Medical Forum 10/12

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Career Transplant Lawyer to Rural GP t 250 Drs E-poll: Complaints; Sponsors; Specialisation t Guest Column: Euthanasia t Loyalties for Regions t Spending Money to Make Money?

October 2012 Major Sponsors

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CONTENTS

Major Sponsors

FEATURES

GUEST COLUMNS

6 Legal Eagle to

8 Culture Can Insulate

Medical Intern

from Suicide Professor Pat Dudgeon

9 Having Loyalties

13 Bureaucracy

for Regions

Affects All

12 Making Life Simpler

Dr James Quirke

and Fairer for IMGs

6

21 Wildcats Captain

on the Rebound

NEWS & VIEWS 2 E-poll: Complaints

Against Doctors

25 Links in the Organ

Donation Chain Dr Alan Duncan

35 Dying in a Vaguely

Horrific Society Dr Bertel Bulten

CLINICAL FOCUS

3 Letters: Dr Michael Marsh, Dr Alison Creagh, Dr Philip Noble, Dr Wilson Lim

5 Cardiology Update Dr Stephen Gordon

7 Diabetes and

3 Showing the

Vitamin D

Spirit of Flynn

Dr Paul Glendenning

10 Medical Market Place:

9

You Have to Spend to Make Money? 14 Awards: College

Honours its Hardworking GPs 16 Have You Heard

32 Translational Research:

Child Brain Tumours 37 Refractive Surgery

Choices Dr Graham Furness

39 Musculoskeletal

Machinations WA Dr Rob McEvoy

18 E-poll: Pharmaceutical

Sponsorship

40 Renal Vascular Access Dr Rob McEvoy

19 E-poll: GPs

who Choose to Subspecialise

LIFESTYLE 42 Doctors of the Deep

23 Beneath the Drapes 26 College News:

12

Elections to Exams – RACGP goes online 28 Referrals on Demand? 29 Prostate Awareness 30 Imagining Imaging

Mr Peter McClelland

44 Perfect – Above and

Below the Water 45 Wine Review:

Glen Eldon Dr Louis Papaelias

46 Culture: Of earth &

sky & Love

31 Medico-Legal: MIAA

Ms Jan Hallam

in Perspective

47 Car Review: More

than a Pretty Face Dr Mike Civil MEDIC RUM AL FO

48 Photography r Caree t plan s n a r T P ural G

r to R Lawye

nts; mplai poll: Co lisation Drs Eecia t 250 rs; Sp asia an Sponso th mn: Eu ons st Colu r Regi t Gue ties fo ey t Loyal g Mon in nd ? t Spe Money e ak to M

21 COVER: Dr Louisa Case: courtesy Health Department of WA.

OCTO

12 ber 20 $10.50 Octo om.au forum.c

Competition: Ready for Action 48 Strike up the Band 49 Funny Side 50 Tim Lawson's Dream Mr Peter McClelland

51 Competitions & Winners

012 BER 2

ww w.m

Spo Major

medicalforum

nsors

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PUBLISHERS 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 2 Thinking Hats

E-poll

Complaints Against Doctors Communities are short of doctors. As the medical workforce ages, keeping more experienced, older doctors working for as long as usefully possible seems a good idea. Those nearing retirement may face proportionally more complaints and registration dilemmas. Will they simply ‘exit right’ because it’s all too hard? CPD and credentialing requirements vary for the doctor winding back, depending on their past experience and whether they want to do bush locums or suchlike. Becoming a professor is trendy but registration for academics cutting back clinical practice still poses questions. Because a complaint could be ‘the straw that broke the camel’s back’ we asked doctors (E-poll – see below) what they considered were indicators of fairness in handling complaints between health professionals, assuming this would filter out vexatious complaints. (We have since learnt that doctors may be more ready to complain about impaired doctors than those showing possible incompetence. Either way, AHPRA takes these complaints more seriously.) Interestingly, doctors seem to suggest our investigators need some credentialing of their own, and they should be quick on their feet in determining if a complaint has merit. But should these investigators be lawyers, doctors or someone else?

has $25m at its disposal from registrations of all health disciplines to fund its activities. Early determination of a complaint's merits and the settling of low-level complaints early through mediation, were priorities for our polled WA GPs, specialists and trainees. Most of the approved medical board panellists from WA, appointed anonymously to adjudicate on matters, were transitioned from the old system to sit on either a Health Panel or Performance & Professional Standards Panel. It is AHPRA staff who choose suitable panellists to hear a matter, subject to availability, their expertise and declared conflicts of interest. Panellists from interstate are meant to be chosen, presumably to avoid complaints of bias. If you work in a public hospital in WA, response to an internal complaint may appear worse (see letters, this edition). There is a Memorandum of Understanding negotiated between HDWA and the AMA as a guide for handling complaints but there is no requirement for this to be followed. In the interest of fairness, there should be, especially if it means a complaint’s merits can be properly determined at a local level before it goes before more distanced committees and individuals. As an aggrieved HDWA doctor you may not get justice until you eventually take everyone to Court, and no one comes away from that experience a winner. O

This is an important question because indications are that the people involved now are making a meal of it – seemingly taking too long and investigating everything in-depth. More than 80% of AHPRA complaints were found to have no merit, according to the last annual report, something that is reflected in our MDOs fielding a steep rise in member requests for assistance. Is the public interest better served by this new system? Are state-based medical boards, still thriving since we went national, being handed poorly worked-up cases by AHPRA for panel hearings? AHPRA now

E-POLL: Fairness in Handling Complaints A total of 250 doctors offered opinions - GPs 43%, Specialists 37%, Doctor in Training 14%, and Other 6% See pages 18 and 19 for further E-poll findings.

Q

What do you consider the three most important points that determine fairness in handling complaints, one health professional against another [only 3 choices]?

All GP Spec DIT ______________________________________________________________________________________________ Those investigating are skilled/trained in conducting a fair investigation.

64%

59%

63%

80%

Early assessment of whether a complaint has merit.

58%

66%

52%

46%

Ability to resolve low level complaints early, through mediation.

53%

58%

50%

49%

Complaint dealt with promptly.

51%

45%

58%

51%

Privacy for both parties until complaint progresses to the disciplinary body.

48%

50%

47%

40%

A known, compulsory pathway in dealing with a complaint.

20%

15%

23%

29%

Other point.

1%

1%

0%

0%

ED. The DIT figures, mainly from hospital-based doctors, are likely to apply to HDWA complaints procedures, rather than AHPRA, so the variance in figures (highlighted) gives some idea of their particular concerns. medicalforum

Letters to the Editor

Investigative skills needed Dear Editor, I was interested in a recent article (Who’s Who on Complaints Panel, August edition) regarding the selection of medical personnel who sit on committees such as the Medical Appeal Panel, State Administrative Tribunal, WA Division of APRHA etc. My interest stems from experiences with the Department of Health (HDWA) and the Medical Board since 1993, and the failure of HDWA to investigate both the truthfulness of complaints and the surgical outcomes of patients identified in those complaints As I understand it, ‘experienced’ senior medical practitioners are nominated for these positions and are subsequently endorsed by ‘the powers that be’. They may well be respected leaders in their particular field of medical expertise but this does not automatically imply they are skilled in complaint resolution. There does not appear to be any scrutiny of their investigative skills, training or expertise in the forensic area of medicolegal practice before appointment, or afterwards a mechanism for assessing their performance, a process enshrined in CPD for all medical practitioners no matter what their specific field. Responses from the Crime and Corruption Commission on appointment of investigators, revealed individuals are selected for this commission on the basis they are well trained, experienced and skilled in such matters under investigation, and have a good performance record in their workplace. Sadly such scrutiny appears lacking in the nomination and acceptance of appointees to these HDWA committees.

If errors in natural justice occur, there is no accountability or scrutiny of the investigator or committee responsible for the flawed decisions that either compromises or destroys a medical practitioner's career and livelihood. The response to questions when injustice occurs, is the decision was made in the "public interest", an explanation for apparent flaws in the investigative process.

The investigator’s responsibility is to carry out a detailed and competent investigation and make sure all procedural steps are followed because of the possibility of personal bias or malicious intent. Failure to do this can be catastrophic for the accused. An independent supervisor should be appointed to ensure all steps in the regulations have been carefully followed in the investigation, before the final decision is announced.

What is even more surprising in such matters of injustice is that any attempt to have the case reopened to carry out a detailed examination of all the charges in the original complaint is refused by the particular government authority, even when evidence is readily available of good outcomes and patient satisfaction. Reasons given are that it is unnecessary, or adequate opportunity has been allowed for the defendant to put his or her case. The authorities are aware of the potential for medicolegal action against them if the decision is overturned and the prohibitive costs to the defendant of civil court action.

Currently these safeguards do not exist, and in cases where a sole investigator is appointed, the medical practitioner under investigation is at risk. The gold standard, particularly for a proceduralist, must always be patient outcomes, not accusations that complainants make.

Truthful accusations or complaints are confirmed by a detailed investigation and analysis of all relevant issues identified leading up to the complaint. It is important ALL evidence and documentation relevant to the case be thoroughly examined – patient notes (public and private), medical or surgical outcomes, patient testimonies, opinions of colleagues present at the time of an incident, opinions of colleagues regarding case management outcomes, etc. Failure to do this will increase the risk of faulty conclusions and a miscarriage of justice. False complaints or accusations are opinions not grounded in factual evidence. There appears to be a belief among inexperienced appointees to these committees, that all complaints are genuine and there are no individuals in our communities with abnormal behaviours.

There should be a mechanism to ensure all appointees understand their legal responsibilities in accepting positions on these committees or boards, and they should be professionally trained to ensure there is a high standard of investigative skills before being nominated and appointed to these positions. Since the Patel case at Bundaberg Hospital, complainants are causing disruption in the delivery of health care to public patients, using the AIMS or non AIMS process, initially bypassing the vital preliminary steps of the Memorandum of Understanding (MOU) for medical practitioners, as drawn up by the AMA and Department of Health. Dr Michael Marsh, Consultant General Surgeon ED. To clarify, Dr Marsh is referring to the internal investigation conducted by the Health Department. He told us a satisfactory response came only after later referral of the matter to the Medical Board. More letters next page

Showing the Spirit of Flynn The work of RFDS Flight Nursing Coordinator Paul Ingram was recognised recently with a Spirit of Flynn award. Paul has worked for RFDS for more than 14 years and his passion shows no sign of dimming. “Every day is different. You never really know what’s going to be at the other end of a call-out. One morning I went out to pick up a 23-week premature baby who weighed about 500g and was about the same size as a margarine container. The next patient we picked up was 150kg!” medicalforum

About 40 doctors, 50 pilots and about the same number of flight nurses work at RFDS Jandakot. “A flight nurse goes on every single flight and as a coordinator I often have to get them out in the middle of the night or dent their weekends. We’re much busier now with the boom up north and a lot of regional hospitals are sending more patients to Perth than they used to.” O

Q Flight Nurse Coordinator Paul Ingram with RFDS CEO Grahame Marshall. 3

Letters to the Editor

Guideline Clarification Dear Editor, I thought it would be helpful to clarify one of the changes to recent contraceptive guidelines. It is now acceptable for women with a current or past venous thromboembolism to use: t "OZ QSPHFTUPHFO POMZ NFUIPE (progestogen only pills, implants, injections and emergency contraception). t *6%T CPUI DPQQFS BOE QSPHFTUPHFO containing. t #BSSJFST BOE GFSUJMJUZ BXBSFOFTT The only methods contra-indicated for these women are the combined hormonal ones: combined pills, and combined vaginal rings. Dr Alison Creagh, Medical Educator, FPWA Sexual Health Services

Sour taste of PCEHR Dear Editor, I have just read where A/Prof Julian Rait, President MDA National, says that "the PCEHR'S capability for patients to add to, delete, or deliberately withhold aspects of their medical conditions or treatments from the PCEHR could lead to patient harm" (Letters, September edition).

4

Just consider if someone could come into your surgery at night and delete, add or otherwise compromise your records, would you still trust them to make rational treatment decisions based on those records? If the answer to that question is no, then you should not have anything to do with PCEHR and if the Government is going to take away PIP payments, so be it. I would not be giving the green light to shonky records if I was a MDO. We are continually being told "complete accurate notes are our best defence" so how is it that the MDO is suddenly tossing that advice to the wind. If it looks like a lemon, smells like a lemon and tastes like a lemon, then it is probably a lemon, unless is it a white elephant? Dr Philip Noble, Cockburn Central

Where’s the evidence? Dear Editor, I wish to comment and add to Dr Borshoff's article (Operating to Stop the Waste, August 2012). I am a specialist anaesthetist and over the years I have noticed the steady encroachment of more and more rules and protocols in the name of infection control and occupation safety and health into our working environment. They are, more often than not, promulgated by people who do not actively work in the theatres. Often, they do not seem to be evidence based.

The process has been hijacked by zealots. It has taken on a quasi-religious bent so that after the declaration of a change in the name of improving patient or staff safety, anyone who questions the change is deemed to be a heretic. All anaethetists will be familiar with the ritual of wiping down the operating table with “handy wipes� after each case. There is also the mopping of the floors, even in clean cases such as ophthalmology procedures. No one has shown me any good evidence that it makes a difference in clean cases. Where are the trials? Perversely, the floors are now wet so staff run the risk of slipping. Is it necessary for all equipment that comes into contact with a patient to be single use? Does single use really reduce cross infection rates? I am sure that GP treatment rooms do not have the same standards as operating theatres. Do they have vastly increased infection rates? Should these stringent procedures be reserved for the vulnerable such as the immune-suppressed? When people are appointed to infection control or occupation safety and health positions to change things, one can expect them to change things. After all, it is in their job description. All I ask is for the changes to be evidence-based because ultimately, any changes will invariably increase the cost of treatment as well as adversely affect the environment. They also increase the workload for the staff. It is all very frustrating. Dr Wilson Lim, Gelorup

medicalforum

Cardiology Update Updating statins Early this year the FDA in the US updated changes in statin labelling. They addressed three issues. Firstly, there was recognition that statins increased the risk of diabetes and increase HBA1c levels. This has been demonstrated in several clinical studies and any concern regarding adverse effects associated with increased blood sugar are far outweighed by the benefits of statins in terms of cardiac and stroke morbidity and mortality. Secondly, there was recognition that statins carry increased risk of cognitive side-effects but indicated that these were usually minor and reversible, with effects most likely on memory function. There is no indication that this means dementia. Thirdly, they indicated that routine testing of liver function was no longer required as a routine in statin patients

given that serious liver dysfunction was rare and generally unpredictable.

Measuring BP in both arms A recent meta-analysis has indicated that a BP difference of greater than 15mm between arms is associated with a marked increase in vascular risk and mortality. This generally is an indicator of subclinical obstructive vascular disease in the subclavian artery system and an indication for further investigation.

Aspirin in primary prevention While the benefits of Aspirin in secondary prevention are well proven, the place of Aspirin in primary prevention has become highly controversial with many recent studies and meta-analysis suggesting that the bleeding risks associated with Aspirin therapy may outweigh any benefits associated with reduction in vascular events.

Dr Stephen Gordon, MBBS, FRACP, FCSANZ, FCANZ Interventional Cardiologist

About the author Stephen Gordon is a graduate in medicine from the University of Western Australia and trained in Cardiology at Sir Charles Gairdner Hospital and subsequently at the Beth Israel Hospital, Harvard Medical School, Boston. Practising in all areas of adult cardiology, Stephen performs cardiac catheterisation, trans-oesophageal echo and has a special interest in echocardiography. He has private practice locations with Western Cardiology at St John of God Health Care Subiaco and Sanori House, Joondalup and Mirrabooka.

Further studies are required, until then Aspirin is not recommended in the majority of primary prevention patients except perhaps those in very high risk categories.

Update on new oral anticoagulants Dabigatran has been available on private prescription and a familiarisation program since last year. A second agent, Rivaroxaban is progressively becoming available on a familiarisation program. Both these agents do not require blood monitoring or dosage adjustment and have very few drug or food interactions. The main concern with these newer agents continues to be the lack of a specific antidote in patients with acute haemorrhage. Severe renal dysfunction remains a contra-indication for both agents and moderate renal dysfunction an indication for caution and dosage modification.

Fish oil and coronary heart disease Despite its popularity, the place of fish oil in primary prevention remains unproven. A recent large study in diabetic patients suggested no benefits. In secondary prevention one large post MI trial indicated a benefit for Omacor which is a highly purified and highly concentrated formulation of fish oil available on private prescription. Standard formulations of fish oil have not yet shown benefits in secondary prevention. Further studies in both primary and secondary prevention are ongoing.

medicalforum

5

Spotlight

Legal Eagle to Medical Intern Dr Louisa Case stepped away from a career as a lawyer to become a doctor. It took courage, commitment and a dose of self-refection. A surgery term as a first year resident at Fremantle Hospital is a long way from heading up the legal department at UWA. To move from a senior position within a prestigious academic environment to one with a long and looming learning curve takes a great deal of courage. And the public perception of the medical professional, with its perceived status and social esteem, raises the bar even higher. Becoming a doctor has been a long-standing desire for Louisa Case that stretches right back to high-school. The opportunity didn’t present itself then but the thought never left her until a few years ago when she decided to act on it. “It was difficult to leave UWA, it was a great job and I enjoyed the contact with students and staff. It was a senior position and I had a great deal of autonomy. It’s quite daunting moving from a position of authority to one where you’re just beginning a new career and everyone else knows more than you do. And that means everyone from nurse assistants to ward clerks and even some of the patients. There’s a lot attached to the title of ‘doctor’ and it’s seen by the wider community as an important position,” Louisa said. This month’s E-poll reveals some interesting opinions on professional ‘musical chairs’. There was a slight weighting towards the medicine to law transition but an even stronger response that there would be ‘no difference either way’. In Louisa’s case the outcome has been spectacularly successful. Acquiring new skills and knowledge can be demanding but there’s often an emotional component too. WA’s medical schools have acknowledged this and are encouraging an open and compassionate approach to some of medicine’s more demanding clinical scenarios. “It is difficult at times to separate yourself from your patients, emotionally. However, senior doctors have told me that as your medical career progresses you’re able to put this sort of thing to one side a little more easily. Nonetheless, I think it’s important to be able to grieve with a patient, particularly if it’s been a long-term clinical relationship. When someone’s very ill they’re looking to you for support and empathy. At medical school we’re taught that it’s OK to shed a few tears and that’s a big change compared with how things used to be.” 6

Q Dr Louisa Case who after a successful career as a lawyer is preparing to embark on her rural stint with her husband and two young children.

“I think there are distinct overlaps between medicine and law. A good practitioner will have a people-centred approach and the best medicine occurs when you have a holistic view of a patient. It’s important to acknowledge how they’re feeling and their family situation. All these things have a huge impact on an individual and the best doctors and lawyers take those factors into account.” Louisa is on a Rural Medical Bonded Scholarship, which is worth about $22,000 a year. And next year will see her at Bunbury and Karratha Hospitals fulfilling some of the requirements for rural GP training. “The Federal Government offers the scholarships and they’re an amazing help during medical school. The scholarship doesn’t cover your HECS fees but it certainly helps with living expenses (especially with two young children)." "When you have finished your specialty training, you have a ‘return of service’ obligation of six years in a rural or remote area. It’s a formal agreement and you won’t get a provider number unless you fulfil the contract but it’s a win-win situation for yourself and the rural communities in Australia.” “The ‘cradle to the grave’ aspect of being a rural GP really appeals to me. I know we live in a world of 15 minute Medicare appointments but continuity of care and a sense of empathy are so important. When people tell me they’ve got a great GP I say, ‘stay with them’.” As the more antiquated gender stereotypes are gradually being broken down and the ratio of male-to-female medical students

tipping in favour of the latter, Louisa has some interesting thoughts on gender balance. “Gender is still an issue even though some people would like to think it’s not. In areas such as surgery it’s still very male dominated. In fact I’m on a seven-person surgical team now and I’m the only female. It’ll be interesting to look at this in 10 years’ time.” She’s the first to recognise that her matureage career move embraces some tricky moments and acknowledges the important part played by her family. “Sometimes I start early and don’t see the children before I leave and then I’m just hoping I’ll be home before they go to bed. It’s a compromise between establishing a career and wanting to be there for the children. It involves sacrifice by the whole family. It’s not easy starting a medical career later in life especially with a young family and I certainly couldn’t do this without my husband’s support.” O

By Mr Peter McClelland

E-POLL: Career Transition Medical Forum asked GPs, specialist and doctors in training in our latest E-Poll what they thought would be the easiest transition between the professions of medicine and law. Transition from law to medicine. Transition from medicine to law. No difference either way. Neither – get another job! Uncertain

16% 22% 35% 8% 18%

medicalforum

Diabetes and vitamin D

By Dr Paul Glendenning, Consultant Endocrinologist and Chemical Pathologist

R

ecent interest in vitamin D metabolism has been fuelled by the increasing prevalence of deficiency worldwide, and vitamin D involvement in a number of ‘non-classical’ modes of action, one of which may be relevant to diabetes. Vitamin D’s action is probably more complex than initially realised and the observed inverse association between vitamin D status and diabetes deserves review.

The classical view Vitamin D is a hormone synthesised by sunlight action on the skin. In this respect, ‘vitamin D’ is a misnomer as a true vitamin compound cannot be synthesised in sufficient quantities and must be obtained from the diet. In contrast, vitamin D can be fully synthesised by the skin before being metabolised to its active form in the body, thus allowing it to exert its appropriate action. Where there is vitamin D deficiency, replacement can be achieved with supplements. Although vitamin D is present in a few foods, the quantities are insufficient to address the body’s requirements and usually account for <10% of the total measured quantity. The classical mode of action for vitamin D is to increase calcium absorption from the gut, indirectly controlling calcium loss by the kidney and, as a consequence, exerting an indirect as well as a direct effect on preserving calcium stores within bone. Loss of bone calcium stores results in Rickets in children and Osteomalacia or Osteoporosis in adults, depending on the degree of calcium loss. While this ‘endocrine’ role of vitamin D (synthesis in one organ and action in another) is well accepted and accounts for the research interests of endocrinologists, vitamin D has more recently been studied because of its non-classical mode of action.

Non-classical mode of action Vitamin D receptors are present in most cells and not just the gut, kidney and bone. Vitamin D can be synthesised in these

cells, including pancreatic cells, since the appropriate cellular machinery is locally present. As a consequence, vitamin D can exert effects in an autocrine or paracrine fashion depending on whether cells synthesising vitamin D, or other cells nearby, are targeted. It is these local effects of vitamin D that have attracted great interest recently. Vitamin D levels, based on either dietary supplement doses or direct measurement of total body stores as indicated by a specific metabolite (25 hydroxyvitamin D; 25OHD), has been inversely associated with the development of type 2 diabetes. That is, the prevalence of type 2 diabetes increases as the level of vitamin D supplementation or the measurement of 25OHD declines. It is biologically plausible that vitamin D may affect diabetes as this hormone is involved in pancreatic cell function and modulates sensitivity to insulin action. In one study, the Women’s Health study, an intake of vitamin D above 511 international units (IU)/day was associated with a 27% lowering in risk of diabetes compared with an intake of <159 IU/day. A similar magnitude of reduction was also seen in the Nurse’s Health Study. Other observational studies have found similar potential beneficial effects of vitamin D on diabetes incidence.

Comment on studies However, this observational data must be assessed cautiously as confounding factors may not have been accounted for in these analyses. For example, vitamin D status may be a marker of health. Ill health could limit outside activity and as a consequence sunlight exposure so vitamin D levels in the body decline. A single measurement of vitamin D in the blood may not be an accurate reflection of vitamin D status over a longer period of time. This is relevant,

as risk factors for vitamin D deficiency (age, activity levels, body weight etc) often increase over time. Furthermore, the outcome of some studies may depend on self-report or review of medical records which could be inaccurate. Randomised clinical trials are less likely to be biased by the factors listed above. However, most studies have shown no effect on glucose control if there is normal glucose tolerance at the commencement of the study or conflicting effects if glucose intolerance is present at the beginning of the study. In patients with type 2 diabetes at baseline, the effect of vitamin D has been equally conflicting, with only one study demonstrating a potential beneficial effect.

Conclusion The biological plausibility of vitamin D affecting type 2 diabetes prevalence is acceptable, the observational data suggesting a relationship is more compelling, yet randomised clinical trial outcomes are disappointing. Based on the overall data, it is premature to measure 25OHD in patients either at risk or already diagnosed with diabetes. It is also too early to determine if routine supplementation of patients could prevent the development or progression of diabetes. However, in patients with symptoms suggestive of vitamin D deficiency or a history of falls or fractures, the assessment of 25OHD continues to be recommended. References available on request

Guest Column

Culture Can Insulate from Suicide Professor Pat Dudgeon, Dr Tom Calma and Adele Cox have been developing a national Indigenous Suicide Prevention Strategy.

T

he Australian Bureau of Statistics’ latest data on suicide rates in Australia, not surprisingly, indicates figures for Aboriginal and Torres Strait Islanders were almost twice that for other Australians. For many of us working in the area and who are part of the community, it feels as if the rate is much more. We know many families that have lost members to suicide. Aboriginal and Torres Strait Islander people have suffered through the effects of colonisation and dispossession. The transgenerational effects of the policies of forced removal of children on Aboriginal emotional and social wellbeing are profound and enduring. Many of the current issues faced by Aboriginal people today are the result of past practices and loss, as well as ongoing racism and discrimination at individual and institutional levels. Suicide is just one of the results. The statistics are appalling but they should not mask the terrible individual, family and community tragedy each event involves. In undertaking any suicide prevention program in Aboriginal communities, two elements are

of utmost importance. Firstly, programs need to be culturally appropriate. The second issue is community engagement leading to ownership of the program from the outset. We found when undertaking to develop a suicide prevention program in the Kimberley, people were eager to talk about what could make their communities stronger and happier. From such consultations emerged rich information that directed our efforts to prevent suicide by working with these communities to develop culturally appropriate empowerment, healing and leadership programs. Much of our work has reflected the work of Prof Michael Chandler, from Canada. His study of First Nation communities found that young people living in communities with a sense of cultural continuity and collective vision were significantly more insulated from suicide. This research demonstrates the importance of culture in constructing the course of Aboriginal identity development, first through young people's emerging sense of ownership of their personal and cultural past, through to their commitment to their personal and community's future wellbeing.

Prof Chandler found in First Nations communities in British Columbia, suicide rates were low when they had achieved a measure of self-government; were pursuing Aboriginal title to traditional lands; promoted women to leadership roles; constructed facilities that preserve their culture; and gained control over their own civic lives, including health, education, policing and child welfare services. These findings are of great interest to Aboriginal people in WA. Prof Chandler’s visit in August was timely. He is well placed to work with us, not just around cultural continuity, but to generate public interest in Aboriginal mental health and wellbeing. He can also help influence government policy, particularly the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy currently in development. O *See Page 46 for Bangarra Dance’s cultural workshops. Declaration: Prof Dudgeon is the director of a grant from the Department of Health and Ageing to undertake a National Indigenous Empowerment Project at UWA.

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Feature

Having Loyalties for Regions He has dispensed millions into regional health, now the Minister for Regional Development Brendon Grylls wants to make cities in the North. health in terms of doctor delivery. Everyone pays the same Medicare levy and not everyone gets the same access to a GP.�

Brendon Grylls grandmother, known simply to her family and community as Ma Grylls, died in her hometown of Corrigin not so long ago. There are two things about that event which inspire the 39-year-old Minister for Regional Development and the state leader of the Nationals – his Ma and that fact that the Wheatbelt town where she lived and raised a family was able to support her during her last days. In a way, it has inspired another focus for the man who has signed billions of dollars of Royalties for Regions cheques in the past 3½ years – $480.27m for health and aged care since February this year, alone. “When Ma was ill, the community embraced her. Her family was there, her friends were there – all these people took a personal interest. That’s where I think governments get it wrong sometimes. We have to measure things in KPIs. I know what the KPIs were for my Ma, and we had some hiccups – there were times when there was no doctor – but it was good to have that experience in an area where I hope to make a difference.â€? “The Southern Inland Health Initiative, (which takes in Corrigin), is a $565m investment in people’s lives.â€? Growing sustainable cities and towns, with family structure and a health system in the North West is now a priority and not the least reason because he is leaving his safe National seat of Central Wheatbelt to contest the Labor-held seat of Pilbara at the state election on March 9 next year. Scepticism aside, the vast North-West booms and busts with the commodity prices and community building has often been left behind in the red dust. “It’s very clear to me that no one has ever really cared about the Pilbara and I am determined to use my role in politics to grow the NW into sustainable communities where families are happily living, working and investing and with grandparents by their side.â€? “Royalties for Regions was built around the Pilbara and it is probably a once in a 100year thing, though we might need 200 years to solve the problems. Regional Queensland has 11 cities with a population of 100,000. In WA we just have Bunbury. Whatever it is, the NW hasn’t been properly developed since 1829 and here’s the chance for the government to work on that.â€? medicalforum

“The Medicare drawdown for someone in Sydney is $500 while the average drawdown from someone living in Kimberley is $50, how is that fair? Why should someone who calls the Kimberley home pay the same Medicare Levy as someone who lives in Sydney?�

I am determined to use my role in politics to grow the NW into sustainable communities where families are happily living, working and investing and with grandparents by their side. “And it’s not just the Pilbara, we must look to expanding the East Kimberley, the Browse Gap precinct north of Broome, the Gascoyne food bowl – most of the Royalties for Regions funding has gone to the NW, as it should.� Developing cities in the north, it seems, will be grey powered, with the Minister’s personal litmus test being the number of grandparents who can be enticed to settle where their children and grandchildren are located. “Grandparents are my new focus, because if you can attract them you have a sustainable community. I have got three young kids under the age of five and I know how much I rely on my parents every single day to be able to do what I do. It must be so difficult for families who move north to function without that family structure. Families drive community development and that’s been left behind.�

The unofficial Northern initiative has already begun with RFR money pouring out. In Karratha, $207.15m is developing a new health campus; $26.1m will go on Kimberley ambulance services; $34.9m to redevelop the Carnarvon Health Campus and Exmouth services; $2.7m for the Broome Mental Health Facility. “We want to grow Port Hedland and Karratha to towns of 50,000 people with land releases and amenities creation to achieve that target. The notion that you’d have a city of 50,000 people and tell them to drive two hours north to get to a hospital just doesn’t cut the mustard. The idea of the previous Labor government that Newman should hub out of Port Hedland four hours away is a sign of why we’re in government now. The north is an important region of WA and the notion that they shouldn’t have a comprehensive health service is offensive.� The sense of urgency in Brendon Grylls could have a lot to do with the looming election. His position as king maker after the last election has given him control over a formidable program and there’s a sense he doesn’t want to waste a minute. “Politics is ‘all, at once’ – my term may finish in March and my opportunity to shape the state will have gone. What I do know is that some of these things are pretty hard to unwind. I’ve been lucky and privileged to be able to shape it.� O

By Ms Jan Hallam

This vision to anchor families relies on being able to drive the cost of living down and sustainable health and education systems.

FACTS: RFR 2012 Health Spend

“The Southern Inland Health Initiative was a revolution. It covers Kalbarri to Esperance and its mission was to be able to say to the people living in those areas, ‘you don’t have to live in Perth or down the coast to be able to access a doctor’. I want to use what we’ve learnt here and apply to the North.�

t N UPQ VQ PG UIF DPNNJUUFE N Karratha Health Campus

“There’s been shrugging of the shoulders forever on this issue and the federal government has to play its part. It has been abrogating its responsibility in primary

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Medical Marketplace

You Have to Spend to Make Money? The not-for-profit sector is growing and includes some very big players. Is duplication and unbridled competition wasteful of the community’s finite pot of gold? A big majority (80%) of the 120 GPs we surveyed had formed an opinion that a not-for-profit organisation that raised $8.4m should spend less than $3m in raising those funds; a minority (10%) said that between $3m and $4m was acceptable (August edition E-poll). In other words, the majority supported spending less than 35c for every dollar raised. The $8.4m figure was actually taken from the Princess Margaret Hospital Foundation annual report, and the amount spent on raising $8,398,971 was reported as $5,241,311. However, the Foundation calculates that only $3.08m was directly spent on both employing fundraising staff and buying goods and services. Using these figures, it calculates a fundraising cost-to-income ratio of 36.9%. This is slightly above their target of 30% and their past average of 28%. In fact, CEO Denys Pearce told Medical Forum that 30% seemed to be the industry standard. We note that the PMH Foundation is assisted by the interest earned from its $12.3m held in trust and its regular bequests ($2 to $2.5m anticipated yearly), which are used to cover yearly administration costs, as is income from dividends and distributions, GST refunds and other liquid financial assets. In this way, PMH Foundation can say that all of the net fundraising income goes to the hospital.

One way of ensuring everything is kosher, is to tighten financial reporting and monitor activities, as the federal government plans to do. But this means more bureaucracy. All this is a departure from the good old days when there were a handful of major charities that big companies or bequests went to at the end of each financial year, and the notfor-profits simply banked what came their way. Now you have to spend money to make money it seems. Why? Competition for one. Every time a drunk driver wreaks havoc, or suchlike, a new Foundation is launched in memoriam. The cross-over in intent and administration must be enormous. It is probably why 71% of the 123 specialists we surveyed said there were too many foundations, support groups, institutes etc. vying for money in WA (October 2010 E-poll). The not-for-profit sector appears to have got out of hand. 10

How do we ensure there is no misappropriation of funds or waste? Not-forprofits operating in the health sector seem do so very efficiently while they remain small, with money going directly to the support group members; then less efficiently when someone is employed to administer and these costs must be covered. One way of ensuring everything is kosher, is to tighten financial reporting and monitor activities, as the federal government plans to do. But this means more bureaucracy. It will include the many medical institutes that appear to have the primary purpose of directing research funds. While 30c to raise every dollar is taken as appropriate in some quarters, others argue we should have freedom to spend proportionally more if the total net figure raised is increased. Everyone has a story of how this has worked brilliantly – e.g. spend more to put on a more lavish ball and raise more overall. Does it matter if we need to employ more project officers or external fundraisers to get where we want?

independent Board and a competent CEO and management team. He is talking from the privileged position of running one of the biggest fundraisers in WA, with large bequests and other passive income each year. The bottom line appears to be the overall donation spend within our community – the finite pot of gold in WA that is our discretionary spend, up when times are good and down when they are not. No number of smart marketing people thinking up entertaining ways for consumers to part with their dollars will change the size of the pot. While times are good, the feeding frenzy is high. But will the smaller players simply go under when times get hard? As if to emphasise the growing symbiosis between NFPs and community sponsors, government is holding a conference this month to cover successful and sustainable not-for-profit/corporate partnerships, or how to build them. See http://ngopartnershipswa. com/agenda/ O

By Dr Rob McEvoy

Denys Pearce said NFPs should be able to do this if there is good governance, that is, an medicalforum

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Feature

Making Life Simpler and Fairer for IMGs As rural communities cry out for more doctors, the red tape is stifling hope and opportunity for overseas trained doctors. Earlier this year a House of Representatives standing committee inquiry into registration processes and support for International Medical Graduates (IMGs) tabled its report, making 45 recommendations to help cut through the tangle of red tape to get these doctors into the field. The Lost in the Labyrinth report has yet to be debated in the House, though the inquiry’s deputy chair Mr Steve Irons, the WA MHR for Swan, won’t let it be forgotten. “WA struggles to get its share of overseas trained doctors and from what we heard at our hearings across Australia, it seems the Q Mr Steve Irons goalposts keep moving. So the purpose of the hearings was to try to find a way out. To see fully trained doctors, who are capable of assisting in Australia, driving taxis is just crazy.” “The report’s recommendations urge the government to come forward with some responses that would encourage all the parties to work together to make this pathway a lot simpler, with less paperwork, for doctors to get registered and practice in Australia.”

On some level it seems that we don’t believe they are doctors... I think there is a certain level of protectionism in Australia. MHR Mr Steve Irons

Examinations are sometimes expensive and when combined with the psychological costs resulting from failure and lack of feedback, the effects could be overwhelming. Dr Matthew Akpo While the House of Reps was examining the lot of IMGs, the Senate was looking into the factors affecting the supply of health services and medical professionals in rural areas. Dr Kathy Kirkpatrick chair of the RACGP National Rural Faculty (NRF) welcomed that report, which has just been tabled in Parliament with its 18 recommendations. That report also acknowledged the contribution IMGs made in rural communities and it also saw a need to redress current inequities and called for the findings of Lost in the Labyrinth to be implemented. “The need to ensure adequate support and supervision for IMGs was a key focus of the NRF submission and the committee’s recommendation and backing of the House of Representatives report sends a strong message to Government,” Dr Kirkpatrick said. Dr Jagadish Krishnan, representing the RACGP WA, told Medical Forum that a pilot program of structured peer mentoring for Q Dr Jagadish Krishnan IMGs, which ran in 2010-11, was doing a great job but funding was discontinued.

Steve said after listening to the hundreds of submissions, he was left with an impression that the current system was unfair on some IMGs. “If they know the process and are prepared to run with it, then good on them. But if they don’t know, and the goalposts keep changing, then that’s not fair. We’re enticing people away from their livelihoods and their families to come here and at the end of the day we can’t guarantee anything because of the labyrinth we put them in.”

FACTS: Where IMGs Work in WA

“On some level it seems that we don’t believe they are doctors. When we asked why the process was so difficult, every argument was “a safety issue.” However, I think there is a certain level of protectionism in Australia.” 12

The table below indicates the number of IMGs in each region as of the RHW annual census date of November 30, 2011. No. of GPs Region ____________________________________ 117

Southwest

50

Midwest

44

Wheatbelt

33

Goldfields

28

Pilbara

24

Kimberley

22

Great Southern

9

Greater Outer Perth Region

“The program funded site visits and consultations between IMGs and their mentors and it gave a formal structure in which the parties could develop their professional relationship. IMGs knew they could access their mentor, and mentoring doctors had guidance about what information to give their mentees on all manner of issues – from immigration issues; rule changes; even how to get a home loan. Everything a person needed to settle into a new country.” Jagadish said that prior to this formal arrangement, support for IMGs relied on GPs volunteering their time. Help was based on friendship and contacts and in some remote areas IMGs just didn’t have a network to sustain that approach. “With funding in place, there was structure and commitment. It was proving to be a wonderful program.” For Nigerianborn Dr Matthew Akpo, who came as an IMG from Namibia in June 2007 where he had been practising for eight years, the Q Dr Matthew Akpo system has worked smoothly. He was sponsored by the AMA (WA) and had a thorough orientation before arriving here, which included information about registration with the different agencies. “Back in 2007, I did not feel that it was a burden to get through the paperwork but that was five years ago.” Matthew said he was well-supported by colleagues and Rural Health West when he joined its Five Year Overseas Trained Doctor Scheme (OTS) in April 2008. Physicians gave freely of their time, especially Dr Jaye Martin, in Broome, and Dr Charlie Greenfield, in Carnarvon. He also had support visits through the OTS from E/Prof Max Kamien and Dr Diana Fakes. But he also drew on the support of other IMGs. “In Carnarvon, I met and joined an active discussion group of IMGS who had passed or were preparing for RACGP exams. We supported each other very well and Dr Salven Pillay steered the discussion group. The value of these groups can’t be overemphasised. In a way, they are akin to grand ward rounds or multi-disciplinary clinical case conferences.” Matthew has successfully completed his RACGP exams and did not have to repeat any segments, though when he spoke to some IMGs who registered in 2008 and onwards, their experiences were different to his. medicalforum

Guest Column

Bureaucracy Affects All Geraldton GP Dr James Quirke who mentors IMGs gives an insider’s perspective. IMGs account for 90% of the new GP workforce recruitment to rural/regional WA. Even with the predicted ‘tsunami’ of medical graduates, it is still expected that IMGs will account for 50% of recruitment to rural WA up to 2020. There are two groups of IMG – those who initially come to Australia through the AMC pathway and work in the regional hospitals, then move onto a GP training scheme or RVTS. The other group comes directly from overseas into general practice. These people are often undecided where they wish to work, many want a taster. There is upwards of a 70% capture rate.

Q Calls are being made to ensure adequate support and supervision for IMGs. Picture: Courtesy of Rural Health West

“There are more exams to sit, depending on the country of primary qualification and the registration pathway. Although results are released under different headings, this does not offer adequate feedback to candidates, except in the case of multiple choice exams. Examinations are sometimes expensive and when combined with the psychological costs resulting from failure and lack of feedback, the effects could be overwhelming. Hopefully, the Lost in the Labyrinth report has addressed this aspect as well, not only for IMGs but for the benefit of other candidates as well.”

Now Matthew and his wife and two children are settling into city life as he has established himself in a GP practice in Clarkson with an interest in occupational health. But he will never forget his rural experience. “There was true meaning of community in every sense of the word.” O

By Ms Jan Hallam

FACTS: Country of Training t 5IF OVNCFS PG 0WFSTFBT USBJOFE (1T IBT risen from 231 in 2005 to 367 in 2011. t 5IF OVNCFS PG (1T XIP USBJOFE JO Australia in the same period rose from 297 to 332. t 5IF QFSDFOUBHFT PG UIF UPUBM PG UIF SVSBM and remote medical workforce in WA who were IMGs has risen from 43.8% in 2005 to 52.5% in 2011 t .BOZ PG UIFTF *.(T BSF OPX "VTUSBMJBO citizens or permanent residents and have practised medicine in Australia for a number of years t /VNCFST BOE DPVOUSZ PG CBTJD NFEJDBM qualifications in 2011: 85 UK; 71 South Africa; 46 India; 26 Nigeria; 15 Ireland; medicalforum

13 The Netherlands; 11 The Philippines; 10 Germany; 10 Sri Lanka; 8 New Zealand; 7 Egypt; 6 Myanmar; 6 Pakistan; 5 Zimbabwe; < 4 from 30 other countries. SOURCE: Rural Health West

IMGs working for DoH 654 IMGs employed by WA Health Department are on temporary working visas. Of this, 600 are employed within the metro health services. Of this 600 numbers unknown are rotating in rural areas of WA. 54 IMGs are employed by WA Country Health Services. Source: WA Department of Health

However, the journey is bumpy and bureaucratic. There is a critical window in which to get these prospective GP recruits on board. By the time they’ve shovelled their way through the mass of paperwork many become despondent and give up just at the point of acceptance. The eight-month breakdown looks something like this – AMC, eight weeks; RACGP, four weeks; AHPRA, 6-8weeks; immigration, 6-8 weeks; Medicare, four weeks. If you can fast-track plumbers, God forbid that we can do it for GPs as well. In a nutshell, the potential eight-month wait to complete the paperwork needs to be condensed into three months. It would provide a trial experience but would also allow the practice to move on if not facilitated. The IMGs are recruited to areas of most need (sorry, Subiaco does not get a look in), where stories of Australian-trained graduates have drifted into folklore. There are also additional restrictions for more salubrious IMG placements such as where I come from – Geraldton! On top of all this, if a practice has been given a DWS (a visa to recruit an IMG), this is only valid for six months (this applies to regional areas of less need), which leaves a very small window to recruit, and if that placement falls over, the original DWS may not still be in place. The rules and nuances surrounding these DWSs are less transparent than the Greek taxation system. O 13

Awards

College Honours its Hardworking GPs More than 300 people attended the RACGP Awards Night at the University Club of WA and after a convivial cocktail party they got down to the business end of the evening. The latter involved the appointment of new board members, the admission of 58 new Fellows and the announcement of award winners. Geraldton GP Dr Stuart Adamson won the Sam Bada IMG Support Award. “It’s nice to receive the recognition,” Stuart said. “I enjoy my teaching and it’s great to see these international graduates develop into mature and effective clinicians.”

Q Dr Julia Marcello with WA faculty Provost Prof Max Kamien

Q Dr Richa Tayal with Prof Kamien

The Edward Gawthorn award winner for 2011.2, Dr Julia Marcello, reinforced the importance of the evening and the role of a GP in the wider community. “The collegial aspect of a night like this is really significant. I was sitting next to one of my former mentors, Sean Stevens, and now I work with him at the Mead Medical Group in Kalamunda. I love being a GP, it’s a privilege in fact,” Julia said.

Q FARGP recipient Dr Jonathan Morling with NRF board member Dr Sarah-Jane McEwan

The Edward Gawthorn award is presented to the doctor who passes all three elements of the College exams in one sitting and attains the highest mark in the clinical section. Doctor Richa Tayal won the award for 2012.1.

The awards evening, sponsored by WAGPET, was addressed by WA Faculty Chair A/Prof Frank Jones and outgoing RACGP National President Claire Jackson. The latter presented E/Prof Max Kamien with the Geoffrey Gates Award. Five new Life Members were inducted into the College: Dr Iain Esselmont, Dr Patrick Nugalewa, Dr Kevin Nikellys, Dr Gilbert Ostberg and Dr Alan Walley. Special mention was also made of the following long-serving examiners: Dr Meredith Arcus, Dr Shazia Qureshi, Dr Syed Shah, Dr Sree Chowdavarapu, Dr Narelle Kealley and Dr Deidre McAlpine. O

Growing to meet Western Australia’s health care needs We are gearing up for the future with major redevelopments at our Bunbury and Murdoch Hospitals, completing in 2012 and 2015 and new public and private hospitals in Midland, opening in late 2015.

SJG25893

There will be more career prospects for doctors as we grow to six Western Australian hospitals, with new and expanded specialties. St John of God Midland Public Hospital will have significant specialist and junior medical workforce requirements.

s 59,400 more patients a year s 551 new beds s 1,230 extra staff s Extensive new facilities s Education and training prospects s For more information, visit www.sjog.org.au HEAD OFFICE Ground Floor 12 Kings Park Road West Perth WA 6005 T (08) 9213 3636 F (08) 9213 3668 E info@sjog.org.au

14

BUNBURY Cnr Robertson Drive & Bussell Hwy Bunbury WA 6230 T (08) 9722 1600 F (08) 9722 1650 E info.bunbury@sjog.org.au

GERALDTON 12 Hermitage Street Geraldton WA 6530 T (08) 9965 8888 F (08) 9964 2015 E info.geraldton@sjog.org.au

MIDLAND T 1800 735 719 F 08 9213 3668 E info.midland@sjog.org.au

MURDOCH 100 Murdoch Drive Murdoch WA 6150 T (08) 9366 1111 F (08) 9366 1133 E info.murdoch@sjog.org.au

SUBIACO 12 Salvado Road Subiaco WA 6008 T (08) 9382 6111 F (08) 9381 7180 E info.subiaco@sjog.org.au

PATHOLOGY 23 Walters Drive Osborne Park WA 6017 T 1300 367 674 F (08) 9204 2974 info.pathology@sjog.org.au

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/FFERÞAPPLIESÞATÞ!UTOÞ#LASSICÞANDÞ7ESTCOASTÞ"-7ÞWHILEÞSTOCKSÞLASTÞONÞNEWÞ"-7ÞVEHICLESÞORDEREDÞANDÞDELIVEREDÞBETWEENÞ Þ3EPTEMBERÞANDÞ Þ/CTOBERÞ ÞANDÞCANNOTÞBEÞCOMBINEDÞWITHÞ ANYÞOTHERÞOFFER Þ3CHEDULEDÞ3ERVICINGÞISÞBASEDÞONÞTHEÞVEHICLEÁSÞ#ONDITIONÞ"ASEDÞ3ERVICEÞMONITORINGÞSYSTEMÞFORÞ ÞYEARSÞFROMÞTHEÞDATEÞOFÞÜÞRSTÞREGISTRATIONÞORÞUPÞTOÞ ÞKMS ÞWHICHEVERÞOCCURSÞ ÜÞRST Þ.ORMALÞWEARÞANDÞTEARÞITEMSÞANDÞOTHERÞEXCLUSIONSÞAPPLY Þ3CHEDULEDÞSERVICINGÞMUSTÞBEÞCONDUCTEDÞBYÞANÞAUTHORISEDÞ"-7Þ$EALER Þ#ONSULTÞ!UTOÞ#LASSICÞORÞ7ESTCOASTÞ"-7ÞFORÞFURTHERÞDETAILS Þ Þ0ROMOTIONALÞPERÞWEEKÞPRICEÞFORÞTHEÞ"-7Þ DÞ3EDANÞWITHÞAUTOMATICÞTRANSMISSIONÞANDÞNON METALLICÞPAINT ÞAVAILABLEÞWHENÞORDEREDÞANDÞDELIVEREDÞBEFOREÞ Þ/FFERÞAVAILABLEÞFROMÞ"-7Þ &INANCIALÞ3ERVICESÞ AÞDIVISIONÞOFÞ"-7Þ!USTRALIAÞ&INANCEÞ,TD Þ!USTRALIANÞCREDITÞLICENCEÞ ÞFORÞBUSINESSÞUSEÞVEHICLESÞONÞAÞ"-7Þ&ULLÞ#IRCLEÞCOMMERCIALÞCHATTELÞMORTGAGEÞAGREEMENT Þ/FFERÞBASEDÞ ONÞTHEÞDRIVEÞAWAYÞPRICEÞFORÞTHEÞALLÞNEWÞ"-7Þ DÞWITHÞAUTOMATICÞTRANSMISSIONÞANDÞNOÞOPTIONALÞEXTRASÞOFÞ Þ ÞMONTHLYÞREPAYMENTSÞOFÞ ÞAÞ ÞKMÞPAÞALLOWANCEÞANDÞAÞ'UARANTEEDÞ &UTUREÞ6ALUEÞ '&6ÞÜÞNALÞPAYMENT ÞOFÞ Þ)NTERESTÞRATEÞISÞ ÞPA Þ4OTALÞAMOUNTÞPAYABLEÞISÞ Þ!TÞTHEÞENDÞOFÞYOURÞCONTRACT ÞYOUÞCANÞTRADE INÞTHEÞVEHICLE ÞORÞEXERCISEÞYOURÞ'&6ÞRIGHTSÞ BYÞPAYINGÞOUTÞORÞREÜÞNANCINGÞTHEÞ'&6ÞORÞRETURNINGÞTHEÞVEHICLEÞTOÞ"-7Þ&INANCIALÞ3ERVICES ÞPROVIDEDÞTHATÞTHEÞVEHICLEÞHASÞNOTÞEXCEEDEDÞTHEÞCONTRACTEDÞKMÞALLOWANCEÞ ÞMEETSÞFAIRÞWEARÞANDÞTEARÞ CONDITIONS Þ/FFERÞAPPLIESÞATÞ!UTOÞ#LASSICÞANDÞ7ESTCOASTÞ"-7ÞWHILEÞSTOCKSÞLASTÞTOÞNEWÞVEHICLESÞORDEREDÞANDÞDELIVEREDÞBEFOREÞ ÞANDÞCANNOTÞBEÞCOMBINEDÞWITHÞANYÞOTHERÞOFFER Þ%XCLUDESÞ ÝÞEET ÞGOVERNMENTÞ ÞRENTALÞBUYERS Þ&EES ÞCHARGES ÞTERMS ÞCONDITIONSÞ ÞAPPROVALÞCRITERIAÞAPPLIES Þ#ONSULTÞ!UTOÞ#LASSICÞORÞ7ESTCOASTÞ"-7ÞFORÞFURTHERÞDETAILS Þ"-7Þ&INANCIALÞ3ERVICESÞRESERVESÞTHEÞ RIGHTÞTOÞCHANGEÞORÞEXTENDÞTHEÞOFFER

Have You Heard? Registration trap

Telehealth support If you are thinking about doing some telehealth consults, then the RACGP has set up an excellent resource page at www.racgp. org.au/telehealth/gettingstarted – dealing with issues such as MBS charging, the necessary software and hardware, internet requirements, standards and safeguards for video consultations. Dr Mike Civil has been involved in the latest advice and no doubt will be updated regularly.

Three weeks out from the September 30 deadline, AHPRA (or was it the Australian Medical Board?) said just over half the 80,000 medical practitioners due to register had not done so. The reminders – by email and letter – encouraged online registration and warned that renewals requested within a month after the due date would attract an extra late fee. After that month doctors are removed from the register and unable to practice until a new application is approved. Notorious for doing things at the last minute, doctors who booked holidays, moved addresses, or took study leave over the crucial time period might be joining the ranks of the unemployed.

WorkCover releases code

Paper tigers Several concerned GPs contacted us when they heard that Medicare billing requirements would be overhauled (effective January 1, 2013, they were told) to take all transactions online and scrapping paper altogether. These doctors were regularly working in the aged care sector, which is still reliant on paper. So Medical Forum approached the Department of Human Services and was told that the situation was not that dire. “Doctors can submit all details either on paper or online,” the spokesman said.

averaging 1-2 per day, mostly by day, which is fortunate for obstetrics services but it does put pressure on elective theatres. This pressure should reduce when the operating theatre at the old Galliers is re-opened for obstetrics soon, with new nursing staff allocated. The hospital is not cutting back on elective surgery, with rumours of increased funding to meet demand, and more nurses recruited in recent times has eased concern in theatres. Of course, winter activity often means elective surgery beds go to general medical admissions. One growing development is academic appointments to meet the required growth in training places – two recent appointments from UWA may herald the hospital as a teaching hospital, with interest in creating nearby teaching facilities.

Armadale powers on Armadale hospital has been flat-strap and with all the increased activity, the hospital has gone $4m over budget. The ED is open but overworked, while the LSCS rate is increasing,

n Pa rvatio m Conse Photo courte sy Tourism Western Australia: Coalsea

The Queensland floods and other catastrophies have put insurers $4b in the red, making everyone risk averse, and the growing mining FIFO workforce fatigue is ripe for increasing Workers’ Comp claims. Timely then that WorkCover WA and the National Insurance Brokers Association have released their Insurance Brokers’ Code of Practice – a key recommendation from a 2009 review of the WC Act 1981. Brokers are critical to the WC scheme and this maps how they can meet their professional obligations when policies are being discussed. Copies of the Code of Practice are at the WorkCover WA website.

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medicalforum

The fighting fund The Australian Doctors Fund (est 1989), chaired by fiercely independent surgeon Bruce Shepherd AM, is still operating to influence health policy. Its latest newsletter suggested we do nothing with PCEHR until all is revealed by the government; remove the July 2013 sunset clause from the AHPRA ‘Public Interest, Occasional Practice’ registration to prevent 1800 doctors being wiped from the profession (see www.asad.net.au); halt medical school expansions while intern post pressures exist; stop AHPRA funding the Independent Health Advisory Service for doctors; and block prescribing by nondoctors. See www.adf.com.au

Volunteers draw success Cancer Council told us that funds raised from their Daffodil Day was $5,246,367,

$4m shy of its $9.2m target with more than 10,000 volunteers taking part. We understand there were more than 30 NFPs involved in cancer awareness about eight years ago and one group involved with brain cancer used acquired donations to supplement the use of drugs not normally available to patients. Cancer Council CEO said that during the GFC, donations dropped from individuals but people still got behind campaigns making their big three - Daffodil Day, Big Morning Tea, Pink Ribbon Day – all successful, thanks partly to high volunteer involvement.

Stroke for stroke Every now and again, press releases appear to be beat-ups trying to break through the medical noise out there. Take “Australia’s Biggest Health Problem is We Don’t Care About – Stroke�, which is the conclusion drawn by the CEO of National Stroke Foundation because only 6% of 1000 people surveyed said stroke was a health concern. This indicated a “dangerous level of ignorance about the realities and prevalence of stroke�, apparently. Stroke isn’t getting enough programfunding even though 20% of strokes happen under the age of 55. Meanwhile, HDWA had no interest for its invitation (DOHROI02) to NFPs to develop, deliver and monitor self-management programs

for people with chronic conditions (from Gascoyne to the South West). It was part of implementing the WA Chronic Condition Self-Management Strategic Framework 2011-2016.

Council Names Board The Australian Health Workforce Ministerial Council announced in July new appointments and reappointments of Chairs, practitioner and community members to vacancies across 10 national boards for the National Registration and Accreditation Scheme (NRAS). They were to fill the expired 105 inaugural terms of appointment made by the Ministerial Council in 2009. National press ads for candidates (which we missed) were run in February this year and 134 health practitioners applied or re-applied for 72 vacancies. About 90% of inaugural national board members sought reappointment. The newly constituted national boards started from August 2012. Representing WA practitioners on the Medical Board of Australia is A/Prof Peter Wallace, the Nursing and Midwifery Board, Ms Louise Horgan RN, the Podiatry Board, A/Prof Laurence Foley, and the Psychology Board, Prof Alfred Allan. O

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17

E-poll

Pharmaceutical Sponsorship Each of the questions are derived from the reasons the federal AMA gave in its rejection of declared sponsorship of individuals, in favour of aggregate figures. There is a minority 10-15% disagreement with the AMA stance on all questions, except the last two, where disagreement is stronger. We provided this preamble to survey respondents: “The federal AMA supports changes to the Medicines Australia Code that will require the reporting, in aggregate, of health professionals receiving sponsorship to attend or speak at educational events, or who advise or consult pharmaceutical companies. It says the sponsorship of individuals should remain undisclosed. Here are some related statements - what is your response?”

Q

Existing disclosure of pharma sponsorship of educational events says for each event how much, what for, and how many attended. The proposed aggregating of sponsorship of health professionals to attend or speak at educational events or to advise pharmaceutical companies offers the same level of transparency. Strongly agree Agree Neutral Disagree Strongly disagree

All 5% 35% 42% 14% 4%

Q

There is public benefit when medical practitioners have ethical relationships with pharmaceutical companies. Strongly agree Agree Neutral Disagree Strongly disagree

Q

All 13% 48% 28% 10% 1%

Educational events sponsored by pharmaceutical companies are needed by the profession.

Strongly agree Agree Neutral Disagree Strongly disagree

All 26% 49% 13% 9% 2%

Q

Pharmaceutical companies should pay medical practitioners who provide independent medical advice and expertise. All 16% 54% 16% 12% 1%

Strongly agree Agree Neutral Disagree Strongly disagree

Q

Current codes of conduct maintain ethical and transparent behaviour between the pharmaceutical industry and the profession. All 10% 41% 32% 14% 4%

Strongly agree Agree Neutral Disagree Strongly disagree

Q

Medical practitioners will declare to their patients any conflicts of interest that arise.

Strongly agree Agree Neutral Disagree Strongly disagree

Q

Total 12% 34% 22% 27% 5%

GP 15% 32% 25% 23% 5%

Spec 10% 37% 15% 30% 8%

DIT 6% 34% 31% 29% 0%

Declaring sponsorship or payments to individual doctors may wrongly damage their independence.

Strongly agree Agree Neutral Disagree Strongly disagree

Total GP 6% 6% 25% 25% 26% 30% 36% 32% 7% 7%

Spec 9% 21% 21% 46% 3%

DIT 6% 31% 34% 20% 9%

DITs Show Differences The only strong craft group differences on questions came from DITs (n=35): t %*5T XFSF NPSF VOEFDJEFE PO whether aggregate figures were as transparent as individual declarations. t .PSF %*5T EJTBHSFFE XJUI UIF JEFB of public benefit flowing from doctorpharma relationships. t 'FXFS %*5T BHSFFE BOE NPSF disagreed (20%) with the stance that doctors should receive pharma money for independent advice.

Comments on pharmaceutical sponsorship There were 35 doctors who took the trouble to comment. This topic involves primarily specialists, one pointed out, while a couple said there is a wide spectrum of relationships, with some “hardly ethical” if

18

Total respondents = 250 GPs

107

43%

Specialists

92

37%

%*5

Other

16

6%

FACTS: Key Survey Findings t %P DVSSFOU DPEFT NBJOUBJO FUIJDBM behaviour between doctors and the pharma industry? Yes, according to about a half of doctors, with a third undecided. t $PVME EFDMBSJOH TQPOTPSTIJQ PG individual doctors wrongly damage their independence? No, according to the majority of GPs and Specialists. t 8JMM EPDUPST EFDMBSF BOZ QIBSNB conflict of interests to patients? Not according to about one third of GPs and Specialists (with a quarter undecided).

audited. No sponsorship or payments from drug or equipment providers, at all, was suggested by three respondents. Effects on ethical behaviour One doctor queried why “people think my conscience can be bought with a pen or dinner?” and another said we should be “fostering ethically acceptable links between the medical fraternity and the health care industry”. Observed behaviours included: t .JTMFBEJOH QSFTFOUBUJPOT EVF UP XJUIIFME commercial interest information. t -BDL PG DPNQMFUF USBOTQBSFODZ BOE declared conflict of interest. “New MMR vaccine anyone?” t 5PP NVDI QIBSNB JOEVTUSZ DPOUSPM over medical education and influence on prescribing. t 1IBSNB NBOBHFNFOU PG QFSDFQUJPOT to overcome sincere doctor belief in their impartiality. t 4QPOTPSTIJQ PS QBZNFOU CFJOH NPSF about want than need. In defence of doctors “McGowan is going over the top – there is unquestionably a self interest in pharmaceutical industry sponsorship and some grants are excessive – but a witch hunt is equally stupid.” “The vast majority of medical practitioners adhere to strong ethical and moral codes within research, education and clinical practice. Sponsorship or payment for ethical provision of education by medical professionals does not imply a loss of objectivity or professionalism, or a departure from ethics or morality by the presenter. Full disclosure of interests and involvement, and pervasive objectivity within the presentations is a hallmark of the ethical internal structure of the individuals medicalforum

E-poll

GPs who Choose to Subspecialise Over their working lives, a significant number of GPs develop different interests and find areas they are really good at. There is no good reason to discourage this and in fact, 35% of our GP and 42% of our specialist respondents said it was desirable in our ageing GP population that they are able to restrict their work to one particular facet of general practice. Whatever the reason behind developing a special interest, the consequent case mix of each GP will be different, often because the GP is sought out by patients through word of mouth. Most GPs who subspecialise do so in the context of broader general practice knowledge and experience, whilst concentrating on their area of interest. Subspecialisation builds expertise that can be used by other doctors to varying degrees e.g. palliative care or GP obstetrics. With general practice only recently being listed as a specialty (2010), how should this craft group of generalists handle those in their midst who have developed a special interest? (Back in 2007, the RACGP presented all the pros and cons – see www.racgp.org.au/gpissues/ specificinterests – before taking its current path).

Q

In an ageing GP population is it desirable that GPs are able to restrict their work to one particular facet of general practice? Total

GP

Spec

DIT

Yes

36%

35%

42%

23%

No

50%

53%

43%

57%

Undecided

14%

12%

15%

20%

Q

If a FRACGP GP wishes to virtually confine his work to GP obstetrics, nutritional medicine, men’s health, counselling or suchlike, how should the rest of the GP community respond? [Choose a statement that most closely represents your point of view.] Let them practice this way as a ‘GP’ and ensure patient safety standards are kept. Encourage such doctors to develop their skills as a ‘GP’ and research their patient outcomes. Insist they do not provide a service under the banner of ‘GP’. Deregister them as a ‘GP’ unless they show competence in all areas of ‘general practice’ as defined by the RACGP. None of the above.

Total

GP

Spec

DIT

54%

63%

48%

49%

22%

17%

26%

25%

11%

12%

9%

17%

6%

4%

7%

10%

6%

5%

10%

0%

ED. Only 12% of GPs say colleagues who almost completely subspecialise should be excluded from calling themselves GPs and only 4% say such GPs should be deregistered as a General Practitioner. When national registration law was introduced in July 2010 under AHPRA, there were about 11,000 GPs in Australia with vocational registration and about 11,000 GPs who were Fellows of either the RACGP or ACRRM. All were given Specialist recognition into the specialty of General Practice by AHPRA because all were maintaining currency through CPD, it was said. Anecdotally, before that time, a number of GPs who were subspecialising had fudged the 50% rule the RACGP said was necessary to claim VR status in general practice. Some truthfully conceded to non-VR status and accepted the financial disadvantage this placed them in (perhaps including some of our 16 ‘Other’ respondents to this e-Poll?).

within the profession.” “Pharma companies pour billions of dollars into research and they should be allowed to educate the profession if they develop an effective drug. Similarly doctors should be free to charge for participating in advisory committees. Why should delegates to a pharma conference have to stay in 4 star medicalforum

Q

*Do you know of a ‘GP’ who is subspecialising in this way, say devoting more than about 60% of their practice to one aspect of care or one patient group? Total GP 48% 70% 40% 24% 12% 6%

Yes No Undecided

Spec 31% 49% 20%

DIT 34% 57% 9%

ED. A large majority of surveyed GPs and almost a third of specialists (121 in total) know of a GP who subspecialises to a large degree.

You answered ‘Yes’ to question* above, so do you believe that the medical practitioner should be financially disadvantaged compared to other GPs as a direct result of their subspecialisation? Total GP 7% 7% 79% 78% 14% 15%

Yes No Undecided

Spec 10% 72% 18%

ED. In this age of accreditation, is it fair to expect subspecialising GPs who do only, say 10% true general practice work, to maintain CPD for that purpose? What about those who wish to subspecialise 100%? Under the current national registration law, referral to SAT can happen if a panel “believes the evidence demonstrates the practitioner’s registration may have been improperly obtained because the practitioner or someone else gave the Board information or a document that was false or misleading in a material particular”. How is “general” practice defined for this purpose?

You answered ‘Yes’ to question* above, so are you happy with their level of competence in their chosen field? Total GP 74% 84% 11% 4% 16% 12%

Yes No Undecided

Spec 45% 24% 31%

ED. Of those GPs and specialists who know of a GP who specialises to a large degree, a minority (4% and 24%, respectively), were unhappy with their level of competence. There are a number of possible explanations for differences in response rates between GPs and specialists. *The E-poll winner this month is Dr AX. O

FACTS: Important Findings t *T JU EFTJSBCMF UIBU BHFJOH (1T DBO TVCTQFDJBMJTF :FT according to half our surveyed Specialists who had formed an opinion. t $BO B (1 XJUI GFMMPXTIJQ XPSL GVMM UJNF JO IJT TQFDJBM JOUFSFTU area? Yes, according to two thirds of our surveyed GPs, provided patient safeguards are in place. t )PX DPNNPO JT (1 TVCTQFDJBMJTBUJPO PG (1T BOE of Specialists knew of someone, and GPs in particular were happy with their colleague’s competence (86%).

hotels rather than 5 star? Why should they not be allowed to go to a good restaurant? These are ludicrous restrictions. Doctors have very little free time and it is reasonable when they give it up they should be comfortable.” How we should do it “Full individual disclosure of sponsorship

is the only way to maintain professional credibility.” “Pharmaceutical influence on 'key opinion leaders' or educational activity can profoundly affect clinical practice. Individual sponsorship should be fully disclosed, to not do so is bordering on fostering corruption.” O 19

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Feature

Captain on the Rebound The Perth Wildcats’ skipper Shawn Redhage has fought back from a rare hip injury with the help of some very specialist care. One of Shawn Redhage’s sporting highlights was representing Australia at the Beijing Olympics but after suffering a career-threatening injury it took a specialist surgeon in the US to keep the slam-dunking captain of the Perth Wildcat’s on the basketball court.

FACTS: Slam-dunking Wildcats t 5IF 8JMEDBUT BSF UIF NPTU TVDDFTTGVM NBL team with 26 consecutive finals and five championships t 4IBXO 3FEIBHF IBT CFFO WPUFE .PTU Valuable Player six times. t 5FBN PXOFS JT +BDL #FOEBU

“Walking into the arena for the opening ceremony in Beijing and playing against the top players in the world was a great moment. But definitely the worst moment was a bad hip injury early last year. I knew something was wrong when I tried to stand up and couldn’t control my left leg.” “The X-rays revealed a dislocated hip but emergency surgery took it a step further. I actually had an acetabular fracture which is an extremely rare sports injury and much more likely to happen in a car accident. They put three pins in my hip and told me my career was over.” The Wildcats' team doctor, Kallaroo GP Dr Russell Bock (see Doctors Below, P42), researched the injury and found that only two players had suffered this kind of damage and neither of them had returned to the court. Fortunately, medicine runs in the Redhage family and those connections made all the difference.

I had an acetabular fracture… they put three pins in my hip and told me my career was over. “My sister-in-law is a surgeon back in the States and she knew one of the best hip specialists, so we sent all the scans to him. I flew to Nashville for surgery, had a

t 5IF TFBTPO TUBSUT 0DUPCFS t 'JSTU IPNF HBNF BU UIF OFX 1FSUI Arena is November 16

couple of weeks in hospital and 12 weeks on crutches. I ended up playing my first game seven months after the operation. It was such a rare injury and I was fortunate this happened to be his specialty.” “I’ve also got a sister who’s an intern back in the US. She went to Vanderbilt University and is doing a residency there. They work incredibly long hours and it’s given me a new appreciation for doctors. My hip injury proves this, if something serious happens it’s reassuring to know that the training is so thorough.” Shawn played college basketball in the US for the University of Arizona on a sports scholarship. It’s a highly competitive arena with gridiron football sitting at the top of a very lucrative pyramid. “The college system is pretty intense in all sports, whether it’s basketball, tennis, golf or football. It’s a wonderful proving ground for a sportsperson who wants to play professionally. And it’s big business with the

universities recruiting all over the world. At UA, basketball is playing in front of 14,000 people and games are televised nationally. Gridiron football is huge and funds all the other sports.” And it’s more than just sport for the elite young athletes in the US college system. They also do a degree course and, in Shawn’s case, that’s helped him plan for life beyond basketball.

I’d like to play another five years at this level and help to keep the team winning, but I’ve also got a young family. “I majored in construction management at university and that’s helped me transition into a career in financial planning. Morning and early afternoon I play basketball and then it’s off to the office in Subiaco. I’m 31 and I know that a sporting career can end at any moment. I’d like to play another five years at this level and help to keep the team winning, but I’ve also got a young family. I’ve got a time-frame in mind and that’s why I’m planning for a second career.” Shawn says the Wildcats have been working hard to improve the financial position of the club in an environment where some of the teams in the NBL have collapsed. “We’re trying to build up some momentum and it’s been improving over the past couple of years. The Sunday games will be live on Channel 10 and the new Perth Arena will be open soon. We also visit regional areas and do a lot of work in schools – we visited nearly 300 last year.” “It’s always been a life-long dream to play professional basketball. It was taken away for a while, so I appreciate it even more now.” O

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BENEATHthe Drapes X Prof Gary Geelhoed will take up the position of Chief Medical Officer for WA Health this month. He has been ED Director at PMH for the past decade and a past president of the AMA (WA). X Mr Ian Anderson has been appointed CEO of St John of God Midland Public and Private Hospitals and will be responsible for overseeing the design, construction, clinical service development and commissioning of the 307 bed public hospital and 60 bed private hospital. Ian previously worked for North Metropolitan Health Service, HBF and SKG Radiology. X The DoH’s Health Information Network has awarded a $90m contract to Amcom L7, ISA Technologies and Fujitsu Australia for a panel arrangement to collectively support the department’s ICT needs across the state. It is expected the new system will improve communication speeds, expand bandwidth, consolidate infrastructure and improve service consistency and reliability by 2019. X 14 individuals will have the chance to win a total of $90,000 towards attendance at a relevant international conference by applying for the 2013 Aspire Awards run by the Perth Convention Bureau and supported by WA’s universities and the RACS among others. The award’s selection criteria is at www.pcb.com.au/aspire. X Fourth-year UWA medical student Madeleine Venables received the national Rural Health Workforce award for her contribution to university’s rural health club, Spinrphex, and her work promoting good health to young people in rural areas. X Adrian Large, nurse practitioner at the Kingsley Family Practice, has been named national Nurse Practitioner of the Year. X Doric Contractors has been named as the preferred contractor for the construction of the $118m new Busselton Hospital. The hospital will include 64 beds, 20 same-day beds, a renal unit, two theatres, a procedure room and expansion of the ED. Construction is expected to be completed by June 2014. X The National Heart Foundation has been awarded a $8.06m Health Department contract to deliver a Healthy Workplace Support Service to regional areas. The foundation is expected to provide free services to “support workplaces to make changes that result in positive lifestyle behaviour changes among their employees”.

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Guest Column

Links in the Organ Donation Chain Dr Alan Duncan, Hospital Medical Director from DonateLife, says doctors need to be aware of donor opportunities and adapt to the changing culture.

D

r Kevin Yuen, as the State Medical Director in 2011, raised some important points regarding the national reform agenda for organ and tissue donation (Letters, November 2011 edition). Dr Yuen discussed the shift in hospital death rates, the consequent impact on the potential donor pool and whether we are, in fact, missing opportunities to maximise the number of potential donors in WA. He also stressed the importance of people registering their intentions regarding organ donation and discussing this with loved ones. A public campaign, ‘Discover, Decide, Discuss’ has been run to improve donation rates and encourage family discussion, and follow-up suggests this has had a positive effect. However, the ‘Chain of Organ Donation’ is brittle and every break in that chain leads to a missed organ donation opportunity. Some of the crucial links are a wellinformed and supportive public, sensitive support for grieving families, well-trained clinical teams and a suitably resourced transplant sector.

More specifically, it is imperative that every intensive care death is thoroughly reviewed to determine whether the hospital ‘link’ has been disrupted. It has occurred in some cases and performance has been degraded as a result. To minimise this, consideration of organ donation must become a routine part of end-of-life care for all staff working in Emergency Departments, Intensive Care Units and medical specialities such as neurosurgery. Families have a right to consider organ donation as an option and it is our responsibility to ensure this is handled in a sensitive and professional manner.

an option for hepatitis positive recipients. Expert advice is freely available and it is essential that clinical staff use this service.

We must embrace a culture of, ‘Consider, Consult, Collaborate’ to ensure our part of the ‘chain’ is robust. Case reviews suggest that organ donation is being ‘Considered’ in the vast majority of instances where it is appropriate.

Everyone in the medical field has a part to play in the ‘chain’, whether it’s ensuring that accurate advice is provided to members of the public or by a hands-on role as a clinician dealing with end-of-life issues. O

‘Consultation’ is somewhat more variable. Medical suitability for organ donation is a moving field. More marginal donors are sometimes being considered, such as hepatitis-infected potential organ donors as

Finally, ‘Collaboration’. Intensivists understandably consider this is their ‘patch’. However, evidence suggests that higher organ donation consent rates can be achieved when highly trained requestors are involved, either alone (the designated requestor model) or in collaboration with treating intensivists. To this end, specialised training in family conversations and requesting is being provided and national trials of designated and collaborative requesting models are being implemented.

ED: Nationally, there were 337 organ donors and 1001 transplant recipients in 2011. See www.donatelife.gov.au

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College News

Elections to Exams – RACGP goes online Like many colleges and associations, the RACGP is conducting more and more of its activities online – from the recent national presidential election to College examinations. And like all new things, it can take a bit of getting used to. Hills GP Dr Mike Civil, who failed in his bid for College president against NSW GP Dr Liz Marles, was philosophical about the result, saying the electronic format of the election was “a bold step that perhaps can be improved into the future”. “We are a very computer literate profession, but that means we get bombarbed with emails. There was a risk that the voting email could have been missed, seen as spam or hit a ‘junk’ filter. If it was missed, then voting became harder. The College was very helpful to those who had missed the email, but many would have found it time consuming to gather the necessary information. Many organisations now use electronic voting systems and it was an obvious move for the College. I felt that the process was robust and fair, but a big change for some.”

Q RACGP WA candidates in online action at the Parmelia Hilton.

experience. While readily acknowledging this disadvantage, I do have considerable experience in many College committees and activities.” Medical Forum was unable to get the percentage of members who voted in the online election from RACGP's head office at the time of going to press.

Applied Knowledge Tests (AKT) and Key Feature Problems (KFP) beings sat by 1330 candidates in major cities and remote centres across Australia. In WA 69 candidates sat the exams – 66 at the Cliftons Parmelia Hilton and three at the Broome Mercure Hotel.

Mike added that the tyranny of distance probably played a role in the result as well.

Mike says he remains passionate about all things e-health, telehealth and training and doesn’t rule out another tilt at the national presidency.

The AKT consisted of 150 multiple choice questions (candidates are given 4 hours to complete). The KFP comprises 26 cases with a series of questions for each case (candidates are given 3.5 hours for this exam). The majority of candidates sit both exams on the day – the College provides a light lunch.

“There are some members who will have been critical of my lack of Council

The College has also recently completed its third round of online examinations with the

Enrolments have now opened for the first round of exams for 2013. O

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Referrals on Demand? The website said ‘Sonseeker Doctors, The Way Medicine Should Be’ and the practice promotes an Australia-wide specialist referral service via the internet (see www. thewalkingp.com.au). Doctors in the practice, “as part of our telemedicine initiatives�, were offering to email, fax or post a referral to anyone who wanted to see a specialist anywhere in Australia. Patients had to email relevant information, pay the $10 fee, and they could receive their referral the same day. Specialists have been complaining about the standard of referrals for ages. The typical story used to be about “Please fix� handwritten on a referral form but now that complaint is somewhat irrelevant, or inaccurate information is generated by a computer. Maybe this advertised service was producing better referrals? The website asked patients to provide symptoms and test results, their usual GP’s details (so the specialist's report can be forwarded to them), and current medication, allergies, and previous medical/surgical history. This information was so the doctor completing the referral could “assess your need to see an Australian specialist in order to comply with the Health Insurance Regulations�. We spoke briefly to Dr Kooi Ang, busy at the Walk-in GP practice in Burswood, about his referral service. He said less than 1% of referrals were from interstate and most were in fact patients from his practice. He said he had rejected a number of referral requests to see psychiatrists, as well as complicated referrals. However, people coming from rural areas to the city seemed to appreciate the service. Both Dr Ang and his associate Dr Than are FRACS graduates with varying medical experiences – we understand they have worked at the Burswood Practice for two years. Their patient information says Walkin GP Practice bulk bills, does not have appointment scheduling (hence the name), and the doctors do not provide medicolegal, insurance, or Centrelink reports. A dietitian visits and a St John of God pathology collection centre is onsite. They will not backdate medical certificates or provide referral for termination of pregnancy. WADEMS covers them for afterhours. Providing ease of access for health consumers can be a positive move but it can also generate some important points for the profession to consider. O medicalforum

Prostate Awareness

‘Wait and See’ is a Luxury Many Don’t Have Prostate cancer was in the spotlight recently with celebrities and urologists working to raise awareness. Spring marks open season for fundraising. This month its breast cancer, November is the month of bad moustaches and awareness raising for men’s health. In September it was International Prostate Cancer Awareness Month. The Prostate Cancer Foundation of Australia (PCFA) held Big Aussie Barbies across the nation, with celebrities such as cricketer Matthew Hayden and celebrity chef Ben O’Donohue leading the charge. In Perth former AFL footballers Paul Hasleby and Ross Glendinning turned the snags with foodies Vince Garreffa and Don Hancey. Cat Harman the state manager of the WA branch of PCFA said the foundation hoped to raise $800,000 nationally. Perth urologist Dr Tom Shannon lent his voice to the campaign. He said that prostate cancer was the most common cancer in Australian men, killing more men than breast cancer killed women, and raising awareness and early detection were essential to improve outcomes. He said GPs had a vital role in minimising the impact of the disease and should feel confident that urologists in WA shared their desire to minimise the impact of this cancer. “It is critical to understand that we need to diagnose the disease with a biopsy before we can determine how best to manage the problem. Once we have a diagnosis we can pause and consider how to progress. With a well-informed patient we can save those that need to be saved and observe those who do not need treatment.� Tom also cautioned about a ‘wait and see’ approach.

“You can only adopt a 'wait and see' approach if you know what the grade and stage of the patient's cancer is. This means a PSA test, early referral and biopsy. It is inappropriate to hold on to a patient with a suspicious PSA or rectal examination as we have no idea whether these patients have a cancer or not, and if so, how aggressive the disease is. Only once the cancer is diagnosed, can you gain Q Butcher Vince Garreffa, ex Eagle Ross Glendinning, chef Don Hancey, food an informed view.� writer Marg Johnson and ex Docker Paul Hasleby at the Big Aussie Barbie in “In our initial the city. publication of WA prostate biopsies, the FACTS: PSA Testing average PSA at first biopsy was 8.1, which is far too high. GPs are being successfully t 0O B QFS DBQJUB CBTJT JO sued for holding onto patients with PSA tests were provided at a rate of abnormal test results and I would caution 20,859 tests per 100,000 males for against taking a wait and see approach for those aged 55-64 years olds anyone who has not had a biopsy in general t UFTUT QFS GPS practice.� year olds “In general younger men have the most t UFTUT QFS GPS to gain from an early diagnosis, as it is year olds essential if we wish to spare nerves and t )PXFWFS UIF SBUFT GPS UIFTF BHF preserve erections. The GP has a crucial groups were much higher in SA, the role in making the diagnosis early and ACT, WA and Tasmania than in I have seen countless examples of GPs making excellent referrals based on early other jurisdictions. PSA movements or abnormal DREs that Source: Medicare Australia statistics: have led to life-saving treatment while Medicare Benefits Schedule Item 66655. preserving function.� O

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News Practice Tips

Imagining Imaging Changes to Medicare that allow primary care doctors to order MRIs for the under 16 age group will excite private providers of MRI services in WA (nine listed at the ANZSPR website) who will be able to provide for older co-operative children. But it will impact little on already stretched MRI services in the public sector. In fact, PMH has the only dedicated paediatric MRI in Perth (one of the oldest too) for which non-urgent MRIs must wait about 11 months and more urgent MRIs (especially those who require a GA) face about a fourmonth waitlist. This despite extended operating hours. This means MRIs for sinus disease, musculoskeletal indications etc are almost never seen at PMH. Prof Richard Mendelson is said to be reviewing Diagnostic Imaging Pathways for MRI to keep this and other factors in mind. The last thing PMH want is more MRI referrals as a result of the MBS changes. Despite PMH’s triage of requests, dedicated

CPD for Nurses Nurses are required to maintain their FEVDBUJPO UIF TBNF BT %PDUPST 5IFJS $POUJOVJOH 1SPGFTTJPOBM %FWFMPQNFOU $1% is 20 points per year. It is important to maintain a record as continuing registration UISPVHI ")13" XJMM CF EFQFOEFOU PO UIJT compliance and random audits are occurring in the workplace. Although some education may not have a points allocation, it may still count towards UIF $1% UBMMZ JG SFDPSEFE JO BO FEVDBUJPO GJMF 5IFSF BSF NBOZ PQUJPOT GPS OVSTFT t 3FBEJOH OVSTJOH KPVSOBMT o TVDI BT Nursing Review, Australian Nurses Journal, Primary Times and Western Nurse

paediatric services remain under pressure, something that may change when the new hospital is built in 2015, with two new MRIs planned. Down at Imaging Central, Shadow Minister for Foreign Affairs and Trade, Hon Julie Bishop, has officially opened the 128 Slice CT Scanner at its Claremont rooms. She is pictured here with (l to r) Dr Sanjay Nadkarni, Dr Joel Scaddan and Dr Mark Hamlin. The scanner is the only private scanner in WA with Safire dose reduction technology for everyone, a match for the same dose reduction that PMH has on offer for kids. O

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Medicolegal

MIIAA In Perspective Medical indemnity insurers compete at many levels and cooperate at others, which is where MIIAA comes in. But where exactly? When we had tort law reform as a national whole-of-industry issue, MDOs had good reason to band together and present government with a united face. WA’s Dr Andrew Miller was at the forefront when the Medical Indemnity Industry Association of Australia (MIIAA) was born in 2005, with that purpose in mind. As chairman of the current board, his medical indemnity interests remain with MDA National, and MIIAA membership is comprised only of Avant and MDA National, a situation that is reflected in the current board members (see www. miiaa.com.au). These two medical indemnity insurers say that together they cover 70% of doctors, and while they attract the interest of anyone with an industry-wide issue, there isn’t much happening at present, not even the National Disability Insurance Scheme, which is at political start-up stage. Medical Defence Organisations (MDOs) or insurers offering medical indemnity that are not members are Invivo (which is 50%

owned by QBE), MIGA (combined Medical Insurance Australia and MDA SA; provider of insurance to midwives), and MIPS (see www.mips.com.au). There seems to be a diversification of services occurring, with Avant offering health and life insurance as well as indemnity insurance, and MDA cover extending to dentists. MIGA was a member early on but withdrew (and they did not respond to our request for information). MIPS spokesperson Allanah Hasler said all medical indemnity insurers (and brokers offering professional indemnity to health professionals) are members of the peak body Insurance Council of Australia and of its Healthcare Indemnity Working Group. “MIPS has not previously, and does not currently, see any needs not being met through membership of the Insurance Council or other organisations,� she said, before adding that the efficient spending of members’ money was a consideration. With its limited secretariat, MIIAA is continuing to provide a forum for ideas, information and views on issues of

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common interest for the medical indemnity industry. The insurers and associated businesses, not the insured, are their focus and the Association underwent a “strategic relocation� to Canberra in 2011. Their annual forum on October 18 is titled “Technology, Workforce and the Medical Professional: Looking to the Future for Medical Indemnity�. Topics include evolving issues (National Disability Strategy, wrongful birth as a form of claim, and open disclosure), state-based management of national registration and disciplinary systems and risk management around the PCEHR. Future health workforce issues and global economic effects on the insurance landscape were also on the program. Medical indemnity insurers can have in-house solicitors but they also use external firms to run court cases and provide opinions. Little wonder then that four legal firms are listed as Industry Partners on the MIIAA website, paying $5500 each for that position. The MIIAA spokesperson said this is a measure of their desire to interact with medical professionals in the indemnity industry. O

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TRANSLATIONAL RESEARCH FEATURE

Medulloblastomas, mice and medicine I n 2008, Dr Nick Gottardo returned from the USA as a consultant paediatric oncologist at Princess Margaret Hospital for Children (PMH) and brain tumour researcher at Telethon Institute for Child Health Research (TICHR), treating all childhood cancers and applying his special expertise in treating children with brain tumours. Ongoing research is integral to clinical success having completed his fellowship through clinical work and research in paediatric neuro-oncology at St Jude Children’s Research Hospital in Memphis, USA.

In particular, animal models that mimic childhood brain tumours allow them to test new treatments. “This includes genetically modified mice, such as transgenic mice that are genetically engineered to express oncogenes identified from the analysis of tumours derived from children. Another mouse model uses tumour tissue obtained from children during surgery, growing the cells in culture and subsequently transplanting the cells into the brain of immune-compromised mice,” he explained.

Test in the mouse model This latter mouse model (called orthotopic xenograft) more closely resembles the natural living microenvironment for tumour growth, allowing more accurate testing of novel targeted therapies that must also traverse the blood-brain barrier. There are other complexities. “For a genetically modified mouse to spontaneously develop the specific tumour you are trying to model, you need to put the right genetic defect identified in children’s tumours only into the correct cell type, otherwise, a variety of unwanted tumours, such as leukaemias, could develop. For example, we found that the important developmental oncogene NOTCH1 was abnormally amplified in childhood supratentorial ependymomas and the putative cell of origin was the radial glia cell. Frequently these tumours also showed concurrent deletion of the INK4a/ARF locus, which encodes for two important tumour suppressor genes. When you put that cocktail together, the mice develop ependymomas.” This very technical and intricate work takes many months. Tumours have to be genetically characterised using human genome data and the hope is the targeted mutation involves a critical gene, which oncologists call a tumour driver gene that is hopefully found across many tumour types and is susceptible to an inhibitor. “Ideally, you will have genetically engineered mouse model for every

Q Dr Nick Gottardo and with Tom and Emily

subgroup of a particular brain tumour type, because we now know that certain brain tumours may look the same under the microscope but they are actually distinct diseases at the molecular level.” Expense and time are against them in creating an ideal mouse model for testing badly needed novel molecular therapies directed at pathways critical for tumour survival. Then they can be moved into clinical practice.

Low toxicity clinical applications High cure rates in some brain tumours require extensive and safe surgical resection, radiotherapy to the whole brain and spine, and intensive chemotherapy, which often leaves children with severe long-term side effects that affect their quality of life. “Our aim is to identify new treatments that will be more effective and less toxic. The first step is to use a novel drug in clinical trials in children who have relapsed. If these are found to be effective the new drug is added

to the current standard care treatment in a randomised clinical trial to see if the new combination will improve survival.” Chemotherapy drugs on offer have generally been tested in clinical trials in adults for breast, colon and lung cancers. Their safety and side effect profile are therefore known in adults. Using the research mice, finding novel targeted therapies that work synergistically with current chemotherapy drugs seems best. However, tumours can up-regulate a sister pathway to by-pass the effect that a novel drug is having on a molecular pathway. “We are rapidly learning that we will have to assess these novel compounds in combination, to block multiple pathways simultaneously. And we can use these permutations and combinations in animal models to show success before taking them into clinical practice.”

Medulloblastoma as an example Nick is heading up a clinical trial for Q Paediatric brain tumour cells, transplanted into the brains of mice, have been altered to react with luciferin to emit light as a measure of tumour growth and response to treatment (shown here; d =days post-implantation).

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medulloblastoma – the most common malignant brain tumour in children – for North America, Canada and Australia so he knows this tumour’s behaviour well. It can mutate to become insensitive to some outstanding inhibitors that have been developed. In response, clinicians, as they would for the treatment of TB, attack the tumour at multiple levels with multiple drugs to prevent the development of resistant tumour clones. “We now know there are at least four molecular subgroups of medulloblastoma. In the near future, we will characterise a patient’s medulloblastoma according to the molecular signature of the tumour, which is important for accurate stratification and treatment. You may cure over 90% of tumours that have one particular signature, while another subgroup has the worst prognosis, as low as 20 to 30% survival. Knowing this at the beginning is important as you can modify treatment intensity according to the risk of relapse, so that patients with a worse prognosis receive more intensive and/or novel therapies. For those who do very well with current treatment, the aim is to reduce the more toxic components of therapy.� In this way, personalised medicine – matching the profile of the brain tumour and the patient’s genetic profile – will be used to predict response or side effects from particular drugs. Such treatment is already standard for childhood leukaemia, which has many subgroups that dictate the intensity of treatment, aimed at preventing relapses that carry a poorer prognosis.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

My Precious Children Being involved in the generation of more than 20,000 IVF babies, I have maintained a “fatherlyâ€? interest in their outcome, particularly WKH HDUO\ RQHV ² ´P\Âľ Ă€UVW LQ :$ LV DJH \HDUV WKLV \HDU *LYHQ WKH DGYHUVH PHGLFDO DQG VFLHQWLĂ€F FOLPDWH IRU ,9) LQ WKH 1970’s when I commenced this activity, I undertook a study with Paediatric colleagues Trevor Parry, Noel French and the late Freddy Grauaug on the “Developmental Assessment of Twenty IVF Infants at Their First Birthdayâ€? 7KLV ZDV WKH Ă€UVW VXFK VWXG\ LQ WKH :RUOG DQG ZDV SXEOLVKHG LQ -,9(7 On the basis of a range of studies evaluating their behaviour, locomotion skills, social interaction, hearing & speech, eye & hand coordination as well as general performance, we scored a general TXRWLHQW *4 DFFRUGLQJ WR WKH *ULIĂ€WKV Developmental Scales for children. This was WKH Ă€UVW HYHU VWXG\ WR VKRZ WKDW ,9) FKLOGUHQ were perfectly normal.

While techniques such as intensive chemotherapy, megatherapy with autologous stem cell rescue, intrathecal chemotherapy, and radiotherapy remain in the treatment mix, Nick’s research is aimed at working smarter and attacking the tumour molecularly.

International collaboration critical “The reasons why treatment of childhood cancers has been so successful – combined five-year survival rate of 80% across all childhood cancers – is that these tumours are in general more sensitive to chemotherapy and radiotherapy, children tolerate more intensive treatment, and the systematic use of international collaborative clinical trials has really made a difference to cure rates.�

Medical Director Dr John Yovich

Dr Chantel Thorn at UWA School of Dentistry

I have kept a close track of these 20 children and could tell many important stories, including the fact that high GQ scorers subsequently became high DFKLHYHUV 2QH RI WKHVH ZDV $XVWUDOLD¡V Ă€UVW ,9) DERULJLQDO FKLOG ² both parents being of Noongar descent.

He said worldwide collaboration is essential because treatment cohorts have shrunk as tumour subtypes have been defined. For over two decades now, Perth has been part of a large international US-based clinical trials group called the Children’s Oncology Group. “This allows us to offer families access to the latest cutting edge therapies and therapeutic approaches through clinical trials. It’s essential these days.� Nick finds himself e-mailing or ringing his old boss at St Jude to discuss complex or unusual brain tumour cases. This sort of mentoring is common in a relatively small global group of clinicians treating childhood cancer. O

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

Condolences to Gail & Len Thorn

With permission from Mum and Dad I can indicate that Chantel Thorn became an energetic and spirited personality who immersed herself in Aboriginal culture as well as graduating as a dentist from UWA. Sadly Dr Chantel Thorn died in March age 28 years from a VXGGHQ WKURPER HPEROLF HSLVRGH FRQVHTXHQW WR DQ DFXWH NQHH injury secondary to sporting trauma. This occurred in Alice Springs where Dr Chantel commenced practice determined to improve oral services for aboriginal communities. Chantel’s obituary was written up in The West Australian on Wed April 18 as “Broken Dreams� – Vale Chantel.

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33

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medicalforum

Guest Column

Dying in a Vaguely Horrific Society Geraldton GP Dr Bertel Bulten draws on his experiences in general practice and in the Netherlands to suggest the profession keeps the debate on euthanasia open.

A

horrific death is what my patient Mr Brown feared the most. Nearly 90 years old with metastatic bowel carcinoma, this ex-marine officer knew his end was nigh and he asked me if I could ensure he would die at home and in dignity. The latter meant not bed-ridden, not with an indwelling catheter, not having to take high-dose opioids and above all, not becoming totally dependent and incontinent.

of legislation of euthanasia here in Australia on the ABC’s Q&A (August, 2012). Euthanasia would lead to an indecent and "vaguely horrific society", he claimed. In this vaguely horrific society Mr Brown would have been confident that his wishes were respected and that his physician would be able to seriously consider his request, giving some piece of mind, even though tough restrictions would be put in place.

Upfront as he was, he asked me if I would help him with what he called “dying with dignity”. Reluctantly, but gratefully for the care he received, he had to accept this would not happen. A few months before he died at home, he slashed both his wrists in an attempt to hasten his death. He died exactly the way he feared so much, incontinent, drugged and emaciated.

The Netherlands, my country of origin, is one of these countries where 'active'/'voluntary' euthanasia has been legalised for 10 years. I come from this vaguely horrific society. It seems that the Dutch euthanasia legislation is supported across the board by population and politicians and scrutinised regularly. It also seems that the Netherlands is not sliding into a state of amorality and denial of the right to live. Euthanasia as a cause of death fluctuates around the 2-3% mark and has remained the same since legislation in 2002.

Recently, I heard Phillip Blond, a theologian/ philosopher, commenting on the possibility

In my 10 years as a GP in the Netherlands, I received regular requests for euthanasia

from terminally ill patients. Almost all died a natural death without the suffering that was so much feared, thanks to state-of-the-art palliative care. They died with the knowledge though, that under strict regulations, their wishes were seriously respected. The legalisation of euthanasia did not happen overnight; it required many years of discussion and profound debate in the political, religious, and public arena. As a GP in a regional town in WA, I enjoy the variegation of being a doctor here working with a broad spectrum of Australian society: Aboriginal people, sixth generation Australians, prisoners and migrants. It's a beautiful and colourful society and certainly not vaguely horrific. I understand the majority of Australians are supportive of legalising euthanasia. Let us therefore keep the debate open. To ensure a real debate we require careful investigation and serious listening to the public and our patients. Let us also look open-mindedly at so called 'vaguely horrific societies'. O

This October, remind your patients to have a free screening mammogram at BreastScreen WA

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DOH23344 SEP‘12

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Delivering a Healthy WA medicalforum

35

CLINICAL UPDATE

Refractive surgery choices

Dr Graham Furness, Ophthalmologist, Cataract & Refractive Surgeon

W

eye or corneal warpage (ectasia), and postoperatively there is less risk of significant injury with minor corneal trauma.

e will all experience or hear of the limitations of both imperfect vision and refractive aides. Whether this is fogging of the glasses behind a theatre mask, or the loss of peripheral vision detail when trying to sink that crucial long putt; or maybe surfing or sailing with the risk of sudden blurred vision due to a lost contact lens or salt sprayed glasses? Refractive surgery might avoid the frustration of being unable to read a text message until you have found your readers, or the embarrassing moment in the spa when you have hugged the wrong person! The opportunity to achieve good quality spectacle-free vision exists for most people.

Presbyopic solutions

Refractive error

Age-based choices

The need for glasses or contact lenses may develop by our teens or early 20s, due to myopia (weak distance vision), hyperopia (weak near vision) or astigmatism. This is due to the lens system of the eye (cornea + lens) not forming a focused image at the retina. By age 50 most have lost the ability to adjust between distance and near focus (presbyopia, or stiff lens). During our 60s and 70s lens opacity (cataract) can impair spectacle vision.

Refractive lens exchange vision correction is stable long-term, and avoids the need for cataract surgery later, but it disturbs any natural accommodation under age 50. Therefore RLE rarely is considered under age 45. Supplementary intraocular lenses do not disturb natural accommodation (suitable age 21 to 45), are reversible, and are well suited to treat high and extreme refractive errors (-6 to -20 and +4 to +10 diopters). Even low to moderate error correction results are at least equal to corneal laser outcomes. The contraindications to LASIK/PRK, such as thin corneas, corneal warpage (keratoconus) and healing disorders (rheumatoid, keloid), will usually not exclude supplementary intraocular lens surgery.

Refractive surgery overview Refractive surgery is very successful at treating the basic errors of myopia, hyperopia and astigmatism. Presbyopia treatment is however unable to restore full adjustment between distance and near focus. This means that independence from spectacles for those over age 50 is achievable, but with slightly reduced clarity compared to full spectacle correction. The most commonly used refractive procedures, with excellent track records, are: 1) Laser corneal reshaping, applied to the surface (photorefractive keratectomy, or PRK) or beneath a flap (laser assisted in situ keratomileusis, or LASIK), 2) Supplementary (phakic) intraocular lens implantation, and 3) Refractive lens exchange (RLE).

Laser vision correction LASIK and PRK are the most commonly used corrections for the pre-presbyopic age group. Advantages include bilateral same day surgery, and retained near vision adjustment until near the age of 50. LASIK has minimal discomfort and enables return to work after 2-3 days, while PRK has more discomfort, and requires 1-2 weeks to return to work. PRK is far less likely to induce dry

After age 50, correcting distance vision in both eyes leaves near vision that requires glasses. Natural lens changes will eventually cause a decline in distance vision in both Laser correction and phakic lens implant. This favours the use of refractive lens exchange (RLE) for stable long term results. RLE is essentially a cataract operation done before any visually significant opacity of the lens has developed. There are several choices of replacement intraocular lenses. Monofocal lens implants can be chosen to correct each eye for distance vision (requiring glasses for clear near vision), or alternatively the dominant eye is corrected for distant and non-dominant eye for near vision. This monovision configuration can provide independence from spectacles, and is very effectively demonstrated by temporary use of contact lenses, ensuring good understanding of what is achievable. Multifocal lens implants achieve balanced bifocal vision in both eyes. Halo and glare, and limited intermediate vision clarity (e.g. computer screen) can occur, and are difficult to demonstrate preoperatively. Occasionally halo and glare intolerance may require bilateral monofocal intraocular lens exchange. Supplemental and replacement lens surgery is typically performed one eye at a time, 1-2 weeks apart. Like LASIK, there is minimal discomfort and return to work after 2-3 days is usual. O

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37

Networks

Musculoskeletal machinations WA A

lot is happening in the musculoskeletal health world in WA, with clinicians getting together to solve problems in the public health sector despite overstretched resources and an increasing prevalence of musculoskeletal health conditions. Our ageing population and those living with chronic pain are prominent in their minds, no doubt.

Setting priorities The Musculoskeletal Health Network, which has more than 500 members, is putting the final touches to its “Service model for community-based musculoskeletal health in WA�. The document has been through expert hands and subjected to feedback, a process chaired by Dr Andrew Briggs (Senior Development Officer, Health Networks System Policy and Planning, HDWA). The final report is soon to be released. The model aims to pull together recommendations from all the musculoskeletal health Models of Care for WA (spinal pain, inflammatory arthritis, osteoporosis, and elective joint replacement surgery) and provide a blueprint of how to implement a comprehensive service for people with musculoskeletal health conditions in the community, Osteoarthritis, rheumatoid arthritis and osteoporosis have been Australian National Health Priority Areas since 2002, with the Australian National Pain Strategy also attuned to musculoskeletal health conditions.

Improving service delivery In WA, service delivery for musculoskeletal health conditions is acknowledged as inadequate, with a widening gap between demand and timely provision of appropriate patient services. This has focused attention on effective prevention, self-management that works, and a greater use of community-based services that are integrated and well-coordinated. To the casual observer, there appears to have emerged an overwhelming array of Models of Care, Strategic Frameworks, and other policy documents from Health Networks division of the Health Department. Bringing people together to agree on what is needed and the best way to deliver has been helpful. The challenge now is to find ways to put policy and recommendations into action. At least everyone will be on the same page and most likely heading in the same direction, with bridging frameworks such as Chronic Health Conditions Framework 2011-2016 and the WA Chronic Conditions SelfManagement Strategic Framework 2011-2015 that provide understanding across different health problems. Once released in its final form, the Musculoskeletal Health Network report will likely point out that planning or developing service delivery across different musculoskeletal conditions needs to emphasise:

medicalforum

t .VMUJQMF DPOEJUJPOT BSF DPNNPO PGUFO with musculoskeletal pain present. t .VTDVMPTLFMFUBM QSPCMFNT PGUFO DPNQMJDBUF other chronic health conditions. t 4FSWJDF EFMJWFSZ JNQSPWFT XIFO NVMUJQMF co-morbidities are addressed together. t $POTVNFST XIP XJMM CFOFGJU GSPN CFUUFS integration of tertiary and primary care. t -POH UFSN QMBOT BSF OFFEFE UP NFFU escalating demand for health services. An example of implementation of this initiative is the establishment of a multidisciplinary rheumatology service at Armadale Hospital, led by Dr Madelynn Chan from RPH.

Chronic pain Pain specialist Dr Stephanie Davies and others have demonstrated that appropriate triaging of patients in chronic pain, and early intervention with a multi-disciplinary team that need not include the pain specialist, can greatly reduce unacceptable wait times for these patients. This work has been recognised by Pain Australia the national body tasked with driving the implementation of the National Pain Strategy (www.painaustralia.org.au). It has recognised the innovative work being done in Western Australia by S. Davies et al, with commentaries making it into the MJA this year. People waiting, in pain, is not what anyone wants. The intervention that is working at Fremantle Hospital and elsewhere in WA is now being expanded successfully into the primary care setting: t 5IF 45&14 QSPHSBN JT OPX BWBJMBCMF BU Perth North Metro Medicare Local. t 5IF .VTDVMPTLFMFUBM )FBMUI /FUXPSL also delivered modified STEPS programs for consumers and pain education programs for health professionals across regional WA in 2010-11. t 8" )FBMUI JT EFWFMPQJOH B XFCTJUF GPS consumers with musculoskeletal pain to skill them in self-management.

Fragility fractures In early September, Perth hosted the 1st Asia-Pacific Bone and Mineral Research Meeting, incorporating the 22nd Australian and New Zealand Bone and Mineral Society Meeting. WA Health was the major sponsor. Inter-disciplinary clinical sessions tackled osteoporosis and falls prevention. The WA Osteoporosis Model of Care (www. healthnetworks.health.wa.gov.au) is a

comprehensive document answering common questions around screening, treatment, health promotion and prevention. It mentions the need to identify initial fractures with osteoporosis as a risk factor, and intervene to prevent further fractures. The WA Osteoporosis Model of Care recommended the establishment of fracture liaison positions within the health sector, to facilitate timely action around people who present with fragility fractures. The costeffectiveness and efficacy of these positions has been argued at a national level, as well as overseas. Locally, Charles Inderjeeth is leading a WA Health-funded project to examine the cost savings and clinical benefits of establishing a fracture liaison service in NMAHS

Nurse training Australian nurses can now access a complete online musculoskeletal nursing course through the Australian College of Nursing. It was developed by members of the WA Musculoskeletal Health Network, NSW Musculoskeletal Network and the Australian College of Nursing. The course firstly focuses on bone disease and inflammatory joint diseases, with connective tissue diseases and noninflammatory joint diseases to follow. Completing all four topics will attract a Graduate Certificate qualification (once accreditation is finalised, see www. nursing.edu.au). Some WA nurses may eligible for scholarships (Tel 9222 2378). O

By Dr Rob McEvoy ED. Thanks to Dr Andrew Briggs in compiling this article.

39

Innovation

Renal vascular access Renal experts struggle to keep up with demand, made harder by staff shortages and competing diseases. We preview the Renal Network’s upcoming report on vascular access. A group of experts is edging closer to the final report on Improving Vascular Access Services for Haemodialysis in WA (Department of Health, Health Networks Branch), having considered things in depth for the draft report. With more than 20 haemodialysis centres across WA, some satellite units and all patients under either RPH, SCGH or Fremantle, we take a sneak preview. Those with end-stage kidney disease (ESKD) and awaiting transplant usually need haemodialysis 3-4 times a week for 4-5 hours at a time. That is about 11 per 100,000 Australians, projected to increase by 80% to 19 per 100,000 in 2020.

Vascular access imperfections Surgical construction of a permanent vascular access (VA) for dialysis is a crucial step. It is best done as an arterio-venous fistula (AVF) as it is most durable and least likely to get infected. (The alternative is an artificial aterio-venous graft or AVG). But an AVF needs to be fashioned 8-12 weeks before first haemodialysis for it to mature and thicken its wall. The alternative is a temporary central venous catheter (CVC), which usually means more time in hospital and more infections. Despite this, CVC use in WA was 70% in 2010 and during 2010-11 blood stream infections in WA generated $1.2m cost with an additional 833 bed days and mortality rate of 25%. In fact, in 2010, permanent VA at the commencement of dialysis in WA patients was about 10% behind other Australian states in prevalence. The year before, an RPH state-wide review found problems of vascular access that still apply today:

radiologists, renal physicians, vascular access nurse coordinators. To meet international benchmarks, more staff is needed, particularly VA nurses, those doing surgical lists, VA nurse coordinators (found to be 50% short in 2009), and pre-dialysis educators. Regional and remote areas present a special challenge. A specialist VA nurse at satellite dialysis units, assessment aided by TeleHealth, ongoing access education for dialysis staff are in the proposed mix. General practitioners can play their part through earlier referral. For example, in 2009, 39% of new patients with ESKD were

referred late to nephrologists and 61% of these patients commenced dialysis with CVC, both not ideal. Identifying stage 3-5 CKD early and referring to nephrologists for vascular access planning are the keys. Surgical VA needs correct imaging and vessel mapping using ultrasound, followed by surgery not impinged by other emergency cases and done by experienced surgeons at least 90 days before the first dialysis. The 2009 review struck a high primary surgical failure rate of 60% (compared to 31-40% internationally). This was said to be clogging the system with repeat surgery that prolonged wait lists – surgeons being called on for early interventions to restore patency (angioplasty, stent, ligation of tributaries, vein patch, etc). In 2011, the primary patency in WA was about 80%, and secondary patency was about 50% (i.e. patency suitable for dialysis). Fee-for-service surgery at private outer metro or regional hospitals is seen to be helping meet demand. Some cases will be urgent but dedicated VA lists are needed, as are multidisciplinary VA teams at each of the hospitals performing VA surgeries. The key aim will probably be to increase the proportion of patients commencing haemodialysis with a functioning vascular access to >50% within three years. We will all need educating about the preservation of crucial veins from the ravages of frequent venepuncture and the

FACTS: Dialysis in WA t 5IF OVNCFS PG QFPQMF SFDFJWJOH EJBMZTJT USJQMFE CFUXFFO BOE UP NBLJOH up 13% of the total hospitalisations for 2009-10.

t MBUF SFGFSSBMT UP SFOBM QIZTJDJBOT

t 3FNPUF BSFB EJBMZTJT *OJUJBUFE JO FBSMZ T JO 8" EVF UP JODSFBTJOH SFGFSSBMT GSPN BSFBT 3000km from Perth with no local dialysis facilities. Now implemented systematically across Kimberley region.

t MBDL PG QSF EJBMZTJT OVSTF FEVDBUPST BOE VA access nurse coordinators

t $VSSFOUMZ "CPSJHJOBM "VTUSBMJBOT IBWF UJNFT UIF &4,% SBUFT PG OPO "CPSJHJOBMT Figures increased rapidly mid-1980s to mid-90s then plateaued in 2000s.

t QPPS WFJO QSFTFSWBUJPO QSBDUJDFT

t 5IF QFBL "CPSJHJOBM SJTL HSPVQ JT NJEEMF BHFE GFNBMFT UJNFT UIF OPO "CPSJHJOBM SBUF in 45-54yrs; females vs 10 times non-Aboriginal rate in 45-54yrs males. Tight correlation with socio-economic status.

t MJNJUFE EFEJDBUFE UIFBUSF TFTTJPOT for VA procedures t TIPSUGBMM PG BWBJMBCMF WBTDVMBS TVSHFPOT t 7" QBUFODZ JTTVFT t TIPSUDPNJOHT JO EBUB DPMMFDUJPO A lack of staff and skills in some remote and regional areas adds further disadvantage.

How do we tackle this? The final report is sure to say that a whole-ofhealth-system approach is needed to improve VA service and renal patient outcomes – predialysis educators, vascular access surgeons, 40

t 3BUFT PG EJBCFUJD OFQISPQBUIZ OPX JODSFBTJOH GBTUFS JO OPO "CPSJHJOBM "VTUSBMJBOT UIBO Aboriginal Australians = next wave of obesity epidemic playing out? t %JBCFUFT SFMBUFE LJEOFZ EBNBHF XBT UIF MFBEJOH DBVTF PG USFBUFE &4,% JO BDDPVOUJOH for 33% of new cases compared with 13% in 1991. t 5IF BWFSBHF BHF PG QFPQMF TUBSUJOH LJEOFZ SFQMBDFNFOU UIFSBQZ ,35 IBT SJTFO GSPN years in 1991 to 61 years in 2009. t " SJTF JO USBOTQMBOU OVNCFST IBT OPU LFQU VQ XJUI UIF JODSFBTJOH OVNCFS PG &4,% QBUJFOUT From 1991 to 2009, the proportion of treated ESKD patients with a functioning transplant decreased from 53% to 43%. Sources Dr Mark Thomas RPH and AHIW medicalforum

indiscriminate use of peripheral intravenous lines, peripherally inserted central catheters (PICCs) or central venous catheters. They can all damage veins, impair venous circulation and make surgical fistula construction or function impossible later.

Practitioner resources Finally, review of practices needs accurate relevant data. The WA Nephrology Database (WAND) helps monitor waiting times, surgical activity and outcomes but, according to the draft report, there are shortcomings in data collection and reporting due to staffing, lack of data standardisation across sites and WAND access at all renal sites. There is also some sense of deja vu. When the Renal Health Network (RHN) developed the “Chronic Kidney Disease Model of Care� in 2007 it made some key recommendations similar to those recommended for improving vascular access, all yet to be implemented. There is an obvious need for this group to keep pushing for change.

You can now prescribe exercise! As part of our commitment to health of Western Australia the team at Obesity Surgery WA, is now offering exercise programmes at no cost.

Q Kimberley satellite dialysis unit

To see what is happening to improve things, go to www.healthnetworks. health.wa.gov.au/network/renal.cfm. And to obtain a copy of Chronic Kidney Disease Management in General Practice go to www.kidney.org. au/HealthProfessionals/tabid/582/Default.aspx

Clinicians Surveyed WA Renal Health Network, as for many other network groups, has surveyed opinion on key issues, to help them shape their final Vascular Access report. The survey asked if people saw a need for improvements in services or systems, agreement or not with proposed recommendations of the draft report, and the level of agreement with recommendations in each section covering referral, access, educators, vein preservation practices, and vascular access nurse coordinators. Finally, respondents were asked to what degree they thought barriers existed to implementation, with room for comments. O medicalforum

To enrol, we need a referral to our practice for exercise. Everyone gets a health review to check their suitability and will get a personal plan or get to join one of our group sessions. The service is open to anyone who needs a little help to get fitter, even if they are not considering surgery. < Mr Harsha Chandraratna Surgeon Jo Climo > Clinical Nurse & Exercise Co-ordinator

Obesity Surgery WA (08) 9332 0066 SUBIACO

MURDOCH 41

Underwater Adventures

Dr Fiona Sharp

Doctors of the Deep Crayfish, shipwrecks, hyperbaric medicine and sharks – tall tales and true from three doctors who dive. By Mr Peter McClelland

Dr Russell Bock “I did my medical training at Monash and TUBSUFE EJWJOH JO 7JDUPSJB BCPVU ZFBST ago and now it’s a real passion. We’ve HPU B N CPBU BOE NZ UXP EBVHIUFST &SJO BOE $BUIFSJOF BSF CPUI LFFO EJWFST w TBJE ,BMMBSPP (1 %S 3VTTFMM #PDL i5IFSF BSFO U too many activities you can share with your teenage children but scuba diving is one of UIFN &SJO BOE $BUIFSJOF BSF NZ EJWF CVEdies and my wife, Jacky, often comes out in the boat. In summer we love heading out to 5SJHH *TMBOE UP HFU B GFX DSBZGJTI w 3VTTFMM EJE IJT EJWF NBTUFS DPVSTF BOE IJT daughters are also more than handy underXBUFS $BUIFSJOF IBT BO "EWBODFE %JWJOH 5JDLFU BOE JT GPDVTJOH PO NBSJOF TDJFODF BU 4U .BSZ T "OHMJDBO (JSMT 4DIPPM BOE &SJO JT in second year medicine at UWA. “It’s great being a doctor and a diver because I get asked along on Catherine’s school dive trips, which is fantastic. We’re very proud of CPUI PVS HJSMT &SJO T LFFO PO EPJOH SVSBM NFEJDJOF BOE JT PO B +PIO 'MZOO 3VSBM 4DIPMBSTIJQ

Five deaths in the past 10 months – I do get a bit nervous, especially when I’m diving with my daughters. Put it this way, we’ve invested in a shark shield. Dr Russell Bock 42

Q Friend Gavin, Dr Russell Bock and daughters Catherine and Erin at a rural practice in NSW. We’ve dived in TPNF FYPUJD MPDBUJPOT CPUI IFSF BOE PWFSTFBT *O 8" XF WF HPU /JOHBMPP 3FFG UIF 3PXMFZ 4IPBMT BOE UIF .POUFCFMMP *TMBOET 5IBJMBOE JT POF PG UIF MBTU XJMEFSOFTTFT BOE IBT HPU TPNF HSFBU EJWF TQPUT BOE 3PUUOFTU JT KVTU BNB[JOH UPP w

Dr Fiona Sharp

"OE UIF FMFQIBOU JO UIF SPPN 4)"3,4

“I’m one of four doctors at the hyperbaric chamber. We use different chambers and pressures with treatments using 100% PYZHFO o JU T RVJUF UFDIOJDBM FTQFDJBMMZ UIF MBSHF DIBNCFS %FDPNQSFTTJPO JMMOFTT JT RVJUF B SBSF EJTPSEFS 8F EP BCPVU USFBUments a year and Australia-wide it’s about UISFF UJNFT UIBU OVNCFS 5IFSF T OP EJBH-

i'JWF EFBUIT JO UIF QBTU NPOUIT o * EP get a bit nervous, especially when I’m diving with my daughters. Put it this way, we’ve invested in a shark shield. Nonetheless, I’d recommend diving to anyone. It’s easy to get a recreational dive ticket so just get out UIFSF BOE HJWF JU B HP w

'PS 'SFNBOUMF )PTQJUBM BOBFTUIFUJTU %S 'JPOB Sharp, diving has taken her all over the world. 4IF T BO FYQFSU JO UIF UFDIOJDBM BTQFDUT PG scuba diving and works one day a week at UIF %FQBSUNFOU PG %JWJOH BOE )ZQFSCBSJD Medicine at Alma St.

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What if? Sometimes a simple day in the sun can go horribly wrong. Carnarvon ED medico Dr Andy Foote tells of a nearmiss during a spear-ďŹ shing expedition at Coral Bay. “We had a couple of medical students who were spending a few weeks at Carnarvon Hospital. We press-ganged them into driving the boat while we went diving and XF TQFBSFE B CJH 4QBOJTI NBDLFSFM 5IF fish took off and four very large and agitated Bronze Whaler sharks appeared from OPXIFSF BOE EFDJEFE JU XBT NFBM UJNF w i5IF NBDLFSFM DPODMVEFE UIBU IJT CFTU option would be to hide among the three of us in the water, so there it was like a racing

Dr Fiona Sharp

OPTUJD UFTU GPS UIF A#FOET o JU BMM DPNFT EPXO UP DMJOJDBM KVEHNFOU o BOE UIFSF T OP PUIFS USFBUNFOU SFHJNF FYDFQU UJNF JO the chamber. i8JUI NZ EJWJOH FYQFSJFODF * N JO B HPPE position to assess whether someone OFFET USFBUNFOU w And sometimes, despite the relatively young age of the patients (average age is late 30s), even that’s not enough to achieve a complete cure. i5JNF EPFTO U IFBM BMM EFDPNQSFTTJPO illnesses and the worst ones never get healed. Most of these patients are quite young and often their diving practice isn’t at GBVMU *U T CBTJDBMMZ B AUJNF EFQUI JMMOFTT BOE it can happen even when you’re within limJUT PO ZPVS EJWF DPNQVUFS 5IFZ MM QSFTFOU with shoulder pain or a rash and say, ‘I didn’t do anything wrong’. And often they’re right o TUBUJTUJDT JO UIF 64 TVHHFTU UIBU BCPVU 70% of decompression illnesses occur XIFO EJWJOH TBGFMZ BOE JO TIBMMPX XBUFS w

a ‘free-flow’ when a valve blew and the air in my tank quickly turned into a line of vertical bubbles. We took 20 minutes to get back to the surface, courtesy of NZ CVEEZ T TJEF TMJOH w As for sharks, “I’ve been trying to spot a shark for BHFT * EP IBWF B TIBSL shield but I’ve never used JU 5IFSF T OFWFS CFFO B double-blind trial to prove if they work. My theory is don’t thrash around, don’t dive in risky conditions and make sure there’s someone CFUXFFO ZPV BOE UIF TIBSL 5IFSF BSF IVHF schools of hammerheads in the Galapagos Islands and I’d love to see them one day. 5IFZ SF TP CFBVUJGVM JO UIF XBUFS w

Dr Andy Foote Andy is a former South African who now XPSLT BU UIF &% BU $BSOBSWPO )PTQJUBM JT B IJHIMZ FYQFSJFODFE GSFF EJWFS “I’m used to working in remote locations. I’ve worked as a doctor in the oil and gas JOEVTUSZ JO "OHPMB ,B[BLITUBO BOE $IJOB One of the employment conditions with 3VSBM )FBMUI 8FTU XBT UP EP GJWF ZFBST SVSBM TFSWJDF BOE XF WF CFFO IFSF TJY ZFBST OPX

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“All that our medical student skippers DPVME IFBS XFSF MPVE HBSCMFE FYQMFUJWFT bursting through our snorkels. We had a good adrenaline-fuelled laugh about it later CVU JO SFUSPTQFDU JU XBT B DMPTF TIBWF w If you’ve had a ‘near miss’ or a ‘what if’ moment while doing adventurous things, Medical Forum would love to hear about it. Email editor@mforum.com.au

* MPWF JU VQ IFSF * WF GSFF EJWFE BMM PWFS the world and Carnarvon is one of the best spots I’ve ever seen. It’s very rugged and in the off-season you’ve got the place pretty NVDI UP ZPVSTFMG w "OEZ TBJE Free-diving with a spear in your hand is about as primal as you can get and not without its risks (see What if? above). A bleeding fish stuck on the end of a spear, throw a few TIBSLT JOUP UIF NJY BOE ZPV WF HPU B TBMU water cocktail that’s not for the faint-hearted.

I’ve free-dived all over the world and Carnarvon is one of the best spots I’ve ever seen. Dr Andy Foote “It is potentially risky but if you’ve done a bit of spear-fishing, you’re aware of the conditions in the water and you can make informed decisions about whether it’s safe to dive. But anywhere with lots of fish is going to have a healthy shark population. I’ve never seen a white pointer up here but I know they follow the whale migration as GBS OPSUI BT &YNPVUI w “I love it up here. Working as a GP in Perth with some sub-specialities such as dive and aviation medicals with some travel mediDJOF XPVME CF JEFBM JO UIF GVUVSF w O

Diving Safety Checklist t " EBZ DPVSTF DPTUT BCPVU

5IF NFEJDBM SJTLT BTJEF 'JPOB TBZT EJWJOH JT a great way to see the world and she’s dived JO TPNF FYPUJD MPDBUJPOT BOE IBT GPVOE IFSself in some sticky situations. “I’ve been stuck inside an engine-room on a wreck off Plymouth until my dive buddy found me, thanks to a very good torch. On another dive I was 70m below the surGBDF PG UIF 3FE 4FB BGUFS CFJOH UPME UIBU XF E GJOE UIF XSFDL BU N 5IFZ E QVU VT PO UIF XSPOH XSFDL *O 7BOVBUV * IBE

car going around the cones with the sharks TOBQQJOH BU JUT UBJM -VDLJMZ UIFZ XFSF NPSF focused on getting a mouthful of fresh mackerel than a chunk of human flesh covered in neoprene. One of the sharks bit the fish’s tail off so we grabbed it and the sharks backed off assisted by some sharp QSPET XJUI UIF UJQT PG PVS TQFBS HVOT w

t 0QFO 8BUFS %JWFS $FSUJGJDBUF 3FDPHOJTFE XPSME XJEF t .BY %JWF %FQUI N t $PTU PG (FBS JODM %JWF $PNQVUFS

t %JWF .FEJDBMT 416.4 www.spums.org.au

X See Dr Rob McEvoy’s diving Q Dr Andy Foote with a spot tusk fish at Ningaloo

the Whitsundays story on P44 43

Travel

Perfect – Above and Below the Water Put diving the Great Barrier Reef into next year’s ‘bucket list’. Beautiful one day, perfect the next and with pictures like these taken on the Great Barrier Reef near Cairns, there’s little wonder the slogan did wonders for Tourism Queensland. 5IFSF BSF QMFOUZ PG XBZT UP TFF UIF 3FFG from Cairns, the obvious one is taking the QMVOHF BOE HFUUJOH XFU 5IF SFFG JT TBGF EJWing between June and August. Snorkelling is an easy matter but if you want the full JNNFSTJPO FYQFSJFODF ZPV DBO TJHO VQ GPS EBZ EJWJOH DPVSTF PS JG ZPV SF QSPGJDJFOU just remember to pack your Open Water scuba ticket. Certified divers will have no trouble finding a boat to take you to the best spots on the

reef. Beginners are equally catered for with a number of carriers visiting the offshore reefs. Serious divers choose fast boats, giving them more time below checking out the TUVOOJOH NBSJOF MJGF 5BLF XXX EPXOVOEFSEJWF DPN BV BT BO FYBNQMF XJUI JUT GBTU 0TQSFZ 7 EBJMZ UPVST UIBU PGGFS GJWF IPVST JO UIF XBUFS BU UXP 0VUFS (SFBU #BSSJFS 3FFG EFTUJOBUJPOT 5IFZ IBWF B NBYJNVN PG people on board and the crew is friendly and efficient. A free glass-bottom boat tour of protected reef locations is also included. Most boats offer morning tea, and barbecue lunch, but look for tours that also offer guides on and in the water. Some charters even offer helicopter scenic tours. Any holiday involving the open sea, it’s always

a good idea to have a few Plan Bs up your sleeve and Cairns makes that part easy too. 5IFSF BSF TPNF CFBVUJGVM FDP TZTUFNT KVTU B comfortable day-trip away from the city. You are best to hire wheels, which gives you UIF GSFFEPN UP FYQMPSF VQ BOE EPXO UIF coast and into the rainforests. 1MBO UP WJTJU 1PSU %PVHMBT PO B 4VOEBZ UP catch the Anzac Park markets on the scenic GPSFTIPSF o BOE GSPN UIFSF ZPV BSF B TIPSU ESJWF UP UIF %BJOUSFF 3JWFS BOE SBJOGPSFTU A combined cable car and scenic train trip to ,VSBOEB JO UIF "UIFSUPO GPPUIJMMT UBLFT JO UIF 3BJOGPSFTU *OUFSQSFUBUJPO $FOUSF BU #BSSPO Falls station, with eating and browsing well DBUFSFE GPS JO ,VSBOEB TFF XXX LVSBOEB org). Add a crocodile park or rainforest tour to your itinerary but it’s best to book ahead (see www.skyrail.com.au). Attractions inland also include the Golden %SPQ 8JOFSZ XIFSF NBOHPFT BSF USBOTformed into tasty wine; the Jacques Coffee Plantation and ultra-light tandem flights. Stop for a break at the picturesque Mareeba townsite for a taste of iconic Queensland life. 4PVUI GSPN $BJSOT JT -BLF 5JOBSPP OFBS UIF Atherton township, with a scenic winding Gillies Highway trip through the tropical rainforests to get there. "OE UIFO UIFSF JT $BJSOT JUTFMG &YQFSJFODF UIF CVTUMJOH 3VTUZ T .BSLFUT 'SJ 4BU 4VO for some tasty local produce, make up a picOJD UIFO IFBE UP UIF &TQMBOBEF GPSFTIPSF "U UIF 3FFG )PUFM $BTJOP UBLF UIF MJGU VQ UP UIF SPPG BOE FYQMPSF UIF 8JMEMJGF %PNF 5IF DJUZ BMTP PGGFST B OVNCFS PG JOUFSFTUing guided walks and in the evening dine at one of the many seafood restaurants dotted around the waterfront. 1SFUUZ QFSGFDU O

By Dr Rob McEvoy

44

medicalforum

Wine Review

BAROSSA FINESSE AT

Glen Eldon By Dr Louis Papaelias 2006 Twisted Trunk Reserve Shiraz 5SBEJUJPOBMMZ WJOJGJFE GSPN ESZ HSPXO WJOFT QMBOUFE JO UIJT GMBHTIJQ XJOF JT POMZ SFMFBTFE JO FYDFQUJPOBM WJOUBHFT 5IFSF JT FOPSNPVT EFQUI PG GMBWPVS BOE DPODFOUSBUJPO JO UIF NPVUI 'BCVMPVT CFSSZ TQJDF MFBUIFS DIBSBDUFST BMM JO JNQFDDBCMF CBMBODF 3JDI GVMM BOE MPOH BOE ESJOLJOH CFBVUJGVMMZ *U T BO PVUTUBOEJOH XJOF UIBU TIPXT UIF #BSPTTB &EFO 7BMMFZ BU JUT CFTU

In 1997 the Sheedy family established Glen Eldon Wines on the Eden Valley property bearing the same name. However, it was ďŹ rst settled by the Herbig family in the 1880s and they grew vines, fruit trees, cattle and sheep. They built the cellar in 1890 along with the house and stables. Richard Sheedy is a highly experienced winemaker, who was for many years winemaker/manager at Elderton and St Halletts Wines. His knowledge of the various sites, soils and micro climates of the Barossa and Eden Valleys has led to a very distinctive portfolio with each wine displaying the unique character of its origin and grape variety. The famed richness of Barossa fruit is evident throughout the range, yet never appears out of balance. It’s an impressive range of skilfully crafted wines displaying ďŹ nesse and character and varying in quality from very good to outstanding.

2009 Black Lady Shiraz )FSF T BOPUIFS PVUTUBOEJOH GMBHTIJQ XJOF o UIJT UJNF DPNJOH GSPN B CMFOE PG UXP WJUJDVMUVSBM SFHJPOT .VOBSJ 8JOFT -BEZ T 1BTT 4IJSB[ GSPN )FBUIDPUF 7JDUPSJB BOE (MFO &MEPO T #MBDL 4QSJOHT 3FTFSWF 4IJSB[ DPNCJOF UP QSPEVDF B GBCVMPVT XJOF 3JDI QMVNT BOE DIPDPMBUF XJUI PWFSMBZT PG QFQQFS BOE TQJDF PO B background of firm but clean, fine tannins have resulted in a super-premium wine. Only 400 bottles were made. 2010 Dry Bore Shiraz 5SBEJUJPOBM WJOJGJDBUJPO UFDIOJRVFT BOE NBUVSBUJPO JO CPUI 'SFODI BOE "NFSJDBO casks for 24 months have produced a powerful wine showing richness and finesse. While not having quite the concentration and length of the flagship XJOFT BCPWF JU JT FYDFMMFOU BOE DBO FBTJMZ UBLF B GFX ZFBST PG CPUUMF BHF 2010 Grenache A particularly pleasing wine showing the attractive, open-knit fruit flavours of the Grenache grape in all its glory, balanced with just enough acidity and soft fine tannins. A great accompaniment to Italian and Spanish style dishes. 2010 Cabernet Sauvignon Another well-crafted highly flavoured wine showing its rich fruity Barossa roots with the unmistakeable tannin backbone of the Cabernet grape. A quality Cabernet that will age well and will partner parmigiano cheese and any red roast well. 2010 Kicking Back Cabernet Shiraz Made for immediate consumption, this is an attractively drinking (and packaged) CMFOE PG UIF UXP DMBTTJD #BSPTTB WBSJFUJFT 5IF QBMBUF JT DIPDL GVMM PG TQJDF BOE QFQQFS UIF BSPNB SFEPMFOU PG SJQF CFSSJFT BOE DIPDPMBUF 7FSZ HPPE JOEFFE

WIN a Doctor’s Dozen! What two wine regions combine to produce the Black Lady Shiraz? Answer:

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ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, October 31, 2012. To enter the draw to win this month’s Doctors Dozen, return this completed coupon to ‘Medical Forum’s Doctors Dozen’, 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

Name:

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Please send more information on Glen Eldon Wines offers for Medical Forum readers.

Q Richard Sheedy plunging Twisted Trunk Shiraz

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45

Culture

Of earth & sky &

Love

Traditional culture is the continuous thread that finds inspirational expression in the work of Bangarra Dance Theatre.

Pictures: Andy Solo

It’s an impossible concept for dancerchoreographer Stephen Page to talk about his life and work without also talking about his culture, his family and the storytelling spirit which courses through his veins. He understands with every ďŹ bre of his being what Prof Pat Dudgeon and Dr Tom Calma say about their studies pointing to connection with culture as being a powerful insulation, which may prevent indigenous people from taking their own lives. He, too, has lost family members to suicide. 5IF BSUJTUJD EJSFDUPS PG #BOHBSSB %BODF 5IFBUSF IBT CFFO CSJOHJOH UIJT SJDI JOEJHenous culture into the theatre and across the nation for more than 20 years but the inspiration goes much deeper and has its roots as a teenager growing up in Brisbane as the 10th child in a family of 12 children. “I was brought up in suburban Brisbane o NZ GBUIFS JT B GSFTIXBUFS NBO GSPN UIF Yugambeh tribe, Munaldjali clan; my mothFS %PSFFO JT B TBMUXBUFS XPNBO GSPN UIF Nunukul- Ngugi mob from Stradbroke Island. 5IFZ XFSF GPSCJEEFO UP DPOOFDU XJUI DPVOtry, and with 12 kids it was really about keeping a roof over our heads and food on the table. In a big family your energies are absorbed by the madness that’s big families, TP * XBT HPOF UP EBODF TDIPPM CZ w “It wasn’t until I was at dance college that I connected with living traditional cultures, XIFUIFS UIFZ CF GSPN UIF $FOUSBM %FTFSU UIF ,JNCFSMFZ 5PSSFT 4USBJU PS QBSUJDVMBSMZ "SOIFN -BOE 5VUPST XPVME HJWF XPSLTIPQT 5IBU T XIFSF * XBUDIFE BOE MFBSOFE BOE DBNF UP TFF XIBU B HMPSJPVT DVMUVSF XF IBE w Stephen’s own spiritual journey led him to OPSUI FBTU "SOIFN -BOE XIFSF IF XBT welcomed into the family of the Yirrkala traditional landowners. He said he and his CSPUIFST 3VTTFMM BOE %BWJE iUIFTF GBJS TLJO 46

was commissioned in 2010 and Stephen EFTDSJCFT JU BT B iHSFBU FWPMVUJPO XPSLw UIBU CFHBO BMM UIPTF ZFBST BHP JO "SOIFN -BOE 5IF TLZ FMFNFOU UP UIF QSPHSBN IBT CFFO DSFBUFE CZ ZFBS PME %BOJFM 3JMFZ .D,JOMFZ XIP VTFT UIF QIPUPHSBQIT PG IJT DPVTJO .JDIBFM 3JMFZ XIP EJEO U MJWF UP see the magic the young dancer weaved GSPN IJT TUVOOJOH QJDUVSFT 5IF SFTVMU TBZT Stephen, is a thrilling, abstact contemporary work with a traditional aesthetic. i5IF GVSUIFTU %BOOZ DPVME HP CBDL UIF DPVOtry was to his cousin Michael, who was just BT DPOUFNQPSBSZ BT %BOJFM )F DBNF GSPN an assimilated clan so the cultural language was hard to embrace, or borrow or rekindle so the work is really a cleansing and a healing FYQSFTTJPO PG UIBU w VSCBO NPCw XFSF FNCSBDFE BOE UJNF TQFOU there was full of creating and storytelling. i* DPVMEO U TUPQ EBODJOH BOE DSFBUJOH 5IFZ thought I was some mad dreaming stoSZNBO 5IFZ BMXBZT CFMJFWFE * IBE UIBU spirit in me and I don’t think it’s ever left me. People say I’m obsessed with wanting to have this connection with traditional living and language that I didn’t get from my own VQCSJOHJOH 5IFSF T BO BSSBZ PG DIBMMFOHFT that come with that but I always keep optimistic about celebrating it, especially in our climate now, where indigenous people are challenged and somehow punished if they DFMFCSBUF CFJOH JOEJHFOPVT w Stephen is also aware of the danger of romanticising traditional culture and the need UP FWPMWF CVU OPU BU UIF FYQFOTF PG EBNBHJOH the integrity of the original. i* RVFTUJPO DPOTUBOUMZ JG JU T 0, GPS B DPOtemporary clan like Bangarra to tell traditional stories through dance theatre in the 21st century, but what I love is that we have evolved UP IBWF UIJT HSFBU DBSFUBLJOH SFTQFDU o UIFTF 'JSTU /BUJPO QSPUPDPMT o UIBU T FWJEFOU JO BMM PVS DSFBUJWF QSPDFTTFT w 5IJT NPOUI #BOHBSSB %BODF 5IFBUSF QVUT on a celebration of culture at the Mandurah Performing Arts Centre. Earth & sky

5IF PUIFS IBMG PG UIF CJMM JT "SUFGBDU DIPSFPHSBQIFE CZ #BOHBSSB T 'SBODFT 3JOH XIP draws from traditional stories of her own ,PLBUIB DMBO JO 4PVUI "VTUSBMJB 5IFSF T OP FOE PG JOTQJSBUJPO GPS 4UFQIFO and his dance clan, and he was reminded of that in no uncertain terms when he took IJT DPNQBOZ UP "SOIFN -BOE GPS XPSLshops recently. “We did this huge show with costumes and MJHIUT o KVTU MJLF XF E EP JU PWFSTFBT "MM UIF old aunties asked me, ‘how long have you been doing this’. When I told them for 20 years, they laughed and said, ‘that’s nothJOH y ZPV IBWF UP CF UIFSF ZFBST CFGPSF ZPV SF EPOF 4P * WF KVTU CFHVO w O

By Ms Jan Hallam

WIN See Competitions page for your chance to win tickets to earth & sky

medicalforum

Car Review

More than a

Pretty Face The Jeep Grand Cherokee puts some luxury back into a 4WD workhorse – if you don’t mind getting it scratched. As one of the State’s regular gravel rally competitors, I am conscious that the second most important car you own (the ďŹ rst being the rally car, of course) is the one you use to tow your wicked machine to the next event. Generally our rally events are at least a two-hour drive from Perth and so having a competent (and comfortable) towing vehicle is important. Competitors usually drive over the course and make ‘pace notes’ so that we can really push the rally car. If the towing car can double as your pace-note car, then you are well sorted. So the chance to review the Jeep Grand $IFSPLFF XBT UPP HPPE UP NJTT 5IF FYJTUJOH XPSLIPSTF GPS NF JT PVS USVTUZ 5PZPUB 1SBEP how would the Jeep compare? *OJUJBM JNQSFTTJPOT BSF WFSZ QPTJUJWF 5IF +FFQ IBT UIF NPEFSO 8% BQQFBSBODF JO UIBU JU seems to be similar to the older models, but PO TUFSPJET 5IFSF JT B QMFUIPSB PG GVODUJPOT accessible from the steering wheel,which are more daunting than anything else. But despite my hesitancy and thoughts of ‘how on earth am I going to remember all this?’ it really is very straight forward. Within half an hour I am starting to feel more confident that I won’t start something VOJOUFOEFE 5IFSF JT B WFSZ VTFGVM AWPJDF recognition’ function for the radio and blue tooth mobile phone device and changing radio stations, using the phone, is relatively simple. Needless to say there is electronic everything o GSPN NPWJOH BOE QPTJUJPOJOH TFBUT NPWJOH wing mirrors, rain-sensing windscreen wipers, automatic full beam dip headlights

medicalforum

and the list goes on. Hopefully the electronic wizardry is as robust as it is sophisticated. 5IF BVUPNBUJD SFBS WJFX DBNFSB XIFO engaging reverse is complemented by the side mirrors gently turning down to BMMPX ZPV UP NJTT UIPTF BOOPZJOH LFSCT " high-intensity torch plugged into the car’s charging circuits is in the passenger side of the boot, which is useful for myriad reasons, great and small. What’s very clear is that the days of tinkering with the car on a Sunday morning are gone unless you have a degree in electrical engineering.

Needless to say there is electronic everything – from moving and positioning seats, moving wing mirrors, rain-sensing windscreen wipers, automatic full beam dip headlights and the list goes on %SJWJOH UIF (SBOE $IFSPLFF DPVMEO U CF FBTJFS o UIFSF T QMFOUZ PG QPXFS NPSF UIBO adequate braking and great visibility to go with the comfortable and well-equipped JOUFSJPS 5PXO ESJWJOH JT B CSFF[F BOE BOZ open road gives plenty of opportunity to UISFBUFO ZPVS MJDFODF BOE BNBTT NPSF QPJOUT On the gravel roads it is sure-footed and EFDFQUJWFMZ BDDPNQMJTIFE 5IPTF BOOPZJOH corrugations are soaked up with ease and there is no feeling of ‘floating’ on the dirt. 5IFSF BSF B OVNCFS PG ESJWF TFUUJOHT GPS EJGGFSFOU SPBE USBDL DPOEJUJPOT CVU * KVTU

Review by Dr Mike Civil

plumped for ‘Auto’ and left it to the computer. 5IF +FFQ JT B CJU PO UIF MBSHF TJ[F GPS B ANFEJVN TJ[FE 8% CVU UIBU TFFNT UP CF the fashion. Unfortunately there was no tow hook, so I didn’t get the chance to drag the 3BMMZ &WP BSPVOE BOE TFF IPX UIF +FFQ performs with a couple of tonnes behind her. Certainly, there is every suggestion of total confidence on that score, particularly given UIF QFSGPSNBODF PG UIF CSBLFT 5IF MBSHF EJTDT BSF DMFBSMZ WJTJCMF CFIJOE UIF w BMMPZT and pull the car up confidently and smoothly. 5IFSF JT QMFOUZ PG TQBDF JO UIF CPPU XJUI B full-sized spare hidden away neatly under the floor but there did not seem to be any GBDJMJUZ GPS QVUUJOH JO BO FYUSB SPX PG TFBUT TP I guess that’s one up for the trusty Prado). However, my 183cm son had no problems in the back seat and was pleased (“that’s totally TJDL w UP TFF UIF 64# QPSUT TP UIBU IJT FWFS present iPhone could join the party. $PNJOH CBDL UP NZ VOGBJS DPNQBSJTPO ageing Prado, or brand new Jeep. Certainly the features and comforts would make USBWFMMJOH UP UIF OFYU SBMMZ FWFOU B MPU NPSF pleasant in the Jeep. But the tracks are pretty narrow and rough and while I have every confidence the Jeep would cope with the terrain, I would feel pretty nervous about pushing along through some of that scratchy CVTI #VU QFSIBQT UIBU JT KVTU UIBU OFX DBS old car divide. 5IF +FFQ JT B MJUUMF MBSHF GPS B HSBWFM CBTIJOH FYQFSJFODF BOE ZFU JU JT WFSZ XFMM FRVJQQFE to be more than just a tarmac cowboy. Now if I can just get the Jeep dealership to put on a tow hook. O

47

Photography Competition

2nd

1st

Ready For ACTION Action frozen in a moment makes for some fascinating photo studies. This month our doctor-photographers have taken a broad interpretation of the topic – “And ‌ Actionâ€? – from the thrilling moment of a giant bubble just out of reach, to a craze of city lights, even an Outback “Bond girlâ€?. First: %S +BOJOB "OEFSTU QJDLFE VQ IFS DBNera just at the right time to capture this thrilled young boy try to catch a bubble. Second: %S $BSPM .D(SBUI T USJQ UP Mozambique has yielded some wonderful pictures. Here a young soccer playing trains with a ball made from condoms Carol adds the condoms were “no doubt donated for PUIFS QVSQPTFT w Third: %S 1FUFS 3BOEFMM T QJDUVSF PG UIF FYDJUFNFOU PG B TU DFOUVSZ 1FSUI DJUZ GSPN the South Perth foreshore. It was shot with B /JLPO % USJQPE NPVOUFE BOE [PPNFE EVSJOH FYQPTVSF TFD ! G BU *40

3rd

5IFO JO OP QBSUJDVMBS PSEFS 1 Practice manager Ms Jo Marks captured her husband in adrenaline-fuelled euphoria at Adventure World. 2 It’s not every day you see an old Aston Martin and a French traveller together PVUTJEF UIF $PPMHBSEJF 3BJMXBZT TUBUJPO CVU %S $IBSMFZ /BEJO QVU UIF UXP UPHFUIFS for this cheeky shot. %S 4VTBO %PXOFT DBVHIU IFS UXP ZFBS old grandson Jarrah checking the tube slide just prior to launch.

1

** Snappers ‌ get in the mood for summer with the theme “Summertime‌ and the living is easyâ€?. 5IF CFTU QJDUVSFT XJMM CF QVCMJTIFE JO our first issue back after our summer break in February, 2013. Send pictures UP FEJUPS!NGPSVN DPN BV Medical Forum.

2

Strike up the Band The City of Albany Band recently took its ninth Queen’s Cup brass band competition and Albany GP Dr Jim Lie kept meticulous time (under the watchful eye of his percussionist wife Sue). 5IF DJUZ PG "MCBOZ #BOE TUBSUFE in 1880 and is one of the oldest continuous bands in the country. It has been competing at the 48

Queen’s Cup in Busselton for the past 11 years but was short of a percussionist this year, which is where Jim comes in. Jim is an accomplished violinist though Sue, who is a talented multi-instrumentalist, had been given Jim some tutoring in the finer art of percussion. “I didn’t make too many mistakes, well none that you could hear and we won by POF QPJOU o JU XBT WFSZ DMPTF * XBT QSFUUZ relieved because if we didn’t win, it would IBWF CFFO NZ NJTUBLF w Jim and Sue have a very musical life in the

medicalforum

funnyside e Q Q A Patient’s Revenge An older gentleman had an appointment to see the urologist who shared offices with TFWFSBM PUIFS EPDUPST 5IF XBJUJOH SPPN was filled with patients. As he approached the receptionist's desk, he noticed that the receptionist was a large, unfriendly woman who looked like a Sumo wrestler. He gave her his name. In a very loud voice, UIF SFDFQUJPOJTU TBJE “Yes, I have your name here; you want to see the doctor about impotence, right?� All the patients in the waiting room snapped their heads around to look at the very embarrassed man. He recovered quickly, and in an equally loud voice replied, “No, I’ve come to inquire about a sex change operation but I don’t want the same doctor that did yours.� 5IF SPPN FSVQUFE JO BQQMBVTF

Q Q A Conversation

in Heaven

3

city. Jim’s violin had been dormant during his university and junior doctor years but one day in 1998 he saw an advertisement for the doctor’s orchestra and he’s been playing ever since. And he relishes the opportunity to bang drums and make a noise.

5XP DMPTF GSJFOET NFFU in Heaven. SYLVIA: )J 8BOEB WANDA )J 4ZMWJB How'd you die? SYLVIA: I froze to death. WANDA: )PX IPSSJCMF SYLVIA: It wasn't so bad. After I quit shaking from the cold, I began to get warm and sleepy, and finally died a peaceful death. What about you? WANDA: I died of a massive heart attack. I suspected that my husband was cheating, so I came home early to catch him in the act. But instead, I found him all by himself JO UIF MPVOHF XBUDIJOH 57 SYLVIA: So, what happened? WANDA: I was so sure there was another woman there somewhere that I started SVOOJOH BMM PWFS UIF IPVTF MPPLJOH 5IFO I went through every closet and checked under all the beds. I kept this up until I had looked everywhere, and finally I became so FYIBVTUFE UIBU * KVTU LFFMFE PWFS with a heart attack and died. SYLVIA: 5PP CBE ZPV EJEOhU MPPL JO UIF GSFF[FS o XF E CPUI TUJMM be alive.

Q Q Too Cute for Words Madge comes home having just been to TFF IFS %PDUPS i4UBO 4UBOw TIF TIPVUT Stan begrudgingly looks up from his QBQFS i8IBU MPWF w IF TBZT i*WF KVTU CFFO UP TFF UIBU %S 5IPNBT BOE IF TBJE * IBWF B OJDF GBOOZ w .BEHF blurts out. i8IBU w TIPVUT 4UBO i the dirty bastard, I'm OPU IBWJOH UIBU w With that, Stan grabs Madge's hand and marches her down to the surgery. He rushes in, with Madge in tow, throws the consulting room door open and DPOGSPOUT %S 5IPNBT “Is it right you said my Madge has a nice GBOOZ w TIPVUT 4UBO %S 5IPNBT CVTZ TDSJCCMJOH TPNF OPUFT looks up bewildered, thinks about JU BOE DBMNMZ TBZT “Of course not Mr Smith, I said * UIPVHIU TIF IBE BDVUF BOHJOB w

Q Q Taking Note An elderly couple with memory problems are advised by their doctor to write notes to help them remember things. One FWFOJOH XIJMF XBUDIJOH 57 UIF wife asks her husband to get IFS B CPXM PG JDF DSFBN i4VSF w he says. i8SJUF JU EPXO w she suggests. i/P w IF TBZT i* DBO SFNFNCFS B TJNQMF UIJOH MJLF UIBU w “I also want strawberries and whipped DSFBN w TIF TBZT i8SJUF JU EPXO w i* EPO U OFFE UP XSJUF JU EPXO w IF JOTJTUT IFBEJOH UP UIF LJUDIFO 5XFOUZ NJOVUFT later he returns, bearing a plate of bacon and scrambled eggs. i* UPME ZPV UP XSJUF JU EPXO w IJT XJGF TBZT i* XBOUFE GSJFE FHHT w

“My wife keeps an eagle eye on me and the stress is terrible. But I can wear it. It’s good for the brain to learn someUIJOH OFX w O

medicalforum

49

Musical Theatre

17 Dancers and Tim Lawson’s

Dream

Former WAAPA grad and Sorrento boy Tim Lawson comes home this month with a world-hit on his hands. Tim Lawson’s story is the stuff of showbiz legend. Known in East Coast circles as a successful producer of a summer season of circus shows at the Sydney Opera House, the Glasgow-born, Perth-raised WAAPA graduate is now putting on some of the hottest shows of the year. It’s Perth’s turn this month when his hit production of A Chorus Line opens at the Crown 5IFBUSF 1FSUI GPSNFSMZ #VSTXPPE 5IFBUSF In November his multi-million dollar show, Chitty Chitty Bang Bang will debut in Sydney. Fast forward to February and he’ll be putting A Chorus Line into one of the biggest theaUSFT PO UIF 8FTU &OE UIF -POEPO 1BMMBEJVN "OE UIFSF T NPSF IJT WBSJFUZ DJSDVT QSPEVDtion, The Illusionist is touring South America. 5JN -BXTPO IBT DPNF B MPOH XBZ GSPN UIF hard slog of being a song and dance man in shows such as Phantom of the Opera, Me and My Girl and How to Succeed in Business Without Really Trying. i* HSFX VQ JO (MBTHPX VOUJM * XBT BOE trained to be a ballet dancer at the Scottish Ballet School. We all moved to Perth just as WAAPA was opening so I auditioned and HPU JOUP UIF NVTJDBM UIFBUSF DPVSTF 5IFO * began my stage career, heading over east BOE TUBZFE CVTZ GPS TJY ZFBST 5JN JT CFIJOE UIF DVSUBJO OPX GPDVTJOH DPNpletely on the production side of blockbuster 50

By Mr Peter McClelland

“Mum, who still lives in Sorrento, is pretty thrilled with it all too because I fly her to FWFSZ PQFOJOH OJHIU 4IF T BT FYDJUFE BT me that we’re taking A Chorus Line to the -POEPO 1BMMBEJVN w It’s A Chorus Line that has been the engine of his recent success. It opened in Adelaide MBTU %FDFNCFS BOE XBT B SFBM ATMFFQFS IJU playing to packed audiences over five weeks. 5IF .FMCPVSOF TFBTPO HSPTTFE N 4ZEOFZ IBE BO FYUFOEFE TFBTPO HSPTTJOH N B XFFL BOE OPX UIFSF T 1FSUI BOE -POEPO UP DPNF

theatrical shows. It was a case of realising the limitations of being a performer and the HMJNNFS PG BO PQQPSUVOJUZ UIBU OVEHFE 5JN into the producer’s chair. i* XBT VOEFSTUVEZJOH 5PN #VSMJOTPO JO How to Succeed in Business and a friend of his, (film producer) Mark Pennell had funding for Sweet Charity but wasn’t too sure how UP HFU UIF TIPX VQ BOE SVOOJOH &WFO BT a performer I’d always been interested in the management side of things and this was a perfect opportunity. Sweet Charity XBT NZ GJSTU TIPX BOE PQFOFE JO * WF had some great breaks in the industry. The Illusionist only happened because of a gap in the Sydney Opera House program and now it’s touring all over the world. I feel very CMFTTFE UP IBWF UIJT XPOEFSGVM DBSFFS w

i5IFSF T TVDI B IBQQZ FOFSHZ XJUI A Chorus Line 5IFZ DPVME TFF * IBE B QBTTJPO GPS UIF show in America and that comes through in UIF QFSGPSNBODFT * MPWF UIF TIPX *U IBTO U CFFO EPOF JO -POEPO TJODF JUT PSJHJOBM TFBTPO JO BOE UIF GBDU UIBU XF WF EPOF UIF revival proves that Australia is very much on UIF JOUFSOBUJPOBM SBEBS w i5IF 1FSUI TIPX XJMM IBWF B NJY PG 8""1" HSBEVBUFT BOE DFMFCSJUZ o Dancing With the Stars judge Josh Horner is terrific. It’s a perfect cast and it will be great to see the theatre full of people and absolutely loving UIF TIPX w O

WIN For your chance to win tickets to A Chorus Line, go to www.medicalhub.com.au

medicalforum

Competitions

Entering Medical Forum’s COMPETITIONS has never been easier! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).

Movie: To Rome, With Love After a hit with Midnight in Paris, veteran director Woody "MMFO JT UVSOJOH IJT BUUFOUJPO UP 3PNF BDDPNQBOJFE CZ B TUFMlar cast in one of the world’s most beautiful cities. Penelope $SV[ "MFD #BMEXJO +FTTF &JTFOCFSH The Social Network), &MMFO 1BHF +VEZ %BWJT BOE 3PCFSUP #FOJHOJ KPJO GPSDFT GPS this romantic comedy, as four storylines all lead to love and PUIFS DBUBTUSPQIFT JO 3PNB At Luna and Luna SX from October 18

Theatre: The Danny Kaye Show Music: Anthony Marwood and Aleksandr MadĹžar 7JPMJOJTU .BSXPPE BOE QJBOJTU .BE[BS IBWF CFFO GSJFOET and collaborates for 20 years and their instinctive musical making has had audiences swooning everywhere they play. .VTJDB 7JWB JT UPVSJOH UIF EVP XJMM QMBZ BO FDMFDUJD QSPHSBN GSPN DPOUFNQPSBSZ DPNQPTFS (PSEPO ,FSSZ UP %FCVTTZ Beethoven and Schubert. Perth Concert Hall, November 15, 7.30pm

Dance: Bangarra Dance Theatre 5IF FWPDBUJWF #BOHBSSB EBODFST QSFTFOU UXP XPSLT JOTQJSFE by old and new customs in a theatrical fusion of dance and visual art. Commissioned by Bangarra’s artistic director, Stephen Page, of earth & sky features the works of DFMFCSBUFE DIPSFPHSBQIFS 'SBODFT 3JOHT BOE %BOJFM 3JMFZ .D,JOMFZ JO IJT DIPSFPHSBQIJD EFCVU 5IJT OFX XPSL IBT this critics raving. Mandurah Performing Arts Centre, October 31, 7.30pm

Music: Remembrance Concert *OUFSOBUJPOBMMZ BDDMBJNFE PSHBOJTU %PNJOJD 1FSJTTJOPUUP XJMM present a moving program paying tribute to those who have lost their lives in war in the beautiful surrounds of the St Patrick’s Basilica in Fremantle. Hear Australian composer (FPSHF 5IBMCFO #BMMhT NFEJUBUJWF Elegy, famously perGPSNFE BU UIF GVOFSBM PG %JBOB 1SJODFTT PG 8BMFT JO BT XFMM BT XPSLT CZ $FTBS 'SBODL &MHBS BOE -JT[U Basilica of St Patrick, November 11, 2.30pm

%VSJOH UIF T BOE T %BOOZ ,BZF XBT IBJMFE the greatest entertainer in the world with Hollywood IJUT TVDI BT 5IF 4FDSFU -JGF PG 8BMUFS .JUUZ TPPO to be a movie starring Ben Stiller), and sell-out variFUZ QFSGPSNBODFT PO #SPBEXBZ BOE UIF -POEPO Palladium. He was also one of the first celebriUZ BNCBTTBEPST GPS 6/*$&' /PX 8PSME $PNFEZ *NQSPWJTBUJPO DIBNQJPO 3VTTFMM 'MFUDIFS CSJOHT UIF [BOZ XPSME PG %BOOZ ,BZF UP UIF 1FSUI TUBHF Subiaco Arts Centre, competition tickets are for the 2pm session on November 10. Other shows November 14 and 17 at 2pm

A warm welcome home from Gilber ts JOFT

IF (JMCFS UT 8 5IF XJOOFS PG U (1 JT (MFOHBSSZ FO P[ %PDUPS T % and ne ay W . ar tin Dr Wayne M ren ild ch wife and his medico st pa e th r fo al Nep have been in ed ttl se w d have no nine years an FS UT MJGF 5IF (JMC " 8 UP JO CBDL SF TV FO TIPVME NJYFE DBTF h- ups tc ca nt sa ea plenty of pl d family. with friends an

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WINNERS FROM AUGUST ISSUE

MEDICAL F ORUM

VÂ… }Â…ĂŠ iÂˆĂ€ĂŠ Â˜ĂŠ Ăƒ°ĂŠ

Mundaring Truffle Festival: %S /BSFMMF 7VKDJDI %S 4JNPO $BSSJWJDL %S %BWJE %BZ %S $BSPMZO #SBDLFO %S 4VF #BOU %S .FMBOJF $IFO %S +BDL 'BJHFOCBVN %S ,PO ,P[BDL %S .JDIFM )VOH This Girl Laughs, This Girl Cries, This Girl Does Nothing – theatre: %S 4UFQIFO 4VO Ice Age 4 - family movie tickets: %S %BWJE $IFX %S "WSJM $IPOH %S &SJD ,IPOH %S ,FWJO ,XBO %S :PIBOB ,VSOJBXBO

The Mousetrap – theatre: %S +FBO 'PTUFS Nutcracker on Ice – theatre: %S +BOJOB "OEFSTU %S (SFH (MB[PW %S 4BSBI ,VSJBO The Sapphires – movie: %S "OHFMJOF 5FP %S 4UFQIFO 3PESJHVFT .T )FMFO .D$BOO %S ,BSFO 1SPTTFS %S &MFOB .POBDP %S )JMBSZ $MBZUPO %S /JDLZ &OEBDPUU %S 4IJI &SO :BP %S "MBO 1SPTTFS %S .BY ,BNJFO

Heart of G

Racing Gloves: %S %FSFL $IFO

AUGUST 20 12

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E Judith Lucy - Nothing Fancy – theatre: %S #BSSZ -FPOBSE

51

old Raising an Olympian t Child

Health t Ears, Eye s and Rehabi litation

August 2012 www.mforum.co m.au

CARDIOLOGY

Western Australia’s Who’s Who for Patient Referrals CLINICAL SERVICES DIRECTORY Cardiology $PTNFUJD .FEJDJOF )BJS -PTT %FSNBUPMPHZ &BS /PTF 5ISPBU Gastroenterology General Surgeons & Subspecialties Gynaecology & Gynaecological Surgery Gynaecology & Infertility Gynaecology, Infertility & Andrology Hand Surgeons *OGFDUJPVT %JTFBTFT Infertility & Andrology Neurology Neurosurgery Nuclear Medicine Obstetrics Obstetrics & Gynaecology Obstetric and Gynaecological Ultrasound Ophthalmology Orthopaedic Surgeons Ortho 1BFEJBUSJD "EPMFTDFOU 3IFVNBUPMPHZ 1BFEJBUSJD 3FTQJSBUPSZ 4MFFQ 1IZTJDJBO Paediatric Surgery Pain Medicine 1MBTUJD 4VSHFSZ 3FDPOTUSVDUJWF 4VSHFSZ Plastic Surgery Podiatry Services Psychiatry Psychology 3BEJPMPHZ 3FQSPEVDUJWF )FBMUI 3FTQJSBUPSZ 4MFFQ .FEJDJOF 3IFVNBUPMPHZ Sports Medicine & Foot Orthodotics 5IPSBDJD 4VSHFSZ Urology 7BTDVMBS &OEPWBTDVMBS 4VSHFSZ 7BTDVMBS *NBHJOH *OUFSWFOUJPO

60 61 61 61 61 61-62 62 62 62-63 64 69 69 70 70 70 70 71 71 71 71 71-72 72 72-73 73-74 74 74 74 74-76 76

Dr Edmund Lee .##4 )POT '3"$1 Interventional cardiologist who has completed post fellowship training in coronary stenting, structural IFBSU JOUFSWFOUJPOT JODMVEJOH "4%T 1'0T )0$. valvuloplasties), cardiac biopsies and right heart catheterisation at the Mazankowski Heart Institute, Canada. 4VJUF .VSEPDI %SJWF .VSEPDI 1IPOF 9366 1891 'BY 9366 1900 $POTVMUT BU 4+0( .VSEPDI 3PDLJOHIBN 8BSXJDL Mandurah, Geraldton and Bunbury. Other special interests include: t Pacemaker implantation t 5SBOTPFTPQIBHFBM FDIPDBSEJPHSBN For all appointments, call 9366 1891 6SHFOU BEWJDF 0422 895 111

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

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

Comprehensive cardiac services will now be provided by the new practice at Perth’s leading metropolitan hospitals including St John of God Hospital Murdoch, Mount Hospital and Hollywood Private Hospital. )FBSU $BSF 8" $PBTUBM XJMM BMTP FYQBOE TFSWJDFT JO +PPOEBMVQ .BOEVSBI #VOCVSZ #VTTFMUPO %VOTCPSPVHI .BSHBSFU 3JWFS "MCBOZ %FONBSL ,BSSBUIB BOE 1PSU )FEMBOE 5IF OFX QSBDUJDF JT UIF POMZ DBSEJPMPHZ HSPVQ UIBU IBT B DMJOJDBM QSFTFODF BU BMM UIF NBKPS UFBDIJOH IPTQJUBMT JO 8" JODMVEJOH 3PZBM 1FSUI )PTQJUBM 4JS Charles Gairdner Hospital and Fremantle Hospital. We provide a full and comprehensive Cardiology service including: t $POTVMUBUJPOT o $MJOJDBM &NQMPZNFOU BOE *NNJHSBUJPO 3FMBUFE t &$( BOE &YFSDJTF 4USFTT 5FTUJOH t &DIPDBSEJPHSBQIZ 4USFTT %PCVUBNJOF 5SBOTPFTPQIBHFBM &DIPDBSEJPHSBQIZ t )PMUFS .POJUPSJOH BOE &WFOU .POJUPSJOH t Blood Pressure Monitoring t "OHJPHSBQIZ 3FWBTDVMBSJTBUJPO XJUI "OHJPQMBTUZ BOE 4UFOUT t "4% $MPTVSF 7BMWVMPQMBTUZ t 1FSNBOFOU 1BDFNBLFS *OTFSUJPOT *NQMBOUBCMF %FmCSJMMBUPST t $BSEJBD 3FTZODISPOJTBUJPO t &MFDUSPQIZTJPMPHZ 4UVEJFT BOE 3BEJPGSFRVFODZ "CMBUJPOT t Pacemaker Checks t Access to Private and Public Hospitals t 3FTPVSDF BOE "EWJTPSZ 4FSWJDF UP (FOFSBM 1SBDUJUJPOFST

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Heart Care To speak to a Cardiologist call our GP Hotline: 1300 4 Heart (1300 443 278) For Appointments Phone: 08 9480 3000 Email: info@heartcarewa.com.au Web: www.heartcarewa.com.au Coastal Cardiology To speak to a Cardiologist call our GP Hotline: 08 9311 4601(24hrs on call) For Appointments Phone: 08 9311 4600 Mount, Joondalup, Murdoch, Nedlands, Yokine, Duncraig, Midland Albany, Augusta, Bunbury, Busselton, Denmark, Dunsborough, Karratha, Mandurah, Margaret River, Port Hedland, Rockingham, Northam

52

medic alFORUMwa

O C TO B E R 2012

CLINIC CLINICAL CAL SERVICES S DIRECTORY DIRECTO ORYY

CARDIOLOGY

CARDIOLOGY

Western Cardiology is the largest WA cardiology practice providing comprehensive expertise in both Adult and Paediatric Cardiology in Metropolitan and Regional Centres. This is combined with both private and public Hospital inpatient management. The comprehensive cardiology services include: Dr Mark Hands Dr Eric Whitford Dr Stephen Gordon Dr Philip Cooke Dr Brendan McQuillan Dr Johan Janssen Dr Paul Stobie Dr Chris Finn Dr Eric Yamen Dr Joe Hung Dr Michelle Ammerer Dr Luigi D’Orsogna Dr Darshan Kothari Dr Andre Kozlowski Dr Tim Gattorna

t Adult & Paediatric consultations. t &DIPDBSEJPHSBQIZ JODMVEFT 4USFTT 5SBOTPFTPQIBHFBM BOE 1BFEJBUSJD &DIPT t 3FTUJOH BOE 4USFTT &$( 4USFTT 5IBMMJVN 4UVEJFT t Ambulatory monitoring )PMUFS #1 BOE &WFOU t *NQMBOUBCMF 1BDFNBLFST %FmCJMMBUPST t $BSEJBD 3FTZODISPOJTBUJPO t Pacemaker Clinic. t &MFDUSPQIZTJPMPHZ 4UVEJFT JODMVEJOH Arrhythmia Ablation. t Coronary Angiography, Coronary Angioplasty and Stenting. t 1FSDVUBOFPVT DMPTVSF PG "4% BOE 1'0 t Percutaneous mitral and aortic valvuloplasty and septal ablation t Coronary Calcium Scoring )FBSU3JTL 4DBO

Western Cardiology is an independent practice without any corporate ownership and with no ďŹ nancial equity in any cardiac catheter laboratory. We provide inpatient cardiology services for all registered health insurance funds in Australia. 08 9346 9300 08 9388 2601 1800 802 601 08 9382 6111 0411 707 017

— — — — —

For all appointments Fax Free call for country enquiries 24/7 On-call Cardiologist Chest Pain Centre: 24 hour emergency cardiac care for your private patients/hospital admission at SJOGH Subiaco

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www.westerncardiology.com.au CARDIOTHORACIC SURGEON

Mr Ian GilďŹ llan .#$I# '3$4 &E $ 5I %.* '3"$4 Has recommenced practice. 0QFSBUJOH BU 'SFNBOUMF 5IF .PVOU )PTQJUBMT Provides a comprehensive service in adult cardiothoracic TVSHFSZ JODMVEJOH t 7BTDVMBS )FBSU %JTFBTF t *TDIBFNJD )FBSU %JTFBTF t -VOH .BTTFT t 1MFVSBM %JTFBTF For routine appointments please call 9481 7655. For my advice and emergencies, please call me directly on 0412 356 216. No gap provider for inpatients services for HBF and Medibank Private. .PVOU .FEJDBM $FOUSF 4VJUF .PVOUT #BZ 3PBE 1FSUI

As a doctor-to-doctor communication, Medical Forum offers you considerable freedom to ethically

promote your services to every medical practitioner in WA.

O C TO B E R 2012

A/Prof David Playford Dr Jenny Deague Dr Barry McKeown Dr Rafeeq Samie Dr Rajesh Kanna Dr Andrew Liu

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We provide a comprehensive service in general cardiology and FMFDUSPQIZTJPMPHZ %S 4BNJF *OUFSWFOUJPOBM $BSEJPMPHZ %S ,BOOB BOE specialist services in echocardiography and cardiac testing. Suite 10, Galliers Specialist Centre, "MCBOZ )JHIXBZ "SNBEBMF Murdoch: 4VJUF -FWFM 4+0( )FBMUI $BSF .VSEPDI .VSEPDI %SJWF .VSEPDI Rockingham: 3PDLJOHIBN ,XJOBOB %JTUSJDU )PTQJUBM .FEJDBM $MJOJD &MBOPSB %SJWF 3PDLJOHIBN Subiaco: Suite 1, Cambridge Specialist Centre, 178 Cambridge St, Subiaco Upper Swan: 4XBO %JTUSJDUT )PTQJUBM &WFMJOF 3PBE 6QQFS 4XBO We have unique automated systems for remote digital reporting to ensure SBQJE SFQPSU UVSO BSPVOE sÂŹ2ESTINGÂŹANDÂŹSTRESSÂŹ%#' sÂŹ(OLTERÂŹANDÂŹAMBULATORYÂŹBLOODÂŹPRESSUREÂŹMONITORING sÂŹ4RANSTHORACICÂŹANDÂŹTRANSOESOPHAGEALÂŹECHO sÂŹ%XERCISEÂŹANDÂŹDOBUTAMINEÂŹSTRESSÂŹECHO sÂŹ#ORONARYÂŹANGIOGRAPHY sÂŹ%LECTROPHYSIOLOGYÂŹSERVICESÂŹ GENERALÂŹANDÂŹ!&IBÂŹABLATIONS sÂŹ#ARDIACÂŹPACING sÂŹ4RANS RADIALÂŹANGIOGRAPHYÂŹ ÂŹINTERVENTION For appointments: 5FMFQIPOF 9391 1234 'BY 9391 1179 & NBJM SFDFQUJPO!IFBSUTXFTU DPN BV www.heartswest.com.au Armadale:

sÂŹ3PECIALÂŹ!NNOUNCEMENTÂŹs Hearts West is the only private practice to offer 3D echocardiography and 3D transoesophageal echocardiography

Dr Jay Baumwol Dr Andrei Catanchin Dr Matthew Erickson Dr Susan Kuruvilla Dr Kaitlyn Lam Prof Gerry O’Driscoll Dr Jamie Rankin Dr Gerald Yong

Dr Matthew Best Dr Michael Davis Dr Arieh Keren Dr Athula Karu Dr Michael Muhlmann Dr Anne Powell Dr Sharad Shetty

It is with great pleasure that we welcome Dr Arieh Keren to our fast growing UFBN PG FYQFSJFODFE DBSEJPMPHJTUT %S ,FSFO XJMM CF DPOTVMUJOH GSPN PVS /FEMBOET BOE +PPOEBMVQ SPPNT )F BMTP holds a public appointment at Sir Charles Gairdner Hospital. His subspecialty includes the advanced management of all cardiac arrhythmias in particular BUSJBM mCSJMMBUJPO BOE BMTP UIF JNQMBOUBUJPO PG QBDFNBLFST EFmCSJMMBUPST BOE DBSEJBD SFTZODISPOJTBUJPO EFWJDFT GPS IFBSU GBJMVSF NBOBHFNFOU %S ,FSFO IBT B QBSUJDVMBS JOUFSFTU JO BEWBODFE NBOBHFNFOU PG EFmCSJMMBUPS TIPDLT BOE ventricular arrhythmias. %S "SJFI ,FSFO JT QMFBTFE UP QSPWJEF UIF POHPJOH DBSF BOE TFSWJDFT UP QBUJFOUT BOE UIF SFGFSSJOH QIZTJDJBOT GPMMPXJOH UIF EFQBSUVSF PG %S "OESFJ $BUBODIJO 'PS CPPLJOHT UP TFF %S ,FSFO PS GPS BOZ JOGPSNBUJPO SFHBSEJOH QBUJFOUT PG %S Catanchin, please phone 6314 6804 PS FNBJM %S,FSFO 1"!QFSUIDBSEJP DPN BV Services offered include: t Cardiology consultations t &DIPDBSEJPHSBQIZ 5SBOTUIPSBDJD BOE USBOTPFTPQIBHFBM

t 4USFTT &DIPDBSEJPHSBQIZ 5SFBENJMM BOE EPCVUBNJOF

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Visit www.perthcardio.com.au for more information on our services. For Cardiology Appointments 'PS 5FTUJOH "QQPJOUNFOUT (FOFSBM &ORVJSJFT 'BY &NBJM

1300 4 CARDIO 1300 HEART TEST 6314 6833 6314 6888 info@perthcardio.com.au

medic alFORUMwa

53

Medical Forum CLASSIFIEDS ANAESTHETIST WANTED MT LAWLEY Dynamic specialist anaesthetist(s) required to replace retiring member. Share rooms with long established hospital based group. Accreditation at Mercy Hospital is mandatory. Computerised billing system with H[FHOOHQW DGPLQLVWUDWLYH VHFUHWDULDO support. For further information please call Lorraine on (08) 370 9733

PRACTICE FOR SALE GIRRAWHEEN Girrawheen Surgery for Sale (Building & Practice). Well established computerised solo practice, purpose built, can accommodate up to 3 doctors, adjacent VKRS LV DYDLODEOH IRU H[SDQVLRQ (currently rent to a pathology company). 6HFXUH FRPSOH[ /DUJH SDWLHQW EDVH HDVLO\ H[SDQG Genuine buyer only. Please contact Joseph on 0403 270 430 or Email: nmjpham@arach.net.au.

FOR LEASE WEST LEEDERVILLE/SUBIACO Specialist Consulting Rooms for Lease/ Sublease. Opposite St John of God Hospital Subiaco. Large Reception and Waiting Areas Consulting Room and 2 Dressing Rooms Ample On Site Parking Please contact 0409 980 198 APPLECROSS Applecross Medical Group is a major medical facility in the southern suburbs. Current tenants include GP clinic, pharmacy, dentist, physiotherapy, fertility clinic and pathology. Both the GP clinic and pharmacy provide a 7 day service. 7KH KLJK SUR¿OH ORFDWLRQ FRUQHU of Canning Hwy and Riseley Street Applecross), provides high visibility to tenants in this facility. A long term lease is available in this facility - the space available is 85m2, with the current layout including 4 consulting rooms, procedure room and reception area. Would suit specialist group, radiology or allied health group. Contact John Dawson – 9284 2333 or 0408 872 633 NEDLANDS Hollywood Medical Centre 1HZ IXOO\ ¿WWHG P VXLWH RQ VW )ORRU available for lease immediately. Tel No. 0409 688 339/ 0400 066 160 MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to admin@sleepmed.com.au 78

NEDLANDS Medical Specialist Consulting Rooms Fully serviced rooms and facilities for Specialist Consulting are available in Suite 31, Hollywood Specialist Centre, 95 Monash Avenue, Nedlands. Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager, Suite 31 Hollywood Specialist Centre 95 Monash Avenue Nedlands, WA 6009 Phone: 9389 1533 Email suite31.hollywood@bigpond.com NEDLANDS Hollywood Medical Centre – 2 fully IXUQLVKHG FRQVXOWLQJ VXLWHV RQ ¿UVW ÀRRU available for lease Secretarial support available if required. Phone 0414 780 751 JOONDALUP Modern sessional suites available in Joondalup CDB Secretarial support available if required. Phone 9300 3380 NEDLANDS Hollywood Medical Centre Fully furnished 2+1 consulting rooms VXLWH RQ QG ÀRRU IRU LPPHGLDWH OHDVH Phone: 0401 289 276

LOCUM WANTED PERTH Locums / Associates wanted. Perth Medical Centre, Hay Street Mall. Busy accredited privately owned SUDFWLFH SULYDWH ELOOLQJ ÀH[LEOH KRXUV ([FHOOHQW UHPXQHUDWLRQ IRU VXLWDEOH candidates. Phone: 9481 4342 Mobile: 0408 665 531

RURAL POSITIONS VACANT BUNBURY

Greater Bunbury Medical Centre Are you ready for a lifestyle change for the better? State of the art non-corporate Medical Centre opens early 2013. GPs, Allied Health staff and Specialists wanted. Employment, contract or tenancies available now various sizes. Contact: 9791 8133 Jill Riggall, Project Manager

BINDOON Fulltime GP required for friendly, progressive rural practice only 60 minutes from central Perth. No after hours or weekends. Accommodation provided in 5 bedroom house with pool. 60-65% of billings dependant on H[SHULHQFH Phone: 9576 1222

MARGARET RIVER Long established accredited family practice seeks GP or trainee to replace retiring Doc. Anaesthetics, Obstetric and surgical scope available but not essential. Some afterhour’s commitment - not onerous. Phone Sally 08 9757 2733 for more info. ALBANY VR GP required to join our 4 Doctor, busy, friendly family practice. Full time or Part time a special interest in Women’s Health would be a bonus. We are Accredited, computerised, full QXUVH VXSSRUW DQG DQ H[SHULHQFHG Admin Team with Healthscope Laboratory on site. 0L[HG ELOOLQJ Phone Gaye - Practice Manager 9841 6711 Email: gaye@hillsidefp.com.au BUSSELTON GP required by privately owned accredited general practice in Western Australia’s most desired rural location. Well-equipped treatment and procedure room, staffed by two full time registered nurses. Obstetrics, anaesthetics and hospital inpatient opportunities are available. Easy 1 in 7 on call roster. Contact Jill Pontague on 9752 1133 Email jill@busseltondoctors.com.au

URBAN POSITIONS VACANT FREMANTLE Fremantle Women’s Health Centre requires a female GP (VR) to provide medical services in the area of women’s health, 2 sessions or 1 day pw. It is a computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. ):+& LV D QRW IRU SUR¿W FRPPXQLW\ facility providing medical and counselling services, health education DQG JURXS DFWLYLWLHV LQ D UHOD[HG IULHQGO\ setting. Phone: 9431 0500 or Email: Diane Snooks director@fwhc.org.au or Erin Embury: clinical-manger@fwhc.org.au GOSNELLS VR GP wanted. Accredited practice with nurse support. 70% of billings. Please phone: 0403 756 338 MIRRABOOKA Full time / Part time GP required for a very busy practice in Mirrabooka. VR preferred. 75% Private and Bulk Billing Applications can be made via Email: mds@mirrabookadoctors.com.au or calling 0400 814 091

INGLEWOOD GP required: full-time or part-time, with or without a view. Hours negotiable. We are a busy 7 doctor (3 male, 4 female) private billing, non-corporate practice in Bedford. Full time Nurse and pathology on site. Friendly and very well staffed. Phone Steve, Carl or Jeremy on 9271 9311 or Email salisburymed@iinet.net.au OUTER METRO PRACTICE – STRATTON Full time/Part time VR/NON VR GP required to join our privately owned, fully computerised non-corporate family practice. Fully supportive including Practice Nurse, onsite pathology and a friendly working environment. Contact Dr Jagadish on 0413 879 023 Email jags.krishnan@gmail.com Or Caroline – Practice Manager 0427 342 488 / caroline@theheights.com.au HILLARYS ([FLWLQJ 2SSRUWXQLW\ Join us in our brand new General Practice located NOR. Non-corporate. We require a full-time or part-time GP for our practice. Hours to suit. No evening or weekend work required. The practice is fully computerised and well equipped. Private Billing and some bulk-billing. Full-time Nursing support. Pathology on site. Please contact Practice Manager on 9448 4815 or Email: smc@westnet.com.au JOONDALUP Edith Cowan University, Student Health Services. Part time VR GP - Tuesday and Thursdays available from August 2012. Interest in Women’s and Student Health. Attractive well equipped purpose built PHGLFDO FHQWUH DFFUHGLWHG H[FHOOHQW work environment, Registered Nurse VXSSRUW ÀH[LEOH ZRUN DUUDQJHPHQWV ECU Joondalup Campus Medical Centre is located in a district of workforce shortage. For information: Dr Robert Chandler Phone 08 6304 5618 Email: r.chandler@ecu.edu.au MUNDARING FT/PT VR GP required to join a busy, friendly, modern, accredited, fully computerised, well managed medical practice. ([FHOOHQW HTXLSSHG WUHDWPHQW URRP with fulltime RN support. Fabulous career opportunity. Attractive remuneration and 6 weeks annual leave. Phone Practice Manager 9295 1988 Email: mundmed@iinet.net.au

NOVEMBER 2012 - next deadline 12md Monday 15th October - Tel 9203 5222 or jen@mforum.com.au

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Medical Forum CLASSIFIEDS Do you want to kill the pig?

Are you wanting to sell your medical practice? 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. We’ll take care of all the paper work to ensure a smooth transition.

Generous relocation packages available at a progressive rural practice 2 hours from Perth. Collie in WA. is not in the dusty hot North of WA but the only serious mining town in the South West close to Perth. Aside from procedural opportunities, great location and a progressive practice with all the usual modern practice requirements, there is some serious money for relocation and retention available. SIHI is offering very generous payments for GPs willing to commit to the town. There are limited numbers of relocation packages, so first in best dressed! Ideal opportunity for a GP registrar with procedural skills, either finishing or about to finish training. We are an accredited training practice and so there is excellent teaching opportunities and support. We have recently expanded the practice for the anticipated growth in the region so there is loads of opportunity for progressive new Drs. For more information, contact Angela 08 9734 4111.

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Ph: 9315 2599 www.thehealthlinc.com.au

PROVIDING PRIMARY HEALTH CARE TO THE HOMELESS URGENTLY REQUIRES ͻ 'ĞŶĞƌĂů WƌĂĐƟƟŽŶĞƌƐ ǁŝƚŚ &Z 'W ͻ ZĞŐŝƐƚĞƌĞĚ EƵƌƐĞƐ

ͻ WŽƐŝƟŽŶƐ ĂƌĞ ĂǀĂŝůĂďůĞ ĨƌŽŵ ŽŶĞ ŚĂůĨ ĚĂLJ ƉĞƌ ĨŽƌƚŶŝŐŚƚ ĂŶĚ ƵƉǁĂƌĚƐ

ͻ džƉĞƌŝĞŶĐĞ ŝŶ ŵĞŶƚĂů ŚĞĂůƚŚ ƉƌŽďůĞŵƐ ĂŶ ĂĚǀĂŶƚĂŐĞ

ͻ ŽŵƉĞƟƟǀĞ ƐĂůĂƌLJ ŽīĞƌĞĚ ĂŶĚ ƐĂůĂƌLJ ƐĂĐƌŝĮĐĞ ĂǀĂŝůĂďůĞ

&Žƌ ĨƵƌƚŚĞƌ ŝŶĨŽƌŵĂƟŽŶ Žƌ ƚŽ ĞdžƉƌĞƐƐ LJŽƵƌ ŝŶƚĞƌĞƐƚ ƉůĞĂƐĞ͗ WŚŽŶĞ͗ 08 6102 2945 ĂŶĚ ůĞĂǀĞ LJŽƵƌ ĐŽŶƚĂĐƚ ĚĞƚĂŝůƐ͘ ŵĂŝů͗ generalmail@mobilegp.org.au

Rural GP- Flying Scholarship An exciting opportunity exists for a vocationally registered general practitioner to obtain their private pilot’s licence in Geraldton, Western Australia. Learn first-hand the symbiosis of flying and rural medicine. This medical centre provides flying services to outlying towns and mine sites throughout the Midwest and is located on the Geraldton airport grounds. There are two hospitals situated in the town of Geraldton, one private and the other public allowing for procedural medicine. Important Information regarding this scholarship includes: å så -USTåBEålTåTOåPASSå#!3!å#LASSå å00,åMEDICALåEXAMINATION å så 5PåTOå HRSåFULLYåPAIDåmYINGåLESSONSåEVERYå åMONTHS å så #ONSOLIDATEåYOURåmYINGåEXPERIENCEåONåOURåREMOTEåAREAåmYINGåCLINICSå å så 3EEåHOWåRURALåGENERALåPRACTICEåMAKESåYOURåmYINGåTAXåDEDUCTIBLE å så 'ETåYOURåSHAREåOFåTHEåLUCRATIVEå7ESTå!USTRALIANåMINERALSåANDåENERGYåBOOM å så )FåTIME MONEYåLETåUSåSHOWåHOWåmYINGåCANåEARNåYOUå Så å så ,ETåmYINGåCHANGEåTHEåWHOLEåWAYåYOUåVIEWåYOURåMEDICALåCAREER å så ,ESSONSåBYåCURRENTå2!!&åINSTRUCTORååå

å å &ORåFURTHERåINFORMATIONåPLEASEåCONTACTå-IDWESTå!EROå-EDICALåONå å or Email: mwaeromedical@westnet.com.au

85% 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.

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

Equipment Provided - WADMS is a Doctors’ cooperative e Essential qualifications:

Freo STREET Doctor is an accredited mobile medical clinic that provides a GP service to marginalised and at-risk people in the greater Fremantle community. If you have an interest in Aboriginal health, women’s health, or helping disadvantaged populations, this practice is for you! We require a GP (VR) for casual and permanent shifts at the van. ALL SHIFTS ARE 3 HOURS IN LENGTH. All clinics operate with a GP, Registered Nurse and Outreach Worker. The practice is computerised and bulk-bills ALL patients. There are no time limits for patient consults. Doctors are paid a competitive hourly rate. The service offers a supportive and friendly working environment. Phone 9319 0555 or Email: Lisa Thirer-Humm lisa.thirer@fremantleml.com.au for additional information www.fremantleml.com.au

80

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

UÊFee for service (low commission). UÊn ÀÊà vÌÃ]Ê`>ÞÊ ÀÊ } Ì° UÊÓ{ ÀÊ iÊÛ Ã Ì }ÊÃiÀÛ Við UÊ VViÃÃÊÌ Ê*À Û `iÀÊ Õ LiÀð

UÊÊ Ê6,Ê>VViÃÃÊ Ì Ê6,ÊÀiL>Ìið UÊ ÕÃÊ Vi Ì ÛiÃÊ«> `° UÊÊ ÌiÀiÃÌ }ÊÜ À Ê environment.

NOVEMBER 2012 - next deadline 12md Monday 15th October - Tel 9203 5222 or jen@mforum.com.au

80

Moving to Best Practice, easy as Like eating brussels sprouts – you know that changing your clinical software will be good for you – but not something you want to face. Best Practice is different. Best Practice makes the changeover so easy you can try it out with all your practice data (the backup version of course) without committing. Sweet! s 7E HAVE MIMS n !USTRALIA S MOST TRUSTED DRUG DATABASE s 3UPPORT PROFESSIONALS WHO ARE TRULY SUPPORTIVE s 3PEED AND SUPERIOR STABILITY OF 31, PERFORMANCE s #ONVERTING YOUR DATA FROM -$ -$ AND -ED4ECH VIRTUALLY AUTOMATIC s .O ADS BOLT ONS OR MIXED lLE FORMATS TO COMPROMISE PERFORMANCE s 'REAT VALUE n SUBSCRIPTION FOR BOTH #LINICAL AND -ANAGEMENT s $ISCOUNTS FOR PRACTICES LARGER THAN %QUIVALENT &ULL TIME '0S s (ALF PRICE FOR PART TIME PRACTITIONERS

s .O DOWNTIME FOR UPDATES OR TIME CONSUMING MAINTENANCE s -ORE '0S VOTING FOR Best Practice WITH THEIR FEET *(includes GST)

TTel: l (07) 4155 8800 0 www.bpsoftware.com.au b

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