Medical Forum 05/12

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Doc of The Swan

Charity Fun Sail 2012

• Drs Across Many Cultures • Opiate Use Reflections • It’s All About the Horse • Going Crazy for You

May 2012

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Contents

Major Sponsors

FEATURES

CLINICAL FOCUS

4 Mental Health

30 Australian Society for

Commissioner Eddie Bartnik

8 Doc of The Swan 16 Cultural Diversity

Challenge

20 The Real Tyranny of

Distance

Dr Sarah McEwan

NEWS & VIEWS

Infectious Diseases

Conference Profile

33 Translational

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Research Feature

Prof Patrick Holt and Dr Dominic Mallon

35 Options for

Management of Chronic Pain Dr Roger Goucke

37 Having a Plan for

Opioid Prescribing

2 Letters:

Dr Revle Bangor-Jones

Dr Philip Green, Prof Peter O'Leary, Prof Annette Mercer, Ms Tracey Brooke, Prof Alan Bryant

38 Towards Universal

Precautions in Opioid Prescribing

12 Have You Heard 19 I Don’t Like Mondays:

Heart Sink Patients

21 Asthma Action Plan Dr Rob McEvoy

Beneath the Drapes

22 Pain: Proceed With

Caution

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23 E-Poll: Coroner Stirs

Drs Stephanie Davies, Eric Visser, Roger Tan and Nick Cooke

40 Dealing With a Strong

Family History of CVD Dr Stephen Gordon

41 Changing How We

Manage Back Pain Prof Peter O’Sullivan

43 Shedding Light on

Fibromyalgia

Opinion

Dr John Quintner

26 GP Ambassadors Fly

43 Fibromyalgia Support

the Flag

LIFESTYLE

Ms Jan Hallam

29 Practice Management

Network

GUEST COLUMNS 14 The System Needs

Official Visitors

Ms Debora Colvin

24 Frontier for Nurse

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44 It’s All About the

Horse

Mr Peter McClelland

46 Bend Zee Neeze!

Dr Hilary Fine

47 Wine Review:

Practitioners

Bellarmine

Prof Phill Della

Dr Martin Buck

25 NP-led Clinics Risk

48 Satire: People

Fragmentation

Management on the Mothership

A/Prof Frank Jones

28 CFS Challenges Us All Mr Marcus Doolette

20 COVER: Fortuosity heads for home (l to r): Winston Almeida, Stuart Salfinger, Janet Hornbuckle (skipper), Jared Watts, Alan Thomas and Mohammed Ballal (with Kylie Waller and Hannah Georgia-Price out of sight). Photo courtesy Peter Fredericks.

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Rural Doctors Honoured

Ms Wendy Wardell

E-Poll: Cutting Loose on Women Medicos

49 Best of Both Worlds 50 Cultivating a Full Life Mr Peter McClelland

Conference Corner

51 Funny Side 52 Competitions 1

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Letters to the Editor

Obstetrics win Dear Editor,

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

ISSN: 1837–2783 Advertising Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) 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 Editorial Advisory Panel Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website.

Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

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

The support of all advertisers, sponsors and contributors is welcome.

Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reflect the views of the authors.

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

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.

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

Graphic Design Thinking Hats 2

Medical Forum had a glowing article about GP Obstetricians at Armadale-Kelmscott (Not Everyone’s Baby But… March 2012) and Dr Ann Karczub wrote about the training of GP Obstetricians (Letters, April 2012).

I have a story about a situation that will drive GPs and possibly specialists out of obstetrics. It is the managers of Medicare and the interpretation of item numbers associated with obstetrics.

Without any notification that I have been aware of, the interpretation of Medicare items associated with managing labours and delivery has changed where either the GP is not able to charge a Medicare refundable fee for managing a complicated labour before referring to a Specialist Obstetrician (Item 16518) or the Specialist cannot charge a valid item for continuing to manage that complicated labour through to delivery.

I am aware of multiple cases of Medicare refusing to provide refunds for Items 16518 and 16519 in these situations.

It is this lack of respect for the skills of doctors at the ‘coalface’ by the bean counters in their ‘ivory towers’ that will leave women in our society without doctors with the necessary skills to manage their pregnancies and labours. It is certainly enough for me to reconsider my future as a GP Obstetrician.

Dr Philip Green, UMed Australind ED: Medial Forum approached Medicare for a response and got this reply from Department of Human Services: “In consultation with the Department of Health and Ageing, the Department of Human Services has reviewed the interpretation of the rules around claiming certain obstetricsitems. As a result, a change will be introduced to allow both a GP and a specialist to claim relevant obstetrics items where care for the patient has been transferred from the GP to the specialist. This change is retrospective, taking effect from 1 November, 2010. Once this change is implemented, (scheduled for mid-April) medical practitioners will be able to resubmit any previously rejected claims”. A win for common sense.

geospatial health mapping, patient blood management, health economics and cancer services.

The outputs from these research programs have been used to guide policy and planning, leading to improved health services. We believe that in many ways, the primary health sector has been underserved and that by collaborating with a GP champion, who is interested in developing a research focus, we could identify areas where health benefits can be achieved.

For instance, how effective are chronic disease intervention programs?

I realise GPs are usually fully occupied with caring for patients, however, if any are interested in developing careers as GP Researchers, we would like to speak with them.

We want to work with GPs who recognise the problems and realise that accumulation and presentation of evidence will deliver the best argument for changing practice.

Prof Peter O’Leary, Deputy Director Centre for Population Health Research, Curtin University

Smiles say it all Dear Editor, I would like to thank all the generous doctors who contributed to the success of the Doc of The Swan charity race and dinner, held at Royal Freshwater Bay Yacht Club on March 25, for such a brilliant day for special kids – well, not just for the kids, but equally for their parents too! There was not a single person there who did not have a great time.

Those of us who have not had the concerns these families face don’t always realise how hard it must be for them every day. Seeing the sheer joy on the faces of the kids and the parents, and the visible relaxation of tension on the parents’ faces makes you realise how rarely they get the chance to just have fun. Along with the superb team of kind and hardworking organisers, you made the day possible for these families. They all had fun, felt accepted and positively special. Words aren’t really enough to say thank you adequately, but I think all the happy faces said it pretty well.

The kindness of the doctors who partook in the race day and showed their generosity by contributing to the success of the fundraising side of the event – it was a perfect blend of ‘fun raising’ and ‘fund raising’.

Calling GP researchers Dear Editor, At the Centre for Population Health Research at Curtin, we would like to develop collaborations with one or more GPs who have an interest in primary care research.

We have a strong background in linking Health and other government databases to address a wide range of health issues, including the effectiveness of population screening programs, surgical audits, medicalforum

Letters to the Editor The three Support Groups that were treated to a lovely fun day and will benefit from much needed financial assistance are: • WA Special Families: A group for parents and carers of children with special needs.

• Childlimbs: Supports families with children who have congenital or acquired limb deficiencies.

• Defence Special Needs Support Group: Provides support, information and assistance to all Defence families who have a dependant with special needs.

You can rest assured that with the guidance of ConnectGroups, all funds donated will be used wisely to enhance the success of each of these groups.

Ms Tracey Brooke, Community Development Officer, Connect Groups ED. Tracey attended on the day and was a huge help. Thanks from us to everyone who took part (see pages 8-10).

Selecting medical students Background.

In our April letters, A/Prof Annette Mercer (UWA medical school) wrote in response to a Guest Column from Dr Lachlan Henderson, saying UWA had used a structured interview in selecting medical students since 1998. She felt this had been validated, in that an interview focused on good communication skills was related to academic outcomes in the latter clinical years of the medical course.

Further queries on medical student selection.

1. Dr Lachlan Henderson pointed out that the 1998 cohort Dr Mercer referred to would have graduated in 2004, so he wondered if Dr Mercer’s longitudinal study was extended beyond academic performance during training, to review the correlation with junior doctor performance or career choice?

Dr Mercer responded it had not, partly due to the difficulty finding suitable measures of performance.

2. A doctor, who wished to remain anonymous, also wrote: “I note in her reply to Lachlan Henderson that A/.Prof Mercer refers to the "security and integrity of the process". I have been informed by someone who seemed in a position to know that the Indian community was benefiting from coaching by an interviewer some years ago. Are you able to discuss this allegation with her?”

Prof Mercer responds: It is unfortunate that the practice of attending preparation courses for aptitude tests and interviews; and receiving tutoring for both these forms of assessment, has become commonplace

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across Australia for aspiring medical students. Medical schools do not support or endorse any specific form of preparation. Indeed it is just this situation which has led UWA to change the questions asked in the interview each year, to deter applicants who come to an interview with a prepared response. We have also seen some of the information disseminated by some ‘tutors’ and we feel that in many cases it would actually be detrimental to the applicants. Interviewers and interviewees sign a confidentiality agreement imposing a moral obligation to ‘do the right thing’. Unfortunately, from time-to-time there are people who don’t adhere to those moral and ethical constraints. We have dealt with several such situations over the years and we will continue to do so when we have the relevant information.

Foot surgery Dear Editor, RE: Letters by Dr Graham Mercer and Mr Frank Pigliardo (February edition).

Readers may not be aware that the standard podiatric education has improved considerably in recent years, delivered within the UWA FMDHS School of Surgery. Much of our present four-year course is taught in common with medical or dental students, and will be replaced in 2013 with a three-year postgraduate Doctor of Podiatric Medicine degree that will further improve podiatric education.

To become a podiatric surgeon at UWA a graduate must also complete a three-year Doctor of Clinical Podiatry program after spending two years in general clinical practice. Surgical training in the DClinPod program includes the correction of digital and metatarsal deformities, hallux valgus/rigidus, removal of Morton’s neuromas and painful ossicles and exostectomies of the foot (under LA, with or without sedation, in a licensed Class-B Day Hospital at UWA).

The Australasian College of Podiatric Surgeons conducts a private parttime practical training program. Podiatrists entering this program have not completed a two-year podiatry internship as Mr Pigliardo contends, as regrettably none is available in Australia. The UWA program takes a more conservative approach than ACPS and is restricted to routine elective foot surgery, in keeping with that currently performed in Australia.

Podiatric surgery in WA has a commendable record. Contrary to Mr Mercer’s belief, patients do understand that podiatric surgeons are not medical practitioners as no Medicare rebates exist for podiatric surgery, including anaesthetist fees. Despite financial disincentives, an increasing number of patients elect to have their foot surgery performed by podiatric surgeons, often on referral from their GP. It is time for orthopaedic and podiatric surgeons to work more collaboratively in Australia as happens in the UK and US. Prof Alan Bryant, Head Podiatric Medicine Unit, UWA

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Spotlight

n Mental Health Commissioner Eddie Bartnik

Mental Health – the Ball is Rolling It’s been two years of meeting thousands of people, now the country’s first Mental Health Commissioner Eddie Bartnik is ready for action.

In 2010, the WA Government became the first in the country to establish a Mental Health Commission, but this was not yet another community awareness exercise.

The MHC was given the mandate to lead the state’s mental health reform along with a $530m budget and a strong political commitment.

Eighteen months into the job and Commissioner Eddie Bartnik is about to deliver a new mental health Bill to Minister Helen Morton which aims to strengthen the rights and protection of people with mental illness and change the emphasis in mental health from hospital-centred care to increased community care and support.

Mr Bartnik, a trained clinical psychologist, held senior positions in the WA public service including the Disability Services Commission and was acting Director General of the Department for Communities. And he has a clear strategic policy for mental health with the recently launched Mental Health 2020: Making it personal and everybody’s business.

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“Our vision for mental health is to bring it into the community and make it part of ordinary life,” he said. “Mental illness has been something that has been hidden away for too long. We were looking for cultural change that would move mental illness out of the mysterious, medical realm into the

When I talk to people who have been in the sector for a long time they say, ‘oh these ideas have been around for ages’, but what’s happened in the past is poor implementation lives of ordinary people in the community with a stronger focus on the unique strengths and needs of people with mental illness and their families, and building a good life for people. We certainly felt that too much focus was on the diagnosis and illness. After all, people are people and it could be any one of us or our families with the illness and we all want to be understood and to be treated as individuals.”

“We are looking at giving people more choice and repositioning the medical and acute care aspect, which, of course, is vitally important, but not so much that it is the defining feature of people’s lives. There was also a view that it was going be left up to the mental health services to deal with these problems, so we wanted to engage the whole community – to get families, schools, workplaces, government services, GPs and community organisations as well as specialist mental health services involved.”

“When I talk to people who have been in the sector for a long time they say, ‘oh these ideas have been around for ages’, but what’s happened in the past is poor implementation.”

The MHC has been putting its money where its mouth is with $25m allocated for transitional support programs, $46.5m for 100 social houses, $12.8m for 44 individual intermediate care units and nearly $20m to support and grow the community groups and not-for-profit sectors.

Continued on Page 6 medicalforum

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Spotlight Continued from Page 4 “When I first came to mental health there was only about 7% of the mental health budget allocated to the NFP sector. People with serious mental illness need support around them – where they live, help them to get work, manage their health, their medication, finances. We have invested more than $6m in the NFP sector to make sure they’ve got good infrastructure and well-trained, reasonably paid staff so they can properly provide the support to the community. This year we are looking to develop a strong partnership with Connect Groups – a network of peer support and self help groups that is doing some fabulous work.”

“A big challenge at the moment is around community mental health in partnership with GPs and others to support people in the community so that treatment in hospital becomes the last resort and not the first resort.”

“In most areas of government reform you need to effectively manage critical needs but you can’t just keep focusing solely on criticality because that’s all you’ll ever do.”

Surveys show that up to 40% of people in mental health in-patient facilities around the state could go home if they had support at home, or a home to go to. If we keep building more beds because of demand, that’s not really addressing the issue of a lack of community support.”

n The Commissioner at the launch of last year's Music to Open Your Mind.

more complex or more serious than they are able to handle, they can have easier access to the next layer of support.

“We have funded a mental health project officer to work with GP Networks to help GPs with training, support and also helping them understand the changes to mental health. I’ve also been meeting with the various chairs and CEOs of Medicare Locals because it’s not always a very connected mental health system and you can have holes, so we’re trying to grow our initiatives closer together.”

n Eddie Bartnik with MLC Wendy Duncan and Mental Health Minister Helen Morton at the opening of Headspace in Esperance

GPs are a vital component of the Commission’s community strategy because they are often sought out first by people experiencing mental illness and their families.

“Although funding of GPs is primarily a Commonwealth responsibility, we have been working with GP Networks and Medicare Locals because we want to bring the specialist mental health system closer to the GP. So when GPs are at the frontline, dealing with someone whose issues may be 6

Public comment on the draft Mental Health Bill closed early in March with more than 1000 submissions from a range of groups and individuals – from consumers, families and carers to government agencies to professional medical groups.

“It aims to create an environment where hospital and involuntary treatment occur only when it is absolutely needed,” Mr Bartnik said.

“When I first came to mental health I got the message loud and clear particularly from families and carers that when their loved one went into hospital, they often didn’t get the information they needed.

People would be discharged and the family wouldn’t know what was going on.

“So the Bill seeks to increase the rights and protection of people, a greater involvement

of families and carers, and strong independent advocacy because when people are detained involuntarily, that’s a very serious step.”

While many of the submissions published on the Commission’s website praised these increased rights, the hot-potato issues of mental health hit raw nerves. Areas such as the use of ECT, children and consent, and advocacy attracted many submissions including the Royal Australian and New Zealand College of Psychiatrists, the Commissioner for Children and Young People as well as a myriad of concerned individuals.

“There was some unfortunate wording in the draft Bill which we will certainly change. We could have taken longer, but we were all keen to get the draft Bill out so people could have a look and give us their feedback,” the Commissioner said.

“One of the classic debates has been around ECT. I went to quite a few of the public forums and in the one room there would be people saying it should be banned and others who said it saved their lives. So the challenge for the Minister and the government is to steer a reasonable course through all this and one of the keys to the heart of it is people being able to make good decisions and giving informed consent.”

The Bill will be introduced into Parliament during this term of government. After gestating so long, the Commissioner says it’s imperative to keep the process moving because “there’s a great appetite for change”.l

By Ms Jan Hallam See the Guest Column on advocacy on P14 medicalforum

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Doc of the Swan In virtually all cases, people pictured at the helm are doctors, most skippers for a day!

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1 1. (l to r) RFBY’s Carol Martin and Rear Commodore Ian Clarke, with organiser Chrissie Jordan, winning boat owner Manfred Speicher (Baccante) and Doc of The Swan skipper Ed Fethers, with crew Luke Ritchie and Bethany Speicher.

2. Children pose for the community newspaper, aboard Nokomis.

3. Zoran Nevjestic, Stefan Golic and Zlatan Golic aboard Zlatan’s Adriatika.

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4. "No Strings” owners Basil and Jenny Twine with guest children who had such a good time they asked Basil for an extra ride!

5. Angel (the fairy) Quinn, and Anneka (pirate girl) won prizes for best dressed children.

6. Libby Galton-Fenzi, Debra Harvey, Penny Hamilton, Phillip Harvey, Angela de Paor aboard En Avant.

7. An exuberant Andrew Dunn with his all-female crew aboard My Kuti.

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Photographer, drag car exhibitor, and policeman Peter Fredericks has placed event photos at www.horseplayphotos.smugmug.com download-purchase to raise more money for charity.

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15 8. Nimbus owner Sean Martin aft of skipper Bret O’Mahoney, Paul Rodoreda, and Marina Wallace.

9. Aboard Indie we can pick Geoff Salter (white brim hat) and Conrad Todd with Dr Jenny Brockis at the helm. The rest are a mystery!

10. Al Fresco (l to r) : representing the SAS Project Brathwaite were Leisa, Ash Haggarty, crew member, guest skipper James FellowsSmith, Nathan Bampton, Gerry Bampton, John Newton, Trevor Gunning and Peter Larter.

11. No Strings makes an ideal observation deck for guest families.

12. Ready to burn rubber! Police officer Michael straps the boys in.

13. A wave from Andiamo – Lance Woods as skipper, unknown crew, and Evan Woods.

14. Marcus Atlas at helm of Men In Black, with Brad Stout alongside, with his son James.

15. Drag car beauties and raffle assistants Nakita De Souza and Nikki Heyden.

16. Claire McTernan helms Mulberry (owner Peter Hickson).

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Philanthropy

Doc of The Swan, 2012 The new Royal Freshwater Bay Yacht Club function centre was ‘christened’ by Doc of The Swan this year, with more than 100 participants in the event – the 20 yachts, skippers and crew for the day, plus invited guests from the three benefiting self-help groups. These groups were chosen by Connect Groups around the theme of ‘children with special needs’ – WA Families with Special Needs, Childlimbs WA and Defence Special Needs Support Group.

Twenty kids were treated to a wonderful day with a trip aboard spectator craft, a sponsored meal, a drag car experience, and face painting, all courtesy of Metro Lintels.

Many dressed up just for the occasion… plenty of smiles.

Dr Ed Fethers (retired) took some flack when the yacht he skippered, Bacchante, one of the older boats in the fleet, won Division 1 on handicap. Second place went to Dr Doug Starling on Slippery Sucker and in third was Dr Bret O’Mahony on Nimbus.

Division 2 handicap winner was Dr David Perlman, owner and skipper of Nell.

Coming a close second was Dr David Roberts, owner and skipper of Norsk, and third place went to Dr Lance Woods at the helm of Andiamo.

Winner of the Baron-Hay Perpetual Trophy (Fastest Time) was Division 1 offshore racing yacht Sled, skippered by Dr Liz Whan.

Other Division 1 skippers-for-a-day were Dr Janet Hornbuckle (Fortuosity), Prof Marcus Atlas (Men in Black), Dr James Fellows-Smith (Alfresco), Dr Zlatan Golic (Adriatika), Dr Simon Dimmit (Windward), Dr Claire McTernan (Mulberry), Dr Malcolm Thompson (Smoke on the Water) and Dr Jenny Brockis (Indie).

Racing in Division 2 were wouldbe skippers Dr Peter Packer retired (Scoundrel), Dr David Mortley (Spirit of Tommy), Dr Jayson Oates (Shades), and Dr Brian Galton-Fenzi (En Avant).

Unplaced were Dr Andrew Dunn (My Kuti) and Dr Ross McLaren retired (Idle Bones).

VIP boat Nokomis carefully manoeuvred among the fleet, thanks to the efforts of Di Porter and Craig Grundman, while children and parents or carers were given a close up of the race on three spectator motorcraft – YO!3 (RFBYC commodore Peter Ahern), Dolphin (skipper Mark Lovelady), and No Strings (skipper Basil Twine).

n Face painting, kids fed and happy, and the new RFBYC venue.

The major raffle of the Fremantle Esplanade Hotel two-night package was won by Ron Reddingius, from Gwelup.

The charity auction of donated products and services raised $3700, thanks to the generosity of Rotorvation Helicopters, Restaurant Amuse, Swan Jet Adventures, Ozwest Aviation, West Coast Eagles, ‘Beat The Heat’ Drag Team, Next Byte, Mulberry Wines, Swan Jet Adventures and Royal Freshwater Bay Yacht Club. Other fundraising came from registrations, a silent auction, and donations – the target of $10,000 should be a shoo-in.

Particular thanks to the Royal Freshwater Bay Yacht Club organisers, boat owners and their skeleton crews, along with the volunteer start team and safety boat.

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Pictured from left: Dr Bernard Chapman, Dr Pascall Burton, Dr Philip House and Emeritus Professor Max Kamien.

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11

Have You Heard?

News flashes WA GP Dr Mike Civil has his wish. It’s a contest, with RACGP vice-president Dr Liz Marles deciding to contest the RACGP presidency. And Ian Morris, Chief Imaging Technologist at PMH is ‘ecstatic!’ after commissioning of the CT Flash Scanner, now up and running. The only one of its kind in WA – faster, lower dose, quieter – the ‘Flash’ does a complete body-scan in 1/16th of a second and reduces radiation doses by up to 40%. Kids at PMH may not appreciate the $1.9m price tag but the extra ‘Gs’ might be an enjoyable ride. Thanks to Telethon.

patient services. Currently, eight orthopods have contracts to operate on public patients at PHC, and there are some transfers of patients to Fremantle and Rockingham hospitals for more specialised treatment.

PHC has about a 70:30 public:private split of services overall and we assume substantial orthopaedic work would come via their busy ED.

Taxing time Some Perth doctors are having a particularly taxing time. The process of trying to find and, in some cases read, old and faded receipts and dockets going back eight years is not much fun. But then again, a tax audit never is. A spokesperson from the ATO told us there was nothing specific regarding the medical profession in the current compliance program (see: www.ato.gov.au/corporate/ content). Details for next year’s fun and games will be released in July.

Broken bones contracts Orthopaedic surgeon Gig Pisano failed to get an interim injunction in the WA courts to stop Health Solutions (WA) from terminating his public patient contract at Peel Health Campus. We do not know the ins and outs of the case but readers are probably curious about ongoing orthopaedic services there. Health Solutions are a private company contracted to provide public

The alcohol debate The medical press is being influenced like the lay press, with zealots one end and guzzlers the other. For a balanced view on alcohol consumption and health effects, try www.alcohol-forum4profs.org out of Boston University. It gives some insights on how research can be tainted with a purpose in mind. And it all depends which part of the U-curve you like, according to one lot. Alcohol consumption and prediabetes/diabetes – drink a little and it staves off diabetes but too much, and you are in trouble. Pushing moderate alcohol as a healthy message is the new mantra for some, with websites to prove it (see www. drinkingandyou.com)

Rock star in our midst Periodontal disease with receding gums can delay conception by about two months, particularly in non-Caucasian women, according to KEMH researchers who quizzed 2000 women. They are looking at gum disease and a range of pregnancy outcomes. The effect was about as strong as being overweight, which has a public health message. This brings us to “the rock star of public health” (according to a Public Health Advocacy Institute e-newsletter), Prof Mike Daube, lauded recipient of the 2012 Luther L. Terry Distinguished Career Award. Luther is renowned for joining the dots in the 1960s between lung cancer and smoking. The

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help GPs do just that. The Faculty of Pain Medicine, A&NZ College of Anaesthetists the RACGP had been given $200,000 by Bupa Health Foundation plus Janssen Australia assistance to make it happen, after all, we had more than 3.2m Australians with chronic pain costing $34.4b a year.

Prof Claire Jackson said it would help relieve tertiary care facilities and clear up confusion for GPs. And the RACGP had a Pain Management Network of GPs and an online gplearning platform that was ideally suited, with anticipated access to all and RACGP accreditation. Where is it? All will be revealed next August, the RACGP said – Pain Management Network Chair Dr Stephen Leow (Adelaide) did not respond to our request for more info.

award comes from the American Cancer Society, which has three board members and an award selection panel that singled out Australia this year. An award for Outstanding Leadership by a Government Ministry also went to the federal DoHA for its stand against tobacco, especially plain packaging laws, and an award for Outstanding Research Contribution went to Prof Melanie Wakefield PhD (Cancer Council Victoria) for her review “The cigarette pack as image”.

Easy come, easy go?

The PMH Foundation, with $26m in assets, lost $1.6m of donated money in 2007 on bad investment advice, they say, and will now attempt recovery with the help of lawyers, at no further cost to the Foundation. The 2011 annual report says only 5% of funds raised comes from wills and bequests, but this figure varies considerably from year-to-year.

PMH Foundation has a benchmark of 20% of revenue as admin and an average 30% limit on outgoings for any fundraiser. In a recent Supreme Court ruling the $3.7m estate of Mr Desmond Taylor will be split between PMH Foundation and Diabetes WA, according to

Painfully slow With too few pain specialists to go around, everyone is dying for GPs with a special interest in pain management to apply their all-rounder skills in this area. So we were pleased that the June 1, 2011, press release announced a new online educational program was on its way to

the partly handwritten will. The Foundation will also receive sizeable amounts when PMH moves in a year or two (current grounds valued at $4.22m). New CEO Denys Pearce is injecting some welcome transparency into the organisation.

How risky are you?

Who are the high risk medicos when it comes to indemnity insurance? Looking at the stratification of risk categories, such as the MDA National Risk Category Guide, worst-to-best-risk picks include O&G specialists practising as obstetricians, neurosurgeons, cosmetic surgeons (no FRACS), cosmetic surgeons (FRACS), orthopaedic surgeons, non-cosmetic ENT surgeons, GP obstetricians doing deliveries, non-surgical gastroenterologists, procedural GPs, non-procedural GPs, cardiologists then geriatricians.

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Guest Column

System Needs Official Visitors

Q

Independent inspection of mental health facilities is under threat in the draft Mental Health Bill, says the Head of the Council of Official Visitors, Debora Colvin.

uestion: What do prisoners and involuntary mental health patients have in common?

Answer: they are both detained against their will. Question: What is one thing

prisoners and involuntary mental health won’t have in common if the Mental Health Bill gets passed in its current format?

Answer: an independent inspection body.

Actually there are a lot of other things they have in common – a substantial proportion of prisoners have a mental illness and both are vulnerable groups of people – for different reasons but, as recognised by the Optional Protocol to the Convention Against Torture, anyone detained is vulnerable, which is why there needs to be an independent inspection body.

Then there is the custodial wording used in the draft Bill – just count up the number of references to detention. And if the person is unlucky enough to live in a “declared area” they can be held for up to 13 days before an assessment has to be made whether they should be involuntary. There are also powers allowing an undefined “authorised person” to search, and seize articles from, any patient and anyone who presents at an authorised hospital with no requirement for a reasonable suspicion of any illegal activity.

There are many good things in the Bill including the greater emphasis on rights (for patients and carers), the concept of the

Charter of Principles, the requirement that psychiatrists must “have regard” to patients’ wishes (including involuntary patients), shorter time periods for involuntary orders and Mental Health Tribunal reviews, patients being given copies of written second opinions, the “nominated person” role, the requirement of a treatment, support and discharge plan and patients being given a copy of the (edited) referral form that results in them being assessed by a psychiatrist.

The lack of an independent inspection body and the related removal of the monthly inspection role of the Council of Official Visitors is not one of the improvements.

Under the current Act, Official Visitors have both an inspection and an advocacy role. They must inspect authorised hospitals every month and psychiatric hostels every second month to ensure they are “safe and suitable” and that rights are observed. They do not have a big stick to do this but there is an Annual Report which must be tabled in Parliament and, in the 13 years of the council’s existence, they have been frank and fearless.

Under the Bill, the Council’s role is to be refocussed onto advocacy. There is a lot which is good about this as the advocacy will be available to a broader group of people including voluntary patients.

However the Mental Health Advocates (who will replace the Official Visitors) will

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This means that some of the most vulnerable people (long-stay patients and hostel residents), will no longer have the protection of someone regularly visiting to ensure that their rights are being observed because, for a myriad of reasons, they don’t tend to call and ask for help.

And, as there is no specific reference in the Bill requiring the Advocates to ensure the hospitals and hostels are “safe and suitable” (as there is now), there will no longer be an independent body enquiring into and reporting publicly on the environmental conditions.

They have powers to demand answers to questions and inspect every part of the place This is because the Henderson Report recommended a self-assessment model with the Mental Health Commission employing contract inspectors. This is not in the Bill so there are no minimum inspection requirements, no specific powers of entry or inquiry, and no independent report to Parliament. In similar models the inspections tend to take place every 3-4 years.

Comments have been made that these new inspectors will, for example, have building and other qualifications and will be “more professional”. This reflects a misunderstanding of the role and benefit of monthly visiting and inspection by Official Visitors. Official Visitors ask themselves, “Would I like my mother/husband/son/ daughter to be in here”, not whether it passes particular building tests.

Much of their inspection is informed by the patients or hostel residents and often staff as well. They have powers to demand answers to questions and inspect every part of the place.

Contractors visiting on a pre-determined date every 3-4 years won’t pick up on many of the things that are affecting the experience of the patients.

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not be required to visit and inspect facilities regularly. They will be required to contact or visit every involuntary patient within seven days of being made involuntary, but otherwise visits will be dependent on the patient or hostel resident requesting an advocate.

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More than 1000 submissions regarding the draft Bill have been received and many, including the Council’s, are on the Mental Health Commission website. (www.mentalhealth.wa.gov.au) It’s compelling reading. l medicalforum

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Feature

Cultural Diversity Challenges WA Doctors Health professionals are learning that delivering effective health care in WA requires a new level of cultural awareness, if only to avoid pitfalls.

WA has the highest proportion of people born overseas in any Australian state or territory. There are more than 200 cultural groups encompassing more than 100 different religious faiths living in WA and this socio-cultural diversity is having a big impact on medical practitioners and patients alike, according to Michele Kosky, Executive Director Health Consumers Council WA.

n Ms Michele Kosky, Health Consumers Council

“According to the last census, WA is home to people from 152 language groups many of whom have different understandings of health and sickness, childbirth and death and everything in between,” Michele said.

“It’s important to remember that we cannot base our knowledge and assumptions on a person’s country of origin. We know, for example, that there are both Christians and Muslims from the African region now living in WA. Medical practitioners are well aware that we’re living in a highly diverse multicultural society. Practical allowances need to be made for this highly disadvantaged group.”

Our response has to match the needs.

Michele reminded us that many are here for humanitarian reasons.

“They’ve lived through periods of extreme violence and witnessed the torture and death of family members, not to mention grinding poverty and fear of the state. Ease of access to interpreting services is essential for good health care and would also facilitate better communication with hospitals. There’s a real need for comprehensive training of health professionals so that they gain understanding of the background and experiences of some of our newest community members.”

A spokesperson from UWA’s Community, Culture and Mental Health Unit (CCMHU) outlines some of the benefits of the impending implementation of the National Cultural Competency Tool (NCCT).

“The NCCT will promote a greater collaboration between mental health professionals and patients from culturally and linguistically diverse backgrounds.

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CCMHU are offering training in implementation of the NCCT which will help services access clinicians with appropriate language skills, interpreters and even traditional healers. It will link services to transcultural mental health experts and assist in embedding culturally appropriate organisational processes.”

“Once it is up and running, this tool will make important and practical differences to people suffering from depression right through to post-natal mental health issues. KEMH is already on board and is presenting a video-seminar on the NCCT to its rural and remote mental health networks. And a lot of NGOs have shown really strong interest.”

Primary care language barriers An astounding 74% of 92 surveyed GPs said every week, consultations were adversely affected by language barriers (see inset).

The majority (53%) put a figure of 1 to 3 consults a week, but 21% pointed to more.

When all the GPs were asked to use their experience to estimate the main problems arising in consultations done through a language barrier, most (83%) said ‘medical risk through miscommunication’.

Presumably, they had misinterpretation of medical advice by the patient, or of the medical history by the doctor, most in mind. In this regard, related influences they were concerned about included consultation time pressures (71%), influence from an interpreting relative (69%), and gender/ cultural effects on patient responsiveness (49%.)

[ED. TIS National is a 24/7 interpreting service with access to 1900 interpreters and more than 170 languages and dialects. Contact: 131 450.]

The Aboriginal experience Marion Kickett PhD is a senior lecturer in the Aboriginal Health and Education Research Unit at Curtin University. She sees great positives n Dr Marion Kickett PhD in students studying Indigenous Cultures and Health as a compulsory core unit.

“Last year, more than 2000 students from disciplines such as social work, pharmacy, physiotherapy, medical imaging and nursing completed the course. Some students aren’t too happy about being compelled to do the unit but we usually see a change in attitude a few weeks into the

April E-poll of 92 GPs

Q

On average, how many patient consultations per week in your practice would be adversely affected by a language barrier (incompletely overcome by whatever means)? >20........................................................ 0% 10-19..................................................... 7% 4-9........................................................14% 1-3........................................................53% 0...........................................................16% Doesn’t apply......................................10% What are the main potential problems in treating patients who have English as a second language - and you don’t speak their native language [choose up to three]?

Medical risk from miscommunication........................... 83% Time factor – it just takes longer to get everything done. .........71% Consultation altered by presence of interpreting relative...................... 69% Influences of gender or cultural hierarchy e.g. woman not allowed to interact freely.................. 49% Doesn’t apply....................................... 0% Other.................................................... 2% All situations easily accommodated = no problem ............1%

semester. These people are our future health professionals and they’ll certainly help close the gap for Aboriginal people.”

Women’s health important Dr Angela Cooney works in general practice and at Family Planning WA and in KEMH’s outpatient clinic and she says she is seeing more Muslim patients of Middle Eastern origin, n Dr Angela Cooney some of whom have excellent English, and also many African people.

“Cultural issues arise, such as a preference for a female doctor and that can’t always be catered for in the public system. By way of example, there’s a low tolerance for irregular vaginal bleeding in this group of women because it impacts on important

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cultural practices such as prayer. And again, for these women, deciding on appropriate methods of contraception can also be an issue.”

KEMH has a proactive in-house approach to cultural awareness amongst staff, with training courses and modules on cultural diversity. For example, the Department of Nursing and Midwifery Education/Research have a Care of Cultures presentation focusing on different cultural beliefs during grief and loss. There is also a Cultural Awareness training day for all staff working with childbearing women and a number of training modules for doctors on cultural understanding. There is also access to interpreters for non-English speakers, parent education classes for people with minimal English and a Salat Prayer room.

Dr Jason Chin, Obstetrics and Gynaecology Registrar at KEMH, says his workplace has always been culturally diverse (see chart). Additional challenges certainly exist today for medical practitioners but, with increasing cultural competency, there are benefits for both doctors and patients within the hospital system.

“The cultural shifts can make my work more challenging and frustrating. Patients

from non-English speaking backgrounds often require additional time, patience and effort and this is particularly so in a busy tertiary hospital. Different cultural priorities, perceptions and beliefs sometimes results in disagreements regarding acceptable treatment plans.”

“Thankfully, a strong cultural component has been an integral part of my medical training. We’ve always been encouraged to establish a socially and culturally sensitive relationship with our patients and their families. And when this happens it enriches the relationship between patient and doctor and there’s a flow-on effect to improve rapport, adherence and outcomes.”

“It’s both rewarding and satisfying when evidence-based medical practice comes together in a culturally diverse Female Ethnicity KEMH Deliveries

2000 2011

Aboriginal Asian/Filipino Indian African Caucasian

421 456 17 535 68 294 43 214 3321 3337

(Source: KEMH)

n Dr Jason Chin

environment. Simple things, such as learning how to pronounce names correctly can make a lot of difference. Cultural diversity tests our ability to care for patients. Clinical proficiency is important, but so is cultural competency. It proves that we truly care.” l

By Mr Peter McClelland

Caring With Spirit Rev Robert Anderson is head of Pastoral Care Services at KEMH and PMH and has helped thousands from different cultures through grief and loss.

T

he phone rings and pretty soon I’m sitting in hospital with a distressed African family. Their baby is a few weeks old and has been admitted for endof-life care following undiagnosed and incurable chromosomal abnormalities.

Their request is for prayer and that’s not unusual. It’s what chaplains are supposed to be good at.

But I’m an Anglo-Saxon male priest, not a literalist charismatic. And that’s a pity because quite unexpectedly an African friend of the family begins to pray loudly and excitedly. He rises to a crescendo and stops.

I understand the meaning and intent of the prayer. Jesus, in whom all things are possible, is meant to raise this baby back to life and health. The man politely leaves and the father asks me to pray, seemingly having no difficulty whatsoever with the syncretism in our markedly different approaches.

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The family could just as easily have been Indian, Afghani, Iranian, Iraqi or even an Aboriginal family from a remote Kimberley community. I would have been equally confronted.

I did not believe their baby would be miraculously healed.

My personal style is to meet these people, and listen to their stories, hopes, dreams and loss. I look and listen for meanings – religious or spiritual – within their world and try to enable expression of those meanings. I try to give them the message that there is nothing more important to me than being present with them in this moment.

What must it have been like in their shoes that night? They are new in this country; an alien culture, language, health and social system where even the freedom and relative safety of Perth is confronting. Sojourners in a strange land, surrounded by strangers and with, ultimately, a dead child in their arms.

They leave behind a previous life and personal identity, a homeland stained by atrocity and violent death. They move from one refugee camp to another as they risk everything to make a new life for their children.

It’s a story about the familiarities of the past balanced against a new freedom containing loneliness and separation. That night their past is relived. Loss, once again, begins to overtake hope.

I am well qualified yet unqualified; experienced yet inexperienced. Theology, pastoral studies and clinical pastoral education are, in themselves, inadequate.

The North Metropolitan Health Service (NMHS) showed insight and courage when it introduced an alternative model to the traditional, church-based chaplaincy service, which involved a full integration of pastoral and spiritual services. It responded to profound changes in the social fabric and evidence focusing on the most appropriate place of spirituality within patient care, especially palliative care. l 17

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Applications open at 9am on 13 February 2012 and must be received by 5pm on 31 May 2012.

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Australia’s Leading MDO

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Guest Column

The Real Tyranny of Distance

A

When all turns pear-shaped in the bush, Dr Sarah McEwan wants to hear more than ‘sedate and ship out’ for her mental health patients.

s a relatively young doctor with an unwavering passion for rural and remote medicine I have focused the last 12 years of my life on living, working and breathing everything rural medicine has to offer. However, when I think about mental health as a facet of rural medicine it’s enough to drive me crazy!

‘Lack of access to services’ is a term much bandied about, and when I hear it I feel nauseous. The phrase has become a mantra.

And, once it has been stated, people accept a lesser standard of care because we just do what we can without pursuing other options.

Rural Link will only take me so far (that’s assuming my patient has a prior mental health history) and GP psych support is less than wonderful in an acute setting. The focus of Community Health teams is, naturally enough, on community clients and they lack both the personnel and the funding to factor in acute patients within their case load.

So, what options do I have when I am the only doctor on an emergency shift when my patient in Bay 7 is fairly well known to me, has no previous mental health history and presents with signs of severe alcohol intoxication?

‘Simple’, you say. ‘Thiamine, anti-emetic and wait until he sobers up, send him on his way and refer him to drug and alcohol services if the patient is willing.’

What do I do then when the same patient unexpectedly decides to run around the department wielding scissors, cutting himself and terrorising other people in a department full of sick patients? ‘Easy’, you say. ‘Sedate and ship out.’

But what support do I have? Inadequate security measures means that staff, including security officers, have to retreat to the ED safe room. The police are called and, ‘Sorry doc, we only have one car tonight … we’ll be there as soon as possible.’ They too, are feeling the pressures of chronic understaffing.

Eventually the patient is scheduled, sedated and transferred to Perth with the muchappreciated help of the RFDS. There’s just no other way of managing a patient such as this without the assistance of an after-hour’s psychiatrist.

Back in Perth the patient will be reviewed and, now no longer under the influence of drugs or alcohol, sent back within days due to a dire shortage of hospital beds. There will be minimal understanding of how far away

the patient actually lives and the almost complete lack of services available to provide treatment and follow-up care.

More often than not there will be no firm diagnosis made, no discharge letter or information provided to the referring doctor and no follow up plan or advice on how to manage this sort of situation next time.

And how do I feel about this? As a practitioner I don’t improve my clinical skills, my patients rarely improve on their own and the whole vicious circle drives me completely insane.

We do what we can with limited training and resources to minimise harm to the patient and others caught in their orbit. But is that really enough?

ED. Dr Sarah McEwan is a District Medical Officer in North West WA. She is a Fellow of both ACRRM and RACGP with extended skills in rural medicine. In 2010 she was the ACRRM/RDAA Registrar of the Year and the following year was awarded the University of Newcastle Indigenous Alumni Award. Sarah is passionately concerned for mentally ill patients in a rural and remote setting. l

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Practice Profiles

Pain: Proceed With Caution How are pain specialists faring? These have offered us a snapshot of some of their concerns and challenges as they labour under a high patient load.

Dr Paul Graziotti is a full-time Pain Medicine Specialist with an anaesthetics background; an interventionalist who assists predominantly elderly patients and those with cancer.

“There is a tendency to dismiss pain in the elderly as an inevitable aspect of ageing.

Sometimes it is – the generalised aching first thing in the morning, and pain in various joints after heavy physical activity. But often the pain of most concern is relatively new or an exacerbation of a more longstanding pain for which certain interventional treatments can be useful,” he said.

Careful clinical assessment and investigation help sift out those pains that might respond to interventions. He suggests we look for these pain features: relatively new; relatively localised; radicular in character e.g. sciatica or neuralgia; and severe pain.

“MRI is the investigation of choice,” he suggested, adding that age should not be a governing factor as even the frail elderly will mostly tolerate the test without problems.

“The information obtained can then direct treatment. Obviously, in older patients it is imperative that the findings are correlated with the clinical picture as there will be a lot of irrelevant ‘pathology’.”

“Of course, in many older patients expectations far exceed realistic outcomes.

Successful treatment of one problem will often lead to an avalanche of other symptoms that really are ageing phenomena and not likely to be responsive to intervention. I believe it’s important to point this out to patients and avoid trying to solve all problems with endless interventions or, worse still, opiates.”

Dr Michael Kent is an anaesthetist who helps patients with chronic pain at RPH and in private practice.

“The burden on the community from pain is enormous. The cost to the community is financial but to the sufferer and their family, friends, colleagues, it’s emotional and social as well as financial.

22

This is now better recognised and the management of pain is multidisciplinary to reflect this. However, some insurers in the workers comp field are slow to accept this.”

He says the ‘disease’ status afforded chronic pain reflects its effects on both the physiology and psychology of sufferers.

“Acute pain has an obvious biological adaptive function – to rest an injured part and let it heal. Chronic pain is maladaptive, with no obvious survival function for the individual but instead, often serious consequences. The opinion leaders in my field are lobbying for this recognition, which will obviously change government funding priority and treatment availability.”

“Closer to home, I do see a more responsible use of opioids by GPs, with earlier referral if opioid use is anticipated. But still some cases of chronic pain are left too long before referral. As a general rule, if pain persists at three months post injury, if it interferes with sleep or activity, or if there is no return of normal work or function, then refer. If one suspects complex regional pain syndrome, refer immediately – it’s difficult to treat but best results come from earlier intervention.”

Dr Max Majedi works mainly with per-operative pain, including neuromodulation and other interventional techniques. He is concerned about the allocation of resources and professionalism in dealing with pain patients.

“We live in a very unequal world of patient care, such as a world food shortage and starvation versus patients getting bariatric surgery.”

“Immense resources have been launched at pain management without convincing evidence for benefit. In fact, we have emerging evidence for extreme harm from some traditional interventions such as chronic opioid therapy. I think as practitioners we all share an immense responsibility to work as a team, to disclose our biases and conflicts of interest and be willing to state the unknown.”

“As professionals, we ought not to blindly follow broken paradigms served to us by misguided government incentives such as item numbers and drug companies pushing for further sales.”

He said the science of medicine means a constant search for better outcomes and explanations, while embracing the humanitarian values of fairness and sustainability.

Dr John Rosenthal working in legal and rehabilitation medicine, has a special interest in pain medicine because of a realisation that rehabilitation often only proceeds if there is adequate pain management.

“Compensable injury provides a special challenge because of its capacity to alter patient and doctor behaviour, and outcomes.

There is inevitably a complex interplay of behavioural and psycho-social factors.

Insurer and employer attitudes can be very detrimental. There is the further potential for iatrogenic disability caused by over investigation and over treatment. The term nomogenic disability refers to that caused by the legal profession.”

“Historically, insurers have often been reluctant to fund pain management initiatives and in denying funding for treatment, they often rely on the opinion of doctors who have had no training or significant experience in the field of pain medicine.”

“The challenge for the medical profession in compensable injury is to prevent chronicity.

All too often, factors convert a simple injury into complex illness behaviour and doctors need to be aware of the potential for medical reinforcement of this.”

“In an ideal world, an early multidisciplinary pain rehabilitation program would address early warning signals. Such signals might include a failure to return to work, increasing pain with somatic spread in the absence of significant discernible pathology, and an increasing requirement for narcotic analgesics.”

He said long wait lists for public pain rehabilitation programs, not designed for the well-person setting, beg private alternatives.

However, past experience elsewhere had shown disruption to private programs from competing medical, legal and insurer interests.

His other concerns are overuse of narcotic analgesics and interventional procedures seemingly performed at variance with peerreviewed guidelines or clinical findings. l medicalforum

E-Poll: Coroner

Coroner’s Remarks Stir Opinion

Q

Following a recent inquest, the Coroner recommended that anyone who takes a call from a person seeking advice about their current chest pain should advise them to immediately call an ambulance or take themselves to hospital, regardless of the outcome of any recent medical assessment.

How do you regard this recommendation?

Of the 92 GPs who responded Agree 40% Disagree 48% Uncertain 12%

Comments When asked to comment, there was a strong reaction by the majority of doctors who felt the coroner had overstepped the mark. Some wrote: “Coroner's recommendations are not a good basis for public health or clinical policy because the cases examined by coroners are unlikely to be representative of the majority of patients presenting with these conditions (i.e. they are a skewed sample). Therefore public health or clinical policy based on coroner's recommendations are unlikely to

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improve health outcomes for the majority of patients.”

“In WA the Coroner is not medically qualified and seeks advice from ED specialists with little or no experience of the real world outside their teaching hospitals.”

“Presumably the coroner is going to provide the fleet of ambulances as well is the facilities and staff (including chaperones in the current political climate) in our grossly underutilised hospitals.”

“Irresponsible comment that increases the cost of medical care for minimal gain in outcome.”

“Let the coroner start taking responsibility for care of patients and their tune will change.”

“Meaningless in a rural setting, where the doctor is the hospital.”

“Some chest pain are very obvious they are not cardiac related. If everyone called an ambulance with chest pain, it will clog up the ambulance services and ED.” “A good history taking should eliminate the non-urgent chest pain.”

“Why not – after all the coroner must know best!!!”

“I would never advise a chest-pain patient to take themselves to hospital!!”

Among the 40% who agreed, some wrote: “This is also what we advise our practice staff to tell patients if someone calls.”

“When in doubt, safer to refer” “Safety first” “If someone has seen a doctor, been told their chest pain is innocent and still call for medical advice, I agree, they need to see another doctor. The symptoms may have progressed towards a coronary event or they need another explanation reassuring them that the pain is due to something else.”

“Obviously if the patient history is well known to the Dr and there are no cardiac risk factors and they've been investigated and they present regularly with non-cardiac chest pain i.e. GORD, one must use their common sense (this is common for me when I receive calls from remote communities).

However, generally this is good advice and better to err on side of caution.”

“An appropriately qualified doctor is in a position to save an ambulance trip with no loss of patient safety, in certain cases. The majority of chest pain is non-cardiac but a high level of suspicion is essential. Caution is best applied.”

“I feel the coroner's office is an extremely important one and should be properly funded and expanded.” l

23

Guest Column

Frontier for Nurse Practitioners

Demand for health care is opening new primary care opportunities, says Prof Phillip Della, head of Nursing and Midwifery at Curtin University.

W

e live in a period of great health-care transformation where the main driver for change is the increasing demand for care, not least from the ‘unattached’ who don’t have a regular primary health professional and who often go untreated. We have seen the emergence of nurse practitionerled primary care clinics overseas where these vulnerable individuals are being provided with health care they would otherwise not receive. For these primary health care clinics to succeed, the skills and competencies of nurse practitioners need to be fully utilised.

Previous Australia-wide research has identified that nurse practitioners are an underutilised resource.1 The AusPrac Study2 found that while the number of nurse practitioners has increased, their utilisation has remained relatively stagnant. The lack of growth relates to barriers created by jurisdiction funders, policy makers and health professionals themselves.

This situation cannot remain if we are to meet the increasing healthcare demands. The barriers need to be broken, a strong policy developed, improved funding and inter-professional collaboration and co-operation.

Increasingly we are seeing enhanced and advanced roles emerging and during this change it is critical that our central focus remains on patient care, including the safety and quality of care and clinical outcomes. One of the new models of care is the nurse practitionerled primary care clinics. There is a strong body of research that has

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clearly demonstrated that nurse practitioners deliver a high level of safe, quality care in a defined scope of practice in primary care clinics.3 The principles of establishing nurse practitioner clinics must include a collaborative framework with other health professionals including doctors and allied health. This will only work if all health professionals accept that nurse practitioners are educationally prepared in the following core elements: • Advanced practice including assessment, diagnosis, treatment, prescription • Research and leadership • Clinical speciality If the skills and competencies of nurse practitioners were accepted, they would then be able to provide comprehensive, accessible and coordinated primary health services to populations who do not have access to a primary care provider and are considered ‘unattached’ patients.

Thus the model would provide improvements in the quality of care through enhanced health promotion, chronic disease management and the prevention of illness. Nurse practitioners in these clinics would also be able to assist the ‘unattached’ patients to navigate other parts of the health-care system at a local level.

Is WA ready for nurse practitioner-led primary care clinics?

In many ways WA has been at the forefront of developing the collaborative role and scope of practice for nurse practitioners.

Initially nurse practitioners practised in hospital specialities such as emergency departments, oncology and remote areas and have gradually moved into community settings. The next logical frontier is primary care.

It has been nearly 20 years since The New England Journal of Medicine published an article by Mundinger4 concluded that: “When measures of diagnostic certainty, management competence, or comprehensiveness, quality and cost are used, virtually every study indicates that the primary care provided by nurse practitioners is equivalent or superior to that provided by physicians.”

It is now time for the Western Australian health community to remove the artificial barriers to collaborative practice and focus on achieving real improvement in patient outcomes especially of those most vulnerable. l Written in conjunction with A/Prof Rene Michael, Curtin University.

References 1. Gardner Anne, Gardner Glenn E., Middleton Sandy, Della Phillip R. (2009). The status of Australian nurse practitioners: the first national census. Australian Health Review 33, 679–689.

2. AusPrac (2010) -Research Title: Leading Responsive Healthcare Reform: The roles of the nurse practitioner in health workforce re-design. (Gardner A, Gardner G, Middleton, Della R.) 3. Harris, Ruth M. (1998). Advanced nursing practice in the 21st Century: Do we want to be right or do we want to win? The Online Journal of Issues in Nursing.

4. Mundinger, M. (1994). Advanced-practice nursing: Good medicine for physicians.

The New England Journal of Medicine. 330, 211-214.

To register your interest/attendance please contact CPU for Registration Form:

Email: LeAnne.Smith@health.wa.gov.au PH: 08 9422 5300. Places are limited, please book now.

24

medicalforum

Guest Column

NP-led Clinics Risk Fragmentation Chair WA Faculty RACGP, Prof Frank Jones, says the specialty of general practice hinges on maintaining the core skills around undifferentiated medicine.

A

t the outset, it is important to state that General Practice has a core set of clinical characteristics and practices unique within medicine, and provides patient-centred, continuing, comprehensive, coordinated primary care to individuals, families and their communities. Recognition of these skills, after 3-5 years specialist training culminates in the FRACGP, enabling Fellows to practise unsupervised general practice anywhere in Australia.

General practice in the 21st century recognises the critical importance of Multidisciplinary Team Care: it is now embedded in our new curriculum (see www.racgp.org/curriculum). Collaboration between health practitioners is crucial for the quality and safety of patient care and is critical when discussing how nurse practitioners collaborate with general practice.

The RACGP is committed to all members of the community receiving high quality, comprehensive, coordinated and timely

primary care. Wherever possible, such care is best provided by an individual’s regular general practice team.

Stand-alone, nurse practitioner primary care clinics risk fragmentation to the detriment of quality continuity of care.

New legislation allowing Nurse Practitioners to treat patients and prescribe medicines under the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) came into effect on 1 November, 2010. In response to the legislative changes, the RACGP released a collaborative care agreement template and an accompanying guide for collaborative care arrangements in general practice. The template and guide are available at www. racgp.org.au/practicesupport/cca. This is a 'living document' giving guidance to general practitioners in discussion with nurse practitioners, enabling realistic clinical templates to ensure patient safety.

NPs have a long-recognised role within subspecialties in medicine, within a relatively controlled hospital environment.

Seamless translation of specific skills

to generalism is problematic. It is not the purpose of this article to detail all the issues, however, one particular area of concern is in the management of undifferentiated conditions (approximately 30% of presentations in general practice).

These conditions challenge diagnostic skills and clinical decision-making processes.

General practitioners are primarily diagnosticians and are experienced in making an expert assessment while minimising over-investigation of patients.

Templates must be developed at a practice/ individual level to ensure patient safety.

Other critical areas of concern involve: • Defining scope of practice, • Duty of care issues, and • Indemnity issues.

The RACGP recognises that appropriately trained and skilled NPs may value-add to quality patient outcomes within general practice but within a collaborative care structure an objective outcome measure is critical, that is, is the model improving patient care? l

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12/04/12 11:11 AM

25

Doctors in Training

Young Doctors Flying the GP Flag The GPRA is giving general practice a dose of youthful enthusiasm with its program of appointing GP ambassadors in our major teaching hospitals.

The GP Ambassador program now has four junior doctors working in Perth hospitals spreading the good word for General Practice among their peers.

Dr Kate Reid-Milligan (Fremantle Hospital), Dr Jemma Smith (RPH), Dr Clark Maul (SCGH) and Dr Tamla Wilke (JHC) are part of the General Practice Registrars Australia (GPRA) Going Places network, which has now placed 44 GP Ambassadors in 42 teaching hospitals across Australia. Membership of the network, which was started 18 months ago, is 1800, with 164 members in WA. Dr Kate Reid-Milligan says the ambassador role is being a voice for general practice in the hospital system.

“The role is quite a new one so many young doctors begin by asking what it is we do,” she said. “Most of them I talk to seem very open to the possibility of pursuing general practice as a career. And then, of course, there are a few who have decided on other pathways and are only interested in the pen and the mints!

“But I think it is important that someone in the hospital is around to remind people of career options outside of hospital medicine.”

Kate says she is drawn to general practice for the variety of presentations and to develop relationships with patients and their families – to become the ‘family doctor’ – and to work with the young and old, men and women and “never being able to guess what might come in the door next”. And not forgetting the lifestyle and work-life balance, which she says is also appealing.

“We all do GP rotations in medical school but once we start work, all we think about is hospital medicine. We find out so much about hospital specialties through working in those fields and hearing about the training programs and careers from our registrars and consultants, but we don’t get exposed to general practice in the same way,” she said.

“It’s important for someone in the hospital to promote GP as a career and distribute information about training.”

n Dr Jemma Smith

n Dr Tamla Wilke

Kate believes that the ambassador progam will also lift the profile of general practice so that it becomes a desirable and soughtafter specialty.

“It may even change the public’s perception of doctors either being a specialist or ‘just a GP’,” she said.

Dr Clark Maul, who is a resident at SCGH, came to medicine after a career in corporate law. He says the GP Ambassador peer-topeer marketing initiative was effective.

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n n Laugh on the run Dr Jemma Smith, at RPH, spent her fifth year in rural clinical school in Busselton working in hospitals and general practices between Bunbury and Augusta. This, for her, was the deal sealer.

“It confirmed my awe of doctors helping people despite lacking in resources and specialists in close vicinity, instead relying on their own knowledge and experience,” she said. n Dr Clark Maul

n Dr Kate Reid-Milligan

“There are notices on the board about GP training but there’s more legitimacy if the recommendation comes from a mate in the system,” he says.

Dr Tamla White decided on general practice after spending a year in Albany during her fifth year at medical school.

“I love the lifestyle, the continuity of care that GPs provide and the fact that you can subspecialise in the areas of medicine that interest you, without excluding everything else.”

“The varied extent of knowledge and skills required of GPs was inspirational – from dermatology to paediatrics, psychiatry, obs and gynae, anaesthetics and procedural work.”

“There are no other career options that offer such a variety. Also the lifestyle, the hours compared to most specialist jobs in hospitals allow for a more comfortable and family friendly career. I’ve never met a miserable GP.” l

By Ms Jan Hallam

1. A woman gets on a bus with her baby.

The bus driver says: ''Ugh, that's the ugliest baby I've ever seen!'' The woman walks to the rear of the bus and sits down, fuming. She says to a man next to her: ''The driver just insulted me!'' The man says: ''You go up there and tell him off. Go on, I'll hold your monkey for you.''

On the Grapevine

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2. ''I went to the zoo the other day, there was only one dog in it, it was a shitzu.''

3. ''Dyslexic man walks into a bra'' 4. A classic Tommy Cooper gag ''I said to the Gym instructor "Can you teach me to do the splits?'' He said, ''How flexible are you?'' I said, ''I can't make Tuesdays'.

5. Police arrested two kids yesterday, one was drinking battery acid, the other was eating fireworks. They charged one – and let the other one off.

6. Two aerials meet on a roof, fall in love and get married. The ceremony was rubbish but the reception was brilliant.

7. Man goes to the GP: “Doc, I can't stop singing the 'Green Green Grass of Home.”

GP: “That sounds like Tom Jones syndrome.” Man: “'Is it common?” GP: “It's not unusual.”

8. There's two fish in a tank, and one says ''How do you drive this thing?''

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medicalforum

27

ASID Annual Scientific Meeting, 2012

Sailing Into The Future

T

he Australasian Society for Infectious Diseases national meeting returned to WA (last held at Busselton, 2005) recently, with record numbers of delegates and presentations. Conference convenor and RPH microbiologist Dr Owen Robinson said the turnout of mainly of infectious diseases physicians or clinical microbiologists was particularly gratifying given the tyranny of distance. “I was delighted with the quality of talks and posters for delegates, most of whom have both clinical and research portfolios and the convention committee were great and made life pretty easy,” he said.

Asked to pick some highlights, Owen pointed to: Prof Gubler’s critique of the injudicious use of biomarker tests, their limited predictive value, and the need to be more critical of how we use them; Prof Elizabeth Phillips’ talk on antibiotic allergy where a rash without mucosal or organ involvement rarely indicated antibiotic allergy; and Prof Jon Iredell’s description of where new technologies were heading, with the jury still out on the clinical usefulness of many.

The meeting explored the origins and spread of new infectious diseases (including host factors and predictive tools), as well as updating the 351 delegates on topics such as malaria, travel-related infections, viral hepatitis, antimicrobial use and abuse, current controversies, and the emergence and spread of multiresistant organisms.

International keynote speakers included: Dr Nick Beeching (Liverpool, UK) who is the Academic Lead for the new Specialist Certificate Examination in Infectious Diseases; Prof Edward Gane (Auckland,

n ASID President AProf Tom Gottlieb with WA clinician Dr Paul Ingram.

30

n Dr Duane Gubler

n Dr Nick Beeching

NZ) with the liver transplant, HCV, HBV, and liver cancer programs; Prof Duane Gubler (Singapore) who specialises particularly in dengue fever and other vector-borne diseases; Prof Robert Read (Sheffield, UK) who is expert on rapidly lethal infections, notably meningococcal sepsis, influenza and pneumococcal disease; and Dr Thomas Walsh (New York, NY) who

n Prof Edward Gane

n Prof Rob Read

researches antifungal chemotherapeutics in the immunocompromised.

Conference gems were offered up by clinicians well known in WA: endocrinologist and tropical medicine specialist Prof Tim Davis; HIV immunologist Prof Martyn French; antibiotic resistance and stewardship expert Dr Paul Ingram; tropical

Conference Excerpts n Dengue Fever Risk. Over half the world’s population live in tropical areas of risk from this arbovirus – epidemic frequency and magnitude has increased dramatically in the past 40 years due to urbanisation, globalisation and lack of effective mosquito control. Dengue viruses have fully adapted to a human-Aedes aegypti-human transmission cycle where crowded populations and large mosquito populations coexist. Periodic epidemic viral strains emerge and modern airports can transport viruses to new cities, resulting in epidemic dengue. In Australia, endemic arbovirus infections comprise: alphaviruses, Ross River (RR) and Barmah Forest viruses (BF) and Chikungunya virus – joint aches and rash; and flaviruses, Murray Valley encephalitis virus, Kunjin virus, Japanese encephalitis virus, and Dengue virus (DV) – encephalitis and/or haemorrhagic fever.

A review of 321 notifications of arboviruses in NSW children (0-14yrs) during 200111 showed mostly RR (191) and BF (98), acquired locally and peaking in Autumn and Spring, with additional DV (29) all acquired overseas and peaking in February and July. n Antiretroviral Therapy. There is a shift to earlier treatment, with contemporary combinations easier to take (three drugs in one or two pills, once daily). With many potent antiretroviral drugs available, treatments are largely driven by individual patient factors. A pharmacogenetic test

(HLA-B*5701) identifies patients at risk for a drug hypersensitivity reaction to the HIV drug abacavir. Pharmacoecologic factors include adherence, convenience, lifestyle, drug interactions, non-AIDS co-morbidities, underlying organ dysfunction and things such as pregnancy and hepatitis B co-infection. CD4+ cell count is still the benchmark for starting treatment (i.e. minimum < or = 500, with individual consideration above). A very important public health finding in 2011 was the HPTN052 study, which showed that HIV treatment given immediately to discordant couples reduced transmission by 96%. n Antibiotic Allergy. Up to 25% or more patients in the community are labelled with at least one antibiotic “allergy”, with implications for increased cost, decreased efficacy of treatments and increased antibiotic resistance risk long term. Patients labelled antibiotic allergic do worse in hospital. Doctors take a poor history to distinguish true drug allergy from side effects (e.g. nausea, headache, etc.).

“Penicillin allergy” label in 10-20% of the population but only 10% have positive skin tests for immediate hypersensitivity (and validated penicillin skin testing requires specialised reagents). To increase the negative predictive value of testing to 100% and effectively de-label ‘allergic’ patients, an oral penicillin challenge is required (penicillin VK, in a hospital setting if medicalforum

paediatric infections expert Dr Laurens Manning; sexual health physician Dr Lewis Marshall; HIV and hepatitis C pathogenesis researcher Dr David Nolan; pathogen adaptation researcher Dr Chris Peacock; paediatric immunologist and immunisation expert A/Prof Peter Richmond; Clostridium difficile disease expert Prof Tom Riley; parasitic zoonoses researcher Prof Andrew Thompson; healthcare associated infection adviser Dr Helen Van Gessel; TB surveillance program head Dr Justin Waring; pulmonary infectious diseases expert Prof Grant Waterer; and clinical pharmacologist and infection specialist Prof Elizabeth Phillips.

Brisbane), Dr Josh Davis (epidemiology of infections, Darwin), Dr John Ferguson (healthcare-associated infection and antibiotic resistance, Newcastle), and Dr Orla Morrissey (mycoses infections, Melbourne).

With session topics such as Infection in Critical Care, Host defences and Sepsis, Arthropod versus Man, Viruses and Vaccines, and Pets and Wildlife, just about everything was covered by the conference program. Poster presentations, panel discussions and a hypothetical “Contagion in the Kimberley – crisis or credence?” added to the mix. The final day had much for trainees.

Interstate invited speakers presented a wide range of topics. They included Dr Penelope Bryant (paediatric infectious diseases, Melbourne), Dr Julia Clark (infections in the immune-compromised,

history suggests anaphylaxis after penicillin or other beta-lactam antimicrobials).

Clinical allergic cross reactivity between different classes of beta-lactam antimicrobials is very low (for instance <5% penicillins-cephalosporins and <2% penicillins-carbapenems). Immediate or IgE-mediated reactions to penicillin are dynamic – about 10% of patients per year lose penicillin skin test reactivity and are amenable to ‘de-labelling’ testing. n Rotavirus round-up. Prior to national vaccine campaign in 2007, rotavirus gastroenteritis was responsible for approximately 10,000 hospitalisations annually in Australian children <age five.

Between 31 July 2001 and 30 June 2010, post-campaign, there was a 71% decline in these hospitalisations (from 261 to 75 per 100,000). Simultaneously, a 38% decline in non-rotavirus coded acute gastroenteritis hospitalisations (from 1419 to 880 per 100,000) occurred. Reductions were also seen in the 5-19 year age group suggesting reduced virus transmission at a population level (herd immunity). Decreases in hospitalisations seen in ATSI children were less than the general population and fluctuated by location and year. n Severity Scoring Pneumonia. A study at a 350-bed tertiary referral hospital showed for 204 CAP admission within a 6-month period, 69 had CXR evidence and symptoms of Community Acquired Pneumonia (CAP) but only one had a medicalforum

Conference Photos

n Dr Ben Clark, Dr Ronan Murray and Dr Duncan McLelland

This Conference Feature is supported

by Clinipath Pathology

severity score recorded, and only 22% were prescribed antibiotics in line with the score (instead, 93% received ceftriaxone). The aetiology of CAP appears to be changing (microbiology practices or pathogen changes?). Hospital-acquired and ventilatorassociated pneumonia (HAP, VAP) are less common but more difficult to treat.

Methods to assess the severity of CAP, HAP and VAP are intended to help clinicians identify more severe illness or greater chance of dying, with a focus more on the patients with hard-to-detect severe disease at presentation.

Prosthetic Joint Infections at Fremantle Hospital. PJI complicates

n Dr Laurens Manning, A/Prof Peter Richmond and Prof Tim Davis

n

~2% of primary arthroplasties. Between 2006-2011, 131 patients with PJI (120 newly diagnosed), required 227 admissions, 321 operations, 5608 hospital days, and 8452 days of IV antibiotics. Affected joints were hips (54%), knees (41%) and other (5%).

While 75% were in primary arthroplasties, infections were early in 54% (<3months), delayed in 12% (3-12m) and late in 34% (>12months). The median (range) symptom duration was 7 days (1-730) with a microbiological aetiology determined in 85%, mostly gram positive organisms.

Management was two stage revision (n=22), single stage revisions (8, with 50% cured), debridement and implant retention (78, with 63% cured; and 14 proceeding to twostage revision and 71% cured).

n Prof David Smith, Dr Ro McFarlane, and Dr Shan Siah with keynote speaker Prof Duane Gubler

n Delegates seek sustenance

31

TRANSLATIONAL RESEARCH FEATURE

Brought exclusively to you by

P

rof Patrick Holt from the Telethon Institute for Child Health Research and Head of Immunology and Allergy Services at Fremantle Hospital, Dr Dominic Mallon, are collaborating on allergy research in the hope of uncovering childhood interventions that will prevent later allergic disease, particularly asthma. The nature versus nurture “discussion”, as Prof Holt calls it, is being played out in research labs everywhere, no more so than in Perth.

“There are a wide range of factors at play; genetic factors that are not changeable but also a host of environmental factors with which genetic factors interact. It’s the gene-by-environment interaction that eventually leads to the expression of disease,” Prof Holt said, adding that the attraction for researchers is to find a way to switch off early childhood changes that lead to more complex adult diseases. It makes sense particularly from a public health perspective. Given the diversity of environmental factors and patient responses, clinicians are moving towards the idea of personalising treatment according to clinical subtypes, with asthma and allergy being a prime example.

Detecting immunotherapy responders

n

The value of immunotherapy is well known in atopic patients sensitive to inhalant allergens.

One difficulty is picking the good responders from n Dr Dominic Mallon the rest. Dr Mallon explained that current immunotherapy is one-size-fits-all. Some allergic people respond quickly, some respond for longer. Success is always measured by questioning the patient, and clinicians are left wondering about the correct duration of treatment.

“We are mapping the T-cell response to these immunotherapy allergens at different stages during treatment and correlating that with clinical response, in the hope of being able to identify those switches that correlate with long-term responsiveness or tolerance to the allergens used,” Dr Mallon said.

“The aim would be personalised medicine, so that at particular points along the immunotherapy course we take a blood test and determine if response has occurred and modify treatment timing or dose, or perhaps introduce adjuvants to try and induce that switch.”

Prof Holt explains further. “We are looking for an objective biomarker for a positive response to immunotherapy so clinicians can treat someone until they begin to stably express that biomarker.”

The research is a novel adaptation of technology developed as a spin-off to the human genome project.

“The technology allows you to look simultaneously at the activity of up to

medicalforum

30,000 genes that might be associated with an immune response. You have a much better chance of spotting something being expressed in the phenotype you are interested in, in this case, someone successfully desensitised with a treating allergen.”

“We take peripheral blood cells and stimulate them with allergens to which they are allergic and measure the pattern of genes that are being expressed before and after successful immunotherapy. We know those patterns will change, so it is the change that equates to the biomarker. Or it may well be a humoral marker, depending on what the gene encodes – something in blood, urine or saliva, or an intracellular blood cell change.”

The pilot study involving 30 patients has virtually completed the first year of immunotherapy and is embarking on the two-year follow-up. If the primary data at the end of this year shows favourable patterns, this will likely lead to larger studies in Europe and the USA.

Early sublingual desensitisation in atopic pre-schoolers n

In this pilot study, they have selected 50 children at very high risk of allergy and asthma based on a personal history of allergy – eczema and food allergy in the first year of life – and a positive family history of allergy and asthma. Half these children have been given sublingual doses of common environmental allergens for a year (grass pollens, dust mite and cat dander), to see if this improves their resistance to atopic asthma in the following three years, by building immune tolerance (compared to 25 blinded placebo treatments).

Data from three centres involved – Telethon Institute for Child Health Research in Perth, Murdoch Institute (Melbourne) and Mt Sinai Hospital (New York) – is now being analysed by the National Institute of Health in the USA and results will be available by the middle of this year.

Depending on the findings, there may be a larger study at several other sites.

“We hope that if follow-up trials are successful, this therapy will become part of normal treatment,” Prof Holt explained.

“It is already feasible to identify high risk children who may benefit from prophylactic treatment. Choosing the relevant treatment allergens will largely be a function of local geography.”

n Prof Patrick Holt

n Anti-IgE therapy to prevent virus- associated asthma during winter

IgE binds to the surface of various immune cells and interacts with allergen to form a complex that triggers the release of the inflammatory mediators responsible for all the symptomatology of allergy. The Telethon Institute lab and others found that in atopic children this IgE response is amplified, making the asthmatic response to viruses worse.

“Having respiratory allergy makes the children susceptible to the asthmapromoting effect of the virus infection.

That’s the proposition that is being tested simultaneously in Brisbane, Melbourne and Perth by the trial designed in Perth,” Prof Holt said.

“Anti-IgE is a monoclonal antibody that you inject and it remains biologically active in the serum for at least a month, at levels high enough to saturate all the IgE, and stop it reacting with allergens.”

For this study they have chosen children who are sensitised to perennial inhalant allergens – cat, dust mite and mould – and who have a history of severe asthma attacks after winter viral infections. The trial starts this year, runs for three years, is NHMRC funded, and answers will be available by the end of 2014.

“If it works, it means you could identify potentially-responsive children through their indoor allergen sensitivity, and if they had a history of severe asthma exacerbations following winter viral infections, you could put them on a protective regime of anti-IgE injections to cover the winter months.”

Medical Forum thanks researchers at the Telethon Institute for Child Health Research for assistance in preparing this feature, supported by an independent educational grant from Avant.

Avant is a leading provider of medical indemnity insurance for doctors and healthcare practitioners.

T: 1800 128 268 E: memberservices@avant.org.au W: www.avant.org.au

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Clinical update

Options for management of chronic pain A

By Dr Roger Goucke, Pain Medicine Physician, Hollywood Private Hospital

s with most conditions, if it is possible to prevent them, we should. In the real world, however, patients often present with longstanding pain and want something done. Options include medications, interventional procedures and behavioural modification, or a combination of these. The somewhat overused term ‘biopsychosocial’ is still a good framework to use when assessing patients with chronic pain. The time and effort put into designing a care plan that encompasses regular reviews can often provide a way forward.

The ‘denervation’ of certain spinal structures following appropriate investigation by hot or cold rhizotomy procedures can reliably give 6-12 months of good pain relief for many degenerative spinal conditions.

Neuromodulation from implantable stimulators that use variable frequencies, pulse widths and power may appear prohibitively expensive, but now have a place in treating certain chronic headaches and spinal radicular pain.

Following a thorough assessment and investigation, biologically, there may be nothing more that can be done to minimise the ongoing cause of the pain, whether it be from a neuropathic or a nociceptive cause.

The psychosocial issues often involved with bothersome chronic pain are huge and many would say much more important than the biological issues. Patients with a motor vehicle accident or worker’s compensation claim that has taken over a year to settle are notoriously difficult to manage because of the huge environmental, financial, work and family influences.

Using a broad approach Pursuing a goal of active rehabilitation for chronic pain patients necessarily involves engaging with allied health colleagues.

It is not surprising then that uni-modal treatment of chronic pain is likely to be suboptimal.

Preventing chronic pain There are many scenarios that lead to chronic pain that we can actively prevent.

One important recent advance is Zostavax vaccination for patients over the age of 60, for the prevention of acute herpes zoster in the elderly, which in turn should prevent postherpetic neuralgia (when the vaccine becomes available).

Prevention of symptoms from other conditions, such as painful peripheral diabetic neuropathy, may be achieved by tighter control of the underlying condition.

By definition, all chronic pain starts as acute pain, with many surveys reporting the onset of chronic pain subsequent to either post-surgical pain or some other painful trauma. More aggressive management of acute postoperative pain is now the norm (see the ANZCA Acute Pain Management Scientific Evidence, 3rd Edition 2010 at www. fpm.anzca.edu.au/resources/books-andpublications).

One of the most common predisposing conditions for chronic pain is acute low back pain and evidence-based guidelines for its management are now widely promulgated (e.g. MJA 2011;195:454 – 457)

Notes on medication use Chronic nociceptive or tissue damage pain is still best treated with regular paracetamol and intermittent, low dose non-steroidal anti-inflammatory drugs. Focusing on function and goal setting, in terms of trying to rehabilitate patients rather than cure them, is now recommended best practice.

Setting realistic expectations for patients and medicalforum

n When acute pain becomes chronic, careful management is needed.

attempting to get them out of any passive dependent role they may have adopted, is also important. An expectation of less pain and more function, rather than no pain, should be reinforced.

While opioids do have a clear role in acute pain management, their role in chronic pain is being questioned mainly because of poor efficacy and increasing concern about tolerance and side effects such as cognitive dysfunction and hypothalamic-pituitary axis suppression leading to osteoporosis, as well as the risk of diversion.

Drugs for neuropathic (i.e. nerve damage) pain have increasing evidence of efficacy, for example, the use of low-dose amitriptyline, the SNRIs (venlafaxine, duloxetine) and the gabanoid drugs (gabapentin, pregabalin), although these are still not available on the PBS for the management of neuropathic pain.

Place of procedures There is an increasing range of invasive techniques with which some patients do remarkably well. Local anaesthetic and steroid injections into joints have long been recognised as giving short-term pain relief that allows greater movement and assists with rehabilitation. However, MBS item numbers for small joint injections have recently been withdrawn.

The techniques of pacing, goal setting and active exercise programs as opposed to passive massage, are offered by physiotherapists specialising in chronic pain. Psychological support and treatment of chronic pain is often very worthwhile for those patients who are psychologically minded, and individuals often respond well to cognitive behavioural therapy either from their physicians (who have the time) or from a clinical psychologist with an interest in this area. Unfortunately, there is limited funding within Medicare for these techniques.

Provided they are affordable, options exist today in urban centres for patients with chronic pain who need advice on lifestyle choices, diet, smoking, alcohol use, exercise, sleep hygiene, etc. n

Take Home Messages • Get to know your patient – is there a clear cause for the pain and is it treatable?

• What’s happening psychologically, how do they cope, how is their mood?

• How is their pain affecting relationships, work, family, socially etc.?

• Use multimodal treatment and include non-drug treatment options such as an explanation of your understanding of the ‘whole patient’, realistic goal setting, pacing, consider allied health involvement where possible.

• Use a range of medications and limit their doses.

The Clinical Update is supported by an independent educational grant to Medical Forum from Hollywood Private Hospital.

35

Clinical update

Having a plan for opioid prescribing T

By Dr Revle Bangor-Jones (DoH) and Ms Anna Gelavis (Drugs of Dependence, Pharmaceutical Services Branch, DoH)

he insidious transition of an acute episode of pain to chronic pain often catches us unawares. A great deal of benefit can be achieved by viewing all acute pain as potential chronic pain, and planning ahead.

The opioid contract (or treatment contract)

The Department of Health recommends use of a contract whenever an opiate is to be prescribed for more than 60 days. Importantly, it can be used as documentation of informed consent – the reasons for medication use, possible side effects, and what doctor and patient agree to in order to ensure the patient safety and compliance with the Poisons Act and Regulations. A useful sample contract, which attempts to pre-empt problems commonly encountered, is at: www.health. wa.gov.au/S8 Opioid use should be considered part of a comprehensive pain management plan, with consideration given to an initial therapy trial with clear start and end points, and a plan for cessation or modification if the trial is unsuccessful.

PBS vs. PSB: who does what?

PBS = Pharmaceutical Benefits Scheme (Commonwealth).

PSB = Pharmaceutical Services Branch (State).

There is (understandably) some confusion about the different government departments that regulate the prescription of drugs.

PBS. Requirements for PBS-subsidised prescriptions are in the Schedule of Pharmaceutical Benefits. Medicare Australia should be contacted regarding authority prescriptions on 1800 552 580.

Authority approval numbers issued by Medicare or Department of Veteran Affairs are always present on prescriptions for items: • Marked ‘Authority required’ in the Pharmaceutical Benefits Schedule, or • When increased quantities and/or repeats are being prescribed.

PSB application to prescribe a drug of addiction. An authorisation to prescribe a Schedule 8 medicine is separate to a PBS “authority prescription”, and is granted by the CEO of Health in the State Health Department. Such authorisation for the prescribing of S8s is required: • To a person notified as an addict.

• Drug, dose and frequency of administration of the S8 medicine(s) required.

Send specialist reports to the Department of Health using: Post: The Pharmaceutical Services Branch, PO Box 8172, Perth Business Centre 6849, or Fax: (08) 9222 2463

Useful contacts and resources For information on authorisations to prescribe S8 medicines contact: Pharmaceutical Services Branch (Mon-Fri 8:30-16:30) Tel: (08) 9222 4424 1. The Royal Australasian College of Physicians, Prescription opioid policy: improving management of chronic nonmalignant pain and prevention of problems associated with prescription opioid use, Sydney 2009. www.racp.edu.au/page/policyand-advocacy/public-health-and-socialpolicy

• For a period longer than 60 days (in any 12 months).

Specialist support Written specialist support for the use of S8 medicines will be required for: • A notified addict; or

2. Drugs of dependence (PSB) webpage: www.health.wa.gov.au/S8

• High-dose S8 medicines prescribed for longer than 60 days; or

3. Morphine equivalent dose calculator – see 2. above under “Resources”

• Short acting S8 preparations (immediate release or injectable formulations); or • When existing support is several years old (renewal of written specialist support may be requested).

The specialist report should detail the: • Patient’s condition and need for ongoing treatment with S8 medicines; and

4. Quick Clinical Guidelines for the Use of Opioids in Chronic Non-Malignant Pain – see 2. above under “Resources” 5. WA regulations for prescribing S8 medicines. See www.dao.health. wa.gov.au/Informationandresources/ Publicationsandresources/ Healthprofessionals.aspx

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37

Clinical update

Towards universal precautions in opioid prescribing O

pioid analgesia for chronic non-cancer pain has increased dramatically over the last 15 years, yet NHMRC Level I evidence of benefit is at best ‘equivocal’ in terms of pain relief or improved patient function. In addition, the risks are significant in terms of dependence, addiction, and diversion, opioid induced hyperalgesia (worsening pain and increased dose requirements), hormonal suppression (testosterone, oestrogen, cortisol), osteoporosis, and the well-known side-effects of sedation, confusion, constipation, and potentially fatal respiratory depression.

Response to opioids varies considerably.

Opioids reduce pain intensity (by at least 50%) in about one-in-three patients (NNT 2.5-4.0). One in four patients report significant side effects starting an opioid and one in four cease treatment within days to weeks because of these side effects (i.e.

NNH = 4.0).

Data is very limited on the effects of longterm opioids on levels of ‘functioning’, such as activities of daily living, recreation or work. Epidemiological data from Denmark and the USA showed that patients prescribed long-term opioids in high doses had very poor socio-economic and health outcomes, with a higher overall mortality.

There is no meaningful difference in efficacy between opioids for treatment of chronic pain, however there are differences in the risk profiles. If you’re prescribing opioids, use the risk reduction strategies below (see flowchart).

There are several guiding principles • Patients have an appropriate diagnosis i.e. neuropathic pain • Prescribe only to well-known patients after considering the risk of illicit diversion e.g. particularly that opioids are not readily available and locked household safe is in use.

Opioid Prescribing Tips for Busy GPs • Avoid opioids in patients you do not know well.

• Don’t allow Registrars to start opioids before discussing with their Supervisor.

• Only allow dose increases by the doctor who initiated opioids.

• If you think the patient is on too big a dose, they probably are.

• Set a patient limit in your practice (e.g. 100 mg morphine or equivalent per day) beyond which no-one prescribes.

38

• Only trial opioids after patients engaged i.e. doing active pain management strategies and other non-opioid analgesia has failed (see table 2).

• Never escalate beyond 120 mg oral morphine equivalents per day. Most patients, who do derive benefit, do so up to this dose. High dose prescribing is associated with adverse outcomes, often worse pain and functional outcomes.

• Prescribers should be aware of morphine equivalents (Table 1).

• Opioids are not ‘set and forget’ drugs.

Consider dose reduction or cessation every 3-6 months.

• The opioid selected is the lowest risk in terms of opioid induced hyperalgesia, constipation, tolerance and diversion (see Table 1).

• Initiate opioids in the context of the patients improving their activities and active management skills during a therapeutic window of 2-4 months.

Thereafter, dose reduction and cessation is the expectation.

ceased. Specialist advice is recommended before escalating opioid doses beyond the ceiling of 120 mg morphine.

When it is safe to consider opiates Access to a specialist service or a GP who has completed pain management CPD provides prescribing reassurance. This aside, one or more of these factors should act as pre-requisites: • Multidisciplinary assessment/Rx available • Patient engaged in active management • Previous failure of non-addictive medications • Failure of appropriate procedures.

• Wish to trial less divertible options: Norspan patch – with observed disposal Observed daily dispensing ER opioids (Jurnista, Methadone).

Remember that if there is a successful four-week opiate trial, this means there is a ‘therapeutic window’ of 2-3 months, during which time, non-opiate options must be implemented. Beyond that time, opiates offer no appreciable long term benefit.

For important contacts, see P 37

When to definitely ask for expert assistance

• Surprisingly, opioid tolerance (dose escalation) is not inevitable, particularly in the elderly. Only 30% of patients demonstrate rapid dose escalation; this usually reflects psychosocial issues or disease progression.

Refer to a specialist service (tertiary, secondary or community), or perhaps a drug addiction service if:

• Screening for neuropathic pain (PainDETECT or DN4) with trial antineuralgics and for anxiety, stress and depression (DASS 21) is very useful.

• The patient plateaus or worsens i.e. does not progress.

• Potential ongoing prescribers – do not provide scripts unless supported by practice documentation and you agree with the indications and management in place.

Medical practitioners should not feel ‘pressured’ to prescribe higher doses of opioids. If an opioid is going to ‘work’, it will do so the majority of patients in the range of 10-120 mg oral morphine equivalents per day (24 hours). No response in this range is considered a treatment failure (called ‘opioid non-responsive pain’), just like a failed chemo or antibiotic treatment, and the drug is best reduced and

• An opioid trial is not useful – hence wean and cease.

• Multidisciplinary assessment or treatment is needed.

• Patient becomes non-engaged in active strategies.

• Secondary failure of medications (tolerance, opioid-induced hyperalgesia).

• Prefer to consider appropriate interventional procedures.

• Seeking access to non-PBS options or group education (STEPS, CBT).

• Prescribing doctor wants another opinion / support.

• Suspected diversion / opioid splitting

medicalforum

By Drs Stephanie Davies, Eric Visser, Roger Tan, Nick Cooke

PIVET MEDICAL CENTRE

Table 1: 100mg/day Morphine Equivalent doses for Opioids: Listed in increasing risk of tolerance: based on receptor potency and receptor activity.

Morphine equivalents (ME)

100mg ME/day

Comments

Tramadol

500mg/day

Non-addictive, part pro-drug, 20% poor converters (like Codeine)

600mg/day

Pro-drug 20% poor converters

Buprenorphine

20mg/day patch

Weekly patch or sublingual

Hydromorphone

16-20mg per day

Methadone

20mg/day

Unpredictable - specialist only

Morphine

100mg per day

“Morphine Blues”

Oxycodone

50-70mg per day

High bioavailability

Fentanyl

25mcg/hr patch

High potency can cause tolerance

Table 2: Number Needed to Treat (NNT) for 50% pain relief compared to Placebo.

Number Needed to Harm (NNH) compared to placebo (minor and major SEs) Drug

Condition

NNT 50% relief

NNH

Opioids

Neuropathic pain

2.5

4.2 8.3

Tramadol (100-150mg)

Neuropathic pain Post-surgical

3.4 2.4 – 4.8

8.3

Tricylics

Neuropathic pain

3.6

28 (major) 6 (minor)

Gabapentin Pregabalin (>300mg/day)

Central Neuropathic Diabetic neuropathy PHN Fibromyalgia

5 2.9 - 5 3.9 13-22

3.7 (minor)

Efexor Duloxetine

Neuropathic pain

3.1 6–8

16.2 (major) 9.6 (minor)

Panadol (4 grams/day)

Chronic arthritis pain

4-5

12 (GI side effects)

DO NOT INITIATE Opioids IF

• No CPD in Pain Management • Unable to set boundaries • Unable to set functional goals (and review) with patient • Poor with documentation (scripts and 6A’s) • Feeling under threat to prescribe

medicalforum

PATIENT: • Unknown to Dr* • Not using active strategies • History of drug misuse *Use high opioid risk tool

Medical Director Dr John Yovich

FERTILITY NEWS

Codeine

DOCTOR: • Visiting / Intern at practice

Specialists in Reproductive Medicine & Gynaecological Services

ENVIRONMENT: Patient: • Drug misuse within the house • Lack of secure storage used • Drug misuse within local society

Safe Stimulation

By Dr John Yovich & IT Specialist Mr Peter Hincliffe Ovarian stimulation has underpinned modern management of subfertility including all ART procedures comprising IVF, ICSI, IUI and OI with timed coital activity.

However a significant hazard beginning in the 1960’s when gonadotrophins were introduced has been the dreadful complication of OHSS. This is a purely iatrogenic condition characterised by the unusual combination of hypovolaemia associated with ascites and pleural effusions. In its severe untreated form there is a progression to renal failure and intravascular coagulopathy including DIC. In modern day some strategies have led to a reduction in this syndrome (GnRH Antagonist protocol, utilising the VEGF-receptor blocker Cabergoline and using GnRH Agonist for the final ovulation trigger). Some IVF Centres have avoided using gonadotrophins completely reverting to natural cycles, or minimal stimulation protocols with oral agents such as Clomiphene or Tamoxifen.

However these low stimulation schedules means that around 30% of patients do not have any mature eggs collected; they also miss out on the opportunity for a cumulative pregnancy chance from frozen oocytes.

At PIVET our data shows that women under 35 years have over 75% chance of a pregnancy from a single egg collection cycle. This requires an average of 10 eggs collected and two blastocyst embryos cryopreserved.

Even for women aged 35 to 40 years, the cumulative pregnancy rate is 65%. This data is based on 90% having a single embryo transferred.

Trans-vaginal ultrasound of polycystic ovary displaying 15 antral follicles per ovary in a slim young woman – high risk for OHSS.

Injecting pens containing rFSH and enabling small incremental doses of 8.3 IU (Puregon) and 12.5 IU (Gonal-F).

In order to gain these benefits without the risk of OHSS, PIVET has developed an Algorithm based on the woman’s age, AFC, serum AMH, day 2 FSH, BMI and smoking history. This enables a targeted approach to stimulation whereby the at-risk women receive minimal stimulation. The Algorithm and the supporting data has been published in last month’s edition of RBM Online (March 2012).

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

39

Clinical update

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ncreasingly, asymptomatic young or middle-aged patients present to their general practitioner with concern about a strong family history of premature CAD. This is often prompted by a cardiac event or sudden cardiac death in a parent or sibling at relatively young age and the patient is justifiably concerned about their risk. The following represents suggestions for dealing with this situation.

The next step is to assess the asymptomatic patient’s cardiovascular risk based on conventional cardiac risk factors. Most familial cases of coronary artery disease are due to familial tendencies to abnormal levels of conventional risk factors (dyslipidaemia, hypertension, diabetes, smoking, etc). Standard risk calculators can then classify the patient’s risk and if high, aggressive treatment is indicated, including consideration of statin therapy etc. Patients in the diagnostic category of Familial Hypercholesterolaemia are best managed by referral to The Lipids Clinic at RPH.

Clarkson

Burns Beach

By Dr Stephen Gordon, Interventional Cardiologist, Western Cardiology

Firstly, not all sudden cardiac death is due to AMI, as there are other familial conditions that can predispose to sudden cardiac death from non-coronary causes. If an autopsy report is available it may be helpful for clarification. If there is uncertainty as to whether the death was due to CAD, then other familial cardiac conditions ought to be evaluated with ECG and echocardiogram to exclude entities such as HOCM, arrhythmogenic RV dysplasia, long QT syndrome, etc.

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There is however a smaller group of patients whose inherited risk of cardiovascular disease is high but not predicted by conventional risk factors, and these patients have posed a management dilemma. Often they are referred for exercise stress tests, stress echocardiograms, or myocardial perfusion scans and reassured if they are negative. These negative tests, however, only exclude advanced severe obstructive disease and will often not detect mild or moderate degrees of atherosclerotic coronary disease that can still put the patient at risk of plaque rupture and AMI. There is substantial evidence now that the better test in this situation is a coronary calcium scan, which determines abnormal levels of calcium in the coronary tree, indicative of premature atherosclerotic disease. A "calcium score" produced by these scans is now held to be an independent and better predictor of coronary risk than assessment of standard risk factors alone (which may be normal in these patients).

The scan involves a modest dose of radiation, which is less than most routine CT examinations, and is not reimbursed by Medicare. Further research is required to determine if the more complicated coronary CT angiogram is a better prognostic test or not, as the scan requires larger doses of radiation and intravenous contrast injection with its attendant risks.

Patients considered at low risk on the basis of the above investigations can be reassured and kept under periodic surveillance. Those considered at high risk by virtue of conventional risk factors or coronary calcium scanning require aggressive treatment of risk factors, consideration of statin therapy, and exclusion of advanced obstructive disease by non-invasive testing (exercise test, stress echo, myocardial perfusion scanning).

Medical Forum Delaration: Western Cardiology contributes towards the publishing costs of this clinical update, and provides coronary calcium scans as part of its cardiology services in WA.

40

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Leaders in Medical Imaging

In Action

It's all

About the

Horse

For OccuMed GP Neil Ozanne, it’s all about the horse. And the parallels between show jumping and the practice of medicine are obvious.

Both disciplines require analysis, accuracy and excellent communication.

And, as Neil suggests, both patients and horses thrive on a similar approach.

Rural Health Conference Driving Change in General Practice More than 140 practitioners from rural and remote WA heard passionate telemedicine advocate Dr Edward Brown, from

Ontario, provide valuable insights into the development and implementation of a successful telemedicine system at the Rural Health West annual conference and trade exhibition.

The Ontario Telemedicine Network, which delivers about 17,000 sessions a year is one of the biggest and most active integrated telemedicine networks in the world.

Dr Peter Rischbieth, from South Australia, gave the Australian perspective in his keynote address on behalf of conference sponsor NEHTA. “All the Telehealth e-health sessions were excellent, thought-provoking and so needed in WA”, commented one of the medical practitioners.

44

n Dr Bernard Chapman, from Moora, receives his award for outstanding service to Rural and Remote Health.

One of the highlights of the conference was the sunset cocktail reception held at the Swan Belltower, where attendees had the

opportunity to ring the famous Swan Bells.

Three doctors who have provided outstanding or extraordinary service to their rural communities won awards for their work.

As a finale to the conference the Governor, Mr Malcolm McCusker, presented the annual Rural Health West Doctors’ Service Awards, recognising the work of rural general practitioners and specialists who have given 20 and 30 or more years of service to patients in rural WA. The Award for Outstanding Service to Rural and Remote Health was presented to Dr Barnard Chapman, of Moora, for his outstanding community leadership.

The Award for Remote and Clinically Challenging Medicine was presented to Dr Pascall Burton for his long standing service to Aboriginal Medical Services in Port Hedland, and his contribution to improving the clinical welfare of the community.

In Action

mathematical, the distance between jumps, the time factor and taking the shortest line without unbalancing the horse. The German team is extremely particular about how they do things.”

“For a while they took this too far and became overly analytical. They dominated and controlled the horse but they’ve softened that now. It’s very different to the English who tend to shout ‘Tallyho!’ and fly by the seat of their pants a bit.”

Injuries are an unavoidable part of showjumping events. As a doctor, Neil has experienced both ends of the spectrum.

“If you dwelt on the injury side of things you couldn’t keep competing at this level.

I’ve had a broken collarbone, a broken arm and I’ve ridden with broken ribs but I never go out there thinking, ‘what if I fall off?’.”

“I used to do Eventing involving cross-country jumping, dressage and show jumping and I was often the assigned doctor on the course. I got to see other people’s injuries and a lot of them weren’t pretty. If my turn was coming up to go out on course that would dent my confidence before I’d even started. I don’t do Eventing anymore and it’s one of the reasons I switched to showjumping.”

“I tell my patients that I like to treat them with the same degree of care as I give my horses. Show jumping is a demanding and expensive diversion from medicine but there’s a real overlap between the two. It’s all about thinking, feeling and communicating and, in the case of the horses, without using words.”

If, as Neil suggests, there is a strong overlap between medicine and show jumping the forensic Germans should make the best doctors in the world.

“At Olympic level, the Germans are completely dominant. If the entire German team were struck down with a mystery virus they’d still win the gold medal. Why? Because their reserve team would still be the best in the world. Show jumping is very

First-class horseflesh is another reason for Neil’s decision to confine his competing to show-jumping events.

“I’m competing on two horses – they’re brothers and both really special. Their names are Sarnia Classic and Sarnia Caesarno.

Sarnia is the original name for Guernsey in the Channel Islands where I was born.”

“Some horses really love show jumping, some tolerate it and some hate it. Even the really good ones can’t keep going at this level for too long. In fact, most horses only compete in one Olympic Games whereas the riders may do many more. There are world-class riders winning medals in their 50s and 60s.”

In the Ozanne household, both show jumping and training competitive horses is a family affair.

n Rachel Ozanne in action.

“I met my wife at an equestrian New Year’s Eve party and it was the only one they ever had! She’s very involved with breeding our horses and then we develop and sell them to riders at a particular level. It’s what we call a ‘well-seasoned’ horse and it’s very important to match them with an appropriate rider. We’ve got 12 horses, including a couple of brood mares producing beautiful foals.”

And both their daughters, one in her final year of Law and the other doing third year Medicine at UWA, are riders.

“Sarah is a qualified show-jumping judge and Rachel, who’s keen on both neurology and rural GP work, is a very competitive rider on state and national squads. She rides at a similar level to me and with medicine she’s certainly got more up-to-date knowledge, but I do have some accumulated wisdom. We have strong debates sometimes.”

For Neil, the future will continue to be a balancing act between show jumping and medicine.

“I see myself show jumping at a high level beyond the age of 60, so I’ve got nine years left. In between all that I plan to sit my occupational health physician exams. I’ve got two horses that love jumping, I know they want to do the jump and I love that feeling when everything is just right.” l

By Mr Peter McClelland

The Award for Extraordinary Contribution to Outreach Services was presented to ophthalmologist Dr Philip House, who has been providing outreach services to the Pilbara community for the past 20 years. He has made a significant impact on the community through the introduction of small incision cataract surgery, which has enabled many patients to receive treatment close to home.

The next Rural Health West conference looks at Aboriginal health and will be held in Perth on July 7-8. . For information: www. ruralhealthwest.com.au/go/ conferences. l

n From left: Mr Ian Taylor, Dr Benjamin Ansell (Kalgoorlie), Dr Keith (Barney) McCallum (Kalgoorlie), Dr Jim Leighton (Albany) (at back), Dr Susan Churchill (Bunbury), Dr Josephus Buters (Mandurah) (at back), Dr Bill Plozza (Albany), Dr Paul Corrigan (Busselton), and the Governor, Mr Malcolm McCusker.

n Dr Karen Pitman and her partner Craig Millard, from Port Hedland, Dr Elena Ghergori, from Meekatharra, and Dr Elaine Sabin, from RFDS South Hedland.

45

Winter Getaways

Bend Zee Neeze!

East Fremantle is a long way from snow, but that distance doesn’t stop GP Hilary Fine from hitting the ski slopes around the world.

I have a passion for skiing. As a schoolgirl I was picked last for every team and knew very early on that sport was never going to be a career choice. At the age of 14, courtesy of my best friend’s father who started a School Travel business in the UK, I discovered that I could move quite nicely on snow.

snow was mirrored in reverse extremis by my first major ski injury.

I cut my first snow plough at an Austrian ski school and ‘bend zee neeze’ still echoes in my brain. Hot lunches of Goulash Soupe and après ski with 14-year-old boys and I was hooked!

I was attending a sports radiology education session when I gladly volunteered my knee for an ultra-sound demonstration.

Eerie silence ensued. My medial collateral ligament was in tatters. A second-degree tear and a MRI confirmed the rest – a

During my university years I progressed (or should I say, regressed) to the French, Italian and Spanish Alps, the actual location dependent on available funding. With that in mind, my parents declared me financially independent when I graduated in 1983.

And after that ski holidays in Europe took a bit of a fall, so to speak.

Australia, and more specifically Western Australia, is a long way from the icy contours of land so necessary for my beloved sport. But where there’s a will there’s a way. I ventured to the moguls of Australia and persevered for a few years in the land of extremes. Too much snow – stranded for three days in Mount Hotham; too little snow – rediscovered the delights of Scrabble at Perisher Blue and then ice, wind, rain and sun all in the space of one day at Falls Creek. So, in 2009 I pulled the pin on patriotism and discovered Japan.

Six weeks after hobbling around and being as painful as only the families of other injured medicos would know, I reluctantly succumbed to the experts – in a roundabout way.

I discovered that I could move quite nicely on snow. complete tear of the anterior cruciate and partial meniscal tear. I was in shock. And I reminded myself that immediately after the injury I’d skied down the offending slope.

No skidoo ride for this over-aged ski bunny!

I’d also limped around the temples of Kyoto before sitting completely imprisoned in economy class between two breast-feeding mothers on the way back to Perth. Denial is a well-practised art.

slopes of Japan with a renewed sense of excitement. As for ski gear, I added three important items. A substantial knee brace, a helmet and an avalanche-detectable ski jacket. I freely admit that I felt somewhat more vulnerable after the accident.

Now, all this may lure you into believing I’m an expert skier. After all, who else would they get to write this article? The truth is I’m not. These days, I can still get down most slopes but with an ever-decreasing degree of finesse and/or speed. I attempted a day of snow-cat skiing with people half my age in Canada and filed the experience under ‘Personal Growth and Physical Exhaustion’.

I ski because I adore the incredible brainemptying high of gliding down mountains, avoiding confrontation with a tree or a snow boarder in search of powder snow, and the exhilarating feeling of floating on powdery white. Reaching the end of another wonderful day, taking off the skis, icicle dripping from the end of my nose, foggy goggles and shaky legs that take me just far enough for après ski drinks with friends and stories of the day’s delights. l

Physiotherapy, determination and a wonderful orthopaedic surgeon’s advice (references on request) got me back on the

The exhilarating mood-high of powder 46

medicalforum

On the Grapevine

Beauty

bellarmine

The Bellarmine vineyard is located in the beautiful forest country near Pemberton. It was planted in 2000 after the owners, Dr Willi and Gudrun Schumacher, identified the area after a worldwide search for the perfect property. The hard gravel over limestone soils at 220m make the vines work hard to produce low yields.

Winemaker Di Miller (left) lives on the property and continues the family passion for cool-climate wines.

Bellarmine produces three styles of riesling with the Riesling Dry 2011 having established a reputation as the signature wine of the vineyard. The nose has lime and spices with some floral hints. It’s a classic, fruit-driven riesling with crisp acidity, wellbalanced fruit and great persistence. With 12.5% alcohol this wine is a perfect seafood wine and highly recommended.

By Dr Martin Buck Dr Martin Buck believes in immersion. He lives in the Swan Valley with his partner, Loraine, where they grow an interesting portfolio of grape varieties including Savagnin, Tempranillo, Graciano and Pedro Ximinez.

Martin, who is a medical oncologist at SCGH, St John of God Subiaco, St John of God Bunbury, St John of God Geraldton and Peel Health Campus, is also a dedicated “wine tourist” having only recently returned from a week of hard work in Bordeaux.

As well as growing specialist Spanish varieties he and Loraine also produce some Swan Valley classics including Chenin, Muscat and Shiraz.

In 1998 he was part-owner of Wovenfield Wines in the Ferguson Valley and managed the business until 2010 when it closed due to cancellation of their fruit contracts.

“In that time we had a busy winery and produced some gold medal wines, produced 100 tonnes of fruit each year and sold premium grapes to some of the state’s largest producers.”

medicalforum

Cool-climate Chardonnay is developing a cult following with more and more West Australian producers embracing the styles of Burgundy, Mornington and Tasmania. The 2010 Bellarmine Chardonnay has wonderful aromas of green apples, apricots and nectarines with some new French oak. The oak has been handled with care and lets the big, round palate of fruit and acid shine through. This is a tight, well-integrated wine with a ‘chablis feel’ showing the quality of the Pemberton fruit.

stable comes as no surprise. By following similar Burgundian wine-making techniques to the chardonnay, the resulting wine has a real old-world feel in a new-world site.

There is a big nose of strawberries and cherries with some background gamey aromas.

Once again the palate is full of balanced fruit but with fine tannins as a result of the 12 months of new French oak. This is a wine able to stand with some of the best pinots in the region.

The 2010 Shiraz is a new release and a full-flavoured 14.5% alcohol wine made from low-yielding vines. This is not a typical cool-climate shiraz but would fit in nicely with a southern Rhone style with its ripe, plummy fruit, soft tannins and nice oak integration. It’s likely to improve with medium-term cellaring.

Bellarmine is making quality, international style wines in our backyard and highlighting the predictions made by Dr Bill Pannell on the potential of this region.

Having a Pinot Noir in the

WIN a Doctor’s Dozen!

Which of Bellarmine’s wines has lime and spices with some floral hints on the nose?

Answer:

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Enter here!... or you can enter online at www.MedicalHub.com.au!

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, May 30, 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.

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47

Humour

People Management on the Mothership

Resident satirist Prof Wendy Wardell questions the mental health of all of us in the modern world. Losing it – is it nature or nurture?

Mental health problems are, contrary to popular belief, contagious. It takes only a single pilot running down the aisle of his plane, screaming "there's a bomb – we’re all going to die" to induce extreme anxiety disorder in more than 300 people. Not to mention a team of aeroplane cleaners.

It's getting harder to tell the normal from the nut-bag these days, especially in the workplace. Just think about it – how many of your own co-workers are rowing with only one oar, psychologically speaking? They may not be licking windows or coming in dressed as Napoleon, but gradually you pick up on things that make you wonder if their job interview should have involved electrodes.

Taking a pro-active approach to HR issues must be especially hard to resist for doctors. It’s unfortunate that well-intentioned but surreptitious medication of your staff can have you hauled in front of various boards and tribunals. People don’t trust water that comes out of the cooler slightly cloudy.

Competitive pressures, stress, and technology create a mental Molotov cocktail in the workplace. MicroSoft alone is doubt-

less responsible for the invention of several new syndromes, assuming serotonin levels crash in sync with operating systems.

But I reckon that being a few cards short of the full deck can be a corporate advantage.

In my book, sweaty palms, anxiety and increased adrenaline are a perfectly valid response to an Excel spreadsheet budget, and AGMs are much better appreciated from the foetal position.

It's getting harder to tell the normal from the nut-bag these days, especially in the workplace.

Every known personality disorder can be found in Australian workplaces including a few that have yet to be defined and published. Body Dysmorphia by Proxy, for example, is a condition whereby sufferers hate their workmates’ guts. Many people have worked with someone who has Ambidextrous Proctological Disorientation Disorder, which renders its victims incapable of finding their backside with both hands.

body-shaping underwear instead of just eating less rubbish.

Technology brings us a plethora of new ways to be dysfunctional. These include Sat Nav Schizophrenia, whose victims hear malicious voices in their heads insisting that they turn left in 300 metres over a sheer cliff, and Apple Amnesia, whereby people become so engrossed in their apps that they completely forget their own identity.

If you throw hormones into this mix as well, then it's no great wonder that women working together often exhibit all the easy-going bonhomie of a flock of vultures on finding a dead donkey.

Little quirks of the personality are crystallised out in the crucible of the workplace, so add a dash of PMT to power and sociopathic tendencies and suddenly you’re working alongside Pol Pot in a frock.

To look at it philosophically, we’re all fellow travellers on the highway of life – it’s just the baggage we bring with us that’s different. All we can do is hope that the nutter on the bus isn’t the driver. l

Today-Tonightis Nervosa produces questionable judgment in sufferers, with compulsions to splurge money on miracle

I don’t like to generalise BUT female doctors are …

Our E-polls usually tell it like is, so when we asked you to complete this sentence: "I don't like to generalise BUT female doctors are..." 92 GPs didn’t hold back. Here is a snapshot of the funny, the serious and the “you’ve got to be kidding” comments.

Laugh Out loud “A very useful cohort to perform the 20 min medicine so I can continue the 6 min stuff!”

“Too gentle when young; too strict when older.”

“The norm now; overtaking the fellas!”

“Not as lovely as male doctors.”

48

“More likely to get pregnant.”

“Expert at making generalisations.”

“Necessary, so I don’t have to do so many PAP smears.”

“Patient magnets.”

“Great fun to work with and allow some male doctors to slough off all emotional issues and Pap smears!”

“Giving the male doctors more opportunities by taking time out to have a family.”

“Better cooks.”

“Dressed much better than their male peers at junior levels.”

“A fact of life.”

“Prettier than their male colleagues!”

“Amazing and fun to be with!”

“Usually better looking than most male doctors ... more often than not, better than male doctors.”

“Better because they have neater writing and warm up the speculum before doing a Pap smear.”

“Just so much better at absolutely everything; more thorough, more understanding, less money-conscious.”

“Probably the future of medicine!”

No Laughing Matter “Doing an often very demanding job with needy difficult patients for relatively less pay while trying to juggle everything else at home.”

“I don't like to generalise but female doctors are very supportive.”

medicalforum

Play Time

Best of Both Worlds Dr Colin Hughes, minus stethoscope, has been treading the boards from Moonee Ponds to Perth and even sung with Angry Anderson Midland GP Colin Hughes lives life to the full. He has a busy medical practice and is actively involved in everything from environmental concerns to teaching and accreditation for the RACGP. He’s passionate about life and community and, when he puts down his stethoscope, Colin loves nothing better than taking a deep breath, whispering his first line and stepping into the spotlight.

“My passionate engagement with life stems from my headmaster, Brian Hone, at Melbourne Grammar. He impressed upon us that we were extremely privileged to have such wonderful opportunities. At that time only 10% of students graduated and went to university. I really felt that it was important to use that education for the betterment of society. It struck a real chord with me and I’ve remained community minded all my life.”

Colin’s passion for theatre began in childhood. His mother would take him to musicals and his father was an amateur actor but money was tight.

“Dad worked for a flourmilling company and mum was a hairdresser.

And yes, I was a scholarship boy! I sang in the choir three days a week and played in the orchestra and band so I got used to the spotlight very early. It all started at the Monee Ponds Town

“More prepared to listen to patients’ stories and spend more time with them getting to the "real" problem.”

“Generally fun, intelligent ... and not uncommonly attractive and certainly amazing colleagues both in and out of work.”

Hall of Edna Everage fame with a Year 5 Essendon North Primary performance of Consider Yourself.”

Colin has found that his theatrical expertise has proven useful in both teaching and mentoring roles in medicine.

“I’m attuned to things like non-verbal communication, mirroring of patient response and respectful listening. These are things I teach the AMC candidates for their clinical exams and as an examiner for the RACGP WA I’m also asked to role play. I’m usually the ‘difficult’ patient. I can certainly turn it on and convince the candidate that there’s a very serious problem.”

And when a stethoscope is required, a little bit of community engagement doesn’t go astray either.

“There’s no doubt that an activity like community theatre develops human insight and empathy and that certainly makes you a better doctor. You become less insular and working in an area such as Midland, where you meet people from all sorts of backgrounds, that’s an advantage. You have to be able to relate to them all, so being able to find some form of common interest puts them at ease and gains their trust.”

When Medical Forum spoke to Colin, he was preparing for his fifth production of Oliver, which played the Regal Theatre in Subiaco last month. Last year he was Uncle Max in The Sound of Music which raised $80,000 for the MS Society.

“Directors often choose a role that runs against a more obvious selection. One director obviously wanted to knock out all my intellectualism by picking me as the Scarecrow in Alice in Wonderland And I did

Are You Serious?

“Too emotional and haven’t the time to practise full-time because of their commitments to their families and household chores.”

“More informed and patient friendly.”

“Always running later than their male counterparts.”

“A valuable contributor to the profession. (That's a safe one isn't it?)”

“Delicate creatures who like their comfort zone.”

“Setting the trend for quality of life and family.”

“More patient, empathetic and kind towards patients, at the same time difficult to manipulate.”

medicalforum

“Lazier than male doctors.”

“Just making up the numbers and generally not working enough hours.”

a TV ad where I was a patient in a hospital bed so there’s some role reversal!”

Did he ever consider acting full-time?

“When I left school some of my friends went straight into a production of Hair.

I was extremely envious, but I’d won a Commonwealth scholarship and entry into medicine so I felt I owed it to my parents to do the university course. I really believe that I’ve had the best of both worlds. How many people can say they’ve sung in Jesus Christ Superstar with Angry Anderson? I’ve had a wonderful life in the theatre.” l

By Mr Peter McClelland

“Too far on the pendulum swing towards empathy and away from science.”

“Less productive.”

“The vectors for spreading rumours.”

“More difficult to work with due to excessive obsessionality and, at times, inability to see the bigger picture.”

“Demanding their bread buttered on both sides.”

"I don't like to generalise but magazine editors sometimes come across as a bit sexist..." (who us?)

49

Lifetimes

They taught me that you must care for the patient before you take over the care of the patient.

There’s a big difference.” .

Going with the Flow

F

rom farmer to physician and back to the land, Arthur Harris has seen a lot of both life and medicine. He was born into a Dalwallinu farming family in 1936 and after retiring from medicine in 2006, he returned to the land working his property situated between Busselton and Margaret River planting die-back resistant jarrah trees, growing proteas and raising beef cattle all with the help of his trusty ancient D4 Caterpillar tractor.

“To give you an idea just how ancient it is we bought the tractor the year I left school in 1954. Back then in Dalwallinu we were getting one pound sterling for one pound of wool. It was also expected that the eldest son would carry on the farming tradition but it was hard and dreary work. There were lonely hours of ploughing, seeding and harvesting going around and around enormous paddocks on noisy, bumpy machines with no protection from the elements. I thought to myself, life must hold more challenges than that!’.”

n Dr Arthur Harris and his grandson.

were enhanced by an ‘overseas’ degree. So I began a MD from UWA and completed the thesis at the University of Massachusetts Medical School in the US. I got my wish! In 1978 I accepted a clinical position in internal medicine and endocrinology at RPH.”

Medicine was calling, though Arthur did it the hard way.

“Doctors were seen as trustworthy professionals and regarded with great respect. So it was an easy ‘change of careers’ choice but my academic record at Scotch College was pretty uninspiring so I went back to Leederville Technical School and from there into medical school.”

While the career path for young doctors these days is more streamlined, Arthur has some wisdom to pass along.

“Graduation opens the door to innumerable postgraduate careers these days but choosing the most appropriate one is the most important career decision they’ll make. So, my advice is to take time to shop around, look for a path that is best suited to your abilities and ambitions and one that will inspire you and provide a lifetime of career satisfaction.”

Arthur was a resident at RPH, SCGH, PMH and KEMH and came away with a profound admiration for the doyens of medicine such as Bob Elphick, Janet Elders, Alan Charters, Harry Rees and Alex Cohen.

“All of them taught by precept and example.

They taught me that you must care for the patient before you take over the care of the patient. There’s a big difference. The desire to become a consultant physician gradually gelled and that meant more study at the College of Physicians.”

“Also listen carefully to the mother’s history, regardless of the patient’s age and always listen to experienced nurses (Luer Mulligan, RPH, and Sister Green, PMH) – they’re usually right.”

“I knew that appointments to the clinical staff weren’t easy to come by and that they

Conference Corner

2nd National Indigenous Drug and Alcohol Conference Dates: 6-8/06/2012 Venue: Esplanade Hotel, Fremantle Website: www.nidaconference.com.au

Asian Pacific Conference on Mental Health Dates: 11-13/06/2012 Venue: Perth Convention and Exhibition Centre Website: www.rfwa.org.au/aspac2012

National Early Childhood Intervention Conference Dates: 9-11/08/2012 Venue: Burswood Entertainment Complex Website: www.eciaconference2012.com.au

Catholic Health National Conference 2012 Dates: 20-22/08/2012 Venue: Pan Pacific Hotel Perth Website: www.cha.org.au/site.php?id=1483

Aged Care Better Practice 2012 Dates: 13-14/09/2012 Venue: Perth Convention Exhibition Centre Website: www.accreditation.org.au/ education/better-practice-2012/

50

medicalforum

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