MedicalForumWA 0817 Public Edition by Medical Forum WA

The Value of Values Origins of Disease Clinicals: Kidsâ&#x20AC;&#x2122; Zone Lifestyle: On Two Wheels

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EDITORIAL

Let the Sunshine In The August issue is traditionally Medical Forum’s spotlight on Child Health. This August, though, the spotlight is on ‘Transparency’ – both within the ‘system’ and the profession. Sadly, yet serendipitously in this instance, the very thing needed in the system supporting child health in WA is a strong burst of sunlight. Individuals come and go but the system remains and if that system supports behaviour that, for whatever reason, impacts negatively on patient care, then no amount of falling on swords is going to fix what’s broke. A systemic problem is never one person’s creation. While personal accountability is necessary for the purposes of transparency and maintaining confidence in the system, it can also distract attention from what is essentially a failure of ‘values’. Corruption and Crime Commissioner John McKechnie told the Doctors Drum breakfast that, in his investigations into WA Health, he has seen little evidence of corruption but a lot of policy failure. As the health system has grown to meet the needs of a growing population with exponentially more effective treatments and technology then, of course, policy regulation is needed to maintain safety and quality.

with you because they trust and respect your leadership (and learn a few important lessons when it is their turn to call the wagons forward), how is that not ticking all the boxes in leading a successful professional life? We get very coy here about throwing up real live examples for fear of privileging some and neglecting others but we’re doing it on this occasion, not as a promotion for an organisation but a simple message that a good culture works. In this magazine, we interviewed the head of paediatrics at Joondalup Health Campus about the establishment of a pregnancy and birth cohort study trying to find some clue about why so many kids have allergies and why some as young as seven want to kill themselves. It’s a valuable study. Its genesis wasn’t an idle day in the lab for its co-leads, wondering what to do next. As clinicians, they were being overwhelmed by suffering children and they wanted to know why. But this was still not THE moment. That came when the hospital CEO Kempton Cowan came into Desiree Silva’s office waving a local newspaper article which told a grim story about Wanneroo children suffering more, in some circumstances, than any other children in the country. This was his patch; it was personal and he wanted to do something about it.

However, despite what bureaucrats think, policy is not an industry unto itself; it is a mere tool to ensure patients are treated with compassion and with the best possible care by people who are supported by the system to do so. This is how respect is forged, by individuals treating individuals appropriately, not as a system directive but because it is the correct way to go about the business of health.

I don’t know Mr Cowan, personally, I’m sure he’s a nice guy, but that’s not the point of the story. It’s an illustration that the culture of this particular hospital enables staff to care, and it has a leader who leads by example. The latest AMA hospital survey shows that the Joondalup staff are the happiest in the state. And if they’re happy, the chances are that their patients will get better more quickly.

Yes… I know, I know, individual ambition and narcissistic, self-centred personalities can make short work of all that Roses-in-the-Garden stuff but that’s where a healthy system steps in.

You don’t need a new hospital to replicate this outcome. You need a culture of respect and leadership that enables the genuinely dedicated people who work for you to do their best with both care and compassion and consequently to improve the lives of sick people.

A culture that puts respect at its core is not self-limiting – in fact, it encourages success. If your patients love you because you care, and your staff will cross the Rubicon

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MEDICAL FORUM

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au 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

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

AUGUST 2017 | 1

CONTENTS AUGUST 2017

25 FEATURES 14 Conflicts of Interest – Who’s to Judge? 18 Doctors Drum: Tansparency Clear as Mud? 25 Origins at Joondalup 48 Spotlight: Henk Vogels Cylist NEWS & VIEWS 1 Editorial: Let the Sunshine In

Jan Hallam Letters to the Editor Theatre’s War on Waste Dr James Anderson Separate Out Hospital Waste Dr Richard Yin Mesh of Problems Ms Carolyn Chisholm Caution for Telehealth Dermatology Dr Genevieve Sadler Risk is Life-Affirming Dr John Hilton Armchair Adrenaline Junkie Dr Lindy Roberts Raine’s Legacy Lives On A/Prof Graham Hall Very Model of a Modern Major-General E/Prof Max Kamien

Men Sought for Trial Dr Serene Lim 12 Have You Heard? 20 ePoll: Transparency and You 29 Police Respond to PTSD

Lifestyle 50 My Local: Saroor 50 Wine Winner: Dr Neil Collins 51 Wine Review: 3drops

Dr Louis Papaelias 52 Social Pulse: New Boss at SJG Subiaco 52 Taste Test: 3drops Olive Oil 53 Doctor in the Arts: Dr Ahmed Kazmi 54 Funny Side 54 Book Review: Another Great Day at Sea 55 Travel: Insider’s New York Dr Lin Arias 56 Rocking the Concert Hall 57 WASO in the Cathedral 58 Competitions

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MEDICAL FORUM

clinicals

Melanoma and Spitz Naevi in Children Dr Trevor Beer

Research in the Hot North Dr Timothy Barnett

Kids’ Inguinoscrotal Conditions Dr Jill Orford

Functional Constipation Dr Kunal Thacker

Adverse Vax Events Dr Alan Leeb

New Frontiers for Paediatric Cardiology Dr Deane Yim

Perinatal OCD Dr Julia Feutrill

Biologics in Childhood Rheumatology Dr Senq Lee

Do Kids Need Supplements? Dr Roslyn Giglia

The PCOS Puzzle Prof Tim Welborn

Rickets Not Always Vit D Deficiency Dr Kiranjit K Joshi

guest columns

A 360 View of Epilepsy Dr Catherine Harrison

Value of Values in Health Dr Michael Watson

Thursday, September 14 7:15 – 8:50am | Royal Perth Yacht Club

Policy on the Run? Mr Hayden Groves

No Quick Fix for Persistent Pain Mr Tom Belotti

Keep this breakfast free! See www.doctorsdrum.com.au for panellists and to reserve a seat

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician) MEDICAL FORUM AUGUST 2017 | 3

LETTERS To THE EDITOR Separate hospital waste

Theatre's war on waste

Dear Editor,

I was interested to read Belinda McManus's letter (War on Waste, July) regarding waste in operating theatres. Data from the UK (AAGBI) suggests that each theatre's anaesthetic team produces 2300kg of waste annually, of which at least 40% is recyclable. Operating theatres contribute 20% of a hospital's waste.

Belinda McManus’s impression of waste in operating theatres is not surprising with more literature emerging advocating for greater sustainability within peri-operative practices. In Australia, more than 260,000 tonnes of solid waste is produced each year with hospitals among the most energy-intensive facilities – with 75-90% of healthcare waste likely to be recyclable. For the health sector to move to a more sustainable footing, as has occurred in the UK through its Sustainable Development Units, we should be doing more to reduce or recycle non-infectious waste. Infectious waste costs about $1/kg to dispose, 10 times more than non-infectious waste and with land-fill levees rising (in Perth it increased from $8/tonne to $60/tonne in 2015). There is a strong financial case to establish reliable waste separation protocols and increase recycling rates within Australian hospitals. The new Sustainable Health Review provides an opportunity to review waste management in the health sector considering a whole-of-life approach especially the role of single-use products. If the cost of waste disposal were accounted for during purchasing, there may be significant savings both financially and environmentally. Within our general practice, over the past decade we have with mixed success trying to reduce waste and recycle. Initiatives have included purchasing recycled paper, minimising single-use instruments and improved separation of infectious and non-infectious waste. But with unsolicited marketing material and unnecessary packaging, going ‘paperless’ still seems to result in lots of paper! But if you really want to reduce waste and cost within the health sector, support and enable primary health care so that fewer patients require hospitalisation and the associated cost. “Because good primary care is associated with better health outcomes (on average), lower costs (robustly and consistently), and greater equity in health (Professor Barbara Starfield)”. References available

Dr Richard Yin, GP, Shenton Park

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.

4 | AUGUST 2017

Dear Editor,

Some of the major WA hospitals (SCGH, FSH and perhaps others) have introduced recycling in theatres, however, it is unclear how successful these schemes have been. In a busy workplace, like theatre, the system for separating and collecting recyclables needs to be clear, consistent and easy. This has been done at one hospital by providing different coloured waste bags attached to the anaesthetic trolley, one for clinical waste (~$1000/tonne) and one for recyclable waste (~cost neutral). Even with careful separation of waste by clinicians, most hospitals don't have a consistent process for cleaners to collect and dispose of recyclables in clinical areas. Across the WA Health system, recycling clinical waste seems piecemeal at the moment and review by the Sustainable Health Review may lead to a more streamlined approach across the system which would certainly save money and reduce theatre’s waste footprint. Our role as clinicians is to advocate for the health of society as well as our individual patients. Reducing our workplace waste is one cost effective and practical way for us to contribute to a healthy community. Dr James Anderson, Anaesthetic Senior Registrar ........................................................................

Pelvic mesh misery for some Dear Editor, My name is Caz (Carolyn) Chisholm. I am a consumer injured by transvaginal mesh. I established the Australian Pelvic Mesh Support Group in November 2014 and there are currently about 700 members. The group is focused on supporting each other through our emotional and painful experiences and equally in preventing this from happening to others.

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.

Many similar stories are told by mesh-injured women about spending years in pain, going from doctor to doctor, having multiple tests and scans and yet nothing in their results point directly to mesh unless it eventually erodes through the vaginal wall or cuts the urethra or creates chronic infection. They are being told that the pain is not meshrelated and that they are depressed or they are a hypochondriac or they are menopausal. Some are treated like drug addicts because they seek strong medications to dull the pain. Women may suffer from urinary tract infections, painful sex, leg pain, mesh through the vaginal wall, infection, severe groin and pelvic pain and voiding difficulty, to name just a few. These complications have become lifealtering for many women who can no longer work or take care of their family. The TGA added an alert for transvaginal mesh complications to their website on August 3, 2016. There appears to be no surgeons in Australia able to remove these prolapse and incontinence meshes from the pelvis and the groin when severe complications arise. Surgeons are performing partial removals or revisions and some women are finding that their pain increases with these surgeries. Women who are suffering from the debilitating pain and the constant urinary tract infections just want the whole mesh out. But this is apparently not an option here in Australia. To date there are 13 women who have travelled to the US for full mesh removal since the support group started in 2014. It seems that mesh is easy to implant but almost impossible to explant. How can mesh, which has the potential to cripple a woman, be allowed to be put into such a complex area of the body and yet it is not able to be removed when complications arise? Ms Carolyn Chisholm, Perth Ed: On July 4, Shine Lawyers began a class action in the Federal Court in Sydney against Johnson & Johnson on behalf of 700 women who claim to have suffered complications from inplantation of the transvaginal mesh. Similar actions are currently underway in the US, UK and Canada.

continued on Page 6

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LETTERS To THE EDITOR continued from Page 4

throughout WA, as well as one dermatologist permanently based in Bunbury. We hope to work with WACHS to reinstate Dermatology Registrar involvement with these visits to promote and foster interest in working in remote areas. We are also proud to host the Rural Dermatology Meeting in Broome on August 11-13.

Caution for telehealth dermatology Dear Editor, The recent letter, Telehealth for Rural Patients (June issue), raises some interesting points. The value of improving access to health services in remote and regional areas is acknowledged. To avoid compromising care, it is important to recognise the limitations of managing dermatological conditions via telehealth. Poor quality images, particularly with videoconferencing, and the inability to do a systematic full-skin examination, including palpation, for cutaneous malignancy or to determine the distribution of an eruption, are just some of the challenges. Biopsies may be required with careful consideration of the site and type of sample, and analysis by a skilled dermatopathologist. The medicolegal considerations surrounding collection, transfer, storage and subsequent use of clinical images can be complex, as outlined in recently published guidelines. Dermatology is generally more suited to a store-and-forward style of telehealth, rather than the current MBS reimbursed model. An established free service of this type can be accessed by any rural GP via www.acrrm. org.au/subscribers/rhof/apply-for-free-limitedaccess-to-telederm. Advice on individual cases is provided by a WA dermatologist, who can facilitate face-to-face follow-up if required. If funding is forthcoming, an enhanced model could be developed locally. The WA Dermatology Faculty is committed to improving rural health. Many dermatologists regularly provide informal support to their rural primary health care and specialist colleagues through telephone advice and email contact. There are about 1300 full-day Rural Outreach Dermatology Clinics operating each year

Dr Genevieve Sadler, Chair, WA Faculty of Dermatologists ........................................................................

Risk is lifeaffirming

While training for the 2014 Avon, I took an experimental line at a bend called ‘The Wall’ and as I fell out I solidly head-butted the said wall with immediate shooting paraesthesia/ anaesthesia into my right C6 dermatome. Fortunately, an expedient MRI ruled out discs and fractures, although the thumb still feels odd. Less lucky for my friend Sue, who lost her life last year doing a routine run down a flooded Blackwood river in Bridgetown. Regardless, life would be less memorable without these experiences. Dr John Hilton, GP, Cooloongup ........................................................................

Dear Editor, In response to Phil Chapman’s story of chasing adrenaline and a near-death experience (Risk it All… Pay the Price?, July) I can see a lot of merit in his argument. Too often we follow our narrow paths, in search of the goals of our profession and building our little kingdoms without facing the risks of realworld experience. Somewhere in the late 1980s I signed up for my first Avon Descent and, armed with rudimentary skills, I set off with training runs down the valley with real palpable risk and many close shaves. I relived a lot of it in disturbing dreams for years afterwards. When I took up whitewater paddling again after 2000 I began to develop skills and a little more control over my own destiny but maintained the thrills of trying to master the river in all its moods. The danger seemed to diminish but there were still some twists left. Competing in the Dusi River marathon, from Pietermaritzburg to Durban in 2012, I overheated and underhydrated on the second day, carrying my kayak overland through a steamy jungle and hill-climb section and crossed the line in delirium. Some IV therapy in the medical tent restored me sufficiently to start the third and final day the following morning.

Armchair adrenaline junkie Dear Editor, I thank Phil Chapman for his very personal piece about what drives medical thrill-seekers to push themselves to physical extremes, despite knowing and (worse) seeing in their day-to-day clinical practice the possible consequences (Risk it All…Pay the Price?, July). Having looked after several colleagues now with pain from acute traumatic injuries, the drive to pursue the endorphin rush that Phil describes appears extremely strong. In my experience, in the medium term, not many doctors seem to put aside their sporting gear after such an event, unless forced to do so by the injury itself. I was particularly interested that Phil seems to be weighing up whether the cost of ‘going to the edge’ is worth it and how this might change his extracurricular interests. As a film enthusiast and amateur musician, my passions outside work are far less physically extreme. His reflections set me thinking about whether “music, arts, literature …” are only for those who are starting to recognise their continued on Page 8

CURIOUS CONVERSATIONS

Meet the Soul Sister Afro-Jazz, lots of great food and fluent in seven languages sounds like heaven to obstetrician and gynaecologist Dr Rae Watson-Jones. I chose my specialty because… it's unpredictable, diverse and full of joy! I had great experiences as a medical student and junior doctor – I reckon it’s the best specialty of them all. If I could live and work overseas I’d go to… the Caribbean. Back to my roots, enjoying my own culture and loving the great weather. The music and food are wonderful, too! And I’d definitely educate local young women about important women's health issues.

6 | AUGUST 2017

I’d love to have more time to spend… pursuing a lifelong dream of being fluent in many, many different languages. If one of my children wanted to do medicine, I’d say… how about we look at a few other careers? But if you still feel that's what you want to do, I'll always support you. If I had to choose a ‘desert island’ disc it would be… impossible to choose just one! I’d take a 64GB USB with a mix of reggae, soul, R&B, Afro Jazz and Gospel tunes. MEDICAL FORUM

Major Sponsor: Clinipath Pathology

Dr Trevor W. Beer MBChB FRCPath FRCPA Dermatopathologist & Pathology Reviewer for WAMAS Clinipath Pathology Osborne Park

Melanoma and Spitz Naevi in Children Melanoma is rare in childhood, representing no more than 2% of all skin melanomas. Diagnosis is often delayed because melanoma is unsuspected, partly due to differences in presentation and its rarity. The diagnosis is made with trepidation by pathologists, since the vast majority of childhood skin lesions are benign. Establishing the true prevalence of juvenile melanoma is complicated by a number of factors, one being the definition of childhood or juvenile. Many studies use a cut-off age of 19 years, but this is not consistent. Cancer registry data may also be unreliable due to misclassified Spitz naevi, for example. ABCDE + ABCDD ABCDE criteria help to identify adult melanoma clinically (Asymmetry, Border irregularity, Colour variation, Diameter >6mm, Evolution). Many melanomas in childhood are non-pigmented (> 50% of 65 recent cases from Victoria). Additional ABCD criteria have been suggested in children: Amelanotic, Bleeding bump, Colour uniformity, De novo, any Diameter to facilitate earlier recognition. Children more often present with advanced disease due to diagnostic delay, reported in 50-60% of patients. Childhood Melanoma in WA A WA study (in press, Am J Dermatopathol) with the WA Melanoma Advisory Service (WAMAS) identified 95 melanomas in patients 19 years or younger over a 14-year period. Three patients died from melanoma. The majority of tumours, 75%, occurred between ages 13 and 19 years, similar to other studies. In all populations, juvenile melanoma is much less common before puberty. Delayed diagnosis was evident with 21 of 23 patients presenting with Clark level 4 or 5 melanomas with Breslow thickness >1mm in 65%. A family history of melanoma was seen in 17%. A study this year in Victoria revealed 65 melanomas during a 19-year period, with seven fatalities. A decrease in juvenile melanoma has been seen in WA despite an increasing population. In Queensland, a substantial decline occurred between 1997 and 2010, attributed to safer sun exposure practices since the 1980s. Prognosis The outlook for childhood melanoma mirrors that in adults being primarily based on stage and Breslow thickness. The exceptions are tumours with spitzoid features. These show appearances resembling Spitz naevi and, although often metastasizing to local nodes,

Even in children, the possibility of melanoma needs to be considered.

are less frequently lethal. Prognostication is complicated by the fact that occasional examples behave aggressively and some spitzoid melanomas in case series may be misdiagnosed Spitz naevi. Treatment Complete excision, as in adults, is required. Further investigations and treatment should be decided in conjunction with expert advice. Treatment of advanced melanoma is progressing rapidly and possible eligibility for clinical trials means that patients will get the best opportunities for positive outcomes with personally tailored, up-to-date guidance. It is recommended that all melanoma diagnoses in childhood are reviewed by pathologists with expertise in melanocytic lesions. Referral to a multidisciplinary team (such as WAMAS) is valuable to ensure correct diagnosis and to optimise treatment and advice to patients and families. Sophie Spitz’s ‘Juvenile Melanoma’ Pathologist Sophie Spitz described 12 unusual ‘juvenile melanomas’ in 1948. Follow-up showed benign behaviour, despite microscopy suggesting melanoma. These lesions are now called Spitz naevi. Although typically childhood lesions, they can occur in adults, reducing in frequency with age. Diagnosis clinically and microscopically can be challenging. Lesions may clinically resemble pyogenic granulomas, haemangioma or dermatofibroma. While most are correctly identified pathologically, some are misdiagnosed as melanoma. Conversely, a leading cause of litigation in pathology is under-diagnosis of melanoma as Spitz naevus.

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Distinction between Spitz naevi and melanoma may be extremely difficult or even impossible. In these histologically ambiguous tumours inter-observer agreement is notoriously poor. Even panels of international experts have demonstrated limited diagnostic conformity with agreement, at times, little better than by chance. There is now a move away from traditional benign versus malignant divisions with suggestions that a histological continuum exists between Spitz nevi at one end and Spitzoid melanoma at the other. Indeterminate lesions may be labelled Spitzoid tumours of uncertain malignant potential (STUMP) with a guarded prognosis. Improving pathological diagnostic accuracy Treatment and prognostication of childhood melanoma requires accurate diagnosis which can be enhanced by experience and consultation between pathologists. Molecular studies such as FISH and aCGH may assist in ambiguous cases, but such methods are still in development and not uniformly available. However, molecular techniques will ultimately lead to more accurate diagnosis, prognostication and tailored treatment for children with melanoma. Because of the rarity of childhood melanoma, individual clinicians or pathologists may have little experience in their recognition or treatment. WAMAS provides a centralised clinical and pathological approach to melanoma, bringing together expertise and experience, so it is regrettable that its future is in jeopardy. References available on request.

LETTERS To THE EDITOR continued from Page 6 physical limitations (and that their naturally degenerating spine might let them down when literal push comes to shove!).

as the Origins Project (see P25), which is currently recruiting families in Perth’s northern suburbs.

Being part of a successful musical performance has its own “high” and movies can certainly get the adrenaline going (schlock horror or zombie flick anyone?) – all without the physical pain of being pounded or dropped or in free fall. On balance, I decided well before my 50s that my adrenaline rush is best had without leaving the ground.

The Raine study wouldn’t exist without the support of Mary Raine, or the incredible participants and their families, many of whom are still actively involved today (we’re even studying some of their children now).

Dr Lindy Roberts, Pain Specialist, SCGH ........................................................................

Raine’s legacy lives on

We need more generous people like Mary who see the importance of medical research and its ongoing value to the community. A/Prof Graham Hall, Deputy Director & Head of Children's Lung Health, Telethon Kids Institute ........................................................................

The very model of a modern major-general

Dear Editor, I wonder if Mary Raine ever imagined the impact her original philanthropic gift would have on medical research in Western Australia (The Raine Foundation 60 Years On, July).

Dear Editor,

Her support has helped fund The Raine Study, which has generated more than a quarter of a century of important health data as researchers follow a cohort of almost 3000 children (who are now adults). We’ve studied these ‘Raine kids’ from 18 weeks gestation – collecting among other things, cord blood, baby teeth, saliva, mental health information, dietary and exercise information, and even sperm to look at reproductive health. And we’ve tested their eyes, lungs, sleep patterns, fitness, body composition, back pain, and much more. Large, longitudinal cohort studies such as The Raine Study have changed how we work as researchers. By following the same individuals over time, we amass a rich collection of data that can be used to influence national and international thinking around a range of diseases, including in asthma, my area of research. Within asthma, The Raine Study has helped deliver new knowledge that is currently being used to develop a vaccine for asthma and has helped highlight the importance of what happens early in life to understanding how asthma develops in adults. The Raine Study model has also helped guide the next generation of cohort studies, such

The Gilbert and Sullivan Society of Western Australia recently put on a production of H.M.S. Pinafore at the Dolphin Theatre, UWA. Dr Colin Hughes sang the lead role of the Rt. Hon. Sir Joseph Porter, K.C.B, First Lord of the Admiralty. He performed admirably fuelling suspicions that this was a dress rehearsal for a more important role in the RACGP. ED: We know that the headline here is from Pirates of Penzance but it was apt nonetheless!

E/Prof Max Kamien ........................................................................

Men sought for trial

High intensity ESWT is used in lithotripsy where kidney stones are targeted in focused mechanical destruction. Medium intensity ESWT is anti-inflammatory and used in treatment of bursitis and tendinitis. Low intensity ESWT using the ED1000 device stimulates the release of angiotensin factors and neovascularisation. The increased localised blood flow can lead to longer lasting spontaneous erections and increased sensitivity. Current ED treatment is palliative with 5-phosphodiesterases, penile injections and implants. The 5-phosphodiesterases cause non-targeted vessel dilation which can result in side effects like facial flushing, headaches etc and penile injections and implants are cumbersome with scarring and priapism as possible side effects. They are also not spontaneous and may lose their effect over time. Our study is a six-week trial as results have been positive in most studies after three weeks. As it's extremely difficult to conduct a blind study, all volunteers will receive treatment with the ED1000 machine (TGA approved). More information on www.betterfunction.me Dr Serene Lim, GP, Claremont References: International Journal of Urology (2015) doi: 10.1111/iju.12955 The Journal of Urology® (2016), doi: 10.1016/j. juro.2015.12.049. Therapeutic advances in Urology (2013) 5(2) 95–99 doi: 10.1177/ 1756287212470696

Dear Editor, More volunteers are required for the erectile dysfunction (ED) trial with low wave extracorporeal shockwave therapy (ESWT) for the treatment of vasculogenic erectile dysfunction. A common problem in diabetics (more than two thirds) and ageing, some studies have shown that up to 50% of men over the age of 50 have some form of ED.

We welcome your letters and leads for stories.

Shockwaves have been successfully used

Please keep them short.

There is more stupidity than hydrogen in the universe, and it has a longer shelf life. Frank Zappa

8 | AUGUST 2017

around the world since 2005 to treat a variety of medical conditions depending on the intensity of energy used. They are pulsed acoustic waves generated outside the body.

Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. Letters, especially those over 300 words, may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.

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* The NovaSure® procedure is performed by a gynaecologist. The average treatment time is 90 seconds, and the entire procedure typically takes less than 5 minutes to complete. 2 References: 1. National Women’s Health Resource Center (United States). Survey of women who experience heavy menstrual bleeding. Data on file, 2005. Based on women aged 30-50 years. 2. NovaSure® Instructions for Use. Bedford, MA: Hologic, Inc. 3. Cooper J, et al. A randomized multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia. J Am Gynecol Laparosc. 2002;9:418-428. 4. Gallinat A. An Impedance-Controlled System for Endometrial Ablation: Five-Year Follow-up of 107 Patients. J Reprod Med. 2007;52(6):467-472. ADS-01814-AUS-EN REV.001. © 2017 Hologic, Inc. All rights reserved. Hologic, NovaSure and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States and/or other countries. This information is not intended as a product solicitation or promotion where such activities are prohibited. Because Hologic materials are distributed through websites, eBroadcasts and tradeshows, it is not always possible to control where such materials appear. Hologic (Australia) Pty Ltd, Level 4, 2-4 Lyon Park Rd, Macquarie Park NSW 2113. Tel. +61 2 9888 8000. ABN 95 079 821 275.

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AUGUST 2017 | 9

INCISIONS

The 360 View of Epilepsy Dr Catherine Harrison’s young son has epilepsy. She shares her insights here. I didn't know anyone with epilepsy when I was growing up. As a medical student, I never saw a seizure. Epilepsy was one of those conditions on the list of every piece of paperwork along with heart disease and diabetes. I learnt about anticonvulsants that sounded fancy and I thought that they worked. As a registrar, none of my patients in general practice talked about seizures even if they were on anticonvulsants. I had no idea that the consequences of having epilepsy are far greater than the immediate effects of a tonic-clonic seizure. Dealing with a blue/grey child who is unconscious, fitting, vomiting and bleeding from their nose is terrible but it is the easy bit compared to the ongoing social and lifestyle complications of the diagnosis. The normal struggles of life are challenging. Parenthood, marriage, maintaining financial stability and one’s own health are not minor accomplishments. With a chronically ill child, such challenges can be overwhelming without an abundance of community support. The thing about epilepsy is that it is so unpredictable, so variable, and so life threatening all the time. If your medication works and you are seizure free that's fantastic. But what if you forget a tablet or have gastroenteritis or your brain changes or your hormones change, and you suddenly begin having seizures? My son has not had more than seven months free of seizure and his favourite past-times include high-risk activities such as skateboarding and ice-skating. Struggle for independence He is 11 and he doesn't want me to wait at the bus stop with him. He wants to walk home by himself. He can’t go on a school camp because parents aren’t allowed on school camps, and initially his seizures occurred during sleep. But if two doctors find having a blue child convulsing stressful at 3am how is it possible for teachers to cope? So all those fantastic esteem-building activities in the bush that schools provide these days are very difficult to attend, and the other students ask why he isn’t there. If you are unlucky enough not to have seizure control, then all the other factors that trigger seizures become paramount. Sleep is the most important element. But if getting to sleep by a certain time becomes more important than anything, then how do you manage your family’s social life? There can be no barbecues that roll past 7pm because you need time for the wind-down. I have become proficient at telling people they have to leave. Subtlety doesn't work. Even prearranged time agreements don’t work; people often think that if it's going well,

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The thing about epilepsy is that it is so unpredictable, so variable, and so life threatening all the time. it should keep going. They don’t know that ‘going well’ can instantly turn into a disastrous evening. Taking tablets three times a day indefinitely, exactly on time, is challenging but do-able. Coping with the side effects of medication that doesn’t work, having to wait and see what will happen with the next kind of tablet is devastating. Steven Johnson rash? Insomnia? Mania? Depression? Suicidal ideation? Psychoactive drugs affect individuals differently. Life is shaped by epilepsy Epilepsy is isolating. It isolates the child; it isolates the parents. We don’t go to movies, not because of the photosensitivity issue but because today's movies have sensory overload. They are too loud, too bright, too fast. They make our son feel unwell. But ask any parent about July school holidays and what kids do during winter, or where today’s kids have birthday parties and movies play a big part. If your child gets invited on a play date how much do you prepare other parents? You don’t want to scare them off having your child, but you want to make sure everyone is equipped to cope in the event of a seizure. I talk openly about that possibility, which luckily is low, but it is not zero. There are a few wonderful mums around who will say: “now just tell me what I would need to do.” They are rare. The financial impact for the family and the individual later in life can be enormous. I have been in the most privileged position of being able to give up my medical career and be available for all the appointments and all the school meetings. Sleep is the starting point of wellness, so if there is a bad night, I can allow a catch-up sleep-in and get to school when it suits us. An understanding and cooperative school is essential. The other children have to be as independent as possible because today might be a sleep-in day and there's no leaving a child with epilepsy asleep unsupervised. Morning marathons Our house is like an Olympic relay team in the mornings. Minutes count. I must return home for my husband to leave for work on time. So if it's hard for us, what about separated families

where there's only one parent at home? Or what if you have two children with difficulties? However, there is a silver lining for us. As awful as even the thought of SUDEP (Sudden Unexplained Death in Epilepsy) is, it makes me grateful when I wake up and my children are alive. This prominent and daily reminder of mortality makes me slow down more. I enjoy the simple moments. I am less worried about life achievements and more conscious about appreciating what I already have. Ironically, I worry less about the future because I think getting through each day well is enough of a goal. Being on the Board of the Epilepsy Association and attending parent support groups has got us through some very tough times. My acquaintance with mothers experiencing similar problems has made all the difference. They had been there; they had tried this and that; they had come up with ideas that had worked. They knew far more about epilepsy than I had ever learnt as a medical student. Most importantly, I wasn’t alone. These mums knew exactly what I was talking about.

My acquaintance with mothers experiencing similar problems has made all the difference. They had been there; they had tried this and that; they had come up with ideas that had worked. They knew far more about epilepsy than I had ever learnt as a medical student. Most importantly, I wasn’t alone. Through the association I have had a glimpse of the discrimination and isolation suffered by many people with epilepsy. The financial hardship faced by those who have been intermittently too unwell to maintain employment but do not qualify for disability services. Epilepsy is not considered a disability. For some people, it is not, for others, it is catastrophic, even if only intermittently. The vision of the Epilepsy Association is to have West Australians with epilepsy living without fear and discrimination. That is a long way off. However, if I have one message to the medical profession, it is to remember that the medical problems of epilepsy are only the tip of the iceberg. www.epilepsywa.asn.au

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AUGUST 2017 | 11

HAVE YOU HEARD?

TGA and Pharma complaints This issue of the magazine explores how pharmaceutical and device companies market their products to the profession (see P14 and our Transparency Doctors Drum write-up, P18). In a timely announcement, the TGA said it was “simplifying and improving” the handling of complaints regarding the advertising of medicines and medical devices to the public. The TGA will now be the only body handling advertising complaints effective from July 1, 2018 where previously the Australian National Regulatory Authority played a role. The reform is made as a part of the recommendations of the Expert Panel Review of Medicines and Medical Devices Regulation and attempts to make it easier for consumers and businesses to have their complaints dealt with more efficiently.

Pharmacy path tests sink When it comes to hot stories, news that Amcal pharmacies would be ordering pathology tests sent temperatures soaring but a cool change quickly set in. Late in June, Amcal (with over 100 pharmacies) trumpeted that it was leading the way in preventive health by entering an agreement with Sonic to offer customers pathology-based health screening for diabetes, heart health, kidney and general health screening, as well as Vitamin D and fatigue testing. Prices would range from $25 for HbA1c testing to $219.50 for a Rolls-Royce over the pits job. Abnormal or out-of-range results would be sent back to their GP. There was no mention of Medicare rebates. The Royal College of Pathologists initially liked the idea but by July 4, no doubt suffering a hail of abuse from 80,000-odd GPs not to mention the RACGP and AMA, issued a statement: “The RCPA does not endorse or have any partnership or alliance with any programs in relation to the non-medical requesting of pathology tests…However, tests may be requested by a wide range of people who are not registered medical practitioners. These may include those who are part of current health care services such as pharmacists, dieticians, physiotherapists, podiatrists and dentists. In these circumstances the RCPA Policy requires the laboratory and the requestor understand the importance of oversight by a medical practitioner.” This is

indeed the problem and put eloquently by a GP, who contacted us after consulting his medical defence insurer. GPs, the advice said, could ultimately be responsible for reviewing the results leaving GPs holding the baby while “the other parties profit”. Not long after, Sonic Healthcare and its subsidiary SmartHealth withdrew from the arrangement with Amcal. It said in its statement that the program was developed in line with the Health Department’s initiative to promote in-pharmacy health screening services. The Health Department might have to think again before the pharmacy lobby have another crack at the Medicare toffee apple.

Open wide for insurers We were contacted by a GP who has become increasingly concerned about private health insurers (PHIs) buying up dental practices in the south-eastern suburbs of Perth. The Australian Dental Association shares her concerns on a national scale. It is urging the Senate inquiry into private health insurance to examine what it describes as anti-competitive practices. The ADA issued a statement urging investigation into “discriminatory rebate practices and the shift towards a conflicted corporatised insurer-owned dental practice model” which its President, Dr Hugo Sachs, says presents a glaring conflict of interest that will ultimately affect the continuity and quality of care. The ADA wants legislation to “outlaw such practices”.

Sad sign of the times Mental Health Commissioners, including WA’s Tim Marney, have released a consensus statement to identify what services will be needed to support the survivors of child sexual abuse now the Royal Commission into Institutional Responses to Child Sexual Abuse has released its report. It makes the powerful point that abuse is not a mental health disorder but a violation of human rights, which often impacts profoundly on a person’s mental health and it is this trauma that should shape service design and delivery. If the system got that right, it would help the broader population who have experienced childhood trauma. Its warning to services was to “prepare for increased demand”.

It’s all a game Trawling, as opposed to trolling, the internet recently, we stumbled across what was at first

glance a happy-go-lucky story on a diabetes app that had added ‘gamification’ to its functions. A simple monster game that hopes to, as its developer told a reporter, “make diabetes suck less”. It is part of a new wave of health ‘tool’ apps appealing to children and adolescents and it makes a lot of sense: fun + info = what’s your HbA1c score? It also represents the next big marketing strategy for Big Pharma. This small German developer has just been acquired by Roche, which will probably mean better games for the kids but, more pertinently for Roche, a new generation of customers. The developer told the news site that his tech company was its own legal entity and would continue to work with other companies. Welcome to the future.

Wheels turn for melanomaWA Back in December 2014, Clinton Heal documented his 10-year journey with melanoma in Medical Forum. Then he wrote how he has had 35 metastases removed in that time. It prompted him to establish the support group melanomaWA to offer support for those who have found themselves on a similar journey. Part of the group’s role is spreading the word about early detection and this month, its efforts have been enhanced with a two-year partnership with the car rental company Thrifty WA. Having wheels will enable melanomaWA crew to visit rural and remote areas from the South West to the Goldfields and the Pilbara encouraging communities, especially teenagers, to be sun smart and to have skin checks.

Flushed away The mainstream media was quick to report the happy news that less methamphetamine was found in the Bunbury waste water in 2015-16 than the previous year. Now we can report some less racy facts, this

Information is the key Lotterywest has contributed $100,000 for the WA rollout of the Epilepsy Action Australia’s resource kit MyEpilepsyKey – neatly and conveniently contained in a USB. About 15,000 MyEpilepsyKeys are available at Friendlies Pharmacies. At the launch last month was the late Tony Greig’s wife, Vivian, who said the key would have made her husband proud. The former England cricket captain and commentator suffered from epilepsy from the age of 12 and had been a supporter of Epilepsy Action Australia for 20 years, serving on its board and raising awareness and funding. The key contains resources such as an electronic seizure diary and a tool to develop a personal ‘seizure management plan’. There are specifically designed online modules for adults and adolescents and parent support information. Content is linked to a portal so information is updated as required.

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MEDICAL FORUM

Bugs on the ropes There has been considerable discussion about the prophylactic or otherwise use of antibiotics in recent editions of the magazine so the announcement of a breakthrough test by the Perkins Institute was timely. Doctoral student Keiran Mulroney (pictured), under the supervision of Dr Aron Chakera and supported by Dr Tim Inglis at Pathwest, has found a new method to determine antibiotic susceptibility of a patient’s individual strain of bacteria in a matter of hours than days.

Medical Forum spoke to Dr Chakera about the development. He said it was ready for action now in tertiary hospitals and for samples coming through Pathwest, but like any new technology there would be a period of validation to ensure its performance in a real world setting was up to expectations. The real game-changer will be the rollout in regional and remote areas, which is a priority for researchers. “The equipment is fairly specialised and expensive like all new technologies but we’re working on some exciting innovations around the development of a portable chip which could be deployed to remote and regional labs,” he said. The new method involves taking a small number of bacteria and exposing them to antibiotics for a short time then using a flow cytometer to examine them for any change in size and shape. Whereas samples might take 1-3 days for a lab result previously, this technology allows analysis within hours and, he said, in controlled conditions it could take less than an hour. Dr Chakera said it changed the paradigm of antibiotic use and would improve patient outcomes.

time from AIHW’s Alcohol and other drug treatment services in Australia: state and territory summaries 2015–16 that suggests amphetamines continue to be a bigger problem in WA than alcohol with 31% of clients, and 35% of episodes, seeking help for their ice drug problem. This compares with alcohol, 30%, cannabis, 23% and heroin, 6%. Closed treatment episodes for amphetamine use in WA was higher than the national average – 35% compared with 23%. Counselling was the most common type of treatment (74% of clients) with withdrawal management and pharmacotherapy both 8%. No surprise that 61% of all treatment agencies in WA was located in major cities with 94% of these agencies non-government.

The Knowledge Whatever we might think of the name Health and Knowledge Precinct we got to hand it to Landcorp, they’re working hard to make it happen. Last month it announced that Fini Group had won the tender to develop the $200m first stage of the Murdoch precinct. It would be building 175 apartments and a community hub of shops and restaurants. Fini has also signed up with Aegis Aged Care Group to build a 150-bed aged care facility and the Labor Government’s first 60-bed medihotel to accommodate patients from FSH and SJG Murdoch.

BY THE NUMBERS: Public Health

$2066 million

The total government spending (Commonwealth and State) on public health across Australia, 2013-14. This is equivalent to $89 per person or 1.34% of all health care expenditure.

• In 2003-04, total public health expenditure was $1200 million (constant price based on 2013-14 was $1616). This was equivalent to $82 per person and 1.63% of all health care expenditure • In 2013-14, the total public health expenditure was 0.13% of GDP; in 2003-04 it was 0.14% of GDP • Per capita expenditure on public health in WA in 2013-14 was $102 compared with a high of $119 in ACT and a low of $72 in Queensland • Internationally Australia was ranked 16th for public health expenditure among OECD countries. Canada spent most with $US 256.50 per capita (Australia spent $US 68.42) and Latvia spent the least, $US 8.05 per capital Source: Preventive Health: How Much Does Australia Spend, and is it Enough?: Hannah Jackson and Alan Shiell, Department of Public Health, La Trobe University, and the Australian Prevention Partnership Centre

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AUGUST 2017 | 13

feature

Conflicts of Interest – Who’s to Judge? The saying ‘no harm comes from shining light on workplace practices’ may leave some doctors uncomfortable. With transparency comes accountability. At the recent Doctors Drum entitled “Transparency – Clear as Mud?” the Corruption and Crime Commissioner John McKechnie QC commented that he thought most doctors were not corrupt but failure to follow policies was the primary reason why serious misdemeanours went undetected. As health spending has come under the spotlight so has the impact of fees on some consumers, from what seems like instances of ‘price gouging’ on privately-insured health consumers to shock ancillary costs. And, of course, reduced consumer access to primary care is touted as a consequence of health spending, for both public and private patients. A raft of market forces influence behaviour. The recent SAT case involving the Lord Mayor Lisa Scaffidi has raised one serious question. What level of transparency should we expect from public officers? A key test for identifying conflicts of interest is whether an impartial observer would reasonably question if the personal factors might inappropriately influence the way an individual carried out their work. These conflicts of interest may be real, perceived, or potential and may be financial or non-financial. Doctors are no different to ‘public officers’ because they deal direct with the public. As food for thought, we look more closely at one thing that may pose a conundrum for doctors, Pharma sponsorship. MA’s reporting requirements We know from experience, the knock-on effect of the PBS listing of a drug. Promotional money becomes available before that listing and during the life of the patent. For scriptonly items, doctors are heavily involved. Key opinion leaders (KOLs) are found to tell other doctors about the benefits of the drug. Doctors, who face a deluge of medical knowledge, are happy with the filtered information pharma companies offer. Some question this relationship, and wonder if it should be declared to the health consumer. The ACCC has ordered Medicine Australia (MA) to stipulate to its 34 member companies the need to report whether “transfers of value” have occurred to health care professionals and member companies and MA are trumpeting the move that makes it sound like it was their idea. All members are now required to report information relating to any declared-by-name health care professional (HCP) who receives payment. These include: • For speaking at an educational meeting or event.

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• To attend an educational event in Australia or overseas– including airfares, accommodation or registration fees. • All consultancy services related to educational meetings, preparation of promotional materials, assistance with training or any other advice to the company. • Payments to HCPs as advisory board members including sitting fees, accommodation and airfares related to activities of the board. • Payments to HCPs for market research. Where payment is made at the request of a HCP to a third party, payments must still be disclosed for the individual healthcare professional but the report will identify that third party. Formulating the Transfer of Value into an easily digestible form is still not easy. MA has ignored the request of its own working party that transfers of value be readily searchable by practitioner across all member pharmaceutical companies. There is no filtering by state or postcode and research payments are not included. With nine possible healthcare categories that pharma companies must declare, we found that medical practitioners took the lions share (the subject of this report) with a small smattering of nurses and pharmacists. By comparison, it was noted that payments to NGOs such as foundations, could be three times that made to doctors. This illnessawareness creation has been criticised as a marketing strategy, and consumers have every right to ask doctors about their involvement and what might be the ‘expected return on investment’ by the pharma company? As examples of the information that can be gleaned for the 2015-16 reporting period: • One pharmaceutical company paid 218 WA doctors an average of $1,323.23 each in “air travel and accommodation” (total $260,675.64) for attendance at “educational meetings” within Australia. Included in this was $21,675 paid to 12 doctors (21 attendances) as “service and consultancy” fees for attending as Educational Meeting Speakers (with two receiving air travel and accommodation costs of just over $1000). • Another pharma company paid seven

doctors $6993 in registration fees and $49,987 in air travel and accommodation for overseas meetings. • Overall, fees of $262,033.52 for “service and consultancy” were made to 257 doctors for company meetings in Australia, with $76,226.46 in air travel and accommodation. • Overall, payments to attend overseas educational meetings amounted to $74,978 (airfares and accommodation) with $14,352 in registration fees paid. • $119,352 + $675,421 were paid for 450 air travel and accommodation claims to attend company meetings in Australia. • $52,198.18 went to employers or third parties for services or consultancy, while $73,010.24 went in airfares and accommodation and $9,289.85 in registration fees. Only 11 of 38 of these meetings were independent – involving 29 doctors. • Have there been individual excesses? It is almost impossible to gauge from the figures provided without knowing what individuals did as part of their “consultancy” or whether they were flown business class, etc. Surprisingly few doctors had conference registrations paid amongst the 1,440 payments made over the 12-month period, but very few doctors appeared only once. A quick glance at the ‘frequent fliers’ revealed: Dr A received about $10,900 for 14 “service and consultancy” episodes from 3 different pharmaceutical companies; Dr C $12,800 for 3 “airfares and accommodation” from 1 company; Dr B received $23,800 for 3 episodes of “airfares and accommodation” and “service and consultancy” from 2 companies; Dr D received $45,000 for 20 episodes of “airfares and accommodation” continued on Page 16

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Feature continued from Page 14

Conflicts of Interest and “service and consultancy” from 1 pharma company; and Dr I received $27,000 for 12 episodes involving payment of “conference fees” “airfares and accommodation” and “service and consultancy” by 4 different pharma companies. Research funding is not covered. It should be. We should question whether payments from some pharmaceutical companies to doctors and labelled for “research” purposes are just that. In any event, health consumers want to know if research findings are published, who financed that research; or if research findings are not published was the doctor involved receiving benefits from any pharmaceutical companies to conduct research. In an epoll published in October 2012, we surveyed specialists, GPs and doctors-intraining in WA (n=250) around the issue of pharmaceutical sponsorship. • Then, about 40% didn’t think declaring sponsorship of individual doctors wrongly damage their independence; 25% were neutral. • 61% believed the public benefited from doctors’ ethical relationship with pharma companies. 28% were neutral • 75% thought educational events sponsored by pharma were needed by the profession; 13% were neutral. This echos a sentiment expressed at the last Doctors Drum meeting and sets down the challenge to colleges and representative groups to do drug education better.

Fiduciary Duty and Conflicts A reader wrote in asking us to source a definition of fiduciary duty as they believed it would be useful for readers “as many in the medical profession fail to understand this concept!” We asked Enore Panetta from the legal firm Panetta McGrath who made some interesting points. He writes:

company property or opportunities that are open to the company. As a collective board, duties owed to the organisation include:

A fiduciary duty is an equitable duty to act in good faith for the benefit of another. It is owed by the fiduciary to a beneficiary in a situation where there is a relationship of trust and confidence.

Do we need to worry about perceived, vs real competing interests?

In a medical context, despite the strong relationship of trust and confidence, a doctorpatient relationship does not automatically create a fiduciary relationship. However, a doctor (the fiduciary) may owe their patient (the beneficiary) certain obligations such as: • A duty of confidentiality; • A duty to avoid exercising undue influence; and • Possibly a duty to avoid conflict of duty and interest. For directors of an organisation (and a number of doctors are on boards) fiduciary duties are owed both individually and collectively as a board to the organisation. Individually, a director (the fiduciary) owes the organisation (the beneficiary) a variety of duties including: • A duty to carry out their role in in good faith and act with reasonable care and diligence; • To not allow a conflict to arise between their duty to the organisation and other interests they may have; and • A duty to not make improper use of

• To exercise the board’s power for a proper purpose; • To retain discretions and utilise them; and • To not disregard the organisation’s interests. Resignation will not necessarily terminate their fiduciary duties to the organisation.

The short answer is yes – you should be worried about all interests or conflicts. A perceived conflict/interest can have just as much impact as a real conflict due to the perception that a private or personal interest may have impacted on a decision of a board member even if it did not. Best practice is to ensure that your board remains transparent and that means managing all conflicts. How should someone on a board act in regards to personal interests? Whenever you are managing potential conflicts of interests it is best be proactive rather than reactive. This requires directors to be aware of the business of the board/organisation as well as their own interests so that they can act in an appropriate and timely manner should they identify a conflict. If they do, it is best for board members to declare any interests in a formal manner. Then best practice is for them to remove themselves from any discussions that may concern those interests, whether that be stepping out of a meeting, refraining from reading certain documents in circulation or abstaining from voting. A worst case scenario would be for the director to resign from their position on the board if the conflicts became unmanageable.

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AUGUST 2017 | 17

Transparency – Clear as Mud?

Trust is the magical ingredient in the complex doctor-patient relationship, but where does transparency sit in this? The latest Doctors Drum breakfast turned the spotlight on, well, turning the spotlight on – the profession, the patients and the system of institutions and commercial businesses that surround them as they go about the task of restoring health. The breakfast was held the day after the Minister for Health Roger Cook announced the establishment of a Sustainable Health Review and much of the discussion spoke to what every clinician hoped from it – efficiency and accountability. To achieve that, a transparent process and a transparent system are necessary.

and in my view of the system in WA it’s pretty inefficient.” “These are not the first reports. I don’t know what it will take for someone to act on them.” A question from the floor took up the problem of Medicare fraud which was facilitated by a flawed system and the ineffective way in which Medicare investigates the problem. This was echoed by one of the respondents of our ePoll survey who believed it was a significant problem that even Medicare acknowledged through its own research. While no one took up the Medicare angle it did open a discussion on what one person described as the flawed medical model how doctors were remunerated.

Corruption or inefficiency?

How much do patients know?

On the panel was the head of the Corruption and Crime Commission who had just released a report into how a pharmacist working at SCGH and FSH could have stolen and consumed Schedule 8 drugs for a period of years without detection. In his opinion it shouldn’t have happened because all the policies were in place to stop it from happening. The failure was in the nonadherence to the policies.

And, asked some, how much do they want to know? In clinical practice how practical is it to be completely transparent?

He also cited the investigation into the Health IT contract that was overrun by $43m. “This was looked at very carefully and it was found there was no corruption just incompetence and failure to follow policy. In my limited time in the job I have seen far more failures to follow policy than corruption. Health constitutes about half the state budget

One doctor put the problem onto timed medicine. “We manage people who are diseased or broken and we have 10 minutes to do it. How can we change what we do? We prescribe antidepressants and after a month less than 50% are taking them...because we didn’t tell the patient enough about their condition and what the medication will do. It is completely opaque and it’s not surprising they come back when the wheels fall off.” The consumer advocate on the panel said most patients made most of their decisions in a complete vacuum and information needed to be democratised. She praised Dr Google, as flawed as it was, for going some way to

address consumer health literacy. Another said time was the key and it was the thing most denied GPs who were often left to help their patients navigate through their health decisions. One GP thought transparency was a doubleedged sword in the context of the therapeutic relationship. “There is a high level of uncertainty in what we do in general practice. Should we communicate that uncertainty to our patients? I think that could be counterproductive. In clinical trials, the placebo is a deception, surely? That is not transparency but we need it because we know that it has an important effect. We also know that about half our patients see people who are not sciencebased (complementary medicines) and what they offer, as well as a lot of time, is an element of certainty about treatment. It is misplaced, of course, but there is a danger for doctors in this area. Full clinical transparency can undermine the therapeutic effect of treatment.” A panellist agreed: “Australians march with their feet and you may say it’s patronising, but people enjoy going to complementary practitioners because they get certainty. Placebos are a wonderful thing and something that is very powerful. ‘I will give you a pill and it will make you feel better’ are powerful words from your GP, particularly if you have had a relationship for a long time. It is not patronising but very useful.” That’s why we can’t have complete transparency because there is some magic and some humanism involved in medicine that

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See www.doctorsdrum.com.au 18 | AUGUST 2017

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we have been using since time immemorial. We are stuck with it and our patients demand it. We need to balance, with the evidence, what we can provide.” The consumer advocate thought the questions doctors asked needed to change. “Some people want to hand over their power and that’s OK other’s need to understand. If they don’t understand the paradigm and it affects your interaction, then it has to change. We are at the dark end of the spectrum so even a little grey would be great.” A specialist felt patients wanted leadership from doctors. “You can share uncertainty with a patient in a positive way. Frequently I divide my decision on the page: this is an evidencebased decision but some decisions we make in medicine are not evidence based because there is not an answer to every question. I often say, this is my clinical judgement; this is a risk. We are being asked to manage risk."

Big call, big bucks? The roles of the pharmaceutical and medical device industries in influencing clinical decisions became the next subject for hot discussion. While one doctor thought pharma offered excellent education, many others thought that it didn’t come free. “The evidence shows that pharma do it for one reason and that’s their bottom line and entirely related to selling their product. More harm is done by that than providing a balanced view of what pharma is going to do.” Several doctors said a spotlight needed to be shone on device companies. “We have gone from a situation where new devices were studied in a controlled environment, outcomes measured then experts determined whether they were worthwhile. Now devices are developed and the companies create the need. Unsubstantiated claims of cures

are put on websites and patients come to us demanding that product,” one said. “Or they come with absolutely no idea that they are having a device put inside them. They are often completely in the dark and they wear it forever,” said the consumer advocate.

Shifting the responsibility Over-testing and over-investigating raised concerns about waste and the litigious and defensive environment doctors live in. While many doctors acknowledged it as a big problem, it was a difficult problem to solve. “There seems to be a trend away from the basic sciences of history and examination to technological verification of our own insecurities. That’s why we lean towards investigation. You’re right we’re a litigious society. I struggle with the idea that we are going to an all-investigation field but Gen Y tends that way,” said one doctor. Common sense seems to have lost ground and there is no cost accountability or transparency and this wasn’t confined to medicine. As one doctor pointed out, technology has changed sport and the notion of umpire irrevocably. However, doctors should back themselves more. “I have been in practice 30 years and now I can say, ‘I’m not going to do that’ but you have to have experience and clinical nous to back yourself and I know many of our young colleagues struggle to deal with that uncertainty. Uncertainty is the hallmark of general practice. We spend our entire time with uncertainty and it’s only as you get older and wiser that you can say, I’ve got no idea.” Evidence also found itself on shaky ground. It has been reported in the US that 50% of research doesn’t get published (at a cost of $180b a year globally) if it didn’t produce the

right answers for its backers and some disease guidelines were based on the work of panels who were financially conflicted.

Outcomes-based funding model Everyone expressed dismay at the current funding model for general practice and a few advocated the need to change to outcomesbased reimbursement. It’s introduction, should it happen, could be rocky given, as one doctor suggested, “few of us look at the long-term satisfaction of our patients.” However this seems to be the direction policy is going. One GP said the model only paid for “doing things” – “that’s why orthopods doing quick operations get paid more than anyone else.” He believed an outcomes model would be “much cheaper and save that huge cost of unnecessary testing and give us time to do the job properly.” Another said a patient’s outcomes were not just clinical but also about quality. “We have too many perverse incentives.” She raised the interesting point that we needed to know what we were measuring. The work of the International Consortium of Health Outcome Measures (ICHOM) was raised which is likely to form the basis of some of the reforms being mooted. ICHOM, an NFP backed by Harvard Business School and others have come up with a combined set of outcomes derived from clinical and patient surveys that looked at a range of issues, from patient satisfaction, quality of life and clinical outcomes of over 100 disease sets. “It allows you to compare across-the-board treatment. So you might have radiotherapy on your prostate cancer versus radical prostatectomy … you are able to not only determine your clinical measures but also satisfaction. It is disease specific, not treatment specific.” continued on Page 20

See www.doctorsdrum.com.au

MEDICAL FORUM

AUGUST 2017 | 19

continued from Page 19

Transparency – Clear as Mud? This 360 degree look at outcomes was welcomed but one sounded a caution that if the government was remunerating on outcomes, there had to be an acknowledgement that many of the factors were outside the control of the doctor. Outcome-measures were OK, said one doctor, as long as the right ones were being measured. He cited the 4-Hour Rule as a policy that got it very wrong. “A casualty visit is deemed a success if it lasts less than four hours. No-one measures the patient outcome clinically. It’s a cynical and very expensive

game.” Patients were shifted from casualty into the laps of other doctors in the system whether it was appropriate or not and the practice was putting unnecessary strain on an already strained system. Returning to the ICHOM model … a final note was sounded. “What is different about this set of outcome measures is that patients’ outcomes measures were weighted higher than the physicians’ and ultimately we have to remember that it’s not whether we think we’ve done a good job, it’s whether the patient thinks we have.

See www.doctorsdrum.com.au

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MEDICAL FORUM

E-Poll

Transparency and You At the Doctors Drum in June, the issue of transparency was thrashed out by our panel. Some of the topics raised have inspired the questions of this ePoll. Issues such as how the profession deals with the inherent uncertainty of illness and disease; are doctors open about clinical and financial issues; and what role do medical device companies play around creating demand. As usual, the results are fascinating from the 107 participants – 45% of whom were GPs, 37% specialists, 7% Doctors-in Training and 10% others. The gender split was roughly 60:40 men and women.

GPs deal with a lot of uncertainty. Will increased

transparency about this uncertainty interfere with the therapeutic relationship between GPs and patients? 53% 24% 23%

Could you do more in your consultations to improve

transparency with patients, whether economic or clinical transparency. Yes No Uncertain

52% 39% 9%

Are doctors prone to burnout, more so than many other professions?

Yes No Uncertain

65% 18% 17%

ED: When over half of those surveyed say more can be done to improve transparency, it begs the question why not try it. The next question goes a long way to answering that – but is time the only issue?

Is the restriction on time a hindrance to being (more) transparent with patients?

Yes No Uncertain

66% 30% 4%

Have you found that most consumers want to know more

about their health?

Yes No Uncertain

decisions about treatment, generally better off having family members decide for them? No Uncertain Yes

37% 36% 27%

Transparency and Commerce

What is your response to this statement: “Device

companies, through illness awareness campaigns involving the profession, can create a need for their products?” I agree I strongly agree Undecided I disagree I strongly disagree

54% 32% 10% 3% 1%

ED. More than 85% of those polled thought device companies went to some lengths to create a demand for their product, not only among doctors but also among the public.

Would it be more in tune with what people want if the profession is funded based on patient outcomes?

No Uncertain Yes

50% 27% 23%

ED: Outcomes-based funding was discussed at length at the breakfast. It seems to be that’s where health funding is heading yet no one is sure how outcomes can be measured and our survey respondents reflected that uncertainty.

Where is the value?

Do you think doctors order tests that are wasteful of health resources (for whatever reason)?

80% 13% 7%

ED. At the Doctors Drum breakfast the stark differences between an average GP and specialist consultation were laid bare and it did come down to time. Patients can learn a lot more from their doctor if they have 45 unhurried minutes (for which the specialist is well remunerated) compared to 10 minutes for a multitude of ailments(for $37).

Transparency and the Elderly

Do you think the decision not to operate on an elderly frail patient is mostly handled appropriately in Perth?

Yes Uncertain No

On average, are the elderly who are not fit/ready to make

Doctor-Patient Relationships

No Yes Uncertain

Aug

e-Poust ll

36% 33% 31%

Yes No Uncertain

74% 22% 4%

Where would you rate patient satisfaction when a health

intervention costs them nothing (e.g. fully covered by Medicare and/or private health insurance)? Average High Very High Low Very Low

37% 28% 19% 13% 3%

ED: Those surveyed were pretty convinced that if patients get a service for free they are pretty happy, which puts a dent in the value-for-money argument. We wonder how many patients understand that bulk billing is not free?

continued on Page 22

MEDICAL FORUM

AUGUST 2017 | 21

E-Poll

e-Po ll

continued from Page 21

Through the Looking Glass We threw the poll open for comment on the topic of transparency and had an array of fascinating responses from wise heads to hot heads. Here’s what some of the 50 respondents had to say. Transparency: Is it possible? ED: At the Doctors Drum breakfast transparency emerged as something of a utopian ideal ... perfect to have, difficult to achieve. A sample of the comments from our ePoll show just why that might be.

“Patients are entitled and deserve transparency in relation to costs of their care. As surgeon, consulting patients for a procedure I find it hard to be transparent about these costs when I myself have no idea what will and won’t be covered.” “As doctors we have been shielded/cocooned from the business/bureaucracy world and we are generally decades behind in how we think about things.” “We live in a society that is NOT transparent. All well and good to aim for more transparency in the health sector, after all, the industry should carry high standards. However, why don't we demand transparency from the ones who are demanding transparency from us – our government, policy makers, hospital executives, politicians, managers, AHPRA, and last, but not least, patients!!!” “Transparency means to be completely open and honest to the patient about their current status and what they can expect in the future. To take the time to listen to their concerns, and take the time to explain all options to them and take the time to listen to their questions that follow. Then take the time to answer them in an open and honest way. As you see, the recurrent themes are 'take time', 'listen' and 'honesty'.” “We all want clinical transparency as it identifies opportunities for improvement and provides patients better understanding of the complexities involved in managing their health. However, with increased clinical transparency clinicians can feel more vulnerable and scrutinised. So long as transparency is used to improve clinical practice rather than penalise clinicians then it can only be a good thing.” Listen to geriatric patients ED: Several doctors surveyed took exception to aspects of the questions regarding elderly patients and thought it reflected clinical ageism.

“It is not ethical to generalise ‘elderly’ – people of all ages may lack competence in decision-making in certain areas. In my extensive experience in geriatric and non-geriatric specialised areas of care I find that those inexperienced with geriatric patients frequently default to ‘they are a very poor historian’ and give up with their

22 | AUGUST 2017

Transparency and Ethics?

Is enough action being taken to ensure policies on bullying and harassment

are being implemented? 46% 35% 19%

No Uncertain Yes

Do you think whistleblowers of the medical profession are protected fairly? 75% 24% 1%

No Uncertain Yes

How strongly do you feel that hospital administrators determine what clinical experts do? 32% 28% 13% 10% 8% 8%

Moderately Extremely Uncertain Neutral Somewhat Not at all

ED: The issue of bullying and sexual harassment hit the headlines nearly two years ago but many of the surveyed docs think there’s still a lot more than can be done. In that light, it’s not surprising that just about everyone thinks blowing the whistle is a dangerous thing to do and more protection should be afforded to anyone who does.

communication effort. These patients are usually competent in the decisions needed but it is easier to say they are confused than to listen to them. Their wishes are then often directly contradicted.” "Elderly people are not a group of people with a high prevalence of decision-making incompetence and labelling them as such is very dangerous as it gives permission for lazy health professionals to not bother communicating with them. They are a group of people who demand respect and this is a craft that demands a very high level of dedication and pride by the professionals [who work in it].” “Asking whether ‘elderly’ are better off having decisions made by others ‘if assessed as not competent with that question’ is a dangerous question to ask. It encourages inexperienced professionals to consider this as an option. The legal, ethical and practical aspects of this are complex. The high rates of elderly abuse often involve family members as perpetrators.” Outcomes-based funding ED: The process of establishing outcomes-based funding is in its infancy and some of the doctors in our ePoll reckon we shouldn’t be holding our breath. A lot of institutions and individuals will need to transform the way they do business and telling the hard cold facts is a good place to start.

“Funding according to outcomes is appropriate if the outcomes are what the patient wants but this is often not the case. Often patients do not want treatment… We have to be careful not to impose our assumptions on what the patient outcomes should be.”

“The risk of adverse outcomes must be discussed with patients, particularly emergency intervention in surgery. WAASM has attempted to deal with the issue of futile surgery. An evaluation of emergency laparotomy has been undertaken in Perth and the College of Surgeons and Anaesthetists are planning a biannual audit. Risk assessment is fundamental to that.” “Transparency needs to start at the top, that is with the HIC, MBS and the state/ federal DOHs...namely by telling the truth with respect to the cost of healthcare, the reason for ‘gaps’, the lies told by private health funds re: ‘gap free’ providers and the reality of public vs private care in terms of service provision and convenience of care.” Bad behaviour still bad ED: This doctor’s views would indicate that there is a lot more to stamping out bullying and harassment than writing a set of guidelines.

“Bullying and harassment, particularly among surgical specialities, are still rife with consultants being very unsupportive of anyone who "creates more work" for them or detracts from their income-producing practice. No matter what the college head says, complainers are readily identifiable and fears on performance micromanagement or career progression / poor references because of personality conflicts are real. One small surgical subspecialty had a formal bullying/ harassment complaint raised successive years by different trainees of the same sex – and the consultants did nothing. Both trainees quit their formal training. The system has not yet changed.” MEDICAL FORUM

GUEST COLUMN

The Value of Values in Health Respect and a genuine regard for values will reap powerful rewards, says child health advocate Dr Michael Watson sees systemic problems in health CAHS and to restore Respect for patients, their families and the staff that serve them.

"We have an illness in France which bids fair to play havoc with us; this illness is called bureaumania".

I recently met Debbie Karasinski, the Chairperson of CAHS. Coming from a disability background it is clear that Debbie understands the concept of Respect and seems determined to inspire this core value in CAHS.

These fateful words were ascribed to the French economist Jacques Claude Marie Vincent de Gournay in the 1750s, not long before the French Revolution. It was from M. de Gournay that the term ‘Bureaucrat’ is thought to have originated. In French it means ‘rule from the office or desk’.

She articulated the attributes of the type of leader she would like to see appointed to the CEO’s position when it is advertised in six months’ time. I believe she hopes to find a strong compassionate leader to inspire the true value of Respect at all levels of the organisation.

We all know the fate of the French monarchy and there are many who believe that our WA health system is plagued with that same bureaucratic culture. When we look at recent events in our Child and Adolescent Health Service (CAHS) some might even say that a revolution had begun! Respect is an important core value that can protect the culture of organisations. However Respect means differing things to different people. In bureaucratic cultures, Respect can translate to unquestioningly obeying those above you in the hierarchy and expecting to be obeyed (rightly or wrongly) by those below you. In bureaucratic cultures, the organisation itself and its hierarchy are the central focus of all activity, not patients or clients.

The review’s findings can be summarised simply as a lack of Respect within the organisation. For staff to be able to effectively care for the vulnerable children whom they serve, they must in turn be cared for by their leaders and administrators. Although there was some focus in the report on the CEO, it seems unfair to me to attribute this shortcoming to one individual. So what is the alternative to a bureaucratic culture? Ideally we want to see ‘public servant’ behaviours with the emphasis on serving rather than ruling. In a ‘public servant’ culture, Respect is viewed quite differently and is more about demonstrating empathy and compassion (understanding and kindness) not only to the patients/clients, who are the principal focus of the organisation’s activity, but also to the people who serve them (i.e. the staff). So what went wrong in the Child and Adolescent Health Service (CAHS)?

MEDICAL FORUM

Surveys that measure how well key people live the values of their organisation are very powerful. Press Ganey surveys (which are robust internationally bench-marked surveys) were introduced into CAHS for the first time recently and raised serious concerns about the culture of the organisation. The results of these and other surveys were so concerning it led to a review of the CAHS administration. The review’s findings can be summarised simply as a lack of Respect within the organisation. For staff to be able to effectively care for the vulnerable children whom they serve, they must in turn be cared for by their leaders and administrators. Although there was some focus in the report on the CEO, it seems unfair to me to attribute this shortcoming to one individual. The CAHS staff with whom I spoke for this article clearly acknowledged that a deterioration of Respect had occurred at many levels of the organisation and over many years. The administration and management of CAHS had been like a game of pass the parcel. The former CEO was simply the one holding the parcel when the music stopped. However, there is hope. We now have a new state government and a new Minister for Health. Roger Cook has indicated that he takes the issue of values, culture and staff morale very seriously. Another major change in WA Health which offers hope is the recent introduction of Area Health Service Boards. It is clear that the CAHS board is not simply made up of symbolic figure heads, but is comprised of a group of capable individuals from diverse backgrounds including the private and notfor-profit sectors. This depth and breadth of experience will be invaluable in helping the future administration to rebuild the culture of

I hope we continue to see internationally bench-marked surveys of lived values conducted regularly, published widely and expanded to the whole of WA Health. If this occurs, I am sure we will see dramatic improvements in the outcomes and satisfaction of patients, their families and also improvements in staff satisfaction and morale in the future.

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Close-Up

Healthy Start, Healthy Future The Origins Project at Joondalup Health Campus seeks to find answers to some of the most worrying health problems facing children today. When the triennial Australian Early Development Index was published in 2012 it set off alarm bells for Prof Desiree Silva, the head of paediatrics at the Joondalup Health Campus. The AEDI showed that some areas in the Wanneroo region had the most vulnerable children in Australia where almost 40% were vulnerable in one domain.

Alongside her clinical work, Desiree is also involved with the Telethon Kids Institute and the idea of such a population study with the backing of a CEO whose hospital delivers more than 4000 babies a year was of immediate interest to Paediatric immunologist Prof Susan Prescott whose work on childhood allergies has led her to an intense study of the microbiome.

While it sounded the alarm, Desiree said it also confirmed her own clinical experience.

Susan has published several books – Origins and The Allergy Epidemic for UWA Publishing and co-authored another book with Dr Alan Logan, The Secret Life of Your Microbiome, which will be published in September.

“I was seeing (and continues to see) increasing numbers of children with mental health issues – anxiety disorders, autism and ADHD. I have had children as young as seven articulating suicide. These symptoms are becoming more prevalent, their degree is worsening and the age of the children is getting younger,” she said. These children with problems become adults with bigger problems if they are not managed appropriately.” “In terms of physical health, there are so many more children presenting with allergies and asthma. About 24% of children by age one has eczema and one in 10 has a food allergy. The children in the Wanneroo survey were not just part of a national average, they were living on the hospital’s doorstep and clinicians had few definitive answers to alleviate their suffering. “We need to understand why these issues have increased and how we can prevent them or, at least, intervene earlier,” Desiree said. Buck stops here The hospital CEO Kempton Cowan when he saw these figures was compelled to do something about it. The hospital draws about 80% of its staff from the local area. It was personal. It was the early stirrings of The ORIGINS Project, a longitudinal pregnancy and birth cohort study that would investigate the foetal origins of many common noncommunicable diseases. MEDICAL FORUM

Desiree and Susan are co-directors of The ORIGINS Project, which has had its initial injection of funds from the Health Department, Telethon Kids and Ramsay Health Care. The ORIGINS Project, which started recruiting in December 2016, will focus on environmental exposures on women during pregnancy and would follow the developmental milestones of the child till the age of five. It marks new territory and, with improving technology, it is hoped the research will penetrate the mysteries of a range of non-communicable diseases that affect so many of the world’s children. A gut feeling “Technology has revolutionised the way we understand the microbiome. We think there are a lot of answers to these questions there because 95% of genetic make-up is bacterial, so the idea that we can change our genes is very real. It is likely that a lot of these NCDs are a result of gene changes from some environmental or epigenetic factor,” Desiree said. So far 300 women have enrolled and researchers are aiming for 10,000 over the next five years and the study will run for 10 years. “We’re encouraging people to join ORIGINS

Prof Desiree Silva

as early as possible – 10 weeks gestation is ideal – so they can join the sub-studies (see P28). The project hopes to answer global questions but individual study participants will also receive real-time feedback.” “We have factored this feedback into the study because I don’t want information sitting on my desk that can make a difference to someone if problems are detected at the various developmental testings.” “There is a lot to be said for putting a child on the right trajectory and if we can discover how to pre-program that trajectory so the child will have less chance of being sick or developmentally vulnerable, then that would be a great thing not only for the child but the community as a whole.” Desiree’s own research interest is in neural disorders. She is involved with Dr James Fitzpatrick’s FASD project in the Kimberley and she has completed her PhD on ADHD in relation to early environmental risk factors. She has just published ADHD Go-To Guide (UWA Publishing) with co-author Dr Michele Toner. The disorder constitutes a significant proportion of her cases. Parents need help “I’ve spent a lot of time with children and families with ADHD and realised there wasn’t enough parent-friendly information available explaining the current issues around ADHD and how to manage their child, with and without medication.” She will be watching with interest what ORIGINS throws up in regards to parents’ use of technology. While there is growing research

continued on Page 26

AUGUST 2017 | 25

Feature continued from Page 25 parents rather than being babysat by an electronic device or have mum or dad glued to their phone.” “We need hard evidence about the developmental delays caused by the use of electronic devices and then find a way to give parents correct advice.” Desiree, who was born in Sri Lanka and did medicine in the UK, did her paediatrics training at Princess Margaret Hospital and Darwin 20 years ago. It is there she met Dr Wendy Hoy, a renowned clinician/researcher who has done ground-breaking research into kidney disease in vulnerable populations.

Desiree running the Busselton Ironman

around children’s use of technology on their behaviour and language development, electronic devices are also coming between parents and their babies. “I see babies at the six-week check who are not smiling as they should be and then I notice their parents excessively looking at their phone. Early facial expressions create the platform for the brain and parents are simply not spending enough time looking at their young children. When the baby is awake, they need to be engaging with their

“Wendy has done some unbelievable work on renal disease in Aboriginal communities, especially the Tiwi Islands. She was one of the first researchers to link low-birthweight with kidney disease and diabetes. She asked me to present some of these findings at an international conference in 1994 and that sparked me off and I have been interested in the origins of disease ever since.”

Burden of mental disorders “We are currently dealing with enormous mental health issues on the ward and we don’t quite know what to do. The link services at CAMHS are completely overwhelmed with the number of children being referred to them and the severity of impairment so we need to find new ways to reverse that.” Desiree has been working at Joondalup Health Campus since 1998 and head of department for 10 years and in that time has seen the hospital expand exponentially. The health campus is serving the fastest growing population of any local government in WA. According to the 2012 AEDI data, the City of Wanneroo has a significantly higher percentage of children aged birth to eight (15%) than anywhere in WA. It has also become a clinical teaching hub with medical students from UWA and allied health students from ECU and Curtin providing exciting opportunities for “youngsters thirsty for research”.

At the Telethon Kids Institute, Desiree undertook the ‘swimming pool study’ a research project that looked at how access to a swimming pool in remote communities could positively impact on children’s wellbeing. Her specific interest in mental health continued with her work in ADHD.

The new 37-bed Telethon Children’s Ward, complete with overnight facilities for parents, was opened in June last year and apart from winning awards for its interior architects, Silver Thomas Hanley, it has lifted the spirit of patients, their families and the health practitioners who treat them.

“It went neatly with Susan Prescott’s research so we joined our enthusiasms and with a little funding we got The ORIGINS team and project off the ground.”

“The new ward has made a big difference to the atmosphere. People love working there and parents get a good night sleep. Everyone seems a lot happier,” Desiree said.

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FEATURE It offers hope that when the new Children’s Hospital is commissioned it will have a similar effect on morale for staff at PMH, but, of course, the culture of an organisation is much more than bricks and mortar. Culture and productivity So what is the secret of this gross national happiness at Joondalup? “I think the main thing is that people feel valued and you work on people’s strengths. We don’t micromanage but there is mutual respect … that said we have to choose the right people as well. We have a great team of consultants who have exceptional clinical skills and love teaching. It’s one of the few places where you can do neonates and general paediatric training, so we all experience some adrenaline at work. We are really quite busy.” Desiree also praised the hospital management, which she said supported its clinicians. “That makes a big difference. It’s not difficult to see the CEO if something is not right and he will attempt to fix it. You don’t feel you have to go through layers to get there. There’s no reason why that model can’t be replicated,” she said. “Junior staff are happy here and that doesn’t happen by accident. A lot of effort goes into developing a positive culture. There is a sense of growing together and taking people with you. And that is why ORIGINS is a perfect fit

The new Telethon ward at Joondalup Health Campus

here – it is embedded in the daily working life of the hospital and people feel included.” Desiree also advocates to her staff the importance of switching off and in her own case there’s not too much lazing around the pool. Feeling her feathers

much to me. People kept telling me before the Ironman about what to do when I hit the wall. I was passing people lying on the side of the road hypothermic, vomiting and cramping wondering when I would feel that bad. I didn’t and I finished under the time limit. People have asked me when will I do the next one and I say when I am 60 !”

“I love being fit and adventure travel – hiking, cycling and swimming. I do the Rottnest swim every year with friends. I was a hopeless runner until I got a dog and started running along the beach. That developed into triathlons and fun runs until I ran the New York marathon with a group of friends. I proved to myself I could do that distance so in December just gone I did the full Ironman in Busselton.”

“That’s my downtime.”

“I’m not competitive – times don’t mean

continued on Page 28

So thrilled with the achievement she gave her three children aged 27, 25 and 23 entry into the half ironman in May as a Christmas present. “They embraced most of the training and all finished well, it was incredible. It goes to show you so much is in the mind. If you want to do something, you can do it.”

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Country WA ... Live, work and play

continued from Page 27

Origins Offshoots There is a nest of sub-studies running off the Origins Project: SYMBA: This study will examine origins of allergic diseases including eczema, asthma, hay fever and food allergies through research into the mother's gut health and the effects of 'Prebiotics'. This is a general term for non-digestible dietary fibre which is the substrate for the growth and/or activity of beneficial gut bacteria. This project will recruit pregnant women (during their routine antenatal visits to Joondalup Health Campus) to receive either a prebiotic supplement or a placebo. They will be asked to take the supplement from 1820 weeks gestation until their baby is six months of age. The study will then examine whether supplementing the mother's diet during pregnancy and breastfeeding with prebiotic fibre will reduce the development of allergies in her child.

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TALK: The aim of this study is to track a large participant cohort from prenatal life to three years of age to understand biological factors that may underpin language development. The data collected will be used to explore several hypotheses relating to the interplay between prenatal testosterone exposure and brain growth, and their relation to language development. The study will recruit 500 pregnant women at their initial antenatal appointment at Joondalup Health Campus (private patients only). The assessment protocol involves two antenatal ultrasounds, a neonatal hearing test, and behavioural assessments at six, 24, and 36 months of age. The protocol will also analyse data collected as part of the ORIGINS study, including umbilical cord blood (for androgen concentrations), and maternal and child DNA samples. PLAN: The aim of the PLAN project is to test whether a lifestyle intervention in early pregnancy reduces offspring adiposity. Recruitment will take place at 6-8 weeks gestation and follow a 12-week lifestyle intervention program in conjunction with routine antenatal care for private and public patients. The project will use smartphone web-based applications to deliver diet, physical activity and wellbeing advice to women who begin their pregnancy overweight (pre-pregnancy BMI > 25). PLAN will examine epigenetic biomarkers (differential DNA methylation), to determine if these are modified by optimisation of gestational weight gain or associated maternal lifestyle changes. Even small changes in infant adiposity have the potential to change future obesity trajectory. CARE dads: Expectant fathers get an opportunity to participate in research as well. This study will look at their cardiovascular health. They will provide a blood sample from which red and white blood cells, DNA and RNA will be prepared and stored for future research. They will also be invited to have a cardiovascular health evaluation and be provided feedback. The study will also look at the distribution of Anti-Mullerian Hormone (AMH) in the expectant fathers, and to examine associations of AMH with reproductive hormones (testosterone, luteinising hormone, follicle-stimulating hormone, sex hormone-binding globulin) and with physical and biochemical markers of cardio-metabolic risk (age, exercise, smoking, alcohol, body mass index, waist circumference, blood pressure, lipids, glucose, HbA1c, and presence of metabolic syndrome). ED: GPs in the Joondalup Health Campus catchment are urged to encourage their newly pregnant patients to join The ORIGINS Project. Contact 9408 3118 or email originsproject@telethonkids.org.au

There has never been a better time to go Country!

28 | AUGUST 2017

MEDICAL FORUM

news & views

PTSD and Police Last month we explored PTSD experienced by first responders with a focus on the ambulance service. Here WA Police explains its policies in this critical health area. The police union last month spoke to Medical Forum and listed its concerns for its members. WA Police was asked to respond but its response came after our deadline. Here are the edited responses to our questions around PTSD in the service. What mental health training and support are given to police? Recruit training/ ongoing education/screening after traumatic events. Is it culturally entrenched in the service that trauma is part of the job and has to be managed? In WA Police it is acknowledged that police officers are exposed to events that have the potential to be traumatic on a more frequent basis than the general public. What events impact people is a very individual experience. The Health and Safety Division is active in training and education initiatives and works closely with the Police Academy to ensure programs are contemporary and relevant. The Psychology Unit is currently partnered with UWA to develop a comprehensive and evidence-based resilience program for trial with recruits. If successful, this program will eventually be adapted for current personnel. The Police Academy has specific internal trainers who deliver Mental Health First Aid training. To date, the agency has trained more than 10% of the agency (as at April 2017, 1223 personnel) in this program (which was Recommendation 19 in The Toll of Trauma on Western Australian Emergency Staff and Volunteers report (2012)). Last month (July), we began a review of the Welfare Services for Officers and their families. This will focus on identifying needs at different ranks in order to create mentally well workplaces, critical incident response processes, knowledge of existing services, use of resources and opportunities for capability building. At the induction ceremony for new recruits, Health and Safety Division present for 40 minutes to the families discussing the challenges of policing and their role in supporting their loved one. Information on the challenges of policing and what changes in behaviour to be aware of is provided to them in a booklet. Additional information on support services both internal and external (ie: Lifeline) is also be provided. This program began early 2016 and has received positive feedback from the families that have attended. What support is offered to staff? Current staff can access a number of internal support processes including Peer Support Officers (PSOs, 130 currently active), Welfare Officers, Chaplains and internal Psychologists along with specialist medical assistance where required. Members and their families MEDICAL FORUM

can also access support from the Employee Assistance Provider (EAP). As per the Industrial Agreement, medical expenses for police officers are paid for both work and non-work related illness or injury. Police officers, who do not wish to use the internal psychological resources, the EAP or the Chaplains, can seek assistance from professionals external to the agency (of their choosing) and will either have these expense paid directly by the agency (work related) or reimbursed (non-work related). There are also free community mental health resources that can be accessed through their GP. There is no financial barrier for police officers seeking assistance. In relation to PTSD Health and Safety Division also utilises external programs and practitioners who are specialists in this field. WA Police is also reviewing software to better capture and record exposure to potentially traumatic events. (Recommendation 4, Toll of Trauma Report) Is there a reluctance for police officers to put their hand up to say they are struggling? Are there management strategies to get around that reluctance? Why people struggle to seek appropriate help is a complex issue and not confined to emergency services personnel. The main cause put forward is normally stigma. Stigma in relation to psychological wellbeing has changed in the past five years but it still remains in the general community. It is not

something that any one workplace can tackle on its own. Awareness raising and education programs show promise in helping to recognise early warning signs and seek assistance earlier. Mental Health First Aid is well recognised and received throughout the agency. This has a very strong message regarding help seeking. WA Police has specific programs for management to help them identify early changes in behaviour and encourage people to seek appropriate help. These are based on the principles of Psychological First Aid. One of the issues raised by the union was a mechanism whereby medically retired officers were processed differently from those who have been accused of misconduct or corruption. Is that on the cards? WA Police has reviewed the process of medical retirement for police officers. Medical retirement is covered by the same section of the legislation as loss of confidence. Changing this requires legislative change and is an ongoing piece of work. Our overall message to police officers regarding PTSD and any psychological challenge is that it is not always career ending. We try to focus on building capacity and having people at work. continued on Page 33

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guest column

Policy on the Run? As noted satirist H.L. Mencken once said, “For every complex problem there’s a simple solution, and it’s always wrong.” The WA President of REIWA, Hayden Groves agrees. • Decision making

It’s a complete ‘no-brainer’ that, when new government policy in critical areas is being considered, an evidence-based approach is the best way to maximise good outcomes. That’s of particular importance in WA’s housing sector. Despite softer market conditions, housing affordability remains a significant concern for many West Australians, particularly those on low incomes. An adhoc approach to policymaking will only add costs to the property market and exacerbate housing and rental affordability in WA. REIWA was more than a little concerned when the rumour-mill began grinding out messages in mid-May regarding a new $270 property tax. This is all part of a broader McGowan Government plan to raise revenue and help alleviate the Budget crisis. But slugging investors with a new tax smacks of policy on the run. It’s interesting to note the comments of Gary Banks (Chairman of the Productivity Commission 1998-2012) in his paper, Challenges of Evidence-Based Policy-Making.

There’s no doubt the State Government is in a difficult financial position and tough decisions need to be made, but introducing yet another property tax is not the answer. He states that the policy-making process must begin with a question, not an answer. In other words, policy must be approached from a neutral standpoint rather than a foregone conclusion. Gary Banks’ mantra is a stellar example of how public policy should be developed to avoid the temptation to draft legislation‘on the run’. The Commission’s key recommendations for good policy include: • Issue identification • Analysis • Identifying possible solutions/options • Consultation with stakeholders

• Future evaluation of the policy to determine its effectiveness. There’s no doubt the State Government is in a difficult financial position and tough decisions need to be made, but introducing yet another property tax is not the answer. A degree of caution is in order here because targeting property investors has the potential to hit tenants when the cost of the levy is passed on. After making enquiries, REIWA has been assured by the State Treasurer that a ‘lot of options are on the table.’ Nonetheless, any precipitate legislation implemented to correct a short-term problem without giving proper consideration to its long-term effects and with inadequate consultation is somewhat reckless. We all know that reform can be tough, but it does need to be inclusive. Australia has been comparatively successful over the past two decades in achieving some good reform outcomes, but many issues that remain are complex and require a considered and evidence-based approach.

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MEDICAL FORUM

guest column

No Quick Fix for Persistent Pain Pain management has become a vastly different practice with exercise an important element of treatment, says physiotherapist Tom Belotti. In any discussion of this nature a useful case-study is back pain, the most prevalent and costly musculoskeletal presentation in the developed world. We know back pain is a problem, but how much do we really know about it? We do know that over 90% of back pain presentations are due to local muscle spasms in response to mechanical or psychological stimulus, with less than 10% of cases linked with sinister pathology. We also know that a person’s pain experience is reliant upon a variety of factors that fall within the well-known, but poorly applied, biopsychosocial model. Research has made it clear that patient suggestibility plays a significant role in the experience of pain. When you pair back pain with a MRI investigation there is a strong correlation between its interpretation and higher rates of disability and work absenteeism, not to mention patient expense. Such a troubling correlation is largely due to incidental findings of advanced disc degeneration, bulges and protrusion, annular tears, facet joint arthritis and spondylolisthesis. These are often presented

A framework encompassing escalating invasive medical steps as a pathway to symptom reversal remains unsupported by research. to the patient as the source of their pain in a biomedical model, despite best evidence showing no reliable correlation. Such interpretations pave the way for unnecessary and potentially harmful injections, surgery and pharmaceutical intervention. So, why hasn’t current research shaped the medical model? Why are we still seeing continual growth in the number of scientifically unsupported medical interventions being performed for pain relief? Is it a compulsion ‘to do something’? If so, surely it’s time to move away from the safetynet of ‘standard practice’ and that also goes for the physiotherapy profession. Positive

change will only come about when we direct patients away from a paternalistic and passive treatment regime based on a biomedical model offering quick fixes. A framework encompassing escalating invasive medical steps as a pathway to symptom reversal remains unsupported by the latest research. The jury is no longer out regarding the ‘best-evidence’ approach for those presenting with persistent pain. There are strong research findings recommending a graduated, exercise-based approach with an emphasis on educating patients regarding pain physiology while also providing ongoing reassurance. A biopsychosocial approach increases both patient self-efficacy and empowerment. An efficacious path needs to be found that addresses the biological, psychological and social variables that influence the experience of pain. The primary aim should always be to restore normal work participation, social and recreational activities all of which which improve the wellbeing of the patient. There are gaping holes in the management of pain and they cost the Australian economy an estimated $34bn annually.

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CLINICAL UPDATE

Research in the hot north

ORT HO C O M P WA

By Dr Timothy Barnett Senior Research Fellow Telethon Kids Institute

Acute rheumatic fever (ARF) is an autoimmune disease triggered by group A Streptococcus (GAS) infection, with adolescents and young people most at risk. Recurrent episodes of ARF lead to cumulative heart valve damage and the development of rheumatic heart disease (RHD). Despite often being referred to as a Third World disease, Australiaâ&#x20AC;&#x2122;s Indigenous communities have some of the highest rates of ARF and RHD in the world. Children from these areas also experience a high burden of GAS skin infections, with an average of 45% of young people having impetigo, commonly known as school sores, at any given time. GAS infection of the throat (strep throat) initiates the development of ARF, but it is not clear whether GAS skin infections can also cause it. Also, the exact mechanism that causes the autoimmunity of ARF is very poorly understood. This has meant that we still donâ&#x20AC;&#x2122;t have a diagnostic test for ARF, and no targeted treatments that improve long-term outcomes. There is a need to better control rampant skin infections in remote communities, but the spectre of antibiotic resistance hangs over these programs. Environmental and social factors contributing to the disease also need to be addressed. As part of the Improving Health Outcomes in the Tropical North: a multidisciplinary collaboration (HOT NORTH) being undertaken at the Telethon Kids Institute under the leadership of Prof Jonathan Carapetis, work is being done to improve methods for monitoring GAS antibiotic susceptibility. Of particular focus is cotrimoxazole, increasingly used to treat GAS and Staphylococcus aureus skin infections in Northern Australia, and the subject of a clinical trial (led by Dr Asha Bowen, Telethon Kids Institute). This work includes the identification of cotrimoxazole-resistance genes, developing improved laboratory testing methods, and systems that will allow genetic testing for impetigo pathogens and antibiotic-resistance genes directly from clinical samples. Unravelling immune system derangements that lead a GAS infection to become ARF is another collaborative project being undertaken. We are working to identify immune signatures of ARF that will then be used to develop a diagnostic test and/or possibly new immunebased therapies. By understanding the types of immune cells and GAS antigens that contribute to ARF, we may also be able to shed light on the significance of GAS skin disease as a trigger for ARF. Hopefully the work will ultimately reduce the incidence of primary GAS infection, and subsequent development of ARF and RHD in children at risk. Improved molecular understanding of the link between GAS infection and ARF should also lead to better treatments and diagnostic tools, thereby reducing the health burden of ARF and RHD. continued from Page 29

PTSD and Police We acknowledge that for some people returning to the police environment is not in their or the communities best interest and we are working at ways to assist people when they have to leave the agency so that there is a transition process to help them get beyond that strong police identity. We can only do this with the help of their medical practitioners. There should be a holistic approach to their care where we focus on what they can do (focus on their fitness to work rather than their illness and keeping them off work) and how do we all support them if being a police officer is no longer best for their ongoing wellbeing. MEDICAL FORUM

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premature infants. If incarcera Irreducible or strangulated hern bowel, testis

CLINICAL UPDATE

Kids inguinoscrotal conditions: when not to wait and see

By Dr Jill Orford Paediatric Surgeon Subiaco

Inguinal hernia, while more common in boys, affects 1-4% of children. One third will present under six months of age and incarceration is common under 12 months of age. Up to 25% of infants will suffer incarceration if treatment is delayed beyond four weeks from onset.

ED. Timely treatment of inguinal and testicular problems is critical and delay in surgical intervention can affect future fertility.

orchidopexy for palpable undescended testes (90% of cases) or laparoscopy for absent testis is recommended between six and 12 months of age. This timing achieves optimum testicular function and spermatogenesis.

The risk of hernia and incarceration is greater in premature infants. If incarcerated at any age and reduced by firm manipulation, reincarceration risk is high. Irreducible or strangulated hernia requires prompt surgical treatment and delay risks infarction of bowel, testis (ovary) or death. Also, more common in boys, Hydrocele affects 1-4% of children where 90% undergo spontaneous resolution by age one and small hydroceles may resolve before two years. Diagnosis is anatomical assessment: trans-illuminable scrotal swelling that does not extend above scrotal skin with thin cord felt above at external ring next to pubic tubercle. Ultrasound is not necessary with obvious hydrocele anatomy and absence of inflammation or symptoms. Beware of confounding clinical presentations such as trans-illuminating, fluid-filled herniated bowel in a young baby. Gonadal tumours are uncommon 0.5/100 000 and will not trans-illuminate. Cystic hydrocele of cord and large inguino scrotal hydrocele may mimic hernia. History of persistent swelling without fluctuation over several days or weeks in a happy baby would indicate hydrocele. In these situations, ultrasound provides reassurance.

Delay in treatment is associated with testicular hypotrophy, decrease in number and size of Leydig cells and decreased size of seminiferous tubules. Testicular abnormality in high testes increases over time. If not treated, 98% of undescended testes have abnormal spermatogenesis after puberty. Inguino scrotal hernia : swelling extends into inguinal region above scrotal skin and over pubic tubercle. The cord cannot be palpated

Refer for surgical treatment if obvious hydrocele remains beyond 12 months. Surgical repair in young childhood is highly successful involving simple ligation of patent processus vaginalis. If not treated, gradual enlargement over several years increases the risk of recurring after surgery.

• Plastics • Podiatry

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Ascending testes are more common if postnatal descent and this group requires observation and annual review until school-age. Retractile testes present in early childhood, not before six months. Testes are in the scrotum at birth and during warm conditions. Scrotal shape is normal and testes can be manipulated to base of scrotum without cord tension. Spontaneous resolution is expected. Ascending testis will become evident in 1-2% usually before five years of age.

1. Baby hernia < 12m

Undescended testes

This occurs in 2-5% of boys at birth. Spontaneous descent is seen in 80% in the first 12 weeks (full gestation). If not,

Ascending testes are descended at, or shortly after, birth, and caused by a tight fibrous remnant of processus vaginalis. Testes are not witnessed low in the scrotum, transient reduction into scrotum is possible, often with discomfort or tight cord and immediately return to superficial inguinal region.

2. Incarcerated hern Acute scrotum Torsion of testis is more common in the second decade and characterised by sudden onset of testicular pain, sometimes with abdominal pain and vomiting. Differential diagnosis includes torsion of hydatid of Morgagni, epididymo-orchitis, idiopathic scrotal oedema and Henoch-Schönlein Purpura. The decision to operate is based on clinical assessment. Ultrasound is not necessarily reliable unless performed, optimally without delay, by an experienced sonographer who examines the length of spermatic cord for twists. Testicular perfusion can continue in early torsion

Again affects 1-‐4% children and resolution by 1 year and very sm assessment: trans illuminable sc felt above at external ring next hydrocele anatomy and absenc

• Dental • Sleep studies

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Testicular maldescent is associated with malignant change in early adulthood. Orchidopexy enables earlier detection.

Key m essage

Hydrocele Offering six theatres accommodating:

Inguino scrot swelling ED exte inguinal regio scrotal skin a pubic tuberc cord cannot b

If de-torsion is delayed beyond six hours, atrophy risk is 50% and after 24 hours atrophy occurs in 70%. Ischaemia then reperfusion of the torted testis is known to injure the contralateral testis and is associated with infertility. Varicocele

Left-sided varicocele is common in adolescents (10-15%) and seen in 35-40% of men assessed for infertility. Dilation of

MEDICAL FORUM

If detorsion is delayed beyond 6 hours, atrophy risk is 50% and after 24 hours atrophy Ischaemia then reperfusion of the torted testis is known to injure the contralateral te associated with infertility. CLINICAL UPDATE pampiniform plexus and counter-current heat exchange with increased testicular temperature is the proposed mechanism leading to testicular dysfunction. Testicular hypotrophy can occur in 30-40% of palpable or visible varicoceles.

24 hours of torsion: testicular infarction

Monitoring testicular growth and consistency is advised. Testicular hypotrophy is reason to consider treatment. Catch up growth is seen in up to 70% after varicocele correction. Management options include laparoscopic ligation of testicular vein, retroperitoneal mass ligation of testicular artery and vein, high inguinal ligation or interventional radiology and selective embolisation.

24 hours of torsion: testicular infarction

Blue piece sign indicates torsion hydatid of Morgagni

References on request.

Idiopathic scro redness extend Blue pea sign indicates torsion the edge of scr hydatid of Morgagni

Key messages • Urgently refer Hernia in < 12 months or incarcerated hernia (reduced or not) • Hydrocele wait and see for 12 months, refer if clinically obvious over 12 months • If incomplete testicular descent by three months refer before six months

Author competing interests –nil relevant disclosures. Questions? Contact the author on 9387 5937

• Monitor delayed descent for ascending testis and refer if suspected

Idiopathic scrotal oedema redness extends Idiopathic scrotal oedema beyond the edge of scrotal skin

• Refer adolescent varicocele with smaller or softer testis

redness extends beyond the edge of scrotal skin

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MEDICAL FORUM

CLINICAL UPDATE

New frontiers for paediatric cardiology

By Dr Deane Yim Paediatric Cardiologist Subiaco

There have been recent advances in paediatric cardiac imaging including new techniques in echocardiography (echo), cardiac magnetic resonance (CMR) and 3D cardiac printed models. Echocardiography Anatomy – Real-time 3D imaging is particularly helpful in assessing the mechanism of valvular abnormalities or the relationship of a ventricular septal defect to inflow or outflow tracts. The main objective of 3D imaging is to gain a better understanding of intracardiac anatomy and to assist with surgical planning.

Improvements in cardiac imaging in children are allowing assessments not previously possible.

Function – Speckle-tracking derived strain is a new modality that has gained interest in assessing systolic function. It uses speckles or pixels to track myocardial thickening and shortening during the cardiac cycle. It is a sensitive measure of subclinical systolic dysfunction and can detect regional abnormalities. Early signs of systolic dysfunction have been found in patients with Duchenne muscular dystrophy or childhood cancer survivors, despite having a normal ejection fraction (the usual method of assessing systolic function). This suggests that strain analysis may have a role in detecting early ventricular dysfunction during long-term cardiac surveillance. Handheld devices – Smaller and more compact handheld echo devices, such as the GE VScanTM, can offer diagnostic cardiac imaging. These devices are easy to use and non-cardiologists can be trained to perform studies. We see a potential role for implementing handheld echo in rural WA communities by local clinicians to provide screening, early detection and surveillance of rheumatic heart disease (RHD). Ultimately we hope this will overcome barriers to service provision in remote communities to improve detection rates of RHD. Cardiac magnetic resonance Anatomy, function and flow – CMR is considered the gold standard in assessing ventricular function and provides a wealth of information including blood flow volumes, volumetry and global and regional function. It is generally favoured over CT when functional information is useful, or if a large field of view is needed such as screening in systemic vasculitis as there is no radiation exposure. Myocardial characteristics – Myocardial viability assessment is one of the many strengths of CMR, including using real-time perfusion sequences to assess for ischaemia, and late gadolinium enhancement to define myocardial fibrosis and scarring. A new technique called T1 mapping can directly quantify diffuse fibrosis and provides important information on tissue characterisation. 3D cardiac models Applications – 3D printed models derived from CMR or CT datasets are a useful adjunct to echo and cross-sectional imaging in preoperative surgical planning of complex cardiac cases. It is also possible for the surgeon to perform surgical simulation on different complex hearts, providing extremely valuable practical skills plus it is an excellent educational resource in better understanding intracardiac anatomy.

Longitudinal left ventricular strain curve showing normal global segmental strain Author competing interests: No relevant disclosures. Questions? Contact the author on Deane.Yim@health.wa.gov.au

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L-R; 3D echocardiogram of a mitral valve cleft, 3D model of double outlet right ventricle (DORV) from the RV side, showing relationship of ventricular septal defect to the aorta (Ao) and pulmonary artery (PA)

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CLINICAL UPDATE

Perinatal ObsessiveCompulsive Disorder OCD is characterised by distressing repetitive thoughts or images (obsessions), related behavioural or mental acts to neutralise the distress (compulsions) and associated functional impairment. The overall population prevalence is 1.2%, rising to between 4-9% for women in the perinatal period. The OCD-like symptoms generally relate to thoughts of risk or harm to the baby. For most, these thoughts pass without problem, but for those with OCD, these thoughts are compellingly and distressingly real. The obsessions can vary from generic thoughts of harm to detailed visual images of their baby being harmed (e.g. an image of baby dead in the bath or of a baby with a knife wound). The distress and desire to keep baby safe drives compensatory compulsions which may provide temporary relief, but tend to reinforce the OCD. Mothers may start avoiding situations related to their obsessions such as not using stairways or bridges, not bathing their baby, or changing the home environment (e.g. packing away sharp knives). For many, the compulsions are cognitive in nature, which are far less apparent but no less

By Dr Julia Feutrill Perinatal and Infant Psychiatrist, Claremont

disabling, as much time and energy is spent in methodically attending to the cognitive compulsion. Mothers are often reluctant to disclose OCD symptoms as they fear their sanity or that their child may be removed from their care. It generally takes direct and careful questioning to uncover OCD symptoms. A good probe question is: Do you have repetitive thoughts or images of something bad happening to you, your baby or someone else in your life? Treatment of OCD This varies according to the severity, duration and presence of other symptoms. Mothers are relieved to know that these thoughts are a manifestation of a treatable condition and that there is no link between them having the thought of harm and acting it out. In fact, they are less likely to harm their babies that those without OCD. SSRI medication is considered first line due to its efficacy and safety profile in breastfeeding and pregnancy. Doses in the high therapeutic range may be necessary. Augmentation with a benzodiazepine is often helpful to ameliorate the initiation side-effects of SSRI

Obsessive-compulsive disorder (OCD) is common in the perinatal period. If detected it is very amenable to treatment.

medication and to allow rapid de-escalation of anxiety. CBT is a successful evidence-based treatment for OCD. Treatment provided by a perinatal and infant mental health specialist is not always necessary but is preferable, as the attachment relationship will almost certainly have been affected. Perinatal OCD is common and responsive to treatment, especially when identified early. Misdiagnosis can lead to protracted symptoms that appear resistant to standard treatment, with a subsequent negative impact on the attachment relationship, which can have lifelong implications for the wellbeing of the baby. Author competing interests: Nil relevant disclosures. Questions? Contact the author on jfelizabethclinic@ iinet.net.au

CLINICAL OPINION

The PCOS puzzle This most common female endocrinopathy is identified by the presence of two out of three features: unexplained menstrual irregularity, androgen excess, and polycystic ovary morphology. There is genetic predisposition plus the adverse environmental factors that cause weight gain. Where to begin to put the pieces of the puzzle together? It is known that pituitary rhythm in PCOS shows sustained rapid FSH/ LH pulsatility and there is no mid-cycle peak to trigger ovulation. Oestradiol secretion is constant rather than cyclical. There is excess androgen production with mild elevation of testosterone and comparatively high levels of free testosterone, because SHBG is suppressed. Also excessive fat tissue aromatises oestrogen to testosterone. Increased insulin resistance is present, leading to obesity, impaired glucose tolerance, and atherogenic dyslipidaemia (high triglyceride, low HDL). The presenting symptoms are agedependent. In adolescence and in in young adults, hirsutism and acne develop and menstruation is irregular and infrequent. By reproductive age, the concern is sub-fertility. In middle-age the dominant issues are obesity-related prediabetes and dyslipidaemia

MEDICAL FORUM

and the increased risk of endometrial cancer. Diagnostic tests must include a full hormonal profile (testosterone, SHBG, oestradiol and progesterone, FSH and LH). More rare androgenic syndromes should be excluded (prolactin, DHEAS, and resting diet, 17-hydroxy progesterone). Metabolic syndrome risk factors should be assessed, including fasting glucose plus HbA1c (or a full GTT), and a complete lipid profile. Measurement of insulin levels is academic and not clinically useful. Imaging studies are optional except in middle-age where endometrial hyperplasia or cancer should be excluded. Treatment must always be supportive, symptomatic, and preventive: • Topical cosmetic management of hirsutism is important. Cyclical low-dose OCPs will achieve regular menstruation and reduce hirsutism. Metformin improves ovulation

By Dr Tim Welborn, Endocrinologist

rate and menstrual rhythm. Specific anti-androgen therapy (Spironolactone, Cyproterone) will reduce new hair growth by 60-70%. Contraception is essential because these agents enhance fertility. If pregnancy occurs, abnormalities may occur in the male foetus. • Sub-fertility is not absolute. Early specialist management is recommended when conception is not achieved within 6 to 12 months. • Risk factors for the metabolic syndrome (insulin resistance) require management of obesity and glucose intolerance and dyslipidaemia. Careful diet and exercise advice plus specific drug therapy of risk factors is essential. References: 1. McCartney CR and Marshall JC. Polycystic Ovary Syndrome NEJM 2016: 375; 54–642. 2. Teede HJ et al. Assessment and management of polycystic ovary syndrome. MJA 2011; 195: S65-112

AUGUST 2017 | 39

Clinical Update

Functional constipation – an update

By Dr Kunal Thacker Paediatric Gastroenterologist, Subiaco

The estimated prevalence of FC is about 3% in the first year of life increasing to 10-14% in the second year. Trigger factors are change in diet in the first year and toilet training in the second to third years of life where excessive caregiver pressure to maintain bowel control and/or inappropriate techniques, such as regular use of toilets without sufficient leg support can lead to stool withholding.

Functional constipation (FC) is one of the most common problems encountered in childhood. Diagnosis is clinical and management is simple.

for hypothyroidism, celiac disease, and hypercalcemia is not recommended in children with constipation in the absence of alarm features.

An underlying disease for constipation is found in less than 5% of children. The rest fulfil the criteria for FC.

The main indication to perform anorectal manometry in the evaluation of intractable constipation is to assess the presence of the recto-anal inhibitory reflex. Rectal biopsy is the gold standard for diagnosing Hirschsprung’s disease. A barium enema should not be used as an initial diagnostic tool for the evaluation of FC.

Diagnostic criteria have been revised in the new Rome IV Criteria published in 2016 (Table 1). The duration of symptoms to make a diagnosis has been reduced from the previous criteria as shorter duration of symptoms and prompt treatment is associated with increased response rate.

After a thorough evaluation to rule out alarm features, age-appropriate treatment is commenced.

The latest recommendation for clinical evaluation and management from the European and North American societies for Pediatric Gastroenterology, Hepatology and Nutrition are as follows: The Rome criteria are recommended for the definition of FC for all age groups. FC diagnosis is based on history and physical examination Alarm signs and symptoms and diagnostic clues should be used to identify an underlying disease responsible for the constipation (Table 2). If only one Rome criterion is present and the diagnosis of FC is uncertain, a digital examination of the anorectum is recommended to confirm the diagnosis and exclude underlying medical conditions. There is no role for the routine use of an abdominal x-ray to diagnose FC. Table 1: Rome IV criteria for diagnosis of FC

First is education of the caregiver and child. Reassurance of the benign nature of the condition generally leads to resolution once the child gains confidence. Progress is not smooth until the toddler is confident that defecation will not be painful. A plain abdominal radiograph may be used if fecal impaction is suspected but in whom physical examination is unreliable/ not possible. Routine testing for cow’s milk allergy is not recommended in children with constipation in the absence of alarm features. Laboratory testing to screen Table 2 – Alarm features in children with Constipation

Diagnostic Criteria for Functional Constipation

Potential Alarm features in constipation

Must include 1 month of at least 2 of the following in Infants up to 4 years of age:

• Passage of meconium >48 h in a term newborn

• 2 or fewer defecations per week

• Family history of Hirschsprung’s disease

• History of excessive stool retention

• Ribbon stools

• History of painful or hard bowel movements

• Blood in the stools in the absence of anal fissures

• History of large-diameter stools

• Failure to thrive

• Presence of a large fecal mass in the rectum

• Bilious vomiting

In toilet-trained children, the following additional Criteria may be used:

• At least 1 episode/week of incontinence after the Acquisition of toileting skills

• History of large-diameter stools that may obstruct the toilet

• Constipation starting in the first month of life

• Severe abdominal distension • Abnormal thyroid gland • Abnormal position of the anus • Absent anal or cremasteric reflex

In addition to behavioural modification that includes toilet routine and improved caregiver and child dynamics around stooling, pharmacologic interventions are the mainstay. This comprises rectal or oral disimpaction and maintenance therapy to prevent reaccumulation. Laxatives containing polyethylene glycol (PEG) are more effective than any other group for both phases. For infants, lactulose is used more often. In the absence of quality evidence, the recent guidelines do not recommend routine use of fibre, increased fluid intake, prebiotics, probiotics, and routine use of multidisciplinary treatment or alternative treatments such as transcutaneous nerve stimulation. FC is a benign condition diagnosed clinically. Abdominal x-ray is rarely required to diagnose or assess response to treatment. Invasive investigations are reserved for those with alarm features and treatment refractory symptoms. Behaviour modification including the family dynamics and oral laxatives are mainstays of treatment. References on request

• Decreased lower extremity strength/tone/reflex • Sacral dimple • Tuft of hair on spine • Gluteal cleft deviation • Anal scars

40 | AUGUST 2017

Author competing interests: no relevant disclosures. Questions? Contact the author on 9340 8355

MEDICAL FORUM

CLINICAL UPDATE

National watch on adverse vax events The first rule of medicine is to do no harm. The events of April 2010 led to the development in WA (by the author and Ian Peters with WA Health Department support) of SmartVax, a software application using SMS and smartphone technology for the active surveillance of adverse events (AEFI) following all immunisations. De-identified data is uploaded to a secure central server for analysis and monitoring.

CLINICAL UPDATE

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

By Dr Alan Leeb GP, Ballajura

Before the ED rise of pyrexia and seizures associated with one brand of flu vaccination in April 2010, Australia had a passive event surveillance system. This has changed.

SmartVax is fully automated, integrates with existing patient management systems, is endorsed by the RACGP and free for practices. A national network now has over 165 sites (over 60 in WA), including general practice, immunisation clinics, Aboriginal medical centres and major hospital immunisation clinics.

by Medical Director Prof John Yovich

Three Amigos … pioneers covering IVF around the world This photograph was taken at the most recent meeting of the International Society of IVF in Copenhagen where I was invited to present our update on the use of adjuvants in poor prognosis cases. The central character is Zev Rosenwaks, Professor of Obstetrics and Gynaecology and Reproductive Medicine at Weill Cornell Medical College in New York, a facility pushing back many boundaries in male and female fertility. These include advanced surgical methods as well as both laboratory and clinical processes. Zev was formerly Director of the Jones Institute for Reproductive Medicine in Norfolk, Virginia, the unit which achieved the first IVF pregnancy in the United States. (Elizabeth Carr was born December 1981). His boss at the time was Howard Jones, an eminent gynaecologist who, with his wife Georgeanna Seeger-Jones, an equally eminent endocrinologist, developed the unit from donated monies after they had faced mandatory retirement from Johns Hopkins University.

The database houses over 500,000 immunisation encounters and over 700,000 individual profiles across more than 50 vaccine brands, including scheduled, private and all travel vaccines. Patient engagement is over 70%. All medically attended AEFI are notified to the GP’s medical software inbox ensuring a record is incorporated in the electronic clinical record as well as an option of automated notification to WA Health department’s WAVVS as statutory notification. AusVaxSafety(AVS) is a collaborative initiative led by the National Centre for Immunisation Research and Surveillance (NCIRS) and funded by the Australian Department of Health (DOH). SmartVax sends AVS de-identified data which analyses it then reports to DOH, Therapeutic Goods Administration (TGA), GPs and, most importantly, the general public. It currently actively monitors the safety of influenza vaccine in all ages, pertussis vaccines in toddlers and young children, and zoster vaccine in adults. NCIRS provides regular reports to the DOH, TGA, vaccine safety experts and clinicians throughout Australia. Any safety concerns are reviewed by its expert leadership group and if necessary more detailed data analysis and clinical follow-ups of patients. AVS is the only national AEFI system of its type in the world. The findings are contributing significantly to international data. For 2017, we can confidently report that there have been no significant safety concerns for adult and paediatric influenza vaccines and no brand variation within the first week of the program. Pertussis has been safely re-introduced to the National Immunisation Program (NIP) at 18 months, and after 12,000 encounters. We have no safety concerns around Zostavax. The plan over the next three years is for AVS to receive and monitor all vaccines on the NIP and continue to monitor all other vaccines locally.

The couple visited my pioneer unit in London (which I established under the direction of Professor Ian Craft) in 1979. Howard continued to practise in his unit and delivered an outstanding lecture on his 100th birthday entitled, Seven Roads Travelled Well and Seven to be Travelled More, a tribute to his English Literature teacher, Nobel Laureate Robert Frost and his poem, The Road Not Taken. The lecture was published in the prestigious journal, Fertility & Sterility, in March 2011. Howard died in July 2015 in his 105th year, attending his clinic until near the end. On the left is Professor Chii-Ruey Cheng, current president of Aspire (Asian Pacific Initiative on Reproduction). He graduated from Harvard University and generated the first IVF infant in Taiwan in 1985. He has become internationally eminent with his work on mitochondrial transfers. It was a pleasure to meet up with these characters I have known over 30-40 years.

The ultimate goal is a nationally coordinated, near real-time AEFI system. References available on request

NOW AT 2 LOCATIONS PERTH & BUNBURY

Author competing interests: The author co-developed SmartVax. Questions? Contact the author alan@illawarramedical.com.au

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

AUGUST 2017 | 41

get your patient’s spine working Workspine’s team of hand picked specialists provide comprehensive occupational spine injury management under one roof. From pain management to surgery, cognitive therapy and rehabilitation exercise programmes, Workspine covers all aspects required for the successful treatment of work related spinal injury. Studies have shown that a comprehensive approach to spinal injury treatment results in better patient outcomes. Put an end to the spiral of endless referrals and self management and send your work related spinal injury patients to Workspine. We get spines working.

Dr. Andrew Miles FRACS NEUROSURGEON

Dr. David Holthouse FRACS INTERVENTIONAL PAIN SPECIALIST

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CLINICAL UPDATE

Biologics in childhood rheumatologic conditions Rheumatology biologics are a group of medications that are proteins/antibodies targeting specific cytokines, blocking pro-inflammatory signalling and thereby reducing inflammation. Their introduction has revolutionised the management of children and adolescents with rheumatologic conditions. Biologics offer hope in improving disease control, providing a treatment option for those with refractory disease who don’t respond to traditional disease modifying agents (DMARDs) such as methotrexate, sulfasalazine, leflunomide, or who are steroid-dependent. By allowing better disease control, this reduces pain/morbidity, improves function and allows reduction in cumulative steroid use and its related adverse effects. Etanercept (an anti-tumour necrosis factor agent) was the first adult rheumatology biologic later approved for paediatric patients in North America in 1999 followed by Australia in 2001 for refractory polyarticular-course juvenile idiopathic arthritis (JIA). Other biologics including infliximab, adalimumab, rituximab, anakinra, tocilizumab and abatacept followed.

By Dr Senq Lee Paediatric Rheumatologist, Shenton Park

Biologics are used in various childhood rheumatologic conditions including polyarticular-course JIA, systemic JIA, juvenile dermatomyositis, systemic lupus erythematosus, autoinflammatory diseases and bone inflammatory disorders (chronic recurrent multifocal osteomyelitis). Unfortunately, currently available biologics are administered either by subcutaneous injection or intravenous infusion, which can lead to needle phobia and reduced compliance.

The number of and use for biologics has grown in paediatric rheumatology over the past 15 years.

fortunate to have other biologic choices (e.g. certolizumab, golimumab, secukinumab and tofacitinib). Through adult safety/efficacy data, further trials are being conducted in paediatric patients before approval for paediatric use. Tofacitinib is the first oral biologic agent currently being studied for use in polyarticular JIA patients. If safe/effective and approved, it will provide an oral alternative.

Biologics have a good safety profile and are generally well tolerated. More common adverse effects include infusion/local injection site reactions, gastrointestinal side effects, headaches, serologic abnormalities and a mildly greater risk of minor infections. Fortunately, in paediatric rheumatology, biologics have not been shown to significantly increase the risk of serious infections or malignancies in worldwide cohort studies.

Biosimilars are a cost saving alternative to the original biologics, saving money for health agencies, the Government and tax-payers. Over the past two years, Inflectra (Infliximab biosimilar) and Brenzys (Etanercept biosimilar) have been released, with more biosimilars to be released in the next few years.

While the recommendation is to avoid live vaccines while taking biologics, emerging literature suggests no serious adverse or infection-causal effects when paediatric patients on biologics have live vaccines.

References available on request Author competing interests, no relevant disclosures. Questions? Contact the author 9380 9484.

Our adult rheumatology colleagues are

Fertility Preservation WA A specialist service to provide counselling, support and fertility preservation options to cancer patients.

We aim to see patients within 3 working days of referral. Cancer treatment can have a significant impact on the subsequent fertility of a cancer patient. The best opportunity for review; provide adequate supportive counselling, arrange appropriate investigations and instigate treatment is afforded to a patient when they are referred as early as is feasible after their diagnosis. This enables the patient to have the maximum opportunity to plan and commence any treatment to preserve their fertility that is considered appropriate.

Prof Roger Hart

Women • Oocyte or embryo freezing (will require partner to attend and have a current referral) • Ovarian stimulation for women with oestrogen sensitive tumours • In-vitro maturation of oocytes (IVM) • Ovarian tissue cryopreservation protocols to minimise follicular damage • GnRH analogue suppression for ovarian protection

Men • Sperm banking • Testicular aspiration/biopsy

Contact Fertility Specialists WA - 9284 2333 for urgent appointments To discuss urgent cases with Prof Roger Hart, call KEMH switchboard 6458 2222

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AUGUST 2017 | 43

The WOMEN Centre has assembled a team. Dr Tarek Meniawy Maria Markus Medical Perioperative Oncologist Nurse

Dr Su Hamid Obstetrician & Gynaecologist

Mel Mosey Midwife, Clinical & Research Nurse

Dr Fred Busch Obstetrician & Gynaecologist

Dr Timothy Pavy Specialist Pain Medicine Physician

Dr Stephen Lee Obstetrician & Gynaecologist

Dr Jeremy Tan General, Upper Gastrointestinal & Bariatric Surgeon

Sarah O’Sullivan Genetic Counsellor

Dr Lesley Ramage Women’s Health GP

Christelle Schofield Exercise Physiologist

Dr Paige Tucker Clinical and Surgical Assistant

Dr Paul Cohen Gynaecologist, Cancer & Menopause Specialist, Director of Gynaecological Cancer Research SJOG Subiaco

Dr Jason Tan Gynaecologic Oncologist

Helena Green Clinical Sexologist & Counsellor

Sophie Dunnet Physiotherapist

Dr Clay Golledge Physician in Infection Management

Jackie Framjee Clinical Nurse and Ward Nurse SJOG Subiaco

Paula Watt Clinical Psychologist

Because no one person has all the answers. As respected as our gynaecologic oncologist is, he’s no sex therapist. Our obstetricians and gynaecologists are skilled at delivering babies, but can’t coax mothers with postnatal challenges to bond with theirs.

will be duly informed and involved in the follow-up care of patients. Our experience has taught us that the benefits of integrated care extend to every stage of a woman’s life.

Part of being a great doctor or health professional is realising when you need to call on the support of others, to ensure your patient’s total wellbeing.

To further enhance positive patient experience, our administration team provides high standard of service – anticipating needs and coordinating appointments.

When you refer a patient to the WOMEN Centre, you’re making sure she will be cared for physically and mentally by a team.

Whether it’s endometriosis, pregnancy or menopause, we don’t just manage the condition – we treat the whole person.

She can draw on as many, or as few, of our services as she needs. For cancer patients especially, this holistic Survivorship model is considered best practice and has been shown to improve quality of life.

The team at the WOMEN Centre takes a truly collaborative and integrated approach to patient care in order to ensure the best outcome possible and patients regaining their quality of life after treatment.

We provide treatment and support for:

• Pregnancy and post-natal care • Pap smear concerns • Prolapse, incontinence and discharge • Heavy periods, fibroids and ovarian cysts

• Endometriosis and chronic pelvic pain

• Complex medical conditions requiring contraception

• Issues arising from surgical and natural menopause

• Cancers of the reproductive system • Management of cancers with cancer

Each recommended treatment will be tailored to suit the individual patient, and referring medical practitioner/specialist

medicine/therapy

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Our Friendly Office Staff: Administration: Tammy Barrett-Izzard, Samantha Carbone, Barbara Ngarimu, Helen McDonough Information Technology: Jun Sato Marketing: Huey Lih Lim

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Suite 20, 2 McCourt Street, West Leederville, WA 6007

www.WOMENcentre.com.au

surgery via laparoscopic or robotassisted approach

• Genetic counselling and testing • Sexual intimacy enhancement • Psychology • Physiotherapy • Exercise physiology

CLINICAL UPDATE

Do children need supplements?

By Dr Roslyn Giglia, Dietitian and Child Health Researcher, Telethon Kids Institute

Children not on a restricted diet or without a medical condition should not need supplements. They need the essential vitamins and minerals to support their growth and development but this is best achieved through a wellbalanced diet. All essential vitamins and minerals are important but iron (brain development) and calcium (growth and bones) are especially so for children.

Supplements remain contentious. Despite advice they are generally not needed, Australians consume billions of dollars’ worth each year.

include meat in their child’s diet until they mature and can make their own choices about eating meat without having their growth and development affected by iron deficiency in the developing years.

The best way for children (and adults) to get all their vitamin and mineral needs is through the organic forms found in foods, as these are the most highly absorbed. Manufactured supplements cannot replicate this and are not as well absorbed.

Food allergies or intolerances may be why children avoid certain foods (e.g. dairy) making it difficult to get adequate vitamins and minerals for growth (e.g. calcium). However, any food allergy needs to be medically diagnosed, as removing foods without good evidence of an allergy may inadvertently create an unnecessary deficiency.

Children’s food need not be organically grown, it just has to be eaten. This is often the most difficult job for a parent and it can seem easier to give a sugary coated vitamin jube. Children regularly given supplements instead of a well-balanced meal might, wrongly, learn that there are shortcuts to health. Parents should give their children lots of variety and encourage repeated tastes of unfamiliar or disliked foods. It takes around nine times of offering a food before a child might actually try it, so even a small bite, nibble or lick can help. I don’t recommend parents giving a supplement to their child after an uneaten meal. Instead, encourage them to eat some of the meal. If they have a variety of foods (fruit and vegetables, breads, cereals, meats and dairy) daily, they will still be getting enough nutrients.

Chronic diseases such as coeliac or Crohn’s also need to be diagnosed before different foods are removed from a child’s diet. In coeliac disease, thiamine (vit B1), riboflavin (vit B2), pyridoxine (vit B6) and folic acid are potential nutrient deficiencies that can occur due to the removal of grain based (e.g. wheat oats barley) foods containing gluten. There are some rare exceptions where children may need supplements. Those on a vegetarian or vegan diet will struggle to get enough iron. It is very unlikely this will be for medical reasons and I recommend parents

Author competing interests, nil relevant disclosures. Questions? Contact the author via roslyn.giglia@telthonkids.org.au

Dr de Wet is a Clinical Haematologist with a special interest in general haematology and chronic malignant conditions including myeloproliferative disorders, myeloma, lymphoma and myelodysplasia with a focus on quality of life and supportive care.

SUBIACO Bendat Comprehensive Cancer Centre, Suite 203, 12 Salvado Road, WA 6008

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MT LAWLEY St John of God Medical Centre, Suite 11, Ellesmere Road, WA 6050

0447 985 661 www.redhaem.com.au

REDMAR-MAG-WA-0001.5 06/17

Now accepting patients

AUGUST 2017 | 45

The Vein Clinic is proud to be celebrating its Third Anniversary We deliver the latest innovations in the diagnosis & treatment of Venous Reflux and Varicose Veins direct from Europe, the UK and USA. Our advanced techniques allow > 95% of patients to be treated as an outpatient with outstanding results, avoiding the need for hospital admissions, private health cover and time off work. We specialise in highly effective “walk in, walk out” non-surgical treatments for varicose veins and venous reflux. • EVLA (Endovenous laser) – cutting edge techniques including perforator ablation • Fast recovery and near painless procedure o Clarivein™ o Cyanoacrylate closure – Medical “Super Glue” for closing veins • “Improved” Foam Sclerotherapy • Ultrasound Guided Ambulatory Phlebectomy • Streamlined assessments and timely cost effective treatment

Before: 59-year-old man; 20 years of pain, heaviness, night cramps, itch. After: six days post VenasealTM & ultrasound-guided phlebectomy. Symptom free.

Before: 37-year-old woman with ‘Hidden varicose veins, severe itch from venous eczema, After: EVLA GSV & SSV & UGFS in single treatment. 14 days later – symptom free.

Dr Luke Matar (MBBS, FRANZCR, FACP) Contact us: E: admin@veinclinicperth.com.au P: 9200 3450 F: 9200 3451 www.veinclinicperth.com.au 46 | AUGUST 2017

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CLINICAL UPDATE

Rickets not always Vitamin D deficiency Presentations of potential vitamin D deficiency are increasingly common in ‘Sunny Australia’. The most severe manifestation is rickets, a condition in growing children resulting from deficient mineralisation of the growth plate due to deficiency of calcium or phosphate. A three-year-old girl, born in Australia to a Caucasian mother and Burmese father, was referred for bone deformities. Her mother noticed ‘swollen’ wrists and ankles from six months of age and ‘knock knees’ from 20 months of age. The patient was born 2090g at term following an uncomplicated pregnancy without maternal vitamin D deficiency and was breast fed for four months. Her diet was balanced and there were no feeding difficulties. She had delayed dentition at 12 months and delayed walking at two years but otherwise normal milestones. There was no family history of rickets, skeletal dysplasia or any bone disease. On examination, she was short (height < 1st centile), had frontal bossing and bilateral non-tender, widened wrists. She had a narrow chest with increased anteroposterior diameter, ‘rachitic rosary’ (from widened costochondral junctions) and ‘Harrison’s sulcus’ (depression in the rib cage at the insertion of diaphragm). She had bilateral valgus deformity and widened ankles. There was no vertebral deformity. X-rays of her wrists and knees showed widening, cupping and fraying of the metaphyses and deformities of the distal femoral metaphyses, consistent with rickets.

• The Canning Vale Medical Centre is among the four finalists in the RACGP General Practice of the Year Award. The winner will be announced at GP17 in October. • Mr Paul Dyer has been appointed as the CEO of St John of God Midland Private Hospital for an initial two-year period.

By Dr Kiranjit K Joshi, Advanced trainee in Paediatric Endocrinology, Princess Margaret Hospital

Investigations showed normal levels of vitamin D, 1,25 dihydroxy Vitamin D level, normal calcium and parathyroid hormone but an elevated alkaline phosphatase of 550 U/L (120-370) low serum phosphate of 0.7 mmol/L (1.2-2.1) and increased urinary phosphate to creatinine ratio of 8.7 (1.2-8.0). This suggested hypophosphataemia secondary to increased urinary phosphate loss resulting in clinical signs of rickets. A genetic test showed a PHEX gene mutation, consistent with a diagnosis of X-linked hypophosphataemic rickets. Rickets is caused by the deficiency of calcium (calcipaenic rickets) or phosphate (phosphopaenic rickets). Worldwide calcipaenic rickets is the most common form caused by the nutritional deficiency of vitamin D and calcium (1-3). Vitamin D resistant rickets results from metabolic or functional defects of Vitamin D. Phosphopaenic rickets is less common and is caused by either increased urinary phosphate loss or decreased intestinal absorption of phosphate. However, dietary deficiency is very rare as phosphate is ubiquitous in food. X-linked hypophosphatemia (XLH) is the most common form of hereditary phosphopaenic rickets caused by loss of function mutations in the PHEX gene. XLH is characterised by hypophosphatemia secondary to renal phosphate wasting caused by high circulating levels of fibroblast growth factor 23 (FGF23). This is a protein regulated by the PHEX gene secreted by osteoblasts and osteoclasts to decrease renal tubular phosphate absorption

Calcium and phosphate deficiencies play roles in any diagnosis of rickets and can require some detective work.

resulting in urinary phosphate loss. Short stature and rachitic osseous lesions are characteristic phenotypic findings of XLH. The severity of these manifestations is highly variable. Dental anomalies resulting in tooth abscesses, arthritis and enthesopathies are additional features. Hearing impairment and spinal stenosis can develop later in life. The treatment of hypophosphataemic rickets includes phosphate replacement and calcitriol (active vitamin D). Phosphate levels need to be closely monitored to avoid overtreatment, which may result in increased parathyroid hormone and in turn hypercalcaemia and nephrocalcinosis. Clinical and radiological features of rickets in the absence of low Vitamin D and calcium levels warrant further investigations. Referral to a specialist endocrinologist should be considered in such cases. References available on request

Author competing interests, nil relevant disclosures. Questions? Contact the author via Kiranjit.Joshi@health.wa.gov.au

West Coast Endoscopy Centre Located in Joondalup CBD north, West Coast Endoscopy Centre is an independent private endoscopy unit with a strong focus on the individual and commitment to quality improvement and excellence in Gastroenterology, since opening in 2008.

• Cancer projects led by Prof Christobel Saunders and Prof Alistair Forrest have received an $18m funding boost from the Cancer Research Trust ($13.5m) and other partners including Cancer Council WA, Telethon Kids Institute, Perkins Institute, Murdoch, Curtin and Notre Dame universities, the WA Department of Health and St John of God Healthcare.

• • • • • • • •

• Online nominations for the 2017 Australian Mental Health Prize close on August 31 (www.australianmentalhealthprize.org.au).

To refer please call 93014437, fax 93014438, email bookings@wcendo.com.au and for further information visit our website www.westcoastendoscopy.com.au.

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Timely, quality GI Endoscopy and Colonoscopy. Private Day Endoscopy Unit licensed with Health Dept of WA. ISO certified and Accredited with National Standards of Quality and Safety in Healthcare. Waiting time usually 1 week for private procedures. Committed to GP education and regular national Gastroenterology conference presentations. Services include endoscopy, colonoscopy, capsule endoscopy, biologic and iron infusions and gastroenterology consultation. Patient satisfaction in excess of 95 % on all criteria assessed since inception. Ongoing procedure audit to ensure continual quality improvement.

AUGUST 2017 | 47

cycling

Riding the White Line How the boy from Roleystone became one of the world’s elite road cyclists and lived to tell the tale.

The life of a professional road cyclist is not for the faint-hearted and Henk Vogels is testament to that! As an integral member in some of Europe’s leading teams the knockabout kid from Roleystone has gone wheel-to-wheel against some of the world’s best. “I had a wonderful career that spanned more than a decade with so many good moments. Finishing in the top three on the charge into Paris in my first Tour de France was amazing. The Champs Elysees just has to be a sprinter’s boulevard of dreams!” “Just to finish that race is such a good feeling. I had tears streaming down my face riding into Paris on the final day.” But the memories aren’t all good ones, says Henk. Professional cycling is an intensely demanding sport and a ‘horror list’ of injuries is on the CV of most riders. Occupational hazards “I broke around 15 bones in my career and one of the worst moments was in 2003 when I crashed at around 110kph, damaging my C7 and totally destroying my left foot. I ended up in surgery where they put six large screws in my ankle that stayed there for the last five years of my career.”

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“It was bone on bone for a long time and then I decided to have ankle fusion surgery in mid-2015. I struggled to recover from that, both mentally and physically. My weight blew out to 110kg and it was 18 months before I decided enough was enough.” “I just wanted my life back.” “I got myself back to 8kg above my old racing weight and now I’m riding around 250km a week, which is great.” Henk first started racing in 1995 and in the early stages of his career they did it all without helmets. “I was in a very fast ‘tuck’ position in a race in Pittsburgh in 2003, looked up and saw a policeman’s speed-gun clocking us at around 100kph and that’s the last thing I remember. I crashed, hit a guard-rail and woke up two weeks later in hospital. Luckily, helmets were compulsory by then and this one cracked in seven different places! It saved my life.” Professional cycling is a highly specialised sport and the medical back-up has to be tailored to that, says Henk.

Docs vital team members “We’ve got cutting edge medical support. The teams have at least two full-time doctors and they’re involved with the riders on a daily basis. They monitor our heart-rate, hook up saline drips if we need them and after a 200km day in the mountains we often do!” “In the early days I was on a Dutch team with doctors on call 24/7 who watched our blood levels closely. If they dropped below a certain level they’d pull us out of competition so the support was always there. And it has to be, because a race such as the Tour is a bit like

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lifestyle running a marathon 20 days in a row.” “Team doctors become close friends, and that’s good when you’re going over the Alps one week and the Pyrenees the next.” We’ve all seen the Peloton snaking its way through the French countryside but, as Henk points out, it’s not a place for the fainthearted. “There’s a lot of mutual respect among the riders but it’s dog-eat-dog in the peloton, particularly approaching the finish-line in a bunch sprint. It probably looks worse from the helicopter than it actually is!” The rat pack “You need to remember that these guys race each other about 150 times a year so if you keep stuffing up you’ll find yourself with a bit of a reputation. If you end up on the ‘outer’ the peloton just won’t let you in. Most riders learn that pretty quickly in their first year as a pro.” “It’s not much fun if you get ostracised.” There’s been plenty of discussion about mental health problems linked with athletes

stepping away from their chosen sport. And professional cyclists are no exception. “Any sportsperson stepping away from elite competition is highly susceptible to depression and, quite frankly, I don’t know of anyone who hasn’t had problems.” “You become so used to having all those endorphins running around your brain, so when you pull the plug it seems as if nothing works properly any more. The crash I had in 2003 was lucky in some ways because they put me on Citalopram so I had an established antidepressant safety-net.” The family tradition Cycling runs in the Vogels family. Henk’s father competed at the 1964 Tokyo Olympics and coached a number of national teams. “There was no pressure from Dad to get into cycling, although we did spend a lot of time with other Roleystone kids running around the Velodrome. I actually played a lot of competitive soccer and didn’t really hop on a bike until I was 15 years-old.” “And then I found myself at the Barcelona

Olympics two years later!” “The track program didn’t really grab me and I remembered Paris-Roubaix videos with my Dad so I thought I’d get into road racing as soon as I could.” Henk may have stepped away from competitive cycling but his life is still all about the bike. “I do some commentating for SBS, train young cyclists and work for Bikebug, a large online retail store that sells high-end bicycles. I’m also involved with Velo Tours that takes people around the big races in Europe.” “I know that a lot of doctors love their road bikes. The only advice I’d give them, to quote Eddy Merckx, is to ‘get out there and ride!’ Cycling is such a social sport. It’s a great cardiovascular workout and a great way to have fun.” “And road rage from 4WDs? Don’t react, keep to the left, smile and wave. It annoys them even more!”

By Peter McClelland

Smoothing Out the Bumps The moniker, Mission #12479, doesn’t quite do justice to one of Angel Flight’s more challenging jobs. In mid-April pilot Keith Godfrey flew to Burringurrah, one of the most remote communities in the Gascoyne region with a population of approximately 130. The stones on the gravel airstrip are both plentiful and large so it can be quite tricky avoiding damage to the propeller. But, for the people of Burringurrah, a free flight in an aeroplane for an important medical appointment in Carnarvon is a wonderful service. And the scenery from above is absolutely stunning, giving a glimpse of

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just why Angel Flight is so appreciated by people living in such isolated areas. The terrain is difficult to negotiate, and there is only one dirt track in and out of Burringurrah that becomes decidedly tricky with winter rains. A road journey to Carnarvon, even in a suitable vehicle, will take about six pretty bumpy hours. All money donated to Angel Flight, including paying for the pilot’s aviation fuel, goes directly to providing this free medical service that helps to alleviate the tyranny of distance in Australia’s remotest regions.

AUGUST 2017 | 49

FOOD & WINE

Saroor

MY LOCAL

388 South Terrace South Fremantle Ph 9335 1366 www.saroorindianrestaurant.com.au Saroor is a really interesting Indian restaurant and bar, bouncing with people enjoying themselves, albeit insanely busy on a Saturday night in an expanding restaurant scene in the port city. The dishes are beautifully presented, decorated with cucumber, pomegranates and flavoured with mouth-watering spices. The pick of the dishes? Honey Chilli Cauliflower in a nest of crispy batter; Samosa Chat; and the Goan Fish Curry. And please don’t walk out the door without trying their signature dessert – Igloo Kulfi Ice-Cream (Pistachio or Mango) and served inside your very own igloo made of ice. We shared one between seven of us! It’s BYO wine and fully licensed, open seven days and they have a take-away menu. Highly recommended!

Cure-All Chicken Soup Ingredients 1 x 1.2kg free-range chicken 1 fennel bulb, finely shredded, with fronds and stalks 1 large brown onion, peeled and quartered 4 carrots, 2 carrots diced 1 tspn black peppercorns 4 cardamon pods, crushed Bunch fresh sage 3 bay leaves Salt to taste Olive oil 1 leek, finely sliced 2 cloves garlic, minced 1 red chilli, finely sliced 2 sticks of celery, chopped 200g short-shaped pasta (Casarecce, penne rigate etc) Flat-leaf parsley, finely chopped

DIRECTIONS 1. Add chicken, fennel fronds, stalks, onion, 2 carrots roughly chopped, peppercorns, cardamom pods, bay leaves, salt and half the sage into a large soup pot and cover generously with cold water and bring to the boil on the stove. 2. Drop temperature and simmer gently for 2½ hours; top up if necessary but don’t dilute stock too much. 3. Remove chicken to a plate to cool. Shred meat off the bones when cool enough to handle. Discard bones. 4. Strain stock of bits into a large bowl. 5. Return stock pot to stove, add about 2 tblspn olive oil and add leek, garlic and chilli and sweat gently. 6. Add shredded fennel and diced carrots, celery and sage, stir for a minute. 7. Add the chicken stock and bring gently to the boil then drop down to a simmer for 15 minutes. 8. Add pasta and cook for a further 10 minutes. 9. Add chicken and heat through. 10. Allow to stand and warm through gently to serve with freshly chopped flat-leaf parsley

Wine

Winner One of the favourite tipples of Doctor’s Dozen Wine Winner, Dr Neil Collins, is a Barossa Valley Shiraz. He’ll be pleased when he cracks the carton because one of Schild Estate’s signature wines is just that – a great 2014 vintage! Neil and his partner have Baby # 2 due in late October so one good reason to twist the screw-cap.

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FOOD & WINE

3drops (or 5) of the Great Southern Wine, olive oil and water. The presence and production of these three precious liquids inspired the name behind this 15ha vineyard located on a farm south west of Mt Barker.

By Dr Louis Papaelias

It was planted in 1998 to shiraz, cabernet sauvignon, cabernet franc, merlot, pinot noir, Riesling, sauvignon blanc and chardonnay along with various mediterranean olive cultivars. This is a cool climate location by Australian standards and the wines demonstrate the characteristics typical of the Mount Barker region. When compared to Margaret River, the wines in general have less fruit richness but tend to show more delicacy and acidity. Winemaking is made under contract by Robert Diletti, of Castle Rock Wines in the Porongurups. Diletti is a very experienced winemaker and has produced many outstanding and long-lived wines, in particular his riesling.

2015 3drops Shiraz REVIEWER'S

PICK

Impressive bouquet of berries, allspice and white pepper. Generous mouth-filling fruit and fine tannins with a whistle clean finish. An excellent example of cool-climate shiraz. Highly recommended.

1. 2016 3drops Riesling Lifted aromas of citrus in abundance. Clean, delicate and crisp with no rough edges, this wine has the lively zing and raciness of good Great Southern riesling. This could easily age for 10 years but is very enjoyable now as an aperitif. Fresh oysters would go very well. Recommended. 2. 2016 3drops Sauvignon Blanc Very appealing bouquet of ripe gooseberries that leap out of the glass. Deliciously mouth filling with abundant flavour and surprisingly good length on the finish. More towards the New Zealand end of the spectrum rather than the Margaret River SSB style. Recommended.

WIN a Doctor’s Dozen! Name Phone

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3. 2015 3drops Chardonnay Toasty oak and white peach on the nose. Medium bodied, richness of fruit balanced with crisp acidity. Finishes long and clean. 4. 2015 3drops Cabernets A blend of Cabernet Sauvignon and Cabernet Franc this shows cool climate characteristics namely red berries and stalkiness. While not overly complex, there is generosity of fruit and fine chalky tannins that make for a pleasant mouthful. All of the above wines sell for $22-$25 dollars a bottle, which is very good value considering the quality on offer.

.. or online at

Wine Question: Which wine makes up the 3drops Cabernets?

P lease send more information on Schild Wine offers for Medical Forum readers.

Answer: ....................................................

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, August 30, 2017. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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AUGUST 2017 | 51

Social Pulse SJG Subiaco Welcomes New CEO

Doctors, politicians and SJG executives gathered to welcome Prof Shirley Bowen to the role of CEO of St John of God Subiaco Hospital. Prof Bowen comes to the position from the University of Notre Dame Medical School, where she was dean. She was officially welcomed by SJGHC’s WA Hospitals Region Executive Director John Fogarty. 1. Prof Shirley Bowen and John Fogarty 2. Dr Paul Cohen and Dr Tarek Meniawy 3. Dr Robyn Yeo, Dr Reshma Pargass, Nedlands MLA Bill Marmion, Dr Harsha Chandraratna 4. Dr Seonaid Mulroy, Dr Richard Murphy, Dr Jo Colvin and Heather Marin 5. Laura Colvin, Subiaco Mayor Heather Henderson and SKG’s Dr Sue Ulreich 6. Multiplex’s Chris Palandri, Dr Christopher Allen and SJGHC CEO Dr Michael Stanford 7. Dr Stuart Salfinger and Dr Jade Acton

3drops Olive Oil

Taste Test

Imagine the delight when the wine reviewer’s dozen arrived with a little something extra – a bottle of 3drops olive oil to be tasted and tested. Our palates have come a long way in respect to (and for) olive oil. Having been around the kitchen long enough to know that some of the imported olive oils we were confined to in the dark ages were often too old and too expensive, it is a delight to taste fresh, first-pressed olive oil that has been made in our own backyard. 3drops is a lively, fruity oil – with a hint of bitterness but perhaps not as muscular as its northern cousins from Moore River and Gingin making it ideal for a pre-dinner nibble. It was good with dukkah, but in the end you only taste cumin, so I recommend it neat with a drop of aged balsamic on quality sourdough. Its clarity really shines. 3drops hails from Mt Barker and is a multicultural blend of Frantoio, Nevadillo Blanco, Koroneki, Kalamata, Manzanillo and Pendolino cultivars giving it the best qualities of Italian, Spanish and Greek olives.

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doctor in the arts

Comedy pick-me-up With splitting his time between GP practices here and the UK, and comedy gigs in between, life is never dull for Dr Ahmed Kazmi. He was a sell-out start of the Perth Fringe Festival earlier this year and as one reviewer put it, only a true artist can make mortality funny! “I like to call my comedy routine, humour with a point! I try to be an all-round entertainer using story-telling, one-liners, singing and dancing. But it’s important that there’s a subtext behind the performance that leaves people thinking about some pretty important issues,” Ahmed said. “In terms of our profession it would be nice if people left the show understanding doctors a little better, and maybe even having a think about how they could get more out of their next appointment. I always have a takehome message – last year it was ‘cancer awareness’ and ‘bereavement’. And in 2017, understandably, it’s all about Islamophobia.” The one question you just have to ask a stand-up comedian is, ‘have you ever died onstage?’. “My first-ever show was a comedy of errors in itself, everything from microphone failure, forgetting lines to getting so emotional that I had to leave the stage. Despite all that, there was a raw authenticity to it all and the audience seemed to enjoy it.” “I’ve refined my schtick since then, thankfully, and moved on from that humbling beginning. Stand-up comedy is an important outlet for me because, although I do love being a GP, it can get a bit intense. Every doctor needs a hobby, and I don’t play golf and I’m terrible at Sudoko. To be quite honest, I started all this to get over my grief at losing my father to cancer. I needed a distraction, something fun preferably.” “Now it’s about creating joy and happiness onstage in front of an audience. To have an opportunity to make people laugh, cry and perhaps reflect a little is a real privilege. The

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applause is such a rush, a bit like a giant hug. And who doesn’t need one of those in these troubled times!” “And one of the really nice aspects is that all things health related, particularly the doctorpatient relationship seem to be universal. I’ve just been on a bit of a mini-world tour and there are cultural nuances, of course. But the show is essentially all about human nature.” And is political correctness the scourge of entertaining, free-flowing comedy? “No, not at all! I think too many people confuse the right to freedom of speech with the right to senselessly offend! In my opinion, you can be a good comedian and make jokes about a variety of serious topics without degenerating into misogyny or racism.” One of the more obvious potential pitfalls of a show such as this is someone in the audience suddenly thinking, hey, he’s talking about Uncle Fred! “I’m way ahead of you there! That’s a very real issue and yes, I had to consider the possibility of that happening. I think I’ve found a way around it by saying at the outset that I don’t compromise patient confidentiality and sticking to common scenarios that are part and parcel of everyday GP experiences.” Ahmed doesn’t spring from a family-line of medicos, but he was probably always destined to be a doctor. “My parents would have been happy with any career path I chose, as long as it involved a university degree and I was the best at it and won lots of prizes! Yes, I had ethnic parents – similar to American parents who enter their children in beauty pageants except that parents such as mine enter you into academic competitions.” “I chose medicine because I wanted a job where other people would benefit from my

privileged education, which was something my parents worked really hard to achieve!” “I loved languages, drama and science. When I put them all in a blender, medicine seemed to be the best choice. And being a GP I get variety, the ability to have good work-life balance and I’m my own boss. I certainly don’t regret my decision.” “If I had to choose between medicine and comedy it would be the former every time. I trained for over a decade to be a GP and it is part of the fabric of who I am. It brings purpose and pleasure to my life and I wouldn’t trade it for anything.” “And anyway, comedy wouldn’t pay my bills!” The travelling medico-comedian divides his time between London and Perth, and makes some interesting observations on the regional differences. “I work in West London and I love the hustle and bustle and all the flashing lights. The demands on service provision in the UK’s NHS means there are a lot of protocols regarding consulting, but I think the NHS is a pretty impressive organisation. And I’m proud to be part of it.” “The sun, the beaches and the relaxed vibe of Perth is pretty nice, too. It’s more fun to practice as a GP here because of increased practitioner freedom. Splitting my time between London and Perth is OK for now I’m going to have to decide where I’ll make my long-term base.” “I’m super-excited about the prospect of a cabaret show and hope to debut it in 2018 at the Perth Fringe. I’d also love to do some TV work, particularly medical documentaries and I’m working on that at the moment.” “Oh, and I’m tired of being single and would like to find a partner!”

By Peter McClelland AUGUST 2017 | 53

Work to Rule 1. Rome did not create a great empire by having meetings; they did it by killing all those who opposed them. 2. If you can stay calm, while all around you is chaos...then you probably haven't completely understood the seriousness of the situation. 3. Eagles may soar, but weasels don't get sucked into jet engines. 4. Artificial Intelligence is no match for Natural Stupidity.

Week 8: Memo No. 4

5. If at first you don't succeed, try management. 6. Never put off until tomorrow what you can avoid altogether.

Week 9: Memo No. 5

7. TEAMWORK...means never having to take all the blame yourself. 8. The beatings will continue until morale improves.

10. We waste time so you don't have to.

Casual Fridays Week 1: Memo No. 1 Effective this week, the company is adopting Fridays as Casual Day. Employees are free to dress in the casual attire of their choice. Spandex and leather micro-miniskirts are not appropriate attire for Casual Day. Neither are string ties, rodeo belt buckles or moccasins.

Week 6: Memo No. 3

The Casual Day Task Force has now completed a 30-page manual entitled Relaxing Dress Without Relaxing Company Standards. A copy has been distributed to every employee. Please review the chapter ‘You Are What You Wear’ and consult the ‘home casual’ versus ‘business casual’ checklist before leaving for work each Friday. If you have doubts about the appropriateness of an item of clothing, contact your CDTF representative before 7am on Friday.

Week 18: Memo No. 7

Week 3: Memo No. 2

As an outgrowth of Friday's seminar, a 14-member Casual Day Task Force has been appointed to prepare guidelines for proper casual-day dress.

Week 14: Memo No. 6

9. Never under estimate the power of very stupid people in large groups.

A seminar on how to dress for Casual Day will be held at 4 p.m. Friday in the cafeteria. A fashion show will follow. Attendance is mandatory.

Our Employee Assistant Plan (EAP) has now been expanded to provide support for psychological counselling for employees who may be having difficulty adjusting to Casual Day.

Week 20: Memo No. 8

Casual Day refers to dress only, not attitude. When planning Friday's wardrobe, remember image is a key to our success.

Due to budget cuts in the HR Department we are no longer able to effectively support or manage Casual Day. Casual Day will be discontinued, effective immediately.

A mathematician is a device for turning coffee into theorems. - Paul Erdos (1913-1996)

Another Great Day At Sea

Book

Review

(Geoff Dyer, Canongate)

Author Geoff Dyer spent two weeks aboard the aircraft carrier USS George W. Bush in November 2011 while the ship was on active service in the Arabian Gulf. He was a floating ‘writer in residence’ on one of the world’s most lethal warships and a funnier, wittier or more perceptive insight into the lives of its crew-members would be difficult to imagine. The sole purpose of the boat is to launch the birds – F18 fighter jets and radar surveillance aircraft – and Dyer paints a vivid picture of the catapult launch and the thundering, deckshaking arrival of a 20-tonne F18 when its tail-hook grabs the arrestor wire. The author, an Airfix model-making tragic as a boy, conveys immense respect and admiration for the men and women who go to sea in a ship that is, in every sense of the word, a runway the size of a postage stamp.

travel

New York from the Inside Wembley GP Dr Lin Arias returns to her hometown of New York to find a 24-hour a day pleasure palace. So what does an expat do when she visits her hometown of New York? Enjoy myself! There are some well-known ‘must-do’ sights and experiences: Riding the Circle Line to get an overview of Manhattan. The nighttime trip (though not in winter unless you are well rugged up) shows the city's lights and heights off best. Strolling through Central Park, the city’s lungs, heart and playground. Taking the boat to Ellis Island. The museum there showcases the lives of the waves of immigrants “yearning to breathe free” who came to the city, settled, worked hard, and made the city their own. If you can, take the last ferry back because the lights are lovely. Visiting the Lady – the Statue of Liberty. If she doesn’t move you, you are over- or undermedicated. Showtime on Broadway. Whether it is the ever-wonderful Lion King, the hysterical Book of Mormon, a play off-Broadway, just see a show. It is part of the New York experience. Around Times Square you may see the Naked Cowboy strumming his guitar. No, he’s not naked: he wears a big cowboy hat and white boxer shorts and is very easy on the eye. Check out TKTS for cheap tickets. Eating, oh yes, where do I start? Weeell,oh my, corned beef on rye, pastrami hot and spicy, kosher dill pickle on the side. You can’t go amiss at the Second Avenue Deli, or the Third Avenue Deli. Double your statin dose before you go and don’t be ashamed to take half of the huge sandwich home. I’m salivating as I write this. Revelling in the art: galleries, public and private, galore. The museums: take your pick! MEDICAL FORUM

Modern? Then visit MOMA and the Whitney. You prefer the ancient world, plus everything else? Then the Metropolitan Museum of Art (the Met, to natives) where those in the know, know you can join free daily-guided tours. Go online to see the free programs and check out MetFridays. Special interest? Perhaps Klimt’s The Woman in Gold? Check it out the Neue Galerie. It is a piece of Vienna in the Big Apple. Exquisite. The cafe downstairs at the Neue Galerie serves the most expensive cup of coffee. For those who find NY coffee just not up to our Australian standard, then spend the $8 (that includes a tip for the Viennese-styled wait staff) on a cup after you have toured the exhibition, and just savour the whole cultural and gustatory experience. The tortes are also divine. Need some exercise after that torte? Jog, walk, rollerblade, row in Central Park. Keep it to daylight hours and you can go anywhere safely. In the winter, glory in the magnificent Christmas tree at the rink and hark the herald angels while you skate at Rockefeller Centre (you will need to seriously RUG UP and drink the wonderful hot chocolate at the nearby cafe, no matter what the cost) or cross country ski in the Park. Subways are safe, easy and fast. Again, stick to daylight hours if you are a newbie, and don't travel at rush hour if you can't stand crowds. There are subway maps on the walls of most of the routes and you can get a map of the subway and bus routes from any visitor centre or newsstand. I always get mine from Grand Central station. It's worth seeing that magnificent meeting place for itself, as well as to take trains and subways to and fro, and, of course, the shopping and eating to be had in and under and around the station.

Take a taxi at nighttime; just hail them from the street. They are all metered. I don't Uber, though I am sure you can. Visit the High Line, New York's newest and grooviest park. Its southern point ends at the new, ever-exciting Whitney Museum. It used to be an old railway track that closed when Lower West side industry stopped using rail. It has recently been revitalised into a lovely 2km walking track with stalls, sculptures and views. It is, like so much else, free. Ah, back to Central Park. I love that place. In the summer there is free Shakespeare at the wonderful, atmospheric outdoor Delacorte theatre on the West side. Coffee and peoplewatch like a New Yorker at the cafe at the Conservatory Water, by East 74th, near the Met, and just south of the delightful bronze Alice in Wonderland sculpture. The coffee and chai are good; grab a seat and watch the flow of the nannies pushing prams while on the phone, the joggers, other people reading their paper while enjoying the greenery and relative peace and quiet. It's a great place if you have kids with the playgrounds an easy walk away and lots of room for kids to run. If you can, rent a remote controlled sailboat, they are spectacular. New Yorkers LOVE their city. You will see fire stations with memorials to their members who died saving others during 9/11. Stop and talk to the men and women of service: police, fire staff, park-keepers. Visit the memorial at Ground Zero. It is well worth the many security checks. Enjoy the most fabulous city on earth. Me, biased? Of course, I’m a New Yorker!

By Dr Lin Arias AUGUST 2017 | 55

Entertainment & Leisure

Rocking the Concert Hall Perth Symphonic Chorus has expanded its calendar of events this year to four, giving Perth audiences an extra chance to catch this highly professional group. The chorus is under the direction of Dr Margaret Pride, who manages to conjole the very best out of her volunteers and when you see the quality of professional musicians she has them perform with, there’s little wonder that the 100-strong chorus rises to every occasion. Next month, Brahms magnificent German Requiem is on the play list and internationally renowned Sydney organist David Drury will be part of the orchestral ensemble accompanying the choir. As well as a soloist, David is also a composer, Director of Music at St Paul’s College, University of Sydney, he plays keyboard for the progressive band, Resonaxis, and is director of the David Jones Staff Christmas Choir! Medical Forum despatched a series of questions to David while he was on holiday and he kindly answered them for our deadline. He writes about his work and his love of the big sounds of the organ and what we can expect when he, Brahms and the PSC rock the Perth Concert Hall on September 23. What led you to the organ and who inspired you? My interest in the organ was a journey from being the son of a Methodist minister who discovered the music of J.S. Bach via a recording, then learning at Trinity Grammar School in Sydney. I had a great choirmaster/ teacher at the school. We also had a chapel and a fine organ so they were my building blocks. You have played on some of the world’s great cathedral organs… tell me what that feels like having such power at your touch? And equally playing such emotionally charged music? This is reason you do it really. The architecture, the sheer size of the buildings, and the acoustics as well as the organs. Some of them are very powerful and fill the building with sound. When you practise in these spaces, you have to concentrate carefully after the initial thrill so that you control your emotions. Playing in places such as Notre Dame Cathedral in Paris on a dazzling French instrument, or the very English sound of the organ in St Paul’s Cathedral, London are so different but equally exciting.

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With Christian congregations waning… has church music (and the physical space) become something else to the modern listener? If you go to an English Cathedral and hear the choir, you can be inspired by the music and get a spiritual experience which is broader than theology. They are also great concert spaces. Great buildings and spaces inspire people, both listeners and composers. There is a growing hunger in the community to participate in choral singing what’s the attraction do you think? I think the attraction is in your question: Community. These days more people are looking for real connection. Food brings people together, so does music. Choirs are great when you have a good leader/teacher. Singing is also good for the brain as well as the lungs! Great commitment is required to join a high-functioning choir, what qualities are needed to lead such a group? Patience! If it is a really fine group of musicians, hand-picked or auditioned, then the sky is the limit. Your own passion and drive fuels their interest. Also, you need musicianship and experience over and above the average to lead them to great things. Your musical interests are broad, tell us a little more about your various projects. What projects excite you?

recitals programs for Sydney – one in St Mary’s Cathedral this year and one in the Opera House next year as well as a Jewish music festival and a Victorian music hall show. I am also writing electronic dance music as well as some choral music. After Christmas I will be the organist for a choir travelling to sing in English cathedrals – 10 in 16 days to be precise! I will also be playing at Notre Dame again next June. I like diversity and I need it in both my performing as well as my leisure listening. The organ is no stranger to popular music with the likes of Georgie Fame making it an essential part of the soundscape in the 70s, 80s … where do you see its role in the future? I also love Rick Wakeman’s use of it in the rock group ‘Yes’ in the 1970s. I hope the organ will be included by composers well into the future, both classical and fusion, but I do think the great sacred spaces in the world will continue and find a resurgence. No music is too good to introduce to children. We need good music education! In regards to the Brahms concert with the Perth Symphonic Chorus it is replacing the wind section of the orchestra. Is there anything it can’t do? This will be interesting. The organ will be joined by strings, harp and tympani. My job is to make my contribution work well with the instruments and voices. With the right organ, anything is possible.

At the moment I am preparing several

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Arts & Entertainment

Old Meets the New It’s a brave new world for home-grown composer Lachlan Skipworth. Not only will his choral piece nestle alongside J.S. Bach and Mahler in a concert at St Mary’s Cathedral next month, but the current WASO Composer-in-Residence is also juggling the demands of a new baby. “She’s just over seven months now and becoming a bit more aware of what’s going on so that means we have to be as well. I’m feeling my way back into writing new compositions, which means that I have to get used to working in smaller time-slots. But I am in the fortunate position of being able to coast along on pieces I wrote before becoming a father.” “It will be interesting to see if my music changes with this new way of working.” Lachlan is currently writing a new choral piece for the Tokyo Philharmonic Chorus and is looking forward to hearing his new work performed in Perth on September 24.

“There aren’t a lot of choral compositions being written at the moment, so that’s an incentive for me to write pieces that will be popular with choirs all over the world. It can be a good way to make your mark as a composer, too. A lot of people love getting together and singing, so hopefully these pieces will end up having a life of their own.” “I’m looking forward to hearing my music in St Mary’s, the entire space has a beautiful sound. It shapes the way I write because the acoustic of the building tends to favour quite slow music, the chords take time to arrive then slowly fade before moving on to the next one.”

“Knowing the actual sequence of works in advance and how they might fit together can be quite helpful. It gives you a hint of the shape for your own piece, and in which direction it may go within the ‘architecture’ of the concert. Last year one of my piano pieces ended between two Mozart quartets and it turned out well. I’d like my music to speak in a similar way to Brahms with an emphasis on musicians coming together to communicate both between themselves and to an audience.” “As long as you try to make it as close to perfection as possible I don’t think it matters where it sits in the program.”

“I’ve been involved in a couple of really interesting concerts at St Mary’s and its soft echo makes for wonderful music.”

Lachlan’s early musical education was conventional enough, but then took a somewhat exotic turn.

One of the interesting things for Lachlan is the way in which his own compositions ‘sit’ within a program. In this case Ligeti’s Lux Aeterna, Bach and Mahler.

“I didn’t come from a family of musicians, but there was always a lot of music at home. I played piano and then had lessons on the recorder, which led to the clarinet. I found a wonderful teacher in Jack Harrison, the ex-principal WASO clarinettist, and was accepted into the Perth Modern music program.” “I studied at UWA, immersed myself in the music of Brahms and Copeland, who both wrote superb music for the clarinet. I’d had about 16 years of education in institutions by then, so I went to Japan to teach English. I was utterly captivated by the Japanese Shakuhachi bamboo flute and eventually went to Sydney to study with a master of the instrument, Riley Lee.” “It’s a very nuanced sound with highly emotive melodies, not unlike Brahms in many ways.” Lachlan’s profile as a composer is on the rise. He was awarded the Paul Lowin Prize for orchestral composition in 2014 and his work, Spiritus, was the winner of last year’s New England Philharmonic’s Call for Scores. “I try to experiment and be creative, but still sit write music that most audiences will enjoy. It can be a struggle to avoid ‘dead spots’ and sometimes I’ll put notes down and think, ‘that’s pretty nice’. But often it’s not ‘nice’ enough and out it comes.” “But you can’t do too much of that one week before a deadline.”

By Peter McClelland ED: WASO Chorus St Mary’s Cathedral Lux Aeterna September 24, 2pm.

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Entering Medical Forum's competitions is easy! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter. Movie: The Emoji Movie They’ve jumped off your text message and into the cinema … and they’ve come from a secret city called Textopolist where everyone puts their one and only game-face on. That is all except Gene who is was born without a filter. He and his mates must battle the hacker emoji Jailbreak to save their world from permanent deletion. In cinemas, September 14

Lavazza Italian Film Festival We take it for granted now but 20 years ago, our diet of interesting foreign language cinema consisted of an annual binge at Perth festival time. Now Luna Palace Cinemas have mini festivals throughout the year to the delight of cinephiles throughout the city. In September, the 18th Lavazza Italian Film Festival comes to Cinema Paradiso and Luna SX, with more than 30 films from the Italian masters of cinema and masters in the making. Featured among the films is Fortunata (pictured above), which tells the story of a young divorced mother, who dreams of opening a hair salon and a life of freedom and independence. Wife and Husband (Moglie e Marito) is not surprisingly a film about divorce but here’s the twist – married for 10 years this couple suddenly find one inside the body of the other. While I Was a Dreamer is the story of an ex-prisoner who decides to become a useful member of society. There are laughs, tears and love in abundance at this year’s Italian film festival. Cinema Paradiso & Luna SX, September 21 to October 11

Movie: Maudie

Based on a true story, Maudie is the story of an unlikely romance in which the reclusive Everett Lewis (Ethan Hawke) hires a fragile yet determined woman named Maudie (Sally Hawkins) to be his housekeeper. Maudie has a passion to create art despite having severe arthritis in her hands and finds an unlikely supporter in her difficult boss. In Cinemas, August 24

Theatre: Switzerland Thriller writer Patricia Highsmith becomes a star of this edge-of-your-seat thriller by acclaimed Australian playwright Joanna Murray-Smith. Highsmith lives a reclusive life in the Swiss Alps surrounded by her collection of books and antique weapons. Until one day a young man intrudes into her refuge. Heath Ledger Theatre, August 19-September 3. MF performance August 19

Winners from June Movie – Baby Driver: Dr Sayanta Jana, Dr Chris Lam, Dr Hock Chua, Dr Jeff La Valette, Mr Ray Barnes, Dr Peter Louie, Dr Tanya Subramaniam, Dr Patrick Lai

Music: Lux Aeterna Here is a glorious blend of the old and new with the WASO Chorus under the baton of Christopher van Tuinen in the acoustically appealing confines of St Mary’s Cathedral. From Bach to Mahler, to the 1966 Lux Aeterna by Gyorgy Ligeti and WASO composer in residence Lachlan Skipworth’s brand new work.

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St Mary's Cathedral, September 24, 2pm

Movie – A Ghost Story: Dr David Jameson, Dr Sue Martin, Dr Stanley Khoo, Dr Heather Brand, Dr Shelley Davies Major Sponsors

Live Event – The Good Food & Wine Show: Dr Keren Witcombe, Dr Brendan Connor, Dr Dorothy Graham Music – Scotland the Brave: Dr Ben Walawski Opera – The Merry Widow: Dr Peter Schrader

June 2017

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Music: Brahms' German Requiem This moving choral masterpiece is being performed by the Perth Symphonic Chorus under the direction of Dr Margaret Pride and features two wonderful soloists in soprano Sara Macliver and baritone Christopher Richardson. The concert hall pipe organ replaces with wind section and it is sure to leave an indelible impression. Perth Concert Hall, September 23, 7.30pm

58 | AUGUST 2017

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