Medical Forum WA 11/13 Public Edition

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November 2013 www.mforum.com.au

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Your Advantage

CONTENTS

Major Sponsors

FEATURES 10

13+ Years, and Going Strong

18

Closing the Alzheimer’s Gap

20 Protecting Abused

Elderly 22 Planning for the End

NEWS & VIEWS 2

Letters t F1SFTDSJCJOH "OTXFST 1MFBTF %S 0MHB 8BSE 3FTQPOTF "VTUSBMJBO %FQBSUNFOU PG )FBMUI t %PDUPST %FBMJOH 8JUI %PDUPST %S )JMBSZ $MBZUPO t $PNNVOJUZ "DUJPO PO &BS )FBMUI $ 1SPG 'SBODJT -BOOJHBO t .PSF (1T GPS )*7 .FEJDJOF %S -FXJT .BSTIBMM t )*7 B .PEFSO 1FSTQFDUJWF .S "OESFX #VSSZ t +VTUJDF GPS 4FOJPS %PDUPST %S , $ 8BO t %PTF 3FEVDUJPO &TTFOUJBM %S .BSL )BNMJO t 5FTUPTUFSPOF "EEJDUJPO BOE *OGFSUJMJUZ %S "OOF +FRVJFS

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E-POLL & EVENTS 16

10

ePolls – Aged Care; Advanced Health Directives; CME; Druh Mishaps

CLINICAL FOCUS 5

Defining Iron Deficiency %S 3FCFDDB )PXNBO

35 Age-Related Macular

Degeneration %S #SBE +PIOTPO

36 Sleep Apnoea and

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37 Investigation of

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38 Osteotomies Around

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39 Hallux Valgus

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LIFESTYLE

Editorial: Passion for Compassion

40 Racing Doctors

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42 The Social Pulse

12

Readership Survey

15

Have You Heard?

25 Busting Myths about

Palliative Care 27

Perth Pathology

Research into Diseases of Age

32 Creative Thinking to

the Test 34 Beyond Blue

Doctors’ Survey

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43 Wine Review: Rosily %S .BSUJO #VDL

44 Car Review:

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44 Photo Competition 46 The Funny Side 47

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48 Brief Encounter

GUEST COLUMNS

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29 Real Cost of Aged

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Don’t Punish the Carers

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More I Care, the Less I Earn

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33 Do We Need a Third

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22 1

PUBLISHERS

Letters

Ms Jenny Heyden - Director Dr Rob McEvoy - Director

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 Journalist Mr Peter McClelland journalist@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

ePrescribing – answers, please

Doctors dealing with doctors

Dear Editor, Since the advent of the E-Health Record into our medical software, I note that for every prescription there’s a box to tick for receiving dispensing notification or not. I’m concerned about this. At some indefinite stage in the future is some legal eagle going to hold me accountable as to whether my patients fill their scripts or not? Does anybody know what advantages there are if we receive dispense notification? And why can we choose sometimes, always, not this time or never? Can anyone give me a straight answer to these questions?

Dear Editor, Thank you for publishing Dr Buntine's brave article on the doctor-parent dilemma [DoctorParent: What Could Be Worse?, October]. Our sympathy goes out to her. Four months is early days, one hopes after 12 months the grief will go away – but it doesn't. Doctors do not deal with doctors well. We got the impression when we were dealing with our son’s terminal illness that we were difficult parents. We found the level of communication to be very poor, often we were just ignored. I think the medical profession can do better in these situations.

Dr Olga Ward, GP and Medical Adviser, Rural Health West Response: With the implementation of Electronic Transfer of Prescriptions (ETP) functionality, the two Prescription Exchange Services (PESs) offered a feature whereby prescribers could request that they be notified when a prescription was dispensed. In February this year there were concerns raised by clinicians regarding an additional duty of care that could arise from the provision of receiving dispense notifications. Following discussion with the Department of Health and the two PES vendors (eRx and MediSecure) this functionality was turned off by the PES vendors in March 2013. Therefore, prescription notifications are not currently supported by either of the PESs. The option to request the notification through your clinical software will not generate any notifications.

Dr Hilary Clayton, Peppermint Grove

Community action on ear health Dear Editor, Prof Kamien’s letter [Bring Back Ear Health Auxiliaries, October] quite rightly documents the multifactorial issues that contribute to the dreadful problem of chronic ear disease in Aboriginal children. In some remote communities this reaches levels of 70%. The World Health Organization considers communities with levels of chronic ear disease above 4% to have major public health problems. As Prof Kamien commented the only identified measure that has improved these levels in other societies is improvement in socio-economic conditions. ENT surgeons alone will not improve poverty levels but

From a spokesperson for the Australian Government Department of Health

Star

Joke

More letters P3

10 BEST CADDIE REMARKS

10 Golfer: "Think I'm going to drown myself in the lake."

4 Golfer: "How do you like my game?"

Caddy: "Think you can keep your head down that long?"

Caddy: "Very good, but personally, I prefer golf."

9 Golfer: "I'd move heaven and earth to break 100 on this course."

3 Golfer: "Do you think it's a sin to play on Sunday?

Caddy: "Try heaven, you've already moved most of the earth."

2 Golfer: "This is the worst course I've ever played on."

Caddy: "The way you play, it's a sin on any day."

8 Golfer: "Do you think my game is improving?"

Caddy: "This isn't the golf course. We left that an hour ago."

Caddy: "Yes, you miss the ball much closer now."

1 Golfer: "That can't be my ball, it's too old."

7 Golfer: "Do you think I can get there with a 5 iron?"

Caddy: "It's been a long time since we teed off, sir."

Caddy: "Eventually."

And an old favourite:

6 Golfer: "You've got to be the worst caddy in the world."

… the one about the Golfer who has been slicing off the tee at every hole. He finally gives up and asks his longsuffering caddy if he has seen any obvious problems to which the caddy replies, "There's a piece of crap on the end of your club." The Golfer picks his club up and cleans the club face at which point the caddy says, "No, the other end."

Caddy: "I don't think so, that would be too much of a coincidence." 5 Golfer: "Please stop checking your watch all the time. It's too much of a distraction." Caddy: "It's not a watch – it's a compass."

medicalforum

Apology and Retraction TO:

The Australian Medical Association (WA) Incorporated Mr Paul Boyatzis Associate Professor Rosanna Capolingua Professor Bernard Pearn-Rowe

We, Dr Robert McEvoy, Ms Jenette Heyden and Rakabee Pty Ltd (being the company through which we publish Medical Forum WA magazine (Magazine) and maintain the website at www.medicalhub.com.au (Website) published an article in April 2011 concerning the AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We each now accept that the article contained some material that was without foundation and that we unreservedly retract and which may have led readers to draw damaging conclusions about AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We apologise for any damage the article has caused AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We also accept that Mr Boyatzis, Associate Professor Capolingua and Professor Pearn- Rowe were hurt and distressed by some subsequent articles we published and we regret this.

Dr Robert McEvoy

Ms Jenette Heyden

Rakabee Pty Ltd

Date: September 2013

Letters Continued from P4 we can attempt to publicise the problem. The ‘Ear Health Auxiliaries’ described by Prof Kamien have become central to current approaches to chronic ear disease in the Aboriginal Communities. There is now an Aboriginal Health Care Workers programme established in many regions of WA and there are an increasing number of committed individuals throughout the regions. They are indeed pivotal to local ongoing management. An Ear, Nose and Throat specialist contributes little other than encouragement and appropriately timed surgery for unresolved problems. The advent of Tele-Health is further improving local medicalforum

management. There are models for this in other Indigenous groups. For example, in Alaska the Native American children do not see an otologist unless and until they require surgery. Community ownership of these chronic conditions is essential if we are to see improvement of the levels of chronic ear disease in Aboriginal children. This will improve educational outcomes and thereby also improve other socioeconomic outcomes. It is a privilege to be involved with colleagues such as Prof Harvey Coates in attempting to address this major problem.

C/Prof Francis Lannigan, University of Western Australia

More GPs for HIV medicine Dear Editor, I read with interest the article about Dr Ric Chaney [A Man of Letters, October]. I have had the privilege of working with Ric over the past 20 years in the management of people with HIV infection and can attest to the outstanding service he has provided in this sphere of medicine. As a sexual health physician involved in the tertiary care of those with HIV, I would like More letters P6 3

Editorial

By Ms Jenny Heyden

Passion for Compassion

I am a partner in Medical Forum and have chosen to keep out of the editorial spotlight. However, our 13-year retrospective in this edition and a genuine concern give me licence to write. My concern is for the level of compassion shown within the profession and where this is heading. Being a woman who comes from a nursing background gives me two claims on this topic. My views are grounded in past work in private and public hospitals as well as private rooms. I have a unique long-term dialogue with GPs, specialists and their practice staff of all ages; plus contacts with people in medical corporations, and conversations with private and public patients in my work with Venosan. As well, like many of my age, I care for an elderly mother. In all these areas, the saying, “You are only as good as the people working with you” makes me mindful that everyone makes a contribution when it comes to compassion and caring for another person. In this,

private-public comparisons are interesting where talk seems to inevitably focus on the bottom line, money, but in different ways. Everyone knows we don’t have enough to go around in the public system, that this pressure will increase, and rationing resources will come. The question for us, as a profession, is how to ensure any redistribution does not lose sight of compassion for our patients. Medical leaders in the public system, usually the older more experienced ones, have a lot more to offer than fixing problems. Doctors who practise private medicine are also patient-focused but money is more about value adding to the patient encounter. They can go that extra mile. They show a personal touch, spend time with patients, monitor staff performance and, where it applies, are sensitive to other doctor referrals. Within this mix some things seem to be eroding the level of caring or compassion. If time spent with patients is our most precious commodity, where are time-poor or under-rewarded health professionals heading?

We have some GPs who mostly triage patients, and it is an open question whether corporatisation or larger group practices encourage this trend or simply become the place where doctors with a lifestyle focus prefer to practise. We have some specialists who see their practices as businesses, work hard to satisfy their patients and their competitive urges, and openly admit that they seek to retire when they are 55 or so. Our community has become more litigious. The patients who prefer legal action have had real impact. This changes how we communicate, for the worse. Professional networks were about sharing care for patients, now it’s more about getting the job done under increasing time pressures, with everyone less accessible. Finding the best way to deliver health care with compassion is a continuous juggling match but there is no real cap on compassion, just our personal limitations. Some seem to have no limits. If we could bottle that, it would be nice! l

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Dr Rebecca Howman

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

www.perthpathology.com.au Collection centres throughout the Perth metropolitan area including: Fremantle (Main Lab); Perth CBD, Atwell, Bedford, Belmont, Bentley, East Perth, Ellenbrook, Hilton, Joondalup, Kardinya, Kinross, Maddington, Malaga, Palmyra, South Lake, South Perth, Southern River

Rebecca is a local graduate who trained at Perth teaching hospitals and at the Peter MacCallum Cancer Centre, Melbourne. Her special interests include myelodysplasia, the diagnosis and management of haematological malignancies, iron deficiency, and obstetric haematology. She works at Perth Pathology, Sir Charles Gairdner Hospital and Hollywood Medical Centre.

Defining Iron Deficiency: New Standardised Reporting of Iron Studies ,URQ GHĂ€FLHQF\ ZKHWKHU DVVRFLDWHG ZLWK anaemia or not, is a debilitating state. In young children it may impair cognitive development while in older children it causes cognitive and behavioural problems. In adults it is a common cause of physical and intellectual under-performance. ,Q DOO FDVHV RI LURQ GHĂ€FLHQF\ D VRXUFH of blood loss should be sought unless the SDWLHQW KDV DQ H[WUHPHO\ LURQ GHĂ€FLHQW GLHW In adult males and post-menopausal females, LURQ GHĂ€FLHQF\ LV IRXQG WR EH DVVRFLDWHG ZLWK a thirty-fold increase in the incidence of colorectal cancer. A low ferritin result is pathognomonic RI LURQ GHĂ€FLHQF\ $OWKRXJK WKLV VHHPV VWUDLJKWIRUZDUG FXUUHQWO\ WKHUH LV VLJQLĂ€FDQW variation in the normal ranges that ODERUDWRULHV XVH WR GHĂ€QH LURQ GHĂ€FLHQF\ Furthermore, as ferritin is an acute phase UHDFWDQW LQ WKH VHWWLQJ RI LQĂ DPPDWLRQ a ferritin level higher than the laboratory FXW RII IRU GHĂ€FLHQF\ GRHV QRW H[FOXGH LURQ GHĂ€FLHQF\ ,Q RUGHU WR VWDQGDUGLVH ODERUDWRU\ reporting of iron studies, the Royal College of Pathologists of Australasia (RCPA) have developed new guidelines for the laboratory UHSRUWLQJ RI LURQ GHĂ€FLHQF\ 7KH NH\ SRLQWV are summarised below.

Men and women are equal Increasingly it is recognised that iron depletion may be associated with neurocognitive effects and impaired cellular IXQFWLRQ 7KHVH HIIHFWV DUH DSSDUHQW ZHOO before patients develop anaemia. Up to 25% of menstruating women are iron depleted; associated with menstrual blood ORVV GLHWDU\ GHĂ€FLHQF\ SUHJQDQF\ DQG EUHDVW IHHGLQJ 7UDGLWLRQDOO\ PHQVWUXDWLQJ ZRPHQ have had a lower ferritin cut-off for iron GHĂ€FLHQF\ WKDQ PHQ 7KH 5&3$ QRZ GHĂ€QHV LURQ GHĂ€FLHQF\ E\ D ferritin concentration <30 mcg/L in adults or <20 mcg/L in pre-pubescent children.

6LJQLĂ€FDQWO\ PHQ DQG ZRPHQ KDYH WKH VDPH cut-off regardless of menstrual status for women.

Iron in pregnancy 7KH 5&3$ KDV DOVR DGRSWHG D WKUHVKROG RI PFJ / IRU LURQ GHĂ€FLHQF\ LQ SUHJQDQF\ consistent with the UK Guidelines. Iron GHĂ€FLHQF\ FRQWULEXWHV WR PDWHUQDO PRUELGLW\ by a number of mechanisms. Impaired psychomotor and/or mental development are ZHOO GHVFULEHG LQ LQIDQWV ZLWK LURQ GHĂ€FLHQF\ anaemia and may also be detrimental to infant social and emotional behaviour.

Combination iron deficiency with inflammation Ferritin is an acute phase reactant and is elevated in liver disease, infection, LQĂ DPPDWLRQ DQG PDOLJQDQF\ 7KH most common cause for raised ferritin in Australia is obesity, as a result of hepatic steatosis (fatty change) and obesity-induced LQĂ DPPDWLRQ ,Q SDWLHQWV ZLWK LQĂ DPPDWLRQ ferritin may increase by three-fold. Such a SDWLHQW ZKR DOVR KDV DEVROXWH LURQ GHĂ€FLHQF\ may have a ferritin concentration higher WKDQ WKH FXW RII RI PFJ / 7KH 5&3$ JXLGHOLQHV UHFRJQLVH WKLV GLIĂ€FXOW\ LQ interpretation and recommends that anaemic adults with ferritin between 30-100 mcg/L (and children with ferritin between 20-60 PFJ / DQG LQĂ DPPDWLRQ EH UHSRUWHG DV LQFRQFOXVLYH L H LURQ GHĂ€FLHQF\ QRW H[FOXGHG In anaemic patients, the RCPA suggest measurement of CRP and follow-up iron VWXGLHV ZKHQ WKH LQĂ DPPDWLRQ KDV UHVROYHG Alternatively the patients may be treated and LQYHVWLJDWHG IRU LURQ GHĂ€FLHQF\

When do these changes come in? Perth Pathology will adopt these new normal UDQJHV IRU UHSRUWLQJ LURQ GHĂ€FLHQF\ IURP November 2013. A ferritin concentration of <30 mcg/L in adults (men, women premenopausal, pregnant and post-menopausal) and <20 mcg/L in pre-pubescent children ZLOO EH UHSRUWHG DV LURQ GHĂ€FLHQF\ ,Q DGXOWV with ferritin between 30-100mcg/L, or

Q Advanced iron deficiency showing typical red cell change seen in anaemia, including size and shape variation, oval and pencil forms. Clinical symptoms often arise well before these blood changes are seen.

children with ferritin between 20-60 mcg/L, LURQ GHĂ€FLHQF\ LV QRW H[FOXGHG LQ WKH VHWWLQJ RI LQĂ DPPDWLRQ References available on request.

Perth Pathology General Pathologist / Managing Partner: Dr Wayne Smit 0410-488736 Histology / Cytology: Dr Michael Armstrong Dr Tony Barham Dr Tom Grieve

0417-094799 0416-577619 0409-849448

Infectious Diseases (Microbiology): Dr Laurens Manning 0400-783194 Haematology: Dr Rebecca Howman

0417-935873

Laboratory Director: Paul Schneider

0417-931850

Providing phone advice to clinicians and a comprehensive range of medical pathology investigations, including: ˆ ,MWXSPSK] 7OMR +- IXG ˆ ']XSPSK] MRGP 4ETW ERH *2%W ˆ ,EIQEXSPSK] ]IW [I HS PEF GSRXVSPPIH -26W ˆ & MSGLIQMWXV] MRGPYHMRK LSVQSRIW ERH QEVOIVW ˆ 1MGVSFMSPSK] ERH 7IVSPSK] Professional personalised service from a noncorporate, pathologist owned and operated laboratory practice

Letters Continued from P3 to encourage more GPs to become involved in this interesting branch of medicine, which has changed dramatically over recent years. HIV has become a chronic infectious illness and those infected need the skills that GPs already possess. As people are now living many years with HIV, there is an increasing need to deal with the common illnesses of advancing age including cardiovascular, renal and metabolic conditions. Some can be accelerated with HIV infection. These are conditions that GPs deal with expertly on a daily basis for many patients, many of whom also see specialists for other chronic conditions. HIV can be managed in exactly the same shared care way. Shared care with the tertiary centres is well supported in WA for interested GPs. The Australasian Society for HIV Medicine (ASHM) continues to provide training*, which can help GPs gain confidence to manage this chronic infectious illness, or GPs can contact the HIV centres at RPH or Fremantle Hospital to explore shared care. While we can never replace Ric, we really need GPs to help provide holistic care to people living with HIV.

Dr Lewis Marshall, Sexual Health Physician * www.ashm.org.au/courses

HIV: a modern perspective Dear Editor, Thank you for the excellent article about Dr Ric Chaney – a true pioneer in our response to HIV. Thirty years of HIV epidemic and almost 20 years of rapid improvements in treatments and management have meant the complexity of patient care now ranges from very high to very low. For many people who acquired the virus before the introduction of effective medication in the mid-1990s, their requirements are often complex and demand a high degree of specialist medical intervention. Someone infected in the past 10 years, however, will require much more straightforward management. This is particularly so if their diagnosis was close to the time of infection. In the near future, a number of highly experienced clinicians such as Ric will retire and there is obvious concern about what this will mean for the many HIV positive patients currently in their care. Rather than view this evolving situation with angst, we might instead look to what opportunities the changing landscape of HIV is offering. It seems to me that this is a time to re-evaluate our model of shared care and recognise that many GPs are already competent to work with positive clients, but don’t realise that they are. This may also be

an opportune time to reconsider the S100 status of HIV medications and whether this is warranted in all cases given the capacity limitations this produces. There is a ‘mystique’ about HIV that was developed in the days of crisis and death; these days now thankfully behind us. It is important that our models of care reflect today’s environment and not that of yesteryear.

Mr Andrew Burry, CEO, WA AIDS Council

Justice for senior doctors Dear Editor, As a follow up to my letter to Medical Forum in February 2013, I felt very sad when a good friend and colleague of mine, who is a respiratory physician, recently informed me that he is retiring and ceasing to sit with me as a member of a Worker's Compensation Medical Panel. He said it was not worthwhile for him to continue to work part-time because of the onerous and expensive AHPRA medical registration renewal requirements such as full registration fees and medical defence insurance. Senior semi-retired or part-time doctors are being denied natural justice. They are More letters P8

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1300 728 133 www.medifit.com.au

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Letters Continued from P6

denied their right to practise should they not achieve full CPD points annually with no right of appeal. This is the equivalent to being deemed incompetent whereas a doctor who commits an offence such as professional incompetence has a right of appeal before they can be denied registration! I have recently joined a group of senior active doctors who have formed the Australian Senior Active Doctors Association (ASADA) to fight this, but we need the support of all doctors. The website is www.asada.net.au/forum.html

Dr K.C.Wan, Consultant Occupational Physician

Dose reduction in WA essential Dear Editor, It is concerning that CT scans in WA have as much as three times the radiation dose as international scans ([1]). A survey in 1996 by the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) found that Australia had the second highest provision of CT scans per capita, three times that of UK and New Zealand. The radiation dose per examination in Australia was 50-69% higher than any other country. The 2013 study performed by Dr Moorin et al reports that CT scans performed by public and private institutions produced higher radiation doses than those reported

AMA WA & Ors v Medical Forum & Ors – Defamation Proceeding In April 2011, Medical Forum published an article concerning the AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. The Proceedings have been settled on commercial terms satisfactory to all parties and without any admissions or concessions as to liability.

Thanks to all readers for their continuing support of Medical Forum magazine.

8

in the international literature. However, it was also noted that the CT protocol chosen by the radiologist can dramatically affect and reduce the radiation dose during a single CT examination. It is accepted that medical radiation exposure is associated with development of cancer, particularly in children and adolescents. [2] CT scans account for almost 50% of all radiation exposure for diagnostic imaging. It is therefore imperative that CT radiation dose is reduced to the lowest acceptable value (ALARA principle), and for all providers to achieve the lowest clinically valid dose. Radiologists (and implicitly, referring doctors) have a duty to become more actively involved in optimising their scan protocols and using dose reduction techniques. The key challenge in dose reduction is to preserve high image quality with less radiation. Fortunately, the latest CT techniques allow us to achieve both goals with minimal trade-off. The radiologist has an option to record the radiation dose estimate as part of the written radiology report which would be of upmost relevance to the patients upcoming Healthcare Record (PEHCR) given the cumulative effect of radiation exposure.

Dr Mark Hamlin, Radiologist, Imaging Central 1. Moorin R, Forysth R, Gibson DJ, Fox R. Radiation dosimetry assessment of routine CT scanning protocols used in WA. J Radiol Prot. 2013 June; 33(2): 295-312 2. Mathews J, Forsythe A, Brady Z et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013; 346: f2369

Testosterone: addiction and infertility? Dear Editor, It is well known that testosterone supplementation enhances physical performance by increasing muscle mass and the rate of tissue repair. In larger doses it also creates a feeling of wellbeing in the long term, a powerful feeling that can be painful on withdrawal. While supplementation can cause uncontrollable erections in some distressed patients, loss of libido on withdrawal can be equally distressing. Commercially available intramuscular preparations can have all of these effects so they should be considered potential drugs of addiction. Understanding more about these agents

is important. First, normal secretion of male testosterone is strongly diurnal, high in the morning and markedly reduced in the afternoon and evening. For this reason, testosterone levels should always be measured between 8am-10am only. Blood taken in the afternoon can lead to an erroneous diagnosis of hypoandrogenisation and unnecessary treatment with testosterone. Importantly, such therapy may have dire effects on fertility. Therapeutic doses of testosterone suppress endogenous LH and thus ablate all intra-testicular production of testosterone, which is in turn mandatory for both spermatogenesis and the normal function of excurrent ducts of the testis. Using many commercially available injectable preparations, the sperm count falls and the patient now has infertility – even one dose is enough to render a patient azoospermic for 4-6 weeks after treatment. The injectable preparations should never be used by infertile patients. (Even cream applications must be carefully titrated; and to re-establish sperm production after therapy, twice weekly subcutaneous hCG may be required for 3-4 months.) The threat of losing the feeling of wellbeing that comes from testosterone injections may result in a form of addiction that can be difficult to overcome. To cease testosterone therapy abruptly risks patient depression and their loss of co-operation.

Dr Anne Jequier, Clinical Andrologist, Concept Fertility

RING

BELLS? We’d like to hear from you. Leave a message on our website www.medicalhub.com.au or email editor@mforum.com.au

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Retrospective

13+ Years, and Going Strong Medical Forum launched for all WA doctors in 2000, as a natural progression from GP Magazine for GPs alone (five years) and before that, Pulse Magazine for the RACGP WA Faculty. Comparing today’s magazine with the inaugural April 2000 edition causes those involved slight embarrassment – back then a less sophisticated look, half the size, no competitions, no lifestyle stories, etc – but enthusiastic support from within the WA medical scene was evident. Some big names amongst Major Sponsors back then were Western Orthopaedic, Pivet, St John of God, Perth Imaging and Formulab (Foundation Health Care), and the list has grown since then, some joining in this relationship longer than others. Clinical updates in the April 2000 edition are another indicator of wide clinician involvement: blepharitis (Dr Malcolm Le May), female incontinence (Dr Lincoln Brett), gastro-oesophageal cancer (Dr Stephen Archer), diagnosing diabetes (Dr Julia Potter), facial skin resurfacing (Dr Cary Kailis), the bone scan (Dr Geoff Groom), insulin resistance and cardiovascular risk (Dr Eric Whitford), haemarthrosis of the knee (Dr Kon Kozak), and anti-filaggrin antibodies (Dr Martin Stuckey). An independent display of expertise that has continued to this day.

Q Our cover: April 2000 to now

Back then, Medical Forum’s respected e-Poll was a Fax Poll! Editorial staff collated faxed responses from GPs, and for April 2000, came up with: t PG (1T TBJE BU MFBTU POF PG UIFJS patients had received surgery earlier, thanks to the Getting Patients Treated program where GPs audited tertiary hospital waitlists.

t (1T QPJOUFE UIF GJOHFS BU SFIBC QSPWJEFST (52%) and lawyers (62%) to explain escalating WorkCover costs. t PG (1T XFSF VODPODFSOFE UIBU of practices were to get blended payments via Better Practice Payments.

WE'VE COME SO FAR The principal partners behind .FEJDBM 'PSVN and its prior publications are Dr Rob McEvoy and Ms Jenny Heyden RN. Jenny speaks for them both: “There is no doubt that we both get a buzz from creating something that most colleagues enjoy reading today." "Mind you, providing this free to doctors for so many years has meant we have had to perform well to attract goodwill, all without losing sight of the bottom line."

Q Dr Rob McEvoy, about 1999. Note physique, monitor, and moustache

10

"Achieving so much with so few people is a big source of pride and I suppose it is the good feedback and being part of the medical community that sustains us. There are exciting times ahead.”

Q Ms Jenny Heyden circa 1999. Beaming amongst the Health Books

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Where Are They Now? Dr Parbodh (Gog) Gogna: THEN – Ex UK and then Beverley GP, keen to unite GP groups for the greater GP good after meeting with Dr Wooldridge. NOW – recently working on Christmas Island and heaps of stories to tell.

Issues Back Then, And Now? Recalling everything in the April 2000 edition would take too much space but… Pathology Turf War. Medical Forum revealed big players of the day moving to integrate pathology acquisitions with mainly medical practices. Foundation Health Care acquires Clinipath. Total Health Care (Revesco) purchases General Pathology. Westpoint Healthcare takes a 25% stake in Russell Pathology. Healthcare of Australia (Mayne Nickless) hospitals link to Western Diagnostics. CTEC Launch. Thanks to $9.7m from UWA and $5.3m from the DoH, WA would soon get its first surgical skills simulation lab. Medical Director Dr Richard Vaughan showed Medical Forum around. As it happens, the use of fresh frozen cadavers and niche marketing helped CTEC survive a later onslaught of similar facilities. Peptic Ulcer Drugs were still in the ‘top three’ for PBS spend (along with lipid lowering agents and psycholeptics). Simvastatin was costing $184m a year. WA’s Nobel laureates, the NPS, generics and tighter drug approval rules have put the brakes on since. Central Wait List disarray – 43% of patients were removed for non-medical reasons and the rest were targeted by GPs within Divisions, who got 22% earlier surgery outside the initially allocated hospital. Over 100 GPs get upskilled to perform minor surgery. O

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Dr Richard Vaughan. THEN – semi-retired neurosurgeon involved with the start-up of WA’s first simulation lab at CTEC. NOW – just doing medicolegal work and keeping current via his respective colleges and his grandchildren. Dr Denis Carragher. THEN – Kalamunda GP involved with Getting Patients Treated, a GP-driven attempt to audit and clean-up the tertiary hospital surgical waitlist. NOW – the “wrong side of 70” and lobbying to continue minor surgery like vasectomies with the impending closure of Swan Districts Hospital, plus extend the work of rural proceduralists. Dr Jenny McConnell. THEN – RACGP education development officer, involved with a college weekend at Busselton providing entertainment, education and relaxation. NOW – until recent months working with Notre Dame in Aboriginal health and living in Broome. Dr Bill Pannell. THEN – reviews the background and wines of Houghton’s winemaker Larry Cherubino. NOW – loves everything French and his Picardy winery in Pemberton; gave up consulting in 2001.

11

Reader Feedback

Medical Forum Earns its Stripes

Q TThe Medical Forum Team: Ms Jenny Heyden, Dr Rob McEvoy, Mr Peter McClelland, Ms Jan Hallam and Mr Glenn Bradbury

Readers of the magazine have spoken! The 2013 readership survey helps Medical Forum excel in WA medical reporting. Heartfelt thanks go to the 393 WA doctors who took time to comment on our current performance and outline what style of Medical Forum content we should aim for in the future. Commiserations to all those who unsuccessfully entered for our random prize draw (see inset for winner’s story). Here, we present a selection of results of interest to you.

medical workplace through balanced ethical reporting. For these reasons, it is particularly gratifying that 90% of our surveyed doctors either agreed or strongly agreed that it is important for the medical profession in WA that Medical Forum continues (with only 9% undecided on that point). Why? Perhaps the 83% overall response saying our editorial independence was important, might have something to do with it (with 16% undecided).

Medical Forum readership remains high, with 72% overall saying they usually read more than half of each edition, and there was only a slight fall-off amongst timestrapped younger graduates. Male GPs were our strongest reader group but not by much. With 93% overall saying they had looked into an edition of Medical Forum in the last month and read or scanned at least two of the last three editions, we must be doing something right. It is also gratifying to note the broad appeal of Medical Forum content, with no significant differences on these points between GP and specialist reader groups.

Thanks to the survey respondents who indicated what they like most in Medical Forum and what they would like to see more of. The things that caught us by surprise were: our feature writing has grown in popularity; GPs rate lifestyle articles and humour higher than specialists do; and specialists rate Guest Columns more highly than do their DIT or GP counterparts.

Amongst those who had formed an opinion, 73% of specialists and 74% of GPs picked Medical Forum as the publication that best covers the Western Australian medical scene in a way that interests them. Males working full-time held this view most strongly. As the only independent industry publication for WA doctors, we are acutely aware that we have to earn our place in the 12

We noticed that a significant number of respondents answered our Readership Survey using their mobile device, and responses indicated a need to encourage more traffic to our website so more doctors can enjoy our competitions and other content. We feel that these days, virtually no one has time to ‘browse’ websites. We had only 9% of our respondents say they prefer only digital or online versions of Medical Forum (a feeling strongest amongst DITs, and something we offer, if doctors ask). ED: 393 respondent demographics: those in general practice 42%, specialist (salaried or private) 37%, DIT 11% and Other 9%; Male 62%; Graduation Pre-1979 29%, 1980–1989 22%, 1990–1999 30%, 2000–2010 17%; and in

A House-warmer from B&O There’s nothing like building your first home and now second year Fremantle Hospital resident Dr Kitty Shakur will be able to enjoy the hi-fidelity of a Bang & Olufsen sound system into her new place in Kardinya. Kitty won our Readership Survey prize courtesy of Bang & Olufsen Subiaco. Kitty, whose mother is a GP, graduated from UWA in 2011 and told Medical Forum that there’s a strong line of female doctors in her family. She also said that she enjoys the wonderful community of medicine that’s reflected within the pages of the magazine and, like most of our readers, the jokes. Kitty also said that she’d like to see more articles on investment, having noticed how hard some doctors were hit by the GFC.

full-time work 70%. O

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Have You Heard? Mobile GP clinics vaccinate

Too much vs not enough

Sanofi Pasteur is at the ready to supply WA’s mobile GP clinics with hepatitis, Pneumococcus, Tetanus and Pertussis vaccines – the 10 mobile GP clinics intend to promote vaccination to Perth’s homeless and disadvantaged using the $20,000 VaxiGrant from the company. Seven Vaxigrants are awarded nationwide to assist seven innovative ideas that promote vaccine uptake in Australia. Vaccination amongst the homeless fits with the idea of targeting under vaccinated groups.

While in this edition our major sponsor give us the run-down on iron deficiency, WA researchers report they have lifted the bar in defining ferritin overload. Figures from the Busselton Population Study show that we also need to accommodate age and BMI, as well as gender, to avoid unnecessary investigations and treatment. For people not homozygous for the C282Y haemochromatosis gene (0.5% prevalence) and not taking iron, anything under 1000 mcg/L ferritin was highly unlikely to indicate clinical iron overload, according to Prof John Olynyk.

Ambo service ramping up In June’s Medical Forum, St John Ambulance CEO Mr Tony Ahern explained the philosophy behind the Ambulance Surge Capacity Unit (ASCU) which was being trialled for four months in the flu season to help alleviate ramping at EDs. The early results are in and they show that 686 patients were sent to the ASCU at Hollywood Hospital. Of those patients, 283 were either sent home after assessment or admitted to a private hospital. A St John spokesman told MF that of those admitted most went to Hollywood with “single figures going to either St John Murdoch or Subiaco”. Given that it costs patients $290 to present at the Murdoch ED, we asked if the patient incurred a cost for being diverted to Hollywood? And if the trial is broadened, which has been mooted, what, if any, other hospitals are being considered? We will tell you when they tell us.

Grog goes with music? The Public Health Advocacy Institute is keeping us healthy, this time examining the music industry and whether or not recent popular music is influencing the drinking habits of young people. In a website poll it asked “Do you think that current popular songs are encouraging young people to abuse alcohol?” and noted in accompanying material that songs that mention drinking alcohol have gone up appreciably in popular music in the past 10 years. How does the medical profession fit in the frame? In the past we have pointed to McDonald’s and CocaCola’s sponsorship at PMH and we note that at their charity dinner, the Ear Science Institute had Little Creatures Brewing and Larry Cherubino Wines as sponsors, and fund raising included a “wine wall” with at least 14 wineries involved. Moderation in all things?

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Helping rural doctors Whether a final year med student (Rural Clinical School), intern, PGY2+, PGPPP, registrar or DRANZCOG candidate, navigating the where and what has been helped by Rural Health West’s online map of 15 rural sites in the Rural Practice Pathway. It is expected junior docs will find various rural training options easier to navigate now (see www.ruralhealthwest. com.au/rppmap). And for those going bush, HealthInfoNet has produced two relevant reviews on Indigenous ear health and rheumatic heart disease. Dr Leanne Heredia recently gave their website a favourable review in Medical Forum so you can find their material at www.healthinfonet.ecu. edu.au

Stretching kids services There appears no truth to the rumour that Colin Barnett’s crew have relented on more floors to what will be called Perth Children's Very Tall Hospital. And neither has the basement been dug out to create storage for the extra 100 beds, ready for later use, when staff can be found. Minister for Hospital Beds, Dr Kim Hames, has said he prefers to rearrange what exists (deck chairs?) to create space for an extra 24 beds. We all know children are small and occupy cots. The Premier reportedly said the AAA downgrading played only a minor role in the decision.

GPs and State Health There are two new leads for the Primary Care Health Network, Dr Michael Civil and Dr Aesen Thambiran. Mike works in the Hills, had a recent crack at the RACGP presidency, and is a champion of IT use in general practice, particularly Telehealth and the problematic PCEHR. Aesen is the Medical Director of the Humanitarian Entrant Health Services for the NMHS and worked as a frontline GP in underprivileged Lockridge for many years. Dr Scott Blackwell bowed out a year ago, having served since the Network launch by the DoH in late 2011. The rest is “partnerships across boundaries” and “the ability to engage stakeholders in a broad, inclusive and collaborative way” according to the media release. This edition’s e-Poll tells us what GPs currently think about their representation in WA.

Health cost spiral OK, Australians spent $140.2b on health in Australia in 2011-12 according to the Australian Institute of Health and Welfare (AIHW). That’s up from $82.9b 10 years earlier (adjusted for inflation), which is a bit scary. Almost 70% was government funded, with the rest from individuals, private health insurers, and other non-government sources. Domestic GDP proportion was 9.5%, up from 8.4% in 2001-02. That’s recurrent expenditure on health per person of $5,881. Public hospitals took 31.8% of recurrent health expenditure in 2011-12, and public hospital services accounted for the largest component of the overall rise in health spending. The federal-state split on public hospital funding was 38%-53%. O

15

e-Poll

GPs Speak Up on Current Issues Medical Forum asked GPs about their practice with elderly patients, CME, drug mishaps and keeping it all in balance. Nearly all the 147 responses arrived within the first three days of our broadcast email. Thanks to all those who took part! The wine-prize winner was Dr DC! Switching Off

Q

Doctors can ‘switch off” from work in a number of different ways – from cooking to walking the dog. How important do you consider regular ‘switching off’ is to being able to perform well as a doctor? Very important

73%

place Aged Care Facility, where high-care can be made available, what do you regard as the biggest hurdles [up to 3 choices]? Lack of available places that fit this description.

33%

Inadequate staff training and numbers to provide ongoing care.

25%

Expense for patient a barrier.

22%

Lack of RNs to assist in this role.

13%

Other

3%

Important

20%

No effect

2%

Uncertain

2%

Unimportant

1%

Not applicable

2%

Very unimportant

4%

Care of the Elderly

Q

If you had an elderly patient you suspected might be the subject of abuse, do you know who could appropriately look into this for you? Yes

37%

No

18%

Uncertain

42%

Not Applicable

3%

Q

In moving someone with Alzheimer’s from low-care independent living to an ageing-in-

Q

Do you think that Advanced Health Directives (AHDs) should be limited mainly to the elderly and chronically sick? Yes

20%

No

70%

Uncertain

10%

Q

Do you think AHDs are important enough to promote more in general practices?

Yes

65%

No

21%

Uncertain

14%

Comments on Aged Care Of the 35 doctors who chose to comment, some thought our most vulnerable citizens were not given the necessary support from government with low-cost accommodation and realistic waiting periods. As for aged care facilities: better training and education of staff were called for; some high-care facilities were dark, depressing and smelt of urine; there were not enough doctors; and there was poor document access, especially finding the I-care software. Mind you, some docs who worked in ACFs said it was thoroughly rewarding. Advanced Health Directives comments suggested some GPs were unfamiliar with them; what they do and who should get one. “All Docs should have a stack of them and hand them out!” one said but one other thought it macabre for doctors to be promoting them. Rural GPs pleaded for more AHDs in their areas to keep patients near their families. For one doctor the experience of treating the elderly in nursing homes has been too much. “I am afraid to say I never want to go to one. I am hoping an Advanced Health Directive and a belief that death should be of my own choosing will mean I never need to go to a nursing home.” ED: See next month's edition for the ePoll results on the practice accreditation issue.

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ll o P e

CME Activities for GPs

As regards CME activities for general practice, how much do you agree/disagree with the following statements? Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

The RACGP’s job is to accredit CME providers and it is then up to the providers to meet guidelines.

12%

52%

20%

12%

4%

Asking the RACGP to screen every CME activity for evidence-based content would be too difficult and expensive.

14%

50%

21%

12%

3%

GPs will critically appraise the usefulness of any CME activity, and vote with their feet if it is substandard.

14%

61%

12%

11%

2%

Allowing some CME content that is not evidence-based, and declaring this, would encourage innovation in general practice.

7%

44%

27%

18%

4%

CME participants should report to the RACGP any CME content they believe is contrary to evidence, and the RACGP should promptly investigate and act.

20%

48%

20%

8%

4%

ED. Four times as many GPs thought CME providers should be responsible for meeting RACGP guidelines as did not. A similar proportion thought it too expensive and difficult for the RACGP to screen CME activities to ensure they are evidence based. The vast majority (75%) of GPs said colleagues would simply not attend substandard CME and just over twice as many wanted to retain some non-evidence-based CME, as did not, to encourage innovation. And the RACGP should promptly investigate any complaint from a CME participant that information was contrary to evidence.

Generic Pharmaceutical Mishaps

Comments on GP representation

Q

The fact that nearly a third (28%) of GPs thought they did a better job of representing themselves, speaks for itself. Of the 29 who chose to comment, fragmentation of representation, and representative groups showing competing interests were strong themes. Influences from rural-urban and GP-specialist differences, along with government bureaucracy and conflicts over funding sources were all sources of discontent. Medicare Locals were not painted as having a clear role in representing GPs. This comment sort of sums it up: “I wish there were not so many organisations all claiming to represent my views when in reality none do!� Mind you, one GP suggested that without apparent fragmentation “we would be a force to be reckoned with�.

Can you recall any instance involving your patients where use of generic pharmaceuticals has created confusion that resulted in a medication mishap?

Yes

66%

No

25%

Uncertain

5%

Doesn’t apply

4%

Q

Given current circumstances with brand substitution, about how often to you believe such medication mishaps occur amongst doctors within your practice, on average?

More than once a week

12%

About once a week

11%

About once a month

17%

Less than once a month

31%

Never

7%

Undecided/Doesn’t apply

22%

ED. These two questions were prompted by a letter to the editor, suggesting that the proliferation of similar sounding names amongst generics, were leading to medication mishaps, such as patients wrongly doubling up on or avoiding medications. Amongst our respondents, two thirds recall an episode where generic pharmaceuticals caused confusion and a medication mishap, and about half said brand substitution was leading to medication mishaps at least once-a-month in around half of general practices. This are big numbers.

GP Representation in WA

Q

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Within the Western Australian setting, who best represents your interests as a general practitioner?

Myself

28%

RACGP WA

25%

AMA WA

21%

Uncertain

18%

Medicare Locals/Divisions

4%

Other

4%

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Feature

Closing the Alzheimer’s Gap Rhonda Parker is on a mission to make Alzheimer’s WA the first call a GP makes xing problem of the patient with dementia. when confronted with the perplexing It is no new news that dementia will play a greater role in the health landscape in the next couple of decades. The statistics below tell a sobering picture but an hour with the CEO of Alzheimer’s WA Ms Rhonda Parker gives cause for optimism. She has overseen a period of rapid expansion of the local organisation’s role and standing in the education and training of the community and carers, both paid and unpaid, and is responsible for delivering a growing suite of support and counselling services under contract from the state and federal governments. “It’s a rapidly growing business – I see it as a business – which grew 15% the last financial year making Alzheimer’s WA (AWA) the largest branch in Australia. We are very proud of the work we do but there’s a lot more to be done.” As way of illustration of how the organisation has grown from a HACC provider a few years ago to now a professional unit rolling out key services, Rhonda points to the recent Dementia Behaviour Management Advisory Service, which AWA ran as a pilot program last year and is now a project with at least another three years funding. The key is, of course, in its usefulness. “It was initially to support carers in the community and in residential facilities where a person’s dementia was impacting on their behaviour. The service has now expanded to acute and primary care settings so our team is working in hospital and with GPs.

Q Alzheimer's WA CEO CEO Rhonda Parker with pop star Sir Cliff Richard who donated $20,000 to the cause

I don’t think people are really familiar with the breadth of services we provide. We don’t provide any residential care but our focus is on education, training and support.” The fact that AWA has experienced such rapid growth is symptomatic of the reality of dementia in the community, which has prompted both the federal and state governments to recognise it as a major health priority. Its status has seen the research funding from the NHMRC rise to a record $32m in 2013-14 but Rhonda says that’s a fraction of

LASTtoDAYS lodge

the funding of other health priority diseases such as cancer, which received $162m. In WA, dementia is the second leading cause of death; nationally, it’s the third and research has not kept pace with the growing incidence of the disease arising from increased life expectancy and population bubbles such as the Baby Boomers. Rhonda says there is a lot to learn from the journey cancer campaigners have been on for the past 30 years. “Research into cancer has led to vastly improved treatment regimes that have

Medical Forum's 2013 Christmas Greetings Supplement

Send Christmas greetings to your colleagues and clients in Medical Forum’s popular special Christmas Greetings Supplement. Deadline: November 8 • Acknowledge the support of colleagues and others • Extend goodwill to those unfamiliar with your services • End 2013 in the spirit of the Christmas season Medical Forum’s Christmas edition is out on December 1 To lodge your greeting in Medical Forum’s Christmas Greetings Supplement Phone Jenny Heyden on 9203 5222 or email jen@mforum.com.au 18 18

medicalforum m me edi dica ca ca allfo foru rum ru m

KEY POINTS FOR DOCTORS t "HFE DBSF GBDJMJUJFT BSF GJMMJOH VQ XJUI IJHI care Alzheimer’s patients. t .PSF DBSF XJMM CF HJWFO BU IPNF o "8" wants to assist GPs and carers. t &BSMZ EJBHOPTJT QSPWJEFT SFMJFG UISPVHI support service access. t &BSMZ EJBHOPTJT QSPNQUT DSJUJDBM MFHBM QBQFSXPSL t )FMQMJOF OVNCFS t XXX GJHIUEFNFOUJB PSH BV 8FTUFSO Australia.aspx

brought the mortality rates way down, but we are not bringing down the mortality rate from dementia. That’s largely because we are so far behind the eight ball in our research investment into prevention and cure as well as better treatment regimes.� Rhonda says Australia is one of only a few countries which has recognised dementia as a national health priority but it seems we’re not so good with our care and treatment responses. “One of AWA’s big tasks is around education, giving people who have been diagnosed with practical information about the disease as well as access to a raft of services available including a helpline, counselling and support. We are also a registered training organisation and run accredited dementia training courses for those usually working in the aged care sector. We have developed the only Certificate IV qualification in dementia care in Australia.� She said that the dementia training GPs received may not equip them for the future demand and hoped they would acquaint themselves with the resources of the AWA, which she believed could help them enormously. “AWA has the national contract for the helpline which offers assistance and information. We would like GPs to

Q The AWA Memory Van outside Garden City as part of Dementia Awareness Week in September. Photographer: David Baylis, Community Newspaper Group

encourage their patients to start their journey of understanding of dementia by calling the number. We’ve had a couple of GPs use it themselves who needed some assistance in diagnosing and we’re very happy to support that.� Rhonda says there is a consistent narrative from people with dementia and their carers about the length time lapse between going to the GP and diagnosis, which delayed their access to vital AWA support. “This is not criticism of GPs, everyone is aware how busy and paper loaded they are. It is an awareness thing. What we hope to do is raise the profile of AWA with every GP clinic

in the state. In Canada there’s a program called First Link, which is the initial access point for GPs if they have a query about a patient’s memory function. We’d like to see our helpline number on the pinboard of every surgery in the state. That link between us and GPs is missing and it’s a glaring gap.� “I don’t think there’s a reluctance of GPs to do that, but it’s a question of funding which I hope we can address sooner than later.� O

By Ms Jan Hallam National Dementia Helpline: 1800 100 500 www.fightdementia.org.au/Western-Australia.aspx

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19

Feature

Standing Up for Abused Elderly An ageing population and care centred in the home have made elder abuse part of a public conversation we need to have. According to the CEO of Advocare, Mr Greg Mahney, hundreds of elderly people in WA are abused by those closest to them, an issue shrouded in silence and shame. And it’s mostly perpetrated by family members and friends of some of the most vulnerable individuals in our society. Greg, a member of the Carers’ Advisory Council and a carer himself, shares his insights with Medical Forum. “I suspect that many carers don’t realise the full extent of the help that’s out there. Carer stress is a really important issue and, unfortunately, it can lead to bad behaviour. Sometimes people aren’t aware of the stress and trauma they put themselves under in this physically and emotionally demanding role. It’s a big responsibility looking after someone.� “We have around 100 cases every month at Advocare and others go directly to the police or the Office of the Public Advocate. I’m sure we’re seeing only a small proportion.�

“It’s also important to note the importance of socio-economic factors such as housing affordability. A married couple coercing Mum to sell her home and move into a granny-flat followed by a job transfer or a marriage breakdown is a not uncommon scenario. And there’s Mum, homeless with no assets and she’s not even mentioned on the deeds of the property!� One of the strongest predictors of EA is a degree of social isolation. “We’ve seen cases where phones have been disconnected and people have been locked in rooms. That’s psychological abuse resulting in an individual being removed from their normal social networks. And when older people become isolated the perpetrator is obviously more likely to get away with their behaviour for a longer period.�

Greg underscores the important role that doctors can play.

“In nursing homes there are more people around so it’s generally less of a problem but, on the other hand, the residents are some of the frailest people in our society and hence the most vulnerable. I’d have to say that most of the staff in nursing homes are pretty aware of what to look out for.�

“A doctor should feel quite comfortable raising the issue of physical or emotional abuse with an elderly person. If there’s even the slightest suspicion that the person accompanying the patient might be involved in some way then the GP should try to speak with the latter on their own. This is a social issue but if a person is being abused their health is obviously going to suffer.�

Advocare has legal links with the Northern Suburbs Community Legal Centre (NSCLC) which has formed the Older People’s Legal Rights Service (OPLRS), to provide free legal advice. Greg said his organisation talks with the older person to find out what they want but it is important to remember that elder abuse often constitutes a crime, everything from embezzlement to physical violence.

He said elder abuse (EA) comprises a complex suite of emotional and psychological issues and manifests itself in a multifarious manner.

“If these things end up involving the police and the legal system there is always the risk that the carer may be sent to prison. And that presents a dilemma for an elderly person because who’s going to look after them then?�

His organisation is increasing awareness through education.

“Financial abuse is by far the dominant form of abuse, both nationally and internationally. It comes in many different forms, everything from a son saying to a mother, ‘If you won’t go guarantor I won’t bring the grandkids to see you,’ to threats of actual violence. One of the most common, sadly, is threatening to harm an older person’s pet. Another ploy is to rake over events from the past and attempt to use guilt as leverage.�

20

“Most of the time they don’t want their son or daughter locked up and they’ll be hoping for a solution that doesn’t involve the legal system. It’s usually enough that the person gives the money back or apologises for doing the wrong thing.� O

FACTS: ELDER ABUSE Defined as ‘Any act which causes harm to an older person and occurs within an informal relationship of trust.’ t PMEFS QFPQMF JO 8" BSF experiencing some form of abuse.

t 5IJT GJHVSF JT FYQFDUFE UP EPVCMF JO UIF OFYU ZFBST BT UIF QPQVMBUJPO BHFT t 8PNFO BOE QFPQMF ZFBST BSF NPSF likely affected. t .PTU DPNNPO SJTL GBDUPST BSF dependency and isolation.

t 'JOBODJBM BCVTF JT PGUFO BDDPNQBOJFE CZ psychological factors. t 1FSQFUSBUPST BSF NPTU MJLFMZ UP CF BEVMU offspring. Contact: Crisis Care XXX EDQ XB HPW BV DSJTJTBOEFNFSHFODZ PS PS Older People’s Rights Service XXX OTDMFHBM PSH BV FMEFS Public Advocate www.publicadvocate.wa.gov.au

By Mr Peter McClelland

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Silent Shame

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As a geriatrician based at Fremantle Hospital, Dr Roger Clarnette sees hundreds of elderly people every year. He says that Elder Abuse (EA) is ‘a constant theme’ within a clinical context and that current literature suggests between 4-10% of people utilising aged care services are victims of EA. “There’s no doubt that a lot of elderly people are vulnerable and isolated. The majority of them aren’t, strictly speaking, being abused but a significant minority are and we’re not aware of a lot of these cases. Sadly, it’s a big issue in our society.” “Many older people are alone and lonely. If you combine that with physical impairment then they’re much less likely to engage in social activities. They are highly vulnerable and, when cognitive problems are present as well, they are often far more trusting than they should be.” A lot of these elderly people are impaired cognitively and that makes it very difficult to bring a formal charge with any chance of success in the courts. And often the abuse is of a subtle nature which exacerbates the legal difficulties. We try to bring services into the home – crisis care, prepared meals, medication checks and community support. Sometimes the only course of action is to remove them from the toxic situation and place them, albeit briefly, in respite care.” “This can act as a circuit breaker and, in the case of financial abuse, we can organise powers of attorney and/or seek an order through the State Administrative Tribunal so that a person’s affairs can be overseen by an independent body such as the Public Trustee.” Roger relates a particularly sad and recent case that didn’t end happily. “An elderly lady was being neglected and physically abused by family members. When we told her that we wanted to speak with her family we strongly suspected that they threatened her and she refused to talk to us. When we applied for a Guardianship Order the lady denied that a problem existed and so the case had to be dismissed.” “These situations are very difficult for GPs. Dealing with them is time-consuming and that’s one thing most GPs don’t have much of. If a doctor has any suspicions of EA they should speak with an organisation like Advocare or make a referral to a hospitalbased geriatric medical team. The office of the Public Advocate can also investigate cases.”O

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21

Feature

Planning for the End Advanced Health Directives sparked intense discussion at the last Doctors Drum Breakfast. Now our ePoll on P16 confirms that it's a conversation doctors want to have. WA Health plans

If there is one message palliative care specialist Dr Kevin Yuen would like to impress on his colleagues and, indeed, the wider community, it’s the necessity for Advanced Health Directives (AHDs) and end-of-life planning. With dementia predicted to become the leading aged care issue of the future, management should start well before cognitive decline begins.

Chief Medical Officer Dr Gary Geelhoed has been meeting department and palliative care networks to work on strategies to encourage a greater uptake of AHDs. “Sometimes it’s easier for doctors to keep on treating than to go through these difficult conversations but the reality is that we could be doing so much better for families and individuals if we started thinking about these things.”

“The conversation we need to be having with patients, at least at the start of the process, is simple. If you have a will, you should also have an advanced health directive,” Kevin said.

“The problem with this subject is, if handled the wrong way it can look like you are rationing care. But the reality is we can literally kill with kindness. People end up in ICU and, instead of people dying with the people they love around them either at home or on the ward, they are surrounded by strangers, noise and bright lights for exactly the same result.”

“Most people think a will is a reasonable and sensible thing to do. They want to be able to have a say in what happens to their property, but what about your body? That’s your ultimate property? We have to ask people what they want to happen to them if they get sick.”

Importance of planning “There is reluctance in the profession and the community to discuss AHDs, it’s as if it’s giving up by another name. People will say, ‘we are not at this situation yet’ or they feel awkward about talking about it. Why can’t it be talked about, just as wills are talked about. It’s not tempting fate, it’s just sensible planning that makes everyone’s life easier.”

Q Left; Dr Kevin Yuen; Dr Gary Geelhoed, above

AHD and will make a medical assessment that sees the patient taken to Emergency when that may not be what the patient wants. That’s not acceptable management.”

However, if AHDs are to be truly effective they need to be properly written and reviewed.

The poor uptake

“There was an instance in hospital where we were told a patient had an AHD, so we found it, signed and dated, but nothing was written in it, so it was like a blank cheque. AHDs need to be visible, accessible and travel with the patient. They’re not any use at 2am in the morning in a filing cabinet somewhere.”

“I know of some nursing homes and some enthusiastic GPs who see the value in it and are doing it well, but everyone else is saying, who’s got the time to do this. We are all hoping that a primary physician or a primary nurse will have the capacity to sit down with a patient and explain what everything means.”

The Federal Department of Health last month announced that it was looking at the inclusion of existing AHDs to the PCEHR by April next year and that will be a boost for clinicians like Kevin.

AHDs were introduced to WA in February 2010 and while they were accompanied by a few workshops, the promotion of them has since petered out. Now the palliative care networks are seeing them as essential tools in aged care because dementia is making this end-of-life medicine a minefield.

“Anything that will trigger a doctor to look at something which guides them in their decision-making is valuable. I think we are still trying to work out how to deal with AHDs because sometimes they are overridden. A locum may visit a patient at 2am and may or may not have seen the

22

From Kevin’s perspective, AHDs are thin on the ground.

“If people were given the choice and had some honest conversations, they probably would elect to die at home or not go through heroic intervention and treatments. This approach is better for patients and their families and it frees those beds up for people who can have life-saving treatment.” While the formal discussions were yet to take place when Medical Forum spoke to the CMO, some of his thoughts on the issue focused on community education, perhaps through Medicare Locals, the primary care network and the department. He also wanted to see what resources could be established in hospitals and emergency departments. “Palliative care should be seen as a positive thing. It needs to be embedded in the culture of the hospitals and a rational conversation needs to happen. The arguments are quite compelling and most people will, when you talk about quality of life and trade-offs, take a pretty balanced view. “At the end of the day, good medicine is all about listening to your patient and respecting their wishes.” O

By Ms Jan Hallam See the full ePoll results on P16.

“It is developing momentum but the number of people who could be approached to have and AHD is quite enormous, so it’s all about having a methodical, steady approach to it,” Kevin said.

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ANSWERS FOR DOCTORS There is a wealth of useful material for clinicians and consumers at the WA Health website, www.health.wa.gov.au/ advancehealthdirective/home, and the Office of the Public Advocate www.publicadvocate.wa.gov.au

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Q: What is an AHD? It is a legal document in which adult persons with capacity can set out their decisions about future treatment. An AHD can come into effect if that person is unable to make reasonable judgments about their treatment later on. Advance Care Planning refers to the process of communicating a person's views, preferences and decisions about their future care, for example, what kind of treatments they agree or not agree to, where a person would like to be cared for when they die, and what kind of funeral would they prefer etc.. Completing an AHD is one option available within this process.

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Q: What if the patient has not made an AHD? A treatment decision will be made on their behalf in the event they are unable to make the treatment decision for themself. The treatment decision will be made by (in the following order of priority) Enduring Guardian (if appointed), Guardian (if appointed), or as per the hierarchy of decision makers (such as spouse, parent, child, sibling or unpaid carer). Q: When does an AHD come into effect? An AHD comes into effect only if the patient has lost capacity i.e. they are unable to make or communicate a treatment decision at the time that the treatment is required, when they have lost full legal capacity. In these circumstances, the AHD acts as their 'voice'.

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No. Q: How long is an Advance Health Directive valid? There is no set time period, however, given that people can change their mind, if a long period of time has elapsed between the making of an AHD and that of a treatment decision, it may create some uncertainty. As such, it is recommended that consumers regularly review their AHD to ensure that it reflects current wishes. Q: My Patient’s AHD and their Enduring Guardian/family are seeking different treatments – what should I do? Once a person has lost capacity, refer to the )JFSBSDIZ PG EFDJTJPO NBLFST OPO VSHFOU GPS consent. The top of the hierarchy is the AHD. If the patient’s AHD is valid, then it overrules UIF QBUJFOU T &OEVSJOH (VBSEJBO GBNJMZ *G UIF family remains concerned, they should be advised that they are welcome to approach SAT to determine the validity of your patient’s AHD.

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News & Views

Busting Myths about Palliative Care The next few decades, as the population ages, will see palliative care services become an essential part of the health system. Despite WA being one of the country’s leading states in its delivery of palliative care services, there are still misconceptions about what palliative care really is – and that’s not just within the community. Much of the medical profession’s treatment focus is on cure and that has been a stumbling block to free and open discussion about palliative care, according to Executive Officer of Palliative Care WA, Ms Amanda Bolleter.

palliative care to encourage people to seek out and refer to palliative care, building capacity across the sector and improving culturally sensitive palliative care are other key priorities for the organisation.

She sees that part of the key to re-opening this important discussion is to first dispel some of the myths, which can limit health professionals seeking specialist knowledge and can affect their willingness to refer to palliative care in a timely way.

She also applauded the inclusion of palliative care into the medical school curriculum.

“We’ve just had World Hospice and Palliative Care Day which did some serious myth-busting. One such myth is: ‘Receiving palliative care means you are going to die soon’. That’s not necessarily the case at all. Some people can receive palliative care for years. And according to the different diagnoses, the role of the palliative care service can be quite different.� “It might be involved early in someone’s diagnosis to manage particular pain and symptom or psychosocial issues and then it might discharge the patient until the service is needed again. It is not a one way street and referral to palliative care doesn’t necessarily mean that death is imminent.� “Another myth is that a referral to palliative care cuts the original treating team out of the equation and increasingly that is not the case. In some cases the treating team has been involved in the person’s care for years.

Useful Palliative Care links Palliative Care WA: IUUQ QBMMJBUJWFDBSFXB BTO BV TJUF Program of Experience in the Palliative Approach (PEPA): www.pepaeducation.com; 8" DPOUBDU #SPPLF 8JMLJOTPO FNBJM 1FQB!DBODFSXB BTO BV 1I Palliative and Supportive Care Education (PaSCE): XXX DBODFSXB BTO BV QSPGFTTJPOBMT QBTDF email pasce@cancerwa.asn.au 1I

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She said education and training sessions are available through Palliative and Supportive Care Education (PASCE), which is funded by the WA Health Department and Cancer Council WA. It offers education and training for health professionals, health care workers and volunteers across WA.

I can understand that they would find it difficult to say, well there’s nothing more we can do and now we’re going to refer you to palliative care. The truth is there is always something that can be done and even more if there is teamwork.� Long-time palliative care practitioner and advocate, and immediate past President of the national group Palliative Care Australia Dr Scott Blackwell was on a wellearned holiday when Medical Forum was investigating this issue. However, his views were recently published on MJA Insight where he emphasised the imperative of team work. He wrote that team work had been a prominent feature of palliative care since it emerged in the modern era, yet it was an aspect of care that clinicians were poorly trained to deliver and that Medicare failed to adequately support. He was hopeful that the Federal Government’s aged care reforms announced earlier this year would be implemented to support particularly GPs and effective team work. Amanda said Palliative Care WA’s strategic plan for the next three years was focused on raising the profile of palliative care and advance care planning with consumers and other peak bodies. Debunking myths about

“That exposure to palliative care as part of someone’s training is really important and is certainly something we’d like to see expanded. Every doctor needs to have an understanding of death and dying, not only to gain knowledge about when to refer to palliative care, but how to provide sympathetic support to the patient and family and how to manage their own reactions to their patients dying.� “Clinicians find discussions around referral to palliative care very difficult to have and while there are good resources around the difficulty remains.� “The Program of Experience in the Palliative Approach (PEPA) is an education program designed to improve quality, availability and access to palliative care by improving the skills and expertise of health professionals and enhancing collaboration between service providers. PEPA placements are available for primary care providers employed in health, aged or community care services including GPs. PEPA enables health professionals to be part of a palliative care team as an observer and to build their professional links with the palliative care service.� “It’s important to emphasise that palliative care is not doing nothing, it’s very active care. It’s providing specialist pain and symptom management and psycho-social support. It reviews treatments that may be no longer effective and it can actually help prolong someone’s life and promote their wellbeing. It is very much an active form of care.� O

By Ms Jan Hallam

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Research

How We Research Ageing Research into ageing is a growth area as the population ages. Here is a rundown of the some of the WA research projects and who is working on them. Western Australian Centre for Health and Ageing (WACHA)

t %FNFOUJB JO 3FTJEFOUJBM $BSF &EVDBUJPO Intervention Trial (DIRECT): Developing further dementia specific training for GPs and residential care staff.

Lead researchers: Prof Leon Flicker, Prof Osvaldo Almeida, Prof Christopher Etherton-Beer, A/Prof Andrew Ford and Assist/ Prof Jon Pfaff (UWA)

t F "HFJOH o EFWFMPQNFOU PG XFC CBTFE teaching and learning tools in aged care (funded by UWA, WACHS, WA Health and WA Dementia Training Study Centre)

t .BJOUBJOJOH 5IF )FBMUI *O .FO 4UVEZ (HIMS, funded by NHMRC): Ongoing study since 1996. t #7JUBHF o *NQSPWJOH UIF USFBUNFOU PG depression with vitamins. t &YFSDJTF 1"$& 4UVEZ If participation in mentally stimulating leisure activity is associated with better cognition and reduced risk of dementia. t 1SFEJDUPST PG 2VBMJUZ PG -JGF JO %FNFOUJB (QoLCog Study). t *OEJHFOPVT %FNFOUJB 4FSWJDFT 4UVEZ (IDSS, funded by NHMRC): Finding practical solutions for Indigenous people with dementia and their families who live in the Kimberley. t $POHFTUJWF )FBSU 'BJMVSF B -POHJUVEJOBM Study of its Impact on Brain Function and Structure in Later Life (The Heart-Mind Study, funded by NHMRC) t 7JUBNJO % BOE $PHOJUJPO 4UVEZ (VITA-D) t "DVUF 4USPLF 5SFBUNFOU XJUI "UPSWBTUBUJO and irbesaRTan (ASTART) t " SBOEPNJTFE DPOUSPMMFE USJBM PG deprescribing to optimise medical therapy for frail older people

t 4UVEFOU 5SBJOJOH 1SPKFDU JO %FNFOUJB (STriDe, funded by WA Dementia Training Study Centre): Developing an undergraduate medical curriculum in dementia.

McCusker Alzheimer’s Research Foundation Leading researchers: Prof Ralph Martins (also director of ECU Centre of Excellence for Alzheimer's Disease Research and Care), A/Prof Roger Clarnette, Mr Kevin Taddei, Dr Ian Martins, Adj A/Prof Giuseppe Verdile t #MPPE #BTFE 1SPUFJO #JPNBSLFST GPS Diagnosis of Alzheimer Disease. t %FWFMPQJOH BHFOUT UIBU TFMFDUJWFMZ UBSHFU the enzyme responsible for beta amyloid generation t &GGJDBDZ PG $PNCJOFE /VUSJUJPOBM Supplement Therapies in the Prevention of Alzheimer's Disease in a mouse model of AD: Evaluating the efficacy of green tea, curcumin, omega-3 essential fatty acids, and lipoic acid. t *EFOUJGJDBUJPO BOE WBMJEBUJPO PG QFQUJEF BHFOUT UIBU OFVUSBMJTF CFUB BNZMPJE UPYJDJUZ

t .PMFDVMBS BOE /FVSPQTZDIPMPHJDBM Predictive Markers of Cognitive Decline. t (POBEPUSPQJOT JO UIF 1BUIPHFOFTJT PG Alzheimer's Disease: Investigating hormonal changes associated with ageing. t 5FTUPTUFSPOF JO "M[IFJNFShT %JTFBTF t 5IFSBQFVUJD &GGJDBDZ PG B $IPMFTUFSPM lowering agent

Centre For Excellence in Alzheimer’s Disease Research and Care Leading researchers: Prof Ralph Martins, Dr Simon Laws, Dr Hamid Sohrabi, Dr Veer Gupta (ECU) t %PNJOBOUMZ *OIFSJUFE "M[IFJNFS /FUXPSL (DIAN) study t "VTUSBMJBO JNBHJOH CJPNBSLFST BOE lifestyle (AIBL2) study on ageing

Centre for Research on Ageing Leading researchers: Prof Barbara Horner, Prof Gill Lewin, Dr Beatriz Cuesta-Briand (Curtin University) t "HFE $BSF 4FSWJDFT t "HFJOH Studying age-friendly public transport, physical activity levels in sedentary elderly, grandparents raising grandchildren t %FNFOUJB $BSF "DVUF DBSF TFUUJOHT

Institute for Health Research Director Prof Beth Hands, Prof Max Bulsara, Dr Anne-Marie Hills (University of Notre Dame) t 8BMLJOH 4UJDLT PS 8BMLJOH 1PMFT t 1BUJFOU &EVDBUJPO GPS 'BMMT 1SFWFOUJPO O

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CT radiation figures we’d like you to notice we include a radiation dose estimate on every 128 Slice CT scan report

Imaging Central is an independent radiology practice delivering the same dose reduction technology as Princess Margaret Hospital for Children: SaďŹ re Iterative Reconstruction CARE Dose kV CARE Dose 4D Adaptive Dose Shield

Australian Adult MDCT DRLs - (95% Cl) (Dose Length Product, mGy.cm) 1200

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In 2011, the Australian Radiation Protection and Nuclear Safety Agency conducted the Australian National Diagnostic Reference Level Survey. The data established a measure of multi-slice detector CT doses for current diagnostic imaging practice in Australia, allowing individual practices to compare their doses against those of their peers.1 At Imaging Central, it is easy to compare our dose achieved with others as we include it on every CT report.

1 Australian Government, Australian Radiation Protection and Nuclear Safety Agency., viewed 29th Jan 2013 http://www.arpansa.gov.au/services/ndrl/index.cfm 2 Imaging Central Practice Reference Level Dose measured from Oct - Dec 2012

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Head to our website for more information about our dose reduction technologies

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Guest Column

Breaking the Silence Aged care has been put in the too-hard basket for too long, says Mr Ray Glickman, and it’s now time for some tough talk and drastic action.

A

nother Federal election has come and gone with barely a whimper about aged care. This seems odd, given that more than 50% of the Australian electorate are baby boomers or older. Of course, older people don’t like to make a fuss so that would be one reason they are being ignored. And perhaps the ‘younger old’ distance themselves from issues they’d rather not face until absolutely necessary. Another reason for the silence is that, from a voting perspective, politicians only see older people as relevant when it comes to considering the hip-pocket with regard to pension levels. But isn’t this also a hip-replacement issue? Isn’t the tsunami of ageing going to impose a potentially unsustainable burden on our health sectors – not to mention our social support systems? It is encouraging that some serious reform has now been contemplated in relation to disability services. However, if our society ignores the aged care issue for much longer, we will do so at our peril.

medicalforum

The current aged care system is essentially broken. The Productivity Commission generated an excellent report in 2011, incorporating a radical overhaul of aged care, which would deliver greater choice in service provision, improved financial sustainability and significantly less red tape. As all governments seem to do with such reports, the Rudd/Gillard/ Rudd governments cherry-picked the recommendations and enacted a so-called reform program that does little more than tinker at the edges. The incoming Abbot government has not, to date, given clear leads about how it will tackle this portfolio. However, it has recognised that the Productivity Commission report needs to be the framework for long-term reform. This is a good start. The facts are that in WA, we are five Fiona Stanley Hospitals short of the number of residential care beds that should be in the pipeline by now. The growing home care system is struggling to deliver the level of support required to keep people out of the

residential care system. Significant numbers of older people are in severe housing stress, at the mercy of the over-heated private rental market. There is a lot that needs to be done, at both structural and grass roots levels. The medical profession, just like older people themselves, seems strangely silent on this issue. There is rightfully much being said about the needs of the acute care sector. But is that not intimately linked with aged care? A failure in aged care definitively impacts on the acute and primary health care systems. Medicos need to be upfront and forthright on aged care issues. I would like to see the needs and concerns of older people discussed openly with patients, and I welcome lobbying and advocacy support from the medical profession. Let’s work together to ensure that the next Federal election campaign creates a bang, not a whimper, in the world of aged care. O ED: Mr Ray Glickman is Chairman of Aged & Community Services WA, a Director of Aged & Community Services Australia and CEO of Amana Living

29

Guest Columns

The Price of Caring CEO of Carers WA, Mr Paul Coates, reminds policy makers that carers save the health system billions so don’t slash their funds when it comes to budget cuts.

I

t was a famous Englishman, a bloke called Benjamin Disraeli, who apparently said: “There are three kinds of lies: lies, damned lies and statistics�. Well, as another Englishman, I am here to present you with a few statistics – which incidentally are true. They come from a report by Access Economics entitled The economic value of informal care in 2010. There are almost three million carers in Australia who provide what is termed ‘informal’ or ‘unpaid’ care to their family members or friends who have a disability, mental or chronic illness or who are frail aged. That is about one in eight of the population and together they provide about 1.32b hours of care a year. The impact of caring on their physical and mental health is well documented. It is another fact that as a cohort they have one of the lowest health and well-being indices in the population.

This number of hours is a phenomenal level of support for something termed ‘informal’. It covers a whole suite of round-the-clock health and social care services ranging from emotional support, wound management and medication supervision, to meeting the hygiene, educational and nutritional needs of the ‘patient’. If these ‘informal’ services were handed over to the ‘formal’ paid health services, the already debt-ridden Federal and State governments would have to find a further $40.9bn a year. Now that would really get the attention of Messrs Abbott, Hockey, Barnett and Buswell. There are certainly reforms, which may be of benefit. The National Disability Insurance Scheme implies more future funding for people with a disability. However, the future is the future and there are only pilot projects around for the next few years. If it is eventually introduced, families may

feel the benefit as their loved ones access greater services. However, early indications are that the government’s scramble for money to fund this initiative may draw away funding provided to support carers themselves (e.g. respite funding). Reforms in the age care sector talk about a new concept called Carer Centres but what they are is unclear and it may simply be a rebadging of the current Commonwealth Respite and Carelink Centres. And, of course, there is the much vaunted panacea of ‘Self Direction’ where the clients ultimately have budgets, manage their affairs and ‘choose’ their services. That is all great, but will it mean more work and administration for the family members as they take on additional responsibilities to employ staff and develop ‘contracts’ with local service providers? Self-direction can suit some people but not everybody has the energy, time and desire to take on this extra role.O

The More I Care, the Less I Earn Bayswater GP Dr Rohan Gay is a systems thinker. He looks at perverse incentives within Medicare and the MBS.

W

ith all the fuss over super clinics and the PCEHR, there has been a notable lack of focus on the fundamental flaws of the Medicare Benefits Schedule which we GPs must wrestle with every day.

The present Medicare schedule is an impediment to good medicine: t *U SFXBSET CSFWJUZ SBUIFS UIBO thoroughness: five minutes is rewarded the same as 20; 20 the same as 40. t $ISPOJD DBSF JUFNT BSF NPSF MVDSBUJWF JG fulfilled to minimal standards. t $PNQMFYJUZ BOE QFOBMUJFT MFBE UP avoidance of special items. When these are used to monitor services, grossly inaccurate figures will be generated.

preventative medicine or chronic care. t %JTJMMVTJPOFE EPDUPST BSF EJTJODMJOFE UP stay in the profession or improve their skills. t &YUSFNF SFMVDUBODF GPS EPDUPST UP UBLF PO the added tasks associated with becoming practice principals. t " CVTJOFTT DBTF GPS DPSQPSBUF NFEJDJOF to employ the youngest doctors to ‘churn and burn’ and to churn out care plans on minimum pretext with little intention of follow up or continuity of care. The current Medicare structure would not be acceptable to any other professionals, public servants or award wage earners. In this computerised age it should: t #F CBTFE PO NFBOJOHGVM UJNF JOUFSWBMT TBZ six minutes)

t 5IFSF JT OP SFDPHOJUJPO PG ZFBST PG experience, skill levels, or the established doctor-patient relationship.

t #F JOEFYFE BDDPSEJOH UP UIF FYQFSJFODF and skills of the practitioner and/or range of services/conditions actually treated.

Negative consequences of these are varied:

Care plans and team care arrangements impede rather than encourage comprehensive care:

t 'JWF NJOVUF NFEJDJOF XIJDI DPTUT NPSF than 15-20 minute medicine but adds little if anything to the health of the public or to medicalforum

t 1BUJFOUT MPWF UIFN CVU EPO U SFBE UIFN BOE

rarely act on them (they will act on recalls and referrals). t 1BUJFOUT EPO U QSFTFOU BU OFBU UISFF NPOUI intervals. t 1BUJFOUT EPO U TFQBSBUF UIF QMBOOJOH visit from the mental health visit, or the therapeutic visit. t 1BUJFOUT EPO U LOPX GPSHFU PS EPO U DBSF about the requirements and limitations of plans. t /FWFS JO UIF IJTUPSZ PG NFEJDJOF IBT a referral not implied the recipient’s involvement in care, yet pre-approval is required in team care arrangements. Care plans should be replaced by FYQBOEJOH UIF DVSSFOU QBUJFOU SFDPSE system so the aims of care planning are systematic and intrinsic not yet another add on. In view of this: t "MM DMBTTJGJDBUJPOT JO B SFDPSE TIPVME IBWF an associated ‘goals/patient notes’ field. t "MM NFEJDBUJPO FOUSJFT TIPVME IBWF BO ‘indications/patient notes field’ We still have some way to go!O

31

News & Views

Creative Thinking to the Test Desperate times inevitably create innovative solutions. That’s the message New Zealand health administrator Mr Geraint Martin will be bringing to Perth this month. Geraint was in the US at the height of the Government shutdown crisis – brought about by conservative reaction to President Obama’ Obama’s health care reforms. He sees it as an extre extreme lesson in what not to do.

Geraint Martin has a deadline. In five years’ time, he doesn’t want to be talking about health system problems, he wants to be promoting solutions. The CEO of one of New Zealand’s largest district health boards, Counties Manukau, will be a keynote speaker at WA Health’s state conference later this month and bringing his message of innovation investment.

“We ma may need a totally different approach to health care restructuring, but shutting down a government isn’t it. So much of the debate is seen through old lenses which o only lead to dead ends. We can’t keep replaying the challenges of the past 20-30 years. The challenge of the third revolution in health (after the first solved the problem of diseases such as cholera and the second was medical and pharmaceutical intervention to improve longevity – both hospital based), is chronic disease. This is the game changer.”

“We have elegantly redefined the problems in health time and time again. What we need to be doing is finding solutions to the major impact ageing populations and chronic disease will have on health systems. There was a presentation in Queensland recently that projected the rising cost of health care in that state would, by 2026, be the entire state budget.” “We know this is coming and I think we’ve probably got about 4-5 years to identity some solutions. The research is largely done, we now need to think through that evidence. Other countries may be able to carry on for a bit longer but in New Zealand, we can’t afford to wait and that’s why we might be the first of the OECD countries to act. We don’t have a lot of money to fall back on.” There’s nothing new in the concept of keeping people well but Geraint urges some speed. “It isn’t simply a case of treating people well and quickly when they come to hospital. It’s keeping people well and at home and contributing rather than defaulting to hospital care which is the very expensive end of the game.The solutions lie in how well we organise primary and community care, and I’m not talking about primary prevention here, it’s almost too late for that. I’m talking about secondary prevention. Too many people are already at risk of Type 2 diabetes, too many have got chronic disease. When three people get three chronic diseases as so many have, the cost of the health system rises exponentially.” “My message is how do we use innovation not simply to palliate some of our current problems but to solve them?” Looking historically, Geraint thinks we are at a critical moment much like the 1930s and ’40s after the Great Depression and World War II. “The big leaps forward in thinking tend to happen at times of financial adversity

32

We need a cultural shift in thinking. We also need politicians and health leaders to become statesmen. It’s not how you protect your little patch of friends or bugbears, it’s how we design a health system for the future. That needs a big shift. than financial plenty. Strategies after the Depression and the war brought universal health care for many countries. Those innovations defined health care for generations to come. Our responsibility now as this generation’s health leaders is to make key decisions about how we re-orientate health care. It’s our responsibility to get that right.” “If we don’t, then in 2026 there will be a pretty big budget crisis in Queensland and a lot of other places. We don’t have the answers at the moment but we know we have to find them and we need to start by addressing methodologies and strategies and most importantly what sacred cows and what hurdles we need to address to make that a reality.”

“This era marks the patient at the centre. We’re leaking masses amount of resources dealing with the issues of availability and q quality, harm, waste and variation i the system – and to that I’d add in siloed working. What we’ve seen in the US is a replaying of the hospital-based debate where so many resources are focused on high-end academic hospital services which completely freeze out primary care, despite the fact that the vast majority of health care is primary.” However, Geraint remains optimistic. “I don’t underestimate the hurdles we’ve got, or that the stakes are very high but you need to approach a problem like this with a sense of optimism, or as Nelson Mandela said, ‘Everything is possible until it isn’t’. If we are faced with a situation where potentially one industry or sector can eat up an entire budget of a state in a country like Australia, then we have to be optimistic to find solutions because the alternative is impossible.” “We need a cultural shift in thinking. We also need politicians and health leaders to become statesmen. It’s not how you protect your little patch of friends or bugbears, it’s how we design a health system for the future. That needs a big shift.” O

By Ms Jan Hallam

medicalforum

Guest Column

Do We Need a Third Med School? The statistics say one thing, the critics another. Curtin University’s head of medical education Prof William Hart argues the evidence speaks for itself.

D

o we have too many young doctors, some of whom won’t find jobs, as a result of the ‘tsunami’ of medical students, or we are not training enough doctors to meet our future needs? The most recent report on medical workforce by the Australian Institute of Health and Welfare (AIHW) reveals that in 2011, Australians had access to an average of 381.4 full-time equivalent (FTE) doctors per 100,000 people. But Western Australians only had 348.8/100,000 i.e. 775 FTE doctors short. This shortage applies to many speciality fields and to general practice and it applies to metropolitan areas as well as rural. We have the lowest supply of doctors in Australia and according to AIHW our doctor numbers have actually declined in recent years because the rate of graduation of new doctors and importation of overseas-trained doctors has not kept pace with retirements and population growth. According to the data of the Committee of Medical Deans of Australia and New Zealand, WA still has the lowest rate of intake of medical students in the country.

Predicting future need WA’s need for doctors will continue to grow. Population growth, ageing, chronic disease and new interventions will increase utilisation. Baby-boomer doctors are expected to retire at an increasing rate between now and 2025. The Health Workforce Australia (HWA) scenario for WA to move to self-sufficiency in doctors (i.e. reducing reliance on OTDs) by 2025, shows a shortfall beginning in 2019, and reaching 1672 doctors short by 2025. But if we re-graph this scenario using the more recent AIHW medical workforce data and ABS demographic data, the gap between supply and need starts to look very alarming. So do we give up on the ideal of self-sufficiency, or do we hope doctors don’t retire, or do we train more domestic doctors?

The role of OTDs Wealthy WHO member states like Australia aim for self-sufficiency in medical practitioners. But currently, even with the large-scale importation of International Medical Graduates, our numbers are not growing fast enough to keep pace with rates of population growth and retirements of doctors. Hospitals in both metropolitan Perth medicalforum

What We Don't Want to See Happen

(including Royal Perth Hospital, Sir Charles Gairdner Hospital and the St John of God Hospitals) and regional areas, are currently declared Areas of Need (AoN) for the recruitment of IMGs to fill junior doctor, RMO and Registrar positions. Health Department policy states that these hospitals must demonstrate and certify that they cannot recruit enough Australiantrained doctors to these jobs.

Geographic and disciplinary maldistribution The Western suburbs of Perth have four times the number of GPs per head of population as the Eastern suburbs. Then there’s the lack of rural doctors (and 52% of those we do have are IMGs). Can we do anything about these disparities? In my experience of carrying out evaluation interviews with students and graduates, a medical school with an ethos of training clinician scientists for academic medicine attracts a very different cohort of applicants with different career ambitions than one with an ethos of general practice in underserviced areas. Establishing the rural Gippsland Medical School (GMS) at Monash was intended to address medical workforce shortages by selective student recruitment and by the way in which the course was taught (context for case scenarios; type of clinical placement; staff who were experienced and enthusiastic about rural general practice) and its overall ethos of general practice/ primary care for underserviced areas. In 2012, all 10 of the Gippsland rural internships were filled by Monash graduates, seven of which were trained at GMS. This is encouraging. In time, a

new medical school in WA could make a substantial contribution to correcting the mal-distribution of doctor supply.

Post-graduate Training In 2012, there were 267 young WA doctors coming out of their internship and 469 PGY2 RMO positions for them to apply for. This report shows that RMO positions and Registrar positions have increased over the past eight years at a greater rate than internships. Some of our young graduates are not getting the jobs they want, apparently because large numbers of IMGs with more experience than the local PGY1 and PGY2 doctors, compete for the RMO and Registrar jobs, which historically have been the training pathway for young graduates. Undoubtedly though, we do need to create more advanced training positions, to enable the training of all the new Fellows we need. So do we need another medical school? If a new medical school was given the necessary Federal approvals and Australian Medical Council accreditation, it might graduate 100 extra local doctors from 2021 on. They would be ready to practise relatively unsupervised by 2025. I think the data indicate that we are already in undersupply and that without a new medical school, the situation in WA will be critical by 2025. It makes sense to site it in the Eastern suburbs. O References on request ED: Prof Hart is Head of the Department of Medical Education at Curtin University. He was previously the head of Monash University’s rural graduate-entry program at Gippsland Medical School.

33

CLINICAL UPDATE

Age-related macular degeneration

By Dr Bradley Johnson Ophthalmologist

M

acular degeneration is a group of degenerative diseases that affect the macular region of the retina. By far, the most common form is age-related macular degeneration (ARMD), which affects 1 in 7 people over the age of 50. Whilst most of these people do not have any symptoms, a proportion will develop blindness and as such this disease accounts for 50% of all registered blindness.

Major risk factors t "3.% JT SBSF CFGPSF UIF BHF PG CVU UIF risk progressively increases thereafter. t )FSFEJUBSZ UIFSF JT B SJTL PG developing ARMD if you have a family history. t 4NPLJOH JODSFBTFT SJTL GPME

Types of ARMD Broadly, there are two forms of ARMD t %SZ "3.% 'JHVSF 5IJT JT UIF NPTU common form and is slowly progressive. A small proportion will develop abnormal blood vessel growth underneath the retina - thus developing ‘wet’ ARMD. t 8FU "3.% 5IJT JT BO BDDFMFSBUFE GPSN that results in rapid blindness if not treated urgently. It is essentially a similar disease to dry ARMD, except that an abnormal choroidal blood vessel membrane has

grown underneath the retina. These membranes have a very high risk of unpredictable subretinal haemorrhage, oedema and consequently retinal scarring. EARLY treatment is essential with intravitreal injections.

Symptoms t %JGGJDVMUZ SFBEJOH UISFBEJOH OFFEMFT PS other fine visual tasks. t %JGGJDVMUZ SFDPHOJTJOH GBDFT t %JTUPSUJPO PG TUSBJHIU MJOFT t $FOUSBM TDPUPNBT

Q Fig2 Amsler grid

How to reduce the risk of deterioration

Advice to patients People who have developed, or are at significant risk of, ARMD should all be given advice on how to detect changes, and how to reduce their risk of further deterioration. How to detect vision changes: t 3FHVMBSMZ NPOJUPS DFOUSBM WJTJPO BU IPNF This can be done with an ‘Amsler grid’ (Figure 2), by looking at the grout pattern of tiles at home, or at the straight lines of window or door frames. t "OZ EJTUPSUJPO PS OFX TDPUPNB TIPVME CF reported and investigated immediately as it may be the first sign of wet ARMD.

t 2VJU TNPLJOH t %FUFDU XFU NBDVMBS EFHFOFSBUJPO FBSMZ BT late treatment is seldom effective). t 7JUBNJO TVQQMFNFOUT $VSSFOUMZ POMZ AREDS formulations have been shown to be effective in a proportion of patients. There is a lack of evidence supporting their use in patients without any sign of ARMD, or in patients with advanced ARMD in both eyes. t %JFU B EJFU IJHI JO HSFFO MFBGZ WFHFUBCMFT lots of fresh fruit and fish 2-3 times per week. Saturated fats should be avoided as much as possible. A handful of raw nuts (e.g. walnuts, brazil nuts) every week may also help. O Declaration: Perth Eye Centre P/L, managing the Eye Surgery Foundation, supports this clinical update through an independent educational grant to Medical Forum.

Q Fig1 dry macular degeneration Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco D’Souza Tel: 9258 5999 Dr Graham Furness Tel: 9440 4033 Dr Annette Gebauer Tel: 9386 9922

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Expert Day Surgery for t $BUBSBDU &YUSBDUJPO BOE -FOT *NQMBOU t 1UFSZHJVN t (MBVDPNB t 0DVMPQMBTUJD 4VSHFSZ t 4USBCJTNVT t $PSOFBM 5SBOTQMBOU

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CLINICAL UPDATE

Sleep apnoea and cardiovascular disease

By Dr Andre Kozlowski, Cardiologist, Western Cardiology. Tel 9346 9300

S

leep apnoea (SA), a frequently unrecognised condition, affects 5-10% of the general population, three times more common in men than women. It is estimated that 80% of sufferers remain undiagnosed, with one in fifteen adults having at least moderate disease, that is, more than 15 episodes of apnoea/hypopnoea during one hour of sleep. SA is associated with significant cardiovascular morbidity and mortality. t 4" JT BTTPDJBUFE XJUI BSSIZUINJB JO QBSUJDVMBS USFBUNFOU SFTJTUBOU atrial fibrillation, and with a 25% greater rate of recurrence after ablation.

SA can be classified into obstructive, central or mixed types. The risk of obstruction rises with obesity, smoking, age, diabetes, use of alcohol and sedatives. Central apnoea is more often associated with heart failure or stroke. Risk factors, signs and symptoms are known but frequently forgotten or dismissed during medical interview. The history of snoring is often the first clue of the condition but its absence must exclude SA.

t "QOPFB TVGGFSFST IBWF NVDI IJHIFS SJTL PG CMBDL PVUT BOE BTZTUPMF t 5IF TFWFSJUZ PG OPDUVSOBM IZQPYFNJB TUSPOHMZ QSFEJDU TVEEFO cardiac death independently of other risk factors. t 4MFFQ BQOPFB JT BTTPDJBUFE XJUI SFTJTUBOU IZQFSUFOTJPO BGGFDUJOH VQ to 80% of patients not responding to three or more medications.

Nocturnal respiratory interruption, fragmentation of sleep and hypoxia are independent risk factors for cardiovascular events including heart failure, ischaemic heart disease, stroke and death. Hypoxemia, CO2 retention and interrupted sleep cause sympathetic overactivity, elevated levels of aldosterone, impaired endothelial function, atherosclerosis, insulin resistance, dyslipidaemia and increased blood viscosity facilitating thrombus formation.

There is a complex reciprocal connection between SAS and heart failure which co-exist in a great majority of the patients. Cardiac decompensation with fluid retention and neck vain congestion in the supine position may lead to further obstruction, worsening hypoxia and initiating a “viscous cycle�. Dyspnoea and hyperventilation, by causing hypocapnia, suppresses respiratory centres that worsen central apnoea. Interestingly, the relationship between SA and pulmonary hypertension is less defined.

Observed cardiovascular effects t 1BUJFOUT XJUI BQOPFB IBWF NVDI XPSTF QSPHOPTJT GPMMPXJOH acute coronary syndrome; a fourfold increase in mortality, a fivefold increase in the rate of stent re-stenosis and twice the rate of major cardiac event.

Treatment overview Appropriate risk assessment involves a detailed family and medical history, sleep study, and patient education – very important because effective treatment of SA may slow the rate of progression, and improve the quality of life and survival. Weight reduction, avoiding alcohol and sedatives, use of CPAP and surgical intervention with uvuloplasty can be effectively used. The use of diuretics, in particular aldosterone inhibitors, is very important in cardiac failure. Central nervous stimulation may be useful in central apnoea. There is increasing evidence of the successful treatment of resistant hypertension with renal denervation. There are also promising results of new treatment with phrenic nerve stimulation in central apnoea. O

t "QOPFB NBZ CF SFTQPOTJCMF GPS SFGSBDUPSZ BOHJOB FWFO XJUIPVU any evidence of critical disease on angiogram. In some studies, apnoea was found with 65% of patients with myocardial infarction.

“Unplanned pregnancy & family planning services�

Declaration: Western Cardiology has contributed to the production costs of this clinical update. No author competing interests.

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medicalforum

Guest Column By Mr Mark Walding, Compliance/Investigations OfďŹ cer, Public Health and Clinical Services Division DoH

PIVET MEDICAL CENTRE

Investigation of poisons misuse T

Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Dr John Yovich

he DoH faces many challenges as State regulator of the lawful prescribing, supply, administration and use of medicines and poisons throughout WA

IVF Productivity Rate

The WA Poisons Act and associated Regulations govern the use of scheduled medicines at all stages from importing to wholesaling, retail sale, supply by doctor, administration, prescribing and consumer use. The task of enforcing the Act is tackled by a small unit of investigators and compliance officers who investigate breaches of the Act state-wide. The main objective is the protection of the public.

The IVF landscape has changed in recent years with several initiatives now impacting to deliver high pregnancy rates consistently and without the previous risks of OHSS or multiple pregnancies.

The Poisons Act stipulates the minimum requirements for the safe use of ‘poisons’. Given the diversity of persons who deal with poisons, officers have to employ many different investigative strategies. One day an officer may be providing friendly training to a health professional, whilst the next day executing a search warrant in pursuit of evidence and dealing with hostile respondents. The powers of inspection are used at pharmacies, medical practices and hospitals. If information is received that items relevant to offences are located at a residential address, the inspectors need to apply to a Justice of the Peace for a search warrant. Such a warrant is often executed in conjunction with the WA Police and recent jobs of this nature have included the home addresses of pharmacists, doctors, business proprietors and members of the public. As an example, a search warrant was executed in late November 2012 on a residential address of a registered nurse who was injecting patients with Botox in her home laundry. Many items of interest were located and seized by investigating officers and subsequent enquiries revealed she was working without the supervision of a medical practitioner and the Botox was being stored unlawfully in the family fridge. A doctor based in the Eastern States was facilitating the supply of Botox to the nurse. Another investigation in March 2013 into an alleged cancer treatment known as black salve (commonly labelled as ‘termite repellent’) was in response to contact from a member of the public who had been sold the product as a treatment for breast cancer – she was horrified by the damage it had done to her skin. Although medication safety is the responsibility of the Therapeutic Goods Administration, investigation by DoH confirmed that the Poisons Regulations had been breached; black salve contains scheduled chemicals for which the product was labelled incorrectly and the vendor did not have authority to distribute the product. In the interest of public health, the DoH issued a media release to warn people of the dangers of black salve. Other actions included the seizure of items at a number of business premises, and legal action (still being considered). The WA Health poisons regulation team face a busy and diverse workload. They believe in and take what they do very seriously and work hard to ensure public safety in relation to all poisons. O

‌ sum of all livebirths from fresh and frozen ET’s

From the clinical perspective this is driven by Algorithms to GHWHUPLQH WKH RSWLPDO 2YDULDQ 6WLPXODWLRQ UHJLPHQ H J Ă DUH vs antagonist) along with the appropriate Trigger drug (hCG vs DJRQLVW DQG VSHFLĂ€F OXWHDO VXSSRUW VFKHGXOH K&* LQMHFWLRQV YV progesterone pessaries). Laboratory improvements means fertilisation rates are high, embryos can be increasingly cultured to the blastocyst stage DQG WKH &U\RWRS YLWULĂ€FDWLRQ WHFKQLTXH XVHG DW 3,9(7 RSWLPLVHV embryo cryopreservation. $OO WKHVH GHYHORSPHQWV PHDQV 3,9(7 KDV EHFRPH D YLUWXDO SET (single embryo transfer) clinic, where more embryos are FU\RSUHVHUYHG IRU WUDQVIHU LQ 3,9(7¡V XQLTXH +57 VFKHGXOH delivering “top-of-the-Wazzaâ€? FET results according to the latest $1=$5' GDWD UHSRUW ,Q SURYLGLQJ SURJQRVWLF LQIRUPDWLRQ IRU SDWLHQWV 3,9(7 KDV SXEOLVKHG WKH LGHD RI D 3URGXFWLYLW\ 5DWH ² PHDQLQJ WKH FKDQFH of a livebirth (from the fresh and frozen embryos) arising from a single egg collection cycle. For women responding well to stimulation, the chance of a successful livebirth is ~60% for women <35yrs and 40% for those aged 35 to 40 years. These rates are among the very best achievable in Australia or the world.

3,9(7 FRQWLQXHV ´7RS RI WKH :D]]D¾ LQ WKLV JUDSK ZKLFK VKRZV WKH live-birth pregnancy rates in quartiles for the <35 yrs age-group from all the IVF clinics in Australia & NZ

NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY

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

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37

CLINICAL UPDATE

Osteotomies around the knee joint

By Prof Markus Kuster Orthopaedic Surgeon, West Perth. Tel 9212 4200

D

espite many advancements in knee arthroplasty, osteoarthritis in young patients remains a difficult problem for the orthopaedic surgeon. Knee arthroplasty in patients younger than 55 show revision rates for unicondylar knee replacements of 13% after five years (25% after 10 years); and for total knee replacements, 12% after 10 years (c.w. 3% if aged over 75). Hence, for active, young patients joint preserving operations around the knee remains a valuable option.

Who is the ideal patient for an osteotomy?

the slope of the tibia can be adjusted accordingly during the surgery.

Generally, high tibial osteotomies are for localised medial compartment osteoarthritis and distal femoral osteotomies for localised lateral compartment problems.

A full leg x-ray (Maquet view) establishes the degree of varus or valgus deformity requiring correction (an overcorrection of 3-50 is ideal).

The ‘ideal’ patient is:

There are several types such as opening wedge and closing wedge osteotomies. Then the correction can either be valgus or varus. The location of the osteotomy is usually at the tibia for valgus correction, or at the femur for varus correction. However, this changes after malunion of a fracture, after unsuccessful epiphysiodesis, or where correction of a large varus deformity (>150) requires an osteotomy at the femoral and tibial sides simultaneously to prevent excessive shear forces on the knee joint (see Figure 1).

What knee osteotomies are there?

t CJPMPHJDBMMZ ZPVOH J F ZFBST and active, t XJUI B HPPE SBOHF PG NPUJPO J F GMFYJPO DPOUSBDUVSF OJM PS 0 and flexion movement >1000), t QBJO JT MPDBMJTFE UP UIF NFEJBM PS MBUFSBM joint line only and the patellofemoral joint is pain free and has no or mild osteoarthritis; and pain has a mechanical nature, that is, pain on starting and after activities. Contrary to total knee replacement, decision for an osteotomy should be made early, to prevent further deterioration in cartilage with mild to moderate changes. Patients with complete loss of joint space have a less favourable outcome but this is not an absolute contra indication in those young and active, who are fully informed.

What investigations are necessary? An MRI assesses whether an osteotomy is still an option. The cartilage, the ligaments and the menisci are assessed. The healthy compartment should have good cartilage both at the femoral and tibial side. An ACL or PCL deficiency is not a contraindication but it is important to know about the ligamentous status of the knee joint, as

Another indication for high tibial osteotomy is varus deformity and ligamentous instability with a combined osteotomy and ligament reconstruction.

What are realistic expectations?

Q Fig 1; Fig 2: Severe varus deformity requiring closing wedge osteotomy at the distal femur, with the removed bone wedge used for an opening wedge osteotomy at the tibia. With the double osteotomy the joint line could remain almost horizontal despite a correction angle of almost 20 degrees.

Dr Ian Rosenberg BDS (WITS), FDSRCS(ED), FFDRCS(IR), FRACDS(OMFS) Oral and Maxillofacial Surgeon Would like to inform his colleagues that he is restricting his practice to: t Tempero-mandibular joint disorders

The intention of an osteotomy is realignment of the mechanical axis and unloading of the osteoarthritic compartment. The cartilage damage and the osteoarthritis in the diseased compartment remain and this is no cure for osteoarthritis. The postoperative recovery is slower than for a total knee replacement and patients must be able to partially weight bear for a period of time. They also have to be aware that the knee joint is not completely pain free after the surgery. However, most studies do show a significant improvement of the pain and functional knee scores over time, especially if the osteotomy is performed in an early disease stage.

Complications Address: Mercy Medical Centre Suite 11-11A Sessional Rooms Ellesmere Road, MT LAWLEY 6050

Tel: 9370 9329 Fax: 9370 9350 Emergencies: 0417 924 422 Email: suite11doctors@mercycare.comau

All correspondence to: 15 Florence Way, Dianella WA 6059

Email: ianrosenberg@iinet.net.au

A complication rate of about 6% has infection and non-union of the osteotomy gap as most common (especially in smokers), followed by under correction and loss of correction, fixation failure and Continued opposite

38

medicalforum

CLINICAL UPDATE

Hallux valgus surgery in the elderly

By Dr Nicole Leeks Orthopaedic Surgeon Nedlands

I

mmobility can be a medical and social risk for the elderly, so gone are the days of a below-knee cast for six weeks and instructions to “stay off it!” – the older patient can now safely undergo hallux valgus surgery to improve general mobility and quality of life. Current techniques for correction of a bunion involve soft tissue releases and osteotomy of the first ray, with internal fixation techniques. The inherent rigidity of such fixation allows immediate safe and relatively pain-free weight-bearing.

Age no barrier Many elderly patients are fit and enjoy moderate exercise into their 80s. Whilst co-morbidities (particularly diabetes and peripheral vascular disease) increase the complication rate, with extra pre-and postop care the final outcome should not be compromised. Older patients are more stoic – at 93, my eldest patient met me halfway down the hospital corridor the morning after her bilateral correction! The older patient with rheumatoid arthritis deserves particular mention. Severe longstanding deformity of all toes can make surgery technically demanding but it can vastly improve pain and quality of life. Such patients are most relieved and grateful following realignment surgery (even allowing for increased complications due to poor tissues and disease modifying agents). Preoperative weight bearing x-rays (AP, oblique and lateral) assess alignment, presence of arthritis and the relative length of the lesser metatarsals – prior to seeing the surgeon.

from custom made footwear and podiatric intervention. Possible surgical corrections of a bunion are many. In Perth, the commonest procedure is the Scarfe Osteotomy, which corrects the alignment of the first ray and is fixed with two or more screws. If further correction is required a closing wedge osteotomy of the proximal phalanx, known as an Akin procedure, is performed and held with a staple or single screw. These procedures require good MTP joint alignment and few arthritic changes. A longstanding deformity with more severe intermetatarsal and hallux valgus angles or significant osteoarthritis is a contraindication to “bunion” correction and necessitates 1st MTP joint fusion instead. Fusion surgery does require prolonged immobilisation, thereby slowing recovery.

Q A bunion left too long but addressed with surgical fusion.

The surgery

When a patient begins to complain of symptoms related to his or her bunion, earlier surgical correction has advantages because less deformity retains soft tissue flexibility and is therefore easier to correct.

Realignment of the great toe is to relieve symptoms – usually pain related to the first ray but also the lesser toes (“metatarsalgia”) and footwear discomfort from intractable callosities. In addition, correction of deformity may allow the patient to buy shoes “off the shelf” and reduce expense

Correcting bilateral bunions together depends on patient and surgeon preference and may minimise the total period of recovery. A padded bandage or forefoot plaster, although not surgictally required, can help reduce pain by immobilising the

References available on request. O

of high tibial osteotomies as 92% at five years, 85% at 10 years, and 72% at 20 years. Hence, this operation must be seen as a time buying operation and not a cure for most patients.

a failure of the operation but rather a sequence.

Post-surgical care

forefoot. A post op shoe further improves mobility until swelling reduces to allow normal shoe wear. For right sided surgery, driving is precluded for a number of weeks.

Author competing interests: No relevant disclosures.

Continued from previous page compartment syndrome. Peroneal nerve lesions occur in 2-5% in closing wedge high tibial osteotomies.

What are the long term results? A large study in Sweden showed that conversion from an osteotomy to total knee replacement occurred in 17% after 10 years. This is similar to conversion of unicondylar knee arthroplasties in the same age group (17-24%). The Finnish joint registry of 3195 osteotomies showed conversion to total knee replacement as 11% after five years, 27% after 10 years, and 50% after 20 years. A 2013 meta-analysis showed survivorship medicalforum

The functional score, patient satisfaction and long term results after high tibial osteotomy is similar to unicondylar knee replacements. However, one must bear in mind that during that time the patients keep their own knee joint and no activity restrictions and no polyethylene wear occurs. The most common cause of failure after osteotomy is increased cartilage wear of the healthy compartment due to overloading. Conversion to a total knee replacement is not

Is knee replacement jeopardised? Some authors are concerned that an osteotomy interferes with the outcome of a future total knee replacement. And indeed the actual surgery of a knee replacement after high tibial osteotomy is more difficult and might take longer. However, most studies have failed to show a significant difference in functional outcome and long term result in comparison to primary knee replacements. O Author competing interests: No relevant disclosures. 39

Horse Racing

Q The excitement of Melbourne Cup Day at Flemington

S P O R T

of K I N G S

The Spring Racing Carnival sets the blood pulsing for two WA doctors who have more than their money on the favourite. Perhaps it’s something to do with the country air? Drs Dick Austin and Kevin Christianson, from Kalgoorlie and Northam, respectively, are boys from the bush with a passion for the thunder of horse-racing hooves. And one of them has lifted the CaulďŹ eld and Melbourne Cups in the same year!

R

acing has been a lifelong passion for Dick. “I was interested in race horses as young kid in Melbourne and when I XBTO U QMBZJOH GPPUZ * E CF BU UIF SBDF USBDL I trained as a pharmacist and then trans ferred to medicine doing my intern years in 8" EVSJOH UIF T * XFOU UP ,BMHPPSMJF ended up buying a practice and ended up staying for a long time.�. “In terms of horse racing it’s been fantastic! * HPU JOWPMWFE XJUI ,FJUI #JHHT B XFMM LOPXO PXOFS PG IPSTFT JO ,BMHPPSMJF BOE we bought a horse called Doriemus that went on to win the Caulfield and Melbourne $VQT JO w On a local level Dick has had plenty of suc cess in the Goldfields region. “I bought a horse called Signpost and that SFTVMUFE JO XJOOJOH UIF 5SJQMF $SPXO

40

...and Medicos

<$PPMHBSEJF #PVMEFS BOE ,BMHPPSMJF $VQT> and it was only the second time that’s hap pened. You got a nice bonus from winning all three but, having said that, you certainly don’t go into racing as an investment option. *U T FYQFOTJWF UP CVZ XFMM CSFE IPSTFT Nobody makes money out of horse racing except the people who work in it, such as trainers and jockeys.�

we’re finding in a lot of sports. Some peo ple will try to get an edge any way they can particularly when there are large monetary rewards on offer. It’s very strictly policed now and I think racing in Australia is pretty fair. And it’s often quite complex because, if you’re aiming to get a horse to peak at a specific time, it’s not always in the best interests of everyone involved for the horse

“The betting scene has changed dramat ically, it’s massive DPNQBSFE XJUI years ago and the proceeds finance a large section of the racing industry. It’s a healthy sector and that’s a good thing for the economy in a broader sense.� It may be called the 4QPSU PG ,JOHT CVU there’s been an unde Q Dr Kevin Christianson and his mare Main Street Miss, which he owned and trained, returning to scale after a win at Ascot in 2000 with niably seamy side to track rider Samantha Fisher. thoroughbred horse flesh charging around the track chasing that pot of gold just UP CF BU JUT CFTU JO UIF MFBE VQ SBDFT w beyond the finish line. i:PV HFU UIF PEE GSFBL IPSTF MJLF #MBDL “Practices such as doping do occur, as Caviar or Atlantic Duel but, to be honest,

medicalforum

Q Legendary trainer Lee Freedman meets up with his 1995 Double winner Doriemus last month at the Living Legends property. Doriemus is a fit and happy 23.

most horses have only got one or two good wins in them. And for that to happen every thing has to be right on the day and that’s difficult to achieve.� Dick readily agrees that his involvement with UIF SBDJOH JOEVTUSZ IBT CFFO B WBMVBCMF DJSDVJU breaker from the pressures of professional life. “I’ve been a committee member for more than ZFBST EVSJOH BO JOUFSFTUJOH QFSJPE PG EFWFM PQNFOU GPS UIF ,BMHPPSMJF SBDJOH DMVC "OE * WF also been involved in a medical sense as club doctor and surgeon. It’s been a great hobby and I’ve had a lot of success. I consider myself very lucky.� FEJDBM 'PSVN TQPLF XJUI %S ,FWJO $ISJTUJBOTPO JO UIF MFBE VQ UP UIF UI Anniversary of the Northam Racing Club. 6OMJLF %JDL ,FWJO IBE CBSFMZ CFFO OFBS B SBDF track in his younger days. He trained as a doc tor in London and Edinburgh before coming to 8" TJHIU VOTFFO XJUI B XJGF BOE UXP ZPVOH children.

M

“I wanted to practise as a GP and do some TVSHJDBM XPSL BOE JU XBT B UPTT VQ CFUXFFO Canada and Australia. The latter had the bet ter climate and we liked Northam so much XF WF CFFO IFSF ZFBST .Z JOWPMWFNFOU with horses started because you can’t run a race meeting without a doctor on course. And also in a small country town it’s good to get involved. As a GP you need to know the people and they need to know you.� “At least half the people who come to the races are my patients and, fortunately, they don’t ask me too many medical questions. They’re happy to let me have my Thursday afternoons off and it’s actually a way of giving something back to the community.� “A lot of money is generated by provincial racing. One thing I have noticed is the prize

medicalforum

money here in Australia. I’ve just CFFO CBDL UP UIF 6, and it’s quite poor by comparison.� ,FWJO T JOWPMWF ment, as with Dick’s, extends to the admin istrative level. “I’ve been on the com mittee of the Northam Racing Club including a stint as secretary and president. And I’ve pushed that even further with my commitment to the 8FTUFSO "VTUSBMJBO 5VSG $MVC *U T CFFO both enjoyable and rewarding because people in the horse racing industry are so keen to get things done.�

Q Dr Richard and Helen Q Austin won the Melbourne Cup in 1995 with their horse, Doriemus.

The world of racing is full of stories and ,FWJO TVQQMJFT BO BNVTJOH POF i*O UIF FBSMZ T * CPVHIU B UISFF ZFBS PME GJMMZ BOE USBJOFE JU NZTFMG .Z QBSFOUT XFSF PVU GSPN UIF 6, BOE XF drove up to Geraldton for a race meet JOH .Z GBUIFS XBOUFE UP QVU PO her but I talked him out of it because the horse had drawn an outside bar rier and was being ridden by an apprentice jockey.� “Yes, it won! Thankfully, my father had put PO JU CVU JG IF E QMBDFE IJT PSJHJOBM XBHFS JU would’ve paid for his international airfares. Six months later she won two in a row at Ascot.� “You can tell with some horses that they really want to race. They put their ears back and they love to run. Training a horse is a bit like a GP XJUI QBUJFOUT o NBLF TVSF UIFZ FBU XFMM BOE get plenty of exercise. And the hard bit? Try and get inside their heads!� O

Q Dr Kevin Christianson and his sister Jill Q Chandler in 2000 with the ďŹ rst foal ready for sale from his winning mare Main Street Miss.

Melbourne Cup Tips Dr Dick Austin: Puissance de Lune and Sea Moon Dr Kevin Christianson: 'JPSFOUF

By Mr Peter McClelland 41

Social Pulse

WA PRACTICE RECOGNISED Kalamunda GP Dr Sean Stevens was thrilled with his Mead Medical Group taking out the RACGP General Practice of the Year award at the recent GP13 conference in Darwin. The practice employs 19 doctors and has trained 26 registrars in the past nine years, Earlier this year the surgery moved into custom-built premises next to the Kalamunda Hospital and is equipped for gynaecological procedures, minor surgery, and has emergency facilities. “It has been a real team effort from the front desk to the back office to service our patients and community,” Sean said. He said the prize money combined with a donation from the practice would be dedicated to an annual award for a student from the Kalamunda shire to study medicine in memory of Associate Dr Jane Talbot.

Q Mead Medical won the General Pratice of the Year Award.

INSPIRING LI The inspirational Li Cunxin proved his magic extends far beyond the ballet stage when he cast his spell over 500 guests at the 2013 MercyCare Oration in September. Recounting his incredible life story, which he chronicled in his bestselling memoir, Mao’s Last Dancer, Li moved the audience. Mercy CEO said Li’s story reflected the importance of faith, self-belief and perseverance.

Q Li Cunxin inspires during his Oration. Q Bottom row: Bishop Donald Sproxton, MercyCare Chair Dianne Bianchini, WA Governor Malcolm McCusker, author Li Cunxin, and Mercy Trustee Irena Harrison. Back left: Mercy Trustee Helen Chaffer, EO Aboriginal Education and Training Lesley Radloff, Mercy CEO Chris Hall, MLA Anthony Simpson and Mercy deputy chair Maurice Spillane.

DRIVING FROM THE TOP About 20 WA practice managers headed to Sydney’s Convention and Exhibition Centre for the national AAPM conference. The spotlight was on Quality Assurance with speakers coming from Canada and UK to lead discussion. Among the WA contingent were Kathy McGeorge, Fiona Wong, Janet Leighton, Pat Dunston, Shim Kingston, Peter Bradshaw, Natalie Watts and Ezelle Neimann.

42

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at R O S I L Y

Wine Review

Finesse

2013 Rosily Vineyard Sauvignon Blanc 5IF WJOFZBSE NPUUP JT ATVTUBJOBCMF TJNQMJDJUZ BOE UIF 4BVWJHOPO #MBOD JT UIF UI DPOTFDVUJWF WJOUBHF PG UIJT WBSJFUZ 5IJT JT B ZPVOH XJOF XJUI QMFOUZ PG lime crispness and gooseberry and apple aromas. A simple style made more JOUFSFTUJOH XJUI PG UIF XJOF BHFE GPS UXP NPOUIT JO OFX 'SFODI PBL %FGJOJUFMZ B HSFBU XJOF GPS TPNF GSFTIMZ TIVDLFE $PGGJO #BZ PZTUFST 2012 Rosily Vineyard Chardonnay

By Dr Martin Buck

The chardonnay plantings were originally the Gingin clone but recent upgrading IBT BEEFE TFWFSBM OFX #VSHVOEJBO DMPOFT 4UJMM B ZPVOH XJOF UIF Chardonnay has plenty of potential. A limey nose with hints of apricot and stone fruit, a palate of grapefruit, minerality and subtle oak, all make this a wine to keep. This is a lean, crisp chardonnay with neutral oak and should mature into a long lasting wine.

Rosily Vineyard was established on Wilyabrup Rd in Margaret River in 1994 and the original vines were sourced from cuttings from Moss Wood.

2011 Rosily Vineyard Cabernet Sauvignon Cabernet Sauvignon is the signature variety of the region but is handled differently JO UIF 3PTJMZ 7JOFZBSE XJOF 5IJT JT B NFEJVN CPEJFE XJOF XJUIPVU UIF EFFQ brooding intensity of many of the other local cabernets. Great aromas of mint, FVDBMZQUVT BOE DJHBS CPY SFGMFDU UIF NPOUIT JO 'SFODI PBL 5IFSF JT BO BQQFBMJOH palate of berry fruit and light, balanced tannins. A wine ready for immediate FOKPZNFOU PS TIPSU UFSN DFMMBSJOH

*U XBT OBNFE BGUFS UIF 'SFODI DBSUPHSBQIFS who served on the vessel that claimed the 4PVUI 8FTU PG 8FTUFSO "VTUSBMJB GPS UIF 'SFODI JO *NBHJOF XIBU B XPSME PG XJOF XF NJHIU OPX CF MJWJOH JO JG UIF #SJUJTI had not stepped in! The first wines under MBCFM XFSF QSPEVDFE JO BOE CZ Rosily Vineyard was recognised as the most PVUTUBOEJOH OFX XJOFSZ JO 8"

2009 Rosily Vineyard The Cartographer 5IJT JT UIF TJHOBUVSF #PSEFBVY CMFOE PG UIF WJOFZBSE BOE JT UIFJS DVSSFOU SFMFBTF Predominately cabernet sauvignon with cabernet franc, merlot and petit verdot UP SPVOE PGG UIF XJOF UP UIF 'SFODI CMFOE 5IJT JT XJOF XJUI BHF BOE NBUVSJUZ in spades. Earthy aromas abound with savoury fruit and blended tannins. There is great complexity and a long palate of plummy fruit. A wine ready to impress now but could be kept for further ageing in the cellar. Priced very reasonably and excellent value. 2008 Rosily Vineyard Shiraz There is good bottle age on this wine. It has lots of earthy, funky aromas with old fruit and white pepper. Age and complexity do not always travel together but in this wine they are bonded by a palate of mature berries and fine tannins with great length. I think this is a wine showing off the local terroir and now at its best.

WIN a Doctor's Dozen!

What two localities did Rosily Vineyard seek out cuttings for its 2012 Chardonnay? Answer:

...................................................................................................................

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, November 30, 2013. 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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Name:

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E-mail: ......................................................................................................... Contact Tel:

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Please send more information on Rosily Vineyard offers for Medical Forum readers.

43

Car Review

Sporty GOOD Looks Dr Daryl Sosa turns heads with the new Lexus IS250 when he takes it out for a spin.

Last month we had the opportunity to test drive the new Lexus IS250 F Sport while on a Driver Training Day at the RAC's Grogan Rd Facility and the ďŹ rst thing to say, this is a great looking car! You may remember some of my comments regarding the odd combination of looks of the GS350 (overdone front and conservative rear), not so the IS250.

5IF UIJSE HFOFSBUJPO *4 JT B NJE TJ[FE luxury sedan and up against the likes PG "VEJhT " 5 #.8hT TFSJFT BOE .FSDFEFT #FO[ $ T * UIJOL UIF -FYVT IBT impressive good looks.

5IF CPEZ IBT CFFO TUSFUDIFE NN IBT B MPXFS $E BOE VUJMJTFT B A-BTFS 4DSFX XFMEJOH UFDIOJRVF BOE A#POEJOH HMVF to increase torsional rigidity for improved handling.

As usual, the Lexus has impeccable build RVBMJUZ BOE * SFBMMZ MJLF UIF OFX GSPOU CVNQFS NFTI HSJMMF RVBSUFS QBOFM USFBUNFOU 5IF SFBS TXPPTI /JLF MJLF MJOF GSPN UIF SPDLFS panels to the rear light clusters gives it a TQPSUZ GMPXJOH TJEF WJFX &WFSZPOF QSFTFOU at the training day commented favourably on its appearance.

It also incorporates Lexus's Pedestrian 4FOTJOH #POOFU BOE IBT FJHIU BJSCBHT standard. 5IF ' 4QPSU JT BMTP FRVJQQFE XJUI #MJOE 4QPU Monitoring, which I found helpful in Perth's increasingly congested traffic! Inside

the

cabin,

the

clean

stacked

Send Your 'Holiday Road' Pictures These stunning pictures of the Pilbara were taken by Mandurah GP and equally famous landscape photographer Dr Tony Tropiano on one of his latest trips out bush. His passion for photography knows no bounds. Not only is he passionate about his own photography but he’d like everyone else to be able to take the best shots they can. Next month, Medical Forum will publish a selection of readers’ favourite travel pictures which fit the theme:

HOLIDAY ROAD Don’t forget to add a paragraph with your photograph to tell us a little about what the picture is about and for the techies, what equipment was used. Send your hi-res 300 dpi pictures to Managing Editor Jan Hallam: editor@mforum.com.au by November 10. 44

medicalforum

appearance to the dash and centre console and the leather seats give it a crisp contemporary feel. There is the option of a ‘Dark Rose’ leather trim for the more adventurous. The foam injected, heated and ventilated electric front seats provide excellent support and comfort. In the rear, seats incorporate B TQMJU GPME BOE XJUI UIF TDVMQUJOH BU the back of the front seats, in addition to the increased cabin size, there is improved rear passenger leg room. 5IF *4 IBT LFZMFTT FOUSZ BOE QVTI button start. Again, the Lexus has an analogue centre DMPDL BOE B 5'5 .VMUJNFEJB TDSFFO incorporating a HDD Sat Nav system. This is controlled via a centre console mouse, which I found difficult to use on the go but would probably become better at with practice! I found the cruise control switchgear TUFFSJOH XIFFM NPVOUFE BU PhDMPDL B CJU difficult for everyday use. 5IF ' 4QPSU IBT B -'" TUZMF 7JSUVBM 5BDIP that physically moves to the right to reveal a trip computer and other vehicle information at the touch of a button ... a bit gimmicky but looks really cool. The audio system looks a little plastic but UIF %"# EJHJUBM SBEJP XBT OPUJDFBCMZ DMFBSFS UIBO '. 8JUI LH LFSC XFJHIU BOE B SFMJBCMF CVU BHFJOH M %JSFDU JOKFDUFE EVBM 775J 7 NPUPS L8 /N NBUFE UP B TJY speed automatic gearbox driving the rears, UIF *4 hT QFSGPSNBODF JT BEFRVBUF JO UIJT segment but struggles up against the Audi 5VSCP /N BOE UIF MJHIUFS #.8 The tall lower ratios make it a little hesitant

medicalforum

BOE JU SFBMMZ SFRVJSFT EFDFOU SFWT UP get into its maximum torque zone but for city driving it’s perfectly adequate. 5IF FMFDUSJD QPXFS TUFFSJOH 7(34 JT B CJU vague in ECO mode but is noticeably better JO 4QPSU

5IF *4 ' 4QPSU JT BCPVU ESJWF away. There are some great deals around at the moment and with interest rates the lowest in decades, it’s a good time to buy. Cheers and drive safe! O

Suspension has been upgraded, featuring a front double wishbone and the new Multilink rear suspension improves tyre grip in the corners. The revised rear suspension has also allowed increased rear boot space.

Dr Daryl Sosa

5IF ' 4QPSU JT FOEPXFE XJUI EJTUJODUJWF BMMPZ XIFFMT BOE MPXFS QSPGJMF UZSFT On the track it was smooth, balanced and very controlled due to the VSC switching UIF %SJWF .PEF 4FMFDUPS UP 4QPSU UIF steering firms as does the dampers via AVS, and the handling noticeably improves. The JOJUJBM UVSO JO JT NPSF DPOUSPMMFE BOE JU TJUT flatter through the corners. ECO mode is for boulevard cruisers! The brakes were progressive, didn't fade BOE EJE OPU FOHBHF "#4 VOMFTT BCTPMVUFMZ necessary. -FYVT RVPUFT DPOTVNQUJPO BU M LN (ADR combined). Perhaps the real world of Perth traffic, expect cruising the freeway _ TVCVSCT _ BOE B IBSE EBZ BU UIF PGGJDF _ LN

fuku

www.thefuku.com booking - internet

20 glyde st mosman park Ri ng 0 4 0 3 47 0 9 6 4 t o a rr a n g e private room for presentations

5IF FOUSZ MFWFM *4 -VYVSZ IBT UIF same engine, driveline and the most highly equipped base specification compared to JUT &VSPQFBO SJWBMT BOE ZPV TBWF , JO UIF bargain. This is a car that you can really feel comfortable in as your daily driver, just keep JU JO 4QPSU PS 4QPSU NPEF -FYVT NPOUI LN XBSSBOUZ BOE roadside assist comes with a starting price PG BCPVU 03$ GPS UIF CBTF NPEFM 45

Music

funnyside e

Q Q A Holy Pitch /JOFUZ ZFBS PMET /FW BOE 7JD IBWF CFFO friends all their lives but Vic’s health is fading, so Nev visits him every day. Somehow their conversation always turns to cricket. "Vic," says Nev, "You know how we have both loved cricket all our lives, and how we played together for so many years, you’ve HPU UP EP NF B GBWPVS 8IFO ZPV HFU UP Heaven, somehow you've got to let me know if they play cricket." 7JD MPPLT VQ BU /FW GSPN IJT EFBUI CFE and says, "Nev, you're my best friend, if it’s possible, I'll give you’re a sign." Shortly after, Vic dies in his sleep. A couple of nights later, Nev is awakened by a blinding flash and a voice calls out to him: "Nev...Nev...it's me, Vic." "It can’t be. Vic just died." "I'm telling you," insists the voice. "It's me, Vic!" 8IFSF BSF ZPV "I'm in heaven," says Vic, "and I've got really good news and a little bad news." "So, tell me the good news first," says Nev. "The good news is that there is cricket JO IFBWFO #FUUFS ZFU BMM PVS PME CVEEJFT XIPhWF HPOF CFGPSF VT BSF UIFSF #FUUFS ZFU XFhSF BMM ZPVOH NFO BHBJO #FUUFS yet, it's always spring time and it never rains or is too hot. And best of all, we can play cricket all we want, and we never get tired!" 3FBMMZ TBZT /FW 5IBU JT GBOUBTUJD #VU what's the bad news?" "You're opening the batting next Tuesday."

Q Q Rules for Non-Pet

Owners Who Visit and Like to Complain About Our Pets

5IFZ MJWF IFSF :PV EPOhU *G ZPV EPOhU XBOU UIFJS IBJS PO ZPVS clothes, stay off the furniture.(That's why they call it "fur"niture.) * MJLF NZ QFUT B MPU CFUUFS UIBO * MJLF NPTU people. 5P ZPV JUhT BO BOJNBM 5P NF IF TIF JT BO BEPQUFE TPO EBVHIUFS XIP JT TIPSU hairy, walks on all fours and doesn't speak clearly. Dogs and cats are better than kids ....they eat less, don't ask for money all the time, are easier to train, usually come when called, never drive ZPVS DBS EPOhU IBOH PVU XJUI ESVH VTJOH friends, don't smoke or drink, don't worry about having to buy the latest fashions, don't wear your clothes, and EPOhU OFFE B HB[JMMJPO EPMMBST GPS VOJ BOE if they get pregnant, you can sell the children. 46

Q Q History Lessons

from Kids

"ODJFOU &HZQU XBT JOIBCJUFE CZ mummies and they all wrote in hydraulics. They lived in the Sarah Dessert.The climate of the Sarah is such that all the inhabitants have to live elsewhere. .PTFT MFE UIF )FCSFX TMBWFT UP UIF Red Sea where they made unleavened bread, which is bread made without any ingredients. Moses went up on Mount Cyanide to get the Ten Commandments. He died before he ever reached Canada. 4PMPNPO IBE UISFF IVOESFE XJWFT BOE seven hundred porcupines. 5IF (SFFLT XFSF B IJHIMZ TDVMQUVSFE people, and without them we wouldn't have history. 4PDSBUFT XBT B GBNPVT Greek teacher who around giving people advice. They killed him. Socrates died from an overdose of wedlock. After his death, his career suffered a dramatic decline.

went

*O UIF 0MZNQJD Games, Greeks ran races, jumped, hurled biscuits, and threw the java. *U XBT BO BHF PG HSFBU inventions and discoveries. Gutenberg invented SFNPWBCMF UZQF BOE UIF #JCMF Another important invention XBT UIF DJSDVMBUJPO PG CMPPE 4JS 8BMUFS Raleigh is a historical figure because he invented cigarettes and started smoking. 4JS 'SBODJT %SBLF DJSDVNDJTFE UIF XPSME XJUI B GPPU DMJQQFS

#FFUIPWFO XSPUF NVTJD FWFO UIPVHI he was deaf. He was so deaf he wrote loud music. He took long walks in the forest even when everyone was calling GPS IJN #FFUIPWFO FYQJSFE JO BOE later died for this. 5IF OJOFUFFOUI DFOUVSZ was a time of a great many thoughts and inventions. People stopped reproducing by hand and started reproducing by machine. The invention of the steamboat caused a network of rivers to spring up. Louis Pasteur discovered a cure for rabbits. Charles Darwin was a naturalist who wrote the Organ of the Species. Madman Curie discovered the SBEJP "OE ,BSM .BSY CFDBNF POF PG UIF .BSY #SPUIFST

5IF HSFBUFTU XSJUFS PG UIF 3FOBJTTBODF XBT 8JMMJBN 4IBLFTQFBSF )F XBT CPSO JO UIF ZFBS TVQQPTFEMZ PO IJT birthday. He never made much money and is famous only because of his plays. He wrote tragedies, comedies, and hysterectomies, all in Islamic pentameter. Romeo and Juliet are an example of a heroic couple. Romeo's last wish was to be laid by Juliet. 8SJUJOH BU UIF TBNF UJNF BT Shakespeare was Miguel Cervantes. He wrote Donkey Hote. The next great author was John Milton. Milton wrote Paradise Lost. Then his wife died and he wrote Paradise Regained.

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Music

Verdi

on Doctors'

Orders

WASO farewells two figures in December XIP IBWF CSPVHIU WJHPVS BOE FYQFSJFODF UP music making in Western Australia.

Verdi’s glorious Requiem next month will be a swan song for two powerhouses of the West Australian Symphony Orchestra. The concerts on December 6 and 7 will be the last for Principal Conductor Paul Daniel and the WASO Chorus director Marilyn Phillips. It will be a particularly poignant time GPS TJY MPDBM EPDUPST %S 0MHB 8BSE %S .PJSB 8FTUNPSF %S 4VTBOOB 'MFDL %S ,BUF -BOHEPO %S +FOOZ 'BZ BOE Dr David Mathias, who despite their busy lives wouldn’t miss the opportunity to sing in the Chorus. And it takes enormous commitment because as Paul and Marilyn BUUFTU XIJMF UIF 8"40 $IPSVT JT OPU QBJE high professional standards are expected. 3PZBM "DBEFNZ PG .VTJD USBJOFE .BSJMZO IBT CFFO JO 1FSUI GPS UIF QBTU ZFBST BGUFS a distinguished career as accompanist. Her XPSL XJUI UIF 8FTUFSO "VTUSBMJBO 0QFSB as Director of Music is legendary and she brought that high degree of professionalism UP UIF 8"40 $IPSVT

Q WASO and Chorus Symphony Picture: Tony McDonough

“I thought when I arrived in Perth it was quite a conservative place. I have been proved wrong.� 1BVM QBJE USJCVUF UP UIF 8"40 $IPSVT

Q Marilyn Phillips JO )POH ,POH BOE FWFSZ POF PG UIFN XBT thrilled to be a part of it. It was one of my highlights of the past eight years.� Marilyn finds it difficult to sit in the Perth Concert Hall just listening.

“Symphony choruses worldwide are amateur in that they produce a professional SFTVMU CVU BSF VOQBJE #VU XF SFIFBSTF BOE perform as we would with a professional DIPSVT o XJUI SFTQFDU BOE VOEFSTUBOEJOH w Marilyn said.

“I am usually so nervous sitting in the hall CVU * N QSPVE PG UIFN o UIFZ IBWF BDIJFWFE a great deal.�

“They are a dedicated bunch. They come to rehearsal exhausted after a day’s work and they leave with a spring in their step. You can see it. Some say as they’re leaving that singing is so much better than a yoga or gym workout.�

“The most thrilling thing for me has been IPX 8"40 IBT EFWFMPQFE o UIF XBZ JU plays and equally how the audience has changed. There’s a palpable liveliness in the way Perth audiences approach the music and the kinds of events they will go to.�

Verdi’s Requiem is a massive work but Marilyn says it is not as difficult to sing as TPNF PUIFS XPSLT DJUJOH MBTU ZFBS T #SBIN T Requiem, performed to wild acclaim in Perth under Simone Young and then in )POH ,POH VOEFS %VUDI NBFTUSP +BBQ WBO Zweden, as a monster.

“The orchestra has expanded its reach in the number of places it plays, the way it plays, the way we present the concerts and UIF BVEJFODF IBT CPVHIU JOUP UIBU 8F WF JODMVEFE NPSF VOVTVBM SFQFSUPJSF more contemporary repertoire made more risky program choices combining pieces that wouldn’t normally be combined in the past. It has been great fun to plan these things but you need an audience that is going to follow you, and Perth audiences have.�

i*O UIF TFDPOE QFSGPSNBODF JO )POH ,POH especially, the chorus sang wonderfully. It was amazing. The Chorus worked so hard GPS UIPTF #SBINT DPODFSUT CPUI IPNF BOE

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Paul has led the orchestra for the past five years and says his experiences have been exciting.

“An orchestra takes complex planning but it’s a business, players are contracted, but the Chorus is different. Their commitment to sing means carving out time from their work and family lives is massive and we shouldn’t take it lightly. The Chorus may be amateur but, goodness, if you asked me to fit in something so completely different from my job as a conductor and do it at B IJHI MFWFM JT B IVHF VOEFSUBLJOH 'PS every singer in the chorus to perform at a level we expect of them is like having two professions. I admire them so much.� “I and the Orchestra love having them there. Not every symphonic chorus is as good or as interested as this one. It is central to my belief of what a musical community should be.� O

By Ms Jan Hallam

WIN To win tickets to Verdi’s Requiem next NPOUI 4FF UIF $PNQFUJUJPOT 1

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Theatre

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Brief but Brilliant

Encounter First it was a play, then it shone on the silver screen and now it’s been creatively ‘mashed-up’ as an off-beat musical. Brief Encounter, adapted by Cornwall’s Kneehigh Theatre, is heading to the Regal Theratre in late November. Noel Coward’s play, Still Life and its rebadged screenplay for the 1945 ďŹ lm, Brief Encounter tells the story of an impossible, brief and wonderfully human love affair set in a railway cafĂŠ. London’s Daily Telegraph describes the current production as ‘a ďŹ rst class return to romance’. Perth audiences now have their chance to share the love. .FEJDBM 'PSVN TQPLF XJUI ,OFFIJHI EJSFDUPS Emma Rice who outlined the genesis of the show. “I’d seen the film as a child and it certainly made an impression on me because, much later on, I knew I wanted to do it. And, as I usually do, instead of going straight to the centre of an idea I circled around the outside. I started listening to Noel Coward songs and reading some of his poetry and I was absolutely knocked out!â€?

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“He was writing dirty, bawdy ditties and turning out these erudite plays at the same time. And I thought, I’m going to use all of that. I’m going to put the songs in, add bits of poetry and mash the whole thing up!� It was sheer chance that led Emma and ,OFFIJHI UP #SJFG &ODPVOUFS in the first place. As Emma told an interviewer in New York ‘the play chose me, not the other way BSPVOE " #SJUJTI QSPEVDFS IBE BTLFE IFS if she’d like to put on 1FUFS 1BO and Emma declined. As she turned to leave she spotted a DVD of #SJFG &ODPVOUFS and said, ‘if you’d asked me to do that I’d have said yes.’ And that’s where it started. “It’s got something I wish I could bottle because it speaks to people on a universal level. And it can be risky mashing around B XFMM LOPXO BOE NVDI MPWFE QSPEVDUJPO Sometimes people don’t like that but, without exception, it’s been really well received and that includes London and New York.� “It’s not a parody, so anyone who loved the original will enjoy this show because it’s got the same heart and soul at its very centre.� &NNB BOE ,OFFIJHI 5IFBUSF BSF XFMM LOPXO

for ‘tweaking’ the canon in their productions. *O UIFZ CSPVHIU 3FE 4IPFT to the Perth *OUFSOBUJPOBM "SUT 'FTUJWBM BOE SFDFJWFE SBWF reviews. They punch far above their weight from their local base in Cornwall and the (VBSEJBO describes them as ‘putting the soul back into storytelling in the theatre.’ “Essentially we’re storytellers and I love UFMMJOH B TUPSZ 8F UBML BCPVU UIBU BTQFDU BT a company and if it grabs the interest of my colleagues we’ll go ahead and make a show. You just have to hope that the public will be interested too.� “#SJFG &ODPVOUFS is a lightly drawn piece and I didn’t want to wrench it out of its time. It sits gently but it’s also full of surprises. I certainly IBWFO U EPOF BOZUIJOH QVOL SPDL XJUI JU w O

By Mr Peter McClelland

WIN To win tickets to #SJFG &ODPVOUFS at the Regal Theatre, Subiaco, see Competitions page opposite.

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Competitions

Entering Medical Forum's COMPETITIONS is easy!

Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' MJOL CFMPX UIF NBHB[JOF DPWFS PO UIF MFGU

Movie: Rooftop Movies .FEJDBM 'PSVN readers have the chance to win double QBTTFT UP 3PPGUPQ .PWJFT UIF QPQVMBS QPQ VQ DJOFNB JO /PSUICSJEHF 8JUI PME TDIPPM HFNT DJOFQIJMF DMBTTJDT BOE cult and arthouse movies thrown in alongside blockbuster new releases, there’s something for everyone. Rooftop Movies is located on the open air, sixth floor of the Roe Street car park in Northbridge with the city skyline as a back drop. www.rooftopmovies.com.au. Season runs, October 31-mid April 2014

Movie: The Secret Life of Walter Mitty Movie: Chinese Puzzle 'JSTU JU XBT #BSDFMPOB GPS 5IF 4QBOJTI "QBSUNFOU, then -POEPO BOE 4U 1FUFSTCVSH GPS 3VTTJBO %PMMT, and now eight ZFBST MBUFS $Ă?ESJD ,MBQJTDI UBLFT IJT DIBSBDUFST UP /FX :PSL City and Paris. They are little greyer, have kids but the story is as compelling as ever. This third opus will give Romain Duris, "VESFZ 5BVUPV $Ă?DJMF EF 'SBODF BOE ,FMMZ 3FJMMZ UIF DIBODF to meet again. In cinemas, December 12

Theatre: Brief Encounter 6, CBTFE ,OFFIJHI 5IFBUSFhT #SPBEXBZ BOE 8FTU &OE IJU Brief Encounter, will take you back to a bygone era of the silver screen with its classic NoÍl Coward tale. The stage show seamlessly switches between theatre, song, and black and white film footage on a giant screen, drawing its inspiration from Coward’s original stage play 4UJMM -JGF BOE %BWJE -FBO T DMBTTJD GJMN #SJFG &ODPVOUFS which starred Trevor Howard and Celia Johnson. Regal Theatre, November 28, Season runs until December 1

Music: Verdi’s Requiem 7FSEJ T TQFDUBDVMBS 3FRVJFN QFSGPSNFE CZ UIF 8FTU "VTUSBMJBO 4ZNQIPOZ 0SDIFTUSB BOE UIF WPJDF 8"40 $IPSVT XJMM BMTP CF UIF GBSFXFMM HBMB GPS UIF Principal Conductor Paul Daniel. A superb cast of solo ists include Daria Masiero, Milijana Nikolic and Perth’s own bass baritone James Clayton. Perth Concert Hall, December 6 and 7

#FO 4UJMMFS EJSFDUT BOE TUBST JO +BNFT 5IVSCFShT DMBTTJD TUPSZ PG B EBZ ESFBNFS XIP FTDBQFT IJT anonymous life by disappearing into a world of fantasies filled with heroism, romance and action. 8IFO IJT KPC BOE UIBU PG IJT DP XPSLFS ,SJTUFO 8JJH BSF UISFBUFOFE 8BMUFS UBLFT BDUJPO JO UIF SFBM world embarking on a global journey that turns into an adventure more extraordinary than anything he could have ever imagined. In cinemas, December 26

Winner Doctors Dozen Swooping Magpie

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CLINICAL SERVICES DIRECTORY

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GPs Wanted - South Metro Multicultural Health Clinic (Belmont, 39 Belvidere Street )

*HQHURXV KRXUO\ UDWHV )OH[LEOH ZRUNLQJ KRXUV &OLQLFDO DQG QXUVLQJ VWDII VXSSRUW 0RGHUQ ZHOO HTXLSSHG IDFLOLWLHV )XOO\ FRPSXWHULVHG

GPs Wanted - GP After Hours Clinics in Belmont, Armadale and Rockingham

*HQHURXV KRXUO\ UDWHV 0RGHUQ ZHOO HTXLSSHG IDFLOLWLHV )XOO\ FRPSXWHUL]HG DQG DFFUHGLWHG FOLQLFV 3ULYDWH DQG %XON %LOOLQJ RSWLRQV &OHULFDO DQG QXUVLQJ VWDII VXSSRUW For more information contact Liz Williams at 08 6253 2100 or l.williams@baml.com.au

Exciting E xci citi ting ng gG GP P Op O Opportunitiesppo port rtunitiesSubiaco Subi Su biaco biac

Are you a VR General Practitionerr looking for a new challenge in the heart of Subiaco? St Francis Medical is a brand new, purpose built, privately owned General Practice. Benefits: Highly experienced Nursing and Admin Team Fully computerised and paperless office, with full IT support Walking distance to public transport, key hospitals and allied health Onsite Pathology 5 consulting rooms, including a 2 bed treatment room Parking Provided Opportunities: Full and part time opportunities are available Welcome bonus available for extended commitments

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For a confidential discussion, pleas please contact Kerry ease ec co contac ontact tact Ke K rry ry on 0455 368 793

ARE YOU READY FOR A CHANGE? We are looking for specialists and GP’s to join the expanding team! Tenancy and room options available for specialist’s. Procedural GP’s and office based GP’s well catered for. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

N O V E M B E R 2013NOVEMBER 2013 - next deadline 12md Tuesday 12th November - Tel 9203 5222 or jen@mforum.com.au medic alFORUMwa

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CLINICAL SERVICES DIRECTORY

78

URBAN POSITIONS VACANT

Are you wanting to sell your medical practice?

SPEARWOOD GP required full time/part time at busy accredited private billing surgery South of Fremantle. Well establish, non-corp practice with immediate patient base. Nurse support. Onsite pathology. Hours and Terms negotiable. Contact C Lacey 0419 937 496 or Email: cmc@cmcentre.com.au

As WA’s only specialised medical business broker we have sold many medical practices to qualified buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible.

To find out what your practice is worth , call:

Brad Potter on 0411 185 006

We are committed to maintaining confidentiality. You will enjoy the benefit of our negotiating skills.

FOR LEASE SOUTH FREMANTLE

We’ll take care of all the paper work to ensure a smooth transition.

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Consulting Rooms available in prestigious South Freo location. t

Conveniently located on South Tce, just a few hundred yards from Fremantle Hospital.

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Interested medical/allied health practitioners seeking consulting rooms with reception facilities for full occupancy or one or more days per week are encouraged to apply. Attractive sub-letting arrangements available for a furnished or unfurnished room with onsite parking.

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Room available March, 2014, but other day occupancy arrangements now available.

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Two senior Clinical Psychologists run a well-established practice here consulting to adults, adolescents and children.

p: Administrator Jodee on 9433 6002 e: reception@fremantleclinicalpsychology.com.au w: www.fremantleclinicalpsychology.com.au

Ph: 9315 2599 www.thehealthlinc.com.au

85% take home,

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

Equipment Provided - WADMS is a Doctors’ cooperative Essential qualifications: s General medical registration. s Minimum of two years post-graduate experience. s Accident and Emergency, Paediatrics & some GP experience. så så så så

Fee for service (low commission).så Non VR access to VR rebates. 8-9hr shifts, day or night. så Bonus incentives paid. 24hr Home visiting services. så Interesting work environment. Access to Provider numbers.

Supplement your income: Are you working towards the RACGP? – we have access to provider number for After Hours work. Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.

Contact Trudy Mailey at WADMS

(08) 9321 9133

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

Jandakot

CVS locations include: Joondalup, Karrinyup, Nedlands, Midland, Mt Lawley, Leeming, East Fremantle, Rockingham and now Mandurah.

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Half-time position in Jandakot for an experienced GP to oversee development of multidisciplinary GP clinics provided to remote communities by RFDS from Derby, Port Hedland, Kalgoorlie and Meekatharra. Key priorities include e-health, quality improvement and chronic disease management systems. This role would be ideal for a GP who will support hard-working colleagues in practical ways and is ready to develop leadership and management skills. Hours are flexible to enable the successful applicant to maintain clinical sessions in Perth or remote FIFO. Phone: 9417 6393 Email: medical@rfdswa.com.au

medic alFORUMwa NOVEMBER 2013 - next deadline 12md Tuesday 12th November - Tel 9203 5222 or jen@mforum.com.auN O V E M B E R 2013

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Are you a general practitioner looking for a tree and sea change opportunity? A fantastic opportunity is available for a general practitioner who would like to operate their own practice and have time to enjoy the beautiful surrounds of this wonderful location. Walpole, located in the beautiful south west, is a small inclusive and supportive rural community surrounded by stunning national parks and peaceful inlets. Servicing a permanent population of around 700, the practice would operate three days per week, providing plenty of time to enjoy the relaxed lifestyle. The GP Clinic is located within a community health facility. Equipment, practice support and housing may be provided by negotiation.

If you are interested in this unique opportunity contact Rural Health Select today! E recruit@ruralhealthselect.com.au T 08 6389 4500 W www.ruralhealthselect.com.au

N O V E M B E R 2013NOVEMBER 2013 - next deadline 12md Tuesday 12th November - Tel 9203 5222 or jen@mforum.com.au medic alFORUMwa

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CLINICAL SERVICES DIRECTORY

For Sale Opposite Bentley Hospital There are plenty of options with these three properties. Either move right in, refurbish, extend, or redevelop. The choice is yours. Located directly opposite the Bentley Hospital they present an outstanding opportunity to establish a medical practice or allied health service. Total land area is 3,483m2 with large frontages to both Mills & Doust Street. The individual lot details: 21 Mills Street – 1,449m2 *NQSPWFNFOUT JODMVEF DPNNFSDJBM PGžDFT PG N2 DBS CBZT VOEFSDPWFS

23 Mills Street - 1,063m2 %FWFMPQNFOU TJUF XJUI QPUFOUJBM DPNNFSDJBM VTF 45$" 25 Mills Street – 971m2 Purpose built consulting/treatment rooms with ample parking

Offers invited. For brochure and further details phone Jason Hughston on 9473 7777 or 0408 902 907 jhughston.victoriapark@ljh.com.au

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medic alFORUMwa NOVEMBER 2013 - next deadline 12md Tuesday 12th November - Tel 9203 5222 or jen@mforum.com.auN O V E M B E R 2013

CRICOS Provider Code 00126G

Are you a GP? Would you like to teach the next generation of WA doctors? In 2014 The University of Western Australia, the State’s only World Top 100 University, is launching the Doctor of Medicine (MD) postgraduate degree course, replacing the Bachelor of Medicine and Bachelor of Surgery (MB BS). Our Faculty of Medicine, Dentistry and Health Sciences is seeking GPs for 2014 onwards to teach medical students in General Practice. These Adjunct Clinical Senior Lecturer positions offer: s s s s s

regular or casual sessions; $120 per hour paid training sessions and all teaching materials small group tutorials for case-based learning and clinical methods eligibility for 40 Category 1 CPD points your choice of work day(s)

Email expressions of interest by Friday 22 November to Kim Rustidge at kim.rustidge@uwa.edu.au, or for more information phone 9346 2621.

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...come to the Sunshine Coast ar from Friday March 14th to an s Sunday 16th March 2014 and discover ing Cha inn mpio why your GP colleagues have given such a w nship d ar 18 h positive thumbs-up for past Bp Summit conferences. Aw ole g olf c For the biggest and best Bp Summit yet – we’ve lined ours e up one of Australia’s finest conference venues at one of Australia’s most attractive resorts – all under the same roof and conveniently accessible from Australian capitals. Novotel Dare to learn the flying trapeze Twin Waters Resort. With eHealth front and centre for the Tours to Fraser Island or Hinterland nation as well as every GP practice as never before, we promise you a wonderful program of speakers, discussion and training at every level. If that’s not enough to get the adrenaline flowing, learning the flying trapeze is just B ring the one of the many diversions for you and your family at kids ; Tw Twin Waters – along with a host of other more in W ater traditional sun, surf and holiday activities. s ha sa S Call, write or email to register your interest kids ai club lo and we’ll send you the full program rk ay and booking details. ak &

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