Medical Forum 02/12 by Medical Forum WA

WAâ&#x20AC;&#x2122;s Independent Monthly for Health Professionals

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FEBRUARY 2012 www.mforum.com.au

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contents

6 News & Views

Features

6 22 30 46

Letters Rewarding NFP Boards. Mr Allen Gianatti Dr Michael Stanford Orthopods on Foot Surgery. Dr Graham Mercer Podiatrists on Foot Surgery. Mr Frank Pigliardo In support of NPs. Ms Susan Hyde

Spotlight: Jonathan Holloway. Mr Peter McClelland

Cancer Researcher and Patient. Mr Peter McClelland or Chew? Ms Shoma Mittra

The Changing Face of Healthway. Dr Rob McEvoy

Lifestyle & Entertainment

12 Have You Heard? 14 Christmas Photos: Clinipath – SJOG Murdoch – Medical Forum - Ear Science Institute – RACGP – Perth Pathology

18 Practice Management Tip. Conference Corner.

19 Beneath the Drapes. Chlamydia Website Award.

29 Gloves Off Over Boxing. 31 Our Social Fabric. Dr Rob McEvoy

Dr Gog at the Rugby Dr Norm Pinsky in PNG Poppins. Mr Peter McClelland

44 The Funny Side. 45 Review: Kalgan River Wines.

Time for a Paradigm Shift in the Management of AF? Dr Tim Gattorna

Medicare Criteria. Requirements for Pathology Rebates. Dr Gordon Harloe

20 ECU Health Simulation Centre.

33 Acanthamoeba Keratitis: The HSV Mimic. Dr Jane Lock

47 Biking South Vietnam.

46 Guest Columns 24 When the Piper Calls the Tune. Dr David Borshoff

25 Selecting the Modern Doctor. Dr Lachlan Henderson

35 Medical Images Speak a Thousand Words. Dr Peter Burke

48 Competitions & Winners.

27 Excellence in Clinical Engagement. A/Prof Kim Gibson

37 Continence Management in ACFs. Dr Rob McEvoy

40 Journal Watch.

AdvERtISIng Glenn Bradbury advertising@mforum.com.au (0403 282 510) EdItORIAL tEAM Managing Editor editor@mforum.com.au (9203 5222) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

37 Beyond the Vale. Mr Allan Anderson

39 Women’s Health –

Clin A/Prof Gerry MacQuillan

Ms Jan Hallam

ISSN: 1837–2783

Doctors Cycling – Fun, Philanthropy, Safety

Dr Martin Buck

35 Kalgoorlie GP Creates Waves. 39 New Patient Support Groups. 41 www.HealthInfoNet

MEdICAL FORUM MAgAzInE 8 Hawker Ave, Warwick WA 6024 telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

Mr Tim Costello AO – Poverty of Silence

Clinical Focus

43 Pippa Returns for Mary

Group. Mr Peter McClelland

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Mixing Medicine and Politics – Dr Graham Jacobs

42 Photo Stories:

Dr Colin Hughes

34 New Pharmacist Lobby

Changing of the Guard – Dr John Whitelaw

10 Sports Sponsorship: Eschew

february 2012

A Passionate Life! Dr Margaret Smith AM

EdItORIAL AdvISORy PAnEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward

SyndICAtIOn And REPROdUCtIOn

magazine reflect the views of the authors.

Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

dISCLAIMER

EdItORIAL POLICy This publication protects and maintains its editorial independence from all sponsors or advertisers.

Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

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

gRAPHIC dESIgn Steve Barwick

The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the

Letters to the Editor Send your letter to: editor@mforum.com.au

Rewarding NFP boards

should be linked to the number of bequests signed up? Non-profit should mean that board members volunteer their time - no exceptions, otherwise give up the charade and also give up the tax benefits.

Dear Editor,

Mr Allen Gianatti

I feel your article (What Makes St John of God Care Tick, August 2011) missed some important points that warranted discussion. I am not a doctor, but follow health issues with great interest.

RESPONSE: The term Not for Profit (NFP) relates to the purpose of an organisation, not whether its board members get paid or not. Like other NFPs, St John of God Health Care (SJGHC) does not exist to make a profit for shareholders. It exists to provide a community benefit. In SJGHC’s case, everything we earn we plough back into communities we serve.

St John God is a not-for-profit institution as is say, the Cancer Council. However, there is an important difference. The board of the Cancer Council is not paid, whilst the Board of St John of God receives financial compensation. I have been told this is around $1.5m a year. I would have thought that board members of St John of God would not want to receive remuneration as they know St John of God is a not-for-profit organisation to which many members of the community make bequests. This would then appear to be a genuine and caring approach that shows respect for the community and demonstrates real morals, ethics and leadership, especially when SJOG has $411 million in net assets.

A logical corollary of your reader’s hypothesis about unpaid board work is that all our staff should work pro bono for us; perhaps all doctors who admit and treat patients in our facilities should use their own instruments. The reality is we would be unable to find sufficient, high quality, committed staff unless we paid them competitively. The same is true of board members.

The pilgrimage to Spain and Ireland to enable a deeper understanding of the organisation’s ethos, begs the question, what is that ethos: volunteering is for mugs; board remuneration

I’ve been personally involved on NFP boards as a board member for 17 years. I’ve also served, as a senior manager, five boards in the NFP

and Public Health sectors. In my experience, all the large complex public and NFP health care organisations remunerate their board members. My personal experience of organisations that don’t remunerate board members is that unless the workload and responsibilities are relatively small, board members often don’t fully commit in terms of preparation, attendance and contribution. Not all NFPs are the same. We are a very large NFP which over 116 years has developed into a major employer (9,535 staff), a major service provider ($943m revenue), and is presently taking the considerable risk of undertaking more than $340m “brownfield” redevelopments, in addition to designing, building and operating the new Midland Health Campus. Our nine external board members each commit approximately 30 full days per year to their roles. This is an enormous commitment of time, especially for people who are very active in the workforce. The total fees paid to them are approximately half the figure indicated by your reader. The complexity and risks, including personal risks, our board members deal with on a day-to-day basis are at least equivalent to the larger size For Profits and NFPs with whom we benchmark all manner of things, including board remuneration. Dr Michael Stanford, Group Chief Executive Officer, SJOG Health Care

Charity Sail enter e Befor March

Join us for an afternoon of relaxing watersport and fun, to support a worthy cause All welcome, from experienced seasalts to novice landlubbers – doctors, families or staff.

Gold entry qualifies for the Bonus

Prize Draw $100

The Royal Freshwater Bay Yacht Club will host you (on water or lawn), with a postevent barbecue, prize presentation and charity auction. Yachts and experienced skippers are provided. Helming doctors compete on a short course – no sheep stations, just nautical rivalry. Put a group together from your practice, hospital department or friends and family. Entry just $55

Enquiries or to Donate: Carol Martin at the yacht club 9384 9100 or 0419 043 623 Register online: www.medicalhub.com.au, click on the banner ad.

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Orthopods on foot surgery Dear Editor, The story following the Australian College of Podiatric Surgeons conference (Medical Forum WA, October 2011) overlooks a number of issues of great significance to patients and GPs. Everyone should be aware that podiatric surgeons do not have the same skills, education, training or professional surgical expertise as orthopaedic surgeons who perform similar procedures. For example: Orthopaedic surgeons have trained for 13 years or more – as a medical practitioner, plus a minimum of five years post graduate surgical training and clinical experience – to carry out complex foot and ankle surgery. Podiatric surgeons do not have the equivalent training and their training program is not closely supervised nor accredited by an authoritative independent body. Orthopaedic surgeons have full training in pharmacology, have the knowledge to safely prescribe medication and are completely aware of the interaction between various medications. Podiatric surgeons do not have the same training. Orthopaedic surgeons have full training in other pathologies around the body that may have an impact on foot surgery. Podiatric surgeons do not. The qualifications of Australian podiatrists and podiatric surgeons are not recognised in key overseas countries and Australian podiatrists are not allowed to perform surgery in other countries. In fact, Australian podiatrists going to the USA and Canada are required to undertake a medical training entrance examination and then retrain. The general public expects that titles such as Orthopaedic Surgeon, Dental Surgeon and Veterinary Surgeon represent rigorous training with appropriate independent assessment. This is not the case for podiatric surgeons – indeed, their use of the title surgeon potentially misleads patients, who believe all surgeons are medically trained doctors. To ensure the best patient care, podiatric surgeons should be required to undergo the same level of training as orthopaedic surgeons and should be accredited by an independent accrediting body. Dr Graham Mercer, President Australian Orthopaedics Association

Podiatrists on foot surgery Dear Editor, Podiatric surgery is a surgical speciality recognised by the Podiatry Board of Australia (PBA) under the National Law Act 2009. The Australian Health Practitioner Registration Agency (AHPRA) administers the regulation of podiatric surgery on behalf of the PBA as it does all medical specialities for the Medical Board of Australia. Podiatric surgery is defined as that part of surgery, which deals with the diagnosis, surgical and adjunctive treatment of disease, injuries and defects of the human foot and ankle and associated structures. The PBA is responsible for the clinical governance of the podiatry profession, and podiatric surgery as a surgical speciality. Podiatric surgeons must undertake CPD activities beyond those required of podiatrists. In addition, Australasian College of Podiatric Surgeons (ACPS) Fellows must participate in CPD activities including surgical audit and peer review, to maintain accreditation. The A&NZ Podiatry Accreditation Council is currently developing an independent accreditation process for podiatric surgery, which ACPS supports.

Selection to the training post involves evaluation of emotional intelligence, neuromuscular coordination and manual dexterity. Successful candidates then undergo an examination and interview to select the most suitable trainee. Podiatric surgery training is a three-part program – progressing from observation, to increasing participation, to case management. Each registrar typically has exposure to 400500 surgical training procedures per year. All registrars must do interstate and overseas clinical placements. Exit examination occurs before a panel of podiatric surgeons and specialist medical practitioners. Surgical training usually takes six years. Private health funds do rebate on podiatric surgery, the rebate level determined by the individual fund. Substantive training documentation is available from www.acps.edu.au/admission_ training.php Mr Frank Pigliardo, Podiatric Surgeon, Vice President ACPS

By way of brief outline, podiatric surgeons are podiatrists who have undergone a formal,

In support of NPs Dear Editor, At this time of workforce shortages and reform, it is timely to review the role that Nurse Practitioners (NPs) can play in addressing some gaps in service delivery. NPs are not medical substitutes. They engage in inter-professional and intra-professional collaborative practice, incorporating consultation and referral in patient management. Although they use some skills from medicine and other health professions (such as dietetics and physiotherapy), their role is firmly grounded in the nursing profession’s values, knowledge, theories and practice. They are first and foremost a Registered Nurse, with expert skills in the assessment and management of a person’s health needs within a particular population group, or a specialist field of nursing. The clinical practice of each NP is determined by the specialty in which the NP is educated, competent and authorised to practice. Despite this, implementation of the NP role in Australia has been a protracted process. The

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surgical training program supervised by the ACPS. Selected candidates have graduated from a four-year undergraduate podiatry course at various universities around Australia, covering essential disciplines in medicine, surgery, pathology, pharmacology, physiology biomechanics and anatomy. Candidates who undertake surgical training must have a minimum two years’ internship in general podiatry and complete a Masters degree, to make them eligible to apply to the college for a training post.

second national census on the status of Nurse Practitioners1 confirms that NPs are not being utilised to their maximum clinical capacity, despite increasing pressures on the health system. The Silver Chain Group has employed Nurse Practitioners within their Home Hospital service, specifically to provide a priority response service to clients in the community who experience deterioration in their health or sustain an injury. This reduces admission to emergency departments of public hospitals and works within a collaborative model with the client’s general practitioner. The organisation will expand the role of the NP into wound management. The increasing prevalence of chronic disease and preventable illnesses requiring lifelong health care, and current workforce shortages, could be partially alleviated by appropriate use of the many endorsed NPs currently employed as Registered Nurses. Ms Susan Hyde, Silver Chain Nurse Practitioner Project Manager 1. The status of Australian nurse practitioners: the second national census Australian Health Review 35(4) 448-454

Spotlight

Photo courtesy Francis Andrijich.

By Peter McClelland

y r a n an imagi life Jonathan Holloway

Jonathan Holloway says he loves that moment of anticipation before the fireworks explode in the night sky. The Perth International Arts Festival (PIAF) 2012 will have fireworks for everyone. As Artistic Director, Jonathan has put together a wonderful program of music, theatre, dance, visual arts, literature and film. He spoke with Medical Forum about his artistic background and his personal vision for the festival. “I always knew that I wanted to work in arts, theatre and music. As a five year-old I’d be down in the back-garden with my friends trying to direct little plays. It’s not just putting on a show either - it’s that whole journey from anticipation and excitement to satisfaction and reflection.” One early formative influence reminds him that great performances do not finish when the curtain comes down.

“My father was a music journalist for the Sheffield Morning Telegraph and I’d often watch him type up his column at the newspaper office. It was a nice reminder that a performance doesn’t stop at the water’s edge. For some people it’s professional and they’ll write a review, for others they’ll remember and relive what they’ve seen and heard. A truly great performance starts long before the first sights and sounds and lives on for many years after that.” And every performance has creativity as its lifeblood. “A creative life is a golden bullet in every profession. I was speaking with Rio Tinto’s CEO Sam Walsh and he said to me that ‘the essence of Rio Tinto is creative people’. I’m really determined that the 60th Perth Festival will be a creative and collective experience that will allow people to see their city in a new way,” he said, adding that Perth’s location has some real positives.

The Artistic Director’s journey to the 2012 Perth International Arts Festival began in a back garden in Sheffield at the age of five.

a lot of atmosphere because of the weather in London, as you can imagine it’s just not the same when the audience is standing under umbrellas. The evenings are so balmy in Perth and there are some iconic outdoor venues for music and cinema. I’m utterly in love with Somerville and Joondalup - I wasn’t able to show films in the same way in the UK. An Arts Festival should be a time when you fall in love with a place and celebrate where you live.” On the other hand, there are times when an umbrella might be useful! “One of the factors in programming the festival is Perth’s summer heat – I’d love to do more street theatre and put a stage in the city at lunchtime but it’s just too hot. We’d end up spending more on doctors than anything else!” Jonathan’s reflections on the links between philanthropy, medicine and the arts are interesting. “There’s a general rule of thumb that for the first generation of wealthy philanthropists, medicine is usually their first choice. That’s understandable, because well-funded medical research can lead to potentially rapid breakthroughs. After that, when their wealth is more stable, many of them will view the Arts sector as equally important and we’re beginning to see more philanthropists in WA supporting the Festival.”

works of art in a clinical environment has a profound effect on the mental and physical recovery of patients.” What of Perth International Arts Festival 2012? What is his vision? “The artists will create moments of dreaming that I hope will allow the people of Perth to experience their city in a new way. Perth has such a wonderful duality – it’s one of the most remote capital cities on the planet yet it has connections that run deeply into Asia. WA is hugely influential as a resource state and increasingly so as a place of ideas.” Yet his distinctly creative imagination detects one irony. “Perth has a wonderful sense of liberation and freedom yet, in some ways, it’s a city with so many rules. It’s a very controlled place from licensing regulations to shopping hours and I think this makes the disruptive potential of the Festival even more delicious.” n

He said the connection between health and the art world goes much deeper. “We live in such a complex and interwoven society that the Arts are absolutely bound up in the social, artistic and spiritual health of a nation. On another level, it’s well known that placing

“There’s a great freedom being next to the sea - that’s why I wanted to begin the festival on the beach at Cottesloe. You lose

Jonathan’s three Picks for Doctors A Magic Flute directed by Peter Brook

“I saw this in Paris – absolutely exquisite!”

Beautiful Burnout National Theatre of Scotland

“A medical theme – the body, brain and boxing.”

Festival Gardens – Perth Cultural Centre

“Twenty three brilliant nights of music from around the world.” PIAF Details: www.perthfestival.com.au

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

Time for a Paradigm Shift in the Management of AF? trial fibrillation (AF) has a prevalence of 0.9% in the general population, increasing to >13% of people over the age of 80. With an ageing population this will bring significant clinical and economic implications.

Current AF treatment guidelines are based on the following principles: 1. Prevention of thromboembolism 2. Symptom relief 3. Optimal management of concomitant cardiovascular disease (CVD) 4. Rate control 5. Correction of rhythm disturbance But when is reversion to sinus rhythm (SR) worth it? The answer is in the better understanding of mechanisms underlying the development and progression of AF, which in turn will help guide therapeutic options.

Pathophysiological atrial changes in AF

Significant structural, electrical and contractile remodelling of the atria results in an inexorable progression from paroxysmal to persistent AF, with arrhythmia perpetuation (“AF begets AF”). Therefore, strategies to prevent and arrest these pathophysiologic processes seem warranted and may represent a shift in our working paradigm. Treatment of ‘correctable’ causes of AF may help prevent atrial remodelling, and ‘upstream therapies’ such as angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, statins and omega-3 fish oil, may be helpful in reducing the propensity to AF. It is likely that there is an early window of opportunity to maintain SR, before atrial remodelling and progressive fibrosis develops, with implications for the timing and success of therapies such as catheter ablation, aimed at altering the natural history of AF (see Figure 1).

Which patient requires rhythm or rate control? The modest ability of antiarrhythmic drugs (AADs) to restore SR has prompted studies comparing rate with rhythm control, which have failed to demonstrate a comparative mortality benefit. Despite this, the all-cause mortality trends in patients with AF remain increased by 1.5 to 1.9-fold, regardless of therapy (compared with individuals in SR). The primary indication for rhythm control therapy is to relieve AF-related symptoms, but therapy may also be warranted where AF will have adverse consequences in the future, such

as patients with left ventricular hypertrophy. Patients with AF exhibit a wide range of clinical symptoms, from none to disabling. However, insidious symptoms such as fatigue and lethargy may not be recognised and it is only following successful reversion to SR that the “asymptomatic” patient feels much better. Ultimately, treatment strategy depends on multiple factors and needs to be tailored to the individual. Issues of quality of life (QOL), the likely effect of AF in that individual, the safety profiles of therapies and chance of success of rhythm control are important. Thus, a rate control strategy is reasonable in elderly patients with minimal symptoms, without attempts to achieve SR. Also, the initial goal may differ from the long term one. For example, in a patient with symptomatic AF over many weeks the initial therapy may be rate control and anticoagulation, while the long term goal may be to restore sinus rhythm. Rate control should be continued throughout a rhythm control approach to ensure adequate control of the ventricular rate during recurrences of AF.

Dr Tim Gattorna MBBS (Syd) FRACP

About the Author Tim Gattorna is a cardiologist and electrophysiologist, whose areas of interest include cardiac arrhythmias (including catheter ablation), along with the implantation and management of cardiac devices. He has a clinical appointment at Sir Charles Gairdner Hospital and Western Cardiology.

When is catheter ablation indicated? This widely adopted technique offers an alternative for maintaining SR – an invasive rhythm control option currently for patients with symptomatic, drug-refractory AF. There is evidence to suggest a favourable QOL compared to AAD therapy and there are currently large randomised clinical trials comparing catheter ablation to best drug therapy (rate and rhythm control) with respect to mortality and morbidity. The ablation strategy, success rates, need for repeat procedures and complications vary depending on clinical type of AF and the LA structural changes (dilatation, fibrosis).

Conclusion AF is a dynamic, progressive disease with no single strategy universally beneficial and the treatment must be individualised with consideration for the underlying atrial pathophysiologic changes.

n Fig 1. A new treatment paradigm for AF, similar to the staged approach in heart failure. This figure expresses

(1) the need for risk factor modification before disease expression, (2) the window of opportunity for aggressive rhythm control therapy during early stages, and (3) the probable failure of aggressive attempts at rhythm control in advanced stages of irreversible atrial remodelling. CAD = coronary artery disease; SR = sinus rhythm.

Prevention

Treat risk factors: Hypertension, CAD Heart failure, Sleep apnoea Obesity, Hyperthyroidism

B All measures under A

C All measures under A

Early cardioversion Maintenance of SR Assess anticoagulation

Attempt to maintain SR Assess anticoagulation

Cellular remodelling reversible) Early adaptive responses Ionic/genomic Paroxysmal

Risk factors

New onset AF

Cellular/Extracellular remodelling (irreversible)

1 g Persistent

TIME Permanent

Taken from Circulation. 2009; 120: 1436-1443

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

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

General Practice By Peter McClelland

Changing of the Guard General practice has undergone many changes. Dr John Whitelaw has worked at the coal-face for nearly three decades and has seen most of them. When he started up his Karrinyup general practice about 30 years ago, John Whitelaw was borrowing more than ten books a week from the local library, a gauge of his patient load. As word-ofmouth gathered momentum, his book borrowing took a nose dive. John recently retired from his original solo-GP practice and he reflects on changes, from sixminute medicine and declining skills to computers and teaching. In earlier days it was not just family medicine.

“The six minute consultation is highly counterproductive and some take that to extremes. I know of one doctor who doesn’t even have a chair for his patients! I had a young guy in here who’d suffered a seizure and was very worried about the consequences. He was with me for an hour – you’ve got to have the flexibility to give them the time they need.”

“I practiced in obstetrics and anaesthetics for around 15 years and GPs do very little of that now. I also did a lot of hands-on teaching with medical students and really enjoyed it. I’d often have them sitting in the consulting room with me. Again, there’ve been changes – not too many doctors have the time to mentor students anymore,” he said, adding that other GP skills tied in with old-school family medicine have changed.

“It wasn’t so long ago that the majority of medical students were male. Now 60% of graduates are female and only about one third of them work fulltime. And what’s even more enlightening is that young male doctors seem to prefer part-time work as well.”

“I didn’t have a practice nurse which means you’re doing things like taking blood samples and doing dressings every day. After a while you get pretty good at those procedures. And that’s one thing that’s changed markedly – some of those skills are gradually being diluted. At different times my role was doctor, nurse, counsellor and priest. It was much more catholic than it is now. ” Then there is the consultation itself.

The gender shift in the GP medical workforce and changing attitudes to work-life balance have not impacted much on John’s work but he is aware solo urban GPs appear to be a thing of the past.

That shift is now so entrenched that John found it impossible give away, let alone sell, his solo Karrinyup practice, which is now closed. The surgery was a computer-free zone with all patient records on index cards written in John’s free-flowing hand. “I probably should’ve become more in tune with computers, but financially that can be a big hole in your pocket and, quite frankly, I didn’t need it. A computer isn’t essential to running a solo-practice… patients didn’t come to see my computer skills, they came for my medical skills.”

Demand for his skills means he has had less than a handful of days off in thirty years. “Life balance is important and attitudes are changing because the job can be stressful. Fortunately, I’m a pretty calm and ordered person and I’ve had wonderful family support.” Working as a family GP continues for John Whitelaw, albeit under the new world order, and at a slower pace. After an emotional send-off from more than 200 of his Karrinyup patients – most of whom were extremely positive about his move – John is working part-time at the Stirling Lakes Medical Centre, a few suburbs away. He did this to help his patients transition to new doctors. It is an IPN practice where his patients have the freedom to move to other doctors and he is working a few sessions each week and is not under contract and has not received a lump payment. He says he has plenty of staff to help sort out his awkwardness with computers. He may still do some country locums. John has three pieces of advice for budding GPs. “First, look after your own health because if you don’t you won’t be able to look after anyone else’s. Second, always listen to what your patient says… and be aware of what they don’t say. Finally, make sure you take time off – the surgery should work for you, you don’t work for the surgery.” n

My role was doctor, nurse, counsellor and priest. It was much more catholic than it is now.

n circa 1999.

John Whitelaw is pictured receiving his competition prize from Medical Forum of a first aid kit – it was in the day of metal boxes, and he still has the kit in his car. John looks much the same in 2012.

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Medicare Criteria Requirements for Pathology Rebates

By Dr Gordon Harloe, CEO Clinipath

Most pathology tests automatically qualify for a Medicare rebate; however, for some tests, Medicare requires that the patient satisfy certain clinical criteria before the rebate applies, or limits the frequency of testing, or both. When clinical criteria need to be met, this information must be supplied on the request form to enable a rebate to be claimed. Some tests do not qualify for a rebate under any circumstances. Due to the stringent fee cuts imposed by Medicare, pathology laboratories may be forced to bill patients for non-rebatable tests. Your pathology service provider will be able to give you details on their billing policies. The list below includes some more frequently requested tests and the criteria required to enable a rebate to be paid. A more extensive list, which includes details on hepatitis serology tests can be found on our website www. clinipathpathology.com.au/

Activated Protein C (APC Resistance) (1) Personal proven history of venous thromboembolism, or (2) Has a first-degree relative with proven APC Resistance.

Antithrombin III (1) Personal proven history of venous thromboembolism, or (2) Has a first-degree relative with proven Antithrombin III.

BhCG (Beta Human Chorionic Gonadotrophin) Total Serum (Pregnant)

Free T4 (Thyroxine)

Protein S

FT4 only available with TSH. For both FT4 and TSH, thyroid history and medications must be included in clinical notes. If no thyroid history is given to satisfy Medicare criteria, only the TSH will be performed. If FT4 is requested and no history is given, it will only be performed if the TSH is abnormal.

(1) Personal proven history of venous thromboembolism, or (2) Has a first-degree relative with proven Protein S deficiency.

Haemochromatosis Gene Test

Quantiferon/Tuberculosis test

Haemoglobin A1c

Maximum of 3 tests per patient per year.

(1) The patient has established diabetes. (2) No more than 4 tests per patient per year.

Methylene Tetrahydrofolate Reductase Gene Test (MTHR) (1) Proven DVT/PE in patient, or (2) Presence of this mutation in a first-degree relative.

Prostate Specific Antigen (PSA): Free/ Total ratio

(1) Proven DVT/PE in patient, or (2) Proven defect of this mutation in a firstdegree relative.

Free T3 (Triiodothyronine)

Prostate Specific Antigen (PSA): Total

FT3 only available with TSH. For both FT3 and TSH, thyroid history and medications must be included in clinical notes. If no thyroid history is given to satisfy Medicare criteria, only the TSH will be performed. If FT3 is requested and no history is given, it will only be performed if the TSH is abnormal.

Only one test per patient per year, unless for the monitoring of previously diagnosed prostatic disease.

Factor V Leiden PCR

(1) Personal proven history of venous thromboembolism, or (2) Presence of this mutation in a first-degree relative.

(1) The patient has an elevated transferrin saturation or elevated serum ferritin on testing of repeated specimens, or (2) The patient has a first-degree relative with haemochromatosis, or (3) The patient has a first-degree relative with homozygosity for the C282Y genetic mutation, or with compound heterozygosity for recognised genetic mutations for haemochromatosis

Only one test per patient per year in the follow-up of a PSA result that: (1) Lies at or above the age related median but below the age related, method specific 97.5% reference limit – 1 test per 12 month period; or (2) Lies at or above the age related, method specific 97.5% reference limit, but below a value of 10 μg/L – 4 tests per 12 month period.

A Medicare rebate is available for one test performed in the diagnosis of threatened abortion, or follow-up of abortion, or diagnosis of ectopic pregnancy.

Prothrombin Gene Mutation (20210)

Protein C (1) History of venous thromboembolism, or (2) Has a first-degree relative with proven Protein C deficiency.

Rebate available for an immunosuppressed or immunocompromised patient.

RAST Up to 4 requests of 4 allergens each may be ordered per year. A maximum of 4 RAST tests may be ordered at any one time.

Red Cell Folate Thrombophilia Testing Screen (1) Personal proven history of venous thromboembolism. (2) Has a first-degree relative with a proven defect of Antithrombin III, Protein C, Protein S, or APC Resistance and testing for that defect only. NOTE: This is not an ‘Acceptable Group Test’ for Medicare purposes. To receive a Medicare rebate, the tests within this group must be ordered individually.

Thyroid Function Tests (TFT) For both TSH and/or FT4, thyroid history and medications must be included in clinical notes. If no thyroid history is given to satisfy Medicare criteria, only TSH test will be performed. If FT4/FT3 is requested and no history is given, they will only be performed if the TSH is abnormal.

Tumour Markers (AFP, BhCG, CA125, CA15.3, CA19.9. CEA, Thyroglobulin) A Medicare rebate is available for test(s) performed in monitoring malignancy, or in the detection or monitoring of hepatic tumours, gestational trophoblastic disease, or germ cell tumour. A Medicare rebate is only available for up to 2 tumour marker tests per episode.

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

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Feature By Peter McClelland

Cancer Researcher and Patient Peter Klinken is passionate about cancer research. Six weeks before Christmas 2009 it became very personal when he found himself on the other side of the microscope. Prof Peter Klinken noticed a change to a mole on his left forearm. Shortly afterwards, the Director of the Western Australian Institute for Medical Research (WAIMR) was diagnosed with malignant melanoma. The 30 year veteran of cancer research spoke to Medical Forum about where he is at, having decided to ‘go public’ early on.

Unfortunately, I don’t have that mutation. Nonetheless, we found a link to melanoma on one of the genes we’re working on and we’re pursuing that.

There’s never an easy way to hear this sort of news, even for an expert in cancer research. Peter has nothing but praise for his GP Jamie Prendiville. “I was in Sydney at the time and Jamie started reading the pathology report to me over the phone… ‘melanocytic cells with proliferation’. It was all happening very quickly. I had to say, ‘Stop, stop, whoa, whoa… Jamie, are you telling me I’ve got a melanoma?’ He said, ‘Yes Klinks… you do’. All those big words flying at you quickly can be quite challenging and it made me realise that for people who aren’t in this field, this sort of thing would be even more daunting.” “Jamie made a very good decision. Within days of returning from Sydney I had a secondary excision even though he wasn’t quite sure about the melanoma. Jamie took the conservative approach and said ‘Let’s take it out just in case’. I’m eternally grateful to him for doing that and I’d urge GPs to be much more confident in their ability to diagnose melanomas.” “I’m being checked by Jamie every six months now and it’s all fine at the moment. There are some links here, too. Jamie was Scott Kirkbride’s GP – Scott died in 2004 from melanoma and we’d been researching and fund-raising for the Scott Kirkbride Melanoma Research Centre.” Scott’s mother Yvonne was instrumental in enlisting Peter’s help to raise melanoma awareness within the community. “To be perfectly honest, I just wanted to deal with this myself but Yvonne and the Research Centre asked me if I would talk about it. I do a lot more

of that now, talking about cancer and cancer genetics and I speak about my own melanoma. I don’t feel uncomfortable about that anymore but the reactions are interesting… some people are genuinely interested and speak to me about the issue while others feel quite awkward.” Early on, Peter delayed telling his children and then decided to make changes in his own life. “I kept the diagnosis quiet for a while because my children were doing university exams and then we spoke about how we’d deal with the situation. I took a sabbatical in the second half of 2010 because there were a lot of things going on at the time. It made me appreciate all the good things in my life. I’m a very positive person, I intend to get on with my life and I’m certainly not going to dwell on this. Work’s been absolutely full-on and somewhere down the track I’ll take a breather – I’ve certainly got an accumulated sleep debt! A bit of surfing down south with my sons will be good, too.” As Peter points out, sometimes there is no logical cause underlying a melanoma diagnosis. In his case, it does not appear linked with excessive sun exposure. “There’s no genetic predisposition in my family for all this so when my GP gave me the diagnosis it made me go back and think. I could only recall twice in my life when my arms got sun-burnt and that was between 15 and 20 years ago. It was only a couple of very rare occasions when that happened.” Melanoma research is crucially important, as Peter’s story illustrates, but there are twists and turns along the way. “I had my DNA tested to see if I would be eligible for a new treatment – there’s a gene mutation in approximately 50% of melanomas known as B-RAFV600E affecting the amino acids. Unfortunately, I don’t have that mutation. Nonetheless, we found a link to melanoma on one of the genes we’re working on and we’re pursuing that. I know there are lots of people all around the world working on melanoma – I’d like them to keep working really hard because I might need it one day.” n

Melanoma Fact Box n The n More

third most common cancer in Australia -10% of all cancers. than 10,000 new cases diagnosed in Australia every year.

n Accounts

n Prof Klinken is throwing himself into work and life.

n Australia

for 75% of skin cancer deaths.

has the highest incidence in the world.

is often identifiable at an early stage and treatment can be curative.

n Melanoma

[Source: Melanoma Institute Australia]

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Feature: Sport & Health By Ms Shoma Mittra

Sports Sponsorship: Eschew or Chew? linking the two but it is up to us to influence what multinationals have on their promotional menu, Mike suggests. “Shouldn’t we be asking the multi nationals who are pouring so much money into advertising to offer more nutritional items on their menus? Children are an important demographic for advertisers. It makes sense to capitalise on the pester power of children and entice them into activity oriented places which also provide healthy food options.” Mike stresses that physical activity is, by far, more effective in combating obesity than restricting junk food. Healthy exercise and participation in sports are the factors that we should be targeting. Sports programs are a significant step in addressing obesity problems. He said the $20m Sports For All government initiative is a step in the right direction.

n Mr Mike Allenby

When we talk about alcoholic beverages, fast food or soft drinks, some preach abstinence while others preach healthy choices. While the former fits with the tobacco model of preventive health, the latter recognises there are health benefits in some products, with plenty of room to improve them. Enter Healthway, originally established to redistribute tobacco taxes for healthier purposes, and now at loggerheads with some in the sporting world because preventive health lobbyists want to restrict Healthway tax dollars from going to sporting organisations that also take sponsorship from manufacturers of what some regard as unhealthy foods and beverages. However, in dollar terms, multi-nationals are the biggest sponsors of sporting events and organisations, not Healthway. Everyone sees the dilemma – whatever we do should not hinder participation in sport and exercise, which prevents a range of health problems, including obesity. Medical Forum spoke to Mike Allenby, Chairman of the WA Sports Federation (WASF) who said he resigned from the board of Healthway six months ago over its execution of policies and behaviour at the board level. “Local sporting clubs and associations play a vital role in our communities. WASF estimates that around $40m is received in revenue from sponsorship of local sporting organisations each year. Of this, only about $6m comes from Healthway while the rest comes from private organisations. If Healthway is to have its way, then sponsorship funds to the tune of $34m will have to come from elsewhere.” “Although Healthway is an important source of income for WA sporting organisations, its restrictive directives are making it increasingly difficult for sports organisations to operate at their optimum level,” he said, adding that feedback from within his group suggests people are not happy with Healthway.

sponsorship money is discretionary. I have spoken at length to the alcohol, soft drink and fast food providers and they say that a certain portion of their budget is allocated for WA. If WA doesn’t want it, it can be given to other States. These companies will still achieve their targeted market share. Does it not then make sense to work with them?”

Mike Allenby says the smarter thing to do is to engage with the multinationals rather than distance them. “When we cannot engage with the corporate giants for productive use of sponsorship money, the loss is all ours. We need to understand that

You can view healthy food choices and healthy exercise as separate things. Both affect obesity. Sponsors see promotional benefits in

“The attitude which Healthway is taking poses some fundamental questions about citizens’ relationship with the government,” adds Allenby, who suggests that banning a commodity from advertising shows a lack of trust in the public and in their right to choose. How far should banning or protectionism go, he asks? Whether you agree with Mikes views or not, these important public health issues should occupy the minds of doctors. n

Some might argue that working with these companies is simply selling our kids into slavery to poor diets and obesity, and all that goes with it? It isn’t that simple, Mike suggests. “A collaborative approach rather than prohibition is the key to promoting health messages. Coca-Cola, which is a major sponsor of football, also supplies Mt Franklin water at the games. We are advised by football in WA that 52% of Coca Cola’s sales at Subiaco Oval come from the sale of water,” he said, pointing out that choosing water over an alcoholic beverage or a soft drink is a choice that the public makes in this instance.

“As a direct comparison the Department of Sports and Recreation has a far better and more equitable distribution of money. If AMA and Healthway are allowed to forge ahead untouched, the non-Healthway organisations are obviously going to be adversely affected.”

Medical Forum’s earlier polling of doctors on sports sponsorship (see opposite) included opinion around Healthway’s approach. Looking more broadly, you have to ask why the profession is content to have Ronald MacDonald House Charities with their free Coca Cola vending machines, with one perched next door to PMH. Advertising to informed adult consumers is one thing while subliminal relationship marketing like this has a broader subtle reach to all age groups, and across all MacDonalds products.

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Feature: Sport & Health By Dr Rob McEvoy

The Changing Face of Healthway Healthway appears to be applying stronger health messages as it distributes tax funds to arts, racing and sporting organisations, as well as involve itself in research and health promotion. With the recent increased medicalisation of the Healthway Board (see inset) doctors have more reason to take an interest. The organisation has shown sensitivity to criticism from the WA Sports Federation over the conditions imposed on only about 10% of grant applicants; those with food, beverage or alcohol co-sponsorship arrangements in conflict with Healthway’s core values, particulary where children are involved. The independent statutory body aims to reduce harm from tobacco and alcohol, prevent overweight and obesity, promote mental health and wellbeing, and improve research into health promotion. According to Healthway, its “board and expert advisory committees are representative of its primary stakeholder groups, to ensure that the needs and objectives of those groups and sectors are considered while focusing on the health promotion objectives of Healthway”. Executive Director David Malone says the people who approve grant applications and set policy have a primary obligation to follow Healthway policy and legislation, and deal appropriately with any conflicts of interest. Healthway must spend at least 30% of its budget on sports and 15% on arts sponsorship under legislation. Health promotion grants (17%) are far less restrictive.

One major point that David made, which was not evident in their website material, is that the vast majority of sporting groups that apply already have co-sponsors, and only a minority have potentially ‘unhealthy’ food, drink or alcohol co-sponsors, for which 10% (of the total) have extra conditions attached to their grant. The condition(s) may be to quarantine participants from unhealthy messages, without dropping the co-sponsor necessarily.

“We are dealing with record numbers of sporting organisations applying for grants each year and I can’t think of one, out of the thousands that we deal with, or has been a partner of Healthway in the past, now ceases to apply for funding,” he said, adding that the WA Sports Federation is unique in shunning Healthway. “The Act requires us to get a net health promotion benefit for each dollar spent so there are rules attached to each grant.” (See inset.) “We monitor attrition and I can only think of one sporting organisation that has previously been funded by Healthway and now doesn’t apply.” David believes the $30m figure that the WA Sports Federation puts on buying out unhealthy sponsorship in WA is exaggerated by 6-7 fold, based on their past experience with tobacco companies and their own investigation.

Research - how valuable?

How best to influence health and behaviours is as much a philosophical argument as hard science, yet Healthway spent $2.88m on research of the latter in 2010-11 (currently 13% of the total spend and open to change by the Board). While stating that its policies are evidence-based, is the research it sponsors of real community benefit or simply soaking up funds that could be used to get kids out on the paddock more for a greater health benefit? There is a growing move towards ‘translational research’ that seeks to make a tangible difference to communities that provide funding. Healthway annual reports outline success stories but there is nothing on the website that seems to justify the expenditure in terms of community returns.

Health Policy Requirements of Sponsorship n All indoor and outdoor areas under the control of the sponsored organisation must be maintained as smoke-free. n Healthy food and drink options must be available should catering be provided. n Free drinking water available at activities or events.

Good research can help us rethink things. For example, recent figures suggest those concerned that 80% of Australian children drink sugary drinks should realise 77% are purchased in supermarkets and 60% drunk at home, which is where our health messages perhaps should be directed.

Deciding what is ‘unhealthy’ A committee of experts decides, as David explains. “The Brand Advisory Committee’s primary purpose is to provide advice to Healthway’s sponsorship advisory committees and Board – non-binding advice as to the risk that co-sponsorship arrangements will undermine health promotion objectives. Committee members have expertise in the areas of nutrition, alcohol, dietetics, health promotion policy and practice, the health and wellbeing of children, and marketing and sponsorship promotions. Membership of the committee is approved by the Board.” Current sponsorship advisory members are: Prof Steve Allsop (Chair), Ms Narelle Finch, Ms Holly Ransom, Prof Rob Donovan, Ms Karen Adie, Dr Christina Pollard, Mr Steve Pratt, Mr Gary Kirby, Ms Jane Martin and Mr David Malone.

WA doctors on Healthway sports sponsorship

A sizeable 39% of docs we surveyed last year said Healthway grants should be withheld where sports have “fast food or unhealthy beverage” sponsors, while 30% agreed with the less stringent Healthway stance of applying conditions (and 28% said ‘no’ to withholding grants). When asked if Healthway should have to makeup funding lost when a children’s sporting body dropped sponsorship from a fast food or unhealthy beverage company, 45% said ‘yes’, 33% replied ‘maybe with conditions’ and only 19% said ‘no’. Interestingly, of those with kids, 26% said their child has participated in a sport with an associated ‘unhealthy’ product advertised. n

Healthway Board Members A/Prof Rosanna Capolingua (Chair – Health Minister appointed) Prof Mike Daube (ACOSH).

Ms Jennifer Riatti (Dept of Sport and Recreation).

n Adequate sun shade available, where applicable.

Mr Andrew Watt (Aust Council for Health, Physical Education and Recreation).

n Safe warm-up practices for physical activity adhered to, where applicable.

Ms Margaret Dawkins (Dept of Communities).

n Alcohol or unhealthy food/drink (or vouchers) not to be provided as prizes or awards.

Mr John Giorgi (WA Local Government Assoc).

n Low strength alcohol and non-alcoholic choices should alcohol be available at activities or events

Mr Colin Walker (Dept of Culture and the Arts). Dr Tarun Weeramanthri (Department of Health). Clin Prof Gary Geelhoed (AMA WA). Mr Cathcart Weatherly (WA Arts Federation). Mr Brett Ashdown (WA Sports Federation).

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Have You Heard?

PNIP tick box vacant Medicare recently withdrew its request for documentation from practices with enrolled nurses (ENs) that had applied for the Practice Nurse Incentive Program payment. Legally, ENs have to be supervised by RNs, yet some applications showed ENs working longer hours than RNs, so Medicare wanted to know the supervisory arrangements in place for all ENs. Not any more. The retraction came with an explanation that RN-EN supervision is a nursing standards thing and no-one is required to outline supervisory arrangements as part of their PNIP application. Go figure.

SJOG Bunbury

The gambling fix

Public and private patients in South West WA will be smiling in October 2012, hopefully. That’s the planned completion date of the SJOGH Bunbury expansion – a cancer centre, coronary care unit, angiography suite and expanded renal dialysis unit plus accommodation for radiotherapy patients. That’s good news for a rapidly growing and ageing population and an attractive magnet for medical specialists. Total cost? About $35.9m and co-funded by Federal and State governments and SJOG Health Care.

LotteryWest, in its most recent annual report, trumpets how it benefits the WA community. In the Age of Gambling, where Mr Packer’s political influence is becoming more obvious, and TV sports are splattered with betting ads and infomercials, the coming generations are gearing up to gamble with their future. Pity about the record household debt. Pity about problem gamblers being mostly those who can’t afford to gamble. WA hospitals are now hooked on gambling ($101m), not to mention sports ($12.6m), and charitable and community groups ($102m). The LotteryWest logo is plastered everywhere and Ozlotto regrets not reaching budget because there were less than expected jackpots this year. Mind you, there are plenty of photo opportunities for pollies, including a recent one for Kim Hames to hand over $1.2m from Lotterywest to UWA’s School of Pathology and Laboratory Medicine for state-of-the-art equipment to improve cancer diagnosis, via more research of course, around cancer biomarkers to predict patient response.

Have a go at… The ACCC is going after alternative breast cancer imaging centres in WA for misleading claims. And the federal AMA has had a go at health insurance funds, because all (except the AMA’s previously owned Doctors Health Fund) offer coverage for treatments using unproven modalities such as homeopathy and aromatherapy. It says government is wasting money subsidising health funds that do this. The AMA may be missing the main point, that health is as much about experiencing wellness for many people as it is about treating disease, and everyone is entitled to a little placebo effect, especially if you are well and thinking about dropping your private health cover! Healthy members keep the wheels running for others, including doctors. And we have the ACCC to sort out false claims about treating illness.

Prevention not working

Coughing a lot? You may have picked up whooping cough, doing the rounds in the community. Vaccinated people can suffer a modified illness. DoH received 3600 case reports for 2011 (compared with 1458 for 2010), peaking at 704 last November. Communicable Disease Control’s Dr Paul Armstrong said epidemics every few years were typical, the last was in 2004, but they worried about babies with low resistance succumbing to infection, as four had in the past four years. That’s why carers and family around young babies were invited to have free whooping cough vaccinations.

More longitudinal than most The Raine Study has just celebrated its 21st birthday! Another milestone – it’s the world’s longest pregnancy and offspring cohort study. Originally set up to assess ultrasound use in pregnancy, nearly 3000 pregnant women (recruited at KEMH 1989-91) and their offspring have had a variety of health parameters assessed over more than two decades, including 2.5 million genetic variants relating to pregnancy, childhood and adolescence. Fittingly, the research was transferred to the Institute for Child Health Research in 2000. Raine has been fuel for over 200 spin-off research groups and 100 national and international collaborators (see www.rainestudy.org.au). 12

Prevention is getting more and more airplay as governments see growing tertiary health costs before us. Take the recent Heart Foundation press release about the lousy reach preventive programs have for post-infarction cardiac patients. Only one in four attend existing prevention programs that could theoretically prevent 51,000 heart attacks and strokes each year, if people received and followed advice. Programs offer a 25% reduction in risk of repeat infarct. Low attendance, often at hospitals, is no surprise, so more flexible and accessible programs are being considered, with phone or on-line interaction.

Hyperbaric chamber stalls Installed in July, but yet to be commissioned, this 12 tonne, 10-person hyperbaric chamber at SJOGH Subiaco is the largest in Australia and the third in WA (Fremantle, Broome). Hyperbaric Oxygen Therapy is recognised treatment for decompression sickness, poorly healing wounds (diabetic ulcers, post radiation), circulatory problems, refractory infections, radiotherapy adjuvant and suchlike. Promotion for autism, stroke recovery, cerebral palsy, brain injury and MS are much more contentious. It will be open to private and public patients, said the unit’s operator Hyperbaric Health, which has another chamber at SJOG Berwick (Vic), and bulk bills for Medicare-funded indications and has no-gap arrangements with DVA and private funds for extended uses. They say they just can’t get builders to finish the job!

What have you HEARD SHARE the NEWS

editor@mforum.com.au or ring the editor on 9203 5222

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Clinipath by Water’s Edge The yearly Clinipath Christmas Gathering at Mosman Bay was held in perfect weather on the water’s edge. The boats moored at the jetty provided a wonderful backdrop to the evening and Dr Gordon Harloe, CEO Clinipath gave a short speech of welcome and thanks to the invited guests. A perfect evening in an ideal setting to wind down and catch up with friends.

Dr Craig Turner and Dr Gordon Harloe (CEO Clinipath, right)

Dr Linley Mitchell and Dr Jenny Ng

Dr Michael Bowles, Dr Cate Mansfield, Dr Jennifer Pike and Mr Clinton Pike

Mrs Jan Stevens, Dr Colin Stevens, Mr Joe Yousif and Dr Fatin Wajdi

Medical Forum WA Magazine

Mr Niall and Dr Eliza McNamara, with Dr Wion and Mrs Gerda Thiart

Wunderkind chef, Hadleigh Troy is the genius twirling the pots and pans at Restaurant Amuse. The staff at Medical Forum and invited guests enjoyed a superb degustation menu before a well-earned Christmas break. Ten courses ranging from Marron, Orange and Fennel Pollen to Buttermilk, Rum and Raisin with beautifully matched wines was a wonderful way to celebrate another successful year of hard work. The only glitch was our inability to master the intricacies of the camera’s Auto setting!

Ms Jenny Heyden and Dr Olga Ward 14

Mrs Siobhan Dormer with Mrs Caroline and Dr Gary Claydon

Dr Rob McEvoy and Mr Peter McClelland

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St John of God Murdoch Forced indoors by unseasonal thunderstorms at SJOG Murdoch, there was no dampening of enthusiasm amongst guests as CEO Peter Mott announced plans for expansion to improve teaching as well as patient services.

Mrs Cathy and Dr Lachlan Henderson

Mr Peter Mott (SJOG Murdoch CEO) with Prof Yee Leung, recipient of the 2011 St John of God Hospital Murdoch Doctor of the Year award.

Ms Yvonne Buters (centre) chats with two ED doctors Dr Julie Dockerty and Dr Dianna (Anna) Varone.

Dr Michael Standford, Ms Jennifer Grove and Health Minister Dr Kim Hames

Dr Rod Moore (left) pictured with Ms Carolyn Lawrence and Mr Boyd Milligan

Prof Vincent Caruso, Mrs Josephine and Hon Mike Board (Social Outreach SJOG)

Flanking Dr Bernard (Barney) and Pamela Cresswell are Dr Caroline Crabb (far left) and partner Dr David Borshoff.

Ms Wendy Wardell with friends

Ms Jenny Heyden and Dr Joe Kosterich

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Mrs Terri Sedgman

Dr John Alvarez and Mr Glenn Bradbury

Dr Louis Papaelias 15

Ear Science Institute 10th anniversary Celebrating 10 years, the Ear Science Institute’s anniversary in the ballroom of Government House coincided with Christmas celebrations elsewhere. Speeches reflected on the success of ESIA, from its humble beginnings in the small office at the Sir Charles Gairdner Hospital, to the opening of the new premises in Subiaco where initiatives such as the “Cheers for Ears” have taken flight. This hearing loss prevention program for primary aged children has enrolled more than 5700 children for 2012.

Mr Phil Hiles, Mr Fabian Kiesenhofer, and Ms Sonja Stemler

Mr Kevin Airey (Lions Hearing Board), Mrs Christina Smelt (Lions Hearing Projects) and Mr Bernie Jennings (ESIA Volunteer)

Dr Phillip Fisher, Dr Rudolph Boeddinghaus, Dr Phillip Grey and Dr Desmond Wee

Madam Zhong Hong (Chinese Embassy) pictured with Adrienne and Prof Barry Marshall, and Prof Marcus Atlas

Mr David and Mrs Pamela Baird (Lions Hearing Foundation), Mr Peter Lamb (Lions Hearing District Governor), Ms Toni Whiteaker (Lions Hearing Board)

Mr George Jones AM CITWA (Fundraising Committee) with daughter Mrs Rebecca Meyerkort

Mr Scott Green (Security Allied Finance), Mr Guy LePage (ESIA Board) and Mr Rob Boggs (ESIA Finance)

RACGP WA The RACGP WA Faculty end-of-year celebration was at the new Faculty offices in West Leederville, early in December. It was a welcome opportunity for the Faculty to thank their stakeholders for support during 2011 and wish them the best for 2012.

Dr Mike Civil with WA State Manager Malvina Nordstrom, Dr Stephen Clarke and Dr Richard Choong 16

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Perth Pathology Waltzing Matilda After a wild and windy day in Perth, the weather and location couldn’t have been better for Perth Pathology’s celebration at Matilda’s on the Bay. Hosted by Dr Wayne Smit, the evening was enjoyed by a large variety of invited guests in perfect weather – a chance to catch up with old and new friends alike.

(l to r) Mr Ralph Treasure, Dr Elena Monaco, Dr Wayne Smit, Dr Damien and Cheryl McCann

Dr John Troy and Dr Wayne Smit Dr Karen Moller and Dr Tony Barham

Dr Benjamin and Mrs Lillian Sung

Mainly Perth Pathology staff (l to r): Ms Chelsea Reid, Mrs Misbah Palekar, Ms Fiona Newman, Mr Matt Tremain and Ms Rachelle Gulland.

Dr Steve Harding, Dr Gavin Steinberg, Dr Alan Donnelly and Dr Ian Churchward

(l to r) WA Faculty Chair A/Prof Frank Jones with RACGP staff members Linda, Yvonne and Sandra.

WA QI&CPD Administrator Linda Cridland with Dr Colin and Barbara Hughes.

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

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WA Health puts the care into your career

Practice Tips From the Committee of AAPM WA

Effective meetings between doctors and the practice manager We all need meetings with our colleagues and practice manager but we all scream how “time poor” we are. Meetings are a necessary evil and go a long way to enhancing the harmony of a practice. These few tips help make meetings an effective use of everyone’s time. (You may want to pass them on to your Practice Manager to assist them co-ordinate a meeting.)

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• At the beginning of the year, map your meeting dates on your practice year planner. • Email a meeting reminder 1 month, 1 fortnight, then 1 week prior to the meeting. • Have your Practice Manager coordinate an agenda – topics for discussion are encouraged from all attendees. • If there are decisions to be made, ensure the attendees receive relevant support documentation to peruse prior to the meeting (and if everyone does their pre-reading, time is saved during the meeting). • Expect all invitees to attend – do your best to make it “compulsory”; it’s for the good of your practice. • Provide basic refreshments.

• Choose a strong “chair” to keep the meeting on track. • Have your Practice Manager summarise some minutes, including actions from the meeting, and distribute to all attendees.

WA Conference Corner Blooming Minds at Work Dates: 14/02/2012 Venue: Perth Convention Centre Web: www.bloomingmindsatwork.com/

Rural Health West 2012 Conference

Taking on Telehealth

Friday 2 March 2012 | Medina Grand Perth (Mounts Bay Road) Rural Health West and The Royal Australian College of General Practitioners (RACGP) WA Faculty are hosting the Taking on Telehealth workshop. Presentations include: l Preparing for Telehealth in your practice l Tips and tricks for using Telehealth in your practice l RACGP implementation guidelines for video consultations l Telehealth success stories l Update on the Personally Controlled Electronic Health Record

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Dates: 3-4/03/2012 Venue: Parmelia Hilton Driving Change in Chronic Care

Aust Society for Infectious Diseases Conference Dates: 21-25/03/2012 Venue: Esplanade Hotel Fremantle Web: www.asid.net.au/Scientific-Program Sailing Into The Future

14th National Nurse Education Conference Dates: 11-13/04/2012 Venue: Pan Pacific Hotel Website: www.iceaustralia.com/nnec2012 Keeping the Flame Alight

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BENEATH the Drapes

u Clinical Nurse Manager Ms Sarah Ward is the new Operations Manager at Mandurah Hospital, having worked at Peel Health Campus for the past four years. PHC’s 22 bed ED sees over 45,000 patients annually, within the 130 bed hospital that was established in 1997. u Dr Moir Sim takes up the post of Medical Director of Silver Chain’s Home Hospital, following the departure of Dr Roslyn Carbon. u UWA medical graduate Dr Vinay Menon has been awarded an AustraliaAt-Large Rhodes Scholarship to Oxford University in the UK. Last year he received the Young People’s Human Rights Medal for his voluntary advocacy work with refugees, indigenous communities and children living with a disability.

u Dr Sam Brophy-Williams (RPH) has won the Sir John Monash scholarship to fund international postgraduate study –$50,000 a year for three years – and Sam hopes to head to Oxford to focus on global health science. u St John of God Health Care has been chosen to design and operate the new 367-bed Midland Health Campus. u Paediatrician and infectious diseases specialist Prof Jonathan Carapetis takes over next July as director of Perth’s Telethon Institute for Child Health Research. He is currently director of Darwin’s Menzies School of Health Research. Prof Stanley will continue with the Telethon Institute as Patron and a Chief Investigator on a number of research grants. The Institute’s Director of Academic and Research Services, Prof Moira Clay, is currently the interim director. u MDA National Insurance has appointed Mr John Trowbridge as a director of the MDA National Insurance Board. John is the Interim Director of Australia’s Centre for International Finance and Regulation, and he chaired the Australian Government’s Natural Disaster Insurance Review Panel and spent four years on executive with APRA.

u SJOG Murdoch has linked up with Notre Dame University to appoint its first ever Professor of Nursing Research, Ms Leanne Monterosso. Dr Tony Robins moves from Director Medical Services, a position now held by Dr Shirley Bowen, to take charge of Medical Education and Training at SJOG’s Group Office. Dr Ian Rogers has been appointed Prof of Emergency Medicine through a partnership with Notre Dame Uni. u SKG Radiology CEO Dr Sue Ulreich has been appointed the new president for the Australian Diagnostic Imaging Association, which has radiology groups as members. In WA, these comprise Global Diagnostics, Perth Radiological Clinics (I-Med Network), SKG Radiology (Sonic Healthcare Ltd) and Insight Clinical Imaging. u Prof Lee Leung received the Doctor of the Year 2011 award at the Christmas function for SJOG Murdoch Hospital. u Prof Con Michael AO has been awarded an Honorary Doctorate of Laws by Notre Dame Uni for his work with the Fremantle School of Medicine and his achievements in the medical profession.

Chlamydia Website for Young Wins Award n Award presentation (l to r): Mr Kim Snowball (Director General DoH), Ms Lisa Bastian (Manager Sexual Health and Blood Borne Virus Program),

Dr Lewis Marshall (Head of Sexual health Service Fremantle Hospital) and Ms Chris Hall (CEO Mercy Care).

The Online Chlamydia Program received the WA Health Award 2011 Excellence in Prevention, Promotion and Early Intervention, an award sponsored by MercyCare. Featured in an earlier edition of Medical Forum, the website and program is run by the Sexual health service of Fremantle Hospital, aimed at young people. Relevant risk is explained and a lab request form for chlamydia testing can be downloaded. It is

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aimed at providing easy screening for asymptomatic people – PathWest does free testing, urine for males or self-obtained low vaginal swab for females. Results are accessed through a 1800 number and those with positive results are all contacted and treatment options given. After two years, a positivity rate of 18% suggests the high risk group it is targeting is being reached.

IT in Medicine By Peter McClelland

ECU Health Simulation Centre While operating on cadavers offers unbeatable reality in some circumstances, simulated training on sophisticated mannequins is reaching new levels.

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.

in Medicine, he sings the praises of the ECU Simulation Centre.

HSC is particularly relevant in three key areas, according to Cobie Rudd.

“Mid-way through 2007 there were a number of funding issues involving both UWA and the State Government regarding the anaesthetics simulation lab at UWA. It was put out to tender in late 2010 and ECU were awarded the contract… it’s a really well-run unit.”

“The Centre is absolutely invaluable for highfidelity simulation training, inter-professional learning and sequential simulation - the latter avoids learning interactions that revolve around a single moment in a ‘patient’s’ journey.”

HSC houses WA’s only patient simulator with the ability to provide respiratory gas exchange, anaesthesia delivery, and patient monitoring with real physiological measures. Such a high fidelity mannequin is needed for the ANZCA anaesthetic training courses offered several times a year.

And, concludes Richard Riley, the future appears to be bright. “Medical simulation and immersive learning appears to be something of a federal government priority and they’re ploughing millions of dollars into this area.” n

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Medicos in Politics By Dr Rob McEvoy

Mixing Medicine and Politics Member for Eyre Dr Graham Jacobs says the practicality of political representation has similarities to general practice, with some major differences. Graham Jacobs is flat out looking after the interests of the 18,000 constituents of Eyre, a pastoral and mining spread of 292,000 sq kms. He says his wife Kathryn is his mainstay and there is no doctor amongst his five grown-up children. Some of us might remember his election in 2005. Graham came to recent prominence as WA’s first Mental Health Minister for two years, before Colin Barnett transferred the portfolio to Helen Morton a year ago. Medical Forum caught up with him in Kalgoorlie, directly north of his home town Esperance, where he has worked as a rural GP for 27 years.

can’t do it but I know someone who can,” he explained. “You are not necessarily going to make everybody happy. They forgive you if it is not going to get them the result they want but if you haven’t made an effort, they won’t forgive that.” As a politician, he can get things before a Minister and elevated to the top of their pile. His time in cabinet made him familiar with how things work, which helps a lot. “A lot of politics is done in the corridor. Question time is a total circus that is basically irrelevant. I found it difficult. I always thought it was about going for the message and perhaps picking it apart but don’t denigrate the messenger but that’s what they do.”

He had just got some action for a Homes West tenant complaining of flaking paint; hardly riveting stuff but…

He remembers the naivety of his private members bill when he entered politics on the opposition benches – it was to remove the $40,000 threshold in the Consumers Affairs Act because 50 of his constituents had been left unprotected when a developer pulled the pin.

“You have to look after the little things as well because they are big to those people. Being a political representative isn’t about knowing everything, it’s about directing people to the right door. There is just a myriad of possibilities and many don’t know where to go with their problem. It’s a bit like general practice – you’ve got this, I

n Dr Jacobs at work in his “medical office”

“The government opposed it, it went to division, and someone said you never call division during dinner on Thursday night, meaning that

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he didn’t have any idea what the legislation was about but he was going to sit in there to vote against it. I thought why don’t I just walk out of here and go back to medical practice where I’m doing something useful!” The way things get done in politics is not like medicine. But has his stereotype of politicians changed in six years? “The view is they have a pretty easy life and do a lot of talking while not much happens. From my point of view, I work just as hard – hours, commitment and travelling – as in general practice. Most politicians I know are hardworking and come there with a view to make a contribution.” “Sometimes I get disappointed in the party room situation. People keep their head down because they think they might offend somebody or it might be against what the party generally feels. I keep saying to government members that they owe their job to their constituents not to their party or the premier. It is important to speak up on issues. There have been examples where there have been anomalies or inconsistencies in legislation that people could see were going to happen.” What of his time as the first Mental Health Minister? “The amount of work we have to do in mental health is enormous, especially younger people and the need to intervene early. We created a Mental Health Commission for the first time and that was really important because we needed to take mental health out of ‘silver city’ and we needed a structure by which to concentrate on mental health. One in 20 people have a serious relapsing mental illness in our community. We need to allocate money and have it work effectively.”

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This includes accommodation for those with mental problems – 25% of people discharged from an acute mental health unit go back in again within about three weeks – with outreach service packages geared for each person’s needs.

People in the supermarket offer him advice on his best career, politician or GP, but he is trying to keep irons in both fires. He tries to do 10 operating days a year and is booked for a four-week stint at his Esperance practice. n

Being an ordinary Member in the last 12 months has allowed him to work more in his community where getting things done is a real buzz – such as the $1.2m CT scanner for Esperance Hospital, after the local community chipped in $470,000. What was his take on the lead contamination scare in Esperance, some time back? “Really there were three areas, Magellan Metals, the Port Authority and the Department of Environment and Conservation. From my point of view, and as a taxpayer, we rely on the environmental watchdog to look after issues such as this and they were asleep at the wheel. The parliamentary committee found that – Kim Hames chaired it and I was co-opted on, while Alana McTiernan fought it – the inspectors didn’t even go into the shed to look at the product. When we were supposed to get palletised lead and it was a fine dust product. When we asked them why they didn’t go in to inspect the product they said, ‘We had some occupational health and safety issues’! Taxpayers fund that agency and would expect them to do their job.” He said his role was to ensure these agencies work. In that respect, being in government, versus opposition, is like chalk and cheese. “If you were playing league in the WAFL you would be in the government and if you were in opposition you would probably be bottom team in the Reserves.” Graham faces re-election in March 2013.

Guest Column

When the Piper Calls the Tune Dr David Borshoff questions how doctors relate to money, and whether their colleagues and the community agree with what goes on. A colleague of mine anaesthetised a medical specialist undergoing a procedure for malignancy. The diagnosis was recent, and the patient was still wrestling with the profound implications of finding himself on the other end of the knife. In this emotional fog, and on the day of surgery, the anaesthetist dutifully obtained ‘informed financial consent’ and went beyond verbal acknowledgement to insist paperwork was signed to accept the charge – full AMA rates. The ability to earn high incomes is not confined to any particular specialty, although some seem more ‘predisposed’. Despite the outcry by some specialists when rebates are reduced, it is well known that some can earn in a week, almost the equivalent of a school teacher’s annual salary for their efforts. They are highly skilled and in demand but are they worth fifty times a schoolteacher when much of their income is also derived from the taxpayer? Currently, at a large teaching hospital there is inter-specialty disgruntlement because small groups of proceduralists have negotiated special deals. Threats to withdraw services have been

involved. This is easily construed as holding the hospitals to ransom. There are now similarly experienced specialists, who for the same public hospital commitment, are receiving vastly different remuneration. Of course, parity will inevitably be pursued and more healthcare dollars will be sucked out of the health budget. Specialists will justifiably argue that it is not all one way. Dismal treatment of loyal staff by a bloated and incompetent hospital management has definitely contributed. How did this happen? When did we in medicine become preoccupied with wealth? Why has it become acceptable in the ‘caring profession’, to demand a pay cheque from the taxpayer that competes with private practice? Isn’t earning seven figure sums enough to give up a Saturday or Sunday every few weeks to provide the poorer punters with a decent service? After all, despite its well-known flaws, it was this public system that trained us. And what about those who choose to commit full time to public service? Why should they be penalised for providing a much-needed service to those unable to afford health insurance? Yes, many well qualified and skilled doctors who genuinely care for their patients deserve

to be well remunerated, but when a colleague walks out from a morning list chuckling to a nurse that the year’s school fees have just been paid, it suggests our profession is in need of moral guidance. Rationalisation of healthcare is a reality and every time powerful minority groups successfully negotiate sweetheart deals with a hospital administration, there is likely less available to GPs and other specialists to provide good healthcare for all. It may seem a romantic notion to suggest that we, as a profession, can exercise restraint and put community before personal gain, particularly when the opposite behaviour is witnessed today throughout most of society. However, having watched Intensive Care colleagues deliberate over patient management for little monetary reward when most of us are sleeping, I still like to think we could all provide that same level of commitment when called upon. Declaration: David Borshoff has a small public hospital commitment but derives most income from his private anaesthetic practice. n

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Guest Column

Selecting the Modern Doctor Dr Lachlan Henderson is experienced and young/old enough to ponder today’s selection of would-be doctors, and what constitutes a good doctor. At age 46, after two decades of life as a doctor, I’m roughly mid-career (or about where my colleague Prof Con Michael no longer calls you a “junior doctor”, while he contributes enormously to medicine well into his 70s!). I wonder what constitutes a good doctor, given that contemporary medical schools, undergraduate or postgraduate, have extensive selection processes for the next generation of would-be doctors. Interviews and aptitude tests now supplement the old-fashioned entry exam grades. If you’re a good listener and problem solver, you’re in with a chance. Being socially aware and having strong ethics and values is an added bonus. But does the ‘all-rounder’ selected today necessarily want to be on call or working antisocial hours two or three decades on? Does this prototype have any interest in laboratory medicine or research? Will they study the extra decade to develop specialist skills? Will they accept the long and often arduous apprenticeship of any area of clinical expertise before becoming the boss? The attributes selected now – listening skills, empathy, problem solving – are not exactly

controversial. The question is whether they match the reality of the time poor, overworked and often sleep-deprived doctor needing to act decisively (often with scant information)? Is the next generation of doctors up for this challenge? Hopefully, well before the end of my career the answer will become known and selection processes adjusted accordingly. The dominant question is can the skills required to be a successful medical practitioner be selected at entry point – or are they only acquired after long hours on the job? My experience interviewing potential medical students reveals an articulate, confident and very capable bunch (“Is it OK if I call you Lachlan?”). I find it quite disconcerting to reflect on a candidate’s skills, compared to mine at a similar age and stage. In my hands, the interview has not been particularly useful in terms of triaging potential candidates – almost without exception they have all been very capable.

most important trait required is insight. The safe doctor exercises caution and reasonable deliberation in treating patients. They must also reflect wisely and show good judgment when they interact with patients because things have not gone according to plan. I’m not sure whether these attributes are genetic or can be acquired - or if they are on the interview scoring sheet! n Ed. Dr Henderson graduated UWA, 1989, and interned at SCGH before working 15 years in general practice – doctor-owned, university and corporate general practices. He is now Group Medical Director for St John of God Health Care after a stint as CEO at the Mount Hospital. He has positions within aged care, pathology, medical defense and a medical school, and is married to a child psychiatrist.

A word of caution. Doctors deal with adverse events more these days, some of their doing. What personality traits or skills equip them to face, say, a hostile family or relative? Well taught communication skills will assist but the

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

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

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Guest Column

Excellence in Clinical Engagement WA Clinical Senate chair Adjunct A/ Prof Kim Gibson feels we are geared for clinician engagement in WA with new national initiatives untested. Now in its ninth year of operation, the Clinical Senate, which had its roots in the Medical Council, sets the benchmark in this state and arguably across the nation, for excellence in clinical engagement. The senate, for the uninitiated, is a forum for robust debate on critical health reform issues by the membership of more than 75 clinicians, including many doctors and two consumers. Session outcomes are recommendations submitted to the Director General for Health. Key to its success is the sharing of perspectives drawn from the broadest, multidisciplinary, clinical spectrum whilst leaving professional and organisational agendas aside. More than just a gabfest, the senate works closely with the current DG, Kim Snowball, to close the loop on debate outcomes. For the last year the DG has responded directly to the senate. At subsequent debates, he indicated his endorsement or otherwise of each recommendation and the actions to be taken. Recently he took this one step further, partnering with the DG for Disability Services, Dr Ron Chalmers, to not only endorse the recommendations from the Senate’s disability debate but to announce funded joint initiatives

for immediate commencement. Thus clinicians engaging in health reform through the Clinical Senate get good tangible return for effort. The National Health and Hospital Reform Commission Report in 2009 bemoaned the lack of clinical engagement around the country, reporting that particularly doctors were disenchanted and disenfranchised. This was less so in WA given acknowledgement of the work of the Clinical Senate and the Health Networks to engage clinicians in health reform. The developmental work of both these groups has fostered a culture and positive professional behaviours of clinical engagement in WA unrivalled in other jurisdictions. Planning such as that conducted by the Clinical Clusters in South Metro Area Health Service has leveraged this clinical leadership utilising a strong interprofessional approach. The government’s response to the NH&HRC report has led to Lead Clinician Groups (LCGs) and Governing Councils providing further clinical engagement opportunities and challenges. Just how the national LCG links to or guides the work of jurisdictional bodies such as the Senate remains to be seen. We are

disappointed by the lack of a West Australian clinician on that group. The Governing Councils will each have four clinician members, three medical. One may question how clinical input into health service governance will now differ given that clinicians, particularly doctors, have served on health service executives in WA for many years. The greatest challenge for clinicians in engaging in clinical service planning, policy driving and health reform of all kinds remains balancing the ever increasing demand for engagement with clinical, academic and research commitments. The answer may lie in valuing the perspectives of all clinicians, across all professional backgrounds, regardless of seniority. The senate debate on eHealth early in 2011 benefited greatly from the contribution of junior doctors given their perspectives as ‘digital natives’. A move away from dependency on our most experienced and revered colleagues when engaging in reform will spread the load and develop clinical leadership more broadly. Whatever the future holds, WA has a strong foundation on which to build its excellence in clinical engagement. n

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Boxing By Peter McClelland

Gloves Off Over Boxing Boxing is one of many contact/combat sports involving doctors. If contestants know the risks, how far should doctors be prepared to assist? In line with the federal AMA stance against boxing, the local AMA Council has withdrawn its legislated representation on the Professional Combat Sports Commission (Combat Sports Act 1987, amended 2009). Others on the eight-member Commission are appointees of the Minister for Sport and Recreation, from boxing, other combat sports, the Police and the Department of Sport and Recreation. Even though boxing is one of the combat sports that can cause brain damage and even death, we presume participants are aware of the risks. What does the profession do? Should it partner with a sport seen to cause health problems, even if attendance at fights is said to be aimed at minimising damage and ensuring compliance with ‘safety’ rules? Is it legitimising a sport that should be banned and where do you draw the line, if at all, on the types of contact or combat sports?

Calendar of Events 2012

More in the genre for doctors, intervention in rugby has changed the way the sport is refereed and played to minimise head and spinal injuries but both can still happen. Rugby team doctors are an integral part of the sport and much admired. With boxing, it is somewhat difficult to take the high ground when the sport consists of opponents trying to punch each other unconscious! Yet it is not so long ago that Police and Citizen Youth Clubs were where you went to learn the art of “sparring” or boxing, amongst other things. The WA government says it will now legislate to recruit doctors outside the AMA. Boxing WA needs ringside doctors. In our October edition e-Poll of 81 GPs, 37% said ‘no’ to the medical profession playing any part in overseeing boxing or extreme combat sports (while 28% said ‘yes’ and a further 26% said ‘perhaps with limitations’). So general practitioners, at least, may be fairly evenly divided on this issue if not slightly in favour of some involvement. The question remains, what level of involvement? Queensland is not going to introduce combat sports legislation, despite the recent death of an amateur boxer. All other states except Tasmania have controls in what is a fast-growing industry, encouraged by on-line testosterone-fuelled bouts and increasingly graphic depiction of violence generally. Legislation can assist with the health and safety of combatants, protect against blood-borne infections, ensure there is accreditation of coaches and officials and minimise exploitative event management. And none of that requires a doctor. The closer you get to the ringside, the more difficult decisions become. n

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April Thursday 12th

May Thursday 10th Friday 18th July Thursday 12th August Friday 10th

Saturday 11th

E Seminar AAPM NSW – Telehealth Human Resources and Legal Aspects in a Medical Practice ”Are your I’s dotted and your T’s crossed?” • Practice and Staff indemnity • Job descriptions • Induction • Staff appraisals E Seminar AAPM NSW – Computer Security E Seminar AAPM NSW – End of Financial Year In the Black and Out of Trouble Management Financial Issues Reporting to your Directors Budgeting and Planning Worksafe Audit/OHS Standards Compulsory E Seminar AAPM NSW – Industrial Relations Friday – Dealing with the Yucky Stuff Bullying, Internet Use, Disciplinary Action, Breach of Confidentiality, Performance Management, Code of Conduct, Templates for Your Use. Saturday – Receptionists Are You Adding Value to the Practice? E Health, Confidentiality.

September Thursday 13th

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November Friday 9th

Keep Your Sanity and Save Your Staff Coaching & Mentoring and Staff Retention

Guest Column

The Poverty of Silence CEO World Vision Australia boss Tim Costello AO asks us to find perspective on what economic retraction means for the health of the poor, and do something about it. Millions of women and children in developing countries live in healthcare deserts, devoid of even the most basic healthcare services. This is despite a promise made by the world’s governments to reduce child deaths by two-thirds and maternal deaths by three-quarters by 2015 (Millennium Development Goals 4 & 5). The situation calls for public outcry, yet doctors, who I believe have the greatest power to turn the tide on this global scandal, remain largely silent on the issue.

Australians are incredibly fortunate to have won the ‘lottery of latitude.’ We were born in the lucky country, which means we have access to food, clean water, universal healthcare and education. The probability that an Australian child will die before their fifth birthday is 4.9 per 1,000 births. In Timor-Leste, a country just a stone’s throw from West Australia’s shores, that statistic jumps to 54.8 deaths per 1,000 births. The great lottery of life is unfair but I believe doctors, simply through the power of their voices, can help to improve the odds for women and children living in poverty.

Photo courtesy Suzy Sainovski

In 2011, World Vision has been vocal about the need for more health workers in the world – 3.5 million more to be exact. A billion people in the world, including 40 million children under five years old, will never see a health worker during their lifetime. Yet health workers could dramatically reduce maternal and child deaths by assisting women during pregnancy and childbirth; the delivery of life-saving medicines and vaccines would help protect against

deadly childhood killers like pneumonia, diarrhoea and malaria. Personally, I can think of no more credible voice in the call for more health workers globally than from health workers themselves. Sadly, there are few Australian doctors flying the maternal and child health flag for developing countries and putting their weight behind issues like the global health worker shortage. I believe one of the reasons why the health Millennium Development Goals are so off-track is because there is not enough pressure on the international community to achieve these goals. If more doctors were actively advocating for improved women’s and children’s health it would help strengthen global accountability for maternal and child death reduction. The lottery of life must be challenged. No woman or child should be deprived of basic healthcare services simply because of where they are born. World Vision launched a new initiative this year as part of our global Child Health Now campaign to give the medical community a platform to speak out. The initiative is called ‘Child Health Now Communities’ which is a name given to a hospital, university, clinical practice or community health centre that has signed on with World Vision to tackle maternal and child mortality. Our goal is to have 150 Child Health Now Communities on board by December 2012, mobilising thousands of Australia’s practicing and training health care professionals. It represents a powerful voice in the fight to address this global healthcare scandal and save millions of lives. For more information visit: worldvision.com. au/chn/communities. n

DonateLife Week 2 12 19 – 26 February Record year for organ and tissue donation in WA Organ and tissue donors help save and improve lives. One organ donor can save or enhance the lives of up to 10 people. A tissue donor can save the lives of dozens more. 2011 was a record year in WA with 99 people donating organs and tissues.

This record number of donations can be attributed to a variety of factors including the increase in community awareness, continued clinical education as well as the introduction of donation after cardiac death (DCD) of which there have been 9 donors in WA.

Accross Australia, 106 people received a second chance at life thanks to the generosity of the 33 Western Australians who, with the consent of their families, became organ donors. A further 66 Western Australians donated corneas, bones and heart valves which have gone on to improve the lives of many more Australians.

DonateLife Week, which runs from 19–26 February is a national call to action for all families to “ask and know your loved ones’ wishes”, as family support for organ and tissue donation is essential for donation to proceed.

For more information or if you would like brochures for your practice please contact DonateLife WA Agency for Organ and Tissue Donation on 9222 0222, www.donatelife.gov.au or donatelife@health.wa.gov.au 30

medicalforum

Welfare Services By Dr Rob McEvoy

Our Social Fabric The biennial report, Australia’s Welfare 2011, has the latest national statistics on welfare services and factors influencing wellbeing in Australia, as presented by the Australian Institute of Health and Welfare. Australia spent $137b on welfare in 2008–09 (excluding unemployment benefits), which is more than the $113b spent on health that year.

Welfare activity Of the total welfare spend, $94b was direct cash payments – with 72% directed to families and older Australians. Welfare spending in Australia, at 12.4% of GDP in 2007, was lower than the OECD average of 13.9% but spending on families, at 2.4% of GDP, was almost double the OECD average of 1.3%. 362,000 full-time equivalent positions were employed by community services organisations in June 2009. Around 325,000 volunteers gave an average of around 78 hours of service a year to these organisations.

Ageing Population Population ageing over the next two decades will shift the proportion of people aged over 65 from 1 in 7 to 1 in 5. Older people are staying in the workforce – in 2010–11, 62% of men and 44% of women aged 60–64 were still working. Many informal carers are ageing – 60% of primary carers aged over 55.

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In line with the Fair Go for All philosophy, Australians look after their own, including those down on their luck. Here’s why. Housing Housing affordability has fallen in the last 10 years (2001-2011) with median house prices increasing 147% while median household disposable income increased 57%. Home ownership dropped between 1995-2010 from 72% to 69%, and private rentals rose from 18% to 24% of all households. Social housing comprised around 400,000 dwellings occupied in June 2010, with around 250,000 applicants waiting for allocations or transfers. While the average number of bedrooms per dwelling has risen over 30 years from 2.8 to 3.1, the average number of residents per household has fallen from 3.1 to 2.6, and couples without children are the fastest-growing family type.

Families

64% of Australians lived in capital cities in 2010 with a ‘generation gap’ in regional areas, that is, an urban population younger on average than in country areas.

The disadvantaged Certain population groups continue to be disadvantaged, particularly those with relatively low rates of employment, and/or low educational attainment levels – Indigenous Australians, people outside capital cities, people with disability and their carers, lone parents, social housing tenants and recent migrants. Around 1 in 3 people could be classified as being poor at some point between 2001 and 2008 (i.e. income less than half of the national median). For most, poverty lasted 1–2 years. n

Marriage and divorce rates are steady although people are marrying later (31.5 is the median marrying age for men, 29.2 for women). Children are staying at home longer – 10% of those with their families in 2009–10 were aged over 25. The average household had a net wealth of $719,600 in 2009–10, of which 41% was the net value of the family home (value minus any mortgage), and 16% was superannuation.

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Acanthamoeba keratitis: the HSV mimic

By Dr Jane Lock, Department of Ophthalmology, Royal Perth Hospital

canthamoeba keratitis is a protozoal infection of the cornea, first reported in 1974. The incidence of this relatively new disease is rising so that awareness of it as a potentially sight-threatening disease is necessary. Acanthamoeba spp. is a family of free-living protozoa that is ubiquitous in water, soil and dust. Naturally, trauma or contamination of the eye in the rural or agricultural setting is a significant risk factor. However, the greatest risk factor is contact lens wear, especially that associated with overnight use, poor lens hygiene and swimming.

Misdiagnosis common for good reason Typically there is increased eye irritation and redness, blurred vision and eye pain that is disproportionate to the clinical findings. Unfortunately, the clinical course more than often involves misdiagnosis – as recurrent HSV keratitis – due to the pseudo-dendritic appearance of the corneal ulcer. Patients are often wrongly prescribed prolonged AcyclovirTM before Acanthamoeba keratitis is considered, which can be detrimental as the prognosis is highly dependent upon the commencement of correct treatment. If left too long, Acanthamoeba will invade through the corneal epithelium into the stroma where it is much more difficult to treat. Once the suspicion of Acanthamoeba has been raised, definitive diagnosis is also complex. Usually, a corneal scraping or biopsy is required for histopathology or microbiological culture; invasive techniques that require E. coli seeded culture medium, special staining and it often takes many days to return a result.

Novel diagnostic method I recently presented a novel diagnostic method for Acanthamoeba (case report, Cornea Society Meeting, Sydney). This case typified the usual progression of Acanthamoeba keratitis – a distant history of rubbing her eye, having lost her contact lens in a paddock, initially misdiagnosed as HSV keratitis, but referred to Royal Perth Hospital after a poor

n Cobalt blue illumination

shows fluorescein uptake in a pseudodendritic pattern.

diagnosis: significantly more pain than expected with these corneal appearances.

n Cornea one week after

intensive treatment with chlorhexidine and propamidine eyedrops.

response to months of antiviral therapy. Perth corneal specialist, Dr Nigel Morlet and ophthalmic pathologist Dr Tersia Vermeulen were able to diagnose Acanthamoeba using the novel technique of impression cytology. This non-invasive method of harvesting epithelial cells from the ocular surface involves gently pressing a Biopore membrane onto the ocular surface under topical anaesthetic, to collect one to three layers of epithelial cells. Routine H&E staining and light microscopy is then performed. This technique is typically used for detecting ocular surface neoplasia, however, in this case it identified Acanthamoeba cysts.

agents are polyhexamethylene and hexamidine, which are actually diluted pesticides and disinfectants. Treatment is often prolonged and extended periods of gradual eyedrop tapering is necessary. As the prevalence of Acanthamoeba keratitis rises, it is important for primary healthcare workers to be aware of its traits. Improperly treated or undiagnosed, sight-threatening corneal perforations may evolve and require corneal transplants. Prevention relies heavily on ensuring appropriate contact lens hygiene and prompt referral to an eye specialist is important should a dendritic or pseudodendritic ulcer be suspected.

Treatment

Perth Eye Centre Pty Ltd being the management company for the Eye Surgery Foundation, kindly provided Dr Jane Lock the opportunity to attend and present at the 28th Annual Australia and New Zealand Cornea Society Meeting, Sydney, 2011.

This patient was lucky to retain good visual function after topical chlorhexidine and propamidine. Other effective treatment

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Pharmacists By Peter McClelland

Pharmacists: The Best Kept Secret in Health Care? Those words leap off the Pharmacist Coalition for Health Reform (PCHR) website. Minus the question mark, of course! The PCHR is a recent affiliation which claims to represent “more than 20,000 Australian pharmacists working in hospitals, community pharmacies, GP clinics and regional and remote health centres” even though there are no financial members. The group aims to “create a voice for pharmacists in the ongoing development of our health system” (see www.pharmacistsforhealth.com.au) Medical Forum rang two Perth pharmacies and neither of them had ever heard of the PCHR. A best kept secret indeed! The coalition comprises members of the Pharmacists’ Division of the Association of Professional Engineers, Scientists & Managers (APESMA),

the National Australian Pharmacy Students’ Association (NAPSA), the Pharmaceutical Society of Australia (PSA) and the Society of Hospital Pharmacists of Australia (SHPA).

and the sale of expensive weight-loss products – have been heavily criticised by the PCHR. There are other rumblings around commercial deals with Blackmores and others.

Two press releases landed on the desk of Medical Forum in quick succession. The first called for pharmacists to be formally included in the rollout of Medicare Locals and the second was a more cautionary warning regarding commercial conflicts of interest involving the Pharmacy Guild.

Australian registered pharmacists – all 25,994 of them – should, according to the PCHR, have tangible input in shaping the legislative framework of health policy, increased professional recognition and greater access to a range of clinical interventions. The unofficial spokesperson we spoke to suggested that the Pharmacy Guild had been talking about promoting pharmacists as caregivers for chronic illness, but not doing much. Hence the new lobby group. n

The latter organisation, comprising most of the 5000 or so retail pharmacy owners in Australia, was invited to join the PCHR but declined. Hardly surprising, given that some of the Guild’s commercial activities – such as the MyGene deal to provide $1600 gene tests

Chlamydia Campaign 2012

A service to WA doctors from

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

In the next year it is estimated that more than 12,000 Western Australians will get the sexually transmitted infection chlamydia. This year’s campaign aims to increase chlamydia testing among 16 and 29 year olds and to raise their awareness about safe sex practices. Please offer opportunistic chlamydia testing to all 16 and 29 year olds presenting to your practice.

Contact tracing the sexual contacts of a person with chlamydia is important to limit the spread of the infection in the community and to prevent re-infection of patients by asymptomatic partners.

FREE online professional development for doctors and practice nurses Contact tracing: www.ashm.org.au/default2.asp?active_page_id=341 STI clinical management: http://sti.ecu.edu.au (accredited with RACGP and RCNA)

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e-Health

Medical Images Speak a Thousand Words Travel Medicine Specialist Dr Peter Burke relates how his version of tele-health has help solve health problems. Combining digital photography and the internet can assist us, outside any formal tele-health arrangement. Take this worker Harry, who visited me in Perth after leaving an offshore gas platform with possible “chicken pox” – a vesicular rash appeared on his buttocks three days earlier, then spread. I took these pictures of him on my iPhone, in case I wanted to send them to an infectious diseases physician. Harry then said his nine-month-old son in Hong Kong, whom he left behind five days

before his rash appeared, had recently visited a paediatrician with a “non-specific viral rash” that required no treatment. Harry rang home, got his wife in Hong Kong to snap the babe’s rash, and send to his mobile phone. The spot diagnosis? Hand, Foot and Mouth Disease (HFMD) passed from son to father. The perioral rash in the child appeared quite typical. This Coxsackie viral infection is easily spread from contact with faeces, vesicular fluid or respiratory secretions. And the buttocks are a common rash location, sometimes causing a nasty type of nappy rash. Incidentally, in Australia HFMD is usually a benign self-limiting condition but it does cause public health alarm from time-to-time in Asian countries. For example, outbreaks in Sarawak

Kalgoorlie GP Creates Waves Late December, Medical Forum received notification that the Trinity Medical Centre in Kalgoorlie and Mundaring Medical Service in Mundaring had each received $100,000 as part of the federal government’s grants to improve afterhours GP services. As we go to press, the promised money is yet to be delivered. Curious about Kalgoorlie, we investigated further. Trinity Medical Centre is the grant recipient. It is a converted house directly opposite the Kalgoorlie Hospital ED that only last October received Council permission to operate as a limited after hours clinic under Dr John Prempeh. He comes from Ghana, via South Africa, and completed his Australian four-year area-of-need stint in 2008. When he recently asked Council about taking on more doctors (namely Dr Kylie Sterry part time and two other Kalgoorlie GPs Dr Alfred Mathazia and Dr Amanuel Barthe) and extending the practice hours, the Kalgoorlie-Boulder Council rejected the planning application. The reasons: deficiencies in patient parking and complaints by a neighbour. Undaunted, John and his wife Lylla have mobilised support. Rural Health West is helping them recruit an Iranian trained doctor living in the Philippines; they will now rent one neighbour’s property and purchase the other neighbour’s, their local MP has helped them put together a petition as part of a push for rezoning, and they are looking at physio services and a prescribing license at the practice. The $100,000 grant, when it arrives, will be used to pay staff and there are big plans and needs to renovate, hopefully after Council approves things within a month. n

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during 1997 caused 31 deaths, then Taiwan (78 deaths), plus large outbreaks in China since 2008 (over 100 fatalities), and currently Vietnam. We have all got used to ‘smart phone’ technology allowing the transmission of real-time images around the world. Situations like this leave you awe-struck by the utility. I am on-call for a number of offshore oil and gas platforms, and e-mailed pictures of rashes and hand injuries in particular, give me information that cannot be easily relayed in words. One of my finest moments in front of a medical student, was to receive by e-mail a photo of a boil on the leg of an engineer living in Equatorial Guinea. This was instantly recognisable as caused by a tumbu fly larva due to the visible distinctive dark spicules at the punctum, through which the larva breathes. Twenty minutes and a dollop of paraffin later, a second e-mail came back with an attached picture of the whole Cordylobia anthropophagia larva lying on an Australian 20 cent piece. A priceless chance to shine in front of a student! n 35

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DENTAL

IT in Practice By Dr Rob McEvoy

Continence Management in ACFs When is a good idea worth it? Many gadgets and gizmos are available to assist health care but the financial bottom line in increasingly important. Medical Forum seems to get a thousand press releases a day, from pollies and product manufacturers through to pharmas and hospitals. One from “SIM” caught our attention. No, it is not the card for your mobile phone or the School of Instrumental Music, it stands for Smart Incontinence Management. In a nutshell, these are ‘electronic underpants’ that won the New Inventors People’s Choice Award in 2008 and hit the commercial markets a year or so later. The Melbourne invention swings on the elderly wearing a disposable continence pad with a sensor embedded that sends an ‘I’m wet’ signal via a wireless network to a monitoring station. Individual voiding profiles are created over three days, and residents monitored in real time. From this comes a personalised toileting schedule that the manufacturer says saves money. Why? Manufacturer Simavita – receiving help from the Queensland government at present – says incontinence among aged care residents accounts for 30% of the cost of managing an aged care facility (labour and linen), while incontinence costs Australia $1.2b a year, and afflicts 1.5m Australians of all ages, including most residents of aged care homes. They say

their system could replace traditional regular checks from staff that are expensive and deprive residents of privacy and dignity. Knowing little about n Ms Di Simpson incontinence management in aged care facilities we asked someone who did, Di Simpson who has been DON at St Lukes Nursing Home in Subiaco for many years. She made these important points: • Aged care facilities (ACFs) are constantly having to watch their bottom line these days. The federal government includes incontinence management in their per-patient allotment and last time she checked there were more cost-effective solutions than SIM. • It is normal practice when ACF patients are new, to measure their continence behaviour for three days, to build a care plan around toileting and continence product use. With 60-70% of ACF patients now having dementia, each can be assumed to have incontinence.

Beyond the Vale

• There are good alternatives to ‘electronic undies’. Continence pads these days can hold up to 1.5 litre fluid and not feel particularly damp or excoriate patients. Moreover, they can be worn as pull-ups by ambulating women and have a colour-change indicator to show when they need changing. Just as important are the observations of staff – they can tell from the body language when toileting is required, or they know when they hand out the fluid tablets that the next hour will be important. • With the measures outlined above, continence costs are kept low (less than the quoted 30% by Simavita) and gone are the days of draw sheets and big loads of wet linen for laundering. Continence pull-ups cost about $1.00 each. • While things are running smoothly the cost of continence pad pull-ups are virtually covered. However, a bout of diarrhoea through the ACF or inexperienced staff who change continence pads too often, and you can have a cost blowout. Keeping male patients dry and managing evenings and nights requires some special skills that ‘electronic underpants’ might nicely monitor, but who can afford it? n

Guest Column

Advisor to funeral directors and minister of religion Allan Anderson reflects on the intersection of death, doctor paperwork and grieving families. Somerset Maugham wrote, “Death is a very dull, dreary affair, and my advice to you is to have nothing whatsoever to do with it. Sometime doctors seem to echo his thoughts. The final moment is the pronouncement of, “Life extinct!” and that concludes their relationship with the deceased.

commence the processes that assist the bereaved in planning the appropriate rite of passage. The timely availability of correct paperwork is important if families are to be assisted through this difficult time.

In fact, they are committed to restoring life and therefore anything to do with death is outside their realm. Unless a doctor is committed to a compassionate, palliative care model of service the processes following death can be seen as a nuisance and an unnecessary demand on their time. Or in our effort to escape from that gloom of death into the light of living again there is a tendency to hurry things through and to neglect some important tasks.

The fact that no provision has been made for the medical records of a frail aged or ill patient to be available to another willing doctor during holiday time can mean that a 97-year-old mother can now be the subject of a Coroner’s enquiry because there is no-one to sign the death certificate.

The filling in of a Certificate of Death and a Cremation Form 7 may be put off. Yet this declaration allows the Funeral Director to transfer the body into their care in order to

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Simple spelling mistakes and incorrect information can further delay a funeral, for legal reasons.

The Funeral Director comes under pressure from the grieving family because there is now uncertainty as to when the funeral can take place because, “This might become a Coroner’s case”, not to mention apprehension over an unnecessary autopsy. Perhaps a doctor needs to speak with the Coroner so that the deceased’s

papers can be viewed and the necessary certificates issued without a full enquiry. Increasingly, the medical profession is charging between $100-$150 for this form filling responsibility. This charge can be viewed as a direct impost on the family, particularly if it is at the end of a long medical relationship that has provided many thousands of dollars to the medical practice. Five minutes of form filling should really be seen as the conclusion of the service already paid for over the years. These legally required forms should be available immediately following the pronouncement of life extinct or within the following 24 hours. Medical centre staff should be aware of the importance of this paperwork, that it is not just about the dead but it is for the well-being of bereaved people who are very much alive. The Funeral Director suffers relatively minor inconvenience. Remember, there is more to do Beyond the Vale, that last farewell when death is pronounced. n 37

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Guest Column

Women’s Health: A Passionate Life! With such a rich and passionate professional life, Dr Margaret Smith AM shares some of the peaks and troughs with some bemusement. “It’s not like it was in my day!” was a cry often tossed in my direction as a young doctor in Adelaide 55 years ago, Now, alas, I hear myself saying it far too often. Back in those days we wore white coats with pockets for stethoscope, notebook and pens. We lined up for inspection before ward rounds and called our esteemed supervisors, ‘Sir.’ They were specialist physicians, not university teachers. Naturally, all of them were male.

Now, more than 50% of medical graduates are women and this has tipped the balance the wrong way because most women want a profession and motherhood. I chose career over motherhood, without regret because my life has been very rewarding – the many thousands of babies I’ve delivered are my substitute family! In those early days, women weren’t really welcome as medical students. There were only four women in my class of 84 and after graduation there were no Resident posts for us because we weren’t expected to do postgraduate training. Fortunately, this appalling decision made the front page of the newspaper and we were grudgingly re-instated. ‘Resident’ doctors in a hospital were indeed resident! Absurdly long hours with neither pagers nor mobile phones. Very few lab tests, with x-rays the only other diagnostic tool. Consequently, we had to take a very full patient history and complete an extremely thorough physical examination. This has stood me in good stead ever since. Travelling to Edinburgh for my post-graduate qualifications presented another barrier. They offered me only short-term employment because women previously had not coped with the long hours. I worked seven days a week, 20 hours a day, one night off a week, and one weekend break every month! I stayed for four years, was awarded the gold medal for my MRCOG exams and my boss changed his mind about women obstetricians!

Intending to settle back in Adelaide, I instead went with my surgeon husband Frank to where the real work was – New Guinea, for seven years. There was plenty of real work for me too - obstetric difficulties not covered in text books! We came to Perth in 1971 and taught for 15 years at King Edward. The first menopause clinic was set up in WA in 1978, and when I gave up obstetrics in 1996, menopause became my main focus. After my own brush with death in 2002, I came back to work to find that HRT was regarded with increasing suspicion. Two large American studies (subsequently shown to have drawn the wrong conclusions) had hit the headlines and many women went off HRT or refused to even consider it. With the help of expert colleagues from the Australasian Menopause Society, such as Prof Henry Burger in Melbourne and Prof Alastair MacLennan in Adelaide, the tide is slowly turning. I never stopped prescribing it and always encourage younger doctors to do the same. I guess that’s why I’m known (at least to my patients) as Mrs Menopause! I’m retiring from the battlefield, but not from the fight! n

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cl i nic al

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“Studies of patients with cirrhosis uncover limitations in liver cancer screening” T

his title announced a press release Medical Forum received from the American Association for the Study of Liver Diseases, about screening for primary liver hepatocellular carcinoma (HCC). One study struck the hurdle of not being able to randomise because most patients (88%) wanted surveillance. The other suggested three monthly ultrasound screening was overkill.

With 90% of all liver cancer cases attributed to chronic liver diseases, typically at the cirrhosis stage, the value of screening is being debated by experts. Interestingly, the first study hailed from Westmead Hospital in Sydney under Prof George. The press release said a survey of 40 gastroenterologists within the Sydney Liver

Group revealed 74% routinely screen cirrhotic patients despite believing that screening did not increase patient survival (37%) or that the surveillance was cost-effective (66%). So the second study about USS screening frequency by French and Belgian researchers – 1278 cirrhotic patients with cirrhosis from excessive alcohol (39%), hepatitis C (44%),

and hepatitis B (13%) – occurred over 200009 and detected at least one focal lesion in 28% of patients but failed to pick up more than 10% of HCC lesions over 30 mm. Their study found that ultrasound surveillance performed every three months detects more small focal lesions than screening at sixmonth intervals but more frequent screening did not improve the detection of liver cancer at an earlier stage. References:

“Feasibility of Conducting a Randomized Control Trial for Liver Cancer Screening: Is a Randomized Controlled Trial for Liver Cancer Screening Feasible or Still Needed?” H. Poustchi, et al.Hepatology; Aug 24, 2011

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“Ultrasonographic Surveillance of Hepatocellular Carcinoma in Cirrhosis: A Randomized Trial Comparing 3- and 6-month Periodicities.” Jean-Claude Trinchet et al Hepatology; Sept 6, 2011

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Clin A/Prof Gerry MacQuillan, Consultant Transplant Hepatologist SCGH. Tel 9346 322

Pregnancy, childbirth and menopause. Three of dozens of reasons why you might wet their pants today.

Standard of care for hepatocellular (HCC) “screening” in cirrhosis is by six-monthly ultrasound (USS) imaging (serum alphaFP levels should only be requested in the presence of a focal liver lesion). These timely articles appearing in Hepatology highlight two important management issues in primary liver cancer (HCC).

Do you wet your pants when you sneeze, cough, lift something heavy, laugh or exercise? Don’t worry, you’re not alone. The good news is it can be treated and, in many cases, cured.

Firstly: A randomised control trial to determine the utility of USS surveillance for HCC in cirrhosis is NOT ethically possible in the era of informed consent.

You could even be eligible for Bladder problem. Treat it. Beat it.

For a free consultation with a trained nurse call 1300 787 055. www.continenceandyou.org.au

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treatment.

Secondly: six-monthly screening with USS is cost-effective when compared to a more intensive regime of three-monthly surveillance for HCC, detecting a similar number of potentially curable sub-3cm HCC lesions. n

Indigenous Health

Bridge Building Sharing vital health information is behind an award-winning website for health workers. Indigenous disadvantage has historically been a target of billions in research and project funding. Putting all that information together and providing a virtual meeting place for health workers of all backgrounds, is one way of ensuring we learn from the past. The resource website HealthInfoNet has been developed by a team working out of Edith Cowan University.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

Top of the Wazza – Again!! The latest ANZARD Data for all IVF Units in Australia and New Zealand puts PIVET at the highest level of the top quartile for all Clinics.

Its director, Prof Neil Thomson, said the website had been Prof Neil Thomson with the award. providing research and policy information to professionals working in the area of indigenous health for more than 14 years enabling them to achieve more potent outcomes for their patients.

In fact PIVET generates the highest live birth rates for initiated cycles undergoing frozen embryo transfers.

Now the website has been acknowledged at the recent Australian New Zealand Internet Awards where it won the Diversity category. “HealthInfoNet has been providing the evidence base to inform decisionmaking for those working or studying in indigenous health by making high quality, relevant information freely accessible via the internet,” Prof Thomson said. “We make academic literature more accessible to indigenous health workers and indigenous environmental health workers in remote, rural and regional areas of the country.”

Medical Director Dr John Yovich

Dr Yovich with one of “his” many babies.

The website, funded by the Department of Health and Ageing, contains wide-ranging topics from the latest research into chronic conditions affecting the indigenous population, such as cardiovascular and kidney disease and diabetes, to the health impact of social policy such as housing. It draws on research conducted both in the field and in universities, relays information about current programs and projects and connects health workers through seminars, conferences and online discussions.

This audited Data is generated from an independent source at the University of NSW including the data returned to PIVET enabling comparison.

The graphs refer to data from the 2011 ANZARD report, detailing all IVF treatments of 2009 and resulting births through 2010 in the under 35 year age group.

In its award citation, judges said the website helped overcome the obstacles posed by the remoteness and isolation affecting many indigenous communities and held HealthInfoNet up as a model for communities and projects outside of Australia to follow. Prof Thomson said HealthInfoNet was used not only by medical and health providers in the field but also by policy makers, government and nongovernment organisations, researchers, academics and the general public. n

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NOW AT 2 LOCATIONS LEEDERVILLE & BUNBURY

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

A Sporting Chance

n (l to r) Dr Parbodh Gogna, Mr Bradley Giblin

(nephew), Dr Charan Gogna (GP in Otley, Yorkshire) and Dr Sabodh Gogna (GP in Leeds).

As the Rugby World Cup becomes a distant memory, spare a thought for Dr Parbodh Gogna who still bears some of the scars, self-inflicted. ‘Gog’ sent us details of his 2003 exploits but since then, the event “has been a byword for

the men folk of Clan Gogna to meet, share tales of medical daring and celebrate that we are all still kicking along”. A refugee from the UK, Gog says he has switched allegiances fully to Oz, having served in the Australian Army and attended the 2007 event in France. “I am now well and truly ensconced as a Wallabies

supporter and you will note in the photo my brother wearing a New Zealand scarf just to wind me up!” he stressed. His first trip to New Zealand was marked by marvellous hospitality and fantastic people, even though the weather while kayaking up the Bay of Isles reminded him of good old England. n

Helping Out in PNG Dr Norm Pinksy has just returned from a medical trip in the mountains of Papua New Guinea, accompanied by one other doctor and two nurses.

They flew by small Cessna to Kanabea in the mountains, a three-day walk from the nearest road. Without stores, phones, cars or electricity, Norm says they were welcomed warmly into the villagers’ huts. People walked for days to see them for treatment of fractures, burns, TB, malaria, meningitis, malnutrition and many other conditions. Norm said the best part was walking to remote aid posts away from the main clinic area, perhaps the only doctor to ever provide medical service, and certainly the only ever ‘white fella’ doctor. Norm said it was a privilege to be part of their lives and to be trusted to treat them and their children. n n Norm Pinsky pictured with the villagers – poor but

certainly happy!

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Theatre

Pippa returns for

By Peter McClelland

MARY POPPINS

West Australians love it when one of their own ‘makes it’ so when Pippa Grandison plays the Burswood soon, ‘kids’ of all ages will have another reason to smile. Perth and Pippa Grandison go back a long way – about forty years in fact! It all began at Hollywood High School when she auditioned for the Wizard of Oz. Pippa is living an actor’s life at full throttle with A Country Practice, Muriel’s Wedding and Babe: Pig in the City on her impressive CV. Now she is flying home to play Winifred Banks in that timeless classic, Mary Poppins. “I really enjoyed singing from an early age and Hollywood High School had a great Music and Performing Arts program. I did a bit of busking as well, although I wasn’t too concerned if it’d take me anywhere… I just loved singing! I read for the part of Dorothy in the school musical and got a call-back so I sang Somewhere Over the Rainbow. I didn’t even know what a callback was!” said Pippa. By her own admission, she was never going to be an academic star at high school. “I was always too busy gazing through the window. My science teacher used to say to me, ‘why don’t you go out and sit under the trees if you’re so interested in looking at them?’ I promised my mother I’d do my TEE, but apart from doing my tax return and telling my daughter how flowers grow I don’t really use much of it. I think I was bound for the stage and I’ve got no regrets… I’m very happy.” medicalforum

Pippa and her actor husband, Steve le Marquand are based in Sydney where they juggle auditions and lots of call-backs for TV, film and theatre work. And now they have a three-year-old daughter, Charlie, to juggle as well! “Steve’s in Melbourne with Summer of the Seventeenth Doll and we miss each other a lot. And Charlie misses her father, too. We usually take it in turns for the acting jobs but you have to take the work when it’s there – sometimes for financial reasons or it’s just a terrific role and you can’t say no. That’s one reason we live on the east coast – most of the auditions happen in Sydney and Melbourne and we’re at a tricky stage of our careers. It’d be nice to fly back to Perth to try out for a show but it’s a very expensive two-day expedition.” Australia, for an actor, is a relatively small pond compared with the USA and Europe. And, as Pippa points out, whenever and wherever you step onto a stage there are always those butterflies.

As a singer you’re working with your body and your vocal chords… The only time I’ve ever been on the point of absolute collapse was childbirth! “I could’ve gone overseas but I’ve always wanted to live in Australia. I’ve been lucky enough to work in almost every genre – television, film and theatre work. Theatre’s definitely my favourite because you’ve got the immediacy of the audience, the excitement and the adrenalin buzz. Sometimes that buzz spills over into nerves - I do suffer from occasional anxiety. With Mary Poppins, I took over the role of Mrs Banks with a short rehearsal time and was thrown on in front of a paying audience. I had a few sweats and tummy aches but I always try and breathe through it and tell myself that it’ll be okay.” Ironically, the most terrifying theatrical experience for Pippa was in a show she wrote herself. “I’d always had a burning desire to do stand-up, so I wrote a onewoman show and performed that with the current musical director of Mary Poppins. It was the most frightened I’ve ever been on a stage… the audience was two-thirds friends and acting peers and I almost couldn’t go on. I kept thinking… if I go out there and no one laughs I’ve still got another hour and a half of material to deliver. They laughed, luckily!” Pippa has never had a serious career-threatening illness, but for an actor in musical theatre a robust constitution needs to be on the CV as well.

n Pippa Grandison plays

Winifred Banks

“I do think sleep’s really important… as a singer you’re working with your body and in particular your vocal chords. If you haven’t slept well your throat becomes swollen, the vocal chords don’t vibrate properly and you lose some of your notes. I take vitamins and eat well and all the running around on stage keeps my cardiovascular system ticking over. The only time I’ve ever been on the point of absolute collapse was childbirth!” Pippa will be playing the part of Winfred Banks, the suffragette matriarch of a distinctly dysfunctional family. Mary Poppins to the rescue! “I really enjoy the character, it’s a lovely role to play and there’s an interesting journey within the story. I like to play intense, slightly edgy people and Mrs Banks is certainly one of those. It’s a very positive narrative but it’s real at the same time… the ensemble cast is amazing, the singing and dancing is incredible and it’s a really well-rounded piece. Theatre can be very uplifting and a wonderful place to escape!” n 43

the funny side Smart arse answers

It was mealtime on a Jetstar flight: “Would you like dinner?” the flight attendant asked. “What are my choices?” the man asked. “Yes or no,” she replied.

his 7-year old granddaughter for a few hours each Saturday morning, usually driving to Bunnings to fix things. One Saturday he caught a bad cold and stayed in bed. Luckily, his wife came to the rescue to take their granddaughter out in the car instead. When they returned, the little girl ran upstairs to see how grandfather was. “Well, did you enjoy your ride with Grandma?” he asked.

A lady was picking through the frozen chickens in Woolies but couldn’t find one big enough for her family. She asked a passing assistant, “Do these Chickens get any bigger?” The assistant replied, “I’m afraid not, they’re dead.” The trainee Scuba diver asked the instructor, “Why do Scuba divers always fall backwards off their boats?” “They have to go backwards. If they fell forwards, they’d still be in the boat,” was the reply.

Grandchild bonding As a family bonding thing, granddad was roped into take

“Sure did,” the girl replied, “and what’s more, we didn›t see a single tosser, blind bastard, dick-head, Asian prick or wanker anywhere today!”

Bunnings Tools Explained DRILL PRESS: An upright machine that suddenly snatches flat metal bars out of your hands, smacks you in the chest and flings your beer across the room. PLIERS: Used to round off bolt heads. Sometimes used in the creation of blood-blisters. BELT SANDER: An electric sanding tool commonly used to convert minor touch-up jobs into major refinishing jobs. BAND SAW: A large stationary power saw primarily used by most shops to cut good aluminum sheet into smaller pieces that more easily fit into the trash can after you cut on the inside of the line instead of the outside edge. STRAIGHT SCREWDRIVER: A tool for opening paint cans. Sometimes used to convert common slotted screws into non-removable screws and butchering your palms. SON-OF-A-BITCH TOOL: Any handy tool that you grab and throw across the garage while yelling ‹Son of a BITCH!› at the top of your lungs. It is also, most often, the next tool that you will need.

Sorry, a blonde joke “Last year I replaced all the windows in my house with those expensive, tinted, energy-efficient kind.

Radio gold

Today, I got another call from the contractor who put them in. He was still complaining that the work was done a year ago and I still hadn›t paid him.

This thank you letter was mailed to Lockridge Primary after the school sponsored a luncheon for seniors at which one elderly lady received a new radio as a raffle prize. She wrote…

Hellloooo....just because I›m blonde doesn›t mean I’m automatically stupid. So, I told him just what his fast-talking sales guy told me last year – that these windows would pay for themselves in a year.

God bless you for the beautiful radio I won at your recent Senior Citizens luncheon. I am 87 years old and live at the St Mary’s Nursing Home. All of my family has passed away so I am all alone.

Helllooooo? It’s been a year, so they’re paid for, I told him. There was only silence at the other end, so I finally hung up. I bet he felt like an idiot.

Dear Lockridge Primary School,

My roommate is 95 and has always had her own radio; but, she would never let me listen to it. She said it belonged to her long dead husband, and understandably, wanted to keep it safe. The other day her radio fell off the nightstand and broke into a dozen pieces. It was awful and she was in tears. She asked if she could listen to mine, and I was overjoyed that I could tell her to piss off. Thank you for that wonderful opportunity. God bless you all. Edna

Peter Brook

CICT/Théâtre des Bouffes du Nord

A MAGIC FLUTE

Purity, simplicity and innocence … come through with startling impact. NY TIMES

Mozart’s enchanting music takes centre stage as Peter Brook turns his hand to this comedic and adventurous tale with a talented ensemble who fill his rich score with new life, energy and colour. Education Program Partner

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Sat 18–Sat 25 Feb

OCTAGON THEATRE, UWA Prices $25–$82

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On the Grapevine By Dr Martin Buck

Kalgan RiveR Wines The Kalgan River is located in the Great Southern wine region and is 40km east of Albany. A few small wineries are located in the upper reaches in a pristine area identified by Californian viticulturalist Harold Olmo as having great potential for cool climate wines. Kalgan River Wines has been in the area for more than 10 years. It was originally established by the Ciprian family and recently purchased by the Fowler family. This range of wines is all single-vineyard grown and unirrigated with emphasis on minimal intervention in both vineyard and winery. The Southern Ocean is only 20km away and has a strong cooling influence on the vines, helping to create a unique terroir. The 2011 riesling follows early success in 2006 – and subsequent years – for this variety. It is not a typical Riesling with its subtle nose and a lively palate with a zingy acid finish. Soft flavours and a hint of residual sugar make this very easy drinking with 12.5% alcohol. Chardonnays from the Great Southern are often in the French Burgundy style and Kalgan River’s wine is definitely complex. Fermentation on new and pre-used oak, left on lees for six months and hand-stirring go to make a soft style with layered fruit flavours. It is an enticing wine with complexity that builds from the first glass. Perfect for those

who like their chardonnay restrained. All three red wines for tasting are from the 2010 vintage and are still young. The vintage report for 2010 in this region indicated a slow ripening period with good flavour development. The 2010 Cabernet is aged in new French oak but has soft tannins and good balance. Aromas of eucalyptus and cigar box oak are followed by a soft-fruit palate. This is a young and a lighter style, which will improve with medium cellaring. Syrah is term indicative of cool-climate shiraz made in the style of the Rhone valley in France. The 2010 Syrah is a coolclimate classic and is a careful balance of fruit and tannins. Trying to let the wine express flavours but at the same time making it more about complex than fruit alone is a challenge. I found this wine improving with another glass (or two) and it is very similar to a few in my cellar from Hermitage. It’s a wine to be savoured slowly and will acquire more complexity with medium cellaring. Lastly, the 2010 Shiraz Viognier has also some similarities to wines a little further upstream in the n Andries Mostert, Willoughby Park and Kalgan River winemaker

Rhone near Ampuis. Here the viognier is grown with the shiraz in the same rows and picked, fermented and bottled together. Again, it is a subtle expression of a wine style that can be a bit overwhelming. The 13.0% alcohol level reflects slow ripening of the fruit and I found this a wine to have some potential. It was probably my favourite of the reds and will look forward to another taste next year. Finally a desert wine, the 2010 Botyritis riesling “liquid Gold” is a very pleasant end to a tasting. It has balanced sweetness without being overwhelming. A very fresh, lively desert wine and a great choice for some after-dinner cheddar and chevre. Kalgan River is a hidden gem and definitely on my list for a return visit Ed. For more information or online purchase, see www. kalganriverwines.com.au

WIN a Doctor’s Dozen! Courtesy of Medical Forum

DOCTOR’S DOZEN COMPETITION

Which Kalgan River Wine does Martin say has similarities to wines of the Rhone valley near Ampuis?

Answer:

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Competition rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, February 28, 2012. To enter the draw to win this month’s Doctors Dozen, return this completed coupon to ‘Medical Forum’s Doctors Dozen’, 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Name:

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Cycling

Fun

By Peter McClelland

Philanthropy

Albany to Perth is 700km of long, demanding and often dangerous bitumen. In the last week of March, three passionate cycling medicos will don the lycra, clip into the pedals and swing into the saddle to raise awareness of youth suicide. This is the 10th Ride for Youth between Albany and Perth and these events have raised more than $4.5m for Youth Focus, a WA charity working with young people at risk of self-harm. Around 88 riders will be wending their way through towns such as Denmark, Bridgetown and Collie before finishing in Perth. They will be keeping self-preservation, as much as fun and philanthropy, in mind. GP Gavin Marsh from the Queen’s Road Surgery in Mt. Pleasant and his wife, Karen are both keen cyclists.

Safety

“My wife cycles with me and it’s become an important part of our recreation and an opportunity to participate in community work. We’re always looking for novel ways to raise money – one year we challenged the locals at the Pemberton Pub to an arm wrestling competition and found out just how puny cyclists’ arms really are!” said Gavin. Gavin plays an important role in mentoring other riders and promoting cycling safety. “I’ve been a team captain in previous Youth Rides. This involves supporting novice riders to achieve their potential while remaining safe on the road at all times. I’m the sweeper – the rider who travels at the back to make sure no one is left to fend for themselves.” Gavin is adamant about two safety issues in particular – sharing the road with motorists and the use of helmets. “It’s really important to help people understand that anger never solves any dispute between a motorist and a cyclist. And, regarding the use of helmets, I’ve seen a stack of broken ones which has meant the difference between a traumatic head injury and normal functioning.”

Dr Mike Aitken, an obstetrician at SJOGH, will be part of the peloton between Albany and Perth. He has as a similar focus on cycling safety, particularly from a planning point of view. “Cycling has so many benefits for individuals and the wider community so I just can’t understand why more resources aren’t used to improve safety. For example, widening the shoulders of key roads would be a great start and the policy of constricting roads with excessive median strips and concrete kerbs isn’t helpful at all. Local government should invite more input from cyclists for all their road and pathway planning,” said Mike. Specialist physician, Arthur Criddle had a very good reason to jump on a bike – by the

Thanks to cycling I’ve lost 14kgs and managed to stay away from the surgeons. Dr Arthur Criddle

One year we challenged the locals to an arm wrestle! Dr Gavin Marsh 46

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HELMETS: An Opposing View n

1991 – Australia introduces mandatory bicycle helmet laws despite opposition from some cycling groups. Helmet use increases from 30 to 80% coupled with a 30-40% decline in cycling numbers. Helmets: designed to absorb direct impact at 19.5km/hr. Commuter cyclists (typical average speed) 25km/hr. Sports cyclists 30-40km/hr. “Australia’s helmet laws are a public health and safety disaster.” Chris Gillham www.cyclehelmets.com

Biking South Vietnam GP Colin Hughes from the Swan View Medical Centre and his wife, Barbara recently saw South Vietnam from the saddle of their bicycles. Colin shares his Vietnam adventures with Medical Forum mocktails of fruit juice and lemonade and dodging trucks, buses and motorcycles along the way. Absolutely stunning scenery! Misty rain above the clouds, terraced rice paddies stretching for 30kms and rice, corn and coffee beans drying by the side of the road – we’re very careful not to run over the produce! The roads make for some interesting cycling – potholes and corrugations, beeping trucks and motor-bikes with dad, mum and a baby squeezed in the middle. We wait for water buffalo being herded along by villagers in triangular coolie hats and then it’s up another hill and the satisfaction of reaching the summit. From the coast with fishermen and their basket-boats and nets to cool, quiet rubber plantations stretching for miles and noisy villages with smiling children calling out,

Getting Ready

he had reached his early 40s he had clocked up three back operations including a spinal fusion. “Thanks to cycling I’ve lost 14kgs and managed to stay away from the surgeons – cycling holidays in France, Spain, Italy and South Africa have been a great reward. I’m making another appearance on the Ride for Youth this year with my wife, Megan. It’s a great cause and I think Australia needs to build a philosophy of philanthropy,” said Arthur. As Arthur points out, the safety planning on the Youth Ride is exemplary. “It’s important to remember that this is a ride and not a race. Having said that, there are 88 cycling two abreast to minimise the size of the peloton and we do reach speeds of around 40kph. There’s only been one accident in ten years – last year a rider took a tumble and broke his pelvis but prior to that every rider who started in Albany has made it to Perth. There are safety vehicles in radio contact at both the front and rear of the peloton allowing cars and trucks to come through safely - when we’re coming through Pemberton with all the logging trucks on the road that’s important.” Protective helmets, for all the cycling medicos, are an absolute must! “We love helmets! It’s compulsory for all the riders in the Tour de France and that’s good enough for us. I know there’s been resistance from some recreational riders and commuters but as far as we’re concerned we wouldn’t ride without them. In fact, in the Ride for Youth you aren’t permitted to ride without a helmet!” said Arthur. n medicalforum

Ride 3x30 minute sessions/week, 10-15km distance.

Month before departure – 4x50km rides on hilly terrain.

Don’t push it! If you need to rest, that’s okay – it is supposed to fun!

Staying Healthy n n n n n n

Powdered Gatorade and personal water-bottle. Riding Gloves, Bike Pants and Shirts. Removable Gel Bike Seat. Sunscreen. Small First Aid Kit: Fixamol/Hypofix/ Betadine Swabs. Backpack for souvenirs and clothes.

n Dr Colin Hughes smiles while his wife and fellow biker, Barbara takes the shot – why no face mask Colin?

‘Hello… what’s your name?’ Their smiles get even wider when we give them a toothbrush, soap and shampoo from the hotel or, even better, a furry toy koala! And the food - dragon fruit, pineapple, watermelon, guava and pears! Lunch of omelette, chicken stew and Vietnamese rolls stuffed with tomato, cucumber and cheese. And then a blissful hot shower, washing filthy shorts and socks and dinner – frogs, water-spinach and morning glory with garlic, chilli and prawns. Day’s end – back to the hotel and a cool Tiger beer, tired bodies and drooping eyelids and a well-earned sleep. n n Group hug after a long ride, with the bus just out of sight!.

COMPETITIONS www.MedicalHub.com.au

Concert: Tafelmusik – Galileo Project Win a double pass! Toronto based ensemble Tafelmusik takes you on an epic space odyssey, performing exquisite period music from memory before stunning images from the Hubble deep space telescope. Combining music, photography and story-telling, The Galileo Project brings to life the brilliant minds of the early astronomers and the music that inspired them, as a large-scale, everychanging backdrop of stars and planets unfolds. The group’s 17 musicians perform works by Vivaldi, Monteverdi, Purcell, Handel, Telemann and JS Bach.

Happy Wine Winners share Moombaki spoils!

Perth Concert Hall, Thursday March 1, 7.30pm

Dickens’ Women Win a double pass to the Friday 30 show! BAFTA® award winning actress Miriam Margolyes returns to Australia for a special encore national tour of her one-woman tour-de-force, Dickens’ Women. The show celebrates the Bicentenary of the birth of Charles Dickens and brings to life twentythree of Dickens’ most affecting and colourful female characters. Margolyes presents her powerful, comprehensive and at times, hilarious exposé of Charles Dickens - the man and his writing. His Majesty’s Theatre, March 30-31. 9484 1133 or www.bocsticketing.com.au

Cinema: He’arat Shulayim Win a double pass! Israeli director Joseph Cedar (Beaufort) directs a satirical drama of sacrifice, temptation and father-son rivalry set in the cut-throat world of ... academia. Curmudgeonly Prof Eliezer Shkolnik has spent his career in anonymity, his only recognition a footnote in the work of a greater scholar. To his chagrin, his son Uziel garners the accolades he has long desired. When a mistake stands to finally bring Eliezer recognition, his son must grapple with the truth. In Hebrew with subtitles. Somerville Mar 12-18, 7:30pm. Joondalup Pines Mar 20-25, 7:30pm. Tel 6488-5555 or perthfestival.com.au

Cinema: The Forgiveness of Blood Win a double pass! Seven years after his acclaimed Maria Full of Grace, director Joshua Marston returns with a unique family drama set in rarely seen Albania. This powerful and atmospheric drama traces the aftereffects of a blood feud on the youngest members of one family. Under house arrest for his father’s crimes, 17-year-old Nik is torn between preserving his safety and pursuing his first love. His sister Rudina must use her ingenuity to support the family. In Albanian with subtitles. Joondalup Pines March 27 – april 1, 7:30pm. Tel 6488 5555 or perthfestival.com.au

Cinema: A Little Bit of Heaven A guarded woman finds out she’s dying of cancer, but when she meets her match, the threat of falling in love is scarier than death. Directed by Nicole Kassell. Starring Kate Hudson, Gael Garcia Bernal, Peter Dinklage and Lucy Punch.

Dr Molly Peters, Senior Consultant Haematologist and her Practice Manager, Marianne Hayter were very happy indeed when they visited the Medical Forum office just before Christmas. And why wouldn’t they be? They drove away with a Doctor’s Dozen carton of mixed whites, and reds and just before the festive season too! Marianne has savoured Moombaki’s delights at a wine-tasting in Albany and she and Molly were looking forward to having some of the winning wines on the Christmas table. Democracy rules at Molly’s Nedlands practice – Marianne entered the competition and they’ll be sharing the Moombaki spoils!

NOVEMBER 2011 $10.50 MAJOR SPONSORS

Perth Pathology www.mforum.com.au

WA’s Independent Monthly for Health Professionals

COMPETITION WINNERS from November edition

Esquisse - Pipe Organ Plus Concert: Mr Colin Lagalia & Dr Jenny Smith

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Aged Care

CIs for Dementia Dementia Living Tips Enriching Ageing Minds Aged Support Groups The Two-Edged Sword PLUS Humour, Guest Columns, Artful Doctors and more …

Clinical Updates Opioid Use Liver Cancer Cervical Cancer Childhood Eczema Cancer Thrombosis Antibiotic Resistance

The Women on the Sixth Floor – Movie: Dr Ruth Highman, Dr Cathy Kan, Dr Andreea Harsanyi, Dr Linda Wong, Dr Kym Silove, Dr Martin Greer, Dr Michael Leung, Dr Katherine Shelley, Dr Sue Bant & Dr Ted Khinsoe Christmas with the andrew Sisters – Cabaret: Dr Lydia Peter We Bought a Zoo – Movie: Dr Hui Jern Loh, Dr Sayanta Jana, Dr Luca Crostella, Dr Germaine Wilkinson, Dr Nerissa Jordan, Dr Julie Copeman, Dr Fiona Whelan, Dr Esther Moses; Dr Boey-Leng Loy & Dr Patricia Dowsett The Iron lady – Movie: Dr Farah Ahmed, Dr Lin McVee, Dr Stuart Salfinger, Dr Ian Walpole, Dr David Bucens, Dr Tanya Subramaniam, Dr Clyde Jumeaux, Dr Robert Weedon, Dr Lawrence Chin & Dr Jenny Hart The Skin I live In – Movie: Dr Trixie Dutton, Dr Colin Lau, Dr Indrani Saharay, Dr Meilyn Hew, Dr Louise Marsh, Dr Parbodh Gogna, Dr Brendan Connor, Dr Andrew Toffoli, Dr Shih-Ern Yao & Dr Leonard Lum

In cinemas March 1, Hoyts Distribution 48

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