Medical Forum WA 06/13 by Medical Forum WA

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June 2013 Major Sponsors

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CONTENTS FEATURES

31 Telehealth in Remote

Ophthalmology

6 Akram Azimi:

Dr Angus Turner

Bridging the Divide

32 Managing Diabetes Dr Lawrence Wapnah

10 Investment Special:

Planning Tomorrow, Today 18 ETS: A Telehealth

Notion 22 Interplast: Making

a Difference

NEWS & VIEWS

34 Diabetes in the Elderly Dr Cathy Parsons

2 Letters to the Editor: WA Compo Compares Favourably: Mr Chris White; Facing the Future: Dr Richard Yin; Secrets of sacro-iliac revealed: Dr Belinda McManus; Good science in drug industry: Dr Michael Morley; National Residential Medication Chart update: Dr Michele Chandler; Kaleeya Services: Dr Helena Goodchild

8 Have You Heard? 16 John Poynton

on Giving Ms Jan Hallam

35 Resistant Neisseria

gonorrhoeae Dr Donna Mak

Young WA Insulin Takers

41 Bali Traveller

Health Risks Dr John Terry

LIFESTYLE Dr Simon Moss

45 The Sculptor’s Model 46 Kitchen Confidential:

Suburban Table

29 Diabetes and

42 Albany Health

37 Support Group

44 Investing in Provence

Mr Peter McClelland

39 Beneath the Drapes

5 The ThinPrep®

Ms Jo Beer

27 Living with Diabetes

34 Conference Corner

Dr Johan Janssen, Cardiologist

33 Gestational Diabetes

26 Fit to Drive

Services Scheme

Cardiac Murmur

Dr Gordon Harloe

Go Bush

32 National Diabetes

3 The Innocent

Imaging System

20 Students Who

Foot Care

CLINICAL FOCUS

47 Wine Review:

Campus Opening

Elderton Wines Dr Louis Papaelias

48 Car Review:

Subaru Forester Dr Daryl Sosa and Dr Peter Bradley

50 Satire: The

Inner Sanctum

43 ASOHNS Awards

Ms Wendy Wardell and Mr Dave Freeman

GUEST COLUMNS

51 The Don is Back! 51 Slava’s Wonderland

21 Thinking Outside

the ED Square

52 The Funny Side

Mr Tony Ahern

53 Competitions

25 What do Patients

Think of Us? Dr Sean Stevens

26 Doctors Looking

Upstream Dr George Crisp

E-POLL & EVENTS 29 Doctors Drum

Breakfast: Doctors – The Care Factor 38 E-Poll: Chronic Care,

Philanthopy, Diabetes Management, Doctor Training. medicalforum

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

MEDICAL FORUM MAGAZINE 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reﬂect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemniﬁes the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN 2 Thinking Hats

Letters to the Editor

WA compo compares favourably Dear Editor, As the CEO of WorkCover WA, the authority overseeing the workers’ compensation and injury management scheme in Western Australia, I wish to respond to the article Management of WA’s Work Injured Needs Reform (May edition). WorkCover WA administers a workers’ compensation scheme that promotes the delivery of services aimed at minimising the social and economic impact of work-related injury and disease on workers, employers and the broader Western Australian community. This includes a strong focus on ensuring workplace injuries are managed in a manner aimed at an injured worker’s prompt and safe return to work. WorkCover WA has been successful in balancing the sometimes disparate requirements and interests of participants in the scheme, making it one that compares very favourably to others in Australia. Premiums paid by WA employers cannot be described as “huge”. On a standardised basis, premium rates in WA are the lowest of all Australian states. Recommended premium rates have fallen by almost 30 per cent since 2005. Recent results indicate that return to work outcomes remain healthy in WA. A 2011 survey of injured workers found 77.3% of claimants in WA had returned to work, and were working, within 11 months of injury; a result that is above the national average of 75%. In relation to the payment of services provided to injured workers, WA is also above the national average as a percentage of the total costs of a claim. WA is also consistently below the Australian average for disputation in the scheme. Less than 2% of claims currently develop into disputes, a fact which reflects positively against the Australian average of 4.8%. WorkCover WA values its relationship with the medical profession. Medical practitioners play an invaluable role in the workers’ compensation scheme and are pivotal to successful outcomes. Feedback from the profession is always welcomed but it is important that consideration of issues relating to the scheme in WA is supported by factual information. Mr Chris White, CEO, WorkCover WA

Facing the future Dear Editor, On June 14, at 6.30 pm, Doctors for the Environment Australia is hosting a talk by Prof Graeme Martin from the Department of Agriculture UWA, at The Warehouse Cafe, 221 Onslow Rd, Shenton Park. The topic for the talk is the Future Farm Project. At the heart of the project is the question of how we are to meet the world’s food requirements while

managing soil, water and fuel resources, addressing problems with pesticide/herbicide use and issues around sustainability into the future? Another four departments at the UWA are also involved in this visionary mission. This project has a variety of implications for human health but also challenges us in medicine to question how we might likewise meet our future challenges, including the broader issue of sustainability. For those interested in this talk and meeting other like-minded doctors, please contact me at yin@arach.net.au or after work on 9381 5759. Dr Richard Yin, Shenton Park

Secrets of sacroiliac revealed Dear Editor, In reference to discussions regarding chronic low back pain (The Pain of Change, May edition) I would like to draw your attention to a joint that seems to be overlooked by many – the sacro-iliac joint. This is the joint with the largest surface area in the human skeleton. In the main it is fibro-cartilaginous though some anatomy books suggest up to 20% have a synovial element. It functions how a 'universal joint' does in a car – weight transferred from the torso, out to the hips and down into the legs – hence it is subject to considerable torque. During pregnancy it is readied for delivery by hormones that loosen the joint, making it more susceptible to twisting forces, which can set up an irritation. Thus senior anaesthetists in maternity hospitals and obstetricians are familiar with the low back pain this can cause. It is not limited to pregnant women, though, and can be easily precipitated by wrenching the joint in some way or even malpositioning unconscious patients in the lithotomy position in theatre. The pain manifests as low back pain worse when lying or sitting but relieved by standing and walking around. This is in stark contrast to the pain of lumbar or disc origin, which is made worse when standing and walking. It can radiate into the buttock, into the groin and down the leg only as far as the knee. It is mostly unilateral but can be bilateral. Very often the patient has point tenderness over the dimple area of the back. Because it can radiate down to the knee it is frequently misnamed "sciatica" and the sciatic nerve stretch test is negative. During a recent "Health Report" on Radio National, dedicated to low back pain, Dr Norman Swan interviewed an American specialist who stated that 30% of low back pain remains unexplained. I would posit that the vast majority of this 30% is in fact S-I pain that warrants serious consideration. More often than not it is amenable to treatment with cortisone injections, including deeper into the

More letters P4

Scan the QR to tell us what you think or email editor@mforum.com.au medicalforum

The Innocent Cardiac Murmur Together with taking a thorough history, the physical examination is thought to be the hallmark of the assessment of a patient. And, today, the great majority of diagnosis of cardiac murmurs can still be made at the office or the bedside. Usually you do not need sophisticated elegant laboratory equipment. In examining the heart, the auscultation starts at the left lower sternal border (SB) for an overview. We listen to the first sound, then the second sound, then sounds in systole, murmurs in systole, and sounds in diastole and murmurs in diastole. Important clues are hidden in the timing of the murmur (see table 1).

Dr Johan Janssen, Cardiologist

most commonly caused by significant valve stenosis. The innocent systolic murmur in the elderly can happen in elderly patients with systolic murmurs over the aortic as well over the pulmonic area. Elderly people aged 60-90 develop an aortic systolic murmur due to a mild to moderate degree of sclerosis or stenosis. Calcium deposits of varying degree occur on the valve, but may not affect its function and the patient may have no symptoms. This murmur is termed ‘innocent systolic aortic murmur of the elderly’. Usually no treatment is required. From age 6 to approximately 60, bicuspid

Murmur

Lesion

Site

Hints

Ejection systolic

Aortic stenosis

Left upper SB/apex

Radiates to carotids

Pulmonary stenosis

Right upper SB

ASD

Fixed split S2

May just appear when cardiac output is high

Innocent

All areas/musical

Mitral regurgitation

Apex

Radiates to axilla

Tricuspid regurgitation

Left SB

Increase with inspiration

Acute communication right to left side of heart

Left SB

Endocarditis

All areas

Relief when patient is sitting forward

Pansystolic

Continuous

Systolic/diastolic rub Pericarditis

Q Table 1

The innocent cardiac murmur is an early to mid-systolic murmur. It needs to be differentiated from murmurs caused by valvular disease or congenital abnormalities. The main valvular murmurs are related to a stenosed aortic valve, and an incompetent mitral valve. The main congenital abnormality is an Atrial Septal Defect (ASD) and pulmonary valve stenosis. As people live longer, they often develop an aortic systolic murmur that may progressively increase in intensity, produce symptoms of fatigue, dyspnea, near syncope or syncope. This is the

medicalforum

aortic valve is the most likely cause of aortic stenosis, and ranks second only to mitral valve prolapse as the most common valvular lesion. For example, if aortic stenosis is diagnosed in a man aged 55 and it is a singular valvular lesion, the diagnosis will be congenital bicuspid aortic valve. Calcification of the valve will be present in virtually 100% of these patients. After the age of 60, the most common cause of aortic stenosis is not congenital in origin, but rather a three leaflet (tricuspid) aortic valve. The innocent systolic murmur is short, occurring in early to mid-systole. It is

Dr Janssen was born in The Netherlands and studied medicine at Maastricht and cardiology under Professor Hein Wellens, specialising in electrophysiology and interventional cardiology. As an A/Professor he worked at the Academic Hospital in Maastricht and Rotterdam. After an interesting time in Saudi Arabia he came with his family to Perth, where he joined the team at Western Cardiology. Dr Janssen runs weekly clinics in Kalgoorlie and monthly clinics in Geraldton. He teaches medical students in rural areas (Rural Medical School UWA and Notre Dame) as well as at SJOG Hospital, Subiaco. He is based at Western Cardiology in Joondalup but also consults and provides inpatient care at St John of God Hospital, Subiaco. Johan provides Telemedicine consultations: his Skype address is Westerncardiology.johan; and these consults can be booked through his Joondalup office +61 8 9300 2545.

not holosystolic. Normal splitting of the second heart sound is present also. The innocent systolic murmur is very common. It is a frequent finding in children and teenagers, and less likely in adults. More sophisticated laboratory studies such as echocardiography and cardiac catheterisation are usually not necessary for diagnosis and only add to the expense incurred by the patient or family. Once the diagnosis of innocent murmur is established, it is not wise or necessary to have the patient return at intervals of several months or a year to keep check on this murmur. Otherwise, it can be logically interpreted: “The doctor is not sure; if not, why do I have to return?” If one hears a holosystolic (or pan systolic) murmur that occupies all of systole, think of three conditions: MR, TR and VSD. The innocent murmur is not holosystolic. Remember, also, that almost all pregnant women have an innocent early to midsystolic murmur, which may not be heard before or after her pregnancy. And, when in doubt: order an echocardiogram!

Letters to the Editor joint under CT guidance by a radiologist familiar with the problem. I was fortunate enough to have been taught this by an experienced GP of the old school who performed surgery, gave anaesthetics and delivered babies. That was 22 years ago and since then I have had enormous reward from diagnosing and treating this problem. My mother even asks me once or twice a year for an injection into one of her S-I joints!

Dr Belinda McManus, GP Anaesthetist

along came Pfizer with their discovery of pregabalin. It is a superb medication. I wish George every success in finding a cure for MS. But when I look back at the work of the likes of Prof Ian Donald (practical obstetrics ultrasound) Godfrey Hounsfield (3-dimensional X-Ray scans) and Peter Mansfield (magnetic resonance imaging) – these men were superb scientists who donated to us doctors the results of their discoveries. Methinks the pharmaceutical industry is the same.

Dr Michael Morley, Crawley

Good science in drug industry Dear Editor, The story of Prof George Jelinek (Doctor Heal Thyself, May) was a great read. I was a gynae registrar when George did his preregistration house jobs at Fremantle Hospital in 1980 and I knew then what a gifted young doctor he was. However, I cannot agree with his comments on the pharmaceutical industry, that it seduces our profession. My personal experiences illustrate this. In the past year I have been suffering from peripheral neuropathy. No cause has ever been found and the old description of the disease – “Flail fingers and flail toes” – is correct. No medication was helping the depression, insomnia and anxiety until, thankfully,

Kaleeya Services Dear Editor, I have recently taken up the position of GP liaison at Kaleeya Hospital, East Fremantle, for Obstetric and Gynaecology services. Following on from your Women's Health edition in April I thought it would be timely to highlight the general gynaecology services on offer to GPs, especially those in the South Metro Area. There are currently General Gynaecology clinics running both at Kaleeya Hospital and Fremantle Hospital. Dr Phillip Rowlands and Dr Ab Basu are the Consultant Gynaecologists at Kaleeya, and perform all non-emergency elective gynaecology procedures, including laparospcopies,

colposcopy, LLETZ, and IUD insertion. Some procedures, such as Colposcopy, LLETZ can be put through the Ambulatory Surgery Initiative (ASI). Dr Steve Harding and Dr John Overton run the Fremantle Hospital Gynaecology services. To make a referral to the gynaecology clinic at either Kaleeya or Fremantle, the usual Teaching Hospital Outpatient form should be filled out and sent to Outpatient Central receipting at Fremantle Hospital. If it is for an ASI surgical procedure, include Dr Rowlands /Dr Basu's name on the referral. Services that cannot be provided by the Fremantle Hospital Gynaecology team include emergency Gynaecology, Termination of Pregnancy, Counselling and Oncology. www.fhhs.health.wa.gov.au/GP /handbook.aspx.

Dr Helena Goodchild, GP Liaison Kaleeya Hospital, East Fremantle

Correction Medical Forum apologises for an error in the Caring for the Carer article in the May edition. The participants in the Families4Families (F4F) support group should have been referred to as ‘consumers’. We regret any distress caused to those involved.

We want to hear what you think. Send in your letters by May 10 to editor@mforum.com.au

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Advances in Cervical Cytology

By Dr Gordon Harloe, Pathologist and CEO Clinipath Pathology

The ThinPrep® Imaging System Cervical cytology (the Pap smear) is behind Australia’s excellent cervical cancer prevention program. As with all screening, the important aim is to reduce false negative rates. This requires a multifaceted approach, to improve specimen collection, slide preparation and disease detection. From the pathologist’s perspective, the ThinPrep® system offers obvious advantages.

Specimen preparation A conventional Pap smear leaves up to 80% of the patient’s cells on the collection device to be discarded with the collection device. Importantly, the subsample transferred onto the slide may not be representative of the entire epithelial sample on the collection device. The ThinPrep®, liquid based cytology system transfers virtually all cells into the collection vial and after mixing of the specimen, a reproducible representative and homogeneous subsample is transferred to the slide. The cells presented on the ThinPrep® slides are well fixed and evenly dispersed without cell crowding or multi-layering of groups of cells. Obscuring inflammatory exudate, blood and mucous are minimised. The thinlayer presentation of cells makes for easier screening and detection of cells that may have otherwise been obscured (see slides). The remaining material in the ThinPrep® vial is suitable for ancillary studies, such as PCR for chlamydia/gonorrhoea or molecular testing for high risk subtypes of human papilloma virus.

Computer enhanced imaging ThinPrep®’s thin-layered cellular presentation on slides lends itself to computer analysis. Clinipath Pathology is the first laboratory in WA to use a computer assisted cytology imaging system with liquid based cytology – the ThinPrep® Imaging System. The ThinPrep® imaging system combines image processing and analysis with human diagnostic expertise. A proprietary DNA stain is used to stain cervical cell nuclei.

An image processor rapidly scans every cell and cell cluster on the slide, measuring DNA content, thereby locating 22 areas of greatest interest or fields of view (FOVs) for each slide. The coordinates of the FOVs for each slide, along with slide identification information, are stored.

Q Conventional Pap smear slide

Cytotechnologist input Each slide is reviewed by cytotechnologists on automated review microscopes that systematically take the cytotechnologist to each of the 22 FOVs. This dual review increases the sensitivity and specificity while reducing the false negative fraction. As the cytotechnologist evaluates each FOV, any abnormal cells are electronically dotted for further evaluation and rescreening of the slide by other cytotechnologists and cytopathologists. Alternatively, if the cytotechnologist determines that the FOVs selected by the imager are negative, the case can be signed out.

Facts and figures A landmark Australian study (Accuracy of reading liquid based cytology slides using the ThinPrep® Imager compared with conventional cytology: A prospective study – BMJ July 2007; Vol 335, No 7609, PP.31-35) was performed on 55 164 split conventional and liquid based cytology samples. The Imager read cytology showed a 55% increase in detection of HPV&CIN1, a 27% increase in CIN2 or greater, a 42% decrease in unsatisfactory samples and a 22% reduction in the inconclusive, high grade abnormality cannot be excluded category. There are 7.7 histologically proven high grade cervical abnormalities per 1000 women screened in Australia. The ThinPrep® Imager comparison study indicates that a further 1.3 high grade abnormalities would be found, increasing the detection rate to 9 per 1000 women screened.

Screening use Screening programs in the USA, UK and NZ have recognised the advantages of liquid based cytology. Liquid based cytology has not been approved for government funding in Australia and liquid based samples are

Q ThinPrep® slide

submitted as an additional test as a split sample specimen. The fee for this nonMedicare rebatable test is $45. Whilst all women could potentially benefit from the adjunct ThinPrep® test, particular target groups would include patients with previous unsatisfactory or atypical smears, a clinically suspicious cervix or clinically obvious inflammation or haemorrhage at the time of cervical sampling. Australia’s highly successful conventional biennial cervical screening program is currently being reviewed. This review process will consider possible increased interval between screening episodes, commencing screening at a later age and new technologies including introducing Liquid Based Cytology as the primary screening test. Evaluation of HPV as the primary screening method (prior to microscopic confirmation of an abnormality) is also being undertaken but the evidence for this is still being gathered in clinical trials worldwide. Despite all these advances, an ongoing challenge is the small group of patients who for various reasons (for example embarrassment or cultural) do not have routine cervical smears and encouraging these women to be screened would go a long way to further reducing the rate of cervical cancer in Australia.

Spotlight

Asking the Right Questions Akram Azimi is using the opportunities as Young Australian of the Year to spread a powerful message of reconciliation and a united future. In May, 1999, 11-year-old Akram Azimi, his mother, Nadira, and younger brother, Azam, arrived in Australia as refugees from Afghanistan, fleeing the ravages of civil war. Fourteen years on, in January this year, Akram was recognised as one of our most valued citizens receiving the Young Australian of the Year award. It has been Akram’s mentoring work with indigenous children and his passion for reconciliation that have brought him to the public’s attention and he’s been using this once-in-lifetime chance to raise his voice in distinguished forums across the country and overseas. “This is a unique opportunity and platform to bring as many people together as possible. As activists, we run around for years banging our heads against the wall hoping someone will listen to the message and suddenly everyone wants to hear from me! I want to use that voice to do as much good as possible in the year I have.” “My message really intrigues people. They’re thinking ‘Why would an AfghanAustralian common law-trained lawyer care about what happens to indigenous Australians?’ They’re also thinking, ‘How come he has such a different story to us and yet his values are so aligned with us’. I have adopted some wonderful Australian values but I come at it from a very different angle. Part of this is the distance that’s created when somebody who looks like a stranger speaks like a friend. People are puzzled because my story is unusual for an Australian and for an Afghan but it gives me an opportunity to be heard because they can’t rationalise me into a category.” How the former Warwick High School head boy ended up on the edge of the Fitzroy River wrestling with a bunch of young Aboriginal boys from the small community of Looma, 200km east of Broome, is as amazing to Akram as it will be for readers.

Unlike us here in the city where we collect things … my Kimberley mob collect people and relationships “I was living at St Georges College at UWA and in 2009 an opportunity came up to go to the Kimberley to mentor some kids. At the time I had no idea what the Kimberley was and even less about indigenous 6

Q Akram Azimi with PM Gillard and Mother Nadira Azimi

Australians. It would be fair to say that I would have met and talked to only a couple of indigenous people before that. I was deeply ignorant.” “However, it sounded like a great adventure, yet for the first four days I really struggled. I just couldn’t connect with these kids. I kept asking questions like ‘what do you want to do when you grow up’. They had no interest in answering. All my small talk strategies failed and by the end of the fourth day, I said ‘I’ve had enough. I can’t connect with these people. They are too different to me, this landscape is too isolated’.” “I literally put my head in the sand. I lay down along the river watching the crocs bask in the sun on the other bank. I was throwing the closest thing to a tantrum that an adult can throw. Slowly, a group of boys carrying footballs made a semi-circle around me. You could smell the mischief in the air. One poked me in the ribs, giggled and ran away. Then the next, until we became this one wrestling, laughing mass. Full-on we were just being a bunch of silly boys.” “Something just broke down. We lay on the sand panting and one boy looked at me and asked a question that would change my life. He said, ‘tell me about your family’. So I did. I told them about my mum and about my dad and my little brother and how he annoyed me. They wanted to know about my family in Afghanistan and in Pakistan.” “I’m not sure how the conversation swung around to it but I began telling them the story of Odysseus and his travels. Here I was an Afghan-Australian, a lawyer, telling ancient Greek stories in English to a bunch of indigenous kids in the Kimberley. It just hit me – the stories we tell about ourselves

to ourselves are the only things that separate us from other people.” “These kids never questioned my Australianness. I was not a hypen Australian to them and that was the first time I felt Australian in Australia. It was a very precious gift those kids gave me and indeed what that community gave me. I fell in love with them. Then I started asking all the right questions.” “I stopped asking them about how much they wanted to earn, or what they wanted to do and started asking them questions about their family, their connections, who they wanted to work with. I started to understand their hierarchy of values.” “Unlike us here in the city where we collect things … my Kimberley mob collect people and relationships. They gave me this whole new way of looking at the world. It’s very personal for me now. I am part of their community. I’m not Aboriginal but I’m part of a family that is Aboriginal. For Akram’s mother Nadira, seeing her oldest son stand alongside the Prime Minister and the Governor General was proof that the family’s huge gamble and her hard work had paid off. The hours of nightshift in an aged care facility, the struggle to give her boys the best education possible were worth it. Akram is now studying postgraduate anthropology and Azim is a fourth year medical student at UWA. “Mum said of the four days we were in the East for the award ceremony. were the happiest days of her life. It was gratifying to know that my mother thought her sacrifices were worthwhile and something good had come out of it.” O

By Ms Jan Hallam medicalforum

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Have You Heard? number of board members or terms a board member can hold (although current chair Dr Frank Jones suggests some re-evaluation of this).

Work it out

Inpatient cost surprise A doc contacted us about a pensioner who had kept private health insurance going for security and to avoid waitlists but had then been surprised by a big co-payment for inpatient imaging. This was after being bulk billed for all outpatient services, which is what the two hospital providers in WA do at present. This circumstance is unusual but the Perth Rad spokesperson said they ask private inpatients if they are pensioners and bulk bill them. SKG said private inpatients pay a gap up to a ceiling of $750, and pensioners are not sought out. We repeatedly hear of private inpatients being surprised by pharmacy, physio or other co-payments after an inpatient episode.

WorkCover WA recently sent around notification of their approved WC premiums. With it came notification of health care professional fee increases. It is interesting to reflect that GPs and Approved Medical Specialists have both had a 32% fee hike in the last seven years. The GP’s in-hours consultation of 45-60 minutes has gone from $158.05 to $208.35, while the maximum fee for an approved specialist to do an examination and provide a report and certificate (straightforward assessment) has gone from $880 to $1160.15.

RACGP calls for nominations We gather nominations for the WA Faculty Board are open now – you need to be financial, a fellow/member/registrar, have two co-member signatories, and send a 100 word cv – to take part in deliberations for two years. Most appointments are uncontested and there is no limit on the

Afterhours clinics that have been set up to divert patients from EDs, and amongst the 68 practices listed are 14 not open during weekends (just extended hours weekdays) and three locum services. Android phone users, about a third of the market, can only view a practice list on their browser. The system promotes accessibility but in today’s world of immediacy, more needs to be done. Enter Medicare Locals.

How government helps It sounds good – $16m in volunteer grants to support and encourage volunteering nationally. Eligible not-forprofit community organisations access between $1000 and $5000. Unspoken, is the zillions that carers and volunteers save the Australian Government in assisting disadvantaged and vulnerable people in our community. For these grants, the smaller you are, the more volunteers you have, the more disadvantaged people you help, the greater your chance of success. The deadline has now passed and the federal government says it will respond early September (just before the election).

Revalidation, here we go GP's after hours State Health has said the 25,000 downloads of its free GP after-hours iPhone app since 2009 is a sign of success. It promotes the GP

Avant celebrates its 120th anniversary with the launch of a new advocacy program for its 60,000 healthcare practitioners and students nationally. It also released its polling of 150 GPs nationally about revalidation for Australian doctors. Although the doctor sample needed its

GESB – an award winning super fund.

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own validation, key findings from the survey were: only 9% gave unconditional support and 65% expressed concerns about implementation; 23% opposed revalidation because current systems were adequate and 41% said current systems ensure doctors are fit to practise; similar respondents said revalidation should detect underperforming doctors as they were currently slipping through the cracks (25%, 19% respectively); half saw revalidation as a personal burden with administration, ineffectiveness and lack of support their main concerns.

Who needs patients? It seems WA is fast becoming a Sim City. News that two of our universities have attracted serious dollars into simulation underscores its evolving role in the training of our future medical practitioners. UWA has opened a $3.7m Simulation Education Centre in Geraldton at the Combined Universities Centre for Rural Health (CUCRH) site. It will obviously be a boost for students completing clinical and

community-based placements in regional areas. The ECU’s simulation centre at the Joondalup campus has just been accredited by ANZCA for the next seven years to deliver the Effective Management of Anaesthetic Crisis (EMAC) course. And when it comes to Teleheath (see our feature on P18), is there nothing that can’t be done by video. In ACRRM’s latest newsletter there were training modules from treating younger women with early breast cancer, pain management and Hep B among others.

Penalised if you do, damned if you don’t Which brings us to the thorny issue arising from the recent federal budget of capping CPD tax deductions (effective July 1, 2014). On one hand, the government insists that doctors keep their skills sharp and up-todate, on the other hand the tax break stops once you hit $2000. The RACGP’s president Dr Liz Marles says this will hit GPs and junior doctors the hardest. She said faceto-face activities, which had “significant advantages” in learning outcomes, were more expensive.

Mandurah still in SJOG sights Now Ramsay has taken the helm of the Peel Health Campus from Health Solutions WA, news comes that St John of God Health Care is still forging on with its plan for its $45m private hospital nearby. Architects Silver Thomas Hanley, project managers Project Directors Australia (PDA) and cost

managers Ralph Beattie Bosworth (RBB) have been appointed to work on the 75-bed hospital, which is expected to open in 2016. SJOGHC sees Mandurah’s growing and ageing population will demand more specialist services. The SJOGHC board will be presented with a financial feasibility study late this year and the decision will be taken then if the hospital will get the three green lights.

First, build your house There’s an old show biz saying, ‘put it on stage and the crowds will come’. It’s an unreliable truism in theatre … but will it prove the deal maker in Port Hedland where seven new houses have been built specifically for GPs? The $4.5m project received money from Royalties for Regions, the Town of Port Hedland and BHP Billiton. The Regional Development Minister Mr Brendon Grylls thinks the houses are essential to attract more doctors to the region. Will he be bowled over in the rush? O

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Investment

Planning Tomorrow, Today Good investments leading to a comfortable retirement is a no-brainer. It’s not much fun untangling a financial mess when you hang up the stethoscope. This month’s E-Poll (see p38) reveals that nearly half of respondents wished they’d been more diligent planning their financial future. In an interesting twist, approximately the same percentage feels that medicine as a career is not well understood by financial planners. Medical Forum spoke with a number of experts to chart a course through the career transition of medical practitioners and explore some solid foundations to underpin an effective investment portfolio.

Rob Pyne, a director with HIH Solutions, paints a picture of ‘doctor as client’, examines some of the subtle differences within the profession Q Rob Pyne and outlines some practical strategies to make the numbers add up before medical practitioners step away from their practice. “The level of investment expertise varies enormously with doctors. There’s no question they have the intellect for it, they’re highly engaging clients and very often you’ll have a detailed conversation regarding investment theory. And a lot of our strategies are evidence-based, which has a direct link with the practice of medicine, so they’re familiar with that style of communication. But when it comes down to

Some doctors struggle with the pathway to reducing their hours and exiting the workforce – Rob Pyne it, they all want to understand the basis of their investment strategies.” “There’s a subtle difference within the specialties. You could probably make a case that surgeons fit the Type A personality profile and I’ve always found that they’re very hands-on. If you’ll pardon the obvious pun, that’s very much a reflection of their own professional practice and they tend to test the waters pretty closely before you gain their trust.” “More broadly, medicine is a high-status profession and some doctors struggle with the pathway to reducing their hours and

exiting the workforce. The conversations aren’t always strictly financial. We talk about bringing in younger associates, reducing session times and the transition to oversight roles.” “There’s often significant wealth to consider so it’s important that a legally binding Will incorporates testamentary trusts to make sure children are well protected. And looking even further ahead we’ll talk about designating power of attorney and individual advanced health directives, which is something they deal with every day.” The actual nuts and bolts of a financial plan that suits doctors is similar to many other professional individuals. But there are, as Rob points out, some important and potentially rewarding niche opportunities. “There’s a strong disposition towards property, which is not atypical of a lot of Continued on P13

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medicalforum

Investment

A Cautionary Tale When you’re making investment decisions a second opinion might help to sort the wood from the trees. You couldn’t accuse psychiatrist Dr Peter Melvill-Smith of not doing his financial planning homework nor of investing without noble intentions. Nonetheless, it didn’t end happily. He’s wiser for the experience and is happy to share both the story and the wisdom with his medical colleagues. “It all began in 1998 when I migrated to Perth. I was working in the public sector and I was given the name of a financial planner to assist Q Dr Peter Melvill-Smith me with salary sacrifice arrangements. He also suggested that I invest in ATO-approved schemes with the underlying principle that they were ecologically friendly and would be a viable deduction to reduce my gross taxable income.” “Initially these investments were in WA and then there was further diversification

into the Northern Territory, Queensland, New South Wales and Victoria. It was spread across the sectors of tree plantations – everything from teak, eucalypts and sandalwood to wood-chips – and also vineyards and fruit trees.” The financial planner put his own capital into the investments and, for a while, the ship was steering a steady course. “All the information I received suggested it was a sound proposition and, in the early days, it looked so promising that I continued to invest year after year. I was hoping it would finance my children’s tertiary education, shore up my superannuation and create some financial stability towards the end of my career.” Markets can change overnight and, unbeknown to both Peter and his financial planner, their eco-friendly investments were sailing into a perfect storm. “The demand for the wood products suddenly decreased and around about the same time the vineyard we’d put quite a bit of money into went into liquidation. The alarm bells started ringing around 2006 when a CEO asked investors to purchase

‘Alarm bells started to ring when a CEO asked investors to purchase shares in the company.’ shares in the actual wood-related company rather than continuing with our previous investment profile.” It soon became apparent that this investment strategy wasn’t going to be the tax-efficient scheme Peter had hoped for. In fact, he was left with a significant retrospective tax bill. A few words of wisdom are timely as the end of another financial year approaches. “There are financial planners out there with good intentions and significant knowledge but, at the end of the day, the ultimate responsibility lies with the investor. I’d suggest getting a second opinion from an accountant or another investment expert and run the scheme past them. And I’d even go so far as speaking with a lawyer to look at the documentation, with a specific focus on ‘escape’ and ‘restitution’ clauses.” “I certainly won’t be investing in anything remotely similar ever again. If in any doubt, stick with bricks and mortar.” O

By Mr Peter McClelland

Planning Tomorrow, Today Continued from P10

high-end investors. We often recommend residential investment properties and this extends to their own consulting rooms if they’re in private practice.” “Conversely, if they work in the public system the GESB superannuation scheme gives doctors a unique opportunity to contribute more than the normal annual concessional contributions allow. This is an untaxed fund and we’ve got some people contributing significant sums in the order of $200,000 per annum into this scheme.” There’s a familiar pattern underpinning the career trajectory of most doctors. Rob suggests that it’s prudent to focus on the shifting priorities within this professional profile. “There are distinctly different needs moving through a medical career. Young doctors are often working extremely hard so we look at the fundamentals of planning and packaging their financial situation. Having a look at Fringe Benefit Tax (FBT) is useful but one of the most important areas is basic income protection. Many doctors may not be aware that insurers can provide more cover than actual current earnings. For example, an endorsed agreed benefit of $10,000 a month before the insured person is even approaching that salary.” “At the early to mid-career stage we’ll often try to dissuade younger doctors from getting too highly geared into investment properties. We’ll suggest that they establish themselves in their own home and

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Continued on P14

medicalforum

Investment

Planning Tomorrow, Today Continued from P10

build equity in that property because the cost of purchasing real-estate can be quite high.” “Closer to retirement we’ll concentrate on non-concessional contributions and unrealised capital gains and sometimes this takes a lot of untangling. Doctors may well have been highly geared throughout their working lives and, because their cash flow has been strong, all the debts have been paid off. Rather than thinking about gearing to minimise tax it’s often better to flip that thinking around and look at more tax-friendly environments.”

Bart Piestrzynski, Slade Burnet and Aaron Swyny (pictured below) from

think about short-to-medium term goals with career progression in mind. A young medical graduate moving into intern and registrar roles will often be on a PAYG structure, salaries will increase as they move into a specialty and then, for some, it’s into a corporate environment with turnover in the tens of millions of dollars.

Medfin pooled their collective wisdom:

The other important aspect is to put in place adequate insurance that will cover any circumstance if you are not able to continue in the profession. There’s often large expenses incurred gaining medical qualifications and that investment needs to be protected. Managing cash flow and having a good hard think about the rollercoaster of life is vital. It is so important to work out your actual cash flow. After purchasing a first home, sit down and calculate how much is left after tax obligations and putting a glass of wine or a beer on the table. Then have a

Financial planning is critically important for medical professionals but a degree of flexibility is required because, even with the best-laid plans, life can get in the way. There’s marriage, the potential for one partner temporarily out of the workforce when a baby comes along and educating children. And divorce? We take that into

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Investment advice has to factor in career transition and personal circumstances – Slade Burnet account, too. We’re seeing doctors on their second and third marriages, and some men in in their 50s and 60s beginning new families. There seems to be more people starting a career in medicine at a later stage and some decide that they don’t want to continue in the profession. Investment advice needs to be tailored to specific career stages and, just as importantly, factor in individual personal circumstances as well. There is a gender aspect to financial planning quite apart from the fact that some female doctors will be temporarily out of the workforce in the early to mid-stages of their careers. It’s fairly common that doctors marry doctors and often it’s the woman who’ll have a better understanding of the finances. They’re usually more focused on estate planning as well. There’s a strong interest in making sure there’s a smooth path in passing assets on to the next generation. If we were speaking to a room full of doctors we’d stress three things. Firstly, make sure you have properly structured and tax-effective insurance in place. If something unpleasant happens you can slide from expensive dark chocolate to boiled lollies very quickly. Secondly, look at investments from a number of different angles, both medium and long-term. Finally, there will come a time when you’re not earning a living and good investment decisions will replace that cash flow. O

By Mr Peter McClelland Suite 15, 20 Kearns Crescent, Applecross

** Tax Tips for High Wealth Individuals: www.ato.gov.au/content/00129961.htm

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Philanthropy

“Give a Little Bit …” This month, about half the doctors in our latest E-Poll thought philanthropy was a desirable way to fund community health. But it begs the question who, and by how much? “Some of our greatest philanthropists have been reluctant to make their giving known. Malcolm McCusker for years was very reluctant to draw any attention to himself. Tonya has helped a lot in getting him to be on the front foot and be recognised for giving.”

This is a question that John Poynton has thought about long and hard for nearly 20 years. The CEO of investment company Azure Capital was one of the driving forces behind creating Giving West – a not-for-profit organisation promoting philanthropy, in all its forms, in WA. For John, whose introduction to giving was being co-opted into a fundraising campaign for the Telethon Child Health Research Institute in the early 1990s, the past 20 years have given him enormous satisfaction, but they have also put him in the sphere of what he terms “the usual suspects” – the same group of people who willingly put their hand up to help community organisations raise funds. Now the primary purpose of Giving West, of which John is chairman, is to widen that pool of “usual suspects” to embrace all aspects of WA society. It has become something of a mission for the businessman, who has brought his corporate nouse and his extensive network to the fund-raising table. The light bulb moment came in 2008 as he prepared to speak to the Fundraising Institute of Australia’s national conference. “At the same time, a friend of mine had sold his mining business and received a very large cheque and he wanted to give a fair bit of it away but wasn’t sure how to go about it. He asked my advice.” “As I wrote out my speech, it occurred to me that despite our unbroken period of prosperity in WA, we were generally less generous than our counterparts in the US and Europe. I wanted to do something about that so I brought together a group of people from all sides of the spectrum.” The working party agreed that in order to draw in more givers, the state of philanthropy in WA needed to be empirically gauged. So with Lotterywest funding, UWA researchers produced The Rising Tide? report in 2010 and a charter for Giving West was created. “Giving West brings together givers and receivers, educating people about the logistics and benefits of giving; it supports the receivers in making their organisations more efficient. We also made a very clear decision not to crowd out anyone else. We would raise enough money to run our show but we were not going to raise money to give it away.” “We wanted to mininise our expenses and 16

“We live in a tribe and we all look up to the leaders of the tribe. If those leaders want to give to help other people then that is an example to the rest of us to follow. Whatever results in the pie getting bigger and more people giving, then I happy with that.” Giving West also runs workshops for NFPs on governernace and potential givers on such things as private ancillary funds so they understand the tax implications of their giving. “We try not to be proscriptive and certainly not be arrogant or suggest Q John Poynton to people how they should behave but the impact on the giving dollar we start from an and work on raising the profile ethos that says … of giving. And as a result we we’re all pretty raised money from friends and associates and Azure Capital fortunate to live has given Giving West free in Australia in a accommodation, communications first world country and logistic support.” with a standard of living we have. Yes, Q Kevin McDonald and John Poynton The CEO is Mr Kevin McDonald we all pay tax and, who has considerable experience yes, the federal government through tax in the field and under him the Giving West deductability provides its own support for portfolio continues to grow. Its current the philanthropic space.” board has representatives across WA society – property developer Adrian Fini, “But we also look at the way people conduct Atlas Iron’s David Flanagan, Lotterwest their lives; how very rich people conduct boss Jan Stewart, the governor’s wife their lives and we take an example of a Tonya McCusker and Dr Marcus Tan Gates or a Buffet, who clearly have worked among others. Its patrons are the Governor out that it’s not really about making the Malcolm McCusker, businessman Stan money, it’s about what they do with it. The Perron, NAB chairman and UWA benefits and good feelings you get from chancellor Michael Chaney and Seven West doing things for other people.” Media Director Don Voelte. “It must go beyond saying, ‘Oh, well I pay At the core of the Giving West philosophy is tax, therefore I’ve done my bit’. It plays what John calls the three Ts – Time, Talent to how much is enough and how you and Treasure, which effectively opens up want to live your life; how you want to giving to just about everyone. be remembered; what kind of society you At the “junior end” children are being want to live in. Encouraging children to be encouraged to be generous with the initiative, generous will leads to adults being more Kids who Give. Businesses are encourage to generous and that ultimately leads to a less join the Give One campaign where employers cynical and a less selfish society.” O encourage and pay their employees to give one day to a charity of their choice. And By Ms Jan Hallam The Giving Index, which is on the Giving West website, encourages organisations to go public about their philanthropy. One thing John Poynton would like to mow down is the “very unhelpful” tall poppy syndrome. medicalforum

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Feature

Rural ETS, a Telehealth Notion Most understand the advantages of providing telehealth emergency support to rural areas and now we are all watching how ETS evolves. Around 20 rostered emergency medicine trained doctors (FACEMs) are providing after hours telehealth consults to 17 rural sites, where 90% of their contact is with nurses needing help with patients presenting to rural hospitals, often when there is no local GP available. The ED specialists sit in the WACHS building in Adelaide Tce or at home taking calls on weekends (8am-11pm) or weeknights (5pm-11pm) – so far they have had more than 700 patient contacts in the Wheatbelt since the service started. It’s called the Emergency Telehealth Service or ETS and while some consider it an expensive solution to have ED consultants helping nurses with predominantly general practice problems, it’s not that simple. WA Country Health Service’s Dr Felicity Jefferies, previous Executive Director (Clinical Reform), said just before she left the job that ETS was expanded Q Dr Felicity Jefferies in February to meet demand. “It’s a fantastic service. GPs in the small towns tend to leave for the weekends, so ETS covers when the GPs are not there,” she said. ETS comes courtesy of WACHS funding through the Southern Inland Health Initiative (SIHI), state-based funding quarantined for WACHS hospitals. The FACEMs were not keen at first but then realised that being able to talk with and see the patients, they used most of their clinical skills. If an asthmatic,

The SIHI is already funding a huge amount of primary care and we need the Commonwealth to play a role in this. – Dr Felicity Jefferies for example, doesn’t appear as bad as the nurse reports they can advise appropriately. All FACEMs are WA based and employed on individual contracts. Dr Jefferies would not divulge their remuneration. “We would love to have a GP level service in. The trouble is we don’t want to fund more of the Commonwealth responsibility. The SIHI is already funding a huge amount of primary care and we need the Commonwealth to play a role in this.” It’s maybe not surprising that GPs have been reluctant to use ETS. “I think they use the networks they currently have, which is fine for those who have them, but we are trying to get those who haven’t to use the new telehealth service,” Felicity said. So far, less than 10% of the calls have a doctor at the other end, so to get a GP-run service going, WACHS is talking to Medicare Locals. And talking money, savings from ETS will come from keeping nurse practitioners in the bush and avoiding unnecessary transport of patients. “I see it as an adjunct that will help keep nurses out there because, apart from the telehealth emergency services, the systems are used for training. We run sessions on snakebite, medications, acute cardiac failure etc – the FACEMS are training nurses for issues that come into the ED.”

“Part of the reason people leave is they feel deskilled and don’t have the support. It is making a big difference to the nurses and it will for the doctors, the more they get accustomed to using it. One of the reasons younger doctors won’t go out into country areas is they feel professionally isolated and unsupported and they are worried about the decisions they make.” She said isolated nurses are comfortable with seeking phone advice from a doctor and they are good at taking a history, but not necessarily good at diagnosing. Although she admits a GP asking questions of the ED specialist might expedite things, the type of problems may not require this. “If you look at the WACHS hospitals, a lot of the work that comes in is triage 4s and 5s – bread and butter stuff for GPs – and not a large number of really sick or acutely ill patients. If it’s a nurse on her own and no GP, she’ll ring the service but often GPs don’t need to.” “The biggest thing for us is not needing to transfer patients to inappropriate places. For example, if you have someone in Kondinin who is really sick and they need to come to Perth, there is no point in them going to Northam first. What the ETS does is arrange transport and transfers.” ETS provides nurses in small country towns with a clear line of support. Hence the lineup of good news stories – from a farmer’s life saved due to telehealth coaching during two defibrillations, and 10 people treated at Southern Cross Hospital following a road accident. The rest is dislocated shoulders, snake bites and everything that comes into an ED.

ETS: The York Experience

r Mark Daykin joined the York General Practice three years ago. He and the other five GPs make up about 4 FTE doctors and until 18 months ago, he was one of three GPs rostered to provide 24/7 after-hours hospital cover but then one GP left for Perth about a year ago. He and Dr Duncan Steed are the only GPs in town currently accredited for York Hospital, which is the biggest user of ETS services in the Wheatbelt.

A number of factors are behind the high useage. Mark said senior experienced nursing staff had left the hospital, which 18

was using a lot of agency staff. There were nurses who couldn’t do things at times, which made it hard to build something sustainable. GPs in town felt unable to support these nurses for after-hours work because the GPs needed a life outside medicine. Mark has two young children and his wife works part-time in the practice. Their surgery

is open until 6pm week days and 9am to midday on Saturday. They are booked three weeks ahead and have around 13,000 medicalforum

The clinical nurse involved in the farmer’s resus said ETS had removed some of the fear of dealing in isolation with emergency situations, which helped make treatment more effective. ETS responds to an average of 16-17 patient calls on a Saturday or Sunday. Local circumstances dictate, such as frequent calls from York because there isn’t a doctor on call there. The FACEMs have faxes and ways of communicating to get drugs ordered and blood tests done, as well as organise patient transfer. “We are hoping to start something similar in Kalgoorlie. They have about 19 GP vacancies there – no GPs at Laverton, Kambalda and so on. Again, where the Commonwealth should be funding general practice services there are no GPs, they all end up in the hospitals and we have to support them all.” O

By Dr Rob McEvoy

ETS FACTS Up until end of January, 2013, 734 calls had been received by ETS doctors: t 0OMZ XFSF GSPN POTJUF (1T t QSFTFOUBUJPOT XFSF DIFTU QBJO t BWPJEFE VOOFDFTTBSZ USBWFM t SFTVMUFE JO GBDJMJUBUFE USBOTGFS The highest users of the service were York, Wyalkatchem, Wongan Hills, Southern Cross, Beverley, Goomalling, Northam, Cunderdin and Jurien Bay.

patients on their books, 75% active. He said there had been an explosion of patients and a decline in doctor numbers, partly because of the ageing population in York, and fewer GPs in Northam, which is only 25 minutes away. He said the Northam Hospital inquiry, which seemed to imply anything less that 100% best care from FACEM doctors was medicalforum

Q ETS Clinical Lead Dr Garth Herrington

FACEMs in the Hot Seat Dr Garth Herrington, FACEM, is clinical lead of the WA Country Health Service’s Emergency Telehealth Service (ETS). He said rostered FACEMs have been busier than expected with predominantly low acuity cases, which take on a different meaning in a rural setting. Nurse experience and the possibility of high acuity cases need to be factored in. Garth said of the 10 or 12 cases phoned in during an average evening, four or five would require admission locally or transfer – about 70% stay in their town. One FACEM on call recently took 28 calls, including thrombolysing someone with an infarct, an MVA chest trauma, and a few other high acuity things, all of which take time. In the past, low acuity work would be phone triaged from centres such as Northam, Merredin or Narrogin, without seeing the patient. “It’s a question of what you can tell on the telephone – a kid with a fever, someone with chest pain – because you are seeing and talking with them you can exchange information and watch them for a time. That’s all we are doing – giving more certainty to what you can tell without actually being there.” The big question is do we need FACEM consultants doing this work? “Everyone in the city and country does general practice in emergency medicine.

likely to fall short, had led them to think defensively about providing after-hours care. And their IPN practice at York had no financial incentive to get involved – it was already bulk billing most patients to accommodate concession card status. He thought the concept of ETS was good although he would prefer more doctors in town. He felt the IMGs came for a limited time, got their exams, and headed back to Perth or nearby. Although he could use ETS himself, the thought of more on-call was onerous. He said he has used ETS at Northam and felt sometimes the nurses were deferring to ETS to get their quotas up

Someone has to deliver it and if not us they would have to travel and that puts pressure on another system. The future plan is to have different arms to this, including a general practice arm, with a coordinator distributing patients based on triage.” “The reason we have gone with a FACEM workforce initially is we need to be able to manage the high acuity cases. Once it becomes overwhelming and the numbers increase, I think there will be a GP service.” ETS is being set up so the FACEMs on call can consult from home, or in his case, from the ED department in Kalgoorlie if he finds a shift is not covered. The home-based service has the same resources and technology as at Wellington St, and once logged onto the secure WA Health system using 4G dongle modems, ADSL2 broadband and dedicated bandwidth are available to protect the quality of audio and video. What about cost? Garth said since they went live last August they have proven they can do it, but cost will come into it at some stage. “It will get cheaper with scale, but there hasn’t been an economic analysis. An RFDS transfer from the Wheatbelt costs $10,000 so you don’t have to prevent many of those to save money. The other thing is the cost and inconvenience to people if they travel.” Continued on P23

and although the specialist advice was often good there were times the urban doctors simply misunderstood the realities of backup available in the bush. For the moment, York GP use of ETS appears virtually nil and Mark agrees that the hospital nurses, assisted by FACEM specialists in Perth, are seeing mainly overflow patients from an area that includes York, mainly with GP-type problems. O

By Dr Rob McEvoy

Rural Training

Going Bush a Way of Life Medical schools are working, often outside the square, to introduce rural and remote locations to students not only as a fulfilling work prospect but also as a lifestyle. As the numbers of medical students climb – 12,946 in 2010 up from 8768 in 2006 – universities are under a certain amount of funding pressure to create programs that will encourage at least a proportion of their medical students to set up practice in rural and remote areas. At Notre Dame School of Medicine, the Rural and Remote Health Placement Program has been running since 2006 but is currently under review. One of its architects is public health physician and Notre Dame academic Professor Donna Mak who is passionate about the program and its learning outcomes. Two non-clinical placements – to the Wheatbelt in the first year of the course and eight days in the Kimberley in second year – require students to live and work alongside their host families. For the longer Kimberley placement, that could mean being placed on a cattle station, an Aboriginal community, in a town centre or anything in between. Students might find themselves droving cattle, fixing windmills, fishing and hunting on traditional lands or working in a family business in town.

gone to the Kimberley on the program, who have returned with completely changed outlooks on life.” “And that’s what it’s about. Without understanding the rural and remote lifestyle, what motivates people who live there, the career thing doesn’t really work. I’ve seen people out there in the bush who say this is really interesting work but that’s all it is for them, work, so they don’t stay that long.” “For me these programs are about building relationships that go on for years and years. That’s how country people think. That’s how they live and that’s how they feel. If a young doctor doesn’t get that, it won’t be a very rewarding career.” And money is not necessarily the solution. “If you look at the salaries paid to attract health practitioners to the bush, it’s pretty clear that money is not the only answer. It will only buy a short-term solution – six months or a year but is that going to deliver the healthcare that people need and deserve? It comes back to culture and thinking differently about your career and the skills you have.”

Notre Dame graduate Dr Pallas O’Hara is doing her GP training at Nhulunbuy on the tip of the Gulf of Carpentaria. Speaking from Darwin where she was attending a training conference, Pallas said she was a city girl, born and bred. Her Kimberley placement was on a cattle station out of Fitzroy Crossing. “I was there with three staff including the owner of this massive cattle property, Jill Jennings, fixing windmills, baking for the staff, soldering tractors. Jill died several years later in a helicopter crash while she was mustering cattle. This is how tough the lives of some of these people are.” Her Kimberley experience changed her career plans. She applied to the Rural Clinical School in Broome for her third year and that completely sold her on a remote medicine pathway. “I realised there is so much to be done here and I really enjoy the work – getting to know people and Indigenous culture. It’s shifted my focus a lot.” For Donna, it is giving her students the opportunity to learn something about themselves that they might not have discovered if they hadn’t been put to the test. “One of my teachers didn’t think I would last more than five minutes in Fitzroy Crossing. I proved her wrong. That taught me not to prejudge my students.” “Last year Robyn Treadwell, former ABC Australian Rural Woman of the Year and one of our Kimberley hosts, died unexpectedly after a short illness. I told the students who knew her and their reactions were amazing. She really touched their lives. At Robyn’s funeral, one student, someone I least expected because she really struggled for the first few days of her placement, told me how much the experience had taught her about herself.”

The conventional wisdom of recruiting students from rural and remote backgrounds to medical school was effective but Donna said there needed to be other strategies, and ‘converting’ students from urban backgrounds was worth the attempt. It certainly worked for her. “I came to WA from Hong Kong and as part of my training I was sent to the Kimberley. If I could learn to survive, anyone can learn it. We have had so many students who have 20

Donna knows there will be some students who will return to Perth saying that they never want to go bush again. “I have no problem with that. I know from our evaluations that those people are not the majority. We don’t need 100% of our graduates to go and work out bush. And it doesn’t stop the experience from being useful for that minority either.”

“She said Robyn had changed her mindset about rural people and working in the bush. She admitted that it might just be a locum or a FIFO, but knowing Robyn and working alongside her had made her a better person.” “For that one student, the Kimberley program has changed the way she interacts with patients … be they from the bush or wherever. How can you put a price on that?” O

By Ms Jan Hallam

For those who are transformed by the process, it literally changes their life. medicalforum

Guest Column

Thinking Outside the ED There were mixed reactions last month to St John Ambulance’s action to deal with ramping but it is time for creative thinking, says CEO Mr Tony Ahern.

n days gone by there may have been a “you call and we haul” approach to ambulance services but this model is irrelevant in 2013 and St John Ambulance WA must find new and better ways to service the community, which as it grows, is putting a greater demand on our services.

The new clinical and operational model we have put in place has involved myriad changes to the organisation ranging from staff rostering, equipment, additional clinical skills, greater use of data and evidence to drive decisions and the introduction of several alternate care pathways. In May we started a four-month trial of the Ambulance Surge Capacity Unit (ASCU), a 15-bed ward at Hollywood Private Hospital where low acuity patients can be assessed and potentially triaged through an alternate care pathway. The alternative, waiting on a stretcher to be admitted to hospital, is uncomfortable for patients, a great waste of ambulance resources and the source of much frustration for our paramedics. The ASCU means we can hand over patients (during periods of high demand

causing ramping) to a registered nurse, a paramedic and GP to provide ongoing clinical care. Importantly, it allows that ambulance crew to get back on the road to respond to the community, including real life-and-death emergencies. In some quarters this move was labelled a waste of money and the creation of little more than a holding pen for patients en route to the ED. We understand the frustrations of clinicians during periods of ramping but to have people being looked after in a safe environment until EDs can accept them, or a patientcentred alternate care pathway is provided, is surely not money down the drain. Others suggested the State Government should create more hospital beds to alleviate demand but this in itself won’t solve the problem of patients being admitted to ED when it may not be necessary for them to be there. The beauty of the ASCU is its capacity to divert patients from the ED – some patients may not require a hospital bed so why present them to the ED? In March 2013, 1261 patients were ramped outside an ED and in April it was 1435.

These figures are undesirable and, with the winter flu season upon us, are a sign of what we can expect. By our calculations, had the ASCU been in place for these two months, at least one third of those patients could have been admitted – from that figure alone, ASCU’s worth can be evaluated. The alternate care pathways, such as the Silver Chain PRA Service, also take the heat off the public purse. The cost per bed day in the public hospital system far outstrips the cost of these alternatives and provides care in the patient’s home. Throughout the ASCU trial we will be monitoring the number of people and their clinical outcomes. The need to change our mindset around the ambulance service has come from unceasing demand (which has steadily grown in the past 10 years and in 2010/11 grew by 7.8 per cent in the metropolitan area). This requires critical thinking and commitment across the organisation. The ASCU and other alternate care pathway initiatives can certainly have an impact. O

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Perth, Joondalup, Bunbury medicalforum

Plastic Surgery

Making a Difference Interplast is celebrating its 30th Anniversary and there’s plenty to cheer about. Plastic surgeon James Savundra has travelled to Sri Lanka, Tanzania and Laos treating patients whose lives are transformed by surgical interventions. From a child with a hand deformity affecting his ability to go to school to a man with horrific facial burns, the need and the rewards are boundless. Item numbers are non-existent and sometimes payment for services can be distinctly unconventional. “We see a lot of children with cleft palate and others who struggle to gain an education because they can’t hold a pencil. There’s another patient, a man in Laos who disturbed a phosphorous bomb lying in farmland since the Vietnam War, who we’ve been seeing since 1983. The villagers told us there were flames coming out of his neck for 48 hours after the explosion and he’d been screaming in pain for three months in his hut. It was a ghastly deformity with his lower lip fused onto his chest, but in one operation we turned his life around,” said James. “On a two-week trip we can change the lives of 40 people. We’re privileged to be plastic surgeons, we only need simple instruments to do our job and not many people would say no to an opportunity like this. On some trips we’ve been given a goat as payment – it’s amazing!” The work in the field with Interplast is demanding but, as James points out, the rewards flow both ways.

Q Dr James Savundra (right), prepares for surgery and (below) consulting in Laos.

“But the real reward lies elsewhere. The things we do make a big difference to people’s lives. They certainly can’t pay for these services. In fact, sometimes a village will raise funds for months to send one person to the main hospital in Vientiane.” Work in developing countries brings James full-circle in some ways. He was born in Sri Lanka, trained in Perth, Melbourne and New York. “I was born in Sri Lanka and my parents migrated here when I was a baby. I did my medical degree at UWA, a year’s specialty in hand surgery in Melbourne and then another stint in New York. We’d treat people in the public County Hospital who were homeless and sleeping in the subway and then, in private hospitals, we’d see patients who were so rich you wouldn’t believe it!” “It’s all a matter of perception. There’s obviously a distinct gap between a child in Laos who can’t go to school because she’s got a hand deformity and a wealthy matron who feels her saggy face is impeding her quality of life at the tennis club.”

“There are about 15 plastic surgeons from Perth who do Interplast trips and the experiences of a fortnight will often equate to a year in Perth. We see a great diversity of deformities and that broadens our surgical skills. And we often operate every day so that pushes us to our physical limits.” 22

“Clearly the work with Interplast and some aspects of cosmetic surgery are at different ends of the scale. In the middle of the spectrum it’s a graduated line and, as plastic surgeons, it all seems to merge. There’s no denying we make a good living from cosmetic surgery but those skills translate across to every facet of our surgical work.”

Local Rotary clubs are the principal funders of the Interplast trips. Their fundraising pays the surgical team’s flights and accommodation. The politics of international aid can be challenging at times and, as James points out, sometimes money has to be pragmatically diverted. “Money is paid to gain access to some hospitals and there are individuals who want to get a small bite of the action, which is unfortunate. Sometimes a minor deformity might come in and there’s a link to a political official so we may well treat that because it gives us tears of goodwill in that region. We have to compromise at times, we don’t like having to do that but most of these things are arranged at a level way above us.” “We do see corruption but our focus is always on the people who are suffering.” James has done three Interplast trips a year for the past few years and, in early 2014, he’ll return to where it all began. “I’ve probably got another trip to Laos coming up and then Sri Lanka early next year. It’s a real privilege to donate both our skills and our time because the work is so worthwhile and the people are eternally grateful.” O

By Mr Peter McClelland ED: www.interplast.org.au

medicalforum

Feature

FACEMs in the Hot Seat Continued from P19

Is there a risk WACHS hospital staff will deskill through reliance on the service? “Take the example of York where the GPs don’t have a great deal to do with the hospital. The nurses pretty much deal with whatever comes in. When we first got there, if something went wrong and you had to intervene, it was clear they didn’t have the practical skills you would expect. Once we got in there and helped, we found that nurses were upskilling to do the practical stuff that a doctor would do if they were there. We’ve made a major difference in the way things are done and the nurses feel very supported.” “The other thing we do is to arrange transfers and do the clinical handover to the receiving hospital – that adds value and we are happy to lend a hand.” He would like to see more GP interaction across the service and he is coming to grips with why this has been slow to date. Some GP encounters have been very positive – assisting with a patient’s cardioversion or adenosine treatment for SVT – and as an example of what can be done, he points to the GPs in Narrogin who have embraced ETS. He wonders if rural patients are missing out because there is no local GP or those available lack some skills. “There have been some pretty average things happen around the country. The reason ETS came into existence is repeated coroner requests for a service like this. It’s a bit of a shame that we haven’t been able to engage a bit more with GPs because I think that having a specialist to give accountable advice and who can actually see what you’re facing is well worth it.” Garth thinks ETS suffers from being unfamiliar rather than rural doctors having open hostility to it. Some doctors are uncomfortable having a colleague in a position to critique what they do. A big selling point is training sessions to get local doctors on side. “We’ve done some remote simulation with GPs in Esperance – a Trauma Sim – and without exception the GPs involved were happy and they’ve asked that we do it monthly. We try not to over-sell ETS. It’s got its limitations and will never be a replacement for GPs.” The aim is to use the current setup to provide a psychiatry service at the network hubs (Narrogin, Northam, Merredin) or through the Wheatbelt, where no service exists. “The success of ETS means people realise there is some value in telemedicine, you just have to figure out how people will use it. I hope government will go in with a similar plan to the Ontario network model and once you have economies of scale, like Canada, it is value for money.” O medicalforum

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medicalforum

Guest Column

What do patients really think of us? Kalamunda General Practitioner and RACGP board member Dr Sean Stevens offers his take on patient perceptions of GPs.

hat are patients actually thinking about us? To get some idea I took the intrepid step of trawling internet GP reviews. A word of warning â&#x20AC;&#x201C; if youâ&#x20AC;&#x2122;re sensitive to criticism, proceed with caution!

At www.ratemds.com the criteria is staff, punctual, helpful, and knowledge. Doctors are given an aggregate score out of five by patients, who make a few telling comments. I found a couple of pearlers I would like to share.

â&#x20AC;&#x153;Missed an infection three times from a surgery even though I knew it was infected. Googled symptoms! Didn't do proper checks on my newborn because he was running late. Looked at her and said â&#x20AC;&#x2DC;she's fineâ&#x20AC;&#x2122;. Don't go to him!â&#x20AC;? More interesting to me were the comments about doctors in the middle to lower range:

â&#x20AC;&#x153;I've been his patient after two doctors diagnosed me incorrectly and he helped me to recover. He's funny, relates to you easily, makes you comfortable and at ease, and really knows his stuff. He's a great doctor.â&#x20AC;?

â&#x20AC;&#x153;Pleasant and helpful but too ready to prescribe unnecessary medication. Always late to very late. Waffles on too much so can charge longer consultation. I have had many concerns about the care provided by this doctor for my elderly mother and the amount of medications prescribed. I believe his pleasant bedside manner would be improved if he could remember my mother's name while talking to her. This guy has big ego; never gets to a point; did not like my baby; was rushing to get us out; will not listen to your problem fully. He is a good doctor, but he is getting a bit old. Iâ&#x20AC;&#x2122;m not sure heâ&#x20AC;&#x2122;s keeping himself up to date.â&#x20AC;?

This contrasts sharply with colleagues near the bottom of the reviews:

What also surprised me in the feedback was the forgiveness patients showed when we

Local GP Dr T.S. rates equal first with a combined score of 5/5 from five reviewers (well done T.S.!). This comment for Dr T.Sâ&#x20AC;&#x2122;s feedback is typical for doctors with top rankings (bearing in mind it only takes one malcontent to drop your score):

Our care surrounds you... medicalforum

ran late if they consistently received caring, good quality care. It seems patients expect competent care, first and foremost, and if they donâ&#x20AC;&#x2122;t get that, theyâ&#x20AC;&#x2122;ll quite rightly slam us. However, most of us do provide competent care, so what differentiates a good from an excellent GP (in the patientâ&#x20AC;&#x2122;s eyes at least)? It is concern for their wellbeing, a good bedside manner, approachability and a long-term relationship. My take-home messages are: t 1SPWJEF UPQ RVBMJUZ DMJOJDBM DBSF t 4UPQ XPSSZJOH BCPVU SVOOJOH MBUF XIJDI is better for my health!) t 4QFOE UJNF JO FBDI DPOTVMU DPOOFDUJOH with the patient and making them feel at ease t 4UBZ VQ UP EBUF t %PO U CF BGSBJE UP VTF B CJU PG IVNPVS About 95% of our â&#x20AC;&#x153;clientsâ&#x20AC;? have a positive interaction with us (as opposed to say a parking inspector or a lawyer!) and we can earn a decent income doing this. At the end of the day, I wouldnâ&#x20AC;&#x2122;t want to be doing any other job. O

hollywoodprivatehospital.com.au

Guest Column

Doctors looking upstream Dr George Crisp has one eye on the politics of diabetes and another on the medical management of the disease.

here is a public health metaphor known as the ‘river story’. It goes something like this: People are drowning in a river, rescuers start to pull them out, but soon realise that no matter how hard they try, more bodies keep floating by. Increasingly overwhelmed, the solution is to go upstream to find out why people are falling in the river.

social determinants that underlie illness:

Anyone working in medicine over the last 2-3 decades would be aware of the escalating incidence of Type 2 diabetes. A previously uncommon illness largely confined to older adults, it now affects about 5% of Australians and includes young adults, even children.

In developed countries, the poorer, more disadvantaged you are, the more likely it is that you will develop diabetes (and for that matter, most other non-communicable diseases and therefore co-morbidities).

Its complications and consequences pose an enormous and growing burden, not just to our health service, but also to our economy, through reduced productivity and welfare, as well as health costs. It is therefore in all of our interests to solve this (and related) problems. We are familiar with the individual ‘lifestyle’ risk factors – inactivity, poor diet etc – and while we may be mindful of these when addressing the immediate needs of the patient in front of us, we tend not to think about the

‘Social determinants of health’ relate to the conditions in which we are born, grow up, live, work and age and are the major contributor to inequitable and avoidable differences in health between and within countries (WHO) Type 2 diabetes is in fact very ‘socially patterned’, meaning it is strongly related to socio-economic factors.

Poorer neighbourhoods tend to be more ‘obesogenic’ and unhealthy. There is also good evidence that inequitable access to health care further worsens diabetic management, the development of complications and outcomes. And, worsening disease can result in socioeconomic decline, so that illness can increase the likelihood of being trapped in poverty. So, how do we stop people from falling into illness? We can and do ask people to voluntarily change their health behaviour, but this approach by itself is undermined by equally

strong inducements (such as advertising and promotion of consumption) in the opposite direction. Successful intervention will likely mean altering our environment by improved urban design, access to recreational space, reducing car dependence and encouraging active transport, making healthy food cheaper and more readily available than unhealthy food, and changing social norms, such as body size and physical activity. It may also mean building a fairer society. The solutions are primarily political and cultural and may seem beyond our control as doctors. But we are the proverbial ‘rescuers by the river’ and are best placed and informed to advocate for action. If we are truly interested in improving the health of our patients and communities, then the time to start looking upstream is well overdue. O Further Reading: Marmot Report - UCL Institute of Health Equity (www.instituteofhealthequity.org) WHO 2010, E Blas and AS Kurup. Equity, Social Determinants and Public Health Programmes (www.who.int/social_ determinants/en/)

Fit to Drive? Look Away Now! It’s one of the tough issues in medicine, assessing an elderly patient for their fitness to drive but despite doctors’ white knuckles, the buck still stops with the patient. A doctor contacted Medical Forum recently probably hoping against all hope that there might be clear lines drawn when it came to elderly patients reporting on their own ability to control a motor vehicle to the Department of Transport (DoT). Is it the patient’s responsibility? What role does their doctor play? It is a fraught issue for patients and doctors alike in a society which values independence of transport and mobility. The DoT told us that the requirements introduced in March 2008 of compulsory self-reporting of medical conditions still held and the state now complies with the national standards for assessing fitness to drive. It is still the responsibility of the licence holder to report in writing any permanent or long-term conditions or treatment which may impair their ability to control a car, which includes conditions affecting perception, judgement, response time and 26

to drive as long as they hold a valid driver’s licence and meet the national standards for assessing fitness to drive. Where the patient no longer meets those guidelines the medical professional may suggest that they consider self-restricting their driving or surrendering their licence. Where the patient poses a road safety risk the medical professional may consider independently reporting to DoT their concerns. There is no legal obligation on medical professionals to report these concerns, however, under 101A of the Road Traffic Act 1974 they are indemnified for expressing an opinion in good faith to the Director General of Transport that a person may be unfit to drive. O

A: The licence holder is entitled to continue

ED: The DoT website has a list of Frequently Asked Questions which may help doctors in this difficult situation: www.transport. wa.gov.au/mediaFiles/LBU_DL_FAQ_ MandatoryReporting.pdf

general physical capability. The AMA issued its guidelines for doctors in April 2008 which said the medical profession had “a duty of care to the wider Australian community to identify patients who suffer from medical conditions that may impair their fitness to drive.” This includes where the patient lacks insight into the risk they pose the general road user. However, it puts the responsibility onto the State to determine whether any individual meets the criteria defined by law. The treating doctor should not be the decision maker. Medical Forum put this GP’s question to the DoT: I suggested to an elderly patient that they should consider relinquishing their licence as they might not be safe on the roads, in my judgement. They said licence renewal was not due for two years. What must I do?

medicalforum

Diabetes

Embracing Life, Diabetes and All Jayne Ross was diagnosed with Type 1 diabetes at the age of 11 and fought against it until her children taught her to manage the disease and embrace life. A supportive partner is crucially important, says Jayne. And, as far as her sons are concerned, sheâ&#x20AC;&#x2122;s very aware of diet, lifestyle and genetic considerations.

Jayne Ross knows a lot about diabetes. Sheâ&#x20AC;&#x2122;s lived with it for the past 30 years and, after losing her left foot, learnt to walk all over again with her 16 monthold son. As a teenager Jayne didnâ&#x20AC;&#x2122;t want to mention the â&#x20AC;&#x2DC;Dâ&#x20AC;&#x2122; word and some of the treatment she received didnâ&#x20AC;&#x2122;t help matters. Times have changed and now Jayne isnâ&#x20AC;&#x2122;t sure sheâ&#x20AC;&#x2122;d want a life without the familiar routine of diabetes management.

â&#x20AC;&#x153;When I was pregnant there were some nights when my blood sugar dropped so low that my partner would ring the ambulance. Heâ&#x20AC;&#x2122;s become very good at dealing with a diabetic in the house. Both my boys [aged 10 and 5] were premature, theyâ&#x20AC;&#x2122;re tested regularly and I watch their diet carefully. Iâ&#x20AC;&#x2122;ve been told that the chances of them getting Type 1 are very low but that thereâ&#x20AC;&#x2122;s a 99% chance theyâ&#x20AC;&#x2122;ll get Type 2 when theyâ&#x20AC;&#x2122;re older. At the moment theyâ&#x20AC;&#x2122;re really healthy.â&#x20AC;?

â&#x20AC;&#x153;When I was younger I didnâ&#x20AC;&#x2122;t want to know anything about my diabetes, I just wanted to be normal. In those early years I was determined not to let my illness control me so I chose not to control it. I was told by a doctor that I probably wouldnâ&#x20AC;&#x2122;t be able to have children and I thought Iâ&#x20AC;&#x2122;d be on my own forever. When I met my partner and became pregnant I realised that I needed to start looking after myself because I needed to be here for someone else.â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m not sure how Iâ&#x20AC;&#x2122;d cope without diabetes now. Itâ&#x20AC;&#x2122;s been so much a part of my life â&#x20AC;&#x201C; blood sugars, injections, insulin pumps â&#x20AC;&#x201C; and itâ&#x20AC;&#x2122;s something I donâ&#x20AC;&#x2122;t even think about anymore. In fact, I think Iâ&#x20AC;&#x2122;d miss it to be honest.â&#x20AC;? â&#x20AC;&#x153;I was diagnosed when I was 11 and I didnâ&#x20AC;&#x2122;t understand what diabetes was and it took me a while to accept that my life was going to change. My mum felt it would be best if I did the injections right from the beginning. I always had very strong opinions and was rebellious like a lot of young people. Teenagers and diabetes isnâ&#x20AC;&#x2122;t a good mix and thatâ&#x20AC;&#x2122;s come back to bite me.â&#x20AC;? â&#x20AC;&#x153;I grew up in a fairly dysfunctional family so that didnâ&#x20AC;&#x2122;t help. My parents split up when I was young, we moved a lot and my step-dad was in and out of prison. My sister and I were left to our own devices and I did not look after my diabetes very well. I had issues with school, so Iâ&#x20AC;&#x2122;d avoid going by not taking my insulin and getting sick. Looking back, Iâ&#x20AC;&#x2122;d have done a lot of things differently.â&#x20AC;? â&#x20AC;&#x153;We lived in Rockingham for a while and the doctor who diagnosed me was great but we moved away and I lost touch with her. They certainly didnâ&#x20AC;&#x2122;t have the diabetes support networks they have now and I canâ&#x20AC;&#x2122;t remember ever going to PMH.â&#x20AC;? The â&#x20AC;&#x2DC;team approachâ&#x20AC;&#x2122; is an integral part of formulating current diabetes treatment but sometimes the ideal falls short of the reality. However, Jayne points out that there have been some high points. medicalforum

Q Jayne Ross with her younger son, Nevan

FACTS: Diabetes in WA t "QQSPY JO 8FTU "VTUSBMJBOT PWFS UIF age of 25 has diabetes (or its early signs). t 5IFSF BSF NPSF UIBO QFPQMF JO WA living with the condition. t %JBCFUFT 8" BENJOJTUFST UIF /BUJPOBM Diabetes Services Scheme (NDSS) and receives more than 900 new registrations every month. t 5IF UPUBM BOOVBM DPTU PG "VTUSBMJBOT MJWJOH with diabetes is approaching $14.6b.

â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s difficult seeing so many different doctors. Iâ&#x20AC;&#x2122;ve lost my leg, there are problems with the other foot and Iâ&#x20AC;&#x2122;ve got kidney disease and some eye problems. My partnerâ&#x20AC;&#x2122;s terrific but weâ&#x20AC;&#x2122;ve got two young boys and itâ&#x20AC;&#x2122;s not easy having so many visits to doctors. I go to SCGH and it would be great to be able to see a team of specialists at the same time. Most of the time Iâ&#x20AC;&#x2122;m not that sick and itâ&#x20AC;&#x2122;s easy to miss appointments. I think thatâ&#x20AC;&#x2122;s one of the reasons that some diabetics fall through the cracks.â&#x20AC;? â&#x20AC;&#x153;Dr Stefan Ponosh, my vascular surgeon, and pathologist Dr Clay Golledge have been amazing! Theyâ&#x20AC;&#x2122;re the only doctors whoâ&#x20AC;&#x2122;ve really understood my situation.â&#x20AC;?

Jayne reflects on the ideal approach to a young person with a diabetes diagnosis compared with her own memories, most of them unpleasant. â&#x20AC;&#x153;You have to tread a fine line and be supportive but itâ&#x20AC;&#x2122;s also important to encourage the person to develop ownership of the disease. They need to know that itâ&#x20AC;&#x2122;s their diabetes and they have to have a mindset that it will be with them forever.â&#x20AC;? Notwithstanding that, Jayne sounds a cautionary note about becoming overly obsessive. â&#x20AC;&#x153;You have to have the mindset that diabetes is going to be with you forever and that you have to live in partnership with this illness. Things are going to happen that will upset the balance and knock it out of control. You just have to adapt to that. But you do have to be careful that the diabetes doesnâ&#x20AC;&#x2122;t overtake everything, otherwise you can get to a stage where youâ&#x20AC;&#x2122;re not leading a life at all.â&#x20AC;? â&#x20AC;&#x153;Diabetes doesnâ&#x20AC;&#x2122;t just affect your body, thereâ&#x20AC;&#x2122;s a mental thing as well. If you get too caught up with it youâ&#x20AC;&#x2122;ll be making an appointment to see a psychiatrist. You have to learn to live life well!â&#x20AC;&#x2122; O www.diabetesaustralia.com.au/ndss National Diabetes Services Scheme (NDSS)

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medicalforum

Diabetes

Speak to the Feet A clear line of communication between medical practitioners and podiatrists is crucial in avoiding unpleasant consequences. Jenny Gugliotta and Glenn Pearce are podiatrists with a particular focus on Diabetes Mellitus. Theyâ&#x20AC;&#x2122;re firm believers that procrastination is the enemy of the diabetic foot. â&#x20AC;&#x153;The podiatrist will consider a number of things at the initial consultation from pedal pulses, micro-circulation and foot morphology to the patientâ&#x20AC;&#x2122;s visual acuity. Weâ&#x20AC;&#x2122;ll send a condensed summary to the GP and, ideally, those notes should form an integral part of the Enhanced Primary Care (EPC) program allowing clear and productive communication between doctor and patient,â&#x20AC;? Glenn said. â&#x20AC;&#x153;The doctor needs to discuss with the patient the importance of monitoring their feet on a regular basis,â&#x20AC;? Jenny added. Statistically, diabetic patients spend more time in hospital with foot problems than any other diabetic complication. About 50% of diabetic hospital admissions fall into this category and the number of lower-limb amputations is increasing. There is an enormous social and economic cost, not to mention the personal distress of the patient. Glenn tells a cautionary tale of one such outcome. â&#x20AC;&#x153;John, in his late-30s, was shaken awake by his parents. He hadnâ&#x20AC;&#x2122;t come down

for breakfast and his diabetic status was brittle, to say the least. He was difficult to rouse, confused and a closer inspection of the blood on his right foot revealed his entire R/1st hallux was missing. Due to his advanced neuropathy, John wasnâ&#x20AC;&#x2122;t feeling any pain.â&#x20AC;? â&#x20AC;&#x153;A trail of blood led to the en-suite bathroom. Johnâ&#x20AC;&#x2122;s much-loved poodlechihuahua cross, Chloe, was lying on the floor looking decidedly ill. John, with a carefully wrapped stump, his parents and Chloe headed for the vet. An emetic did the trick and up came the macerated remains of Johnâ&#x20AC;&#x2122;s toe. The dog was admitted for a night of observation. Their next stop was the hospital for John.â&#x20AC;? â&#x20AC;&#x153;John, who smoked, ate a high-sugar diet and walked barefoot in the garden, told the

FACTS t PG EJBCFUJD BNQVUBUJPOT BSF preventable in the long term. t PG EJBCFUJDT XJMM EFWFMPQ a foot ulcer. t JT BWFSBHF DPTU PG IPTQJUBM admission for a diabetic foot.

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doctors in hospital that thereâ&#x20AC;&#x2122;d been a lesion on the apex of his toe for some weeks.â&#x20AC;? Jenny expands on some of the lessons to be learnt from this unfortunate experience. â&#x20AC;&#x153;This, sadly, is a true story. Johnâ&#x20AC;&#x2122;s noncompliance and virtual denial of his diabetic condition coupled with the fact that the dog was monitored overnight and he wasnâ&#x20AC;&#x2122;t, are bad enough. But the worst aspect is surely that they took the dog to the vet first! The gravity of the diabetic condition is often underrated. Feet can be tricky at the best of times, and diabetic feet even more so.â&#x20AC;? The concerns expressed by Jenny Gugliotta proved to be well-founded and Glenn describes the eventual outcome. â&#x20AC;&#x153;John was never going to change his spots. His non-compliance continued and â&#x20AC;&#x2DC;salami surgeryâ&#x20AC;&#x2122; was the end result. A series of â&#x20AC;&#x2DC;slicesâ&#x20AC;&#x2122; culminated in a below-knee amputation that was debilitating for John and distressing for his parents.â&#x20AC;? A sobering coda to this story is that the statistical probability of John losing his other leg within 18 months equates to the toss of a coin. O

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DENTAL

Guest Column

Telehealth in remote ophthalmology By Dr Angus Turner, Opthalmologist, A/Professor UWA, Fremantle Hospital & Lions Eye Institute

here has been a long history of telehealth for retinal imaging, as part of screening for diabetic retinopathy. This is conducted in a ‘store and forward’ fashion, where images are reviewed and reported upon without the patient present. Recent Medicare changes (for video consultations) pushed telehealth for other eye health conditions into the arena. Over five months, an audit of 100 consecutive cases of tele-ophthalmology provided a snapshot of its use in Western Australia. Here are some points worth highlighting.

Anterior and posterior segment imaging is difficult to obtain for inexperienced GPs using a slit lamp and many do not have access to this examination equipment.

Who used the service?

Special technology and infrastructure required?

The majority of consultations were conducted with optometrists, followed by hospital district medical officers in Emergency Departments. Private GPs provided 3% of referrals for a video consultation. This is an interesting mismatch in intended use, as Medicare rebates and incentives only apply to the private GP minority group.

What imaging was used? Images are often integral to providing a satisfactory examination during ophthalmological tele-consultation.

An interesting finding of the audit was that a Smartphone image was provided more often than digital slit lamps, when providing anterior images. Smartphones have small lenses that are capable of taking excellent images through the slit lamp eyepiece. Multiple adapters have been designed to stabilise docking with the eyepiece to assist the process.

The guidelines for video-conferencing are pragmatic, allowing for any software to be used. This means that Skype has been most commonly used as it is familiar to many doctors and free of significant set-up costs. Many other video-conferencing platforms have been promoted.

inherent in the process. To overcome these logistical barriers, a new website has recently been launched that provides a booking service and calendar (see www. outbackvision.com.au). This website also provides other resources regarding telehealth use, including a demonstration video of iPhone adapters and information about outreach services, to help plan any required follow-up.

Diabetic screening? A network of retinal cameras now available in remote areas provides improved coverage for diabetic eye screening. Annual review is recommended for indigenous diabetic patients. To increase patient awareness of the need for screening, a wonderful resource has been developed – a cartoon narrated by two health workers from Derby and a patient from Fitzroy Crossing. It can be viewed on the website, and free copies ordered from Lions Outback Vision, 2 Verdun St, Nedlands, 6009. O

The logistics? Timing a consultation between health providers and patients can be a challenge. With busy schedules on both ends, there are potential time delays and inefficiencies

Declaration: No competing author interests.

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SC0556

Guest Column

Routine management of diabetes By Dr Lawrence Wapnah, exDirector Diabetes WA

anaging Type 2 diabetes mellitus can be almost as routine as managing blood pressure. It is a common medical problem suited to general practice â&#x20AC;&#x201C; a chronic disease requiring a whole-of-person approach that often involves the wider family, and requires familiarity with the patientâ&#x20AC;&#x2122;s history, and continuity of care beyond managing the HbA1c. GPs do all these things daily, for many patients.

The management of blood pressure causes little fear in doctors despite the proliferation of medications but not so diabetes, which for many, has followed a different path. Perhaps fears have left some scars? As medical students many of us had exams in which we had to draw up insulin from vials, trying to remember to mix the cloudy with the non-cloudy (or was it the other way around?) and titrate to some sugar level or a sliding scale that still has little meaning. I remember one nervous non-diabetic friend, now a local consultant, who accidentally injected himself in the exam and then straight after scored a century at an A-grade cricket match â&#x20AC;&#x201C; beware the injured batsman! Things have changed. The modern insulins are excellent and very easy to use. There are new challenges. Todayâ&#x20AC;&#x2122;s hospital doctors, in an increasingly specialised world, may say someone with

uncomplicated but sub-optimally managed Type 2 diabetes is a problem for the â&#x20AC;&#x153;endocrine or diabetes teamâ&#x20AC;?. Instead, that patient probably has a very routine diabetic problem that does not need the specialist to manage it, which will save the hospital and patient. There are two ways to look at the newer diabetic medications, both correct. Firstly, tried and tested medications, although â&#x20AC;&#x2DC;oldâ&#x20AC;&#x2122; (i.e. off patent with generics competing), may suit a patient perfectly and be cheaper both for them and the government. Secondly, newer medications often make a lot of basic physiological sense and may revolutionise diabetes management, so staying up-to-date is important. Access to quality, timely and inexpensive education is a challenge for GPs. The new federal budget plans to reduce deductible education expenses. Many of us reject the dumbed down drug company marketing exercise and Medicine Australia is doing its best to destroy everything else.

centred. A big fish in a small pond is still a small fish! Avail yourselves of opportunities to attend Australian and international conferences to see what the rest of the world may already be doing. All, however, is not completely lost in our lovely State. At least one and possibly two of the insulin making pharmaceutical companies have retained a WA annual insulin training weekend targeted at experienced GPs who wish to obtain more knowledge on insulin use and management for their patients. These specific weekends (all one or two of them with 40 places each, maximum) are not drug affiliated, marketing exercises per se and deliberately demonstrate and teach the use of all the main brand insulins with current best evidence following College guidelines. O

Western Australia in addition, despite paying for the East, receives less than a full dividend in return (â&#x20AC;&#x2DC;Oh its too far awayâ&#x20AC;&#x2122;, â&#x20AC;&#x2DC;Oh Perthâ&#x20AC;&#x2122;s a really small city â&#x20AC;&#x201C; like Hobart or somethingâ&#x20AC;&#x2122;, â&#x20AC;&#x2DC;Oh we donâ&#x20AC;&#x2122;t have anyone that manages (ie with a budget) west of Adelaideâ&#x20AC;&#x2122;). Now this divide cuts two ways. We in the West are also at risk of falling behind by becoming isolated and therefore self-

Diabetes and the NDSS Patients with diabetes are eligible for the National Diabetes Services Scheme (NDSS) â&#x20AC;&#x201C; subsidised products, information and support â&#x20AC;&#x201C; which is an Australian Government initiative administered in Western Australia by Diabetes WA. With the growing emphasis on self-care and early intervention in chronic disease, anyone who is first point of contact with someone diagnosed with diabetes can suggest they register with NDSS for assistance (see www.diabeteswa.com.au or phone 1300 136 588). NDSS registered patients can attend free group education given by credentialed diabetes educators and dietitians, including: t %&4.0/% %JBCFUFT &EVDBUJPO BOE Self Management for Ongoing and 32

Newly Diagnosed): a one-day workshop that teaches self-management of Type 2 diabetes through improved knowledge and understanding. t %"'/& %PTF "EKVTUNFOU GPS /PSNBM Eating): a week-long group program designed for adults with Type 1 diabetes to assist themself-manage insulin doses, exercise, illness and alcohol safely. t -JWJOH XJUI %JBCFUFT B TJY XFFL QSPHSBN to improve skills and live a healthier lifestyle. t $PPLTNBSU B NJOVUF TFTTJPO providing cooking techniques to prepare tasty and healthy, low GI snacks and meals.

Participants can also attend a number of specialised information sessions such as Diabetes and Your Kidneys or Peripheral Neuropathy, as well as access a range of support groups throughout the community for people to meet others similarly affected. Cost savings on diabetes products include many available free (e.g. insulin syringes and pen needles) and others subsidised (e.g. blood glucose testing strips and insulin pump consumables). NDSS registration is free to anyone eligible for Medicare rebates, is for life, and requires diabetes diagnosed by a medical practitioner or endocrinologist. O

t 4IPQTNBSU B UXP IPVS TVQFSNBSLFU tour demonstrating how to decipher and analyse food labels to make healthy choices for every day meals. medicalforum

CLINICAL UPDATE

Managing patients with gestational diabetes

By Ms Jo Beer, Accredited Practising Dietitian & Diabetes Educator. Tel 9385 6153

estational diabetes (GDM) is associated with an increased risk of miscarriage, pre-eclampsia and pre-term labour. For the newborn, there are higher rates of congenital malformations and macrosomia (large for gestational age), and in early childhood, obesity and associated diseases.

GDM is glucose intolerance either beginning or first being recognised during pregnancy â&#x20AC;&#x201C; around 10% of pregnant Australian women, likely to increase to 15% if criteria by the International Association of Diabetes and Pregnancy Study Groups are adopted. Currently, the recommended screening test for GDM is a non-fasting glucose challenge performed at 26â&#x20AC;&#x201C;28 weeks gestation. If a positive result of blood glucose â&#x2030;Ľ 7.8 mmol/L is reported, a further fasting sample of 75g oral glucose tolerance test is performed. A diagnosis of GDM is made if the fasting glucose level is â&#x2030;Ľ 5.5 mmol/L or if the two-hour result is â&#x2030;Ľ 8.0 mmol/L. According to the Australasian Diabetes in Pregnancy Society (www.adips.org), dietary therapy and education are the primary therapeutic strategies for GDM. They advocate: t MPX HMZDFNJD JOEFY GPPET t MFBO QSPUFJO t BQQSPQSJBUF DBMPSJF JOUBLF QPSUJPO DPOUSPM

t TJY TNBMM NFBMT QFS EBZ t FOTVSJOH UIBU UIF OVUSJUJPOBM requirements of pregnancy are met t EFWJTJOH BO JOEJWJEVBMJTFE BQQSPBDI based on weight, body mass index and activity level (using an accredited practising dietitian) t B DVMUVSBMMZ BQQSPQSJBUF BQQSPBDI The glycaemic index (GI) ranks carbohydrate foods according to their effect

SUITABLE LOW GI FOODS t .VMUJHSBJO TPVSEPVHI NPVOUBJO BOE pumpernickel bread

on blood glucose levels (BGL). Lower GI foods produce a smaller rise in BGL, with higher GI foods such as sucrose producing a more rapid and higher rise in BGL, stimulating a surge in insulin. Since glucose is a primary determinant of the foetusâ&#x20AC;&#x2122;s growth, high glucose levels in pregnancy can cause macrosomia, increasing the need for caesarean delivery, and promoting associated co-morbidities. However, carbohydrates should not be ranked by GI alone. The total quantity of carbohydrate consumed (glycemic load) has a profound impact on BGL and insulin secretion, influencing maternal health and foetal outcome. An Australian study found that women who developed GDM were eating more high GI foods than those who didnâ&#x20AC;&#x2122;t develop the condition. In women diagnosed with GDM, a low GI diet has been shown to halve the number needing insulin, without compromising obstetric or foetal outcomes. A recent meta- analysis of 24 prospective studies confirmed that the glycaemic load is a key indicator of diabetes risk.

t 0BUT "MM #SBO NVFTMJ BOE 4VTUBJO DFSFBMT t #BTNBUJ BOE %PPOHBSB SJDF t 8IFBU QBTUB CVMHIVS CBSMFZ RVJOPB HSBJOT t $PSO t 4XFFU QPUBUP $BSJTNB BOE /JDPMB QPUBUPFT t -FHVNFT BOE MFOUJMT t .FBU GJTI QPVMUSZ FHHT BOE EBJSZ t "QQMFT DJUSVT TUPOF GSVJUT BOE berries, as whole fruits

What does this mean in practice? t &ODPVSBHF ZPVS QBUJFOUT UP GPMMPX B healthy, balanced, low GI diet, with appropriate portions t &OMJTU UIF TFSWJDFT PG BO BQQSPQSJBUFMZ qualified and experienced dietitian to assist with the monitoring and review of women during pregnancy

t 3FDPNNFOE NJOVUFT PG EBJMZ OPO strenuous activity (e.g. walking)

Resources www.glycemicindex.com â&#x20AC;&#x201C; University of Sydneyâ&#x20AC;&#x2122;s Glycemic Index Foundation (information and patient fact sheets). www.health.qld.gov.au/psq/Networks/ diabetes.asp - Queenslandâ&#x20AC;&#x2122;s Statewide Diabetes Clinical Network. www.bumptobabydiet.com â&#x20AC;&#x201C; Low GI diet written by Professor Jennie Brand Miller. www.daa.asn.au â&#x20AC;&#x201C; Dietitians Association of Australia (to finding your local accredited practising dietitian). www.iadpsg.org - International Association of Diabetes and Pregnancy Study Groups (new diagnostic criteria). O References on request Declaration: No author competing interests.

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Guest Column

Perspective: diabetes in the elderly The profession is recognising how management of diabetes must be tempered to fit the frail elderly, for which Dr Cathy Parsons has some observations. position statement on managing diabetes in older adults in aged care residences (JAMDA July 2012, 13:497-502) recommends that the primary aims should be to: prevent hypoglycaemia; avoid acute metabolic complications; decrease the risk of infection; prevent hospitalisation; and introduce timely endof-life care and advanced care directives.

end organ damage, in the aged care setting we subject diabetic patients to greater risk of serious hypoglycaemia by aiming for ‘tight’ sugar control. The position statement acknowledges this in saying strictly avoid BSLs <5.0 mmol/l, make the HBAIC target 7-7.5%, and defer starting any drug treatment until the FBSL is >7.0 mmol/l.

Although I do not consider myself an expert, most of my work in general practice focuses on care of the frail elderly in Residential Aged Care Facilities. On that basis, I have some observations about care.

Our treatment should aim to give them the best chance of enjoying what time they have left.

The well elderly often have surprisingly resilient bodies that can bounce back from pneumonia, sepsis, pulmonary oedema, etc – a cardiorespiratory system that has proven its strength for decades and not succumbed to atheroma. By comparison, those whose physical or cognitive conditions have seen them placed in care, the frail older adults, have limited life expectancy and are often living with disability, discomfort and dependence. Our treatment should aim to give them the best chance of enjoying what time they have left. Decisions need to be made in each patient about medications, particularly whether antihypertensives and cholesterol lowering agents are needed as there is little evidence for their use in the very elderly. When dealing with diabetes (or really any illness) in the very frail aged, it is about quality of life rather than prevention of long-term complications. While with middle age the focus is on prevention of

Diet and exercise, the backbone of diabetic treatment in the younger population, presents special challenges in the aged care population. The statement encourages individualised exercise such as resistance training, balance exercises, and cardiovascular fitness training. However, capacity to exercise is often very limited, through arthritis, muscle weakness, stroke, dyspnoea or other conditions. And with restricted one-on-one staff time, opportunities for coached exercise may be few. Where possible, enlisting the help of visiting carers or relatives and ancillary health workers provides some structure and purpose to an exercise program. Their diet is largely dictated by what is served at the facility or what visitors bring in. Elderly people in aged care are at risk of under-nutrition, a situation made worse in diabetics by well-intentioned care staff restricting the diets of obese and/or diabetic residents, perhaps because a resident’s BSL

is considered “too high”. Food choice can be in the hands of staff with very limited or no training in diabetes care, and outdated opinions abound. On the other hand, compliance with diet by aged care residents can be compromised by such things as cognitive impairment, depression, and the habits of a lifetime. The position statement advises against restrictive diets. Medical treatment of hyperglycaemia in the frail aged aims to prevent complications – acute ketoacidosis, delirium, urinary incontinence, skin infections and poor wound healing – to prevent hospitalisation, and for which the GP can make a real difference. This may require education of all involved. For example, aged care facility workers are generally conscientious and caring but restriction of meals, withholding of insulin doses and illogical timing of BSL measurement are widespread. Finally, ageism is alive and well in the medical system. Young doctors faced with a delirious, febrile 90-year-old from a nursing home may not realise this person is usually mentally agile and enjoys a life with some quality, despite their frailty, and need to be treated with dignity and respect. They may feel compelled to offer extreme treatment to someone who might rather have just been kept comfortable and allowed to pass with dignity. GPs are in a position to discuss with their patients what level of treatment they would prefer in a lifethreatening situation and alert hospital staff accordingly when and if the time comes. O

Conference Corner Rural Health West Aboriginal Health Conference, July 6-7 Dates: July 6-7 Venue: Pan Pacific, Perth Website: www.ruralhealthwest.com.au

GPET Convention 2013 Dates: September 11-12 Venue: Crown Perth Website: www.agpt.com.au/NewEvents/ GPETConvention2

Rural Health West Fremantle Conference Date: October 19 Venue: Fremantle Website: www.ruralhealthwest.com.au

WA ANZCA Winter Scientific Meeting Date: July 20 Venue: University Club, UWA Website: www.anzca.edu.au/events

2013 Rural and Remote Mental Health Conference Dates: September 17-19 Venue: Bridgeley Community Centre, Northam Website: www.wacountry.health.wa.gov.au

WA Transcultural Mental Health and Australasian Refugee Health Conference 2013 Dates: October 31-November 1 Venue: Duxton Hotel, Perth Website: www.transrefugee2013.com.au

General Practitioner Conference & Exhibition Dates July 20-21 Venue: Perth Convention Exhibition Centre Website: www.gpce.com.au/en/visit/perth/ Rural Health West Remote Coastal Emergency Medicine Conference Dates: September 6-8 Venue: Gnaraloo Station Website: www.ruralhealthwest.com.au 34

National Environmental Health Conference Dates: September 24-26 Venue: Parmelia Hilton Website: www.eh.org.au/events WA ANZCA Meeting Bunker Bay Dates: October 11-13 Website: www.anzca.edu.au/events

Australasian Injury Prevention & Safety Promotion Conference Dates: November 11-13 Venue: The Esplanade Hotel, Fremantle Website: www.injuryprevention2013.com.au

medicalforum

CLINICAL UPDATE

Resistant Neisseria gonorrhoeae changes treatment

Dr Donna Mak, Public Health Physician

n 2012, 2,126 Western Australians were infected with gonorrhoea. Since 2009 gonorrhoea notifications more than doubled in the metropolitan area.

The emergence of multidrug-resistant Neisseria gonorrhoeae is a major public health concern worldwide. The USAâ&#x20AC;&#x2122;s Centers for Disease Control and the British Association for Sexual Health and HIV have now changed their gonorrhoea treatment recommendations from ceftriaxone alone to ceftriaxone and azithromycin. WA is fortunate not to have multidrugresistant Neisseria gonorrhoeae. To ensure these organisms do not become established, the treatment recommendations in WA Healthâ&#x20AC;&#x2122;s Guidelines for Managing Sexually Transmitted Infections (Silver Book) now include additional azithromycin. For patients with suspected gonorrhoea and a purulent discharge, always collect a swab for culture and antibiotic sensitivity, as antimicrobial surveillance is a vital public health measure. O

t 'PS JOGPSNBUJPO PO NBOBHFNFOU PG gonorrhoea and other STIs please visit http://silverbook.health.wa.gov.au

CONDITION

TREATMENT

Uncomplicated gonorrhoea contracted in the Perth metro area; Great Southern, South West and Wheatbelt regions of WA; interstate; overseas; or where place of BDRVJTJUJPO JT OPU LOPXO OR Anorectal or pharyngeal gonorrhoea

t $FGUSJBYPOF NH JO N- lignocaine intramuscularly AND t B[JUISPNZDJO H PSBM HJWFO UPHFUIFS BT a single dose

Uncomplicated gonorrhoea contracted in the Goldfields, Kimberley, Pilbara or Midwest regions of WA*

t BNPYZDJMMJO H PSBMMZ AND t QSPCFOFDJE H PSBMMZ HJWFO UPHFUIFS BT a single dose

* The ZAP pack (azithromycin 1g, amoxycillin 3g and probenecid 1g single dose, directly observed therapy) should continue as empirical treatment of uncomplicated gonorrhoea and/or chlamydia infections contracted in the Goldfields, Kimberley, Pilbara or Midwest regions of WA.

WA Gonorrhoea Notifications (2009-12)

t 'PS DPOUJOVJOH '3&& QSPGFTTJPOBM EFWFMPQNFOU about managing STIs visit http://sti.ecu.edu.au to access online learning (accredited with the RACGP and RCN, Australia).

Refer your patients to BreastScreen WAâ&#x20AC;&#x2122;s new Rose Clinic at David Jones BreastScreen WA in partnership with David Jones, has been operating a breast cancer screening clinic in the city store since the beginning of 2013. This joint venture has been highly successful in Melbourne and Sydney. In addition to raising awareness of breast cancer VFUHHQLQJ DQG WKH SURÂżOH RI %UHDVW6FUHHQ :$ LW allows women who work and shop in the CBD the opportunity to have their screening mammograms. Women aged 40 and over with no breast symptoms are eligible for a free breast screening mammogram. They may book an appointment at the Rose Clinic or any BreastScreen WA clinic by

20 50.

www.breastscreen.health.wa.gov.au

APRIL 2013

phoning 13

In partnership with

Delivering a Healthy WA medicalforum

We currently provide MRI services at the follow locations Booragoon*

Joondalup Health Campus

Mount Hospital

Midland*

Subiaco

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Support Group

Young Western "VTUSBMJBO *OTVMJO Takers Y

WAIT was formed after the urging of Ms Patsy Wyndham, the Diabetes Educator at Fremantle Hospital, who connected the three co-founders and then has offered her support to the group ever since. YWAIT is a dynamic, independent social support space for young people and adults with Type 1 diabetes in WA. YWAIT’s priorities are to support its members’ emotional health and promote a sense of community and belonging through the shared experience of living with Type 1. We aim to provide a safe and supportive online environment where Q YWAIT rock climbing members can connect and share learning experiences to enhance their knowledge and understanding of diabetes management. We also encourage opportunities for members to meet and socialise. YWAIT is committed to raising awareness of Type 1 diabetes in the local community. Type 1 diabetics are necessarily independent in caring for ourselves, but ongoing self management can be complex, tiring and isolating. Medical professionals can provide education and advice but often they cannot comprehensively or meaningfully address the emotional demands of managing Type 1. YWAIT acknowledges the critical need for emotional support amongst young Type 1s, and aims to address it.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

Vale IVF pioneers

Medical Director Dr John Yovich

Patrick Steptoe (died 1988) & Bob Edwards (died 2013) … heroes against a wall of ethical negativism 7KLV SLFWXUH ÀUVW appeared in the Daily Mail following the birth of Louise Brown on 25 July 1978 in Oldham, England. It shows the IVF pioneers Robert (Bob) Edwards holding Louise, with Patrick Steptoe on the right and Jean Purdy between. This was WKH ZRUOG·V ÀUVW ,9) ´WHDPµ The birth heralds an event that ranks among those exceptional VFLHQWLÀF PLOHVWRQHV UHFRUGHG WKURXJKRXW KLVWRU\ 6DGO\ %RE passed away April 10 this year, aged 88 years – he was the only member of the team to receive the well-earned accolades. He was awarded both a Knighthood and the Nobel prize in 2010 – but he was by then too frail to collect it personally in Stockholm. Jean Purdy, a research nurse, was the junior member of the team but died young aged 39 years in 1985.

Q YWAIT rock climbing

The group offers community, support, understanding, acceptance, a sense of belonging, a peer support network and empathy. O Q YWAIT Dome event

YWAIT AT A GLANCE Membership: 150+ Main source of funds: Fund raising/sponsorship

Patrick, an obstetrician and gynaecologist was already a SLRQHHU ODSDURVFRSLF VXUJHRQ ZKR KDG SXEOLVKHG WKH ÀUVW English monograph on laparoscopic surgery, having learnt the new ideas mainly from French gynaecologist Raoul Palmer. He died in 1988, aged 74 years. I met and shadowed these men, particularly Bob Edwards during my time in London (19761980) and tried to learn their innermost thoughts and ideas whilst setting up my programme at the Royal Free Hospital Bob Edwards at Bourn Hall in in Hampstead with Cambridge (~1990), at celebration Professor Ian Craft. I of 500 IVF children. felt their discomfort following criticisms from respected colleagues, many of whom continue to regard IVF as controversial and effectively blocked the deserved accolades until 5 million births demanded the appropriate recognition.

Contact person: 3BDIFM -BNC Twitter: @insulin_takers Phone: 0423 411 171 (Rachel) Email: Rachellamb14@hotmail.com; ywait@live.com.au Website: http://insulintakers.org Contact hours: Email any time, phone business hours

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NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY

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

E-Poll

Moneyâ&#x20AC;&#x2122;s Not Everything, But Everything Needs Money Our May survey went to 1880 GPs. Many viewed the survey and 142 took the 10 minutes to participate, during the sevenday window. Winner of the wine pack, selected from those who opted-in to this competition, was Dr RH, picked at random. Congratulations to him/her and thanks to all who participated.

Do you support philanthropy by Western Australians as a desirable way of funding community health care? Yes

Perhaps

Uncertain

Comments Respondents swung between those who thought the wealth of the stateâ&#x20AC;&#x2122;s resources boom should help those less fortunate to health care being the responsibility of government. â&#x20AC;&#x153;We pay so much tax surely community health care should not need donations.â&#x20AC;? Many felt that philanthropy offered â&#x20AC;&#x153;unequal careâ&#x20AC;? and the government should provide even and sustainable funding. Funding from philanthropy should be viewed as a â&#x20AC;&#x153;top-upâ&#x20AC;? source for the health budget. â&#x20AC;&#x153;[Philanthropy] makes a valuable contribution but cannot be relied upon as primary funding. Funding universal health care is a government function. If left to private or philanthropic sources, the most vulnerable will fall through the cracks.â&#x20AC;? However, a number acknowledged that there was a limit to health care funding. â&#x20AC;&#x153;It is best that all of us who are capable i.e. healthy, working, reliable, regard it essential, like defence spending.â&#x20AC;? â&#x20AC;&#x153;Those who can afford to give should be encouraged to do so.â&#x20AC;? Several respondents said philanthropy could be best used to top up research which was chronically underfunded. For one doctor, the issue was close to home. While time constraints made personal philanthropy tricky, this person thought it existed in the profession â&#x20AC;&#x201C; among GPs â&#x20AC;&#x153;more likely than those in other specialities.â&#x20AC;? â&#x20AC;&#x153;There is, however, still a perception amongst the public that all doctors are greedy and earn much too much money. This can be very irritating, particularly if comments extend to oneâ&#x20AC;&#x2122;s children which happened to mine community.â&#x20AC;? Last word: â&#x20AC;&#x153;We should all be doing SOME pro bono work.â&#x20AC;?

Do you agree with the RACGP idea that patients with specified health problems in need of chronic care are registered with a particular general practice to receive that care? Yes

Perhaps

Uncertain

Comments Among those who chose to comment, there was a general consensus that chronic disease management was hamstrung by patients not being registered with a practice and noting a waste of resources chasing up patients who flit between practices. Medicare came in for criticism. â&#x20AC;&#x153;If patients are to register with a practice for complex care there needs to be more flexible remuneration so we can get nurses to actually spend time coordinating that care.â&#x20AC;? For one respondent, registration needs to be even more personal. â&#x20AC;&#x153;Rather than registering with a practice, a patient should register with a doctor. I have worked in multi-doctor practices and find patients who will only see me and not happy seeing other doctors in the practice.â&#x20AC;? However, there was also suspicion that once patients were enrolled. The â&#x20AC;&#x153;feds will take over the purse strings completely and we will do nothing but tick boxes to achieve an ever changing set of goals that we will have little control over.â&#x20AC;?

Choose UP TO THREE of the following, if you consider they are most needed for GPs to deal with the impending rise in diabetes incidence? Diabetes nurse educators

Special interest GPs

Podiatrists

Dietitians

Improved patient education

Other Uncertain

None of the above

Do you think encouraging more patient self-management of Type 2 diabetes will produce better outcomes, dollar for dollar, than most other measures?

Trained in the same State

Rural background

"VTUSBMJBO USBJOFE

"VTUSBMJBO DJUJ[FOT

No priority â&#x20AC;&#x201C; should be a level playing field in all these areas

Other

Uncertain

Comments Those who commented on this question were largely in favour of priority to WA trained doctors for local internships, regardless of being an Australian or overseas doctor. â&#x20AC;&#x153;If they've trained in WA, they have a better understanding of the health issues specific to this state.â&#x20AC;? However, overseas students did come in for some treatment â&#x20AC;Ś â&#x20AC;&#x153;it should be made clear that they will not be considered in the first draft for intern positionsâ&#x20AC;?.

How often do you think busy doctors are likely to treat or manage a health problem in a way that is outside recommended guidelines? Very often

Often

Occasionally

Yes

Rarely

Not at all

Uncertain

Maybe, with conditions Uncertain

As a general rule, do you believe internship placements for junior doctors should give priority to graduates who are ... [up to THREE choices possible]

medicalforum

E-Poll

Doctors: The Care Factor E-POLL: State of Caring Guidelines, for those who commented, needed to be flexible â&#x20AC;&#x201C; with no one patient (or doctor for that matter) being alike. As one doctor said, â&#x20AC;&#x153;a doctor has to devise a treatment suitable to those individual patients Unlike researchers we can't just say they didn't make it to the end of the study.â&#x20AC;? Last word: â&#x20AC;&#x153;My opinion is that clinical guidelines are drawn up by groups of people who have no experience of what it means to practically carry out those guidelines.â&#x20AC;?

Looking back over the last 10 years, do you wish you had spent more time planning your financial future? Yes

Uncertain

Doesnâ&#x20AC;&#x2122;t apply

Does your experience with financial planners indicate they understand adequately your chosen career? Yes

On June 28, the Doctors Drum breakfast event will look at this very issue. We asked doctors JO PVS .BZ & QPMM XIFSF UIFZ UIPVHIU UIF TUBUF PG DBSJOH XJUIJO UIF QSPGFTTJPO XBT BU

From your experience, is the level of personal caring shown by general practitioners towards patients over the last 10 years...

Increasing

Decreasing

About the same

Uncertain/Canâ&#x20AC;&#x2122;t say

Comments Time pressure was the clear defining factor for respondents. The increasing complexity [â&#x20AC;&#x153;more time is needed to organise diagnoses and treatmentâ&#x20AC;?], corporatisation [â&#x20AC;&#x153;increasingly difficult for GPs to develop personal care/relationships in large practicesâ&#x20AC;? and â&#x20AC;&#x153;the aggressive approach to five-minute medicine is resulting in decreased personal caringâ&#x20AC;?] and bureaucratisation [â&#x20AC;&#x153;Too little time because of red tape and concerns over litigationâ&#x20AC;?] are taking their toll and inhibiting doctorsâ&#x20AC;&#x2122; ability to give as much of themselves to their patients. Some are struggling to maintain their historical levels of caring [â&#x20AC;&#x153;I know a lot of my colleagues would like to continue caring but have had to toughen up to protect their own mental healthâ&#x20AC;?] but some think the next generation are less keen on self-sacrifice. The problem could be more widespread: â&#x20AC;&#x153;As a society we have become more individualised and less caring about others. GPs are in many ways right to not be working such long hours but the pendulum seems to have swung too much in the other direction. Many will only work hours to suit themselves with little thought for patient convenience or for those that cannot afford to pay.â&#x20AC;? The light at the end of the tunnel? â&#x20AC;&#x153;Doctors will always care.â&#x20AC;?

Uncertain

Doesnâ&#x20AC;&#x2122;t apply

X To book a seat at the Doctors Drum breakfast at Observation Rendezvous

on June 28, go to www.doctorsdrum.com.au.

BENEATH the Drapes X Esperance GP anaesthetist Dr Donald Howarth, who appeared on the cover of our July 2012 edition, received the Outstanding Service to Rural and Remote Health Award at the recent Rural Health West Doctorsâ&#x20AC;&#x2122; Service Awards 2013. Dr Cherelle Fitzclarence, who appeared in the June 2012 edition for the Kimberley Renal Support Service, received the award for Remote and Clinically Challenging Medicine. Paediatrician Dr Rex Harrison received the award for Extraordinary Contribution to Outreach Services for his work in the Goldfields. Dr Geoffrey Rudeforth was recognised for his work at the Carnarvon Hospital with the Award for Outstanding Hospital Doctor. Retired Wongan Hills GP Dr Richard Walkeyâ&#x20AC;&#x2122;s community service was acknowledged with the Above and Beyond Award â&#x20AC;&#x201C; Community First award. Dr Felicity Jefferies was given life membership of Rural Health West. X Dr Michael Stanford will continue as Group CEO of St John of God Health Care after he was recontracted by the Board. He has been at the helm for the past 11 years.

medicalforum

X Dr Lachlan Henderson has been appointed as Executive Director Perth Northern Hospitals, including CEO St John of God Subiaco Hospital. He will be responsible for day-to-day operation at SJOG Subiaco and line accountability for the 367-bed Midland Public and Private Hospitals. He will step into the roles from June 17. X The State Government has awarded the $17 million tender to Pindan for new outpatient and specialist clinics as part of the redevelopment of the Kalgoorlie Health Campus. These works will link in with the newly-built emergency department, high dependency unit and medical imaging department, which were opened in November. X Child and Adolescent Community Health child health nurse Mrs Sara Lohmeyer, who works in Perthâ&#x20AC;&#x2122;s eastern suburbs, has been named Nurse of the Year at the 2013 HESTA Australian Nursing Awards in Melbourne. X Curtin University Professor Moyez Jiwa, Chair of the Health Innovation Research Institute, has been inducted as a Fellow of the Royal College of Physicians in the UK.

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ADD ON BENEFITS t Arthritic patients ďŹ nd easier to use. t Also works for lyphoedema and burns. t Acute or chronic ulcers, or preventive use. t Attractively priced. t Quality Swiss-made, providing durable and fashionable wear (beige). t Support for tired aching legs and travel.

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Liners can be purchased separately and used with any stocking in the Venosan range. A stocking type for most medical conditions. 40

medicalforum

CLINICAL UPDATE

Bali Traveller Health Risks M

ore than 400,000 Western Australians faced these risks last year. Some are prepared to take risks without knowing what they are. Others see risk management as: â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve got it covered: my friend gave me red cordial, Iâ&#x20AC;&#x2122;ve been 20 times to Bali and never had a vaccine, and everyone goes to the monkey forest.â&#x20AC;? What risks should we advise patients of?

Baliâ&#x20AC;&#x2122;s health risks Recent WA Health Department figures showed that 46% of all â&#x20AC;&#x2DC;exoticâ&#x20AC;&#x2122; infections brought back to WA every year are from Bali. t .PSF UIBO QFPQMF IBWF OPX IBE post-exposure prophylaxis to prevent rabies after an animal bite in Bali (157 people from Perth last year, mostly after visiting the monkey forest in Ubud).

Travel diarrhoea (Bali belly) is the most common health problem, affecting 1 in 5 travellers, and the risk can be dramatically reduced by following simple food and drink rules. Travellersâ&#x20AC;&#x2122; diarrhoea is also easily treated, and a medical kit with rehydration solution, Imodium and appropriate antibiotics is recommended.

t 4USFTT UIF SJTL PG SBCJFT JO #BMJ BOE the need to seek treatment if bitten or scratched by an animal. There is no rabies immunoglobulin in Bali. Longer term travellers or expats should consider having a course of rabies vaccine, to avoid a premature return to Perth for post-bite rabies prophylaxis.

The following is recommended:

Many health problems cannot be vaccinated against so seeking medical advice tailored to travel plans makes sense. O

t 3PVUJOF WBDDJOBUJPOT TIPVME CF VQ UP date (including Hepatitis B for all but the low risk, one-off older traveller).

t "T NBOZ BT PG QSPTUJUVUFT BSF )*7 positive, and nearly 50% have one or more STDs including chlamydia, gonorrhea or syphilis.

t )FQBUJUJT " WBDDJOBUJPO GPS BMM FYDFQU UIF very young, where advice may vary).

t (BTUSPJOUFTUJOBM JOGFDUJPOT BSF WFSZ common in Indonesia. Typhoid cases do occur in Bali.

t 5ZQIPJE WBDDJOBUJPO JG USBWFMMJOH GPS more than two weeks; off the beaten track; or repeat trips (cumulative risk).

t 8" IBE DBTFT PG %FOHVF GFWFS JO 2012, nearly all from Bali.

t .PTRVJUP BWPJEBODF GPS BMM USBWFMMFST In the last month there's been a rising incidence of Chikungunya with similar symptoms to Dengue fever though arthralgia can be more sever and last longer. Dengue fever is also becoming more prevalent. Japanese encephalitis (JE) vaccine is recommended for a stay beyond four weeks in rural areas or one year in urban areas (higher risk during and post wet season, December to February); the two JE vaccines are the two-dose JespectTM vaccine and the live vaccine ImojevTM. While malaria risk is almost non-existent in Bali, there is risk on other nearby islands, including Lombok.

What advice for prospective travellers? Firstly, we distinguish between the low-risk resort traveller and others who may make multiple trips, stay for extended periods or indulge in high risk activities such as moped riding, trekking or travelling to remote areas with limited medical care and poor sanitation. There is risk from tattoos and piercings, physical trauma and accidents (including the â&#x20AC;&#x2DC;Bali tattooâ&#x20AC;&#x2122;: a calf burn from a scooter exhaust pipe), skin infections, and coral cuts for surfers.

By Dr John Terry, Fremantle. Tel 9336 6630.

Declaration: Dr Terry provides travel medicine services through his Travel Doctor practice. Nil else.

Travel Health Excerpts VFRs Almost 1.4 million Australians travel to visit family and friends overseas each year and according to research by Sanofi Pasteur, these people (called VFRs), tend to disregard health warnings as they believe their heritage and connection with the region gives them some kind of immunity. As a result, they are less likely to get vaccinated â&#x20AC;&#x201C; especially those VFRs travelling to Asia and India, where Yellow Fever, Hepatitis A and Typhoid are all relatively common. WA travellers were more likely to take out full travel insurance before departing for the high risk regions (79%; cf. national average 69%) but were the least likely to get full vaccinations (17%; cf. national average 25%). Overall, only about three quarters of travellers are not medicalforum

fully vaccinated, as recommended for their travel, and less than a third say seeing a doctor to get vaccinated is very important.

Notifiable diseases acquired overseas Dr Gary Dowse and others from the Communicable Disease Control Directorate, Department of Health, Western Australia recently presented some Bali travel health figures to the Australasian Society for Infectious Diseases in Canberra. Airplane trips to Bali from WA during 2006 to 2011 increased more than five-fold. During the same time the number of Indonesian-acquired infections increased 6-fold (from 178 cases to 1078 cases). Dengue fever was the disease most commonly acquired in Indonesia in 2012 (415 notifications, 80% of all WA dengue cases) and also demonstrated the largest

increase compared to 2006 (9 cases). As 90% of Indonesian travellers visit Bali, it is interesting to note that of the 2,605 notifiable infectious diseases acquired overseas in 2012, 41% came from Indonesia travel. Other Indonesianacquired diseases commonly notified in 2012 included Salmonella gastroenteritis (263 cases â&#x20AC;&#x201C; 23% of notified cases), Campylobacter gastroenteritis (157 cases, 8%), chlamydia (95 cases, 1%), and gonorrhoea (37 cases, 2%). Less frequently notified diseases included chikungunya, hepatitis A, HIV, Legionnairesâ&#x20AC;&#x2122; disease, malaria, typhus and typhoid fever. In addition, 157 Western Australians required rabies post-exposure prophylaxis after animal exposures in Bali. O

News & Views

Albany Prepares for Ageing Times Premier Colin Barnett and Health Minister Kim Hames travelled to Albany to cut the ribbon on the new $170m Albany Health Campus. Alongside the old sprawling huts with haphazard airconditioning rose the new four-storey complex with a bigger ED, more mental health beds, expanded renal dialysis and cancer services, a new surgical centre and upgraded obstetric and birthing suites. About 1000 people took a peek after the opening ceremony. Albany now has a big hospital, entertainment centre, Rural Clinical School, UWA branch, and Medicare Local, which strengthens the town’s claim to fame as a retirement mecca (if you like cooler, windy weather). The hospital will cater for about 55,000 patients a year and its new facilities have already attracted medical personnel to look after the ageing population. More doctors mean more capacity. Albany Hospital now has eight medical officers, six interns and five registrars. Ten medical students from the Rural Clinical School attend. Specialists include a consultant anaesthetist, general and breast surgeon, two obstetricians and gynaecologists, one

Q After the Premier and guests left, the Albany mist rolled in.

general physician, and two ED specialists – with procedural Albany GPs accredited to the hospital as well. Great Southern Radiology (GSR) has the 10-year contract to provide imaging services, which includes a full MBS access for MRI (but no operational machine yet) and no-gap arrangements for public inpatients and concession cardholder outpatients. O Q It’s time to take the sign down.

New Honour Society for Nursing The Western Australian at Large Honor Society of Nursing (WAHSN) was launched last month with the induction of 100 members from all sectors of the nursing profession. The WAHSN is supported by the tertiary nursing programs at UWA, ECU, Notre Dame and Curtin universities, and the Nursing and Midwifery Office of the Department of Health. Vice Chancellors, nursing academics, the Chief Nursing Officer and the inaugural President of the WAHSN, Professor Desley Hegney from Curtin University, were at the ceremony. The WAHSN is a precursor to the formation of a Sigma Theta Tau International (STTI) Chapter at Large in WA. STTI has more than 469 chapters in 86 countries. Professor Hegney said the chance to become a part of STTI was an important opportunity to look at how other countries dealt with common health care issues. It also acknowledged the contribution of WA nurses to the health of the community. O 42

Q Ms Yasmin Naglazas (Bethesda Hospital), Dr Joanne McGlown (PhD, STTI), Prof Di Twigg (ECU), Prof Desley Hegney (Curtin), Prof Selma Alliex (NDU), Prof Leanne Monterosso (NDU), A/Prof Helene Metcalfe (UWA), A/Prof Anne Williams (ECU), A/Prof Chris Toye, A/Prof Rosemary Saunders (UWA), Ms Michelle Dillon (WA Health). Q Prof Gavin Lesley, Ms Joanne Harding, Ms Heidi Pavicic and A/Chief Nursing and Midwifery Officer Brett Evan.

medicalforum

Awards

Dedication Rewarded Five of WA’s most distinguished specialists were recognised for their service to the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) at the society’s recent scientific meeting in Perth. Dr Cameron Bracks and Dr Stuart Miller were awarded the Society Medal for Distinguished Service while Prof Marcus Atlas, Prof Harvey Coates AO and Dr Alastair Mackendrick received the Society Medal for Distinguished Contribution to the Art and Science of Otolaryngology, Head and Neck Surgery. Dr Bracks has been an active member of ASOHNS holding executive positions including Vice-President, President, Immediate Past President and, until recently, Adviser to the Executive Committee. In the early 1980s, Dr Bracks began practising the translab approach and teamed with the late Dr Peter Packer and Dr Ian Wallace to perform a series of about 180 cases. Both he and Dr Packer established a cochlear implant program in 1983. Dr Miller’s contribution to ASOHNS has been on both state and national levels taking on numerous executive roles including WA Chair and Secretary and federal positions of Vice-President, President and Immediate Past President. He was in private practice with the late Dr Peter Packer OAM and joined the ENT Department at Royal Perth Hospital, later becoming department head. Prof Coates was largely responsible for establishing the neonatal hearing program in WA. He has published widely on treating and managing otitis media and

was co-founder of the first Paediatric Otorhinolaryngology (ORL) group in Australia. He has been active for many years in both the clinical and policy aspects of indigenous health and has been widely recognised for his work. Prof Coates is a Paediatric Otolaryngologist and Clinical Professor at UWA School of Paediatrics and Child Health and University Department of OHNS. Dr Mackendrick’s work over more than two decades in the Kimberley was honoured. He began visiting the severely disadvantaged area in 1987, working especially in remote Aboriginal communities where the incidence of ear disease is high. Dr Mackendrick has co-authored several Aborginal ear health manuals. He published a paper in the Australian Journal of Otolaryngology in 1999 on the results of myringoplasties in Aboriginal children over a 10-year period. Prof Marcus Atlas is a surgeon scientist and a world leader in the field of ear and skull base surgery. He holds the Garnett Passe and Rodney Williams Memorial Foundation Chair in Otolaryngology at UWA. He is head of the Ear Sciences Centre (ESC) at UWA and founding director of the Ear Science Institute Australia (ESIA). He has helped create four major groups involved with clinical research, molecular and cellular otolaryngology, computer and information science, as well as epidemiology. Mr Philip Grey and Prof Peter Friedland were awarded Certificates of Appreciation for Services to ASOHNS at the recent meeting. O

Q From top: Dr Alistair Mackendrick, Dr Cameron Bracks, Prof Harvey Coates, Prof Marcus Atlas and Dr Stuart Miller receive their awards from ASOHNS President Dr John Curotta.

THAT WORKS FOR YOU! Front cover devoted to your practice information AGPAL and GPA approved for accreditation Full photographic colour on quality art paper; reputable health info for patients Flexibility – no contracts; order when you need it

Order online at www.healthnews.net.au Phone (08) 9203 5599 or email info@healthnews.net.au medicalforum

Investing in Lifestyle

France

Figures Add Up in

West Leederville GP Simon Moss and his partner, Dellas, decided to invest in property in the Luberon region in Southern France. He shares with Medical Forum the pleasures and pitfalls of his investment decision.

Sunny France with waterwheels, a rosĂŠ with lunch at a table beside the canal and the purple haze of the Luberon ranges in the distance. That was the dream! And the reality? A delayed aircraft into Nice, an interminable queue at the hire-car desk and two hours on the road resulting in opening the door to our new property in Lâ&#x20AC;&#x2122;Isle sur la Sorgue in complete darkness. Even travel fatigue couldnâ&#x20AC;&#x2122;t erase the inevi UBCMF FNPUJPOT PG FYDJUFNFOU MBDFE XJUI doubt associated with buying a property sight unseen from the other side of the globe. It wasnâ&#x20AC;&#x2122;t a complete leap into the unknown. We knew the town and the pre vious owner, and had watched a detailed WJEFP AXBML UISPVHI CFGPSF TJHOJOH PO UIF dotted line. But, even though this is beau tiful Peter Mayle country, you never know do you?

The vicious rumours regarding French bureaucracy arenâ&#x20AC;&#x2122;t true â&#x20AC;&#x201C; theyâ&#x20AC;&#x2122;re worse! Dellas and I love France! We travel there every year, always stay in private accommo dation and live like locals. So, an investment QMBO CFHBO UP FNFSHF 8IZ OPU BDRVJSF B few properties, pay them off over the last years of our working lives and use them as an income source to fund summers of long lunches in southern France? It helped that three investment â&#x20AC;&#x2DC;planetsâ&#x20AC;&#x2122; had lined up beautifully: a booming Aussie dollar, a depressed European property mar LFU BOE UIF BEEFE BUUSBDUJPO PG B GJYFE SBUF NPSUHBHF PG VOEFS PWFS ZFBST 5IBU adds up to good value, particularly com pared with property investment in WA.

YFT UIFSF BSF SJTLT 8F WF FYQPTFE PVS selves to any further downturn in Europe, the devaluation of the Euro and a soften ing of tourist demand. But the sword cuts both ways â&#x20AC;&#x201C; a falling Euro would make our properties less valuable from an Australian perspective, but the repayments would be less in Australian dollar terms. Two other factors are worth mentioning: GJSTUMZ XF SF GPDVTJOH PO TIPSU UFSN IPMJEBZ rentals on UK letting sites at the lower end of the pricing market in a highly desirable location. It would take a monumental GFC Mk. 2 to pull us under 22 weeks occupan DZ PVS ACSFBL FWFO QPJOU 4FDPOEMZ NPTU of our clientele are from Australia, the UK and the US so the relative strength of the European financial landscape is of minimal DPOTFRVFODF

One of the secrets to success is finding competent people on location in France. 8F WF HPU B 4DPUUJTI CPSO MPDBM real estate agent complete with r a tatty Renault and an even tat Dr Simon Moss tier t Border Terrier named Thelma. Then thereâ&#x20AC;&#x2122;s Jonathan, a rather

Simonâ&#x20AC;&#x2122;s Provence Tips t " OFHBUJWFMZ HFBSFE JOWFTUNFOU TIPXJOH OP BDUVBM QSPGJU " 'SFODI UBY return will be submitted. t 5IF 'SFODI SBSFMZ SFEVDF TBMF QSJDF Theyâ&#x20AC;&#x2122;re happy to wait until a willing wallet comes along. t 4NBMM UXP CFESPPN BQBSUNFOU ĂŠ BQQSPY #SFBL FWFO SFOUBM weeks/year on a UK rental listing. t 3FOUBM ĂŠ XFFL -PX High Season).

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Investing in Lifestyle

ATOâ&#x20AC;&#x2122;s Provence Tips t *ODPNF GSPN PWFSTFBT JOWFTUNFOUT in property is deemed â&#x20AC;&#x2DC;Foreign Source Incomeâ&#x20AC;&#x2122;. t 5IF GVMM SFOUBM BNPVOU SFHBSEMFTT PG whether itâ&#x20AC;&#x2122;s paid to you or your agent, NVTU CF EFDMBSFE JO ZPVS UBY SFUVSO comical English teacher turned Anglophone CBOLFS JO JMM GJUUJOH TVJUT XJUI B SFTJHOFE acceptance of the mysteries of French commerce. And finally thereâ&#x20AC;&#x2122;s Francine, the elegant notaire in her designer office on the FEHF PG B QJDUVSF QFSGFDU WJMMBHF OFBS BVUIPS Peter Mayleâ&#x20AC;&#x2122;s first farmhouse, who handles the legal side. 5IF OFUXPSL FYQBOET $BUI EPFT UIF cleaning, her daughter will manage minor renovations and she knows a carpenter whoâ&#x20AC;&#x2122;ll knock down a wall and reshape the kitchen. We leave a key with Robyn from the boulangerie who we know rather too well. All the vicious rumours regarding French

t *G ZPV QBZ GPSFJHO UBY JO BOPUIFS DPVOUSZ you may be entitled to an Australian GPSFJHO JODPNF UBY PGGTFU XXX BUP HPW BV UBYQSPGFTTJPOBMT bureaucracy arenâ&#x20AC;&#x2122;t true â&#x20AC;&#x201C; theyâ&#x20AC;&#x2122;re much worse! Just opening a simple bank account will have you jumping through the hoops. In fact, it was harder to give them our money to put in the bank than it was to negotiate a mortgage to take it out again. Thereâ&#x20AC;&#x2122;s always another document to scan, more papers to sign and another courier envelope PO UIF XBZ #VU UIF CFBVUZ PG NVMUJ QBHF documents in tiny font written in French

llegalese l i that h you donâ&#x20AC;&#x2122;t d â&#x20AC;&#x2122; even have h is to pre tend to read them. And sometimes you do have a win. Our second property is connected to mains gas, itâ&#x20AC;&#x2122;s never had a meter and none of the previ ous owners felt the urge to install one. We wonâ&#x20AC;&#x2122;t either. We feel like locals already. O

As told to Mr Peter McClelland

From Clay, Adam was Made Levator labii superioris alaeque nasi, levator anguli oris â&#x20AC;&#x201C; they are words and structures that bring back the horror of medical school anatomy to be ďŹ led away hopefully in the distance of acceptable knowledge never to be revisited. Once one enters the realm of artist and TDVMQUPS UIFTF UFSNT SF FNFSHF JO B QSBD tical way. Sculpting life models, both head and torso, has plunged me back into this dark science with a new burst of energy and pleasure. The aesthetic of working with silken like clay fashioning delicate parts of human anatomy to the sounds of soft music and good wine has given me insight into the public lives of the Greek gods. To be able to reproduce a lifelike replica â&#x20AC;&#x201C; if not without some artistic licence â&#x20AC;&#x201C; is a total joy. Your gardens are forever filled with

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these objects! The use of multiple media and abstract shapes and varied patina is totally engrossing. O

Dr Tony Barr 45

Kitchen Confidential

What is the one dish you couldn’t leave off your menu? Snapper, prawn and leek pie. The regulars love it! We took it off the menu for a day and I’ve never had so many people come into the kitchen and demand its return! How important is healthy food choices to the Suburban Table menu? Good food needs cream and butter! Having said this, we always listen to what the public wants and try to have meals available to suit. Diners are becoming more health conscious, which most chefs hate but with the growing number of vegetarians, coeliacs and the like, restaurants need to respond. Mum is very health conscious and this has made me think about healthier options. NATASHA Did you enjoy cooking before you chose to study medicine? Before I started studying, I ran a catering company. I love organising parties, menu planning and food preparation so it was a great way of doing the things I enjoyed without the stress of having a party myself! While I was studying (I graduated 2011), we would have Sunday night ‘study sessions’. Migrating from house to house, we would start with a great dinner, some (usually cheap) wine and after we would run through case scenarios to prepare for the OSCEs. It was so much fun, it’s almost a shame we aren’t studying anymore. Do you still cook? Not half as much as I used to, however, now I am working, I can go out to eat a lot more, which is great. I have been travelling a lot in the last few years and have squeezed in a few cooking classes whenever I can. Some of my favourites were Cooking Alaturka in Turkey, Café Clock in Morocco and the amazing Royal Blue Elephant in Thailand. I don’t think I am brave enough to apron it up in a commercial kitchen anymore, the pace might be too much.

10 minutes with... Josh & Natasha Prosser Natasha is a junior doctor at RPH, her son Josh is a bright young chef and together they own one of the city’s most interesting eateries – the Suburban Table in Mosman Park. JOSH Tell us about your food philosophy at Suburban Table? We love fresh seasonal produce – focusing mainly on old favourites but there’s something for everyone. My day starts at around 7.30am. I love going to farmers markets. I shop every day because it gives me access to the freshest produce and gives me the ability to change the menu depending on what is available and freshest. What seasonal ingredients coming into winter are you itching to use? Fennel, potatoes and pumpkin. I love slow hearty braises – things like beef cheeks and lamb shanks.

Suburban Table has become a great supporter of WA artists. What is behind this initiative? When Josh started talking about taking over the restaurant late last year, my mum and I joked that it would be great to have a gallery there as well. It’s evolved from there. Mum has been an art teacher for over 40 years and since retiring, has taken on running life drawing classes at Tresillian Centre. She has been a collector for many years and we both love attending exhibitions and following new artists. Our idea for the gallery was to showcase local artists, providing an environment for them to display their work, and link it with local people. The artwork is for sale, however more importantly, it allows people to get to know the artists. With big celebrity players entering the market (Neil Perry, Jamie Oliver, Guillaume Brahimi, Pete Evans) what does a suburban restaurant need to keep doing? JP: I think quality and attention to detail, to produce good food. I work really hard with every dish that we send out to ensure the high standard is met. Developing a good relationship with customers is also something we take pride in. Our amazing front of house staff led by Kelly is an important part of this. She is so welcoming and friendly, recognizing repeat and regular customers but also welcoming new customers. What would be your last meal?

Where did you train?

JP: A big steak cooked medium rare with mushroom sauce and mash.

I started my career as an apprentice baker at Bakers Delight. I’ve always had a passion for bread. But I decided I loved the fast pace of the kitchen and began an apprenticeship at Kuppa in Claremont. Since then I have worked at various restaurants around Perth including Pronto and Twisted Fork. I still bake bread for the restaurant every day, which I love.

NP: If I had to cook myself, it would be salmon poached in white wine with a cream reduction, capers and dill served with steamed asparagus and spring vegetables; pannacotta with fresh berries for dessert and an hour in Simon Johnson’s fromagerie with a glass of merlot. Someone else would have to do the dishes.

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Wine Review

WinningWays Eldertonâ&#x20AC;&#x2122;s

2009 Command Shiraz 5IJT GMBHTIJQ XJOF JT QSPEVDFE GSPN HSBQFT HSPXO JO UIF GJSTU QMBOUFE CMPDLT JO 5IFSF JT OP EPVCUJOH UIF RVBMJUZ PG UIJT XJOF 3JDI BOE SJQF CVU OPU PWFSSJQF GMBWPVST PG QMVNT CFSSJFT BOE MJRVPSJDF BSF FWJEFOU *U T GVMM CPEJFE BOE MVTI UIF tannins are plentiful yet soft and supple. The aftertaste finishes clean and lingers MPOH 5IF $PNNBOE 4IJSB[ JT B XJOF PG EJTUJODUJPO QPXFS BOE CBMBODF UIBU XJMM HFU even better with time.

By Dr Louis Papaelias

2010 Ashmead Cabernet Sauvignon This flagship Cabernet comes from a block planted in 1944. Itâ&#x20AC;&#x2122;s matured in French oak casks for 18 months and kept for a further year in bottle. Itâ&#x20AC;&#x2122;s finely structured and concentrated with a long lingering finish. It shows the fleshiness and beauty of fully ripened Cabernet with ripe plums, violets and cassis which ride in check on UIF CBDL PG B DMFBO UJHIU TUSVDUVSF -JLF UIF $PNNBOE 4IJSB[ JU JT B XJOF PG GJOFTTF BOE CBMBODF UIBU XJMM BHF JO UIF CPUUMF UIPVHI FYUSFNFMZ BUUSBDUJWF OPX

In 1894 the Scholz family planted what is now known as the original Elderton vineyard in Nuriootpa, in the heart of the Barossa Valley ďŹ&#x201A;oor. Bought for a song in the 1970s by the Ashmead family, the vineyard began its new life by supplying grapes for the likes of Penfolds, Wolf Blass and Peter Lehmann. By 1982 the family took the next step and began making wine under its own label and Elderton was born.

2009 Ode to Lorraine 5IJT $BCFSOFU 4IJSB[ BOE .FSMPU CMFOE JT EFEJDBUFE UP -PSSBJOF "TINFBE B DP GPVOEFS PG UIF FTUBUF .BEF GSPN UIF CFTU CBSSFMT PG FBDI WBSJFUZ JU JT CSPBEFS UIBO UIF $BCFSOFU CVU UJHIUFS BOE NPSF TBWPVSZ UIBO UIF 4IJSB[ -JLF the previous two, it is beautifully balanced, long and supple. Oak maturation is 'SFODI "NFSJDBO 5IJT JT B EFMJDJPVT BOE IBSNPOJPVT XJOF 2010 Elderton Barossa Shiraz 5IJT IBT TPNFUJNFT CFFO EVCCFE BT i4PO PG $PNNBOE 4IJSB[w CFDBVTF MJLF JUT famous sibling it is made from premium grapes and has a good maturation time in PBL BMCFJU OPU UP UIF FYBDU TBNF FYUFOU NPOUIT BT PQQPTFE UP NPOUIT 5IF SFTVMU JT B MPWFMZ TIJSB[ SFEPMFOU PG CFSSJFT QMVNT BOE DIPDPMBUF *U IBT HPPE TUSVDUVSF and balance. Beautiful to drink now but has the pedigree to age for a few years.

A lot of hard work in the vineyard and winery followed, paying dividends in 1993 when Elderton won the coveted Jimmy Watson Trophy at the Royal Melbourne wine show. In 2000 Elderton was named best shiraz at the London International Wine and Spirits competition. It has also been recognised by US wine critic Robert Parker and Wine Spectator magazine. Today the company makes a large variety of wine styles, both red and white, but it is the traditional varieties of Shiraz and Cabernet Sauvignon that are rightly responsible for drawing the many accolades given to this winery. All the wines I tasted showed attractive primary fruit ďŹ&#x201A;avours with expert use of French or American oak that never dominated the taste of the wine.

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2009 Elderton Barossa Cabernet Sauvignon .BEF XJUI UIF TBNF BQQSPBDI BT UIF TVQFS QSFNJVN "TINFBE $BCFSOFU UIJT wine is already supple and approachable. No stalky astringent tannins here, just lots of delicious blackberry and chocolate flavours that easily soak up the two ZFBST PBL NBUVSBUJPO -JLF BMM UIF PUIFST JU IBT B XFMM CBMBODFE TUSVDUVSF XJUI B clean finish. It will certainly age, but why bother?

WIN a Doctor's Dozen! Who is Lorraine Ashmead and what wine is named after her? Answer:

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ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, June 30, 2013. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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Car Review

Subaru is a

Family Affair Driving Docs, Daryl Sosa and Peter Bradley, jump into the brand new Subaru Forester GT for a hi-tech 2013 ride back to the future.

Remember Y2K ... when supposedly the world’s computers would meltdown, trafﬁc would be gridlocked and planes would fall from the sky! It was also the "gestation period" of the new GST and Patty Sosa was looking to replace her trusty (but ageing) VH Commodore. A Subaru Outback was in the spotlight but the four-cylinder was a bit underpowered and the seating a bit low for her arthritic knees. Almost jokingly I suggested that we take the Subaru demo Forester GT for a spin – low pressure turbo, two-litre and a well-matched four-speed auto box. Seating was 110mm higher and allowed easier entry and exit and better all-round vision. What a treat. Immediately the higher torque paid dividends, the snappy acceleration and effortless cruising and the sweepers around Point Walter Drive sealed the deal! Word spread. Dr Clare Matthews and ‘Wazza’ (fellow Tarmac Rally stalwarts) and Dr Chris "Griffo" (Nuclear Scientist and Team HSR member) each bought one; Leonie (Freo ED, Team HSR) followed suit with an XS Forester and Dr Pete's sister bought one too! No wonder the Forester is Subaru's No. 1 volume seller with about 170,000 sold since its Australian debut in 1997.

< 40kg increase across all models (ranging from 1.51.6 tonnes) by the clever use of high-tensile steel and an aluminium bonnet. Its generic good looks are Three generations of the Sosa family are dedicated Subaru Forester fans enhanced by pushing the A pillars 200mm forward. The "cabin forward" look and interior airiness are enhanced by the quarter windows up front, while The Forester’s 5-star crash rating is also improving side vision. The conservachieved with seven airbags and suppleative but contemporary interior features mented by ‘Eyesight’, a Stereo 3D radar soft touch plastics and multifunction camera located at the top of the winddisplays – a definite improvement on the screen. This monitors forward obstacles outgoing model. The luggage compartsuch as pedestrians, lane departure ment is reasonably small at 422 litres and slow or stopped vehicles ahead, but with the rear seats down (which is a providing pre-collision braking. When breeze), it balloons to 1480 litres. combined with the cruise control, the The iS test vehicle was supplied with car will automatically adjust the speed premium leather, Harmon Kardon to maintain a safe distance to the vehiSound, Smart Key/Push button start, cle in front. It’s a great feature but a bit dual zone climate air, sat-nav and a intrusive and makes overtaking while huge sunroof. Also included are autoin ‘Cruise’ difficult. Thankfully it can be matic wipers and headlights, electric deactivated! front seats, Bluetooth, reversing camera, The switch-gear and instrument funcmotorised rear tailgate and 18" Alloys. tionality are reasonably intuitive.

Enter the fourth generation 2013 Forester 2.5iS Line-artronic CVT.

The Forester’s naturally aspirated 2.5 litre petrol motor retains its previous power and torque 126 kw/235Nm, while the entry level 2.0 litre has 108kw/198Nm (also fitted to the XV). Stop/ Start on all petrol models and& reduced cd 0.33 helps improve economy by 13% (quoted 8.1 l/100 km).

Like most manufacturers, Subaru has increased the size of its AWD SUV. The new Forester has increased in length and height while keeping weight down to

The improved economy is also T achieved by a Continuously a Variable Transmission replacV ing the old four-speed Auto. i The CVT has a manual mode – T

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Culture

ONE R ING to RULE Them A ll six pre-set ratios controlled by paddle shifters. Unfortunately the CVT has no low range capability but the iS comes equipped with X-Mode option, an electronic aid that controls the centre and rear diffs and brakes to individually adjust torque to the wheels with the most traction. X-Mode also incorporates Hill Descent Assist & Traction Control. The Forester 2.5 iS petrol has improved response due mainly to the CVT, which is reasonably quiet. It definitely feels like it has more than 235Nm up its sleeve. Quoted acceleration of 0-100 in 9.3 seconds sounds about right. Unfortunately most drivers will spend their time navigating the urban jungle rather than seeing any serious off-roading and the 2013 Forester proved quite athletic zipping around or skipping over roundabouts while maintaining its composure! The X-Mode option definitely enhances its off-road ability. The electric assisted steering felt a little vague but the combination of a slightly soft suspension setup with McPherson struts front and double wishbone independent rears provides excellent rough-road ability. Brakes handled some aggressive driving without fading. So what's the verdict? The 2013 Subaru Forester is bigger, better, smarter, safer and more efficient than its predecessor. True to its phylogeny it maintains excellent value for money in a highly competitive niche. Perhaps I should leave the last word up to my 11-year-old daughter El. "Can we keep this one Dad?" At $43,500, start saving princess! O

medicalforum

The Western Australian Symphony Orchestra and Chorus, the St George’s Cathedral Choristers and Lord of the Rings on a massive screen adds up to a big night in every way! Epic events such as The Lord of the Rings (LOTR) at the Riverside Theatre on June 21 accompanied by a full orchestra don’t just happen with a flick of the fingers. David Cotgreave, WASO’s Production and Technical Manager, is the miracle worker pulling the strings on this one. And yes, there will be a doctor in the house – five of them, in fact! Dr Olga Ward and four colleagues (see Medical Forum March 2013) will be singing their hearts out in the chorus.

huge projectors, highly specialised playback equipment and the sound system uses the same rigging points from the CHOGM Opening Ceremony. And a lot of the audio-visual gear came across from Melbourne.”

“This show is a huge undertaking and the first problem was finding a venue that was large enough. It’s all based around the size of the screen – 6m x 14.5m in this case! We’ve shoe-horned it into the Riverside Theatre at the Perth Convention Centre and we’ll have 80 adults and 40 children singing on-stage plus the full WASO orchestra in front of them,” David said.

LOTR is excitement on a grand scale, from the emotion of Tolkein’s narrative to the full-octane power of an orchestra with massed voices.

The technical logistics for LOTR are mindboggling and some of the equipment had to be brought in from interstate. Nonetheless, David’s CV is impressive having been at the helm as Production Manager at four of the largest Arts companies in Australia.

By Mr Peter McClelland

“We used a sophisticated computerised design program to draw up the specifications for the show. There are two

“I’m a WAAPA graduate and I’ve been very fortunate with my career. It all started with the Perth Festival and then I threw my CV in for the Sydney 2000 Olympic Games [David also worked on last year’s London Olympics]. After that I worked with the Sydney Theatre Company, back to WAAPA and now the WASO. There’s always something exciting happening!”

“You can’t help but focus on the music, although the subtitles will be up on the screen so you won’t miss a word of the dialogue. I saw the show in Melbourne – it’s awesome!” O

COMPETITION ** For you chance to see the show on June 21, go to the competitions page for details.

Satire

Scrubbing the

Inner Sanctum Resident satirist Wendy Wardell explores the ramifications of inner beauty and ponders just how far we will have to go! The quest for inner beauty was, I had always thought, about being kind and generous of spirit; the possession of personal qualities that people could admire, even if you had a face like a hatful of frogs. But once again, advertising has gone literal, stripped of soft-focus allusion and gentle metaphor. Billboards at bus stops close to fast food outlets are now emblazoned with images of unhealthy innards. This is intended to shock people out of their harmful eating habits in a way that being too fat to walk or having to wear a marquee canâ&#x20AC;&#x2122;t achieve. Clearly the anti-obesity campaigners are desperately seeking some of the antismoking groups' action. How graphic will the exhortations become to 'spare a care' for our plumbing? Will our favourite bottle of cabernet soon come with images of cirrhotic livers, making us wonder if the latest Leeuwin Art Series was featuring Western Desert dot painting? Can we expect to see a picture of a pancreas

in its death throes adorning our next bar of Dairy Milk? Frankly, with creeping middle age, I find it hard enough to hold up external appearances so that popping to the shops without make-up on doesn't scare small children. The sudden need to ensure good-looking entrails is just another imposed standard I can do without. Who exactly determines where intestinal loveliness lies anyway? Sure, a fatty gut looks pretty grotesque, but a pink and pert gall bladder is unlikely to be winning a 'face of Lâ&#x20AC;&#x2122;Oreal' contract anytime soon. Perhaps though, exposure to these images does have a cumulative effect. Iâ&#x20AC;&#x2122;ll confess that after two days of gruelling preparation for a colonoscopy I did have a small frisson of pride in the knowledge that my intestine was probably cleaner than my kitchen. It's also an opportunity for those not blessed in conventional ways to get into the modelling game. I'd imagine the digestive tract of 'normal' supermodels to have been rendered so desiccated and lifeless through under-use as to be completely unsuitable. But just how fat a

pay packet does it take to lure any model out of bed for a photo shoot that involves surgical gowns and scalpels? There's great potential here too for expanding the market in aesthetic treatments. Why stop at anal bleaching when there's a demand to be exploited for villi whitening? I can foresee new exercise classes created to improve our digestive efficiency, called Peristalates. Your colon will become as ripped as Madonna and move like Jagger. Home liposuction parties will hit the 'burbs using Dyson-esque tools to get into those hard-to-reach nooks and crannies between body parts. Eventually, this will all reach mainstream consciousness and be absorbed into social media. Facebook may well get re-badged, with a whole new look and organ. Taking 'selfies' will require a high degree of dexterity and a large jar of Vaseline. Navel-gazing will not be something undertaken lightly or without a general anaesthetic. Thank Heavens we'll still have Twitter as a beacon of superficiality. O

medicalforum

Opera

Don

Q Teddy Tahu Rhodes as Don Giovanni. Picture: Jeff Busby

THE

IS BACK In the opera repertoire, they donâ&#x20AC;&#x2122;t get much naughtier or sexier than Don Giovanni, Mozartâ&#x20AC;&#x2122;s spirited take on the story of serial seducer Don Juan. Put New Zealand, and Australiaâ&#x20AC;&#x2122;s adopted son, baritone Teddy Tahu Rhodes in the role, have him hop around the stage shirtless and the excitement is sure to spill over into the audience! Itâ&#x20AC;&#x2122;s a role Teddy adores and will reprise for WA Operaâ&#x20AC;&#x2122;s production at His Majestyâ&#x20AC;&#x2122;s Theatre opening on July 16. â&#x20AC;&#x153;The thing I love about this role is its drama, which is very powerful. I think itâ&#x20AC;&#x2122;s a perfect QJFDF PG TUBHFE .P[BSU BOE * WF EPOF TFWFSBM different productions of Giovanni but this is by far the best. It is set in period and yet it is still FEHZ :PV SFBMMZ HFU IPPLFE VQ JOUP UIF TUPSZ w Whenever and wherever Teddy sings, the crowds follow. But it took him a bit longer than most to embrace the life of an opera singer. Born in Christchurch, Teddy studied accounting before he overcame his stage shyness and found confidence in his singing abilities.

Slavaâ&#x20AC;&#x2122;s Show

In a world crying out for fantasy and magic, Russian clown Slava Poluninâ&#x20AC;&#x2122;s gloriously whimsical show continues to ďŹ ll theatres around the world with all that [and tonnes of white paper] for the past 20 years. medicalforum

Q Teddy Tahu Rhodes Picture: Cal Crary

â&#x20AC;&#x153;I was in my late teens â&#x20AC;&#x201C; 19 â&#x20AC;&#x201C; when I started singing and I donâ&#x20AC;&#x2122;t think as a boy or as a guy youâ&#x20AC;&#x2122;ve grown up by then. I guess there was a great deal of vulnerability and shyness getting up on stage and stepping out of being the person I am when I wasnâ&#x20AC;&#x2122;t PO TUBHF w â&#x20AC;&#x153;Coming to Australia several years later for my first gig was liberating. I didnâ&#x20AC;&#x2122;t know anybody and no one knew who I was or what I was about, so I got the chance to go on stage and just be. I remember telling myself that I was just going to throw myself into it XJUI BCBOEPO BOE OPU CF TFMG DPOTDJPVT 5IBU XBT MJCFSBUJOH BOE B SFWFMBUJPO w Now Teddy Tahu Rhodes is one of the most TPVHIU BGUFS CBSJUPOFT JO PQFSB IPVTFT BMM over the world, throwing himself into classical BOE DPOUFNQPSBSZ PQFSB JO FRVBM NFBTVSF When Medical Forum caught up with him, he had just returned to Melbourne from New York where he had performed in A Streetcar Named Desire. â&#x20AC;&#x153;I love singing in shows that resonate with peopleâ&#x20AC;&#x2122;s life right now, Giovanni is like that, he is a fleshy, real character. As beautiful as the old opera is and as glorious as the music is, itâ&#x20AC;&#x2122;s a joy to be able to do something that

Slavaâ&#x20AC;&#x2122;s Snowshow, which returns to the Regal Theatre, Subiaco, from July 31, is Poluninâ&#x20AC;&#x2122;s captivating brainchild, born from his QFSGPSNBODFT JO $JSRVF Du Soleilâ&#x20AC;&#x2122;s Alegria and has played in more than 130 countries since 1993. Medical Forum caught up with Slava this month and asked him how he kept himself and the show fresh after such a long time. â&#x20AC;&#x153;The secret to its longevity is that it never HFUT GSP[FO JU DIBOHFT FWFSZ EBZ o EFQFOEJOH on the country, the people, the cast, the weather and the mood. Improvisation plays a very big part, so artists can dream and look for new approaches. This makes the QMBZ BMJWF w

SFRVJSFT B EJGGFSFOU TUZMF PG BDUJOH BOE B EJGGFSFOU TUZMF PG UIFBUSF GSPN UJNF UP UJNF w This year, we will see some different moves from the boy with the molasses voice. He will head west again in October in Opera Australiaâ&#x20AC;&#x2122;s production of South Pacific XJUI 1FSUI CPSO -JTB .D$VOF BOE IF T JO SFIFBSTBM XJUI ,BUF $FCFSBOP GPS UIFJS UXP hander at the Adelaide Cabaret Festival. i* MPWF TUFQQJOH PVU PG NZ DPNGPSU [POF *U T BO FYDJUJOH UIJOH UP EP BOE UIF CFBVUZ PG UIF job I do. Every job you go to you can never just rely on the last thing you did because you walk into a different group of people, a different audience. Even if itâ&#x20AC;&#x2122;s old, it JT OFX w O

By Ms Jan Hallam

WIN For you chance to win tickets to see WA Operaâ&#x20AC;&#x2122;s Don Giovanni, go to the competitions page for details.

Slava, who turns 63 this month, is a romantic in the grand sense of the word. â&#x20AC;&#x153;It seems to me that a man should always follow a dream. To live without a dream for me is impossible, and if it is possible, it is very boring. Itâ&#x20AC;&#x2122;s our job to keep the magic alive for the audience. I perform each night as if I were on a first date. Is it possible to MPTF UIF NBHJD PO UIF GJSTU EBUF w Without a word spoken, Slava and his cast weave a wonderful narrative thread through the show, which is what Slava loves most. â&#x20AC;&#x153;This is the magic and art of theatre; it's communication with the hearts of the BVEJFODF w O

WIN For you chance to win tickets to Slavaâ&#x20AC;&#x2122;s Snowshow, turn to the competitions page for details. 51

funnyside e

Q Q Courtroom Comedians The things you hear under oath: Q: Are you sexually active? A: No, I just lie there. Q: What gear were you in at the moment of the impact? A: Gucci sweats and Reeboks. Q: This myasthenia gravis, does it affect your memory at all? A: Yes. Q: And in what ways does it affect your memory? A: I forget. 2 :PV GPSHFU $BO ZPV HJWF VT BO FYBNQMF of something that you've forgotten? Q: How old is your son, the one living with you? " 5IJSUZ FJHIU PS UIJSUZ GJWF * DBOhU remember which. Q: How long has he lived with you? " 'PSUZ GJWF ZFBST

Q: Doctor, how many autopsies have you performed on dead people? A: All my autopsies are performed on dead people. Q: Do you recall the time that you FYBNJOFE UIF CPEZ A: The autopsy started around 8.30pm. Q: And Mr Dennington was dead at the time? A: No, he was sitting on the table wondering why I was doing an autopsy. Q: Doctor, before you performed the autopsy, did you check for a pulse? A: No. Q: Did you check for blood pressure? A: No. Q: Did you check for breathing? A: No. Q: So, then it is possible that the patient was alive when you began the autopsy? A: No. Q: How can you be so sure, Doctor? A: Because his brain was sitting on my desk in a jar. Q: But could the patient have still been alive, nevertheless? A: Yes, it is possible that he could have been alive and practising law somewhere.

Q Q Puns on

the Run

I tried to catch some fog. I mist. When chemists die, they barium.

Q: What was the first thing your husband said to you when he woke up that morning? A: He said, "Where am I, Cathy?" Q: And why did that upset you? A: My name is Susan.

I know a guy who's addicted to brake fluid. He says he can stop any time.

Q: Now doctor, isn't it true that when a person dies in his sleep, he doesn't know about it until the next morning? " %JE ZPV BDUVBMMZ QBTT UIF CBS FYBN

I stayed up all night to see where the sun went. Then it dawned on me.

How does Moses make tea? Hebrews it.

5IF HJSM TBJE TIF SFDPHOJ[FE NF GSPN UIF vegetarian club, but I never met herbivore.

Q: So the date of conception (of the baby) was August 8? A: Yes. Q: And what were you doing at that time?

*hN SFBEJOH B CPPL BCPVU BOUJ HSBWJUZ * can't put it down.

Q: She had three children, right? A: Yes. Q: How many were boys? A: None. Q: Were there any girls?

They told me I had type A blood, but it was a Type O.

Q: Can you describe the individual? A: He was about medium height and had a beard. Q: Was this a male, or a female?

I did a theatrical performance about puns. It was a play on words.

$MBTT USJQ UP UIF $PDB $PMB GBDUPSZ * IPQF UIFSFhT OP QPQ RVJ[ &OFSHJ[FS #VOOZ BSSFTUFE $IBSHFE XJUI battery. I didn't like my beard at first. Then it grew on me. What do you call a dinosaur with an FYUFOTJWF WPDBCVMBSZ " UIFTBVSVT When you get a bladder infection, urine trouble.

Q Q Theyâ&#x20AC;&#x2122;re Not Kidding Two Guys are out hunting, and as they are walking along they come upon a huge hole in the ground. 5IFZ BQQSPBDI JU BOE BSF BNB[FE CZ UIF TJ[F PG JU The first Guy says, "Wow, that's some hole; I can't even see the bottom. I wonder how deep it is." The second Guy says," I don't know, let's throw something down and listen and see how long it takes to hit bottom." The first Guy says, "There's this old truck HFBSCPY IFSF HJWF NF B IBOE BOE XFhMM throw it in and see". So they pick it up and carry it over, and count one, and two and three, and throw it in the hole. They are standing there listening and looking over the edge and they hear a rustling in the bushes behind them. As they turn around they see a goat come crashing through the bushes, run up to the hole and with no hesitation, jump in head first. While they are standing there looking at each other, looking in the hole and trying to figure out what that was all about, an old farmer walks up. "Say there," says the farmer, "you fellas didn't happen to see my goat around here anywhere, did you?" The first Guy says, " Funny you should ask, but we were just standing here a minute ago and a goat came running out of the bushes doin' about a hundred miles an hour and jumped head first into this hole here!" The old farmer said, "That's impossible, I IBE IJN DIBJOFE UP B HFBSCPY

Q Q Quickies Why is Cinderella no good at sports? Because her coach is a pumpkin, and she is always running away from the ball! What did the chicken say to the duck when the duck was about to cross the road? 'Don't do it! They will never let you forget it!' What's old, grey and still hiding in the cupboard? A hide and seek champion! Why do black widow spiders kill their males after mating? To stop the snoring before it starts.

What does a clock do when it's hungry? It goes back four seconds.

medicalforum

Competitions

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

Family: Slavaâ&#x20AC;&#x2122;s Snowshow The renowned Russian clown Slava Polunin returns to the Regal Theatre in Subiaco showering audiences with laughs and magic in his internationally acclaimed Slavaâ&#x20AC;&#x2122;s Snow Show. " CFE CFDPNFT B CPBU JO B TUPSN UPTTFE TFB B XPNBO JT wrapped in cellophane and becomes flowers in a vase; a DIJME XBMLT JO BNB[FNFOU JOTJEF B CVCCMF o XFMDPNF UP UIJT fantastical world. Regal Theatre, July 31. Season continues until August 4

Movie: Before Midnight Opera: Don Giovanni Don Giovanni is one of opera's most shameless and charm ing seducers brought to life by New Zealand baritone Teddy 5BIV 3IPEFT JO UIJT TFYZ QSPEVDUJPO GSPN 8FTU "VTUSBMJBO 0QFSB 'SPN UIF PQFOJOH TDFOF PG UIJT NVDI MPWFE .P[BSU opera, the reckless libertine and his bumbling attendant -FQPSFMMP +BNFT $MBZUPO DSBTI GSPN POF TIPDLJOH TJUVBUJPO UP UIF OFYU His Majesty's Theatre, July 16. Shows also on July 18, 20, 23, 25, 27

Theatre: Other Desert Cities Black Swan Theatre Company presents this newly NJOUFE "NFSJDBO QMBZ CZ +PO 3PCJO #BJU[ XIJDI IBT everyone raving. Nominated for five Tony Awards BOE UIF 1VMJU[FS 1SJ[F GPS ESBNB Other Desert Cities QMVNCT UIF EFQUIT PG B NJEEMF DMBTT GBNJMZ UP DSBDL open its murky secrets. Brooke returns home and announces to her parents that she is going to publish a memoir. It unravels from there. Heath Ledger Theatre, July 20. Season continues until August 4

WASO Event: Lord of the Rings

Lavina a Gold Standard

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The West Australian Symphony Orchestra creates the magic of the movies live at this special event at the Riverside Theatre. The epic first episode of Peter Jacksonâ&#x20AC;&#x2122;s film trilogy will screen with the WASO, the WASO Chorus and the St Georgeâ&#x20AC;&#x2122;s Cathedral Choristers performing the Howard Shore soundtrack MJWF $POEVDUPS -VEXJH 8JDLJ QVMMT UIFN BMUPHFUIFS Riverside Theatre, PCEC, June 21. Second performance June 22

Here is an alluring love story between Jesse (Ethan Hawke) and Celine (Julie Delpy), who met as strangers on a train bound for Vienna 20 years earlier. Now on a blissful summer idyll in Greece, theyâ&#x20AC;&#x2122;re wrestling with life and love and new responsibilities, while trying to LFFQ UIFJS PXO ESFBNT BMJWF %JSFDUPS 3JDIBSE -JOLMBUFS DPOUJOVFT UIJT FODIBOUJOH UBMF BGUFS UIF NVDI MPWFE Before Sunrise and Before Sunset. At once a great romance and a hilarious and wondrously wise story about relationships, Before Midnight is truly madly, deeply perfect. In Cinemas, July 18

WINNERS FROM THE FEBRUARY ISSUE Bell Shakespeare's Henry 4 â&#x20AC;&#x201C; theatre: Dr Stephen Massey Operamania â&#x20AC;&#x201C; theatre: Dr Jen Martins Kon Tiki â&#x20AC;&#x201C; movie: %S 4BSB $IJTIPMN %S )FMFO 4MBUUFSZ %S #JCBOB 5JF %S .BSJBO 8FMTI %S (MFOO -JFX Dr Kamlesh Bhatt, Dr Melanie Chen, Dr Ruby Chan, Dr Ian Walpole & Dr Ernest Tan The Company You Keep â&#x20AC;&#x201C; movie: Dr Tobias Strunk, Dr Amy Gates, Dr Hock C Chua, Dr Byrne Redgrave, %S .BY 5SBVC %S 7BOFTTB 1FSDJWBM %S "OESFFB )BSTBOZJ %S #PFZ -FOH -PZ %S $SBJH 4DIXBC %S .JDIBFM -FVOH

Death of a Salesman â&#x20AC;&#x201C; theatre: Dr Jennifer Sisson, Dr Weng Chin, Dr Meg Ritchie & Dr Mandy Croft

APRIL 2013

Drift â&#x20AC;&#x201C; movie: %S #SBOLB .BOEJD %S &SOTU %F +POH %S 5POZ $POOFMM %S 1FUFS .FMWJMM 4NJUI %S .PJSB 8FTUNPSF Dr Kym Phillips, Dr May Ann Ho, Dr Kevin Kwan, Dr Andrew Toffoli & Dr Caroline Chin

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April 2013

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medical forum ANAESTHETIST

RURAL POSITIONS VACANT

MT LAWLEY Dynamic specialist anaesthetist(s) required to replace retiring member. Share rooms with long established hospital based group. There will be no joining fee. Accreditation at Mercy Hospital is mandatory. Computerised billing system with excellent administrative/secretarial support. For further information please call Lorraine on (08) 9370 9733

ALBANY VR GP required to join our 4 Doctor, busy, friendly family practice. Full or Part time. We are Accredited, computerised, full nurse support, experienced Admin team. Excellent remuneration. Clinipath pathology on site. Phone Gaye - Practice Manager 9841 6711 Email: admin@hillsidefp.com.au

BOARD MEMBER WANTED BOARD MEMBER WANTED Fremantle Women’s Health Centre seeks a female GP (VR) as a Board member. This is a voluntary position that would suit someone with expertise in women’s health medicine and an interest in the governance of a not-for-profit organisation. FWHC is a community facility providing medical and counselling services, health education and group activities. The Board currently has 8 members who are responsible for the governance and strategic direction of the organisation and meets monthly. For more information check www.fwhc.org.au or Contact Diane Snooks 9431 0500 / director@fwhc.org.au

GENERAL Medical Transcriptionist/Typist available after hours. High quality, professional service. All work proofread. 24/7 turnaround. Contact: lyn@expertypetranscriptions.com

FOR LEASE AVELEY Suitable for dental practice and/or allied health services (eg. Physiotherapy, Psychology, Podiatrist, Radiology etc). Medical centre located in the same building. Located in a fast growing community beside a shopping centre, close to secondary schools, primary schools, church and Child Care Centre. Contact: 0400 814 091 NEDLANDS Hollywood Medical Centre- Sessional suites available with Secretarial support if required. Please contact 0414 780 751 MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to admin@ sleepmed.com.au JOONDALUP Modern sessional suites available in Joondalup CDB Secretarial support available if required. Phone 9300 3380

MANDURAH SPECIALIST CENTRE Fully furnished consulting suites are now available on a sessional basis in the new Mandurah Specialist Centre. Reception support available if required. Phone: Graeme Dedman on 0413 065 009 Email: graemed@wacardiology.com.au ROCKINGHAM Sessional room for rent in specialist medical centre in central Rockingham. Choice of two rooms, medical or allied health with communal patient waiting room. Reception staff not available. Sessions are four hours and currently available a.m. and p.m. $120 plus GST per session for allied health room and $160 plus GST per session for medical consult room, negotiable. Contact Julie Neet, Practice Manager at julieneet@drbillpatton.com.au Telephone 9528 1511 (select option 0) Tuesday – Thursday mornings after 9.30 am

WEST LEEDERVILLE Specialists Consulting Suite (waiting room, office, consulting rooms). Onsite parking. Easy access to freeway. Phone: 9380 6457

FOR SALE MEDICAL SUITE(S) 10 McCOURT STREET WEST LEEDERVILLE These well located 61sqm medical suite(s) with two car bays each are located opposite St John of God Hospital and ready for immediate occupation. GORDON TUCKER R/E 0408 093 731 gtrealestate@iinet.net.au

PRACTICE FOR SALE OR LEASE WEST PERTH Lincoln House, Ventnor Avenue, WEST PERTH 35 sqm Office area 1 undercover car bay Onsite Pharmacy and Café Suit Medical Practitioner. Contact Lee Taylor on 0434 520 036 to arrange a viewing. Darrell Crouch & Associates Pty Ltd. (08)9242 3000 Email: leet@crouchgroup.biz web: www.crouchgroup.biz

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URBAN POSITIONS VACANT PALMYRA Palin Street Family Practice requires a full or part-time VR GP. We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens. Earn 65% of mixed billings. For further information call Lyn on 9319 1577 or Dr Paul Babich on 0401 265 881

MELVILLE Rare chance for happy and motivated GP to replace long-term colleague moving soon from our stable, unique & boutique private, 6 Dr, General Practice here in Melville. Great Staff, Nursing & Allied Health support. Confidential enquiries welcomed to Robyn (Mgr) Tel: 9330 3922 a/h 0417 920 525 Email: health4u@westnet.com.au FREMANTLE General Practice in Fremantle requires VR GP FT or PT for privately owned family practice. Accredited, computerised with fulltime Nurse support available. 65% of billings. Phone: Practice Manager 9336 3665 BEACONSFIELD Well established, niche family friendly practice seeking VR Female GP to work flexible days and hours. Fully computerised and accredited. Good mix of private and bulk billing. Please contact Practice Manager Linda on 9335 9884 or Email: centralavenuemc@optusnet.com.au ARMADALE Wanted VR/Non VR Female Doctors DWS/Aon Area Outer Metropolitan Perth Phone: Kerry 9498 1099 Email: sevilledrive@medicalcentral.com.au SOUTH PERTH VR GP required FT & PT Excellent River location in South Perth. Non-corporate, private billing, fully computerised. Friendly and efficient support staff. F/T registered nurse and onsite pathology. For more information contact Paris on 9367 1185. Email: bhabibi@bigpond.com

FREMANTLE Fremantle Women’s Health Centre requires a female GP (VR) to provide medical services in the area of women’s health 1or 2 days pw. It is a computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical and counselling services, health education and group activities in a relaxed friendly setting. Phone: 9431 0500 or Email: Diane Snooks - director@fwhc.org.au or Dawn Needham clinical-manager@fwhc.org.au WEST LEEDERVILLE - GREAT LIFESTYLE Part time VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: practicemanager@eftel.net.au or Jacky 9381 7111 CANNING VALE Part time VR doctor wanted to join very busy family practice. Fully computerised, excellent treatment room with full nursing support. Opportunity to extend hours in the near future. Email your resume to kate.westlake@canningvalemedical.com or telephone Neda 0414 641 963 MIRRABOOKA Mirrabooka Medical Centre F/T Female VR GP wanted for busy and diverse practice. This recently renovated medical centre offers a well-equipped 6 bay treatment room, 2 procedure rooms, 12 consult rooms and onsite Pathology. Newly renovated car park and bus station nearby. You will be supported by a professional network consisting of Administration, Nurses and Practice Manager. For all confidential enquiries, please contact esther.mortimer@ipnet.com.au or 0418 371 724 SOUTH PERTH VR GP required FT & PT Excellent River location in South Perth. Non-corporate, private billing, fully computerised. Friendly and efficient support staff. F/T registered nurse and onsite pathology. For more information contact Paris on 9367 1185. Email: bhabibi@bigpond.com NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. Ring Helen 9227 0170

JULY 2013 - next deadline 12md Thursday 13th June - Tel 9203 5222 or jen@mforum.com.au

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HILLARYS Exciting Opportunity. Join us in our brand new General Practice located NOR. Non-corporate. We require a full-time or part-time GP for our practice. Hours to suit. No evening or weekend work required. The practice is fully computerised and well equipped. Private Billing and some bulk-billing Full-time Nursing support. Pathology on site. Please contact Practice Manager on 9448 4815 or Email: smc@westnet.com.au WEMBLEY GP wanted for long established private, accredited Wembley Practice. Sessions are negotiable but ideally Thurs/ Fri am or Mon to Fri pm or part thereof. Our practice is fully computerised using Med Director/Pracsoft. Practice Nurse on site, pathology and theatre. Adjacent services include Physiotherapist, Podiatrist, Psychologist and Dietician including diabetic educator. Please phone Pauline on 9381 9010 Email: wembleygp@westnet.com.au WINTHROP/MURDOCH Full time/Part time VR GPs needed to join Hatherley Medical Centre. No longer Corporate and reopening in March 2013 with very experienced GP. Had been open for over 20 yrs and become a successful 8 doctor practice. Services a large private billing underserviced area. Purpose built centre, well-equipped with on-site procedural room, large nursing station, pathology, physiotherapy, pharmacy and dental. Please call 0400 364 901 and get in early. BAYSWATER Wanted General Practitioner (VR) F/T or P/T required within our friendly non corporate medical practice. We are a fully computerised, wellequipped, teaching, accredited general practice seeking an enthusiastic person to join our team with a view in assisting our growing patient load. We are a proudly independent practice which offers a friendly environment, flexible working hours, pleasant rooms, great staff, with wonderful patients. Email resume to: manager@walterrdegps.com.au or Fax: 9279 1390 QUEENS PARK Looking for GP VR to join our growing medical centre. Efficient, helpful admin staff and RN support. Mixed billing, excellent facilities, accredited and fully computerised. On-site physiotherapy, occupational health and pathology. Please phone Tim 9356 8993 Email:admin@queensparkmedical.com.au Website: www.queensparkmedical.com.au

MT HAWTHORN Mt Hawthorn Medical Centre, a noncorporate accredited long established practice situated in a fast growing inner city suburb of Perth, seeks a part time or full time VR GP to join this highly desirable practice. Fully computerised, Nurse Assistant. Phone Rose 9444 1644 BIBRA LAKE PT/FT VR GP with/without view to replace PT female Dr in a small privately owned 2 person accredited private billing practice in Bibra Lake. The practice is computerised, and has nursing and pathology support. For further information contact Ashley on 0417 181 070 Email: ashleyr@iinet.net.au

WEST PERTH GP sessions available at our private-billing, accredited and fully computerised general practice. Our busy practice serves a young, professional demographic as well as providing specialist sexual health services. This represents an exciting opportunity for an enthusiastic practitioner to join our friendly team. Morning and afternoon sessions are available. Experience in family planning, sexual health and mental health would be an advantage. Contact Stephen on 0411-223-120 Email: stephen@estperthmedicalcentre.com.au

UNIVERSITY OF WESTERN AUSTRALIA, CRAWLEY VR GP required for our fully computerised, accredited, well equipped and newly renovated practice. Our busy centre is complimented with full time nursing staff, Mental Health Nurses, Physiotherapy and onsite Pathology and Pharmacy Sessions negotiable - no evening or weekend work required. Very friendly team, attractive remuneration and free, reserved bay parking on campus. Please contact Judi Hicks, Practice Manager, judith.hicks@uwa.edu.au or Dr Christine Pascott christine.pascott@uwa.edu.au Ph: 6488 2118 COCKBURN CENTRAL VR P/T Female GP Small Boutique Private Practice Fully Computerised Fantastic work environment and support Nurse Available Please call Ely on 9417 3337 Email: drpatel@medivive.com.au SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979

MIRRABOOKA Full time / Part time GP required for a very busy practice in Mirrabooka. VR preferred. 75% Private and Bulk Billing Applications can be made via Email: mds@mirrabookadoctors.com.au or calling 0400 814 091

INGLEWOOD / Mt LAWLEY GPs Required for Skin Checks Unique opportunity to join a busy noncorporate skin cancer practice. Friendly atmosphere with strong emphasis on quality and patient service. Urgent need for VR doctors to perform skin checks. No dermoscopy experience required. Flexibility to explore any area of skin cancer medicine of your choosing, from dermoscopy, biopsies, to surgical procedures. Fully computerised, with modern facilities and nurse support. Great peer support with continuing education and training. Suit VR doctors looking for reduced paperwork, flexible hours and above average income. Please contact admin@skincheckwa.com.au BENTLEY GP VR needed for privately owned family orientated practice. 15mins from Perth CBD, AGPAL accredited, fully computerised using MD/ Pracsoft. Private billing. Supported by clinical and CDM nurses operating from purpose built practice. We offer 65% of billings. Contact Alison on 0401 047 063

Australian Skin Cancer Clinics Specialise in Skin Health in Western Australia t CANNINGTON t -&..*/( .63%0$)

Great opportunities for experienced GPs to join these two busy Australian Skin Cancer Clinics. t 'MFYJCMF XPSLJOH IPVST UP TVJU your lifestyle; t (SFBU FBSOJOH QPUFOUJBM t .PEFSO XFMM FRVJQQFE DMJOJD t 1SPGFTTJPOBM BENJOJTUSBUJPO BOE practice management staff; These are not DWS listed sites. For more information please contact Fiona James on 0447 006 846 or fiona.james@ipnet.com.au www.ausskinclinics.com.au/

AGED CARE Medical Practitioners for Aged Care Service - Compassion – Efficiency Medical Practitioners for Aged Care (MPFAC) is seeking Medical Practitioners to join our expanding service to Residential Aged Care Facilities (RACF) throughout the Perth metro area. Our aim is to provide a compassionate and evidence based medical care to RACF. t .1'"$ QSPWJEFT GMFYJCMF XPSL PQUJPOT t 3FNPUF MPH JO UP QBUJFOU SFDPSET and appointment scheduling t /VSTJOH BOE "MMJFE )FBMUI Care support t .1'"$ NFUIPEPMPHZ VUJMJTFT the doctor’s time and resources more effectively t &GGJDJFOU PQFSBUJPOBM TVQQPSU FOTVSFT rewarding outcomes for doctor For more information or confidential interview please contact Rollo Witton – CEO Mobile 0417 921 632 Email: rollo@gpagedcare.com.au

APPLECROSS FULL TIME GP wanted. A rare opportunity to join Reynolds Rd 7 Day Medical Centre has just presented itself as a long term colleague moves out of general practice. Commencing now, don’t miss out on your chance to join this private billing, vibrant practice with immediate access to a full patient data base. Confidential enquiries to the practice manager 9364 6633. MADDINGTON Maddington (DWS) is looking for a VR full-time GP. This privately owned and managed practice will offer up to75% billing to the right doctor. Various locations North, South and CBD also available. Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com KWINANA VR GP Full Time or Part Time required for GP owned practice in an excellent location (centre of Kwinana). We are fully equipped and have excellent nursing and admin support. On site allied health, pharmacy and pathology. Mixed billing. Fully accredited. Contact practice manager Bili. Phone: 9419 2122 Email: chishamave@westnet.com.au

Reach every known practising doctor in WA through Medical Forum Classifieds...

JULY 2013 - next deadline 12md Thursday 13th June - Tel 9203 5222 or jen@mforum.com.au

medical forum NEDLANDS Full time or sessions available for VR GP in brand new 2-doctor, non-corporate practice in shopping centre Predominantly private billing, weekends optional. Close to UWA. Onsite practice nurse, pharmacy, physiotherapy, podiatry and dietitian in shopping centre. Please contact Vasanthi at 0402 440 966 Email: nedlandsdoctor@yahoo.com.au WOODLANDS P/T or F/T VR GP wanted to join happy, non-corporate, mainly private billing practice. Good mix of patients, no weekends or afterhours. Great location, RN support. Would suit female GP. Contact help@thewoodsmedical.com.au or 9204 3900 GOLDEN BAY PT female GP required. Fully computerised, DWS, private/bulkbilling, Fully accredited, Practice Nurse, onsite pathology. Contact: Sheelagh 08 9537 3738 Email CV to: pracman@eftel.net.au

FREMANTLE Part time or Full time (preferably VR) GPs wanted. ELLEN HEALTH is a doctor-owned and managed General Practice operating from two locations in port city of Fremantle. Well established patient base, offering a broad suite of services including nutrition and lifestyle, specialised pregnancy and midwifery care, community mental health nursing and skin clinic consultations. If you were to join our team we will offer you: t " HSPXJOH EBUBCBTF PG 1SJWBUF Billing patients t " QSPGFTTJPOBM BOE EFEJDBUFE support team t " MJGFTUZMF UBJMPSFE UP UIF MPDBUJPO t )PVST PG XPSL UP TVJU PVS CBMBODFE lifestyle approach - Practice hours are Weekdays 8am-6pm, Saturday, 8am-4pm - No after hours, on-call or hospital work required at this time t )JHI MFWFM PG FBSOJOHT Contact Practice Manager Bridie Hutton 0413 994 484 Email: bridie.hutton@ellenhealth.com.au

DIANELLA Non Corporate practice requires F/T and P/T VR GP’s to join 6 female and 1 male doctor team. Our newly extended, long established, accredited, fully computerised practice is supported with 4 excellent nurses and 5 very friendly admin staff. Our practice is mostly private billing and we offer excellent remuneration. Please contact Practice Manager on 9276 3472 Email: dfmc@dianellamedical.com.au GREENWOOD Greenwood/Kingsley Family Practice In today’s market where there is an oversupply of GPs, are you feeling frustrated that you have to work exceedingly long hours and with little take home income? Are you pressurised to bulk-bill in order to stay afloat on today’s competitive GP market? Are you committed to offer quality personalised services to your patients? Are you to looking for likeminded GPs to work with? Come and have an obligation free confidential chat with us. Average gross billing $ 2500 to $ 3000 a day achievable for GPs who offer exceptional services to our clients. Contact Dr Chao 0402 201 311 or Email:shenychao@hotmail.com Sorry we do not have DWS status.

KARDINYA Kelso Medical Group requires P/T and/ or F/T GP This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest in CDM and minor surgical procedures. Located in Kardinya in newly refurbished premises with onsite pathology and allied health with growing patient base. Currently supported by 7 GP’s and 3 RN’s . www.kelsomg.com.au Please call 0419 959 246 for further information. MANDURAH Mandurah coastal lifestyle 40 minutes from Perth. VR non VR doctor required short term or long term. No weekends or after hours. Good remuneration. Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist and orthotics. Contact practice manager Elaine 9535 8700 Email: elaine@mandurahdoctors.com.au CANNING VALE Seeking GP’s to work in a new purpose built practice in Canning Vale. Modern, fully computerised and equipped with a Practice Nurse available. Also Pathology and Dental onsite. Please forward interest to ahgpcvale@ gmail.com or Contact the Practice Manager on 0416 022 721

With a reputation built on quality ality of service, Optima Press has the WKH resources, the people and the e commitment to provide every client y client with the finest printing and value DOXH IRU for money.

What’s on Offer? This is an opportunity for a Doctor to become a part of our team of health professionals who have a passion for travel and a keen interest in international health and travel medicine. This clinic is located in the heart of Perth CBD.

Who we are The Travel Doctor – TMVC is the travel health line of business with Medibank Health Solutions, and provides services to both retail and corporate travellers. Services include health advice and preparation as well as medical assessments.

9 Carbon Court, Osborne Park 6017 Tel 9445 8380

The Role The Travel Doctor – TMVC is the travel health line of business with Medibank Health Solutions, and provides services to both retail and corporate travellers. Services include health advice and preparation as well as medical assessments.

Who we are An opportunity exists for a Doctor to join our excellent team of health professionals; providing travel health services and advice to both the retail and corporate markets. Training is provided and we continuously encourage ongoing education. We have a nationally established network of travel clinics that provide excellent support and good incentives are on offer. Sessional hours are available, as well as Part Time hours. Day to day you will conduct travel medicine consultations and medical examinations as well as being exposed to travel, tropical and occupational medicine. To be successful in this role you will ideally have a background in General Practice, Travel Medicine, Tropical Health or preventative medicine. You will be medically registered and have an unrestricted provider number.

In return Enjoy the beneﬁts of working in a collegial environment for an established business. Medibank Health Solutions offers a dynamic working environment with real variability. We encourage and support continuous professional growth and development and focus on striking a strong work life balance. You won’t be required to work long shifts.

To apply, please visit our website submit your resume via email to anthony.pace@medibankhealth.com.au

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

9791 8133 or 0418 921 073

JULY 2013 - next deadline 12md Thursday 13th June - Tel 9203 5222 or jen@mforum.com.au

medical forum

Make a difference in country WA

CVS are a leading cardiology practice that provides high quality diagnostic stress testing services. We are seeking medical practitioners who meet the following pre-requisites: Â&#x2021; 5HJLVWUDWLRQ ZLWK WKH $XVWUDOLDQ 0HGLFDO %RDUG Â&#x2021; 0HGLFDO ,QGHPQLW\ ,QVXUDQFH Â&#x2021; /LIH 6XSSRUW 6NLOOV RU H[SHULHQFH Â&#x2021; +LJK UHJDUG WR GHOLYHU RXWVWDQGLQJ SDWLHQW FDUH

Rural Health Select has vacancies for locums throughout Western Australia.

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Are you looking to buy a medical practice? As WAâ&#x20AC;&#x2122;s only specialised medical business broker we have helped many buyers find medical practices that match their experience.

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enjoy ďŹ&#x201A;exible hours, less paperwork, & interesting variety...

Equipment Provided - WADMS is a Doctorsâ&#x20AC;&#x2122; cooperative Essential qualifications: s General medical registration. s Minimum of two years post-graduate experience. s Accident and Emergency, Paediatrics & some GP experience. Fee for service (low commission).sĂĽ Non VR access to VR rebates. 8-9hr shifts, day or night. sĂĽ Bonus incentives paid. 24hr Home visiting services. sĂĽ Interesting work environment. Access to Provider numbers.

Contact Trudy Mailey at WADMS

(08) 9321 9133

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

For further information please contact Rural Health Select on T 08 6389 4500 | E locums@ruralhealthwest.com.au.

www.ruralhealthselect.com.au

Become a foundation doctor with Apollo Health. 3 positions remaining.

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

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Travel and accommodation covered Administration support provided Upskilling available Locum subsidy available

Brad Potter on 0411 185 006

Weâ&#x20AC;&#x2122;ll take care of all the bits and pieces and youâ&#x20AC;&#x2122;ll benefit from our experience to ensure a smooth transition.

take home,

To find a practice that meets your needs, call:

Youâ&#x20AC;&#x2122;ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision.

85%

If you can help a rural and remote community, contact us today!

Supplement your income: Are you working towards the RACGP? â&#x20AC;&#x201C; we have access to provider number for After Hours work. Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.

Apollo is new healthcare group being established in Perth. We aim to push the boundaries of primary care through the provision of state of the art facilities offering a broad range of fully integrated healthcare services. Our ďŹ rst two sites open shortly in Armadale and Cannington. We offer the opportunity to be part of this exciting project and to help shape its future. We are particularly interested in hearing from individuals with ideas on how to do thing differently and do them better. We plan to encourage innovation and are always looking to improve. We have particular interest in doctors who wish to help us develop speciďŹ c treatment modules in areas such as womenâ&#x20AC;&#x2122;s health, walk-in urgent care, musculoskeletal and sports medicine, skin cancer treatment, chronic disease management, back pain, nutritional medicine and weight loss. We are offering certain incentives to our foundation doctors that will not be available in the future, acknowledging that it is a brave move to join something new.

If interested, we would love to hear from you. To arrange a conďŹ dential chat with our Medical Director please email: ofďŹ ce@apollohealth.biz

JULY 2013 - next deadline 12md Thursday 13th June - Tel 9203 5222 or jen@mforum.com.au

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TKHUH V QHYHU EHHQ D EHWWHU WLPH WR VZLWFK WR 'RFWRUVn +HDOWK )XQG Join today at www.doctorshealthfund.com.au or call us on 1800 226 126. *Avant will subsidise 15% of your Doctors' Health Fund private health insurance premiums for the first 12 months, provided that you join Doctors' Health Fund by June 30, 2013. The offer is only open to Avant members who are eligible to join the Doctors' Health Fund restricted access group as set out in the Schedule to the Private Health Insurance (Registration) Rules 2009 (No 2) (Cth). The offer is not open to Avant members who are already Doctors' Health Fund private health insurance policy holders as at October 31, 2012. This offer is made by Avant and not by the Doctors' Health Fund and this offer does not apply to any other products or services issued or provided by Avant or its related bodies corporate. For full Terms & Conditions, please refer to www.doctorshealthfund.com.au.

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