike also has a consultant position at KEMH.

Glandular Neoplasia of the Cervix A brief overview focusing on the pathology and management of endocervical adenocarcinoma in situ (AIS)

ervical screening has been successful in reducing the incidence of cervical cancer by the detection and management of pre-invasive precursor lesions. The incidence of squamous cell carcinoma of the cervix has fallen dramatically. However, the incidence of endocervical adenocarcinoma (EAC) has not fallen (~1.8 per 100 000) and EAC now accounts for 20-25% of cervical malignancy. This relates to the pathology of its precursor lesion (AIS), its distribution in the endocervical canal and the problematic nature of the interpretation of abnormal glandular cells in cervical cytology. Around 80 to 90% of cases of EAC are associated with exposure to human papilloma virus (HPV). HPV types 16 and 18 account for 80-90% of cases. Endocervical adenocarcinoma in situ (AIS) is now acknowledged as the precursor lesion to invasive EAC. AIS usually involves the transformation zone (tz) of the cervix but may be located widely within the endocervical canal. It may be located high up in the canal, sometimes may be multifocal and may involve glands deep to the surface. It is associated with a synchronous high grade squamous lesion in up to 50-60% cases.

Management of reported glandular abnormality on cervical cytology The frequency of a glandular abnormality reported in cervical cytology is ~1%. Adenocarcinoma. Patient should be referred to a gynaecological oncologist.

Cytologic Diagnosis

Adenocarcinoma in situ. Colposcopy is much less reliable in the assessment of glandular lesions than for squamous lesions. Negative findings on colposcopy cannot be relied upon to exclude AIS following a cytologic prediction of a glandular abnormality. With a cytologic diagnosis of AIS and no visible lesion on colposcopy, cone biopsy is recommended. Once AIS is confirmed histologically, management should be guided by the age and fertility requirements of the woman and the status of the surgical margins. Hysterectomy is recommended for women who have completed childbearing as there is a high incidence of residual and recurrent disease even when the cone biopsy margins are reported as clear. If fertility is required and hysterectomy is not performed, follow up is essential. Conservative management should only be contemplated if all of the surgical margins of the cone biopsy are clear and if the woman understands that strict follow up is required. Future hysterectomy should be discussed once childbearing is completed. With conservative management, the cumulative risk of recurrent disease is 15% at 4 years.

% with High Grade Disease

Management

(confirmed histologically within 24 months after abnormal smear) AIS

70% (16%)*

Colposcopy

Possible High Grade Glandular Lesion

25% (5%)*

Colposcopy

Atypical Endocervical or Glandular Cells of uncertain clinical significance

10% (<1%)*

Colposcopy

*Figures in parentheses indicate % with histologically confirmed invasive carcinoma within 24 months of the abnormal smear

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Possible High Grade Glandular lesion. Further management is guided by the colposcopy findings and is dependent on whether the tz is visible or not. If the tz is visible and appears normal the management options would include cone biopsy or follow up with repeat cytology and colposcopy in three months. Atypical glandular or endocervical cells of uncertain clinical significance. There is considerable debate regarding the management of this group of women. Subsequent management should be based on the colposcopic findings, cytology, histology, and HPV DNA assessment. If colposcopy is normal with a normal tz identified, close follow up with repeat Pap smear and colposcopy at 6 months may be an option. **Much of the information and data have been reproduced from the NHMRC Guidelines for Cervical Screening 2005.

Perth Pathology General Pathologist / Managing Partner: Dr Wayne Smit 0410-488736 Histology / Cytology: Dr Michael Armstrong Dr Tony Barham Dr Bruce Latham

0417-094799 0416-577619 0407-080608

Infectious Diseases (Microbiology): Dr Laurens Manning 0400-783194 Haematology: Dr Rebecca Howman

0417-935873

Laboratory Director: Paul Schneider

0417-931850

Providing phone advice to clinicians and a comprehensive range of medical pathology investigations, including: • • • •

Histology (Skin, GI, etc) Cytology (incl. Paps and FNAs) Haematology (yes, we do lab controlled INRs) B iochemistry (including hormones and markers) • Microbiology and Serology Professional personalised service from a noncorporate, pathologist owned and operated laboratory practice 7

Have You Heard?

Multi-tasking medico National registration has created opportunities for some. There’s an orthopaedic specialist in Melbourne who is promoting his medico-legal skills via LinkedIn. He promotes himself as an accredited impairment assessor for Worksafe in Victoria, NSW, and Tasmania, and an independent medical examiner for Worksafe Victoria, the Transport Accident Commission (TAC), and WorkCover WA.

Armadale running short

PathWest more tests

Having spent >$9m on an ED upgrade last year, we understand Armadale Kelmscott Hospital is running into problems staffing theatres, ED, and the ICU, and with no afterhours surgery apart from obstetrics being done, ED is doing little more than triaging surgical patients for the 40 minute trip to Fremantle Hospital. On the bright side, the public hospital is using 8 GP obstetricians to provide antenatal clinic services and oversee deliveries, backed by a rostered afterhours specialist obstetrician (2000 confinements p.a.). A Medicare funding agreement, Canning Division, and some indemnity cost assistance from WA Health all make it possible.

The concrete pour is complete on the sixth and final level of the PathWest building at the QEII Medical Centre and Health Minister Kim Hames is happy about the advanced level of automation and sophisticated technology to do several million tests each year. There won’t be a cement mixer in sight by the end of 2012, and the staff and patients at Charlies and the new Children’s Hospital on the QEIIMC site will be happy too. See http://www.qeiiredevelopment. health.wa.gov.au

Mindful of cancer The NHMRC, in conjunction with the National Cancer Control Initiative, has just released clinical practice guidelines for the psychosocial care of adults with cancer, which outlines some of the scientific evidence around issues concerning dying patients. See www. nhmrc.gov.au/_files_nhmrc/publications/ attachments/cp90.pdf

An apple in your pocket

Legal retrograde step Public hospital reporting of adverse events will take a dive under new incident reporting rules. Advanced Incident Management Systems (AIMS) in WA will no longer be protected by qualified privilege under Commonwealth legislation. This appears to be a side effect of nationalisation, as WA has prided itself on no-blame, legally privileged reporting of incidents that allowed full disclosure of circumstances around an adverse event, and a systems approach to putting it right. Doctors are now being told to consult with their MDO before filling anything out. The irony is that the biggest impediment to admitting fault in any quarter is that everyone now seems to have a lawyer in their back pocket.

Telehealth trepidation One MDO has issued guidelines on telehealth consults, as has the RACGP (www.racgp. org.au/telehealth). Some good advice for specialists and GPs – make sure your telehealth standard of care matches your faceto-face consultations. You will not be able to use use a lousy video/audio linkup as an excuse for a cock-up. And don’t forget about security, confidentiality, and information storage – like someone looking over your shoulder. Document everything and don’t hang up without all parties knowing who is meant to be doing what and when. 8

This research comes from one of the G8 unis, so it must be true. An apple a day keeps the doctor away, and a three-year joint project between UWA and the Department of Agriculture and Food proves just that. Apples are super-rich in flavonoids – commonly known as antioxidants – and that’s great news for your heart. The popular WA Pink Lady had the highest flavonoid levels of all, most of it in the skin. The study, led by Prof Jonathan Hodgson from the School of Medicine and Pharmacology, was in Free Radical Biology and Medicine Journal.

Genes revisited Did you know? October 2009 amendments to the Privacy Act allow a doctor to breach confidentiality and disclose a patient’s genetic information, without the patient’s consent, where there is reasonable belief that disclosure is necessary to lessen or prevent a serious threat to life, health or safety of his or her genetic relatives. This is set to become more of a grey area as more gene discoveries show linkage to behavioural or mental conditions.

Joondalup kicks goal Construction of a 22-bed, 24-hour sub-acute care facility in Joondalup kicked off Mental Health Week. The first of its kind in WA, the $3.8m facility will accommodate patients for up to 90 days to receive supportive care and participate in programs to help them live independently, essential to recovery said Mental Health Minister Helen Morton. The Department of Housing should finish construction in mid-2012.

Albany art The $170m Albany Health Campus is due for completion in 2013. This will make the patients and local artists happy. Albany artists, Mark Hewson and Paris-Donele Johansen of Torbay Glass Studio, have been chosen to create artworks for the new medical facility – a cascade of colours into the public area of the hospital to reflect a sense of movement from land to sea. The work is funded by the state government’s Percent for Art Scheme, which applies to all public construction valued over $2m.

RPH radiology upgrade Kim Hames has just announced a new $2.2m MRI scanner will be installed at RPH. The busy RPH radiology department saw 180,000 inpatients and outpatients last year, so the increase in MRI scan capacity will no doubt be welcomed by staff and patients alike. The new scanner spend is on top of the recent $1.5m refurbishment of the department, which resulted in a major redesign to improve access and staff work flow.

What have you heard Share the news editor@mforum.com.au or ring the editor on 9203 5222

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Aged Care By Peter McClelland

The Two-Edged Sword of Aged Care GPs working in aged care describe it as frustrating yet rewarding. Their insights perhaps illustrate why only a dedicated handful of GPs are attracted to the field. Drs Cathy Horton and Simon Torvaldsen are two GPs with many years of clinical experience between them in the aged care sector. Cathy is based at the Glen Street Practice, West Leederville, and Simon at the Third Avenue Surgery in Mt Lawley. Both have some instructive, challenging, and thought-provoking things to say about the pleasure and pain of providing high quality medical care to aged patients.

both family and clinical,” she said. “There’s no doubt whatsoever that my aged care work has allowed me to work more effectively than if I’d been constrained by the appointment system within a conventional GP practice.” For Cathy, aged care is now a significant component of her clinical workload. But, as she freely admits, it’s not always smooth sailing.

Some of the people who run aged care facilities don’t help matters much. They’re not particularly doctor friendly.

That’s not surprising because aged care is a complex area, and not just for doctors and their patients. All those acronyms for a start! Just when you’ve got your head around one label, the bureaucrats can’t resist changing a few letters. The highly successful Evidence-Based Clinical Practice Program (EBCPR) has been rebadged as Encouraging Better Practice in Aged Care (EBPAC). (Cathy Horton is soon to undergo the ‘rebadging’ process. Following a midOctober marriage, she will morph into Dr Cathy Parsons). Whichever way the letters are shuffled on the upper-deck of aged care, the reality for doctors working in the engine room is a complicated story with many different chapter headings. The words difficult, frustrating, rewarding, and incredibly satisfying are ever-present. “The message I’d like to get across is that clinical practice within an aged care environment can be both interesting and rewarding,” said Cathy. Aged care was very much a decision driven by circumstance for Cathy, who regularly visits three large aged care establishments: Little Sisters of the Poor (Glendalough), Villa Pelletier (West Leederville), and Catherine McAuley (Wembley). “As a single-parent with three young children, and one with a disability, I needed to find a flexible way to meet my responsibilities – 10

Dr Simon Torvaldsen “It’s a challenging sector. There just isn’t enough funding being put into aged care, and the issue with nurses and carers is a serious one. Nurses are underpaid compared with their colleagues in the hospital system and carers are being asked to make clinical decisions well beyond their level of training and responsibility. And the fact that so much of the nurses’ time is spent on documentation relating to compliance and accreditation definitely impacts on patient care.” Recent research carried out by Prof John Stevens from Southern Cross University underscores some of these problems.

Three Key Challenges for Aged Care

• Capital and recurrent funding mechanisms are inadequate. • Planning and allocation mechanisms are not responsive to actual need. • Regulatory compliance framework is unreasonable, unwieldy and impacts negatively on patient care.

“Despite government and nursing profession reforms to make caring for older people more attractive, the results are identical to a 1992-95 study,” A/Prof Stevens said in a media release. “The professional socialisation of nursing students aligns with a broader culture of devaluing older people themselves.” With the current demographics of ageing in Australia, that’s a worrying trend. “Given the inevitable ageing of our population and the increasing demand for aged care services it begs the question, who will care for us when we can’t care for ourselves?” Prof Stevens said. Dr Scott Blackwell directed the very same question to medical practitioners nearly a decade ago. “People are getting older, including doctors. One day, you, too, may be a resident in an aged care facility. Who will look after you? Who will be responsible for your health needs? These are very real questions with uncertain answers because aged care facilities are having trouble attracting GPs. Why?” Dr Simon Torvaldsen, who has a particular interest in palliative care and works with Silver Chain Hospice Care, has a few thoughts on the matter. “There’s a great shortage of doctors willing to work in aged care,” said Simon, who partly blame the institutions themselves. “Some of the groups who run these nursing homes, and that includes religious institutions, don’t help matters much. They do very little to support doctors. Staff to patient ratios are getting worse and they’re not particularly doctor friendly.” It’s no wonder that younger doctors are not attracted to the aged care sector in higher numbers. Apart from the fact that it’s not regarded as a particularly ‘sexy’ area of medicine, in some cases, there are basic

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impediments to providing even a reasonable standard of care. The increasing use of poorly trained and lower-wage staff is one example.

a sobering statistic for all of us that more than 80% of Australians in the 65+ age bracket have three or more long-term conditions.

“All too often, the n Dr Scott Blackwell GP care-aides have had a six week TAFE course and their language skills are poor,” said Simon. “I visited one nursing home with a specific cultural focus and there wasn’t one staff member who could speak that language.”

Consultant n Dr Simon Torvaldsen GP geriatrician, Dr Hannah Seymour – Royal Perth Hospital and Clinical Advisor, HDWA Aged Care Policy Directorate – has a distinctly positive outlook. She sees many opportunities for doctors.

Cathy and Simon are in the fortunate position of viewing aged care from twin perspectives. As practicing GPs, they see the elderly and the frail both in their surgeries and in nursing homes. From now on, they’ll be seeing them in increasing numbers. The medical system in Australia is under increasing pressure; there are rising levels of chronic disease and a greater complexity of patient presentations. About 75% of the population suffer from one or more ongoing medical issues and our ageing population is compounding this situation. It’s

GP’s Wish List for Aged Care • Economy of scale – a cohort of patients in each nursing home facility. • A dedicated and fully equipped consulting room with computer facilities and internet connection. • Improved access to medical notes and medication charts. • A trained nurse to assist the doctor – the patient is more relaxed and it also ensures that any important medical information is conveyed to the nursing home.

“Working as a physician in hospital, aged care is really interesting. There’s great clinical diversity, we see the full spectrum of medical issues, and I think we’ve used our available funding pretty well. We haven’t got little old ladies lying on trollies in hospital corridors for hours and there are positive benefits from that, such as better patient outcomes and reduced length of stay.” Hannah is the first to concede that there are significant differences between hospitals and nursing homes. “Our funding models don’t flow directly on to nursing homes, but there’s still a strong connection. Any community initiatives, if they’re targeted and effective, will hopefully push back decision time for an elderly person and their family when it comes to entering an aged care institution.” From the perspective of a GP treating an aged care patient who’s been admitted to hospital, the flow of information between hospital and clinician is vitally important. “It can be very unsatisfactory at times,” Cathy said. “Some hospital doctors think of GPs as glorified social workers and that’s a real shame because good interaction is so beneficial for the patient. I love it when a hospital doctor rings and informs me regarding a patient’s

treatment regime.” One strong theme coming from GPs who do choose to work in aged care is the immense satisfaction that comes from participating in a ‘whole of life’ clinical overview.

n Dr Hanna Seymour, Geriatrician

“There’s a wonderful feeling of continuity,” said Simon. “It’s very much cradle to the grave medicine.” “It’s incredibly worthwhile, and it doesn’t have to be a burden on your practice,” Cathy said. In fact, despite all the problems and difficulties it can be both professionally and financially rewarding. “You can actually make a good living and the level of flexibility is wonderful. A career in aged care has been a really positive thing for me. It’s a great shame that it’s often regarded as something of a poor relation,” Cathy added. There’s no denying that there are some bleak aspects attached to the aged care scene – inappropriate funding models, overly zealous compliance regimes, and a government that keeps echoing the line that aged care is a ‘high priority’ when nothing much seems to change on the ground. The last word from Dr John Whitelaw. He’s been a regular visitor to the Chrystal Halliday Nursing Home for more than 25 years and is approaching his own retirement. “The patients have grown old as I’ve grown older,’ said John. “You can prevent a lot of serious problems just by good communication. I’ve found it to be immensely rewarding.” n

Aged care has allowed me to work more effectively than if I’d been constrained by the appointment system within a conventional GP practice. Dr Cathy Parsons

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Guest Column

Stop Burying Your Head in the Sand ECU medical information security expert, Dr Trish Williams PhD, is concerned that small practices will be the Achilles heel of the national e-health system. Are you going to be the weakest link in the national e-health system? Unless you have been on an island for the past year, you cannot have failed to notice that e-health is about to sweep you up in its looming wave. Many practices are preparing to join the surf, whilst others have been riding on it for some time. Unfortunately, there will be many that will crash headlong into the water because too little attention has been paid to the security of their information systems.

controlled, but the connectedness that makes information sharing attractive necessitates a much higher level of security. Information transfer and exchange (rather than just receipt), remote access, and the new services such as electronic transfer of prescriptions (ETP) create a different information security risk profile. This will draw attention to the real confidentiality, privacy, and control of the information, the flaws in the integrity of the information, and the crucial issue of availability of patient information when it is unavailable.

As the old adage says, ‘you are only as strong as your weakest link’. Unfortunately, the weak links will not be fully visible until the national system is up and running. Whilst encryption of message transfer is important, information security is so much more than this.

So what can you do about this to ensure your practice is not dragged under by the riptide?

The issues include fundamental computer and information security aspects such as access control, backup, internet and email usage, malware, physical, system, and software security, portable devices, wireless networks, network perimeter controls, and business continuity. When your system is contained within one organisation, the environment can be more

Doctors can start by taking the governance of their information security seriously. For instance, do you ‘know’ that your third party contractor has done everything that meets the requirements for your specific environment, and that these comply with your statutory obligations and professional standards? This is not to say that your ‘trusted’ third parties have not done this, but the responsibility lies with the practice to ensure and prove this, not with the provider. Do you have a signed confidentiality agreement with your hardware,

software and service providers? If you do, excellent, but how do you monitor this? Having worked for many years in providing such support, I know that there is inherent trust (or should that be failure to recognise, acknowledge, and accept the danger) of open access for third parties to your system to assist you. You often provide full backups of your data to the company to investigate issues for you – do you know where this information is loaded or stored, who has viewed it, or that it is securely deleted after the incident is resolved? With the new national e-health system, the privacy legislation will make you liable for viewing of patient information that is not directly linked to care of that patient. Avoiding your responsibility and burying your head in the sand is not a sensible or professional option. Appropriate advice is available from the professions, such as the newly launch RACGP Computer and Information Security Standards. The national response is that the responsibility for security is delegated to the individual health care provider organisations. Are you ready to take this on and ride the wave when it arrives? n

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Guest Column

What Triggers a Disciplinary Action? Experienced Perth lawyer, Leslie Buchbinder, outlines the main considerations of disciplinary action – and how public interest is often overlooked. What happens when a doctor fails to live up to the professional expectations of a patient? While the Medical Board of Australia is obliged to supervise those registered with it, not every alleged failure of care or professional behaviour becomes the subject of disciplinary proceedings. Instead, there are three sets of considerations which are taken into account when considering the need for disciplinary action.

The legal framework The first of these is the legal framework. Circumstances that usually trigger possible action are breaches of professional conduct include unprofessional conduct, professional misconduct, and notifiable conduct, as defined by the relevant legislation, Codes and Guidelines and the Registration Standards. Unprofessional conduct covers such matters as conviction for an offence that may affect suitability to continue practice, as well as excessive or unnecessary service provision and accepting inducements for referrals to another health care provider. Professional misconduct

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relates to standards of treatment substantially below those reasonably expected – typically over a period of time or several cases. Notifiable conduct concerns intoxication and sexual misconduct while training or practising as a doctor, which places the public at risk of harm. Actions may also be considered where a practitioner’s health becomes impaired in a way that could affect their safe practice capabilities.

The facts The second set of considerations are the actual facts of a matter. Most of the focus of any disciplinary proceedings is on determining what did or didn’t happen. Even if there is a ‘primae facie’ (at first sight) case against a doctor, if there is insufficient evidence or little prospect of a conviction, this will also influence the likelihood of disciplinary proceedings. In cases of serious allegations, a matter will be heard in the WA State Administrative Tribunal, where Rules of Natural Justice require that the doctor who is the subject of the disciplinary inquiry be given reasonable opportunity to know the allegations against them, to be heard in relation to the allegations and to be represented by a lawyer.

The public interest The third set of considerations determining possible disciplinary action is public interest. Public interest factors include: the seriousness of the alleged misconduct; the risk of harm to the public; the legal and other costs likely to be incurred in proceeding; whether the doctor concerned has a history of non-compliance with accepted standards of clinical and professional conduct; and whether any concerns can be allayed by taking action other than disciplinary action. Even when evidence is very likely to establish misconduct, it may clearly be not in the public interest to pursue the matter. For example, it could be argued that a doctor caught driving over the legal alcohol limit and who abuses a police officer has brought the profession into disrepute, but there may be little public interest in taking disciplinary action. It is my view that public interest factors are often given insufficient weight, with the result that disciplinary proceedings are initiated against doctors when they are simply inappropriate and unnecessary. n

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Photo courtesy City of Albany

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National Health Reform By Dr Robert McEvoy

Health Reform Comes to Perth Too many sick people and not enough health dollars or workers. What is our federal government doing to remedy the situation? When Departmental Secretary Graeme Head finished, he took questions from an aged care consumer advocate, a homebirth provider, a Doctors Reform Society member, Silver Chain spokesperson and an advocate for consumer mental health, amongst others. They represented the diversity of interest in the National Health Reform presentation in Perth, one of 14 nationwide visits since the states all signed the National Health Reform Agreement on August 2, 2011. Medicare Locals, eHealth, hospital reforms and funding changes are just some of the items already spotlighted by a government faced with the harsh reality that by 2045, the current trajectory of health spending will outstrip all revenue raised by state and local governments.

demand more from within their health silo. This includes the broad focus and governance of Medicare Locals within the primary care setting, the funding of Local Hospital Networks that swings on real service delivery to health consumers and is monitored by the National Health Performance Authority, and eHealth aimed at more flexible and coordinated care.

The enormity of the task and the undeniable need to breathe efficiencies into our public health system is mobilising people as they watch to see if those at ground level will be truly assisted or we will end up with a dysfunctional top-down system and a new bunch of acronyms to remember. There are a few encouraging signs.

Some important ponderables remain. Can governments really work together to achieve common goals without political interference e.g. states will have to agree on a national comparative recording system and pricing system? Are the proposed changes to regulation and agencies, coupled with increased transparency, going to create enough efficiency or just rearrange the deckchairs? Can activity based funding work for the three

Service providers are being asked to take a whole-of-system approach, rather than

Having major urban hospitals compete for an independently administered National Health Funding Pool, centralisation of aged care services (except for WA and Victoria), comparative performance reporting (e.g. MyHospitals website), and more effort on prevention and mental health early intervention, are all meant to encourage innovation while lessening fragmentation and duplication of services.

Beneaththe Drapes u Shenton Park GP Dr Janice Bell was awarded the RACGP’s most prestigious honour, the Rose-Hunt Award. This award is presented to a GP who has rendered outstanding service in the promotion of the aims and objectives of the RACGP. u Winthrop Professor and Director of UWA’s Centre for Aboriginal Medical and Dental Health, Prof Helen Milroy, has won two international awards. The 2011 World Council for Psychotherapy’s Sigmund Freud Award and the 2011 Yachad Scholar, awarded by the Women’s International Zionist Organisation. u Silver Chain volunteer Ms Kate O’Brien is a finalist in the 2011 WA Senior the Year Awards, Community Award category. Kate is an active participant of the Walpole Health Service Advisory Committee.

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u The WA Health Good Outcomes Awards were announced during Mental Health Week. The winners included A/Prof Jonathon Rampono (McCusker Charitable Foundation Award for Excellence), South Metropolitan Community Drug Service and South Metropolitan Mental Health Service (GESB Partnerships Award), Rural Community Support Services (Edith Cowan University Prevention and early intervention Award), Mark Morton (Freehills Mental Health Employee Award), and Margaret Doherty (John Da Silva Award for Consumer and Carer Participation). u Ms Jacinta Lack, Senior Program Officer (Immunisation Program), Midwest GP Network, has been awarded the Network Employee Award 2011 on behalf of the WA

arms of hospital care – inpatient, outpatient and ED – with all hospitals agreeing to fix prices for services through the new Independent Hospital Pricing Authority? If control of hospital services is brought closer to the end user through Local Hospital Networks, will it result in the intended responsiveness to community needs? In private medicine you measure some tasks as you go but focus mainly on measuring outcomes against spend. Where tax dollars are concerned, measuring everything seems a bureaucratic imperative but does it define and confine our thinking and in that way stifle innovation, just when innovation is badly needed? For the moment, the federal government is committing money in directions it wants to see change – a sort of stimulus package – and is partly moving control away from the usual health bureaucrats while saying it will inject efficiency into some more centralised services. Some of those at the meeting in Perth were craving a cultural change within government so that the right people were given the opportunity to drive change. See http://www.yourhealth.gov.au/internet/ yourhealth/publishing.nsf/Content/nhrprogress-delivery n

Divisions of General Practice Network. Jacinta was recognised for working in collaboration with her community, including Geraldton Regional Aboriginal Medical Service, to improve immunisation coverage in the region. u Ms Kaye Mazzoleni has recently joined WA General Practice Network as Strategy and Development Manager. Kaye has more than 20 years’ experience in the health industry across the public and private sectors as a consultant and senior manager. u Mr Michael Cain, of the Cancer Clinical Service Unit at Sir Charles Gairdner Hospital, was named Pharmacist of the Year in the Pharmaceutical Society of Australia’s Excellence Awards for his contribution to the whole of Australian society. Michael is known around Charlies as an enthusiastic teacher and mentor. u Aged care provider Southern Cross Care has announced two new board members: Ms Anne Arnold, the Chief Executive of the Real Estate Institute of Western Australia, and Mr Chris Hunt, who has held senior management roles within the Financial Markets Division of BankWest. Chris is also a former State Chairman and State Executive Officer of the Knights of the Southern Cross in WA. n 15

E-Poll

Your Say on Aged Care and Palliative Care WA medicos yearn for simplified access to aged care for patients and a smoother palliative care transition but have shied away from supporting voluntary euthanasia laws. 173 GPs and Specialists lent their voices to this edition’s twin themes of aged care and palliative care. Three of our questions, to do with end-of-life decision-making, were plucked from our similarly-themed July 2008 e-poll. The difference three years has made to your colleagues’ opinions might surprise you. Dr Bill Sands won the draw for the wine pack (optional).

Telehealth and Specialist Advice n Accessing specialist advice is difficult with immobile patients in aged care facilities.

Tele-health, where the specialist uses an audio-visual link to the doctor or staff to advise on care, is suggested as one solution. What is your response?

I agree – it could be a big help for most things. ........................................................................ 20% Helpful but only for limited clinical scenarios. ......................................................................... 33% Very limited uses due to the logistics and time constraints. .................................................... 23% Good in theory, virtually useless in practice. ............................................................................ 21% Uncertain...................................................................................................................................... 2% None of the above.......................................................................................................................... 1%

Barriers to Doctor Involvement

End-of-Life Decisions

n Imagine you are semi-retiring soon and

n How well equipped do you feel to

you are considering limiting your practice to just aged care. As things stand today, what would be a strong barrier to you doing this? [more than one choice possible]

GPs doing aged care is that they think it’s too hard to arrange in a way that doesn’t lose them money/time.” Negative (or at least, pessimistic) comments included:

Remuneration for the effort involved is not worth it. ..................................... 54%

“The stress of rushing there during lunch break or after surgery is just not worth it.”

Too much paperwork involved............... 42%

“Very time consuming to assess nursing home patients and the need to be on-call for them.”

Lack of on-site facilities to assess nursing home patients properly. .......... 42% Lack of competent nursing staff to provide support............................... 28% Elderly patient problems are too complex and overwhelming. ........ 25% Lack of backup support from specialists and suchlike. ....................................... 22% Clinical practice rather limited and potentially unsatisfying. .............. 22% Too many end-of-the-line high care patients in aged care facilities. ........... 16% None of the above................................... 16%

“Unrealistic expectations by residents’ family members.” “Funding needs addressing – the bonus payment for seeing a certain number of patients per year is only available to PIP practices, which cuts out all those GPs who are specialising in aged care in semi-retirement (and I think they are the only hope for aged care as younger GPs don’t seem to be taking it up).” “Most aged care facilities are not doctor friendly. Medical record keeping is poor and variable.”

Other ........................................................ 9%

Finally, these two medicos have first-hand, mixed experiences:

n Would you work in aged care?

“I do go to nursing home patients now. The staff do a great job but many lack the skills to adequately assess the patient, resulting in increased visits to see the person as you are not sure from the information given how ill the patient is. I feel remuneration is very poor as a great deal is unpaid phone advice and writing multiple scripts in your own time.”

Ruling out the eight medicos who said they are either currently working in the field or found the question not applicable (largely because they were committed to a different field), the remaining 28 comments were split down the middle. In the positive camp were comments such as: “I consider that aged care is little different from general practice and that once you get motivated enough to visit the aged in nursing homes, the medicine, support, and remuneration etc. is fine.” “I already focus my practice on aged care and I am nowhere near retirement myself. It is extremely rewarding professionally, and I make a decent income. The main barrier to

“I actually have 100 patients in ACFs and am very pro-active regarding their care. The basic problem is that too few GPs are actually organised enough to do the job well. I led a discussion at a GP trainer’s weekend meet and was somewhat dismayed to find that many of the processes I use in managing aged care in the practice were new to (and very much welcomed by) the GP trainers. It needs to be a core part of GP training! I should write a book on it!”

answer questions from your patients about the 2009 living wills laws?

2009 2011

I know the laws very well. ........ 1%...... 10% I have a good idea but don’t know specifics. ...........30%......36% I know a little about them but would need some education on how they apply to my patients............. 61%...... 51% I have never heard of living wills before! ................8%........ 3%

n If legislation on voluntary euthanasia in WA could be drafted with suitable safeguards, do you think it would be supported by the medical profession?

2009 2011

Yes ........................................... 35%..... 21% No ............................................ 37%..... 56% Unsure ..................................... 28%..... 23%

n During your working life as a doctor, have you ever accelerated the death of a terminally ill patient with the consent of both patient and relatives?

2009 2011

Yes ........................................... 22%...... 18% No ............................................ 78%......66% Doesn’t apply .............................n/a...... 16%

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Oncologist to Palliative Care n This is for anyone who has cared for

or been involved with patients with a terminal illness. Please tell us what you or the nurses involved generally think about the transition of care from oncologist to palliative care doctor?

Often occurs too early ...............................2% Often occurs too late .............................. 33% Usually happens at the appropriate time.36% Mostly not managed properly .................. 9% Doesn’t apply ............................................ 8% None of the above ..................................... 2% Uncertain ................................................ 10%

Care to comment on this difficult issue? The palliative care transition conundrum elicited 40 responses. Here is a good representative sample: “The palliative care physicians complain the patients are not referred early enough, but usually the patients don’t want to transfer. They don’t want to lose their treating doctor and they don’t want to ‘concede defeat’ and accept death is inevitable.”

“I see patients on the acute pain service rounds frequently that should have already been acquainted with palliative care. Often, this service is not offered to patients as part of their ongoing oncological care. Doctors remain scared of tackling this situation as it is an admission that treatment has failed ... and at this stage, patients are often left to fend for themselves as their life draws to a close.” “Oncologists loathe admitting that they do not have a useful role any more. It is frequently up to the GP to suggest that a palliative approach would be a better option.” “I have frequently been missed out of the loop. I endeavour to avoid those specialists in future cases. They are downright rude, and then on a weekend or some other time, the family or the nurse rings me requesting my help. Very frustrating is about all I will type.”

simplify patient access to services for the elderly such as one-stop enquiry lines?

Badly needed for all (patients and relatives) .................... 47% Yes, but for some services only ............ 21% Current system works well – no change needed .............................. 7% Uncertain ............................................. 22% None of the above .................................. 2% Comments on simplifying patient access to aged care services The 33 medicos who commented found the issue of simplifying access to aged care services to be complex. Seven confessed they knew nothing (or next to nothing) about the issue, and in particular, an enquiry line. Confusion reigned for a quarter of the respondents, with comments such as: “Isn’t that what Carelink is?” “Perhaps this could be the role of Medicare Locals, but I haven’t a clue what they are going to do.” “Oh dear, yet another service I do not know about!” Three said technology was an issue, such as: “Need to remember the elderly can find technology difficult (e.g. automated phone service) and many don’t have computers. They need to speak with a real person. Few people seem to know about the Commonwealth Carelink number.” Three had concerns about the GP being removed from the equation, such as: “If patient care is removed from GPs’ responsibilities, it will be taken over by lesser trained bureaucrats and rapidly become another dog’s breakfast.”

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“The only problems have been where patients have entered a period of rapid decline after a long period of stability and the carers and patient have ‘missed’ the observation that the end is near.” “Palliative care services have never been anything except brilliant in the nursing home setting. I am very obliged to the backup this provides.”

“Pallative care doctors are great, but the concept of palliative care teams – often nurse lead – often frustrate the issue of transfer from oncology to palliation in the public setting.”

“For my dying elderly patients, it is exceptional to have the involvement of either an oncologist or palliative care specialist, even if they are dying of cancer. It would be different for younger patients in the general community, but in aged care, the GP can do it all. Palliative care assistance is easy to get as a GP – excellent service in WA.”

“An oncologist told a patient that she could

Ed. Refer to article by Dr Davray, page 35.

Nine medicos felt the system needs a good shakeup:

Drug Reactions and Living Aids

Simplifying Access n What do you think of attempts to

not continue active treatment if referred to a palliative care specialist (although management of patient’s nausea was poorly controlled and I wished specialist input). Patient did not want to choose but had severe nausea/vomiting/ dehydration not addressed by the oncologist. The patient died less than two weeks later.”

“Current system is far too disjointed and fragmentary.” “Ignorance of services available is a major barrier to care. It would be cost-effective in the long run to invest in coordination of care from early contact, including phone/online/ face-to-face.” “From the hospital perspective, every year there appears to be more bureaucratic nonsense and less appreciation for the complex clinical care that this vulnerable group of people requires. The pressure to discharge from tertiary centres is disturbing.” “The trouble with one-stop enquiry lines is that they are often of limited utility. How often does ‘Health Direct’ direct people to their local GP or hospital ED? Passing the buck is frustrating, a duplication of services, and of limited value. I think an on-call geriatrician service for primary care providers would be useful, but again, it would be limited by cost, availability, and medicolegal liability for phone advice.”

n For whatever reason, what proportion of suspected adverse drug reactions in the elderly would you report to the appropriate authorities? [single answer]

Nearly all ............................................... 13% Most ...................................................... 25% Less than half ......................................... 3% Less than a quarter ................................. 5% Rarely report ......................................... 33% None ........................................................ 5% Uncertain ................................................ 7% Doesn’t apply .......................................... 9%

n Various daily living aids are available to assist family or carers look after an elderly relative at home. Do you know how and where to access such aids? Yes .............................................................. 62% No ............................................................... 19% Uncertain .................................................. 16% Doesn’t apply ...................................... 3%

“The experience in my own family was that the professional believed everything my elderly, frail, optimistic father believed he could do and did not validate any of it with my mother or other (non-medical) family members present. It did not give me much faith that the system is up to the task. The system is also very confusing for consumers at present, but it is not so much the health system as the accommodation system.”

Dementia By Jason Burton, Manager Research and Consultancy Services, Alzheimer’s Australia WA

Creating an Enabling Home for People with

dementia n The person with dementia can see items

you want them to find.

With over 250,000 people in Australia currently diagnosed with a dementia the challenges families face in supporting the person at home are significant. The number of people living with dementia is set to rise dramatically – it is predicted over 7,400 people a week will be diagnosed with dementia by 2050, with most living at home for a significant part of their illness. Key issues faced by people living with dementia include: • Disorientation and other symptoms caused by memory loss and brain changes.

intervention. Cognitive impairment is very individual and solutions need to be tailored to each person and their home situation. A quality dementia specialist assessment is key.

• Risk and safety concerns.

• Maintaining independence in activities of daily living.

n One button radio operation.

• Engaging in meaningful occupation. Creating an enabling environment for someone with dementia requires a person-centred approach to both assessment and

n Keeping track of time and day

Home adaptations to overcome the disabilities of dementia

n Speed dialling

using buttons made of family member photos.

Memory loss is most common, manifest as disorientation to time and place, misplacing belongings or an inability to find everyday household items. Simple principles can assist: Line of sight orientation – make sure the person with dementia can see the items you want them to find. For example, use clear containers to put the tea and coffee in and leave them on the kitchen top, change cupboard doors to glass or remove some doors all together, leave one set of clothes out in a morning to get dressed, and ensure the toilet door is open.

Orientation aids – things that orientate in time and place as well as reminding prompts can ease anxiety and frustration. Things such as: easy-to-read clocks that tell the time and date; a white board to leave memory jogs and prompts; memory prompting devices to remind of appointment times or medication alerts; a time-delayed sensor alert next to the front door that encourages the person not to go out of an evening; sensor lighting in the toilet can aid with finding the bathroom in an evening; and simple signage, especially if the person has moved into a new environment within the previous year. Using familiarity – ensuring items in the home fit the person’s long term memory, may make the home more accessible. For example, a mixer tap may be much more difficult for an older person with dementia than more traditional separate hot and cold taps. Adapting radios, TV remotes, telephones etc for simplicity of use, will lengthen their useful life.

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or carers and can lead to early admission to residential care or hospital. A range of assistive technologies are now available to help minimise risk whilst maintaining opportunities to be involved in meaningful activities and household chores. These are some examples. Sensor iron – a sensor in the handle detects if the person is no longer holding it and switches itself off after 30 seconds, switching back on when the person picks it up. Simple mobile phone – a one touch mobile phone with pre-programmed one-touch dialling and a GPS locator should the person becomes lost or summons assistance. Home monitoring system – a sensor based system that can monitor the activity of a person at home to give a clearer picture on how the person is coping by themselves.

n No problems discerning the toilet seat or plate.

Door alarm – simple off-the-shelf alarm that attaches to the door to alert the carer if the person opens the door to go out.

Overcoming perception difficulties – many people with dementia have problems with visual perception that creates difficulty in judging spatial distances and in fixing objects within their spatial context. This issue can be greatly assisted through the use of colour definition to highlight objects and provide clearer spatial definition between object and background. Easy adaptations include changing the toilet seat for a contrasting one, using coloured crockery, or highlighting door frames with different colours, as well as identifying floor patterns that cause difficulties such as stripes or threshold changes that mimic differing floor height levels.

Reducing risk and maintaining safety Dementia can create risk – the cooker left on, becoming lost when out shopping, impaired perceptual awareness leads to falls, etc. – which in turn creates great anxiety for family

For more details on equipment available, visit the Independent living Centre.

Maintaining meaningful activity Home adaptations can support a meaningful life that reinforces the sense of identity and wellbeing. For example, ensuring taps are easy to use, cupboards are in line-of-sight and countertops are correct height will support washing and drying dishes. The garden can be adapted with raised garden beds and easily accessed watering cans etc, while in the home, brushes, mops, dusters etc are in easy reach and line-of-sight for familiar household chores. Having large print books, easy to use jigsaws and photo life stories to prompt reminiscence are important activities to consider. n

n Door

alarm

n Raised and visible gardening

Other resources

• Alzheimer’s Australia – Dementia helpline 1800 100 500 • Useful Websites: www.ilcaustralia.org www.atdementia.org.uk http://www.alzheimers.org.au/westernaustralia/assistive-technology---productinformation-sheets.aspx

• The Dementia Enabling Environments Project over the next two years will provide a range of information and resources nationally, starting early 2012 (see www.enablingenvironments.com.au). • Aged Care Assessment Teams • Independent Living Centre Australia

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ail em u e s a lea m. , p d.co s ad me lp rra leep e f s r re n@ Fo dmi a 19

Aged Care By Peter McLelland

Enriching Ageing Minds Diversional therapy is making a real difference in the lives of aged care patients, according to GP Dr Jenny Brockis. Dr Jenny Brockis is a passionate advocate for neurological health, particularly in relation to the elderly. “Older people can become highly anxious and fearful. Singing and listening to music is a wonderfully calming activity within an aged care environment,” she said. Diversionary therapies – everything from orchestrated physical movement with a musical backdrop to visiting theatre groups complete with a court jester – are becoming an increasingly popular activity in nursing homes. “There’s often a distinct loss of autonomy within a nursing home and an increasing tendency for patients to feel they’ve lost control of their life.” But it doesn’t have to be that way. As far as Jenny is concerned, we can all – the elderly included – do a lot more to improve the ageing experience. “We can’t choose our genes but we can choose our environment. Good nutrition, physical exercise, and managing stress and anxiety are important areas for elderly patients. It keeps the brain active and encourages a positive attitude.”

It’s well known that social activities such as choirs and informal singa-longs have enormous benefits for people suffering from neurological disorders. The social interaction alone is immensely beneficial for the elderly. Jenny has seen the effects of Alzheimer’s and dementia within her own family. She nursed her parents-in-law through a very difficult time and this convinced her of the importance of diversional therapies within an aged care environment. “I encouraged all my elderly patients to try and do as much as they can for as long as they can,” said Jenny. A woman in her ‘80s told Jenny she was, ‘sick of being told what she couldn’t do. I’m going to do what I bloody well like.’ Jenny obviously sings from the same song-sheet. She’s a WA medico who’s worn many different hats during a diverse and interesting career. Jenny commenced her medical training in Bristol, UK, before migrating to Australia in 1985 and qualifying as a GP in the late 80s. After running a medical practice in Ocean Reef for 13 years she turned her hand to property development. “I decided it was time to take a break from my clinical work. It was wonderful to develop my business skills in the investment world and engage with people on a completely different level.” For all of us, not just the elderly, it’s so important to keep our brains challenged, active and engaged. The last word to Jenny: “to be a lifelong learner is a wonderful thing and a nice red wine and a bit of dark chocolate makes it even more enjoyable.” n

We think your practice should work as hard as you do Since 2002, Medifit has completed over 200 healthcare, medical and dental design and construction projects across Australia. We’re healthcare design and construction specialists, and we make it our business to stay abreast of the latest technologies, equipment and compliance requirements. From renovations to complete ground up builds, we’ll help you to get the most out of your available space and transform your practice to work the way you do. And we’ll do it on time and on budget. For advice on making your practice work as hard as you do, contact us today for a no obligation consultation. Your patients won’t be the only ones smiling.

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Aged Care

A Fix for Older Australians? The Productivity Commission report, Caring for Older Australians, is hot off the government press and its recommendations could significantly shake up the aged care sector. Australia’s aged care system is often experienced as fragmented and difficult to navigate. Not only that, there is tangible evidence that many of the most vulnerable – the elderly themselves – fall through gaps in service delivery due to inefficiencies and inequalities in the distribution of resources. The Productivity Commission report, Caring for Older Australians, and its plan for a simplified gateway to access aged care will hopefully change all that. Dr Emil Djakic, the chairman of the Australian General Practice Network (AGPN), is cautiously optimistic. “This report will provide the right platform for Medicare Locals to work within the aged care sector. Just as importantly, it will link the primary health care sector with aged care services.” There are a number of bureaucratic hurdles to jump along the way to achieve some of the report’s recommendations such as the establishment of the Aged Care Implementation Taskforce and Advisory Group and the Australian Seniors Gateway Agency.

The two-to-five-year program aims to reduce the distinction between low and high care, introduce price monitoring for residential accommodation, and increase the number of community care places by 20%. There will be a closer focus on region-specific issues with an attempt to set supported resident ratios for all new and existing residential providers. A pilot scheme for trading supported resident ratio obligations is also recommended. Australia’s largest specialist medical college, The Royal Australasian College of Physicians (RACP), supports the proposed new model. RACP President Prof John Kolbe stated that the report has identified “serious gaps in the health services being offered to the elderly in Australia.” The aged care sector is a complex and demanding area, and that’s not going to change anytime soon. Within a decade, there will be an increasing number of older people with higher service expectations, coupled with a projected shortage of trained aged care staff. It’s estimated that by 2050, in excess of 3.5 million Australians will be utilising aged care services.

Mark Butler, the Federal Minister for Ageing, has expressed a preference for a balance between market economics and cautious regulation. “Caring for Older Australians clearly sets out the advantages of a market approach, in the sense that the supply of aged care places should be opened up. Nonetheless, the aged care sector needs to be overseen by an independent regulator,” said the Minister. For some aged care professionals, profit is clearly not their prime motive. Emil Djakic has backed the Productivity Commission’s recommendation to review Medicare rebates for GPs working in aged care. “There is a need for increased remuneration for GPs providing medical services to elderly Australians and the report has recognised that fact,” he said. Despite some cautionary concerns, the release of the Caring for Older Australians report has provided a blueprint for reform which aims to provide an accessible gateway towards a more coordinated model for aged care services. The full recommendations can be downloaded from www.pc.gov.au/projects/inquiry/aged-care. n

(52264) Vocational Graduate Diploma of Women’s Health again on offer for WA GPs The KEMH and AMA invite you to enjoy built-in flexibility, CPD rewards, and up-to-date content make the course value for money. Fine tune your knowledge and build useful clinical contacts. Participants can access the information in part or in whole (i.e. full Diploma). There are only 40 places – kept low to safeguard interactive learning – so enquire early. The course is designed by educational gurus at King Edward Memorial Hospital.

The 2012 Diploma’s three themes are:

Women’s Health Education for GPs and the VGDWH

1. Family Planning & Sexual Health — Feb 14 – May 1 2. Office Gynaecology — May 15 – July 31 3. Non-procedural Obstetrics — Aug 14 – Oct 30 Each theme is delivered over 10 evening sessions, with light refreshments beforehand. If you miss a session unexpectedly, a DVD and handouts fill the gap. Some GPs are keen to update on one theme only. They can, or they can attend selected evening sessions within a theme. Up-to-date information builds clinical confidence in women’s health, and participants learn of relevant services at KEMH and across WA.

Theme: Family Planning & Sexual Health • Multicultural issues & female genital mutilation • Contraception – hormonal & non-hormonal • STIs • Managing an unplanned pregnancy & terminations at KEMH • Eating disorders & weight loss • Vulval disease & vaginal discharge • Sexual partnership problems

GP Paulien de Boer. “As a graduate from out of state, the Diploma enabled me to gain an awareness of all the women’s health and information services in WA… and make some very useful contacts.”

Course Details

• Child & adolescent gynaecology • Sexual assault, domestic violence & child protection

Glen Forrest GP Liz Wysocki overcame the daunting exam with eventual ease. “The lectures are of a very high quality, good notes and plenty of interaction and the obstetrics module is particularly useful to those of us attempting shared care.”

rts Sta Feb 14 12 20

Tuesday evenings, 6.20-8.30pm. (Light refreshments 6pm). Agnes Walsh Lounge, KEMH. CPD points: 40 Category 1 per theme, 4 Category 2 per session (capped at 30 points) Cost: $685 (incl GST) per theme (10 sessions) or $80 per session. Exam fee additional. Contacts: kemhpostgrad@health.wa.gov.au

For those completing the Vocational Diploma, attendance at all three themes is required, with written and clinical assessments that include a Clinical Logbook of women’s health cases seen over six months.

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Guest Column

Prescribing is Not the Same as Caring Is the medical model of care best for our elderly? Dr Joe Kosterich has some doubts and suggests doctors can shift their focus. After many years in medicine, you have seen most things. Then one day something takes you by surprise. This was a person who was on 19, yes 19, different medications. Given some of these were taken more than once a day, this person was taking over 30 tablets per day. Most had been started by a variety of specialists who, as specialists do, look at one part of the body in isolation. Hence each additional tablet could be justified in some way. Taking two steps back, though, the overarching questions are, ‘What are all these tablets doing and are they all needed?’

conference. He asked the doctors to raise their hand if they wanted to end up in a nursing home. No hands went up. He then asked why we keep building them if nobody wants to go there. Good question. A mountain of research shows that the key to healthy aging is a sensible diet, regular exercise and good relationships. Having companionship and interests that make you want to get out of bed in the morning are far more important than taking tablets. One group that gets this is the Eden Alternative (www.edeninoznz.com.au). Scientific medicine is fixated on the quantity rather than quality of life. The older you get, the less valuable it is having a few months added on, just for the sake of it. This is especially if the trade-off is a lower quality of life.

A view is forming in some quarters that we confuse prescribing with care, particularly in the elderly. The solution to most things is to whack in another tablet. This next statement may come as a shock. There is no evidence that we are doing any good by doing this. Medications are trialled in isolation and in people generally under the age of 60. There are no trials that show, for example, that cholesterol lowering drugs given to a 70-yearold also on drugs for diabetes and high blood pressure, work! We assume it does because of trials in different population groups, but we do not know for sure. More importantly, we have no idea if it makes any difference to that person or just to a number on a piece of paper. Worse still is the potential for drugs to interact in unrecognised ways, and of course, the more tablets you take, the higher the chance of side effects. Unrecognised side effects can be seen as another problem needing another pill! A recent piece in the British Medical Journal touched on this. It describes one family’s efforts to reduce the amount of medication given to their 88-year-old relative. Johanna Trimble, who is quoted in the article, has now become a patient advocate in Canada promoting the notion that the best prescription can be to stop prescribing. Here in Australia, it was disappointing to see that only 16% of people think that families are best placed to care for elderly relatives and 53% think government care is best. I suspect this is because we do not actually understand what care is or what elderly people need and want. What elderly people want (indeed, what people at any age want) is love, support, and understanding from those around them. Studies show that strong social relationships have been correlated with a 50% reduction in mortality. Pleasant surroundings, and a reason to get up in the morning, matter too. Governments cannot provide this but families can.

Only 16% of people think that families are best placed to care for elderly relatives.

Dr Simon Turner MBBS, FRANZCOG, FRCOG

Dr Roger Perkins MBBS, BSc, DA (UK), MRCOG, FRANZCOG

Dr Lincoln Br ett BMedsC, BSc (Hon), MBBS, FRANZCOG

Dr Julia Barton MBBS, FRANZCOG

Dr Bill Patton MBBch, BAO, DCG, DRCOG, MRCOG, MRCPI, FACGO,

Life expectancy continues to increase and the world’s population is ageing. We need to move away from medical-based notions of “care” which involve prescriptions and “treatment” and towards people orientated care that focuses on quality of life for the mind, body, and spirit. n

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Clinical Product Review

Imaging Support Tool Dr Muntasser Islam reviews the iPad version of Diagnostic Imaging Pathways, designed in Perth for doctors in need of an update. In 2009, we favourably reviewed the web-based Diagnostic Imaging Pathways (www.imagingpathways.com.au), designed at Royal Perth Hospital. The background aim is to reduce inappropriate imaging through education because an estimated one third of requests by doctors are inappropriate in some way. Radiation hazard needs to be considered, particularly with the advent of newer imaging. DIP is a decision support tool. Does the recently released iPad version designed by UWA Centre for Software Practice live up to expectations? We asked Dr Muntasser Islam, a service registrar in radiation oncology, to take a look. A user since iPads were launched two years ago, he has a personal interest in IT and his prior knowledge of the web version DIP made him the right man for the job. Read on…

Pathways for iPad (Version 1.1)

Diagnostic Imaging Pathways is a breakthrough Australian app for iPad that does what it says on the box. The product is aimed at junior doctors/medical student or referrers practising in the outpatient setting. At its core, Diagnostic Imaging Pathways is a flowchart based decision making tool to help you choose the correct test at the lowest reasonably achievable radiation dosage. CONTENT hhhhh User confidence in the content is increased as all content is endorsed by the Royal Australian and New Zealand College of Radiologists (RANZCR) as well as the RACGP. Content has been streamed logically into systems i.e. Gastrointestinal, Respiratory, Breast Imaging and submenus make it easy to locate the over 140 commonly encountered clinical scenarios covered. Once clicked, scenarios i.e. “Suspected Pulmonary Embolism” take you through simple questions with comprehensive and easy to follow pathways adapted from clinical guidelines, the literature and consensus from specialists and GPs alike. The software is aware of controversial situations, and will let you know (e.g. use of CTPA in pregnancy) to be mindful of local practices. The intention of the creators is clear. The level of radiation exposure is detailed for every scan and in-depth articles on the effect of ionising radiation from diagnostic imaging are outlined. This is a tool designed to justify the appropriateness of a scan on a potential benefit vs. risk (i.e. cancer induction). DESIGN hhhii Unfortunately, excellent content is let down by subpar design that does not take advantage of the touchscreen format and interactivity expected on an iPad app.

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students, Sinead and Yuen (right).

By faithfully reproducing the website, the user experience is not only bland but links are tiny and difficult to press on. Hoverlinks clearly designed for a mouse and PC environment are lazily copied over and navigate users completely off the imaging pathway. In landscape mode, precious screen real estate is sadly not optimised with large flowcharts rarely fitting on screen due to persisting menus requiring some serious finger hockey to bring items into view. Additionally, there is no ability to flag topics of interest for later re-learning. A simple star icon would solve this issue. Cost hhhii Price: $25.99. Category: Medical. Current Version: 1.1. Size: 90.1 MB. Language: English. Seller: UWA

Overall hhhhi Expensive for the target audience, and with significant room to improve the user interface, Diagnostic Imaging Pathways still scores highly as a unique addition to the iTunes App store as the definitive Radiology clinical decision support tool for both junior doctors and referring clinicians.

Things to consider about your iPad

• If using it for decision support and your hospital has WiFi, maybe cruising the web is better for you, although without Flash, you cannot use popular web-based animation. • Cleaning and disinfection is not easy and the touch screen does not work while wearing surgical gloves, and it does not have a stylus. • Integration with IT infrastructure and network support is still being figured out.

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n Dr Islam is pictured with his iPad, flanked by two of his medical

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Guest Column

The Mind-Body Connection Council Chair of Australia’s Private Hospital Association Christine Gee addresses how exercise and diet can prove vital in treating the mentally ill. Everyone knows that a healthy body equals a healthy mind, but not so apparent is just how fundamental this link between physical and mental health can be in improving the outcomes for Australians suffering with psychiatric illness. Due to a lack of motivation that extends far past what the average person feels when they are having a bad day, mental health patients can experience severe metabolic side effects as a result of both their condition and their treatment medication. Recording higher rates of obesity and glucose intolerance, the situation has now reached a point where mental health patients are not only two and a half times more likely to die from a cardiac condition but their life expectancy is also about 20 years less than for those without a mental illness. While these findings are not new, they are confronting, particularly since they can be easily addressed by taking into consideration how mental illness affects physical health and vice versa – the two are intrinsically linked and need to be given the same level of care and attention. How can hospitals,

medical and nursing staff achieve this? How can we, while treating a patient’s mental illness, also work to better their physical outcomes? One method that is proving highly successful across a number of private mental healthcare hospitals is the adoption of a more holistic, healthy lifestyle and wellbeing approach that

Mental health patients are two and a half times more likely to die from a cardiac condition looks to treat the whole person – not just the mind. For example, by encouraging patients to take part in regular exercise programs or to adopt healthy eating alternatives, this lifestyle approach is aimed at getting patients to be healthier and giving them a reason to get out of bed and to begin coping with their illness. It encourages patients to be active, eat more

healthily, and engage more with one another, positively stimulating the brain to create a natural high that ultimately provides mental healthcare providers and patients with a more effective and efficient long-term treatment plan. It’s not difficult to implement and can be tailored to each facility’s needs. I have seen a diverse range of initiatives, from traffic light programs that educate patients on nutrition, to employment schemes that help patients to find work after they’ve left the hospital’s care. Having witnessed the results first hand, I can honestly say that this approach is the way of the future for mental healthcare and my goal, which I hope is mirrored by the mental healthcare community, is to encourage the adoption of such programs on a national scale. If this is achieved, then we will not only be providing mental health patients with the fundamental skills they need to sustain a mentally and physically healthier lifestyle after they leave our care, but I strongly believe we will reduce the number of poor physical outcomes that currently exist amongst our mental health patients. n

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funny side n n n The shredder

n Bethesda Hospital recently held a cocktail reception to launch the combined services of Coastal Orthopaedic and physiotherapy practice Body Logic. Pictured (L-R) are Mr Bryan Taylor (CEO Plan B), Prof Peter O’Sullivan (Body Logic) and Dr Mark Hurworth (Coastal Orthopaedic).

A young office worker was leaving the office at 5.45pm when he found the CEO standing in front of a shredder with a piece of paper in his hand. “Listen,” the CEO said, “this is a very sensitive and important document, and my secretary isn’t here. Can you make this thing work?” “Sure,” the young bloke said. He turned on the machine, inserted the paper, and pressed the start button. “Excellent!” said the CEO as the paper disappeared inside the machine. “I just need one copy.” Lesson: Never, ever assume your boss knows what he’s doing!

n AAPM WA convenors (L to R): Fiona Wong, Denise Martin, Natalie Watts, Sue Stark, Jane Reid, Dorothy Melkus, Shayne Murray, Kathy McGeorge, Narelle Supanz and Sharon Cooper. Medical Forum was pleased to present the second placegetter for Practice Manager of the Year with a gift of wine an chocolates.

Isn’t it time your UK Pension emigrated too? If you’ve moved permanently from the UK to Australia, isn’t it time your pension did the same? GESB is one of the few funds authorised to accept the transfer of pension benets from the UK, so you can consolidate all your funds into one account with one set of fees and one set of tax rules. To nd out how you can transfer your UK Pension, call GESB on 13 43 72. This information has been prepared without taking into account your personal investment objectives, nancial situation or needs. Before you act and rely on this information, you should read the relevant Product Information Booklet and consider seeking professional nancial and taxation advice. GESP0203B-188wx125h UK Pension.indd medicalforum

9/20/11 12:16 27 PM

Guest Column

Palliative Care: Remember the Carers Carers WA CEO Paul Coates suggests greater coordination between carers and medicos during palliative care and its aftermath. I repeat the same plea that I made when I last wrote for the Medical Forum. Of course you focus on the patient but remember their family or friends who look after them. They will provide the majority of care and support for your patient, and to do the best by your patient, you must ensure that those around them get the support they need. With palliative care and terminal illness, the needs of those caring at home can both magnify and multiply along with the complexity of healthcare, emotional, financial, and legal issues that arise in these circumstances. If the appropriate family supports are not provided, the care that your patient receives in the home is likely to suffer. Consistently, carers have reported a number of common experiences. They need more support and information from health professionals. They feel a sense of helplessness associated with illness progression and feel distraught at their inability to relieve pain and discomfort. They feel disempowered in key decisions such as admission of the patient to a palliative unit.

They report that these feelings of uncertainty and anxiety increase when they do not have access to familiar sources of help. They report that lack of support from health professionals accelerated their decision to seek inpatient admissions for their family member. There are many opportunities for the family physician to intervene. GPs can keep communication lines open and facilitate appropriate advanced care planning and decision making. GPs can demonstrate empathy for family emotions and relationships and encourage families to contact Carers WA for counselling and emotional support. Throughout the palliative process, there is much the GP can do. Firstly, you can provide information on support services available within the community to prepare families for their role, and educate the family or carer on the condition, treatment options and medication available to the patient. You can ensure that the various health care professionals available to provide services to the patient are in place and are

communicating with each other. Also, identify supports that are available to the family (specialised counselling, respite, social support, information etc.) and facilitate improved access to these supports. Explanation about the existence of Advance Health Directives and Enduring Power of Guardianship is also beneficial. As the cliché goes … it’s the ones who are left behind. After the patient has passed on, what impact has the palliative and terminal processes had on family and carers? In a South Australian health survey, some 28% of participants had cared for a person close to them who had died. Those that accessed palliative care support services reported that they were able to move on in their lives. However, the majority of those that did not access supports said that after five years they still could not move on. The emotional fallout can be immense for the family, as can the financial and physical health impacts. This fallout could manifest itself in increased traffic to your surgery, some of which could have been avoided with your timely support. n

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Guest Column

It’s Tough to Make a Difference Bunbury-based Bethanie Foundation Manager Laurette LeCras praises the hard, often unsung, work of rural GPs who visit aged care facilities. It is a sad truth that despite all the planning and resourcing, the residents of aged care facilities (as well as the community at large) continue to have difficulty accessing medical care through local general practitioners. Due to geographical constraints, many residents entering aged care facilities face the additional stress of not being able to continue with their historical GPs. This means ending a relationship and medical rapport of many years standing. The circumstances around this situation may be due to residents leaving a rural community, and thus, they are unable travel the distances to their former GP. Other circumstances may include the GP’s extremely heavy workload that does not allow doctors to leave their busy general practice to attend the resident at the facility. This situation is often exacerbated during ‘out of hours’ times, resulting in stressful transfers to hectic emergency departments, where the elderly may lie on a hard trolley for hours waiting to be reviewed. Despite the best efforts of the hospital staff, residents are forced to wait anxiously, often confused and frightened, wondering what the future might now hold for them. Regional GPs work under undue circumstances, with the added challenge of limited specialist services (such as a psychogeriatrician) to which they can refer patients. For the GPs who do visit aged care facilities, we cannot underestimate the significant contribution they make to many lives. Despite being over-worked, over-stretched, and under-paid, these modern day heroes provide medical care that many living in a large city take for granted.

Aged care residents appreciate and value the holistic care GPs provide

Though these GPs may not often be recognised, it is widely felt within the aged care community, the elderly and their families, that their contribution to improving the quality of life towards residents is invaluable. The residents appreciate and value the holistic care provided. In the words of American journalist Tom Brokaw: “It’s easy to make a buck; it’s a lot tougher to make a difference”. GPs who choose to take an active interest in caring for the elderly really do make a world of difference in the lives of the frail and aged. n

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Workers’ Comp matters By Michelle Reynolds Chief Executive Officer, WorkCover WA

Musculoskeletal Injuries Did you know that musculoskeletal injuries account for more than 50 per cent of all workers’ compensation claims in Western Australia and that costs on average per year are $386 million? The main causes of these injuries are manual handling, falls on the same level and lifting/carrying objects. More than half of the injuries affect the lower/upper back, shoulder and knee. They mainly occur in the health care and social assistance industries, followed by manufacturing and construction, in males aged between 25-34 and 35-44 years. Medical literature1 states that musculoskeletal injuries are 10 times more costly to workplaces than any other type of injury. However, the costs associated with a work-related injury are not only borne by the worker, but also the employer and the community. Direct costs include medical expenses (hospitalisation, doctors’ visits and rehabilitation), legal costs, and the cost of hiring a replacement worker. Indirect costs include lost output due to reduced productivity, reduced staff morale and the administration of workers’ compensation claims. Over the past four years, there has been a shifting trend towards people with musculoskeletal injuries taking longer to get back to work. The average workers’ compensation claim duration in 2005/06 was 73 days compared with 81 days in 2009/10. Not surprisingly, the average claim cost for musculoskeletal injuries is also increasing, up from $16,274 per claim in 2005 to $20,849 in 2009 (28% increase). And this does not include additional direct and indirect costs to companies of lost productivity or the personal costs to the injured worker. The reasons some workers do not return to work are varied, ranging from severity of injury through to emotional and economic factors. Whatever the reason, research shows workers who do not return work after this amount of time become increasingly unlikely to return to work at all.I believe there are opportunities to return many longer-duration claimants back to work faster through better collaboration and communication. Calling a case conference with your patient, their employer, the workplace rehabilitation provider and (where appropriate) the insurance claims manager is a good way to discuss work requirements and the worker’s capacity. It helps resolve issues quickly and provides the opportunity for everyone to progress a return to work program. You can call a case conference as soon as you deem your patient has some capacity for work. I’d like to remind you that you are entitled to charge separate fees for case conferences under the approved general practitioners rates, fees and payments schedule for workers’ compensation. For more information please visit our website www.workcover. wa.gov.au

Advisory Services call centre 8am – 5pm weekdays 1300 794 744 1 Arnetz BB, Sjoren B, Rydehn B, and Meisel R (2003). Early workplace interventions for employees with musculoskeletal related absenteeism. Journal of Occupational and Environmental Medicine. 45 (5) pp 499-506.

Guest Column

Protecting Doctors from Armed Violence With violence against doctors on the rise around the world, head of the Australian office of the International Committee of Red Cross Jeremy England calls for local action.

What is being done and what is needed? ICRC, together with its Red Cross and Red Crescent partners, has launched a global four-year project and communications campaign to address the issue of health care in danger. What is needed is greater action from governments – to implement stronger legal sanctions, promote preventive measures, and work with others globally to reinforce a common minimum standard.

n Libya: A doctor cries for four of his friends (a doctor, an ambulance driver, and two nurses) killed in an air strike.

Some 655 incidents where 1834 individuals, either giving or receiving medical care, were killed or injured. These are not WA statistics. They are the results of an International Committee of Red Cross (ICRC) study done across 16 war zones in the last 2.5 years – the first study of its type. Increasing insecurity for medical workers, facilities, or transport mean people are being denied health care exactly when they need it most. And medicos themselves are increasingly facing direct threats, attacks, harassment, or even prosecution – simply for doing their job and living up to their oath. The knock-on effects are disastrous. Not only are the immediate war wounded at risk of not being treated in time, but the whole range of preventive programs, chronic condition care, and basic services like maternal and child care risk becoming inaccessible to those who need them. In the 655 incidents above, fully half of them resulted in temporary or permanent closures to health services.

and resources across a range of sectors that it can bring to bear on problems like these. It’s declared national interest in a global rulesbased society, one where a middle power and an active civil society (such as Australia) can feel safe, but if ever there were issues where it might be worth Australia punching above its weight, this might be one of them.

indigenous, and emergency experience, coupled with the reliable technical standards Australian doctors offer, is well received across the world. Second, many of our communities have fled countries affected by this lack of protected health care. From Somalia to Afghanistan, from Sri Lanka to Gaza, the taboo against attacking health care providers has been regularly broken. According to the Iraqi Ministry of Health, 18,000 of their 34,000 doctors have themselves fled the country due to threats, direct attacks, kidnapping, and harassment between 2003 and 2006. Our communities now, as throughout our history, remain integrally linked to concerns and family members at home. Third, Australia has expertise, experience,

We need militaries globally to review their procedures and training (approximately a third of the attacks recorded were the responsibility of governmental armed forces – either by accident or intention). We need to intervene more regularly with irregular armed forces on this issue – holding them to the same accountabilities. We need to better train health workers, strengthen their facilities against blasts (some 50% of casualties were found to be related to explosions) and against intrusions, negotiating clearer safe or neutral spaces around them. We need better research, analysis, and monitoring of this trend to see what’s causing it and if our measures are working. And we need this issue better reported – we cannot consider it normal to be witnessing increasing attacks on health workers. We need informed coverage to build a community of concern and action. The ICRC does not have all the answers and we want every sector to consider its role. We don’t intend to leave health workers, and those seeking health care, alone to face this trend, but we are delighted the World Medical Association has agreed to become a strategic partner in this project. Here in Australia, the AMA has already declared its support. What will you do? n Ed. More information on the ICRC campaign is here: www.icrc.org/eng/what-we-do/ safeguarding-health-care/index.jsp.

Why would a West Australian care? Apart from a general concern for humankind, how does any of this matter to us here? Australians are increasingly related to these issues in three ways. First, we travel more than ever – 6.8 million international trips in the 12 months to June 2010 (according to the Australian Bureau of Statistics). We like to explore and adventure, but we also deploy in our official capacities and very often to unstable areas. We deploy as soldiers, diplomats, and business people, as journalists and aid workers, and as much sought after medics. The remote, rural,

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C L I N I C A L

By Dr Ashwini Davray, Palliative Care Consultant, Hollywood Private Hospital

“Life is pleasant. Death is peaceful. It’s the transition that’s troublesome.” Isaac Asimov. Palliative medicine endeavours to make the transition comfortable.

he advent of new chemotherapy, smart molecules and monoclonal antibodies, the VEGF inhibitors and TKI, has led to cancer patients living longer, and days and weeks have turned into many months. Palliative medicine is more about living these months in comfort and allowing the patient to prepare for death at their pace, without giving up hope! Now that palliative medicine is no longer linked to prognosis, seamless transition between oncology and palliative care is possible and need not occur too late. In fact, early involvement of palliative medicine in patients with advanced cancer has proven benefits. In one landmark study in 2010, early involvement of palliative medicine in metastatic non-small cell lung cancer resulted in improved quality of life, improved rates of depression and prolonged survival1.

Pain management is pivotal! The symptom burden in advanced cancer is high – pain, nausea, fatigue, breathlessness, insomnia, etc. Sadly, it has a ripple effect on the health of the caregiver too, who understandably gets stressed, and this leads to prolonged grief disorders and increased mortality. Pain and its impact are often underestimated. Recent systematic review found that pain prevalence is as high as 33% in cancer survivors, 59% in those undergoing active cancer treatment and 64% among patients with advanced cancer2. Pain not only reduces the quality of life but also leads to detrimental effects like depression3 (an independent predictor of survival), anxiety, delirium and functional decline. Case illustration Mrs PC, a 78-year-old lady with metastatic adenocarcinoma of the lung was admitted to a Palliative Care Unit after an attempted suicide on prescribed diazepam, saying she had considered “placing a plastic bag over her head and ending it all”. She had experienced a lot of grief during her life: two failed marriages; two of her children diagnosed with cancer, one died of cancer and the other committed suicide; and her last surviving child had mental illness. In spite of this, she had been a highly functioning person with many interests and a vibrant life, until the diagnosis of advanced cancer six months prior to admission. Suddenly, she felt she had nothing to look forward to and she questioned futility of living on. The suicide attempt was precipitated by a pain crisis – uncontrolled pain in the left lower chest wall, despite medicines, pushed

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her in a downward spiral. Depressed and fearful, she pondered “this is how it ends, in agony and despair”. On admission, that lasted 25 days, her analgesia was optimised, radiotherapy administered for pain control for metastases at T10, 12 and left 11th rib (revealed on CT) and constipation was treated. She was seen by a psychiatrist regarding her depression and anxiety and was linked in with a counselor, chaplain and social worker. She also received assistance with the financial issues worrying her. A family meeting resulted in a long discussion around her disease, prognosis, the likely progression of symptoms and the plan of action if she was confronted by a pain crisis again. Plans were made to discharge her with the support of family and community services.

The aim is to facilitate discussions regarding: • treatment options and patient preferences;

• goals of care as seen by the patient, their family and the treating team;

• discharge planning and enlisting community services to ensure a sustainable and safe discharge from the hospital; • advanced care planning; and most importantly • addressing fears that the patient and family have regarding the journey ahead and issues around dying.

Referral timing is important Deferring palliative medicine involvement until too near end-of-life can deprive the patient and families of support services and information that empowers them to live the remainder of their lives rather than exist in constant fear as to what the next day might bring. In Japan, a study of bereaved families’ perceptions about the appropriateness of timing of referral to palliative medicine found that half of the bereaved family members felt that the timing of referral was late (30%) or very late (19%)4.

On discharge, Mrs. PC was pain free, had a better understanding of pain and did not need suicide watch. She was thankful for her time in the unit.

Disease control and providing comfort can go hand in hand. Palliative medicine is not something to do ‘When there is nothing more that we can do’. Au contraire, early involvement in advanced cancer and shared care with the oncologist can benefit not only patients but also their families.

Two months later she was readmitted for terminal care and died peacefully.

1. Temel J, Greer J. “Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer.” NEJM 363, no. 8 (2010): 733-42.

Although the efforts of specialist palliative medicine seemed to offer Mrs PC improved quality of life in the last two months of her life, her story begs the question that had these efforts been applied earlier would her quality of life period been longer?

The art of communication Experience gained in palliative medicine not only brings expertise in symptom control, it also offers communication skills around topics that many clinicians find difficult, such as preparing for death and spirituality. Enlisting the support of family, carers and other health professionals is integral.

2. van den Beuken-van Everdingen MH, de Rijke JM. “Prevalence of Pain in patients with cancer: A systematic review of the past 40 years.” Annals of oncology 18 (2007): 1437-1449. 3. Satin JR, Linden W, Phillips MJ. “Depression as a predictor of disease progression and mortality in cancer patient: A meta analysis.” Cancer 115 (2009): 5349-5361. 4. Morita T, Akechi T, Ikenaga M. “Late referrals to specialised Palliative care Services in Japan.” Journal of Clinical Oncology 23, no. 12 (2005): 2637-2644.

This clinical update is supported by Hollywood Private Hospital. n

U P D A T E

Using palliative medicine effectively in advanced cancer

Aged Care Support Groups n Council on the Ageing (WA) Inc. Protects and promotes the well-being of older people in WA. Services include computing classes for seniors and strength training for over 50s. Also provides insurance for members. Location: West Perth Email: admin@cotawa.asn.au Web: www.cotawa.asn.au Tel: 9321 2133 Hours: 8.30am – 5pm n Dutch Aged Care (Western Australia) Inc. Provides culturally appropriate services for frail seniors from a Dutch/ German speaking background in the community who may be at risk of social isolation for linguistic or cultural reasons. They provide community aged care packages by bilingual support workers, a community visitor’s scheme, and a home visitor’s scheme by bilingual volunteers. Location: Wembley Email: dutchagedcare@iinet.net.au Web: http://dacwa.org Tel: 9382 4186 or 9382 1983 Hours: 9am – 3pm n Haldane House Provides day centre respite and in-home respite to younger people with disabilities and frail-aged seniors living in the lower north metropolitan area. Location: Mt Claremont Tel: 9408 1188 Email: ann-marie.enders@cocwa.asn.au Hours: 9am – 3.30pm (Mon – Sat)

■ Dr Jennifer Martinick.

First Female President

r Jennifer Martinick is a proven valued member of the hair loss international community.

Not only has Dr Martinick developed the Martinick Technique™; a process of methods and practices performed during each procedure to minimize trauma, she has also pioneered new techniques, including the ‘snail-track’ method to provide both natural and undetectable results in hair transplantation. As a result of her sustained contribution, Dr Jennifer Martinick has recently been elected as President of the International Society of Hair Restoration Surgery (ISHRS), with over 2000 members representing 43 countries. Dr Martinick is the first female president of the Society and her contribution has been mainly the artistic dimension essential to achieving natural and undetectable results. Whilst building on a long established and valued role of promoting education, research, ethics and camaraderie, Dr Martinick is committed to ensuring that the International Society of Hair Restoration Surgery (ISHRS) remains both prominent and relevant in our changing and challenging economic and social environment. In her new role, Dr Martinick intends to continue to promote the Society’s presence at large and encourage the practice of delivering the ‘Gold Standard’ in hair transplantation throughout the world. Dr Martinick’s first prominence on the world scene was the receipt of the ISHRS ‘Platinum Follicle’ award in New York (2003.) Since then, she has progressively made significant contribution to the scientific, technical and artistic knowhow in this area of cosmetic medicine. For further information regarding Dr Martinick’s new international role, visit her website www.martinick.com.

n Hills Community Support Group Inc. Offers a caring community service for frail older people, people with disabilities, carers, and youth who need support, assistance, advice and encouragement in their daily lives. Services include respite care, transport assistance, home maintenance, social support, craft classes, library services, and the “Get Away Club” leisure program. Location: Mundaring Email: hcsg@hcsg.com.au Web: www.hcsg.com.au Note: For residents of the Shire of Mundaring and adjacent areas only. n The Partners of Veterans’ Association of WA Inc. Provides support groups and practical assistance, promoting the issues faced by the partners and families of veterans, and discussing these with government. Members comprise present and former partners of veterans, seeking emotional and psychological support, and friendship of others in a similar situation. Location: East Perth Email: pvawainc@bigpond.com; pvawa@yahoo.com.au Tel: 9228 3350 Hours: Mon & Thur. n People Who Care Inc. Offers practical assistance to the frail-aged and people with disabilities, such as transport, gardening, nursing home visiting, shopping, etc. Location: Guildford Email: pwcinc@iinet.net.au Web: www.peoplewhocare.org.au Tel: 9379 1944 Hours: 9am – 4.30pm n Residential Care Support Network Provides information and support for consumers and family members of aged care services. Location: Coolbellup Web: www.users.bigpond.net.au/bluegum/agedcare Tel: 9331 3141 n Retirees WA Inc. Provides information to, and lobbies the government on behalf of, pensioners to develop better lifestyle options and provide a strong representative voice for all retirees living in Western Australia. Offers services for seniors, including podiatry, legal information, monthly meetings, and social activities across the metro and country areas. Location: East Victoria Park Email: info@retireeswa.com.au Web: www.retireeswa.com.au Tel: 1800 198 489 Hours: 9am – 4.30pm n Southern District Support Association Inc. Assists people living within the Perth south-east corridor to remain in their own homes for as long as they wish, to prevent inappropriate placement in hostels and nursing homes. Provides respite, domestic assistance, home maintenance, and social support, and assists with transport to medical appointments. Also has an adult daycentre for seniors, social groups for young adults with disabilities, and a men’s program for acquired brain injuries. Location: Armadale Email: info@sdsa.info Web: www.sdsa.info Tel: 9498 4800 Hours: 8.30am – 5pm

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Antibiotic resistance threatens clinical effectiveness

Population Health

Supported by the Western Australian Department of Health

Antibiotic resistance could render many doctors powerless to help. Imagine having to tell someone with a UTI, wound infection, abscess, otitis media or pelvic infection that there is little you can do to rid them of infection. Or if you are a surgeon performing transplants, hip replacements, open heart surgery or bowel surgery, telling your patients that if infection complicates things it could mean the end of them. “If we don’t act and it happens, then the consequences are dire. You only have to see some infections with resistant bacteria to know how poor the outcome can be,” said microbiologist Clin Prof Keryn Christiansen who would like to see more action taken to dispel her pessimism. “Major medical advances we have made will be lost and I don’t think our population is aware of how serious this is. A very large part of medical practice these days is based on the use of antibiotics. We fall back on antibiotics if patients get infected and we give prophylaxis,” she said. If we regress to the pre-antibiotic era, as some predict, and routine infections become untreatable, what does that do to the risk profile for common surgery, ICU, organ transplantation, neonatology and cancer services? Bacterial resistance is now common in many Australian hospitals towards some last-line antibiotics such as, fluoroquinolones, glycopeptides and third-generation cephalosporins. MRSA, vancomycin resistant enterococci (VRE) and multiresistant E coli are good examples. Various people ranked highly in this field say the problem is partly due to the indiscriminate use of antibiotics. That includes hospital and community doctors, as well as vets and farming where antibiotics can be used for prophylaxis and growth promotion.

How resistance establishes and spreads “Overuse of antibiotics then creates selective pressure for any resistance mechanisms,” Keryn explains, pointing to fluoroquinolones as a good example. “In Australia, we have never used the fluoroquinolones in animals [ciprofloxacin, moxifloxacin, norflox] while GPs have had to get authority from Canberra. Our resistance levels are very low compared to the USA or UK where these antibiotics have lost their usefulness.” Overuse of antibiotics encourages the natural selection of resistant strains. This is because most antibiotics are manufactured by bacteria looking to eliminate competitors and they develop resistance mechanisms to keep themselves out of the firing line. Add in the fact that resistant bacteria can live commensally across different animal or human populations, and these populations move freely around the planet, then you have a threatening situation from which there is largely no return. Most resistances establish relatively quickly by active transfer of mobile genetic elements. Keryn explains. “It can be on a plasmid, completely separate from the chromosome, that carries multiple resistance genes. It can also be on a transposon or integron, two pieces of genetic information inserted into

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the chromosome that can be excised and transferred like a plasmid, by conjugation. That is, the two bacteria grow a connecting tube through which the genetic information passes and then replicates. Plasmids that control multiresistance can be transferred across genera, that is, completely different types of bacteria, or from different species of the same bugs.” Once you start an antibiotic, it facilitates the transfer of resistance information, selecting out the more resistant strains. Resistant organisms can then be transported fairly easily as people who harbour them move around.

More real-life examples “The bugs with multi-resistance coming out of India are ordinary bowel flora such as E. coli and Klebsiella species but they have plasmids that carry resistance basically to every antibiotic we have. The bugs are virtually untreatable. You may have heard of NDM1, named by its enzyme, which has been found in the New Delhi drinking water and many of India’s hospitals. If you have an E. coli UTI, pelvic abscess, wound infection or suchlike with a NDM, you cannot treat it.” “One of these bugs got into a hospital in Rotterdam. Holland has very high standards of infection control – 98 people were infected and there were 27 deaths, so we have to be very careful and aware.” She said vancomycin resistant enterococci (VRE) is a big problem in eastern states hospitals and it is starting to emerge in WA. And unlike MRSA on the skin, there is no hope of treating the bowel of patients to get clearance.

n Conjugation tube between two bacteria. Methicillin resistant Staph aureus (MRSA) has been largely controlled in WA hospitals through a program of hospital surveillance, rapid lab genotyping (virulence testing), and outbreak isolation. As a result, MRSA is not endemic in WA hospitals, unlike other parts of Australia. Importantly, decolonisation treatment will work for MRSA – first topical treatment has 70% success, increasing to 90% if repeated, and to about 95% if oral antibiotics are given. Such treatment is essential to controlling communityacquired MRSA, where GPs are at the frontline. “They should look for skin and soft tissue infections with a lot of pus or abscess formation. Some of the community MRSA carry a toxin Panton-Valentine leukocidin that actually kills white cells, leading to big abscess collections. GPs will see more patients with recurrent boils. Treatment is with drainage and antibiotics only if it is spreading and only after susceptibilities, because flucloxacillin and cephalexin won’t work.” “In the USA they have an MRSA USA300 in the community, a toxin producing bacteria that can cause a severe necrotising pneumonia and death. We have had one case in a young man in WA and our surveillance picked it up and the Health Department are doing a search and destroy, to decolonise people.” Keryn and others are pushing for improved surveillance to detect the entry of multiresistant bacteria into Australia. “All these interventions will increase the lifespan of our antibiotics. It’s not going to stop resistance,” she said.

Take Home Points

• Emerging antibiotic resistance could render common treatments useless, increase complications, and overstretch limited health resources. • With few antibiotics in the pipeline, doctors need to intervene to increase the shelf-life of current antibiotics. • This means less antibiotic use across the community, with education and stewardship programs, along with performance audits, for those training in hospitals and working in the community. • GP vigilance will help control community acquired MRSA by culturing for sensitivities, deploying effective decolonisation, and pre-warning hospitals. • Controlling infection spread with well-directed nursing procedures, hand hygiene, cleaning and disinfection and care with invasive procedures all help, as do identifying those patients most at risk. • Improved surveillance for multi-resistant bacteria entering Australia will help define the best screening methods and the size of the problem. 39

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U P D A T E

By Dr Brendan McQuillan, Cardiologist, Western Cardiology. Tel 9346 9300

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

Medical Director Dr John Yovich

Coronary calcium scores and CT coronary angiography Risk prediction with coronary artery calcium scores (CACS)

By Drs John Yovich and Philip Rowlands

Outside the Box – Appendix

In recent months we have had the surprise finding of appendix pathology masquerading as gynaecological “pelvic” pain. The first was a patient aged 47 years who presented with RIF pain in Queensland whilst on holidays, considered to be a possible ruptured corpus luteal cyst. The pain grumbled on for several weeks and on return to Perth her GP arranged pelvic scan which showed a right tuboovarian mass. At PIVET this led to an arrangement for laparoscopic hysterectomy with BSO. At the procedure, unravelling the inflammatory complex of the right adnexae revealed an appendix abscess, carefully dissected out and removed laparoscopically at the same time (fig 1) with an excellent post-op outcome.

Figure 1 Appendix unravelled from right tubo-ovarian mass

Figure 2 Endo-knot excision of nodular appendix removed in Endo-bag

The second was a case I managed in Cairns on my recent quarterly stint. This was a 37 year old woman with infertility, failed IVF procedures and background colicky pelvic pain with previous laparoscopy in Melbourne for severe pelvic endometriosis. On my review hysteroscopy & laparoscopy, there was minimal residual endometriosis but an oddlooking thick and hard nodular appendix. Although not consented for such, the appendix was removed (fig 2) and subsequent histology showed a mucinous epithelial neoplasm. In discussion with the Pathologist, such tumours are graded potentially malignant and may be the main underlying cause for that enigmatic condition known as pseudomyxoma peritonei. The patient is very well now and will proceed with fertility management but an MRI follow-up is planned.

NOW AT 2 LOCATIONS LEEDERVILLE & BUNBURY

For ALL appts/queries: T:9422 5400 F: 9382 4576 E: info@pivet.com.au W: www.pivet.com.au

Our ability to predict those at high risk prior to their first clinical coronary artery disease (CAD) event is limited. CACS has become established as a strong predictor of cardiovascular (CV) events in asymptomatic subjects. While a low CACS (zero score) indicates truly low risk, high scores (typically above 100) indicate a relative risk of greater than four when compared with no calcium. When considered in age and gender-specific percentiles, CACS gives a near linear prediction of CV risk. CACS has great clinical value in refinement of risk among asymptomatic subjects that would be considered at intermediate risk by conventional risk scores (e.g. the Framingham, Cardiac Society of Australia and New Zealand or EuroScores). Approximately half of subjects considered at intermediate risk may be more accurately reclassified. Among these subjects CACS can usefully identify those at true low risk in whom ongoing lifestyle advice rather than additional pharmacological therapies may be appropriate. About 20% of subjects may be reclassified from intermediate to high risk by CACS and should be carefully assessed and managed for all modifiable CV risk factors. It may also be appropriate to perform exercise or pharmacological stress testing in some asymptomatic individuals with very high CACS to further assess the functional significance of the atherosclerotic coronary plaques that are likely to be present. Disappointingly, there remains limited long-term clinical trial data using CACS-guided therapy but it does appear to improve treatment compliance. CACS results appear valid for at least four years, with very few subjects changing their score from zero to a low score or a low to high score within this time frame in longitudinal studies. The CACS may also improve risk prediction among patients undergoing myocardial perfusion scans (MPS). With no contrast injection and very low overall radiation exposure, a CACS obtained at the time of a MPS can increase the sensitivity for the detection of clinically important coronary artery disease as well as improving the negative predictive (rule-out) value of a normal or negative scan.

Evaluation of chest pain with computed tomography coronary angiography (CTCA) CTCA is the most accurate and reproducible tool for noninvasive coronary angiography. While patients with irregular heart rhythms remain a challenge, recent technical advances and development of scanning protocols have enabled CTCA to be performed with low radiation exposure in the majority of subjects. Diagnostic accuracy is probably higher than early studies suggest, comparing older CT technology to invasive coronary angiography. In fact, evaluations using the current gold-standard of invasive coronary intravascular ultrasound indicate that 64-slice CTCA may exceed the ability of invasive coronary angiography to detect non-obstructive plaques within the vessel wall. CTCA has been well established in the assessment of patients with chest pain presenting to the ED. CTCA carries a very high NPV – close to 100% – and can effectively rule out CAD in symptomatic subjects with a low to intermediate pre-test likelihood. Conversely, those subjects found to have coronary atherosclerosis with greater than 50% stenosis of a major vessel by CTCA are at increased risk of adverse CV outcomes with up to a third suffering an event within two years. For stable patients with positive stress test results but a pre-test likelihood still less than 50%, stress echocardiography is still a valuable test. CTCA however, is becoming an important alternative to invasive coronary angiography when more definite exclusion of CAD is required especially for patients at higher risk from an invasive approach because of limited vascular access, extensive aortic atherosclerosis or prior ischaemic stroke. High-risk patients presenting with typical angina-like pain remain best suited to an invasive angiography strategy that permits early percutaneous coronary intervention. n

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Itch and scratch: allergic eye disease

Eye Surgery Foundation

llergic eye disease (AED) can sometimes be frustrating and difficult to treat. This refresher on disease classification and management, often listed in complicated subtypes, is simplified here into three main groups. There is usually a family or patient history of atopy. The cardinal symptom of all subtypes of AED is itching.

Seasonal and perennial allergy Seasonal allergy at specific times of the year usually links to a particular seasonal allergen such as grass pollens or mould spores. Perennial allergy is often due to partly avoidable allergens such as house dust mite or indoor pets. Seasonal allergy tends to be more severe than perennial allergy. The eyes tend to be red with swollen conjunctiva (chemosis).

Vernal keratoconjunctivitis

years and usually resolves after puberty. Around 75% of patients have a history of eczema or asthma. The hallmarks of the disease are lesions at the limbus (Trantas dots – see Figure 1), giant subtarsal papillae and corneal ulcers (shield ulcers). The eyelids very Perth’s only rarely become involved in VKC.

freestanding Ophthalmic Day Atopic keratoconjunctivis typically affects young adult males and may presentHospital up until Atopic keratoconjunctivitis

the 5th decade. It very rarely presents before• puberty. The disease tends to be perennial in nature. Due to chronic rubbingSupporting of the eyes, ophthalmic these patients are more susceptible to develop keratoconus, cataract and retinal detachment. research and They are also more prone to develop blepharitis development and Herpes simplex keratitis. The disease can have severe direct complications including • corneal neovascularisation and scarring Certified to ofISO Expert day surgery for the conjunctiva (sympblepharon –Standard see Figure 9001 • Cataract Extraction and Lens Implant • Pterygium • Glaucoma 2). This disease needs to be treated early and • Oculoplastic Surgery • Strabismus • Corneal aggressively Transplant to prevent these complications.

Vernal keratoconjunctivitis (VKC) tends to occur in predominately male children below the age of 10. It tends to be seasonal (but can be perennial), chronic, recurring and bilateral in nature. The disease tends to last 2 to 10

• All types of Refractive Surgery – LASIK, LASEK, PRK, CTK, Phakic Treatment options Lens and Refractive Lens Exchange (RLE)

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For AED these range from conservative management to immunosuppression. The with cold compresses and Matthew Whitfield Ph: 9216 7900former Email:starts info@eyesurgeryfoundation.com.au 42 OrdFigure Street2 West Perth WA 6005 FigureContact: 1 simple lubricants, but most patients will

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Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156 Dr Jane Khan Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600 Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Andrew Stewart Tel: 9381 5955 Dr Michael Wertheim Tel: 9312 6033

Contact: Matthew Whitfield Ph: 9216 7900 Email: info@eyesurgeryfoundation.com.au 42 Ord Street West Perth WA 6005 medicalforum

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n the last 10 years, major changes in the assessment and management of cognitive disorders has come from our improved understanding of Alzheimer’s disease (AD). Earlier diagnosis is now possible, which means the efficacy of interventions applied earlier (e.g. before the onset of dementia) can be better assessed. It is unlikely that a new treatment, beyond cholinesterase inhibitors (CIs), will be available within the next few years. As clinicians we should hone our diagnostic skills in an endeavour to diagnose AD earlier and give all patients a trial of a CI. Other early intervention, such as emphasising the importance of enduring powers of attorney and guardianship, are also relevant.

Pathogenesis better understood Laboratory and observational research has provided a vast knowledge base that has facilitated early diagnosis and provided insights into molecular pathogenesis. We now know more about the genetic basis of early onset AD, the role of oxidative stress, transition metal ions, insulin degrading enzyme and receptor malfunction (to name a few). Observational data has informed us of possible protective factors such exercise and diet. In addition, the considerable vascular pathology seen in AD has prompted some to describe AD as ‘brain endothelial disease’.

Early diagnosis is reshaping our approach We no longer require someone to be demented before a diagnosis of AD is made. The presence of a deficit in episodic memory (recall of a personal experience) plus the demonstration of an AD biomarker is all that is needed for diagnosis now. And those at risk of AD can be identified with biomarker tests (CSF, MRI and PET). We know that 30% of cognitively normal subjects over age 70 have sub-clinical AD as identified by CSF proteins (characteristic changes in amyloid β, tau, and phospho-tau concentrations) and amyloid PET (retention of specific amyloid labelling radioligands). In addition, sophisticated psychometric tests can identify those likely to develop cognitive decline. The ability to diagnose AD before dementia is present has meant that AD clinical drug trials are now targeting those with so called ‘prodromal AD’. We know that once a person has developed dementia syndrome, the

pathological process is advanced. This may be one reason that CIs or experimental drug trials show little or no effect. Atypical behavioural manifestations of AD have also become clearer. These include primary progressive non-fluent aphasia, logopenic aphasia, frontal variant of AD, and posterior cortical atrophy for which the diagnosis of AD is supported by in-vivo evidence of amyloidosis in the brain or in the CSF.

Pharmacological treatments In 2001, the PBS funding of cholinesterase inhibitors medicalised the treatment of AD. Until then, AD was diagnosed by excluding other relevant medical conditions, ordering a brain scan, and applying the DSM IV or NINCDS criteria. The patient was then provided some counselling and access to support services. The arrival of CIs compelled us as clinicians to consider the accuracy of our diagnoses and to use more sophisticated cognitive tests. AD had now become a disease that could be treated as another single organ disease.

By Clin Assoc Prof Roger Clarnette, Dept of Community and Geriatric Medicine, Fremantle Hospital and Health Service

specialist is to ‘confirm’ the diagnosis of AD. Currently, GPs write about 25% of initial CI scripts, geriatricians 33%, neurologists 11%, psychiatrists/ psychogeriatricians 13% and general physicians 8%.

Prescribing tips for CIs PBS funded CIs are available for any person with AD with a MMSE of 10/30 or above; a two point improvement is needed within the first six months of treatment for eligibility to continue. For those with a MMSE of >24 the ADAS Cog can be used as the baseline cognitive test (which takes about 20 minutes); a four point improvement is needed for eligibility. For those who fail to improve on the first CI, a second drug can be prescribed. It is recommended that a new baseline score is used for the second drug. It is possible for a patient to fail to improve on three CIs but still have access to 18 months of a treatment on the PBS.

Stabilisation of brain function is the aim of treatment. Significant improvements in memory are unusual. The stabilising effect is temporary but treated patients generally do better long term than those not treated.

The CIs should be continued long term and not stopped if a patient enters residential care, as cognitive function is likely to decline with such a change in environment and cessation of the CI may dramatically worsen this.

Despite the availability of CIs, less than 50% of AD subjects are treated in Australia and the rise in the ageing population has only been matched by a 0.2% rise in the volume of CIs used in the last two years. Factors thought responsible for the low uptake of CIs include:

CIs also have an ameliorating effect on dysfunctional behaviour in AD.

• The PBS authority script system is a barrier to prescribing. • A false belief is that only specialists can prescribe CIs. In fact, the only role of the

Looking ahead Standard treatment for AD is only modestly effective. Hence, hundreds of experimental drugs have been tested over the past 20 years to try and find a so called ‘disease modifying’ treatment but to date, this endeavour has not been successful. A big focus recently has been on passive immunisation using monoclonal antibodies (Mabs) directed at amyloid peptides. These drugs have a clear biological effect as PET shows clearance of amyloid load after treatment. However, clinical benefits have not been shown so far (with a number of trials yet to report findings). One possible explanation is that, in dementia trials, treatment is started too late in the natural history of the disease. Therefore, recruitment of those with prodromal AD is now a focus in the hope that using Mabs earlier will result in clinical benefit. Other anti-amyloid strategies include secretase inhibitors that reduce production of the amyloid peptides from the precursor protein. n

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Towards better management of Alzheimer’s disease

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Managing opioid-related side effects in treatment of cancer-related pain By Dr Derek Eng, Palliative Care Physician

sing opioids to manage severe pain related to cancer is an essential step in symptom control. According to the World Health Organisation Cancer Pain ‘Ladder’, opioids are prescribed when simple analgesics are inadequate. However, opioids commonly cause adverse side effects, all too familiar to many of our patients.

for reasons described below, many of us are choosing the synthetic or semisynthetic opioids ahead of the traditional favourite. The important principle that doctors should only prescribed drugs they are familiar with, is relevant here.

Most of us are familiar with the common opioid side-effects: sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance and respiratory depression. Less commonly, there is gastroparesis, hyperalgesia, immune and hormone dysfunction, muscle rigidity and myoclonus.

When commencing an opioid for cancer pain, start with a low dose of ‘immediate release’ formulation, such as morphine elixir or oxycodone 2.5 to 5 mg. Instruct your patient to take a dose on demand, but not more frequently than every one hour (to allow time for gastrointestinal absorption) – that is, oral titration to allow patients to safely take enough opioid to achieve adequate analgesia.

Management of opioid-induced constipation is essential in the treatment of cancer pain with opioids. One of the most paraphrased quotes Figure 1: HDWA Opioid Conversion chart

in medicine is, “The hand that prescribes the opioid, also prescribes the laxative”. As a rule of thumb, a combination of stool softener and bowel stimulant (e.g. ColoxylTM with Senna) is an ideal first choice. Avoid advising patients to increase dietary fibre intake (e.g. psyllium husks) as this can exacerbate constipation by increasing stool bulk. Nausea occurs in approximately one third of patients who commence on oral opioids, which is probably dosage or bioavailability dependent. Simple antiemetics such as metoclopramide should be prescribed and instructions provided to use only should nausea occur. In most cases, nausea is self-limiting to about one week. The alternative to managing opioid related sideeffects is to choose a different opioid.

Opioid choice We are spoilt with choice in Australia – PBS opioids are listed in Table 1. Morphine continues to be a popular choice in treatment of cancer pain because most of us are familiar with its use and available formulations/preparations. However,

A slow-release formulation can then be calculated based on the previous 24 or 48 hour total opioid consumption. This becomes their ‘background’ analgesia, to provide around-theclock analgesia. Occasionally, episodes of severe ‘breakthrough’ pain require a ‘breakthrough’ dose of opioid; a dose usually calculated to be 1/12th to 1/6th of the daily dose of opioid. To simplify dosage titration (and reduce prescriber confusion), I recommend using the same opioid for breakthrough and background analgesia (e.g. if using OxyContinTM, add breakthrough doses of OxyNormTM or EndoneTM). Sometimes this is not possible, especially if you use fentanyl transdermal patches as background

TABLE 1 Opioids on PBS

Trade Name

Formulation

Advantages

Disadvantage

Comments

Codeine

Panadeine Codalgin Mersyndol etc

Tablets/Caplets

Commonly available

Very constipating. Combination with paracetamol. Cyt P450 2D6 slow metabolisers will have poor analgesia (10% Caucasians)

Excessively constipating makes it less ideal. No slow release preparation

Morphine

Ordine

Immediate release liquid Slow release (12 hour duration of action)

Familiar to many prescribers. Range of dose strengths. Stocked in many pharmacies.

Patients fear morphine. Side effects more likely in elderly and renal impaired.

Avoid in renal dysfunction

MS Contin Endone

Immediate release tablets, Familiar to many prescribers. capsules or liquid Range of dose strengths. Safer in renal dysfunction than Slow release (8-12 hour morphine duration of action)

Cyt P450 3A4 & 2D6 metabolic pathways. May have idio-syncratic analgesic effects in slow or rapid metabolizers.Drug interactions.

Generally good first choice for most patients starting an opioid.

Actiq

Immediate release Lozenges

Rapid onset (5-10min). Short duration of action (1 hour).

Patients need good cognition and dexterity to use. Specific instructions for use.

Good for predictable and acute pain eg. Dressings changes or incident bone pain

Durogesic Denpax

Transdermal Patch to be changed every 3 days

Convenient. Good treatment adherence. Ideal in renal failure.

Adhesion problems. May not last a full 72 hours in some patients.

Dose titration is slower and not appropriate for unstable or escalating pain

Dilaudid

Immediate release tablets or liquid or injections

Oxycodone

OxyNorm OxyContin

Fentanyl

Hydromorphone

Jurnista

Good alternative to morphine or Unfamiliarity. 5 times more potent than morphine. oxycodone. Slow release (24 hr action) Anecdotally fewer cognitive Unfamiliarity – latest slow release Metabolite is less toxic than side effects than morphine. morphine’s opioid to hit the market Safer in renal dysfunction than morphine

Buprenorphine

Norspan

Weekly transdermal patch

Patient adherence

Relatively low dose strengths limits its use in severe pain

10mcg/hr patch equivalent to about 20mg Morphine per day OR 200mg codeine per day

Methadone

Physeptone

Tablets/liquid

Refractory pain. Hyperalgesia

Variable and long half life – potential for delayed onset narcosis

Restricted use - only Palliative Care or Pain Specialists

Injections

Nil

Seizures. Short duration of action. Abuse.

Unsuitable for chronic or cancer pain

Pethidine

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Childhood atopic dermatitis and skin infections Dr Graham Thom, Dermatologist, Southbank Dermatology, Suite 14a, 38 Meadowvale Ave, South Perth. Tel 6162 1864

he relationship between microbial pathogens and atopic dermatitis can be complex, where the impaired skin barrier encourages colonisation and infection by pathogens, and pathogens themselves may exacerbate or modify the inflammation of atopic dermatitis (AD).

Staphylococcus aureus Staph aureus on the skin is extremely common in AD, usually as colonisation rather than infection. True secondary infection of pre-existing eczema will tend to manifest as weeping and yellowish crusting, or follicular pustules / furuncles, together with an exacerbation of the AD. On the other hand, eczema itself may appear moist, weepy and crusted, in the absence of infection (e.g. cheeks of infants; older children with thickened discoid eczema) and may be mistaken for impetigo, with a resultant tendency to over-treat infection with repeated courses of oral antibiotics and undertreat inflammation.

Figure 1

Figure 2

n In both these cases (severe eczema on the

cheeks of an infant, and discoid eczema on the limbs), secondary infection is likely to be present, but it is essential that the underlying eczema is treated with a topical corticosteroid of appropriate potency.

Bacteriological swabs of apparently infected eczema and anterior nares should be taken for two main reasons; to demonstrate Staph aureus infection and/or colonisation and to pick up any cases of community acquired MRSA (which require more stringent decolonisation procedures). For suspected Staph aureus infection (nonMRSA) a 7-10 day course of oral antibiotics (e.g. flucloxacillin/dicloxacillin; cephalexin) may be indicated. Topical steroids should generally not be withheld when treating infected AD, as treatment of the underlying inflammation is essential to facilitate healing of the skin. This can be a source of confusion for parents, who have often been instructed not 46

to apply topical steroids to broken skin. In the presence of folliculitis/furunculosis, occlusive ointment-based emollients are best avoided. Topical antibiotics (e.g. mupirocin) have a limited role for short-term use on localised areas of infected eczema, but indiscriminate use is to be avoided to prevent bacterial resistance developing, given that mupirocin use is important in MRSA decolonisation. Children whose AD has been persistently severe, or repeatedly complicated by secondary infection, often benefit from attempts at reducing the bacterial load (or decolonisation, if MRSA). Even in the absence of overt infection, high bacterial loads of Staph aureus may exacerbate AD through mechanisms including the production of toxins, which act as superantigens, causing widespread activation of T-cells. Positive nasal swabs are followed by mupirocin 2% nasal ointment bd for 7 days. Ideally this should be combined with an antiseptic skin wash (e.g. 2% chlorhexidine or 1% triclosan) for 7 days, but in practice these preparations are often rather drying and irritating to the skin. Similarly, some of the proprietary bath oils with added antiseptic agents can be irritating, particularly in infants. ‘Bleach baths’ are a cheap and simple adjunct – ¼ cup of household bleach is added to a normal bath (to give a final concentration of 0.005% sodium hypochlorite), together with a bland emollient bath oil (e.g. QV TM oil, Alpha KeriTM oil). The child is bathed for 10 minutes 1-2 times per week, before rinsing off in the shower. An additional strategy in recurrently infected AD, where culture sensitivities are confirmed, is a 3-4 week course of an oral antibiotic (e.g. cephalexin). If MRSA is isolated, then further advice from a clinical microbiologist or infectious diseases physician may be helpful.

Figure 3

n Eczematised molluscum contagiosum in the popliteal fossae.

Herpes simplex Herpes simplex virus superinfection (eczema herpeticum) is always borne in mind in cases of acute severe exacerbations of eczema. The herpes simplex virus spreads rapidly on broken skin; multiple scattered small vesicles appear, which rapidly develop into erosions and crusts, with a miliary ‘shotgun-like’ appearance. These cases often require hospital management. For facial involvement, seek an ophthalmologic evaluation for corneal ulceration. After swabs for viral PCR, an oral antiviral (e.g. acyclovir) is given (although not PBS listed for this purpose), and topical corticosteroids withheld while there are active vesicles or moist ulcers (usually a few days). A topical astringent such as very dilute Condy’s crystals (potassium permanganate) can be helpful to dry up moist, exudative areas. Some cases can be recurrent. Figure 4

Occasionally, a localised or regional eczematous reaction may complicate a primary skin infection (such as impetigo or folliculitis) in individuals without a prior history of AD. This may be termed an ‘infective dermatitis’ and generally requires a combination of antibiotic and topical corticosteroid treatment.

n Eczema herpeticum on the face of an infant.

Molluscum contagiosum

Dermatophyte fungi

The lesions of molluscum contagiosum often become irritated and eczematised. This can be quite pronounced in children with preexisting AD, but can also be seen in patients without a prior history of AD. New cases of localised ‘eczema’ should always be examined for molluscum, treatment of which presents its own challenges but first priority is usually treatment of the secondary eczematous reaction.

Dermatophyte infections are uncommon in atopic dermatitis. Tinea corporis can mimic discoid eczema, so fungal scrapings are helpful if there is clinical uncertainty. Dermatophyte infections can cause a secondary generalised hypersensitivity reaction (‘id reaction’), which usually presents as pompholyx or papular eczema rather than classical atopic dermatitis. n

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rimary Liver Cancer in adults used to be considered a rare tumor with very limited treatment options in sick cirrhotic patients. This article focuses primarily on Hepatocellular Carcinoma (HCC), now the fifth most common malignancy in the world and the third major carcinoma killer. One million new cases are diagnosed annually worldwide and the occurrence of HCC is rising in the Western world, with viral hepatitis (HBV and HCV) and alcoholic liver disease accounting for most cases (1-6% annual incidence amongst liver cirrhosis patients). However, with the increasing incidence of non-alcoholic steatohepatitis (NASH) secondary to the obesity/ diabetes epidemic, there may be a second wave of HCC in the future. with six-monthly ultrasounds. The American Association for Liver Disease has recently updated its guidelines for the management of HCC (www.aasld.org).

There can be a very fine line between palliation (TACE/ sorafenib) and curative treatment options (transplantation/ surgery/ RFA) depending on the size and number of tumours n 3.5 cm HCC successfully treated by T.A.C.E. and liver transplantation. and underlying Picture courtesy ClinAssoc Prof Bastiaan de Boer liver synthetic function. HCC treatment is best conducted Diagnosis and treatment by a multidisciplinary team of surgeons, This is relatively straightforward using modern radiologists, pathologists and hepatologists. imaging (although MRI liver with gadolinium The West Australian Pathologists Liver is NOT rebatable under Medicare). Transplant Service based at Sir Charles Treatment options vary depending on the Gairdner Hospital services Western Australia tumour stage at diagnosis. Early asymptomatic and is referred between 1 and 2 new patients patients have curable treatment options (80% per week with HCC. 5 year survival) such as liver transplantation, Prevention of HCC desirable surgery or radio frequency ablation (RFA). Late symptomatic patients are not curable and ‘Prevention is better than cure’ and nothing the only treatment options are transarterial could be closer to this truth than HCC, which chemoembolisation (TACE) or sorafenib. is a preventable disease. The best chance of picking up a HCC early in patients is by screening cirrhotic patients

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If abnormal LFTs yield a positive screen for viral hepatitis (HBV/ HCV) or alcohol use,

By Clin Assoc Prof Gerry MacQuillan, Deputy Medical Director, West Australian Liver Transplant Service, SCGH

this should trigger at minimum a one-off liver ultrasound. Identifying patients with viral hepatitis during routine health checks will, in time, reduce the incidence of HCC. Screening patients for HBV and HCV is recommended in non-Caucasian overseas born individuals, indigenous patients and intravenous drug users. HBV is a silent community based disease in patients who often don’t seek medical help. We can hope that in time, with HBV vaccination and new Direct Acting Antivirals (DAAs) for HCV, the incidence of HCC will eventually fall worldwide; but it may take several decades. Tackling liver disease may not appear “sexy” to many but it can be very rewarding at times – there are very few diseases in which organ transplantation can cure a potentially fatal malignancy. For more information on liver disease your patients can visit www.liverfoundation.org.au. n References available on request.

Take Home Points

• Primary liver cancer is becoming more common. • Treatment of early stage disease offers a possible cure. • Screening cirrhotic patients with six monthly USS is standard of care. • Testing “at risk” patients for viral hepatitis is important.

U P D A T E

Primary Liver Cancer

WA Medical Art Society By Peter McLelland

r i A n i e l P

n L-R: Robert Wade,

Dr Tony Taylor, Lorraine Lewitzka and Terry Lewitzka.

in South West WA

Enthusiast Dr Tony Taylor and a group of doctors with artistic palettes enjoyed a session of plein air painting in the beautiful outdoors. A recent ‘Artists in Residence’ gathering in the Augusta/Margaret River region was both enlightening and enjoyable for members of the WA Medical Art Society (WAMAS). Three eminent artists shared their knowledge and expertise with WAMAS medicos and members of the Watercolour Society of WA and the Augusta Art Group.

galleries around the country and have a long list of awards.

mixing tonal greys to the artworks of Matisse and Picasso.”

Tony, the Director of Surgery at Armadale Hospital, was instrumental in the formation of the WA Medical Art Society. “I took a break from surgical practice in 1996 and went to London and enrolled in the Slade School of Art,” Tony said.

“It was wonderful to see Robert Wade – regarded as one of the world’s leading watercolourists – and Terry and Lorraine Lewitzka painting in the South West,” said Tony Taylor.

It was on his return to Perth that Tony decided to set up the WA Medical Art Society. “We meet on the 4th Wednesday of every month at my studio in Fremantle. There’s some very nice wine and cheese plus some stimulating conversation on everything from

The next big project for the WA Medical Art Society is an exhibition at the St. John of God Hospital, Subiaco. “It’s quite early in the planning stage,” said Tony, “and cardiologist Marcel Goodman is helping me with this one. There’ll be a distinctly medical theme – images from within a hospital environment including paintings of surgeons in theatre.”

Robert Wade has exhibited with major art societies around the world, and in 1986, was awarded the Advance Australia Medal for his outstanding contribution to Australian art. The Lewitzka’s are represented in

n Dr Helen Mead –

now what shall I mix?

The WA Medical Art Society also welcomes doctors with a steady hand behind a camera. “We have a number of doctors with a penchant for photography,” said Tony. n Ed. For more information or to join the WA Medical Art Society, contact Dr Tony Taylor: thuff@conceptual.net.au

n Dr Andrew Harper – sketching Leeuwin lighthouse

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n Lorraine Lewitzka demonstrates portrait painting to WA Medical Art Society members. Artist Robert Wade is the subject (see image at left).

Myrtle the Turtle By Wendy Wardell Myrtle the turtle was two hundred and three She felt fit and healthy, but sore in one knee She was a bit overweight but carried it well You can’t see a muffin top covered with shell But the doc reckoned Myrtle was long in the tooth (He was just ninety seven, so still in his youth) He examined this turtle from her head to her tail And told her, “‘It looks like you’re old and you’re frail’ With cartilage weak, if you fall you might die” Myrtle thought this unlikely, being nine inches high. A wily old reptile, with no signs of dementia Myrtle cared not about medical censure I won’t go in a home, I’m in pretty good health My family will help me take care of myself But her kids were all busy and way out of reach Laying their eggs on some far Queensland beach Now Myrtle wasn’t a looker – her legs short and stumpy Over two hundred years old, but she rarely got grumpy She had friends by the dozen, friends by the score In every State and on every shore She’d lived her life well and done many a favour For friends and for strangers and near every neighbour Her community knew what they needed to do And rallied the dozens of folk Myrtle knew Who each helped a little but mostly gave care And Myrtle was happy to know they were there

n Robert Wong,

well pleased with the result

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n Lorraine Lewitzka’s demo portrait

A child needs a village to raise it, they say The same thing applies when you’re old and you’re grey Or you may have to go back to nursery school With someone to clean up your food spills and drool Without friends that you’ve gathered on life’s rocky road Who’ll join forces together to shoulder the load 49

Moombaki Wines

On the Grapevine By Dr Louis Papaelias

A Sense of Place “Where the river meets the sky” is a special place situated on a bend of the Kent River between Denmark and Walpole. The Noongar name for this spot is Moombaki, and it appears on the label of the wines made from the vineyard that David Britten and Melissa Boughey established there in 1997. It is special, viticulturally speaking, being on a north-facing slope and composed of gravelly soils that once grew Marri. This pea gravel soil type is stonier than Karri loam. The vines have less leaf vigour and produce better quality fruit and ripen a few weeks earlier than other sites in Denmark. As a consequence, the Bordeaux varieties Cabernet Sauvignon, Cabernet Franc, and Malbec easily reach full ripeness here. The cool climate also produces elegant whites, with chardonnay doing particularly well. There is plenty of passion in this place. David and Melissa insist on doing everything themselves. Accordingly, no more than five acres are planted to vines, with each vine being carefully cane pruned by hand – a job that takes three months of each year to complete. Many would see this as commercially not viable, but David and Melissa have succeeded through determination and a dedication to growing grapes of the highest quality. Their viticultural practices eschew the use of pesticides. David and Melissa will proudly point out to the visitor that the evidence for this is to be seen by

Image: Rob Frith

the abundant wildlife thriving in the wetlands draining the vineyard. There are spoonbills and frogs aplenty amongst the paperbarks nearby. The wines are expertly and sensitively made by James Kellie at Harewood Estate. James is a gifted winemaker, who also makes beautiful wines under his own label. He was previously winemaker at Howard Park winery in Denmark and is highly experienced. If I had one word to describe the wines of Moombaki it would have to be … vibrant. All the wines tasted had a pristine fruit character to them with no rough edges, making them quite moreish. The 2011 Classic White is a good place to start. This is an easily palatable blend of various varieties. Fresh, fruity, and lively, it makes for attractive drinking in the short term. The 2010 Chardonnay is made from estategrown fruit and typifies the Great Southern style of chardonnay. It is exceptionally clean and elegant; restrained peaches and flowers dominate, with oak barely noticeable. A refreshing lighter style of chardonnay, it is crisp and subtle. I found the 2008 Cabernet Sauvignon, Cabernet Franc, Malbec to be utterly delicious. The vibrancy of fruit mentioned earlier was very evident, and the inclusion of malbec contributes to the attractive,

WIN a Doctor’s Dozen! Courtesy of Medical Forum DOCTOR’S DOZEN COMPETITION

For how many months is the 2008 Shiraz matured in premium French oak casks?

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Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, November 30, 2011. To enter the draw to win this month’s Doctors Dozen, return this completed coupon to ‘Medical Forum’s Doctors Dozen’, 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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lip-smacking character of this wine. Made entirely from estate-grown grapes, this lovingly crafted red from a great vintage is a true expression of the site and micro climate – Terroir as the French would say. The oak treatment is refined and complements the very fine tannins. All in all, this is a very fine Bordeaux blend that provides an interesting contrast to the more robust Margaret River styles. The 2008 Shiraz is a lovely example of this variety, very much in the Great Southern mode. It is made up of 65% Frankland fruit and 35% Denmark fruit matured for 22 months in premium French oak casks. Again, this wine is from a great vintage, and it shows vibrancy and a balance of flavours, with berries, spice and chocolate evident. It will age in the bottle and develop further. 2007 Moombaki Reserve: Small quantities are made from the best barrels of the Bordeaux blend with added Frankland Shiraz (50%). This is a classy, fragrant, complex wine. It spent two years in French barriques and shows a fine balance of flavours. Generous and mouth-filling, it is yet not a “big” wine in the Australian context. These wines made quite an impression. They are artisanal products, lovingly made and well worth seeking out. Visitors to the property are made to feel very welcome. Well worth a visit.

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The Arts

Musical Medicos in Fine Voice Performing with the WASO Chorus is a highlight for a cadre of musically-inclined WA doctors. There are long-standing and well-established links between medicine and the arts, and this relationship is happily played out in the West Australian Symphony Orchestra Chorus. The chorus is the off duty playground for many WA doctors and has been for many years. In the recently presented WASO gala concert A Night at the Proms, six WA medicos were part of the performing WASO Chorus All of the doctors find time to rehearse and switch off from work. The chorus rehearses on a weeknight, and it can be a challenge to get there on time – but all agree it’s worth it! “There is such great value in having a passion and pastime that is away from work,” said Jenny. “We all lead busy lives, and spend many hours listening to other people, so it’s great to be able to do something completely different for a short time each week. That we are able to perform such glorious music is a wonderful bonus.” Dr David Matthias has been a member of the chorus for many years – and arguably considered a patriarchal figure therein! When asked why he enjoyed singing with WASO Chorus, David said the special opportunity of rehearsing and performing with the WASO Chorus director, and then the orchestra, is a personal privilege. Of course, the necktingling delight of the choir blending all their efforts with the orchestra at performance night is exhilarating. David said that preparation requires periods of exclusive concentration, attending to note value, pitch, tonal accuracy, dynamics, and text – and blending all to deliver a meaningful message. Combining the foregoing with one’s vocal ability is the art of vocal music. All matters medical are put aside at these times!

n L to R: Dr Jenny Fay (GP), Dr Susanna Fleck (emergency doctor), Dr Moira Westmore (anaesthetist), Dr Olga Ward (GP), Dr David Mathias (GP), and Dr Katherine Langford (paediatrician).

Both doctors agree that there are mental health benefits to be had for doctors in pursuing an artistic outlet. “Part of it is about mixing socially with people well away from work, but there is also something in the performance of music that is just good for the soul. It’s about switching off from the stresses of daily life; it’s soothing for busy brains!” said Jenny.

“Only occasionally,” said Jenny. “We have toured with the Chorus to Melbourne and Sydney, and it has been of some use when chorus members have needed medical advice. It’s always good for touring groups to know they have some medical expertise on board. We will have the chance to tour with the chorus to Hong Kong in 2012, but hopefully no medical issues will arise!”

Have medical skills ever been drawn on?

funny side n n n Doing the rounds Dr Jones went to the retirement home for his monthly rounds. He sees old Joe and asks him, “Joe, how much is three times three?” Joe responds “59.” He goes over to Tom and asks, “Tom, how much is three times three?” Tom responds, “Wednesday.” He finally goes over to John and asks, “John, how much is three times three?” “Nine,” replies John. “That’s right ... now how did you come to that answer?” “It was easy. I just subtracted 59 from Wednesday!”

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n n n Mule raffle Dad and Dave saw an ad in the newspapers and bought a mule for $100. The farmer agreed to deliver the mule the next day. The next morning, the farmer drove up and said, “Sorry, fellas, I have some bad news. The mule died last night.” Dad and Dave replied, “Well, then just give us our money back.” The farmer said, “Can’t do that. I spent it already.” They said, “OK then, just bring us the dead mule.” The farmer asked, “What in the world are you gonna do with a dead mule?” Dad said, “We’re gonna raffle him off.”

The farmer said, “You can’t raffle off a dead mule!” Dad said, “We sure can! Heck, we don’t have to tell nobody he’s dead!” A couple of weeks later, the farmer ran into Dad and Dave at the local supermarket and asked, “What’d you fellas ever do with that dead mule?” They said, “We raffled him off like we said we would. We sold 500 tickets for two dollars apiece and made a profit of $898.” The farmer said, “My Lord, didn’t anyone complain?” Dave said, “Well, the bloke who won got upset, so we gave him his two dollars back.” Dad and Dave now work for the Gillard government. 53