MedicalForumWA 1116 Public Edition by Medical Forum WA

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

November 2016 Major Sponsors

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Editorial

Relative Values A little book called Matthew’s Story landed on the desk last week which sparked a challenging conversation about values – what values underpin our society, our government, our health system. That’s not bad going for a 14-page booklet. Matthew’s Story is an anonymous piece being distributed far and wide by Children’s Equity, a charity formed last year by Perth physician Dr Michael Watson to make life easier for disadvantaged children, focusing on kids with developmental challenges and ear problems in remote communities. So what’s different about this story from all the other hearttugging stories we see every day in the media? Well, I guess it’s because it has no intention to tug at your heart strings. It doesn’t seek your pity, nor does it seek your cash. It simply wants you to question. What does an individual have to do or be in order to be considered simply themselves and valued as such? It is a serious question for our times. To retell the story here would diminish its impact; it would also be difficult not to resort to the very labels it sets out to challenge. We live in a world of labels which distinguish whether we belong or not. But to what do we belong? And who makes those decisions of whose labels are ‘in’ and whose are not? This is the reality of our world in 2016 where fear, rather than kindness, controls our values and decision-making. The health profession is a rare beast – doctors set out on their life’s work with these words ringing in their ears: “Into whatsoever houses I enter, I will enter to help the sick”. It underpins the core value of health care for all. ‘Regardless of your label, if you’re sick, I will help.’ Even though we are likely to fall short for a whole lot of reasons, it remains at the heart of a caring profession. That’s immensely powerful and yet so many things get between the healer and the sick. Matthew’s Story identifies ‘bureaucrats’ as one significant hurdle; there would be plenty of doctors who concur. The challenge for those labelled ‘bureaucrats’ is to construct policy that encourages good outcomes, while being flexible enough to acknowledge an individual’s right to be themselves, indeed, encouraged to be their very best self.

It was harsh and for many genuine public servants who work hard to make big systems work efﬁciently for the good of many, unfair. However, in order to protect society from Matthew’s ‘bureaucrats’, who run amok with their rulebooks and clipboards, transparency and accountability become critical to maintaining our rights.

In this issue, we examine the early days of the Consumer Directed Care revolution in aged care, thought up by politicians and bureaucrats to solve some difﬁcult problems, g for so many ageing namely the brutal cost of caring Baby Boomers and creating new ways to care that would maintain some of their rights while addressing basic needs. And what an eye-opener it was to learn how organisations, many notfor-proﬁt and religiously underpinned, are approaching the prospect of a deregulated and commercial marketplace where once stood an institution.

Ms Jan Hallam

Some in the aged care sector are even starting to re-evaluate the label ‘care’. They say the health system is paternalistic and has for too long being doing things ‘to patients’ rather doing things ‘with patients’ and the label ‘care’ robs the consumer of any say in their own lives. That’s a big leap but you get the idea!

In December, a copy of Matthew’s Story will be included with your magazine. Please accept it as a gift of the season. We think it has value and values to share, which may make a difference to the way we view the world and the people in it who are simply trying to be their best selves. Please pass it on to someone. By Jan Hallam

In 1949, as the icy winds of the Cold War blew across the world, George Orwell published the dystopic novel Nineteen Eight-Four and astounded the world with its bleak outlook on an individual’s frail chances of maintaining any sense of personal freedom in a world run by bureaucrats.

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

MEDICAL FORUM

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

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

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

NOVEMBER 2016 | 1

November 2016 12

Contents 14

CDC HERE

FEATURES 12 Spotlight: Ms Anne Carey 14 Doctors Drum: Training and ‘Dud’ Doctors 18 Consumer Directed Home Care 26 Artists of the Seventh Age

LIFESTYLE 46 Soccer Dad: Dr Jeff Thavaseelan 47 Funny Side 48 Social Pulse: GP16, Rotary 49 Wine Review: Rockcliffe Wines

NEWS & VIEWS 1 Editorial: Relative Values

50 51 52 52

6 6 10 25 26 36 44

Jan Hallam Letters to the Editor Being the best GP you can be: Dr Frank Jones Coaches should lead the way: Ms Amy Dyer Hitting the Funny Bone: Dr Izaak Lim Curious Conversation: Dr Ben Hewitt Have You Heard? Advanced Planning Lessens Suffering Targeting Tinnitis Beneath the Drapes Preventing Falls

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Dr Martin Buck Theatre: Avenue Q Music: The Messiah Music: Welcome to Wagner Review: Cole Dr Lin Arias Competitions

Get the Spirit in Medical Forum’s

XMAS GREETINGS FEATURE DECEMBER ISSUE Contact Jenny at jen@mforum.com.au

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Clinical Contributors

Dr Tony Barham Barrett’s Oesophagus

Clin A/Prof Timothy Bates Preventing Stroke

Dr Astrid Arellano Resistant Gram Negatives

Dr Sean Maher Exercising the Brain

Dr Michelle Lai Timing Residential Care

Dr Sergio Starkstein Managing Adult Autism

Prof Gunesh Rajan & Dr Vincent Seet Vertigo Diagnosis & Management

Dr Angamuthu Arun Vulvodynia

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Dr Rita Malik Sarcopaenia – How Important?

Guest Columnists

Dr Siany Hopkins Let’s Talk About It

Dr Chris Fox GPs and the Aged

Dr Natalie Ward No Progress Without Research

Capt David Martin Inﬂight Emergencies

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM NOVEMBER 2016 | 3

Letters to the Editor

change, a number of tenets of our existing system should be incorporated into the new revalidation approach, with a focus on continuous improvement and lifelong learning.

Being the best GP you can be Dear Editor, The Medical Board of Australia’s (MBA) August interim discussion paper on revalidation had several parallels with the work the RACGP had already undertaken to strengthen continued professional development (CPD) for general practice. The 2017-19 Quality Improvement and Continuing Professional Development (QI & CPD) continues our approach of providing opportunities for GPs to reflect on their current knowledge and skill base, and make appropriate determinations on possible improvements in accord with their patient needs and that of their own professional pursuits. The addition of a planning learning and need (PLAN) activity makes this possible in an electronic format the first time. A PLAN activity involves a comparison of individual skill and knowledge to that of the expected standard of the profession. PLAN and the revised QI&CPD program were announced at our annual conference GP16 in Perth. The MBA’s initial proposals, should they be implemented, will have long-term consequences for the medical profession in Australia – many positive, but others requiring careful appraisal and reflection. Revalidation has been gathering apace, most notably in Europe. Prior to 2000, only six of 18 European countries mandated a compulsory CPD system. That number has since increased to 16 out of the 18 countries. (The other two countries make use of an incentivebased program.)

Being the best GP you wish to be means maintaining skills and knowledge to the level required by the profession for unsupervised general practice, and also having the opportunity to pursue knowledge and skills based upon practice and community need, and personal aspiration. Dr Frank Jones, Immediate Past President RACGP ........................................................................

Coaches should lead the way Dear Editor, Re: ‘What is the Ultimate Elixire of Sport?’ (October issue), what is frequently talked about in the media is the need for antidoping organisations to improve and advance their ability to test for prohibited substances and use increasingly advanced technology and intelligent testing regimes. What is often overlooked is anti-doping education and promoting a culture of anti-doping in sport. The World Anti-Doping Code states doping is fundamentally contrary to the spirit of sport and to ﬁght it Anti-Doping Organisations must develop and implement education and prevention programs for athletes, including youth, and their support personnel (e.g., coaches).

Although a form of revalidation will bring us in line with our international contemporaries, the RACGP believes any proposal must reﬂect the unique Australian health provision environment.

Researchers (e.g., Barkoukis et al., 2013; Whitaker et al., 2014) have argued for the merits of a preventative stance by fostering young athletes’ anti-doping attitudes, diminished willingness to dope, and efﬁcacy to resist doping-related temptations early in their sporting careers.

The RACGP considers that before any

As architects of the talent development

Good people do not need laws to tell them to act responsibly, while bad people will ﬁnd a way around the laws. Plato (427-347 B.C.)

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reﬂect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

environment in sport, coaches play a crucial role in shaping the psychological experiences and actions of athletes. Under the WADC, part of the role of coaches is to educate and counsel athletes regarding anti-doping policies and rules, and use their influence on athlete values and behaviour to foster anti-doping attitudes. Coaches are uniquely placed to influence athletes’ attitudes and behaviours and reduce the risk of doping. Encouraging coaches to talk about anti-doping with athletes and maximise the effectiveness by which they communicate these messages is key to protecting clean sport. Led by Prof Nikos Ntoumanis of Curtin University, a group of internationally recognised experts in anti-doping, motivation and applied psychology are developing a coach-based program to prevent current and future willingness to dope in adolescent sport. The project, CoachMADE, is funded by the International Olympic Committee (IOC) and involves researchers from Curtin University (Australia), Leeds Beckett University (England), and Aristotle University of Thessaloniki (Greece). The results of CoachMADE will enable more efficient and evidence-based educational programs and campaigns to prevent doping through athlete support personnel. Coaches of athletes aged 14-18 years are being invited to take part by contacting coachMADE@curtin.edu.au or visit www.coachMADE.com. Ms Amy Dyer, Research, Curtin University ........................................................................

Editorial Comment Readers have asked about Major Sponsors… Major Sponsors of Medical Forum magazine work within the WA medical community. Each strives to offer something extra to the medical profession and is happy to be involved with this reputable industry publication. Medical Forum was founded over 20 years ago by two people within the profession, and the improved quality and readership of the publication since then speaks volumes for all involved. Independence, dedicated WA focus, and ethical behaviour are the cornerstones of the publication’s success. Major sponsorships are offered on that basis.

advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemniﬁes the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

Advertisers are responsible for ensuring that

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News & Views

Hitting the Funny Bone A psychiatric registrar hits the boards to tell a cabaret audience some of the tricks of the trade – and how doctors are people too! “I loved theatre in school and then I became involved in cabaret and storytelling. My family has always been very supportive of the arts, my brother is a talented organist and my sister is an excellent dancer.”

One reviewer of Dr Izaac Lim performing Hamlet said he’d “turn up to watch him recite the phone book”. Izaac’s show, Malpractical Jokes, with its behind-the-scenes glimpses into the humour, absurdity and pathos of medical moments, promises to be far more interesting that!

“Our mother gets a lot of joy seeing us create something unique and she always comes to my shows multiple times.”

“It’s no secret that most people are curious about just what happens inside a hospital. This show goes one step further by lifting the lid on what might be happening inside the mind of a doctor.” “There are some funny moments but essentially this taps into the absurdity of it all, that life is a bit of a joke and sometimes we, as doctors, also feel like a bit of a joke. I hope there’ll be some emotional resonance with these stories and that the audience will see that we’re neither gods nor robots.” “I want people to know that doctors are mere human beings with ﬂaws and quirks just like everyone else. And I’m aiming to entertain people, too!” The psychiatric registrar currently based at Albany Hospital readily concedes that medicos often see the raw side of life and sometimes it’s not all that amusing.

Dr Izaak Lim performs at the GP16 in Perth. Pic: Courtesy of RACGP

you’d cry. It’s well known that a lot of doctors develop a protective black humour because we’re often dealing with extreme situations.” “Sometimes it’s difﬁcult to believe what happens out there in the real world. We see the ‘pointy’ end in a hospital environment and sometimes you come across things that are so terrible, so sad and yet there’s humour there too.” “I think it’s important to acknowledge just how uncomfortable we feel sometimes, and that life is essentially pretty absurd.”

“There are funny things that happen all the time in medicine. And there are others you just have to laugh about because if you didn’t

Izaac is the ﬁrst doctor in his family but the artistic gene runs like a thread through the Lim clan.

Isaac certainly doesn’t regard medicine as a ‘second career’ and he’s under no illusion regarding the difﬁculties of the ‘creative’ life.

“I love my job as a doctor and I could never be a full-time artist. It’s a really difﬁcult way to live with all kinds of uncertainties and genuine talent doesn’t always bring success. Nonetheless, the arts are important to me and I intend to keep that very much alive.” “I’m hoping this show at the Maj will humanise the doctor/patient relationship and enrich people’s understanding of just what’s going on in the consultation room.”

By Peter McClelland ED: Izaak performs Malpractical Jokes: A Medical Cabaret, at Downstairs at the Maj, November 3-5

Curious Conversations

Swimming with the Sharks If Dr Ben Hewitt decides on a career change, it’ll be safe for all of us to go back in the water The worst memory of my school days is… I don’t have any bad memories from school. It was pretty easy back then, there were no ‘parent projects’ and you weren’t judged by how many orphanages you visited. You were given a text book, you learnt it and reproduced it for the exams. If I could have one moment of glory on a sporting ﬁeld… I’d love to win the Rottnest Swim because that would mean I’d beaten my brother, Tim. This is very unlikely to happen as I’ve undoubtedly entered a downward physiological spiral. My parents gave me… a set of golf clubs, which was the worst present I’ve ever received. After many years of a ‘hate/hate’ relationship with

6 | NOVEMBER 2016

these torture sticks I abandoned them in a golf course car park. They’re probably bringing pain and unhappiness to someone else now. I love orthopaedics because… it’s simple. The majority of problems we deal with are straightforward and our patients get better. We only really get into trouble if we try to fix the unfixable or operate when it’s not necessary. If I hadn’t chosen medicine I think I’d have made a good… professional shark fisherman. We have an acute shortage of these highly skilled men in WA. My new career, combining my love of fishing and my dislike of sharks, could only have a positive outcome.

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By Dr Tony Barham Tony is a graduate of the University of Newcastle. He moved to Western Australia in 2000 to commence specialist training in pathology, receiving his FRCPA in 2005.

Perth Pathology (Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 26 Leura St, Nedlands WA 6009 Ph 9433 5696 Fax 9433 5472

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Tony's interests include skin, gastrointestinal and gynaecological pathology. He has been a consultant at Perth Pathology since 2011.

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Barrettâ&#x20AC;&#x2122;s Oesophagus Barrettâ&#x20AC;&#x2122;s oesophagus represents an adaptive response of the oesophageal mucosa to chronic reďŹ&#x201A;ux-related injury. Its signiďŹ cance lies in the fact that it is the only recognised precursor of oesophageal adenocarcinoma. Management of Barrettâ&#x20AC;&#x2122;s oesophagus has progressed signiďŹ cantly thanks to therapeutic advances, but incompletely resolved issues remain. In Barrettâ&#x20AC;&#x2122;s oesophagus, the normal squamous epithelium is replaced by metaplastic columnar epithelium. For diagnosis, the alteration must be visible endoscopically and conďŹ rmed histologically. Similar to US practice, in Australia the metaplastic epithelium must be of intestinal type to be regarded as Barrettâ&#x20AC;&#x2122;s oesophagus. (British authorities continue to regard any type of metaplastic columnar mucosa as Barrettâ&#x20AC;&#x2122;s, but only intestinal metaplasia clearly predisposes to carcinoma.) Although intestinal mucosa comprises several different cell types, in the oesophageal setting essentially only goblet cells are relevant â&#x20AC;&#x201C; the terms intestinal metaplasia and goblet cell metaplasia can be considered synonymous. Carcinoma arises in Barrettâ&#x20AC;&#x2122;s oesophagus from a progressive series of genetic events that manifest histologically in the form of dysplasia. Patients with conďŹ rmed Barrettâ&#x20AC;&#x2122;s oesophagus therefore enter a program of endoscopic surveillance, allowing risk assessment and early intervention.

Surveillance biopsies are classiďŹ ed as either negative for dysplasia, low grade dysplasia (LGD) or high grade dysplasia (HGD). In some difďŹ cult cases, it is not possible to be certain if dysplasia is present or not. In this situation a provisional diagnosis of â&#x20AC;&#x153;indeďŹ nite for dysplasiaâ&#x20AC;? is made. LGD confers a risk of progression to either HGD or carcinoma of approximately 1% per year. A diagnosis of LGD hence warrants increased surveillance (intervention may later be considered if LGD persists and is multifocal). On the other hand, HGD is associated with an incidence of carcinoma of at least 6% per year, necessitating deďŹ nitive treatment. Follow-up of a diagnosis of indeďŹ nite for dysplasia may vary depending on the endoscopic or histologic ďŹ ndings pertaining to a particular case, but generally includes increased surveillance. Research continues into other factors that may assist in prediction of progression, such as the extent of dysplasia. Unfortunately, histologic diagnosis and grading can be problematic. Potential areas of difďŹ culty include: sĂĽ h2EACTIVEvĂĽATYPIAĂĽDUEĂĽTOĂĽINmAMMATIONĂĽVSĂĽ true dysplasia sĂĽ ,'$ĂĽVSĂĽ('$ sĂĽ ('$ĂĽVSĂĽEARLYĂĽINVASIVEĂĽCARCINOMA sĂĽ2ECOGNITIONĂĽOFĂĽLESSĂĽ common variants of dysplasia (e.g. foveolar) sĂĽ)NTER OBSERVERĂĽVARIATION

Oesophageal biopsy containing metaplastic columnar epithelium. Numerous goblet cells are present (intestinal metaplasia), conďŹ rming Barrett's oesophagus.

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There have been multiple attempts to develop ancillary techniques such as immunohistochemistry to assist in the diagnosis of dysplasia, but none have proved satisfactory. At present, the gold standard remains morphologic assessment. Like most laboratories, we routinely show abnormal biopsies to other colleagues with expertise in GI pathology.

The treatment of HGD and early invasive carcinoma in Barrettâ&#x20AC;&#x2122;s oesophagus has been transformed by the development of sophisticated endoscopic techniques. Lesions previously treatable only by oesophagectomy are now routinely managed by endoscopic mucosal resection and radiofrequency ablation. Multiple trials have shown that these procedures are effective in the treatment of HGD and early invasive carcinoma, with low complication rates. Incomplete response or recurrence of Barrettâ&#x20AC;&#x2122;s oesophagus (with or without dysplasia) is not uncommon, however, necessitating ongoing endoscopic surveillance.

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Letters to the Editor

Incisions

It's All About the Patient As an early-career dentist, Dr Siany Hopkins suggests that better communication between doctors and dentists would benefit everyone, patients most of all. I was told a somewhat disturbing story recently by a fellow dentist regarding a frustrating encounter he had had with a local GP. The dentist was treating a patient who required a tooth extraction and was taking one of the newer anticoagulant medications. The current Dental Guidelines are quite specific regarding the required protocols when treating patients who are taking Warfarin, but the general recommendation for newer medications is to consult with the patient’s doctor. So the dentist wrote to the patient’s GP and again, a week or so later, when the initial contact was ignored. He followed this up with a phone call, was assured by the receptionist that the GP had received the email and would reply the same afternoon. The day of the extraction duly arrived and the GP still hadn’t responded. So, quite literally, the dentist decided to take the matter into his own hands. He walked into the surgery and handed the letter to the doctor. I’m not suggesting that this story reflects the usual practice of all GPs. In fact, I’ve found most to be very helpful and prompt to respond to my queries. And that’s coming from someone who works part-time in the public health system with patients who have complex medical histories requiring both chemotherapy and/or blood work.

On a broader scale, the above anecdote highlights the importance of inter-disciplinary communication between health professionals. When I studied at UWA, the medical, dentistry and podiatry students all commenced their studies together. While some dental students found diabetic ulcers disturbing and future podiatrists couldn’t handle looking at photos of periodontal disease, it was patently obvious that there are more similarities than differences between our professions.

a commitment to form open and productive relationships.

What is abundantly clear is that the patient’s best interests should always be our prime concern.

Common, recurring questions and ongoing issues could be aired in a collegial manner. And, who knows, there may be the added bonus of forming a professional network or two?

Perhaps it was less than desirable when these undergraduate degrees began to diverge down separate pathways. By the time I graduated I didn’t know any of the students graduating in other health areas. I think it’s important that we, as a younger generation of health professionals, begin our careers with

And compared with our older colleagues it’s probably much easier for us because email and related social media make contact simpler and almost instantaneous. It’s just so easy to keep lines of communication open. We’re all required to complete ongoing education so wouldn’t it be beneﬁcial to have a multi-disciplinary ‘talk-fest’ every so often?

The medical sector is constantly changing, new medications are being introduced and antibiotic resistance remains an issue. Pooling our knowledge and engaging in open communication can only beneﬁt our patients.

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Have You Heard?

Revalidated and Disrupted The hour-long member forum at the GP16 in Perth tackled the big issues of revalidation and digital disruption – an ambitious plan by anyone’s reckoning. The 30-minute digital discussion got bogged down in a 10-minute lamentation over the apparent phasing out of faxes, which left tech innovator and panellist Dr Marcus Tan a little bewildered. Yes, the profession has that far to go before it gets into coo-ee distance of the 21st century. Revalidation fared better. When MC Ali Moore asked WAGPET CEO Dr Janice Bell if she thought the Medical Board of Australia had made its case for revalidation her one-word answer – NO – brought the house down. The new College president Dr Bastian Seidel told the forum the College would work with the MBA on its revalidation quest but only to ensure common sense prevails. A no might be simpler.

It’s virtually a reality Jim is an elderly Australian farmer with mild dementia. He’s also an avatar with 50 different verbal and non-verbal responses and lives entirely in his own virtual world. Even so, some Curtin University Psychology and Speech Pathology students think he’s better than the real thing when it comes to learning how to communicate with patients. A study led by Dr Janet Beilby investigated undergrads self-rated communication skills, knowledge, conﬁdence and empathy. After 30 minutes with either a current nursing home patient, an older actor trained to portray an elderly patient or Avatar Jim, Jim got the thumbs up. He apparently presented a communication challenge and students thought that was more realistic. Students had to work harder to build rapport and empathy because they couldn’t use comforting cues. “We recently gave Jim an avatar wife, Moira. They live together in an independent unit in an aged-care facility. While Moira mostly placates Jim or pulls him into line, she can also pose other challenges for students – not only having to deal with a patient’s reaction, but also the reaction of the patient’s carer or loved one,” Janet said.

Rural policies are working “General practice is not the sewer for people who think they can get a job there if they can’t get a job anywhere else.” That was the gauntlet thrown down at the last Doctors Drum forum on doctor training. This sentiment appears to be conﬁrmed by the news from WAGPET that of the 1500 positions advertised this year, 170 remain unﬁlled because there weren’t enough good applicants. It was better news at GP16 with the launch of a WAGPET commissioned report by Kim Snowball revealing that more specialists were heading

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Have You Heard?

bush (numbers up 25% from 2007). Sustained investment in education and training has been the driver along with Royalties for Regions money rebuilding and upgrading country hospitals. However, GP proceduralists remain the backbone of country medical services, the report said. Reliance on overseas recruitment has also fallen. In 2005, 70% of procedural doctors were recruited from overseas and in 2015 this had fallen to 45%. For the ďŹ rst time, locally trained doctors were making up the majority of new arrivals into rural practice.

Anxiety over genital normality Back in May, we looked at the growing demand for female genital cosmetic surgery and now a survey of 443 GPs published in BMJ Open shows that a third of them had been asked for referrals by girls under 18 for genital cosmetic surgery. Lead author Dr Magdalena Simonis said girls as young as 15 were undergoing labiaplasties and other procedures, even though the medical consensus was that female genitalia did not reach maturity until around the age of 18.

At least half the requests came from girls and women whom GPs considered emotionally vulnerable, suffering from anxiety, depression, relationship difďŹ culties or body dysmorphic disorder. â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s an epidemic of anxiety about normality,â&#x20AC;? she said. The study identiďŹ ed fashion, online pornography, perceptions of beauty, as well as brazilian waxes as playing a major role in forming womenâ&#x20AC;&#x2122;s idea of â&#x20AC;&#x2DC;normalâ&#x20AC;&#x2122;. As of October 1, the Medical Board advises that girls under 18 receive mandatory counselling and a three-month cooling-off period.

Sugar-coated stats We took a second look at a media release sent early August by the Public Health Association (PHA), just after the report, Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011 was released by the Australian Institute of Health and Welfare. Diet, it said, had been underplayed as a contributor of the burden of disease, estimated at 7.2% of the 31% of preventable disease factors that include diet, tobacco use, alcohol use and physical inactivity. It went on to say that the Australian Bureau of Statistics (ABS) has assessed dietary intake directly against dietary recommendations and found only 4% of Australians ate enough nutritious food such as fruit and vegetables, grains, lean meats and dairy foods. ABS said a third of daily energy intake in the same survey came from discretionary food and drinks, yet PHA said that 75% of young people aged 9-18 regularly exceeded the WHO advice that free sugars should contribute less than 10% of total energy intake. There is such big disagreement

between these ďŹ gures we can only assume we are waiting for the obese kids to reach â&#x20AC;&#x2DC;burden of diseaseâ&#x20AC;&#x2122; age before the ďŹ gures blow out. PHA suggests action like a sugar tax on soft drink, additional support for the Health Star Rating on packaged foods; and a comprehensive National Food and Nutrition Policy.

Path labs handover Ownership of 19 of St John of God Pathologyâ&#x20AC;&#x2122;s laboratories and 180 collection centres in WA and Victoria transferred to Clinical Labs on October 10. SJG Health Care will hold a minority shareholding in Clinical Labs and CEO Dr Michael Stanford is on its board. The labs will operate under the SJG brand for up to 12 months until the company is fully integrated. Clinical Labs have a long-term contract with SJG hospitals for pathology services.

Protecting the vulnerable Submissions to the Australian Law Reform Commissionâ&#x20AC;&#x2122;s inquiry into Elder Abuse have closed and on December 12 a set of proposals for law reform will be launched. WA Police and Advocare were among the local submissions. The inquiry will head to Perth again at the end of January for a new round of consultations and submissions on the actual reform proposals close on February 27. A report will be delivered to the Attorney General in May. See http://www.alrc.gov.au/ inquiries/elder-abuse/submissions

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MEDICAL FORUM

NOVEMBER 2016 | 11

Spotlight

Battling Ebola and Bullies Esperance RN Anne Carey has battled disease threats in developing countries all over the world but some time the hardest battles are closer to home.

The effects of systemic workplace bullying was the catalyst for WA Australian of the Year Anne Carey to ﬂy to Sierra Leone and work for the Red Cross during the Ebola crisis. It was a dangerous and distressing time in West Africa, but the shadow of a bigger battle loomed large. “I’d honestly have to say that trying to negotiate my way through the experience of workplace bullying at the Esperance Hospital was a lot harder than dealing with the Ebola crisis. When someone in charge is denying a problem even exists there’s no possible way to move forward,” she said. “In some ways I feel fortunate to have had the Esperance experience, it certainly gave me a dose of added courage and that helped me through some tough times in West Africa.” “I’d had seven years of very happy work at Esperance before a new management regime made life hell for me and many others. I put in a formal complaint fully expecting to be treated with integrity and achieve a resolution that contained some degree of justice but I don’t think the current system is capable of producing an outcome like that.” “It was a very difﬁcult period and the Health Department was taking an inordinate amount of time to process my complaint so I volunteered to go to West Africa in 2015.”

“After that, I spent time in the Tiwi Islands and One Arm Point in the Kimberley. It’s so sad to see the ongoing problems of indigenous health, they’re so entrenched and it’s affecting generation after generation. I think any form of solution lies in better education and improved communication. It’s absolutely imperative that Aboriginal people are involved in the process. A lot of money has been thrown in and a lot has been wasted.” “If we’re to have any hope of closing the gap we need to fully involve the people concerned and that means talking with indigenous Australians.” The Ebola crisis of 2015 ﬁgured prominently in our media and provided some pretty graphic footage. Anne was well aware of the dangers before she left to work in the treatment centres, so much so that she thought the outcome could have been highly problematic. Gotta go, get away “It was seven months into the workplace complaint process and I’d pretty much had enough so I put my hand up for the Red Cross position in Sierra Leone. There was a great deal of fear generated around this disease, much of it well deserved.” “At times, I honestly did wonder if I’d get back to Australia because there was no real capacity to evacuate if I contracted the disease.”

Answering the call in PNG Anne’s background was in nursing and midwifery within a missionary order in Papua New Guinea where she spent 18 years before leaving to do similar work in remote areas of the Northern Territory. “I’d always wanted to do that sort of thing so I went to the Central Provinces region. It was a very isolated and remote village and some of the people walked six hours to get to us for medical treatment. It’s a dangerous country. I was held up a few times on the road to Port Moresby and I was very lucky not to be physically assaulted.”

12 | NOVEMBER 2016

“The first hour in the treatment centre changed everything for me. A two-week old baby boy bled to death in my arms while his mother was sitting there in front of me. That was her seventh child to die from Ebola.” “The mortality rate was pretty close to 80%, which was just horrendous.” “All the people working in the field were so passionate about beating this disease and it was wonderful to be part of that. It was a privilege to go, and so inspiring to see the selflessness of the people who went there to help.”

“We won the battle in the end.” On her return to Perth, Anne found there was another hurdle to negotiate. Overreaction at home “I was disappointed with the bureaucratic process when I came back to Australia. At one stage, despite the fact that I had no symptoms and I was well beyond the contagious period, the health authorities wanted to put me in isolation, forcibly if needed.” “There needs to be a lot more support in place for aid workers when they return to Australia.” Anne’s role as WA Australian of the Year isn’t over yet and will see her stepping on to podiums across the country to spread the message. “I’m doing quite a lot of speaking around WA and then it’s on to Melbourne to spread the message. It’s important to bring about change in the area of workplace bullying and I’d like to see it put on the same platform as domestic violence. The suffering inﬂicted can be enormous.” “After that I’ll be back in Esperance. My partner, Donald Howarth, has set up a new GP practice and they need a Practice Nurse. And that’ll be me, for the time being.”

By Peter McClelland

As Medical Forum went to print Anne advised us that an external consultant found the bullying charge fully substantiated. Anne spoke in Melbourne, Ballarat and Bendigo on both Ebola and Workplace Bullying. She is now working as a Practice Nurse in Esperance and will be giving the Red Cross Oration at the University of Tasmania in December.

MEDICAL FORUM

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MEDICAL FORUM

NOVEMBER 2016 | 13

‘Training and Dud Doctors’

It was a provocative title and it elicited some provocative discussion at our 10th Doctors Drum forum. The term ‘dud’ itself came under scrutiny but the meeting agreed with our surveyed doctors and the medical trainers who had been in our ear – that underperforming doctors were getting through the system. So was it having an effect on the image of doctors in the community and how does the profession propose to deal with ‘dud’ doctors? The answers were complex and with several trainers, a lawyer, a recent postgraduate and a consumer rep on the panel, the ideas came from many angles, however, if one word summed up the entire discussion it was communication – both on a personal and professional level. Without good communication skills, doctors would not be “competent, caring, compassionate or resilient”. The panel thought doctors’ good image was safe but there was no room for complacency. The answer really depended on who you asked. Patients almost universally would say ‘no’, especially those who interacted well with their doctor, whereas aggrieved patients or the media would say ‘yes’. But doctors subject to a complaint perhaps beat themselves up too much over just one unsatisfactory patient interaction: “High achievers and high performers can be very self-critical when someone responds to them in a difﬁcult way,” said one panellist. And to solve the problem led us back to training.

Medical School: The Weeding Process

quotas and revalidation, because those are the doctors we really want.”

Ideally, it is at medical school the wheat from the chaff should be sorted. One senior trainer and panellist said high demand for places meant the rigorous stages of selection, instruction and assessment eliminated many candidates – but there was always room for improvement.

A director of medical education on the panel believed we shouldn’t undersell the current selection processes, they were rigorous and – “what we are ending up with is a cohort of high-achieving people, who mostly perform at a wonderful level.” He predicted that in the future there would be more multi-station interview panels to get the widest possible view of the candidate.

Communication skills were at the heart of the current selection process. The UMAT test which gauges interpersonal skills, empathy and personal understanding was tripping up many of the 1200 applicants for the 60 places at one medical school. And responding to an earlier Doctors Drum meeting when it was suggested that potential ﬁnancial and legal consequences of failing non-performing students were frightening some trainers off, he said students would fail if they “demonstrated their inability to perform or were inappropriate” but every attempt to remediate poor students would be made. The room was asked what the qualities were of a good doctor. SMART, COMMUNICATORS, CARING, ADAPATABLE, PASSIONATE, ENERGETIC, RELISIENT, CLEVER, RESPECTFUL, DEDICATED were the responses. So how, asked one guest, do universities “ﬁnd people with that spark and passion for continuous learning; who will be self-stimulated rather than being driven by things such as

This was music to the ears of the consumer advocate, who thought a consumer rep should be on the selection panel so that doctors of the future will not only be “clever people who can pass tests but people who can deal with the whole person they will eventually be seeing and who will also be able to ask for help if they need it.” She went on to call for medical students to have greater access to real patients with real problems before they left the classroom. From her experience, a lack of courtesy and helpfulness and poor health communication were responsible for most consumer complaints. By giving students exposure to patients early, she said, would help them learn to listen and understand the person sitting in front of them. Recent ﬁgures which showed Australia enjoyed one of the highest doctor-patient ratios in the world brought one doctor to his feet questioning the validity of our apparent shortage of doctors. The response from the

Supported by:

See www.doctorsdrum.com.au

14 | NOVEMBER 2016

MEDICAL FORUM

panel suggested that WA was adrift from doctor numbers in the Eastern States and we also had a serious distribution problem. Apparently there’s a ratio of four GPs in the Western suburbs to one in the Eastern Suburbs and rural and remote areas were still seriously under-doctored. “We need to ﬁnd appropriate ways to channel post-grad training in such a way that working as a generalist (surgeon, physician or practitioner) in those areas is seen as a suitable career.”

Postgraduate Training: Crunch Time The critical clinical years of training became the hot topic of the morning – it was in these years the cracks in the training system and the flaws in the individual would become most apparent. So how are these flaws identified, remediated or removed? One young doctor on the panel said the increasing numbers of post grads was severely reducing the clinical opportunities for junior doctors, which in turn led to early commitment to training pathways because of the pressure on RMO jobs. Early honest mentoring was paramount if trainees were to address their flaws early, before training starts in earnest and mediation is required. One doctor questioned the all-round preparedness of junior doctors. She had “grave concerns” about the reduction of faceto-face training with a growing online focus, and important areas of medicine were not getting the attention they deserved.

A hospital trainer on the panel said there were gaps in the system where junior doctors were more likely to see a lung transplant than someone who needs a pap smear. “Some of that training and how registration is achieved will need to be deﬁned because exposure to some procedures in a tertiary hospital will be quite limited, particularly as hospitals become more specialised.” He added community medicine as part of an internship was bound to happen. For now, rotation to hospitals around the state was being used to help close those gaps.

doctors. The struggling learner, whether it be in maths or some element of clinical training, needs scaffolding.” Team-based structure was lauded by the lawyer on the panel who said it was the very thing that held up when things went awry. Trust and team building One doctor voiced his concern about the reluctance of junior doctors to seek help

Need for outcomes en an engineer and A panellist who had been e doing medicine a maths teacher before ch could be learnt told the forum that much acher education. from the structure of teacher nical exposure The competition for clinical and experience meant a junior doctor could graduate withoutt experience in a number of areas. gameWhile some were not “gamechangers” she felt that every rotation nstrable needed to have demonstrable o support our outcomes. “We need to g them some junior doctors by giving d learning will structure. Standardised es for our produce great outcomes

See www.doctorsdrum.com.au See www ww w.d doctor t sdrum.com d m.au

MEDICAL FORUM

NOVEMBER 2016 | 15

‘Training and Dud Doctors’

OTDs and should we be looking to hire more Australian-trained doctors?

recounting just 6% of 60 junior doctors present at another forum said they would approach their supervisor for support. How, he asked, could that culture be changed to encourage people who needed help to seek it from the right people? Mentors and peer support were the common suggestions along with regular feedback from consultants and registrars. Is it time for 360 assessment? [360 is a form of assessment where feedback on an employee’s performance is elicited from subordinates, peers and supervisors, as well as a self-evaluation by the employee themselves.] The panel generally favoured the process but it needed to be done sensibly and carefully to ensure it didn’t become destructive. For one GP on the panel, 360 gave him insight into how others perceived his practice. “Understanding what it means to the person you’re treating ensures that you are giving appropriate care.” However, it does require training. The lawyer on the panel said delivering feedback posed challenges for trainers. Done well the 360 scenario supported the messenger (we’re here

16 | NOVEMBER 2016

to help”) but there are legal challenges with bullying and harassment ever in focus. Training in general practice was brought into sharp focus with a doctor in the audience asking how it could be made more appealing to graduates rather than what he described as a default position. A representative from WAGPET made no bones about the fact that GP training selection was tough and uncompromising. Of the 1500 positions advertised this year, 170 remain unﬁlled because the quality of applicant was not there. “General practice is not the sewer for people who think they can get a job there if they can’t get a job anywhere else,” she said. Drawing students to general practice is an aim of the university trainer on the panel. “Most of the training is done in tertiary hospitals but most of the medicine is delivered in the community. Students need to spend more time with GPs.”

Continuous Learning: The Supervisor Lack of support for overseas trained doctors (OTDs) was raised and the questioner asked if complaints were proportionally higher for

Interesting, the three panellists who tackled this thorny issue didn’t have any facts or ﬁgures. One said we needed to do more training: anecdotally no one should be driving a taxi because they failed the exam and English as a second language should not be a barrier. Another panellist with rural experience said they preferred the term “unfellowed OTDs” – “we do have a problem in some rural and remote areas, which are hardest to staff, we take the doctors who are least experienced from overseas” – whereas greater respect to communities is shown if you can ﬁnd the right doctor for the right area, who can practice with safety. Learning doesn’t stop at fellowship, though creating a culture of learning starts much earlier. Supervisors have an enormous role to play, in the pursuit of standards and lifelong learning according to one panellist. “Nurturing, professional development, supervision and passion are more important for shaping the future career of doctors than anything.” Performance management is a skill not many doctors are well trained in, said one panellist. Colleges are now mandating training for supervisors and a recent conference was convened to establish networks and peer support for GP supervisors. A good supervisor, said one panellist, needs training not to be hasty in passing judgement and in assessment must be spread across not just professional domains but other domains as well.

MEDICAL FORUM

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MEDICAL FORUM

NOVEMBER 2016 | 17

Feature

Hello Consumer Directed Care!

CDC HERE

The aged care sector has often complained it is the poor relation, but government changes next year will see it become one of the most dynamic sectors in health. On February 27 next year, the vision of Living Longer, Living Better, introduced by the Gillard Government in 2011, reaches a milestone. On this date, the world of in-home care becomes a deregulated market and along with that revolutionary change comes stories of endeavour, frustration and, yes, excitement among the organisations which will be delivering the services. The area of most concentrated effort has been the cultural change necessary to transform these organisations – not-for-profit (and in some cases mission based), and for-profit – from care providers to a term now universally adopted, service providers. Their clients are now ‘customers’, who as of next year will decide which organisation provides what services with a budget in their control, subsided by Government, if eligible. Welcome to the world of Consumer Directed Care (CDC). Over the next several pages, Medical Forum retells the conversations with leaders of six aged care organisations to convey their individual stories of change and transition and what it means to them, their organisation, you and, most importantly, the ageing individual hoping to end their days in their own home. It is fascinating to hear how each organisation has set about facing the challenge, which one CEO described as the biggest social change since the introduction of Medicare. The policy has, since conception, had bipartisan political support – a concord that remains an island in a sea of political turmoil. It was popular for two essential reasons – it would save the Government billions as the country hurtles towards an aged care bubble brought on by ageing Baby Boomers and it was what the electorate resoundingly wanted. Votes and a money saver – what politician could ask for more? Over the interceding years, the Government has invested heavily in the MyAgedCare portal with the intention of it being the omnibus for individuals and their families on what will always be, at times, a difficult and tumultuous journey to end-of-life. Hopefully, Living Longer, Living Better will live up to its name. The MyAgedCare website probably does have all the answers, if you know the questions to ask and have the time to navigate through a labyrinth. If you haven’t had a play on this site, do. It is eye-opening and not just as a familiarisation to help your patients. With time’s winged chariot ever hurrying near, it can also offer insight for your own ageing plans. As the program hurtles on, it is expected to offer the transparency necessary in a free market to keep service providers on their game, including cost comparisons between

18 | NOVEMBER 2016

providers, and to keep consumers up-todate with policy changes and subsidy rates, which are reviewed bi-annually and aligned to welfare payments. The concept is based on the individual, their needs and wants to fulﬁl the goal of staying in their own home, so ﬁgures become a little meaningless until you nominate an income as a starting point. However, there are baselines and grades of assessed need. INCOME THRESHOLDS The income point where a co-payment will be charged Single...$25,792 Single, (separated due to illness)... $25,324 Couple...$40,050

HOME CARE PACKAGE LEVELS Subsidy rates paid per allocation day Level 1 (basic care needs)...$22.04 Level 2 (low care needs)...$40.09 Level 3 (intermediate care needs)...$88.14 Level 4 (high level previously Extended Aged Care at Home)...$133.99 ED: There are also subsidies for dementia, veterans, oxygen and feeding tubes.

The steps to get into the system are not complicated, but there are time delays to get ACAT assessment, which is necessary to instigate a care package. Anecdotally, the delays for ACAT assessment are between 6-8 weeks in WA, which is still receiving some state-funds until February. Wait times in the Eastern States are said to be much higher. This could simply be a bubble as people rush to get assessments done before February 27, but the Government will need to ensure there are enough assessors for future demand because unreasonable delays are critical for individuals and their families. However, service providers have indicated to us that interim help can be provided until an assessment was made. Here’s what some of them have to say. Mr Chris How, CEO Bethanie (NFP) Bethanie is doing a lot of work to reengineer itself to position itself in the market and to provide an awesome customer experience. At the same token, the world is not

“

Mr Chris How

going to stop turning come March 1. There will be a slow transition. We are applying the philosophy/approach of CDC across the board – to our retirement villages, residential care, home care and social housing. I find it really surprising that person-centre care is such a talked about topic. Who would have thought that putting the customer in the centre of their own care is so innovative! The customer should always be at the centre of your business. CDC is innovative only in the historical context of health care, which comes from a military model where medical and nursing care is regimented and task orientated. What that does is to create the patient as a passive participant – we ‘do to you, not do with you’. And that’s been translated to aged care. It is a paternalistic model. Changing government policy to deregulate the market and give funds to the consumer rather than the provider is the right model. We have to be flexible and offer services for various stages as people age. That’s at the heart of ‘person-centre care’, providing wants and needs for a particular stage of life. You can’t take a cookie cutter approach. Commerce comes to Aged Care CDC is making Bethanie more commercially astute and we are looking at other industries and how they do things and that’s no bad thing. There are commercial ways to influence your customer base, consider Qantas and its frequent flyer points. These ideas have been around for decades, it’s just that Aged Care has never thought that way. The Bethanie staff has been on a real journey with CDC for the past three years, especially as we come from a benevolent, church-based NFP space. We’re doing subtle things such as changing terminology. The collective term for our clients and residents is now ‘customer’. You can do interesting things around vernacular to change culture. Two years ago we would never have talked about sales and conversion rates and we are now and that slowly changes perception. It’s not confined to us – government is no longer talking about aged care funding, but rather aged care subsidy, which means the individual, if able, needs to put some skin in the game to get the care they need and we have to be able to advise them what their service options are. You can’t do that rapidly. Any provider who thinks they can change the culture of their organisation from one of benevolence to commercial sales in a short period will struggle. This doesn’t change our mission focus – we’re not looking at the commercial aspects to increase the bottom line, but to remain viable so we can maintain mission. MEDICAL FORUM

CDC

HERE It will be a challenge and we will be living in a washing machine for the next 3-5 year but we have a strong strategy that has positioned us well. Having that customer/hospitality approach to services is really where we need to be. When you think of the basic logic of that, how can that be wrong? Ms Michelle de Ronchi, COO St Ives (For Proﬁt) About 18 months ago, St Ives sold its two residential facilities to grow services in the mobile and home-based businesses as the deregulation of the market presents opportunities.

One of the biggest challenges for this industry is workforce sustainability. We know that by 2050 we will need triple the workforce. The current Senate Hearing on the Aged Care Workforce is revealing the cracks and the real risks of casualisation of the sector. Unions want shifts of minimum four hours, while clients are now free to chop and change providers, because that’s their choice.

“

Ms Michelle de Ronchi

There have been huge changes for staff and consumers and there is a danger of industry fatigue. As of July last year we have transitioned about 1000 clients from the old world to the new world. That was bewildering for a lot of people. From a staff perspective, it’s all about looking at the client experience as the most important thing. If clients get a good service, staff are realising they will keep coming back. In the past, the system was very patriarchal: ‘We’ll send Lara to deliver your services and if you don’t like Lara well that’s too bad’. That’s not going to rub anymore because clients are paying for the service. There are potential risks of unscrupulous operators in a deregulated environment so people looking for services need to choose providers carefully. Look at those who provide transparency and haven’t just started up two months ago. Margins will be tight whether you are a for-proﬁt or an NFP. We have invested in technology to help drive that consumer experience, developing a mobile app to monitor our service delivery. The biggest concern clients express to us is late service. Despite best intentions, trafﬁc, breakdown etc can cause delays. Technology adds vale In the past we have relied on manual time sheets and hearing back from clients when something doesn’t happen, often well after the event. Now we have provided all 250 of our mobile staff in WA with a smart phone so any late changes and client alerts are logged into the app. When they arrive at the job, they scan a client barcode which tells us that the carer has arrived safely and updates the time sheet. If the carer has a problem getting to the job, we can alert the client immediately. There is accountability and support for everybody and allows us to stay in touch with our mobile workforce. These workers are undervalued by society yet they do a tremendous job. They work alone and are sometimes the only people our clients see during the week. Educating the public has landed with the providers and our liaison staff work with MEDICAL FORUM

clients and families to help them navigate the system. St Ives has also had booths in shopping centres, visited GP practices and pharmacies. A lot of people even those health professions don’t really understand what these changes have meant. At least we have been able to direct them where to go. CDC is a positive for GPs who are able to keep patients in their homes.

About 80% of my staff is part-time but if we are locked into minimum four hours, it will drive us to put people on casual contracts and that starts another ball rolling. We are competing for staff against acute, disability and residential aged care and we don’t have the population growth to go on. The community needs to embrace aged care. In the recent election, aged care didn’t crack a mention even though it is a $3.1b industry. The sector needs to be acknowledged and valued and deserves more funding than the prisons. Ms Anne-Marie Cox, Silver Chain General Manager, Social Care (NFP) In July 1 2015, the world of Consumer Directed Care in Home Care Packages came to our clients. The ﬁrst wave of change was about choice and control but Ms Anne-Marie Cox I like the word participation – participating in how they want services deployed and for them to know how much their care costs – to themselves and to the provider.

“

The second wave peaks on February 27 with full market deregulation of Home Care Packages where the client has total choice of where they would like their money to go. And so the market is changing with competition and new market entrants and brands popping up. The challenge for us over the past 12 months has been educating clients and encouraging them to take their time to understand what’s right for them so their package can reap the full beneﬁts to help them lead their best life at home. Organisations are creating new troubleshooter roles to help clients navigate the system and we seeing the emergence of private businesses operating purely as aggregators of services. Lots of different solutions are starting to emerge. Clients have to be able to trust whoever they sit down with. It’s not a 30-minute conversation. We don’t think that anyway.

Helping clients, carers and their families to understand what’s available and how that affects their life goals takes time and understanding over a number of conversations. When a GP has a patient in need of help, the ﬁrst thing they need to know is how to access support. Doctors may refer patients to an ACAT and once the assessment is done, a level of care is approved. Eligibilities withstanding, from February 2017 clients will go into a prioritised queue, which the government will manage (the sector hasn’t been informed yet how prioritisation within that queue will be managed). Then depending on your prioritisation, sometime later you get your referral code and have 56 days to choose a provider. I’m sure there will be complexities, particularly in rural and remote settings where clients might not have a choice of provider because the cost of care delivery is much higher, which should not, but will naturally disadvantage those clients. From the moment of entering a service, it is the responsibility of service providers to start building relationships with their clients. Silver Chain has home care and health care divisions, which includes our well known palliative care services, so we can stay with a person all of their life. The next few months will be tricky as we move to that February deadline so clients need to be kept in the loop. Some have the beneﬁt of time, others don’t so it’s important to encourage clients to educate themselves beforehand. Things are changing quickly and so can people’s circumstances. They are the vulnerable ones. CDC should be about building capacity in clients and improving supports to stay independent at home and their budget should be working towards their goals, not just their immediate needs. Ms Jenny Lawrence, CEO, Brightwater (NFP) If you look at the aged care and disability sectors – and we have businesses in both areas – we are living through the biggest social Ms Jenny Lawrence change in Australia since the introduction of Medicare. It’s a very positive change but organisations like ours, and we are not any different from any of the others, have got to respond on a number of fronts.

“

CDC is a completely new way of thinking. We are working with our staff, some who have been with us 40 years, to support them through the changes. The cultural changes are huge. We have to look at our staff culture;

continued on Page 21

NOVEMBER 2016 | 19

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CDC

HERE continued from Page 19 how staff interacts with our clients; how attractive we are to clients â&#x20AC;&#x201C; we havenâ&#x20AC;&#x2122;t had to do that before.

have been working hard to attract staff to the sector and have been innovative in attracting younger people.

Weâ&#x20AC;&#x2122;ve also got to look at the systems and processes we have. So while we have good computer systems they have worked for a different model. We are looking at a customer portal so that clients can log in and look up how much money they have left in their package and then they can communicate with us to let us know how they want to spend it.

Our inter-professional student programs involve students enrolled in medicine, nursing, dietetics, physiotherapy and OT from three universities. Itâ&#x20AC;&#x2122;s a positive way we hope to change perceptions of working in this industry and given that 60-70% of our business costs is staff, it is a priority to keep people happy and well paid and safe in their jobs.

I agree with the change. Once I get to the stage where I need support, I will want to be able to manage my care and my money. Right now the system in WA is still transitioning with the number of packages still licenced by the Government and allocated to various states. Until it becomes fully deregulated, there will be waitlists. Clients hold purse strings Clients will manage their packages and want more control over who comes into their home. They will also want to decide the means by which they remain independent. Weâ&#x20AC;&#x2122;re seeing people choosing to spend their money on things we didnâ&#x20AC;&#x2122;t expect. One person wanted to buy a Thermomix. If you have arthritic hands and you canâ&#x20AC;&#x2122;t chop your food, something like that makes a big difference to your life and your independence. Thereâ&#x20AC;&#x2122;s been very little government support for providers in the transition process. That means there are some advantages for the larger organisations as there is signiďŹ cant investment needed for new software, new processes, websites â&#x20AC;&#x201C; but thatâ&#x20AC;&#x2122;s what it takes in a more competitive world. We are creating a different industry. Workforce issues are substantial. It has stabilised post-boom but by 2050 the workforce in aged care will need to quadruple to cope with the Baby Boom demand. We

Itâ&#x20AC;&#x2122;s my job to demystify the changes so staff can see things from the clientâ&#x20AC;&#x2122;s viewpoint. There will be some people who wonâ&#x20AC;&#x2122;t like working in that way but mostly people will embrace the change. Sometimes we think we know whatâ&#x20AC;&#x2122;s best for the client and changing that attitude is the biggest challenge. The client will now direct care and we need to listen. If the client wants the lawns mowed rather than the bath cleaned, we have to accept that. To ensure needs are being met, we must build really good relationships with clients and families. We have coordinators who assess needs and talk to clients and families â&#x20AC;&#x201C; that relationship is critical. Every so often it wonâ&#x20AC;&#x2122;t work but more often or not we will be able to advise and negotiate. The CDC model is not unlike a hospitality model. It is about trust and relationships. Ms Stephanie Buckland, CEO, Amana Living (NFP) CDC in home care is probably just the beginning of aged are changes but they had to happen.

â&#x20AC;&#x153;

People are increasingly

Ms Stephanie Buckland

expecting to have a say in their own health care and are actively managing that care, so if they are requiring aged care services in general, we expect them to be more educated and savvy about their options. Itâ&#x20AC;&#x2122;s important that consumers are aware of their rights and what services are available. Come March next year the consumer will be sitting with us at the table working through what is the best suite of services â&#x20AC;&#x201C; what is the appropriate suite of services for that person? Itâ&#x20AC;&#x2122;s an interesting question from an ethical perspective. The Government has strict guidelines as to what constitutes a service. One of the challenges from a government policy perspective is how will regulations change as the relationship shifts from one between provider and the government and the consumer and the government to simply consumers and the provider. Consumers will now be scrutinising statements and asking if they are getting value for money. Squeezing the little guys This new competitiveness in the market will put pressure on the smaller providers who are not going to stay competitive. Government is reducing barriers to entry so there will be more entrants in the market but there will also be winners and losers. With more elderly patients staying at home, GPs have an important role to play in their continued management. One of the things that weâ&#x20AC;&#x2122;re doing with home-care clients at the top level is to coordinate what weâ&#x20AC;&#x2122;re doing with the care plan of the clientâ&#x20AC;&#x2122;s GP. We are working on a pilot project with Telstra to enable our home care coordinators, clients and doctor to connect so there can be a three-way consultation, which at the moment isnâ&#x20AC;&#x2122;t very practical. But there are challenges ahead. Recent cuts continued on Page 23

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HERE continued from Page 21 to the aged care funding instrument need to be analysed and home care funding needs to be increased. The most effective way to meet the care needs of our ageing population and reduce overall costs to the government, is to increase Home Care funding above the current Level 4 package. This will give more older people a choice to stay at home for longer. Mr Ashley Butler, WA Manager KinCare (For Proﬁt) Kincare is a private family business established 25 years ago in NSW. It has been in WA since 2007 and it specialises in in-home care. We have about 500 customers Mr Ashley Butler in the WA market and employ about 225 people. We have a number of clients with complex care needs. We have invested heavily over the past 12-18 months to ensure that the customers are at the centre of care – and we have to acknowledge that care could be different for every person. We want Kincare to be an easy business to work with because it can be a convoluted space and we want to help people through the process, alleviate concerns and make it as simple as possible.

We have also invested heavily in employee engagement, training and educating our team about the important role they play. They see the customers every day of the week and can pick up changes in behaviour, in condition and really look for opportunities to engage with family to help them in changing circumstances. Our team is our single most important asset because they are face-toface with the customer every single day. It is an exciting time for in-home care – it is the future. The customer base want to stay at home for as long as they possibly can. A person looking to go into residential care pays a bond of $400,000 perhaps $600,000 or there is an in-home care provision option where you can access Government funds and supplement the number of hours. The cost of a residential bond would give you a lot of in-home care services for a lot of years. Family top – up packages For family not living close to ageing parents, adding an extra $100 a week can increase inhome care and make those family members more comfortable about being away from their parent. In April this year we launched Value Packs at various levels which can drive up 20% additional value. There is a built-in contingency for emergency but the extra hours in the packs allows more activity such as social networking, IT, home maintenance etc. Customers get a clear statement so they know where their money is going and it allows us to lock in staff because we know what services that customer will be receiving.

We are also working on a health package which would include nursing services. Contingencies would be built into those packages depending on how many hours of nursing is required. Currently we have a demographic which doesn't spend and takes the bare minimum but that market will deﬁnitely change in the next 5-10 years when we see the Baby Boomers needing care. They will drive value on their packages. It will be a different dynamic and we must remain nimble as we approach different scenarios. Delays in assessment have seen us working on a transition package. On March 1 there will be more ﬂexibility where if someone has a sudden ‘life event’ and the hospital is looking to discharge, we can put services in to help tide them over until they are assessed and approved. Then they can decide who will provide the services going foreward. If it’s Kincare, great, if not that’s OK too at least they have received services that they needed when they needed them. We are starting to stretch out legs now and are forging good relationships with local GPs, not just with the referral processes but feeding back some of the health information we have collected from clients via our MyKincare app. That’s the kind of social support that people are looking for.

As told to Jan Hallam

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Guest Column

Advanced Planning Lessens Suffering Albany physician Dr Kirsten Auret writes here about her team’s research into advanced care planning and the good news is … it works. I’m a physician living in Albany, which means I may look after a person from ﬁrst presentation of nasty symptoms, supporting their disease management to maximise quality of life and on to providing palliative care at the end of their life. This kind of practice has inevitably meant some of my patients have experienced medical crises before communicating what they would have us do in such circumstances and suffering unnecessarily. These clinical experiences dovetailed with a growing interest in advance care planning (ACP) and the passage of Western Australian legislation in 2010 that strengthened the law around end-of-life care provision. At about that time, my colleague, psychologistresearcher, Dr Craig Sinclair, joined me in the Rural Clinical School of WA. Hence the start our small team’s wonderful ﬁve years of researching ACP in the Great Southern.

Research nurse Ms Jill Thomas, Dr Kirsten Auret, Dr Craig Sinclair and research nurse Ms Fiona Williamson are involved in the RCS study into advanced care planning.

Going through the steps We have come to regard ACP as a health behaviour where patients may be more or less ready to engage in such types of conversations and documentation based on their particular illness experiences, their culture and their social circumstances. Framing ACP, like we do smoking cessation, with a change model in which people may be in precontemplation, contemplation, preparation, action or maintenance phases has been supported by our discussions with elderly residential care patients, those with cancer and those cared for in general practice. A simple prompt to consider ACP coming from a trusted doctor, especially following a change in health such as a new diagnosis or a recent hospitalisation seems to be a quick way of moving some patients into contemplation or action. Equally there are a minority for whom ACP is really ‘not for them’ and they are unlikely to ever engage in the process, rather preferring to leave management decisions at times when they may be unable to speak for themselves to the family or doctors. Our work in the Noongar community and with Dutch and Italian migrants suggest that ACP is a safe topic across these cultural groups but there may be differences in how people would like these discussions to occur and how willing they are to express and document individual preferences. Cultural and social factors As an example, the Noongar people we spoke with said that it was important that ACP was understood as being something “for all Australians” and that such conversations were ﬁrst raised in safe, community-based settings, rather than when a person was

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acutely unwell and perhaps isolated in hospital. Exploring how ACP best happens in rural general practice and hospitals shows us that there is keen interest in ACP and that most healthcare professionals in our region feel that the GP is a central facilitator of the process. Interestingly there are quite clear gaps between discipline groups in regards to who does what. No one seems to feel it is his or her role to ensure documentation is appropriately distributed or intermittently reviewed. Something that clinical teams still need to thrash out in their own contexts!

We are now seeing that engagement with clinicians about ACP has gradually resulted in changed culture and practice The Albany hospital has been a great collaborator and, through working with frontline staff, we have successfully created a locally accessible electronic register of ACP documents, which means it is much more likely that a patient’s plan will be available to the treating doctor in a timely manner. We are now seeing that engagement with clinicians about ACP has gradually resulted in changed culture and practice, with ACPs being done earlier and with patients themselves participating (rather than just their family) and the content of ACP documents being referenced in the clinical decisionmaking record.

Negotiating through conflict At times, ACP can be a tricky process to negotiate, especially if there is family conflict, and we’ve found some things that help. The first is that some of the skill set used by professional mediators in interest-based negotiation can be used successfully in the clinical context. This supplements the skills we are taught about breaking bad news and running family meetings. The Respecting Patient Choices model of using a trained nurse facilitator to provide time and practical assistance to patients and families in completing ACP does work in our setting and has been particularly successful in a recent project based in rural general practice and in the tertiary hospital setting. Helping a vulnerable cohort We are now completing a three-year study with Dr Fraser Brims’ group at SCGH Respiratory Unit looking at ACP in severe respiratory disease. The ‘surprise question’ was asking if the doctor would be surprised if a particular person died within the next 12 months. It has helped us identify a very sick cohort with over 30% not living out a year. We have clearly demonstrated that the nurse facilitation model does increase uptake of ACP in such patients. We look forward to reporting on the health-related quality of life, satisfaction with care and actual end-of-life care experienced by our participants. As part of this work, we will also be able to explore the health economic impact of ACP within our state health system. Important results are anticipated!

NOVEMBER 2016 | 25

Feature

Never too Old for an Artistic Life A collaboration between dementia patients and artists has produced outstanding results and hours of pleasure for all. A creative collaboration between Amana Living and Black Swan Portraiture Prize is a win-win for everyone. Amana residents have enjoyed workshops and screen printing sessions to create Andy Warhol inspired self-portraits, some of which will be exhibited in the Perth Cultural Centre. Amana Living Enrichment Manager Ms Emily Scarff is doubly pleased with a project that forms part of the Amana Spring Arts Festival. “It’s been a wonderful partnership, the ﬁrst

time for both organisations to team-up in this way. Black Swan has never been involved with an aged care group before and this is the ﬁrst time for us to be involved in an artistic endeavour.”

mentor our residents but they also speak passionately about their work and that’s taken this project to a new level.” Enrichment rocks!

“We expected a few hiccups but we’ve been pleasantly surprised.”

“Our residents quickly realised that this was a lot more than their usual Thursday morning craft activity!”

“There’s nothing particularly new about offering arts and crafts to older people but what’s different here is that we’ve got professional artists sharing their skills. They

The importance of enrichment programs can’t be overstated, says Emily. But the storm clouds of economic rationalism loom large.

Targeting ‘Ringing in the Ears’ Tinnitus is associated with deafness and can be helped by hearing aids, which is probably why many think of tinnitus as affecting just the elderly. Sure, age-related hearing loss and exposure to loud noise are predisposing factors. However, according to the Australian Tinnitus Association, around 20-30% of people experience tinnitus at some point in their lives, at any age, and it is persistent in about 10% of Australians. Australian Hearing hold regular workshops for tinnitus sufferers: this month’s meetings are November 23 (Bunbury) and November 30 (Busselton and Mandurah). Those with

26 | NOVEMBER 2016

tinnitus or their carers can attend (phone 97921200) – sessions are free and most appropriate for those over 18 years. The technologies available and suggested lifestyle changes are discussed. We know tinnitus is more common in people with a hearing loss or other ear problems but it can occur in people with normal hearing – annoying tinnitus can lead to fear, anxiety and depression, with frustration from poor concentration or hearing. How an individual thinks and feels about tinnitus is important. From the doctor’s perspective, some medications can cause or worsen tinnitus (see www.tinnitus.asn.au) – aspirin, quinine,

aminoglycoside antibiotics, diuretics and some cytotoxics are the most well-known. Other common suggestions for management include avoiding silence, doing things to keep calm and relaxed, and limiting caffeine. Removing excessive earwax can also help. Patients can ask for online advice from an audiologist and get other information at www.hearing.com.au As an aside, we are told celebrities that have suffered from tinnitus include Liza Minelli, Bob Dylan, Will.i.am, William Shatner and Barbara Streisand.

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“I see my role as an important one, enabling older people to live the second half of their lives in the best possible way. It’s all well and good providing nursing and basic needs care but that needs to be complemented with meaningful activities that enrich lives.”

Emily Scarff

“That’s why this partnership with Black Swan and the artwork that’s coming out of it is so important.”

“This is a sector that has the potential to be severely affected by funding cutbacks and enrichment programs may well end up being ﬁrst in the ﬁring line. The market economy is becoming increasingly deregulated and while it hasn’t hit residential aged care quite yet, it will do.”

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Everyone is welcome Emily tells the story of one woman who beneﬁted from the inclusiveness of the Black Swan/Amana art program. “This person heard the group laughing and joined us at the table. She’s severely vision impaired and would often miss out on some of the activities but we were able to tailor the screen printing by talking about images and colours. She was actually able to ‘feel’ the ink sliding over the screen.” “My background is in occupational therapy so I try to look at ageing in a holistic way. I spend a fair amount of time thinking about that and it’s certainly given me a greater appreciation of my own grandparents.” Ms Tina Wilson is the Executive Director of ARTrinsic, the not-forproﬁt organisation behind the Black Swan Portraiture Prize, and is a passionate advocate for the visual arts in WA. “We approached Amana with the idea of doing these workshops and it’s turned out to be something exceptional! Amana also sponsors the People’s Choice Award, which encourages people to visit the exhibition and that, in turn, creates healthy debate and community engagement.”

Tina Wilson

“Anything that raises public awareness of older people is good because they’re often not given much prominence in current society.”

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“I haven’t got parents in aged care so I’m not too familiar with this area. It was wonderful to walk in and see the residents engaging with something that was obviously bringing interest and joy to everyone in the room. One lady was proudly holding up a pillowcase with her face on it and showing it to everyone!”

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“The faces of older people have so much character and that intensiﬁes with age.”

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Tina, an artist herself, sees the spin-offs from creative expression in highly social terms. “I see portraiture as a real opportunity to build a sense of community. In so many ways, it’s really all about people. When visitors come into a portrait gallery it generates so much conversation, the paintings tell human stories.” “So much of today’s world is obsessed with 10 second soundbites and a collaboration such as this is all about making long-term connections between people.” “I hope this project raises awareness and appreciation of older people. It’s so important to get their stories out there and give them the respect they deserve. We’re all going to be old one day!”

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28 | NOVEMBER 2016

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Guest Column

GPs and the Aged It’s not all doom and gloom treating the elderly, suggests Dr Chris Fox. And there’s the added bonus of valuable insight into our own lives. As GPs we see patients of all ages but, if you stay in one place long enough, the appointment book ﬁlls up with lots of elderly patients with complex problems. We see them quite often and become familiar with their histories, their personalities, their foibles. If we’re doing our jobs well, they place trust in us and we become an essential support in their lives, particularly as they become frailer. And that’s a salutary reminder that we’re all on the same chronological conveyor-belt. So it makes sense to treat our elderly patients as we would like to be treated. Our youth-obsessed culture tends to view ageing as a descent into inﬁrmity, ineptitude and irrelevance. Government health departments and medical insurers have a tendency to quantify the cost of the ‘Aged’ in monetary terms. If we look at the cost of health care in an average person's life, the bulk of it is concentrated in the autumn years and even more so in the last few weeks of life. We’ve all seen elderly people who see

Our youth-obsessed culture tends to view ageing as a descent into inﬁrmity, ineptitude and irrelevance.

themselves as a burden to society. It’s hardly surprising that depression is relatively common and we, as GPs, need to be careful that we don’t confuse it with cognitive impairment. And yet there’s a tendency for some elderly people to try and hold on to the past with a thoroughly natural yearning to retain all the vigour and relevance they can muster. This can translate into a fear of change leading to a reluctance or refusal to comply with treatment regimes. We’re all well aware of the rising tide of geriatric Baby-Boomers but it’s important to acknowledge that every ageing patient is unique. Clear communication with a healthy dose of empathy is absolutely indispensable,

particularly when we have to strongly suggest that having a driver’s licence may not be such a good idea. I've worked in palliative care with Silver Chain Hospice for many years and it has strongly influenced my work as a GP. Here’s one story that’s instructive. A woman in her 90s with dementia was referred to the service. She was living in an aged-care hostel, her family was distressed to find her continually agitated and she felt that no-one really cared about her. A few years previously, she’d said that she wouldn’t want ongoing treatment if the quality of her life had diminished. Consequently, the family wanted us to cease her medication and allow her to pass away peacefully. The only trouble was that with the support from our service and the residential staff she brightened up considerably. She became more engaged, was clearly happier and ended up being discharged from the hospice. And that leads me to one of the positive aspects of our job as GPs. Sometimes we’re able to tell an elderly patient that they’re doing fine and just go out and enjoy life!

stiveshomecare.com.au MEDICAL FORUM

NOVEMBER 2016 | 29

Guest Column

No Progress Without Research Volunteering for medical research is a “win-win” for all concerned says Dr Natalie Ward from the School of Biomedical Sciences at Curtin University. Medical research is an important and necessary part of our health system. It’s a fundamental tool for driving change and underpins major advances in modern medicine. Clinical trials form the basis for the development of new therapies and treatment options, and often have the added benefit of exploring important preventative measures. There are many different reasons why an individual might volunteer for a medical research study. They often do so because they want to improve their own health and there are others who hope that the findings may help someone else, too. Altruism, in other words and that’s a very good reason. Medical researchers are always grateful to see a volunteer walk through the door. They make a valuable contribution to every project and, just as importantly, they get something back in return. Some of the benefits include a comprehensive medical review including an ECG and blood analysis over a lengthy period, depending on the nature of the study. Participants in research are also more aware of their own health and also more attuned to any significant changes. One of the real

If a change in medication implemented by an individual’s GP compromises the integrity of the research study, then, such is life! pluses is that feedback on health status, from blood analysis to diet, is sent to the volunteer’s GP as well. However, despite this ‘win-win’ scenario, recruiting volunteers for medical research is frequently a long and difﬁcult process. Understandably, study-speciﬁc exclusion criteria often limit those who can take part in a particular study but there’s also an underlying lack of awareness regarding the importance of medical research. There may even be some understandable trepidation that studies may actually be harmful or have unintended consequences. Any person considering putting their name forward should be assured that strict protocols are in place and ethical considerations have been rigorously assessed

before a clinical study is implemented. And, of course, any vested commercial interests linked with a particular study are openly discussed in the initial stages of every research program. When a person volunteers for any form of medical research they should do so knowing that every precaution is taken to ensure that the process is both safe and potentially beneﬁcial. Furthermore, all volunteers are monitored throughout the study and any adverse events are noted and prompt action taken. Any treatments are only administered after extensive background checks and researchers would always consult with a participant’s GP about these matters. If a change in medication implemented by an individual’s GP compromises the integrity of the research study, then, such is life! So for all the GPs out there, if any of your patients express an interest in volunteering for a medical research project there’s really nothing to lose and, potentially, a lot to gain for everyone!

BreastScreen WA is going paperless for GPs I’m excited that BreastScreen WA is changing the way they communicate with GPs. Shortly, GPs will receive the majority of correspondence (patients’ normal results and screening reminder letters) by electronic secure messaging. If you do not wish to receive your patient’s screening mammogram results electronically please email BreastScreen WA at breastscreenwa@health.wa.gov.au

Sep 2016

- Dr Jas Mudhar, Cannington GP -

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

30 | NOVEMBER 2016

MEDICAL FORUM

Guest Column

The Sharp End A lot can happen when you're 10,000m above the ground. An inflight medical emergency conjures up a variety of scenarios, says Capt. David Martin. We’re sitting there, five miles above the earth, and hoping that today is not one that goes horribly wrong. Modern aviation is safe and highly routine, however, when problems occur things can turn pearshaped rapidly. Engine failure or fire, severe weather and turbulence are some of the scenarios that spring to mind but an inflight medical emergency poses some interesting dilemmas. There’s the balancing act between aircraft safety and the convenience of other passengers compared with the health concerns, often serious, of one individual. When someone is unwell and flying at a relatively high cabin altitude (possibly several hours from an airport let alone a hospital), the decision-making process can be problematic, at best. In the course of my airline career I’ve had to deal with medical issues from scuba-diving related Bends, to seizures, hypoxia and significant cardiac events. I’ve even heard another aircraft reporting an on-board brawl to Air Traffic Control (ATC) and requesting a medical team and police to meet the aircraft on arrival.

woman had gone into labour. We placed her in a more comfortable crew bunk and considered our options. Fortunately the weather was fine and there were a number of suitable alternate airfields along the east coast. We prepared for a potential change of destination and made radio contact with the RAAF Senior Medical Officer.

Here’s the balancing act between aircraft safety and the convenience of other passengers compared with the health concerns, often serious, of one individual.

We were able to listen to the ongoing dialogue between patient and doctor and descended to a lower altitude to minimise the time required to divert to an alternate airﬁeld. All the time this was going on I wondered if I’d be the ﬁrst Hercules captain to announce that the number of persons on board had increased by one!

I also know of at least one inflight suicide attempt, unsuccessful thankfully. And, of course, people do die. The cabin crew are then faced with the unenviable task of securing and screening the body in an often crowded passenger cabin. Flight attendants have basic first-aid certificates, there’s on-board medical oxygen and most airline operators carry a portable defibrillator. Before I joined the airlines I was in the Royal Australian Air Force (RAAF) flying C130 Hercules aircraft and one day, flying between Sydney and Townsville, we were presented with the following situation. I was advised by the loadmaster that a

Fortunately, the patient’s condition stabilised and we continued on to Townsville. An ambulance and medical team met our aircraft and took the woman to hospital. Later that night, we were informed that she’d been suffering from anxiety and stress and hadn’t gone into labour at all. Nonetheless, we weren’t to know that at the time and decisions had to be made. The buck stops with the captain and it’s my name on the ﬂight-plan.

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MEDICAL FORUM

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Clinical Update

Preventing stroke

PIVET MEDICAL CENTRE

By Clin A/Prof Timothy Bates Medical Head of Stroke Service SJOG Midland Age is undeniably the greatest risk factor for stroke. Whilst non-modiﬁable, it reminds us that choices made in early life can have consequences later. All the risk factors mentioned below contribute to the increased stroke risk through all age groups, but especially older people. Risk factors explained

While the ED neurological disability that comes from stroke is well known, the ageing population means there is growing emphasis on identiﬁable risk factors. So what interventions work?

Hypertension is the leading modifiable risk factor for stroke and has multiple ways of causing stroke, including small and large vessel cerebrovascular disease, atrial fibrillation and left ventricular dysfunction. Recent trials have given discordant findings as to the degree of blood pressure lowering required for benefit. A pragmatic individualised approach of life style modification (e.g.; salt restriction, weight reduction) and medication to reach a systolic blood pressure of under 140mmHg is reasonable.

Lifestyle factors account for much of the observed modifiable stroke risk. Tobacco consumption, excessive alcohol intake, poor diet, lack of exercise and increased waist to hip ratio all increase stroke risk, and can also lead to other vascular diseases and malignancies. Abnormal lipids are a stroke risk factor, but are relatively more important in coronary artery disease. Consider treatment in those who qualify for lipid lowering therapy as per current guidelines. Although diabetes is a significant stroke risk factor, treatment hasn’t been shown to be significant in terms of stroke reduction, unlike microvascular complications of diabetes. Either way good control of diabetes should lead to stroke reductions. Atrial fibrillation (AF) is often protean and undetected until the time of stroke. Many AF strokes sit at the more severe end of the spectrum and frequently in elderly people. We need to identify and anticoagulate as many with AF as we can to prevent stroke including the elderly with a reasonable quality of life. Antiplatelet agents are not a suitable alternative. Post-stroke interventions Medication nonadherence is endemic worldwide. It is estimated that up to two thirds of patients discontinue their cardiovascular medications after stroke. Merely increasing compliance would lead to substantial reductions in all types of vascular disease. Finally, there is another prevention strategy. Many people can’t recognise stroke and have no idea what to do with someone having one. The NSF FAST (Facial weakness, arm weakness, speech disturbance, time to act) message is an easy way to educate patients. If people arrive at hospital early they may be able to access reperfusion therapy such as thrombolysis and clot extraction, which are both effective, but time dependent (preferred within 4.5 hours).

KEY MESSAGES så 3TROKEåISåTHEåMOSTåCOMMONåCAUSEåOFåACQUIREDåADULTå neurological disability. så 2ISKåFACTORåMODIlCATIONåCANåLEADåTOåSTROKEåREDUCTION åESPECIALLYå via anticoagulation for AF. så !DDRESSINGåMEDICATIONåNON ADHERENCEåANDåEARLYåPRESENTATIONå could lead to substantial beneﬁts.

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by Medical Director PROF JOHN YOVICH

Ovarian stimulation ... gentler, safer with targeted efﬁciency PIVET has been exploring treatment algorithms aimed at gentler stimulation for younger women with high ovarian reserve and stronger dosages for those, often older cases, with low ovarian reserve. Our latest rFSH dosing algorithms have recently been published in the prestigious journal Drug Design, Development and Therapy (2016:10 2561-2573). With the aim of collecting around 10 oocytes per case (a safe number to avoid OHSS; ovarian hyperFig 1: Proportion responding without stimulation syndrome), dosage increase. it shows that 24% of women respond well to dosages under 150 IU, whilst 48% of women require more than 300 IU to attain the appropriate response (Figure 1). World-wide the standard dosing schedules range from 150 IU to 225IU for most Fig 2: Egg numbers across all ages 20-51 clinics but egg numbers recently reported years. exceeded 15 in 38.2% compared with PIVET’s 11.6% (p<0.0001) which means most women outside PIVET are given dosages excess to need. OHSS has been an unpleasant side-effect of ovarian stimulation from the outset of using gonadotrophins in the 1960s and many women have required admission for complex IV ﬂuid management along with paracenteses to drain ascites and pleural effusions as well as managing increased coagulopathy in extreme cases. Until recently most clinics reported 5-10% severe OHSS cases, and mortality has sometimes resulted. These cases were mostly associated with high oocyte retrievals (>15 eggs) and often highorder multiple pregnancies in the early period of ovulation induction. In Australia these problems have been controlled by ancillary strategies including a freeze-all policy when oocytes exceed 20, an uncommon event at PIVET nowadays (Figure 2). Applying the PIVET algorithms, OHSS is a rare event, occurring only when clinicians “over-ride” the algorithm dose trying to appease patients who believe their best hope is in “pushing the boundary”, an outmoded idea. PIVET continues to have results in the highest quartile for frozen embryos (Top of the Wazza) whilst collecting around 10 oocytes per case.

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Author competing interests: nil relevant disclosures. Questions? Contact the author 9462 4000.

MEDICAL FORUM

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

NOVEMBER 2016 | 35

Clinical Update

Resistant Gram negatives - a growing threat Since the early days of penicillin we have assumed infections are treatable and curable but we cannot be so conﬁdent now. Resistant Gram negatives have arrived in our community and are here to stay. Without a serious effort from every prescriber to change how we use antibiotics the future looks grim and we risk a return to the pre-penicillin era of people dying from untreatable infections.

Antibiotic resistance is a growing global problem and dealing with it appropriately requires a major shift in professional behaviours.

Her gut will continue to be colonised with an extremely resistant organism, with no effective eradication treatment. What happens when this E.coli acquires a carbapenemase plasmid that renders meropenem ineffective? And how did she acquire such a resistant organism, given she had never been in hospital and had no prior medical history? This organism is already in our community. Rapid resistance spread Enterobacteriaceae acquire resistance genes on plasmids that spread between organisms rapidly. Previously susceptible bacteria are

over 50%. There have been outbreaks of highly resistant Klebsiella sp. in Victorian hospitals traced back to individuals who travelled to Italy and Greece. With frequent travel overseas, many resistant Gram negatives are imported in peoples’ gastrointestinal tracts.

Case in point Recently I saw a young woman with pyelonephritis from an extended-spectrum betalactamase (ESBL) E.coli resistant to all antimicrobials, except carbapenems. Given there was no oral option for her treatment, she was hospitalised and received meropenem, usually a ‘last resort’ antibiotic for the most resistant of Gram-negative infections. While she recovered, this story has some pessimistic overtones.

By Dr Astrid Arellano, Infectious Diseases Physician, Palmyra

GNR infections have higher mortality and morbidity rates (18-48%). Even in less severe infections, morbidity and costs can be higher because parenteral therapy is needed when no oral options are available. rendered resistant. More than one plasmid can spread at once rendering several classes of antibiotics useless in one bacterial interaction. Billions of bacteria colonise our gut and resistance plasmids spread quickly within and between people, so that resistant Gram negatives (GNRs), for which there is no effective eradication therapy, become part of the individual’s normal ﬂora. Most GNRs are acquired and circulate primarily in hospitals and aged care facilities. This case heralds a scenario feared for years - highly resistant Gram negatives in the community. Australian rates are low but have doubled in eight years to around 4%, while South East Asia rates of carbapenemresistant E.coli (CRE) are 25-40%, and the Indian subcontinent and China have rates

Solutions in our hands A multi-pronged approach is needed. Most important is the practitioner’s ownership of the problem, asking whether an antibiotic is really needed. We hear how “just in case” antibiotics are prescribed without a clear infection diagnosis, when in reality very few people become septic in a timeframe that does not allow appropriate action. Harm is done by exposing the person’s colonising ﬂora to multiple broad spectrum antibiotics – emerging resistance precludes antibiotic use when really needed. Studies show that up to 50% of antibiotic prescribing is incorrect. Aged care facilities have one of the poorest prescribing practices. Each year 50-75% of residents receive at

såBunbury GP Dr Andrew Kirke has joined the board of Rural Health West. såMs Malvina Nordstrom is the new WA state manager of IPN. såMr Paul Forden has been appointed to Executive Director for Fiona Stanley Fremantle Hospitals Group.

We are located close to the Swan River and offer a variety of specialties. Southbank Day Surgery has established an excellent reputation in the community for its high commitment to customer service, patient care and quality improvement.

såDr Ric Charlesworth (AO), Dr Jack Edleman (AM), Prof John Fletcher (AM). Dr Hannes Gebauer and Dr Diane Mohen were all recognised in the Queen’s Birthday honours in September.

We have undergone major refurbishments which include six theatres, CSSD and Dermatology and consisting of three procedural theatres. These are speciﬁcally designed to meet all Moh’s (Microscopically controlled surgical technique to remove skin cancers) patient needs. These have been designed to cope with the growing needs of the hospital and community.

såUWA medical student Will Crohan has won this year’s Alan Charters Prize for his essay on his overseas clinical placement in Lesotho. Meredith Cully won the WAMS Elective Photograph Competition for a picture taken during her placement in Timor.

Any queries please contact Bronwyn Grant on 0429 368 730 38 Meadowvale Ave, South Perth WA 6151 PH: 0893687344 WEB: www.southbankdaysurgery.com.au

såDomestic violence survivor and advocate Dr Ann O’Neill PhD has been awarded the John Curtin Medal 2016 for her efforts in raising awareness and providing support to victims of family violence.

36 | NOVEMBER 2016

MEDICAL FORUM

Clinical Update

Managing Infections by Multi-drug Resistant Gram Negative Bacilli Treatment

ESBL Enterobacteriaceae

Carbapenem-resistant Enterobacteriaceae

Mild illness e.g. cystitis (Must have symptoms of UTI, beware of asymptomatic bacteriuria which does not require antibiotic therapy)

Trimethoprimsulphamethoxazole or ďŹ&#x201A;uoroquinolone can be used if susceptible.

Always discuss with infectious diseases physician or microbiologist. Often no oral therapy available.

Severe illness requiring intravenous therapy (includes pyelonephritis)

Discuss with infectious diseases physician or microbiologist. Typically treated with carbapenem e.g. meropenem. Maybe aminoglycoside or quinolone, if susceptible.

Always discuss with infectious diseases physician or microbiologist. Requires specialised therapy.

McGreer infection criteria and only 20% had a microbiological specimen collected. Residents with impaired communication can have clinical deterioration without localising symptoms, making urinary tract infection difďŹ cult to diagnose. However, treatment of asymptomatic bacteriuria contributes to excess antimicrobial use in these facilities, as does inappropriately prescribed antibiotics for general deterioration of uncertain cause.

Glossary

In this environment judicious antibiotic prescribing is likely to have the greatest impact and antimicrobial stewardship programs (required for hospital accreditation) will likely reach aged care facilities soon.

Plasmid: small mobile DNA package within bacterial cytoplasm containing resistance genes.

least one course of antibiotics. A recent Aged Care National Antimicrobial Prescribing Survey showed 70% of antibiotic prescriptions had no documented indication. In 60% there was no stop or review date. In one third of cases antibiotics were prescribed for longer than six months.

Antimicrobial use in our community is vast and extends beyond our prescriptions. Animal feeds and crops are affected in agriculture. National strategies now restrict agricultural use of antibiotics used in humans. There is also a push for a national database for antimicrobial prescribing, improving rapid microbiological diagnostics and reducing barriers for antimicrobial development.

Over 60% of residents did not meet

References available on request.

Extended spectrum beta-lactamase (ESBL): bacterial enzymes that confer resistance to beta-lactam antibiotics, including penicillins, cephalosporins and the monobactam aztreonam; Enterobacteriaceae: large family of Gram-negative pathogens such as Salmonella, Escherichia coli, Klebsiella, Shigella and Yersinia.

Carbapenem-resistant Enterobacteriaceae (CRE): Gram-negative bacteria resistant to carbapenem class of antibiotics, a class of drugs of last resort for multi-resistant Gram negative infections. ED: Pictures courtesy Dr Jonathan Chambers, Fiona Stanley Hospital

Author competing interests: no relevant disclosures. Questions? Contact the author on 9319 3811

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MEDICAL FORUM

NOVEMBER 2016 | 37

Fertility, Gynaecology and Endometriosis Treatment Clinic

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MBBS, MRCOG (UK) CCT (UK), CGES FRANZCOG

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Fertility, Gynaecology and Endometriosis Treatment Clinic 38 | NOVEMBER 2016

MEDICAL FORUM

Clinical Update

Exercise reduces dementia risk Dementia incidence in developed countries is falling! This has been attributed to better education building stronger neural networks, and better population control of cardiovascular risk factors. Smoking, diabetes, hypertension, obesity and physical inactivity are strongly linked to risk of dementia.

By Dr Sean Maher, Geriatrician, SJG Mt Lawley

We hear much ED about lifestyle modiﬁcations reducing dementia risk. What does the evidence tell us is good advice for patients?

One longitudinal study showed being overweight at 50 correlated with risk of Alzheimer’s Disease (AD). The higher the BMI, the earlier the onset of AD, and the greater the burden of beta amyloid seen on PET scans and neuroﬁbrillary tangles at autopsy.

Another study showed that the fittest at age 50 had a 36% less chance of dementia than the least fit. Evidence shows improved cognition with exercise at all ages. Several randomised trials show significant cognitive benefits in older people undertaking moderate-intensity exercise for 150 minutes per week for six months, compared with gentle stretching exercise. Improvements are seen in executive functioning, and are durable, with benefits lasting for at least 12 months. Grey matter volumes on MRI improved and beta amyloid decreased. Which exercise? Resistance training benefits executive function while aerobic training improves verbal memory. Australian guidelines for physical activity recommend 30 minutes of moderate intensity aerobic activity (e.g. walking, swimming) on most days, and strength or resistance (e.g. weights) two days and including flexibility/balance activity where possible daily (e.g. tai chi, yoga). Further work is needed to provide the optimum balance of duration and intensity. Participating in cognitively stimulating activities and remaining socially engaged is associated with reduced dementia risk. Formal cognitive training can result in long lasting benefits. Evidence that it can delay dementia is limited. Social engagement is highly desirable for mood and quality of life. Consuming “brain healthy” foods and limiting unhealthy ones also has cardiovascular benefits. A 10-year study showed those with the best adherence to a variation of the Mediterranean diet, the MIND diet, reduced their AD risk by up to 53%. Modestly following the diet reduced risk by 35%.

THE EAR & CARDIOVASCULAR FUNCTION

Anne Gardner

Andre Wedekind

Post Dip. Aud., BSc

M.Clin.Aud., BHSc (Physiotherapy)

Dr Vesna Maric AUD., M.Clin.Aud., BSc (Hons)

The inner ear is particularly vascular and thus it is sensitive to poor cardiovascular function. Haemorrhagic or ischemic changes of the inner ear can manifest as a hearing loss with recent research indicating an initial decrease of low frequency hearing in such individuals. Cardiovascular risk factors coupled with an initial low frequency hearing loss may be used in the future to assist in Ì i i>À Þ `i Ì wV>Ì v V>À` Û>ÃVÕ >À ` Ãi>Ãi° Smoking and its effect on the cardiovascular system Ài«ÀiÃi ÌÃ > ` w>L i À Ã v>VÌ À v À i>À } ÃÃ° - } may impact the auditory system directly by its ototoxic effects, as well as indirectly by the vascular effects of smoking, such as increase blood viscosity and reduced availability of oxygen causing cochlear hypoxia. Smokers are 15% more likely to have a hearing loss than nonsmokers. The link of smoking with hearing loss risk has been shown to be dose dependant, so that the risk of hearing loss is increased in people who smoked more. Diabetes is known to be associated with cardiovascular disease. Uncontrolled type 1 or 2 diabetes can lead to angiopathy as well as neuropathy and these individuals are twice more likely to have a hearing loss compared to those without diabetes.

Multiple modalities is best

Hearing loss cannot be attributed to diabetes alone because of other compounding variables (presbycusis or noise exposure for example). However, the pathogenic effects of diabetes on the ear are thought to be due to both angiopathic and neuropathic properties.

In a Finnish RCT, 1260 older people at risk of dementia were advised that diet, exercise, mental stimulation and social activities could reduce vascular risk factors and dementia risk.

High blood glucose levels associated with diabetes can cause damage to the small blood vessels of the inner ear, similar to the way diabetes can damage the eyes and kidneys.

The intervention group received an individual diet, physiotherapistguided strength and aerobic training, computer-based cognitive training, group meetings to increase social time and more frequent feedback from clinical staff about their progress. After two years, the intervention group increased their cognitive scores by 40%, and reduced their vascular risk factors. Follow up over ﬁve years will examine if there are fewer cases of dementia.

Further, current research is investigating the effect diabetes has on the auditory nerve, with reports showing myelin `i}i iÀ>Ì > ` wLÀ Ã Ã v Ì i «iÀ iÕÀ Õ Õ V ÌÀ i` diabetics. References on request

Making these lifestyle measures enjoyable and accessible will have the best population beneﬁt. Proven risk reduction programs may warrant reimbursement from health funds and Medicare! References on request. Author competing interests: no relevant disclosures. Questions? Contact the author 9370 9329

MEDICAL FORUM

51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au

NOVEMBER 2016 | 39

Clinical Update

Too early for residential care placement? Moving to long-term residential care is a life changing decision, perhaps emotionally devastating as it represents a loss of independence or separation from loved ones. It may be inevitable but many forms of alternative support are designed speciﬁcally for people with substantial needs but that do not need full-time care or who can live with disability, safely at home. Premature access to costly nursing care in a residential facility may preclude another person with disability from the necessary care.

Dr Michelle Mei Yee Lai, Deputy Director Medical Education FSH, Geriatrician and Perioperative physician, RPH and SJG Subiaco

and managing dementia to delay cognitive symptom progression. If family or spouse cannot provide tangible support, the clinician can initiate home care packages or HACC programs for people living with a disability – to promote quality of life and without losing independence that keeps them at home. By organising respite care in situations when the person’s carer is unavailable (e.g. spouse hospitalised or family travelling overseas), the person’s care needs can be met without the need for permanent placement.

Moving into full-time residential ED care is not taken lightly by patients. There is much the attending physician can do to assist patients struggling to live independently as this author tells us. with dementia, the current view supports an ongoing use of dementia drugs, as the withdrawal of optimal treatment is shown to double the risk of placement during 12 months of treatment2.

Questions to prevent premature placement CASE REPORT: A man on a disability pension due to chronic back pain from a car accident, presented with severe acute pain after a fall but was considered safe to discharge from the ED. Since then, he mostly stayed in bed and concerned neighbours brought him meals. Requiring increasing doses of opioids for his back pain, his GP was concerned he may no longer be able to live at home and referred him to Aged Care Assessment Team (ACAT).

Some situations, difﬁcult to assess for family physicians, may be reversible without resorting to unnecessary placement in a care facility. When a person shows signs of struggling to live independently, ask these questions: 1. What is the patient’s premorbid function? Patients often compensate well in the setting of chronic conditions and continue to live independently with stable functional capacity. Those who live alone or socially isolated, physical frailty, have multiple comorbidities and polypharmacy are at risk of premature placement. Recent changes in mobility or function are red ﬂags that should prompt a review.

His recent functional decline prompted the ACAT social worker to look further and after discussing with a geriatrician, the patient was admitted to subacute hospital care.

2. What is the trigger? Explore reasons for an increase in care needs, such as intolerance to new medication, undiagnosed altered cognition and recent acute medical illness. Care needs may be met with family or community support without placement. 3. Are contributing factors reversible or transient? Identifying and addressing factors that contribute to unmet care needs can delay placement. Reversible causes may be medical (overuse of drugs and suboptimal pain control), social (family on holiday) or psychological (self-neglect due to depression). The care needs may be transient while the initial triggers are being addressed. 4. What support systems are available? Social isolation or changes in social circumstances can be challenging but can be manageable with family support e.g. a new widow. Formal support service or respite care can be used to maintain the well-being of family carers and to prevent stress-related burnout. Simple questions to carers such as asking, ‘How are you coping?’ may uncover issues before a crisis. How can clinicians help? Early recognition and treatment of underlying conditions can reduce care requirements and costs in the long run. Examples include treating asymptomatic osteoporosis, using rehabilitative therapy to regain function after deconditioning from acute illness,

40 | NOVEMBER 2016

Diagnoses of severe vitamin D deﬁciency and a new T12 osteoporotic fracture were made. With vertebroplasty and optimisation of analgesia, he made functional gains to return home with a gait aid.

Prescribe for the elderly cautiously and ‘do no harm’ – regular reviews to keep treatment regimens as simple as possible is a useful strategy because those on complex medication regimes are prone to noncompliance and drug interactions. These can lead to non-speciﬁc symptoms and falls, and a cycle of ‘prescribing cascade’ (i.e. new medications are used to treat the side effects of another)1. Deprescribing high-risk and nonessential medications, and a Webster pack or medication monitoring may help. In patients

KEY POINTS så &ORåPATIENTSåSTRUGGLINGåTOåLIVEåå independently the solution may not be full-time residential care. så 4HEREåAREåKEYåAREASåTHATåDOCTORSåCANåå reassess to lighten the patient's load.

Finally, encourage partnerships between carers and community health workers. The carers keep patients socially engaged, and monitor their well-being. They should be encouraged to raise concerns. If in doubt, liaise with ACAT clinicians or case managers to explore supports available in the local community as alternatives to placement and arrange the best use of community services for assisted living at home. References 1 Kalisch LM, Caughey GE, Roughead EE, et al. The prescribing cascade. Aust Prescr. 2011;34: 162-6. 2. Howard R, McShane R, Lindesay J, Ritchie C, Baldwin A, Barber R, et al. Nursing home placement in the Donepezil and Memantine in Moderate to Severe Alzheimer's Disease (DOMINOAD) trial: secondary and post-hoc analyses. Lancet Neurol. 2015;14(12):1171-81.

så 4HEREåAREåDOCTORåINTERVENTIONSåTHATåå can work. så 4HEåRESULTSåMAYåNOTåBEåEASYåBUTåCANåå be rewarding.

MEDICAL FORUM

Clinical Update

Managing adult autism spectrum disorder Autism Spectrum Disorder (ASD) has a frequency of one in one hundred , thus GPs will be managing increasing numbers of individuals with ASD. What are some of the challenges that general practitioners face? About 60-70% of those with ASD have an intellectual disability and about 30% have no or minimal language, making communication difﬁcult or impossible.

By Prof Sergio Starkstein School of Psychiatry, UWA, Fremantle Hospital & Autism Assoc. of WA

Autism ED spectrum disorder is increasingly recognised in children. But what happens when these children grow up?

Compounded with the high threshold for pain frequently seen in ASD, it is not unusual for patients to present with serious medical conditions such as gastric ulcers with minimal complaint. One strategy to diagnose clinical problems in this population is to look for emerging or increased frequency of challenging behaviours, most often episodes of physical or verbal aggression, destruction of property, or self-harm. Communication barriers Since poor communication skills such as short and concrete speech and difﬁculty in understanding the abstract message are cardinal symptoms of ASD, to understand the problem at hand needs extra time for assessment. Another challenge is that ASD individuals may have poor social skills and usually eschew social contact. They are also uncomfortable with any change in their routines such as going to the doctor for a check-up. Those with challenging behaviours are often treated with neuroleptic medications that need control in terms of the metabolic syndrome. Some ASD individuals have 'needle phobia' making the basic routine evaluations almost impossible.

By Mr Peter Ammon Foot Ankle & Knee Surgery

Surgery for Heel Pain Heel pain is a frequent problem that presents to the general practitioner. Plantar fasciitis is the most common cause of under the heel pain. Most patients will improve with non-operative treatment but not all. Surgery is a very effective form of treatment for this condition in patients with long standing refractory symptoms. Before being considered for surgery patients should undergo at least six months of non-operative treatment that includes the following (in the appropriate order): så 2EST åAVOIDANCEåOFåACTIVITY så .3!)$S åSTRETCHING exercise program så /RTHOTICS åOFFåTHEåSHELF or custom så #ORTISONEåINJECTION (one only) så 3HOCKWAVEåTHERAPY

Plantar fascia origin

Surgery can be open or endoscopic. The principle part of the procedure is release of the plantar fascia near its origin on the heel. Historically only the medial half was released but recent literature supports more complete release. Open surgery is performed through a 3cm incision in the proximal arch and allows not just plantar fascia release but also decompression of the tarsal tunnel and Baxters nerve which is often implicated in heel pain.

We know little about how ASD individuals age. Those with intellectual disability living in group homes may present with the motor side-effects of psychotropic medication, and the author has recently published a study showing that ASD individuals over age 50 have a 10 times higher chance of developing Parkinson's disease, compared to epidemiological norms. Strategies for management Given these limitations, what should be the best strategy to medically manage individuals with ASD? There is no empirical evidence to answer this question but here are some suggestions. I believe ASD individuals with moderate-extreme intellectual disability and/or no or poor speech should be treated in specialised general practices, fully trained in the management of this population. This will provide an innovative and high-quality service, which will allow further specialisation (e.g. neurological, dietetic and gynaecological areas). ASD individuals with mild intellectual disability and those with high functioning may be referred to their local GP but every practitioner should be provided with speciﬁc education courses, as well as access to a specialised tertiary ASD centre.

Endoscopic plantar fascia release is indicated for those without nerve compression symptoms and is done through a much smaller incision using a camera assisted cutting device much like a carpal tunnel release. Both open and endoscopic releases are performed as day cases and require approximately two weeks on crutches. Recovery is slightly quicker for endoscopic patients as you would expect. Patients can expect an 80-90% chance of a good result from surgery. Complications are rare.

St John of God Medical Centre Suite 10, 100 Murdoch Drive Murdoch WA 6150 Telephone: (08) 6332 6332 Facsimile: (08) 6332 6308 www.murdochorthopaedic.com.au Author competing interests: no relevant disclosures. Questions? Contact the author on 9431 3333

MEDICAL FORUM

Murdoch Orthopaedic Clinic Pty Ltd ACN 064 146 774 ABN 23 070 745 210

NOVEMBER 2016 | 41

Left Intentionally Blank to comply with Medicines Australia Code

Clinical Update

Vertigo diagnosis and management

By Prof Gunesh Rajan (surgical) Dr Vincent Seet (medical) Vestibular Specialists

Targeted history and the examination are instrumental for correct diagnosis and subsequent treatment of vertigo. The challenge is to identify the speciﬁc aetiology.

Duration, Signs-Symptoms, Onset, Brain, Evolution, and Triggers.

We know from studies that tests alone identify about 5% of causes. History taking is therefore crucial. Patients often use unspeciﬁc terms such as ‘dizziness’ or ‘vertigo’ to describe a whole array of different symptoms and signs. Key indicators, which help generate a differential diagnosis, are in the symptom pattern, time pattern and trigger proﬁle.

Ears: Is the ear affected during the attack? Hearing loss or hyperacusis during attack; ﬂuctuating hearing loss; tinnitus, presence and character; otalgia; ear discharge; or correlation of ear symptoms with vestibular symptoms.

Some patients also require functional testing of the vestibular system, and imaging (MRI of the cerebellopontine angle and internal acoustic meatus, and CT of the temporal bones). For patients with acute vestibular symptoms, a two minute, three-item bedside oculomotor examination comprising head impulse test, nystagmus, skew test (HINTS) allows differentiation between acute peripheral vestibular lesions or central pathologies such as cerebellopontine angle infarctions.

Signs-Symptoms: The main symptoms and signs during the attack? Vertigo or head spin; imbalance-ataxia; nausea; light headedness; double-vision; oscillopsia; falling tendency; positional dependency; tilt sensations; falls; or associated loss of consciousness or syncope.

Frequency: How often are attacks? Several times a day; daily; weekly; monthly; unpredictable; or only trigger-related.

The FEDSOBET diagnostic mnemonic The most common vestibular conditions have distinct patterns of symptoms and signs that identify the cause. Rarer entities might require additional radiologic or laboratory testing. Our diagnostic algorithm is based on eight key questions, with mnemonic FEDSOBET representing the eight speciﬁc variables required for the diagnosis: Frequency, Ears,

Duration: How long are attacks? Seconds; minutes; hours; days; constant; event or trigger-related; or exercise-related.

Onset: When and how did it start? Brain: Any associated neurologic symptoms? Headaches; associated deficits; altered mental status; loss of consciousness; altered proprioception; polyneuropathies; or cerebellar signs. Evolution: Change over time? Progressive; declining; fluctuating; stable; or only related to triggers. Triggers: What triggers or actions bring on symptoms? Positional; pressure-related; noiseinduced; or head movements. A detailed targeted history and the neurotologic examination identifies the cause in

most cases. Imaging, objective audio vestibular testing and bloods might be required to rule out rare causes. Some treatments Most causes can be treated specifically with appropriate medication and/or vestibular physio. Around 5% of patients need surgery for pathologies such as the superior semicircular canal dehiscence syndrome, perilymphatic fistula (more common in Australia due to the popular recreational water sports and diving culture), tumours of the cerebellopontine angle (e.g. vestibular schwannoma) and vestibular disorders not responding to conservative treatment (e.g. BPPV; Meniere’s syndrome). Chemical ablation of the peripheral vestibular organ with Gentamicin has become very popular over the last decade as a first line treatment for Meniere’s disease not responsive to standard medical treatment, especially if there is functional hearing in the affected ear. It has also emerged as a tool to support and promote vestibular rehabilitation for certain chronic medical vestibular conditions where vestibular compensation is impaired (e.g. Ramsay-Hunt-syndrome). Latest treatments for a symptomatic Meniere’s disease with a deaf affected ear now include a surgical labyrinthectomy with simultaneous cochlear implantation – immediate resolution of vestibular symptoms with restoration of hearing. Any surgery to the vestibular system requires postoperative vestibular rehabilitation. References available on request.

CAUSE

FREQUENCY

EARS

DURATION

SIGNS

ONSET

BRAIN

EVOLUTION

TRIGGERS

BPPV

Daily depending on triggers

_____

Seconds

Vertigo; Imbalance

Posttraumatic; Idiopathic; postsurgical

_____

recurrent,days to weeks; migraine associated

Speciﬁc head positions

MAV

Individual cycle (daily,weekly, monthly etc.)

Aural fullness; Tinnitus

Seconds to days

Vertigo;imbalance; Motion hypersensitivity

migraine history; puberty

Sensory ura; Headaches; Photophobia, phonophobia

recurrent; intensity and pattern ﬂuctuations

Visual stimuli; head movements; hormonal dependence; foods; fatigue and exertion

Individual cycle

Hearing loss, tinnitus, aural fullness during attacks

30 min to 24 hours

Vertigo in conjunction with the other ear symptoms

Sudden;

_____

progressive with stable intervals of unpredictable duration

Exacerbations from: position; during cough or sneeze; or visual stimuli

Daily to monthly

Inconsistent ear symptoms; hearing loss; pulsatile tinnitus

Seconds

Vertigo;imbalance; positional dependence of symptoms; motion hypersensitivity

Spontaneous; migraine history;

_____

progressive

Positional exacerbation; exacerbation during cough or sneeze; visual stimuli

APV

Once

_________

Vertigo & Nausea: days Imbalance: Weeks to months

Vertigo, Nausea-complex & Imbalance

Post infectious; spontaneous

_____

Acute phase: days Recovery: Weeks

Spontaneous

CVE

Once

_________

Depends on location & extent: days to weeks

Vertigo,imbalance,ataxia, motion intolerance; nausea-complex

Sudden; associated risk factors

Cerebellar or brainstem signs

Recovery over weeks with neurologic sequelae

Spontaneous; Head movements

PPPD

Constant or individual cycle

_________

Minutes to hours

Unspeciﬁc dizziness; imbalance;

Slowly progressive; frequently preceding vestibular disorder; associated personality disorders (panic attacks)

_____

Stable to progressive

Visual stimuli; heights; crowded places; spontaneous

Table 1. Modifed after Wuyts FL, et al (2016) “SO STONED”: Common Sense Approach of the Dizzy Patient.. BPPV: benign paroxysmal positional vertigo; MAV: migraine-associated vertigo; MD: Meniere’s disease; VP: Vestibular paroxysmia; APV: acute peripheral vestibulopathy (formerly vestibular neuronitis); CVE: cerebrovascular event; PPPD: persistent postural perceptive dizziness;

MEDICAL FORUM

NOVEMBER 2016 | 43

Clinical Update

Vulvodynia Vulvodynia is a chronic discomfort involving the vulva without relevant visible findings or a specific, clinically identifiable, neurological disorder. A diagnosis of exclusion, it is usually described as a burning or soreness rather than a pain. While generalized vulvodynia affects the whole vulva, localized vulvodynia affects a specific part (e.g. provoked vestibulodynia is pain felt only in the vestibule – the area around the opening of the vagina – usually in response to touch or pressure). Causation theories include damage or irritation of the vulval nerves (e.g. after childbirth), increased number of nerve endings in the vestibule, increased production of chemicals by vulval cells (causing inflammation), long-term reactions to certain infections, changes in hormone response and history of sexual abuse. Who gets it and examination? Vulvodynia affects women of all ethnic groups and ages. It is not hereditary. Lifetime prevalence is estimated at 8%. Provoked vestibulodynia is the commonest. Diagnosis starts with looking for causes of pain. Ask when symptoms occur, what treatments have been tried, and any prior chronic infections or skin problems. Examine the vulva and vagina carefully, using a moist cotton swab to touch areas of the vulva and vestibule to determine if pain is generalised or localised. The goal is to find where the pain is and the severity.

By Dr Angamuthu Arun Gynaecologist, Waikiki

Swabs for infection or biopsy may be needed. Treatment – things to try Advise avoiding soap, bubble baths, shower gels, shampoos, special wipes and deodorants. Suggest washing with a soap substitute (e.g. greasy ointments) to keep the skin soft and provide a barrier against irritation, and use petroleum jelly to protect the area from chlorine when swimming. Advise cotton underwear and cotton menstrual products if regular ones are perhaps irritating. Avoid any know triggers. Applying cool gel packs may bring pain relief. Local anaesthetic ointment can numb the area, bringing short-term pain relief. It can be used for extended periods. Long term use can (rarely) cause allergy to lignocaine. Medication options include amitriptyline (cream or tablet), gabapentin, pregabalin or vaginal diazepam pessary (from compounding pharmacies). Patients with vulvodynia who complain of sexrelated pain frequently have pelvic floor muscle dysfunction. Pelvic physiotherapy can relax tissues in the pelvic floor and release tension in muscles and joints. Biofeedback can train patients to strengthen the pelvic floor muscles. Trigger point therapy is another option. Painful intercourse may have emotional and psychological effects on sexual relationships; patients need to understand this, and communicate fully with their partner, discovering suitable techniques and lubricants.; psychotherapy and sexual

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

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44 | NOVEMBER 2016

Conditions that are relatively ED common and have a diagnosis based on the history alone (i.e. no physical ﬁndings) may prove frustrating to both medical practitioners and patients. These notes may help. counselling may be helpful. A vestibulectomy to remove painful tissue in provoked vestibulodynia, if other treatments have failed, helps relieve pain and makes sex more comfortable. It is not recommended for generalized vulvodynia. Further reading: www.racgp.org.au/afp/2015/july/

KEY POINTS så 6ULVODYNIAåISåCHRONICå LONG LASTING åå pain and discomfort of the vulva where there is no cause found.

så 6ULVODYNIAåCANåBEåGENERALISEDåORåå localised and provoked vestibulodynia is the most common presentation of the latter. så !LTHOUGHåSYMPTOMSåLASTåFORåYEARS ååå there are treatments to manage the symptoms. så 3URGICALåTREATMENTåSUCHåASååå vestibulectomy is indicated for women with provoked vestibulodynia when conservative measures fail.

Author competing interests: no relevant disclosures. Questions? Contact the author 9550 0300.

Falls and the elderly One in three people aged 65 years and over fall every year and the likelihood of falling increases for those with conditions such as dementia, Parkinson’s disease or receive services from home care agencies. While many falls don’t result in a serious injury, the older person is reluctant to let family or their doctor know for fear it might precipitate going into care. Curtin University Dr Elissa Burton said old age was not a cause, rather it was a loss of balance and strength, polypharmacy, problems with prescription glasses, wearing incorrect footwear or environmental issues such as tripping on a matt or poor lighting. “If the reasons for the fall can be determined the older person can receive some strategies from a falls specialist or a physiotherapist which may help and hopefully avoid or minimise falls in the future could lead to injury,” she said.

MEDICAL FORUM

Clinical Updates

Sarcopaenia how important? Sarcopaenia is associated with frailty, cognitive decline and malnutrition. Identifying cases is important in order to prevent negative health outcomes such as falls (risk trebled), malnutrition and comorbidities, institutionalisation and death. The economic burden of sarcopaenia is significant (similar to osteoporosis) and set to escalate further. Diagnosis According to European guidelines, sarcopaenia is diagnosed initially by demonstrating poor physical performance. Specifically slow gait speed (less than 0.8 m/sec), low muscle strength (hand held dynamometry) and reduced muscle mass are the main factors used to identify cases. The SARC-F scale is a useful screening test. This measures strength, assistance in walking, any difficulty in rising from a chair, any difficulty in climbing stairs and number of falls in the past year Most cases of sarcopaenia are associated with a high Frailty index and mild cognitive impairment. It is vital to identify and treat the frailty.

By Dr Rita Malik Physician in Geriatric Medicine Nedlands

The FRAIL Scale is a very useful well-validated tool. It assesses fatigue, resistance, aerobic exercise capacity, illness and loss of weight. The presence of up to two factors determines a pre-frail state. Frailty is reversible and treatment may reduce further decline. Psychosocial frailty overlaps with physical frailty and includes depression, fear of falling, cognitive decline, anxiety, negative health perception, and fatigue. Physical factors Risk factors include anorexia of ageing, increasing age, impaired activities of daily living (ADL), impairment of the more complex instrumental ADL (IADL), cognitive impairment, physical inactivity, and depression. Comorbidities include CCF and COPD. The consequences of losing lean body mass and muscle are signiﬁcant and include poor immunity, wound healing, increased risk of infection, falls, aspiration and pressure ulcers.

Awareness of the loss of muscle ED mass and associated function in the elderly is crucial in preventing an increasing epidemic of this problem that currently affects up to 9% of Australians aged over 65 and 20% in people over 80. for higher protein intake in order to prevent the sarcopaenia epidemic and its associated complications. Adequate protein intake (>1g/kg/day), adequate vitamin D and increased physical activity may assist in reducing sarcopaenia. Protein requirements increase further in the presence of chronic disease to 1.5mg/kg/day. Resistance exercise is of particular beneﬁt. Replacement of deﬁcient testosterone may be necessary. References available on request

Important aspects of management Dietary protein is essential to maintain muscle mass. Most older adults do not consume sufﬁcient protein. New recommendations call

Put all your patients’ sleep disorders comfortably to bed. At SleepMed, we understand the value of a good night’s sleep. As Perth’s ﬁrst accredited and licensed sleep investigation centre outside of a hospital, we focus on individual and holistic care to diagnose sleep disorders including snoring, sleep apnoea, and insomnia. Our highly trained sleep experts and therapists then develop personalised treatment solutions, prioritising the comfort of our patients at all times. Both insured and non-insured patients can access our professional Level-1 sleep studies, now in the comfort of a non-hospital environment.

Author competing interests: no relevant disclosures. Questions? Contact the author on 9386 3055

Comfortable, non-hospital environment.

Get in touch today Murdoch Specialist Centre 78 Farrington Rd Leeming 6149 Dr Sina M Keihani T (08) 6161 7647 F (08) 6162 0547 E info@sleepmed.com.au Online referral welcome: www.sleepmed.com.au

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MEDICAL FORUM

NOVEMBER 2016 | 45

Community

COACHING HELPS GET THE BALANCE RIGHT Kids wait for no one, and when you’re the coach of their soccer team you can’t be late for training as urologist Dr Jeff Thavaseelan has discovered.

One Perth urologist has found the perfect way to carve out time away from his surgical list. Dr Jeff Thavaseelan is a junior soccer coach and in the process that gives him plenty of quality ‘dad-time’ with his own children.

“Football West runs coaching certiﬁcate and licence courses. I did the Grassroots program initially, which focuses on the youngest kids and then completed a Junior coaching licence.”

“I really like coaching the younger age groups, I’ve taken my three boys through this stage and I’ll be doing the same thing with my daughter who’ll be in Under 8s next year. It’s great to be involved in our children’s sport and the Wembley Downs club is terriﬁc!”

“I’m pleased to say that we don’t have too many problems with the ‘Ugly Parent’ syndrome. As coaches we try to make sure that the sheer enjoyment of playing the game comes ﬁrst. One of the most important things is to make sure that every child gets a fair go. My pre-game nights are usually spent working out player rotations to keep the kids and their parents happy.”

“You can always ﬁnd excuses to stay at work but when you’ve got 20 kids waiting for you for an afternoon training session you’ve just got to be there. It makes it so much easier to tweak the roster.” Jeff’s passion for the ‘beautiful game’ goes back to his own childhood. Soccer’s all in the family “I played club soccer as a young kid in a country town, but nothing even approaching a serious level. My wife’s equally keen. She has a German background so all the kids have the overseas club shirts and we all supported Germany in the last World Cup.” “All through the European season we have football on the television, from the English Premier League to the Bundesliga… whatever’s on, really. We’ve been members of Perth Glory for the past four years and we enjoy going to see them play.” “We took the kids to Melbourne to see Real Madrid and AS Roma but we’d really love to see some World Cup matches. We were in Europe when the last one was on and the atmosphere was amazing!” Jeff’s involvement with junior sport is underpinned by formal coaching qualiﬁcations and a commitment to inclusive participation.

46 | NOVEMBER 2016

Soccer boys

It’s all about the kids

Jeff's own su

persta rs

“When four of your own children are actively involved it does create some interesting situations. A typical football weekend means a lot of time in the car and some logistical coordination with other soccer families.” “My role does mean I’m pretty much tied to the team I’m coaching but I do the occasional swap with another soccer dad so that we can each see our other children play.” Jeff’s medical background adds yet another element to the equation. “Taking my mobile phone is a necessary evil but it stays in my back-pocket most of the time. People usually understand if I’m in the middle of screaming at the team and I just tell them I’ll call them back.” “I had one incident where an amazingly tough young girl broke her arm so I took off her shinguards and strapped it up until she could get to hospital. Apparently PMH thought it was a pretty interesting technique.” “One part of my specialty is neuro-urology dealing with spinal cord injuries. I’ve seen a bit of that coming from other codes at junior level because they try to mimic the professional

Scores again!

players. A lot of parents have switched their kids to soccer because of those concerns.” “Thankfully our children have been injury-free, apart from the usual skateboard dramas. They get a lot of enjoyment from their football and they’re better at it than I ever was.”

By Peter McClelland

MEDICAL FORUM

architect can mistakes but an s hi ry bu n ca es. A doctor ents to plant vin only advise his cli

ght - Frank Lloyd Wri

(1868-1959)

THE GODFATHER The maﬁa godfather, accompanied by his lawyer, walks into a room to meet with his accountant. The godfather asks the accountant, "Where's the three million bucks you embezzled from me?" The accountant doesn't answer. The lawyer interrupts, "Sir, the man is a deaf-mute and cannot understand you, but I can interpret for you." The godfather says, "Well, ask him where the @#!*ing money is." The lawyer, using sign language, repeats the question to the accountant. The accountant signs back, "I don't know what you're talking about." The lawyer interprets to the Godfather, "He doesn't know what you're talking about." The godfather pulls out a pistol, puts it to the accountant’s head, cocks the trigger, and says, "Ask him again where the @#!*ing money is!" The lawyer signs to the accountant, "He wants to know where it is!"

MEXICAN SMUGGLER Juan rides up to the Mexican border on his bicycle. He's got two large bags over his shoulders. The guard stops him and asks, “What''s in the bags?” “Sand,” Juan answers. The guard says, “We'll just see about that. Get off the bike.” The guard takes the bags and rips them apart; he empties them out and ﬁnds nothing in them but sand. He detains Juan overnight and has the sand analyzed, only to discover that there is nothing but pure sand in the bags. The guard releases Juan, puts the sand into new bags, hefts them onto the man’s shoulders, and lets him cross the border. A week later, the same thing happens. In fact, this sequence of events is repeated every day for three years, until ﬁnally, Juan stops showing up. The guard later ran into him in a Mexican cantina. “Hey, buddy,” says the guard, “I know you are smuggling something. It's driving me crazy. It's all I think about. I can't sleep. Just between you and me, what are you smuggling?” Juan sips his beer and says, “Bicycles.”

The accountant signs back, "Okay! Okay! The money's hidden in a suitcase behind my backyard shed!" The godfather asks, "Well, what did he say?" The lawyer tells to the godfather, "He says that you don't have the guts to pull the trigger."

OBSERVATIONS ON GROWING OLDER Your kids are becoming you...and you don't like it ...but your grandchildren are perfect! Going out is good. …coming home is better! When people say you look "Great"... …they add "for your age!" You read 100 pages into a book before you realise you've read it. Everybody whispers.

BETTY SUE A guy is reading his paper when his wife walks up behind him and smacks him on the back of the head with a frying pan. “Hey!” He says, “What was that for?” She says, “I found a piece of paper in your pocket with 'Betty Sue' written on it.” “Jeez, sweetheart,” he replies, “remember last week when I went to the track? Betty Sue was the name of the horse I bet on.” “Ok,” she shrugs and walks away. Three days later he's reading his paper when she walks up and smacks him again with the frying pan. “What was that for?” He says. “Your horse called,” she replies.

MEDICAL FORUM

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NOVEMBER 2016 | 47

Social Pulse

A record 1800 delegates attended the national RACGP conference in Perth and while there were three solid days of workshops, plenaries, posters and forums, there was also time for all-important social networking. The gala dinner was a light-hearted affair with the nowregular appearance of Iron Man, organised by head of the SA faculty Dr Danny Byrne who delivers the workshops on iron therapy. WA doctors Dr Rohan Gay and Dr Fintan Andrews took our national awards – Rohan as GP Supervisor of the Year, beﬁtting his dedication and commitment to GP training; and Broome-based Fintan the national GP Rural Registrar. The conference also saw the presidential baton change from WA’s Dr Frank Jones to Tasmanian Dr Bastien Seidel.

Research work at the National Centre for Asbestos Related Diseases (see September edition) has been given a $50,000 boost from a man who has deﬁed the mesothelioma odds. However, time is running out for 72-year-old former builder Barry Knowles, who was diagnosed with the disease in 2010.

GP16

Clockwise from left: Retiring president Dr Frank Jones; New College president Dr Bastien Seidel; Former College president Prof Claire Jackson, AMA President Dr Michael Gannon and GP Dr Marian Bahemia; Dr Edwin Kruys, Dr Mike Civil and Dr Brad Murphy enjoy the evening; WA registrars kick up their heels at the dinner; Dr Jill Benson with her family.

Funds to carry on the ﬁght

Only recently the tumours have become aggressive and Barry wanted to contribute to the work of NCARD in a fundamental way. He and his family handed NCARD’s Prof Bruce Robinson a cheque for $50,000 from the Reﬂections Through Reality Foundation at a Rotary Club Perth lunch last month. The Rotary clubs of Perth and Esperance and families affected by mesothelioma helped raised most of the money.

48 | NOVEMBER 2016

MEDICAL FORUM

Wine Review

Surf and Turf at Rockcliffe The Rockcliffe vineyard started as an apple orchard in Denmark, which was planted to dry-grown vines in the late 1980s. In 2002 it was purchased by Steve Hall and in 2007 he was joined by Coby Ladwig, from West Cape Howe, and later Luke Eckersley, from Forest Hill. With this experience the winery has become diversiﬁed into single vineyard and regional wines as well as contract winemaking with a generous portfolio of wines. This tasting focused on the Quarram Rocks and Third Reef ranges, which are named after local surﬁng spots around Denmark. Rockcliffe has a generous portfolio of wines with the Third Reef Chardonnay and Shiraz being the standout wines.

By Dr Martin Buck

1. 2016 Quarram Rocks Sauvignon Blanc Semillon, $21 This is a very nicely balanced cool-climate blend with a great lifted floral nose and tropical aromas. The palate is clean, crisp, full of citrus flavours and finishing with grassy Semillon. This is lively, easy drinking blend ready for summer. 2. 2016 Third Reef 2016 Riesling, $25 The Third Reef Riesling are Chardonnay are very well made wines. The Riesling is a lighter, 11.5% alcohol, but does not lack anything in punch. Blossom and lime aromas are intense and lead to a full palate of green apple, citrus and steely acid. A combination with some fresh Albany oysters would be sublime. 3. 2015 Third Reef Chardonnay, $30 The Chardonnay is also a surprise packet with a strong French protocol, including whole bunch pressing, wild yeast and barrel fermentation. Delicate aromas of nectarines, lime and French oak add to the complexity. On the palate there is full, fresh fruit with a lingering softness and persistence. A very Burgundian wine with a twist of Denmark – certainly one for my cellar.

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4. 2014 Quarram Rocks Shiraz Cabernet, $21 This wine ticks all the right boxes for this blend – plenty of berries, some soft tannins, plums and spice. A medium-bodied wine ready for drinking and would be great with roast lamb. 5. 2015 Third Reef Pinot Noir, $30 Pinot is a challenge for any winemaker and Great Southern Pinot fruit has a great reputation. The 2015 Third Reef has great structure for a young wine. Big cherry ﬂavours combine with delicate tannins to make this a very drinkable wine. Aged in French oak for 10 months, it has plenty of potential and would be fantastic with gamey meats.

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6. 2014 Third Reef Shiraz, $30 This is a real beauty. Spicy, complex and brooding aromas merge into a palate of big fruit and savoury ﬂavours. A “Syrah style” cool-climate Shiraz with a long, generous palate. This was my favourite of the reds and would only improve with medium to long term cellaring.

Wine Question: Which Rockcliffe wine has Burgundian inﬂuences?

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MEDICAL FORUM

NOVEMBER 2016 | 49

Comedy

n w o D g n i l l St ro

Q e u n e v A It’s a show that’s been described as the love child of South Park and The Muppets and it manages to steer its way through the precarious waters of political incorrectness with wit, charm and humour. So, why wouldn’t Melbourne actor Ross Hannaford, who plays Princeton/Rod, be excited? The actor/singer/dancer, who was last in Perth earlier this year in CATS, will be returning to Crown Theatre on November 26 with this Tony-award winning Broadway hit that has been packing crowds for the past 13 years. Avenue Q is described as a ‘coming-of-age parable’ with three human characters trying to look more convincing that the 11 puppets who tend to steal the show. “I feel a bit of cheat,” Ross told Medical Forum. “I just get out there and say the lines and the audience is in hysterics … it is written so well and is so clever, it makes it seem easy. The energy it generates on stage in the audience makes it a really great night out – it’s like seeing a comedy festival show.” The poster for the show trumpets FULL PUPPET NUDITY AND OTHER VULGARITIES but it is also moving, honest and has the ability to get people thinking. “Avenue Q is not frightened to touch on politically sensitive topics but that’s a good

50 | NOVEMBER 2016

thing, to get people talking about issues and ideas,” Ross said. “There are a lot of shows out there that may have gone so far they are no longer to everyone’s taste. Avenue Q sits in a world that is accessible, relevant and still makes people laugh about the absurdities of the world.” Ross, at 33, is a 24-year veteran of show business having made his professional debut in 1992 as a nine-year-old in Scrooge the Musical as Tiny Tim. “I must have done something right because I’m still hanging in here. Scrooge is a magical musical and it planted a seed for me. As a child I always wanted to go into the performing arts. I just wanted to sing and dance and tell stories and this show demonstrated to me that I could. I’m lucky enough to be still doing it.” Ross is considered one of the most versatile performers in Australia – Avenue Q is a singing/acting role but he has danced almost all of his life. Not surprising then to learn that all his siblings share the performing passion. His sister Esther was in Perth recently playing Audrey in Little Shop of Horrors, another sister Lauren was an elite gymnast who has moved into personal training and brother Calvin is in the Australian Ballet.

Ross Hannaford and 'Princeton'

dance and always took us to the theatre. She was very encouraging but never pushed … we just all fell into it. Dad was an industrial electrician. So we say we get our chutzpah from mum and coordination and focus from Dad. But, you know, he’s got a good voice, though he wouldn’t be caught dead singing outside the house, and he can move really well. Mum can’t sing or dance but has a huge personality!” “I studied at the Victorian College of the Arts secondary school and did a crazy amount of dancing. But I also wanted to sing and dance. My ﬁrst gig as an adult was in We Will Rock You and the shows have kept coming so I never ﬁnished post grad – I’ve learnt on the job with some of the best in the business.” “Mum’s advice to be as versatile and as employable as possible rings in my ears. It’s a really tough industry to make a living in and get by day by day but it is so rewarding.” In that spirit, Ross is a great believer in creating his own shows. He and a friend are putting together a cabaret show Cheek to Cheek about Fred Astaire and Ginger Rogers and he has his third EP of original songs coming out this month.

So something must have been in the water at the Hannaford household!

“I like to be busy – you need to be in this business. If you want to work, you often have to create it yourself and learn to enjoy the great shows like Avenue Q when they come along.

“Mum is very arty. She encouraged us to

By Jan Hallam

MEDICAL FORUM

Music

All Roads Lead to Messiah

Christopher Richa

Bass-baritone Christopher Richardson, who heads to Perth for the Perth Symphonic Chorus’s annual performance of Handel’s Messiah on December 17, has taken his considerable musical talent on a ride through the lands of performancelevel cello and piano to a flirtation with contemporary singing to settle in the rich soils of operatic bass baritone where a career in oratorio and opera has taken hold and is flourishing. Thirteen years ago, on his graduation from the Hobart Conservatorium, he and his university sweetheart, classical singer Amy Dean, were married and the proud parents of a daughter. At 23, the aspiring professional musicians were up to their ears in nappies. “When our first child was born, Amy and I decided that we would have our family early and work where and when we could,” Christopher told Medical Forum. “We now have three children – two girls and a boy aged 13, 11 and 10.” The arts industry in Australia is relatively small, so networks and connections are vital. At the Tasmanian Con some serious musicians had made tree changes to the Apple Isle allowing Christopher to study with internationally regarded teachers such as pianist Beryl Sedivka, mezzo soprano Marilyn Smith and the acclaimed soprano Jane Edwards. Starting out a singing career with a young family may not have been the traditional

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rdson

route to operatic fame and fortune but neither was it the end of opportunity for the couple – it meant thinking outside the box.

Music projects such as David Chisolm’s extraordinary work Kursk (a requiem for a Russian submariner) are among the performances on a large CV.

Christopher graduated with a performance award for piano and the most promising award for his singing but then came the hard slog of learning his craft. Performances in the concert halls of Hobart and oratorios around Tasmania with teaching in between helped pay the bills. Some luck with property investment in 2003 on the eve of the property boom helped the young couple keep their heads above water.

And critics are taking notice and awards are springing up too – a 2011 Royal Melbourne Philharmonic Aria Award and a scholarship to famous Wagnerian soprano Lisa Gasteen’s National Opera School among them.

“In 2003, we scraped together the money to buy a 4 x 2 just 10 minutes south of Hobart for $140,000 and in 12 months it had doubled in value, so for a few years we bought up property, renovated and sold,” Christopher said. “Five years ago, we decided it was time to become more adventurous with our careers. The children were all in school and we had transitioned through that hard slog of pre-schoolers. We considered relocating to the UK but talking to trusted friends and colleagues we decided to stay where our professional and personal networks were. So we made the move to Sydney.” And the work has rolled in – regular appearances with orchestras along the eastern seaboard, interesting roles with Pinchgut Opera, and exciting New

Christopher’s outing with Dr Margaret Pride’s Perth Symphonic Chorus will be the ﬁrst time he has been west but the Perth concert will be his second Messiah for the season. “I’m looking forward to working with the PSC – and singing Messiah is wonderful. Handel and Bach are masters.” Christopher will share the stage this year with soprano Jennifer Barrington, countertenor Christopher Field and tenor Paul McMahon and the Perth Baroque Orchestra, led by violinist Paul Wright. Last year’s experiment to supplement the chorus with a people’s choir proved so successful that it is on again with rehearsals beginning in November. If you would like to sing in four of Handel’s magniﬁcent choruses with the PSC then go to the website www. perthsymphonicchorus.com.au/event/ handels-messiah-christmas-choir-2016 for more details. By Jan Hallam

NOVEMBER 2016 | 51

Music

PULSE-RAISING WAGNER Brass sections of orchestras love having the chance to play Wagner and stir up audiences. Richard Wagner (1813-83) is a composer who triggers some division among music lovers. There are those slavish devotees who adore every elongated note and those who have difﬁculty dissociating the politics of the man. However, what can’t be questioned are the sublime – and the revolutionary – aspects of the music. Wagner brought something new and very exciting to the ears of the world. On November 26 and 27 at the Perth Concert Hall, WASO principal conductor Asher Fisch leads the orchestra and acclaimed Wagnerian tenor Stuart Skelton in a program of Wagner arias, with Anton Bruckner’ s ninth symphony to send you home buzzing. Asher is himself a great Wagnerian scholar and when he’s not in Perth ﬁnds himself conducting in opera houses all over the world, often Wagner operas. “Wagner is one of history’s truly transformative composers. His music is endlessly

Franz von Lenbach’s 1895 portrait of Richard Wagner.

fascinating, dramatic and deeply moving. For a conductor, the chance to share and explore Wagner’s revelatory works with a wonderful orchestra and audience is quite simply a joy,” he told Medical Forum. One of the musical windows Wagner ﬂew open was the use of brass as a solo and melody leading instrument. WASO’s principal trombonist Joshua Davis relishes the opportunity to take a dramatic lead in the concert. But the trombonist, who began playing in Salvation Army bands, told Medical Forum that even he came a little late for the Wagner love fest. “My background has been mostly the Romantics. I love listening and playing a lot of Beethoven and Brahms and have come to Wagner only in the past few years. It started with Mahler and Strauss and Wagner. To tell you the truth, the thought of playing in The Ring Cycle (Wagner’s epic four-opera magnus

Anything Goes Last month, Shenton Park GP Dr Lin Arias won tickets to see Michael Cole’s cabaret, Cole. This is what she thought of the show. He’s delightful, he’s delicious, he’s delovely. That’s Michael Grifﬁths as Cole Porter. As Porter, Grifﬁths crooned, chatted, and captivated us with stories. Porter was happily married while pursuing an active gay life, enjoying a wealthy, hedonistic lifestyle in New York, Hollywood and Europe. Tales of opening night worries, Porter’s musical inspirations and the woeful fear of having lunch with someone terribly boring, were

52 | NOVEMBER 2016

WASO Principal Tro mb onist Joshua Davis

opus) would terrify me,” Joshua said. “This upcoming concert is the perfect – bite-sized pieces and Wagner at his most dramatic and lyrical. People will know the music as soon as they hear it. It will be a great entry-point to his music.” “Asher understands the music to its core – and a commitment to doing it right. It is a joy to be playing these iconic themes.” Wagner requires big sound and that gives the brass a good opportunity to make their presence felt. “We have expanded the volume levels and the brass section has to give it a bit! The strings just have to forgive us. Wager’s big sound in the concert hall is a bit of an endurance test, but it’s also a lot of fun to do.”

By Jan Hallam

interspersed with much-loved tunes such as Miss Otis Regrets, Let’s Do It, Let’s Misbehave, It’s De-Lovely, Night and Day, and more. Griffiths camped it up, playing the piano with definitive style and flair, singing Porter’s songs as if he had written them. As an audience, we were smitten. By the end of the night, we all happily did as he asked, singing our hearts out, repeatedly, to the chorus of Another Op’ning, Another Show… until he said we could stop. WAAPA graduate Griffiths was in Perth earlier in the year for the Fringe Festival when he performed his Annie Lennox tribute. He is utterly charming and extremely talented. Hopefully he’ll be back soon.

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Movie: Office Christmas Party A good cast, potentially scary theme. Jennifer Aniston and Jason Bateman (Bad Bosses, Arrested Development) join the youngsters for an office comedy that hinges on sibling rivalry and hideous office Christmas parties. The safe hands behind the camera were also on Blades of Glory. In cinemas, December 08

Music: WASO & Wagner Principal conductor Asher Fisch is an expert on the Wagner repertoire and in his capable hands the orchestra and one of the world’s best Wagner tenors Stuart Skelton bring the master’s music to life. The ﬁrst half features excerpts from Wagner’s Parsifal and Lohengrin; second half the giant ninth by Bruckner. Perth Concert Hall, November 25 and 26; MF performance 25/11, 7.30pm

Movie: Underworld: Blood Wars Vampire death dealer Selene (Kate Beckinsale) fends off brutal attacks from her many enemies of previous outings. In the next instalment of this popular franchise, she just might have to make the ultimate sacriﬁce. Fangs for the memories.

FEATURE

COMP Movie: Trolls (3D) In the beginning of Shrek (and its mandatory sequels) now the makes are focusing on another childhood favourite, Trolls, complete with colourful hear and magical properties. A fun family ﬂick with the talents of Justin Timberlake and Gwen Stefani among others. In cinemas, December 1

In cinemas, December

Theatre: Avenue Q It has been described as an adults-only Sesame Street and this coming-of-age musical show has all the charm of the long-running kids TV show but that’s probably where the comparison should end. Puppets, animated by unconcealed puppeteers, sing and act alongside human actors a satire of high anxiety in a big wide world. Crown Theatre, November 26-December 10, 8pm

Music: Handel’s Messiah A highlight of the Perth Symphonic Chorus’s calendar is their annual performance of Handel’s Messiah, directed by Dr Margaret Pride. This year there is an impressive line-up of soloists including Jennifer Barrington, Christopher Richardson, Christopher Field and Paul McMahon.

Doctors Dozen Winner It was the lure of Upper Reach Wines that prompted Dr Chris Cokis to give himself a shot at winning this particular Doctors Dozen. Chris and his wife recently visited the winery in the Swan Valley and thoroughly enjoyed their 2014 Reserve Chardonnay. And, says Chris, there’s room in the cellar for more!

Perth Concert Hall, December 17, 7.30pm

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September 2016 www.mforum.com.au

Movie – The Magniﬁcent 7: Dr Dian Harun, Dr Anne Beaton, Ms Vincenza Frisina, Dr Andrew Toffoli, Dr Braad Sowman, Dr Simon Machlin, Dr Twain Russell, Dr Michael Allen, Dr Max Traub, Dr Beverly Teh Movie – The Girl on the Train: Mr Ray Barnes, Dr Narelle Kealley, Ms Kellie Ashman, Dr Leanne Hosking, Dr Alison Stanning, Dr Helena Goodchild, Dr Charles Armstrong, Dr Meilyn Hew, Dr Barry Leonard, Dr Alem Bajrovic Movie – Inferno: Dr Rachel Price, Dr Crystal Durell, Dr Michel Hung, Dr Heather Brand, Dr Amir Travasoli, Dr Glen Koski, Dr Alarna Boothroyd, Dr Sara Chisholm, Dr Jane Whitaker, Dr Peter Louie Movie – Café Society: Dr James Flynn, Dr Michelle Bennett, Dr Jenny Elson, Dr Lin Chan, Dr Senq J Lee, Dr Jun Wei Neo, Dr Ernest Tan, Dr Vesna Stanojevic, Dr Sayanta Jana, Dr Julia Charkey-Papp Cabaret – Cole: Dr Lin Arias Opera – The Pearl Fishers: Dr Stephen Adams

NOVEMBER 2016 | 53