MedicalForumWA 0217 Public Edition

t Squeeze on Primary Care t Costs for Specialists t Health & Politics t Investing Wisely t Clinicals: 3D Printing; Cystic Fibrosis; Tremor; Hep C; Immunotherapy & More

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EDITORIAL

When Fast Information is King Remember the French silicone breast implants at risk of bursting? And the defective metal-on-metal hip prostheses that led to recalls and warnings? That was in 2012-13! While the voluntary device manufacturers’ Code of Practice is pretty tight, much like the Medicines Australia Code, some drug or medical device manufacturers may still profit from sales while slow-moving systems first highlight then investigate claims that products could be or are damaging consumers.

All this before the weight of adverse opinion leads them to scuttle their product. Income from sales might exceed the cost of eventual legal payouts.

The medical profession is meant to be on the patient’s side.

But when we resist greater transparency under the Medicines Australia Code, have key opinion leaders spruiking what’s new or preferred, and doctors looking at their incomes rather than the community cost of their preferences, then why shouldn’t health consumers wonder?

Why shouldn’t they demand easier traceability of performance, regular checks on manufacturers, better clinical evidence and closer scrutiny of the relationships between product manufacturers and other providers?

Health is a hungry beast that must be fed. But we have to give it the right diet.

Rapidly advancing technology, slow and expensive approval, even slower investigation if things go wrong, and perhaps larger profits to be made if a product is PBS listed or TGA approved, can be a recipe for keeping a dud product going as long as possible. Fewer companies rely on brand loyalty these days so damage to a brand is not as important. Protection of product investment and share price is.

As an aside, my mobile number, freely available on the Medical Forum website, was fraudulently put into an online survey. This number then populated a list which I think was on-sold by a firm in Queensland that prides itself on the best online “live data”. Within 24 hours I received an SMS for an education product and phone calls from someone trying to sell me pet insurance, a new energy provider (not based in WA) and life insurance.

Doctors are caught up in this too. With US studies showing about 30% of patients don’t pick “Transparency may be the most disruptive and up newly prescribed medicines Doctors can register mobiles far-reaching innovation to come out of social media” and we know compliance in used for personal calls with – Paul Gillin, social media commentator Oz is poor, pharmaceutical www.donotcall.gov.au. It is manufacturers need to better target well known that many people physician-patient engagement. Wearable devices, mobile give false or misleading information when online forms don’t apps, telemedicine, electronic medical records and other allow optional responses. This sort of behaviour does not auger technologies have the potential to influence health outcomes, well for the patient controlled electronic health record! Are we patient behaviours and treatment decisions. entering an age of misinformation?

The ongoing questions are: Will things on offer truly improve patient care? Is it what the patient wants? Or will it just make me look good?

In this edition we look at Innovations and Trends – both clinical Professional wariness about who gains access to Big Data and professional. There are a lot of doctors doing plenty of and social media is not a bad thing. Unbridled access could interesting work. We interview some of the key players before put manufacturers in indirect contact with health consumers. the State election and wonder what deals have been done.

This takes on greater importance with the rise of orphan And more importantly, provide you with a pot pouri of ideas and drugs and the associated need for community pressures to get PBS listings. opinion to stimulate and entertain. Please enjoy.

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director Advertising Marketing Manager (0403 282 510) advertising@mforum.com.au

MEDICAL FORUM

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

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

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

FEBRUARY 2017 | 1

CONTENTS FEBRUARY 2017

20

16 FEATURES 16 Innovation & Trends: General Practice 20 Home Care & Silver Chain 23 Vision Van Meets Needs 50 Investing in Choppy Waters NEWS & VIEWS 1 Editorial: When Fast Information is King

4

Dr Rob McEvoy Letters to the Editor An Easy Way to Save a Life Mr Rodney Hatch Making hep C History Dr Donna Mak Tax Alcohol Across the Board Dr Michael Christmass Phones Aren’t the Problem Dr Skye Croeser Thumbs Down for Marijuana Dr Max Majedi Changes to Endoscopy Referrals Euthanasia Spin Dr John Hayes The Unhappy Hypothyroid Dr Tim Welborn Notification of Induced Abortion Dr Revle Bangor-Jones

23

50

12 13 15 24 26

Have You Heard?

Beneath the Drapes Is Labor Fit for the Job? Innovation & Trends: Specialists Motivational Interviewing

Dr Monica Moore 38 Managing the Trickster 39 Psychiatry Master Class

Lifestyle 44 Christmas Parties

Ramsay Health Care; Clinipath Pathology ; Mount Hospital; SJG Subiaco; SJG Mt Lawley; SJG Murdoch; Bethesda Health Care 49 Funny Side 51 Wine Review: Edenvale

Dr Louis Papaelias 52 Doctors in the Arts:

Dr Lindy Roberts: Film Noir 53 WA Opera 50 Years 53 Ludovico Einaudi 54 Competitions

FIND US ON FACEBOOK & TWITTER! /medicalforumwa/

/medicalforumwa/

Major Sponsors 2 | FEBRUARY 2017

MEDICAL FORUM

clinicals

5

National Cervical Screening Program Changes Dr Mark Neville

33

Paediatric Services & PCH Prof Jonathan Carapetis

34

Unravelling Cystic Fibrosis Dr Andre Schultz

34

Insights into WA Medical Workforce Mr Kim Snowball

35

Mental Health’s Direction Dr Nathan Gibson

36

3D in Otolaryngology Dr Jenn Ha

37

Hepatitis C Treatment Evolves Dr Eric Khong

38

Instrumentation in Joint Replacement Dr Simon Wall

39

Trends in Tattoos Dr David Main

41

Ongoing Legacy of Asbestos in WA Dr Fraser Brims

42

Side Effects of Immunotherapy Dr Mihitha Ariyapperuma

43

Tremors: When to Intervene Dr Rick Stell

43

Myth: Radio Contrast Reactions Dr Meilyn Hew

Come and enjoy breakfast and the lively discussion:

‘Serving the Community: Risk vs Reward’ Limited Places – Beat the Wait List!

March 23 | 7.30am Royal Perth Yacht Club

Register at doctorsdrum.com.au

guest columns

10

Health Looms Large for Libs and Labor A/Prof Peter Kennedy

28

Court Costs Dr Hilary Fine

29

New Hope for Alcoholics Dr Amanda Stafford

31

Patient as Customer Mr Gihan Perera

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM FEBRUARY 2017 | 3

LETTERS To THE EDITOR An easy way to save a life Dear Editor, In the early 1990s word got around among consumers on the methadone program in Perth. “It looks like most of us have Hepatitis C”. My wife and I weren’t on the methadone program at the time but a friend said to us, “Just about everyone I know who has ever been an injecting drug user seems to have this new thing called Hepatitis C. I’ve got it. You had better have a test.”

My wife and I went to a local GP to have a test. We both tested positive. My LFT at that time was fine. However, my wife’s was problematic. I lived on virtually symptomfree. My wife died within a few years from liver complications. She was very sick before she died, both mentally and physically. I am convinced now that many of her symptoms were hepatitis induced and not from other causes.

No treatment options had been offered to her in those early years. It is likely that her drug use and drinking would have disqualified her from accessing whatever treatment was available at that time.

I remained symptom-free for decades. My LFTs remained in a healthy range. However, I saw many friends and acquaintance’s health deteriorate over that time. Many healthy young people fade before my eyes. I attended a clinic regularly for LFTs and to keep abreast of treatment options.

The various Interferon cocktails were slowly improving over the years but people were not encouraged to take up treatment unless they were becoming very sick. Horror stories concerning the side effects were rife. I had a friend who became quite emotionally unstable and suicidal whilst on treatment. The length of treatment time, the uncertain prospect of a cure and the possible side effects were daunting. Most people I knew shied away.

We have the pharmaceutical means now to cure virtually everyone living with this timebomb of a disease. I believe doctors need to take a harm reduction, non-judgemental, matter-of-fact approach to broaching the subject with patients they believe may be at risk. Quietly and respectfully having a conversation about IDU history is not condoning drug use. Most people who

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.

4 | FEBRUARY 2017

have experience with IDU are comfortable to discuss it in a setting of confidentiality when they do not feel they are being judged.

Some were briefly experimental and some got trapped in it or chose to continue that lifestyle. Either way, all of them will potentially be a huge burden on our health system as they age and as their disease progresses.

I embarked on a course of Harvoni pills earlier this year. Within three months, without any side effects, I was cured. I didn’t think I was very symptomatic but I am surprised at how much better I feel without that virus living in my body. I actually feel 10 years younger. I energetically tend to my work, my garden and my grandchildren.

Upskill yourself. There are many free training opportunities – online (https://lms.ashm. org.au/; http://www.nps.org.au/healthprofessionals/cpd/activities/online-courses/ managing-hepatitis-c-in-primary-care; http:// hepatitis.ecu.edu.au/) and face-to-face seminars (contact ashm@ashm.org.au) GPs can now initiate PBS-funded S85 hepatitis C treatments without specialist authorisation.

Patients must be treated by a medical practitioner experienced in the treatment of chronic hepatitis C infection; or in consultation with a gastroenterologist, hepatologist or infectious diseases physician experienced in the treatment of chronic hepatitis C infection.

I encourage all Western Australian GPs to get on board with prescribing the new treatments. It’s an easy way to save a life.

For more information about how to prescribe, see The Silver Book (Guidelines for managing STI and BBVs ww2.health.wa.gov.au/Silverbook)

Mr Rodney Ian Hatch, health consumer, ex-hepatitis C sufferer

Prof Donna Mak, Communicable Disease Control Directorate, WA Health

ED: Rodney is pictured with his grandson.

ED: We received a TGA warning that “direct-acting antiviral (DAA) medicines for the treatment of chronic hepatitis C virus (HCV) infection have been associated with reactivation of hepatitis B virus (HBV) in patients with a current or previous HBV infection. Reactivation of HBV can cause serious liver problems, including hepatitis, liver failure and in rare cases death.”

When we asked Prof Mak about this she said those co-infected with hep B and C would normally be referred for specialist consultation by their treating GP, they made up a very small percentage of the many untreated people, and that as testing for hep B and HIV are in the routine protocols for working-up a patient for hep C treatment, the situation was taken care of. The TGA is working with sponsors of the seven DAA medicines currently available in Australia to update their Product Information to contain warnings about HBV reactivation.

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Making hep C history Dear Editor, Do your bit to make hep C history by making a new year’s resolution to cure your patients with chronic hepatitis C. Despite highly effective, well-tolerated, oral anti-viral treatments for hepatitis C being available on PBS since March 2016, WA is still lagging behind other states in terms of treatment uptake with only 7% of patients with chronic hepatitis C having been started on treatment, in contrast with 19% in the ACT and 11-13% in NSW, Qld, SA and Vic. Remember that most patients with chronic hepatitis C are asymptomatic until they develop advanced liver disease. Therefore it is important to be proactive about offering hepatitis C testing to people who have current or past risk factors for chronic hepatitis C, e.g. current or past IV drug use, born in a high prevalence area (i.e. Africa, and Central and East Asia), imprisonment.

Inform your patients that directly active antiviral treatments have cure rates of 9095% after 8-12 weeks treatment, and are oral and well-tolerated – no interferon injections required.

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.

The TGA website goes on to say: If you are currently treating patients for chronic HCV infection with DAA medicines, advise them of this issue and screen for evidence of HBV infection, including testing for HBV surface antigen (HBsAg) and HBV core antibody (antiHBc). It is important to be aware that reactivation of HBV can occur in patients with serologic evidence of past infection (HBsAg negative and anti-HBc positive).

HBV reactivation is diagnosed when there is an abrupt, marked increase in serum HBV DNA level, and may be accompanied by hepatitis ranging from mild to severe. Patients with HCV-HBV co-infection should be cared for by a clinician experienced in managing both conditions. For patients with no serologic evidence of current or past HBV infection, consider vaccination against HBV.

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EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

Advertisers are responsible for ensuring that

MEDICAL FORUM

Major Sponsor: Clinipath Pathology

By Dr Mark Neville Cytopathologist

National Cervical Screening Program Changes, 1 May 2017 From 1 May 2017, new guidelines developed by the Cancer Council Australia include:

Cervical Screening Pathway

Oncogenic HPV Test with partial genotyping

• The two-yearly Pap test will be replaced by a five-yearly human papillomavirus (HPV) test, followed by liquid based cytology (LBC) if the HPV test is positive.

• Commencement age for cervical screening changes from 18 to 25 years.

• Women can cease screening between the ages of 70-74 years, after a negative HPV test.

HPV not detected

Before 1 May 2017 it is ‘business as usual’ The usual two yearly Pap test is not delayed and a primary HPV test is not recommended because: Unsatisfactory LBC

• The infrastructure and supporting quality and safety activities will not be in place.

Negative

• MBS items for the new screening program will not be available (but private billing will be for women who choose LBC i.e.

ThinPrep or SurePath) in addition to conventional cytology.

HPV not detected

Women aged 25 to 74 years will be invited every five years to have a primary HPV test.

If oncogenic HPV is detected a liquid based cytology (LBC) will be done reflexly on the same cervical specimen.

The pathology report is expressed as one of three risk categories, along with the recommended management: • Low risk - invited to screen in five years.

• Intermediate risk - invited to have another HPV test in 12 months to check that HPV infection has cleared.

• Higher risk – colposcopy referral suggested for further investigation.

Self-collection for cervical screening Self-collection will only be available for women never-screened or under-screened, that is, no Pap test for over two years or no HPV test for over seven years. (Clinician collected cervical samples are preferred as HPV testing is better on these samples. Ref: Smith et al, 2016. MJA).

(not 16/18)

(16/18)

Reflex LBC

Reflex LBC

pLSIL/LSIL

pHSIL/HSIL

Unsatisfactory HPV test

Any LBC result or unsatisfactory

HPV detected (any type)

Reflex LBC

Rescreen in 5 years

Retest for LBC only within 6 weeks

Rescreen in 5 years

Refer for colposcopy

A simple dry flocked swab is all that is required to self-collect a vaginal sample, which has to be done on the premises of the healthcare professional.

Self collection for HPV testing is not recommended in pregnancy.

HPV (not 16/18) detected in the vaginal sample requires the woman to return for a clinician-collected cervical sample for LBC, to determine their clinical follow-up.

HPV (16/18) detected in the vaginal sample requires referral for colposcopic assessment and cervical sample for LBC to be collected at that visit.

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

HPV detected

Repeat HPV test in 12 months

New cervical screening pathway explained

From there, management is a risk-based approach, managed according to the risk of developing cervical cancer determined by their HPV test result and any subsequent LBC result.

HPV detected

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

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Refer for colposcopy

Refer for colposcopy

Retest within 6 weeks

Transitioning arrangements From 1 May 2017 when women present for cervical screening they will be offered a Medicare funded HPV test. This replaces the conventional Pap smear which will no longer attract a Medicare rebate after 1 May 2017.

LETTERS To THE EDITOR continued from Page 4

Tax alcohol across the board Dear Editor, Dr Ralph Longhorn’s Guest Column Road Less Travelled (While Sober) (December) was a welcome prompt to consider our own relationship with alcohol. It also highlighted the pervasiveness of alcohol as component of Australian identity. On reflection, it reminded me of the important role we have, as health care professionals, to effect positive change in alcohol public policy.

My work place is situated near an inner city park. Substance misuse and social disadvantage are on daily display here, along with remains of cheap alcohol containers. In Australia, one can buy four litres of wine for $10 and a litre of bottled water might cost $3.08.

But we know higher alcohol prices are linked to lower alcohol consumption and fewer alcoholrelated harms (e.g. dependence, trauma, crime, death due to cirrhosis). So why is wine so cheap?

Australia has an inconsistent approach to alcohol taxation with an ad valorum tax (socalled Wine Equalisation Tax [WET]) on wine but a volumetric tax on beer and spirits. Thus, cask wine (12.5% alcohol) is taxed at 5 cents per standard drink compared to beer (3% alcohol) at 32 cents. Other examples exist but the main point here is the discrepancy between tax payable and amount of pure alcohol purchased.

Evidence suggests a public health approach to alcohol taxation, focused on reducing alcoholrelated harms, should include a minimum price with a volumetric tax on all products. The Federal Government’s own taxation review was critical of the WET and recommended a volumetric tax on all alcohol products.

The National Preventative Health Taskforce, implemented by the Federal Government, also disapproved of the WET and suggested a tiered volumetric tax and minimum alcohol price.

Despite the evidence, and multiple costly reviews, it seems we are no closer to minimum pricing or volumetric taxation.

Of course, taxation is by no means the only public health issue involving alcohol.

Advertising to children and adolescents in televised sport and the so-called ‘lockout’ laws are others that come to mind.

Dr Longhorn’s article reflects on a personal relationship with alcohol. Perhaps this is an important starting point in developing the political will, as a health-care community, to advocate for public policy change?

Dr Michael Christmass, Next Step Alcohol and Drug Service References on request

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Phones aren’t the problem Dear Editor, It’s easy to feel overwhelmed by technology. Even as a ‘professor of the Internet’, as my friends jokingly refer to my job, there are times when it feels impossible to keep up with the demands of email and social media. But it’s a mistake to focus too closely on smartphones, even with their pervasive reach into our lives.

Dr Astrid Arellano’s recent suggestions around setting tighter boundaries on smartphone use (December) are an excellent starting point. Turning phones to silent, or off completely, can help us refocus on the present and the people around us. It can also be useful not to install work email or social media apps like Facebook on our phones, or to turn off notifications.

Most apps will notify you when a friend posts an update, when someone tries to communicate with you, or even when you haven’t opened them in a while.

That’s because they’re designed to meet companies’ needs, not yours, and most

companies make their money from selling your data and attention on to marketers.

This also provides a hint as to the underlying problem, and it’s not smartphones: it’s the increasing spread of work, and advertising, into our leisure time.

There’s been significant media coverage of France’s “right to turn off”, allowing staff to disconnect after working hours. This legislation only passed because unions in France retain a strong role in advocating for better working conditions.

Workers in Australia, including in the health services, may be able to manage stress by turning off their phones. But in many cases, this will have an impact either in terms of direct pressure to be more available, or through longer-term assumptions about how ‘committed’ someone is to their career.

This makes it vital to look beyond our smartphones. We also need to think about how we organise to limit working hours and maintain reasonable workloads. Ironically, social media have become a key campaigning tool in such struggles.

Dr Sky Croeser, Curtin University ........................................................................

Thumbs down for marijuana Dear Editor, Re: Medicinal Marijuana: Position Statement of the WA Regional Committee of Faculty of Pain Medicine of Australia.

After our recent meeting in November 2016, it was decided that in line with Faculty of Pain Medicine, we do not support the use of medicinal marijuana for persistent nonterminal cancer pain.

Dr Max Majedi, Chair Regional Committee of Faculty of Pain Medicine ........................................................................ continued on Page 8

‘Serving the Community: Risk vs Reward’ The next Doctor’s Drum breakfast on Thursday, March 23, should be a boomer. Styled after the ABC’s lively and entertaining discussion program, Q&A, WA doctors will find this topic and panel particularly interesting (see www.doctorsdrum.com.au).

Places are limited so head to the website to book online. www.doctorsdrum.com.au The discussion is stimulating and at times lighthearted and it comes with a delicious breakfast, courtesy of the sponsors (both medical).

The Doctors Drum helps everyone better understand the other’s point-of-view (without necessarily arriving at a solution) – all with good humour. The event is hosted by an independent MC.

Reserve your place at doctorsdrum.com.au

6 | FEBRUARY 2017

Medical Forum’s aim is to give you a voice on topics important to you. This is a safe and relaxed environment for doctors to discuss the important issues of the day.

Although the discussion has a mind of its own, we expect things like this might turn up…

• Are doctors prone to burnout because they can't/won't get away?

• The work-lifestyle balance – how important is it?

• You hear about doctors who get abused in EDs, suffer depression that can lead to suicide. Do we support them?

• Are new graduates trained to anticipate social problems?

• Doctors are human too – are we attracting the right people?

MEDICAL FORUM

An after hours number?

That’s an idea we pinched from you We’ve been designing products and services for the medical profession for over 25 years and we’re well aware that your working day doesn’t always end when everyone else goes home.

So, we’ve taken a leaf out of your book.

In case you need us and our office is closed, we’ll make sure you have a number you can call. It’s not just for emergencies. Our client service centre here in Australia is open round the clock, so we’re always ‘on call’ to provide help when you need it.

Visit us at boqspecialist.com.au or speak to a local finance specialist on 1300 160 160.

Equipment and fit-out finance / Credit cards / Home loans / Commercial property finance / Car finance / Practice purchase loans SMSF lending and deposits / Transactional banking and overdrafts / Savings and deposits / Foreign exchange The issuer and credit provider of these products and services is BOQ Specialist - a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL and Australian credit licence no. 244616 (“BOQ Specialist”).

MEDICAL FORUM

FEBRUARY 2017 | 7

LETTERS To THE EDITOR continued from Page 4

Changes to endoscopy referrals Dear Editor, Significant changes have been be introduced which impact on the referral of adult patients to public gastrointestinal endoscopy services.

As of January 20, all colonoscopy and gastroscopy procedure requests to metropolitan public hospitals are submitted to the Central Referral Service (CRS). Referral guidelines have been developed to assist GPs to make appropriate referrals for patients with strong clinical indications for colonoscopy/ gastroscopy and to define the access criteria for public gastrointestinal endoscopy services.

The guidelines align with the WAPHA Endoscopy Request Health Pathway which has been released concurrently. Referrals not meeting the guidelines, as determined by the triaging clinician, will be returned.

A standardised referral form for colonoscopy/ gastroscopy is available via the CRS website. Electronic templates compatible with commonly-used practice management software packages will be released in February.

Use of one of the standardised templates will become mandatory after a short phase-in period.

The department, in collaboration with the WAPHA, has been contacting GP practices and hospitals to disseminate information.

Further details can be found at http://ww2. health.wa.gov.au/Articles/A_E/Colonoscopyand-Gastroscopy-requests Enquiries are welcome at EndoscopyProjectEnquiries@ health.wa.gov.au WA Adult Gastrointestinal Endoscopy Services (WAGES) Project ........................................................................

Calling out euthanasia ‘spin’ Dear Editor, In 2015, the World Medical Association re-affirmed its condemnation of euthanasia/ physiciansssisted Suicide, which it regards as a violation of the Declaration of Geneva, the modern version of the Hippocratic Oath.

It is no surprise that every national medical association in the world (except The Netherlands) is opposed to euthanasia. The AMA has obligations as a member of the WMA and a signatory to the Declaration of Geneva.

In publicly opposing euthanasia, the PM Mr Turnbull remarked that "they cannot get their house in order". If Euthanasia is to be limited to the "terminally ill", why do we have Dr Nitschke advocating "rational suicide" and Andrew Denton supporting assisted suicide for the elderly, mentally ill, and "anyone who is suffering"?(Q&A,"Facing Death"). Mr Denton's recent policy backflip is hardly convincing and reeks of political expediency.

8 | FEBRUARY 2017

Dr Nitschke and Exit have done a good job sabotaging the euthanasia cause. Clearly, they have NO intention of limiting euthanasia to the "terminally ill". This is all spin and it is time the AMA leadership woke up to this.

Dr John Hayes, Consultant Physician, Subiaco ED: For the record, the medical editor of this publication is pro-choice for both the doctor and patient - euthanasia should be an option for patients and participating doctors should receive legal protection. The building-in of whatever safeguards depends on the community.

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The unhappy hypothyroid Dear Editor, Most of our patients with hypothyroidism are diagnosed early and most are satisfied with their treatment.

Many of these will retain residual thyroid function for some time.

A small proportion of patients on thyroid hormone replacement are distressed and unsatisfied. They represent possibly 5-10% of all hypothyroidism cases. They have diffuse symptoms including fatigue, brain fog, or more typical dysthyroid phenomena such as cold sensitivity, dry skin, or constipation.

Most of this minority can be identified from their patterns of laboratory tests. Many have quite frequent blood tests on record, as repeated adjustments of thyroxine therapy are made. Often they show high normal levels of free T4, accompanied by low or subnormal TSH levels. A common clinical sign in this setting is delayed tendon reflexes. The knee and ankle jerks showed very slow relaxation (a typical sign of hypothyroidism).

These patients have T4/T3 imbalance, due to a relative deficiency of deiodinase enzymes that convert T4 to T3 (a genetic trait). They will show free T3 levels towards the lower limit of the normal range and they will have a high T4 to T3 ratio (greater than 4.0).

A total of 11 clinical trials have been conducted to clarify this issue. Only two trials showed a benefit of adding T3 (Tertroxin) to the T4 (Thyroxine) treatment. This lack of compelling evidence is explained by inappropriate selection criteria. All of the trials were conducted on unselected patients with various forms of hypothyroidism, and without specific symptoms. The proper trial should be confined to that subset of patients who have symptoms and signs to suggest T4/T3 imbalance.

Identifying these patients is often gratifying, for most will respond dramatically to the addition of Tertroxin (T3) to the Thyroxine (T4) at a reduced dose. Tertroxin requires an Authority Prescription. To give an example: An unhappy patient taking Thyroxine 150 µg daily will do very well on Thyroxine 100 µg daily with Tertroxin 10 µg twice daily added.

Reflexes will also improve.

This remains a controversial topic with endocrinologists, because of the lack of sufficient clinical trial evidence.

Dr Tim Welborn, Endocrinologist and Clinical Professor of Medicine ED: Reference: Welborn TA. Endocrine Practice 2013: 19; 1062–1065

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Notification of induced abortion Dear Editor, What are my obligations under WA law?

Since 1998, legislation in WA has enabled doctors to perform induced abortions and terminations before 20 weeks gestation may be performed for any reason after counselling and informed consent. It is a statutory requirement that the doctor undertaking the procedure notifies the Chief Health Officer (previously termed the Executive Director, Public Health) within 14 days of the procedure.

Are there different rules for late abortions?

For pregnancies of a gestation of 20 weeks or more, the reason for the termination must be considered by a panel of doctors appointed by the Minister for Health, and the abortion must be approved by at least two members of the panel before the termination can proceed.

These terminations can only occur at a facility approved for the purpose by the Minister for Health.

What about medical terminations?

Doctors who perform terminations using Mifepristone must ensure that the notification process is completed using the appropriate forms, which are submitted within 14 days of the abortion.

Where can I get more information?

The WA Department of Health publishes a triennial report which is available at http:// ww2.health.wa.gov.au/Reports-andpublications The notification process is explained at: http:// ww2.health.wa.gov.au/Articles/A_E/AbortionNotification-System Notification forms can be downloaded under the tab ‘reference material’ and can be ordered by contacting 9222 2417; Email: birthdata@health.wa.gov.au Dr Revle Bangor-Jones, Medical Adviser, Office of the Chief Health Officer

MEDICAL FORUM

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FEBRUARY 2017 | 9

Letters to the Editor

INCISIONS

Health Looms Large in Poll Political pundit A/Prof Peter Kennedy suggests that a report card on WA Health will be critical to the outcome of the state election.

Premier Colin Barnett will be hoping that his government's rebuilding of the public hospital system will work as a plus and help him lead the Liberals to a historic third four-year term in power with their prickly alliance partners, the National Party.

No political party has won a third term since four years became the norm after the 1989 poll. The general election coming up on the March 11 will provide a real test for the Barnett government.

The $5b-plus investment in public hospitals over the past four years should be a big positive for any government but, as we all know, it hasn’t entirely gone to plan and it has caused the Liberals/Nationals a degree of political pain.

The proliferation of new parties seeking registration and the resurgence of support for Pauline Hanson's One Nation makes the election result difficult to predict. serious questions about the government's competence. Privately, Mr Barnett and Health Minister John Day have been fuming in frustration. Better news for the government

The ongoing delays in the opening of Perth Children's Hospital have raised

Health has traditionally been a strong area for Labor but the party has been taking a cautious approach this time.

One of Opposition Leader Mark McGowan's early promises was for a Labor government to introduce an unspecified number of ‘medihotels’ to deliver a ‘better patient experience’. They would be located near major hospitals for use by recuperating patients and family members, freeing up expensive hospital beds for more urgent cases.

And there is an undertaking to oppose the privatisation of hospital services and the outsourcing of traditional public sector jobs, both moves designed to firm up support and donations from the union movement.

The groundwork for the rejuvenation of public hospitals was laid by the previous Labor administration when then Health Minister Jim McGinty commissioned experienced health administrator, Prof Mick Reid, to review the system. It was the Liberal-National alliance that brought the plans to fruition.

Fiona Stanley Hospital is a first-class facility but its initial 12 months were anything but smooth.

There were inevitable teething problems, many of which were given greater attention because of Labor and union antipathy to the ‘contracting out’ of many services normally done by government workers.

The late December commitment to build a new $7m helipad at the ageing Royal Perth Hospital suggests the former flagship – recommended for downgrading in the Reid Report – has a future.

Country hospitals, understandably, have been included in the government's upgrading of services to ensure the National Party remains onside.

has been the successful negotiation of pay agreements in the labour-intensive health system. And that means no repetition of the sweetheart deal with the Australian Nursing Federation to (successfully) ‘buy’ industrial peace during the last election campaign.

On a broader scale, the proliferation of new parties seeking registration and the resurgence of support for Pauline Hanson's One Nation makes the election result difficult to predict.

With high unemployment in the wake of the resources boom, economic management will undoubtedly be a big election issue. It will be a tight contest.

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FEBRUARY 2017 | 11

HAVE YOU HEARD?

Making a Splash for ROLLIS Mt Claremont GP Dr Rosemary Quinlivan (left) has been preparing for her third solo crossing in the annual Rottnest Channel Swim, which splashes down at Cottesloe Beach on February 25. Her cheer squad is a band of doctors, two of whom were in her year group at the UWA medical school. Mandurah GP Dr Tony Tropiano is skipper of her support boat alongside his son, Mike (pictured), and Rosemary’s daughter, dermatology registrar Dr Louise O’Halloran, herself a veteran of the swim, will be paddling. On dry land but very much involved is Dr Pam Hendry who approached her friend Rosemary to swim on behalf of the Ladybird Foundation, of which Pam is a founder. Funds raised by Rosemary’s swim will go to the ROLLIS (Radio-guided Occult Lesion Localisation using Iodine 125 Seeds) breast cancer clinical trial after the trial’s colead, Prof Christobel Saunders, asked the foundation for urgent funds to hire a Clinical Trial Coordinator to see the project to its completion. Pam said that donations can be made on Rosemary’s supporter page https://rottnestswim2017.everydayhero. com/au/rosemary-o-halloran-solo-rottnestchanel-swim-for-ladybird-f

Peel stays with Ramsay The WA Government has extended Ramsay’s operating contract for the Peel Health campus for a further five years. The announcement was made a year before the current contract had expired. Minister John Day said the extension secured the service and allowed time for forward planning. The new competitive pricing contract brings Peel in line with other Public Private Partnerships (PPPs), namely with St John of God Midland Public Hospital, which signed an initial 20-year contract with the government.

Since the announcement, the government has committed an extra $1.9m to clear the backlog of public elective surgeries at Peel.

Going by media reports, it will need all that in the ENT area alone.

AAPM weighs in on rentals The Australian Association of Practice Management (AAPM) released a position statement last October in response to the Federal Government’s intentions to reverse its 2010 decision and control collecting centre rental arrangements between pathology providers and co-located medical centres (see GP Trends, P17). Interference with free market negotiations, unsustainable regulation and red tape with disproportionate benefits to a few large corporations that owned medical practices were among its grievances.

AAPM, with 60% of its membership from GP practices, let it be known that the sustainability of many general practices was now dependent on cash flow from rental arrangements. It said that mainly larger pathology companies had chosen to colocate with medical practices, out-competing others and increasing their market share. The proposed rule changes sought to advantage

12 | FEBRUARY 2017

them further. The controversial deal between the government and Pathology Australia was struck in the heat of last year’s federal election campaign – effectively buying PA’s silence over the bulk billing policies. A free market?

Patient advantage is behind competition over patient fees and onsite pathology collection centres. APPM said it had not seen evidence that high rents were acting as an inducement for doctors to increase pathology referrals.

Solutions. CMS is a software company started by two doctors in South Australia in the public hospital system. Their flagship product BOSSnet is the “clinical information system of choice”. The business, which was “actively seeking to partner/ joint venture with similarly minded organisations”, was doing something right in November because soon after the HITWA meeting it was acquired by US electronic medical record (EMR) giant Allscripts (which had just undergone a decline in share price). Pulse+IT reported that in WA, BOSSnet is in FSH, will be in the new Perth Children's Hospital, and …has gone live at Bunbury and Busselton hospitals, part of a 14-strong roll-out for WACHS. Separately, an independent report in 2015 pointed to problems with BOSSnet’s EMR at FSH. Now, a patient portal is top of their agenda.

Allscripts is rolling out the Enterprise Patient Administration System (EPAS) for the SA Department for Health. Both Sunrise PAS and dbMotion™ (a population health solution) are Allscript products that CMS’s co-founder said would be introduced into Australia.

Midland hub takes shape There is still 19 years to run on the contract with St John of God Health Care for the Midland public hospital but we received news late last year that SJGHC has had government planning approval of its purchase of 3ha for $10.6m in the historic Midlands Workshops precinct for a private facility.

Soon to be opening in Midland is Perth's only bone and tissue bank, while the Icon Group has announced that it would open a cancer treatment centre (it will also be building one in Rockingham) at the precinct in April. The Curtin Midland Campus is due to open in 2019 after the government announced a $22m cash and land deal.

Compulsory rehab on the cards In December, the WA Mental Health Minister Andrea Mitchell announced a consultation process over draft legislation that would make it compulsory for some people with severe alcohol or drug addiction to undergo treatment for 12 weeks and voluntary residential rehab for a further nine months. It sounds a measured response to the chaos drugs such as methamphetamine and alcohol are causing in the community. The process for the Exposure Draft Bill closed at the end of January. It’s to be hoped the proposal gets some bipartisan support given the looming state election.

Hard-selling pharma In 2013, under “insights from the frontline” FirstWord Dossier reported that China had more pharma sales reps than the United States; only 3-5% of China's physicians were being detailed by pharma; and the previous year e-detailing expenditure in China increased 40%.

IT business moves Medical Forum attended the HITWA innovations conference in Perth late last year and was intrigued by the connections of one of its sponsors, Core Medical

Hippy, hippy shake When it comes to judging patient outcomes, you could do worse than line up a team with hip replacements and pit them against a team with knee replacements on a hockey pitch. Just before Christmas, the Australian Orthopaedic Association did just that at an event at the Perth Hockey Stadium to mark the AOA’s 80th anniversary. It was the brainchild of Simon Thomson, the president of Western Hockey Masters, when he realised the growing number of players wanting to play after their various joint replacement surgeries.

So 27 players over the age of 50 (average age of 69) with at least one knee or hip replaced took to the field in a battle of the prosthetics.

For the record, the Hip team won 3-1 and local AOA representative Dr Greg Witherow presented it with the Hip-Knee trophy.

MEDICAL FORUM

• Greg Hunt is the new federal Minister for Health after the resignation of Sussan Ley. Former Assistant Minister Ken Wyatt is now Minister for Aged Care and Indigenous Health.

• Australian Clinical Labs has bought Perth Pathology from owner Dr Wayne Smit, who will retain a “significant” minority equity share and will continue their involvement as executives. Clinical Labs’ purchase of St John of God Pathology went through in October 2016.

• WA Health is concluding its hospital investment program with some redevelopments and refurbishments of regional health services. Pindan has won contracts worth $50.9m to redevelop Northam and Merredin and refurb Dalwallinu.

Cockram has won the $35.5m contract to redevelop the Narrogin health service and FIRM will undertake the refurbishments of Jurien Bay ($3.1m) and Wongan Hills ($2.1m).

Lycra for a Cause The Hawaiian Ride for Youth from Albany to Perth is one of the big cycling charity events on the calendar and a group of keen cyclists from Hollywood Private Hospital have put their pedals on the line for the March ride. Urologists Drs Andrew Tan and Tom Shannon, orthopaedic surgeons Drs Clem McCormick and Ryan Lisle, anaesthetist Dr Steven Myles and hospital CEO Peter Mott have been training hard for the 420km ride. Peter is riding the CEO leg alongside other WA CEOs. Funds raised from the ride help young people in need, many suffering from mental health. Since 2003 $15m has been raised. The Hollywood team is doing its own fundraising with a “Champagne Sunsets” event on February 11 at the City of Perth Surf Lifesaving Club at City Beach. Info at www.rideforyouth.com.au/events/ champagne-sunsets

Fees, fees and more fees As the clock ticks down to February 27 and the new era of consumer directed care in the aged care sector begins, the pointy end of CDC – funds – are in the sights of service providers and the legal eagles. Panetta McGrath lawyers issued a statement over exit fees, which providers have the option of charging if a consumer decides to move their funds to another service provider (the essence of the reforms). Enore Panetta gives

BY THE NUMBERS Staphylococcus aureus bacteraemia (SAB) in WA public hospitals 2015–16

SAB CASES Methicillin-resistant SAB Methicillin-sensitive SAB

30 102

SAB CASES

PER 10,000 DAYS OF CARE Methicillin-resistant SAB Methicillin-sensitive SAB

.20 .69

RATES

(SAB per 10,000 days of care) Principal referral hospitals 1.36* Public Acute Group A .42 Public Acute Group B .71 Other .57 *This was the highest rate in the country Source: AIHW

MEDICAL FORUM

this advice to providers regarding exit fees.

1. Providers must notify DSS of the maximum fee, which will be published on the My Aged Care website; 2. The agreement signed with the consumer must set out the maximum exit fee; 3. The provider must notify the consumer within 56 days of termination of the exit fee deducted from unspent funds; 4. The fee cannot be more than the consumer’s unspent funds. The devil is always in the detail.

$7b WA Health investment in hospital construction and refurbishment between 2008 and 2018

• BGC Construction has won the tender to build the new $8.8m Pingelly Health Centre, which will include an ED and Emergency Telehealth Service facilities. Cockram has started building the $41.8m health service at Onslow. It is due to be completed by mid2018. It is partially being funded with $22m from the Chevron-operated Wheatstone LNG project, located 12km from Onslow.

• Dr Christine Clinch has been appointed St John of God Midland Public Hospital’s Director of Aboriginal Health. It is the first time an Indigenous person has been appointed to a metropolitan public hospital’s executive board.

• GP and director of the UWA Medical Centre Dr Christine Pascott has been elected to the MDA National Mutual Board while A/Prof Max Baumwol has been re-elected to the board.

• St Emilie’s Convent, a 40-bed facility in Kalamunda, will have a $3.4m upgrade thanks to Lotterywest funding to improve its capacity to help young women who are at risk of abuse, domestic violence, self-harm or risk homelessness. The building is leased to the Esther Foundation.

• Hard on the heels of the recently opened Rockingham mental health facility, the WA Government has found the site in Robinson St, Broome, for its $4.8m six-bed step-up, step-down mental health facility. In Bunbury, $9m has been promised to develop a 10-bed mental health facility and a $97m, six-bed facility would be built in the Pilbara.

• The former Port Hedland hospital has been demolished and the site remediated after a fire swept through the vacant building.

The Government allocated $9.7m for the clean-up which included asbestos removal.

The site overlooks the planned $152m Spoilbank Marina development.

FEBRUARY 2017 | 13

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SPOTLIGHT

Is Labor Fit for the Job? The Coalition Government has had eight years directing health policy which has seen hospital investment peak. What would Labor bring to the system?

Health planners tell us the four-year election cycle is both a pain and a godsend – a pain because short-term election solutions often require more long-term fixes, and a godsend because the election draws attention to some otherwise unsolved problems.

fend for themselves if they come to Perth for their operation. The length of stay for a country patient in WA is at least two days more than the length of stay for a country patient in NSW. So we know WA patients are staying in hospital longer than they perhaps need. You can conceive a different way of doing it.”

Will Roger Cook, as an alternative Health Minister, take a more long-term view? During our interview at his Kwinana electoral office he said he was aware of the importance of keeping things on a sustainable footing beyond the election cycles.

That’s where Medihotels come in and, of course, there is “a cost element to it”. We put it to him that with a hospital bed costing around $1000 a day any reasonable alternative will be cost-efficient. He agreed.

“It’s always a challenge because health requires a long term view. When we were in government last we brought in the Reid Review, which took in some long-term predictions. To the current government’s credit there were elements – such the development of Fiona Stanley, the children’s hospital and the QE2 precinct – that were bipartisan.”

We suggested health policy often appeared reactionary. He responded that most people have a view of where the health system should be going, that’s politics, though current health consumers appear restless.

Mood for change?

“I think people are looking for change. In the early stages of this current government you had a Minister and party leadership who were highly engaged with leadership partners. I think Kim [Hames] got tired and distracted quite frankly.”

Will Labor give voters what they want, especially with WA as cash-strapped as it is?

Surely Medihotels is all about saving money?

“It’s all about improving the service. We have a lot of patients from the regions who have to

“You can put someone in a four-star hotel cheaper than a hospital bed per day. Making sure they are looked after strikes me as a better choice.”

He said no one had been earmarked to provide the service, if Labor were elected, but envisaged it would be “similar to a hospital in the home service”, and different organisations were keen. He had spoken to Chris McGowan at Silver Chain about it.

“We could save the hospital system at least $50m a year, freeing up 50 beds a day, and provide extra care for 5000 patients a year. It’s not a cost saving, it’s an efficiency gain.”

Relationship with doctors He suggested efficiencies could be gained if you approached things differently. The patient should remain the central concern throughout.

We suggested that frustrated doctors in hospitals may not accept his global view.

“Doctors have done many years study to get there and have formed views over that time.

Also there are traditions but [governments must] be able to work with the medical profession. About 60-70% of the health budget is for people so you have to take people with you and you will if you have a

Roger Cook MLA

strong vision of where you want to go.”

“Everyone wants to make life better for patients. There are different views about how you get there but we have to all start with the same principles.”

Relationship with consumers He said part of Labor’s election platform was to increase the voice of the consumer.

Gesturing to his mobile phone, social media was clearly a drawcard for him. He envisages consumer websites that rate hospitals (and cites positive US experiences) and suggests successful hospitals here will respond to these ratings. We are moving towards more immediate communications or the “disruption of the digital age”, as he put it.

“Patients have said they are ready for it and we have to embrace it,” he said. We suggested that social media often made complainants the loudest voice and politicians moved quickly to stop criticism rather than pause and listen to considered opinion.

“I guess we don’t have a choice with social media – it is how we engage and use it.”

We suggested that relying on patient feedback had problems. People could ignore feedback they disagreed with.

“Good feedback empowers the hospitals and the bad feedback is obviously a red flag.

If you ignore feedback that’s a problem,” he said. continued on Page 18

Labor policy in a nutshell The WA Labor health policy, Putting Patients First*, is pitched to the electorate with Medihotels, Urgent Care Clinics, increased consumer feedback and stalled privatisation all designed to improve access and increase accountability in the public health system.

State hospitals, the big budget items, get precedence.

Medihotels will free up hospitals beds, improve the flow of patient care, improve the health journey for regional patients and take pressure off ED departments. The idea is based on interstate experience. There is no indication who will fund, construct or run Medihotels and what role private health funds will play. It talks of co-location with tertiary MEDICAL FORUM

hospitals without any specifics.

Urgent Care Clinics will be based at major hospitals or at select bulk-billing GP clinics and be promoted as an alternative to EDs to take some pressure off ambulance ramping and give health consumers more choice in after-hours service. There is no reference to FACEM doctors.

Patient opinion will be tapped into using social media, smartphones and websites so patients are put first across the public health system (mainly hospitals).

Technology and innovations will be used to make the health system more sustainable – it will conduct the Sustainable Health Review informed by statewide meetings (called Patient First Dialogues).

The remainder of the document outlines deficiencies at Fiona Stanley and Midland Hospitals, ambulance ramping, surgical waitlists, delays with Perth Children’s Hospital, growing population demands and cuts to hospital staff. It closes by saying, “The patient journey begins with good primary care, a first class hospital, clear discharge plans with their GP, and connected community health services to assist them to manage their condition.”

ED: *US and UK organisations have the same slogan, according to Google.

FEBRUARY 2017 | 15

Feature

GPs Find Their Political Feet

general practice

General Practice has faced some stiff political winds and there is more to come in 2017. Dr Frank Jones says GPs must be prepared and agile to meet the challenge.

When Mandurah GP Dr Frank Jones took up the presidency of the RACGP in September 2014, general practice was in the midst of a political storm created by the Federal Budget just four months earlier. There was a ‘non-negotiable’ copayment introduced by the then Minister Peter Dutton which threatened to unstitch Medicare. The air was so charged it could ignite.

The co-payment and the minister were dumped a few weeks later and replaced by a Medicare freeze and a new health minister in Sussan Ley. Fast forward to 2017 and the script in Canberra is repeating itself, while Frank, now immediate past president, is back in his Mandurah surgery.

Frank took up the presidency in an atmosphere of hostility, at least on the part of the bean counters. He was elected with a mandate to advocate for GPs who had had enough of being the forgotten branch of the profession, particularly rankling as government rhetoric would have general practice central to its policy of keeping people out of hospital. It remains the ultimate irony – a government pursuing a policy of blatant disinvestment in the very machinery that will save it billions.

Ministerial merry-go-round Frank reflected on his two years in the College hot seat in an interview with Medical Forum just before Christmas. In hindsight, it was the calm before yet another storm front, with the resignation of Minister Sussan Ley and the installation Greg Hunt to the role.

While the past two years have been hectic, Frank said he was privileged to advocate for his GP colleagues and believed the Government was better informed about the views of GPs. Was the Government listening?

“Yes, there’s no question about that – they might not like what we’re saying but they are certainly listening, but in the end Health is being hogtied by Treasury,” he said.

16 | FEBRUARY 2017

Presuming Mr Hunt has no magic bullet, the issues for the profession remain unchanged.

The College has produced significant policy documents (available on the College website) to match every twist and turn of government – the MBS review and freeze, Health Care Homes, revalidation, eHealth, research and After Hours.

“As an academic College it is our role to advise government with policies based on good evidence and disinvesting in general practice will give poor overall health outcomes and be cost inefficient,” he said.

The College has also taken its advocacy role direct to consumers with its high-profile (and expensive) Good GP campaign, which Frank said was money well spent.

Versatile skills and roles “It raises the profile of General Practice reflecting the multiple skills that generalists provide to our patients and communities,” he said .

This marketing of GPs’ versatility not only as health professionals but patient’s advocates in a system with its eye on the numbers is being watched and emulated by other Colleges.

“The surgeons and physicians now use words that we have always used such as ‘having conversations’ with patients rather than ‘consultations’. Our specialist colleagues are now openly acknowledging the importance of general practice and that real life happens outside hospitals.”

While the community perception is changing, frontline GPs are struggling to meet the demands at multiple levels.

Health Care Homes “Our 2015 paper position paper took a forward view – how to provide the best care in General Practice in the 21st century, reflecting the dramatic changes in health demography and demand. It was a good

BACK TO CONTENTS

paper and suggested parameters as to how a GP-led medical home would work to improve the patient journey, especially for those with chronic conditions,” Frank said.

“The disappointment for us was that it has been twisted to fit a government agenda and focusing mainly on one parameter, reducing hospital admission rates. There has also been a subtle change in terminology from a ‘trial’ to ‘implementation’ and this is of major concern."

“A trial has defined parameters including a control group and an evaluation process so that we can see what works and what doesn’t. An implementation presumes it will work and be put into effect.”

“In addition, the dollars input is woefully inadequate and it looks as if the Government is setting it up to fail.”

MBS and the Freeze In December, the government had to clarify its bulk billing figures – the oft-quoted political justification for the freeze/co-payment of about 80% when, in reality, it’s about 65%, depending on which area was in the spotlight.

It was the worst-kept secret but it was finally an admission and a sign that figures can be rubbery when politics require it. Though the announcement came months after the Federal election, the College’s ‘Targeted’ election campaign bit deep in the opinion polls.

“That campaign reminded politicians that people’s health is at the top of their priority list. There is no wealth without health."

“General Practice is struggling with the ongoing freeze and providing optimum quality care is proving increasingly difficult. Medicare rebates just do not cover the real cost of a consult in general practice and many more patients will be have to bear out of pocket costs: what then of our disadvantaged groups? Delayed presentation, more unwell, potentially more admissions to our expensive continued on Page 17 MEDICAL FORUM

FEATURE

GPs Find Weight in Numbers

general practice

More GPs are tackling the business side of things to maintain their independence.

Medical Forum spoke to some local practice leads who had decided to grow it alone.

Corporate medicine has been a growing part of the medical landscape for close on two decades – enough time for GPs to assess the model and decide if it suits them or not. Asking around the traps for trends in general practice, it was apparent that the current administrative burden and the volatile political climate were making life difficult for every GP. Put that GP in a solo or two-doctor practice and life could become near impossible.

In response, an emerging trend seems to be an increasing number of independent practices that are growing their own businesses to preserve their clinical independence while ensuring their commercial viability and sustainability.

Mead Medical Mead Medical, which runs practices in Kalamunda and Forrestfield, has seven associates who have equal shares.

It is a cost-sharing rather than profitDr Sean Stevens sharing arrangement.

It has tripled in size over the past decade and now employs 21 doctors and a staff of 60. We spoke to two associates, Dr Sean Stevens and Dr Rob Paul, about Mead’s structure and the challenges it faces in the year ahead.

“We have recently gone through interesting times at Mead. Our excellent practice manager Dot Melkus retired in August and even with a six-month lead-in it wasn’t long before we realised that there was no way we could replace her. No one person could fill Dot’s shoes, so we began looking at the structure of the business,” Sean said.

“We formed a transition committee and sat around at those weekly meetings scratching our heads. In the end we engaged a professional recruitment agency that specialised in SMEs to look at our business.

It gave us some really good advice and in the end we’ve gone for a board structure with a non-executive chairman who’s a businessman.”

Rob is associate chair. He said the recruitment company’s report was hugely helpful in demonstrating how the different stages in a business’s life required management to adapt to break through the various ceilings encountered as it grew.

Dr Rob Paul

“There was nervousness about the transition because Dot had been such a complete manager and her corporate knowledge was extensive. We

hope this new model will encourage staff to develop a little more autonomy,” Rob said.

Just how big Mead will grow will depend on the outcome of the board’s current strategic planning.

“We think our Executive Chairman will help us break though some of those ceilings but determining if that is what everyone wants to do is central to our current planning. It’s important to make sure that everyone is on board, otherwise it will stall.”

While the board structure may help manage a growing business, Sean said the associates were all masters of their own destiny.

“We pride ourselves on the quality of clinical care and quality service and we didn’t want to lose control of that by selling to a national corporate. Personally I would have found that difficult. There’s a lot in the philosophy of having skin in the game and having pride in your work. Those values flow from the top down and there a lot to be said for that,” Sean said.

Being involved keeps you ahead The past 12 months have seen intense focus on primary care reform. Rob cites Sean’s close involvement with the RACGP as invaluable when it comes to keeping informed of the latest twist and turn.

But Mead has always had doctors who have continued on Page 19

continued from Page 16

GPs Find Their Political Feet hospital system.”

“Something has to give: I’m optimistic that there will some shift in the political perception.”

PLAN & Revalidation “Evidence for a revalidation process improving patient outcomes is very thin on the ground, however, there is obviously public and political pressure on the Medical Board to look at it,” Frank said.

“I have been to multiple meetings on the issue and if it becomes within the province of lawyers and legislators it will be an absolute disaster.”

“The philosophy of the College is that we should be ahead of the game and start to have formal reflections on what we do in our work – actively measuring and assessing what is working and making changes to clinical practice if necessary.”

“The College has been working on various concepts that reinforce reflective learning for many years and the Planned Activity Learning

MEDICAL FORUM

and Need (PLAN) has been assessed as the best way forward.”

resilient general practice that is central and sensitive to its patients’ needs.

PLAN caused a kerfuffle among the membership in October when it was released, mostly due to its compulsory nature, and angst for some education providers because the course would be delivered by the College in-house.

“I think there will be a trend towards amalgamating smaller practices because of cost efficiencies and possibly even better patient outcomes through better continuity.

It would be a great shame if private general practice ceased to exist in Australia. While we have good corporate practices, they are answerable to their shareholders.”

Frank defended PLAN as an important mechanism for GPs “to explore where the gaps in your knowledge are”.

“GPs don’t be like being told what to do and this is a compulsory College activity but I believe once they take a dispassionate look at it and reflect on it, most GPs will see this as the way to go forward. And while it is not tied to revalidation argument, we are trying to keep ahead of that as well and I think the Medical Board will also see PLAN as a major step forward which may put revalidation to the side for a year or two.”

Where to now Frank’s hope for the future is an enthusiastic,

Along with all the other pressures private general practice faced, Frank cited the proposed changes to pathology leasing arrangements as a real threat to those smaller businesses.

“A lot of young GPs who have started their own private business depend on pathology rentals to sustain their business model. If the Minister changes that under pressure from the pathologists, those general practices will have to close and then who comes along to buy them out … the corporates. That would be a tragedy.”.

By Jan Hallam FEBRUARY 2017 | 17

Feature continued from Page 17 taken an active role in medical organisations – Dr Dennis Carragher, Dr Jane Talbot and Dr Bill Bade playing key roles in the Divisions and the local Hospital MAC, for example.

“I am just the latest in a long line of people at Mead involved in more senior levels of medical organisations,” Sean said.

“Most GPs, myself included, are in our rooms head down and bum up. You hear things but you don’t have much idea how they will affect you. Being involved in the College has brought home to me how much work goes behind the scenes not just with the RACGP but also the AMA and WAPHA – there are a lot of people putting in a huge amount of effort who don’t get a lot of airplay.”

Pathology rental crisis Sean sees one of those sleeping monster issues being the pathology rental controversy that began, as we reported back in June, as a piece of election pork barrelling – where the Turnbull Government bought Pathology Australia’s silence during the campaign with the promise of collection centre rental reductions – which has now evolved into yet another mess on the Health Minister’s desk.

Sean is an outspoken critic of the move, saying if the rental revision was to go ahead as promised on June 1, independent general practices that rely on the guaranteed income to pay their overdrafts and stay in business will push many to the wall.

“In Primary Health Care's June 2016 strategic update, they spelt out to investors that the policy will mean financial distress for many small practices which will make them easy pickings for the corporates. It is also a blatant attack on general practice. These changed circumstances will not affect collection centres in pharmacies or in corporate practices where pathology companies own the practices.”

“It is such an important issue and few understand its ramifications. We need to make a noise about it before it is too late.”

Dr Jags Krishan, Perth GP

Not all doctors are businessmen and don’t relish the business side of things but that’s not Jags.

“Some people are really keen on business and I think I am one of them. I worked for a big corporate in India and cut my business teeth there. However, when I started my own practice here, it was much more thrilling. It’s not just about business and profit, its being able to shape good clinical outcomes that I find satisfying.”

“If you look back 10 years, doctors Dr Jags Krishan who wanted to close or pull back would contact the corporates and give their practices over to them. But in the past five years, I have had three people from smaller practices contact me, particularly if the owner wanted to continue to work in practice,” he said.

“I’ve learnt over the years, if you put patient care in the centre, everything else falls into place. That is also good for GPs who work with you – they can achieve what they want to achieve in terms of clinical outcomes.”

Shaping good outcomes

The sticking point for many is the time needed to maintain and grow a medical business and Jags admits that even when he’s on holiday there is a tendency to log on and find out what’s happening – all on his phone.

continued from Page 15

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“I rate Russ highly as DG. He has come from the coalface. He knows how hard it can be with the commissioning issues at Fiona Stanley. He has also been across many problems in health.”

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“They prefer a doctor-owned business rather than a corporate. I think there is less appetite now among local doctors for someone in the eastern states telling them how to work according to a spreadsheet. They want the ground-level reality of a GP owner who knows how to make ends meet without compromising patient care.”

Jags is committed to keeping WA medical practices locally owned. He has 10 practices and partnerships in nine others which employ 60 doctors and nearly 100 staff.

He believes the trend to local ownership is growing.

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general practice

“I’m excited about working with chairs of the Area Health Boards – people like Bryant Stokes who has been around many years – and I work closely with the AMA and the other health unions, but there are other people in the system who offer valuable insights.”

Doctors know of the pull between the private and public sectors and Roger said making it “worthwhile to work in the public sector” would attract the many who wanted to work there. But we still hear of people begrudgingly leaving the public sector after many years, often frustrated.

So is his solution of “putting the patient first” powerful enough?

He acknowledged the complexity of the portfolio and the more pressure there was on the health dollar the more pressure there was on him personally.

In that regard he said that activity based funding was a long way from perfect but that every funding system produced its own distortions, even when some viewed clinical outcomes based funding more to the point.

“Activity based funding has longer to run yet. It allows us a look at the inefficiencies of health systems by allowing transparent comparisons between hospitals. That’s important. You have to be able to benchmark against others.”

“We will work with the system we inherit,” he said, knowing full well that getting elected is his first hurdle.

By Dr Rob McEvoy MEDICAL FORUM

FEATURE “You tend to marry your business. (For the record, Jags is married with two children.) But my long-term goal is to make the business independent of my office. I don’t give my role priority because we are a team, everyone is crucial and each plays a unique role. We empower people to make their own decisions.

We don’t like breathing down people’s necks.”

As to the challenges ahead, Jags is philosophical.

“Changes are going to come no matter what.

Some will be for the better and we will fight when we have to fight. What is keeping us going is innovation and changing our models when we have to. Patient care and clinical outcomes must be our focus.”

GP West, Dr Kiran Puttappa Kiran says by operating an independent medical business, he can give as much time as each individual Dr Kiran Puttappa patient needs without reference to anyone, especially not a person who is probably not a doctor sitting in an office 3000km away.

“GPs like to work as part of a team – and I am an employee, experiencing similar things to them. That makes GPs happy. At the end of the day, quality general practice is what we have to build,” he said.

Kiran only began owning practices from 2011, before that he said he was part of the team at a “very good medical centre in Mandurah” where he gained some business knowledge and, more importantly, learnt how a practice achieved quality care.

The learning curve continued with the purchase of his first practice in 2011, then others quickly followed so that today he has nine GP practices, including two ‘super clinics’, in the Hills, northern, eastern and southern suburbs.

Freeze, politics and keeping afloat However, government policy and competition in the metropolitan area is making life tough for independent practice owners. The Medicare Freeze has bitten hard. Some of his practices are in struggling suburbs where bulk billing is important to encourage consumers to look after their health.

“If we charged people in these areas, they would not seek medical attention when they should. So GP practices are bearing the brunt in order that patients are not denied good quality care when they need it,” he said.

Kiran says he is not a businessman per se, the only business he can run is a medical business and times are tough. The density and number of medical practices in the metropolitan area often mean that in some areas there are not enough patients to meet the expectations of doctors working in the practice.

general practice

Keeping docs happy “I consult seven days a week and employ a staff of 65-70 with about 35 doctors and it is a challenge to keep them happy for the long term. There are so many medical centres in Perth and everyone wants to see a good number of patients. How can you provide 40 patients a day for all your doctors when there are practices just down the road trying to do the same?”

“If you don’t meet your doctors’ expectations, they move on. It is becoming tougher.”

While there are challenges, Kiran says, there are positives. His Mundaring super clinic has had an amazing start in its first six months and Waikiki was to open on February 1 but he’s drawing a line under any more expansion.

“I still have a passion for medicine but I’m focusing on consolidating the business now.”

By Jan Hallam

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FEBRUARY 2017 | 19

Feature

Silver Chain Eyes the Home Market In a world where the consumer is increasingly shaping health delivery, the CEO of Silver Chain, Chris McGowan, explains how the organisation fits into this landscape. everything looks like a nail, so doctors in a hospital who see someone who is unwell default to admitting them because it is safe and familiar.”

“Ninety eight per cent of people prefer to be treated at home – it’s safer and it’s a fraction of the cost.”

Mr Chris McGowan

For starters, this is a big organisation with an interstate reach, primarily funded by WA taxpayers ($179m 2015 annual report).

In WA, Silver Chain’s reputation has been built around its hospice and palliative care service of 30 years’ standing. This and its ability to tackle the more difficult, expensive patients has drawn government attention to its ‘hospital at home’ services as a means of providing savings while meeting growing demand.

It arguably gives Silver Chain some leverage in an increasingly crowded and competitive market, particularly with the advent of the federal government’s Consumer Directed Care policy that gives ageing consumers control over who provides their home care services.

Hospital at home

When it comes to pinpointing the actual figures on how many patients each day benefit from ‘hospital at home’ care, it gets a bit rubbery. Patients going for early discharge may have been occupying a hospital bed for non-medical reasons, no one has a classification for ED referrals, and it is an educated guess as to whether treatment at home prevents a hospital admission. Even Chris varied the figure between 600 (certainly) and 1100 (likely) during our conversation.

He prefers the view that Silver Chain’s “virtual hospital” treats about 1100 a day, saying this figure is more than the total beds available at Fiona Stanley. His 1100 is made up of: • About 50% of the 300 early discharges from hospital (“Rolls Royce service, better care at a fraction of the price”).

• 450 patients referred from ED departments (“a substitution for a hospital admission”).

• The remainder from community nursing (“preventative care”).

We asked “Why haven’t we done it before, if it’s such a good idea?” He replied that Silver Chain had been doing it for some years, using palliative care’s good reputation.

Chris praised the WA public health system, Medicare, GPs, pharmacy, the PBS system and imaging facilities, “but the reality is, if you are too sick for your GP to look after you […] you kick up into hospital at a thousand dollars a day where it is safe, until you see your GP. There’s a huge gap and Silver Chain is all about filling that gap. We don’t do hospital care or general practice.”

Most doctors have heard that 70-85% of health consumers entering palliative care prefer to die at home. Chris said in Perth about 70% will die at home while the national average is 15-20%. About 85% of these patients avoid hospital admission in their last 81 days. This service to about 650 people at any one time has been going for about 30 years.

“There is fairly good evidence that 30% of patients in hospital don’t need to be there; they are there because hospitals don’t realise the care you can get in the community.”

“WA has about half the number of palliative care [hospital] beds per head of population,” he said.

He specifically pointed to the monitoring technology available, logistics, and over 3000 Silver Chain staff visiting people in their homes.

We suggested that a captured population for research in public hospitals and silos of specialised care may mean getting people away from hospitals is difficult.

“It is a complicated thing. A lot of people say hospitals are incentivised to admit people because they get their activity up. As Einstein said, if all you’ve got is a hammer then

20 | FEBRUARY 2017

About eight years ago, the then Health Minister Dr Kim Hames, who in medical practice had used the palliative care service regularly, raised the idea of a similar service for those needing acute care.

“It was part of his election platform and it has been a huge success – now every other state is trying to do the same thing,” Chris said.

What role for doctors?

He said creating awareness among hospital doctors was a key to changing the system.

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“One day every doctor who graduates might do a placement with Silver Chain. They might end up radiologists or pathologists but they’ll know what the community health system can deliver.”

“When you don’t know what the quality of care is like, or how the system works, there is a sense for hospital doctors that they are discharging people to an unsafe environment.

That’s why it’s important to get doctors trained so they become familiar with another part of the system.”

In 2016 Silver Chain helped train 60 doctors for 10 weeks each but during 2017 the number is set to halve. Chris is hopeful that a growth in demand from clinical schools will see more doctors getting wider experience of seeing patients at home.

Who relies on Silver Chain?

“It is primarily aged people,” Chris said.

“We see about 50,000 a year in our social care system but see about 30,000 a year needing clinical care. Some are wounds, stomas, diabetics with leg ulcers or pressure ulcers, and we do a lot of post-acute wound management.”

Taxpayers fund Silver Chain, through government grants.

“Annual indexation for our grants is 1.5% because the government is under pressure.

We try and make a small surplus each year to put back into research and innovation in technology, particularly to improve communication between general practice and hospitals. We are constantly trying to reduce our costs.”

I suggested that Silver Chain had a reputation for being top heavy and bureaucratic.

“We took about $17m out of our back office systems last year, so you might have said we were a bit top heavy. We are on target to take another $12-13m out this year so we are continually pushing that boundary. We did have a large research team, about 12-15 people, all making sure our clinical protocols were evidence-based and tested.”

“So if you were to compare us with other aged care providers you might say we were top heavy, but if you were to look after as many people as we do who would otherwise be in hospital, you do need doctors and proper medical governance and top-notch clinical management systems and nurses who are more senior.”

Consumer Directed Care Chris applauded the federal government for introducing more consumer choice in home care services but the downside for providers was that each consumer’s allocation was

MEDICAL FORUM

Feature

quarantined, which meant that organisations such as Silver Chain lost the ability to average things out by passing funds from those who don’t use all their allocation to those who need it.

“We see a benefit for people in their late life who prefer to stay at home and get quality care. That is no doubt going to bring us to work with WAPHA on various innovations, trials and programs.”

He wasn’t worried about the efficacy of consumer choice under the CDC packaging.

“At the end of the day it is the consumer’s life. We should be responding to what the consumer wants. Our expertise is making sure consumers have the confidence to stay at home until the end.”

“That’s part of reducing our costs, to represent value for consumers. We have consumers that have health needs that sit alongside their aged care needs. If you have a more comprehensive provider like Silver Chain you are more likely to stay at home.”

Plans to integrate Eight months ago, Chris stepped down from board of WA Primary Health Alliance.

He said he joined the board because he saw efficiencies in “one united primary care system that the state could work with”.

However, Silver Chain secured a WAPHA contract and Chris said he stepped down as there was a conflict of interest. But he defended his initial presence on the board saying it was related to his skills and experience in primary care. He had transferred to WAPHA from a previous Medicare Local board.

“When we started to talk about commissioning, I decided I didn’t want to be part of that.”

What sort of commissioning?

Consumer focus means what?

How will consumers choose the right provider in a health system that is hard to navigate at the best of times? Silver Chain has asked consumers what is important to them and staff is the top of the list.

“Most important is that they like the person who comes to help. They form relationships with staff. If you are old or at home, the person who comes and cleans or helps you shower may represent the most exciting thing that happens to you in a day – it’s important to get along with them.”

“The other thing is consistency – they don’t like it when personnel changes and they want to know when the carer is arriving. One of the big anxieties for ageing consumers is access to high quality, reliable care. Much more than a casual nurse who drops in on you.”

So the emphasis is on attracting and keeping good nurses.

Innovations Global management consulting firm McKinsey is paying Silver Chain $500,000 to be involved in the business, “We are about to do some work here with WAPHA, work that McKinsey is buying into, looking into how we look after people at end-of-life: What is the wrap-around service for those people who want to stay at home?

There are about 12,000 deaths each year in WA, about 3000 of those are in palliative care and we could expect another 3000 or so.”

The organisation is also working with the NSW and Victorian governments offering endof-life services in NSW and chronic disease management in Western Health in Victoria.

The NSW government is paying Silver Chain “a little less than usual hospital care costs” to keep people out of hospital during their endof-life care. “It will be the first health-social impact bond in the world,” he said having explained that similar efforts to keep prisoners out of prison had worked effectively.

“We are particularly interested in this gap between primary and tertiary care, the commonwealth funded out-of-hospital plan doesn’t connect well with the state funded in-hospital plan.”

“The voter is realising that the gap between the two is costing the community a lot.”

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FEATURE

Vision Van Meets Eye Care Need The Lions Outback Vision Van (LOVV) is one response to a growing problem with vision disorders in WA that result in significant economic, social and quality of life impacts.

Proponents of this outreach service are faced with these facts: • Indigenous Australians suffer three times the level of blindness, are 12 times more likely to have cataract-related blindness and 14 times more likely to have diabetesrelated blindness (cw the general population).

• In remote WA, specialist coverage is about 20 times less than urban Australia and rural residents are three times less likely to have seen an ophthalmologist.

• While most vision loss can be corrected overnight, 35% of indigenous adults have never had an eye examination.

• Anecdotally, eye care close to home is very important. As an example, a 60-year-old Indigenous man was seen by a visiting optometrist in a remote Kimberley community; he was very shy, was mourning his wife and prepared for an aged-care facility; he had hypermature cataracts (legally blind) that were cleared later with prioritised eye surgery at Kununurra thanks to the assistance of clinic staff. He is now back with his community, speaks fluently, and drives a car again.

LOVV, which first hit the road just over 10 months ago, has an ambitious goal – to close the eye health gap in regional and remote WA by delivering outreach services for all major eye conditions where people live.

It is normally staffed by a resident doctor, ophthalmologist and nurse/driver and a typical visit lasts from 1-5 days, depending on the size of the community.

The Lions Outback Vision Van at a country town stop off

• About 1679 patients seen – 707 Aboriginal and Torres Strait Islanders.

Aboriginal Medical Services and existing health facilities (e.g. cataract removal).

According to Dr Angus Turner, enthusiastic ophthalmologist and McCusker Director Lions Outback Vision, LOVV provides access to clinical equipment usually only available in tertiary centres. Equipped with a range of state-of-the art ocular imaging and lasers, the LOVV and its team have provided care that exceeds some tertiary hospital facilities. LOVV saves patients having to fly to Perth to access this care.

“Other priorities are tele-ophthalmology, building stronger connections between GPs, Aboriginal Medical Services, Aboriginal liaison officers and health workers, robust screening programs for diabetic retinopathy and the identification of local ‘eye champions’ to spread the word about caring for your eyes.”

“While it was logistically challenging, the LOVV and its team have been given an enthusiastic reception and extra effort from local community health staff,” he said.

“Visiting ophthalmologists who help out on the LOVV for a week at a time are amazed at the facilities available and patients are often a bit shocked at the size of this ‘van’ which is probably the wrong description for a rig of this size.”

Ophthalmologist Dr Turner examines a patient in one of the van’s consulting rooms

Is this outreach service needed and do we have the personnel available? Maybe we should reflect on the early successes and challenges of the LOV Van project.

• 16 different communities visited and 85 clinics conducted, from Albany to Kununurra

MEDICAL FORUM

“The last decade has seen new technology used in daily practice to monitor and treat common eye conditions. The management of diabetes, glaucoma, macular degeneration and measurements of lenses for cataract surgery have all moved beyond what can be offered on standard outreach eye trips.”

Each week LOV clinicians across the State discuss complex cases and can use the technology on board, again, to avoid travel to Perth. Where more complex surgery has been required, LOVV works closely with

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“LOV often coordinates closely with the AMS health workers, to complement things like the LOV DR [diabetic retinopathy] screening which has retinal cameras located in local health services.”

“Telehealth transmission of images for retinal screening has been occurring for many years. In November, a new MBS item number for GPs to take retinal photos will improve awareness and access to DR screening. There are also new item numbers for optometrists to do video consults with specialists and help consent patients to surgery, for example, to save waiting times and directly book patients. This has been very successful in 2016 with high attendance, patient acceptance and uptake by optometrists.”

“It is a wonderful thing to be a part of this great tradition – the first mass screening programs for glaucoma by the Lions Eye Institute began in the 1960s – and it is exciting to see what can be achieved with technology in protecting the eye health of some of our most vulnerable citizens.”

FEBRUARY 2017 | 23

Feature

Costs A Byword for Specialties

specialist

Innovation has opened up exciting avenues in every corner of medicine but spiralling costs will put a dampener on the party.

Dr Sue Ulreich, Radiologist

patients. Not only do they pay gaps, but they need to pay the full cost of the service upfront then claim the rebate from Medicare.”

“We regularly hear about West Australians who don’t present for radiology services requested for them by their GP or specialist because upfront costs averaging $235 – and $500 or more for CT and MRI – are out of reach.” She considers this potentially damaging to a patient’s health.

“It is a very strange anomaly that I’m able to pay just the gap when I go to the dentist, while they claim the rebate directly from my private health insurer using the HICAPS system.”

Dr Gordon Harloe, Pathologist Dr Sue Ulreich

Dr Sue Ulreich, CEO of SKG Radiology, sees funding for private radiology as one of the challenges ahead. She said affordable access to radiology services resulted in early diagnosis which improved outcomes but some patients were missing out due to cost barriers.

“It’s time to end the freeze on patient rebates,” she said, pointing out that the radiology indexation freeze had been in place for 19 years. Her point was that health professionals made up 60% of SKG’s costs and their services were not a commodity to be treated that way.

All practices look for efficiencies while facing the freeze but inevitably some costs filter down to patients. She said one-third of radiology services in WA were not bulk billed, with out-of-pocket contributions by patients averaging $114 in 2015-16 (a 70% increase since 2007).

Dr Gordon Harloe, is a practising pathologist and CEO of Clinipath Pathology. He has seen many changes, the latest of which is the recent sale of Perth Pathology and SJOG Pathology to private equity company Australian Clinical Laboratories. What pressures are labs under?

“With the chronic Federal Government underfunding of pathology and increasing cost pressures, laboratories have had to sell in the eastern states. These ‘forced aggregations’ enable laboratories to survive with economies of scale,” he said.

“Path labs are only paid by Medicare for the three most expensive groups of tests ordered

by GPs [the cone] while specialist work is currently not coned and all tests requested by them are paid for. Successive governments have cut pathology rebates and it concerns the pathology sector that the MBS Review, under the guise of best practice and quality,

“Many services have rebates so far removed from the cost of providing the service – diagnostic mammography is a good example – that practices either charge significant gaps or don’t offer the service at all because they can’t even afford to bulk bill concession patients.”

Test costs are coming down “As computing costs drop molecular tests will become more affordable. For example, the non-invasive prenatal test [NIPT] was well over $1000 and it has now dropped to $425 in 2017. If the government drags its heels on paying for new tests, such as the NIPT, the patient pays and there are big savings for government.”

In the example of the NIPT, Medical Forum guesses that pregnant mums may be more willing to pay, particularly if they (and government) benefit from reducing the number of amniocenteses.

We have also noted the proliferation of pathology collecting centres since the government stopped regulating them in 2010. Increased numbers must be adding to each provider’s bottom line although the final number of collection centres is sure to reflect market forces, with factors such as colocation within medical practices, rental paid, and staffing costs coming into play. In a twist, in response to threat from the government to again regulate, the AAPM has come out against this idea partly because many medical practices now rely on the income from collecting centres.

Consumerism is having an influence.

“Patients expect everything to be just around the corner. Having pathology collection centres located in every suburb comes at a significant cost as does being open after hours. Where does it end? The Medicare rebate doesn’t properly support this extended level of service and convenience,” Gordon said.

“Those women who were averse to Pap smears can now be screened using selfcollection of a sample under supervision in medical practices.”

“There is also provision for HPV screening of women after their second episode of post-coital bleeding and for those who are immuno-compromised. So it’s a very comprehensive, safe system that is going to prevent cervical cancer in up to 30% more patients and we hope make inroads into reducing adenocarcinoma of the cervix.”

She wants a HICAPS-style billing system for radiology.

24 | FEBRUARY 2017

“About 70% of clinical diagnoses are supported by a pathology test and 100% of cancer diagnoses. So we will always need that scientific confirmation of the clinical diagnosis. Tests also monitor chronic disease, such as diabetes using glycosylated Hb, and molecular pathology is already being used to monitor cancer and cancer therapy”

In the pathology world, one big change this year is to cervical cancer screening with added benefits for women poorly screened under the previous regime.

“Before the election last year, the Government announced that it would index radiology rebates when it ended the GP freeze but this isn’t scheduled to happen until mid-2020.”

She felt the funding shortfall was more urgent than that, for the patients’ sake.

“Bulk billing has become increasingly difficult for radiology practices, yet the Medicare rules and systems impose a double whammy on

may introduce further fee cuts.”

Dr Gordon Harloe and Mr Chris Atkin

On the downside, with the reduction in Pap MEDICAL FORUM

FEATURE smears, fewer cytologists will be required to review the cytology specimens and there will be redundancies. Furthermore, the draft guidelines suggest 2000 screening tests per month are needed to maintain competency, and some labs will fall below this minimum threshold and Pap smear cytology departments will have to close.

Liquid biopsies break new ground

“Telehealth has given us better access to regional and rural patients; electronic referrals and reports provide rapid turnaround times; we can report and review wherever there is internet access, electronic scripts have reduced prescribing errors; we have better recording keeping and generally there is improved communication with everyone on the patient journey.”

Another big change coming is ‘liquid biopsies’ for cancer by sampling peripheral blood. Testing is currently for research and is expensive but has the potential to replace either direct tumour biopsies or imaging as it can detect very early recurrences and small metastases. By detecting either circulating tumour cells or circulating free tumour DNA, future testing may help identify mutations that lead to tumour resistance, changes that might be missed on biopsies.

non-valvular atrial fibrillation without the need for INR blood-test monitoring. Advances also include the development of the potent lipid-lowering PCSK 9 inhibitor (Repatha) for resistant significant secondary dyslipidaemia.

“But in the end it is the high quality health professionals we have today that make all these innovations work to produce good patient outcomes. We have to be a highly qualified and trained team to achieve those outcomes,” he said.

However he saw troubled times ahead with little innovation in the timely treatment of uninsured patients requiring inpatient services, and the lack of complete cardiology services in rural and regional areas.

“Immuno-oncology is a rapidly growing area.

Testing can be used to identify tumours with a particular gene expression that would benefit from particular immunotherapy, such as PD-L1 expression in non-small cell lung cancer. Genomic tests are used to analyse tumours, identifying the active genes, and provide guidance as to the likely behaviour of the tumour. For example, the Prosigna test is used to predict the risk of recurrence of hormonally sensitive breast carcinoma in post-menopausal women.”

For those privately insured, Mark believes that health funds are not providing adequate cover and while the Federal Government’s review into private health insurance is exploring some of these thorny issues, he’s not hopeful of its success.

Dr Mark Hands

“Where will it end?” he said, referring to future screening for cancer.

Equipment technology

Gordon wants Clinipath to remain the laboratory of choice in 10 years’ time, providing a high quality diagnostic service that WA doctors and patients trust and rely on. This means stronger linkages with the parent company to ensure access to the latest advances.

Open-heart surgery with its attendant risks and morbidity is now often avoidable with the development of percutaneous procedures such as aortic valve replacement for significant stenosis, reduction of significant mitral regurgitation (with Mitraclip), and closure of the left atrial appendage for stroke prevention.

Dr Mark Hands, Cardiologist

specialist

Dr Mark Hands has been chair of Western Cardiology for 25 years so it’s fair to say he’s seen some changes in his time. He believes the great agents of change and innovation have been IT, equipment technology and pharmaceutical advances.

“An enormous advance is that we can now accurately and percutaneously measure blood flow across coronary artery blockages to determine if an intervention such as coronary stenting should be undertaken or not. This approach now has proven prognostic benefit,” he said.

Information Technology

Pharmaceutical advances

“IT has certainly changed the way we do things,” Mark said.

These include the new novel oral anticoagulants which Mark says provide safer stroke prevention in the very common

He believes that over the next five to 10 years, methods of reimbursement will change and will be related to outcome data.

“I suspect governments of all persuasions and private health funds will demand this given the present exponential growth of health care costs. The biggest issue here will be the accuracy of the collected data,” he said.

He also sees a significant growth in procedures done as day cases, with increased patient convenience and reduced overall costs.

“Also expect to see an explosion in genetic testing and diagnosis. That is sure to come.”

And putting it out there, Mark reckons that in 10 years, drones will be the medical couriers of choice.

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MEDICAL FORUM

FEBRUARY 2017 | 25

GUEST COLUMN

GP as Life Coach As chronic illness increases, GPs may find counselling skills will help them motivate patients to help themselves, says Dr Monica Moore.

Do you sometimes wonder why patients don’t take more responsibility for their own health? Do you have conversations with patients about diet or exercise where you just know that the person in front of you has no intention of following through on your advice?

Much of our work as GPs involves treating the impact of lifestyle on health – both physical and mental. And there is no pill for motivation.

emotion and show concern. “You sound... overwhelmed/stressed/angry/sad/frustrated...”

Once the patient can think clearly, the focus of the conversation needs to be on what is in the interests of positive change – or ‘change talk’. The more change talk there is, the more likely patients are to find ways to make actual change come about.

The rewards for doing so are an increase in positive behaviour change in patients.

Motivational Interviewing is a counselling technique first used in addiction medicine.

It’s not about convincing someone to do something you think they should do. It’s about exploring, in a curious and respectful way, how patients can make changes which are consistent with their values and life circumstances.

Targeted open questions are a great way to evoke change talk.

I find it helpful to think of the role emotions play in making decisions. The way our brain is wired, strong emotional reactions ‘trump’ frontal-lobe decision-making. To solve the problem of habit change, our limbic systems need to be ‘settled’.

“Tell me, what would you like to be different?”

“What are three reasons for making this change?”

When you hear change talk, you can evoke more by saying “Tell me more…” and affirming “you seem really determined/it matters to you.”

You do this by listening to what the patient has to say, then reflecting it to show you have understood. It is especially helpful to reflect

‘Sustain talk’ is anything the patient says that is in the interests of staying the same.

“Yes, but…” “I’m too (tired/stressed/busy/

poor)”. When you hear sustain talk, reflect back the emotion. Listen and validate, it’s understandable they feel that way. Be curious… “On the one hand, you’re saying … (sustain talk), and on the other hand, you’re saying … (change talk)…”

Beware the ‘righting reflex’. As doctors, we have so much help to give. The ‘righting reflex’ occurs when you see someone doing something detrimental to their health, and you try to convince them to do otherwise.

Sometimes, your concern is welcomed, when this is not the case, when you hear sustain talk or discord it’s time to use your MI skills.

It’s OK to accept ‘no’, and offer the option to discuss it next time.

Share your expertise without direction.

Ask the patient what they know about the issue, and whether they would like to hear what you have to say. Then provide some information and ask how that sits with them.

MI is like another language, and therefore requires training and practice. The rewards for doing so are an increase in positive behaviour change in patients, consultations which feel pleasant rather than stressful, and improved time management.

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Guest Column

ORT HO C O M P WA

Court Costs In the legal system, GP Dr Hilary Fine suggests, it can be hard to work out who’s actually on trial.

Most of us are blissfully ignorant of the possibility of fraud occurring right under our nose. When a new employee came to work for me in November 2013 she wanted to change a few things. And one of them was her insistence that she – my new practice manager – and she alone, would take the money to the bank. Alarm bells should have rung.

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Our reception staff would seal the cash in bags and place it in the overnight-safe. I noticed that something strange was happening to the money-bags, the bank balance didn’t look quite right and my book-keeper confirmed there were discrepancies.

We headed off to court but, believe me, the legal system is not what you expect. The woman managed to avoid arrest on several occasions, then pleaded not guilty and chose to remain silent in court. Her lawyer had two years to prepare her case and the police prosecutor had three days to prepare the State’s case. All the time this was going on there were no restrictions on her continuing to work as a practice manager.

Under cross-examination in the witness-box by a particularly aggressive lawyer, I was thrown offbalance. My usual calm and confident manner was replaced by feelings of irritability and nervousness.

I felt thoroughly unprofessional.

Professor Piers Yates - Hip, Knee, Trauma The magistrate needed to be convinced ‘beyond reasonable doubt’ that the bank bags had been tampered with and the explicit intention was to deprive the medical practice of funds. It seemed pretty clear to me.

Mr Satyen Gohil - Shoulder, Knee, Trauma

But I was beginning to get the impression that the law is there to protect those who’ve been charged while turning witnesses into victims. The police prosecutor had no formal legal qualifications, was juggling three cases a week and his detective colleague was around the same age as my 26-year-old daughter. The trial, for me, was aptly named. It was an intense and demanding experience.

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Under cross-examination in the witness-box by a particularly aggressive lawyer, I was thrown off-balance. My usual calm and confident manner was replaced by feelings of irritability and nervousness. I felt thoroughly unprofessional.

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When her lawyer said, ‘I think the good doctor needs a break’, I decided that if he’d had a heart attack right then and there I’d think twice about resuscitating him. He summed up by describing me as an unreliable witness and added a few more hurtful personal comments for good measure. On the other side of the equation, the magistrate tried very hard to gain some understanding of how a medical practice actually functions. I remained hopeful.

The woman was found guilty on three out of six charges of ‘stealing as a servant’, a relatively small fine was imposed and her criminal record cannot be expunged. Her lawyer applied for, and won, 50% of costs on behalf of his client.

Another $12,000 of taxpayers’ money!

Going to court was not pleasant but I’d do it all again. It cost me time, personal stress, a few sleepless nights and extortionate car-parking fees.

Next time I’ll take the train.

MEDICAL FORUM

Guest Column

New Hope for Alcoholics RPH’s Dr Amanda Stafford was frustrated by the apparent helplessness of the system to tackle ‘ED Super-users’ and decided to do something about it.

I jokingly call myself a Specialist in Hopeless Medicine. My passion for helping alcoholics and homeless people, two of the most unloved groups of patients coming through the door of ED, often puzzles my colleagues. The general view seems to be that it’s admirable, albeit dreadful, work.

But nothing could be further from the truth.

The other group of deeply entrenched frequent flyers were homeless people coming to our ED in search of medical care, food, drugs and a place to stay. We had to tread a fine line between compassion and pragmatism otherwise we risked becoming a homeless shelter every night.

We felt helpless and often angry, both with the patients and at our own inability to make a difference.

About four years ago I became interested in a notorious ED ‘species’, the ‘frequent flyer’ – officially known as the ‘ED Super-user’. These patients could reach truly astonishing levels of ED attendance. Some presented so frequently with chest pain that a copy of their ECG was left pinned to a wall so we didn’t have to wait for the old notes.

The alcoholic patients we saw in ED were train-wrecks trapped in an addiction of incomprehensible ferocity. Most had been through the gamut of treatment options, often repeatedly and without any appreciable effect.

We felt helpless and often angry, both with the patients and at our own inability to make a difference.

Dealing with these people taught me the importance of forming networks both within hospital and on the ‘outside’ to provide the support these patients need to loosen their attachment to the ED. Presentations that, incidentally, rarely solve their problems.

In late 2013 I stumbled across Baclofen, an old medication being used in France with unprecedented effectiveness for alcoholism due to its ability to literally extinguish cravings.

But as some of the simpler problems melted away, two in particular came to dominate the frequent flyer list: alcoholism and homelessness.

No one in addiction medicine here in Perth was prepared to give it a try so I started treating alcoholics myself. Baclofen works, it’s that simple. My focus is now on getting this form of treatment into GPs’ surgeries where it will do the most good.

We started ‘doing it better’ by bringing staff from the Homeless Healthcare GP practice into RPH and they link our homeless patients to housing, the only thing that actually improves their lives.

Yes, I’m more than exasperated by our willingness to spend large and seemingly limitless amounts of public money on the consequences of homelessness. We spend and spend on health, welfare, justice and policing while simultaneously baulk at paying the infinitely smaller cost of improving housing and support services.

If we addressed this issue effectively it would permanently eliminate our chronic street homelessness within two years and reap immense savings in both human misery and the health budget.

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MEDICAL FORUM

Guest Column

Patient as Customer Futurist Gihan Perera looks into his crystal ball and he sees some significant changes in the how patients want to be treated in the new world order.

After four decades in the same home my parents moved house in 2015. In order to find a new local GP my 80-year-old father searched reviews on Google. Yes, he’s intelligent and computer-savvy but he’s hardly the stereotype of an obsessed social-media user. Yet even he tapped into the power at his fingertips.

The past few years have seen dramatic changes in healthcare technology. We’ve got 3-D printed organs, smartphone ECG devices, predictive analytics, Big Data and nanotechnology robotic surgery. But surely the biggest change in healthcare is the profoundly different relationship between patients and their doctors.

It’s become something of a cliché to say that healthcare is becoming a business and patients are acting like customers. But it’s true, and yet it would seem that many healthcare providers don’t fully understand the effect of this profound change.

Global tech-giants such as Siemens clearly do and they highlighted the fact in their Picture the Future report focusing on healthcare in 2020

Australia: "We’re changing focus from cure to prevention, from sickness to wellness, from acute events to chronic diseases and – most importantly – from patients to customers."

It’s an inconvenient truth that healthcare consumers are customers first and patients second and expect to be treated that way.

They expect instant access to information, communication via email and SMS, ownership of their private data, fast response times and the right to review poor service.

And, hopefully, praise exceptional service.

Deloitte’s Centre for Health Solutions asked patients about different modes of healthcare delivery.

• 60% would be comfortable with video consultations.

• 55% were happy to receive medical images by email.

• Almost three-quarters would be happy choosing a treatment online based on advice sent by their doctor

In most other industries, suppliers would be falling over each other to service these customer needs, but in healthcare that doesn’t seem to be the case. A recent PwC survey of doctors revealed that many are reluctant to hop aboard the e-train.

• 45% said they have concerns about patients’ privacy and security.

• Roughly the same number said they don’t get paid for things like email, SMS and video consults. There’s no CMBS code for all that.

• One in three said it would be too expensive to implement.

• A third didn’t know enough to make an informed decision.

• A quarter said it would disrupt their current workflow.

What about you? Are these valid reasons to avoid change – or just excuses? It’s easy to find reasons to say ‘No’, but it often requires leadership and foresight to say ‘Yes’.

• About three-quarters would prefer email and SMS consultations.

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Fertility, Gynaecology and Endometriosis Treatment Clinic 32 | FEBRUARY 2017

MEDICAL FORUM

FEATURE

Paediatric services and Perth Children’s Hospital

By Prof Jonathan Carapetis, Director Telethon Kids Institute

Big Data can aid research, especially when numbers are small.

But electronic medical records, properly linked, are the key.

Prof Jonathan Carapetis

ED

With headlines often focused elsewhere, what is often missed is the extraordinary opportunity the new Perth Children’s Hospital presents for paediatric health care and research in WA. Perth could be about to get one of the world’s great children’s hospitals.

What do I mean by ‘great’? It is more than excellent infrastructure, equipment and staff. Great means making sure children benefit from the latest advances from around the world, constantly contributing to new knowledge, acting as a beacon to attract the best and brightest staff, and giving its home town and state immense pride and confidence.

Around the world the very best children’s hospitals– Great Ormond St in London, Sick Kids in Toronto, Boston Children’s and more – all have in common research as part of their very fabric. Families know their children will likely be asked to participate in research, clinicians come to work there so they can combine research with clinical care, and the leadership takes pride in and celebrates research outcomes.

For those who don’t know, Telethon Kids Institute will be relocating into the top two floors of the Perth’s Children’s Hospital towards the end of 2017, along with other paediatric focused research groups.

There’s no doubt that bringing medical research and clinical care under the one roof will improve care for sick children, mean faster translation of research results into clinical practice and seed emerging clinical questions into research.

Careers and recruitment will be boosted. Many top clinicians have strong research interests and wouldn’t look to WA without a robust research environment. For families, it brings confidence that their child is receiving world-class care.

However, something quite fundamental is missing. While our state-ofthe-art children’s hospital is teeming with technology, it will open using paper records.

As a clinical research colleague put it to me, we’re moving with “clipboards!”

Electronic records undoubtedly reduce errors in medication and treatment, saving lives as well as money – that’s an immediate benefit for our patients. It allows a hospital to constantly evaluate and improve the quality of care.

But there’s an even bigger picture here. Wonderful software packages called Integrated Health Solutions bring together all of the information from an entire hospital into one ‘super’ electronic record. Data collected electronically – and de-identified – is rich information for the research sector and can fast-track the type of treatment improvements and breakthroughs the community is craving.

Of course, there are lessons from failed implementations of electronic health records in other hospitals and in my view it’s a good thing that the Perth Children’s Hospital is not trying to implement a new electronic records system at the very same time it commissions itself, but it should be top of the future agenda. Planning needs to start now because it takes at least two years of careful preparation to make sure everything works well right from the start.

The Perth Children’s Hospital has nearly all the ingredients to be a great children’s hospital of the world – electronic health records is the last piece of the puzzle.

Author competing interests declaration: nil relevant.

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FEBRUARY 2017 | 33

Feature

Unravelling cystic fibrosis

By Dr André Schultz, Respiratory Physician & Clinical Lead for Cystic Fibrosis, PMH

By Dr André Schultz

Drugs for CF (one PBS listed) Arguably the most exciting thing in CF therapies have been the development of new disease modifying drugs that improve Cystic Fibrosis Transmembrane Regulator (CFTR) gene expression. Disease causing mutations of the CFTR gene can be grouped into six different classes. Ivacaftor is a small molecule oral drug that improves the function of abnormal CFTR protein present on the apical surface of epithelial cells. Ivacaftor is extremely effective in improving CF disease in people with class III CFTR mutations (about

ED

with ivacaftor for class III mutations. Ivacaftorlumacaftor is available in other countries, is approved by the TGA but unfortunately has not been PBS listed due to cost. Hopefully the manufacturer and PBAC will reach agreement in 2017.

One important paradigm shift in our understanding of cystic fibrosis, driven by the Australian Respiratory Early Surveillance Team for CF, is that lung disease is present in young children before symptoms appear. We also know that CF lung disease prevention is better than treating established disease, so the focus is to develop therapies to halt CF lung disease early in life.

The testing of therapies in young children requires appropriate, sensitive outcome measures. Perth researchers have been at the forefront in developing imaging methods and lung function tests to monitor very early lung disease.

Knowledge of CF disease, especially the genetics, has led to advances in treatment. And there is more to come.

Gene therapy

Early structural airway changes in the right lower lobe of a 2-year-old with CF

5% of Australians with CF). It is available on the PBS for people with CF aged six or older (but not for children aged 2 to 5 years, although evidence suggests its safety in this population).

A second disease modifying therapy for people homozygous for the most common CF mutation (ΔF508) is a combination drug, lumacaftor-ivacaftor. After transcription and translation lumacaftor helps correct CFTR protein folding and trafficking up the apical cell membrane while ivacaftor then improves CFTR function once the protein is located on the cell surface. This combination drug safely improves CF lung disease, although less than

Insights into our WA medical workforce

By Mr Kim Snowball, Healthfix Consulting

Since the CF gene was discovered in 1989 scientists have worked hard on this front although progress has been fraught with challenges.

A group in the United Kingdom recently proved that CF gene therapy can work. Using a liposomal vector delivered by monthly nebulisation for a year, they demonstrated improved lung function in the treatment group versus the control group, in adults with CF. Scientists are now fine tuning the vectors used to deliver the genes and hope to have safe and effective gene therapy for people with CF in the not too distant future.

Further reading: Claire Edmondson and Jane C. Davies Current and future treatment options for cystic fibrosis lung disease: latest evidence and clinical implications. Ther Adv Chronic Dis. 2016 May; 7(3): 170–183.

Author competing interests: no relevant disclosures.

Questions? Contact the author 0n 9340 8222

WA still bucks the national ED oversupply of doctors by having the lowest per capita GP to population ratio of any State and the highest reliance on International Medical Graduates, but we do have some bright spots.

Mr Kim Snowball

Addressing maldistribution of the GP workforce While WA is challenged by poor distribution of its GP workforce, things are slowly turning around.

2015 marked the first year in which most new recruits to rural WA were from our own WA trained GPs with only 15% recruited from overseas – a far cry from 2008 where 42% of the new recruits into rural practice were from overseas.

The Southern Inland Health initiative supported by the WA Government through Royalties for Regions, has seen 59% of doctors remain in practice in these inland towns for at least five years compared to 32% before the initiative in 2009.

While we are not yet ready to cease international recruitment, we are ready for a

34 | FEBRUARY 2017

transition plan to manage a shift from overseas recruitment to our own home-grown graduates.

Providing high quality education and training in outer metropolitan and rural areas is critical to this.

Collaboration between WACHS, WAGPET, Rural Health West and the Rural Clinical School has been pivotal to the success in rural areas.

The new Curtin Medical School brings with it the opportunity to increase further rural and outer metropolitan-based vocational training and strengthen the career pipeline to see more doctors working where they are needed most.

Integrating nursing and allied health WA’s primary health care and ultimately the health of our community depend on a strong and vibrant general practice. But, primary health care is delivered by many, including nurses, allied health professionals and Aboriginal health workers.

BACK TO CONTENTS

What does the ideal primary health care team look like? Does it need to be left to chance or the market to decide? Maybe it’s time to consider, in a more organised way, how WA can better integrate these health professionals into general practice and the broader primary health care effort?

Much of the future innovation in primary health care will be driven by clinicians, new technology and research, but there are also some new change agents such as the WA Primary Health Alliance, Telstrahealth and Health Boards that will hopefully push the boundaries and also test new ways of delivering better health outcomes.

ED. The author and Dr Felicity Jefferies consult on workforce issues ranging from trends in the rural procedural workforce (GPs and Specialists) to reviewing GP Education/Training in WA.

MEDICAL FORUM

Feature

PIVET MEDICAL CENTRE

Mental health’s direction

Specialists in Reproductive Medicine & Gynaecological Services

By Dr Nathan Gibson, Chief Psychiatrist

Dr Nathan Gibson

Mental Health may not be ED 'sexy' or grab the headlines but community expectations have changed and the profession must change with them. Changing pathways is the easy bit. Changing attitudes is harder.

If it’s not front page news, it can appear that mental health is going through a quiet patch. This is pure perception. The inherent challenges in the mental health sector are constant, regardless of the media visibility – just ask the clinicians, patients and their families.

I am charged with monitoring standards across WA’s mental health services. The Chief Psychiatrist’s Standards were rolled-out with the Mental Health Act 2014. These are statutory standards mental health practitioners must familiarise themselves with.

Here is a brief look at some important future issues.

I will leave aside the Fifth National Mental Health Plan consultation and major mental health standards development from the Australian Commission for Safety and Quality, but will mention the National Disability Insurance Scheme. The concept is timely, but it appears unlikely to be broad enough to appropriately fund the community-managed organisations to capture the real psychosocial support need for those with severe and enduring mental illness. Strong community psychosocial support is needed to back-up clinical services.

Unsurprisingly, points of transition between services remain a risk for serious negative outcomes for patients – the sentinel event data I receive confirms this. There is a statutory standard for transfer of mental health care between services, including transfer to primary care. With the new Health Services Act 2016, we now have several Boards overseeing the new Health Service Providers (HSPs; previously Area Health Services). The HSPs have a governance responsibility to ensure that individuals needing care across services have clear and timely co-ordination.

With the tepid findings in the recent release of the Headspace report card nationally, it is worthwhile noting that the WA Department of Health and Mental Health Commission have taken active steps to expand local clinical youth mental health services. I note the challenge for primary care in this space. I would strongly encourage Health to advertise widely the pathways and resources for youth mental health as they emerge.

On a pleasing note, I’m impressed so far with the mental health component of the new WA online Health Pathways program that will provide, for GPs, summarised information, timely decision trees, pathways and direct instruction on local referrals, all on the desktop. Modelled on established eastern states and NZ programs, it’s still building local mental health content, but the quality of information being developed is robust.

Well done WAPHA. Issues don’t disappear with the media cycle. While the mainstream news attention is often narrowly focused on methamphetamine, we must also keep a spotlight turned to the needs of the ubiquitous broader mental health sphere.

by Medical Director Prof John Yovich

Hormone action dependent upon receptors ...lessons from the Booroola Merino Sheep Despite developing the highest skills in clinical, procedural and laboratory practices over the past four decades, advances in IVF technologies have been limited by the female biological clock.

The current ANZARD data show that the proportion of women >40 years accessing IVF in Australia was 25.5% in 2014 and continues to increase. These women expect to achieve pregnancy with their own oocytes, however, the chance of a live-birth is ~10% compared to ~35% for women <35 years on fresh cycles; rising to ~15% and 50% respectively when the contribution from cryopreserved embryos is added.

A depleted ovarian reserve, as well as reduced oocyte quality giving rise to chromosome errors, cause the reduced live birth rate. New scientific knowledge is needed to improve our understanding Prolific Curtin researcher of these age-related Dr Sheena Regan in the PIVET factors which laboratory with Professor John Yovich negatively affect the Genome.

Curtin-PIVET researcher Dr Sheena Regan was awarded her PhD based on her findings of age-related changes in receptor density in the granulosa cells which surround the oocyte. Her research revealed that typically, in older women, the receptor density is dysregulated when compared to young women, and this was associated with the reduced fertility (MCE 2016a).

The level of receptor density appears to regulate the recruitment and growth of the oocyte. Sheena’s research commenced in Booroola ewes that are highly fecund due to a mutation in the bone morphogenetic protein (BMP) receptor. This affects regulation of follicles progressing from the primordial pool leading to multiple ovulations (Reprod 2015). Sheena’s studies in women show that BMP receptors are increased and dysregulated during stimulation in poor prognosis women of advanced age (MCE 2016b). Her latest studies show that growth hormone co-treatment in IVF can restore receptor expression in older women.

We believe these fundamental scientific studies will show the way to improve oocyte quality and control the process of follicle recruitment from the primordial pool.

Reference: Chief Psychiatrist’s Standards of Care are at www.chiefpsychiatrist. wa.gov.au ED. Mental health organisations recently highlighted shortcomings in the Fifth National Mental Health Plan. Their joint letter (https://mhaustralia.org) said there were alarming gaps between previous commitments by the Council of Australian Governments (COAG) on mental health and the consultation draft for the Plan released last October. Wide feedback was that the draft Plan reflected old modes of thinking. The group asked for the roles and responsibilities of governments be clarified, targets and indicators be included, more focus on early intervention and prevention, and expanded community services to be imbedded where the need was.

Signatories to the joint letter include the National Mental Health Consumer & Carer Forum, Suicide Prevention Australia, Orygen, Sane Australia, ReachOut, R U OK?, the Black Dog Institute and a further 50 organisations.

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FEBRUARY 2017 | 35

Feature

Three-dimensional printing in otolaryngology

By Dr Jenn Ha, ENT Surgeon, Murdoch Dr Jenn Ha

3D printing has its roots in the automotive and aerospace industry in the mid-1980s but now its application is vast, including all ENT subspecialties. Personalised patient data is used by computer aided design software to create a virtual 3D object. This is computationally sliced into thin 2D layers, which are sent to a 3D printer – the object is built layer by layer using UV light to harden a liquid photopolymer.

Emerging from other industries, the medical potential for 3D printing is considerable. This author gets down to specifics in the field of ENT.

ED

procedures in craniofacial surgery. University of Michigan (UM) printed the first maxillofacial model and this has the potential to change management with foetal airway emergencies.

Head and neck surgeons have used 3D printed models to create intra-operative cutting and reconstruction guides, helpful in sculpting bony reconstructions.

Customised 3D printed CPAP masks

The one-size-fits-all conventional CPAP masks often fails in children with craniofacial abnormality. Custom-made CPAP masks have the potential to treat their obstructive sleep apnoea more efficiently.

In the 1990s, 3D models of patients’ skull defects were used to plan grafting

Best described is the 3D printed temporal bone model for surgical simulation. Now, it has been extended to skull base surgery simulation, and more recently at the UM a 3D model using costal cartilage airway reconstruction and training for repair of microtia (underdeveloped pinna).

Multiple groups have made great strides in 3D printed scaffolds for tissue engineering. UM has printed nasal and ear scaffolds made out of polycaprolactone. These were seeded with

The life-saving 3D tracheal splint

ENT applications of 3D modelling The 3D printed tracheal splint (a lifesaving implant in a five month-old child in 2013), had a bellowed design that resisted collapse while allowing for flexion, extension, expansion with growth and subsequent bio-resorption. This has now been implanted successfully in three children with localised tracheobronchomalacia.

A 3D printed model based on fetal MRI changes emergency airway management

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chondrogenic growth factors and implanted subcutaneously in animal models. They have demonstrated new cartilage growth.

For the future, bioprinting (3D printing with living cells suspended in hydrogels and other substrates) remains a possibility.

Located in Joondalup CBD north, West Coast Endoscopy Centre is an independent private endoscopy unit with a strong focus on the individual and commitment to quality improvement and excellence in Gastroenterology, since opening in 2008.

• • • • •

•

• •

3D printed tissue scaffolds implanted in animals

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While 3D printing promises much, its validation for clinical applications using objective data does not include RCT comparisons with traditional approaches because reports are of individual cases or limited series. Reported benefits are subjective, primarily perceived improvements in outcome.

Initially available only at selected academic centres, large commercial groups have made the technology more widely accessible.

FDA/TGA approval of biocompatibility testing and sterilisation protocols remains costly. Nevertheless, it is a rapidly evolving, exciting aspect of personalised medicine with enormous potential.

Author competing interests: no relevant disclosures.

Questions? Contact the author drjennha@yahoo.com

MEDICAL FORUM

FEATURE

Hepatitis C treatment evolves Hepatitis C treatment has a bad track record amongst both GPs and patients. Not now! If you still need convincing read our letters pages!

By Dr Eric Khong Dr Eric Khong

Dr Eric Khong, a GP and Senior Lecturer at ECU, said in the Hepatitis C session at the GP16 Conference in Perth that 2016 saw a major change in chronic hepatitis C treatment in Australia – for the first time, GPs could prescribe antiviral treatment.

“The new generation PBS-funded antiviral drugs have very good cure rates of 90-95%, with few side effects,” he said. “This is timely as Australia’s treatment rates for hepatitis C have historically been very low, mainly due to poor tolerance of interferon based regimens and access to specialist services.”

Over 100 GPs attended the GP16 session, many keen to learn how to provide treatment.

Some said treating Hep C was not as hard as they thought, particularly if they followed a step-wise process for assessment and safe prescribing using resources from organisations such as ASHM (Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine), GESA (Gastroenterological Society of Australia) and ALA (Australian Liver Association). The PBS handbook maps out the qualifying criteria that patients must fulfil

to be prescribed these expensive drugs.

GPs who attended said patients had remarked how well they felt after being cured because they had had the disease for many years and never felt healthy. Some rural doctors suggested they could eradicate Hep C from their region.

The arrangements for WA GPs to prescribe the drugs encountered problems, which may partly explain why WA GPs had one of the lowest rates of prescribing nationally – 5%, of individuals living with chronic HCV that had started treatment with the new drugs since they were introduced in March 2016 (Kirby Institute).

ED

that patients can be “treated by a medical practitioner experienced in the treatment of chronic hepatitis C infection”. Experienced GPs can avoid the hurdle and red tape of contacting a specialist.

However, wait times remain of over a year to see specialists in the public hospitals, so it is important GPs are supported to treat hepatitis C. ED: Dr Khong developed the Hepatitis C online learning modules along with with Prof. Wendy Cheng and Dr Moira Sim (see http://hepatitis.ecu.edu.au).

Dr Khong said poor numbers for WA GPs came partly from the requirement to consult with a specialist (either by phone or by a faxed template) prior to prescribing. Some clinics were hard to reach and slow to respond.

The PBS listed drugs were expensive, so the federal government wanted protocols around prescribing. The restictions on GPs were loosened in November 2016 when the PBS amended the criteria for subsidisation to add

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FEBRUARY 2017 | 37

Feature

Instrumentation in joint replacement Different assisted methods are promoted for joint replacements, osteotomies, etc. that say they take account of anatomical variations and lessen complications e.g. dislocations. Will revision surgery be prevented?

By Dr Simon Wall, Orthopaedic Surgeon Dr Simon Wall

Joint replacement surgery aims to place a correctly sized implant in a precise position (in all three planes) to achieve a stable, functional, pain-free joint – patients can be offered joint replacement that uses traditional jigs, computer navigation or patient specific instrumentation (PSI).

All are proven safe and effective and assist surgeons achieve optimal implant positioning and size, so it is important for surgeons to say the likely benefits, in their hands, of one method over another.

Fig 2. In THR, a predetermined laser point on the operating theatre ceiling is used to guide the acetabular cup into place with a second laser.

Plain radiographs allow a certain amount of pre-operative planning in all joint replacements.

Traditional jigs in total knee replacement (TKR) use rods placed into the femoral and tibial intramedullary canals, or held outside the tibial shaft, to guide bony cuts using generic adjustable cutting blocks. This is the most commonly used system worldwide.

Computer navigated surgery in hip and knee replacement came in the early 2000s.

It uses markers fixed to pins in the bone with a camera or sensor unit tracking the instruments. This allows very accurate assessment of limb alignment and real time tracking and adjustment to ensure more accurate placement of implants. Although computer navigation improves implant placement, there is conflicting evidence on long-term benefits and some surgeons worry about complications from pin sites and longer operating times, as well as added cost.

Patient specific instrumentation (PSI) is relatively new. It is most widely used for TKR, but also has application in partial knee replacement and total hip replacement (THR). It uses pre-operative imaging to create customised blocks, which exactly fit each individual patient’s bone in order to guide the cuts for a standard joint replacement.

It should not be confused with customised implants.

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Fig 1. In TKR, PSI cutting blocks fit the patient’s bone precisely and guide the bony cuts.

Over recent years, implant companies have refined PSI – most work off pre-operative X-rays, CT or MRI to produce a model and subsequent cutting guides that conform to each patient’s anatomy (fig. 1). Once again, some studies show PSI offers improved implant positioning, faster surgery, and a smaller surgical inventory, whilst other studies found little or no benefit. It may confer a greater advantage in cases of limb deformity or complex anatomy.

In PSI for THR, where implant positioning is traditionally more forgiving than in knee replacement, the main benefits appear to be in the setting of ceramic head and liner combinations where precise implant positioning is more critical. Also, in severe lumbar spondylosis or previous lumbar spinal fusion (when abnormal pelvic posture affects greatly the hip-spine relationship), it is especially important to position the acetabulum functionally, to avoid excessive edge loading or dislocation. Through preoperative dynamic assessment and intra-operative laser-line guidance (fig.2), this optimal positioning can be achieved.

Author competing interests: nil relevant.

Questions? Contact the author 9467 2259.

MEDICAL FORUM

FEATURE

Trends in Tattoos When we surveyed them in 2013, 94% of 328 Specialists and GPs had not been tattooed. Has overseas travel and fashion changed all that?

By Dr David Main, South Perth Dr David Main

Since I last wrote in 2013 the main trends have been: • Increasing frequency and size of tattoos, including in women • Increased availability of laser tattoo removal services • Less clinics offering ‘miracle’ removal techniques that frequently lead to scarring • Increased availability of the new picosecond laser for removal of green ink Tattooing seems to be moving in the same direction as street art. Where once it was grimy railway sidings, now it's Town Councils commissioning murals. Women continue to be the strongest market for new tattoos, and anecdotally, they are getting larger.

promises to remove professional tattoos in a shorter time-frame: picosecond lasers have been available since 2013, and whilst initial models were superior for green ink removal, the latest generation promise rapid removal of black, red and other coloured inks.

Laser treatment carries a 5% risk of hypopigmentation or scarring.

Complications from tattoos Complaints such as sun sensitivity and mild pruritis are common, whilst medical complications most commonly relate to pigment allergy, especially to red ink.

Inflammatory reaction to red ink tattoo

mostly related to tattoos performed in Southeast Asia. Differentiation of these reactions from atypical infections such as mycobacteria or granulomatous inflammation usually requires biopsy.

Treatment is difficult and repeated steroid injection or in some cases serial excision may be required.

There are two reasons why this is medically interesting. Most obviously is the late desire to have the tattoo removed, typically 10-14 years later but in many cases 10-14 minutes after application! The second reason is the management of complications.

Removal of tattoos In general, removal of tattoos is laborious (for the patient) with multiple sessions of Q-switched laser treatment. Some tattoos fade readily including cosmetic tattoos, radiation tattoos, and traumatic tattoos such as bitumen staining. Amateur tattoos generally fall into this category. All other tattoos take a lot longer. New technology

ED

Black ink tattoo before and after 10 sessions Q-switched laser

Clinically, hyperkeratotic plaques are typically highly pruritic and commonly ulcerate and scar. Black ink may occasionally cause lumpy papulo-nodular reactions and scarring.

In my experience, both these issues are

Of course Hepatitis B and C and HIV infection is a small but significant risk, again especially prevalent in Asia. Cancer arising in tattoos has been reported (BCC, SCC, keratoacanthoma, melanoma and others), but is rare and the risk may have been overestimated.

References available on request

Author competing interests: no relevant disclosures.

Questions? Contact the author on 0411 665 098.

Psychiatry 'Heavies' Head to Perth A couple of years ago Dr Mathew Samuel, who is a senior psychiatrist at Hollywood Clinic, was feeling disillusioned about the paucity of psychiatry conferences in Perth so he did what not many people do – he decided to hold his own.

Health Care his first Psychiatry Master Class was held in March last year boasting an impressive line-up of speakers from the eastern states including Professors Gordon Parker, John McGrath, Dennis Velakoulis and Jeffery Looi plus local neurologist Dr Julian Rodrigues.

“It was becoming difficult to get good speakers and generate good debates in Perth and yet these forums are so important for Dr Mathew Samuel the exchange of information from people working at the frontline of clinical research and trials in Australia,” he told Medical Forum after last year’s inaugural conference.

“It was an experiment as we weren’t sure if people would come.”

With support from his colleagues and Ramsay MEDICAL FORUM

But they did – more than 80 in fact, including several from the east.

The second Psychiatry Master Class is being held on February 17 at the University Club at UWA with a theme of Anxiety and Stress Disorders.

This year Mathew has managed to secure Prof David Nutt, a provocative world leader in the areas of anxiety and addiction.

“I was really blown away when David Nutt, who is at Imperial College London said he

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would come to our conference. That was very humbling.

Also coming is one of Australia’s top authorities on Post Traumatic Stress Disorder, Prof Gavin Andrews, from UNSW. Prof Philippa Hay (University of Western Sydney), an authority on eating disorders, and Prof David Castle (Melbourne University, OCD and body dysmorphic disorders) will be here, joining FSH lead Prof Megan Galbally (perinatal psychiatry).

Attendance is by registration fee and there are industry and pharma sponsors, but Mathew stressed it was not a pharma-run meeting.

“This is really an opportunity for Perth clinicians to talk and mingle with some of the best minds in their fields.”

ED: For more information contact Letisha Hilton, 9346 6663 or hiltonl@ramsayhealth.com.au ; to register www.trybooking.com/NBPL.

FEBRUARY 2017 | 39

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MEDICAL FORUM

FEATURE

Ongoing legacy of asbestos in WA

By A/Prof Fraser Brims, Dept Respiratory Medicine SCGH & Curtin Medical School A/Prof Fraser Brims

Asbestos was widely used throughout the last century – mined from Wittenoom in the Pilbara up until 50 years ago as crocidolite (blue asbestos) and used in manufacturing and industry along with chrysoltile (white asbestos) in considerable quantities within WA. A complete Australian ban was introduced on the use of all types of asbestos in 2004 but globally there is a very large chrysotile industry (Russian and Chinese exports in 2015 estimated at 1.5m tonnes).

In WA, asbestos legacy is likely to remain for many years to come and while advances in treatment of mesothelioma have been modest at best, the most effective strategy to deal with asbestos is raising public awareness about its presence in our environment.

Accurate estimates of the prevalence of asbestos related lung disease in the community are sparse although a recent analysis of the WA Asbestos Review Program that follows ~1300 asbestos exposed individuals annually suggests that 64% have evidence of pleural plaque and 40%

radiological signs suggestive of asbestosis (i.e. pulmonary fibrosis). Asbestosis from high dose exposures is becoming less common, with a similar picture for diffuse pleural thickening.

The risk of an asbestos related disease is generally dose-dependent and may have a long latency (for malignant mesothelioma at least 15 years and the risk 50 years after first exposure remains). Australia has the third highest incidence of malignant mesothelioma in the world (behind the United Kingdom and the Netherlands).

Data from the Australian Mesothelioma Registry suggest the much anticipated peak of mesothelioma incidence may be upon us, although it is still too early to be sure. The predicted ‘waves’ of mesothelioma incidence have come to fruition with the initial tranche primarily among asbestos miners and workers, which transitioned into occupations among tradesmen where asbestos was used, principally construction and manufacture.

The ‘third wave’ affects those exposed to asbestos in our environment and community,

The long latency of mesothelioma is a worry for all doctors - no wonder then jumpiness over any avoidable asbestos exposure.

ED

particularly those involved in renovations of property containing asbestos. While this exposure is likely to be transient and relatively low dose, the population at risk is potentially very large. Thus, mesothelioma incidence may well begin to fall in coming years but there may be a long tail due to the persistence of asbestos in our environment and the long latency between exposure and onset of disease.

Ongoing clinical trials in immunotherapy for mesothelioma suggest a modest benefit, similar to chemotherapy in trial populations.

In WA the most effective approach is likely to be screening for lung cancer through the coordinated specialist Asbestos Review Program, based at SCGH Department of Respiratory Medicine.

ED. The Asbestos Review Program is open to anyone with more than three months (cumulative) exposure to asbestos and/or radiographic evidence of asbestos related lung disease. Contact the author at fraser.brims@health.wa.gov.au References available on request.

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FEBRUARY 2017 | 41

CLINICAL UPDATEs

Side effects of immunotherapy

By Dr Mihitha Ariyapperuma Medical Oncology Research Fellow Linear Clinical Research, SCGH

Immunotherapy offers new hope for cancer patients. Immune checkpoint inhibitors (ICIs) are a new class of immune modulating monoclonal antibodies, used in the treatment of a variety of cancers.

These drugs target molecules expressed on either the surface of T lymphocytes (CTLA-4, PD-1) or on the tumour cells themselves (PD-L1), and allow an antitumour immune response to be generated, potentially giving patients durable tumour control or complete remission.

include vitiligo, alopecia and Stevens Johnson Syndrome/ Toxic Epidermal Necrolysis.

Part of the rapid drug development involves combination immunotherapies, which also increases the risk of toxicities. Toxicities are mainly due to the dysregulation of the immune system caused by these drugs and the offtarget effect on organ systems. Toxicities are novel and across multiple disciplines, and the key to patient safety is recognition and prompt discussion with the treating specialist to allow early appropriate intervention.

Hepatotoxicity

A challenge is to raise awareness about the side effect profile of immunotherapy.

Although, toxicities can be more favourable than with chemotherapy, some adverse events if left untreated can be fatal. Moreover, immune-related adverse effects (irAE) can sometimes appear late into treatment or even after treatment completion.

Skin toxicity is most common Rash and/or pruritus can occur in up to 50% of patients and is typically described as reticular, erythematous and/or maculopapular.

Other less common skin manifestations

Gastrointestinal Diarrhoea can also be associated with colitis, for which symptoms include abdominal pain, mucous or blood in the stool. Rare complications of colitis include bowel obstruction and perforation. Infectious causes of diarrhoea should be considered, however, physicians should have a low threshold to suspect immune related adverse effects.

Immune-related hepatitis is largely asymptomatic and noted on routine blood tests. Mild elevations in liver enzymes can be treated expectantly but more severe derangements need prompt therapy.

Endocrinopathies Hypopituitarism caused by autoimmune hypophysitis is a common endocrine irAE. Symptoms include headache, nausea, vertigo, behavioural changes and visual disturbances.

Other immune related endocrinopathies include hyperthyroidism, hypothyroidism, hypogonadism and type I diabetes.

Tests include serum hormone levels to assess pituitary function, with electrolytes and glucose levels. MRI brain may be indicated for investigation of hypophysitis.

Treatment involves replacement of deficient hormones and perhaps steroids.

Myth: radio contrast reactions, shellfish and iodine It is a common misconception that radiocontrast media (RCM) reactions, shellfish allergy and reactions to povidone-iodine antiseptics are all linked to the common element iodine.

As elemental iodine has no role in these reactions, explaining this to patients can be beneficial.

Seafood, in a way that is not related to allergy, is high in dietary iodine. Seafood allergy is due to specific IgE antibodies to proteins such as tropomyosin in shellfish and mussels, and parvalbumin in fish.

Povidone is a carrier molecule used to deliver

42 | FEBRUARY 2017

bactericidal iodine in a less irritant manner than free elemental iodine. Though elemental iodine can cause irritant dermatitis, it is the povidone component that is the culprit in the rare reports of anaphylaxis to povidoneiodine.

Iodinated radio contrast media (RCM) are tri-iodinated benzoic acid derivative salts of different types. Iodine confers the radio-opacity but there is little free iodine in solution. RCM can be classified into ionic and non-ionic, and according to osmolality (high, low and iso-osmolar). Non-ionic RCM were developed in the 1970s and have now superseded ionic contrast agents which had

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ED Immunotherapy is establishing itself as standard treatment for several tumours. Doctors can avoid problems of misinterpretation by being aware of immunotherapy side effects.

Less common side effects These are pneumonitis, nephrotoxicity, neurological side effects such as neuropathies, Gillian-Barre syndrome, myasthenia gravis and autonomic neuropathy, and ophthalmic side effects such as episcleritis and uveitis.

Management Most irAEs are easily reversible if recognised and treated early. Immunosuppression with corticosteroids is the mainstay treatment – between oral steroids for persistent low grade side effects and hospitalisation for high dose intravenous steroids for more serious irAEs. In cases resistant to corticosteroids more potent immunosuppression is required with drugs such as infliximab, mycophenolate or tacrolimus.

Dr Mihitha acknowledges the support of Drs WeiSen Lam (Medical Oncologist, Mount Hospital) and Samantha Bowyer (Medical Oncologist, Rockingham General Hospital) in compiling this article. Competing interests disclosures: all authors nil relevant except Dr Lam has received travel assistance from BMS, Roche and Pfizer.

By Dr Meilyn Hew Allergist and Clinical Immunologist, Murdoch

Severe reactions to contrast media ED concern doctors and patients – understanding what is behind them is important to prevent misconceptions.

higher reaction rates. Some of the crossreactivity between various RCM relates to their ionic and osmolality status – the Radiologist can use charts to choose a less reactive alternative.

continued on Page 43

MEDICAL FORUM

CLINICAL UPDATEs

Tremors: when to intervene?

Tremor, defined as a rhythmic involuntary oscillatory movement of a body part about an axis, is the most common of all movement disorders. It can be a symptom, a sign, a syndrome and an etiological diagnosis.

Tremor may be isolated (primary) or combined (Tremor-Plus) with other conditions.

Classification methods include anatomic distribution and presence at rest or on action.

The most common isolated tremor syndrome is Essential Tremor and the most common combined tremor syndrome is Parkinson’s disease.

What you can do Before starting therapy, potential provocative and aggravating factors should be identified and if possible, addressed. Drugs in particular are a common cause of tremor and can also aggravate primary tremor disorders. A thorough drug history should be undertaken in every patient presenting with tremor. Drug induced tremors can be of any type but combined postural and rest tremors should suggest neuroleptic use, (often denied or omitted in the history) especially if associated with akathisia, parkinsonism and/or orobuccolingual dyskinesias. Caffeine is a common aggravating factor for postural tremors, as are other stimulants. Every patient with tremor should be screened for thyrotoxicosis and Wilson’s disease. Structural neuroimaging is not necessary unless clinically indicated. Red flags include: tremors of sudden onset with associated focal neurological signs e.g. diplopia, palatal tremor.

In many patients reassurance is all that is

By Dr Rick Stell Neurologist, Subiaco

necessary. Some patients do require treatment (medical or surgical), because their tremors cause significant emotional upset and/or functional disability.

Key Points • Tremor is common and usually benign.

• Reassurance and addressing provocative factors is often all that is required.

•

Therapy is indicated for tremor if the tremor causes function disability or impairs quality of life.

Drug therapy should be tried first unless contraindicated. Surgical intervention should be reserved for severe drug resistant tremors.

Therapy is most often required for postural and kinetic tremors, which are more likely to interfere with function.

Drug therapy Drug therapy for tremors is mainly symptomatic and empirical as the neurotransmitter systems involved in pathological tremors are largely unknown as are the mechanisms of action of most tremorlytic drugs.

Some 70-80% of patients with Parkinsons disease and Essential Tremor improve with adequate drug therapy. The most effective drugs for Parkinsonian tremor are dopaminergic agents (levodopa and dopamine agonists) and anticholinergics. In Essential tremor, beta-blockers and primidone, alone or in combination are considered first line.

Tremors are common and most need reassurance but only after appropriate screening for predisposing factors.

ED

Benzodiazepines can be helpful in primary kinetic tremors. Botulinum toxin injections are effective in focal dystonic tremors, especially of the head. Cerebellar tremors are usually refractory to medical therapy, though there are anecdotal reports of response to 5-HTP, clonazepam and carbamazepine. Orthostatic Tremor may respond to clonazepam, or gabapentin.

Deep brain stimulation In severe (functionally significant) drug unresponsive tremors stereotactic deep brain stimulation (DBS) is an option. The venterolateral thalamus (VIM-nucleus) is the surgical target of choice for most tremors, though the posterior subthalamic region may be even more effective.

Thalamic stimulation may be performed unilaterally or bilaterally as required. Bilateral stimulation is more likely to cause side effects, including gait ataxia and dysarthria, at stimulation levels necessary to control tremor.

In patients with parkinsonian tremor, the target of choice is the subthalamic nucleus or the posterior subthalamic region. Stimulation at either site provides a similar beneficial effect on the tremor (as VIM stimulation) and also alleviates akinesia.

References available on request Author competing interests: no relevant disclosures.

Questions? Contact the author 9381 7312

Myth: radio contrast reactions, shellfish and iodine continued from opposite The basis of anaphylaxis RCM were thought to directly stimulate mast cells and basophils or to activate complement in a non-IgE manner and reactions were referred to as “anaphylactoid” or “non-allergic anaphylaxis”. Severe reactions may be associated with elevated histamine and mast cell tryptase. More recently it is likely that some reactions are immunologically mediated as evidenced by positive allergy testing.

Skin prick and intradermal testing to neat and diluted RCM respectively is used for immediate reactions. Intradermal skin testing with diluted RCM for delayed reactions is thought to be more sensitive than patch testing. The sensitivity of skin testing ranges widely from 4-73% of confirmed cases and falls with time thus testing is ideally performed within 2-6 months of the original reaction.

MEDICAL FORUM

Key Points •

Enquiring after “shellfish allergy” or withholding RCM based on shellfish history is not necessary. This is a longstanding misconception.

• Povidone-iodine reactions, while rare, are due to povidone not iodine.

• RCM reactions have been reduced since the introduction of low-osmolality contrast agents.

• Skin testing 2 to 6 months following a severe reaction can be useful •

The negative predictive value of negative skin testing is not well established. Therefore, most guidelines recommend giving premedications when using an alternative RCM to which the patient has tested negative.

References available on request

Author competing interests: nil relevant disclosures.

Questions? Contact the author on 9332 2861

Skin testing can identify alternative RCMs to which the patient is negative which can be used in future in combination with premedications.

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FEBRUARY 2017 | 43

CHRISTMAS Social pulse Ramsay Health Care

1

Glamour sparkled from every corner of Ramsay Health Care’s Paint the Town Red end-of-year doctors’ function at Fraser’s in Kings Park. With the lights of Perth City twinkling below and ballroom dancers burning the floor, it was a night for celebration.

1. Dr Judith Futtermenger, Dr George Raynor and Dr Margaret Sturdy 2. Kempton Cowan, Julie Geddes and Dr Tony Geddes 3. Prof Yuben Moodley, Dr Vash Singh, Peter Mott and Sharon Mott 4. Debra Lynch and Leonie Gardiner 5. Dr Andrew Savery, Tanya Savery, Aoife Griffin and Jane Case 6. Dr Hans Stampfer and Rosalind Stampfer 7. Dr Desiree Silva, Dr Jay Natalwala, Mette Jongeling and Barry Ashwin 8. Dr Stephen Lewis, Dr Stephen Rodrigues, Dr Richard Lewis and Dr Tuan Pham 9. Dr John Stanley, Dr Sydney Weinstein, Leila Maddison, Rene Tuch and Dr Phillip Tuch 10. Dr Amanda Ling, Dr Rita Malik, Kate Munnings and Dr Stephen Rodrigues

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Clinipath Pathology The traditional Mosman’s Restaurant end-of-year function at Peppermint Grove is the traditional location for Clinipath’s Christmas get-together. CEO Dr Gordon Harloe was short with his welcome and news and wished EA Louise Campbell a happy birthday that day.

1. Dr Fiona Campbell 2 Ms Louise Campbell 3 Dr Jill Christophers, Ms Lucy Patton and Dr Cameron Gent 4 Dr Cathryn D’Cruz, Dr Yu-Ti Tien, Dr Henry Law 5 Dr Gordon Harloe 6 Jenny Heyden, Sheila Harloe, Janice Lawrence and Dr Pam Hendry 7 Dr Shahrooz Roohi, Dr Sarah Jarum, Jacky Bock, Dr Russell Bock, Rachel Parker-Roohi 8 Mirza Salleh, Dr Indrani Saharay, Dr Stephen Bertolini 9 Dr Beverly Teh and Jean Mumba 10 Dr Tarun Yamdagni, Priya Krishna Kumar, Dr Keith Ananda, Dr Kanlesh Bhatt and Rucha Bhatt.

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CHRISTMAS Social pulse Mount Hospital

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The Mount Hospital’s Christmas function was also a time for staff to celebrate 30 years’ service to the community and even in this relatively short time, there is no shortage of characters. Mr Philippe Binder, who ensures patient’s dietary requirements are suitable was former maitre de of the Riverside Hotel, where the current Mount Medical Centre is sited. He transferred to the hospital when it opened at its present location.

1. Peri-operative educator Gabrielle WarrenChainey celebrates with her husband.

2. Orthopaedic surgeon Dr Bo Nivbrant with nurses Franceska Gontran and Melissa Schuberg 3. Anaethetist Dr Ross Ireland and Mrs Ireland 4. Anaethetist Dr Craig Schwabb and orthopaedic surgeon Dr Ben Kimberley 5. Cardiologist Dr Michael Nguyen and Mrs Nguyen 6. Dr Geoff Dobb, Dr Philippe Binder and Dr Stephen Same

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SJG Mt Lawley

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Acting CEO Ben Edwards welcomed guests to the doctors’ Christmas party at Fraser’s Kings Park with new Director of Medical Services Dr Stuart Prosser announcing the launch of two awards – Doctor of the Year (won by general and laparoscopic Surgeon Dr David Cooke) and the Ellis Pixley Award (won by obstetrician and gynaecologist Dr Donald Clark, who retired at the end of 2016. This last award is named in honour of Ellis Pixley, an Obstetrician/Gynaecologist who was a renowned pioneer in colposcopy and a Medical Director of the then St Anne’s Hospital.

1. Dr Vara Mukundala and Dr Lakshmi Balakrishnan 2. Dr Paul McRae and Jenny Tomson 3. Dr Mohammad Jehangir, Dr Don Clark & Chris Hanna 4. Dr Charles Armstrong and Susie Armstrong

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CHRISTMAS Social pulse 1

St John of God Subiaco Medicos at St John of God Subiaco Hospital headed to Royal Freshwater Bay Yacht Club for fine food, wine and sunset for their Christmas gathering. It was also a chance for staff to farewell popular CEO Dr Lachlan Henderson, who has left Perth to take up the CEO position at Epworth Health Care in Victoria. Also saying goodbye was Dr Rosanna Capolingua who leaves the GP Liaison position she has held at the hospital for the past 15 years.

1. Adele Swan, Dr Paul Swan, Dr Dru Daniels and Dr Gerod Hardisty 2. Grace Mowtschan and Dr Anthony Rengel 3. Dr Melissa O'Neil, Dr Jade Acton and Dr Stuart Salfinger 4. Dr Jeremy Macfarlane, Yvette Hankeri and Dr Mark Hankeri 5. Dr Susan Taylor, Dr Eva Denholm, Dr Hugh Welch, Kate Leech and Dr Christopher Leech 6. Prasad Ranasinghe, Dr Melani Solangaarachchi, Dr Aesha Gandhi, Dr Linda Vu and Shaun Ong

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CHRISTMAS Social pulse St John of God Murdoch

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SJG Murdochâ&#x20AC;&#x2122;s traditional Christmas celebrations by the picturesque lake at the hospital was a great place for colleagues to catch up after a year of hard work. Director of Anaesthesia and Pain Medicine Dr David Borshoff was named Doctor of the Year.

1. Murdoch CEO John Fogartyl, Caroline Crabb, Dr Michael Halliday and Dr David Borshoff 2. CEO St John of God Foundation Nick Harvey and Sheilah Harvey 3. Dr Ian Jenkins, Sharon Connolly, Sally Stanford, Dr Michael Halliday and Dr Lionel Lim 4. Dr Charlotte Jorgenson, Dr Andrew Barker and SJGHC CEO Dr Michael Stanford 5. Dr Randall Hendriks, Leanne Merchant, Robyn Sutherland and Stephanie Hendriks 6. Brontie Hicks, Dr Andrew Christophers and Michelle Christophers 7. Sapna Sharma, Brenda Narula, Dr Soni Narula and Dr Sanjay Sharma 8. Dr Kai Oon Goh, Dr Caroline Yapp, Dr Sonia Dale and Dr Nick Wambeek 9. Dr Stephen Latimer, Carmen McKenzie, Des McKenzie and Laura Latimer 10. Dr Nat Lenzo, Natalia Marais, Dr Wayne Smit and Robyn Lenzo

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CHRISTMAS Social pulse 1

Bethesda Health Care The team at Bethesda had a lot to celebrate at their end-of-year Glitter & Gold Doctors’ Christmas Function. The hospital’s $10m expansion project is complete and doctors and staff can now enjoy new operating theatres and amenities. Chairman Dr Neale Fong and CEO Yasmin Naglazas welcomed guests and after the AGM of the Clinical Association, where the 2017 Medical Advisory Committee was announced, it was time to have fun.

1. Dr Peter D’Alessandro, Dr Toby Leys, Dr Oscar D’Souza and Lisha D’Souza 2. Dr Neale Fong and Peta Fong 3. Dr Grant Booth, Laura Booth, Dr Franc Henze, Meg Henze and Dr Paul Swan (Anaesthetist)

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7. A hole has been found in the nudist camp wall. The police are looking into it.

19. Two fish swim into a concrete wall. One turns to the other and says 'Dam!'

8. Time flies like an arrow. Fruit flies like a banana.

20. Two Eskimos sitting in a kayak were chilly, so they lit a fire in the craft. Unsurprisingly it sank, proving once again that you can't have your kayak and heat it too.

9. Atheism is a non-prophet organisation.

10. Two hats were hanging on a hat rack in the hallway. One hat said to the other: 'You stay here; I'll go on a head.'

The Punny Page 1. The fattest knight at King Arthur's round table was Sir Cumference. He acquired his size from too much pi.

2. I thought I saw an eye doctor on an Alaskan island, but it turned out to be an optical Aleutian.

3. She was only a whiskey maker, but he loved her still.

4. A rubber band pistol was confiscated from algebra class, because it was a weapon of math disruption.

5. No matter how much you push the envelope, it'll still be stationery.

6. Two silk worms had a race. They ended up in a tie.

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11. I wondered why the baseball kept getting bigger. Then it hit me.

12. A sign on the lawn at a drug rehab centre said: 'Keep off the Grass.'

13. The midget fortune-teller who escaped from prison was a small medium at large.

14. A backward poet writes inverse.

15. In a democracy it's your vote that counts.

In feudalism it's your Count that votes.

21. Two hydrogen atoms meet. One says, 'I've lost my electron.' The other says 'Are you sure?' The first replies, 'Yes, I'm positive.'

22. Did you hear about the Buddhist who refused Novocain during a root canal?

His goal: transcend dental medication.

23. There was the person who sent ten puns to friends, with the hope that at least one of the puns would make them laugh.

No pun in ten did.

16. When cannibals ate a missionary, they got a taste of religion.

17. If you jumped off the bridge in Paris, you'd be in Seine.

18. A vulture boards an airplane, carrying two dead raccoons. The stewardess looks at him and says, 'I'm sorry, sir, only one carrion allowed per passenger.'

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Finance

Choppy but Navigable Waters Ahead The commentators are predicting uncertain economic times ahead in 2017 but it might not all be doom and gloom.

It’s the beginning of a new calendar year and a time when many of us take a look at where our money is invested and how it might perform. We asked the fund managers at BT Investment Management to put their heads together and they have come up with some interesting scenarios for 2017. And it may not be as bleak as everyone says.

Last year saw a series of significant changes and largely unexpected decisions that are now poised to play-out in the financial sector during 2017. Two notable factors are: • the substantial recovery in commodity prices in 2016, and that included a large percentage rise in the iron ore price – good for WA! • the ‘Rise of the Populists’ via Brexit and the US election. The latter, in particular, places a degree of uncertainty over some investment markets. It’s interesting to note that some shares have risen off the back of higher economic growth expectations.

WA will also see a State election in March amid ongoing concerns about post-boom growth rates and property prices. [See Peter Kennedy’s column, PX].

There are three distinct areas that may well dominate investment markets this year.

Bond Markets – International and Domestic There are three aspects that will shape the performance of this sector: • The election of Donald Trump and the initial noise around both domestic and foreign policy will impact on inflation and economic growth.

• European elections in Holland, France and Germany. How far will these populist movements go? And what’s the likely impact on the Euro?

• China. Will Chinese officials continue stimulus into 2017? How will they react if Trump initiates protectionist policies against US imports?

Australian Shares There are some distinct themes emerging here: • Low return environment: notwithstanding the Trump hype, we remain in a low-return environment. Few companies are receiving any ‘free kicks’ and low-revenue growth is impacting on corporate earnings. This has two important implications: firstly, stock selection is critical and, secondly, share market returns are likely to be relatively muted.

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• Shifting market leadership: as Bond yields rose through 2016 the best performing shares on the ASX changed substantially. They moved away from ‘Bond proxies’ such as listed property trusts, infrastructure and utilities and, while this might not persist, it is difficult to see these stocks performing well without the tailwind of falling bond yields.

High-growth stocks have also done well in recent years, despite their relative scarcity. However, a steady stream of management downgrades followed by a plunge in stock prices has illustrated the vulnerabilities inherent in their sometimes heady valuations. Again, a stock-specific approach is essential.

• Valuations and industrial disruption drives significant opportunities: the key in this environment is to find companies that are generating positive cash flow and hence the ability to deploy capital at good returns.

The surge in high-growth and bond proxy stocks over the first half of 2016 left a lot of stocks behind, creating significant opportunities to pick up attractive companies at a decent price. We are also seeing the continued industrial disruption of several industries in Australia. Again, this creates opportunity as some domestic companies struggle to respond while others take decisive action. Our view is the Australian share market remains reasonably attractive compared with other asset classes. The ability to ‘cherry-pick’ companies that are able to deal with the current environment will be crucial.

Overseas Shares There is little doubt that reflation, rotation and restructuring will be important in 2017.

• Reflation: rising inflation, higher interest rates and higher global GDP growth stands in stark contrast to the last few years.

• Rotation: companies leveraged to rising interest rates and global growth should

BACK TO CONTENTS

do well. We will probably see a shift in the ‘leaders’ in the stock market. One thing’s for sure, the best stock performers over the past five years will not be claiming the same status during the next five. It may be prudent to opt for a more focused portfolio rather than be broadly diversified.

• Restructuring: The world should see a more positive revenue outlook on a broad scale but costs will remain a battleground.

The quality of management will be a key factor.

An Investment Trend?

Yet again, the Populist movement linked with Brexit and Trump may tell the story. There is a clear shift in the political mood as a direct backlash to disappointing growth and growing income inequality. People are becoming frustrated at the monetary policy response and are now looking for fiscal and protectionist policies to alleviate these issues. This is something to think about when considering potential investments because these factors will impact the market.

And Western Australia?

The big question for West Australian investors looking at commodity prices is ‘what next?’.

There were some strong returns from resource company share prices in 2016 and, after years of cost cutting, the mining sector is well positioned to deliver stronger profits off the back of surging prices.

There’s no doubt that Chinese government policy will shape local commodity prices.

It’s interesting to see that the prices of iron ore, copper and some other commodities have benefited from an anticipated pick-up in demand from the USA. Disclaimer: This information has been prepared without taking into account any personal objectives and/or financial situation. Recipients should, before acting on this information, consider its appropriateness in regard to their personal financial situation. This information is not to be regarded as a securities recommendation or personal financial advice.

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FOOD & WINE

Edenvale Keeping it Light I bemusedly accepted my editor’s offer when asked to review a range of alcohol-free wine; bemused simply because I had never really taken the idea of de-alcoholised wine very seriously.

By Dr Louis Papaelias

When compared to the ‘real thing’ these wines tasted weak and watery without the presence of 12-14% of ethanol to fill out the palate and satisfy the taste buds.

In addition there was the quality factor. No maker of fine wine was going to subject his or her best barrels of wine to alcohol removal so that inevitably the sources of grapes for these products were never going to be from premium vineyards.

Removing the alcohol substantially changes the taste impact. Firstly bouquet and aromas are more subdued without the volatility provided by ethanol.

Secondly, and more noticeably, the balance of flavours is altered without the richness of ethanol being present. Tannin levels, sweetness and acidity show up differently under these circumstances so that a degree of skill is required to adjust these factors in order to end up with a product likely to please.

When approaching the tasting I found it helpful to disregard these as wines per se. Wine is the product of fermented grape must (juice) and alcohol is a natural and integral part. Much better in my view to see them as non-alcoholic beverages with a health and flavour profile which have a definite niche in the market.

With my doctor’s hat on I can see the benefits of high vitamin C and E levels as well as the reduced calorie count (around half that of wine). It must also be a boon for those intolerant of alcohol and those who need to avoid it.

Wine

Winner

With my consumer’s hat on these drinks provide an extra dimension of flavour when accompanying food. Their relative dryness and wine flavours lend them to matching with food throughout a meal and if presented in good glassware look just as elegant on the table as any fine wine.

Rather than giving blow-by-blow tasting notes I thought it more appropriate for some general comments.

What I tasted was two bubblies – a sparkling rose and a sparkling cuvee (white), a Riesling, a Sauvignon Blanc, a Chardonnay and a Shiraz.

All were clean and expertly made with no faults of oxidation or fermentation evident. The Riesling smelt like Riesling, the Sauvignon Blanc smelt just like Sauvignon Blanc and the Chardonnay and Shiraz showed aromas similar to their vinous counterparts.

On the palate the absence of alcohol showed up as a wateriness when compared to table wine but there were enough wine and grape flavours there to make a reasonable argument for food accompaniment. Both the sparkling wines I felt were the most convincing, the bubbles helping to compensate for the absence of alcoholic strength.

It is salient to point out that the Edenvale range is very reasonably priced. Dan Murphy’s website had them all at less than $10 retail. They are certainly affordable, eminently quaffable and bound to please their target audience.

Medical Forum’s Doctors Dozen was the first competition Dr Jonathan Ryan has ever won and the dozen bottles of Harewood Estate wines were much appreciated. Irish-born Jonathan, a radiologist with SKG, is enjoying Perth’s summer sunshine that included a hot Christmas.

Jonathan recalls another rather warm country – the UAE. He was there in the 1980s and recalls beautifully paved highways running out of Dubai and coming to a grinding halt in the middle of the desert. And no wine at the end of the rainbow, either!

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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, February 28, 2017. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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FEBRUARY 2017 | 51

doctors in the arts

Ways of Seeing Anaesthetist and pain specialist Dr Lindy Roberts’ passion for film noir has taken her to some pretty interesting destinations, all from the comfort of her armchair.

“Watching films is the way I relax. It’s a highly contemplative activity that takes me to another place and it’s a nice balance to a busy professional life,” Dr Lindy Roberts said.

“In both pain management and anaesthesia you’re dealing with people who are at a vulnerable and stressful point in their lives. The reflective nature of viewing films, particularly film noir, feeds into the complexity of other people’s lives and creates a space that facilitates a depth of compassion and a deeper understanding of clinical interactions.”

The portrayal of medicos in action on the silver screen varies from the sublime to the ridiculous, says Lindy.

“I’m interested in depictions of anaesthesia on film and some of the early ones are ridiculously funny. In Dark Passage, Humphrey Bogart has his entire face remodelled by a deregistered doctor under local anaesthetic in a derelict building. He recuperates in an apartment owned by a sympathetic artist played by Lauren Bacall.

It’s masterly!”

“Bacall’s film debut, To Have and Have Not, is set around a love triangle with her character wafting ether towards the ‘other’ woman until she falls unconscious on the floor. It’s unrealistic, but hilarious.”

“Needless to say, this sort of stuff doesn’t spill over into my own practice. I stick to modern principles and guidelines.”

The Collector There’s another side of Lindy’s passion for cinema that is distinctly academic with an extensive film collection complemented by an ever-increasing library of reference books.

“I haven’t gone into the old projector stuff so my collection is pretty much all DVDs. I’ve got about 700 and adding to it all the time, but I’d still call it a work-in-progress. ‘Streaming’ isn’t much help because the films I like aren’t available in this format, so a lot of my stuff comes from overseas. And I always keep an eye out for interesting material when I’m travelling.”

“I’ve also got a research library of about 300 film books. I’d describe myself as an ‘enthusiast’ but I have done some short,

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residential film courses at Cambridge University. One focused on Hollywood and American Foreign Policy and that helps me to understand the socio-political context of the films I’m watching.”

“Another one is the 1945 production Detour, a film noir, low-budget classic. It has all the film noir elements with a dark, hapless leading man who makes terrible choices and ends up with more than a few bodies on his hands.”

“I tend to watch a film more than once, make notes as I go and annotate the margins of my books in pencil. I’m learning as I go.”

Creating a future

Making connections Lindy’s medical practice combined with a deep cultural engagement harks back to her earlier education.

“I studied about half-and-half arts and science courses at school and was very interested in history. There are some strong links with film noir and post-WWII paranoia relating to communism and the possibility of nuclear annihilation.”

“And, of course, it’s not just what’s up on the screen. The political context of ‘blacklisting’ in America during the 1950s had a huge impact on writers, actors and directors. It was a very turbulent period. It’s easy to see a lot of historical parallels in modern America with its current progressive isolation.”

“The vast majority of films I watch have the historical ‘feel’ that comes with black and white. It’s a beautiful aesthetic and many are regarded as masterpieces. Director Martin Scorsese has been instrumental in getting these films back out there in restored format.”

Lindy and her partner of 20 years, retired anaesthetist Robert Edeson, have carved out a creative space away from the practice of medicine. The latter’s book, The Weaver Fish was published in 2014 by Fremantle Press. To describe it as ‘brilliantly imaginative’ would be an understatement.

“We’re both quite introspective and interested in slightly academic pursuits. And it would be fair to say that Robert has a very unusual mind. He has another book coming out later this year.”

“There are many people in medicine with lots of different interests and talents. It’s important that we nurture that and find space to pursue creative activities. Most of us invest a lot in our professional identity and, in that decade leading up to retirement, it’s crucial to think about those ‘other’ sides of our personality.”

“My passion for film noir is also a transitional approach to addressing a sense of self beyond my professional role. Almost everyone struggles with it, and I’m planning well ahead!”

By Peter McClelland

Once is not enough Lindy has a long list of films that she loves to watch, some of them a lot more than once.

“Classic such as The Third Man, Citizen Kane and all the Bogart films are wonderful. I also like films with strong women because the feminist readings are interesting.”

W IN

“One film I really love is Buster Keaton’s The General. It was made in 1925 and the title comes from the name of a train used in the American Civil War. It was a very physical comedy and in those days there were no stunt doubles and pretty crude special effects so it must’ve been highly dangerous.”

“One of Buster’s famous lines to his cameraman was, keep filming until I call ‘cut’ or I die!”

Name Lindy’s film and win a bottle of wine.

Email answer to editor@mforum.com.au

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Entertainment & Leisure

Golden Years of WA Opera Mandy Farmer.

The WA Opera Company celebrates its 50th anniversary in 2017 and one person who has been associated with the company for 34 of those years is production manager Mandy Farmer.

Mandy was a young student at Perth Technical School doing lighting and sound when she saw her first opera backstage at the invitation of one of her tutors.

“I’d never listened to classical music in any serious way. I was into Queen and Glam Rock and I went to one rehearsal of Don Giovanni and I was hooked. I asked my mother for a Don Giovanni record for my 21st birthday.

After than I had to listen to everything Mozart,” she said.

“The following year, in 1984, I got my first paid job for the opera company on Lucia Di Lammermoor and I went out and got everything by Donizetti. When I went to my first rehearsal it felt like this life was planned.”

Over the years, Mandy has risen to Production Manager and is responsible for logistics – from ensuring wigs and costumes are ready for action to lights, sets and schedules in place so productions are on time and on budget.

Mandy started in her current role in 2001 the same year CEO Carolyn Chard took up the management of the company, which like many state companies was looking at very grim bank ledgers. It was founded back in 1967 by composer James Penberthy and Guiseppe Bertinazzo on the simple but fundamental premise that Perth needed its own State opera company.

But running arts companies at any time is a tricky business but in a boom and bust town like Perth, even more precarious.

By the time Carolyn took up the reins, the company was shaky. But her determination and vision, which has enabled the likes of Artistic Director and composer Richard Mills and current director Brad Cohen to shape

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the quality of the company’s output, has seen fortunes turn around.

Mandy believes Carolyn and Richard back in 2001 set a new benchmark for the company.

It has grown new markets and produced home-grown operas, including a world premiere of Richard’s Love of a Nightingale (2007) and Iain Grandage’s The Riders (2016).

“I’ve seen how we went from doing one show a year to the busy program we have now (the company has three mainstage productions a year, its annual Opera in the Park and an array of education and singing traineeships in place).”

“The company became solvent again by sound programming and sound economic management. It’s amazing to be part of this side of the company because the audience never sees this. We are now artistically successful and solvent.”

In this anniversary year, audiences will see the return of the much-loved operas – Tosca by Puccini (the ultimate in drama), the sparkling The Merry Widow and the powerful Lucia Di Lammermoor.

The scale of these productions is immense.

“When I started back in 1983, the set of Don Giovanni fitted into three 12m containers. Last year, sets for The Pearl Fishers arrived from Sydney in six containers. Sets are getting bigger and more elaborate.”

Sometimes Mandy finds herself in the tug of war between artistic vision and fiscal reality, but she takes a no-nonsense view of that.

“The thing that drives me is my love of opera. I do love the people I work with but I don’t care whether they like me or not. I’m working to ensure my children and my grandchildren can see opera and that’s only going to happen if opera is solvent.”

By Jan Hallam

Ludovico Einaudi Nearly 2.5m people have watched composer and pianist Einaudi’s YouTube clip where he plays one of his compositions on a grand piano on the Wahlenbergbreen glacier to raise awareness of Arctic erosion. Well he’s heading into a fiery Perth summer to play his chart-topping hits for us.

Perth Concert Hall, February 13, 8pm

FEBRUARY 2017 | 53

COMPETITIONS

FEATURE

COMP

Entering Medical Forum's competitions is easy!

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

Music: Beethoven 7

The first main stage gig of the year for the WASO sees them pull out Beethoven’s intriguing Symphony No.7 and visiting violinist Yu-Chien Tseng tackles Bruch’s fiendishly glorious Scottish Fantasy and to kick the program off – the overture to Tchaikovsky’s Romeo and Juliet.

Perth Concert Hall, March 17 & 18.

MF prize, March 17m 7.30pm

Movie: Jasper Jones It has been a much-loved and much-talked about novel since its release in 2009 and now Craig Silvey’s Jasper Jones has been adapted to a movie directed by Rachel Perkins and starring Toni Collette and Hugo Weaving.

Movie: A Few Less Men

In the sequel to A Few Best Men, a destination wedding in the Blue Mountains goes horribly wrong with the groom falling off a cliff and his groomsmen faced with having to deliver the bad news to the bride and the groom’s family back in the UK. Mayhem ensues.

The story is set in a small rural town in Western Australia where two young friends (a white boy and an Aboriginal boy) discover a dark world of adult violence, corruption and racial hatred.

How they react to it packs a punch and brings significant insight to the viewer.

In cinemas, March 9

In cinemas, March 2

Opera: Tosca

A full-blooded story of revolution, love and sacrifice conveyed with signature Puccini passion – a perfect start to WA Opera’s 50th anniversary season.

Antoinette Halloran and Paul O’Neill are the lovers Tosca and Cavaradossi while TT Rhodes makes a brilliant evil Scarpia.

His Majesty's Theatre, March 28-April 8; MF prize, March 28, 7.30pm

Winners from November Movie – Underworld Blood Wars: Dr Greg Glazov, Dr John Williams, Dr Lyn Minsker, Dr Diana Fakes, Dr Bastiaan de Boer, Dr David Storer, Dr Lin Chan, Dr Wen Loong Yeow, Dr Trixie Dutton, Dr Andrew Christophers

Movie: The Eagle Huntress Caring to the End t Home Care: Consumers Rule t Training & ‘Dud’ Doctors t Ebola and Bullying t Art of Ageing t Clinicals: Stroke; Vertigo; Sarcopania; Resistant Bugs; Brain Exercise & More…

Major Sponsors

November 2016 Perth Pathology

Movie – Trolls 3D: Dr Deby Rori, Dr Yvonne Zissiadis, Dr Rhyon Johnson, Dr Kevin Kwan, Dr Parambil Rajam Kollam, Dr Sarah Longhorn, Dr Joe Cardaci, Dr Ade Kusumawardhani Movie – Office Christmas Party: Dr Barry Leonard, Dr Andrew Toffoli, Dr Crystal Durell, Dr Twain Russell, Dr William Thong, Dr Cathy Kan, Dr Hock Chua, Ms Andrea Piesse, Dr Michael Bray, Dr Yulia Wilken Music – Handel’s Messiah: Dr David Graham Music – WASO & Wagner: Dr Susanne Sperber

www.mforum.com.au

This doco follows Aisholpan, a 13-year-old girl living on the Mongolian Steppes, who trains to become the first female in 12 generations of her family to become an eagle hunter, and rises to the pinnacle of a tradition that has been handed down from father to son for centuries.

In cinemas, March 16

Movie: Loving

This historical film speaks of the racial unrest in the US today. In 1958 a white man, Richard Loving, marries an African American woman Mildred which sees them jailed and then vanished from their home.

The film and its performers are in Oscar contention.

In Cinemas, March

Theatre – Avenue Q: Dr Claire Armanasco

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