MedicalForumWA 0617 Public Edition by Medical Forum WA

The Human Touch Technology and Caring After-Hours Blowout Teleheath Reaches Out CTEC of the Future Clinical Updates Your Lifestyle

June 2017

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EDITORIAL

Technology and the Human Touch The news release from the Technical University of Munich reminds us how much the medical profession relies on new technological advances. This news was about how to overcome biofilms, the protective layer that bacteria secrete that create havoc for middle ear infections and implants, as well as stuffing up our bathroom pipes and our dog’s teeth. “Dental plaque and the viscous brown slime in drainpipes are two familiar examples of bacterial biofilms,” the news release said. It is the water-repellent polymers that bacteria produce that protect against environmental hazards. Mucous is a beneficial biofilm that protects vaginal, gut and respiratory passages but the protection it offers is broken down by H pylori when it establishes itself in the gut.

www.doctorsdrum.com.au). In this day and age where strong doubt is cast on politicians acting for the community good, any sort of competing interests around scientific advancement may be viewed with suspicion. Here’s a sample to reflect on: a handheld multispectral analysis tool that examines tissue morphology and helps in the clinical analysis of melanoma; continuous glucose monitors and insulin pumps; aortic valve replacement by catheter inserted at the groin; analysing big health data to help in fields like oncology; simulation and augmented or virtual reality in medical teaching; personalised diets for better health or sports performance based on genetic makeup; 3D bioprinting of body parts; and health trackers, wearables and sensors. Many of these technologies seem to offer cost savings, which has got the interest of cash-strapped people who hold the public purse. Here’s the rub. We badly need bold advancement using new technologies but this will not happen in a no-risk environment and the public service appears full of people who are risk-averse.

So it is with other pathogens, they can have different ways of overcoming biofilm protection. Mind you, bacterial biofilms are tough. And the same bacteria can produce different biofilms, depending on growth nutrients, with different water repellent properties when it comes to nature (see picture).

On the other hand, what the profession doesn’t want are new technologies that have them working faster in a more impersonal way. This is technology for technology’s sake. It begs the question: How valuable is the human touch?

Bacteria in biofilms are often difficult to kill with antibiotics and other chemicals. These researchers now propose tackling the water-repellent properties of biofilms: “An antibacterial substance cannot work if it is unable to reach the surface of a biofilm because it rolls off. Thus, we need to modify this water-repellent surface texture. This would be a new approach to the removal of biofilms from surfaces such as tubes, catheters and infected wounds.” Designing and testing new technologies like this is contentious. Some want the system relaxed so things reach the marketplace sooner. We see enough TGA hazard warnings or recalls to be cautious about this. Some technologies are clearly open to abuse for financial gain so checkpoints become important to the community at large. Greater transparency may be the key (see

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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

n this edition, you get a real smorgasbord. Abnormal LFTs and back pain imaging – the what and wherefore are explained; apparently you can have a ferritin of 1000 without iron overload; and there seems more certainty about no imaging with acute uncomplicated lumbar back pain. On Page 16 we learn that consumer convenience may be taking the community on a doctor-expensive ride when it comes to afterhours services. ATAPS has gone so what's coming in its place and where does WAPHA fit in? And we have the technology of the ETS and CTEC to divert us, both covered in this edition.

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

JUNE 2017 | 1

CONTENTS JUNE 2017

14 FEATURES 14 Doctor as Artist: Dr Toby Bell 16 After-Hours Blowouts 19 The Super Circus 24 CTECâ&#x20AC;&#x2122;s New Frontiers NEWS & VIEWS 1 Editorial: Technology and the Human Touch

Dr Rob McEvoy Letters to the Editor More Telehealth Specialists, Please Dr Toby Pearn MBI for Breast Screening Ms Rhonda Harrup Spare a Cultural Thought Dr Aesen Thambiran Hope for FDV Change Ms Kedy Kristal SCOFF for Eating Disorders A/Prof Anthea Fursland 6 Curious Conversation Dr Rick Bond 8 Mental Health in Primary Care 10 Have You Heard? 11 Beneath the Drapes 21 Story of a Stock: AusCann

19 26 43 45

Telehealth Closing the gaps New Ways to Lower BP Smart Headphones

Lifestyle 40 Salty Heart of Inside Australia

Peter McClelland & Dr Rob Davies Funny Side What Fuels Millennials Rusty to Beautiful Music My Local: Shou Japanese Wine Review: Schild Estate Dr Craig Drummond MW 52 Silver for Black Swan 53 The Merriest Widow 54 Competitions

48 48 49 50 51

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Cervical Screening Test Dr Gordon Harloe

Bariatric Surgery & Obese type 2 Diabetes Prof Tim Welborn

Lumbar Diagnostic Imaging Dr Mark Hamlin

Abnormal LFTs Dr Andrew Klimaitis

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Stress and Developing Brains Dr David Roberts

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

LETTERS To THE EDITOR Telehealth for rural patients Dear Editor, More specialists are doing Telehealth but it remains a slow uptake. For example, there is still not a single dermatologist that I am aware of in WA who does Telehealth consults, which is crazy given it is a speciality well suited, especially if high quality photos can be emailed. Neurology is another specialty where Telehealth would be so useful, to aid tinkering with anti-epileptic or Parkinson’s medications. Rural patients are well known to have significantly higher morbidity and earlier mortality across all diseases. I believe more needs to be done to address this imbalance such as positive discrimination for rural patients to access specialist clinics using Telehealth. There should be mandatory Telehealth capability for all genres of public clinics for rural patients. The Central Referral Service should instigate this, and not be the barrier to care for rural patients that it has become. Private specialists need to have either carrot, stick, or both to get them to provide the service. However, there are glimpses of the future. For example, Perth Cardiovascular Institute should be congratulated for making steps towards the “Telehealth Dream”. Their system works like this: Bob comes to see me in Esperance with a complex medical history and a new cardiac problem. He doesn't need urgent hospital admission and I can organise initial investigation and treatment but I need specialist input. With Bob still with me in the consulting room, I can go online to Perth Cardiovascular Institute’s website, and click on Telehealth Appointments, find the next available, cross check it with my timetable, and book it for Bob there and then.

cardiologist and we set about fine tuning the management plan. Perth Cardiovascular use the Blue Jeans App, which is similar to Skype but allows things like screen share, which means I can open up Bob’s ECG on my computer and the cardiologist can view it instantly during the Telehealth consult. I charge my patient the Medicare fee plus a gap, as does the cardiologist. Bob gets timely specialist care and avoids an expensive hospital admission, does not have a 1400km round trip to Perth, and the cardiologist and myself are remunerated for our efforts. A great service like this will get lots of referrals from rural GPs.

detection of almost four times more cancers than conventional mammography alone in women with dense breast tissue. The high specificity of MBI also leads to a reduction in the number of unnecessary (negative) biopsies compared to other secondary screening modalities and generates a cost saving of around 15% per cancer detected. MBI is now used routinely for secondary screening in women with dense breast tissue at all Mayo Clinic sites, along with several other breast imaging centres throughout the US and Asia.

Dr Toby Pearn, GP, Esperance

Ms Rhonda Harrup, Nuclear Medicine Technologist, Perth

ED. PCI says their system complies with all security specifications set by government.

ED. References available on request

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MBI for breast screening Dear Editor, For those not familiar with Molecular Breast Imaging (MBI) mentioned by Dr Liz Wylie (Dense breasts and mammograms, May edition), it is an emerging technology new to Australia. The first MBI camera is now operating in WA, the only state in Australia where the BreastScreen program discloses breast density composition to its patients. MBI is a high resolution functional imaging technique developed at the Mayo Clinic in response to the requirement for a more effective secondary screening technique in women with dense breast tissue. MBI employs the common radiotracer 99mTc-Sestamibi, which is also used for myocardial perfusion imaging. Two standard views are acquired for each breast in the same projections as mammography. Each view is acquired for around 8-10 minutes with the patient seated.

Spare a cultural thought Dear Editor, Almost a third of WA’s population is born overseas. Migrants and refugees living in WA come from more than 190 countries and speak around 270 languages. This is also reflected in our culturally diverse medical and nursing workforce. Breaking Down Cultural Barriers (May, 2017), highlighted the challenges women from Africa face when accessing health care in WA. Providing health care to an individual from an unfamiliar cultural background can be quite challenging for a GP. Effective communication is the cornerstone of gaining an accurate medical history and building trust. It is essential to work with a professional interpreter if the patient has low proficiency in English. Despite being free and relatively easy to use, the Telephone Interpreter Service (TIS) is still underused in Australia.

Bob can then go off and get his investigations done and commence treatment. My practice nurse chases him up and ensures he is in front of our practice computer with all the technology working prior to the appointment time and Perth Cardiovascular Institute admin set it all up at their end.

Unlike mammography, MBI does not require compression, merely immobilisation of the breast between the dual gamma detectors. The effective whole body radiation dose from MBI is approximately 2mSv, which is comparable to the level of annual natural background radiation in Australia.

Evidence shows that patients who don’t speak English are more satisfied with their care and are more likely to take their treatments correctly when interpreters are used. There are also medicolegal implications if an interpreter is not used. This is especially so for medical procedures where informed consent is required.

Then at the appointment time, I walk in and join the Telehealth consult, as does the

US studies have shown that the addition of MBI to a screening mammogram leads to the

continued on Page 6

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4 | JUNE 2017

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Major Sponsor: Clinipath Pathology

By Dr Gordon Harloe CEO Clinipath Laboratory

Update: Cervical Screening Test BACK TO CONTENTS

The renewed National Cervical Cancer Screening Program (NCSP) commences on December 1, 2017. From May 1 to November 30 interim cervical cytology cancer screening options are in place and this article summarises the transition arrangements and screening options. Key Points • The Federal Government has deferred the start date of the revised NCSP from May 1 to December 1, 2017. • From May 1 to November 30, cervical cancer screening continues with cytology. • During May 1 to November 30 the Federal Government will provide a Medicare rebate for either a Pap smear or ThinPrep® liquid based cytology (LBC). If both are sent, Clinipath Pathology will continue to privately charge ThinPrep®. • Clinipath Pathology recommends ThinPrep® (see below for reasons). • From December 1, 2017, the primary screening method will change from cervical cytology to human papilloma virus (HPV) polymerase chain reaction (PCR) testing, supplemented under certain conditions by LBC. ThinPrep® (LBC) During the transition period May 1 to November 30, 2017, a Medicare rebate will be available for either a ThinPrep®, or a conventional Pap smear – not for both tests. If both samples are sent, Clinipath Pathology will privately bill the patient for ThinPrep®. Benefits of ThinPrep® and the ThinPrep® Imager We recommend the collection of ThinPrep® samples, which allows you to transition to using ThinPrep® ahead of the implementation of the new Cervical Screening Test program. ThinPrep® provides improved detection of cytological abnormalities and enables an HPV PCR test to be requested on the same sample. The cells on the ThinPrep® slides are well fixed and evenly dispersed without cell crowding or multi-layering of groups of cells. Obscuring inflammatory exudate, blood and mucous are minimised. The thin-layer presentation of cells facilitates easier, faster screening and detection of abnormal cells that may have otherwise been obscured. The monolayer of cells on the ThinPrep® slides enables computerized examination by the ThinPrep® imaging system. The image processor scans every cell and cell cluster

ThinPrep Test

on the slides, measuring the DNA content and identifies the 22 areas of greatest interest or fields of view (FOVs) for each slide. Each slide is subsequently reviewed by cytotechnologists on automated review microscopes which direct the cytotechnologist to each of the 22 FOVs. The dual review increases the sensitivity and specificity, reducing the false negative fraction.

Clinipath Pathology will offer the option of ThinPrep® plus HPV PCR. The ThinPrep® test will attract a Medicare rebate and there will be a private fee for the screening HPV test. To ensure informed financial consent please discuss this option with your patients and state on the request form –“ThinPrep® and private HPV.”

An Australian study was performed on 55 164 split conventional Pap smears and ThinPrep® samples. The Imager read cytology showed a 55% increase in detection of HPV&CIN1, a 27% increase in CIN2 or greater, a 42% decrease in unsatisfactory samples and a 22% reduction in the ‘inconclusive, high grade abnormality cannot be excluded’ category.

While the current NH&MRC management cervical screening guidelines remain relevant until December 1, 2017, our cytologists and pathologists will take a concurrent positive HPV result into account when recommending appropriate clinical follow-up for your patients.

HPV Test

In addition to providing routine five-yearly primary HPV screening, the renewed NCSP identifies specific groups with increased risk of cervical cancer. The program offers more frequent screening in the case of immune deficient patients, or additional cytology testing from the same vial for women with a positive HPV result (reflex LBC) or abnormal vaginal bleeding (co-test LBC). Patients with in utero DES exposure should be offered annual HPV, co-test LBC and colposcopic examination of the cervix and vagina indefinitely.

There is no Medicare rebate for screening HPV testing until December 1. Until November 30, 2017, a Medicare rebate is only available for HPV testing done as “test of cure” following histologically confirmed CIN 2 or CIN 3. “HPV test of Cure” must be stated on the request form for a patient to be eligible for the Medicare rebate. Some practitioners and patients deferred their cervical screening test until after May 1, in anticipation of the new primary HPV PCR cervical screening test. Since this delay has been announced we have had enquiries about the option of privately funded screening HPV PCR testing in this transition period. Ideally, doctors and patients should wait until the NCSP starts on December 1. However, for patients who want the reassurance of knowing their HPV status, from May 1 to November 30,

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

Patient Results: 9371 4340

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

www.clinipathpathology.com.au

The Renewed National Cervical Screening Program – from December 1, 2017

Further Information For any queries on the interim screening options, contact the cytology department on (08) 9371 4381. Information on how to collect a ThinPrep® sample is on our website www.clinipathpathology.com.au

LETTERS To THE EDITOR continued from Page 4 Culture is another important aspect to consider. Culture is deeply ingrained in all of us and is reflected in our norms, values and behaviour. This includes our concepts of illness and health, and our expectations of health care. Misunderstandings can arise if the practitioner and patient are from different backgrounds. It would be impossible to learn about all cultures that exist in WA. One practical solution is to use a Cultural Awareness Tool which can be applied to any patient you consult. Simple questions such as what do you think caused your illness? can give the practitioner insight into the patient’s cultural beliefs about health. It is also important to remember that many of our patients are coming from countries with very different health systems to ours. The Australian health care system is very complex with its mix of public, private, primary, secondary and tertiary care. It can be quite bewildering for new arrivals. Even going to the pharmacy to fill a prescription may be new experience for some migrants. Over the years, I have come across many refugees who have shown me their unfilled scripts; unsure what the pieces of green paper are for! Dr Aesen Thambiran, GP ED: Dr Thambiran is an associate of Cross Cultural Intellect, a training and service development consultancy.

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Hope on the horizon for FDV Dear Editor, The Women’s Council for Domestic and Family Violence Services represents over 60 domestic and family violence services in WA and this year celebrates its 40th anniversary. WA was one of the first states to

recognise and provide funding to resource a peak DFV organisation to ensure there was a victim-focused voice to inform government policy, legislation and program responses. Over the past two years there have been several new collaborations between the Women’s Council and the Department of Child Protection and Family Support to develop an emergency accommodation and response framework. This innovation was developed following the Ombudsmen’s report into the death of Ms Andrea Pickett which found there was a lack of safe accommodation for Ms Pickett and her children when she was in imminent danger of harm. The new Refuge Service System Model Emergency Response (RSSMER) has funded three lead refuges to quarantine 4-8 beds in each refuge for emergency accommodation for up to 48 hours for single women and women with children assessed as being at high risk of harm and in need of safe accommodation. The refuge then transfers the client to alternate and ongoing refuge accommodation for up to three months. The model was evaluated after 12 months by Prof Donna Chung and others from Curtin University with recommendations which are being progressed. The long-awaited changes to the Restraining Orders Act finally received Royal Assent on 29 November 2016. Most of the DFV changes will start on July 1, 2017. The changes are in response to a number of recent reviews and reports intended to provide better information to Magistrates and Justices of Peace when making restraining orders and to provide better protection for victims of family violence. There will be a new type of restraining order called a Family Violence Restraining Order and Courts will be empowered to order a person who is subject to an FVRO to participate in a mandatory ‘behaviour change’ program and various existing provisions of the RO Act have been amended to strengthen victim protection and perpetrator accountability.

A key area in a coordinated response to the pervasive issue of DFV is to provide a credible and evidence-based response to perpetrators to enable them to change their behaviour. Stopping Family Violence is the new not-forprofit peak body in WA to grow the evidence base to support this essential work. Stopping Family Violence will focus on developing skills knowledge in the DV sector through research and pilot activities. It was launched in May. Ms Kedy Kristal, Policy Officer, Women's Council for Domestic and Family Violence Services ........................................................................

SCOFF for eating disorders Dear Editor, Eating disorders are particularly complex because they sit at the interface of physical and mental health. We know that if an eating disorder is treated early – particularly in the first three years – the prognosis greatly improves. Yet because of the stigma associated with eating disorders – anorexia nervosa is more stigmatised than schizophrenia – sufferers are often reluctant to disclose, and their disorder goes undetected, often for years. Those presenting to the specialist public clinic in Perth, the Centre for Clinical Interventions (CCI), have had their disorder for an average of nearly eight years. This condition is more common than most people think – one in 20 Australians at any one time will have an eating disorder, and one in eight Australian women will experience one in her lifetime. People from all social and ethnic groups are affected and it’s not just adolescent girls who suffer, but boys, men and transgender individuals, as well as older women. While alcohol use and smoking are routinely continued on Page 8

CURIOUS CONVERSATIONS

The name’s Bond, Dr Rick Bond Vascular surgeon Dr Rick Bond dreams of fast cars and playing saxaphone but pizza night with the fam is pretty good too. The main reason I chose medicine was… fast cars, money and women... of course! If I could suddenly be transformed into a super-hot musician I’d play… the saxophone, just so I could play Jerry Rafferty's, Baker Street. My most upsetting moment in medicine was… as a junior vascular registrar in the UK. I saw a fit and healthy 80-year-old woman in ED with a ruptured abdominal aneurysm. I told her that she needed an urgent

6 | JUNE 2017

operation with a greater than 50% chance of survival, and that she’d die if she didn’t have surgery. I checked with my consultant who said, ‘I don’t operate on anyone over the age of 80 so tell her she’ll be palliated’. That was ‘upsetting’! My next long holiday is going to be… holiday? Dream on! The best movie I’ve ever seen is… the last one I watched with my wife and kids on pizza and movie night Friday!

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LETTERS To THE EDITOR continued from Page 6 screened, it is rare for GPs to ask patients about their eating habits and any disordered patterns of eating and exercise. Utilising a short screen, the SCOFF, may help GPs identify eating problems. The SCOFF contains five questions addressing salient features of anorexia nervosa and bulimia nervosa and takes only a few minutes to complete and score. The questions are: S Do you make yourself SICK (vomit) because you feel uncomfortably full?

For those aged 15 and under, a referral can be made to PMH’s Eating Disorders Program (EDP): 9340 7012 or pmhedp@health.wa.gov. au; over 16, a referral can be made to the Centre for Clinical Interventions (CCI) 9227 4399 or info.cci@health.wa.gov.au; support and guidance from WA Eating Disorders Outreach & Consultation Service (WAEDOCS) 1300 620 208. A/Prof Anthea Fursland, Curtin University, Clinical Director of CCI

C Do you worry that you have lost CONTROL over how much you eat?

We welcome your letters and leads for stories. Please keep them short. Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. Letters, especially those over 300 words, may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.

O Have you recently lost more than ONE stone (6.3kg) in a three-month period? F Do you believe yourself to be FAT when others say you are thin? F Would you say that FOOD dominates your life?

When we ask for advice, we are usually looking for an accomplice.

A positive response to two or more questions raises the suspicion of an eating disorder, and warrants further investigation.

Saul Bellow

Mental Health in Primary Care Last issue Woodlands GP Dr Jane Ralls wrote to us about her dismay at the axing of ATAPS, which has been subject to review as part of the Federal Government’s revamping of mental health programs to a stepped care model. We asked the CEO of WAPHA Learne Durrington to comment then and in her reply, which was published in the May edition, she outlined some of the programs that will be replacing ATAPS. We asked some specific questions of Learne and WAPHA to gain a better picture of the changes. Q: How much has the Federal Government given WAPHA to deliver mental health programs this financial year? How much of that money has WAPHA distributed to service providers in the past six months? Has ATAPS money been specifically redistributed to WAPHA for PORTS. How much was that? How much will PORTS cost to set up and deliver? (WAPHA has combined these questions in its response) A: There has been a significant change in the way mental health programs are funded. The Commonwealth Government formerly would fund individual programs, such as ATAPS, through a combination of base funding and special purpose funding. In very general terms, the base funding was designed to enable GPs to access psychological services for hard-to-reach

8 | JUNE 2017

groups to complement Medicare-subsidised mental health services, while special funding provided additional support for those groups whose needs were not being adequately met through ATAPS. As of 1 July, 2016, funding for a range of former programs, as well as additional mental health funding, was redirected to a Primary Mental Health Care flexible funding pool, which must be used by PHNs to support commissioning of mental health and suicide prevention services in six key service delivery areas: • Low-intensity psychological interventions for people with, or at risk of, mild mental illness; • Psychological therapies delivered by mental health professionals to underserviced groups; • Early intervention services for children and young people with, or at risk of, mental illness; • Services for people with severe and complex mental illness who are being managed in a primary care setting; • Enhanced Aboriginal and Torres Strait Islander mental health services; and • A regional approach to suicide prevention activities with a focus on improved followup for people who have attempted suicide or are at high-risk of suicide. ATAPS in WA received $10,478,265 during 2015-16, the final Commonweath funding period. The equivalent funding was allocated to providers in 2015/16 to deliver low intensity mental health services.

However, $41m has been allocated to WAPHA for 2016-17 to commission mental health services across WA. Of this, WAPHA allocated $13 million for low intensity services which include face-to-face, telephone-based, group therapy and online services. The remainder has been made available for headspace services, early psychosis, mental health nursing and mainstream and ATSI suicide prevention services. The 2017-18 funding for mental health is projected to slightly increase. Q: How many West Australians accessed ATAPS the past 12 months? A total of 10,596 patients in the 2015-16 financial year, with 9893 attending at least one session. (Depending on the location, 3-8% of those referred did not go on to have an ATAPS session.) Our understanding is that about 70% received five or fewer ATAPS sessions and 95% received 11 or fewer. Patients on ATAPS were required to pay a co-payment to an ATAPS provider, with about $150,000 in co-payments recorded in 2015-16. Under the new system, all services commissioned by WAPHA will be at no cost to people with a Health Care Card. GPs can refer people in rural and remote communities who would otherwise have little or no access to mental health services, including in areas where access to Medicare-subsidised mental health services is low.

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HAVE YOU HEARD?

Budget for sceptics There’s been summaries, analyses and theories in abundance since the Federal Budget was brought down. The Government aimed for a muted response and it gave almost enough to get it, though it has left some very big questions pending. The pathology rental decision called a draw between independent GPs and Pathology Australia – the winner was the bureaucracy which will get $18m over the next five years to ensure that the parties comply with the law (which allows a fluctuation of 20% of market price of rentals). Health Care Homes – the policy that no one except the corporate practices says they are ready for. Some conspiracy theorists believe that the government is giving a free kick to Primary and IPN which are both getting up to 50% of the initial funding for the trials. Malcolm Parmenter, who we report below has left IPN for Primary, was a member of the Government’s Primary Health Care Advisory Group on chronic and complex illnesses which recommended the Health Care Home model. Then there’s MyHealthRecord and another $350m for little to show for the $1b investment so far. And so the circle turns.

Crescent rising The Sydney based Crescent Capital has been busy in the dental space in the past few months. Its National Dental Care ‘roll-up’ has acquired DB Dental and its 17 multi-surgery practices in Perth for an undisclosed sum. In June 2015 Crescent Capital bought up Healthscope’s pathology business. Its other health interests include National Hearing Care which has branches in WA and is also backer of the largest after hours provider National Home Doctor Service (see p16 for a run-down on GP after hours).

e-cigs out of puff The Federal Court has ordered three online e-cigarette retailers Joystick, Social-Lites and Elusion to pay penalties for breaching the Australian Consumer Law, which the ACCC understands is the first time any regulator globally has successfully taken action for false and misleading claims about the presence of carcinogens in e-cigarettes. The Court ordered Joy Stick and Social-Lites to pay a

fine of $50,000 each with Joystick’s director and Social-Lites’ CEO being fined $10,000 each. Elusion was fined $40,000 and its director, $15,000. The Acting Chair of the ACCC Delia Rickard said consumers were led to believe that by using these products they would not be exposed to harmful chemicals found in ordinary cigarettes. “In fact, they were exposed to the same chemicals, including a known carcinogen that has no safe level of exposure,” she said.

Corporate deckchairs Last month we learnt about Henry Bateman’s launch into GP corporate land, in another twist the CEO of Sonic Clinical Services, Dr Malcolm Parmenter, has resigned to become the CEO of rival Primary Healthcare. Dr Parmenter, who also heads up IPN, Sonic’s primary care division, will take up his new role in September. But what is a blow for Sonic, could be a boon for MediTracker, the smartphone app developed by Precedence Health Care for patients to view their medical summary. IPN is rolling out MediTracker across its 180 practices nationally over the next few months giving two million people the chance to have mobile access to their GP medical record summaries. Dr Parmenter might just see the benefit of rolling it out at Primary too.

Political sweetners The anti-sugar lobby was hoping to get some action when Australian and New Zealand ministers responsible for food safety met last month. If there’s any movement, it’s at a snail’s pace. In November, Ministers agreed to a program that would investigate labelling to inform consumers about sugars contained in their food. Now they have agreed to “further evidence gathering activities” by Food Standards Australia New Zealand (FSANZ) which would report in November. A tax seems a long way away. Health Minister David Gillespie in response to a Grattan Institute report urging a sugar tax said he regularly told his patients to lose weight by going on the ELF (East Less Food) and the DME (Do More Exercise) program. "You are what you eat but also a result of how often and how much you eat. We are not food fascists, we let people choose what they eat. We are trying to

help people make better, wiser, more nutritious choices.” That sounds like a no from him.

Whoever pays the piper… The Grattan Institute’s Health Program Director Stephen Duckett is on the chronic disease bandwagon, saying simple health system reforms could save over $320m each year by stopping unnecessary hospital admissions and providing better care for people with diabetes, asthma, heart disease and other chronic conditions. At $1000 a day or thereabouts it doesn’t take the prevention of many hospital admissions to demonstrate benefit. And if they recur that’s even better! The Institute says the government spends over $1 billion each year on planning, coordinating and reviewing chronic disease management, yet many people with chronic conditions do not receive best care and end up with unnecessary hospital stays. Medicare’s fee-for-service should be changed for payments to health teams for integrated, long-term care of patients with chronic conditions. GPs would be financially rewarded for outcomes, rather than for seeing patients more often. Primary Health Networks should be held accountable for making improvements.

HaDSCO – who cares? HaDSCO’s annual report for 2015-16 said it handled 1777 complaints about health services in WA. The gender mix was about 50:50 with 70% of complaints from the affected adult (while 16% came from a child or parent, and 8% came from a partner or spouse). Nearly half complaints involved more than one issue, and the most popular complaints were about ‘Treatment’ (32%; mostly outcomes or complications), ‘Fees and costs’ (14%; mostly billing practices) and ‘Communication and information’ (14%; mostly wrong attitude and manner). Private and public complaints were roughly the same in type and not-for-profits took longer to resolve things. Complaints about disability services and mental health services were small in comparison.

Penis enlarging made hard Medical Forum subscribes to TGA safety information and has noticed a flurry of warnings about medications presumably coming out of Africa or China. But this one takes the cake:

Going, Going … It’s been a landmark at the St John of God Subiaco Hospital site since 1962 and by the time you read this, it will be a hole in the ground. The old nurses quarters, which in more recent years it has been used for consulting suites, administration offices and parent education workshops went under the demolition ball to make way for the first stage of the hospital’s redevelopment. Executive Director WA Hospitals and acting CEO of SJGSH John Fogarty said the redevelopment would include extra parking, operating theatres, single rooms and consulting suites and a research and education facility.

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MEDICAL FORUM

• Black Swan Health took out two awards at the 2017 WA Disability Support Awards. Chris Black and Nadia Bamasri won the Excellence in Advocacy and Rights Promotion Award as well as the Overall Award for Excellence.

Recession proof (for some) Bankwest’s national overview of the Medical and Other Health Care Services, which excludes hospitals, is a chronicle of our times. On one side of the ledger, it tells a story of industry expansion and growing employment and salaries, on the other, the inevitable consequence of the former, an increased cost burden on the taxpayer. It studied data from private sector GPs and specialists, pathology, allied health and other services. It is a sector responsible at this time, within the broader health care and social assistance industry, for

“XXXL Penis Enlarging Ointment poses a serious risk to your health and should not be taken.” What does this actually mean? Apparently it contains the active ingredient of

65.9% of its income, 80.1% of its profits yet only 36.6% of its employment. Even with this said, employment had risen 83.6% over the past 10 years in this subset, its profit margins were 33.2% higher than the all-industry average of 10.9% (finance sector excepted). In 2014-16 the total costs of the subset had risen to $41.8b while income had grown to $60.2b. There were 9564 operators in WA in this period, 5056 had turnovers of between $200,000 and < $2m; 364 had turnovers > $2m (or 3.8%). WA employment data indicated 5469 were non-employing, 3962 employed 1-19 people, 124 employed 20-199 and nine had 200+ employees. This is an 8% contraction of the workforce The report projects a five-year growth rate of 3.3% a year to $68.2m driven largely on the back of the ageing population, government expenditure (which is expected to rise to $79.2b in 202021), higher disposable income, a higher birth rate and more people visiting GPs. Apparently in 2014-15, 83.7% of the population aged over 15 visited a GP once a year or more or 15.9m visits up from 15.6m the previous year.

Cialis (see www.tga.gov.au/alert/xxxl-penisenlarging-ointment).

BY THE NUMBERS

53,420

The number of separations paid by private insurance companies in public hospitals in WA in 2015-16. This represents an increase on average of 10.5% each year between 2011-12 and 2015-16 Admitted Patient Care 2015-16

• Prof Girish Dwivedi (pictured) is the first incumbent of the Wesfarmers Chair in Cardiovascular Disease at the Perkins Institute. • Winners of the Health Consumers Council awards include: Physiotherapist Ellie Newman, who specialises in aged care, won the Health Professional Award. Finalists in the category included Clin A/Prof Tim Bates and chemo@home’s Lorna Cook, Dr Lee Jackson and Dr Aesen Thambiran. The Health Organisation Award was won by Moorditj Djena, a diabetes education and podiatry service for Aboriginal people. Bentley Mental Health Services and ConnectGroups were finalists. The Health Consumer Award was won by Carolyn Chisholm who created a support group for women permanently injured by transvaginal mesh devices. • WA-Based John of God Health Care has brought the Marillac disability service in Victoria. Marillac will be operated by SJGHC’s disability service St John of God Accord. • UWA’s Prof Ryan Lister is one of 41 scientists worldwide to be appointed an International Research Scholar by the USbased Howard Hughes Medical Institute (HHMI). • Ms Nadine Magill has replaced Ms Cate Harman as WA State Manager of the Prostate Cancer Foundation of Australia. • Ms Janina Faulkner, a volunteer with miscarriage, stillbirth and newborn death charity, Sands Australia is inaugural recipient of the organisation’s Jenny Miolin Volunteer Award. • Former Ngala CEO Mr Ashley Reid is the new CEO of Cancer Council WA replacing Ms Susan Rooney who has taken up the CEO’s job at St Vincent de Paul Society WA. • Disability services provider Rocky Bay has appointed Martin Wandmaker and Richard Diermajer to its board.

• Public hospitals in WA recorded 630,739 separations (a 5% increase on 2014-15)

• Amanda Hunt has been appointed CEO of UnitingCare West.

• Private hospitals in WA recorded 497,498 separations (a 3.5% increase on 2014-15)

• The RACGP has been awarded the international Jive Digital Transformation Award for its shareGP platform which encourages secure online collaboration between GPs.

• Same-day separations in WA public hospitals reached 128 per 1000 population; the rate in WA private hospitals was 131.4 per 1000 • More women than men in WA were treated in hospital in 2015-16 – 320,877 women compared with 309,860 • Diseases of the digestive system accounted for the most presentations of specific symptoms to WA public hospitals (23,117) followed by neoplasms (15,132) • In WA private hospitals the most presentations were for diseases of the digestive system (40,031) followed by diseases of the eye and adnexa (30,737) MEDICAL FORUM

• The Sarich Neuroscience Research Institute has opened at the QEII Medical Centre. The $37.7m facility will house the Ear Science Institute Australia, Curtin University’s Neuroscience Research Laboratory, the Perron Institute for Translational and Neuroscience Research and the Australian Alzheimer’s Research Foundation. Ralph and Patricia Sarich donated $20 million to the project.

JUNE 2017 | 11

Letters to the Editor

INCISIONS

Forensics of Honey To ‘fingerprint’ the floral origin of honey is just as important as the product itself, suggests Dr Liz Barbour from UWA. glyoxal (MGO), which has stable antimicrobial activity. It’s probably a timely warning that the marketing of Manuka honey has been so successful that its price has soared. Counterfeit products are rife!

Why, I hear you ask? Because every jar of honey is vastly different and that’s where the Cooperative Research Centre (CRC) for Honey Bee Products comes in. We focus on the ‘forensics of honey’ and that allows us to ‘fingerprint’ its origins. And that’s important, because the floral source significantly influences levels of bioactivity and the medicinal value of the honey. Sure, the bee (Apis mellifera) does all the work but the flora determines the chemical signature of the honey. Phytochemicals such as sugar, phenolic and flavonoid levels combined with other bioactive constituents are critically important because they help to determine the anti-microbial and anti-inflammatory properties. Honey’s complex constituents make it of great interest in the war against the decreasing efficacy of antibiotics. Honey has significant antimicrobial potential due to its high osmolarity associated with its high sugar content and low pH. Some honey also produces hydrogen peroxide in an enzymatic process and the flowers of the Jarrah tree (Eucalyptus marginata) is known to contain particularly high levels. The CRC both tracks and ascertains the influences of floral source on honey bee products. We have a high level of biodiversity in Australia, and WA is home to eight of Australia’s

In the development of Honey Health markets, quality control and traceability will be highly important. The CRC is developing a ‘Chain of Custody’ that will reinforce to the next generation of beekeepers the importance of maintaining product value.

15 biodiversity hotspots so it’s highly likely that there is new and unique honey just waiting to be discovered. Some exciting new research is showing that Australia has a suite of unique Leptospermum species that produce the precursor molecule, dihydroxyacetone (DHA). This is the same molecule produced by New Zealand’s Leptospermum scoparium that produces their stunning Manuka honey. When DHA is combined with bee enzymes it forms methyl

The marketing of Manuka honey has been so successful that its price has soared. Counterfeit products are rife!

An important aspect in the development of high-grade medicinal honey is the establishment of hive sites close to carefully selected Leptospermum plants. This will maximise the production of high-DHA honey. We have 80 species of Leptospermum and the CRC is using information gathered by the University of the Sunshine Coast to breed a uniquely Australian, high-value Leptospermum species. The end result, ideally, will be a new on-farm industry that will ensure honey bee pollination will take place close to the flora linked with its production. The CRC is focused on maximising the amount of information relating to flora type, honey bee product production and its medical properties. We’re especially concerned with any downstream effects on flora and the health of the honey bee. We have to get the balance exactly right.

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When you pick up a jar of honey, you think ‘Bees’! But you should also be thinking… which plants have these bees been feeding on?

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JUNE 2017 | 13

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Doctor to Cosmic Blacksmith

A life-changing trip to the Burning Man Festival has refocused Dr Toby Bell’s life and art. A stunning and larger-than-life artwork at this year’s Sculpture by the Sea has a compelling back-story. The concept came to its creator, Dr Toby Bell, in a flash and fully-formed but it was a moment accompanied by supraventricular tachycardia that almost cost him his life. “I won a sculpture competition in 2010 and used some of the money to go to the Burning Man Festival in Nevada, which is a wonderful celebration of music and art with a strong sense of community. One night I felt a few brief palpitations and pretty much knew that I was going to need serious medical help. I was in the middle of a desert in a tent and my chances of survival weren’t looking too good.” “I could see the defibrillator paddles hovering above me and I thought I was probably going to die. And if the dominos had fallen the wrong way I would have.” “I remember feeling quite calm and peaceful, it was a moment of intense pressure and then complete acceptance. That’s when I had this image of The Cosmic Blacksmith. It came into my head as a completely finished sculpture. I knew exactly how it would look.” “It’s that idea of unbearable pressure followed by a sense of acceptance that I’m trying to communicate to people who take the time to look at the sculpture closely.”

14 | JUNE 2017

Art and life “Burning Man utterly changed my life. It was just an avalanche of emotions and when I came back to Perth I knew I’d have to become much more serious about my art. Before that I used to do it almost in secret. I felt that I couldn’t really call myself an artist, that I wasn’t worthy of being regarded in that way.” The festival in the Nevada desert was a moment of transformation for Toby, but it was not without its own set of consequences. “I’d changed radically by the time I came back from Burning Man. I actually looked physically different and some people I knew didn’t even recognise me. There were, inevitably, some difficult times ahead. My marriage couldn’t continue and that was hard because we have two children, but once you buy that sort of ticket you’re on the ride.” “Art became the medicine to express my emotions, it was therapy.” And, given Toby’s family background in the UK, it’s hardly surprising that there were long-standing issues that needed some form of resolution. Early struggles “I grew up in a pretty dysfunctional family. My father was a doctor, a typical alpha male,

highly successful and charismatic. He was also an alcoholic and not one for expressing emotions in a positive way. And that’s not surprising because the job of being a doctor predisposes you to playing the role of the ‘carer’ and the ‘strong’ one.” “It’s not entirely appropriate to display vulnerability in front of a patient, as we all know.” “And my mother had her own set of problems. She became addicted to opiates and was in a drug-induced haze most of the time.” “It was really difficult for me as a young child watching my siblings fall by the wayside one after another. It was terrible, really. I decided I wasn’t going to succumb to that so I became highly controlled, emotionally detached and shutdown.” Toby trained as a doctor in the UK and, perversely, the very qualities that enabled him to survive a difficult childhood suited the practice of medicine. “Being a doctor was quite good in a way. The whole idea of being professional encourages the building of emotional walls so there was no need to feel much outside welldefined boundaries. I’d become a lot like my father, although I hasten to add I wasn’t an alcoholic!” MEDICAL FORUM

Time for a change of pace. Time to go Country.

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Left: Dr Toby Bell with the flame thrower that formed part of his circus act. Inset: Toby's sculpture The Cosmic Blacksmith, which featured at this year's Sculptures by the Sea in Cottesloe. Above: Toby in his Fremantle studio.

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“I thought I was fine, but there were niggling feelings that something was missing.” Finding the balance If it came to a choice between medicine and art, Toby would have no hesitation in choosing the latter. “Initially, it was quite difficult to balance medicine and art. It was like being two people, with both of them wanting to do everything. It’s all too easy to end up thinking like a doctor all the time, and being an artist is not that dissimilar.” “I break the week up with two or three days working in the area of skin cancer, which I really enjoy. The transition between medicine and art is pretty seamless now, I came to realise that they’re both ‘me’ and that’s been beneficial in both areas.” “But I have to say that being a sculptor is not an occupation for me, it’s more like breathing. It’s so intertwined with how I live my life and, if I had to, I could always find something to do other than medicine.” In May 2016 Toby did find something to do other than being a doctor. He, quite literally, ran away and joined the circus!

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Life’s a circus “I spent a month touring WA with a bunch of amazing people. I had this incredible costume and they gave me a flame-thrower to play with, which I used in a fire show and backing a band. It was wonderfully inspiring to be with people who were so dedicated to their art.” “But it’s always sculpture that I come back to because it’s an extraordinary medium. The three-dimensionality brings the artwork to life and, at its best, embraces the universal human experience.” “I would hope that a piece such as The Cosmic Blacksmith becomes a conversation that connects people and resonates with their own experiences.”

There has never been a better time to go Country!

By Peter McClelland MEDICAL FORUM

JUNE 2017 | 15

Feature

After-Hours: Urgent or Free-For-All? With competition fierce in the after-hours space, a pending MBS taskforce review could spell tougher times ahead for some providers.

It’s is believed he is in receipt of the taskforce report initiated by Sussan Ley last year, and will make public the recommendations. Whatever they may be, it has been enough for the peak deputising body National Association for Medical Deputising Services (NAMDS) to launch a campaign appealing direct to the public for support. Its Protect Home Visits website, with a logo looking suspiciously like the Medicare Logo, has had 59,839 registrations of support at the time of going to press. However, the campaign has anything but the support from key deputising services which have been in the business a long time – Western Australian-based WADMS also known as Doctor Home Visits, the Sydney Medical Service Cooperative, the Canberra After Hours Locum Service (CALMS) and DoctorDoctor (formerly ALMS). These organisations were

so concerned about the Protect Home Visits campaign that they split from NAMDS in December last year and have formed their own industry group, the GP Deputising Association. Galloping forces The direction of NAMDS appears to have changed over the past few years. What was once an association working for the good of all medical deputising services, regardless of their business model, NAMDS seems to have encouraged a more ‘free market’ position among its members if some of the vigorous marketing campaigns direct to the public are any indication. Convenience and accessibility for the consumer, regardless of the medical issue being treated, is being promoted rather than the primary role of a deputising service, which is to attend the patient on behalf of their regular GP. Concerns have been raised by the RACGP and independent GPs for months now questioning whether all of the players in the crowded afterhours market are true deputising services for daytime GPs or they’re simply running their own race.

Medical Forum spoke to Tanya Steele Business Development Manager from the not-for-profit Doctor Home Visits (WADMS) about the unrest that led to the formation of new group. “NAMDS was formed as an industry body to represent the interest of the Medical Deputising industry and of its individual members’ services, regardless of their business models. Unfortunately with private equity companies acquiring a majority of MDS service members, the focus of NAMDS changed dramatically. The true definitions of a deputising service to work for and on behalf of GP general practice was basically taken off the table, corporates adopting a direct-to-patient market focus. WADMS guiding principle for the past 40 years has been to act for and on behalf of GPs first and foremost. The changes the corporates were implementing is not a true reflection of what MDS services should be,” she said. Scare campaign last straw “The clincher for us was the Protect Home Visits campaign and the sensationalism in the message the corporates were inciting. It was a scare campaign that was indicating

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Last month’s budget may not have addressed the blow-out of the MBS urgent after-hours item numbers – to the tune of $250m in the past year – but that probably shouldn’t be read as a victory for providers because Minister Greg Hunt has flagged his intention to take action.

Feature to the public that changes to the MBS would make home visits a thing of the past. This is not the case for genuine deputising service providers. When no resolution to this difference of opinion in regards to the direction the campaign, WADMS’ view was that the interests of our GP members were best served outside of NAMDS.” The result of this free market behaviour in the controlled environment of the MBS has seen a staggering blowout of the use of Item 597 for urgent home visits. With a rebate of $129.80 (sociable after-hours) compared to rebates for non-urgent numbers ($29 [short] to $117.75 [extended]) claims for Item 597 have grown from just over one million claims in 2014 to 1.5 million in 2016.

that was costing the system $246m. The RACGP has expressed concern that some after-hours companies using junior doctors were putting patients’ safety at risk but has not linked their hiring with the Item 597 blowout.

This intimate relationship between NAMDS and National Home Doctor is not a new one. Last year CEO of National Home Doctor Ben Keneally was also president of NAMDS before he resigned from both posts in September.

The move of private equity companies into the after-hours landscape, however, has been considered a game changer by some, including evidently, the Minister.

Then, a controversy with National Home Doctor activities in the Gold Coast was called out by local GPs who collected evidence that suggested the service was claiming ‘urgent’

GPs protest loudly

The Minister Greg Hunt in a television interview, and reported in The Medical Republic, said that doctors were claiming to be giving urgent services when they were simply providing repeat scripts or “other things”. The Professional Services Review in 2016 found through an examination of clinical records that some practitioners “have billed these items for medical conditions such as an uncomplicated rash, reissuing prescriptions for patients’ regular medication and for routine completion of medication charts in residential aged care facilities”. Minister points the finger

One of the most influential players in NAMDS is the largest after-hours provider in the country, National Home Doctor Service, which is owned by Sydney-based equity firm, Crescent Capital.

The Minister also put the onus on “junior doctors and corporate firms” for claiming ‘urgent’ items that were not really urgent and

Dr Spiro Doukakis is NAMDS president and also general manager of clinical governance at National Home Doctor in South Australia.

items that were not, after-hours antibiotic prescribing had gone through the roof, and that ED presentations had not decreased as claimed. The WA market has been saturated with an influx of MDSs. WADMS Doctor Home Visits is the only not-for-profit, 24-hour deputising continued on Page 28

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Finance

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Help to Negotiate the Super Circus Taxation and Superannuation are topics on high rotation in legislative circles. Keeping in touch can be a full-time job. The tax and superannuation sectors are complex, even for those with the appropriate skills and expertise. The legislation surrounding these areas is both obtuse Mr Brendon Read and fluid. Independent financial planner Brendon Read surveys the scene and unpicks some of the knots. “The superannuation and taxation system boils down to a balance between simplicity and fairness – you can’t have both. Up until around 2005 it was a reasonably fair system, probably aided by the fact that the government was drowning in revenue from the mining boom. Despite that, then Federal Treasurer Peter Costello decided that it was too complex and initiated a ‘Simpler Super’ model, getting rid of a range of taxes and MEDICAL FORUM

surcharges and removing the impost on pensions for people over the age of 60. And that worked fine until the GFC!” “Predictably, the revenue underpinning those changes fell away and the past four years have seen a winding back of a more relaxed regime, particularly for some high-income earners who were deemed to be taking unfair advantage of the system.” Zombie budgets “And lately it’s been a bit like watching a zombie crawl out of the ground! A lot of the old rules are coming back under a different name. For example, the axed Super Surcharge has been rebranded as the Division 293 Tax.” “And all these difficulties are exacerbated in Australia because it’s difficult to combine a progressive tax system on the income side with a flat-tax model tied to superannuation.” So, given all that, what should a busy medico be looking for?

“The government is making it far more difficult to get money into the tax-effective environment of superannuation. The after-tax contribution cap of $180,000 per year has dropped to $100,000, but wait there’s more. It will be the pre-tax contributions that will affect high-income earners more because they are inclusive of the [9.5%] employer contribution.” “So, if you’re earning around $300,000 a year with a 9.5% employer contribution you’re not going to be able to salary-sacrifice anything at all.” Tricky mixed incomes “And if, as many doctors do, you’re working in both the public and private system you’ll be entering the hazy, twilight zone of legislation involving things like constitutionally protected funds. It’s highly complex, and most people will need to get some advice.” On financial planners, Brendon has some

continued on Page 21

JUNE 2017 | 19

From personal wealth creation to business asset acquisition.

Arthritis and connective tissue diseases specialist Dr Jack Edelman has first-hand experience of how sound private wealth management can aid mobility in business. When he and his wife Ann decided to invest in a Bunbury office for their private practice, they were able to purchase the property outright, thanks to the growth of their self-managed superfund set up by Brad Gordon of Entrust. ‘Spreading out investments, Brad has never overexposed our superfund to a single investment, giving us complete confidence, consistent growth and increased security,’ says Dr Edelman. During the 2008 market decline, Brad placed the superannuation in a holding pattern while the market bottomed out. As a result, none of the investments suffered any redemption problems. ‘Brad ensured we avoided funds that had any liquidity issues or subsequently became frozen, and eliminated unnecessary spending by running the superfund in a very tax effective manner. So, when we needed money for the Bunbury practice there were no problems,’ he adds. To alleviate the headaches associated with compliance, Brad also carefully managed the investment documentation that is so vital to self-managed superfunds. ‘Ann and I have been able to relax knowing that Brad is taking care of the book keeping,’ he says. ‘It’s an even greater convenience knowing our office is owned outright and I can focus on looking after my clients.’ If you would like to see how Entrust can help you, please call Brad Gordon on 9476 3959 for an obligation free initial consultation. Entrust Private Wealth Management Pty Ltd Level 18 Alluvion, 58 Mounts Bay Road Perth Western Australia 6000 Important Information. The circumstances described relate to a particular client and his particular circumstances, and are atypical. Investing in volatile and unpredictable markets car r y financial risks including the risk of loss of capital. Past per formance is not an indicator of future per formance.

20 | JUNE 2017

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

MEDICAL FORUM

Finance

continued from Page 19

Help to Negotiate the Super Circus pretty specific ideas regarding a productive adviser/client relationship. “I always tell someone at their first appointment that they should think about this process as an education, and that they should regard themselves as an active participant. It’s not a good outcome if the client decides to delegate all the responsibility to a planner.” “They don’t have to fully grasp the intricacies of Subsection 14G of the Tax Act but they do need to understand the logic of what the advice is. If an adviser can’t explain clearly and simply why a client should do something then the latter shouldn’t act on it, it’s as simple as that.” “The important thing to remember is that we’re aiming for incremental improvement over the longer-term, not a shortcut to multimillionaire status in 12 months. There’s no quick-fix to all this!” Planners and planners The financial planning sector attracted some negative press in 2016, and most of it linked to the major banks. “There’s a slow, and sometimes painful, move from being an industry to becoming

a profession. And, at the moment, there’s a great deal of regulation and oversight that probably needed to happen. Financial Planning emerged from the old life insurance model in the 1960s, agents going door-todoor selling policies. It’s all about selling a product and problems, both then and now, stem from that concept.” “Selling product should be the last piece of the puzzle, the regulators are determined to put a stop to this and I think they’re succeeding. Our profession is heading in the right direction.” “And one important indicator is the positive changes in the way financial planners earn their salaries. There are three broad categories of fee structure, the flat fee, commission and the percentage-based fee. Thankfully, the commission model has been largely phased out since 2013 and there are new regulations banning the practice where superannuation and investment products are concerned.” “The percentage-based fee has problems, too. It’s based on the stable of assets under management so the advice process can become conflicted. I’m convinced that the flat fee is the best option, particularly for those at the higher end of the earnings scale.”

Spend in haste… Brendon finishes with a cautionary tale that, unfortunately, is not uncommon. “Ideally, if a financial planner and his/her client have enjoyed a productive working relationship the former should be able to say, ‘we’ve spent a long time working together and you can head towards retirement with no concerns about money’.” “There’s another side to the coin and it’s relevant for individuals on high salaries. At the peak of their earning capacity there’s probably nothing really limiting expenditure. They can buy almost anything they want – cars, boats and overseas holidays – and it’s all too easy to lose touch with the real value of money.” “Sometimes, when such an individual approaches retirement, expenses can blow out. What that can mean is a forced readjustment from spending $350,000 a year down to $34,000, which effectively is an aged pension.” “It’s a horror story, and it happens all the time.”

By Peter McClelland

Story of a Stock There are plenty of hoops to jump through before you can list a public company on the ASX. And that’s particularly so if your company is breaking new ground in the medicinal cannabis market. Medical Forum spoke with AUSCANN Chairman, Dr Mal Washer and Managing Director, Ms Elaine Darby. “We first listed the stock on February 3, 2017 and it’s moving pretty well. The price rose 170% in a month and it currently stands at around 57.5c so the initial investors who bought in at 20c are feeling pretty happy,” Mal said. “We’ll also be conducting education seminars and webinars for doctors in Perth in the coming months. There’ll be Canadian doctors speaking who’ve got more than a decade’s experience in this field.” Elaine outlines some of the complexities involved in obtaining a public listing. “We did a reverse-takeover of a company called TW Holdings and, to be honest, I wouldn’t recommend that particular method to anyone. It was lengthy, and probably exacerbated by the fact that the ASX was turning their spotlight on this form of listing.” “I think the nature of our industry raised a few more questions, too.

MEDICAL FORUM

The ASX needed to think about the existing regulatory framework and whether we could legally proceed with our plans for the company.” “AUSCANN’s first crop was harvested in Chile in early May and extracts will be used in clinical trials prior to its release in Chile.” ED: Australian drug regulators recently gave AusCann the first licence to grow medical cannabis in WA. Just as we were going to press, Auscann Managing Director Elaine Darby announced to the ASX that AusCann had entered into a partnership with the world's biggest producer and exporter of thebaine, Tasmanian Alkaloids, to produce its medical cannabis stock. The firm produces 40% of the world's opiate crop and has extensive manufacturing facilities. This deal has accelerated AusCann's plans greatly.

JUNE 2017 | 21

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MEDICAL FORUM

Finance

Twiddling the Knobs With Government’s persistent tinkering with superannuation policy, it’s tricky finding a safe course to chart towards retirement. The ink on the 2017-18 Federal Budget is barely dry and, predictably, there are some surprises. You don’t have to read the financial pages too closely to realise that the pundits, and even the occasional academic, disagree on some of the fundamentals and that their predictions are often wildly askew.

A/Prof Helen Hodgson

A/Prof Helen Hodgson from the Curtin Business School crunches the numbers on economic policy and looks at what that might mean for the above average punter and some of it sounds a bit like Groundhog Day.

“It’s important to remember that the superannuation changes proposed in the last budget will come into effect on July 1, 2017. So before that happens it’s important that people make sure they’re fully compliant with changes to things such as concessional contributions. Beware 10% Rule “This is actually something that may assist doctors because under what’s known as the ‘10% Rule’ if more than 10% of your income has superannuation occupation guarantee support then you can’t claim a tax deduction. Many doctors have complained about this, particularly those who work in locum positions.” “Under the new rules people will be able to top up their super to an upper limit of $25,000 and claim a tax deduction. This will help people who aren’t able to salary sacrifice and/or earn a relatively small amount of income from a salaried position.” “The non-concessional cap environment is interesting at the moment, and there’s a definite move from investment to super. There’s a three-year transition period and a lot of advice out there is to push as much as you can into non-concessional contributions before June 30.” Helen provides her reading on just what the government is trying to achieve. “This is a policy that’s seeking to address a relatively small section of the community, those high income/high wealth individuals. If they transfer a lot of money into superannuation then that equates to diminished tax revenue. And we’re talking about a reduction in the order of 40% down to 15%.” “There’s also an estate-planning aspect to all this because those funds can be passed to beneficiaries tax-free when an individual dies.” “That’s a double-whammy for the government.

MEDICAL FORUM

They lose the initial tax revenue and, down the track, they can’t claw any of it back. And let’s not forget that, as far as the government is concerned, superannuation is intended to support people in their retirement not create yet another tax reduction opportunity.”

“Questions do need to be asked regarding the state of the housing market linked with negative gearing. There’s only so much that can be done on the housing supply side.”

By Peter McClelland

“At the moment there’s a $1.6m cap in a personal superannuation fund and once you retire you can start drawing it tax free. If too many people do just that and then draw a few hundred thousand dollars every year tax free, that’s a policy problem!” And Helen’s ‘take’ on twiddling the legislative knobs? “One of the awkward aspects of retirement savings is the fact that people plan their strategy using the rules that exist at the time. So policy changes at a government level can shift the goal-posts. In 1993 they said, ‘let’s change everything’! That’s not an easy thing to do, and it’s important to think about the consequences for those who may have made plans based on a different set of circumstances.”

2017 ANNUAL SCIENTIFIC MEETING

THE LAW AND ETHICS OF THERAPEUTICS

Changing scenarios “At the moment we’re tinkering at the edges. Nonetheless, there are a lot of different scenarios including the potential effects on financial markets.” In terms of investment strategies the elephant in the room is Negative Gearing, particularly in an overheated housing market. “This really does depend on individual circumstances. Setting up an arrangement where you’re declaring a financial loss each year resulting in a lower tax rate with the hope of accumulated capital growth is coming under increasing scrutiny. It’s becoming more difficult for young people to afford a home, particularly in Sydney and Melbourne.”

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JUNE 2017 | 23

Feature

BACK TO CONTENTS

CTEC Grows With the Times With more medical graduates comes pressure on training and CTEC is developing ways to ensure that doctors are not only competent but proficient as well.

The Clinical Training and Evaluation Centre, known simply as CTEC, was visionary when it was opened by the Queen 17 years ago on the UWA campus. There was rightly a lot of fanfare then – the facility was the first of its kind in Australia which is still pushing the boundaries of surgical and trauma training both nationally and internationally. Last year it held just over 260 educational workshops and events and trained 2639 health professionals – 76% of them from WA with the rest coming from various states and New Zealand. While simulation centres have sprung up in other places since, CTEC manages to stay ahead through smart innovation. Locally, it is playing an increasingly important role in the training of junior doctors in the state.

Dr Ruth Blackham

Its director Prof Jeff Hamdorf and senior lecturer Dr Ruth Blackham are set on giving that training real academic and professional clout. Jeff told Medical Forum that he and Ruth were the only funded clinicians at CTEC, while workshops were often run by clinicians on an honorary basis.

“We have been borrowing their expertise for the past 17 years. It’s a very Prof Jeff Hamdorf generous thing about our community of doctors. Since Ruth began working at CTEC we have benefited from her academic insight and we’re hoping to break new ground in the next couple of years,” he said.

24 | JUNE 2017

Training with rigour “Now, if you go on a course anywhere in the world, you will receive a certificate of participation but that is not a test of your competency or proficiency in any way. So we are developing a platform for academic proficiency in all of our courses. It’s an exciting and certainly challenging process. “It’s not a simple case of here’s a test – it has to be a validated test that holds meaning to the statutory bodies and others. It must have third party confirmation.” This certification process began at CTEC a couple of years ago for courses in which the junior doctors considering a surgical career would attend. “These courses help them apply for surgical training; help give them basic and intermediate skills and we have some validation metrics showing they are competent and proficient in various areas. My aim over the next four years is to promulgate that proficiency assessment through all of our core skills courses.” “We will be doing this in parallel – each time we review a course we will add that proficiency assessment. It’s a big job but it is good work.” Medical Forum has reported over the past months on the difficulties interns are experiencing in acquiring the necessary skills to launch them into the next phase of their careers. We have also heard from young doctors who feel vulnerable because they don’t feel they possess the right skills to do their job well. Support for juniors Jeff said one response to this was ‘boot camp’, a three-day intensive skills course to prepare brand new interns for life on the wards and CTEC is looking to host this for the first time this year involving academics from other universities.

The JDocs suite of courses is for those looking at a career in surgery. The Royal Australian College of Surgeons has a formidable pre-application checklist of skills and knowledge expected and JDocs works through those items preparing applicants for their best shot at entry. CTEC has designed a package to meet the need with four skills courses, a professional development day and an exam preparation course. Those courses are booked out in advance and are no walk in the park. The exam preparation alone involves two evening sessions a week over 22 weeks but, as Jeff says, “that’s what you have to do”. “It doesn’t matter how good our education system or how good the training, it doesn’t seem enough to satisfy the appetite,” Jeff said. CTEC runs as a not-for-profit with funding from the WA Department of Health, registration fees and donations from industry, usually in kind. Mutual benefits “We meet regularly with WA Health on training issues for junior hospital staff, who are predominately its employees. Almost every course we run is subsidised by WA Health, which is strongly supportive of our vision. We are now producing outcomes and some proficiency data, which is fantastic for us and for WA Health because we can go to them and say, ‘here’s proof’.” Jeff said while the data is useful locally, its effects can be felt more widely. Medicine is a mobile profession, particularly among its junior ranks, and CTEC is a useful recruitment strategy for the Department of Health. Looking to the future, CTEC is looking at developing a curriculum to help young doctors approach one of the fastest growing operations in the world – a sleeve gastrectomy.

MEDICAL FORUM

ORT HO C O M P WA

Orthopaedic Surgeons specialising in Workers Compensation & Motor Vehicle Accident injuries The Orthocomp WA Specialists are a dedicated team of highly experienced Surgeons trained in trauma and elective surgery. With Guardian Exercise Rehabilitation as our preferred provider, we cover ALL aspects required for the successful treatment of upper & lower limb injuries. OUR SPECIALISTS: Associate Professor Gareth Prosser - Hip, Knee, Trauma Professor Piers Yates - Hip, Knee, Trauma Mr Satyen Gohil - Shoulder, Knee, Trauma Mr Ben Witte - Knee, Hip, Trauma Mr Andrew Mattin - Shoulder, Knee, Hip, Trauma “In 2008 there were 18,000 sleeve gastrectomies performed worldwide, in 2013 there were 172,000 all without a training curriculum or a systematic way of looking at how it is taught. So we are developing our own model so we can teach it in the lab before people learn it on people,” Jeff said. “Ruth and I have engaged a number of key academics and clinicians around the world as thoughts leaders and we hope to develop a curriculum and promulgate that through CTEC as a training platform but I don’t want to get the cart too far in front of the horse. To be involved in something that leads to international change and safer practice is just fantastic.” In the meantime, the engine room of CTEC whirrs on and its labs and workshops remain filled with health professionals.

By Jan Hallam

MEDICAL FORUM

Mr Thomas Bucher - Hip, Knee, Trauma Mr Simon Wall - Hip, Knee, Trauma Mr Simon Zilko - Foot and Ankle Surgery

O RT H O C O M P

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JUNE 2017 | 25

Feature

Telehealth Spreads Its Wings Early suspicious of WA’s Emergency Telehealth Service has largely dissipated as it spreads it reach across the state. Now to get more specialists on board for telehealth! Last month the Medical Lead of the WA Country Health Service Emergency Telehealth Service, Dr Andrew Jamieson, took some of the learning points from WA’s ETS to a national telehealth conference and came away thinking that the service had come a long way in its four years and had broken new ground. “What differentiates ETS in WA from other emergency telehealth services around the country is that ours in the only one currently provisioned as a virtual emergency department. Our staff don’t have multiple roles, they don’t work in a coordination centre organising retrievals at the same time as taking calls, they’re not working in an Emergency Department taking telehealth calls in between seeing patients,” he said. “Clinical staff are available 100% of their time for telehealth consultations.” Over the next six months the ETS will move to a 24/7 service but now it is 24 hours on four days and 15 hours on the other three days. Keeping connected “ETS is available at 76 sites – wherever connectivity is possible really. We will be

establishing our 77th site shortly at a remote coastal site which is an interesting test case because it has been a challenge to connect. The town is well off the main road in terms of connectivity but we have come up with a funding solution to provide the connection.”

that we can help them manage their fatigue. If someone comes in at 2am they don’t necessarily have to be called because there is a safe alternative.” Demand for ETS grows Where the early days saw the ETS be driven by ‘push’ by head office, today there is a strong ‘pull’ factor.

In Canada, Andrew said, their extensive telehealth service is connected by satellite but the distance from the earth’s service can produce latency in pictures and sound.

“Once people hear the service is available they want it. We have had a lot of pressure among clients to get ETS into sites,” Andrew said.

“It does make it harder to consult but not impossible,” he said. “We have stayed away from satellite operations but it is certainly not off the table if we can work around its limitations.” The first years of ETS were challenging, he said, and as with the introduction of any new and technically advanced idea, there was some resistance.

New initiatives are extending the possibilities of the ETS. Also speaking at the Melbourne conference was Prof Chris Bladin, clinical lead of the Victorian Stroke Telemedicine. Andrew said Chris had been an occasional visitor to the West advising WA Health on its own telestroke program.

“There was initially concern in some quarters that we were going to tread on toes but we’ve managed to convince people that we are a supportive and patient-centric service and not a threat to GPs’ livelihoods. On the contrary, I think we have been able to show GPs, particularly in smaller towns,

“The telestroke program, which enables country people to be rapidly assessed by a stroke specialist using telehealth, has had some success stories already. The pilot, which is broadly modelled on the Victorian program, has been running in Bunbury for about six months.”

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26 | JUNE 2017

MEDICAL FORUM

FEATURE “We already know this works and we are looking at a phased introduction to other sites. We want to ensure that country patients have the opportunity of getting the best stroke care. It can be very difficult if the person is living remotely but we are working on coordinating with retrieval services so stroke patients can be rapidly transported to tertiary facilities.” “Dr Andrew Wesseldine, the WA Stroke lead, is steering the pilot along with the ED and a team of specialist physicians at Bunbury Hospital.” Convincing specialists In the letters pages this issue, an Esperance GP pleads with specialists to embrace telehealth. Andrew couldn’t agree more. “We’re always looking for opportunities to take specialist care to the country via telehealth. We have our specialist champions but there is a measure of scepticism and concern on the part of some specialists, not so much about telehealth’s clinical efficacy but how it will disrupt their work flow.” “Initially when telehealth was promulgated it was pretty clunky. Things didn’t always go right but that’s long in the past. The technology has improved and telehealth is available at all the major rural and regional hospitals and that’s helped enormously.” “The important thing is for people to try it. They think their specialty wouldn’t necessarily be suited to telehealth consultations until they do and then it opens up possibilities. What is really important is for people to give it a

proper go; be realistic and set the boundaries. Telehealth may not be suitable for every single case but it can be a game changer.” Andrew said that while telehealth was closing some of the gaps for rural and remote clinicians and patients, it was also playing an increasing role in the outer metropolitan area.

areas, people access the telehealth facilities at the local hospital or health centre. While not all cases will be suitable because some people may need support from a nurse or doctor through the consultation, there is certainly significant potential there.”

By Jan Hallam

“Another of our pilots is telehealth consultations in people’s homes. In rural

Recommend the free flu and whooping cough vaccines to your pregnant patients. health.wa.gov.au

MEDICAL FORUM

JUNE 2017 | 27

CLINICAL OPINION continued from Page 17

After-Hours: Urgent or Free-for-All? your regular GP and make an appointment’. We’re here for an unexpected illness, and not to replace your regular GP. WADMS role is to support GPs in practice, we are in essence doctors working for doctors.”

service operating in WA. The for-profits include National Home Doctor Service, which has been buying up smaller operations in other states, DoctorDoctor (ALMS), Perth After Hours Medical Services, Dial-A-Doctor; Doctor2U, Doctor on Wheels and a range of telephone and video services.

Wise heads lead change The new GP Deputising Association board certainly has serious experience in its ranks.

All operators have clinical oversight but the market is highly competitive and the concerns of some in the sector is that some operators are going outside of RACGP and AMA guidelines especially when it comes to marketing to consumers, focusing strongly on engaging patients directly to their services. Convenient emergency Then there is the question of consumer demand. Understandably, having a doctor come to you at any hour between 6pm and 8am and have that service bulk-billed is an attractive proposition and consumers have responded to advertising campaigns which have at various times been published on Social Media, TV, in cinemas, radio and newspapers. Tanya Steele told Medical Forum that even though the code of conduct for deputisers banned advertising of after-hours medical services for convenience purposes, many of the corporate equity backed companies disregarded this guideline. It would be easy for the Department of Health to change those

guidelines to align with the (RACGP) position paper which called for the prohibition of mass-media advertising. “What is clearly emerging in the afterhours space is on-demand healthcare for people who are reacting to the mass media advertising and not booking into GP Practice but want to utilise at home visit for routine care. You would be amazed at the number calls we get from people asking for an afterhours doctor to visit to write them a script or a referral.” “As all reputable deputising services should, our answer is, ‘sorry no, you need to ring

The make-up of GPDA is Chair, Melbourne GP Dr Nathan Pinskier (from Doctor Doctor), Nic Richardson (General Manager of Doctor Doctor, formerly ALMS, which has been established nearly 50 years), Ms Tanya Steele (WADMS, which is celebrating 40 years) Mr Adel Badawy (CEO of the oldest deputising service in Sydney since 1966), Dr Ian Brown and Mr Graeme Sellar (from CAHMS, nearly 40 years). Tanya said the GPDA was in active discussion with other entities regarding membership to the association. It had, she said been received positively by other healthcare stakeholders. (The GPDA will seek an inclusive membership base not only limited to six Medical Deputising Services to enhance the efficacy of the association. We will work together with other stakeholders like the RACGP, GPs and other primary health care providers to continued on Page 31

BreastScreen WA is paper-lite for GPs I’m excited that BreastScreen WA has changed the way they communicate with GPs. GPs will now receive the majority of correspondence by secure messaging.

May 2017

If you don’t wish to receive your patient’s screening mammogram results electronically or if you have any queries please email BreastScreen WA at breastscreenwa@health.wa.gov.au - Dr Jas Mudhar, Cannington GP -

Women may book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50

28 | JUNE 2017

MEDICAL FORUM

GUEST COLUMN

Rethinking the Training Model Dr Paul Myhill addresses the issue of GP supply and distribution and considers new options for training our junior doctors. BACK TO CONTENTS

GPs play an essential role in the provision of health care in WA, however, WA’s access to primary care is lower than the national average and it has one of the lowest rates of bulk-billing in Australia. Growth in WA’s general practice workforce is lower than that of nonprimary care specialities. Evidence suggests a number of factors are impacting on the availability of primary care and GP workforce supply in WA – a shortfall which is projected to increase to 2025: • The inequitable distribution of the GP workforce within and between metropolitan, outer metropolitan, rural and remote locations which manifests in supply deficits or super-saturation. • An ageing GP workforce with a significant volume approaching retirement. In 2015, 11% of primary care full-time equivalents (FTE) in WA were provided by GPs over the age of 65. • A significant disparity in the ratio between GP headcount and FTE/Full-time service equivalents (FSE), which is anticipated to increase as the older cohort retires and given younger GPs are more likely to work part-time. • A fall in average GP hours worked indicating a need to train a minimum of 2.1 GPs for 1 FSE in clinical practice. (see above) • Currently WA is graduating insufficient GP trainees to meet maintenance-model requirements. Training readiness prior to selection and attrition in training are priority areas that need to be addressed. • The level of retention of WA GP trainees in the WA workforce requires further investigation. Australia’s comprehensive provision of primary care may be at risk without workforce development strategies to ensure a sufficient supply of GPs with the appropriate scope of practice to meet future demand in all locations. GP workforce planning must ameliorate the impact of increasing part-time work and improve exposure to general practice in prevocational years. Changing population and medical demographics (e.g. gender balance), and the lifestyle choices of the emerging specialist population are other variables that must be considered, as significantly more GPs will be required to achieve the same level of FSE than in the past. Pressure on rural GPs Evidence suggests that rural and remote GPs work longer hours and provide more FSE than their metropolitan counterparts, and 59 towns in WA are solo GP towns. Given the dependence of these and other rural and

MEDICAL FORUM

remote locations on GP services, WA can ill afford a reduction in the scope of practice of its GPs. WA has relied on international recruitment to fill primary care supply gaps. As the number of Australian-trained junior doctors increases, there will need to be a transition to greater self-sufficiency. However, despite strategies to improve the number of WA vocational trainees achieving GP fellowship, including reform in prevocational training and increasing prevocational and vocational training capacity, interstate and/or overseas recruitment will need to continue in the short-to-medium term to meet shortfalls in some locations.

The modelling indicated that a ‘siloed’ approach, in which junior doctors complete all rotations… would not facilitate efficiency of training, nor provide the breadth and depth of training necessary for enough junior doctors to achieve readiness for GP training. GP training is the largest vocational training pathway and, in 2016, 49% of all training registrars in WA were undertaking Australian General Practice Training (AGPT) with WAGPET. GP trainees complete their prevocational training, hospital year and advanced skills training in WA hospitals. While further delineation of GP training readiness is required, the WA Department of Health has undertaken modelling to identify WA’s capacity to provide junior doctors with exposure to the prevocational specialty rotations (PGY2+), identified by WAGPET as optimal for vocational GP training.

The modelling identified that four of the key specialities – paediatrics, obstetrics and gynaecology, psychiatry and geriatrics – have limited prevocational training capacity, particularly given competing specialty demands. Where JMOs are missing out While these specialty rotations are pinch points in junior doctor training, by taking a system-wide strategic approach, those junior doctors with an interest in GP training can still be provided with the prevocational rotations, skills and experience necessary to achieve GP Recognition of Prior Learning (RPL). There were 12 generalist prevocational exposure programs (models) explored, which would equip between 100 and 160 junior doctors with the broad range of skills and experience required to achieve RPL for vocational GP training. The modelling indicated that a ‘siloed’ approach, in which junior doctors complete all rotations within their employing Health Service Provider (HSP) network, would not facilitate efficiency of training, nor provide the breadth and depth of training necessary for enough junior doctors to achieve readiness for GP training. This is an issue facing other specialties. The recommended achievable model, which will be explored further, including HSPs, is a networked matrix of rotations. This appears to be increasingly necessary to optimise WA’s training capacity to accommodate the increase in medical graduate numbers and progress junior doctors efficiently and costeffectively to vocational training. The modelling undertaken for general practice is the start of a system-wide mapping of speciality requirements to balance training and workforce needs in WA and align supply and demand for all 49 medical specialties. References on request ED: Dr Paul Myhill is Medical Adviser on Medical Workforce in the Office of the WA Chief Medical Officer.

JUNE 2017 | 29

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www.perthradclinic.com.au 30 | JUNE 2017

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Leaders in Medical Imaging MEDICAL FORUM

CLINICAL OPINION

Is bariatric surgery preferred for obese type 2 diabetes? BACK TO CONTENTS

Since 1996, 6 observational studies and 12 randomised control trials confirm that bariatric surgery achieves substantial improvement in glycaemic control and cardiovascular risk. The Australian study of 60 patients reported by Dixon et al showed that Lap-band surgery performed within two years of the diagnosis of type 2 diabetes achieved weight loss of 20%, and resulted in “remission” of diabetes in 73% of cases. In comparison 13% of control subjects achieved remission but lost only 5% of their initial weight. Remission implies good blood sugar control (HbA1c less than 6.2%) without medications. The latest report from the STAMPEDE study, funded by NIH, the Cleveland Clinic, and Ethicon, shows the benefits of surgery after five years – 150 patients were randomised into three groups: intensive medical therapy, sleeve gastrectomy, or gastric bypass surgery – mean age was 50, body mass index 37 (range 27–43), mean HbA1c 9.2%, and 44% were on insulin injections. In the surgical groups, mean HbA1c came down to 7.4%, weight loss was 20-26%, and insulin use fell from 44% to 11%. Remission of diabetes occurred in 25% of the sleeve gastrectomy group and 45% of the gastric bypass group. Those patients in the intensive medical therapy group reduced their HbA1c to 8.5% and weight loss was 5%. This adds to the evidence that type 2 diabetic patients with obesity should be offered surgery as an alternative to conventional

continued from Page 29

After-Hours: Urgent or Free-for-All? promote innovative and ethical models of afterhours healthcare delivery focused on safety, quality improvement and the appropriate use of healthcare resources,” she said. “We do see the need for the public to understand what deputising really is and how important it is to have a GP for continuity of care it is important for us to work with GPs in educating patients of when to utilise the after hours services.” The next few weeks will be crucial to the afterhours landscape. Government action to tighten up the guidelines which would see the use of Item 597 restricted may throw some business models a curved ball and irritate consumers, but it will benefit everyone in the long run, not least the taxpayers who have had to foot the bill of this after-hours free-for-all.

Vertical Sleeve Gastrectomy

By Prof Tim Welborn Endocrinologist

While some overseas clinics ED appear to be 'making hay while the sun shines', others are taking a more measured look at gastric sleeve removal.

$2000-$5000. There is limited access to bariatric surgery in the public sector, where there should be much more government support. The diagnosis of type 2 diabetes indicates a progressive disorder with escalation of therapy over the years, and often the need for insulin in addition to oral therapy to prevent the risk of vascular complications. Insulin therapy inevitably exacerbates weight gain and the attendant comorbidities of obesity including hypertension, sleep apnoea, and osteoarthritis. The evidence is now strong that some surgery can improve the course of the disease and the quality of life in these cases. medical treatment. At the time of diagnosis, the need for substantial weight loss should always be discussed in parallel with the goal of strict blood sugar control. Routine review should focus on weight as well as glycaemic measures. Most patients will reject the suggestion of surgical treatment. Some will be more motivated to comply with lifestyle measures including strict diet and spirited exercise. A few will opt for surgery. In Western Australia the out-of-pocket expense for insured patients having bariatric surgery is about

References: Dixon J B et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: Randomised controlled trial. JAMA 2008; 299: 316-323. Schauer P R et al. Bariatric surgery versus intensive medical therapy for diabetes–five year outcome from the STAMPEDE Study. NEJM 2017; 376; 641651. ED. We are told that over the last few years laparoscopic gastric banding has gone out of favour (reduced weight loss and more adverse events), and the current preferred surgery is gastric sleeve. Some surgeons promote on this basis.

WADMS 40th BIRTHDAY WADMS chair Dr Steve Jarvis has been associated with the organisation since in its early days. Steve arrived in Perth as a New Zealand graduate in 1977 and joined WADMS as a locum – a position he held for many years. “I certainly appreciated WADMS ethical management. It was extremely well run by a woman called Norma Pryor and when I started my own practice in 1983, I used WADMS for my own practice,” Steve said. While technology and communication has improved and the organisation always strives to make the services better, ethical deputising remains its core. “It is a badge of pride that we are a true deputising service,” he said. Steve has been a member of the WADMS board for a number of years and is currently chair. He said in that time he as seen changes wrought by the corporatisation of general practice. “Doctors don’t have the same connection with management issues as those who own their own practice. When you manage your own practice you see the whole picture and appreciate why a deputising service is so important.” “Drs Gordon Kendall, Jamie Prendiville and Peter Kiel are on the board and we strongly believe in the future of WADMS Doctor Home Visits but it would be great if we could attract some younger board members.” “We are financially stable and we're still going strong.” Just as Norma Pryor would expect.

By Jan Hallam

MEDICAL FORUM

JUNE 2017 | 31

GUEST COLUMN

HREC Governance, Transparency and Accountability

By Dr Peter O’Leary Chair Human Research Ethics Committee Curtin University

Modern human research ethics draws on Hippocratic literature that directs doctors to use their knowledge and power to benefit the sick, heal and not harm, preserve life and maintain the confidentiality of the physicianpatient relationship. After World War II it became clear that traditional medical ethics required revision to meet contemporary challenges. The primary focus was to protect human research subjects in the wake of the Nazi experiments conducted on prisoners (the Nuremberg Code [1] and the Declaration of Helsinki [2]). In the beginning, self-regulation was left to professional scientists’ discretion, but more recently, self-regulation has been replaced by external regulation through institutional governance protocols[3]. Australian Human Research Ethics Committees (HRECs) are guided by the principles of respect for autonomy, nonmaleficence, beneficence and justice[4] as well as the guidelines outlined in the National Statement on Ethical Conduct in Human Research guidelines[5], in combination

with legislative regulations and institutional protocols. HRECs members combine these responsibilities and contribute their time, knowledge and experience, largely on a voluntary basis. Overall, the HREC system seems to work quite effectively, according to feedback from researchers. Like other Universities, Curtin HREC reviews a diverse range of human research applications that involve a range of research fields such as anthropology, performing arts, marketing, ethnography, psychology, physical activity and epidemiology. University HRECs are usually constituted as advisory committees with primary responsibilities to review, approve (or not) research involving human participants and to determine whether they are ethically acceptable in accordance with relevant standards and guidelines. Governance Three different approaches have evolved for research governance: the technocratic style, which focusses primarily on risk and risk assessment; ethical and scientific review to

promote research integrity; and community participation in HREC deliberations to demonstrate public accountability[6,7]. These themes arose from community pressure for research, and science in general, to be more overtly regulated, to incorporate risk assessment for participants and researchers and to recognise the role of public opinion in framing the research agenda. Research governance involves multiple processes, including review of local, reciprocal and multi-institutional human research ethics applications (HREA); risk assessment; project monitoring; waiver of consent processes; material transfer agreements and budgetary review. Research projects conducted across institutions are best managed by reciprocal agreements between HRECs that minimise duplication of application and review activities. In our experience at Curtin University, the average processing time from submission to approval for Low Risk applications is 20 days and 50 days for NonLow Risk applications. In a recent study, the average total time that ethics applications

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BACK TO CONTENTS

Ethics

CLINICAL OPINION spent in review in New South Wales was 77 days[8].

References 1. Shuster, E., Fifty Years Later: The Significance of the Nuremberg Code. N Engl J Med, 1997. 337: p. 1436-40.

Further harmonisation of HREC processes occurs through meetings of University Ethics Officers and HREC Chairs to strengthen communications and provide training for HREC members. In addition, Curtin University hosts an annual public lecture to promote awareness of human research ethics.

2. World Medical Association Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. JAMA, 2013. 10(20): p. 2191-4. 3. OECD, Guidelines on the Protection of Privacy and Transborder Flows of Personal Data: Explanatory Memorandum, OECD, Paris http:// www.oecd.org/ document/18/0,3343, en_2649_34255_1815186_1_ 1_1_1,00.html.1980 (Accessed May 2017).

Accountability Almost all institutions require formal peer review by an external agency (e.g. NHMRC) or alternatively, by internal specialist advisory committees to complement ethics review. Many institutions have deployed online management systems to facilitate application processes and link to reporting and review of research progress. Annual and final reporting of research outcomes is mandatory and forms one of the requirements for institutional certification by NHMRC. During 2016-17, Curtin HREC approved approximately 7% of applications without amendment, 83% with minor amendments, 10% with major amendments and 2% submissions were not approved; no major problems have arisen from any of the research studies approved during this period. Ethical review and monitoring aims to promote good ethical practice and reduce adverse outcomes. Frequently, the HREC will require researchers to compile an adverse event protocol before approval is granted. All HRECs attempt to guide researchers in the protection of participants’ welfare and privacy, with particular attention given to vulnerable

4. Beauchamp, T.L., Childress JF, Principles of Biomedical Ethics 2013 (Seventh Edition): Oxford University Press. 5. NHMRC, National Statement on Ethical Conduct in Human Research (Updated May 2015). www. nhmrc.gov.au/guidelines/publications/e72 (accessed May 2017).

groups (minors, elderly and cognitively or physically impaired). However, despite all the governance protocols, reviews, monitoring and research integrity guidelines, human research approvals still rely on risk minimisation and therefore individual researchers are responsibile for a degree of self-regulation. If we all start from the point of view that “a good scientific question is based on sound ethics” then the potential risks will be reduced and transparency and accountability will be enhanced.

6. Landeweerd, L., Townend D, Mesman J, Van Hoyweghen I, Reflections on different governance styles in regulating science: a contribution to 'Responsible Research and Innovation'. Life Sci Soc Policy, 2015. 11(8). 7. NHMRC, Statement on Consumer and Community involvement in Health and Medical Research, National Health and Medical Research Council (2016), Consumers Health Forum of Australia. September 2016. . www.nhmrc.gov.au/ guidelines/publications/s01 (accessed June 2017). 8. Hunter, D., Is research ethics regulation really killing people? Med J Aust, 2015. 202(6): p. 338-9.

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Fertility, Gynaecology and Endometriosis Treatment Clinic 34 | JUNE 2017

MEDICAL FORUM

CLINICAL UPDATE

Update: lumbar diagnostic imaging BACK TO CONTENTS

When considering imaging of the lumbar spine, it is useful to consider groups that have distinctly different uses of diagnostic imaging.

The current recommendations are for trial conservative management including physical activity, physiotherapy and simple analgesia [2].

• Diagnostic imaging unhelpful

• Radiographs initially and CT/MRI on-hold

For uncomplicated low back pain with perhaps radiculopathy but no red flags and no previous surgery, there is no advantage in diagnostic imaging: imaging does not improve outcomes; there is a high prevalence of spinal abnormalities, including annular disc bulge and facet joint DJD, in asymptomatic patients [1]; and in most patients, no specific pathology for low back pain can be identified.

If there is low velocity trauma, osteoporosis, an elderly individual, or chronic steroid use all three imaging modalities may be appropriate. X-ray is particularly useful in the setting of osteoporosis or chronic steroid use. CT offers detailed osseous analysis, making it advantageous if there is a high risk of fracture

By Dr Mark Hamlin Radiologist Claremont/Morley

ED. This article presents one ED experienced Radiologist’s clinical system for imaging the back. Whatever your system, we agree that regular liaison with a radiologist you trust is helpful.

from trauma, or for advanced analysis of facet joints when intervention is being considered. MRI has the advantages of showing bone marrow oedema, the acuity of a fracture, and can differentiate malignant from benign compression fractures. • Suspicion of cancer, infection or immunosuppression

Summary of Recommendations • Uncomplicated acute LBP and/or radiculopathy are usually benign, self-limited conditions that do not warrant imaging. • MRI of the lumbar spine should be considered where there is suspicion of a serious underlying condition, such as cauda equina syndrome (CES), malignancy, or infection. • In patients with low-velocity trauma, osteoporosis, or chronic steroid use, initial evaluation with radiographs is recommended. (High velocity trauma – CT or MRI.) • If persistent or progressive symptoms and the patient is a surgical or CT-intervention candidate, MRI of the lumbar spine is more accurate than CT or radiography. (Medicare funding may preclude MRI and lead to CT in some situations.) • MRI where there is suspected cord compression or spinal cord injury.

In these specific cases MRI is highly recommended and CT could be considered second. MRI advantages: localises pathology as intramedullary, intradural (extramedullary), and extradural; offers a greater specificity than bone scan with similar sensitivity but improved anatomical detail; and detects an abscess before CT or radiography picks up extensive bone destruction. Technetium bone scan can be useful for problem-solving and in the setting of metastatic disease to assess the widespread tumour burden.

• If recurrent low back pain and prior surgery, evaluate with MRI, or if there is metal hardware request a CT. continued on Page 37

1. Fat saturated sagittal. L4-5 fusion. Hardware artefact "blooming" is severe, however severe central canal stenosis confirmed at the higher, L3-4. 2. MRI Lumbar spine - T2 transverse at L4-5 level. Red circle demonstrates left L5 nerve root impingement due to disc bulge and facet joint OA. Patient presented with chronic left leg radicular pain in the L5 dermatome. 3.T2 sagittal MRI. Aged 83 male presents with focal neurological deficit of the right lower limb. Past history includes advanced prostate carcinoma. Arrow indicates a drop metastasis resulting in the neurological abnormality.

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JUNE 2017 | 35

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CLINICAL UPDATE

continued from Page 35

Update: lumbar diagnostic imaging

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• Unimproved or progressive low back pain, or radiculopathy Where conservative management fails, consider: is the patient a candidate for surgery or CT-interventional procedures? If so, MRI is strongly recommended (or a CT if MRI unavailable or contra indicated). X-ray of the lumbar spine is not sufficiently detailed to provide information preoperatively or pre-CT intervention. MRI can accurately demonstrate disc abnormalities that may lead to spinal canal stenosis or nerve root compression. One study found a 57% prevalence of disc herniation in patients with low back pain and 65% prevalence in patients with radiculopathy and 28% prevalence in asymptomatic patients. [3] The results of an MRI spinal examination therefore need to be carefully interpreted in the clinical context, something the radiologist can assist with. • New or progressive symptoms after previous lumbar surgery The causes could include a free disc or bone fragment, post-operative fibrosis, failure of bone graft fusion, and recurrent disc protrusion. MRI is required to help differentiate the disc protrusion from surgical fibrosis. CT lumbar spine is recommended if metal hardware (e.g. fusion) is likely to create an imaging artefact on MRI.

Elonva; long acting rFSH … useful in the PIVET Algorithms within a restricted range PIVET has developed unique dosing algorithms for using preparations of recombinant follicle stimulating hormone (rFSH) in order to collect 10 ± 2 oocytes for women undergoing IVF treatment. This optimizes their chance of achieving a pregnancy from the treatment cycle as well as enabling 1 or 2 blastocysts to be cryopreserved for future use. It also minimizes the risk of the lifethreatening condition of ovarian hyperstimulation syndrome (OHSS). The algorithms were presented in the journal RBM Online in 2012, and validated in a large study published by Dovepress in 2016.

• Suspected cauda equina syndrome (CES) or rapidly progressive neurological deficit Urgent imaging and specialist referral are essential when suspected or evident CES – most commonly due to lumbar disc herniation at L4-5 and L5-S1 levels – or there is a rapidly progressive neurological deficit increasing the likelihood of surgical intervention. MRI has the ability to accurately depict soft tissue pathology, vertebral marrow oedema and central canal patency (whereas CT lumbar spine may not demonstrate the degree of spinal canal stenosis or nerve root impingement adequately). References [1] Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. [2] Last AR, Hulbert K. Chronic low back pain: evaluation and management. Am Fam Physician. 2009;79(12):1067-1074. [3] Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005;237(2):597-604.

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Number of eggs collected following stimulation with Elonva or rFSH (without Elonva). The results are comparable except for high (A) and low (E) AFC ratings.

In 2012 the long acting recombinant gonadotrophin corifollitropin (Elonva) was approved for use in Australia and Europe. It is a glycoprotein with the same 92-amino acid ß-subunit as human FSH but the ß-subunit has been extended from 110 amino acids to 138 with a 28-amino acid carboxy-terminal peptide identical to the ßhCG ß–subunit terminal sequence. This configuration extends the half-life from ~30 hours for rFSH to ~70 hours enabling a duration of FSH activity above the therapeutic threshold for ~7 days. This has been welcomed by women undertaking IVF because of the reduced number of injections. We have recently presented our further study to RBM Online showing that Elonva generates the same number of oocytes at transvaginal oocyte aspiration (TVOA) as rFSH across AFC ratings B, C & D (5-19 follicles; see Figure). However it generates higher egg numbers when the AFC rating is A (≥20 follicles) increasing the risk of OHSS. Furthermore it generates fewer oocytes for the low AFC rating E (<5 follicles). This means that Elonva can replace rFSH dosage ranging 200-400 IU but standard rFSH dosages should be applied outside this range.

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CLINICAL UPDATE

A rational approach to abnormal LFTs BACK TO CONTENTS

Referred patient with abnormal liver function tests (LFTs) are often asymptomatic and overweight (a little, at least). Assuming alcohol intake is not excessive, glucose intolerance/ diabetes and hypertriglyceridaemia need to be ruled out. Reactions to medications can raise suspicions but surprisingly, are unlikely as a major factor: statins are often blamed but are rarely responsible; more likely culprits are antiinflammatories, anticonvulsants, and antibiotics. In the Case Report (see inset) the most likely diagnosis is non-alcoholic fatty liver disease (NAFLD). Thinking of possibilities Iron studies are important, to not miss haemochromatosis. However, ferritin, an acute phase reactant, commonly goes up with liver inflammation, even to levels of 1000, without implying iron overload. Transferrin saturation is the best indicator of haemochromatosis and the normal result here excludes the diagnosis. Hep B surface antigen and Hep C antibodies should be checked, and an abdominal ultrasound to rule out overt pathology such as obstruction or secondaries. The presence or absence of fatty change on ultrasound is of little value in diagnosing NAFLD. Similarly, the ultrasound doesn’t confirm or refute cirrhosis. Wilson’s disease is rare, so do not routinely test copper levels in adults unless there is some suggestion of neurological disturbance (including psychiatric issues). Alpha-1-antitrypsin (AAT) deficiency can cause liver disease but patients are usually diagnosed because of pulmonary features. Measure AAT level in someone younger (< 25 years) or with more severe liver disease.

Anti-nuclear factor, anti-LKM and antimitochondrial ABs can suggest chronic active hepatitis or primary biliary sclerosis. I also check the INR. If prolonged, it points to a more serious derangement of liver function. NAFLD outcomes NAFLD runs a spectrum from non-alcoholic fatty liver (NAFL), which is relatively benign, to non-alcoholic steatohepatitis (NASH), which is associated with inflammation. Lifetime risk of NAFLD progressing to fibrosis is 36%, remaining stable 46%, and improving 21%; the risk is 2.5-fold higher with NASH compared to NAFL. In addition, hepatocellular carcinoma (at least in European populations) is now more common in cirrhotic NAFLD patients than from end stage hepatitis B or C. Risk factors for progression to fibrosis include older age, diabetes, hypertension, transaminase levels greater than twice normal (GGT doesn’t matter that much), and BMI greater than 28. Statins and coffee consumption seem to be protective. Metformin has not been shown to improve histological features of NASH; glitazones (e.g. pioglitazone) have, but the side effects (weight gain, fluid retention, bladder cancer) outweigh any potential benefit. Weight loss remains the only therapy, which is both safe and proven to be effective. Differentiating NAFL from NASH It is important to differentiate NAFL from NASH. Liver biopsy is the ‘gold standard’ but has a significant morbidity (and mortality), so the search is on for non-invasive ways of separating the two. The Hepascore is a locally validated calculation from a number of blood markers that predicts hepatic fibrosis and cirrhosis:

By Dr Andrew Klimaitis Physician Duncraig

Abnormal LFTs are extremely ED common. How do we approach this, perhaps when there is a “fatty liver” as well, without going overboard?

a result below 0.5 makes fibrosis unlikely whereas a result above 0.80 gives a risk of cirrhosis of over 85%; it applies to patients with chronic hepatitis B and C, alcoholic liver disease and NAFLD and is best requested in patients where there is clinical concern, not everybody with a raised GGT. Several imaging techniques have been studied. These include transient elastography, acoustic radiation force impulse imaging and magnetic resonance elastography (MRE), which seems the most promising, though costly. (Personally, I would happily pay for an MRI if it meant my liver didn’t need to have a needle stuck into it!) The largest study in USA adults found no increase in mortality with either NAFL or NASH, though a smaller Swedish study did, most from cardiovascular disease rather than liver failure. Control of lipids, blood pressure and diabetes thus remain cornerstones of therapy. What to tell someone with a fatty liver? Patients with a doubling of ALT, diabetes, or a raised ferritin should ideally abstain from alcohol and be aggressively encouraged to lose weight. But there is also a place for reassurance. Part of the liver’s job is to store fat. Ultrasound reports of fatty infiltration with minimal change in LFTs shouldn’t cause undue concern.

Author competing interests: no relevant disclosures. Questions? Contact the author on 9246 5072.

CASE REPORT Uncomplicated acute LBP and/or radiculopathy are usually benign, self-limited conditions A 58 yo man presents for a check up. He is asymptomatic and has a history of hypertension and hyperlipidaemia. He takes perindopril and rosuvastatin. His BMI is 31.0. Blood results are: Bilirubin 16 (< 16) Alk Phos 215 (30 – 110) GT 250 (< 36) ALT 100 (< 31) Albumin 40 (36 – 48) The most likely diagnosis is non-alcoholic fatty liver disease (NAFLD). Fe 26 (11 - 27) Transferrin 28 (20 - 45) % sat 25% (15 – 55) Ferritin 900 (30 – 300)

MEDICAL FORUM

JUNE 2017 | 39

Clinical Update

Bowel cancer: patients miss out on screening?

Since implementation, 7% of FOBTs have been positive. Contrary to popular belief, a positive FOBT has a low risk of cancer (~2%) – half have a normal colonoscopy and the rest are mainly simple polyps. Poor uptake disappointing The overwhelming disappointment from NBCS is the poor uptake rate (see Table 1) – just 36% (cf. similar English programme ~60%). This is thought to be due to: no direct promotion of the program; low community understanding of bowel cancer risk and the purpose of bowel cancer screening; and some low acceptance of FOBT testing as a screening method amongst primary health care practitioners. Participation rates increase amongst the older age cohorts most at risk of bowel cancer overall, but is lower in males from lower socioeconomic areas amongst whom there are higher rates of colorectal cancer (CRCa). There is already evidence NBCSP reduces CRCa mortality in Australia (by 15-33%). Bowel cancer is an ideal disease to screen for: a long premalignant phase (polyps take about 10 years to become cancerous); CRCa survival is strongly stage-dependent (early stage cancers have a high cure rate); Table 1: Results of NBCSP 2016 Invitations

1 400 000

FOBTs

504 000 36%

Positive FOBT

37 700

7.5%

Colonoscopies

25 636

68%

Advanced adenomas

1 691

Cancers (Suspected)

599

2.3%

Cancers (Confirmed)

149

0.6%

and unmeasurable general awareness encourages symptomatic patients to present early. The ideal screening method is highly debatable: international guidelines differ considerably; and the most recent US guidelines (2016 USPSTF) endorse seven different screening strategies. Methods of bowel cancer screening NBCSP uses a 4th generation immunochemical (iFOBT or FIT), which detects antibodies to human haemoglobin. It is more specific than the old guaiac based gFOBT. But both need two or three samples even though the current iFOBT avoids pretest dietary restriction. Other faecal and plasma based tests are available (e.g. CEA, circulating tumour DNA) but they are less useful for early stage disease. FIT-DNA may become the FOBT of choice but costs are currently almost as much as a colonoscopy. Current bowel screening recommendations Table 2 details current screening recommendations. Almost all patients are in Category 1 (average or slightly increased risk) and hence only need the NBCSP FOBT. A common clinical issue is screening first degree relatives of a patient with CRCa. This large group (~10% of the population) has a 1 in 7 lifelong risk but colonoscopy is only recommended if the cancer was diagnosed in a young (<55yo) relative; 10 yearly colonoscopy +/- FOBT in-between is a good solution from age 50 (although this is outside guidelines). The FOBT program selects a high-risk subgroup to undergo colonoscopy. Hence while excellent as a population screening test, it is inaccurate on an individual basis. High quality colonoscopy is essential for screening and requires good prep; the modern split prep administered four to five hours before colonoscopy is best. Completion rates, complication rates and withdrawal times are

Bowel cancer is highly prevalent – 17 000 new cases diagnosed in Australia this year, and a lifelong risk of 1 in 13. Because ‘no symptom’ is the most common symptom, bowel screening for cancer assumes high importance.

important. The most widely accepted quality measure is adenoma detection rate (ADR): US data shows significant variation in ADR amongst colonoscopists; and a correlation between ADR and lower risk of developing CRCa. Colonoscopy is the most commonly performed procedure in WA. However, cost effectiveness is a major issue. The government is formulating new evidencebased codes for colonoscopy e.g. if a patient undergoes a colonoscopy earlier than guidelines recommend for polyp surveillance, this won’t attract a Medicare rebate. While this is commendable from a public health perspective, and we should be scoping more first time patients and doing less follow-ups, patients often do not fit neatly into guideline categories.

Key Messages • Bowel cancer screening is beneficial and all patients 50-75 years should have it, starting earlier for high risk groups. • Low uptake of free screening (<36%) in Australia needs improving for which doctors have a large impact – GPs should focus on getting all their 50-75 year olds screened. • Scope more first time patients and less for follow-up (where colonoscopy is over used).

Author competing interests: no relevant disclosures. Questions? Contact the author on 0421 522 058

Table 2: Current Screening Recommendations Category (risk)

Screening recommended Australian Guidelines 2006

Australian Guidelines 2017 (Draft form)

0-1 first-degree relative ≥55 yo

gFOBT 2 yearly 50-75yo flex sigmoidoscopy >50yo

iFOBT 2 yearly 50-74 ?low-dose aspirin (100 mg) daily

3-6x

1 first degree rel <55yo 2x rel (same side of family)

Colonoscopy 5 years 50-75 ? gFOBT 2 yearly

iFOBT 2 yearly age > 40 colonoscopy 5 yearly 50 - 74 yo ?low-dose aspirin (100 mg) daily

>15x

more rels than in Cat 2 multiple CRCa's in <50yo Lynch/HNPCC related cancers FHx FAP, Lynch, MUTYH

usually annual colonoscopy referral to geneticist referral to gastro/surgeon

iFOBT 2 yearly from age 35 colonoscopy 5 yearly 45- 74yo low-dose aspirin (100 mg) daily

% of Popn

CRCa Risk ratio

Category 1 yearly 50-74 (average)

98%

1-2x

Category 2 (moderate)

1-2%

Category 3 (high)

<1%

40 | JUNE 2017

Family History

MEDICAL FORUM

BACK TO CONTENTS

The National Bowel Cancer Screening Program (NBCSP) commenced in 2006, with free faecal occult blood testing (FOBT) targeting the highest incidence ages (50-70) every 5 years, then testing every 2 years at 72 and 74 years (full implementation planned by 2020).

By Dr Nigel Barwood Colorectal Surgeon Murdoch

Guest Column

Making Life Better in 3D New technology is creating an array of opportunities for enhanced patient outcomes, according to RPH Bioengineer, Alex Hayes. BACK TO CONTENTS

There’s no doubt about it, the ability to capture objects in 3D has been a boon for ‘reverse engineering’. This is particularly so in personalised medicine, in which patient imaging is used to create customised devices. 3D Scanning, as its name suggests, uses optical techniques to reconstruct the surface of an object in three dimensions. In the past, scanners required trained operators and spatial tracking, and were highly sensitive to reflections and other interferences linked with ambient surroundings. Recent advances in computing power and electronics have made 3D scanning much more affordable and userfriendly. There are even hobbyists using it! New technology such as stereophotography and mobile-phone accessibility creates possibilities for practical applications in realworld situations. In medicine, the ability to replicate the ‘shape’ of a patient without the need for radiation or expensive medical imaging offers new and improved ways to streamline patient care. Its use is becoming the new standard of care at both RPH and FSH, particularly in orthotics

3D Scanning allows a hands-off approach to manufacturing allowing staff more time to see patients. and prosthetics clinics. And the advantages are significant. Patients can now be scanned in minutes and without the complications of traditional casting techniques. The ability to model a patient’s anatomy without direct contact mean less discomfort and a reduced risk of injury to fragile patients. In cases such as scoliosis the modifications can be optimised via computer simulation to improve results. This technology, used in conjunction with sophisticated manufacturing techniques such as 3D printing and robotic carving vastly improves patient outcomes. Digital storage means models can be reproduced on demand, replacing the need to store bulky, heavy plaster casts. And it’s also significantly easier to handle for imaging staff and clinicians.

More and more clinical services are using this technology. The Rehabilitation Technology Unit, which operates out of RPH, and the State Rehabilitation Service has successfully introduced 3D scanning into clinical practice. They produce custom spinal jackets, anklefoot orthoses and contoured cushions, which includes an entire prone-mattress with significantly improved turnaround times. Patients can be digitally ‘cast’ in the clinic, on the wards or in their own home. The scan is then modified virtually and the final product is then carved on a seven-axis robotic milling machine at RPH. At FSH, the Maxillofacial Prosthetics department has utilised 3D scanning to develop a variety of cosmetic prostheses for exenteration and otectomy patients. In the past, a cast of the contralateral side had to be painstakingly mirrored by eye using expert judgment. Now, scans of the contralateral side can be captured, mirrored and modelled within minutes and are ready for 3D printing. 3D Scanning allows a hands-off approach to manufacturing allowing staff more time to see patients. While it does have limitations – only external surface images can be captured – 3D scanning offers a wide range of possibilities in the digital age of medicine.

HeartsWest is pleased to announce some important new developments.

Dr Amit Shah MBChB, AMC, FRACP Consultant Cardiologist Sub-Specialty – Heart Failure

Special Interests: Heart failure, non-ischaemic cardiomyopathies, mechanical circulatory support and cardiac transplantation. Amit is a cardiologist providing expertise in the management of general cardiology conditions including, but not limited to, ischaemic heart disease, valvular disease and arrhythmias, with a particular subspecialty interest in heart failure, non-ischaemic cardiomyopathies, mechanical circulatory support and cardiac transplantation. In addition to consultation, he performs coronary angiography, right heart catheterisation and myocardial biopsies. He is part of a dedicated team of cardiologists at Hearts West in Armadale, Rockingham & Murdoch Hospitals. Amit is committed to his patients, closely overseeing all aspects of their management. He emphasises individually tailored care, with attention to ensure that patients understand the condition and can make informed decisions. After completing undergraduate training in the UK, Amit completed cardiology training in Australia, prior to a two-year fellowship in advanced heart failure, mechanical circulatory support and cardiac transplant. He holds an appointment as Cardiologist for the Advanced Heart Failure and Cardiac Transplant Service at Fiona Stanley Hospital and is actively involved in research in this field.

Armadale Health Service * Rockingham General Hospital * SJOG Murdoch * Fiona Stanley Hospital Telephone 9391 1234 Fax 9391 1179 Email reception@heartswest.com.au www.heartswest.com.au

MEDICAL FORUM

JUNE 2017 | 41

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MEDICAL FORUM

CLINICAL OPINION

Stress and the developing brain BACK TO CONTENTS

In his recent visit to Perth, eminent paediatrician Jack Shonkoff showcased the remarkable developments in our understanding of the impact of psychological stress on the developing brain of the young child. Modern techniques such as functional MRI (fMRI) and DNA microarray analysis of the hippocampus and the amygdala have shed new light on an age-old observation; ‘Why do children raised in stressful households often develop behavioural and developmental problems?’ The limbic system is a set of structures (including the hippocampus and amygdala) above the midbrain. Its functions relate to emotion, behaviour, motivation and memory. Seen in mammals, its function seems consistent right across the mammalian group. It has connections with other parts of the brain, especially the prefrontal cortex (PFC). The histologies of the hippocampus and the amygdala are highly structured, with sharply demarcated layers of cell bodies and axons. Their neural architecture can be demonstrated clearly using fMRI. Brains rewired to cope with stress Neurobiologists have made surprising discoveries about the brain’s response to psychological stress in both humans and animals (rodents, lesser primates). Neural architecture is remodelled in parts of the limbic system and the PFC following stress, representing allostasis (successful adaptation to stress). Neural connections are modified to accommodate different pathways and networks, correlating with different behaviours and emotional states. At a physiological level, this response to stress occurs through a bewildering complex of interactions between the hypothalamicpituitary-adrenal axis (HPA), the autonomic nervous system, and pro- and antiinflammatory components of the immune defence system. Several cellular mechanisms effect neural remodelling, including repression and activation of genes for such functions as dendritic growth and pruning, synapse

By Dr David Roberts Paediatrician Joondalup

We now have a more detailed ED understanding of why children from troubled backgrounds so often do poorly despite intervention. Unfortunately we don’t yet have a solution to the problem.

density and axonal myelination. Cortisol and the amino acid transmitter glutamate are central in these processes. The foetal/infant brain undergoes a similar process during the critical early phase of growth. Babies are born with many neurons but few neural connections; which are then established in a rapid phase of growth. From here, connections that form part of frequently used pathways become reinforced (e.g. myelinated). Underused connections are pruned and their associated neural networks are discarded. Remodelling of the neural architecture goes on throughout life, but is exceptionally active in the early years. Whilst neural remodelling is an ongoing process, some of its mechanisms in individual cells are established early and become permanent (e.g. gene expression/repression). The psychological environment in which the young child spends his earliest years leaves an indelible imprint upon his emotional regulation and mental wellbeing. This affects memory, cognition, and learning. The child’s developmental trajectory is not wholly genetically determined, nor wholly amenable to modification through environmental influences later in life. Good and bad stress Chronic or severe psychological stress in early childhood disrupts the physiological adaption to stress, called allostatic overload.

Excessive stress then becomes toxic to the young brain, producing effects at both the cellular level and in neural architecture – effects that last a lifetime. When expressed, the emotional and behavioural dysregulation associated with allostatic overload may be seen as hypervigilance, aggression, mood lability, inattention and overactivity, and predisposition to anxiety. Neglect appears to be just as harmful to children as abuse. Stress is more likely to become toxic when it is severe or prolonged, and this is more likely when stress derives from several sources (e.g. antenatal drug exposure, violence, parental separation or mental illness, drug and financial problems in the household). This is not to say all psychological stress is harmful. Indeed, stress is a part of the normal life experience, and a functional response to it is adaptive. The boundary between good or tolerable stress and toxic stress is defined by its consequences and only revealed in retrospect. Neurobiologists are at pains to point out that the relationship between the severity of stress and the dysregulation of allostasis is both ‘nonlinear’ and affected by the timing of stress and the physiological response to it. It appears many other factors are at play in explaining the wide individual variability seen in cohorts exposed to the same stressful conditions. The single greatest protective factor against psychological stress in the young child is the presence of a strong attachment to a parent/care-giver, or more precisely, the child’s confidence in the security of that attachment. Unexplained variability is attributed to temperament or resilience.

Author competing interests, no relevant disclosures. Questions? Contact the author 9300 3002.

Study Looks to New Ways to Lower BP Curtin University has just launched a clinical trial to investigate a new strategy for treating hypertension as part of a collaboration with The George Institute. The nationwide study will involve 650 adults and local researchers will be looking to recruit 100 adults (older than 18 years) to volunteer to take part through The Healthy Living Clinic (HLC) at Curtin University. MEDICAL FORUM

The QUARTET clinical trial, which is funded by a grant from the NHMRC, will assess whether ultra-low-dose quadruple therapy (LDQT) will lower blood pressure more effectively than standard dose monotherapy, which is currently offered to patients with hypertension. A recent pilot study at the George showed encouraging results with all participants’ blood pressure lowered within one month.

Medical Forum spoke to researcher Dr Jacquita Affandi who said the research was not just focused on the effect on blood pressure of a quarter-dose of four drugs (Irbersartan, Amlodipine, Indapamide, Bisoprolol), it would also take a close look at safety and compliance.

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The Vein Clinic is proud to be celebrating its Third Anniversary We deliver the latest innovations in the diagnosis & treatment of Venous Reflux and Varicose Veins direct from Europe, the UK and USA. Our advanced techniques allow > 95% of patients to be treated as an outpatient with outstanding results, avoiding the need for hospital admissions, private health cover and time off work. We specialise in highly effective “walk in, walk out” non-surgical treatments for varicose veins and venous reflux. • EVLA (Endovenous laser) – cutting edge techniques including perforator ablation • Fast recovery and near painless procedure o Clarivein™ o Cyanoacrylate closure – Medical “Super Glue” for closing veins • “Improved” Foam Sclerotherapy • Ultrasound Guided Ambulatory Phlebectomy • Streamlined assessments and timely cost effective treatment

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Technology

Smart Headphones Hearables and wearables are revolutionising the way we intereact. Technically advanced in-ear devices are used for everything from music to fitness tracking and medical monitoring. They’re known in the trade as Hearables and they’re coming to an electronic device near you! Augmented hearing is the new buzz word in personal audio and the tech companies are jumping for joy. Apple recently reported a 62% surge in sales due, in part, to the release of virtual reality ear-pieces for its smartphones. “It began with the Sony Walkman in the late 1970s and morphed into the wireless technology of Bluetooth,” according to Prof Sven Nordholm from Curtin University’s School of Electrical Engineering and Computing. “New devices such as Hearables show just how far we’ve come from personal audio players with a cable connection. The untethered headset now dominates the market. In fact, midway through last year Bluetooth sales revenue overtook their competitors for the first time. They now have 54% of headphone revenue and 17% of unit sales in the US.” “There’s been a lot of research recently into ‘natural’ hearing technology with spinoff applications for a number of different electronic communication devices from hearing aids to audio conferencing, gaming and virtual reality.” “It’s been made possible by the development of high-complexity electronics and the use of algorithms to provide a more natural listening environment that ‘augments’ the audio signal.” “The number of different hearing profiles is interesting, too. There’s everything from noise equalisation to audio mixing and the former is particularly applicable to noisy social settings.” “That’s something that may prove useful for our increasingly ageing population.” This technology is being researched and developed with practical applications in mind.

Prof Sven Nordholm from Curtin University

Sven said he found it difficult to pick up conversation is a noisy restaurant. Hearables with multiple microphones utilising directional techniques enhances speech from the direction in which the wearer is looking, minimising extraneous noise while, at the same time, maintaining speech cues. “When I use this new technology my conversations are much more relaxed, the accompanying ‘babble’ is minimised and actual speech more prominent.” The use of digital signal processing (DSP) is particularly applicable in the noise-cancelling applications and the very best ones are priced accordingly, says Richard Pawel from Sound Town Audio.

“The technology underpinning these devices is advancing rapidly and some of it is using highly advanced DSP. You can pay anything up to $5000 for devices that are individually moulded with multiple audio-drivers inside each ear-piece.” “An in-built microphone picks up extraneous noises and runs them through an equalisation filter. The end result is much improved communication.” Richard warns that wireless technology compresses the audio signal and some sound quality can be lost because of that.

By Peter McClelland

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MEDICAL FORUM

JUNE 2017 | 45

Travel

Salty Heart of Inside Australia It’s a long trip from Perth to Kalgoorlie on dead-straight bitumen with not much else for company than an equally arrowlike water pipeline. And if your eventual destination is the Lake Ballard statues don’t be tempted to tarry long at the Super Pit because you’ve got another two hours driving in front of you.

Antony Gormley's Inside Australia installation at Lake Ballard north-west of Menzies. Pictures courtesy of Dr Rob Davies

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If you tell people that you intend to spend at least a couple of days on the Great Eastern Highway to walk on a muddy salt lake they’ll probably look at you twice. But there’s a lot more to it than that! And it all began with the 2003 Perth International Arts Festival – its 50th anniversary, no less – when world renowned artist Antony Gormley was commissioned to install his Inside Australia exhibit on what must surely be the world’s most remote art gallery. The London-trained sculptor has degrees in archaeology, anthropology and art history and an obvious fascination with the the human image, most of which are distinctly unusual in both form and setting. Gormley’s famous Angel of the North sits atop a hill

MEDICAL FORUM

Travel

But there’s plenty of interest along the way before your wheels hit the dirt, despite the fact that after you leave Perth on the Goldfields Highway you’ll be behind the wheel for nearly eight hours without passing through a town with a population of more than a few thousand. You’ll see plenty of trucks and road-trains, some with a DANGEROUS EXPLOSIVES label emblazoned down both sides. There are also plenty of kangaroo carcasses, both fresh and not-so-fresh, along the side of the road and each one of them should have a label on their swollen stomach saying, DON’T DRIVE AT NIGHT! The Ettamogah Pub in Cunderdin, derived from a Ken Maynard comic strip, is a uniquely unmissable piece of architecture and the town of Northam is well worth a pause for coffee and cake. In winter the Avon River is spectacular. near Gateshead in England, its steel structure standing 20m and its wide horizontal wings spanning 54m. An installation on an English beach entitled Another Place has 100 cast-iron sculptures of the artist’s own body facing towards the ocean, many of which are completely submerged at high tide. So, anything attached to the Gormley brand is bound to be quirky. By the time you get to the statues you’ll have around 700km of bitumen in your rear-view mirror plus a short 50km blip of unsealed road from Menzies to Lake Ballard. If there’s rain around it’s worth listening to ABC Local Radio or checking with the friendly Menzies Visitor Centre on the state of the red-gravel road.

MEDICAL FORUM

Towns such as Merredin, Southern Cross, Coolgardie and Kalgoorlie all have easily accessible and well-appointed caravan parks but be warned – some are situated uncomfortably close to the railway line. Train drivers are legally obliged to blow their horn approaching every single town and that’s not great in the early hours of a cold morning!

The salt lake covers approximately 10sq km with an occasional domed hill rising above its surface that shifts from soft and muddy to firm and crystalline. Wear old shoes, wetsuit boots or even go barefoot because the red mud sticks like glue and there is no tap of any kind at the camping ground. An overnight stay would be basic at best, with a few BBQ fire-pits and a drop toilet the only ‘luxuries’. Nonetheless, you’re almost guaranteed to witness a stunning sunrise with Gormley’s sculptures spread in stark relief across the lake. The sculptor laser-scanned tourists and Menzies residents and mapped half-amillion digital coordinates to create bodily cross-sections before drastically reducing them in size to form Insiders – a total of 51 ‘taught abstract shapes’ to quote the artist. They were then cast in an alloy containing molybdenum, vanadium and titanium. It’s a typically thought-provoking work-of-art from Gormley and the entire trip is well worth taking. Go there, it’s wonderful!

By Peter McClelland

Many of the hotels in Coolgardie and Kalgoorlie have bars with names such as The Golden Dawn and The Shiny Nugget. The food and service can be variable and we’ll never forget a stop for coffee and cheese toasties in one particular Coolgardie pub. Suffice to say it’s not a pleasant memory. But the first sight of Lake Ballard and Gormley’s statues is stunningly unforgettable!

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Will the eRecord be as much fun? They may be a dying breed but the medical typist’s typos will live on. Here’s a few to treasure:

One of the disadvantages of wine is that it makes a man mistake words for thoughts. - Samuel Johnson

• Patient has left her white blood cells at another hospital. • Patient's medical history has been remarkably insignificant with only a 20kg weight gain in the past three days. • She has no rigors or shaking chills, but her husband states she was very hot in bed last night. • Patient has chest pain if she lies on her left side for over a year. • On the second day the knee was better and on the third day it disappeared. • The patient has been depressed since she began seeing me in 1993. • Discharge status: Alive, but without my permission. • Healthy appearing decrepit 69-year old male, mentally alert, but forgetful.

• Both breasts are equal and reactive to light and accommodation.

• Between you and me, we ought to be able to get this lady pregnant.

• Examination of genitalia reveals that he is circus sized.

• She slipped on the ice and apparently her legs went in separate directions in early December.

• The lab test indicated abnormal lover function.

• She is numb from her toes down.

• The pelvic exam will be done later on the floor.

• While in ER, she was examined, x-rated and sent home.

• Large brown stool ambulating in the hall.

• Rectal examination revealed a normal size thyroid. • She stated that she had been constipated for most of her life until she got a divorce. • I saw your patient today, who is still under our care for physical therapy.

• Patient has two teenage children, but no other abnormalities • When she fainted, her eyes rolled around the room. • The patient was in his usual state of good health until his airplane ran out of fuel and crashed.

• Patient was seen in consultation by Dr Smith, who felt we should sit on the abdomen and I agree. • The patient was to have a bowel resection. However, he took a job as a stock broker instead. • By the time he was admitted, his rapid heart had stopped, and he was feeling better.

Millennials Show Their Foodie Side When they do go out (which seems to be a lot) the most popular cuisine is Asian (40%) followed by Modern Australian (18%), which topped the preferences of Perth Millennials.

Trend surveys should always be treated with a healthy dose of cautious scepticism and The Urban List’s recent food and drink survey is no different. While not a basis for complete lifestyle overhaul, it does give some insight into the food and lifestyle priorities of the youngest generation in the economy.

There were 6% who sought out good vegan/ vegetarian options. The survey seems not to have asked if Millennials were keen cooks. That might not happen until if and when they can afford a mortgage.

Perth was among the four cities surveyed and there were 6189 respondents. Millennials, formerly known as Gen Ys – the ones surveyed at least – claim to be a healthy lot with 63% saying they exercised three times a week. And 93% said they strived for clean living (which we think meant they liked to eat healthy food, but the love of vodka may make some of them slightly less cleaning living). The most popular shopping-cart item was a2 Milk followed by milk alternatives such as rice, oat, almond and soy milk.

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When it comes to entertainment, 86% said they ate out at least once a week and for 60% the main reason to eat out was to try new places; 5% said they ate out because they couldn’t cook. The average spend for a typical night out was $109 and men spent 12% more than women. Nearly three quarters of the surveyed group spent between $50 and $150.

When it comes to Friday nights, 37% stayed at home for the couch, wine and a takeaway while 30% headed to pubs, bars and clubs. It wouldn’t be a survey of note unless attention was paid to alcohol. While the survey did not ask about beer or wine, the hard liquor of choice was vodka by a country mile with 37% and gin second with 25% preference.

MEDICAL FORUM

doctors in the arts

Rusty To Beautiful Music WASO is giving amateur musicians, doctors included, some one-on-one tutoring. A good many doctors will have memories, fond or otherwise, of playing a musical instrument during their school days. For a number of them still, the joy of playing either solo or in a group is intrinsic to their mental wellbeing after the rigours clinical practice. However, there are a number of other outlets in WA for amateur musicians to keep their musical ear tuned in. The WA Symphony Orchestra next month will mentor musicians including some doctors in its Rusty Orchestra program. Once participants have been through a selection process, repertoire selected and disseminated, players buddy up with a member of WASO in preparation for an hourlong performance on June 24 at the Perth Concert Hall. Perth psychiatrist Dr Lynne Cunningham will be playing on violin at her second Rusty Orchestra concert this year. Her debut at last year’s concert was a game-changer for Lynne where she met violinist Jane Serrangeli. “At last year’s Rusty Orchestra I sat next to Jane, who plays second violin in WASO. I had just lost my violin teacher because his MEDICAL FORUM

wife was very ill, so I asked Jane if she could give me lessons. It’s been excellent. She’s changed my technique and made a huge difference to my sound. She has been very positive,” she said. “Playing with WASO is another experience altogether it’s fantastic. The standard of professional playing is way above anything I’ve ever done, it’s a great privilege to play with the professionals. But they are so helpful and nice. Last year Jane gave me tips as we went along.” Lynne, like many doctors, learnt an instrument at school. In her case, it was the flute but once she left school, music making dropped away. When she turned 40 the then radiologist decided to take up the violin because, she said, the repertoire for the flute was limited. She’s made up for lost time in the past 20 years, now playing at any opportunity she can get. “I play with the Fremantle and Metropolitan (MetSo) symphony orchestras and I’ve been in the Doctors Orchestra since 2013.” The Rusty Orchestra has people from all walks of life and seems like a lot of fun, but

WASO's Jane Serrangeli, left and Dr Lynne Cunningham

that’s not to say there isn’t a little pressure. Players work on the scores in the lead-up to the first rehearsal a couple of weeks before the concert, then a rehearsal on the day of the concert and in the evening the performance, when everyone will have their game-face on. As Lynne says, “you have to do your homework,” but that’s not to say it’s ever a chore. “I have always had music in my life. It’s been a real life saver for me in lots of ways and something I really enjoy doing and I have met so many fantastic people through music.” About 15 years ago, Lynne retrained as a psychiatrist and works two days a week at a private clinic. “I still don’t have enough time to do the music I want to do but I love my work too. I don’t want to retire. I love the contact and talking to people.”

By Jan Hallam ED: The Rusty Orchestra performs at the Perth Concert Hall, on June 24.

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FOOD & WINE

Shou Japanese

MY LOCAL

24/18 Calectasia St. Greenwood Ph 9448 9964 Nestled in a nondescript, suburban shopping-centre north of the river would have to be one of Perth’s best-kept secrets when it comes to casual Japanese dining. Sho Japanese is superb and serves up fresh, authentic fare such as gyoza, fried squid, sashimi and the most wonderful beef tataki. Don’t expect to be wowed by fancy décor and expensive tableware. This isn’t, and doesn’t pretend to be, fine dining! But they’re obviously doing something right because there are always far more people queuing up than can possibly be seated at the raised bar or the three tables in the seated area. If you have to cool your heels for a while you can watch Japanese baseball on a wall-mounted TV. You must try the katsu chicken bento box – it’s one of the best value under-$20 dishes in Perth. Shou Japanese is BYO so a bottle of pinot gris with friends all adds up to a great night out!

Oxtail Carbonnade Ingredients 2 oxtail 3 large brown onions, sliced 4 cloves garlic, chopped finely 1 cup plain flour for dusting 100ml olive oil 2 tblspn fresh thyme, chopped 6 bay leaves 500ml stout Salt & pepper

DIRECTIONS 1. Preheat oven to 150C 2. Put oil into a heavy based pan and heat. Meanwhile put flour to a medium freezer bag and add a several rounds of oxtail into the bag and dust. Shake off excess flour and brown in pan. After 3-4 minutes each side, add to a large ovenproof dish with a wellfitting lid. Repeat process until all the oxtail has been browned. 3. Wipe out pan, but don’t wash. Add more olive oil. Gently sweat onions and garlic and scape any beef scraps off the bottom and sides of pan. When onions have become soft but not brown add thyme and bay leaves then salt and pepper. Add the bottle of stout to the pan and bring to the boil. Remove from the stove and add to the oxtail. 4. Place in the oven and forget about it for 1½ hours. Give the oxtail a stir and return to oven for a further 1½ hours. 5. Serve with mashed root vegetable of your choice and steamed broccolini. Make sure crusty bread is on hand for the gravy.

Wine

Winner

The winner of the St Aidans Doctor’s Dozen, Dr Bo Arys is a real wine aficionado. She’s visited the Bordeaux region in France and made plenty of trips to Margaret River, the Barossa, the Yarra Valley and the Mornington Peninsula. Bo’s favourite tipple is a Chateau Lascombes Margaux and she freely admits that she’s quite partial to a nice, long bath because it’s so difficult to drink wine in the shower.

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MEDICAL FORUM

FOOD & WINE

Schild Estate – a Barossa Icon A journalist interviewing Madame Rothschild, a famous Bordeaux producer, asked, "Madame, does your family find the wine industry a difficult business with so many competitors?" Madame paused for a moment and then answered, "No ... not really. It was only the first 100 years that the family found difficult."

By Dr Craig Drummond Master of Wine

The Schild family has not reached the 100-year mark yet but with three generations producing Barossa Valley wines since 1952, they are well on the way. In 1952, Ben Schild bought land at Rowland Flat and established a mixed farm with a focus on sustainable viticulture. Ben died just four years later and his son Ed took over the property at age just 16. Since then Ed's hard work and keen business sense has resulted in the family becoming one of the largest independent premium grape growers in the Barossa with more than 182ha under vine. Their vineyards are in the cooler southern end of the Barossa, predominantly around Lyndock. They include some of Australia's oldest vineyards, including the famous Moorooroo vineyard near Jacob's Creek, planted in 1847. These dry-grown, deep-rooted, old-bush pruned vines give very low yields of inky dark purple essence resulting in the most wonderful wines. The wines tasted here, all red, are definitely recommended.

REVIEWER'S

PICK

WOW! This wine is sublime and the best of the tasting. It’s seen 21 months in French, American and Hungarian oak followed by 19 months silently maturing in bottle before release and the result repays the detailed care it has received. Sweet, spicy fruit, vanilla bean aromas. Blackberry and chocolate. It combines refinement, yet power. Smooth ripe tannins. Supple, flavoursome and long on the palate. You can still taste this wine an hour after drinking. Drink now but I hope I'm still here in 20 years’ time to enjoy this wine again.

1. Schild Estate Sparkling Shiraz 2015 It's not often I drink this uniquely Australian-style of wine, usually only at Christmas, but when I do I wonder why I don't pop the cork more often. This wine shows a dark cherry colour, wonderfully lively and effervescent in the glass. Aromas are rich – spicy plum and licorice and deep flavours – black cherry and mulberry. The tannins are skilfully softened by maturation in seasoned oak and a touch of residual sugar, which is important for the style. A great accompaniment to game meats. 2. Schild Estate Barossa Valley Grenache Mourvedre Shiraz 2014 With 52% Grenache, 24% Mourvedre and 24% Shiraz, this is an enjoyable early drinking wine, reliant on fruit character as it has no oak influence. Shows exotic spices, briary, bucolic, a nice oxidative edge typical of the Grenache. The flavours are warm, juicy and mouthfilling. Redcurrant, earth and spice. Shiraz adds acidity and holds the wine nicely together.

WIN a Doctor’s Dozen! Name Phone

Enter here!

Schild Estate Barossa Valley `Ben Schild Reserve ' Single Vineyard Shiraz 2013

3. Schild Estate Barossa Valley Cabernet Sauvignon 2014 Here’s a cabernet in the real Barossa style. Nose is ripe, warm, and complex. There’s blackcurrant with fresh oak showing through. The palate is generous, round, supple, nicely balanced. Blackcurrant and succulent black plum. Twelve months in French oak has added great dimension and good length. 4. Schild Estate Barossa Valley Shiraz 2014 True-Blue Barossa. Vibrant deep-red brick colour. Powerful fruit on the nose – it’s very savoury with exotic spice, cloves and camphor. Flavours burst in the mouth – warm, welcoming, mellow and rounded. Dark fruits and chocolate. This wine has another 8-10 years to go.

.. or online at

www.medicalhub.com.au

Email P lease send more information on Schild Wine offers for Medical Forum readers.

Wine Question: How long has the Schild family been making wines in the Barossa Valley? Answer: ....................................................

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, June 30, 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.

MEDICAL FORUM

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Entertainment & Leisure

New Era For Black Swan Theatre lovers in WA have seen a lot of theatre companies come … and a lot of theatre companies go, so when one hits the milestone of a quarter of a century, that’s something to shout about. Black Swan State Theatre Company is entering a new era in 2017. At a time when it can be excused for a spot of nostalgic reminiscing, it also has a new artistic director in Clare Watson, who brings some new, challenging ideas to Perth from her background as teacher and youth theatre artistic director in Victoria. One of her greatest fans is the company’s first director, Andrew Ross, who has returned to Perth to live and to get treatment for an ongoing illness. He’s also here to work and next month Perth audiences will be able to see what he does best in directing the company’s production of Samuel Beckett’s Endgame. It was 1982 when a debut production of Aboriginal playwright Jack Davis’s The Dreamers was premiered at the Festival of Perth stirred up ideas for a new Western Australian theatre company. In 1985, Davis’s No Sugar was mounted, as Andrew recounts under the auspices of the interim state theatre company. “At the time, it looked as if WA theatre was drifting in two separate directions: one mainstream, the other a theatre that rooted itself in WA, which sought to emphasise new work and specifically work of Aboriginal writers and directors. I didn’t think those interests should be split,” he said. “It really was Janet Holmes à Court’s idea for a dedicated company. I didn’t think it

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was possible but at the closing night of Bran Nue Dae, Janet, who had had been several times bringing friends, put it to a group of people including Duncan Ord (now Culture and the Arts DG) and Will Quekett (formerly of Perth Theatre Trust) and me.” “If that impetus came from anyone else I don’t think it would have got off the ground but it was her optimism and determination that enabled it to happen. Black Swan has ended up becoming the state theatre company.” In 1991 the first production under the Black Swan Theatre Company banner was Shakespeare’s Twelfth Night that prompted theatre critic Alison Farmer to declare “at last West Australian theatre can be said to have found its own unique way of dealing with the Bard”. It’s been interpreting the new world and the old in the same innovative way for 25 years. While every good company needs strong leaders and strong backers, it also needs creative drive and Andrew Ross brought some wonderful WA theatre to the stages in his tenure as Black Swan’s artistic director – a position he held until 2003. Alongside excellent indigenous work (Bran Nue Dae, Sistergirl, Corrugation Road), there were adaptations of works of WA authors – Randolph Stowe’s Tourmaline and The Merry-Go-Round in the Sea and Winton’s Cloudstreet. He introduced live music as an integral part of dramatic theatre – composer Iain Grandage had his early outings in David Britton’s Plainsong, The Merry-Go-Round

Andrew Ross

and Cloudstreet all under Andrew’s direction. It was, when added to the broader theatre tapestry of the city, an exciting, enticing time for the dramatic arts. Andrew returning to direct Beckett’s Endgame (named for the final stages of a chess game) is a homecoming not only for the director but for his handpicked WA cast – all friends and collaborators over the decades – Geoff Kelso, Kelton Pel, Caroline McKenzie and George Shevtsov. The publicity blurb quotes Andrew as describing the play as more a piece of minimalist chamber music than a play with all the players so attuned to each other's rhythms they are like a fine string quartet. The work itself was written in 1957 and is one of Beckett’s great absurdist conundrums. Andrew suggests audiences should just come and listen and not search for meaning. “It’s a play where everything on stage is studied and deliberate to achieve the effect that nothing is going on – yet everything is going on at the same time. The great productions of Beckett are absolutely compelling because they have been so economical and spare.” “The director is there to give the actors a framework and confidence in what they are doing.” In Beckett and Andrew Ross they trust. ED: Endgame opens at the Heath Ledger Theatre on May 27 until June 11.

MEDICAL FORUM

Opera

Passions Run High The Merry Widow

Vanessa Scammell

Suckers for swelling melodies and hopelessly romantic duets – and who is not – will have all their breathless wishes granted in one of the most beautiful operettas to be conceived – Franz Lehar’s The Merry Widow – which will be staged next month in all its sumptuous glory by WA Opera. The operetta was premiered in 1905 in Vienna which inevitably cued full tulle skirts and plenty of opportunities for the famous waltz. WA Opera’s production will hurtle the story to Art Deco Europe but expect some fancy footwork here, too, as it is in the creative hands of guest director Graeme Murphy. Graeme, in his former life as Sydney Dance Company founder, was beloved of Perth audiences for his extraordinary abilities to tell stories in movement. With opera, which he has ventured into over the past 10 years, he has a very broad canvas. The roles of Hanna (the ‘Merry Widow’) and Count Danilo are played by two singers with growing reputations. Perth-born Taryn Fiebig is now a principal artist with Opera Australia and possesses one of the most magically lyrical soprano voices around. She is matched by Alexander Lewis’s tenor voice which was shaped by his time spent here at WAAPA. Together they make a crushingly handsome pair.

Keeping passions in check in the orchestra pit is one of the busiest conductors in Australia, Vanessa Scammell, who spoke to Medical Forum from Melbourne where she was in rehearsal for a new production of Hello Dolly.

studying singing and coaching of singers and I thought I had something to offer. Around that time a friend put on a charity fundraising production of Oliver! and asked me to conduct it.,” Vanessa said.

The Merry Widow is Vanessa’s first mainstage production for Opera Australia, though she’s taken Oz Opera’s La Traviata on the road in what is known as the ‘hot tour’.

“I did and I loved it but I also knew that I wasn’t going to be hold up without extra study so while I was on tour with a variety of musical theatre shows, I did a Masters in conducting and studied with various teachers overseas while I was on tour.”

“We performed in Tennant Creek, Darwin, an open-air venue in some rainforest where it didn’t stop raining and to Perth. It’s a tough gig where everyone works really hard but there’s such a great standard of singing and it is such a lot of fun.” Being in the dry confines of His Majesty’s Theatre is an “absolute thrill”, she said. While the ranks of women conductors in Australia is growing, it still makes a headline but for Vanessa, whose musical journey began as a repetiteur for Opera Australia, it is a perfect fit but it’s been hard work to get there and it has meant embracing her opportunities when they arise. This philosophy has seen her taking up the baton before symphony orchestras one evening and in the pit for productions such as South Pacific (for Opera Australia), Phantom of the Opera, Chicago and West Side Story on another. It was hours in rehearsal rooms listening to singers and artistic directors when she began to wonder if there wasn’t more she could give to the creative process.

“If I was to stand up in front of a group of professionals, I needed to be proficient and confident in what I was doing. That is how it started and I fell into it and things took off pretty quickly.” Vanessa said one her greatest influences has been conductor Simone Young, for whom she auditioned when Young was artistic director of Opera Australia. “I spent a lot of time watching Simone in the rehearsal room and learnt so much. I’ve also been lucky to work with Australian Ballet’s Nicolette Fraillon, another great female conductor who has been completely encouraging and generous with her time with me. And Guy Noble has been a steadfast friend. He gave me my first orchestral gig. It’s quite a collegial environment in Australia.” Of Graeme Murphy, Vanessa said he had an unbelievable ability to tell stories. “I can’t wait to collaborate with someone who is such an intuitive storyteller.”

By Jan Hallam

“As a piano player you sit back and play, you don’t really have a voice but I had been

Homo Deus: A Brief History of Tomorrow

Book

Review MEDICAL FORUM

(Yuval Noah Harari, Harvill Secker)

The broad and elegant sweep of Harari’s pen (OK, more likely a mouse) explores the communal life and organisational skills of Homo Sapiens, the most dominant and destructive species ever to walk on planet Earth. This brilliant and often funny book has garnered rave reviews, and rightly so. The future we’re staring at will, says Harari, ultimately belong to the Human God. Predictability, the queue for immortality won’t be overly long because only the very rich will be able to afford it. The age of Artificial Intelligence and Big Data is just around the corner and medicine will be utterly transformed. Yes, the algorithm will see you now. Winter is coming!

JUNE 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: Scotland the Brave Perth will turn a little tartan when 100 singers, dancers and musicians perform the best of traditional Scottish music including soprano Cheryl Barker, tenor Gregory Moore, members of the WA Police Pipe Band and the Scottish Highland Dance Academy will take to the stage. Perth Concert Hall, July 22 July, 2pm & 8pm

The Good Food & Wine Show This year’s event reflects the growing interest in farmers’ markets and food provenance with a the introduction of the Good Food Village packed with premium artisan producers (including Riki Kaspar’s popular Shakshuka, picture above). Other exciting debuts include the Champagne Taittinger Lounge and Oyster Bar, where freshly shucked oysters are best served with a cold glass of bubbles. A traditional high tea is also available. The masterclasses feature exciting foods and wine to discover. The Smelly Cheese Club may have you wondering if you’ve changed your socks but delicious cheeses are ripe and ready to delight. At the Cape Mentelle VIP Lounge guests can enjoy a light meal and prime seating to face the Good Food Theatre and wines Cape Mentelle. A range of local exhibitors include Noshing Naturally, with its vegan cheese selection, Charli G – a new player in the local cheese space, and Great Southern truffles and cupcakes from Baked 180. Then there is of course the plethora of celebrity chefs. See Manu Feildel, Matt Moran, Gary Mehigan, Jack Stein and Adam Liaw in action at the Chef’s Lunch series.

Movie: A Ghost Story An exploration of legacy, love, loss and existence as a recently deceased ghost returns in a white sheet to his suburban home to try to reconnect with his bereft widow. Casey Affleck and Rooney Mara light up the screen. NB: This is not a horror flick. In cinemas, July 13

Movie: Baby Driver A young getaway driver meets the girl of his dreams (Lily James) and Baby sees a chance to ditch his criminal life and make a clean getaway. But the crime boss (Kevin Spacey) has other ideas. In cinemas, July 13

Perth Convention & Exhibition Centre, July 14-16

Movie: Hampstead

Winners from April Comedy – Perth Comedy Festival: Dr Anna Nowak Kids’ Theatre – Mr Stink: Dr Jan Parker

Set in the leafy Hampstead Village, an American widow (Diane Keaton) finds new purpose protecting the rights of an eccentric (Brendan Gleeson) who has lived in a ramshackle hut on the heath for more than 17 years as developers plan to move in. In Cinemas July 6

Hearts & Hands • Skilling Africa • Tightening the Belts • Perils of Place & Politics

Movie – John Wick 2: Dr Kamlesh Bhatt, Dr Kylie Seow, Dr Christine Troy, Dr Crystal Durell, Dr Catherine Keating, Dr Eric Khong, Dr Astrid Valentine, Dr Susanne Sperber, Dr Lyn Minsker, Dr Andrew Toffoli

• Clinicals: Testing Heart; DVT; Arrythmia; Lipids & More…

Major Sponsors

April 2017

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Opera: The Merry Widow

Movie – Viceroy’s House: Dr Rafal Francikiewicz, Dr David Bucens, Dr Katherine Shelley, Dr Farhan Shahzad, Dr Hock Chua, Dr Tony Connell, Dr Helen Slattery, Dr Lin Arias, Dr Geoff Mullins, Mr Ray Barnes

Composer Franz Lehar was on a winner when he combined heart-stopping arias with toe-tapping dance tunes in a romantic comedy of manners, money and matrimony. Directed by Graeme Murphy this opera has something for everyone.

Theatre – Stones in His Pockets: Dr Ric Bergesio

His Majesty’s Theatre, July 15-22

Theatre – The Play That Goes Wrong: Dr Sue Sparrow, Dr Smitha Pillay

54 | JUNE 2017

MEDICAL FORUM

Allergy & Immunology DrDr Meilyn Meilyn Hew Hew MBBS MBBS FRACP FRACP FRCPA FRCPA Allergy Allergy and and Clinical Clinical Immunology Immunology Meilyn Meilyn is is anan adult adult immunologist, immunologist, allergist allergist and and immunopathologist immunopathologist seeing seeing allall general general allergy allergy and and immunology immunology patients. patients.

CLINICAL SERVICES DIRECTORY

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For For appointments: appointments: Suite Suite 42,42, Level Level 2, 2, Wexford Wexford Medical Medical Centre Centre 3 Barry 3 Barry Marshall Marshall Parade, Parade, Murdoch Murdoch WA WA 6150 6150 Phone: Phone: (08) (08) 9332 9332 2861 2861| Fax: | Fax: (08) (08) 9312 9312 1576 1576 Email: Email: reception@drmeilynhew.com.au reception@drmeilynhew.com.au Web: Web: drmeilynhew.com.au drmeilynhew.com.au

Dr Jack Bourke MBBS (Hons) FRACP FRCPA Clinical Immunologist and Allergist Allergy West 64 Farrington Road, Leeming 6149 Phone: 9313 5171 Fax: 9313 6162 Clinical Immunologist and Allergist specialising in management of; ••adult allergy and general immunology •• paediatric allergy (6 years and older).

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Dr Jody Tansy MBBS FRACP tansyallergy.com.au Jody has commenced private practice at the Wexford Medical Centre managing all aspects of allergy and general immunology in adolescents and adults. Consulting from: Suite 42, Level 2, Wexford Medical Centre, 3 Barry Marshall Parade, Murdoch 6150 Please send referrals to: contact@tansyallergy.com.au Phone: 9332 2861 Fax: 9312 1576

For urgent advice: 0435 084 085 or jody@tansyallergy.com.au

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CONTACT Jenny Heyden Mobile 0403 350 810 | Email jen@mforum.com.au

MEDICAL FORUM MAGAZINE

DEADLINE 12md June 2nd for July 2017 edition

8 Hawker Avenue, Warwick WA 6024 | Ph 08 9203 5222 | Fax 08 9203 5333

MEDICAL FORUM

JUNE 2017 | 55

medical forum CLASSIFIEDS

Ready to sell your practice? Want to retire or keep working without the administration burden? We are looking to expand our network of practices – if you are considering a sale we would be delighted to hear from you.

Does this sound like you? For a confidential discussion please contact either business Manager Damian Green on 0423 844 268, damian.green@breckenhealth.com.au or Dr brenda Murrison on 0418 921 073, brenda.murrison@breckenhealth.com.au

North Street Medical centre, Midland We are seeking more Dr’s to join our happy team, as a group we plan to increase our opening hours to include full days Saturday and Sunday. Clinical autonomy, computerised, accredited, full nursing support, collocated with allied health and pharmacy. Procedural GPs welcome – Ft/Pt Email manager@northstmed.com.au or call: 9274 2456 and ask for Zoe or Damian

GPs Wanted! Procedural GPs for our women’s clinic and GPs for our busy family practice based in Rockingham adjacent to the district hospital which offers a full after hours service. All the usual bells and whistles! We would love to hear from you. Call Kate or Pauline on 08 9527 2211 or email Manager@woodbridgefp.com.au to arrange an interview with our clinical team.

GP Obstetrician Role in bunbury

405 Oxford street, Mount Hawthorn

Large number of deliveries available in town where number of GP Obstetricians is shrinking

Beautiful new premises with extensive patient base. Join a fully committed patient team in a prime location for growth.

Clinic co-located in Greater Bunbury Medical Centre alongside Brecken Health Care.

All interested GPs applications to the Practice Manager

Submit CV or call 0418 921 073 / 0400 052 119 Reception@bunburymaternity.com.au

www.mthawthornmedical.com.au Phone: 9444 1644 or email office.mthawthorn@buildingblocksmedical.com.au

July 2017 - next deadline 12md Thursday 15th June – Tel 9203 5222 or jasmine@mforum.com.au