Medical Forum 04/12 Public Edition by Medical Forum WA

WA’s Independent Monthly for Health Professionals

Sexualisation of girls Too Much, Too Soon

• • • •

The Question of Trust Women Doctors, Master Jugglers Clinical Updates: Menorrhagia, OC, PMDD, Renal, Statins Singing Floats Their Boat

April 2012 www.mforum.com.au

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Contents

Major Sponsors

FEATURES

CLINICAL FOCUS

4 Helen Wilcox:

5 Kidney Disease, eGFR

Master Juggler

and the Importance of Accurate Creatinine

10 Live Slow and

Prosper: Drs Sue Taylor, Sarah Moore, Julia Barton & Manal Rezkalla

22 Why Doctors Do Rural

Locums

24 E-poll: Trust Me,

I’m a Doctor

NEWS & VIEWS

Dr Sydney Sacks

3 E-poll:

Doctor Representation

6 Editorial: Doctors

Having Their Say Dr Rob McEvoy

12 Prof Sandy Thompson,

Beneath the Drapes

18 Have You Heard?

Cancer Care

Ms Nerissa Ferrie

Pharma Dealings

50 E-poll: WA Doctors

Comment on Trust

medicalforum

Dr Mini Zachariah

39 Premenstrual

Dysphoric Disorder & Contraceptive Update

GUEST COLUMNS 27 How ‘Workers’

Compo’ and Sickness Certificates Leave You Exposed Mr Les Buchbinder

48 Support Group:

Women’s Healthworks

52 Singing Floats Their

Boat

41 E-poll: Child

48 Transparency in

Management of Chronic Menorrhagia

LIFESTYLE

PP Deterioration

Ms Jan Hallam

36 Evaluation and

Ms Mandy Stringer

29 Medicolegal: Rapid

43 Sexualisation of Girls

Dr Donna Mak

Mr Robert Wardrop

21 Nurses Coordinate

Sexualisation and Abuse; Vaccination in Pregnancy

Benefits Pregnant Mums and Babies

Point of Care Testing

Dr Rob McEvoy

The Swan

Lung Cancer?

46 Sticking Points in

Campaign Trail

17 Big Buzz for Doc of

31 Screening Imaging for

Dr Maria Garefalakis

14 Dr Mike Civil on

Mr Peter McClelland

Ms Lois Newsome

35 Flu Vaccination

Mr Peter McClelland

Bullying on Steroids

in The Wheatbelt

Eye Surgery Foundation

Whispering Loudly

16 Prof Donna Cross,

20 Helping Treat Cancer

Auditing Tool

Dr Anne Karzcub

A/Prof Annette Mercer

Dr Chris Finn

33 Electronic Cataract

Obstetrician Numbers

Selecting Medical Students

Diabetes or Dementia?

Dr Brendan Adler

2 Letters: GP

9 Do Statins Cause

Mr Peter McClelland

53 Wine Review:

Juniper Estate

Dr Louis Papaelias

54 Competition Winners 55 On the Funny Side 56 Photography: Enter

Your Favourite Pictures

Spotlight

Helen Wilcox: Master Juggler Helen acknowledges the valuable role her family plays as a support network.

to our members and put firm pressure on the federal government,” she said.

“I know I’m very fortunate to have two healthy children and to be practising medicine at a time when women have so much more autonomy. We’re able to shape our own careers, far more so than our counterparts in the legal and corporate world. There are periods of guilt, which I find an excellent motivator, but I’ve got a great support network. My husband is wonderful, he’s in the finance sector,” she said.

“The College achieves a fair bit in maintaining GP remuneration and good patient care but we don’t shout it off the rooftops, unlike some other medical advocacy groups. I think we need to do a little better in that regard.”

“Yes, it’s definitely a juggle at times and the cup is 9/10ths full. It’s a very precarious cup, one little wobble and it might overbalance and topple over.”

elen Wilcox is a very busy medico. She teaches at UWA, practises as a GP in Mt Lawley and is the WA Censor for the RACGP. Add to the mix twins, Claudia and James crawling towards their first birthday and finding time to play the piano, it adds up to a pretty dynamic existence.

Helen believes the status of GPs has changed in one generation. “I think the perception of our profession has shifted. If you speak with anyone who’s had a wonderful GP for a number of years, they can’t speak highly enough about them. Perhaps our status has decreased a little in the eyes of our specialist colleagues, but it’s up to us to maintain a high standard of practice and not devolve our skills to our specialist colleagues,” she said.

“My husband jokingly calls me the ‘Sensei’ referring to my role as Censor at the College, which involves overseeing the State-based Fellowship issues, whether doctors have satisfied our training and experience requirements and assessing the skills of overseas and rural doctors. It’s a very interesting and rewarding role and I’m always inspired by the more senior GPs I work with at the College,” she said. “Regarding the twins, I’m acutely aware that I’m very lucky to be able to combine work and family. Ten years from now the twins will be 11 and hopefully they’ll be able to drive themselves around and cook their own meals. And being digital natives they’ll be able to download their own homework,” said Helen with a wry note in her voice. If Helen had listened to her mother, a doctor herself, medicine would not have been at the top of the career check-list. “My mother actively discouraged me from practising medicine. The equitable arrangements for women in medicine weren’t there for her, so it was difficult to serve the masters of work and family. So, perversely I decided to do medicine. We make these decisions at 16 years of age based on an idea of a career we think might be exciting. At that age I was also thinking of flying a plane or fronting a band! Luckily, medicine ended up suiting me down to the ground. It’s a pleasure and a privilege to look after patients.” 4

And, as Helen reaffirms, there is no shortage of pressing issues for both GPs and the College. “At a federal level there’s Medicare Locals and here in WA we have the new Health Services Governing Councils. There’s quite an interest among local GPs to be involved in both those processes and we’re coordinating that here at the College. As I suggested earlier, we have to be very careful in devolving clinical responsibilities to our colleagues in other specialties because it may lead to a perception that we are less skilled. There’s a strong need to maintain our generalist focus to guard against this.” It is clear that she holds general practice not only in high esteem, but also great affection. “Inevitably there are sad outcomes. I rarely look after one patient in isolation so if there is a death or a poor outcome I’m usually fully involved in supporting the wider family. And I regularly debrief with my best medical mate in the next room. That’s one of the main reasons I moved into general practice rather than my initial tendency towards medical oncology. I balance my sad stories and predictable terminal outcomes with gorgeous healthy babies coming in for a weight a measurement and a chat,” she said. “Do I take the negative stuff home? Less so now, because as soon as I get there I’m up to my eyeballs in purees, lullabies and toys with bells and whistles.”

n Yes, it’s definitely a juggle at times and the cup is 9/10ths full.”

Helen has a few hard-won words of wisdom for the next generation of doctors.

“That’s why I’m focused on maintaining a really high standard of care and also why I enjoy my teaching role at the College so much. It does a wonderful job in rolling out education and encouraging GPs to be innovative.”

“I spent my medical elective year sunning myself on a beach in the Cook Islands and drinking a combination of rum and tropical juice. At one point all the local doctors went back to their villages and we, the inmates, were in charge of the asylum. We had a great time!

Helen has a clear vision of the role of the RACGP beyond its teaching and mentoring function. “I think GPs are more vulnerable to the vagaries of government policy than other specialities. Many of us feel they can’t respond to the complex care needs of our patients because there’s a practice to serve and an infrastructure to maintain. And sometimes it feels like we’re doing it on an honorarium rather than a Medicare rebate. We need to make our advocacy more visible

“It provided a really well-rounded experience and I hope that young doctors coming through have time to enjoy medicine rather than funnel into speciality and sub-speciality training too early. It’s all part of inculcating a good work/life balance and focusing on a generalist perspective. And that’s much better than putting a foot on their necks so they come out as Fellows in record time.” l

By Mr Peter McClelland

medicalforum

Kidney disease, eGFR and the importance of accurate creatinine R

enal failure is an insidious killer and the incidence in Australia has ballooned along with our waistlines (due to Diabetes Mellitus Type 2). To facilitate early diagnosis and thus reduce progression to end stage disease, eGFR reporting was introduced in 2005.

The eGFR is calculated by an equation that divides a factor, determined by the age and sex of the patient, by the serum creatinine. The factor is related to muscle mass, (which is proportional to creatinine production and hence urinary creatinine excretion). eGFR is therefore a surrogate for the formal creatinine clearance test which requires precise 24 - hour urine collection to actually measure creatinine excretion.

Provided the patient has average muscle mass and the serum creatinine is accurately measured, the eGFR has been shown to be an excellent measure of true glomerular filtration rate. Patients with unusually high muscle mass (e.g. bodybuilders, larger individuals) will, however, have higher creatinines (despite normal renal function) and thus a falsely low eGFR and may have Chronic Kidney Disease (CKD) incorrectly diagnosed. Those with low muscle mass (amputees, anorexics, paralysis) have low creatinine and thus falsely high eGFR which can mask the presence of CKD. In these cases it is advisable to perform a formal creatinine clearance to better assess renal function. Aside from muscle mass variation, the measurement of creatinine is also problematic. The majority of Australian medical laboratories use methods based on the Jaffe reaction (first used in 1886), which is prone to:

False elevation of creatinine by e.g. • medications (cephalosporins), • ketones, • glucose • proteins; and

False reduction of creatinine by e.g. • bilirubin and • HbF. Jaffe methods also have poor precision, particularly at low (i.e. normal) creatinine levels and the lower the creatinine, the more a given creatinine variation will cause eGFR changes. Accurate measurement of low creatinine levels of between 80-150 umol/L are most important for diagnosing early kidney disease as they equate to eGFR levels of around 60 ml/min/1.73m2, depending on age and sex. This is where Jaffe methods are in fact most imprecise, with typical CV (coefficient of variation) of around 3.5%. A creatinine of 80 umol/L, if measured by a Jaffe method, is thus expected to give a result of anywhere between 74-86 umol/L and still be considered to be within method performance specifications! Assuming the patient is a 70 year old woman, this translates to an eGFR of between 67 and 57 ml/min/1.73m2, or the difference between a possibly normal result and stage 3 CKD.

Is there an alternative to this unsatisfactory situation? There is a specific enzymatic method for creatinine using creatininase, which is not subject to the above interferences and is also much more precise (typical CV of 0.7%) than Jaffe methods. Using this method the creatinine in the patient above would be expected to be measured at between 79-81 umol/L and resultant eGFR would be between 62 and 61 ml/min/1.73m2, a major improvement on the Jaffe method

By Dr Sydney Sacks, Chemical Pathologist

performance. This is also the only routine method which has been shown to be equivalent to the research reference method (IDMS) for creatinine measurement1. In fact the Roche creatininase assay was used to derive the current IDMS aligned MDRD equation which is now used to calculate the eGFR. Not only is the creatininase assay more reliable at all creatinine levels, it is also more accurate in patients with low serum protein that have false low creatinine by Jaffe methods (pregnancy, elderly, chronic illness), and in those with false elevation of creatinine due to non creatinine reactants seen in delayed sample centrifugation, renal failure and in children. Unfortunately the reagent is not in general use in pathology laboratories in Australia as it is much more expensive than Jaffe methods. It is thus generally reserved for some neonatal patients as, unlike Jaffe methods, it is unaffected by high bilirubin and HbF levels. This approach, while benefiting babies, means adults may have random artefactual variations in eGFR and potentially unreliable classifications of CKD. Clinipath Pathology has decided to routinely provide the benefits of the creatininase method to all patients and will be switching to the Roche creatininase method in March 2012. The improved precision and accuracy will also enable reliable reporting of eGFR up to 90 ml/ min/1.73m2. Precise and accurate creatinine measurement is clinically so important that the increased cost is justified in our view, despite the erosion of the Medicare benefits received in payment. This service enhancement will be provided to patients at the standard Medicare benefit rate. 1. Levey et al, Clinical Chemistry p766-772, 53, No 4, 2007 2. Panteghini, Scand J Clin Lab Inv p84-88, 68, No S241 2008

If you’re a doctor in training interested in a research placement, would $25,000 or $50,000 help? Avant is delighted to announce the launch of the Avant Doctor in Training Research Scholarships Program. Each year we will award two full-time scholarships to the value of $50,000 each and four part-time scholarships of $25,000 each. Let us help turn your dream of that elusive research placement into a reality.

As a recipient of grants in the past, I would encourage you to put as much detail as possible into the application, it’s worth the time and effort to get it right. Dr Gareth Crouch Cardiothoracic Registrar (SA) Member, Avant’s Doctor in Training Advisory Council

Applications open at 9am on 13 February 2012 and must be received by 5pm on 31 May 2012. For more information or to download the application form, please visit www.avant.org.au/scholarship

Australia’s Leading MDO

Do Statins Cause Diabetes or Dementia? S

tatins have an established role for reduction of cardiovascular morbidity and mortality, particularly in secondary prevention. In this setting, their use has continued to increase worldwide.

Yet, uncertainty regarding potential adverse long term effects of statin therapy have continued to surface in recent years. Two concerning potential adverse effects are hyperglycaemia and cognitive impairment. Recently (28th February, 2012) the US FDA added warnings to statin labeling related to both issues – should we be concerned?

Diabetes The FDA warning related to hyperglycaemia states ‘increases in HbA1c and fasting serum glucose levels have been reported with statin use’. But what is the scope of the problem? Despite not being designed to answer this question, relevant data from some of the largest statin trials has been published. The JUPITER trial1 (17,802 patients) which randomised patients to rosuvastatin 20mg daily had a 25% higher rate of physician-reported diabetes - an excess risk of 1 case per 330 patients per year. Recent meta-analyses of large statin trials (including a range of statin types and dosages) published in JAMA 2 (2011) and Lancet3 (2010) suggested a lower overall risk. In the case of the latter the excess risk was 1 case per 1000 patients per year, while 9 patients per 1000 avoided death, heart attack, stroke or invasive vascular treatment. It is likely that the small risk of new onset diabetes with statin therapy, which appears to be a dose dependent class effect, is a real phenomenon. It is not clear at this stage however whether the excess hyperglycaemia in the case of statins equates to ‘true’ diabetes (with the associated health risk), and whether it is reversible with treatment cessation – this requires further study. So, how does this affect our practice? Substantial benefits of statin therapy

medicalforum

for secondary prevention have been repeatedly demonstrated, and likely outweigh the diabetes concern. It may be relevant however when considering the case for statin therapy in the primary prevention setting. For primary prevention the role of high dose statin therapy is not clearly defined, and it may be prudent to use lower dose therapy for those at lower risk where statin therapy is indicated. For those with obesity or impaired fasting glucose, broad recommendations are difficult given there is a higher baseline cardiovascular risk to balance against potentially adding to the risk of progression to diabetes.

Dementia An FDA warning states that there are ‘rare reports of cognitive impairment (eg. memory loss, forgetfulness, amnesia, memory impairment, confusion) associated with statin use. These reported symptoms are generally not serious and reversible upon statin discontinuation.’ The data to support this statement included analysis of four randomised trials, in a range of different statins, as well as adverse event databases, case reports and observational data. The randomised trial data does not provide convincing evidence of a link – with two small studies4,5 (by the same group) showing a small measurable effect on some cognition tests, while two larger studies showed no effect at all6,7. The conclusion drawn by the FDA is that adverse events of this kind appear to be rare and are not associated with a particular statin or dosage. The symptoms that have been reported are illdefined, and have a variable time of onset after statin commencements – from days to years.

Dr Chris Finn MBBS FRACP FCSANZ

About the author Chris Finn is a consultant cardiologist with Western Cardiology, and practices at Sir Charles Gairdner Hospital and St John of God Hospital Subiaco. He completed his medical degree at UWA before he trained and worked in clinical cardiology at Sir Charles Gairdner Hospital, and undertook specialised fellowship training in echocardiography at National Heart Centre, Singapore, and Princess Alexandra Hospital, Brisbane. Chris practises general cardiology, performs coronary angiography and has special interests in coronary artery disease, valvular heart disease and advanced echocardiography including transoesophageal echocardiography and stress echocardiography.

A consistent resolution of these symptoms has been seen within a short period after statin cessation (median of 3 weeks), and there are no data to suggest that statin use is linked to fixed or progressive cognitive decline including Alzheimer’s disease. In summary, cognitive impairment should be considered a rare and reversible adverse effect that requires consideration, but need not alter prescribing practice based on the current available evidence. In all discussions with patients the point should be made that all medicines have the potential to cause adverse effects, and a careful appraisal of the benefits and the risks must be taken before a decision is made. References 1. Ridker PM et al (for the JUPITER study group). Rosuvastatin to prevent vascular events in men and women with elevated c-reactive protein. N Engl J Med. 2008;359:2195-207 2. Preiss D et al. Risk of incident diabetes with intensivedose compared with moderate-dose statin therapy. JAMA. 2011;305(24):2556-64 3. Sattar N et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet. 2010;375:735-742 4. Muldoon M et al. Effects of lovastatin on cognitive function and psychological well-being. Am J Med. 2000;108:538-546 5. Muldoon M et al. Randomized trial of the effects of simvastatin on cognitive functioning in hypercholesterolemic adults. Am J Med. 2004;117:823-829 6. Trompet S et al. Pravastatin and cognitive function in the elderly. Results of the PROSPER study. J Neurol. 2010;257:85-90 7. Feldman H et al. Randomised controlled trial of atorvastatin in mild to moderate Alzheimer disease: LEADe. Neurology. 2010;74:956-964

Work-Life Balance

Live slow, and prosper Bariatric surgeon Sue Taylor says it’s important to live simply and help others to simply live.

he world was a simpler place in my youth. Life goals and self-identity were wrapped up in passing exams, gaining approval from mentors, and fulfilling salaried job requirements. I was proud of how quickly I could arrive at a diagnosis or management plan, and how quickly I could operate. There wasn’t much time to do or think about other things. Just ask my husband – he loves to remind me of how uncharitable I could be. Thankfully, he often reminds me of how much better things are now. Working as a general surgeon in the private sector means that I have the privilege of earning enough to be able to support my family while only working part-time. Working less means I have a little more room in my calendar to move. I have time to cycle between Hollywood hospital and Osborne Park Hospital when required, so I don’t need to run a car at all. I’m lucky.

I also have the time to engage in issues of importance beyond the operating room. Having children has highlighted the urgency and importance of protecting our future – of walking lightly on the earth, living simply so that others might simply live, and nurturing a resilient community. Whether you look at our changing climate, global economic issues, peak oil, the fall of the US and Europe and rise of Asia, or merely the injustices of our comfortable lifestyles built on the back of slaves we can’t see (in China, India, Korea …) the rate of change of our lives is accelerating at a hyperbolic pace. So in my spare time I enjoy gardening in my front yard, my backyard and on the garage roof. I also love working alongside my neighbours in the West Leederville Community Garden [www.wlra.org.au]. The garden is a wonderful place to invite the local primary school kids where they can have a break from the classroom and learn maths, science, biology and art in the real world.

Be active I am active in the residents’ association, which has a role in encouraging locals to walk, cycle, use public transport, use water and power wisely, and to get involved in local government planning issues in a constructive way. Donating money to worthy causes is good, but it isn’t enough. We must give of ourselves, or we have given nothing. And then, back at work in the operating theatre, I am reminded of my hypocrisy as I use disposable harmonic scalpels and silicone bands, single use drapes and scissors, and copious packaging, which will end up incinerated or in landfill. Perhaps we all would benefit from taking a break from wanting everything instantly. Waiting for the autumn rains to cool the earth, and for the seeds we have sown to grow in their own sweet time can be good for the soul, body, family, community and planet.

Medical Forum asked some women doctors about how they achieved a balanced lifestyle. Here’s what they had to say about their career, patients and families. Dr Sarah Moore GP Obstetrician, Busselton I currently have three jobs – GP obstetrician, medical coordinator for Rural Clinical School and Director Postgraduate Medical Education Unit for WA Country Health Service. I’m based in Busselton, where I work in a private GP practice 2.5 days a week, and provide obstetric services at Busselton Hospital. My RCS job is 2.5 days a week and involves teaching and supervising six medical students. My director role is one day per week and I do this remotely, as the office is based in Perth. I work from home and do lots of teleconference and video-conference meetings, plus the odd trip to Perth. I have one daughter, Alice, who is 10 months old. I am very lucky to have a husband, Brad, who is at home with her full time. He also takes responsibility for running the household, which means I can spend quality time with Alice when I get home from work. We work as a team and I am very grateful for the work he does. Brad is an electrician. He is extremely handy 10

around the house! I think if I married a doctor I would talk about work too much, so I appreciate having a non-doctor around to keep my mind off medicine. We have a couple of holidays booked already for this year, which I’m looking forward to already! My RCS and director roles are flexible. I often work from home when I’m not teaching, which means I can fit my hours around family commitments. I can also swap my GP shifts if necessary. As far as medicine being a boy’s club, I think there are some areas that are but GP isn’t one of them. I work with a number of men and women doctors and they respect each other, no matter what their gender. I think female patients seek out female doctors because they think they understand women’s problems and prefer to speak to a woman about their women’s business. I know I like to see a female GP for that reason. I think many women doctors, especially those with children, do feel empathy with their patients and are able to convey that in a consultation, which does a lot for the therapeutic relationship they have with their patients. And our fantasy question: You have three free hours, how would you spend them?

I seem to be dreaming about this a lot lately, and I’m not sure if these three hours will ever become a reality! My fantasy is pretty simple – I’d have a full body massage then get comfy with a good book and read uninterrupted for a few hours.

Dr Julia Barton Specialist Obstetrician and Gynaecologist I currently work two sessions a week at KEMH, one in Emergency and the other in charge of the Adolescent Antenatal Clinic. I also consult at Hollywood Fertility Centre two sessions a week and do IVF procedures one session a week. That is my standard week which increases a bit when my colleagues at Hollywood take leave. I tend to do most of the leave cover as I am the only one with flexible enough hours to fit in extra! I am divorced and have a daughter aged six for whom I provide the majority of care. Fortunately a lot of my work sessions fit in with school hours – the beauty of being able to schedule my own private consulting medicalforum

hours. For times that are not so negotiable like early theatre starts and afternoon public clinic I rely on a combination of neighbours with children in same class at school, a long-term nanny who has been with me since my daughter was a year old, and a number of babysitters – mostly local uni students. Apart from one day a week I am usually able to pick her up from school and take her to dancing classes/music etc.

Oh and three free hours? – I do get that on alternate weekends when my daughter is with her dad. Mostly it is used catching up on the housework but I do make sure I have a regular massage and an occasional visit to the beautician. Every now and then I treat myself to a DVD on the couch with a cup of tea or glass of wine, depending on the time of day!!

I have certainly found that my decision to commit time to my daughter has meant that I have restricted my specialist practice to a very limited area. This has certainly led to my becoming deskilled in other areas, particularly obstetrics and the more complex surgical side of gynaecology. The way I look at it is that I can always retrain in these areas later if I want to expand my practice again. I think that being a mother and having to juggle that with a career has made me a lot more empathetic as a doctor. Our fertility clinic nurses certainly encourage the patients who ‘need someone to talk to’ to see me ahead of my male colleagues. At the same time, I am happy to direct patients who require complicated surgery to one of them, so it works well.

Dr Manal Rezkalla

I am getting much better now at booking regular holidays and find that it is actually easier to arrange from my private practice than it is from my public appointment. medicalforum

GP, Warwick and Kingsley Family Practices My work covers the full range of GP services as well as the specialised areas of skin cancer medicine, cosmetic medicine and the treatment of varicose veins. My eldest son has recently graduated from uni, however, my youngest son has just started school, so that involves quite a bit of planning to arrange school runs, afterschool activities, etc. I always take him to school and my husband and I share the responsibility of picking him up. We are also fortunate to have parents in Perth who can take care of him when we are both working.

As a responsible doctor, there is a limit to how flexible I, or the practice, can be. Obviously an emergency situation is different, but generally I would have to rely on family to step up in the case of something like a cough/cold that keeps my son out of school, and likewise during school holidays. My spouse is a doctor – we work together! The pluses are that he understands the time issues, after-hours meetings and stresses related to being a doctor. On the downside, work often encroaches on family time. It is definitely hard to plan work-free holidays! Time away from the practices is often taken up attending courses and keeping myself updated on developments in my areas of interest, so it is not really a holiday! I don’t believe that medicine is a boy’s club. Women doctors on the whole are busier than their male counterparts. I feel that the strengths of women doctors are that they are often more approachable and easier to talk to. Mostly patients seem to find women doctors more understanding, patient and compassionate. Whether this is just a perception is hard to tell. Ah... three free hours?! I would head to the beach with my fishing rod and relax! And hopefully catch a lot of fish! 11

Aboriginal Health

Sandy Thompson – Whispering Loudly A Whispered Sort of Stuff paints a picture of Aboriginal people and cancer. Prof Sandy Thompson, the report’s co-author, sheds light on a broader landscape. Prof Sandy Thompson’s breakthrough translational research into Aboriginal health and, in particular, indigenous beliefs regarding cancer shed new light on Aboriginal experiences within the health system and interactions with doctors and allied health professionals. The findings are published in A Whispered Sort of Stuff and funded by Cancer Council Western Australia and the National Health and Medical Research Council (NHMRC). The three-year study began in 2007 with Aboriginal people in the Mid-West (mostly Geraldton) and the Pilbara (Roebourne) and also patients from other regions when they travelled to Perth for treatment. “We focused on researching, evaluating and implementing interventions that can make a difference. It’s important to have support mechanisms in place and the Geraldtonbased, Midwest Aboriginal Women’s Cancer Support Group is a good example of that. A lot of effort goes into mentoring Aboriginal leaders so that they have the skills to refine programs which will suit their own community,” she said. The audience for this research was not primarily Aboriginal people. Sandy says a far more important goal is developing a health system which is more responsive to the needs of Aboriginal patients. Sandy, a former GP from NSW and now Chair in Rural Health at UWA and the Director of the Combined Universities Centre for Rural Health, is forthright about the form and function of this type of research. “Working closely with people and having robust discussions is absolutely critical. There’s no doubt that effective participatory processes that increase the understanding of issues and of another person’s position offer a greater chance of translation,” she said. “Getting researchers, health consumers, service providers and policy makers together is important – and it’s doubly important when you’re working with Aboriginal communities on issues that they’ve identified as a priority.” The ‘social determinants’ of health is a phrase much bandied about. Sandy has firm views on the wider context of Aboriginal health: “What is often called ‘lifestyle’ is often more about ‘life opportunities’. The ‘social determinants’ of health sounds rather trite but there’s no point in giving people advice if we don’t do something 12

about helping them achieve good outcomes. “We need to engineer better support systems and reduce the environmental influences which encourage bad lifestyle choices – those choices are incredibly limited when you have limited resources, poor education and no financial security. If Aboriginal people n Report authors Dr Shaouli Shahid, left, Professor Sandy Thompson and A/ are to share equally in the Professor Dawn Bessarab (missing Heath Greville). advances in cancer treatment, in the treatment models. There are now better linkages between centres opportunities for case conferencing so that in the metropolitan areas and a patient’s patients don’t have to travel to a tertiary local health service would make a big hospital in the city but if they do, they’re difference,” she said. now much better prepared before they leave It’s not only the precursors to cancer which their community.” impact on Aboriginal people differently compared to the white population. Aboriginal outcomes are often diminished as well. She said Aboriginal people with cancer were more likely to die from the disease than non-Aboriginals because their cancer, when detected, was often more advanced because they were often reluctant to present.

“Aboriginal people also tend to get serious cancers such as lung and liver,” Sandy said. “Some of the traditional Aboriginal responses aren’t unique but the common element is that they’re looking at this from a non-scientific spiritual belief system. And, somewhat surprisingly, that also applies to individuals who’ve had health training. That’s part of the reason for the report’s title – A Whispered Sort of Stuff.

We still have a long way to go in providing culturally appropriate care. “For Aboriginal people there’s almost a sense of shame about having cancer. So there’s still a long way to go before we can really say we’re providing culturally appropriate care.” However, she says there have been positive changes with Regional Cancer Care Coordinators working between the community, and the hospital and more Aboriginal people in liaison positions – for instance RPH has appointed an Aboriginal worker in its oncology section. “A lot of this is linked with ‘Close the Gap’ funding and it’s led to practical outcomes

As far as doctors are concerned, Sandy suggests a number of areas worthy of attention.

“There needs to be a renewed focus on attribution of cause. Some Aboriginal people still see cancer as a curse or ‘payback’ so doctors need to ensure they ‘see’ and treat the whole person. Sometimes that might mean asking, ‘what does this person need in order to heal’ and that may even lead to using some of their own traditional medicines,” she said. “Doctors also need to realise that some models of care are less than ideal. For example, a public clinic with its revolving door, in/out patient movement doesn’t build good relationships, and when that happens to Aboriginal people they are less likely to comply with a treatment regime. “Including the wider family group is important too. Doctors can’t have unrealistic expectations because family obligations will sometimes result in a patient not placing a high priority on their own health. “I hope this research resonates with Aboriginal people but what I’m really hoping is that health providers will look at this and say, ‘I never really understood that properly. Maybe I need to do things a little bit differently.’ We’re really at the end of putting Bandaids on people and we need to look at the health system as an entire package. Unless we get the cultural aspect of our services right it will be difficult to engage with our patients. “Put simply, they just won’t trust our advice.” l

By Mr Peter McClelland medicalforum

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Medical Politics

Dr Mike Civil on Campaign Trail This tech-minded GP gears up for a tilt at the RACGP presidency. Local GP Dr Mike Civil intends to run for RACGP national president come July. Unusually, he has not held a senior post with the WA faculty and his IT knowledge means his main campaign platform will be around impending government initiatives, the e-health record for patients and tele-health. If there is a contest, odds are against a WA candidate where only 10% of the national constituency reside, but with a low turnout among non-compulsory member voters, some media savvy and federal alliances can get you over the line. Mind you, he may yet be the only candidate. “I support a democratic process and in some ways I would feel better if I won a contest – that I became president with the support of those who chose to vote. On the other hand it’s a harder ask for a WA candidate to win,” he said. “My involvement with the college has always been national, such as the GP Computing Group when it was around, and Standards. “I know [immediate past president] Chris Mitchell well, having been on the Standards Committee since 2007. “I’ve been flying all over the place doing work for the college in the past six months, primarily with e-health and tele-health, but recently with nurse practitioners as well – I have put my hand up for anything. As Chair of the Standing Committee for Standards in General Practice [since October] I have been invited to the strategic planning day for Council.”

We asked him what general practice flavour does he bring to the boardroom table? “I would bring the GP-on-the-street viewpoint. I’m the principal of a large private practice in the Hills, split between three locations, and depending on the number of registrars and juniors, we have about 15 doctors. We have overseas-trained doctors, PGPPP doctors and medical students. “GPs are struggling to do the things that the government wants and make a business profitable in general practice. “I’m almost loathe to say e-health and telehealth is my focus because the training of junior doctors and integrating international medical graduates into the health system are the other big tickets – but there are a lot of important things if you are a coalface GP trying to make it work. “Regarding e-health, you just have to get out there and do it, and I have no doubt we will need to modify and adapt the systems we use. We have most of what is required here, although line speeds in more remote areas such as the Kimberley will be a big issue. “Hospital based tele-health already has many of the facilities but you get the feeling that a fancy bit of equipment gets pushed to the back of the room and hardly used. A case in point is the hospital system uses [video-conferencing] software called SCOPIA and we in general practice don’t get access to it. If government want GPs to save money in the system they have to enable us.”

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Mike Civil’s Drum Telehealth: Intends to lead by example. His practice did 240 of the 704 MBS item video consultations in the first six months in WA, using a rheumatologist in particular. He wants the college to get involved in producing a directory of specialist video-consultation services. He’s on the tele-health advisory group with Rural Health West. Was involved in writing the RACGP standards for video consultations and worked for NEHTA. Medicare Locals: Takes a pragmatic view – get involved and see what happens. Not knowing their full function is a problem. Boards could be good or bad for GPs. After-hours care is an important unknown for local practices like his. His practice: Stirk Medical Group in the Hills, for 11 years. Involved with the outer-metro regional training for WAGPET. He and his wife (working part-time) are the principals. Super clinics: Says we cannot afford to dilute what a GP specialist does using nurse practitioners or allied health professionals. GP-led teams are a good idea. Feels super clinics may be propped up with money when the business case may be towards existing general practice services within an area. GP recruitment: More GPs needed despite financial attraction of the specialist fields. Origins and family: Trained in the UK where he met his wife. Arrived in WA 20 years ago. Three children, twin daughters in third year Science at UWA, and a son studying mechanical engineering. A regular dirt rally competitor for more than 10 years.

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Feature: Celebrity

Bullying on Steroids From Harlem to Perth, bullying is a pervasive social phenomenon and WA’s Australian of The Year, Prof Donna Cross, believes GPs are on the front line. The Foundation Professor of Child and Adolescent Health at the Child Health Promotion Research Centre has been researching the effects of bullying, which includes health effects. "There’s such a need out there. Our research indicates that one in four children sitting in a classroom has been bullied and one in 10 have, at some stage, bullied others. In the consulting room when a young person presents with a physical problem, there may well be a mental or social component lying underneath that. I know they only have a limited amount of time, but GPs are in a wonderful position to discuss these issues and refer a young person for appropriate help,” said Donna. She began her professional life in the classroom, including teaching disadvantaged schools in Harlem. “I spent five years in Harlem from 1988 until 1993, which was before Mayor Giuliani’s reforms, so it definitely had its moments, but it inspired me to look at the changes we could initiate using schools as a vehicle to focus on families, and young people in particular, who were struggling under great social disadvantage which led to all sort of health problems,” she said. And for Donna, who has a 10-year-old daughter and a 15-year-old son, those speaking for children need to be heard. “One of the biggest challenges is that children have no constituency, they don’t vote and their voices aren’t heard. They have so many important things to say and not very many vehicles with which to do it. The wider community trusts GPs and when they speak out people pay attention,” she said. Prof Cross has been doing her best to bring issues such as bullying to greater prominence. “The most fundamental issue is the influence of peers. We need to address issues such as the pastoral care of young people, how they interact with each other, the quality of their relationships and how they can be more effective communicators. The CHPRC looks at influences, both positive and negative, and the most insidious of these is bullying. The amount of harm that comes from it is extraordinary, children are often derailed socially and it severely affects academic potential,” she said. There is a strong gender component to bullying, with girls often more cutthroat, 16

n Prof Cross camping with her offspring: “Children have so many important things to say and not many vehicles with which to do it. The community trusts GPs when they speak.”

more underhand and efficient at spreading rumours and excluding others. Boys, on the other hand, are more overt and physical.

Linked with cyber-bullying are the findings surrounding regional and cultural differences.

“Research suggests that covert bullying is extremely harmful, particularly if adults don’t take it seriously. For example, if a child is excluded from a group and an adult responds with something like, ‘Don’t worry, there are lots of other children to play with’, it’s almost condoning that behaviour. And children stop telling the important adults in their lives, which can lead to mental health concerns.”

“I recently attended a conference in Europe where I discovered the trends there are quite different to Australia and Asia. For example, in Germany it’s ‘Chat Rooms’ and other public platforms where they can be ‘seen’ by their peers whereas here in Australia texting and social media sites such as Facebook are used much more commonly used,” she said.

Any parent with children in mid-primary school or above will be well aware of the potential perils of the internet. “Since 2006 we’ve seen cyber-bullying appearing in our surveys. We’ve got crosssectional data indicating that children who have been bullied are now, within the safety of their home, getting some sort of retribution by anonymously attacking someone online in a public forum,” she said. “Technology has enabled some young people, who may not have bullied others in the past, to bully using a highly pervasive platform. It’s all about disinhibition – they’re not actually looking at someone’s face when bullying and they have anonymity. Not only does that make it easier to perpetrate this behaviour, but the victim suffers a real sense of paranoia. They’re asking themselves, ‘who is it?’ and ‘why are they doing it?’ The end result is a loss of social capital because often there’s an unwillingness to form friends. It’s bullying on steroids.”

In Asia, particularly in South Korea and Japan, young people are far more likely to be bullied on ‘Gaming Sites’. There are avatars called ‘Griefers’ who forcibly enter the games and do all sorts of dreadful things to other children. “Attitudes towards aggression, violence and bullying such as ‘you just have to put up with it, it’s a rite of passage and you’ll be a better adult as a result’ just can’t be tolerated. Some people who’ve been bullied can remember the actual day that it happened, even down to what they were wearing. This sort of behaviour relies on an audience, it’s socially driven and it establishes social hierarchies. It’s an important issue for us as a community and there’s still a lot we can do to shift the social norms around this type of behaviour,” she said. l

By Mr Peter McClelland

medicalforum

The Drum

Big Buzz for Doc of The Swan as injections and blood sampling. The ‘bee’ also has ‘cool’ wings that can be chilled to provide an alternative sensation.

Last months Doc of The Swan raised funds for charity and doctors had a great time. Last year the charity sail raised $10,000 to kickstart the Gordon BarronHay scholarship which went to Victoria Corkish, a UK-trained nurse who works at the PMH Acute Pain Service. We asked Victoria for an update:

“This project has involved liaising with activity co-coordinators, occupational therapists, phlebotomists and allergy testing and infection control staff among others. We are currently working on cleaning and storage protocols for the ‘bees’, in addition to developing infection control audits to ensure the devices do not spread bugs. For children who suffer from bee allergies or phobias, there are buzzy people or ‘dudes’ and we hope to buy some of these too. “We have also bought distraction cards that can be placed in the devices to help ‘hide’ medical procedures. The find and seek activities on the cards help divert the child’s attention away from the procedure and hence alleviate anxiety.

“Although I am the designated recipient of the Gordon Baron-Hay scholarship for 2011, I’d like to point out that I work with a fabulous team of pharmacists and anaesthetists. We are using the grant money to fund two projects. The first is the introduction of new non-pharmacological resources for procedural pain management – some ‘buzzy bees’ which we hope will be hospital-wide swarm,” she said.

“The second project will examine the education and information given to parents regarding pain management, and to assess how useful this is. Based on the results of this work, some grant money will then be used to improve existing resources and/or develop new ones. One possible outcome is to produce a web-based resource as part of the hospital site.”

“These ‘bees’ are actually small devices that vibrate to reduce pain and provide distraction during painful procedures such

This year’s Doc of the Swan fundraiser will help several self-help groups working with children with special needs.

Beneaththe Drapes u Dr Brad Zhang is the 2012 BrightSpark Foundation fellowship winner. He has been awarded more than $350,000 over the next three years to investigate causes of the dramatic rise in asthma over the past 50 years. Applications for the 2013 fellowship close 5pm, May 4. Email info@ brightsparkfoundaiton.com.au for details. u Samantha Dowling has left the WA General Practice Network to become Deputy CEO of the Canning Division of General Practice soon to become the Bentley Armadale Medicare Local. u Jay Pintado has resigned as CEO of Smith Coffey after 14 years. He will continue as interim CEO for six months to facilitate a smooth transition. u Dr Frank Daly is the new Executive Director at RPH. It is a return home for Dr Daly – RPH was his first placement as an intern.

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Have You Heard? distributing his Sonoplex ultrasound-guided needle into many overseas countries. Most WA hospitals already use it. He did all the development and made prototypes at home using equipment from Bunnings. His ideas change the way ultrasound is reflected off a long local anaesthetic needle, improving greatly the picture generated, particularly at depth in non-fibrous tissues. The same echogenic technique is now to be used on other needles, for CVP line placement or to gain arterial access.

Time for an implant registry The PIP breast implant saga, following hip and stent implant problems, highlights the need for a compulsory implant registry in Australia. Up to 12,000 PIP implants have been used Australia-wide and nobody can say by whom, after an initial TGA tick. Dr Tim Cooper says he personally knows at least six surgeons who have implanted the prostheses in WA and he is working through his 134 patients (2005-08) on a case-by-case basis. He said ultrasound (not the government-offered MRIs) plus clinical assessment is 100% accurate in picking a rupture. He is offering to replace at cost. When Cochlear recalled their defective implants, replacement with an earlier model was offered free.

Units? Yet another clinical guideline, this time colonoscopy? The Breast Implant Information Line open 24/7, the TGA alert, or the free MRI by government at $700 a pop? Medical Forum recieved press releases on all of these.

GP recruitment booming A record 1000 medical school graduates (89 in WA) have begun vocational training with AGPT to become GPs this year. The number of registrar places increased from 700 in 2010 and is projected to increase to 1100 next year and 1200 in 2014. The 2012 intake includes nine Aboriginal and Torres Strait Islander people and 24 from the Australian Defence Force.

SJGHC Midland dilemma

Scramble for headlines What makes a story? Is it Prof Christobel Saunders hosting Bhutan’s public health doctor and only gynaecologist-oncologist? Is it the Cancer Council pushing for more bowel cancer screening? Or the new smart phone application so parents of premature and sick babies can understand medical speak in Neonatal Intensive Care

Invention at the sharp end He says it will never fund his retirement, but after only two years in development, Perth anaesthetist Dr Chris Mitchell has German company Pajunk manufacturing and

With the current government keen to privatise our public hospitals, diverting operating profits to a “charity” like SJOG seems better than to shareholders. Except for one dilemma, according to a local GP who contacted us. The Catholic ethos means there will be no contraceptive advice or procedures, counselling for termination after nuchal scans or terminations themselves, or IVF work within the Midland Health Campus precincts while under SJOG administration. Is a contract with religious strings OK with the community, regarding separation of church and state?

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that normally limits immune response); and the clearance of growth factor TGF-β that reverses the initial Treg suppression. With these three pathways blocked there is complete clearance of tumours for a long time in mice.

Peel palliative services It’s got you covered When we queried how HBF handles overdue payments of hospital insurance. ‘Brooke’ told us HBF reminded members who pay by statement three times¬ – six weeks before the due date, two weeks after, and six weeks after. Then comes three separate phone calls. If the policy was to lapse due to non-payment, HBF wait a maximum of six months (for long-term members), in which time they can reinstate and back pay their policy without losing any benefits.

MM research breakthrough Science Network WA reports that the UWA School of Pathology and Laboratory Medicine has used ‘triple immunotherapy’ to clear malignant mesothelioma in animals, with human trials at least five years off. The method refers to use of: an antibody that depletes a suppressive cell-type (Treg), thereby promoting the natural immune response that includes an increase in activated anti-tumour T cells; blockade of the antigen CTLA-4 (a checkpoint marker

Peel Health Campus has appointed Dr AjiBola Oki as the new Palliative Care registrar at PHC, to improve palliative services there. Dr Oki is a GP Registrar who will continue to work part time at Murray Medical Centre and the new training position has been created in collaboration with Adjunct A/ Prof Willie Walker of MMC (also chair of the PHC MAC), WAGPET, and the WA Palliative Care Network. Dr Oki will work closely with the community-based Peel Community Palliative Care service under Dr Sarah Pickstock, spanning community and hospital. PHC will increase its five dedicated palliative care beds under private operator Health Solutions (WA) Pty Ltd.

ESIA pushes nature The Ear Science Institute is teaming up with Deakin University’s Future Fibres Research and Innovation Centre in Melbourne to try to replicate nature in constructing artificial tympanic membranes that have the right acoustic and mechanical properties important for the function of reconstituted TMs. It’s to do with the microstructure, particularly the specialised nanofibre

scaffolds to which ESIA can apply its regeneration technology. A reconstituted TM is expected to support the overgrowth of native TM cells and biodegrade at a rate that matches the healing process, making current myringoplasty with autologous grafts redundant.

Your say on child exercise The Australian Curriculum, Assessment and Reporting Authority (ACARA) is inviting public comment on its draft health and physical education curriculum for school children K-Year 10. The draft recognises that with increased screen-based learning, health and physical education need to be rethought. Have your say at www.acara.edu.au until June 3.

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medicalforum

Clinical update

Helping Treat Cancer in The Wheatbelt H

ow does a rural GP care for the complex physical, social and emotional needs of a patient with cancer? The Rural Cancer Nurse Coordinator (RCNC) can assist as part of a multidisciplinary team; an important link between metropolitan and country services. The key to effective use of this service is early referral – as easy as telling the patient and sending the RCNC a copy of the initial referral letter to the cancer specialist.

Metro-rural divide GPs have access to health professionals who support them and their cancer patients – oncologists, radiation oncologists, surgeons, specialist nurses, counsellors, allied health professionals and support-care providers. However, many of these are metro-based and the RCNC’s role can be to bring providers together, to ensure a patient’s care is as seamless and effective as possible. There has been a RCNC in the Wheatbelt since 2007 – to help patients negotiate the arduous treatment programs associated with cancer, and to discuss diagnosis and possible treatments. The RCNC has acquired specialised knowledge of specific cancer treatments and can facilitate care locally.

Some practical help A simple example of how this works is coordination of appointments. This means fewer delays and reduced travel costs. Instead

of patients having appointments over several weeks, with multiple trips to the metropolitan area, grouped appointments reduce physical and social impacts. They also result in quicker diagnosis and staging and consequently, quicker treatment. This in turn leads to less patient distress, improved compliance and better treatment outcomes. The RCNC works to ensure that rural health care providers have the relevant information about the care of their patient in a timely manner. As the primary healthcare provider, the GP must have current information about their patients. And country patients invariably return home at every opportunity between treatment cycles, to be with family and friends. If these journeys are disrupted by sickness, patients may present to another local GP or hospital. Providing that service with current information can be an important part of RCNC assistance with

By Ms Lois Newsome RN, Rural Cancer Nurse Coordinator, Northam care coordination, hopefully ahead of time. Delays in information sharing can impact on outcomes.

Keeping up with the latest Cancer treatments are very specialised and change frequently. Cancer specialists are experts in this field and the RCNC’s role is designed to pass on some of this knowledge to support the primary care providers. While coordinating care of individual cancer patients they can update those they work with, and provide feedback to cancer specialists. They are actively involved in quality improvement and research.

New coordinated efforts As part of the CanNet 2 project, together with others in the care team, the cancer nurse coordinators are now designing region-specific referral pathways for cancer patients. These are designed to minimise delays in diagnosis and staging and maximise treatment outcomes. Rural multidisplinary teams are being initiated, comprising cancer specialists, allied health and nursing people. This ‘forum’ will allow rural GPs to present a patient with a new cancer diagnosis for expert opinion and for commencement of treatment.

medicalforum

Cancer Care

Nurses Coordinate Cancer Care

The complexity of cancer care begs someone to coordinate. The task is falling to Cancer Nurse Coordinators organised from the tertiary end of care.

The media statement heralded a decision to continue to fund and expand the service at $3.84m per annum, for 21 cancer nurses across metropolitan Perth and a seven across regional WA. Metro Cancer Nurse Coordinators (CNCs) are allocated to specific tumour collaboratives (multidisciplinary teams established for the main tumour types) while regional CNCs are assigned to specific regions and work across all tumour streams. A Department of Health spokesperson told us they plan: “To expand teams in the near future to include geriatric oncology,

primary care, survivorship and Aboriginal coordinators. We are also involved in research studies addressing complexity indicators and nurse led clinics.”

care and no general practitioners), 90 patients and 46 carers, all during 2008. Here is some of the report's findings:

In his preface to the Final Report, Chief Medical Officer Dr Simon Towler pointed out it was the Cancer Services Framework that advocated for a state-wide CNC service back in 2005. It was then developed by the Health Department’s Palliative Care Network in conjunction with a range of relevant providers, public and private, before commencing in October 2006. “As cancer nurse leaders, the team members are responsible for many strategic change developments on a national and state level to maintain the continuous improvement of cancer service delivery,” Dr Towler said, adding that the research in the document confirms the impact of CNCs on cancer care delivery in WA. See www. healthnetworks.health.wa.gov.au/cancer/ docs/CANCER_REPORT_aug2011.pdf. The research was conducted by Edith Cowan, Notre Dame Uni and Curtin University after surveying and interviewing most of the CNCs, and surveying 148 healthcare professionals (37% in primary

• CNCs spent 70% of time on clinical consultation and 30% on administrative and strategic tasks. • Implementation of the cancer nurse has reduced CNC clinical workload and increased time for strategic activities. • Most referrals arose from within the CNC team, physicians and medical staff, or multidisciplinary team meetings. Only 3% came from GPs. • Case load, funding and resources were considered the main barriers to impact on the CNC role by health-care professionals. • Health-care professionals and patients recommended increasing the availability of CNCs. • Aspects of care most valued by patients were provision of information, emotional and practical support. • Carers required assistance to develop communication skills to facilitate open communication with doctors.

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A media statement from the Health Department alerted us to the WA Cancer Nurse Coordination service, unique, state-wide, and nurse-led, between the patient and cancer nurse specialist. There was 88% patient approval rating, citing access to information, and emotional and practical support as most valuable. We learnt of the August 2011 report Evaluation of the WA Cancer Nurse Coordinator Role Final Report and that around 3000 new patients a year access the service, now in its sixth year.

While you care for others, we care for your career. find your opportunity at www.health.wa.gov.au

Alternatively, call (08) 6444 5815 medicalforum

Rural Medicine

Why Doctors Do Rural Locums

octors who enjoy doing rural locums seem to know something we don’t. Certainly, the assistance offered metro doctors in doing rural locums, from organisations like Rural Health West, seems almost over the top at times (see box below). Couple this with patients who really value your doctoring, staff who know the patient group and work with you, and a lifestyle that is a welcome contrast to the impersonal hassles of the city, and you have to wonder why more doctors aren’t joining in. We talk to three WA GPs who find rural locums a great match for their needs and talents, and we find out more.

n Judith locuming at the highest town in WA, Mt Tom Price.

Dr Judith Findlay “I now combine my desire to travel with my enjoyment of medicine.” “You meet amazing people - both staff and patients – and hear some incredible stories,” Judith said before listing some of her locum places as Southern Cross, Lake Grace, Narrogin, Bunbury, Pemberton, Pannawonica, Karratha, Halls Creek and Morawa. She started locums in 2007 and by 2009 was facing burnout, mainly because she was doing FIFO for International SOS into Papua New Guinea, not to mention some work in Darwin and Alice Springs Correctional Facilities and some locums in the 35 Gemini practices across Australia. How did she prepare for remote area locum work? “When I first came to Australia from England in 1989 I had done more than most in subspecialty areas. Then I did four years in Morawa, three of those solo. I recently did the College of GPs Advanced Life Support course to keep those skills up – you have got to be able to resuscitate people and get them to a specialised centre,” she suggested. Any anxiety about managing tricky problems alone has decreased with experience. Remuneration is good, varies, and Rural Health West subsidise travel to some areas. “I am sure I gravitate towards some of the higher bidder practices, but then that gives

me financial space to manoeuvre towards some of the areas of greater medical need at other times. I enjoy mixing general practice with hospital work so working in a solo practice with a hospital facility can be both challenging and rewarding.” For those who want to stretch their wings and try the rural locum experience, Judith suggest a major centre, which means you are not out on a limb initially. “Don’t be afraid to use the resources of others, including the local health team. I remember I was grateful for some advice from the doctors in Bunbury when I had a patient with mental health problems while working in Pemberton.” “Rural Health West will organise all the paperwork, travel etc. and liaise directly with the practice. All I need to do is touch base with the practice a week before I go and Rural Health West is always on the end of the phone if there is a hiccup.” Her biggest bugbear used to be the different medical software packages but a few locums later, she is familiar with most. Accommodation can be variable but generally not a problem, and hospital staff have been very helpful and obliging. “Even at Wickham and Roebourne everyone sort of pitches in – I remember stitching someone’s ear back on using torchlight because the generators weren’t working! The types of people who are going to work remote are dedicated to what they are going to do.”

“A big majority of what you see in rural practice is what you see in the city – the other you may not see because they turn up at the ED. Working in the hospital setting as well as general practice gives you the opportunity to see a case through to its conclusion and I feel more aware that I am making a difference in people’s lives.” The five skills she picks for rural locums are: •

A sense of adventure.

•

Advanced life support skills.

•

Good listening skills.

•

Must be a team player.

•

Being prepared to leave family for 1-3 weeks (although they can go too in some circumstances - a holiday for all!)

Rural Health West With the assistance available today, barriers to a rural locum have largely evaporated for any GP contemplating the idea… • There are no fees – either ongoing or booking. • Anyone who feels unprepared for “emergency” work can take advantage of a free refresher course. • Get a good match with your likes and dislikes, thanks to a network of well-known practices and towns.

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Dr Marie Fox

“Taking a bicycle [as an avid cyclist] and using this when at the practice, I find is a good stress reliever. The main advantages of locum work are you do not have to handle the day-to-day management of a practice and you can pick and choose between practices and when you want to work.”

“A great cure for burnout.” Marie Fox sold her Northam practice after 14 years in group practice in the town she grew up in. She now does 6-8 rural locums a year of about 2-3 weeks duration. “It’s just a great cure for being a burnt-out GP. Now I make plenty doing regular locums and I really enjoy it,” she said. She works at Northam, Wongan Hills and Goomalling (“when I’m around home”), Halls Creek, Roebourne and Balgo, which is 200km south of Halls Creek on the edge of The Great Sandy Desert. Does she have any favourites? “I really enjoy going back to Halls Creek as I’ve been going since 2006 and I’ve got to know the place and the people. I joined the Buddy Program through Rural Health West, which is designed to get GPs doing regular locums at about six different Aboriginal Medical Services in the Kimberley. The doctor who goes on holidays knows who they are getting, the locum doctor knows what they are coming to and the AMS and Rural Health West pay together.” “I try to keep my emergency skills up-todate because I work at Northam ED sometimes. The specific upskilling I needed to do was the cultural awareness. I enjoyed it, run in Perth by a woman from Broome and provided by Rural Health West.” Forget about heart-in-mouth situations as the only doctor, miles from anywhere! “There’s a hospital 200 yards up the track and that’s staffed by 3 or 4 doctors, and usually there’s another doctor working with me at the Aboriginal Medical Service as well. The AMS locum is 8 to 5 and lots of these places have a hospital close by and there is the RFDS who are very useful for telephone advice.” “The only time it’s challenging and isolated is when I go to Balgo, which is a very remote area with 600 to 800 people. Work at the clinic is in a team, with specialist nurses and Aboriginal Health Workers. You deal with emergencies as they come in, in close liaison with the RFDS. The patient profiles involve a lot more difficult-to-manage

Locum Package • • •

Rural Health West will act as your facilitator to negotiate suitable terms and conditions. Assistance with essentials provided (e.g. Medicare provider number, credentialing, travel and accommodation). ‘Welcome’ handover to both practice and locum for a smooth transition.

medicalforum

n Marie is pictured with her mother Laura, in front of a natural rock formation, fondly called the Halls Creek Wall of China. Her parents visited last year, up for the performance of the Jundamarra (Pigeon) Story performed by an international group and local Aboriginals. She has a chance to look around in the provided car on weekends.

diabetes and renal failure, compared to Northam. I’ve had to learn quite a lot about both.” On the one hand, she describes poor crowded living with variable access to money and medications, and on the other, the joys of working with the Aboriginal Medical Services team. “They inform you about what’s reasonable and possible, and how to manage in difficult social circumstances. There’s usually a nurse or two focusing on chronic disease, or child health, STDs…and in an ideal situation, Aboriginal Health Workers as well.” Halls Creek is cosmopolitan in comparison and Marie has successfully tried tele-health once from there, linking to a radiation oncologist at Darwin Hospital so a woman with breast cancer could demonstrate arm movement in preparation for radiotherapy.

Dr Andrew Trappitt

“You can pick and choose between practices.” Andrew started rural locums four years ago. Switching from his busy solo general practice and fortnightly biomechanics clinics to locums was a way to slow down. With his pilot’s licence he can often fly himself from his Pemberton base and avoid hours driving – Dalwallinu, Gnowangerup, Kondinin, Kellerberrin, Boyup Brook, Wyalkatchem, Boddington, Manjimup and Albany. He chooses solo practices and single doctor communities because their need is greatest.

Pay is recognition for the professionalism of locums. However, Andrew has noted some practices are still offering pay he used for locums 15 years ago. Being on call and away from home has a price, so there has to be realism on both sides. “I also believe that rural practices should be provided with some form of government subsidy to enable a realistic payment to be offered to locums,” he said. We asked Andrew to characterise those things important to keeping him in his comfort zone as a locum doctor. “This includes a well-run practice with friendly staff and adequate examination and treatment equipment; also good patient notes and good ethical prescribing practices by the doctor. In addition, a hospital that has friendly and efficient staff and is well equipped and organised, including an x-ray machine. Good hospital staff will triage and limit the number of call-outs the doctor has to make.” “Living in and getting to know the different rural communities makes locum work interesting and enjoyable,” he said, adding that uncomfortable accommodation is a turn-off but city doctors would have a good time once they sorted this and got over any initial anxiety. “The agency I am with, Rural Health West, does an amazing job organising my locums and although I have not experienced others, I would be surprised if there were any better.” l

n Andrew flies his Australian-made Jabiru J200 to his locums. It is big

enough to carry his gear and his bicycle. Using his general aviation pilot’s “There are several practices I licence this way shortens the trip to Dalwallinu from 6 to 2 hours, for example. tend to return to as both the practices and the local hospital are well run with excellent staff and facilities, Medical Forum Declaration: Rural Health West which make them comfortable to work in. If has contributed towards the cost of this feature, which has been prepared independently by another practice is really stuck for a locum Medical Forum magazine. and I am free, I am willing to try that one.” 23

ITE-poll in Medicine By Peter McClelland

ECU Health Simulation Centre Trust Me, I’m a Doctor While operating on cadavers offers unbeatable reality some training We continue our talkinwith 100 circumstances, public stancesimulated taken by our leaders on ethical GPs and 71 Specialists from last issues’ was eroding public confidence in on sophisticated mannequins is reaching new levels. edition’s poll.

Pro-Vice-Chancellor of Health Advancement Prof Cobie Rudd is justifiably proud of the ECU Health Simulation Centre (HSC) on the Joondalup Campus. “The Centre is unique in its design and the focus is specifically on learning through simulated challenges and sequential scenarios. Practitioners follow a ‘patient’ across settings and providers from high to low acuity in clinical environments. Sessions range from clinical skills, human factors and patient safety training for multidisciplinary health teams using simulation mannequins, professional actors and task trainers,” said Cobie. Clinical A/Prof Anaesthetics at RPH, Dr Richard Riley, is well aware of the human factor element in his field of anaesthetics and its links with simulation training in the aviation sector. “Medicine is 30 years behind the aviation sector in the use of simulators for training and accreditation. There’s a strong parallel, obviously - Captain Chesley Sullenberger, who ditched the Airbus on the Hudson River, was the guest speaker at a conference I attended,” said Richard.

n Trust is hard earned and easily lost.

The common idea behind Question 1 is that the ability of doctors to assist patients is built on a bond of trust, where the patient trusts the doctor to act in their best interests. Around 90% of respondents felt such a bond was extremely or very important to their success doctors. in Medicine, he singsasthe praises of the ECU Interestingly, Simulation Centre. virtually all doctors

(97%through specialists; “Mid-way 2007 96% there GPs) were said a number personal trust in another doctor, of funding issues involving both UWA andfor the whatever reason, wasthe extremely or State Government regarding anaesthetics verylab important were simulation at UWA.ifItthey was put outtotohave tender aingood late 2010 and ECU were awarded working relationship with the contract… a really well-run that it’s doctor. This raises unit.” the question

whether a distrusted within HSC houses WA’s only patientdoctor simulator witha the ability to provide respiratory gas exchange, group brings on adverse perceptions anaesthesia and patient monitoring of thedelivery, whole group? with real physiological measures. Such a high What is it the profession does that fidelity mannequin is needed for the ANZCA erodes the public’s trust in doctors? anaesthetic training courses offered several According to our respondents, times a year.

‘commercialisation of medicine’ and ‘depersonalisation of medical care dueCourses to corporatisation’ are the ECU Simulator top concerns, particularly among n Advanced and Complex Medical specialists. Hiding adverse events Emergencies (ACME). and mistakes from the media come n Effective Management of Anaesthetic Crises next. (EMAC).

One surprise is that around one and New Zealand College of third of both GP and specialist Anaesthetists (ANZCA) training course. respondents felt the ‘incorrect

n Australian n ECU

Inter-Professional Ambulatory Care.

doctors. Should this figure be less? Given these results, it makes common sense for the profession’s leaders to set about explaining to all doctors why they portray particular opinions to the media. 1. How important is a patient’s personal ‘trust’ in you, when it comes to you performing to your best for them as their doctor? relevant in three key areas, HSC is particularly according to Cobie Rudd.

Specialists GPs

“The Centre is absolutely invaluable for high59% 45% fidelity simulation training, inter-professional important Very 31%- the latter 46% learning and sequential simulation avoids learning interactions that4% revolve around important Slightly 9% a single moment in a ‘patient’s’ journey.”

Extremely important

Not important

sure to be bright. Not appears

And, concludes Richard Riley, the future

Doesn’t 1% learning 0% “Medicalapply simulation and immersive appears to be something of a federal government priority andpersonal they’re ploughing 2. How much is your trust in millions of dollars into this area.” n another doctor, for whatever reason(s), important to you in having a good working relationship with them?

Simulation Principles

Specialists GPs

Extremely important

59%

43%

important Very building confidence.

38%

53%

n The

immersive simulations are great for

important Slightly 2% in n Simulation illustrates deficiencies

interaction but allows reflection and important Notteam 1% 0%

about differences 0% between sure Notdiscussion 0% professions, in a safe way.

Doesn’t apply n It

highlights weaknesses in practice skills and communication.

As chair of the WA Society for Simulation

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2. Tick if you think any of these actions by the profession have/are damaging the trust patients generally put in doctors? [multiple choice]

Specialists GPs

Commercialisation of medicine.

79%

65%

Depersonalisation of medical care due to corporatisation.

69%

Lack of transparency over adverse events reported in the media.

46%

44%

Doctors make 49% mistakes and do not admit fallibility and apologise.

33%

Incorrect public stance taken by our leaders on ethical issues.

38%

33%

Other (please indicate below).

19%

Uncertain.

‘Other’ damaging reasons? Among the 8% of specialists who chose this response, their comments pointed to: unbalanced media reporting and inconsequential retractions; ‘free’ Medicare services; some cosmetic procedures; politicisation of public hospital medicine; time constraints in the doctor-patient encounter; and doctor insensitivity and disregard for patient’s concerns. More GPs (19%) chose ‘other’ and 32 provided comments that perhaps reflected the more diverse setting in which GPs work. Media sensationalism and bias took a big hit (n=6), while doctors taking an interest in unproven alternative medicines or the popularity and competition from alternative therapies was also targeted (n=5).

Changing attitudes to patients were mentioned, including lack of compassion and humanity, failure to recognise and address the patient’s agenda, and too much reliance on technology and medications and not enough attention to the social, cultural and emotional wellbeing. We had comments about doctor greed, the immigration of poorly qualified doctors, reduced continuity of care, doctors who advertise to the public, bulk-billing, and poor advocacy for ourselves. For some, patients took centre stage: “The patient-has-no-blame approach is problematic; trust is two way; we can do best for patients if they help us and work with us and are truthful” and “Patients often have unrealistic expectations and when these are not met, they lose trust.” This idea speaks for itself: “Most Australian universities employ people from nonclinical backgrounds (nurses, psychologists, OTs, PTs, etc) to teach medical students

in clinical training. This is a recognised disadvantage for students and ultimately to patients.”

April Edition Poll Results This edition, we asked another question of our 92 GP respondents to qualify which ethical issues our leaders were dealing with that they felt were being handled incorrectly in the public eye. 4. Last month, close to a third of doctors said the incorrect public stance taken by our leaders on ethical issues was contributing to damage done to the trust patients put in doctors. If you agree with this point of view, which of these ethical issues apply? [multiple choice] Money misappropriation

38%

Medical mistakes by doctors

37%

Sexual misconduct by doctors

37%

Drug abuse while practising

22%

Failure to report adverse events affecting patients

22%

Consulting while significantly impaired

19%

Combat sport

11%

Pregnancy termination Other (see below)

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8% 6%

Uncertain

14%

None – disagree with this idea

20%

‘Other’ responses: These included management and inefficiencies within the health system, failure to represent members and lack of transparency of selection of representatives, the lack of bulk billing and failure of Medicare rebates to cover cost. “Failure to advocate for reduced privatisation, which has lined our pockets at the expense of public health,” replied one, while health inequity and the reputation of the profession were also a concern. Continued on Page 50 25

Photo courtesy T o

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Locum Placement Service Are you a doctor interested in providing a Locum service?

Are you a practice seeking a Locum doctor?

Would you like to experience a remote outback location or the spirit of a small community?

Rural Health West provides a FREE PLACEMENT SERVICE to Western Australian rural and remote general practices with No agency fees.

Rural Health West works to find the right practice and community for you. Our Locum team makes the process easy, whether it is booking accommodation or organising upskilling courses before you go.

We are continually updating our database of Locums and may already have the right general practitioner waiting to work in your practice.

Contact us today for further information on our Locum Placement Service on T 08 6389 4500 | E locum@ruralhealthwest.com.au

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medicalforum

jin i

How ‘workers’ compo’, sickness certificates and similar documents can leave you exposed W

hen the words ‘Professional Indemnity’ and ‘lawyer’ appear in the same sentence, most doctors think of professional negligence. It is true that negligence claims comprise a large proportion of claims against doctors. But in my experience, most medical professionals are well aware of their responsibilities in this area and the consequences of not correctly attending to professional indemnity insurance – as well, of course, to their patients. There is another area of exposure for doctors that deserves much more attention, and is the purpose of this article. I am referring to doctors’ obligations when completing sickness certificates, workers’ compensation Progress claim certificates, medical reports and the like. Doctors can face something of a conflict of interest when a patient presents asking them to sign them off work or complete a compensation form. It’s only natural that the doctor may strongly empathise if the person is well known to the doctor, or comes via the same family or friends also known to the doctor. When examining the patient, in matters where there is doubt, it would be understandable if the doctor gives the patient the benefit of any doubt, taking their word at face value and trying to help the patient by signing the paperwork as requested. However in these situations, a doctor’s obligation is not only to the patient who is paying for the services, it is also to the patient’s employer and to themselves. Acting

as a representative of the patient, a doctor is essentially providing a professional medical appraisal that employers, insurers or Courts expect to be both accurate and reliable. This applies to all requests for time off from work or insurance compensation, from the initial medical review to the completion of claim forms, say every month, while their medical condition persists. When a doctor signs a certificate saying he has examined a patient and found him to be physically incapable of working, he is putting his professional reputation on the line. He is exposing himself to potential legal liability should this claim later prove incorrect. And in my experience, such claims are being disputed in increasing numbers. We need only read newspaper headlines to be aware how much of a problem productivity is becoming in Australia today. In February, Toyota’s boss Max Yasuda caused a row when he said that absenteeism was as high as 30 per cent at the company’s Altona plant, particularly around long weekends. Research has found almost a third of businesses believe non-genuine sick days are on the rise, with Australian employees taking 9.4 days sick leave a year on average. Economic pressures in the non-resource parts of the economy are putting increasing pressures on both insurers and employers – and both can be expected to look more closely at medical claims, especially in the case of serial ‘sick day’ employees and those seeking compensation. Surveillance by insurance companies is not uncommon. There can be few things

Les Buchbinder, Director, Bowen Buchbinder Vilensky

more damning of a doctor who has signed a medical certificate on behalf of a patient claiming compensation for a back injury, than video footage showing the patient lifting heavy tyres off the back of a ute or doubling over backwards to repair the ceiling of a campervan. These are not hypothetic examples. The consequences for doctors can be severe. At the very least, when such matters end up in Court, typically with insurers seeking to terminate payments or recoup compensation paid out, the disclosure of the doctor’s name can significantly damage their professional standing and reputation. Credibility with insurers is lost and Professional Indemnity insurance premiums may rise. However, lost credibility can be the least problem if there is an accusation of reckless disregard in signing a compensation certificate. Disciplinary action by the Medical Board may be a consequence and the doctor may also face being sued for negligence or for being complicit in conspiring to defraud an insurer. In summary, your exposure arising from signing sickness certificates, compensation claim forms or similar documents should not be underestimated. As companies increasingly focus on productivity, and insurers on payouts, this is an area of exposure where doctors need to tread with caution. Medical Forum Delaration: Bowen Buchbinder Vilensky contributes to the cost of this article and the editor makes every attempt to ensure information is generic and to our standard.

For more than 20 years, Bowen Buchbinder Vilensky has assisted members of the medical profession and allied areas of health care. We are the only law firm in Perth offering a truly fixed fee service – giving you financial certainty and peace of mind when you engage us. Some areas of law in which we can assist you include:

For an informed, confidential and sympathetic discussion of your legal concerns call us on (Tel) 08 9325 9644. Initial telephone consultations are free of charge. www.bbvlegal.com.au medicalforum

Professional Indemnity and Liabilities Insurance Law Disciplinary Proceedings Selling your Practice Mergers & Acquisitions Commercial Disputes Business Succession Planning

Wills & Estate Planning Enduring Powers of Guardianship and Advanced Health Directives Family Law including Financial settlements (‘Pre-nups’), divorce, property settlements and children’s issues.

BBV LEGAL: PROUDLY SERVING HEALTH PROFESSIONALS FOR OVER 20 YEARS. 27

From personal wealth creation to business asset acquisition.

Arthritis and connective tissue diseases specialist Dr Jack Edelman has first-hand experience of how sound private wealth management can aid mobility in business. When he and his wife Ann decided to invest in a Bunbury office for their private practice, they were able to purchase the property outright, thanks to the enormous growth of their self-managed superfund set up by Brad Gordon of Entrust. ‘Spreading out investments, Brad has never overexposed our superfund to a single investment, giving us complete confidence, consistent growth and increased security,’ says Dr Edelman. During the 2008 market decline, Brad placed the superannuation in a holding pattern while the market bottomed out. As a result, none of the investments suffered any redemption problems. ‘Brad ensured we avoided funds that had any liquidity issues or subsequently became frozen, and eliminated unnecessary spending by running the superfund in a very tax effective manner. So, when we needed money for the Bunbury practice there were no problems,’ he adds. To alleviate the headaches associated with compliance, Brad also carefully managed the investment documentation that is so vital to self-managed superfunds. ‘Ann and I have been able to relax knowing that Brad is taking care of the book keeping,’ he says. ‘It’s an even greater convenience knowing our office is owned outright and I can focus on looking after my clients.’

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

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

Medico-Legal

Rapid PP Deterioration

Medico-legal adviser with MDA National, Nerissa Ferrie, relates how good communication is key to acting in a timely manner.

he preventable death of a 38-yearold woman from post-partum puerperal sepsis after the birth of her fourth child was investigated by Coroner Alastair Hope at an inquest in 2010. Susannah McLevie was admitted to Osborne Park Hospital on the afternoon of 4 April 2006 and delivered a healthy baby girl about midnight. The delivery was uncomplicated and Ms McLevie reported feeling good, but tired. Around 3am, Ms McLevie’s temperature was 38C and she had developed rigors. At 5am she began vomiting and reported severe headache and abdominal pain. Her pain was managed by the RMO who handed over to the consultant during rounds at 8am. Bloods were ordered but antibiotics were not commenced due to confusion about whether Ms McLevie’s temperature had spiked more than once during the night. The consultant had not reviewed the notes and based his treatment on the RMO’s verbal handover. Ms McLevie received morphine for increasing pain, and by that evening she had frank haematuria and hypotension.

medicalforum

Possible diagnoses which were considered throughout the admission included involution pain, a possible dural tap and renal colic. Although infection was considered as a possible cause for her symptoms, none of the treating doctors made the decision to commence antibiotic therapy. Her condition continued to deteriorate, and when nursing staff were unable to obtain a recordable blood pressure at 1.30am, the on-call consultant arranged urgent transfer to Sir Charles Gairdner Hospital where Ms McLevie died at 4.21am. An intensive care expert identified at least 14 system failures which contributed to Ms McLevie’s death. The Coroner considered the evidence and found that Ms McLevie would have survived the infection had she received antibiotic treatment in a timely manner. The Coroner made several recommendations including: 1. A review of systems whereby registrars take a closer supervisory role of inexperienced RMOs; 2. A review of protocols to ensure immediate response to concerning

observations reflecting a significant deterioration in a patient’s condition; and 3. Training on accurate and complete communication and, in particular, training for RMOs, including effective communication with registrars and consultants. Although written in the context of obstetrics and gynaecology, this can be applied to senior doctors over a range of specialties: “This case has highlighted the dangers associated with consultants relying entirely on oral presentations of the history of patients given by residents who have only had a brief exposure to postgraduate obstetrics and gynaecology.” Junior doctors are often inexperienced and will be relying heavily on your knowledge and expertise when providing a verbal handover. If the history provided is unclear or insufficient, further questioning or a review of the notes can clarify the clinical picture and inform your subsequent advice and actions. l This information is intended as a guide only. MDA National recommends you always contact your indemnity provider when you require specific advice in relation to your insurance policy.

Clinical update

Screening imaging for lung cancer? L

By Dr Brendan Adler, Radiologist, Envision Medical Imaging

ung cancer causes the most cancer deaths worldwide, for men and women, and is almost always fatal within five years of diagnosis because it presents at late-stage. While CXR screening is ineffective for lung cancer screening (JAMA, Oct 2011), low dose CT (LDCT) screening in selected high-risk patients can reduce mortality but there are cost considerations around false positives and flow-on interventions. Individuals at high risk have up to a 30% risk of dying from lung cancer. These are people with greater than 30 pack-year smoking history or 20 pack-year history with chronic lung disease, significant occupational exposure to lung carcinogens (e.g. asbestos), family history of lung cancer or personal history of another smokingrelated epithelial cancer (e.g. many head and neck cancers).

Risk-benefit and cost considerations

References:

Benign nodules accounted for the majority of the 24% of subjects recalled for further investigation. This was typically a repeat LDCT within 12 months for monitoring and further characterisation of nodules greater than 4mm. Subjects with large (> 8mm) nodules typically underwent a PET scan, percutaneous biopsy and/or surgical excision. Procedural major complications were very low (1.4%).

NEJM 365:395-409, Aug 4, 2011. Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. Various contributors. Ann Intern Med. 155:537-539, Sept 6, 2011. Screening for Lung Cancer: It Works, but Does It Really Work? Gerard Silvestri. Ann Intern Med. 155:540-542, Sept 6, 2011. Screening for Lung Cancer: For Patients at Increased Risk for Lung Cancer, It Works. James Jett, David Midthun. Declaration: Neither the author nor Medical Forum has received payment for this article. Envision Medical Imaging provides LDCT services.

n Low density CT showing tumour (arrowed)

Significance of recent study Lung cancer detection with LDCT has been consistently more sensitive than CXR in studies over the last decade, though large screening studies showing substantial relative mortality benefits have had no control arm and therefore the degree of lead-time or over-diagnosis bias was uncertain. The recently concluded US National Lung Cancer Screening Trial was commenced in 2002 and enrolled 53,000 healthy volunteers aged 50-74 years, with a 30 packyear history or more. The subjects were randomised to annual CXR or annual low dose CT. Similar numbers of cancers were detected in each arm of the trial. After three years, those in the CT group showed a 20% disease specific mortality reduction (from 309 to 247 lung cancer deaths per 100,000 person-years) and the trial was ceased, having achieved its primary aim. It is possible the survival curves will continue to diverge, as was observed with mammographic screening for breast cancer. medicalforum

n High density CT in the same patient.

In the Western Australian setting, with much less granulomatous disease than in the US, we would expect a recall rate for an earlier than 12-month CT to be 10-15%, similar to screening mammography. The radiation dose of a single LDCT is approximately 0.75 mSv. This is equivalent to seven CXR series or three monthsâ&#x20AC;&#x2122; natural background radiation. The risk of a 20-year screening program inducing a cancer is approximately 1 in 10,000 (0.01%), magnitudes less than the lifetime risk of high risk patients dying of lung cancer. The expected disease specific mortality reduction of LDCT screening is at least 20% and the all-cause mortality reduction 7%. To minimise risk and maximise benefits, it is important that screening LDCT is performed at appropriate low dose and results reported by experienced people, such as sub-specialist thoracic radiologists. In this way, the individual benefits outweigh the risks and are more likely to exceed the population cost-effectiveness targets for many currently accepted screening interventions.

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D E N TAL

Clinical update

Electronic Cataract Auditing Tool D r Nigel Morlet from the Eye Surgery Foundation and others have developed a webbased audit tool for cataract surgery that is being used in public hospitals and one private hospital in WA, with hopes the system will be refined and adopted nationally. The Electronic Cataract Auditing Tool (eCAT) system is designed to collect the information required for assessment of operative factors on cataract surgery outcomes.

It has been available for about a year now and if its use becomes a quality audit activity with CPD points attached, uptake is expected to increase. Dr Jonathon Ng was involved in developing the system, along with Project Officer Trish Barrett from UWA. Cataract surgery is the most common operation in Australia. Over the next decade the number of cataract procedures each year, along with the number of complications, is expected to double as a result of our ageing population. Whilst complications are uncommon, they can impact greatly on patients, so auditing operative information may provide important clues.

Accuracy of data collection paramount eCAT was inspired by the realisation that retrospective research from paper-based records did not provide enough accurate detail to research aspects of cataract surgery. Studies into cataract complications by the Centre for Population Health Research (CPHR) group and the Royal Australian College of Surgeons highlighted the need for a prospective and more detailed method of collecting data. Hospital administrative databases do not record basic operative information, and even chart review is not sufficient since the level of detail on operation sheets is extremely variable and clinically important information is often not recorded. Without

allows separate institutions to make changes/additions to suit their particular context. This includes customisable:

this information, comment upon the impact of operative factors on the outcomes of cataract surgery cannot be reliably made.

How eCAT works The system is web-based, with data entry via a web-browser. Design favours quick and efficient entry of detailed cataract surgery information in theatre, at the time of surgery. Surgeons are able to set up templates by entering and saving their preferences so the template and its data can be used repeatedly for each new patient within an operating list. It takes about one minute to enter operative details once template pages are set up that include information about instruments, anaesthetist and medications. Public hospital data for patient identification is stored separately on Health Department servers, as are private hospital sites. Patient details (e.g. UNMR) can be pulled from the hospital’s operative list for the day. This includes details of any historic procedures the patient has undergone. One advantage for ophthalmic surgeons is that eCAT can generate a report for patient discharge, entry in the patient notes, or for the referring GP.

• System menus (e.g. the addition of particular intraocular lens types, or a particular type of phaco machine). • Perioperative medications. • Operative difficulties section. • Operation reports for patient notes, discharge summaries and GP letters. As well, each health institution can control user-level access.

Security and privacy No information is shared across institutions, including patient information, although user ophthalmologists can be linked to more than one service provider, such as hospitals. A key feature of the registry will be to provide readily accessible, valid and up-todate information on a statewide level. Data from the registry will complement the evidence base generated on the major sight-threatening complications of cataract surgery from previous research. This will be incorporated with the techniques developed for monitoring complications to provide a platform to improve the outcomes from cataract surgery and minimise the burden from complications. The system not only improves the accuracy of the data collection, it also encourages data entry.

Customisation

Declaration: This clinical update is supported by an independent educational grant to Medical Forum from the Eye Surgery Foundation.

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Clinical update

Flu vaccination benefits pregnant mums and babies O

By Dr Donna Mak, Public Health Physician, Communicable Disease Control Directorate

nly half (52%) of Medical Forum E-poll respondents (see Page 41) are aware that influenza (flu) vaccination is recommended for pregnant women anytime during the flu season and regardless of gestational age. The safety of the flu vaccine in pregnancy is well established. Flu vaccine does not contain live virus, cross the placenta or multiply within the foetus. Extensive follow up of about 2 million women in the USA who received flu vaccine during 2000 to 2003 showed no problems for mother or baby due to vaccination.1 The Australian Government and Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG College Statement C-Obs 45) recommend that all pregnant women be offered vaccination against influenza. Maternal and infant benefits of antenatal flu vaccination have been demonstrated. Only five pregnant women need to be vaccinated to prevent one case of serious maternal or infant respiratory illness.2 Influenza vaccination is estimated to prevent 1 to 2 hospitalisations per 1000 women vaccinated during the second or third trimester. 3 Active placental transfer of maternal antibodies makes influenza vaccine during pregnancy a highly effective measure to protect infants from influenza during the first 6 months of life, reducing rates of infection in babies by about one third. The flu vaccine is generally well-tolerated. Common minor side-effects include redness, tenderness, discomfort or swelling at the injection site; these usually settle within a few days. Significant side-effects are uncommon, and should be reported to the Western Australian Vaccine Safety Surveillance (WAVSS) online: www.wavss. health.wa.gov.au (24 hours a day, 7 days a week), or by telephone (9321 1312, Mon – Fri 8.30am-4.30pm). For more information see www.public. health.wa.gov.au/3/469/2/immunisation_ homepage.pm n References Tamma PD, Ault KA, del Rio C, Steinhoff MC, Halsey NA, Omer SB. Safety in influenza vaccination during pregnancy. Am J Obstet Gynecol. 2009 Dec;201(6):547-52. Epub 2009 Oct 21. Zaman, K. Eliza Roy, Shams E. Arifeen et al. Effectiveness of Maternal Influenza Immunization in Mothers and Infants; N Engl J Med 2008; 359: 1555-1564. Australian Dept. Health and Ageing, NHMRC. The Australian Immunisation Handbook 9th Edition. Available online at www.health.gov.au/internet/ immunise/publishing.nsf/Content/Handbook-influenza

What’s the best time TO vaccinate pregnant women? • The ideal time is during autumn, from March onwards, before the height of the winter flu season but can still be effective once winter has begun and influenza infections are present in the community • Flu vaccine may be given pre-pregnancy or during the first, second or third trimesters.

Expert Comment

Dr Louise Farrell, Clinical Director of Obstetrics & Gynaecology, St John of God Hospital Subiaco “WA obstetricians are supporting RANZCOG’s recommendation to vaccinate pregnant women against influenza by promoting the benefits of flu vaccine in antenatal care settings, and providing vaccination to pregnant women where possible or giving them a written recommendation for flu vaccination to take to their GP.

Dr Tony Keil, Medical Microbiologist, King Edward Memorial and Princess Margaret Hospitals “WA’s push to vaccinate pregnant women and children aged 6 months to 4 years will prevent serious flu illness and hospital admissions in both mothers and babies this winter. Neonates and infants are at very high risk for flu complications. Maternal vaccination with placental antibody transfer is the only way to provide clear protection from flu for both neonates and infants under 6 months who can’t receive the flu vaccine.

Dr Tim Koh, Deputy Chair, RACGP WA Faculty Board “GPs are the largest providers of influenza vaccination in WA and also encounter most pregnant women at least once during their pregnancy. The vast majority of pregnant women will accept flu vaccination if ecommended by a health professional. GPs are well placed to encourage antenatal patients to have flu vaccine because of the trust and ongoing relationship they have with patients.

Dr Steven Webb, Intensivist, Royal Perth Hospital “Pregnant women are often more severely affected by flu than non-pregnant women of similar age and health. During the 2009 pandemic pregnant women with flu were 13 times more likely to require ICU admission compared with their non-pregnant counterparts. Pregnant women and their babies died from flu in Australia during the pandemic. We never know how bad a flu season will be and the most effective strategy for protecting pregnant women and their babies is vaccination.

The Australian Government and Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG College Statement C-Obs 45) recommend that all pregnant women be offered vaccination against influenza (flu). medicalforum

Clinical update

Evaluation and management of chronic menorrhagia A round 10-35% of all women complain of menorrhagia, while 5% aged between 30-49 will consult with a doctor for this reason. For the doctor, after deciding loss is abnormal (see inset) and uterine, choice of management involves considerations such as: the cause and severity of bleeding; associated symptoms; contraceptive needs or plans for future pregnancy; contraindications to hormonal or other medications; medical comorbidities; and patient preferences for medical versus surgical and short- versus longterm therapy.

Questions during clinical evaluation

30-55%. Other pointers are:

• Pre- or postmenopausal?

• Taken during days of menses; does not interfere with fertility.

• Is the bleeding pattern: (a) ovulatory – typically cyclic but heavy or prolonged. Rule out anatomic causes like fibroids, adenomyosis, Copper IUD, etc. (b) anovulatory – unpredictable endometrial bleeding of variable flow and duration. Think menarche or menopause transition (age 40-55), PCOS, etc. • Could the bleeding be related to pregnancy, infection, bleeding disorders, endocrine disorders, anatomic causes or malignancy. Rule these out.

Investigations needed • FBC to rule out anaemia. TFTs and coagulopathy tests only if clinically indicated. • Pelvic sonography • Up-to-date Pap smear • Endometrial sampling (e.g. Pipelle) to exclude endometrial hyperplasia/ neoplasia or endometritis in all women over age 35 with abnormal uterine bleeding, plus at any age where there are risk factors for endometrial cancer: family or personal history of ovarian, breast, colon, or endometrial cancer; tamoxifen use; chronic anovulation; obesity; estrogen therapy; or prior endometrial hyperplasia.

Treatment options available Expectant. Women who are not anaemic and not at risk for endometrial neoplasia may only need reassurance, along with regular haematocrit checks.

Medical - non-hormonal Oral NSAIDs reduce bleeding by 20-50%. Other pointers are: • Low cost, acceptable side effects, treats dysmenorrhea. • Taken during days of menstruation; does not interfere with fertility. • As effective as cyclical progesterone, but less effective than levonorgestrel-IUD (MirenaTM) or tranexamic Acid Antifibrinolytic agents (tranexamic acid, 1gm QID) reduce menstrual flow by 36

• More effective than NSAIDs and luteal phase progestins but less effective than MirenaTM • Contraindicated in women at high risk for thrombosis.

Medical - hormonal Estrogen-progestin contraceptives as a standard dose pill reduce menstrual flow by 30-50%. Other pointers are: • Regulates menstrual cycle, provides effective contraception, prevents development of hyperplasia in anovulatory patients, and treats dysmenorrhea. • As effective as NSAIDs and tranexamic acid, but less effective than MirenaTM • Contraindicated in women at risk for thrombosis, or who have medical conditions like migraine or hypertension, and in smokers >age 35. Progestins • For treatment of acute or excessive bleeding related to chronic anovulation (e.g. medroxy progesterone acetate [ProveraTM] 10 mg 1-3 times daily for 14–21 days out of 28 days). • Low dose luteal phase progestins are not effective in women with ovulatory menorrhagia. • Depot ProveraTM and ImplanonTM are effective options for women who need contraception, however less effective than MirenaTM

Levonorgestrel IUD system (MirenaTM) reduces menstrual blood loss by 74-97% after one year of use. Other pointers are: • Effective for five years. • Effective in managing pelvic pain and dysmenorrhea, and appropriate for women with bleeding disorders. • Effective in prevention and treatment of endometrial hyperplasia, management of endometriosis related symptoms and reduces the risk of pelvic inflammatory disease.

• Efficacy for contraception is similar to tubal ligation. • More effective than all medical options, as effective as endometrial ablation, but less effective than hysterectomy. • Less expensive used long term. • Causes irregular bleeding for over six months of initial use. • Involves a minor outpatient procedure. • Contraindicated in women with: progesterone receptor positive breast cancer; significantly distorted endometrial cavity; active pelvic infection; undiagnosed abnormal uterine bleeding; and severe depression.

Surgery - endometrial ablation. This minimally invasive option is for when medical therapy fails or in women who do not want to use long term medical therapy. It reduces menstrual blood loss by 75-94%. Other pointers: • More effective than medical therapy, as effective as MirenaTM, but less effective than hysterectomy. • Pregnancy is contraindicated afterwards but contraception is still required. • Involves minor day surgical procedure and anaesthesia. • Contraindicated in women with known or suspected endometrial hyperplasia, undiagnosed abnormal uterine bleeding, desire to preserve fertility, active pelvic infection and severe myometrial thinning. • Not the right choice in women with conditions like adenomyosis, significantly distorted uterine cavity with large submucosal leiomyomas (>3cm), or congenital anomalies like bicornuate uterus or large cavity size of more than 10 – 12cm. • First generation techniques – Transcervical Resection of Endometrium (TCRE) or Roller Ball Endometrial Ablation (REA) that use electrosurgery are suitable options when a submucous fibroid needs to be resected.

Normal Menstrual Loss • 1-7 days/21–35 days • <1 pad/tampon per 3 hr period • Seldom need to change pads/ tampons during the night • Clots < 1 inch in size • Total loss <80ml per cycle

medicalforum

Dr Mini Zachariah, Consultant Gynaecologist KEMH • Second generation techniques are used when no structural abnormality is present – different forms include Bipolar Radiofrequency wave (Novasure), Microwave (MEA), Heated Balloon (Thermachoice), Cryoablation (HER Option), Hot Water (Hydro ThermAblation – HTA)

Surgery – hysterectomy. This carries risks of perioperative complications and prolonged recovery, as well as pelvic floor dysfunctions and urinary incontinence, with these favourable points: • Definitive treatment for uterine bleeding. • High rate of patient satisfaction. • Not associated with drug-related side effects, and does not require repeated procedures or prolonged follow-up.

Comparisons: Medical vs surgical • A review of eight randomised trials found that 58% of women randomised to medical treatment underwent surgery by two years1. • Both endometrial ablation and hysterectomy resulted in significantly better control of bleeding

Comparisons: MirenaTM vs endometrial ablation • Similar rates of reduction in menstrual blood loss (75–95%), improvements in quality of life, and patient satisfaction (83% for Mirena vs 82% for ablation at one year). • Mirena is a reversible contraceptive. Contraception is required following ablation because pregnancy is contraindicated. • LNG-IUD placement is an office procedure for almost all women, with local anesthesia (every five years). Endometrial ablation is often done in an operating room under GA (as a one-off).

Comparisons: MirenaTM vs hysterectomy • Trials suggest similar improvements in quality of life in both groups; however, 40% of women in the LNG-IUD group ultimately underwent hysterectomy2. • On the other hand, 10-year follow-up from a randomised trial reported that women in the IUD group had significantly less stress incontinence (34% vs 48%) as well as medications for urinary incontinence (1% vs 12%)3.

Comparisons: Endometrial ablation vs hysterectomy • Endometrial ablation is associated with a shorter duration of surgery, hospital stay, time to return to usual activities, and fewer complications. • However, hysterectomy provides significantly better control of bleeding, a lower rate of repeat surgery, and improved patient satisfaction at follow-up. References: 1. Marjoribanks J et al. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006 2. Hurskainen R et al. Quality of life and cost-effectiveness of levonorgestrelreleasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomised trial. Lancet. 2001;357(9252):273.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

Andrology

Varicocele

Everything about varicoceles is controversial, including the spelling (proper English is “varicocoele” but even the British Medical Journal uses “varicocele”). Varicoceles are very common, being present in 15% of men overall but 45% of males in a sub-fertile setting. Our routine ultrasound screening at PIVET shows 85% left side, 14% bilateral and 1% right side only. In one third of men there is a discrepancy of testicular volumes ≥ 3ml and such cases usually display semen profile anomalies, often with reduced serum testosterone levels and even mild elevations of FSH. The semen profile is characteristically described as OAT syndrome (oligoasthenoteratospermia). Urologist Selby Tulloch published his seminal article in the BMJ in 1955 showing that varicocele ligation normalised the fertility of 10 of his 30 cases i.e. one third. In the modern era, varicocele ligation is not recommended for fertility management as the life-table studies have failed to show a benefit. However symptomatic men and adolescents with reduced testicular volumes should have their varicoceles treated.

Left varicocele visible on Valsalva manoeuvre.

PIVET introduced laparoscopic varicocele ligation in 1990 but ceased after 10 years because of the complication of hydroceles, although the procedure was otherwise highly successful. Conventional surgical Doppler ultrasound of varicocele procedures often fail because (veins >2mm on Valsalva) of the complex collateral venous drainage systems (from 5 separate vascular sources) but two procedures have recently shown good results – even improving sperm quality for IVF and ICSI procedures. These include embolization of the testicular veins and collaterals with coils (± sclerosant) and subinguinal microsurgical ligation. Laparoscopic view of left testicular vascular bundle.

3. Heliövaara-Peippo S et al. The effect of hysterectomy or levonorgestrel-releasing intrauterine system on lower urinary tract symptoms: a 10-year follow-up study of a randomised trial. BJOG. 2010;117(5):602.

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Clinical update

Premenstrual Dysphoric Disorder P

remenstrual Syndrome and Premenstrual Dysphoric Disorder (PMDD) are characterised by physical and/or psychological symptoms that occur during the luteal phase of the cycle, resolve within a few days of the onset of menses and are followed by a symptom-free interval. Significant impairment of daily activities may occur. Around 3-8% of women of reproductive age meet the strict DSM-IV research criteria for a diagnosis of premenstrual dysphoric disorder (PMDD).

Diagnosis The diagnosis should be confirmed by asking the woman to keep a prospective daily record for two cycles. There are several daily symptom diaries available. The Daily Record of Severity of Problems is available for download via http://pmdd. factsforhealth.org/have/dailyrecord.asp The aetiology remains unknown but the current consensus is that symptoms are triggered by normal cyclic ovarian activity rather than a hormone “imbalance”. There are no significant differences in hormone levels of those experiencing PMDD compared with other women. Symptoms may be experienced by women who are not menstruating such as those using the levonorgestrel intrauterine system or who have had an endometrial ablation or hysterectomy (with conservation of ovaries). Laboratory tests may be useful if another condition is being considered. A significant proportion of women seeking treatment for premenstrual symptoms have another condition, with or without premenstrual

exacerbation, such as endometriosis, depression, anxiety or endocrine disorders.

Management Regular aerobic exercise may help relieve symptoms and is it reasonable to recommend a reduced intake of alcohol, caffeine, salt and refined sugars. Although there is no evidence that premenstrual symptoms are caused by vitamin or mineral deficiencies, supplements are popular and there is some evidence from placebocontrolled trials that pyridoxine (Vitamin B6) up to 100mg daily and calcium carbonate 1200mg daily may be of benefit. Other non-prescription management options may be considered. In one trial, cognitive-behavioural therapy showed efficacy comparable to treatment with fluoxetine. PMDD can be treated with psychotropic medications or suppression of ovulation with hormonal agents. First line medical options include SSRIs and the combined oral contraceptive pill, for those desiring contraception. Randomised-controlled trials of oral contraceptive containing

currently being trialled in several countries including Australia (recruitment now closed).

Contraceptive Update Whilst awaiting new contraceptive technologies including a reliable, acceptable, long-acting and reversible contraceptive for men, we welcome the modifications of available methods which make them easier to use and deliver. Implanon NXTTM was released in 2011 with a new applicator facilitating insertion, reducing the chance of too-deep or non-insertion of the implant. A new “mini” intrauterine contraceptive system that releases 12 micrograms of levonorgestrel per day (compared to MirenaTM 20 micrograms per day), and expected to be effective for three years, is medicalforum

For those who prefer a combined oral contraceptive method, a pill containing oestradiol instead of ethinyloestradiol and a shortened hormone-free interval has recently become available in Australia (i.e. ZoelyTM). It consists of the selective progestogen nomegestrol acetate (NOMAC) and 17ß-oestradiol (E2) in a monophasic 24 active/4 inactive pill regimen. As with other combined hormonal methods, most women will experience lighter, shorter and less painful periods and some will have unscheduled (breakthrough) bleeding, particularly in the first few months. In a trial comparing the 24/4 NOMAC/E2 regimen with a 21/7 drospirenone/ 30mcg ethinyloestradiol pill, significantly more users of the NOMAC/ E2 pill reported ‘absence of withdrawal bleeding’. It is advisable to inform women that they may have no ‘period’ despite taking the inactive tablets. If a woman

By Dr Maria Garefalakis, Medical Director FPWA Sexual Health Services drospirenone suggested benefit in women with PMDD over placebo. Extended regimens, where active pills are taken continuously without a placebo break have been shown to be beneficial for some women in managing symptoms of PMS and PMDD. Both continuous and intermittent dosing of SSRIs and SNRIs have demonstrated efficacy. The rapid response (1-2 days) to selective serotonin uptake inhibitors for PMDD is in contrast to the slower onset when used in the management of major depression. Fluoxetine or sertraline are TGA-approved for treatment of PMDD (though not PBS-listed) and may be prescribed as a continuous daily dose or as a course starting 14 days before the expected start of the next menses and continued until the first day of menses (luteal phase dosing). When taken intermittently, there may be fewer side effects and gradual discontinuation is not necessary. It is particularly important to ensure that mood symptoms are not present in the follicular phase of the cycle to avoid inadequate treatment of a condition that is better treated with continuous daily dosing, such as depression. A systematic review showed that progestogens and progesterone alone are ineffective and may exacerbate symptoms. has missed doses, had vomiting or severe diarrhoea or taken liver-enzyme inducing medications, the possibility of pregnancy should be considered. Whilst oestradiol-containing pills appear to have less overall impact on haemostatic and other parameters, it is not yet clear whether there will be any clinically significant short or long-term benefits over other currently available combined hormonal contraceptives. This preparation has the same indications, contraindications and drug interactions as oral contraceptives containing ethinyloestradiol. It is not PBS-listed, making it significantly more costly than the subsidised levonorgestreland norethisterone-containing combined pills. The third edition of the excellent practical resource Contraception: an Australian clinical practice handbook (produced by Sexual Health & Family Planning Australia) is expected to be released later this year. 39

E-poll: Women’s Issues

Child Sexualisation and Abuse; Vaccination in Pregnancy

Which of these vaccines are registered for use in pregnant women in Australia (when the clinical benefits are judged to outweigh the risks)? [multiple responses]

Thanks to the general practitioners (n=92) who took part in the April edition E-poll. Winner of our wine pack was Dr P.N. and because this edition’s theme is Women’s Health, we have separated out these questions for your interest. They point to us arming children to self-protect against abuse and the role of the media in sexualisation of young girls. And when it comes to vaccination recommendations in pregnancy, most have got it right.

Early education of children 76% in schools to say no and/or speak up 62%

Better training of people in authority such as doctors, police and teachers

62%

Police clearances for people working with children

37%

Restrictions on legal practitioners

13%

Other

What do you think is mostly behind the sexualisation of some young girls [choose up to 4 answers]?

Television and cinema shows

84%

Advertising

80%

Media coverage

72%

Peer pressure

69%

Schooling

14%

Environmental chemicals

Natural biological change

“Parents! Anyone who responds ‘environmental chemicals’ needs to go back to school! Incidentally, young boys are equally precocious in their awareness of sexuality – it’s just that people don’t seem to have as much of a problem with it.” “Yes – the poor kids with parents who are trying to relive their youth by offloading parental responsibility and pretending kids are more mature than they are.” “Parents do have a responsibility and, where I live, boundaries are often non-existent for children.”

Hepatitis A

34%

Hepatitis B

42%

Influenza

70%

Haemophilus influenzae type b (Hib)

20%

23-valent pneumococcal polysaccharide (23vPPV)

22%

Inactivated polio (IPV)

23%

Meningococcal C conjugate (MenCCV)

21%

All of the above

10%

None of the above

12%

ED. Correct answer is all vaccines but MMR and VZV, which as live attenuated vaccines, are contraindicated for pregnant women because of the hypothetical risk of harm to the foetus should disease transmission occur.

When is it recommended to give influenza vaccine to a pregnant woman? [select one response]

Never – contraindicated in pregnancy

First trimester

“I am continually horrified about the topics that are covered during prime time on the radio (eg during school drop-offs) and the content of songs, to name just a couple of issues that contribute to this problem.”

Second or third trimesters

22%

Anytime during influenza season and regardless of gestational age

52%

Uncertain

14%

ED. Most chose correctly, “anytime” – see the update from the WA Health Department on flu vaccination, page35.

Uncertain

“I recently heard from an ex-model that she was too old at 22!!”

Care to comment on the above issue?

Marketing could be the culprit: “Bratz dolls and the like are to blame.”

medicalforum

40%

The media – and social media – came in for criticism:

Other

Some of the responses put the role of parents in the spotlight: “Parents can minimise this if they are mindful from the beginning about what their child sees on TV and film, and the behaviour that they themselves model. The media cannot take all the blame, although overtly sexual messages are everywhere.”

Adolescent/adult diphtheria, tetanus, acellular pertussis (dTpa) Varicella zoster virus (VZV)

Regarding sexual abuse of children, such as at Katanning, which of the following do you think hold the most promise in preventing future recurrences? [multiple choice]

Mandatory reporting for those in public office

Measles-mumps-rubella (MMR)

“Advertising creates the need to sell more products, aided and abetted by a selfinterested, self-important media and, of course, some ‘Mummies from Hell’.” There was a view that it is the natural cycle: “Children imitate those older. Who didn’t want to be 16 when they were 12?”

Life Matters

Sexualisation of Girls – When Resistance is Imperative

n Young girls are putting their health at risk by trying to emulate images like this from the fashion catwalk.

Appearances can be deceptive and dangerous, as young women come under increasing pressure to be provocative and sexy at younger and younger ages. But there is a fightback. They may not have even left school yet but girls and young women have become the new frontier for marketers and corporations, and it’s putting a strain on their health. Dr Emma Rush’s 2006 report for the Australia Institute pulled no punches, when she described the “sexualisation” of girls for the purpose of selling products as a form of “corporate paedophilia”. Her wrath has not dimmed as she spoke out recently about a new clothing range for 8-14 year-olds produced by a popular adult women’s retail chain. She wrote in the Fairfax media: “Tween fashion is an expanding market, but it remains worth saying – the implication that eight-year-olds are simply physically miniature versions of 14-year-olds, and that 14-year-olds are simply physically miniature versions of 18-year-olds, is garbage. They’re all at quite different developmental stages. Putting the older ones up as ‘style models’ for the younger ones is not appropriate. “Girl after girl tells the people who work with her and the people who love her that she is anxious about her appearance, and that this distorts her life in various ways. Study after study shows body dissatisfaction is now high among primary school age children. This is associated with anxiety, depression, and eating disorders.”

n Prof Donna Chung

Professor Donna Chung of the School of Population Health at UWA is also concerned about this increasing sexualisation of girls, especially with the dominance of the internet and rise of the digital age. “Teen pressures are pushing sexualisation further down the age spectrum, manifesting in the desire of pre-adolescent girls to wear padded bras, make-up and have spray tans,” she said. medicalforum

“Equally worrying is that girls are sending provocative – and indelible – images of themselves and sometimes others via mobile phones, digital cameras and social networking sites. “Some girls as young as 12 years are taking pictures of themselves in sexual poses – sometimes of their genitals – and sending them to friends. However, those images can be circulated and used in ways they can’t control, and that can have extreme consequences.”

n Prof Tim Jones

Prof Timothy Jones, from the School of Paediatrics and Child Health at UWA and head of the Department of Endocrinology and Diabetes at PMH, offers a clinical perspective. “Interest in sexual matters is driven by hormones and when children have early puberty their behaviour follows (as we see sometimes in a child of six or so who has entered puberty early and is found looking at pornography, so the reduction in age of puberty over the last generations has resulted in earlier sexuality. “On the other hand there is no doubt that there has been a cultural or societal influence that has tended to sexualise girls earlier that may not be dependent on hormones as many of these children are not really in puberty. There needs to be more studies.” Prof Chung says the digital era has ramped up expectations of sexuality in young women. “There is wide and easy access to provocative imagery, music videos, TV programs, digital applications and games that emphasise particular sexualised forms of femininity for girls and that translates to pressure on them because they want to replicate it,” she said. “Concern about what is a sexually attractive body and attire is shifting back

earlier and earlier so that very young girls are becoming concerned about their appearances. This is heightening peer pressure and dividing girls who rank themselves and their cohort according to body image and sexual awareness.” With this apparent no-holds-barred assault on impressionable young girls, schools are taking leadership roles in the reinforcing of life skills. Medical Forum approached several schools for their strategies that support and educate young women as they navigated their way through the most impressionable years of their lives. At the co-educational Carey Baptist College in the southern Perth suburb of Harrisdale, principal Rowan Clark said that his school responded to this need with the Eve program, which has been developed by health coordinator Emily Lockhart and evaluated by UWA’s Faculty of Life Science. Eve is a voluntary program which holds weekly breakfast workshops for Year 10 girls (aged 14-15 years) in Term 3 where topics range from sexuality, sexual behaviour, drug and alcohol use, relationships, dating, body image and mental health issues such as anxiety and depression. Life skills such as resiliency, Continued on Page 45 43

Continued from Page 43 respect, assertiveness, coping skills, leadership and positive values are also incorporated into the program. “Each breakfast workshop focuses on a core value from the WA Curriculum Framework, with particular emphasis on self-acceptance and respect of self,” Emily said. “This is done by empowering girls to respect individual uniqueness, develop a sense of personal meaning and recognise truthfulness, integrity, ethical behaviour and responsibility. “Eve has adopted the Self Determination Theory as its theoretical framework. If teenage girls feel a heightened sense of choice and empowerment towards managing their health and relationships, they will be more engaged in help-seeking behaviour and to integrate learning to make positive behaviour changes. “The theory is that if girls feel a greater sense of self-esteem they will better be able to manage their own health.” Emily says the program has gone down well at the school, with discussions at the workshops (with up to 20-30 girls at one time) often spilling over into the school yard and classrooms and many students saying they would like the program extended to all year round. “Girls have expressed that they need support to feel autonomous and liked the opportunity to discuss their views and hear others’ points of view,” she said.

Felicity McCarthy, from Perth College in Mt Lawley, said the challenge facing educators was how to deal with the sexualisation of girls, when there was a bombardment of airbrushed images of unnaturally shaped bodies. Like Carey College, Perth College’s approach is about empowerment and reinforcing sound decision-making. This year the school launched Inside Out, a sequential self-leadership program where all students are encouraged to understand their own self strengths, and gain leadership strategies, which in turn empower them to face the challenges and pressures of society. And the school believes that girls are never too young to learn, with the program starting in kindergarten, where students work on their emotional intelligence. By Year 5 and 6, they attend GirlPower workshops, where friendship is the theme and developing self-esteem and learning to think about their actions are the key outcomes. The transition to senior school sees Year 8 girls encouraged to communicate beyond text messaging and MSN, and the girls may participate in a mother/daughter program, where both can learn how to keep the communication strong throughout adolescence, particularly when times get challenging. By Year 9 the program specifically targets the sexualisation of girls.

Pregnancy, childbirth and menopause. Three of dozens of reasons why your patients might wet their pants today. If you have patients with leaky bladders or other symptoms, we can help. Bladder problems are very common, affecting

UWA is undertaking a research project with Perth College to evaluate the quantitative difference of self-leadership training, which will provide measurable outcomes. Two other schools in the eastern states will also participate in this research. Prof Chung believes the family GP also plays a vital role in supporting young women to make sound decisions about themselves and their health. “Doctors should not underestimate their standing in the community,” she said. “Not only are they there for the parents but because of the confidential nature of the doctor-patient relationship, they are important to young women as well, who can feel empowered to tell a doctor what they can’t tell their parents or their friends.” l

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Clinical update

Sticking Points in Point of Care Testing P

By Mr Robert Wardrop, Medical Scientist in charge POCT, PathWest

oint of Care Testing (POCT) has been growing steadily over the years both within the public hospital system and in the private sector. However it has not been introduced without some issues coming to the fore. Issues not related to the point of care device. Experience in WA Health and PathWest Laboratory Medicine WA in the last 12 months has shown that unforseen factors can tarnish POCT processes, lead to doubts about results and potentially lead to inappropriate treatment. Although the latest POC systems are designed to be user friendly, rapid and reliable they suffer the same issues as laboratory methods and are further compromised when immersed into a busy clinical environment. POCT devices rely on a well-mixed whole blood sample. Yet we know from experience and empirical data that mixing a sample at collection point is least likely to happen in a busy clinical location. The device requires time to do the test. It takes time to maintain and quality control the device to ensure analytically reliable results. Yet we know that time is not widely available in busy clinical areas. Thirdly we know that immunoassay point of care tests such as Troponin and BhCG do suffer from interferences that lead to

false positives. These interferences are patient based and can be investigated in a laboratory but not at point of care. These three prongs constitute a trident of complexity that needs to be understood before POCT is considered by a site. They need to be recognised, understood and if possible controlled. POCT is fundamentally about people, their competency, understanding and the environment they work in. ED. We asked three others working in this field for comment. None wanted to be named but made these points: • In the POCT trial the quality framework (training, regular quality control, maintenance) was carefully designed and implemented and added substantially to the cost (on average, double). About 5-10% of people failed operator training and were not allowed to use the devices. • There is a prevalent view that POCT instruments are ‘ fool proof ’ but inadequate training underlies many failures, plus a lot of the variation relates

to specimen quality, which often comes down to training/knowledge. • Costs of machines and reagents (e.g. staff retest the patient ‘to be sure’), of retraining when staff leave the practice, and of time needed to do these tests can be underestimated. • There is the potential for transcription errors (a major problem where computers are not doing the work) and medico-legal risk. • POCTesting for drugs of abuse may be satisfactory for ‘general monitoring’ however this will not have the same legal standing as samples which have been tested in AS4308 Accredited laboratory. • INR monitoring, which is accurate and cheap – importance of this will decrease as new drugs come onto the market and such testing will no longer be required. • Maybe accreditation of general practices or staff for use of these devices is required? For more information about POCT contact PathWest 9346 3564 or email POCT. PathWest@health.wa.gov.au

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Helping Women Get Through the Tough Times ED Mandy Stringer outlines how WOMEN’S Healthworks reaches out to women when life gets tough.

OMEN’s Healthworks is an innovative health, education and referral service for women in the northern suburbs of Perth. We aim to empower women, enabling them to make informed decisions about their health and well-being by providing health promotion, counselling, self-help groups, support services and medical clinics.

Here is a snapshot of our services: • Body Esteem Program is unique to WA and offers group programs for women living with anorexia, bulimia or bingeeating disorder, as well as support for people living with someone who has an eating disorder. The programs are guided self-help, which supports people to set their own goals for recovery and commit to achieving them for themselves. With the facilitators’ assistance participants learn strategies to understand their eating

difficulties and ultimately overcome them. These groups are facilitated by women who have experience of an eating disorder and can understand the complex challenges of recovery. All participants are required to access regular individual therapy and be physically stable. • The Village Program offers support and counselling for women who are or have experienced problems as a result of drug and/or alcohol use and women who are pregnant and seek to change their use of drugs and/or alcohol. The program also helps relationships between a mother and her children, damaged by drugs and/or alcohol.

While many organisations are avoiding transparency and accountability, GSK has opened the door on its involvement with doctors.

GSK disclosures GlaxoSmithKline Australia paid Australian health professionals and organisations more than $2.2m last year. The break-up of payments was as follows: • $287,384 to individual pharmacists, doctors and other health professionals to attend domestic and international conferences and symposia. • $372,695 to health professionals for work on clinical development advisory boards and for “speaker presentations”, and

for mothers to share their thoughts and explore the many adjustments that accompany parenting and motherhood, and how those can impact on how a mother feels about her role, capabilities and confidence. This program has been designed to help women discover themselves as a mother and their baby in a non-judgmental environment. Mothers and babies participate together. Mothers grow to understand more about how their baby communicates, learns and explores. No formal referral forms are required for any of the programs. Information at www.womenshealthworks.org.au

• Making SENSE of Motherhood is a program for new mothers who are experiencing postnatal anxiety and or depression. It provides opportunities

Transparency in Pharma Dealings The commercial connections between the pharmaceutical industry and the medical professsion have been highlighted by a couple of things recently – the release by GSK of its summary of 2011 payments to health professionals and Medicine Australia’s fining of Sanofi for a breach of its advertising code arising from the interview by 6PR’s Howard Sattler with a WA specialist.

n Mandy Stringer

• $1.5m to health-related organisations in sponsorship, donations or grants. GSK’s added transparency is to be admired, and it goes outside the reporting of payments it makes for CPD events, which it and other pharma companies are obliged to report to Medicines Australia following an ACCC ruling. Each pharma company’s results are posted on the website (http:// medicinesaustralia.com.au/code-ofconduct/education-events-reports). The accumulated figures of 37 pharma companies shows that in the six months up to October, at an average cost of $96.20 per head, 18,174 events attended by 423,516 people were subsidised to the tune of $40.7m (with $18.2m of that amount spent on hospitality). GSK alone spent more than $.84m on 531 CPD eventsin the preceding six months, according to the website. GSK said its spending on health professionals and organisations had remained steady overall compared to 2010, with a decrease in both grants and

consultancy fee payments to individuals and a significant increase in sponsorships to health-related organisations. Of the $1.5 million paid to health organisations, GSK revealed $505,553 was given as either financial support or donations to patient and community groups including Terry White Chemists, the McGrath Foundation, Movember and others. GSK has been disclosing individual payments to patient and community groups for the past four years.

Howard Sattler and the physician A $40,000 fine was imposed on Sanofi by the Medicines Australia Appeals Committee after it overturned an original decision by the Code Committee that no breach of the Code had occurred. The successful appeal was around an interview Dr Charles Inderjeeth gave to Howard Sattler on 6PR in June 2011, which came about because of a media release and media alert issued by Sanofi that the committee considered were promotional and exaggerated the benefits of its product, Actonel EC. The committee said that Dr Inderjeeth and Mr Sattler were improperly briefed of the requirement to avoid any promotion of the product on air. The interview about osteoporosis had Mr Sattler spelling out the name of the product for his audience! l medicalforum

•

• •

E-poll

Doctors Comment on the Importance of Trust in Medicine Continued from Page 25

“Working in the medical field is like any other job. To function efficiently as a unit, trust is the most fundamental aspect; trust that your colleagues have done their best and you would expect them to trust you too.”

From our poll, 71 specialists and 100 GPs were invited to provide their perspective on the importance of trust. Here is a selection.

Specialists “It’s fundamental. But trust has to be rewarded with very good performance.”

“I currently work with a couple of poorly trained and/or disinterested doctors and I find it exasperating.”

“Evolution of treatment protocols and supervision/mentoring is very important. Clinical outcomes are better if doctors work together in group arrangements. Stretches across to nurses employed by doctors as well. We can learn from each other and share the skills, all to the advantage of patients.”

“I don’t refer to those I don’t trust.” “There are ‘crooks’ in every area of life, and medicine is no exception. Doctors, particularly some types of specialists, appear to believe they are above the law or ethics, and treat patients as statistics. I cannot trust a colleague who acts this way.”

“Unfortunately doctors tend to turn a blind eye towards the misdeeds of their colleagues.”

“A percentage of medicine is psychological – trust is fundamental to allowing health improvement. Psychologically, if you trust your doctor and his/her judgment, you are more likely to heal using their advice.”

General Practitioners “Trust and respect are measures of integrity – they are essential in any professional relationship.” “The ‘other doctor’ is representing you in the management of your patient.”

“I could not work with another Dr whose management principle and ethics I could not trust.”

“Sometimes you just have to take what you are offered.” “Skill can override trust, depending on the field.”

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Singing Floats

Their Boat

n Doctors in the boat: James Turner, 2nd from left; Airell Hodgkinson, 5th from left; Piet Claassen, 8th from left, Andrew Knight, 9th from left; Andrew Wenzel, far right.

A Capella literally means, ‘in the manner of the church’. It is singing without music and a male choir from Albany, five of whom are GPs and specialist psychiatrists, does it in great style. The following words on its website, written by the singing psychiatrist Dr Andrew Wenzel, from Headspace in Albany, are music on the page. ‘The Southern Right Males are a pod of 14 men from the breeding grounds in the freezing wastes of WA’s Great Southern who breach at irregular intervals to entertain the public with their haunting songs.’

GP Dr James Turner, from Pioneer Health General Practice, is the choir's director and musical arranger. “It all started with a visit to Albany by another male choir, the Spooky Men of the West. I put my hand up and said, ‘we should do something like that!’ There were 12 of us initially, the majority of them are still in the group and at the moment we don’t have any vacancies. We do have quite a few medicos, there’s a strong connection between doctors and music. There are teachers, engineers, an orderly from the hospital and a couple of retired people all with varying musical ability. Quite a few of them can’t read music,” said James.

As James points out, one thing they all share is their passion for living in a small regional town and the opportunity to enrich their own community. “That’s the lovely thing about living in a country town. People tend to have a real ownership of things and I don’t think the choir would be as successful in the city. Here in Albany it’s been wonderful, people want to come along and hear us sing and we pop up in the local newspaper from time to time. “We’ve come a long way since standing up at the Albany Farmer’s Market three years ago and singing a few songs. Now we’re performing at places such as the Albany Entertainment Centre and the Town Hall and we did a concert recently at Wignall’s Winery for about 1000 people. “We’re always very well received, there’s something about a bunch of men standing up and singing in harmony. We do what’s called a ‘mob dance’ involving synchronised movements to the songs and people seem to really appreciate it. It’s probably because we look a sight doing it, but it adds a bit of fun.” The Southern Right Males have an extensive repertoire which includes a few favourites. “We started with arrangements of wellknown songs that people know and love. One of my favourites is a Black Eyed Peas number and we’ve got songs from Gotye and Sting. Most of our pieces are in four or more parts and some of them are quite complex. We also do vocal percussion mimicking a number of different instruments.” The collegial aspect of a male choir is very important, says James. “Part of the fun is getting together over a bottle of wine and doing a rehearsal or two. You don’t often get a bunch of blokes together around a unified cause that doesn’t revolve around drinking or sport,” he said. “Some people have been through hard times over the last few years and it’s been a support line for them. It’s a good reminder that a bunch of blokes getting together is a very positive thing, whether it’s singing, woodwork or a Men’s Shed.” All the other medical ‘blokes’, for different reasons, agree with James. “Singing in a male choir hits a sweet spot of fellowship without any competitiveness,” says Andrew Knight. For Airell Hodgkinson it’s all about enjoyment. “We figure if we enjoy ourselves, then the audience probably will too.” Psychiatrist Piet Claassen adopts a more reflective tone. “Being part of a choir has helped develop my creativity and nurtured my deepest sense of self.” And Andrew Wenzel response is the simplest of all. “After I joined, one of the guys asked me what I love about singing. I told him, ‘it makes me smile!'.” And the final note from the choir’s director. “We’re thinking about touring, maybe even the eastern states festival circuit. We’ve got a lot of momentum and we’re evolving all the time,” said James.

By Mr Peter McClelland 52

medicalforum

Fine

By Dr Louis Papaelias

Wines from Old Vines

On the Grapevine

Juniper Estate

It has been a pleasurable month for yours truly – I have had the good fortune to taste a fine range of wines from Juniper Estate, which is located in Wilyabrup in the historic heart of the Margaret River wine region. The vineyard was planted in 1973 by Henry and Maureen Wright with cabernet sauvignon, shiraz, semillon and riesling. It is the Juniper family of artistic fame that is now the current owners and patriarch Robert’s fine paintings adorn the labels The earth here is deep, well-drained gravelly loam originally home to the marri tree. It is no secret that this soil type is a major contributing factor to the production of great Margaret River wine. The vineyard is located near the Wilyabrup Creek on Harmans Mill Rd, where the vines are dry grown. They do not rely on supplementary water, having adequate access to this natural water supply. Most if not all of the truly great wines of Australia and the rest of the world have this in common. Winter pruning is done by hand as is harvesting at vintage. Vinification is careful and meticulous. Mark Messenger, the winemaker since 1998, has built a reputation for finely crafted wines that are a true expression of what is best about the Wilyabrup sub-region. He has a swag of medals from Australian wine shows to prove it. The wines produced are in two tiers of quality. The Estate range is made from the pick of the crop. These wines are Margaret River classics that will easily accommodate bottle age. The Crossing range consists of wines more suited to early consumption, say within a year or two. Both ranges have won gold medals and trophies to their name. Wines tasted were 2009 Estate Cabernet Sauvignon, 2008 Estate Shiraz, 2010 Estate Chardonnay, 2010 Estate Semillon and 2011 Crossing Semillon Sauvignon Blanc. The Crossing Semillon Sauvignon Blanc won a trophy last year and it is typical of a quality Margaret River ‘Classic’. Fresh, lifted aromas abound and a clean, crisp

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mouthfeel makes this ideal for seafood or for pure enjoyment on a summer afternoon. A step up in complexity is the 2010 Estate Semillon. Its 100% barrel fermentation adds depth to the mineral and citrus typical of young semillon. Like its Hunter counterpart, Margaret River semillon develops and improves, taking on a lovely honeyed richness after five years or so in the bottle. The Juniper example is an ideal food wine and a genuine alternative to chardonnay. Moving up the ladder, the 2010 Estate Chardonnay is very fine indeed. The fruit comes from both Wilyabrup and Forest Grove. The latter produces fruit that is less rich than its northerly neighbour but has greater finesse and restraint. Mark Messenger has managed to walk the fine line between over ripeness and fullness on one hand and under ripeness and excessive leanness on the other. There is attractive white peach balanced with a fine minerality making for a delicious and refreshing drink – either with poultry and seafood or just plain unaccompanied sipping. It will also age well. Of the reds, it was the 2009 Estate Cabernet Sauvignon that won my attention. The 40-year old cabernet vines are now fully mature. There is also about 10% of more recently planted but still dry-grown malbec, cabernet franc and petit verdot. The resultant blend is an utterly delicious marriage of pristine berries with savoury, restrained oak. This is a wine of real complexity with subtle nuances of tannin and flavour. It will undoubtedly improve in the bottle for 10 years or more, but you won’t

be disappointed if you open a bottle now. Just remember to bring the wine to about 18-20C. Room temperature in a Perth summer does not make for enjoyable red wine appreciation. The 2008 Estate Shiraz is also a very fine wine. Made entirely from drygrown shiraz from Wilyabrup, this is a full-bodied, mouth-filling drink. Warm spice, berries and savoury chocolate are present in abundance. An easy wine to drink now or in 2-4 years’ time.

WIN a Doctor’s Dozen! What two Margaret River wine sub-regions produce fruit for the 2010 Estate Chardonnay? Answer:

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Theatre: Yes, Prime Minister Win a double ticket to see the hilarious BBC comedy onstage with Philip Quast as the suave cabinet secretary Sir Humphrey Appleby, Mark Owen-Taylor as the embattled PM Jim Hacker and John Lloyd Fillingham is Jim’s hapless assistant, Bernard Woolley. Throw in “my dear lady” Caroline Craig as the PM’s Special Policy Adviser and the GFC you have the cutting political satire Yes, Prime Minister. His Majesty’s Theatre from May 31

Kids’ Theatre: Spare Parts Season Subscription Win a family subscription to the Spare Parts Puppet Theatre’s 2012 season which kicks off this month with the classic Tim Winton hit, The Deep. Watch out for Miss Lily’s Fabulous Feather Boa, Cat Balloon, and The Velveteen Rabbit later in the year. For the first time, patrons will be able to book for all the company’s shows at the same time, reserve seats, and beat the queues. Spare Parts Puppet Theatre, The Deep, from April 10

Music: BEAT Concert Win a double ticket to BEAT – the fusion of renowned organist Dominic Perissinotto, award-winning composer and virtuoso piano accordionist Cathie Travers and internationally acclaimed saxophonist Matthew Styles playing a unique program of contemporary and classical works. The concert highlight will be a repeat performance of heartBEAT, a dynamic contemporary piece composed by Travers in 2009 especially for the ensemble. St Patrick’s Basilica, Fremantle, May 20, at 2.30pm

Cinema: Trishna Win a double ticket to see Trishna, a drama set in contemporary Rajasthan and based on Thomas Hardy's novel, Tess of the D'Urbervilles. Trishna (Freida Pinto) meets a wealthy young British businessman, Jay Singh (Riz Ahmed) who has come to India to work in his father's hotel business. Despite their feelings for each other, they cannot escape the conflicts of modernising India. In cinemas May 10

Celebrating with Kalgan River Nedlands GP Dr Hira Singh had a couple of reasons to feel pleased with himself. He’d only just returned from a 10-day holiday in Bali when he called in to Medical Forum to pick up his Kalgan River Doctor’s Dozen. Hira loves big, full-bodied reds from WA and the Barossa Valley and, what’s more, there’s a distant family connection with the Kalgan River winery. His daughter has a birthday coming up so there’s bound to be a bottle or two of Kalgan Cabernet Sauvignon sitting on the table. .

COMPETITION WINNERS From February issue Tafelmusik - The Galileo Project – Concert: Dr David Storer He'arat Shulayim: Footnote – Movie: Dr Dorothy O'Hara, Dr Kooi Ang and Dr Jun Wei Neo Switch to Be The Forgiveness of on automatic st Practice and swit ch SM Blood – Movie:S reminders/replies Dr Cathy Parsons, Dr Gavin Leong and Dr Eng Gan Your appoin tment remind the wash but er today’s patie cards may disappear in their jeans nts can’t forge pockets going t appointmen constant com ts when you through For just a few panion, their cents and virtu mobile phone remind them via the reply) in Bes ir ! t Practice can ally no effort, new automa tic SMS remind do much to e There’s no fas liminate the c ers (and confi ter, more strea rmation ost and disru ption o mlined system Benefits of SMS than BP SMS! f No Shows. in Best

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Music: Trio Dali Young, glamorous and very French, Trio Dali is taking the chamber music world by storm. The new kid on the block has already won awards and turned heads from Osaka to Frankfurt with original and compelling performances, and now it makes its Australian debut for Musica Viva. From Gordon Kerry to Maurice Ravel, Trio Dali tackles new and old works head-on with fresh eyes and open minds. Perth Concert Hall, May 29, at 7.30pm

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medicalforum

24/01/12 1:36 PM

n n A lean and hungry look

n n Code crackers

Yesterday I was at my local Woolworths buying a large bag of Purina dog food for my loyal pet and was in the checkout queue when a woman behind me asked if I had a dog. What did she think I had, an elephant? So, since I'm retired and have little to do, on impulse I told her that no, I didn't have a dog, I was starting the Purina Diet again. I added that I probably shouldn’t, because I ended up in hospital last time, but that I'd lost 12kg before I woke up in intensive care with tubes coming out of most of my orifices and IVs in both arms. I told her that it was essentially a perfect diet and that the way that it works is to load your pockets with Purina nuggets and simply eat one or two every time you feel hungry. The food is nutritionally complete so it works well and I was going to try it again. (I have to mention here that practically everyone in queue was now enthralled with my story.) Horrified, she asked me if I ended up in intensive care because the dog food poisoned me. I told her no, I stepped off a curb to sniff an Irish Setter's arse and a car hit us both. I thought the guy behind her was going to have a heart attack he was laughing so hard. I'm now banned from Woolworths. Moral of the story: Watch what you ask retired people. They have all the time in the world to think of daft things to

The kids have all their little SMS codes... like BFF, WTF, LOL etc. So here are some codes for the seniors: ATD - At The Doctor's BFF - Best Friend’s Funeral BTW - Bring The Wheelchair CBM - Covered By Medicare CUATSC - See You at the Senior Centre DWI - Driving While Incontinent FWBB - Friend With Beta Blockers FWIW - Forgot Where I Was FYI - Found Your Insulin GGLKI - Gotta Go, Laxative Setting In GGPBL - Gotta Go, Pacemaker Battery Low GHA - Got Heartburn Again HGBM - Had Good Bowel Movement IMHO - Is My Hearing Aid On? LMDO - Laughing My Dentures Out OMMR - On My Massage Recliner OMSG - Oh My! Sorry, Gas ROFL...CGU - Rolling On the Floor Laughing...Can't Get Up! TTYL - Talk To You Louder WAITT - Who Am I Talking To? WTFA - Wet The Furniture Again WTP - Where's The Prunes WWNO - Walker Wheels Need Oil

say.”

n n Lovemaking Tips For Seniors: 1. Wear your glasses to make sure your partner is actually in the bed. 2. Set timer for three minutes, in case you doze off in the middle. 3. Set the mood with lighting. (Turn them ALL OFF!) 4. Make sure you put 000 on your speed dial before you begin. 5. Write partner's name on your hand in case you can't remember it later on. 6. Use extra Polygrip so your teeth don't end up under the bed. 7. Have oxygen ready in case you actually complete the act.. 8. Make all the noise you want....the neighbours are deaf, too. 9. If it works, call everyone you know with the good news!! 10. Don't even think about trying it twice.

medicalforum

n n A father’s worst nightmare A father passing by his son's bedroom, was astonished to see the bed was nicely made, and everything was picked up. Then, he saw an envelope, propped up prominently on the pillow. It was addressed, 'Dad.' With the worst premonition, he opened the envelope and, with trembling hands, read the letter... 'Dear, Dad. It is with great regret and sorrow that I'm writing you. I had to elope with my new girlfriend, because I wanted to avoid a scene with Mum and you. I've been finding real passion with Julie, and she is so nice, but I knew you would not approve of her, because of all her piercings, tattoos, her tight motorcycle clothes, and because she is so much older than I am. But it's not only the passion, Dad. She's pregnant. Julie said that we will be very happy. She owns a trailer in the woods, and has a stack of firewood for the whole winter. We share a dream of having many more children. Julie has opened my eyes to the fact that marijuana doesn't really hurt anyone. We'll be growing it for ourselves, and trade it with the other people in the commune for all the cocaine and ecstasy we want. In the meantime, we'll pray that science will find a cure for AIDS, so Julie can get better. She sure deserves it! Don't worry Dad, I'm 15, and I know how to take care of myself. Someday, I'm sure we'll be back to visit, so you can get to know your many grandchildren. Love, your son, Joshua PS. Dad, none of the above is true. I'm over at Jason's house. I just wanted to remind you that there are worse things in life than the school report that's on the kitchen table. Call me when it is safe for me to come home.”

On the Grapevine

funny side

Photography

They say a picture is worth a thousand words but when docs get behind a camera, we reckon its worth a photo spread. Every two months, Medical Forum will publish a selection of pictures from all you camera-happy medicos and the best, judged by our eagle-eyed editors, will win a couple of bottles of premium wine.

Email your WET and WILD pictures to editor@mforum.com.au by May 1.

The competition kicks off... In June with the theme WET and WILD, and it’s easy to enter, just send hi-res pictures and a small caption story (with an optional brief technical description of how you took your picture) to editor@mforum.com.au by May 1. To kick things off and to inspire you, we asked some MF regulars to send in some of their current pictures.

Dr Clive Addison on a trip to Nicky Amazon Lodge in Ecuador in October: “Wearing rubber boots on squelchy night walks, the fireflies darted overhead as they too navigated the Amazon jungle. The fruit bats gave us a haircut as they zoomed by like stealth fighters in the darkness. The spider webs came from nowhere. Strong LED torches targeted the night life. A taranchula ( hand-sized ), a boa constrictor (practising on a tree branch), a beautiful chameleon lizard – every inch revealed new jungle life. The Amazon is ALIVE!

Photography

Dr Robert Davies: “I love this intriguing photo that I took of my son, Isaac, lying in a bubble bath with his swimming goggles on. Seeing a photo opportunity I asked him to lower his head into the water and look straight at the camera. He ended up with a quite surreal countenance. It was a nice picture in colour, but better, I think, in black and white with the green of his goggles kept for interest. This photo was shot on a Nikon D80 50mm f/4 ISO 200 1/60

Dr Tony Tropiano: Photography is a bit like fishing – you don’t always get the “Big One”, however, if you know the hotspots it helps. There are also generic factors such as incoming tide (fishing), just about and around sunrise and sunset (photography). Then there’s the issue of how you go about it – whether it is hooking a fish and keeping it on or getting a clear well-exposed interesting picture. I know quite a few hotspots in around WA – my passion is to photograph mainly Western Australia – rural, coastal, urban, harvesting, seeding, shearing, wildflower season and it goes on.

Dr Charley Nadin: Escape to New York. The impressive towering lady of Liberty welcomes visitors to soak in the new post 9/11 skyline of New York City minus the looming Twin Towers. I took this picture during a river cruise when we were in New York in July. The boat had just turned around and I was at the back of the boat and this picture loomed out at me. It was a dull day, so I chose black and white.

Cardiology

Western Australia’s Who’s Who for Patient Referrals clinical services directory Cardiology Cosmetic Medicine - Hair Loss Dermatology Ear, Nose & Throat Gastroenterology General Surgeons & Subspecialties Gynaecology & Gynaecological Surgery Gynaecology & Infertility Gynaecology, Infertility & Andrology Hand Surgeons Infecctious Diseases Infertility & Andrology Neurology Neurosurgery Nuclear Medicine Obstetrics Obstetrics & Gynaecology Obstetric and Gynaecological Ultrasound Ophthalmology Orthopaedic Surgeons Orthotics Paediatric & Adolescent Rheumatology Paediatric Respiratory & Sleep Physician Paediatric Surgery Pain Medicine Plastic & Reconstructive Surgery Podiatry Services Psychiatry Psychology Radiology Renal Medicine Reproductive Health Respiratory & Sleep Medicine Rheumatology Sexual Health Sports Medicine & Foot Orthodotics Thoracic Surgery Vascular & Endovascular Surgery Vascular Imaging/Intervention

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58-60 60 60 60-61 61 61-63 63-64 64-65 65 66 66 66 66 66-67 67 67 67-68 68 69-70 70-74 74 74 74-75 75 75 75-76 76 76 77 77 77 77 78-79 79 79 79 79 80-81 81

Dr Edmund Lee MBBS (Hons), FRACP Cardiologist with post-fellowship training in interventional cardiology (Canada). Suite 34/100 Murdoch Drive Murdoch 6150 Phone: 9366 1891 Fax: 9366 1900 Consults at SJOG Murdoch, Rockingham, Mandurah, Bentley, Geraldton and Bunbury with Dr John O’Shea. Special interests: •• Coronary intervention •• Structural heart intervention •• PPM insertion •• TOE For all appointments, call 9366 1891 Urgent advice: 0422 895 111

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Medical Forum Magazine 8 Hawker Ave Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333

Heart Care Western Australia & Coastal Cardiology Heart Care WA and Coastal Cardiology have combined to provide coverage for all aspects of adult cardiology requested by referrers in Western Australia Dr Bernard Hockings Dr Mark Ireland Dr Mark Nidorf Dr Peter Purnell Dr Nigel Sinclair Dr Isabel Tan Dr Peter Thompson

Dr Randall Hendriks Dr Donald Latchem Dr Vince Paul Dr Alan Whelan Dr Xiao-Fang Xu

Comprehensive cardiac services will now be provided by the new practice at Perth’s leading metropolitan hospitals including St John of God Hospital Murdoch, Mount Hospital and Hollywood Private Hospital. Heart Care WA/Coastal will also expand services in Joondalup, Mandurah, Bunbury, Busselton, Dunsborough, Margaret River, Albany, Denmark, Karratha and Port Hedland. The new practice is the only cardiology group that has a clinical presence at all the major teaching hospitals in WA, including Royal Perth Hospital, Sir Charles Gairdner Hospital and Fremantle Hospital. We provide a full and comprehensive Cardiology service including: •• Consultations – Clinical, Employment and Immigration Related •• ECG and Exercise Stress Testing •• Echocardiography, Stress, Dobutamine & Transoesophageal Echocardiography •• Holter Monitoring and Event Monitoring •• Blood Pressure Monitoring •• Angiography, Revascularisation with Angioplasty and Stents •• ASD Closure, Valvuloplasty •• Permanent Pacemaker Insertions, Implantable Defibrillators •• Cardiac Resynchronisation •• Electrophysiology Studies and Radiofrequency Ablations •• Pacemaker Checks •• Access to Private and Public Hospitals •• Resource and Advisory Service to General Practitioners Heart Care To speak to a Cardiologist call our GP Hotline: 1300 4 Heart (1300 443 278) For Appointments Phone: 08 9480 3000 Email: info@heartcarewa.com.au Web: www.heartcarewa.com.au Coastal Cardiology To speak to a Cardiologist call our GP Hotline: 08 9311 4601(24hrs on call) For Appointments Phone: 08 9311 4600 Mount, Joondalup, Murdoch, Nedlands, Yokine, Duncraig, Midland Albany, Augusta, Bunbury, Busselton, Denmark, Dunsborough, Karratha, Mandurah, Margaret River, Port Hedland, Rockingham, Northam

Contact: Jenny Heyden RN on 9203 5222 Mobile: 0403 350 810 Email: jen@mforum.com.au Deadline: 9th of each month

medic alFORUMwa

a p r i l 2012

Medical Forum CLASSIFIEDS GeneRaL - FoR SaLe hospItal DoCtor pgy 2+

Locum Wanted

1. Examination Bed 2mL x .7mW (2) PeRtH Brand new never used Locums / Associates wanted. 2. Filing cabinets 4 drawer x (2) Perth Medical Centre, Hay Street Mall. 3. X-ray viewer Busy accredited privately owned POA billing, flexible hours. for high paying job in metro Goldpractice, Coast,private Queensland. Call PracticeisManager on 0419 959 246 Excellent remuneration Position full time General Practice, complete on site for suitable or Email: will be provided. candidates. training practicemanager@kelsomg.com.au Phone: 9481 4342 Must have full registration, FRACGP not necessary Mobile: 0408 665 531

opportunIty exIsts

uRBan PoSItIonS Vacant

BecKenHam Full Time VR GP wanted with special interest in Women's Health. Fully computerised, accredited, mixed billing and Registered Nurse available. Area of need and District Workforce Shortage eligibility. Phone: 0416 255 423 Email: bmcreception@westnet.com.au

Keen to fit in more rounds of golf each week?

GooSeBeRRY HILL Part-time GP, Pref. VR, required for our busy, accredited family practice in Gooseberry Hill. We are fully computerised with excellent administration and nursing support. Please contact Peter on 9257 1121 or email details to – office@hillsfamilymedical.com.au

Finally planning to enrol in that MBA course?

FRemantLe Fremantle Women’s Health Centre requires a femaleprovides GP (VR) to provide KaRdInYa-do You SPeaK The Australian Locum Medical Service PaLmYRa email your cv to: medical services in the area of women’s cRoatIan? aVeLeY Palin Family Practice requires a health, 2 sessions or 1 dayto pw. anStreet after-hours home visiting medical service Located 25kms North of Perth0409 – dr tom Challenger 761 VR/GP 053 - Locum with a view to joining full or part-time VR GP. It is a computerised, private and the team required for part time sessions proposed Vale Medical Centre patients over 700bulk Perth We, at this privately ownedof fully billingGPs. practice, with nursing by Privately owned busy General Consulting Suites for lease – suitable serviced practice enjoy a relaxed support, scope for spending Practice. for specialists or Allied Health, Dental, As an Area of Workforce Shortage, non-VR Doctors working with usmore can environment with space and gardens. time with patients, and provides This well managed long established Radiology, Physiotherapy etc earn up to $10,000 per week depending on the number of patients seen. recently increased remuneration plus For further information call Karen on 6-doctor practice offers comprehensive Close to shopping centre and is within Imagine rounds of golf week. salary superannuation andper generous 0409 376these 686 earnings and still fit in three CDM program supported with 3 RGN’s 2km radius to 2 schools & Child Health packaging. FWHC isare a not-for-profit, and onsite pathology. Flexible roster arrangements are available and earnings based Centre. community facility providing medical WemBLeY doWnSstructure. Doctors working to Practice Manager on QFor u e information e n Phone: s l a n Enquiries d on a fee-for-service with us pay a variable further and counselling services, health 0419 959 246 Inviting enthusiastic FT GPs join based upon their commitment. commission of any feestobilled, 0400 814 091 education and group activities in a this long established, non-corporate, www.kelsomg.com.au relaxed friendly setting. practice withon a huge well our growing medical team, Forprivate morebilling information joining nedLandS Phone 9431 0500 or established patient load. Chad Stewart on (08) 9227 6658 or visit our medical centre RuRaL PoSItIonS Vacant contact Email: Diane Snooks (no FRACGP needed) • Hollywood If you have full regIstratIon Attractive remuneration. New fully furnished 69 m2 consulting website: afterhoursmedical.com.au director@fwhc.org.au or Email: managerbmc@gmail.com • suites Would to work as for a Doctor aLBanYPractice on on like 2nd floor available lease. in Private Erin Embury: VR GP required to join our 4 Doctor, Phone: 0401 289Gold 276 Coast? Queensland’s, clinical-manger@fwhc.org.au FootHILLS busy, friendly family orientated practice. • To earn $ 500,000 ++ per year Accredited Family Practice in complex Full time or Part time a special interest muRdocH InGLeWood with Physio, Psych, Spec. Phys, in Women’s Health would be a bonus. Medical Clinic SJOG Murdoch GP required. Hours negotiable with Pathology req F/T or P/T GP pref VR. email your cv to: We are Accredited, computerised, full guaranteed 6-8 weeks holidays per Specialist consulting sessions available Area of unmet need & workforce nurse support and an experienced year. with secretarial MedCall, drsupport. tom Challenger 0409 761 053 shortage; RIG eligible area. Part priv. Admin Team with Healthscope We are a friendly six doctor (3 male, 3 SMS 0417 182 789 billing. No A/H. Laboratory on site. Mixed billing. female) private billing, non-corporate Email: pmanager@hvmc.com.au Phone: Gaye - Practice Manager practice on the Bedford/Inglewood aPPLecRoSS or ph: (08) 9255 1161 9841 6711 boundary. Applecross Medical Group is a major Email: gaye@hillsidefp.com.au Generously staffed, including practice medical facility in the southern suburbs. GoSneLLS nurse and pathology on site. Current tenants include GP clinic, VR GP needed part time or full time. › 244m² maRGaRet RIVeR Phone Steve, Carl or Jeremy on pharmacy, dentist, physiotherapy, › practice Rent:with $325/m² outgoings and 9311 GST or Accredited nurseplus support. 9271 Long established accredited family fertility clinic and pathology. › Fitted out – waiting room, consulting rooms, dressing room, 65% of gross but negotiable. practice seeks GP or trainee to replace Email salisburymed@iinet.net.au Both the GP clinic and pharmacy x-ray room and reception retiring Doc. Nice comfortable environment and provide a 7 day service. › Fully cabled great patients. Anaesthetics, Obstetric and surgical The high profile location (corner › 5 secure bays available. manduRaH scope available but not essential. The medical centre beencar here since of Canning Hwy and Riseley Street VR GP to replace retiring female. 1992, upgraded in 2002. Some afterhours commitment - not Applecross), provides high visibility to No on-call or afterhours. 2FTE nurses Contact Matt Campbell onerous. Mainly private billings. tenants in this facility. support 4 docs. CPG Corporate Phone Sally 08 9757 2733 for more Come and have a chat withReal us. Estate A long term lease is available in this RA2, mixed billing, paperless practice. information 0423 477 facility - the space available is 85m2, Please ring Carol on 333 9490 8288 or Phone: Robin 9586 2122 or withWe the are current layout including 4 Medical Officer to join our seeking a Senior Email: ashburt@highway1.com.au Email: accounts@metcenihealth.com.au consulting rooms, procedure room and GeRaLdton Emergency Department at St John of God Hospital Murdoch. reception area. Expressions of Interest required Would suit specialist group, radiology for exciting new medicalAcentre Anaesthetic and Acute Medicineorexperience is preferred. GP DECEASED ESTATE allied health group. with anaesthetic and procedural development skills would in becentral ideal.Geraldton. Contact John Dawson – 9284 2333 or Due for completion late 2012. Our633 Emergency Department, located adjacent to the 0408 872 Options to be an owner/occupier Fiona Stanley Hospital site, treatsor approximately incentives given25,000 for early leesee · Practice currently fully Located in Maddington adjacent patients per annum with significantsignings. acuity, and plays a key nedLandS accredited, computerised to Maddington Centro Shopping role in the training of medical students and trainees in Hollywood medical centre – 2 fully For more information, please contact Dr including Pathology centre, Centre Emergency Medicine. furnished consulting suites on first floor, Ray Cockerill 0418 939 027 or Psychologist and Chiropractor · Opportunity to buy real estate – available for lease. Email: ray@skingeraldton.com.au If you wish to practice high quality patient care and continue · One room leased to pathology deceased estate Secretarial available ifinrequired. yoursupport own education pleasant surroundings, you are centre · Modern brick and tile construction Phone 0414 780 751 encouraged to apply. Opportunities for weekend work and BUNBURY · Close to retirement village

PotentialFoR to LeaSe earn $ 500,000 ++ per year

docs@medcall.com.au

GPs for Gold Coast

docs@medcall.com.au

West Perth Medical suites available

MEDICAL PROPERTY FOR SALE

salary sacrifice benefits enhance the competitive salary.

BeaconSFIeLd Greater Bunbury Medical Centre For further please contact Director of Emergency Opportunity to information, lease newly renovated Andrew Jan on 9366 1271 or for a lifestyle Are you ready rear buildingMedicine, adjacent toDr medical change for the better? email andrew.jan@sjog.org.au practice. State of the art non-corporate Approx 120sqm total which includes 3 Medical Centreand opens early 2013. consultingTo rooms, reception area and apply, visit www.sjog.org.au/murdoch bathroom. click on “Job Search”GPs, Allied Health staff and Specialists wanted. Employment, In prime location on South Street, contract or tenancies available now with close proximity to St. John of God various sizes. Murdoch, Fiona Stanley Hospital & Fremantle Hospital. Contact: 9791 8133 Jill Riggall, Project Manager Contact E-Mae Lim 0423 282 762 / 9335 9884

Large block

Current practice not operating at full capacity - plenty of room for expansion

“Arcadia Waters” ·

Demographics – retirees, young families and industrial workers

This property is a rare find and would not be available except for deceased estate. So hurry to secure!

For more information please contact Centex Commercial Rick Bantleman 0413 555 441

APRIL 2012 - next deadline April 16 - Tel 9203 5222 or jen@mforum.com.au

Medical Forum CLASSIFIEDS WHItFoRd GP F/t or P/t to replace female doctor We are fully computerised, well equipped, accredited practice. Friendly practice Nurse and admin staff to support at all times, including Careplan/Health Assessment Nurse. Medical Centre has on site pathology, pharmacy and physiotherapy. Please contact Jacqui, Practice Manager on 9307 4222 or Email: jmarkouloop@iinet.net.au LocKRIdGe VR GPs or Subsequent Registrar PT / FT To work at our recently renovated modern, independent, accredited, innovative, teaching practice. Fully computerised, FT practice nurse onsite support (team of 5), chronic disease nurse support, onsite pathology and a friendly supportive work environment including yum morning teas :) Flexible working hours, great practice systems in place to support chronic disease which assists the remuneration package. Practice is located approximately 16kms from the city centre in an area of district workforce shortage (approx. 35 min drive). Before you make up your mind - Our practice is definitely worth a visit :) If you are interested we would be keen to speak with you! Please phone Natalie Watts on Phone: 6278 2555 or Email: natalie.watts@lockridgegp.com noRtH BeacH VR GP wanted for a small beachside surgery, close to great surfing beaches and restaurant strip. Fully computerised practice, accredited, practice nurse, on site pathology and psychologist. Hours negotiable . Please phone Helen or David 9447 1233 mt HaWtHoRn Mt Hawthorn Medical Centre, a non corporate accredited long established practice situated in a fast growing inner city suburb of Perth, seeks a part time or full time VR GP to join this highly desirable practice. Fully computerised, Nurse Assistant. Phone Rose 9444 1644 KaRdInYa Non-corporate General Practice presents opportunity for VR P/T or F/T GP to join exceptional team locating to newly refurbished premises. Well managed long established 6 doctor practice offers a comprehensive CDM program thru 3 RGN support and onsite pathology. Enquiries to Practice Manager on 0419 959 246 or Email: practicemanager@kelsomg.com.au HoLLYWood - nedLandS VR GP required for part time work in a unique surgery in Nedlands caring for the aged. Call 0413 749 808 or Email to pracman@westnet.com.au

WeSteRn SuBuRBS VR GP required for our accredited, newly renovated and well equipped practice in Nedlands. We are fully computerised, with full time nursing staff, a Mental Health Nurse, onsite pathology, and Health Promotion Team. Sessions negotiable - no evening or weekend work required Please contact Judi Hicks, Practice Manager, on 6488 2118 or Email: judith.hicks@uwa.edu.au for further information WemBLeY Energetic GP wanted for longestablished private Wembley Practice. Convenient location makes this position perfect for a GP obstetrician, although not essential. Fully computerised, Practice Nurse, pathology and theatre. Adjacent services include Psychologist, Physio, Podiatrist and Dietician including diabetic educator. Phone Pauline on 9381 9010 or Email: wembleygp@westnet.com.au. daLKeItH medIcaL centRe Full or part time VR GP required for private billing, long established group practice in the Western Suburbs. Non Corporate, accredited, computerised, full time practice nurse support. Outstanding career opportunity. Phone 0412 224 535 como Do you want to practice quality medicine and spend more time with your patients? Do you have a passion for skin cancer diagnosis and management? If the answer to both questions is yes, we would like to speak with you. PT is fine, hours negotiable. Contact Sian via email: skinspectrum@gmail.com BuLLcReeK Come and join us in our New General Practice located SOR. Non-Corporate Practice. We require Full-time or Part-time GP’s for our Surgery. The surgery is Computerised, Private and Bulkbilling. Practice Nurse available part-time. Please contact the Practice ManagerAnnette on 9332 5556 outeR metRo PRactIceS GP required for our outer metro Practices Full time / Part time GP required to join our privately owned outer metro practices. Fully supportive and friendly working environment. Contact Dr Jagadish on 0413 879 023 Email jags.krishnan@gmail.com Or Caroline – Practice Manager 9247 9804 / 0409 342 488 Email: caroline@theheights.com.au

BYFoRd GP F/T- P/T Byford is a rapidly growing area and is continuing to expand. Byford Family Practice is privately owned. Practice has 5 GPs and is fully equipped with 7 consulting rooms, 2 treatment rooms & employs 2 nurses. Onsite Pharmacist, Pathology, Podiatrist, Chiropractor, Masseur and Dentist Excellent terms and conditions are negotiable Area of Unmet Need & District of Workforce Shortage Contact: David Cowden Email: byfordfp@westnet.com.au Fax: 9525 0093 Phone: 0413 273 778 SoutH PeRtH Located 12 minutes from the Perth CBD, the Independent Practitioner Network’s Accredited Southern Medical Centre is in an ideal location to provide quality healthcare services. The Centre would like an enthusiastic FT VR GP to join its dedicated team. The recently refurbished, fully computerised Centre is supported by a great administration team and full time nursing coverage. For confidential enquires or a tour of this centre contact Amanda Piercy 0419 046 997 or E:Amanda.piercy@ipnet.com.au WeSt PeRtH GP sessions available at our private-billing, accredited and fully computerised general practice. Our busy practice serves a young, professional demographic as well as providing specialist sexual health services. This represents an exciting opportunity for an enthusiastic practitioner to join our friendly team. Morning and afternoon sessions are available. Experience in family planning, sexual health and mental health would be an advantage. Contact Stephen on 0411-223-120 or at stephen@westperthmedicalcentre. com.au HaLLS Head/manduRaH FT/PT VR GP required for busy privately owned practice. Fully computerised Accom avail for rent on request Contact us on: 08 9581 2345 or Email: robyn@peelwoodmedical.com.au GP aFteR HouRS – eLLenBRooK We are seeking GP’s to join our committed team for week days and week end shifts. We are accredited, fully computerised practice offering attractive rates. Further information contact Colleen 9297 2555 or Email: ellenbkmc@bigpond.com Reach every known practising doctor in WA through Medical Forum Classifieds...

WanneRoo FT / PT GP required for non-corporate family practice delivering excellent healthcare to our local community in Wanneroo (Perth's northern suburbs). Our practice is fully computerised (Pracsoft and Medical Director), paperless and accredited. We have a wonderful reception team, professional Practice Managers, and full nursing support. Contact: Jody Saunders 0410 617 094 or Cheryl Barber 08-9405 1234 E-Mail CV to: jsaunders.wthc@gmail.com or cbarber.wthc@gmail.com manduRaH Mandurah coastal lifestyle 40 minutes from Perth. VR non VR doctor required short term or long term. No weekends or after hours. Good remuneration. Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist, aromatherapy, reflexology, and orthotics. Contact practice manager Elaine 9535 8700 or elaine@mandurahdoctors.com.au WILLetton AMPM Doctors Willetton, Requires Part Or Full Time VR GP. Computerised, Non-Corporate, Flexible hours, 70% Full Time. E-Mail: ampmdoctors@westnet.com.au StReSS teStInG – aLL LocatIonS CVS requires Stress Physician Our CVS specialist practice is seeking GPs or registrars to supervise exercise stress testing. Excellent remuneration and working conditions. Working with state of the art diagnostic equipment conducting quality specialist testing. Joondalup, Mt Lawley, Midland, Nedlands, Leeming, East Fremantle and Rockingham locations. If interested, please phone: Adam Lunghi to discuss, at CVS on 1300 887 997 or 0402 825 570 RIVeRton RIVeRton medIcaL centRe is looking for a PT or FT VR GP. Access to full-time practice nurse. Fully computerised accredited practice. Friendly working environment. Pay 65% of receipts. Ring Dr Sovann on 0412 711 197 if interested dIaneLLa General Practice requires FT / PT VR GP’s to join this established and busy practice. Mostly private billing, supported by 4 practice nurses and upon completion of extensions a Pharmacy on premises. Phone: Practice Manager Helen 9276 3472 Email: dfmc@dianellamedical.com.au

APRIL 2012 - next deadline April 16 - Tel 9203 5222 or jen@mforum.com.au

s: n e y,

pArABurdoo

pibara

Perth Primary Care Network (PPCN) is a not-for-profit organisation in the primary health care industry. PPCN operates a mobile medical StreetDoctor service that takes primary healthcare to the marginalised populations of Perth. We are currently seeking a Vocationally Registered General Practitioner to join our committed team for two shifts per week. The two shifts that we are currently seeking to fill are on a Monday between 9am-3pm, and on a Tuesday between 12-3pm.

email your cv to: docs@medcall.com.au Aredryou of not 0409 seeing MedCall, tomsick Challenger 761your 053 family?

Medical Forum CLASSIFIEDS

Do you like to be independent?BuRSWood Are you looking for a PeRtH country change? Then this is the job for you!!! GP Opportunity Wanting higher remuneration and is not afraid of aGP. bit of hardtown work? has Do you enjoy travel? Are you lookingneeds for Paraburdoo Township a new The an alternative to General established busy bulk billing a population ofPractice? 2000, mostly Well young families. walk-in clinic looking for a full/part time Travel Medicine may be for you. • 7hrs consulting, 4.5 days per week. VR GP. • Training Provided • Solo on-call but minimal call out, full hospital support. Higher return than private billing clinics. • Good incentives • Huge on-call bonus and excellentNon income. full relocation corporate, RN support with onsite • Excellent available. team Computerised and accredited. 300k pathology. plus package. • Established national home network of pool traveland gardening team plus • 4 bedroom with No patient base required. clinics providing excellent support subsidies, allows you to earn a great with lotshours. of DWS ncome available after • Sessionalhours hoursto join the family. Phone Dr Ang 9472 9306 or email • Ongoing Education is encouraged sonseeker@gmail.com • Travel medicine/Tropical Medicine/ Occupational medicine Contact roger 0427 960 722 or Email: rb.tpmed@bigpond.com Werequire: are seeking a advantage. Senior Medical Officer to join our We GP – VR an Emergency Department at St John of God Hospital Murdoch. Team Player General Practice & Occupational Health Doctors Send resume to: We are seeking General Practice and Occupational Health Doctors Anaesthetic and Acute Medicine experience is preferred. A GP tony.gherardin@traveldoctor.com.au for opportunities to and support our metropolitan, regional rural clinics with anaesthetic procedural skills would be and ideal. or phone: 6461 7353 across Australia. Locations in Western Australia can include the Pilbara

General Practitioner – After Hours Clinics

West Perth Medical suites available

PPCN operates the Perth After Hours GP Clinic, located in East Perth and the Swans After Hours GP Clinic, located in Middle Swan. The Clinics are General Practice Centre’s offering medical services directly public and to patients via the overflow from hospital emergency. We are currently › to the244m² seeking GP to join our committed at our Perth Clinic on alternate Saturdays from 5.30pm › a VRRent: $325/m² plus team outgoings and GST – 10.30pm, and at ourout Swans Clinic on Mondays from 6pm-10.30pm, and dressing up to three hours on › Fitted – waiting room, consulting rooms, room, Wednesday and Thursday These shifts may be filled by one GP or shifts may be separated.. x-ray roomnights. and reception

› positions Fullyoffer cabled these an attractive rate and a pleasant and professional working › 5 secure bays available. environment. for morecar information please contact tracey Snowden, Human resources Manager on 9376 9200 or to apply please send your resume to hr@ppcn.org.au for further information ppCn please visit our website at www.ppcn.org.au Contact MattonCampbell

CPG Corporate Real Estate 0423 477 333

DECEASED ESTATE

MidlAnd - $598,000 (no GSt)

MEDICAL PROPERTY FOR SALE

and regions, and interstate locations may range OurWheatbelt Emergency Department, located adjacent to thefrom

FRemantLe Tasmania and Hospital Queensland to Victoria. We also regularly provide services moRLeY Fiona Stanley site, treats approximately 25,000 for Clients at their remote sites or offshore Youtime will enjoy the VR) Partfacilities. time Full (preferably patients practice per annum with seeking significant acuity, andorplays a key Accredited in Morley following benefits: GPs wanted. role and trainees in FT VR GP.in the training of medical students • Full time, time or short term locum eLLenpositions HeaLtH is a doctor-owned and Emergency Medicine. Attractive terms andpart conditions. • Mentoring, ongoing training and development managed General Practice operating Please contact Mrs Karen Meiers at • wish Exposure to all high aspects of general practice or occupational If you to practice quality patient care and continue from two locations in port city of cms100@iinet.net.au medicine with quality client consultations your own education in pleasant surroundings, Fremantle. you are • Opportunities advance into travel, diving andwork aviation encouraged to apply.toOpportunities for weekend andmedicine Well established patient base, offering WaRWIcK/GReenWood The role will encompass: salary sacrifice benefits enhance thea competitive broad suite ofsalary. services including Are you of working in a family bulk billing nutrition and lifestyle, specialised • tired General practice, and accident / emergency medicine For further information, please contact Director ofand Emergency Two consulting rooms, suit GP Practice and having to see patients • 2 Complete consulting rooms • self-contained Shared on call and other services to hospitals and/or multipurpose pregnancy midwifery care, any practitioners, partially leased. Medicine, Drand Andrew Jan on community 9366 1271mental or health nursing and every 5 health minutes? centres [rural remote locations] • Fenced 737sqm block on-site parking. Rustic charm with email andrew.jan@sjog.org.au • feeling Occupational Health medical assessments and General Practice Are Fenced you unappreciated? skin clinic consultations. • Quality construction & fitout construction and fit-out. units • a small, Acute injury treatment andBoth management We quality are friendly, private billing If you were to join our team we have own reception and • Practice Health surveillance • Loads of parking Family which provides thewaiting will offer Totheir apply, visit www.sjog.org.au/murdoch and you: • Employer liaison and and consulting site work toilets, storage full rooms, range of General Practice Services click on “Job Search” • Air conditioned • A growing database of Private room. Theneed: lovely treed gardens You as well aswill Mole Max dermoscopy andblend well Billing • Partially tenanted patients with paved verandahs. procedure work. for registration in Western Australia, Queensland or • Eligibility • A professional and dedicated and/or National registration We have aVictoria fully equipped, dedicated support team • A caring and quality driven commitment to providing general and Procedure Room. 0403 621 899 or 9274 5000 www.realestateplus.com.au Mike palmer • A lifestyle the location occupational practitioner health services and a tailored desire to to continue No after hours or weekend work. • Hours of work to suit our learning. Contact: Sheng 0402 201 311 balanced lifestyle approach To register your interest or for further information, please contact - Practice hours are Weekdays 8amour HR Department on (08) 9242 0830 or aScot 6pm, Saturday, 8am-4pm email careers@primehealth.com.au or jobs@gemini.com.au medic alFORUMwa We require Part-time VR GP for our - No after hours, on-call or hospital friendly family oriented surgery. work required at this time We are an Accredited Non-Corporate • High level of earnings Practice. - 60% of Gross Billings The surgery is computerised; Private Contact Practice Manager and Bulkbilling practice. Bridie Hutton 0413 994 484 56 medic alFORUMwa Practice Nurse available part-time. email: finance@ellenstreet.com Please contact Practice Manager – Annette on 9479 4722.

Located in Maddington adjacent to Maddington Centro Shopping Centre ·

Opportunity to buy real estate – deceased estate

Modern brick and tile construction

Large block

Current practice not operating at full capacity - plenty of room for expansion

d te n a W s GP to pathologyprivately · One room leased : managed, new centre d n i practice with option l · Close village to buy in. tra to retirement s“Arcadia Waters” u 3 senior GP’s to support. –A ·

Practice currently fully accredited, computerised including Pathology centre, privately Psychologist and Chiropractorowned,

· Demographics – retirees, Procedural not req but available. young on Visitingfamilies rights to and localindustrial hospital. Specialist i t workers a and emergency department cover nearby. c Facilities with latest technology and equipment. Lo d Experienced full time nurses to support. This property is a rare find and would not n adeceased estate. be available except for e email details to practice Manager; So hurry to secure! tyl s elaine@leschmed.com.au or contact 9725 8471. e For more information please Lif contact Centex Commercial Rick Bantleman 0413 555 441

With a reputation built on quality of service, Optima Press has the resources, the people and the C S D M a S t e R pag e S commitment to provide every client with the finest printing and value for money. 9 Carbon Court, C S D M a S t e R pag e S Osborne Park 6017 tel 9445 8380

Produced right here in Western Australia!

PROVIDING PRIMARY HEALTH CARE TO THE HOMELESS URGENTLY REQUIRES • General Practitioners with FRACGP • Registered Nurses • Experience in mental health problems an advantage

• Positions are available from one half day per fortnight and upwards • Competitive salary offered and salary sacrifice available

For further information or to express your interest please: Phone: 08 6102 2945 and leave your contact details. Email: generalmail@mobilegp.org.au

Join over 300 satisfied medical practices across Australia who provide Health News as a valuable patient service in their practice. It assists with accreditation and we do all the work for you! Very reasonably priced and a Free trial offer for those starting out. Simply phone Terri on 9203 5599.

APRIL 2012 - next deadline April 16 - Tel 9203 5222 or jen@mforum.com.au

To register your interest or for further information, please contact our HR Department on (08) 9242 0830 or email careers@primehealth.com.au or jobs@gemini.com.au

Medical Forum CLASSIFIEDS

85%

85% take home,

enjoy flexible hours, less paperwork, & interesting variety... BENTLEY, WA ARMADALE, WA ROCKINGHAM, WA

take home, enjoy flexible hours, less paperwork, & interesting variety...

BENTLEY, WA

Equipment Provided WADMS Doctors’ cooperative GPs requiredis foraGP After Hours Clinics in Bentley, Armadale or Rockingham, and for(low a Multicultural Health Clinic in Bentley, WA. • Fee for WA service commission). • 8-9hr shifts, day or night. • •Modern well equipped facilities 24hr Home visiting services. • Fully computerized and accredited clinics • Access to Provider numbers. • Private and Bulk Billing options • Non VR access to VR rebates. • Clerical and nursing staff support • Bonus incentives paid. • Generous hourly rates (plus percentages of billings for the After Hours •Clinics) Interesting work environment. Essential qualifications: For further information please contact • General medical registration Jenny Wells on • Minimum of two years post-graduate experience 0405 303 093 or gpahmanager@canningdivision.com.au • Accident and Emergency, Paediatrics and some GP experience. Contact Trudy Mailey at WADMS

Are you looking to buy a medical practice?

T: (08) 9321 9133 F: (08) 9481 0943 E: trudy.mailey@wadms.org.au WADMS is AGPAL registered (accredited ID.6155)

www.wadms.org.au

As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience.

You won’t have to go through the onerous process of trying to find C S D Msomeone A S T E R PAG ES interested in selling.

Equipment Provided - WADMS is a Doctors’ cooperative • Non VR access • Fee for service to VR rebates. (low commission). • Bonus incentives paid. • 8-9hr shifts, day or night. • Interesting work • 24hr Home visiting services. environment. • Access to Provider numbers. Essential qualifications:

• General medical registration. • Minimum of two years post-graduate experience. • Accident and Emergency, Paediatrics & some GP experience.

Contact Trudy Mailey at WADMS

(08) 9321 9133

F: (08) 9481 0943 E: trudy.mailey@wadms.org.au www.wadms.org.au

WADMS is AGPAL registered (accredited ID.6155)

To find a practice that meets your needs, call:

Brad Potter on 0411 185 006

medic alFORUMwa

Clinic Rooms Available for Lease Now in Albany

You’ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision. We’ll take care of all the bits and pieces and you’ll benefit from our experience to ensure a smooth transition.

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Ph: 9315 2599 www.thehealthlinc.com.au

Easy to find

Disabled access and facilities

Centrally located for ease of access

Reasonable rates

Extensive off street parking available

Friendly reception staff

All rooms on ground level

Close to excellent eateries

Call now to secure your room

07.HealthLinc_Advert_medical_90x80.indd 2

For further enquiries

19/07/2011 10:00:12 AM

Sian Bushell – 9842 2797Health Doctors General Practice & Occupational

General Practitioner PPCN operates a mobile medical service, known as the StreetDoctor. This service provides primary healthcare to homeless and disadvantaged populations of Perth.

We are currently seeking experienced VR GP(s) who have an interest in community health and have a true passion for helping people in need. This position offers an opportunity to work in an environment where your work really does make a difference to people’s lives.

For further information please visit our website at www.ppcn.org.au or contact Tracey Snowden (08) 9376 9200. To apply please forward CV to hr@ppcn.org.au

APRIL 2012 - next deadline April 16 - Tel

sbushell@gsgpn.com.au We are seeking General Practice and Occupational Health Doctors 106 Stirling Terrace, Albany WA 6330 and rural clinics for opportunities to support our metropolitan, regional across Australia. Locations in Western Australia can include the Pilbara www.gsgpn.com.au and Wheatbelt regions, and interstate locations may range from Visit ourand website and take a virtual our rooms Tasmania Queensland to Victoria. Wetour also of regularly provide services for Clients at their remote sites or offshore facilities. You will enjoy the following benefits: • • • •

Full time, part time or short term locum positions Mentoring, ongoing training and development Exposure to all aspects of general practice or occupational medicine with quality client consultations Opportunities to advance into travel, diving and aviation medicine

The role will encompass: • •

General practice, family and accident / emergency medicine Shared on call and other services to hospitals and/or multipurpose centres [rural and remote locations] • Occupational Health medical assessments and General Practice injury treatment and management 9203 •5222Acute or jen@mforum.com.au • Health surveillance

Switch to Best Practice and switch on automatic SMS reminders/replies

Your appointment reminder cards may disappear in their jeans pockets going through the wash but today’s patients can’t forget appointments when you remind them via their constant companion, their mobile phone! For just a few cents and virtually no effort, new automatic SMS reminders (and confirmation reply) in Best Practice can do much to eliminate the cost and disruption of No Shows. There’s no faster, more streamlined system than BP SMS! Benefits of SMS in Best Practice Management

Features

• Integrates seamlessly into the Best Practice Management Appointment module.

• Interchangeable Practice SMS templates allow tailored messages with a single click. • Complies with National Privacy standards of an opt in or out system. • Exclude SMS Appointments reminders for Appointments made within a certain number of days. • Practice allocated mobile number (additional costs apply) • Delivery reports - Confirmation the Patient received the SMS (2 delivery reports = 1 SMS Credit). • Only quality Tier 1 Australian SMS Providers used.

• Patients can be reminded within minutes of making a new appointment on their Mobile phone. • Seamless two-way SMS communications, allows Patients to confirm an appointment via SMS with a simple YES reply. • SMS messaging simplifies Patient communication, it saves time and money while greatly reducing the risk of No Show appointments.

Cost Prepaid • 1000 SMS credits

$200+GST

(20c Per SMS)

• 2500 SMS credits

• 5000 SMS credits

$400

+GST

(16c Per SMS)

$700

+GST

(14c Per SMS)

• 10000 SMS credits

$1200+GST

• 25000 SMS credits

$3000+GST

Practice allocated mobile number = $50

+GST

Setup Fee / $300

(12c Per SMS) (12c Per SMS) +GST

per year (subscription based)

For more information contact us: T: (07) 4155 8800, SMS: 0427 767 833 or E: SMS@bpsoftware.com.au