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The World at your Fingertips WA Medicos using Social Media

Ethical dilemmas

GPs voice their opinion

Doctors

Beware! Script Pad Theft

Opiate Prescribing Ballet Medico Exercise as Prevention Extreme Marathons

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Contents Dr Scott Isbel: Doctor in the House.

News & Opinion

Guest Columns

26 All Too Human: Doctors in Distress

AA Going Strong. Pain Patients Please.

Ms Tasha Broomhall

Dr John Williams

4 Stolen Scripts Just a Symptom? Dr Rob McEvoy

6 Have You Heard? 18 WAIS: Managing Sporting Success. Mr Peter McClelland

2 Shaun Tan: Painting a Powerful Picture. Mr Shane Cummings

22 Transplant Performance Hurry-up. Dr Rob McEvoy

24 Year 12 Exams: Sickness Exemptions. Beneath the Drapes. 33 Event and Conference Corner. 43 Podiatric Surgeons Claim Their Place. Dr Rob McEvoy

MDA National’s New HQ.

By Drs Daryl Sosa and Peter Bradley Dr Martin Buck

Mr Damien Cummings

Immigrant Help.

27 The Funny Side. 44 Car Review: BMW M3: Luxury and Aggression. 46 On the Grapevine: Hentley Farm.

29 Social Media Lessons.

Dr John Salmon

Social Media Medicos

Lifestyle & Entertainment

Dr Mary Hegarty

Dr Geoffrey Kirkman

Script Pad Theft Warning.

8 Preparing for Disaster – Are We Ready?

2 Letters. No Strings Attached.

E-poll: Pain, Prescribing, Ethics, and E-health.

32 Turning the Tables on Chronic Pain? Ms Lesley Brydon

36 Exercise in Prevention: Less Couch, More Coach. Prof Danny Green

38 Helping Curtail Opioid Dependence in WA. Mr Craig Carmichael

47 Competitions. Competition Winners – August edition. 48 Seriously Extreme! Iron Man Triathlons and Ultra Marathons. Mr Peter McClelland

Directories 51 Clinical Services Directory. 74 Classifieds.

Clinical Focus 5 Important Advances in Antiplatelet Therapy for Coronary Patients. Dr Mark Hands

9 Homocysteine in Vascular Disease and Depression. Dr Sydney Sacks

37 Activity, Attitudes & Sport. Dr Peter Nathan

39 Urogynaecological Use of Sacral Nerve Stimulation. Dr Phil Daborn

41 Opiate Monitoring: Pharmacists, Patients and Prescribers.

Dr Revle Bangor-Jones and Mr Neil Keen

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

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

Advertising 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 www.pierredesigns.com.au

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

No strings attached Dear Editor, I have been consulted three times in the past month by Chinese women, speaking through interpreters, requesting to have their IUCD’s removed. The first two were sisters and came in together. The third was accompanied by her older husband. In no case has the IUCD string been visible. The penny finally dropped. The IUCD strings are removed at insertion in China, to prevent women “fishing them out”, according to internet searches I did. If approached, save yourself the potential embarrassment and explain it can only be removed without anaesthetic if the string is present and visible. Dr Geoffrey Kirkman, Roleystone

AA still going strong Dear Editor, It is fairly common knowledge that many of the medical and emotional problems that patients bring to their doctors’ surgeries are the consequences of excessive consumption of alcohol. A hallmark behaviour is persistent denial that drinking is in any way the cause of difficulties. We at Alcoholics Anonymous (AA) regard alcoholism as a progressive disease. The loss of friends, spouse, career, and health accumulates. As this journey of decline continues, the alcoholic will find it increasingly difficult to maintain the denial underpinning his/her drinking. At some point there will occur a disaster of such magnitude it will make the individual vulnerable and despairing to the point where it is possible to break down resistance to change. Doctors, especially general practitioners, are in a special position to take advantage of the alcoholic’s weakness at this time. The doctor could suggest an approach to AA, perhaps phoning the AA Central Office while their patient is still with them and arranging for someone to take him or her to a meeting. While the alcoholic may drink again, they will also know where they can find a solution and return whenever they wish. Many never drink again from their first meeting. The enduring track record of Alcoholics Anonymous is remarkable by any standards. It has been around for some 75 years now and remains unchanged from its inception. In Western Australia, there are meetings in many country towns, and on average, 15 meetings every day in the Perth metropolitan area. AA is loosely defined as a fellowship of men and women who share their experience, strength, and hope with each other so they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. Many observers 2

describe AA as a religious organisation, which it is not. It is certainly a spiritual program but it has no dogma or creed. Alcoholics Anonymous is open to people from all walks of life, all levels of society and from any philosophical and cultural background. There are no membership committees or application and selection procedures to be followed. Anyone who says he is a member is a member. The only requirement is a desire to stop drinking. By simply placing themselves in meetings and listening with an open mind, any alcoholic can follow the example of many success stories they will hear and accept the help from members that can deliver them from their helplessness and despair. For more information please check out www. aa.org.au or email swandistrict@gmail.com for a Doctor’s Information Pack. The National Helpline number is 1300 222 222. AA Spokesperson, Name Withheld on Request (AA Policy)

Pain Patients Please Dear Editor, Most people with disabling persistent pain fail to access adequate multidisciplinary treatment orientated towards self-management. They can miss out on quality of life and return to function. And liberalisation of opiate prescribing has not delivered positive outcomes, particularly for younger patients, and is now a cause of considerable concern. Persistent pain, although most often triggered by peripheral pathology, is now broadly conceptualised as a variable neurophysiological disorder with genetic and environmental factors. It is a condition hugely interactive with an individual’s psychosocial environment, beliefs and behaviours and activity patterns. Fortunately, neuroplasticity works both ways – the complex pathophysiology of pain can be positively reformed by a biobehavioural approach. Adequately intensive multidisciplinary cognitive behavioural therapy (MCBT) has level I evidence for efficacy in this arena. Prof Peter O’Sullivan of Curtin University has recently put the case for changing treatment of non-specific chronic low back pain to a patientcentred MCBT approach, veering sharply away from the demonstrably unsuccessful biomedical treatment model. This is particularly relevant to workers injured in WA where insurers sustain disability by their exclusive focus on biomedical assessment and management. Integrating MCBT with selected pain medicine interventions further amplifies efficacy. Implanted neuromodulation is the only other treatment for severe neurogenic pain with an unequivocal level I evidence base and guidelines for spinal cord stimulation in Australia have been published recently. Effective MCBT delivery demands an enthusiastic

team approach. Patient belief and behaviour change flows from consistent messages, adequate treatment intensity, and reinforcement from treating doctors. The treatment goal is for patients to become confident in self-management, increase activity, and minimise medications and the need for further interventions. The Pain Care team in Fremantle is one of three Australian centres participating in a RCT of spinal cord stimulation and CBT for failed spinal surgery patients and we wish to recruit patients. The trial, directed by Prof Nicholas of the Royal North Shore Hospital pain unit, will compare spinal cord stimulation ‘treatment as usual’ versus spinal cord stimulation integrated with MCBT. We ask doctors to refer patients to this trial via any member of the team consisting of pain specialist, psychologists, occupational therapist and physiotherapist (Tel 9335 7733). Referrers receive regular reports documenting progress. There are a number of otherwise intractable pain syndromes now proving amenable to implanted neuromodulation therapy including chronic migraine, cluster and cervicogenic (including whiplash) pain syndromes and many post surgical pain syndromes. Visceral and pelvic neuropathic pain syndromes and even fibromyalgia (brainstem modulation via occipital nerve stimulation) also appear to be responsive to neuromodulation. Dr John Salmon, Pain Specialist, Cottesloe References are available on request.

Immigrant offer Dear Editor, The hundreds of wouldbe immigrants, trying to escape persecution and seeking a better lifestyle in Australia, have become frustratingly detained in various ‘detention centres’ while (quite reasonably) being screened before being accepted as physically and medically (and politically?) fit to integrate into our population. If shortage of experienced medical manpower is contributing to the delay in the health screening process, would it not be possible for the government (Medical Boards) to offer ‘temporary employment’ to those recently retired GPs who have retained registration solely for “occasional practice”, in an attempt to speed up the screening process for those unfortunate, mostly young men, women, and children? I, and I am sure several of my contemporaries, would be interested in travelling to Christmas Island for stints of 2-4 weeks at a time, if we could assist in the relief of frustration and delay in this humanitarian crisis. All we need is a ‘roll-call for volunteers’ by the Minister for Health, and I think there would be a good response. Dr John Williams, ‘Occasional Practice’ GP, Augusta.

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Editorial Dr Rob McEvoy

Stolen Scripts Just a Symptom? Opiate drug use has become a community concern, with considerable cross-over between legitimate prescription use and illicit use. Obviously, many confounding factors are at play but consensus is emerging that too many people are relying on opiates for pain relief and one solution for our community is to help them self-manage without drugs. Easy availability of opiates is a contentious issue as it brings into question the prescribing habits of doctors. This edition’s E-poll compares some results with our 2009 survey around narcotic prescribing (see page 12). Since 2009, the profession has lost the Medicine Information Line for doctor shopping on PBS scripts, a service that 17% of our surveyed GPs found ‘very helpful’ and 31% found ‘sometimes helpful’ (while 40% never used it). This edition’s survey shows doctor usage of WA Health’s patient information service for opiate prescribing has gone up about 50% but the ‘helpfulness rating’ has not increased much. And while GPs today seem more in agreement that particular specialists or pain services should be involved in regular opioid prescribing, relatively fewer are satisfied with public Pain Clinic services in WA. The stolen script stories (see page 14) seem to suggest that leaving those who are drug addicted circulating in the community leaves a trail of damage and a lot of resources go into policing. Little wonder then that 71% of surveyed GPs in 2009 gave ‘timely access’ as the thing GPs appreciate most about Pain Clinics in WA’s public hospitals, and why federal MP Dr Mal Washer says decriminalisation should be a major part of illicit drug law reform (Prohibition Counterproductive in Drug Law Reform, August edition).

Is the medical profession unknowingly a contributor to the problem? E-poll respondents previously said long waits could allow opiate addiction to become established or entrenched in chronic pain sufferers. While the finger has been pointed at community prescribing of opiates, some GPs said opiates were overused in Pain Clinics and hospital wards and poor communication with GPs and inadequate patient follow-up were fuelling drug problems. The parliamentary tabling of the Education and Health Standing Committee report on Changing Patterns in Illicit Drug Use in Western Australia chaired by Dr Janet Woollard and including Dr Graham Jacobs, echoed the idea of addiction to dangerous prescription drugs coming from long wait times to see a specialist and it said there was deficient tracking of opiate scripts due to a three-month delay before they appeared on the WA Health database. It said prescription opioid misuse was now on a par with heroin use in the community. Information from the National Drug Strategy Household Survey was old (2007) with new figures not due to emerge until early 2012. However, based on these figures WA illicit drug use was above the national average, with amphetamine use one of the highest in the world. The report also recommended freezing of funding to the Fresh Start Recovery Program that uses naltrexone implants to treat heroin addicts. It said school education programs were best combined with family education to prevent drug use in children. And there was also an urgent need to address drug addiction of prisoners using rehabilitation programs. Where do we start? If you take the view that addiction to prescription drugs occurs because

Christmas Greetings

Is the medical profession unknowingly a contributor to the problem? people unintentionally go that way, then we need to lessen the scenarios that allow it to happen. Second is handing back more control to the health consumer through education, which is where government is heading in its relationship with NPS. l

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14 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services.

Important advances in antiplatelet therapy for coronary patients A

ntiplatelet therapy over the past decades has played a major prognostic role in patients with coronary artery disease(CAD). This is particularly so in patients presenting with an acute coronary syndrome (ACS) and those undergoing coronary angioplasty and stenting. Rupture of an atherosclerotic plaque is the usual initiating event in ACS, leading to subsequent thrombus formation. Persistent thrombotic occlusion leads to acute myocardial infarction (MI). Metallic stents deployed in coronary arteries are potentially highly thrombogenic, exacerbated by the delayed endothelialisation associated with drug-eluting stents (DES). In both ACS and in-stent thrombosis, aggregating platelets form the core of the thrombotic mass.

Available oral antiplatelet agents include aspirin, clopidogrel, prasugrel and the recently released ticagrelor. • Aspirin inhibits the production of thromboxane A2 (the latter stimulates platelet aggregation). It has only modest antiplatelet effect but is relatively safe and inexpensive. Aspirin is indicated in patients with both stable and unstable CAD and those undergoing coronary artery stenting. Loading dose is 300 mgs with a maintenance dose of 100-150 mgs daily. • Clopidogrel (PlavixTM/IscoverTM), a thienopyridine, inhibits ADP-mediated platelet aggregation and has similar antiplatelet effect as aspirin with perhaps fewer side effects; however it is more expensive. It is used when aspirin is contraindicated or not tolerated and in conjunction with aspirin in patients with ACS and/or coronary stenting. Loading dose is 300 or 600 mgs and maintenance is 75mgs daily. Limitations of clopidogrel are delayed onset of action, variable platelet response with clinically unpredictable resistance (20-25% patients) and irreversibility of its inhibitory effect on platelets. This has led to the development of newer more potent antiplatelet agents such as the thienopyridine prasugrel and the cyclopentyltriazolopyrimidine ticagrelor. All block the ADP receptor P2Y12 on platelets (ticagrelor reversibly).

clopidogrel. It has been shown (1) to be more effective than clopidogrel in patients younger than 75 with ACS undergoing coronary stenting and who have relatively low risk of bleeding, no history of stroke and weigh more than 60kgs. Loading dose is 60 mgs with maintenance dose of 10mgs daily. • Ticagrelor (BrilintaTM) now has TGA approval for use in all ACS patients (regardless of intervention), although it is still awaiting PBS listing. It inhibits platelet function more intensely than clopidogrel. In the PLATO study (2) of platelet inhibition and outcomes in 18,624 ACS patients, ticagrelor demonstrated a 16% relative risk reduction of CV death, MI or stroke compared to clopidogrel, without significant increase in overall major bleeds (11.6% vs 11.2%) or fatal/life threatening bleeds (both groups 5.8%). Both groups received concomitant aspirin. Recommended oral loading dose is 180 mgs followed by 90 mgs twice daily for 12 months in conjunction with aspirin therapy.

By Dr Mark Hands, Clinical Associate Professor (UWA), Interventional Cardiologist

About the Author Dr Mark Hands graduated from UWA and trained in cardiology at Sir Charles Gairdner Hospital and the Brigham Women’s Hospital, Harvard Medical School. He is an interventional cardiologist in private practice at Western Cardiology (chairman) and emeritus consultant cardiologist at SCGH. In addition to general cardiology and echocardiography his special interests include investigation and treatment of acute and chronic ischemic heart disease. Dr Hands’ interventional procedural skills include: • Coronary angiography, angioplasty and stenting in stable angina and in acute unstable angina and acute myocardial infarction, • Cardiac pacing, • Percutaneous closure of atrial septal defects and patent foramen ovale.

Increasingly, practitioners will be asked to oversee patients on prasugrel or ticagrelor; thus it is important that they have an awareness and knowledge of these newer generation antiplatelet agents. 1. Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007; 357:2001. 2. Wallentin L et al . Ticagrelor versus clopidogrel in patients with acute coronary syndromes. NEJM 2009;361: 1045-1057.

• Prasugrel (EffientTM) has a rapid onset of action, no resistance problems and comparable significant bleeding rate with

Visit www.westerncardiology.com.au to search information on locations, cardiologists and services.

Main Rooms: St John of God Hospital, Suite 324 / 25 McCourt Street, Subiaco 6008 Tel 9346 9300 • Country Free Call: 1800 702 600. Urban Branches: Applecross, Balcatta, Duncraig, Joondalup & Midland Regional Clinics: Busselton, Geraldton, Kalgoorlie, Mandurah & Northam After Hours on call cardiologist: Ph 08 9382 6111 SJOG Chest pain Service 0411 707 017 medicalforum

Have You Heard?

Autism on the rise

Software evolving ASX listed health software company Medtech Global Ltd (ASX: MDG), big in NZ, claimed a 40-practice footprint in WA five or so years ago, having bought out two software packages developed in WA, Rx and Medical Windows. Medtech is following the IT trend with the development of population health analysis tools, a tele-health system, a patient held medical record, and a clinical audit tool to match its standard practice management and patient record software Medtech32. The company has gone relatively quiet since its rather aggressive launch across the Tasman a few years back, and Medical Forum last caught up with them in May last year when they were promoting their clinical audit tool at the RACS conference. CEO Vino Ramayah has just increased his personal shareholding in MDG.

be offered internships in WA’s public hospitals next year, a 20% increase since 2009. Health Minister Dr Kim Hames says an extra $12.5m was allocated in 2011-12 for increased training and supervision, simulated learning, and medical education infrastructure at SCGH, RPH, and Fremantle Hospital, as well as WA Country Health Services, community clinics and private hospitals. Around 100 interns based at Charlies will be rotated to Joondalup Health Campus, Swan Districts, and Osborne Park Hospitals. Another 100 at RPH will get placements at Bentley Hospital and Shenton Park Campus. The 80 interns at Freo will rotate to Armadale-Kelmscott Hospital, Rockingham General Hospital, Peel Health Campus, and Kaleeya Hospital. Interestingly, all interns will rotate through country health services, community clinics, and private hospitals.

Clear thinking

Breathe easy If you are wondering what treatments are jockeying for position in the minds of respiratory people managing COPD, the revised COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease, Version 2.26, has just been released. Changes are summarised at www.copdx.org.au/ summary-of-changes-in-version-226

Regulate to bits West Australian Coroner Alastair Hope has reportedly suggested to the family of a woman who died from an overdose in Geraldton last September that we should have a central database for all PBS scripts, to keep track of doctor shoppers. This was after the 40-yearold mother of seven died from an overdose of methadone while being treated for an addiction to prescription drugs, including Stilnox. This a bit ironic after Medicare cut out its doctor advice line for doctor shoppers two years ago (but maintained the one for consumers). Maybe consumers can be accountable, too?

Training young ’uns The pressure is on WA Health to meet its commitment to find internships for a growing number of WA medical graduates. A record 280 graduates from WA medical schools will 6

Scotland has brought us Allies in Change, a new six-month program to develop leaders in the mental health sector who will then advocate for change in the system. WA Health is putting $150,000 into the program in 2012, after graduating the first 32 people from amongst mental health patients, families or carers, and professionals working in the sector. The WA Association for Mental Health is overseeing things and Minister Helen Morton hopes these people will champion reform in mental health. It sure beats another government enquiry! The program was developed and brought to WA with the assistance of Heather Simmons, Learning and Development Consultant at Perth Home Care Services.

Simulation success The new ECU Health Simulation Centre has delivered its first course with the help of people from St Vincent’s Hospital in Melbourne and educators from the Australian College of Emergency Medicine. 12 ED consultant physicians from the major public hospitals in Perth took part, under contract arrangements with WA Health. ECU is an approved provider of the Advanced and Complex Medical Emergencies (ACME) Course for the Australasian College for Emergency Medicine – to develop clinical skills and team-based care for cardiovascular, airway, respiratory and complex emergencies. ECU is now looking to build a sustainable instructor workforce in WA.

The Autism Association of WA, sponsored primarily by the WA Government, has just held an international conference on autism attended by over 1000 delegates from 21 countries. The Asia Pacific Autism Conference for three days featured interim results for the Autism Phenome Project (Uni of California), research done at WA’s Telethon Institute into pregnancy factors in autism, and longitudinal studies into people with autism from age 2 to middle age. US autism prevalence is put at 1 in 110 children (Australia 1 in 160) with the rate estimated at 1 in 1000 in the 1980s and no clear explanation for the increase. Four of every five children with autism are boys and services demand exceeds that for children with cerebral palsy, Down Syndrome, or sensory disabilities.

Practice staff upskilling Assisting practices is on a few people’s minds … Rural Health West (RHW) has developed a program to assist rural and remote practices, while the WA GP Network, through Primary Care Education Solutions (PCES), is focusing on accredited and nationally recognised qualifications for practice managers. Running a remote practice is challenging and by providing updates on the MBS, e-health initiatives, and related practice support, RHW hopes benefits will flow to health care in remote communities. Medical Forum’s February 2011 edition e-poll revealed that 45% of WA’s practice managers have no formal qualifications. The nationally-accredited Diploma of Practice Management course offered by PCES, with flexible delivery options, is facilitated by experts with local industry knowledge, and is one way to fill the formal qualifications gap.

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

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Guest Column

Preparing for Disaster - Are We Ready? PMH anaesthetist Dr Mary Hegarty reflects on her experiences with the London bombings and in the light of CHOGM, asks the obvious. In May this year verdicts from the inquest into the July 2005 bombings in London were announced. I had a particular interest in the inquest’s findings because at the time of the bombings I was working as a pre-hospital doctor at the London Helicopter Emergency Medical Service (HEMS) and was part of a team that was tasked to the scene of the attacks. London HEMS is an air ambulance service covering a population of 12 million people. It delivers pre-hospital teams consisting of experienced doctors and paramedics to the scenes of incidents. All the doctors have been trained in trauma management and major disasters. On July 7, 2005, terrorist bombs on underground trains and a bus outside the British Medical Association killed 56 people and injured over 700. Whilst medical experts in disaster medicine were tasked to respond to the incidents, there were significant delays in the emergency medical response. Consequently many doctors, untrained in the management of such events, ended up being first responders at the scene of the bombings.

B U S

S U B I

C E N T R O

S U B I

C E N T R O

Since moving to Perth, I have familiarised myself with disaster planning in WA and attended courses that can prepare you for these type of events, thankfully rare. WA Health is currently making disaster plans for CHOGM in Perth in October. In 1978 the only terrorist attack to occur on Australian soil took place at the Sydney Hilton Hotel, which was hosting CHOGM that year. Some argue that it is inevitable that such an attack will occur again. I hope that isn’t the case, but as health care professionals we can and should take measures to ensure that we are prepared for every eventuality.

Some argue it is inevitable that a terrorist attack will occur in Australia again. So how has this experience changed me? It has certainly given me a greater appreciation for our medical colleagues who experience terrorist attacks as part of their normal routine.

My thanks go to the many retrieval colleagues in Australia and the UK who trained and supported me throughout my time spent working in pre-hospital medicine. l

It has made me more aware of the importance of documentation, especially if you respond to an emergency in a ‘good samaritan’ capacity.

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Health care workers who attended casualties at the scene of the bombings were called to the inquest in London and asked to recall detailed facts many years after the event. An altruistic motive to help can come back to haunt you many years later if you haven’t made adequate notes whilst events are fresh in your memory.

For example, a group of doctors were meeting at BMA House on the day of the attacks. Despite lack of formal disaster medicine training, they managed to take command and control of the situation. Communications had failed and roads were congested, so it was some time before expert medical assistance arrived. They had minimal equipment and yet they triaged, resuscitated and prioritised patients for transport in an organised manner. Most of these doctors had not looked after emergency patients for 20 years.

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Homocysteine in Vascular Disease and Depression Role of homocysteine, B12 and folate Homocysteine is the precursor of methionine, vital for the synthesis (methylation) of proteins, DNA, RNA, and neurotransmitters (see Figure 1). Conversion of homocysteine to methionine requires B12 and active folate (5 methyl tetrahydrafolate). Activation of folate requires the enzyme MTHFR (methylene tetrahydrafolate reductase). In countries with folate fortification of flour, such as Australia, the normal plasma level of homocysteine is <12 umol/L. Elevations of homocysteine thus occur in B12 and folate deficiency and enzyme defects (especially of MTHFR) in the pathway above.

Dr Sydney Sacks, Chemical Pathologist

FOLATE

Fig 1

THF

Methionine S adenosyl methionine METHYLATION S adenosyl homocysteine

5,10 methylene B12 THF MTHFR 5 methyl THF

Homocysteine

THF = tetrahydrafolate MTHFR = 5,10 methylene THF reductase

Homocysteine in vascular disease Interest in homocysteine first arose in 1969 with the description of the strong association of homocystinuria, a rare inherited metabolic disease with very high serum homocysteine levels of >100 umol/L, with severe atherosclerotic CVD. Marked elevations (25-35 umol/L) also occur in chronic kidney disease patients with ESRD; these patients also have a very high incidence of CVD.

In light of these findings, measurement of homocysteine in the general population to screen for CVD risk is not recommended. It is reasonable, however, to measure homocysteine in patients with (or at high risk of) CVD, as those with levels above 15 umol/L have worse outcomes and thus require more vigorous lifestyle changes and treatment for other known causal risk factors e.g. hyperlipidaemia.

Meta-analysis has now shown that even mild elevations of homocysteine, with baseline levels in the range of 10-14 umol/L are an independent predictor of CVD in the general population, with a 3 umol/L rise predicting an 11% increase in ischaemic heart disease and a 19% increase in risk of stroke.

The routine administration of high dose B vitamins to patients with, or at risk of CVD is not recommended but Vitamin B12 and folate deficiencies should always be excluded if homocysteine is elevated.

Most mild homocysteine elevations in the general population are due to a variant MTHFR enzyme (MTHFR 677TT, present in approximately 10% of the population, elevates the plasma homocysteine by approximately 3 umol/L, compared with MTHFR 677CC normals). Treating these patients with folate and B12 was shown to lower homocysteine levels and subsequently RCTs of folate and B12 therapy were initiated in the hope of preventing CVD. Meta-analyses of these RCTs proved disappointing as despite lowering homocysteine levels, vitamin therapy did not reduce CVD morbidity or mortality. In addition, the most recent Mendelian randomisation studies failed to show that the presence of the MTHFR T allele is a predictor of CVD, thus the homocysteine level is a marker of CVD but is probably not causative.

Homocysteine in depression CNS methylation and neurotransmitter synthesis are dependent on the pathway in Fig 1. Many studies have shown an association between homocysteine levels and depression and a number of RCTs using folate and B12 to treat depression have shown positive results. A recent meta-analysis (Almeida, 2008) of seven studies confirmed that elevated homocysteine is associated with depression (odds ratio 1.7), and further meta-analysis of 5 Mendelian randomisation studies showed that the presence of the MTHFR T allele is a predictor of depression (odds ratio of 1.22), which suggests that elevated homocysteine may be causative of depression. Review of 5 RCTs of vitamin B12 and folate therapy were consistent with an antidepressant effect, and the authors conclude that

lowering homocysteine by 1.4 umol/L could potentially reduce the odds of depression by approximately 20% in the overall population.

Neural tube defects (NTD) and folate fortification of flour In 1976, women pregnant with a NTD-affected foetus were found to be folate deficient. Folate supplementation was subsequently found to significantly reduce NTD occurrence and the MTHFR 677TT genotype was found to increase the risk of NTD. The likely cause of the birth defects is defective methylation of DNA and protein, rather than homocysteine toxicity. To reduce the risk of NTD, folate fortification of flour was made mandatory in a number of countries internationally. Folate fortification of USA flour lowered mean plasma homocysteine from 12 umol/L to 8 umol/L. In Australia, folate fortification of flour was made mandatory in September 2009 and we would expect a similar lowering of homocysteine levels here. An intriguing thought is that if the above conclusions linking homocysteine and depression are valid, we can expect a significant future reduction in depressive illness in Australia. Doubtless this will be explored in future studies. References 1. De Koning: Circulation 2010;121:1379-1381 2. Almeida: Arch Gen Psychiatry. 2008:65(11): 1286-1294

Main Laboratory located at 647 Murray Street, West Perth Contact 9476 5222 for General Enquiries or 9476 5252 for Patient Results. Information on our extensive network of Collection Centres, as well as other clinical information, can be viewed at www.clinipath.net.

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Sports Medicine By Peter McClelland

Doctor in the House Sports Medicine isn’t just about sport, as Dr Scott Isbel, company doctor for the WA Ballet, demonstrates. On opening night at the WA Ballet, there’s one audience member who casts his eyes over the dancers with both artistic and clinical interest. His name is Dr Scott Isbel, and his association with the WA Ballet goes back a long way. And he loves every minute of it! “I’ve been working with the dancers for 22 years now, and it’s been a wonderful experience,” said Scott, a consultant sports physician. “I’m in the audience for just about every opening performance, but I’m there as a guest, not in a clinical capacity. Although I do sit there sometimes and wonder – will this be the night for some sort of medical emergency? It hasn’t happened yet, and I hope it remains that way!”

Dancer’s injuries are mainly strains and tears. They’re not normally the traumatic injuries you see in other areas.

Scott told Medical Forum that a physiotherapist attends every single performance of the WA Ballet. “It’s so important that the dancers do their stretching exercises and warm up properly before going on stage. That’s done under the supervision of a physiotherapist. It’s an integral part of ensuring we minimise the potential injury risk for the entire company.” Scott’s interest in sports medicine stems from his own sporting background. “I was a keen gymnast in my younger days and competed at national and international level. It certainly played a big part in the eventual direction of my medical career.” Scott consults as a sports physician at SportsMed Subiaco, St. John of God Health Care (SJGHC) and treats acute and chronic musculoskeletal injuries. He has a special interest in children’s sporting injuries, computer-aided design foot orthotics, compartment pressure measurement, and dexamethasone iontophoresis. One of Scott’s more high-profile patients at the WA Ballet is leading artist Daryl Brandwood. Daryl’s one-man show, Helix, wowed Perth audiences earlier this year. “It was a very tough show,” said Daryl. “I only just made it through the season. If I perform it again, I’ll have to be even fitter than I was.” Any one-man show at this level of artistry is particularly demanding, and Daryl wasn’t immune from the after-effects. “I suffered from back spasms after Helix and had to miss our next season, Neon Lights, which was a pity. It turned out to be a really tough year physically for me.” But five years ago, Daryl suffered an injury which made him question his entire future as a professional dancer.

“We were in rehearsal and it was late in the afternoon,” said Daryl. “I was tired, went up for a jump and landed very awkwardly. I was wearing jazz shoes which didn’t help matters much.” So, enter Dr Scott Isbel – stage right! “I saw Scott the next day with my foot wrapped up in ice. He did the scans and the results weren’t good at all.” Daryl had torn the ligaments in his ankle and it was a long uphill battle to regain his fitness. ‘I’ve known Scott since he came on the WA Ballet company’s tour to China in 2005, and he did a wonderful job to get me back on my feet again after the rehearsal incident.” But it took six months of treatment and rehabilitation before Daryl was able slip his ballet shoes back on again. Daryl’s injury was somewhat unusual. “Dancer’s injuries are mainly strains and tears – ankle and feet with the female dancers, shoulders, hips and back with the males who do all the lifting,” said Scott. “They’re not normally the traumatic injuries you see in other areas.” One of the more bizarre injuries occurred on the WA Ballet’s tour of China – and it didn’t involve a dancer at all! “It was a wonderful experience to see China before its current modernisation program. We were treated like royalty, picked up in limousines and dined at some highly unusual restaurants,” said Scott. “One night, just before the curtain went up, a section of the ceiling collapsed and part of it landed on the stage manager’s head. I had to stitch him up – that was definitely my most unusual medical moment with the company.” Scott makes the point that “dancers often retire at a relatively young age.” Even for superbly fit dancers n Dr Scott Isbel such as Daryl, it’s absolutely imperative that they develop a close professional relationship with a highly skilled sports physician. “If a structured and well-managed program is put in place,” said Scott, “there’s no reason a dancer’s professional career can’t be significantly extended.’ Daryl agrees with Scott. “I learnt a lot about my own physical limitations during that six month period away from the stage. Scott gave me some really useful feedback – I’m much more confident about pacing myself better now. Hopefully, that means I’ll be able to keep dancing for a lot longer.” l

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E-Poll

Pain, Prescribing, Ethics, and E-health A mixed bag of issues provoked thoughtful responses from GPs. Not deterred by the variety in our October edition e-poll, 81 GPs had their say on our theme of pain (on resources for, and management of, pain), ethical conundrums such as whistleblowing and medico involvement in combat sports, and the ever-topical subject of e-health records.

Ethical Transparency nD o you believe it is in the medical profession’s best interests to be more receptive to the reporting of patient harm, financial rorting or unethical behaviour by doctors? [multiple answers possible]

Tackling Pain

Yes, in the private or not-for-profit sector �� 58%

With pain as one of our editorial themes this month, we asked the same three questions on the subject as appeared in our May 2009 e-poll. In just two and a half years, there’s been a small but significant shift in GPs’ views …

nD octors can check the prescription history of new patients, or of existing patients whose behaviour causes concern, prior to prescribing S8 Opiates by calling the Pharmaceutical Services Branch of the WA Health Dept. How would you rate this service?

No �� 15% Uncertain ��20%

Process takes too long �� 40%

Any comment on this issue?

Not enough protection for the person who is complained against ��37%

18 GPs were moved to comment on the appropriateness of whistleblowing. Five suggested a measured approach, such as: “Prefer to counsel if it arose rather than report”, “A doctor may see a lot of behaviour that he wouldn’t do himself. Is that appropriate to report?”, and “Bad doctors should not be hidden, but vexatious litigant patients should not be encouraged! A difficult thing to balance.”

Very helpful ............................ 28% ��22% Sometimes helpful .................. 36% ��28%

Other comments had money as a theme:

Not helpful .............................. 9% ��4%

“Has the government ever done a cost-benefit analysis on their random audits and on the investigation of doctors for financial rorting? (Is it worth spending thousands to find a few rotten eggs?)”

2011 2009

Never used ............................... 22% ��42% Unsure ..................................... 5% ��4%

nW hat is your response to this statement: “Regular opioid prescribing should only occur in consultation with a specialist who specialises in the condition giving rise to the pain, or a recognised pain service”? .................................................. 2011 2009 Fully agree............................... 28% ��31% Partly agree ............................. 31% ��35% Disagree................................... 25% ��25% Strongly disagree .................... 15% ��8% Unsure...................................... 1% ��1%

nA re you satisfied with existing Pain Clinic services in WA?

2011 2009

“I work in a large group corporate practice. Some of the overseas trained doctors there continue to gobsmack me as to how quickly they churn through patients and how badly they practice. Money is the only driver. They simply don’t care. I secretly hope they get audited.” While about a quarter of respondents were concerned for the profession’s reputation: “It does the profession no good to have its dirty linen hung out in public.” “Our ethical standards as a profession have been slipping for many years, we all need to consider what a tremendous privilege it is to be trusted and able to help the ill and infirm and cease fixating on our already deeply stuffed pockets.” “We need robust mechanisms for removing incompetent or dodgy or dishonest doctors. Need to protect the whistleblower from getting dragged into it too much.”

Yes............................................ 14% ��17%

Two commenters saw red:

No ............................................ 64% ��56%

“This has taken self-flagellating to new depths. It is like we are in kindergarten!”

Unsure...................................... 22% ��27%

nW hat do you consider the most important impediments to fairness in dealing with a complaint against a doctor in the private sector? [multiple answers possible]

Yes, in the public sector �� 51%

One commenter saw the human side: “It is important, and the person who is sick and doing these acts is probably unaware of his deeds and needs help.”

“Only if the same standards are enforced on the lawyers, accountants, licensed salesmen, and financial ‘advisors’. Let’s have a level playing field. Oh, and by the way, include medical administrations here and hospital administrators, too.”

Process lacks transparency ��28% Too many lawyers involved ��26% Lack of impartiality in assessing a complain ��23% Not enough protection for the whistleblower ��14% Uncertain ��27% Other ��4% Any comments on impediments to dealing with ethical misdemeanours? While only 10 GPs provided comment, they offered food for thought, such as “The lifelong guilt of ‘dobbing in’ other doctors”, “You are guilty and made to feel guilty even if you have done nothing wrong. There should be a complaints process safe guarding doctors from vicious patients”, “More published examples within the profession might help – particularly where apparent ethical/administrative misdemeanours (a la HIC) are concerned”, and “The cost of legal barriers protects bad doctors at the expense of the rest. We need better whistleblowing protection in all areas of health to weed out the few bad eggs, and tort law reform to protect the innocent against malicious and vexatious complainants.” One commenter suggested Medical Forum could help: “There is no discretion by the Medical board all complaints, even trivial, are subject to a legal review. There needs to be a simple review with a consumer rep and member of the profession to offer an apology or reply to complainant for minor and trivial offences. Current complaints of a minor nature are taking over two years to be reviewed, let alone heard. I suggest Medical Forum runs an anonymous webpage to let doctors complain about the Medical Board and its ridiculous processes that are costing all of us increased fees and medical defence costs.”

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Other ethical issues nD o you think the medical profession should play any part in overseeing boxing or extreme combat sports? Yes ��28% Perhaps, with limitations ��26% No ��37% Uncertain ��9%

n I n your practice, what do you consider is the main reason for getting patients back for a doctor consultation to review their test results? Only results that are abnormal or require specific follow-up are treated this way. ��68% Most tests are treated this way for medicolegal reasons (e.g. ensure no important result is missed). ��25% Most tests are treated this way for doctor convenience. �� 1% Most tests are treated this way to generate income. �� 1%

make sure records are up-to-date, and while doing so, can also recall any patient that needs attention” and “NOT a nurse practitioner.” Three gave IT integration some thought, with this comment typical: “Should be available for each patient throughout WA on something like MMEX or Medical director or the like.”

E-health n F or patients over age 65, who do you believe is in the best position overall, to ensure any e-health record is up-to-date and accurate? General practitioner, as selected by the patient ��60% Patient themselves ��0% Nurse practitioner given that task ��5% None of the above ��4% General practitioner, as selected by health authorities ��% Specialist involved in patient’s care ��2% All of the above ��12% Uncertain ��% Care to comment on maintaining the accuracy of any e-health record? Incredibly, 69 of the 81 poll respondents commented on e-health. Clearly, it’s an issue on GPs’ minds! Not surprisingly, more than 50% of the comments said a “GP is the most logical choice” or variations thereof. Nurse practitioners as record keepers divided opinion, with the likes of: “Nurse practitioner can spend some time and

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Most other commenters saw e-health records as a huge undertaking that needed a considered approach: “Without knowing what model is going to be used it is hard to say (so much of this has been done in the dark). I feel it will be necessary for cooperation between all health care providers to ensure the e-health record is accurate. After all, the driving reasons for such a record have been accuracy and communication.” “Damn big and important job. Again, the problem is time and expertise costs and, as with most medical services, the recompense is not commensurate with the time and expertise required.” “Can be complex but good records will decrease the risk of misadventure.” “Can only be maintained if everyone supplies data in an appropriate and timely fashion. That hasn’t ever been what happens in Government hospitals.” “Accuracy of e-health record depends on the history patient provides and record of details on e-health by all the professionals listed above.” “Patients should be free to choose who provides their care. Medicare benefits will need to reflect the added administration required.”

Other ��5% A third of the ‘Other’ results felt face-to-face contact was the best way to inform patients of results. The rest suggested specific ways for patients to obtain their results, such as phoning or emailing the practice.

Medication mishaps n “ About 30% of all unplanned hospital admissions for patients over 75 years are due to prescribing errors.” What is your response to this statement? Percentage is probably higher ��7% Seems accurate ��21% Percentage is probably lower �� 40% Uncertain of percentage ��32% Any comments on rates of medication mishaps in WA? Of the 22 comments, 60% felt the 30% mishap figure was “hard to believe” (one going so far as to call it “bullshit”). Three called into question the definition of a ‘prescribing error’. Three saw generics as an issue, such as this comment: “Working in a rural ED, admissions occur for non-compliance and for confusion using generics, but rarely due to a prescribing error.” Three medicos largely held the patient at fault, with one saying: “More are due to medication misunderstanding by the patient (including giving wrong information about current meds to other doctors).” One GP saw the writing on the wall: “And they are opening prescribing up to podiatrists, nurses, and potentially, pharmacists!”

Havin’ a laugh Spurred on by a reader’s comments about jokes in Medical Forum that raised his ire (which initiated an intense lunchtime discussion in the Medical Forum office), we sought clarification from our readers on what truly tickles your funny bone. Thanks for the advice, which we will try and follow in coming jokes pages. l 13

Illicit Drugs Dr Rob McEvoy

Script Pad Theft Warning Forged scripts and stolen script pads are focusing attention on doctor security but is medicine all about looking for the worst in people? No one likes to be caught napping, so when someone who is drug addicted pinches a script pad and forges illicit scripts, the doctor involved transitions from stunned disbelief to anger and defensiveness. Apparently, the level of script pad thefts has got the authorities worried, which is why we agreed to profile the experience of three doctors, as a warning to others. The main message is stay alert, not alarmed! n Dr Yvette Bruce was a medical intern

on the private side at Joondalup Health Campus when she was caught out.

“We had run out of prescription pads. I asked the ward clerk for another. She said they relied on the doctors ordering pads and leaving them on the ward because they are not able to have the blank prescription pads that the public hospitals use. I had no reason to doubt this as we had been using other doctors’ personalised pads, crossing out their details and putting in our own.” “As requested, I ordered some pads and left five behind the desk for the doctors to use.” “About a month later I had my first call from a pharmacy regarding a prescription for a narcotic. I had not written the prescription. The person writing these bogus scripts did not know I was a recent graduate and they always used a date before the pad had been issued.” “I had at least 6–10 calls per week for about four months from pharmacists. I was also contacted by the police. Pharmacy people at the hospital were talking about how careless I had been with my pads. The ones I kept were locked up in a chest at home, and I felt the hospital or other doctors had not treated my script pad with care.” “I still see consultants’ pads lying around the private wards of the hospital, but you will not see my pads there again. I will never try to help out in this way again.” Yvette said no-one has mentioned a similar thing happening to them, although one consultant said a pad was stolen from his car but absolutely nothing happened. “I think the person who took mine had a particularly bad narcotics habit and was desperate to feed it leading to a large number of scripts being written. She has since been arrested and charged,” she said. This stolen script episode is now part of Yvette’s learning experience as she heads for a career in general practice. “The pharmacy at Armadale called me asking to confirm a script for pseudoephedrine for a Mr X. I remembered the patient, as he had only presented four days prior. Just to make sure, I opened up my Communik8 letter on the computer and checked. I had only written him up for antibiotics and regular analgesia.” n Dr Shanil Yapa was an ED intern in a

public hospital, when it happened.

Shanil said her handwritten script was on a hospital script pad, that it could be filled at any community pharmacy, and a unique number on each script allowed pharmacists to track the hospital of origin. “What surprised me the most was how much effort some people would go to score some pseudoephedrine to support their drug habit.” 14

“This particular patient had added an item into the white space of the script I had given him at Armadale ED. But later on, I got another phone call from the pharmacy regarding pseudoephedrine prescriptions under my prescriber number and signature but on Sir Charles Gairdner Hospital script pads. I have never worked at SCGH. This patient had obviously stolen a script pad from there and was using my prescriber number to fill out forged scripts.” So how has this experience changed Shanil? “I am now a lot more vigilant and ever judgmental. If I feel a patient is dodgy or has documented past issues, I tend not to prescribe any narcotics. If I do need to write out a script, I make sure I cross out the white space underneath my writing.” When asked how systems could be improved, Shanil said documenting things for others was important, such as the notes ED triage nurses made in the ‘alerts’ boxes, before the patient saw the intern. She would like to see the same done on wards so doctors are more aware and can be more vigilant. “My particular patient was quite desperate to get his hands on some pseudoephedrine which is no surprise since he has had past admissions with methamphetamine overdoses.” Until systems change maybe history is set to repeat itself, as she has heard similar stories from consultants and registrars? “I hope we have a system in place to alert other staff to such patients and make sure serious legal action is taken because forging someone’s signature and stealing their prescriber number is a serious issue,” she said. n Dr Andrew Dennis is a

longstanding GP who relies on his experience to recognise addicts, but even he got caught out, his first time.

“I keep an old prescription pad on my desk, for home visits, whereas normally I do computer scripts. This guy came in from Albany requesting Oxycontin and he had nice pin-point pupils so I said to myself ‘I think this guy is a doctor-shopping drug addict’. I refused him and gave some valium to pour oil on the waters. I just choof these guys off.” He admits that patients like this end up going to another practice down the road and he has only used the doctor shopping phone service once or twice., yet on this occasion his ‘pass the parcel’ method did not work. “While I’m typing on the computer he sneakily stole my script pad and I didn’t notice it was missing. I get a call the next day, my day off, from the practice manager that a chemist some distance away is questioning a script of mine for Oxycontin because she knows my handwriting. It was faxed to the surgery and the practice manager instantly recognised it was not my writing.” “He has written his name and address on the script, the pharmacy have CCTV footage of him, and I gave them a good description, so the police went around to his address and, low and behold, my script pad was there on his bed! An open and shut case! He may as well have gone in there and said, ‘Here, arrest me’!” Although Andrew said the bloke involved may not have been the sharpest tool in the shed, he did manage to do some damage to Andrew’s confidence. “I haven’t got a script pad on my desk now. It’s in a locked drawer as no-one is going to do that to me again! Everyone in the practice is doing the same now,” he said. l

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The doctor-financial advisor relationship. It’s a matter of trust.

almost twenty years ago, Perth G.P. Dr Franz bumped into Brad Gordon at a friend’s wedding. And Brad’s been taking care of Dr Franz’s financial affairs ever since. ‘I met Brad purely by chance, but I’m so glad I did,’ says Dr Franz. ‘He introduced me to the way Entrust manages their clients’ portfolios, nearly ten years ago and I thought it was the perfect arrangement. Brad has my authority to buy and sell investments as he sees fit. He’s quite conservative, but very strategic, which suits my style of thinking.’ The big test of Brad’s strategy for Dr Franz came during the global financial crisis, which was felt by varying degrees by his clients. ‘I was lucky. A friend of mine in Germany told me he lost over half of his retirement savings.’ Dr Franz now only works a few days a week, and relies on supplementary income from his superannuation fund. ‘Brad’s always invested appropriately for my circumstances, and makes sure there’s always plenty of cash available for my immediate needs, like holidays. When I compare notes with my friends, I can see that their portfolios are nowhere in the same league as mine.’ I’m one of the fortunate ones. I have a financial adviser who I’m really happy with and, most importantly, can trust.

Entrust Private Wealth Management Pty Ltd Level 17, 140 St Georges Terrace Perth Western Australia 6000 Important Information. The circumstances described relate to a particular client and his particular circumstances, and are atypical. Investing in volatile and unpredictable markets car r y financial risks including the risk of loss of capital. Past per formance is not an indicator of future per formance.

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Telephone 08 9476 3959 Email info@entrustpwm.com.au Web www.entrustpwm.com.au AFSL No. 222152 15

Technology By Shane Cummings

Social Media Medicos Given the medical profession’s emphasis on a traditional approach to adopting change –particularly the older generation – it has been slow to embrace social media, but a few early adopters have been making their mark online. The term ‘social media’ includes Facebook, Twitter, blogging, Youtube (videos), and LinkedIn, amongst a very noisy crowd of sites clamouring for your attention. In a very short time, the social media phenomenon has transformed the way people interact, the means with which companies do business, and turned a steadily shrinking world into a genuine global village.

Why get involved? Social media is about wordof-mouth, and this is exactly what attracted ED consultant Dr Michelle Johnston (Twitter @ Eleytherius). n Dr Michelle Johnston

n Dr Marcus Tan

n Dr Dawn Barker

“There are some extraordinary medical bloggers from Perth, particularly people that I respect in the field of emergency medicine such as Dr Mike Cadogan and Dr Chris Nickson of Life in the Fast Lane [www. lifeinthefastlane.com] amongst others. Prior to reading their sites, I had presumed Twitter was about celebrities and ‘lesser mortals’ tweeting what they had for breakfast, with less than optimal spelling,” Michelle said. GP Dr Marcus Tan (Twitter @drmarcustan) was similarly influenced by Mike, whom he considers a “health IT and social media guru”, to join Twitter.

Other medicos were drawn to sites like Twitter to enhance their ‘voice’ while working on books or media. Childhood and adolescent n Dr Joe Kosterich psychiatrist Dr Dawn Barker (Twitter @drdawnbarker) joined Twitter because of her interest in writing. Similarly, GP Dr Joe Kosterich (Twitter @drjoesDIYhealth) opened up Facebook and Twitter accounts to help promote his book, Dr Joe’s DIY Health. He’s since used social networking to expand his media profile.

The right platform With so many social media sites to choose from (and on multiple formats: online, iPads, and smartphones), which one is right for you? 16

“A good analogy for Facebook is that it’s like a school reunion; Twitter is like a cocktail party; and LinkedIn like a professional conference, so they are actually quite different in their dynamics. I’ve linked all the sites up, downloaded the respective iPhone apps, and use Tweetdeck as a client to view and tweet,” Marcus said. Joe said it came down to a numbers game for him. “Facebook has more than 700 million users, Twitter more than 200 million users. That’s where it’s at. People go to Twitter to find out what’s happening in real time, as with the Arab uprising,” he said, adding, “I see LinkedIn as something for people in middle-management who might want to change jobs. It’s more for business networking.” To truly understand the reach of social media, at time of press, Joe had 40,487 Twitter followers (making him one of the most ‘followed’ doctors on Twitter in the world). If Joe’s followers lived in the same town, that town would be the 36th largest city in Australia (nudging past Orange, NSW, and streaks ahead of Kalgoorlie-Boulder, with ~32,000 residents). Such is the power of social media that ‘thought leaders’ like Joe can broadcast a message, and entire populations will read it, and more importantly, many will engage with that message. While Michelle describes Facebook as “mostly just fun”, she sees professional value in blogs and Twitter. “I have discovered the unbelievably rich world of the medical blog – sites written by amazing people all over the world. Medical Forum readers will be aware of the near impossibility of keeping up with the tidal waves of literature and medical opinions. Being selective about reading the opinions of those you respect, those who are actively engaged in discussion of relevant literature, has allowed me to become more focused in what I read. They do not replace reading the journals, but they streamline the process. Using Google Reader to subscribe to RSS feeds is invaluable to simplify this,” she said. Michelle added: “Twitter is a site of extremes. It takes some time to find your own niche. Like the internet itself, it seems to be 85% rubbish, and 15 % brilliance, and thus it does take a while to mould your own site to fulfil your own requirements. I have my own little ‘hashtag’ on Twitter where I summarise human pathologic conditions, in 140 characters, using laymen’s terms and slightly poetic phrasing: #path140. It really is of no global value, but it does seem to

Australia’s Social Media Snapshot Users per month as at June 2011 1. Facebook – 10.4 million 2. Youtube – 9.9 million 3. Blogspot – 5.6 million 4. WordPress – 2.3 million 5. LinkedIn – 2 million 6. Twitter – 1.9 million 7. Flickr – 1.5 million 8. MySpace – 1 million 9. Tumblr – 900,000 10. Digg – 160,000

amuse medical students with ADHD.” Dawn uses Twitter and Facebook, “but in quite different ways.” “I have had a Facebook account for years, and I use this solely to keep in touch with family and friends all over the world. My privacy setting are high: I post photos of my children and details of my personal life that I would not want to be publicly available. Twitter, on the other hand, is a professional networking tool for me,” she said.

Threat to the establishment? The AMA’s Social Media and the Medical Profession Guide (Nov 2010) is a cautionary document, with a focus on confidentiality, privacy, and doctor-patient boundaries. The WA Health Department is likewise cautious about staff using social media. In a May 2011 Operational Directive (Policy on Use of Social Media), the Department stated that use of social media (including while off-duty) to make ‘disparaging comments about WA Health and/or colleagues is a breach of an employee’s duty of fidelity and good faith which will result in disciplinary action and in some cases termination of employment’. “There is no question that medicos need to be extremely careful about the use of social media – primarily as there is a real risk of breaking

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AMA (WA) declined to comment on their social media policy. Dawn, meanwhile, saw the writing on the wall. “I think that it’s naive to expect doctors to resist the world of social media. Many professional organisations (including Medical Forum and the Royal Colleges) are active on Twitter, and I think that we have every right to do so, too,” she said. It all comes down to common sense. While our interviewed medicos had few, if any, negative experiences, as Joe said, “If people don’t like what you say, then they stop following you.”

Wanting to take the plunge? Marcus had specific tips for aspiring Twitter users: • Learn the basic terminology and different uses for Twitter by using the excellent guide: http://mashable.com/guidebook/twitter/ • Start on Twitter by following people, organisations, or groups in areas that interest you. • Follow the hashtag #hcsmanz, which is the Australia & New Zealand Social Media in Health Care group. It’s full of the who’s who of people using social media in health care settings.

confidentiality, even unwittingly so. Thus such guidelines are important,” Michelle commented. “Anything you post on any site should pass your own test of whether it would be suitable for a patient to read. Social media, whereby the Health Department has no right of reply, is also the wrong forum for posting criticism, so I do support this particular aspect. Other appropriate fora, though? Fair game.”

• Be patient, share, interact, but be mindful of how what you say could be perceived if it was found on the front page of the newspaper before you communicate it publicly via social media. “I would advise WA doctors to think about why they are using it. If it is to post comments about your weekend, and photos of that party you went to, then use Facebook and keep your privacy setting high. If you want to use Twitter, then see

it for what it is: an excellent way to keep up to date with information and network with other professionals and organisations. Just remember that every tweet is visible to everyone, so if it’s not something you would share with your patients, then don’t share it with Twitter,” Dawn said. Michelle agreed: “It’s worth taking your time when you start. It seems to take a while to develop your own voice. Find somebody you respect on Twitter and look at their ‘Following’ list to see who you might like to follow. There is a wealth of incredible people out there, including modern philosophers (such as Alain De Botton), writers, comedians, inspirational humans (the Dalai Lama is on Twitter!), news agencies, real time traffic notifications, and of course, medical professionals. Have fun, but have a filter.” Ed. One word of caution, though … any media person allowed into your Facebook site might gladly take and publish any photo or comment knowing that it would be virtually impossible to sue them for breach of copyright through Facebook, although in reverse, there have been instances of people suing for defamation for postings on Facebook. l

Connect with Medical Forum • Twitter: @MedicalForumWA

• Facebook: www.facebook.com/pages/ Medical-Forum-WA/206413212725470 • LinkedIn: www.linkedin.com/company/ medical-forum-wa-magazine • Online: www.mforum.com.au

Joe agreed with a common sense approach. “You don’t put anything on Facebook you wouldn’t say to someone’s face. The same applies to doctors. You don’t put anything on social media that you wouldn’t publicly say, such as patient information. To use a real world analogy, doctors are allowed to join the local tennis club and interact with people there. Even more so in rural areas, it’s likely you’ll interact with patients at these places. Nobody seems to think you can’t do that,” he said. But to Joe, strict social media policies from the medical establishment are about control. “I think the Health Department and the AMA may be struggling to make it into the 21st century. The Health Department as an employer has a right to set terms of employment, of course, but the Health Department, like most government departments, doesn’t like dissenting voices. For the AMA, it may also be an issue of control. They say they are the voice of the medical profession, and suddenly, there are 20,000 doctors with a voice on Twitter. Where does that leave them?” Joe said.

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n Unlike his younger colleagues, Dr Werther didn’t understand all the fuss about “Face Book”. 17

Sports Medicine By Peter McClelland

WAIS: Managing Sporting Success WAIS Medical Director Dr Carmel Goodman has the challenging task of helping to mould WA’s youngsters into tomorrow’s sporting superstars. Whether it’s hurtling down a white-water course in a slalom kayak or ripping an offforehand down the line for a scorching winner on the tennis court, one factor remains crucially important – it’s absolutely imperative that young athletes competing at an elite level have a professional and effective musculoskeletal management program in place. And for all those aspiring champions at the Western Australian Institute of Sport (WAIS), that’s where specialist sports physician Dr Carmel Goodman comes in. Carmel, who consults at Challenge Stadium, has been the Medical Director of Sport at WAIS since 1998 and plays a pivotal role in coordinating and managing the full spectrum of medical services at the Institute. Dr Goodman was an elite athlete in South Africa during the 1970s. “My passion as a young person was swimming. I absolutely loved

n Dr Carmel Goodman puts tennis sensation Casey Dellacqua through her paces.

competing, and as a very proud South African, it was a real highlight to represent my country as a junior swimmer.”

screening involving everything from fitness and physical conditioning, dietary supplements, and an athlete’s individual educational requirements.

Carmel is still a very keen distance runner with regular early morning training sessions leading up to half-marathon races.

Coaching parents

WAIS’s role “We’re really talking about elite and highly competitive athletes here at WAIS,” said Carmel. “I’m the national team doctor for hockey and rowing, so it’s vitally important that I play an active role in managing the medical side of things here at WAIS.” It’s a highly rewarding role and one which Carmel Goodman takes very seriously. “To watch these young people come into the WAIS program and develop into successful competitors is absolutely wonderful. But to achieve that level of excellence, we have to monitor and manage them very carefully.” For Carmel, that means regular and rigorous

“Sometimes, the most difficult aspect of the job is dealing with parents,” said Carmel. “This is particularly relevant in the WAIS tennis program. Trying to understand and moderate the behaviour of some parents can be quite frustrating.” Quite often, Carmel and her medical team feel compelled to point out the potentially serious consequences for young athletes who attempt to play through the pain barrier. “As a parent myself, it never ceases to amaze me how some parents push these boundaries.” One parent who’s very aware of his role is Graeme Allan, father of 17 year-old Robert, who is a member of the WAIS National High Performance Tennis Academy. “I don’t want to blow my own trumpet, but as parents, I

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Sports Medicine

think we’ve got it about right. We took it very slowly in the early stages with Rob’s physical development and it’s certainly paid off. Now he’s rated as one of the best athletes on a tennis court in his national age division.” Graeme also pointed out the importance of making a clear distinction regarding the lines of communication. “When I feel there’s a need to say something about Rob’s on-court performance, I’ll speak with his coach first. First and foremost, I want to be his father, not someone who interferes with the technical side of his tennis game.”

The role of dietary supplements One thing that Rob and his parents don’t feel the need for is dietary supplements – and that’s just fine by Carmel. “I’m a firm believer in sports drinks – when an athlete’s dehydrated, water’s just not enough at this level. But that’s definitely not the case with supplements. A balanced, healthy diet

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with plenty of fresh fruit and vegetables is more than adequate,” she said.

readily available products. Some of them sit there on supermarket shelves!

Quite apart from artificially pushing the training envelope and increasing the risk of serious musculoskeletal damage, supplements such as protein powders have another potentially disastrous consequence.

“For a young athlete, a balanced diet with sufficient carbohydrates and proteins is easily achievable with the usual food groups, particularly fresh fruit and vegetables,” Carmel said.

“We’ve had some unfortunate cases of inadvertent doping linked with dietary supplements,” Carmel said. “The big problem with supplements is that there’s no effective control regarding either their content or their use. That’s led to a few athletes testing positive, so now we have a blanket ‘no supplement’ policy here at WAIS.”

High performance role model

Dr Goodman went on to point out that the athletes concerned were not attempting to gain an illegal competitive edge. The central issue is really the lack of control over the supplements themselves and an individual athlete’s level of knowledge in relation to the effects of these

“I always encouraged my daughters to engage in sporting activity,” said Carmel. “As you can see, I’m very serious about sport, but it’s much more important to participate than to win. And that’s something I’ve told my own children.” l

Carmel’s own children have followed their mother’s example – one daughter, Dr Jodi Cartoon, is training as a psychiatry registrar at Fremantle Hospital and is a very keen longdistance runner. In fact, when Medical Forum spoke with Jodi, she was preparing for the Fremantle Half-Marathon.

Spotlight By Shane Cummings

Painting a Powerful Picture Confronting social injustice in his artwork is a strong motivation for Shaun Tan, WA’s latest Academy Award winner. If you have kids, you’ve probably heard of Shaun Tan. He has sparked the imaginations of the young – and the young at heart – for the past two decades with his charming, bizarre, and sometimes confronting art. Unlike many other illustrators whose message is toned down for children, Shaun has tackled significant social issues head on. Capping a spectacular rise to prominence (with various important literary and illustration awards under his belt), WA-born and bred Shaun won an Academy Award earlier this year for his animated short film, The Lost Thing. But had his life taken a different turn, the Oscar winner could have been working at WAIMR as a genetic scientist instead. “My older brother is a geologist, and my Dad studied civil engineering and architecture, so my family is inclined towards science and engineering. My best subject in high school was not art, actually, or even English literature – it was chemistry and physics. My interest in genetics had two causes: a fascination with evolution and an inkling in the late 1980s that genetic engineering would be the next big thing in the future, a wetter version the IT revolution, and it could present a good career,” Shaun said. “In the end, however, my love of painting and literature won out, and at the last moment, I diverted from biotechnology to an arts degree. But I still maintain a casual interest in science. I don’t see it as being so different from the arts – it’s all a critical investigation of reality, after all.” With illustrated books such as The Rabbits and The Arrival, Shaun has brought sharp focus to significant social issues such as the stolen generation and immigration. “I rarely set out to make a political statement or deal with a ‘big issue’. That’s something that just seems to emerge in the process of drawing 20

much more trivial things, such as a man holding a suitcase, standing in front of a strange creature. It then occurs to me that it’s a picture of an immigrant situation, so I begin to explore that area, but there is no conscious agenda to address refugee issues. They just emerge of their own accord and are very moving on a personal level.” Social justice is an to a single person in a important issue to Shaun. ‘Why’ questions are the narrative context, everyone He said he is not motivated fuel for any artistic, academic, or immediately empathises by political ideology, but with that one example and he is moved to write and scientific practise their imagination proceeds paint about injustices to stretch outwards. The as a way to understand problem is grasped in hearts more effectively how they can happen. He cites The Rabbits than minds.” (his collaboration with bestselling children’s With the surreal and bizarre creations in author John Marsden), which substitutes rabbits his books, some may speculate that Shaun’s for European colonists and native animals as work could be too dark for children and the indigenous people in a fantasy depiction of underlying messages too complex, but Shaun Australian colonisation, as an example. disagrees, arguing that it’s a “publisher’s “[Social injustices] generate very strong ‘why’ problem.” questions, and these are the fuel for any artistic “I remember being a kid and actually enjoying practise – or academic or scientific practise, a greater range of things than adults gave credit for that matter. I’m sure medical professionals for – and also understanding a lot more. In identify this, too. We are naturally drawn to any case, a lot of my work does not need to be examine things that are not in equilibrium; ‘understood’ as such. It can be enjoyed on many they play on our minds. Children, too, are levels, and you take from a book whatever you naturally very anxious about social injustice, bring to it; it’s a highly reflective medium. The as if this is our innate nature, something that only moral, if there is any, would be something risks being corrupted or suppressed, at times, in like ‘life is strange and interesting’. Kids can adulthood.” probably relate to this even more strongly than Shaun’s advice to doctors in speaking their adults.” mind on social issues is to focus on the human Shaun’s next big project – and another possible story. Academy Award opportunity – could be “Big ideas begin as small, personal ones. a feature film adaptation of his criticallyStories work because they avoid abstract acclaimed graphic novel The Arrival, but he generalisations; they focus on specific details said it is “very speculative, and if it occurs, it’s at a good scale for human imagination and a long way off.” sympathy. For instance, if you say that an “Right now I’m working on a much simpler injustice affects so many thousands of people project: a picture book about two brothers statistically, people may not be moved at all enjoying weird adventures on their summer (even though they ought to be). If you present holidays.” l one single story of that injustice happening

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Organ Transplantation By Dr Rob McEvoy

Transplant Performance Hurry-up Every kidney, lung or liver is potentially life-saving, which is why recipients think differently to administrators in judging Australia’s transplant performance. ShareLife, the independent lobby group for reform of organ transplantation in Australia (www.sharelife.org.au), is keeping the heat on DonateLife branches across Australia, saying they should be doing better. Back in 2007-08, ShareLife took figures from places like Spain, Belgium, France and the United States to show Australia was under-performing in the organ donation stakes. The federal government agreed and adopted their reform package, committed $151m, and established the Australian Organ and Tissue Transplant Authority to both nationalise and improve organ donation performance. DonateLife branches were born, but Sharelife co-founder Mr Marvin Weinman recently suggested implementation has not been truly ‘best practice’ and results are disappointing, over two years and $100m later. Amongst those disappointed within Sharelife are some with personal experiences around organ transplantation, who know how it feels to wait desperately. They simply want Australia to achieve similar transplantation rates to the leading countries, and the quicker the better. The Organ and Tissue Authority (OTA) currently funds the DonateLife Australian network of 233 staff made up of 162 clinical specialists in 77 hospitals and 71 staff in eight specialised organ donation agencies across Australia. WA’s DonateLife office

Fig 1. Annual Transplant Recipients per Million Population (TRPM) 2008

2009

2010

June ‘11

‘08 to ‘11, % Change

43.9

28.2

30.0

35.3

-19.7%

Australia

39.6

36.5

41.7

43.2

9.2%

has appointed an extra 11 doctors and nurses across nine hospitals. At the core is 14 DonateLife agency staff that co-ordinate the network hospitals and their specialist nurses, provide Donor Family Support services, and administer the agency – a total of 25 people led by State Medical Director Dr Kevin Yuen. Since OTA was established nationally in January 2009, Sharelife has been publishing their performance and in June 2011 it said that yearly transplant recipients per million population (TRPM) has only increased from 39.5 in December 2008 to 43.2 in June 2011, an increase of 3.7% per annum, and that’s after $100m has been spent on the problem. The figure they give for WA is worse – a 19.7% decline over the same period (see Fig 1). ShareLife says 90 TRPM is the achievable goal that compares favourably with top performing countries overseas, which means at current rates, 1,056 more Australians are missing out on a transplant (compared with the 976 actually transplanted between July10 and June11). For anyone trying to make sense of things, benchmarking figures seem at odds. Absolute transplant numbers in Australia are small and

quoting recipient vs. donor figures is confusing – multiple organs can be harvested from a single donor and one recipient can receive multiple organs. When figures are quoted from the donor side, high achievers like the Gift of Life Donor Program in Philadephia, USA, tout figures of 40 organ donors per million population, averaging 3 organs transplanted per donor. Another confusing example - DonateLife talks about WA achieving 37.2 organs transplanted per million population in the year to July 2011, whereas Sharelife quotes 35.3 transplant recipients per million (the difference explained by people receiving multiple organs?). Of course, the perspective of someone working for government is going to be different to someone sitting on a dialysis machine. It is encouraging that TRPM figures have gone up since OTA was established. On the other hand, Sharelife says the rate of increase is unacceptably poor and they point to only a small increase in ranking Australia has undergone amongst 62 countries in organ donation and transplantation figures (from 24 in 2008 to 28 in 2010, Council of Europe 2011 data). They point to the comparatively poor performance of Australia in the first three

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Fig 2. Donors per million population Year 1

Year 2

Year 3

% Change

Spain since 1989

14.3

17.8

20.2

41.3%

Australia since 2008

11.9

11.1

13.8

16.4%

Croatia since 2006

12.9

13.2

17.9

38.8%

Portugal since 2006

20.1

23.9

26.7

32.8

without any additional funding, extra staffing, training etc.”

years of the newly introduced program, up against European countries that did similar (IRODat and Council of Europe Reports, see Fig 2).

“The stage was set for rates to further increase with the establishment of the national authority and the employment of staff. But alas, the implementation was marred with confusion, and the rates for 2009 declined. Why? Those who had controlled the space with all the failed initiatives over the last 20 years remained in control. Were any of those who had catalogued the Reform Package involved in the implementation? Why not?”

Moreover, they say 2008 was a good year for transplants n Mr Brian Myerson in Australia for good reason, as Sharelife committee member and transplant recipient Brian Myerson explains.

“Slowly the rates have improved but with such a large injection of funds (greater than any other country on a per capita basis) the increase should have been at a far greater rate.”

“Exceptional years do not happen just out of the blue. During the first half of the year [2008] ShareLife engaged with DoHA, politicians and many intensivists and ‘transplanters’ while cataloguing the proven best practices of the leading countries. This generated an amazing amount of enthusiasm within the transplant community. Those in the hospitals were enthused resulting in the increase in the donation for transplantation rates. This showed what could be achieved

“The Reform Package must be implemented in its entirety to effectively achieve the goal set by the PM to ‘establish Australia as a world leader in organ donation for transplantation’. The $150m was to achieve the goal in the fouryear term, not to achieve a slow increase in transplantation rates.”

DonateLife’s response to ShareLife is to quote national figures of “the highest donation and transplantation outcomes [in 2010] since national records began with 309 organ donors saving or improving the lives of 931 transplant recipients. This equates to a 25% increase in the number of deceased organ donors over the 2009 outcomes and a 17% increase in the number of transplant recipients nationally.” Sharelife acknowledges that these figures are correct but says a 25% improvement on an already poor performance loses meaning, especially when improvements each year have not matched other countries in similar circumstances. DonateLife explains further; “While these are encouraging results, it is acknowledged there is much more work to be done. Implementing a clinical reform agenda in organ and tissue donation takes time - as borne out by international experience. Spain, for example, took ten years to implement its national reform agenda and to build up to its present donation rates.” Sharelife says people on the transplant waitlist do not have time. DonateLife counters that most of the measures suggested by ShareLife are being implemented and consent and request rates are high in WA, showing awareness has increased. l

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5/07/11 11:34 AM

General Practice

Year 12 Exams: Sickness Exemptions With the pressure of Year 12 exams this month, many students will buckle under the strain with illness. It falls to GPs to exempt them. This year, more than 16,000 WA students will look up at the clock, open their exam papers, and groan loudly. The Western Australian Certificate of Examination (WACE) period – formerly known as the Tertiary Entrance Examination (TEE) – begins this month.

especially if their request for special consideration is denied. • Evidence of sickness is required if a candidate does not sit an exam. GPs are to use their discretion regarding exams occurring on consecutive days.

It’s a tense time for Year 12 students, and in 2010, more than 700 students applied to the Curriculum Council for special consideration due to sickness or misadventure within the exam period. The sick and injured are strewn all over the WACE war zone – it’s a battlefield out there! The following information should make life a bit easier for GPs who are assessing sick or injured Year 12 students: • The sickness/misadventure period begins two weeks before a candidate’s first written examination and lasts until the exam schedule is complete. • Candidates should sit the exam if possible. It will give them the added protection of actually recording a mark. That’s useful,

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• If a candidate sits an exam while unwell, they should obtain medical evidence within two days of the exam. After that time, the evidence will not be considered. • All details must be on the prescribed form – available from schools, exam centres, and www.curriculum.wa.edu.au • Doctors should clearly explain the relevancy of the stated medical condition. • The sickness/misadventure process is not applicable to students with minor ailments. • Examination anxiety is not accepted as a valid reason for special consideration.

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Guest Column

Social Media Lessons Social media expert Damien Cummings applies corporate principles to doctors testing the social media waters. Social media presents considerable commercial risks and opportunities. On one hand, there’s a risk that employees could say the wrong thing – anything from inappropriate comments about or to customers, offensive remarks, inappropriate behavior, or even releasing confidential company information (often inadvertently, but in the worst case scenario, deliberately). The opportunities, however, hugely outweigh the negatives. No longer are big companies faceless corporations. The real people within a brand can talk directly to customers – the guy who designs a product can have a meaningful conversation with customers who use it; feedback can be given directly to staff developing, managing, or supporting a product; and of course, customers can talk to each other about their experiences. Much of this applies to the medical profession. There are lessons from the world of business that can be of great benefit to patients and a real professional advantage for doctors who have the courage to embrace these new opportunities early on.

actually ever seeing the patient)? And of course, there’s a challenge in maintaining the time required to “seed” content into these communities, directly respond to patient enquiries, and maintain your Facebook, Twitter, LinkedIn (etc.) profiles.

The opportunities There’s a real opportunity to differentiate your practice and be seen as a medical thought leader because of your presence in social media. Patients talk. Social media amplifies this talk in an unprecedented way. Social media is fast becoming the preferred method for patients to understand their health and how to get the best treatment. Previously, I worked with a baby milk brand who was marketing their products directly to pregnant women in the early stages of pregnancy. Their entire customer relationship management and engagement plan was based around one key customer insight – in the early stages of pregnancy, there is a large amount of doubt and risk. In those first three months of pregnancy, mothers will not reach out to their families and friends, but they will turn to strangers anonymously to understand if what they’re going through is normal, what they should expect, and to understand what they should do next. The brand’s strategy involved mothers managing their communities (Facebook, Twitter, Blogs, etc.), being available via online chat, as well as a more traditional call centre/telephone option. This remarkable strategy was the core pillar of their marketing and has built enormous loyalty (close to 90% of mothers choose to stay

Patients talk. Social media amplifies this talk in an unprecedented way.

The risks

Doctors face a dilemma in both engaging patients directly through social media and in managing social media platforms (like a Facebook page or blog) where patients can meet and swap health information. Should you be too involved in a patient’s life? What if people come to the wrong conclusion about a medical procedure or diagnosis (made worse by the social media community validating that diagnosis, without

with the first baby milk brand they choose. This is up to 4–5 years of brand loyalty.).

Getting started Take the plunge into social media by listening. Whether this is watching medical or health forums, or your own Facebook or Twitter profile, or all the way up to working with a specialist provider of social media listening services, depends on how deeply you want to engage. At Dell, where I am Online and Social Media Director Asia Pacific, there are 25,000 daily conversations about the brand. We use a global software tool called Radian6 to monitor those conversations. It’s as simple as setting up “key words” in the web-based software. For Dell, its phrases like “Dell”, “Laptop” and “Alienware gaming laptop”. For doctors, this could be anything from symptoms to medicines to medical procedures. The important thing is that you, or someone you trust, is listening. Then it’s a matter of thinking about your social media presence as an editorial calendar. Social media is not static – it’s constantly evolving and needs to be continually updated. If you’re setting up a Facebook profile for your medical practice, consider having at least a 6 month editorial plan and plan to make at least one daily update (4 – 12 updates per day would be ideal). It is critical to really engage. Whether it be a simple acknowledgement of someone’s question, or publishing an in-depth research report or article, just get out there, start engaging, and you’ll see tremendous benefits. Ed. Damien can be reached on Twitter on @damiencummings and his Blog “Digital Future” http://damiencummings.blogspot.com. l

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Guest Column

Turning the Tables on Chronic Pain? Painaustralia CEO Lesley Brydon believes Centrelink does not adequately take into account chronic pain with its new Disability Impairment Tables. The predicament of many people who suffer chronic pain has been ignored in the recent review of Centrelink’s Disability Support Pension Impairment Tables, which determine who does – and doesn’t – qualify for a disability support pension. It is of particular concern that the review dismisses pain as a “symptom”, completely overlooking the growing body of evidence that chronic pain becomes a disease in its own right. This is surprising given the impressive clinical line up in the review panel – but may be explained by the fact that it did not include a pain medicine specialist. Consequently, the remarkable advances in neuroscience and medical knowledge made over the past decade have not been taken into account. Working with people in pain, I have come to realise that knowledge about chronic pain in the community is about where depression was thirty years ago. In those days, depression was often dismissed as weakness of character – an inability to cope with the ups and downs of life. However, medical research and community awareness campaigns have changed that, to the point where politicians and superstars everywhere are prepared to talk or

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write about their battles with depression. Not so with chronic pain. People who live with severe debilitating pain continue to be stigmatised. Many feel they cannot talk about their pain. They are not taken seriously by friends and family or even by the family doctor. It is an indictment on much the medical profession that many fail to embrace the fact that pain is real and those who suffer chronic pain are not simply weak, but like people with depression, victims of an unfortunate biological reality.

Knowledge about chronic pain in the community is about where depression was thirty years ago. Whilst pain is associated with many of the conditions that would be assessed under tables relating to functional impairment – for example, of the upper or lower limbs, spinal function, etc. Others, for example, with severe migraine, might be assessable under criteria for brain function or mental health function. This does not acknowledge the biological reality of chronic pain, and in some instances, is likely to perpetuate the stigma.

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The recent report by the US National Academy of Sciences, Institute of Medicine, Relieving Pain in America, states: “Chronic pain has a distinct pathology, causing changes throughout the nervous system that often worsen over time. It has significant psychological and cognitive correlates and can constitute a serious, separate disease entity.” Much of the research that has led to this knowledge was conducted in Australia and constitutes a key focus of the National Pain Strategy. There is no doubt the existing Impairment Tables were due for an over-haul. Previously, pain was dealt with under a grab bag of conditions including malignancy, morbid obesity, HIV infection, organ transplants, and other “miscellaneous” conditions. The new tables are a step up from this. However, they fail to take into account new knowledge or to address the stigma of chronic pain, in an enlightened, humane, and ethical manner. Let’s hope it’s not too late to remedy this. l Ed. References available on request.

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Podiatric Surgery Dr Rob McEvoy

Podiatric Surgeons Claim Their Place A group of podiatric surgeons are emerging with the skills to compete with general surgeons and orthopods over surgical management of foot problems. The Australian College of Podiatric Surgeons (ACPS) recently held its Annual Scientific Symposium at Burswood, and it lists 23 podiatric surgeons on its list of accredited specialist surgeons, including two based in the USA and seven in Perth, which includes current president Mr Mario Horta. Training appears to be based on the USA model. Reading between the lines, national registration of podiatric surgeons appears to have allowed them to organise so they can deal with an ongoing turf war over what surgery podiatric surgeons should be trained to do. The ACPS conference program included sessions on complex rearfoot surgery, surgical management of lateral ankle instability, and surgical management of the rheumatoid forefoot, all surgery seen in most three-year US residency programs in podiatric surgery. [The writer remembers anaesthetising for a USA-trained podiatric surgeon in the 1970s – he was often repairing prior surgery done by orthopaedic surgeons but was not acknowledged for his skills by others.] The other turf war appears to be over who should train them. As if on cue, UWA has announced a new podiatric surgery clinic to offer reduced fees for elective foot surgery patients and provide training for postgraduate students. The facility is licensed by WA Health as a Class-B Day Hospital and UWA is keen to make it part of the teaching of podiatric medicine within their Faculty of Medicine, Dentistry and Health Sciences. While UWA says teaching podiatry in a medical school is unique to UWA, the extension that now includes podiatric surgery may not go far enough for the rival ACPS.

Bryant explained to Medical Forum that the new Podiatry Board of Australia is the regulatory body for podiatry, including deciding where the foot ends in terms of surgical problems tackled by podiatric surgeons, and if they are suitably trained.

three year Doctor of Clinical Podiatry program to qualify as a podiatric surgeon, following a period of general practice experience.”

“Podiatric surgeons should restrict their scope of practice to elective foot surgery of conditions that have traditionally been managed by podiatrists – ingrown toenails, corns, calluses, claw toes, hammer toes, hallux valgus, hallux limitus/rigidus, heel spurs, etc.,” he suggested.

In 2013, UWA will replace its undergraduate course with a graduate entry three-year Doctor of Podiatric Medicine program. You will need a 3-4 year Bachelor’s degree with a minimum Grade Point Average of 5.5 and a pass grade in the GAMSAT examination.

From these comments we gather that UWA podiatric surgery training is not as advanced as that promoted by ACPS members.

“Improving interaction and communication between medical practitioners and podiatrists/ podiatric surgeons is necessary to provide an enhanced interdisciplinary approach to patient care. In a limited fashion in the UK and certainly in the US, podiatric surgeons undertake various medical and surgical rotations during their training and on qualifying work collaboratively with orthopaedic surgeons in hospital departments and in private practice,” Alan explained. In WA, podiatrists and podiatric surgeons operate privately and you do not need a referral. Podiatric surgeons have operated in this state on that basis since 1979. “I believe that gradually the medical profession is coming to accept that podiatric surgeons have a valid role to play in the care of patients, probably being driven by the patients themselves to a large extent,” he said.

“The Faculty of Medicine, Dentistry and Health Sciences is now the sole provider of education and training of podiatrists in WA and presently conducts a four-year undergraduate Bachelor of Podiatric Medicine course to become a general podiatrist and a

Accordingly, private health funds have lifted their game and usually provide rebates for hospital and theatre charges and some funds also provide a rebate of approximately 50% of the podiatrist’s surgical fees. Unfortunately, the specialist anaesthetist is not covered. You have to ask, why not? l

UWA Prof of Podiatric Medicine Mr Alan

MDA National’s New HQ Medical defence organisation MDA National has been something of an institution for WA medicos for almost 90 years, and this month, they’ve revamped their presence in their home state, relocating to a new 2876 square metre building in the Perth CBD. MDA’s WA team now both own and occupy the entire third floor at 88 Colin Street, West Perth. MDA National President, A/Prof Julian Rait, said that the move represents a significant milestone in the organisation’s 86 year heritage and clearly demonstrates both the long term financial

stability of MDA and a high degree of member loyalty. “We support more than 90% of WA’s medical practitioners, and to have our own flagship office in Perth is a celebration of our wonderful legacy.” The new office was purchased nearly three years ago and will be the national operational cornerstone for MDA National. “There’s a growing demand for member support services here in WA and we support approximately 24% of medical practitioners in Australia.”l

Guest Column

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

Medical Director Dr John Yovich

Prostatic Utricle PIVET has reported previously the findings from its longstanding policy to undertake ultrasound scanning of the genito-urinary tract of all males in an infertility setting, regardless of the semen analysis profile or factors identified in the female. Dr John Yovich

In May 2009, we reported on a high rate of identifying pathologies in males who were otherwise asymptomatic. These included Microlithiasis (“stars by night”) in 6%, Cystic Ectasia of the rete testis in 1.2% and suspicious testicular tumour scans in 1.2%; confirming malignancy in almost 1%! The enclosed transvesical scans reveal a 1.5cm cystic lesion in the prostate gland of a completely asymptomatic young male being the husband of a wife with premature ovarian failure; the management will be focused on donor oocytes.

Transverse and longitudinal views of prostatic utricle

Prostatic Utricle can be an incidental finding in up to 1% of male scans. It is thought to represent vestigial Mullerian ducts at their point of fusion, failing to fully regress. This may be a simple dimple in the prostatic urethra or a full cyst. It is usually asymptomatic unless it impacts on the ejaculatory ducts or develops calculi; in which case surgical treatment can be required i.e. Cystoscopy to marsupialise the cyst. In this case, the semen profile was essentially normal but with low volume at 0.2ml and normal pH 8.2. His reproductive hormones and chromosomes were also normal but further investigations such as trans-rectal scanning and MRI should be considered as the cyst is left of the midline and may be compressing the left ejaculatory duct.

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

By Prof Danny Green, Winthrop Professor of Exercise Physiology, School of Sports Science, Exercise and Health, UWA

Exercise in Prevention: Less Couch, More Coach I vividly recall the first talk I gave as an enthusiastic PhD student to a room full of busy cardiologists. After proselytizing the “undoubted benefits of exercise and cardiac rehabilitation”, a senior consultant stood up and solemnly said “.... one is born with a certain number of heart beats .... the more you exercise the quicker they get used up”. I’m still not sure he was joking. More recently, through the era of ‘block-buster’ drugs, the suggestion that exercise may be important has been met with “Prevention should consist of making sure patients are compliant with their drug regimes”. The truth is that the effects of exercise on traditional risk factors are, on average, relatively modest compared to drugs. Even if exercise is a “poly-pill” and the benefits on each risk factor summate, they probably do not approach the combined impact of drug treatment with agents like statins and ACE inhibitors. Nonetheless, exercise (or increased fitness) is associated with ~30% CV risk reduction, relative to “usual care” (read “inactivity”). In cardiac rehabilitation studies, this level of benefit is additional to that associated with optimal contemporary medical and interventional management. Interestingly, analysis of the Women’s Health study suggested that only half of the risk reduction associated with exercise is accounted for by impacts on risk factors. For several years we have been studying the direct impacts of exercise on the vasculature. Exercise induces profound changes in artery function and structure, largely mediated by the repeated impact of increased arterial blood flow and pressure on the cells of the artery wall. Just as episodic exercise is a stimulus to skeletal muscle hypertrophy and increased strength, repeated exercise has direct effects on cells of the artery wall that are anti-atherogenic. For instance, the brachial arteries of the racquet arm of elite squash players are much larger than their opposing limb and the arterial wall thickness in athletes is also affected by exercise training. Such beneficial effects have been observed in conduit arteries, associated with catastrophic CV events, and in smaller arteries that control blood pressure. Benefits are evident in coronary and peripheral arteries in asymptomatic subjects and those with CVD. Finally, there is evidence that the vascular impacts of exercise are systemic; e.g. leg exercise induces upper limb vascular adaptation. The point is that exercise is beneficial, even in those patients who may not manifest obvious changes in risk factors. But are exercise and prevention really relevant in an era of effective drugs and interventions? In a small study completed by a German group, the effects of optimal interventional management of CAD, including stenting, were directly compared to exercise training. Both groups received comparable medical management. After 12 months, the “stent” group exhibited markedly decreased stenosis diameter, whereas the exercise training group, who did not have an angioplasty or stent, exhibited no change in lesion size. No surprises there. But the exercise group had significantly higher event-free survival. Exercise exerts beneficial effects in the entire arterial bed, whereas stents apply a band-aid to a focal lesion. The authors, a group of cardiologists, concluded that in contrast to exercise training, “...coronary interventions must be regarded as a palliative therapy with regard to the underlying process of atherosclerosis.” Obviously, current management strategies are worthy and effective. But the benefits of exercise are real, large and predominantly unexploited. References available on request. Ed. Danny will be speaking at the upcoming Science & Sport in Medicine national conference, in Perth, October 19. See http://sma.org.au/conference/program/ l

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C L I N I C A L

hile few doubt the benefit of exercise and activity in promoting general health and well-being, the specifics of exercise and activity prescription can be complex. Interpreting and applying the many different guidelines can be challenging. Although it is exciting to deal with elite athletes and international sport, a great deal of work in sports medicine involves assisting people to return to activity following injury or surgery. The scientific techniques of rehabilitation and motivation that have been developed can offer a great deal to others striving for a greater level of physical fitness.

During last year’s Sports Medicine Australia conference at Port Douglas, Prof Bengt Saltin outlined the history of exercise physiology in Scandinavian countries where much of the research into the benefits of exercise and activity comes from, assisted by extensive health service databases and a population that cooperates with community programs. It is unlikely that residents of adjacent apartment buildings in Perth would enter separate activity programs and consent to having such things as body fat, immune markers, lipids and insulin levels measured but it is this kind of research that provides dramatic evidence of the health benefits of simple activity programs.

Inactivity is unhealthy More recent research turns exercise physiology on its head by proposing that inactivity is an unhealthy state. Quite worrying rises in unhealthy metabolic markers were observed in university students when they were required to be as inactive as possible. Data in cohorts of office workers using sensitive GPS systems and potentiometers reveal quite marked differences in activity levels during a normal working day. There is emerging evidence that regular activity

throughout the day may be equally as important to physical health as regular bouts of exercise. While this research may give us more ammunition to encourage our sedentary patients to increase their daily activity, this is difficult to achieve. A team approach can help. Many sports medicine practitioners work in multidisciplinary clinics with nurses, podiatrists, physiotherapists, exercise physiologists, occupational therapists, dieticians, and massage therapists. This team approach is already established in rehabilitation.

Community approach essential Research in activity and exercise also focuses on community interventions. For example, considerable health gains were achieved by enrolling fathers in a school program with their sons – simple exercises and activities together at the school gymnasium – with important gains still observed at one year follow-up. Providing an environment conducive to exercise is important. Evidence is emerging of important gains in physical and social well-being when cities close streets to car traffic on a day during

By Dr Peter Nathan, Sportreat, Palmyra.

Key Points

• Exercise programs may not lead to weight loss unless combined with healthier eating patterns. • General health will improve with exercise and activity even if weight loss is modest. • Including more regular activity throughout the day may be just as important as intense exercise sessions. • Start slowly and build up gradually.

• If in doubt seek advice from health professionals.

a weekend. Providing safe areas for families to exercise and socialise is very important. Other cities are exploring the benefits of providing safe cycle-ways for city commuters, thereby improving the health of the commuters and reducing inner-city congestion and pollution. Ed. Following a recent fall Peter Nathan is confident he will be back on his bike and commuting to the Esplanade. n

A M A Z I N G

Respiratory Services

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U P D A T E

Activity, Attitudes & Sport

Guest Column

Eye Surgery Foundation Our Vision Is Improved Vision

By Mr Craig Carmichael, Provider Support, Drug & Alcohol Office

Helping Curtail Opioid Dependence in WA The limitations and time constraints in modern medical practice mean that assessment of pain conditions can be challenging. Additionally the difficulty of identifying and responding to drug-seeking behaviour is a dilemma faced almost daily by medical practitioners. Prescribing practices and patient demands have led to an increasing availability of drugs like oxycodone. A recent study by the National Drug Research Institute published in this month’s Medical Journal of Australia identified a 152% increase in prescriptions for oxycodone within a five year time period.

• Perth’s only freestanding Ophthalmic Day Hospital • Supporting ophthalmic research and development • Certified to ISO 9001 Standard Dr Ross Agnello Tel: 9448 9955 Dr Ian Anderson Tel: 6380 1855 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco D’Souza Tel: 9258 5999 Dr Graham Furness Tel: 9440 4033

Dr Richard Gardner Tel: 9382 9421 Dr Annette Gebauer Tel: 9386 9922 Dr David Greer Tel: 9481 1916 Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156 Dr Brad Johnson Tel: 9381 3409 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

Expert day surgery for • Cataract Extraction and Lens Implant • Pterygium • Glaucoma • Oculoplastic Surgery • Strabismus • Corneal Transplant • All types of Refractive Surgery – LASIK, LASEK, PRK, CTK, Phakic Lens and Refractive Lens Exchange (RLE)

Contact: Matthew Whitfield Ph: 9216 7900 Email: info@eyesurgeryfoundation.com.au 42 Ord Street West Perth WA 6005 38

Opioid medications have a legitimate place in the treatment of pain in general practice. To assist in identifying appropriate treatment pathways, the Drug and Alcohol Office in conjunction with the WA Department of Health, produced a resource kit for GPs on Managing Chronic Non-Malignant Pain with Opioids. The kit includes clinical guidelines, details on WA regulatory requirements, treatment contracts and signage for surgeries. Dealing with drug-dependent patients presents a range of unique issues. Under the WA Poisons Regulations doctors must undertake additional training to be able to prescribe the two forms of pharmacotherapy that are approved for the treatment of opioid dependence - methadone and buprenorphine. There is a need for more authorised prescribers in WA with less than 4% of GPs being able to provide this form of treatment. Community Program for Opioid Pharmacotherapies (CPOP) clients meet the criteria for Mental Health Care Plans, and in the initial stages of treatment require regular reviews, meaning that the remuneration under Medicare, while not extravagant, does provide a regular income stream. Many GPs have the misconception that becoming an authorised prescriber may create a ‘honeypot effect’ of drug-seeking patients flooding their surgeries. The reality is often the opposite. GPs who become part of the CPOP find they develop skills in responding appropriately to issues of opioid dependence. The support provided by the program in terms of guidelines and education, as well as clinical support and greater knowledge of the drug treatment sector, enhances medical practitioner confidence and skills in dealing with other alcohol and illicit drug-related presentations. CPOP prescribers quickly learn that opioid dependence cuts across social and economic classes and the provision of treatment allows doctors to play a valuable part in improving their patients’ health and social functioning. To obtain copies of the GP Resource Kit or get details on CPOP Prescriber Training contact the Coordinator of Provider Support on (08) 9219 1896. Any doctor who requires clinical advice on any drug and alcoholrelated treatment issue can contact the Clinical Advisory Service on (08) 9442 5042 or 1800 688 847. 1. Medical Journal of Australia 2011; 195 (5): 280-284 l

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C L I N I C A L U P D A T E

Urogynaecological use of sacral nerve stimulation S

acral nerve stimulation (SNS) uses an electrode to unilaterally stimulate the 3rd sacral nerve root and thereby modify autonomic function of the bladder, anal spincter and pelvic floor. If initial implantation of an electrode linked to an external generator is clinically successful, a second stage implantation of a permanent pulse generator can be carried out 7-10 days later and configuration programmed using an external controller. Since May 2010, approved use of neuromodulation in Australia has extended beyond the indication of refractory faecal incontinence to include some refractory bladder dysfunction (refractory urinary urge incontinence and non obstructive voiding disorder). It is providing new options for patients with intractable symptoms or who are unable to tolerate conventional therapies. An obvious advantage of SNS is the reversible, low invasive nature of treatment. Long term data on its efficacy and safety are promising.

Background Well known clinical applications of neural stimulation include cardiac pacemakers, CNS implantation for tremor control, gastroparesis therapy and chronic pain management (spinal or peripheral nerve stimulation). Sacral nerve stimulation can modulate the neural reflexes that control bladder function, urinary and anal sphincters and pelvic floor musculature, making it an effective alternative treatment in many patients refractory to or intolerant of conservative treatments. The University of California developed SNS in 1981 and after multi-center RCTs, approval was given in 1994 for use in Europe and in 1999 FDA (USA) approval came for use in urge/frequency and urinary retention. In May 2010, the Medicare Service Advisory Committee (MSAC) licensed Interstim® (Medtronic) for use in Australia in the treatment of refractory detrusor overactivity, urge/frequency and non-obstructive urinary voiding disorder. Over 100,000 of these devices have been implanted worldwide, with use covering detrusor overactivity, voiding disorder, chronic pelvic pain and fecal incontinence. Over time, new developments in the leads, impulse generators and procedural techniques (e.g. implantation sites) have improved patient selection and efficacy whilst reducing complications.

Clinical indications for SNS

• • • •

Refractory faecal incontinence Refractory detrusor overactivity Non-obstructive urinary voiding dysfunction Chronic pelvic pain and interstitial cystitis*

*Not currently licensed for these indications.

Mechanism of action This is not fully understood. The Interstim® device has effects at various levels including the central nervous system, spine cord (reduction in nitric oxide synthase), peripheral nervous system and pelvic floor. These effects, amongst others, leads to the modification of voiding and guarding reflexes. Treatment is largely empirical, involving initial placement to assess symptomatic improvement and lack of adverse response (e.g. pain), as well as allow adjustment of frequency and amplitude of stimulation, before more permanent implantation of the pulse generator.

Patient assessment and work up The large majority of patients fall into the detrusor overactivity group.

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A thorough assessment is required including the patient’s history, physical examination, bladder diary, urinalysis, urodynamics, cystoscopy and upper renal tract evaluation. A baseline assessment of the main urinary symptom (e.g. urge incontinence episodes, urinary frequency, or number of catheterisations per day) is taken to compare with the results of the SNS trial period.

By Dr Phil Daborn, Urogynaecologist, Suite 5/400 Barker Rd, Subiaco. Tel 93822055

reasons include pain at the generator site, lead fracture, unpleasant sensory response and rarer complications such as infection and seroma formation. The revision rate appears to be reducing with newer techniques.

Alternative treatments to SNS Intravesical Botox therapy may be considered for patients with detrusor overactivity.

• Obstructed voiding

Clean intermittent self-catheterisation, permanent suprapubic catheterisation or urinary diversion are other alternatives for voiding dysfunction or severe incontinence.

• Acute neurological disease

Other considerations

Contraindications to SNS • Pregnancy

• Active infections

The procedure Most clinicians now perform a two-stage procedure using permanent tined (deployable barbed) leads that reduce the rate of lead migration. An initial trial helps improve patient selection so that only patients with a good response proceed to the second stage. The initial percutaneous placement of a tined electrode is via the third sacral foramen under x-ray guidance. This is performed under local anaesthetic with sedation, so the patient can report sensory responses and motor responses are visualized. Once the correct S3 stimulation is achieved the lead is connected to an external generator.

Cost is a factor. The total implanted device costs approximately $17,500. Patients with private health insurance are typically covered for the cost of the device. An application for a limited number of devices for public patients at KEMH is being sort. Several long-term issues need to be considered. The battery life of the impulse generator is variable, depending on the type used and its rate of usage but typically the implantable device lasts between 4 and 7 years before requiring replacement. Precautions include future use of MRI (device malfunction and disintegration) and the necessity to use bipolar rather than unipolar diathermy during surgery due to potential damage of the device. n

The patient then has a home evaluation for one week. Successful trial criteria would be a reduction of greater than 50% of the most significant symptom without significant adverse effect. If this happens, then a permanent impulse generator is placed subcutaneously, typically over the buttock. From then on, the patients have their own magnetic activation controller for day-to-day use, for turning the device on and off. A specialised technician is able to reprogram the implanted generator to modify the stimulation to achieve the greatest response.

Clinical results Bearing in mind that the patient population usually consists of those with severe intractable symptoms, the largest systematic review of RCTs and case series demonstrate: • 50% of patients have a 90% improvement in symptom scores • 80% of patients have a 50% improvement in symptom scores Historical data would suggest a device revision rate of approximately 30% of cases. Although lead repositioning due to lead migration is the most common indication for revision, other

n Positioning of the implant and electrodes. 39

Car Review By Drs Daryl Sosa and Peter Bradley

BMW M3: Luxury and Aggression On a test drive to Toodyay, Daryl and Pete found the M3 to be the benchmark for performance sport coupes. What a dilemma! It’s the last Sunday for reconnaissance of Quit Targa West, and I am outside Pete Bradley’s garage, staring at two ‘cult cars’, both toying with my passion for high speed thrills. I’ve never driven an R35 GTR or an M3! … and suddenly, I can have either for the day. Fortunately, Auto Classic has provided the E92 M3 Coupe for this month’s appraisal, and after much anticipation and excitement, we fired up the cracking V8 in BMWs 4th generation M3 and headed for the hills. The M3 has become the benchmark for performance sport coupes, and although there are undoubtedly faster and more powerful vehicles on the market, one would be hard pushed to find a superior combination of luxury styling, stunning performance, and overall drivability. The current M3 series launched in 2007 is powered by a compact 90 degree 4.0 l V8 in contrast to all the previous 6 cylinder M3 models. This award-winning naturally-aspirated power plant is fed by eight individually electronically-controlled single throttle butterflies and M Double Vanos V.C.C, delivering 309 kW @ 8300 rpm and a fat 400 Nm @ 3900 rpm. What the figures don’t tell you is just how sweet that V8 sounds. From the moment you

push the ignition button, right through to the 8400 cut-out, the beautiful exhaust note combines with truckloads of torque from 2000 RPM and acceleration of 4.8 sec to 100kph, confirming that you are in control of something very special!

Unfortunately, the cabin is where I have two minor problems:

The ‘Pure Edition’ M3 coupe test driven comes with 19” M Light Black Alloy rims, four additional Dark Chrome/Black exterior highlights, and 6-speed manual transmission. There are ten minor deletions, but at $153,800 drive-away, this represents a significant $20K saving off the regular coupe price! (The 19” alloys are normally part of a $9900 ‘Competition’ option on the M3).

The centre console elbow rest gets in the way of rapid gear changes – 2nd, 4th, and 6th gears – which is frustrating in a high performance manual coupe that is destined for occasional use on track days/ motorsport.

The BMW M3 weighs in at 1580 kg, and a low 5.2 kg per/kW is achieved by extensive use of lightweight alloys and carbon fibre reinforced plastic (CRFP) in the construction of the chassis and suspension components. Rumour has it that the next M3 may revert to a 6 cylinder power plant and thus this purist traditional 6 speed manual without the M DCT (Double Clutch Transmission) may become a collector’s item. Slipping behind the wheel, there are a few subtle styling changes in the cabin that hint at a more aggressive performance orientation.

The drink holders are not big enough for a decent water bottle (who needs deep, narrow map holders in the door nowadays with GPS? I just want somewhere to stick a wine bottle!).

On the upside, the familiar centre consolemounted drive controller and 8.8” HD TFT monitor/GPS are sensational at monitoring vehicle functions and provide the best 3D Terrain View of any GPS I have ever used! As we were winding our way out to Toodyay, the M3 proved impressive in terms of straightline speed – and overtaking was a breeze. The steering was reasonably direct, and it was evident that there was no tendency towards understeer through corners (in contrast to most of the turbo 4WD vehicles we usually drive). The cross-drilled ventilated front discs remained rock solid with no hint of fade and no perception of the Dynamic Brake Control. The rear end tracked faithfully, and even under

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Disengaging Traction Control at the start of the ‘racecourse road’ stage, we were finally able to sense the true performance potential of this road weapon. that we could explore its limits further on a closed track without the risk of incarceration as a public menace! Alas, the fun ended too soon. The BMW M3 really is the embodiment of an affordable high performance luxury coupe that one could use as a daily driver. It takes a little getting used to, but then, the rewards begin to flow!

Daryl and Pete comparing what’s in their garages. balls-out acceleration, there was little hint of oversteer …whilst he Traction Control was engaged. Disengaging Traction Control at the start of the ‘racecourse road’ stage, we were finally able to sense the true performance potential of this road weapon.

It’s not cheap, but in the current climate, it represents great value. Knowing BMW, it will probably maintain a very reasonable resale even after years of exhilarating service. The 1M about to be released in Australia would give it a run for its money, but the 100 destined for sale in Australia are already sold out. So what are you waiting for? Now, Pete, what about that other car in your garage?

The coupe was transformed once the electronic nanny was silenced, and after a few minutes scything through a string of corners, I wished

Impressed by the BMW M3, our reviewers’ next challenge is to roadtest Pete’s R35 GTR.

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On the Grapevine By Dr Martin Buck

Hentley Farm Wines Hentley Farm Wines are located in the heart of the Barossa wine region on the banks of the Greenock Creek in Seppeltsfield. Keith and Alison Hentschke come from a long line of Barossa pioneers and ventured into the wine business with the purchase of an old 100-acre farm in the 1990s. As a result of careful site selection, the vineyard is ideally suited to the warm, dry Barossa climate. Classic varieties such as Shiraz, Grenache, and Cabernet are mixed with newer players including Viognier and Zinfandel. Hentley Farm Wines are located in the heart of the Barossa wine region on the banks of the Greenock Creek in Seppeltsfield. Keith and Alison Hentschke come from a long line of Barossa pioneers and ventured into the wine business with the purchase of an old 100-acre farm in the 1990s. As a result of careful site selection, the vineyard is ideally suited to the warm, dry Barossa climate. Classic varieties such as Shiraz, Grenache, and Cabernet are mixed with newer players including Viognier and Zinfandel. The 2011 Exception Riesling is the only wine of the Hentley Farm range that is made from fruit sourced outside the Farm. In search of the perfect Riesling, winemaker Andrew Quin located a parcel of fruit in one of the highest reaches of the Eden Valley. The Exception Riesling is a classic cool-climate style with minerality and aromas of citrus and green apples. It has a lengthy, crisp palate with complexity and persistence. At only 11.0% alcohol, it is as close as we get to German austerity and class. Of the two Shiraz provided, I decided to start with “The Beauty”, which is a 2009 single vineyard wine with 14.4% alcohol. It is aged for 16 months in half new and old French barrels. In “The Beauty”, you will find the big, ripe

berry aromas expected of a Barossa Shiraz but with subtle hints of the 3% Viognier. Co-fermentation of the varieties has given the wine a great lift in complexity. The soft, well-integrated tannins meld with the silky fruit, resulting in a long, smooth palate. James Halliday gave this wine a well-deserved 95 points, so perhaps Shiraz Viognier is the new classic Barossa wine? “The Beast” is best viewed as a Barossa Shiraz on steroids! 2009 was a once-in-a-decade vintage with exceptional ripening conditions. Winemaking involved basket-pressing and ageing in predominately new French oak for 22 months, with the final wine left unfiltered or fined. The result is a wine that leaps out of the glass with earthy aromas, berries, and white pepper. Although young and capable of considerable cellaring, this wine is ready to go. It has a wonderful palate of deep, intense dark fruits and ripe tannins in terrific balance. At least 14.6% alcohol, it does not seem too hot and will be a stunner for some time. And it is rated at 95 points as well. “The Beast” is too good a wine to waste with food! I have put Hentley Farm on my must-see list for the next Barossa visit. These three very exceptional wines might only be the tip of the iceberg.

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

Which wine is “best viewed as a Barossa Shiraz on steroids

Answer:

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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, October 31, 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.

Enter here!... or you can enter online at www.MedicalHub.com.au! Name:

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COMPETITIONS www.MedicalHub.com.au

Entering Medical Forum’s competitions has never been easier! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).

Dr Mohan Jayasundera, winner of the Cullen Wines Doctors Dozen.

Competition winners from August edition Cullen Wines Doctor Dozen: Dr Mohan Jayasundera. Tarraki Tarraki Tata – Dance: Dr Johana Stegan. Cello Fantasy – Orchestral: Dr Tom Lee and Dr Elena Monaco. Cat on a Hot Tin Roof – Theatre: Dr Darren Kester and Dr Tuck Chin. Truly, Madly Deeply – Cabaret: Dr Emma Allanson and Dr Parbodh Gogna. Submarine – Movie: Dr Lucas Sanders, Dr Tanya Ha, Dr Brendan Connor, Dr Nai Lai, Dr Irina Kurowski, and Dr Sanjay Sharma. The Eye of the Storm – Movie: Dr Kevin Murphy, Dr Norman Juengling, Dr Jenny Fay, Dr Bastiaan de Boer, Dr Jackie Wysocki, Dr Narelle Vujcich, Dr Kon Kozak, Dr Gabriel Hammond, Dr Derek Johns, and Dr Donal Reid.

Thank you! “Just a quick thank you to all at Medical Forum. We have enjoyed a number of the mixed dozen wines which I won (Rusden Wines Doctors Dozen, July). In particular, we shared the Black Guts with some ‘wine buff’ friends who were very impressed. Thank you once again and who knows, maybe New York next time?” – Dr Judy Galloway

Concert: A Night in Vienna Win a double A reserve pass! Richard Strauss’s opera Der Rosenkavalier is a favourite in the operatic repertoire, and the West Australian Symphony Orchestra present highlights of this moving masterpiece, packed full of gorgeous tunes, and sung by a stellar cast. Join WASO as they perform some of the most exquisite music ever written. Perth Concert Hall. November 18 & 19. Tickets: 9326 0000 or www.waso.com

Cinema: Moneyball Win a double pass! Based on a true story, Moneyball is a movie for anybody who has ever dreamed of taking on the system. Brad Pitt stars as Billy Beane, the general manager of the Oakland A’s, who is forced to reinvent his baseball team on a very tight budget. He teams with a young recent graduate Peter Brand (Jonah Hill) in an unlikely partnership, recruiting bargain players and trying and outsmart the richer clubs. In cinemas November 10.

Cinema: Anonymous Win a double pass! Set in the political snake-pit of Elizabethan England, Anonymous speculates on an issue that has for centuries intrigued academics and brilliant minds such as Mark Twain, Charles Dickens, and Sigmund Freud, namely: who actually created the body of work credited to William Shakespeare? Stars Rhys Ifans, Vanessa Redgrave, and Joely Richardson. In cinemas November 3.

Cinema: Santa’s Apprentice Win a family pass! Santa’s Apprentice is a timeless and heart-warming Christmas animated adventure featuring an allstar voice cast including Shane Jacobsen, Magda Szubanski, and Delta Goodrem, Hugh Sheridan and Georgie Parker. It follows the story of young Nicolas, a 7-year-old Australian boy on his adventure as he struggles with the ups and downs of being the next Santa Claus. In cinemas November 10.

Documentary: Bill Cunningham New York Win a double pass! “We all get dressed for Bill,” says Vogue editrix Anna Wintour. The “Bill” in question is 80+ New York Times photographer Bill Cunningham. For decades, this Schwinn-riding cultural anthropologist has been obsessively and inventively chronicling fashion trends and high society charity soirées for the Times Style section in his columns “On the Street” and “Evening Hours”. In cinemas November 3. Info: http://www.madman.com.au/ catalogue/view/14334/bill-cunningham-new-york

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Extreme Sports By Peter McClelland

Iron Man Triathlons and Ultra Marathons Some WA medicos practise what they preach by competing in ultra-distance races. The iron man triathlon and the Comrades UltraMarathon are the “new black” for the fitness elite. For health professionals who love pushing themselves to the limit – and orthopaedic registrars seem to be leading the pack – the ordinary old marathon is looking a bit tired. Apparently 42.2kms of pavement pounding just doesn’t cut the mustard anymore. Dr Gary Couanis, who practices as a sports medicine specialist at Sports, Exercise, Movement in Cottesloe agrees. “Extreme Sports and iron man triathlon events, in particular, are booming like crazy,” said Gary. And he should know. Gary’s got a solo Rottnest Channel Swim under his belt, he’s run a subthree hour marathon, and the icing on the cake was a strong finish in his first iron man triathlon. And that last one is seriously extreme!

other extreme sports devotees from South Korea, Japan, Canada, South Africa, and the United Kingdom. In an interesting demographic twist, Gary pointed out that orthopaedic specialists seem to prefer the iron man events while anaesthetists are more likely to line up for the traditional foot-slog of the 42.2 km marathon. “I don’t really know what that says about orthopods or anaesthetists,” said Gary. Medical Forum might explore that topic at a later date? Gary has a keen professional interest in a range of extreme and endurance sports. And when

sity”. Vic Clapham knew all about adversity. His own highly personal ultra-marathon was an exercise in survival – a 2,700km forced routemarch through sweltering German East Africa in war-time. “I’ve got a number of patients who run Comrades,” said Gary Couanis “but I don’t usually see them before the race unless a problem crops up.” It’s often a very different story when the race is all over. “It’s extremely tough, so it’s not surprising when runners present with injuries when they come back from South Africa.”

South Africa’s Comrades Ultra-Marathon is gruelling.

An iron man event consists of a 3.8 km swim, a 180 km bicycle ride, followed by a 42km marathon. Yes, in that order, and one after the other! The World Triathlon Corporation controls the sport extremely rigorously and sanctions every event. Tony Abbott, the Liberal Federal Opposition leader, went the full iron man distance earlier this year. For someone who usually has plenty to say on any number of topics, Mr Abbott was struggling for words when he finally staggered across the finish line. Gary Couannis’s passion for sport began in the junior ranks – he competed at state, national, and international level in swimming and has gone on to work professionally with national sporting teams in hockey, soccer and surf lifesaving. Gary is the team doctor for the Perth Wildcats, and he has worked with the South Fremantle Football Club and those extremely energetic performers from Cirque de Soleil. When the starting siren cuts through the crisp morning air at the Busselton Iron Man on Sunday December 4, 2011, Gary will be one of nearly 2,000 competitors hitting the water and heading for the turning buoy at the end of the jetty. “There’s less than 20 of these events worldwide and the Busselton race sold out in four hours!” said Gary. “The Iron Man is becoming something of a mid-life crisis event for executives and health professionals. I had a quick look through my age category for Busselton and spotted the names of a couple of doctors from medical school.” The age categories range from 18-year-old youngsters right through to 70+ with competitors flying in from all corners of the globe. There’ll be lots of Australians lining up at Busselton, of course, and they’ll be joined by

Dr Gary Couanis you put the two words Extreme and Endurance together, there’s one name that pops up every time – the Comrades Ultra-Marathon. It’s been described as the ‘Ultimate Human Race’ 90kms of hard, tough road-running between Durban and Pietermaritzburg in South Africa’s Kwazulu-Natal Province. The Comrades Ultra-Marathon has a colourful history. The first race was run on 24 May 1921, and with the exception of a pause during World War II, has been run every year since then. In the race’s history, more than 300,000 runners have lined up on the starting line. It all began with war veteran Vic Clapham, who wanted to honour the South African soldiers who fell during World War I. Clapham’s aim was to “celebrate mankind’s spirit over adver-

Another Perth medico with first-hand experience of the medical side of Comrades is Dr Peter Mevill-Smith. He practices as a consultant psychiatrist at the Specialist Medical Centre and Mental Health Unit (MHU) in-patient facility at Joondalup Health Campus. Peter is also a senior lecturer for the School of Psychiatry and Neurosciences at UWA, where he supervises medical students and psychiatric registrars. And if that isn’t enough to keep him busy, he has a professional interest in bariatric medicine. Peter is a committed distance runner, and before relocating to Perth, often assisted in the medical tent on Comrades race-day. “There’s always plenty to do and the atmosphere on the day is absolutely terrific,” he said. The medical facility has room for approximately

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90 beds with volunteer doctors and paramedics in attendance for the full 12 hours of the race. Some competitors are weighed both before and after the race and relevant medical information collected for future study. Little wonder that South Africa is one of the leading countries in the field of ultra-marathon research! South Africans are obsessed with distance running. Just like our local tennis clubs, almost every suburb in the country has a strong and active running club. It’s very much an integral part of the social fabric of the country. One of Peter’s close friends is fellow expatriate South African, Brenda Erskine. She’s completed eight Comrades and her training regime is serious in the extreme. “You actually need to run an ultra-marathon as part of your training,” Brenda said. “I’d often travel to Cape Town and run the Two Oceans Marathon before doing the Comrades race.” Just to make it a bit more interesting, the Two Oceans is the normal marathon distance with another 14kms tacked on the end! “I’d build my weekly runs up to around 70-85kms a week from March until May and then taper off,” said Brenda. “The start line’s always an exciting time and then you try and settle down into some sort of rhythm. I always carry a laminated card with times and checkpoints because your brain can get a bit fuzzy.” In something of an understatement Brenda added, “60kms into the race, you feel like

you’ve had enough and you’re starting to lose your sense of humour.”

Sports medico Gary doing the hard slog in an iron man triathlon.

As sports physician Gary Couanis suggests, iron man triathlons and ultra-marathons are here to stay. In fact, for medical professionals and corporate executives, these extreme sports are becoming increasingly popular. As far as a mid-life crisis goes, it’ll work out a lot cheaper than buying a Porsche 911 Aero Sport Carrera. But extreme sports such as triathlons and ultra-marathons are definitely not for the faint hearted. There’ll be lots of early mornings, plenty of clapped out running shoes and your knees will never be the same again. And that brings us back to where it all began – sitting in Gary Couanis’s Cottesloe waitingroom.

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