Medical Forum 02-13 by Medical Forum WA

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CONTENTS FEATURES

GUEST COLUMNS

6 Todd Jefferis, St

16 Power of Positive

Andrew’s Hostel Whistle-blower

Thought Prof Stephan Millett

26 Doctors Crucial in

12 GP Groups in WA

Pension Process

20 Chief Medical Officer

Dr Gary Geelhoed 36 Medical Innovations

and Trends

NEWS & VIEWS 2 Letters to the Editor: Treating Patients at Home: Dr Gene Mettimano; Devolving COPD to community care: A/Prof Peter Kendall; Protecting Rights of Senior Doctors: Dr K C Wan, Medical Board Response: Dr Joanna Flynn; General Practice training capacity: Dr Janice Bell

10 Have You Heard? 13 Medicare Locals...

Who, What, When 14 RACGP WA Directions

Dr Mike Jones

29 Drug Policy Needs

Debate Mr Paul Dessauer

33 End of the Inner

Urban General Practice? Dr Peter Winterton

43 No Flies on Him? Dr Ian Dadour

CLINICAL FOCUS 5 Floppy Mitral Valve Dr Andre Kozlowski

15 Primary Care Research

7 Bruising Dr Ram Tampi

42 Q&A: Pulmonary

Embolism Prof Richard Mendelson & Dr Kay-Vin Lam

42 Endoscopic Ultrasound Dr Andre Chong

18 Fair Work

Amendments and You

LIFESTYLE

19 Confidentiality and

STIs

44 Dr Helga Weaving,

31 E-Poll: Doctors Never

Sydney to Hobart

Had it So Good? 32 GP IT Systems 35 Beneath the Drapes 35 Pilbara Surgical Skills

COLUMNS EVENTS

Mr Peter McClelland

46 Kitchen Confidential:

Shannon Wilson 47 Wine Review:

Hillsview Vineyard 48 Photography

Competition: Summer Days

22 Christmas 2012:

Dr Carol McGrath, Dr Robert Davies, Dr Susan Downes, Mr Clive Addison, Dr Gary Dowse, Dr Tony Tropiano, Dr John Williams

Photos 27 Doc of The Swan

2013 30 Doctors Drum

49 Satire: Future’s

Breakfast

Looking Bright

Ms Wendy Wardell

50 2013 Arts Preview Ms Jan Hallam

51 Shakespeare Via

Africa 51 Competitions 51 The Funny Side

medicalforum

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Letters to the Editor

Treating Patients at Home Dear Editor,

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

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au 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

After 22 years in metropolitan general practice, I am now working in Silver Chain's Hospital at The Home program (HATH). My role is to review patients, and assist the nurses, who are the mainstay of HATH. I also hope to make the referral process less onerous for the GP. When in my own practice, I often found it quicker to give the patient a referral letter to take to ED, rather than spend more time making phone calls to Silver Chain. We are all under tremendous time pressure, so human nature means we often do what's quicker and easier, rather than what is best. In that situation, the patient may be admitted to hospital, or end up with HATH after all, having spent many hours in ED, and using up scarce resources there. Most of the patients referred to HATH come via ED. In many cases, they are referred with only sketchy medical information. I know a good GP can do a much better referral, having all the patient's history on hand. Our message to GPs is simple. We can treat many of your patients in the comfort of their own home. Consider referring to HATH cases of DVT or PE, new AF needing anticoagulation, cellulitis, pyelonephritis, pneumonia, mastitis or hyperemesis gravidarum. We can also handle bridging anticoagulation before and after surgical procedures. Phone: 9242 0347 Fax: 9444 7265. We are working hard to make sure that we take as little of your time as possible. A comprehensive referral letter, such as what you would send with the patient to ED, will minimise the time spent on the phone with the HATH liaison nurse. Patient satisfaction with HATH is very high. A couple of extra minutes from you will mean a very happy patient, and will save the health budget a lot of money. Dr Gene Mettimano, Silver Chain’s Hospital at The Home

Devolving COPD to community care Dear Editor, I commend your readers to the articles relating to the Respiratory Health Network's recent forum (Reform Not Running Out of Puff, December edition). Chronic disease has definitely changed over the past 20 years, from a dependence on in-patient and out-patient tertiary hospital management, to predominant out-patient assessment and community based self-management. From the graph, it is clearly evident that with COPD in South Metropolitan Health hospitals, total beddays have reduced steadily over the past decade, and possibly "bottomed out" in the last couple of years.

The steeper decline from Royal Perth Hospital may reflect the COPD Linkage program and the general decline in Fremantle and Rockingham General Hospitals may well reflect a series of contributors. Average Length of Stay (ALOS), long regarded as an important indicator (see above), has reduced. There has been a determined effort to sort out these patients in the outpatient setting, with accurate measurement of lung function, use of basic management plans and, in particular, effective Quit programs and an increasing use of pulmonary rehabilitation programs. Armadale Hospital is the only one in SMHS without such a service and perhaps that is why the line is flat in that region. With fewer admissions to hospital, the only patients who are admitted are, by definition, sicker, such that ALOS is likely to go up. In this context, this measurement is no longer a ‘quality’ indicator in chronic disease. All of this empowers the patient, their general practitioner and community support facilities, such that the major disruptions from hospital admissions are reduced. Further, the paradigm of huge lists of patients with chronic disease in public hospital Outpatients, having recurrent visits, seen by yet another junior doctor, and for no obvious benefit, is long since dated. Western Australia is the most expensive of all States in the delivery of health services. Hopefully the paradigms are shifting. A/Prof Peter Kendall, HOD Respiratory Medicine, Fremantle Hospital

Protecting Rights of Senior Doctors Dear Editor, I read with interest Power of 50 Shades of Grey (Medical Forum, November edition). Subsequently, I wrote to my local Federal MP, Hon. Stephen Smith, asking him to help semi-retired doctors such as myself who practise part-time but who are encountering financial disadvantage and difficulty meeting the new mandatory full medical defence insurance, medical registration fee and Continuing Professional Development (CPD) requirements for renewal of registration with the Medical Board of Australia under the Australian Health Practitioners Regulation Agency (AHPRA). Continued Page 4 medicalforum

medicalforum

Letters to the Editor This could be one of the reasons there is an artificial shortage of doctors because many senior general practitioners and specialists, such as myself, with many years of experience, can’t or don’t choose to renew their registration. This mandatory requirement is a huge waste of expensive human resources and should be of concern to all Australians. The new requirement is quite insulting to doctors who have been competent to practise for many years but unless they achieve the full CPD points are now deemed incompetent. As of 1 July, 2013, 1800 medical practitioners with "Limited Registration Public Interest Occasional Practice (LRPIOP)" will no longer be able to participate effectively in the profession. Legislation has determined that this category will be abolished; it was closed to new entrants from 1 July 2010. Is AHPRA's definition of Practice (any role, whether remunerated or not, in which the individual uses their skills and knowledge as a health practitioner) valid, legally enforceable and are the penalties overwhelmingly punitive? For the purposes of this registration standard, practice is not restricted to the provision of direct clinical care. It also includes using professional knowledge in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services. To make matters worse, the Australasian Faculty of Occupational and Environmental Medicine (AFOEM) require full 100 CPD points every calendar year replacing the previous more reasonable requirement for 500 points averaged over five years. Hopefully the medical profession will be motivated to take some action

However, the Board’s core role is to protect the public, including by upholding professional standards. In this case, the Board believes that the public interest, and the interests of the profession, are best served by making sure that a doctor’s ‘right’ to prescribe and refer is linked to his or her responsibility to provide safe patient care and that, therefore, those who wish to practise must meet the standards for full registration. Across Australia there are about 1200 medical practitioners with limited registration (public interest – occasional practice, LRPIOP). In effect this limited their practice to prescribing and referring. By law, this type of registration was timelimited (to three registration renewals) and only available as a transition to those who held similar types of registration before. For most practitioners, this type of registration will not be available after this year. There are three options for medical practitioners who hold limited registration who wish to continue to practise after their third renewal of registration in the National Scheme: apply for general registration; apply for non-practising registration; or let their registration lapse. The Board will shortly be publishing on its website guidance about these options for practitioners who hold LRPIOP. When making a decision about whether to remain registered, individual practitioners should take into account the Board’s advice about who needs to be registered. This advice about Medical Registration – What does it mean? Who should be registered? – outlines a number of activities such as many teaching and advisory roles, for which registration may not be necessary. The advice is published on the Board’s website at www.medicalboard.gov.au/ Codes-Guidelines-Policies.aspx; also see May 2011 newsletter www.medicalboard. gov.au/News/Newsletters.aspx.

Dr K C Wan, Consultant Occupational Physician

Dr Joanna Flynn, Chair, Medical Board of Australia

Medical Board response Dear Editor, The Board is aware and respectful of the dedicated, highly-professional services that retiring doctors have given to their communities over many years and supports the right of any doctor to continue to use the title ‘doctor’ whether or not he or she maintains registration. The Board understands the depth of feeling about prescribing by retired doctors and recognises that not having a script-pad on hand for the first time in decades can represent a very significant change. 4

GP training capacity Dear Editor, Thank you for your review of GP training capacity issues (December edition), your inspiring report on quality training, and for the opportunity to respond to both. Capacity: At present WAGPET has enough interest from new and existing practices to take interested prevocational and vocational doctors-in-training. Future capacity, however, does need to be carefully managed, as things can change rapidly. All of your contributors have made valid suggestions about how this can be managed. Quality: WAGPET now tracks practice

quality above and beyond the accreditation requirements. We are reassured by the high baseline quality for WAGPET practices and the practices’ self-generated continuous quality improvement activities. This is now embedded in our work together and easily monitored. Red Tape: Streamlined one-stop accreditation for RACGP, ACRRM and (in a pilot) PMCWA, streamlined contracts and up-front payments for our long-standing practices all reduce red tape. However, we are all accountable for taxpayers’ dollars and to both ACRRM and RACGP who have delegated their training obligations to WAGPET and these must be reportable. Funding: It helps that since 2010, WAGPET has significantly increased the funding for relocation, accommodation, travel, supervisor education, external education courses for rural registrars, exam support, external clinical teachers, education resources for practices and infrastructure grants to those taking prevocational doctors. We try to target this funding to regions struggling to attract enough doctors-in-training. Supervisor Training: Registrars now learn to mentor, teach and supervise. Some regions such as the Kimberley as well as larger practices have junior and senior supervisors, so the training continues after fellowship. All supervisors attend training matched to their experience, with increasing flexibility for long-term supervisors with a solid track record. Distribution: Although rural training terms are optional for most registrars, WAGPET has been able to maintain its registrar distribution to rural and remote areas. We are attracting almost as many rural as general applicants now, by choice. That is a significant comment about the quality experience registrars are receiving in rural and remote areas. Additionally, WAGPET will be investing millions in Aboriginal health training over the next three years, as this is another underresourced sector to which WAGPET can help attract registrars. Doctors-in-Training: There is likely to be greater demand for general practice training for OTDs, registrars, prevocational doctors and interns. How we manage this will depend on the relationships we have across the community health care sector and the training pipeline. We will need to better align available training positions into attractive packages, just as WACHS and WAGPET have done for the WA Rural Practice Pathway. What may not be viable as a stand-alone becomes sustainable when combined with other posts across the medical disciplines in one region. Monitoring: Our regional advisory committees monitor capacity on the ground in real time. They have an important say in where, and when, to bring on new practices and posts. Dr Janice Bell, Chair, CEO,WAGPET medicalforum

Floppy Mitral Valve M

itral Valve Prolapse (syn. Barlowâ&#x20AC;&#x2122;s syndrome or â&#x20AC;&#x2DC;floppy valveâ&#x20AC;&#x2122;) affects about 2.5 % of the population if strict echocardiographic criteria are applied but up to 10% if a more liberal interpretation is used. â&#x20AC;&#x2DC;Primaryâ&#x20AC;&#x2122; mitral prolapse should be distinguished from mitral incompetency secondary to other condition; it is often seen after myocardial ischaemia or in cardiomyopathy due to remodelling of the subvalvular apparatus. Clinically mitral prolapse is a highly heterogeneous syndrome, from entirely asymptomatic in two thirds of cases to part of complex cardiac disease with severe consequences in <1% of patients. One third of patients develop palpitation, fatigue, dizziness, syncope and chest pain. Most affected individuals have an excellent prognosis but the condition requires careful assessment and monitoring with echocardiography being the best tool. MVP is twice as common in females, is sporadically genetically linked, and is frequently associated with Marfanâ&#x20AC;&#x2122;s syndrome, Von Villebrandt coagulopathy, connective tissue disease, straight thoracic syndrome, pectus excavatum, ASD, and interestingly with panic attacks. It occasionally co-exists with arrhythmias such as WPW, SVT and long QT syndrome. Classical findings (often incidental) are a systolic click and late-systolic murmur on auscultation, with the delay exaggerated by squatting and shortened during a Valsalva manoeuvre. However, many patients have normal heart sounds. Diagnosis requires an Echo evidence of

redundancy of one or both the mitral cusp of more than 2mm below the line of coaptation during systole. It is usually associated with some degree of valvular incompetency.

Clinical picture The majority of the patients with an incompetent mitral valve remain stable with no or minimal progression; however in 5-10% of cases regurgitation deteriorates into a severe form. The risk of progression is associated with advanced age, degree of regurgitation (MR), LV size and function and the degree of LA dilatation. Ejection fraction below 60% and systolic LV dimension above 40mm in the presence of significant MR should be a warning sign requiring regular assessments as the dynamics of changes is a sensitive indicator of potential deterioration. The degree of MR is often underestimated by highly eccentric jet, no problem for an experienced operator of contemporary echo machines. Recommendations for management.

Assessment and monitoring t "TZNQUPNBUJD QBUJFOUT XJUI DPNQFUFOU valve or mild regurgitation (MR) require yearly medical review and an Echo every 3-5 years. t "TZNQUPNBUJD QBUJFOUT XJUI NPEFSBUF to-severe MR require medical review every six months and Echo every year. t 4FWFSF .3 XJUI TJHOT TZNQUPNT PG deterioration requires evaluation with TOE and occasionally with cardiac catheterization. t 4USFTT &DIP JT SFDPNNFOEFE GPS UIF investigation of chest pain and evaluation

By Dr Andre Kozlowski Cardiologist Dr Andre Kozlowski graduated from Jagiellonian University, Krakow, Poland. He completed his training in all aspect of clinical cardiology with special interest in valvular disease in the major European centres before moving to Australia. He provides consultations in Subiaco and Balcatta rooms in association with Western Cardiology. He currently provides comprehensive cardiac services in his private rooms in SJGH in Bunbury.

of cardiac function in patients with exertional dyspnoea. t 1BMQJUBUJPO EJ[[JOFTT GBJOUJOH PS blackouts may indicate malignant arrhythmia and should be investigated with an ambulatory ECG monitoring (Holter, implantable recorders).

Management t /P USFBUNFOU JG BTZNQUPNBUJD t .71 IBT B MPX SJTL PG FOEPDBSEJUJT (not exceeding 4%) and routine prophylaxis with antibiotics is not recommended but as in any valvular disease this should be considered during any procedures with high risk of infection or in patients with past history of infective endocarditis. t "USJBM GJCSJMMBUJPO JODMVEJOH paroxysmal) carries a similar risk of stroke as in the general population. Antiplatelet or anticoagulation treatment BT SFDPNNFOEFE BDDPSEJOH UP $)"%4 CHA2DS2-VASc and HES- BLED risk stratification. According to current recommendation Warfarin is the only agent approved for treatment in patients requiring anticoagulation as no firm data are available regarding the safety and efficacy of new anticoagulants such as dabigatran, rivaroxaban and apixaban in patients with valvular disease and AF. t 4ZNQUPNBUJD QBUJFOUT XJUI TFWFSF .3 worsening LV size and function and with pulmonary hypertension may require valvular repair (surgical valvuloplasty or percutaneously using MitraClipTM) or replacement.

Q Echocardiogram of mitral valve prolapse with "warning signs" â&#x20AC;&#x201C; aneurysmatic deformation of the posterior cusp with redundancy 23 mm below the line of coaptation (small arrow), severe regurgitation (MR) into a markedly dilated left atrium (LA), eccentric regurgitant jet (large arrow) directed towards the intra-atrial septum, plus dilated left ventricle (LV).

medicalforum

t $PNQFUJUJWF TQPSU JT OPU SFDPNNFOEFE for patients with LV dilatation, dysfunction, poorly controlled arrhythmia, long QT, and with a IJTUPSZ PG TZODPQF PS DBSEJBD BSSFTU resuscitation.

Feature

We Must Protect Our Kids Todd Jefferis road to justice has taken 22 years. Now the boy who blew the whistle on Dennis McKenna’s child sex abuse at a Katanning student hostel is ready to move on. The boy who spoke out has become a 40 year-old man who has pushed uphill all the way for justice – for himself and the other victims of McKenna. Todd Jefferis has had to move on, but there’s a piece of him that will be forever a scared 17-yearold schoolboy who lay in bed one night at the school hostel and decided that ‘enough was enough’. He said of that night, three options presented themselves to him – he could kill himself, do and say nothing or stand up. “I decided to stand up. It was a difficult thing to get my head around, but for better or worse, I made it, and I’ve had to make the best of it. It wasn’t long after I made the decision to speak up that I wished I hadn’t, in some respects. It was bloody awful at the time but when I look back at it now, it turned out to be the only decision because in the end we took the bastard down. And he was stopped.” “There were so many people before me who had to the opportunity to speak out and didn’t, and I can see why they didn’t. I’m mentally tough; my mum is a strong person and gave me those tools. She didn’t doubt me for a second but my father wasn’t strong enough for that fight. He would have walked away quietly, but mum showed me not to back away.” The fight turned into a long battle that culminated in last year’s Blaxell inquiry, which heard testimony from some of McKenna’s victims as well as former school principal Ian Murray and former chairman of the Country High School Hostels Authority, Colin Philpott. Six months on from Judge Blaxell’s findings, where he called for a formal complaints system for children and schools to deliver protective behaviours programs among other things, Todd and his wife Becki have embarked on a personal campaign to see that those educational programs become mandatory. “Kids from kindy to Year 10 need to be taught about the behaviours of child predators so they can recognise the signs. They need to understand what is right and wrong, what is appropriate and inappropriate contact and that their bodies are untouchable. I know it’s harsh, and kids are innocent, but it’s their innocence that’s preyed upon. These predators rely on this innocence. By teaching kids, you’re giving power back to them.” “The Blaxell recommendations are a good

Q Todd Jefferis with his wife Becki and children

If every one of those Katanning kids had gone through one of those education programs, they would have all walked back across the road and gone … ‘f****** hell, here’s the one that we’ve been learning about’. step in the right direction but it needs to go a lot further.” Todd has been in contact with awardwinning Carnarvon police officer Andrea Musulin, who has been delivering a protective behaviours program on the School of the Air. “This program is on the Education Department portal but it hasn’t been picked up by everyone. I have encouraged our local member for Albany, Peter Watson, to take this issue up. I’d like to see the government allocate funds for training teachers who want to specialise in this field and travel around to schools teaching this properly,” Todd said. The other aspect that has given him heart is the independent complaints line, which has been set up so children and adults can come forward with legal impunity. “The threat of defamation was one of McKenna’s tools and he used it to

maximum effect, again and again. The complaints line will encourage kids to speak out and educate them about where to go, what they can do and who they can talk to. This openness takes away a lot of those little dark areas where paedophiles hide and operate in.” “Someone asked me on radio that if we had been educated, would McKenna have gotten away with it for so long, and my answer was no, he wouldn’t have. If every one of those Katanning kids had gone through one of those education programs, they would have all walked back across the road and gone … ‘f****** hell, here’s the one that we’ve been learning about’. It would have been that simple.” “You have to educate that there’s strength in numbers. The boys were all too scared to talk about it to each other because everyone was very much under the spell of this person. Psychologically he had everyone beat.” That strength in numbers wasn’t afforded to Todd, who as a 17-year-old had to face enormous opposition from people in authority. He said just two of the school’s teachers would speak to him when he returned to school after making the allegation, and malicious rumours began circulating that he had been caught stealing. Only his mother, and eventually his father Continued Page 8

medicalforum

Bruising Bruises are caused by traumatic injury to tissue resulting in damaged underlying blood vessels and with consequent extravasation into the surrounding tissue. Such lesions are non-blanching and fall into the category of ecchymosis (1-3cm in diameter), purpura (3mm-1cm) or petechiae that are much finer. Often the location of extended bruising may indicate an underlying bleeding disorder, such as large ecchymosis on the trunk without known trauma, whereas minor bruising on the extremities is more likely to be benign. Extensive truncal ecchymosis may suggest an acquired coagulation disorder such as liver disease, intravascular coagulation (DIC) or acquired haemophilia. Some generalisations can be made: bruising tends to occur more often in females and those with lighter complexions; and in older people bruising can occur because of laxity of the underlying vascular supporting structures, permitting rupture of small blood vessels.

Causes of Ecchymosis (1-3cm)

Dr Ram Tampi Clinical Haematologist

Causes of Purpura (3mm-1cm) Purpuric lesions arise from a number of conditions (see below) and may display colour changes from red to purple. The hallmark of purpura is partial blanching that suggests not only inflammation but some haemorrhage. It may result from vessel occlusion causing ischaemic damage to the skin. Inflammation around the blood vessel may lead to palpable purpura whereas simple haemorrhage is rarely associated with such a feature unless there is haematoma present. Overall, these lesions occur predominantly in inflammatory vasculitis and sepsis. Small vessels: t 7BTDVMJUJT F H )FOPDI 4DIPOMFJO purpura or meningococcal septicaemia) t *NNVOF DPNQMFY EJTFBTF t 4#& t 8BMEFOTUSPN T .BDSPHMPCVMJOBFNJB Small and medium sized vessels: t .JYFE DSZPHMPCVMJOBFNJB t 3IFVNBUJD WBTDVMJUJT 4-& dermatomyositis, RA) Large vessels:

Q Fig 1. Large bruise on the thigh due to over-anticoagulation.

t "OUJDPBHVMBOU VTF 'JH BOE PS vit K deficiency t 5SBVNB t -JWFS GBJMVSF t 7PO 8JMMFCSBOE T EJTFBTF t %*$ BDRVJSFE )BFNPQIJMJB t "HF SFMBUFE t 4UFSPJE UIFSBQZ t 7JUBNJO $ EFGJDJFODZ

medicalforum

t -FVLPDZUPDMBTUJD WBTDVMJUJT MPDBMJTFE randomly): o Antineutrophilic antibodies BTTPDJBUFE "/$" o Wegenerâ&#x20AC;&#x2122;s granulomatosis, Churg-Strauss, polyangitis. t /PO MFVLPDZUPDMBTUJD o haemorrhage o inflammation o vessel occlusion About a third of cases of cutaneous vasculitis are idiopathic. Others causes may be drug induced (beta blocker drugs, /4"*% NPOPDMPOBM BOUJCPEZ UIFSBQZ with serum sickness, as well as bacterial and viral (HIV, Hepatitis C) infections. Collagen vascular disease (SLE, Sjogrenâ&#x20AC;&#x2122;s, RA), IBD (Crohnâ&#x20AC;&#x2122;s, ulcerative colitis) and lymphoproliferative neoplasm form the bulk of the rest. Large vessel disease may express itself in Wegenerâ&#x20AC;&#x2122;s granulomatosis,

1"/ PS $IVSH 4USBVTT WBTDVMJUJT Leukoclastic vasculitis with fibrinoid necrosis and neutrophilic degeneration may arise in multiple settings and may be seen with either small or large vessel disease.

Q Close up view of purpura.

Causes of Petechiae (<3mm) Petechiae are pinpoint capillary haemorrhages that are characteristically non-blanching and mainly caused by UISPNCPDZUPQFOJB QMBUFMFUT OM PS abnormalities of platelet function. t 1SJNBSZ PS TFDPOEBSZ thrombocytopenia t $POHFOJUBM BOE BDRVJSFE QMBUFMFU function defects t /PO QMBUFMFU FUJPMPHJFT t $ISPOJD QJHNFOUFE QVSQVSB t )ZQFSHBNNBHMPCVMJOBFNJB t *OUSBWBTDVMBS QSFTTVSF JODSFBTF (e.g. coughing) t 5SBVNB Treatment for simple bruising would follow along the lines of RICE (rest, ice, compression, elevation), analgesics and, in some instances, the use of tranexamic acid may lessen the impact of the bruising. The management of the above lesions depends on the underlying cause and, if remediable, may lead to the resolution of the bruising, ecchymosis, purpura or petechiae. The diagnosis of the type of bruise may be narrowed down by the history and further aided by investigations, which will include a full blood count, coagulation profile, biochemical, immunological and imaging studies. In difficult cases a skin biopsy may be helpful.

Feature

We Must Protect Our Kids Continued from Page 6

and stepmother came to realise that what their son had experienced was very real, but even they were not immune from McKenna’s threats. Then the cracks began to appear when police began to investigate. “It was only a matter of days after we went to them that they told us I wasn’t on my own, there were other boys. Other guys had come forward. They weren’t from my era, but from years before. And that was a real boost. Suddenly I knew I wasn’t going to have the fight on my own and it proved I wasn’t lying. It made a few people sit up in their chairs.” For the past 22 years, Todd Jefferis has had one foot in the past while trying to forge a life with his wife and two young children (aged five and eight) and he now sees some clear daylight ahead. “I don’t want this role for the rest of my life. I did what I had to do back then, and I’ve done what I felt I needed to do now to not only make sure that this story was told in its entirety, but to clear my name properly. This was an opportunity to do that even though it has only just happened.” “There are things I’ll keep fighting for – good protective education for our kids.

And when and if terrible things do happen, I’d like to see the law deal with them appropriately. I applaud the register where people can log on and see if paedophiles live in their area. I think it should go further. I don’t see why, if these people are tried and found guilty, they can’t be GPS banded, so police know where they are. They might say that is against their human rights, but I think they lose their rights when they abuse children.”

I don’t want this role for the rest of my life. I did what I had to do back then, and I’ve done what I felt I needed to do now to not only make sure that this story was told in its entirety, but to clear my name properly. “This is the world we live in, sadly, and everyone needs to be realistic in how we deal with it. We shouldn’t stop children hearing about these things, because that’s what causes them.” “I’m really glad we’ve had this Blaxell

inquiry and shaken a few people up. It’s been distressing for a lot of the lads and their families because a lot of victims had suppressed it for 30 years and had told nobody. I don’t know how any of them have done it, but I know how badly it has affected them. Seven of them are dead as much as we know.” “That’s why I applaud the Royal Commission. It will give all victims of child sexual abuse an opportunity to tell their story, and be listened to. That is a really big part of the healing process … to have your story heard and believed. The lads I’ve met through this – and there are about 30 of us – you can see the difference in them already. It’s like a huge weight has lifted.” “I really want to move on from it now. I want to enjoy my life and make sure my children are safe. Believe me, it’s my one goal in life, to make sure they are protected.” A few daus after this interview Todd sent us this quote: "It is easier to build strong children, than to repair broken men.” “Not a more truthful word spoken, in relation to us boys,” he wrote, and that could be true for the rest of the community. O By Ms Jan Hallam

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medicalforum

You’re not exactly patient We hear you

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medicalforum

Have You Heard? Mental health Joondalup

Pharmas paying docs

What WA GP Network?

Doctors and pharmacists are on notice from the ACCC that Medicines Australia must improve disclosure of payments to individual healthcare professionals by early 2015. Edition 17 of Medicines Australia’s Code of Conduct will be the interim standard for two years. The ACCC says it’s about community confidence in the integrity of payments to healthcare professionals. See www.accc.gov. au/AuthorisationsRegister.

The Feds stopped funding state-based organisations on Dec 31. WAGPN has now ‘morphed’ into Primary Care WA, moved to South Perth, retained Dr Marcus Tan (AMA Council; Health Engine CEO; Chair Perth Central & East Metro ML); and Dr Andrew Png (Chair previous Rockingham Kwinana Division) on the board. The CEO is Debra Barnes, Office Manager Loretta Allen, and Marketer Alex Meagher, plus new faces from nursing, aged care, podiatry, chiropractors and Aboriginal health on the board. The website says the organisation is independent (but funded how?) and it’s the central advocacy group for primary care in WA because primary care organisations want it that way. Not all, it seems, and primary care bodies of different sorts are seeking direct links with the Commonwealth Government. Samantha Dowling, who was Senior Policy Officer at WAGPN, is now doing Planning and Partnerships at Perth Central & East Metro ML.

Photo courte sy Tour

a tion P nserva seam Co ism Western Australia: Coal

When the State’s first 22-bed subacute mental health service opens at Joondalup soon, this step-down facility for people aged over 16 will be run by NGO Neami, which operates 31 sites in Australia. Rehabilitation and recovery support for people with serious mental illness is the aim, using programs to help people develop strategies to recognise symptoms, stay well and maintain their health. It’s a three-year tender under the new Mental Health Commission. More non-acute beds, community rehab beds and supported housing were flagged in the Mental Health Report, July 2012.

Old docs rebel The Australian Senior Active Doctors Association (ASADA) refuses to be scrapheaped by new national registration. They want dignity and respect despite wings clipped by Limited Registration Public Interest Occasional Practice (LRPIOP). They say LRPIOPs are rarely a risk, can contribute within safeguards, can mentor younger docs, and need to step down to retirement. ASADA president Dr Frank Johnson has written to MBA Chair Dr Joanna Flynn to ask is if the decision to terminate LRPIOP is to be reviewed, and what role does the MBA see for LRPIOPs in Australian healthcare. July 1, 2013, is D-Day. (See Letters Page)

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medicalforum

GP Training Gambling helps kids?

The PHC-SJOG connection

There is no doubting that Ngala is a WA institution, providing early parenting and child development services to WA families since 1890. Many GPs and paediatricians refer their patients to its services. Premier Colin Barnett noted how Ngala “promoted the right of every child to grow up in a healthy, safe and caring environment” without mentioning that some types of problem gambling is more common among families in need. The irony was the occasion – handing over $1.5m from Lotterywest so Ngala could upgrade its Kensington head office, including its helpline, which takes 20,000 calls a year. Demand is outstripping services.

The inquiry into Peel Health Campus by Dr Bryant Stokes may not have the appearance of independence that a judicial inquiry has, and results are unlikely to emerge before the election. Dr Kim Hames’ past contacts with Tony Solin, who ceased his marketing job at PHC to contest Mandurah for the Liberals, has been recalled in a different light by Ms Ashton Foley who largely kick-started the PHC investigation. Tony was followed by Liz Drew who left the marketing job at PHC after only a short time. SJOG Murdoch CEO Peter Mott referred to reported problems at PHC when he announced during their Christmas function that SJOG had purchased land in Mandurah and soon expected Council approval for their planned 75-bed private hospital.

State health drug deals It passed without a fanfare – the WA Auditor General’s Report on Purchase and Management of Pharmaceuticals in Public Hospitals – but $205m was spent on more than 250,000 pharma orders from over 250 suppliers during 2010-11, with about 75% through the big three metro hospitals. The report said potential conflicts of interest connected with pharmaceutical purchasing are not managed well, mostly gifts and travel sponsorship, with no process to identify potential conflicts around drug selection or recommendation. State Health is changing things to reassure us.

Medical mining Let’s spend $675k to explore if UWA should expand its teaching and research services into the Pilbara. It’s the Royalties for Regions Pilbara Cities Education Partnership Fund at work, before an election. With 70% of the mining workforce aiming to be fly-in fly-out, a “diversified regional economy” seems a pipe dream given that local retail businesses are folding and rents are unaffordable. Regional medical services are stretched, with UWA’s Rural Clinical School trucking fifthyear medical students to the Pilbara and other parts of regional WA to get doctors to go bush. Notre Dame Uni joined in around 2002. Of the 180 MBBS graduates from UWA last November, 30 had rural backgrounds.

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Primary Care

GP Groups in WA In the changing world of WA primary care, Medical Forum has sought information from representative groups and elsewhere. There are close to 2400 GPs in 560 general practices (130 solo), employing 1080 practice nurses â&#x20AC;&#x201C; all serving a WA populace of 2.4 million. Hard working GPs say they have listened to a lot of talk of change but experienced little to make their lives easier. Canberra focus has shifted from unsustainable hospital medicine to primary care and self-care, with a multidisciplinary approach. Medicare Locals and Superclinics reflect that shift in emphasis, and WA Health has released the WA Primary Health Care Strategy with a similar bent. The foreword by Director General Kim Snowball says in part the Strategy â&#x20AC;&#x153;provides an opportunity for primary health care to â&#x20AC;&#x2DC;come of ageâ&#x20AC;&#x2122; as an equal partner with care provided in the hospital system, in an environment of mutual respect and trust. Robust primary health care services will not only enhance the effectiveness of the hospital system, but will contribute to improved health and quality of life for all Western Australiansâ&#x20AC;?. It sounds good yet Commonwealth-State cost shifting and duplication remains one big bugbear of reformers, not to mention primary care GPs. So how to represent WA GPs in amongst system changes? In bringing you information, where possible, we focus on: a) the dialogue that groups have with GPs b) whether leaders record, publish and seek feedback on decisions they make on behalf of GPs c) whether GPs are surveyed as widely as possible for their opinions, and d) membership

t 3"$(1 8" The organisation has an active WA office with restricted autonomy, instead referring matters to Melbourne head office. The website for the WA operations is an example; a WA slice of the national website with little interaction, just a list of contacts and the Faculty Board, with nowhere to subscribe to the RACGP WA e-news. The WA office has its own internal communication package with members. Nearly all of the interaction for core business has a federal focus, albeit it fairly transparent and comprehensive â&#x20AC;&#x201C; QI & CPD, annual and financial reporting, publications, standards, fellowship, etc. 12

Using our criteria, we note the following: t 8" 'BDVMUZ #PBSE '# .JOVUFT PS agendas for coming meetings are not posted on the web. t 8" .FNCFS PQJOJPO EPFT OPU BQQFBS UP be canvassed using polling. t .FNCFST IBWF OP XBZ PG SPVUJOFMZ knowing how WA FB members voted on particular issues, or FB reasons for decisions, and whether conflicts of interest were declared. t 'FFECBDL QPTTJCJMJUJFT BSF MJNJUFE WA GP Membership Fellows who are Members 1193 ($1050 p.a. if FT i.e. >20 hrs/wk) Members without fellowship

Associates Registrars

157

Associates Others

388

QI & CPD non-member participants

692 ($524 p.a.)

Source of membership: WA office and federal Annual Report 2011-12 NOTE: Melbourne says financial membership of the College is not required to use the FRACP title, and attractions available to only financial members include CHECK program, partner discounts, workshop and conference discounts and library service.

t MEDICARE LOCALS Medicare Locals (MLs) in WA are still working it out. Most have finalised their Constitutions (some only just), and the top performers have financials, board membersâ&#x20AC;&#x2122; details, members lists and strategic plans displayed on websites. Some of the divisions that MLs were meant to replace are still operational, and understandably so in rural areas, where amalgamations from 8 Divisions to 3 MLs have been unpopular (see map). MLs have GPs represented as either individuals (â&#x20AC;&#x2DC;grandfatheredâ&#x20AC;&#x2122; across from some Divisions as a one-off) or within organisations that have ABNs, such as medical practices. Membership fees vary between MLs, from $100 to $1000, depending on the size of the organisation. It is impossible to determine the exact number of GPs represented at this time, but MLs also represent a range of non-doctor disciplines on their boards.

Using our criteria, we note the following: t #PBSE .JOVUFT PS DPNJOH BHFOEBT BSF not visible. t &OHBHFNFOU PG (1T UISPVHI QPMMJOH JT not evident although anecdotally, polling of members or relevant community groups occurs before strategic plans or before decisions on particular issues.

WA GP Membership: Impossible to determine individually. Source of membership: WA websites for MLs and phone contact with some.

t "." 8" WA GP Membership: A proportion of 3699 total membership ($1,434 p.a. if FT i.e. >30 hrs/wk) Source of membership: January 1, 2012, figures lodged with the WA Industrial Relations Commission by AMA (WA) - the 3699 figure includes specialists, GPs and doctors in training who are registered medical practitioners; AMA WA website.

medicalforum

Primary Care

Medicare Locals – Who, What, When? There are eight Medicare Locals (MLs) in WA, the oldest two only 18 months old. While much of the work done under the 14 Divisions in WA has been rolled over into these new bodies, the degree of cohesion and GP involvement varies dramatically. In line with the broader focus of MLs to involve allied health and consumers, the Federal Government has stipulated that not one professional group should dominate a ML board. GP board membership varies considerably, as does GP membership. We spoke with Prof Alistair Vickery, head of both the Perth North Metro ML and the ML Alliance. He believes one of the main roles of MLs Prof Alistair Vickery will be to reduce fragmentation in the current delivery of primary care. As an example, his ML looked at one particular disease affecting about 1000 patients in their demographic, and 37 agencies of all sorts were providing services, with many not talking to the others.

REPRESENTATION OF GPS Perth North Metro Medicare Local (PNMML) is a bit different to the rest. Osborne Division GPs (in fact 45% of the 230 GP members taken from the 400 GPs in their area) voted unanimously to transfer to the new organisation. This means about two thirds of PNMML members are now GPs, with voting rights. Since the move, the organisation’s size has trebled, including budget ($6.8m) and employees (about 60). The PNMML Board, which meets monthly, has six people elected every two years by members and three appointed by the board according to the skills needed. Prof Vickery said the way for local GPs to be heard are: t 5P EJTDVTT TFSWJDFT XJUI QSPHSBN PGGJDFST running the allied health, Aboriginal patients, chronic disease, etc. programs, t 5P EJTDVTT TUSBUFHZ PS QPMJDZ XJUI CPBSE members or attend the AGM, or t /PNJOBUF GPS UIF CPBSE JG ZPV BSF B member. Only people who are part of an organisation (e.g. medical practice with an ABN) can become members now (a Federal Government stipulation supposedly to prevent board ‘stacking’). He says chronic disease prevention, management and allied health support, is one area where MLs can deliver. medicalforum

“Mental health and aged care are the major thrust in our area but each Medicare Local has different needs. We do a lot of surveying of members to find out what’s important. The Federal Government also has national strategic health priorities, important to us because they are our chief funder. State Health also has priorities so the MoU we signed with North Metro Health Authority means we try and align our strategic priorities. Our consumers are important as well – we have a population of 500,000, a consumer reference group which meets monthly, plus at targeted events we ask them what’s important,” he said. Annual questionnaires to all clinicians (including non-doctors) get the expected 15-20% response. If there is a regional or discipline-specific need, they survey the appropriate people at that time. A major strategic plan is done every three years, with one due March this year. “Observational research is vital – trying to determine if a service has achieved the desired outcome. But you also need to identify the counterfactual, or what would have happened if you hadn’t intervened. Randomised blind controlled trials are good if you can use them. But with complex longstanding interventions you can’t do a blind trial because multiple different people are delivering services and none of the patients are standardised.” “Chronic disease management is a complex intervention and we really have difficulties knowing what works and what doesn’t. State and Federal Governments are putting heaps of money into care coordination teams and disease management programs without really knowing if they work or not.”

“We know that if you see your GP regularly, you reduce your number of hospital visits but there is no evidence that increasing afterhours GP services will have any effect on ED demand. Barbara Starfield has done some wonderful work; essentially, the better your access to primary health care, the better your outcomes and the cheaper your health.” Government is saying general practice is a key component of primary care but not the only one. “Medicare Locals will fail if they don’t engage effectively with general practice but on the other hand, general practitioners will fail Medicare Locals if they don’t engage with them because pharmacists, dentists and allied health will take over and realise their own goals.” “Medicare Locals are less bureaucratic than Health Departments and more responsive to conditions on the ground. Afterhours is a good example. It is currently run by a department in Canberra. They took the PIP away because it wasn’t working and hopefully, when it is finally worked out, we are going to be able to respond much better to the afterhours GP needs of our community.” Maintaining relevancy and getting GP engagement were major challenges but they need the feedback and good quality representation. The heartening thing is that government wants MLs to work. “The biggest risk to high-performing Medicare Locals is those that are lowperforming,” Alistair stressed. O

WA Medicare Locals Name

Website

Prior Division

Bentley-Armadale ML

www.baml.com.au

[ex-Canning Division]

Fremantle ML

www.fremantlemedicarelocal.com.au

[ex-Fremantle GP Network]

GoldfieldsMidwest ML

www.gmml.org.au

[ex-Midwest GP Network and Goldfields-Esperance Division]

Kimberley-Pilbara ML

www.kpml.org.au

[ex-Pilbara Health Network and Kimberley Division]

Perth Central & East Metro ML

www.pcemml.org.au

[ex-Perth Primary Care Network]

Perth North Metro ML

www.pnml.com.au

[ex-Osborne GP Network]

Perth South Coastal ML

www.pscml.com.au

[ex-Rockingham Kwinana Division & GP Down South]

South West WA ML

www.sw-medicarelocal.com.au

[ex-Great Southern GP Network, GP Down South, Wheatbelt GP Network, Greater Bunbury Division]

Primary Care

RACGP WA Directions Advocacy for patients and GPs is the road ahead for the local branch of the RACGP and it's finding its feet. $VSSFOU 3"$(1 $IBJS " 1SPG 'SBOL Jones is trying to fit his vision for the college around his busy Mandurah general practice life. The role has cost him, with time off for frequent trips to Perth, but he thinks positive change is afoot and that older GPs can give back a lot. “My perspective is we have a voice and should be advocating stronger for patients, our prime concern, and for the profession. In Q A/Prof Frank Jones WA I’m trying to correct the disconnect between general practices and other health organisations, especially the Health Department. Decisions have been made about general practice without our input. We have to be at the table

to be heard. I guess I’m talking about advocacy – for our patients, communities and profession,” he said, adding that the RACGP’s core business is promoting standards. He is obviously pleased about the rise in GP financial membership in WA. “GPs are certainly well represented within the college and my goal is to increase the rural representation [currently around 35% of members]. With technology we need to be get much more rural representation on our RACGP Faculty Board so we can present member views to various committees we sit on.” What is he doing to gather opinion and better communicate with members? “After each national Council meeting I do a deliberation document for our board members in WA so they know what’s going on at a national level. For members in WA we have our weekly member message, with a Chair report every month or so, including a report from me about WA Faculty Board deliberations. I’m hoping to engage

membership so they know what their board is talking about.” He relies on board members to reflect and debate GP issues with colleagues but this offers a relatively short reach. Call-backs from his weekly e-newsletter are only occasional and often reflect extreme points of view! It appears that the College is not particularly using technology to garner opinion or generate interest in WA. “We are a member-based organisation so our funds are limited. I would love to go to Geraldton, Esperance, Narrogin etc and give a talk about what the college is doing for them but most people have got their heads down, busy doing other things. You are right we can improve communication. Time is at a premium for all of us.” “We’ve made some positive steps in the last two years. We are more in your face, if you like. We need to raise our profile for our patients and colleagues.” He said they asked members two years ago what they could do better and a higher profile, more advocacy and a voice in Canberra were top of the list. Today, he believes GPs belong to the RACGP because they are fond of general practice, believe in the standards the College sets, the level of advocacy it now has, and the emphasis on evidence-based care. ED. Frank Jones wanted to make it clear these are his personal opinions.

How the College Works Faculty Board This is a misnomer. There is no fiduciary responsibility or set positions open for election – the Board is only advisory to the National Council of RACGP and only the WA Chair sits on national council as a director. How people are selected to each State’s board is different. WA’s system is being reviewed. Currently, people selfselect, and are nominated by a colleague before being voted on – no one has been knocked back in recent memory. The FB meets five times a year for 2.5 hours and has a planning meeting in November. Future changes will be aimed at reducing FB numbers and improving proportional representation of rural doctors, probably including reps from geographical locations and those on National Standing Committees. A Faculty general meeting is held before the October national AGM, usually coupled with graduand presentations (although this will probably now be uncoupled to increase Registrar involvement).

External Committees The college has about 30 representatives on committees, including most of the Health Department networks. Early, it is stipulated 14

if the representative has a College purpose (in which case they report back and are informed of the College’s stance) or comes as a GP in general.

Engaging Members Information about meetings is reported in the weekly e-newsletter to members, and where relevant, member comment sought.

Current officeholders WA Faculty Board A/Prof Frank Jones (Chair, NSC Advocacy & Support) Dr Tim Koh (Deputy Chair) Prof Max Kamien (Provost)* Dr Helen Wilcox (Censor) Dr Bill Diamond (Assessment Panel) Members Dr Janice Bell (NSC Education) Prof Tom Brett* Dr Frances Cadden Dr Mike Civil (Chair NSC Standards) Dr Nicolette De Zoete (Rural) Prof Jonathan Emery* A/Prof Hilary Fine Dr Colin Hughes (NSC Advocacy & Support) Dr Krishnan Jagadish (IMG Group) Prof Moyez Jiwa (NSCs Research & Standards)

Dr Jamil Khan* Dr Jags Krishnan* Dr Alan Leeb (NSC Standards)* Dr Peter Maguire (Chair NSC Education) Dr Sarah-Jane McEwan (Rural) Dr Aru Moodley Dr James Ogundipe* Dr Kiran Puttappa* Dr James Quirke* Dr Harpreet Singh* Dr Sean Stevens* A/Prof Peter Winterton Dr Penny Wilson (Associate-Registrar)* Dr Stephen Wilson (AMA rep) Dr Belinda Wozencroft (NSC Quality) Dr Mahinda Yogam (Associate-IMG)* * The usual two-year term for these Board members ends in 2013. They can re-elect if they wish. NSC = National Standing Commitee O

medicalforum

Research

Perspective: Primary Care Research GP Dr Kathleen Potter and geriatrician Dr Chris Etherton-Beer have shown how the right backing and a good idea can give you wings. West Australians will forgive Dr Kathleen 1PUUFS GPS CFJOH B /; HSBEVBUF PODF UIFZ learn she has been living and working in Australia for the past 10 years, and in 2008 gained a PhD from UWA. In TIF SFDFJWFE B GPVS ZFBS /).3$ post-doctoral training fellowship and the $57,000 p.a. salary over four years has allowed her to conduct some interesting primary care research working with Dr Chris Etherton-Beer and the WA Centre for Health and Aging. â&#x20AC;&#x153;My plan was to always do research but because you can always fall back on general practice earnings, it takes the pressure off you as a researcher. Research is a hard gig because you have to apply for funding, there is a lot of bureaucracy, and you can get caught up in the machinery of university.â&#x20AC;? â&#x20AC;&#x153;You are almost doing it for love. The advantage [of the NHMRC fellowship] is a guaranteed income from the research and it has given me time to apply for other grants.â&#x20AC;? We now know how successful that has been. With the pilot project still running, they

have attracted a further $1.44m to conduct a national study that will trial the reduction of medications in residents of Aged Care Facilities.

ability to bring together a group of people with a common interest and strong research record in deprescribing is what has really given us the edge, I think.â&#x20AC;?

In her case, aware that a yearâ&#x20AC;&#x2122;s gap in funding could be a major setback, she and her colleagues were initially criticised for applying too early for more NHMRC funding for a bigger national trial.

â&#x20AC;&#x153;A common problem with doctor researchers is they get side-tracked into administration and teaching. They also tend to be set up at the top of the research pyramid with PhD students and research assistants doing most of the work for them.â&#x20AC;?

Around 70% of GPs and Specialists surveyed by Medical Forum wanted tangible community benefits from research, and 85% agree we should aspire to evidence-based medicine (see November edition Page 26) but getting coalface doctors to lead research is not easy. A BMedSci and PhD gives Kathleen a huge advantage in gaining acceptance as a primary care researcher. â&#x20AC;&#x153;Unless you have had good training in hands-on science, it is difficult to be taken seriously as a doctorresearcher,â&#x20AC;? she said. Collaboration with other researchers is also critical.

Moreover, the questions GPs want answered through research may not appear all that glamorous to others, plus the patient population is not captive, as it is for hospitalbased research. â&#x20AC;&#x153;Most research starts from anecdotes â&#x20AC;&#x201C; people observing what happens at the coalface, which translates into a hypothesis that is then tested in a proper trial. GPs are often doing their own n = 1 experiments. Itâ&#x20AC;&#x2122;s how they build their own clinical experience but how you aggregate all this useful information from these individuals I just donâ&#x20AC;&#x2122;t know,â&#x20AC;? she confessed. O

By Dr Rob McEvoy

â&#x20AC;&#x153;Most of the credit for our recent NHMRC success goes to my colleague, Chris. His

after 40 years, weâ&#x20AC;&#x2122;re still excited about our business

introducing our fantastic new look and brand vision more than just a makeover Smith Coffey is proud to launch its new look and feel. Fresh and vibrant, it reďŹ&#x201A;ects our ongoing passion for the business and our continued energy and enthusiasm for our clients.

paving a brighter future Weâ&#x20AC;&#x2122;re determined to make the next 40 years at Smith Coffey as successful and as enjoyable as the last. This means you can be sure you will receive the same great service and adviceâ&#x20AC;Śbut with an even brighter smile.

call us anytime Thank you again for your continued support. We look forward to making every day a happy day for you. For more information about any of the changes, please call us on (08) 9388 2833. See you soon!

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make every day a good day

Guest Column

Power of Positive Thought Ethicist Prof Stephan Millett says the key to protecting children from all manner of social pressures is to teach them to think better.

bout three quarters of GPs who responded to the Medical Forum E-poll on child sexual abuse last year (April) got it right: early education of children in schools is likely to be the key to protecting kids from the sorts of abuses that have made headlines in Australia recently. But what sort of education is needed and what new skills might teachers need to make the education effective? One possible answer to both these questions lies in the clear evidence that teaching children to think collaboratively about important issues improves their ability to reason, improves their behaviour in and out of class and improves their ability to communicate clearly and effectively.1 Children who learn to reason together are better able to distinguish good reasons from bad and develop what in Australian colloquial terms we might call a bulldust detector: they are better able to know when they are being misled and will have better verbal tools to ensure that they can explain what has happened. They will develop lifelong skills that will enable them to work more intelligently2 and that can protect them from poor arguments and improper pressure. This collaborative approach to thinking is known generically as Philosophy for

Children, and more specifically as a collaborative philosophical community of inquiry. It began with Matthew Lipmanâ&#x20AC;&#x2122;s work in the US and has extended to every continent. It is not new. It is not expensive. But it works. It is the heart of the ethics curriculum introduced into NSW schools by Philip Cam and is the heart of the Philosophy and Ethics curriculum being taught in high schools as part of the Western Australian Certificate of Education. But teaching children to think more clearly requires teachers to know how to teach collaborative thinking. And for the full effects to be felt, the adults who come into contact with the children have to learn how to listen. This involves not just listening to what kids are saying, but listening for what might be hidden within what is said and learning ways to keep communication open so that truth can emerge, and be believed. To teach collaborative thinking, teachers need to allow children to come up with their own questions, to allow children to provide their own answers to these questions and, most crucially, their own critiques of each otherâ&#x20AC;&#x2122;s answers. This can be a major challenge to teachers who want a quiet and compliant class, but are not quiet and compliance the very things that sexual abusers rely upon to keep their activities secret?

Teaching collaborative thinking will not necessarily be a quiet activity and children will not be compliant, but in a good classroom community of inquiry children (and adults) will be respectful and cooperative and will come to a rich understanding of the issues being explored. And understanding is much more powerful than mere knowing. Whatever formal process is put in place to assist children when they perceive something is going wrong, having children who know good reasons from poor and how to communicate clearly will help that process. Letâ&#x20AC;&#x2122;s teach our kids to think better, for their sakes. O References: 1 See e.g. Millett, S. and Tapper, A. (2011). Benefits of Collaborative Philosophical Inquiry in Schools. Educational Philosophy and Theory. doi: 10.1111/j.1469-5812.2010.00727.x 2 See the various works by Steve Trickey and Keith Topping in the UK.

ED: Prof Millett is Chair of the Human Research Ethics Committee at Curtin University. He is a moral philosopher, a co-author of the WACE course in Philosophy and Ethics and co-author of three textbooks for the course.

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Fair Work Changes and You Mr David Wenban outlines some of the effects of recent amendments to the Fair Work Act on medical practices and warns of changes in the pipeline. Legislative amendments introduced and passed by the Federal Government in the last sitting days of Q CCYP Principal Policy 2012 will have Officer Amy Tait limited impact on your ongoing obligations to employees. Further and more significantly the introduction of the Fair Work Amendment (Tackling Job Insecurity) Bill, which is yet to be passed will have a significant impact on your obligations. Amendments passed include: The Fair Work Amendments Bill 2012 (the Bill) makes a number of changes to the existing legislation including: t $SFBUJOH B QSPDFTT UP EFBM XJUI complaints against Fair Work Commission (FWC) members and streamlining provisions dealing with conflicts of interest of FWC members; t " UFDIOJDBM BNFOENFOU UP TFDUJPO " of the FW Act. This section requires an employer, before engaging an employee to perform the work of another employee who is going to take or is taking unpaid parental leave, to notify the replacement employee that the

engagement is temporary and that the employee and employer have particular rights under the FW Act. The Fair Entitlements Guarantee Bill 2012 replaces the General Employee Entitlements and Redundancy Scheme with a new scheme which allows employees made redundant through their employer’s bankruptcy or insolvency to access an advance on their entitlements, which the Commonwealth will then seek to recover from the employer. The Fair Work Amendments (Transfer of Business) Bill 2012 provides for public sector employees who are transferred to a private sector organisation with a connection to the old employer to retain their existing terms and conditions of employment. When these three pieces of legislation commence the practical impact for medical practices or series of medical practices will be minimal with the exception of the amendment to section 84A of the FW Act. However, there could be significant impact from the last proposed legislative amendment, Fair Work Amendment (Tackling Job Insecurity) Bill 2012, if passed. This amendment provides a process for ‘insecure’ workers who are casual or on rolling contracts to move to ongoing employment on a part-time or full-time basis with paid leave entitlements.

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It should be noted that the right of small businesses to use genuine casual employees would be preserved, with such employees excluded from the operation of the Bill. By way of explanation and for the purpose of this Bill: t " DBTVBM FNQMPZFF JT FMJHJCMF UP NBLF a request regardless of their length of service with the employer. However, genuine casuals employed by small business would be exempt; and t " SPMMJOH DPOUSBDU FNQMPZFF JT EFGJOFE “an employee” if they have been employed on a fixed term contract by the same employer doing the same type of work on two or more occasions. Under these amendments the process for ‘insecure’ workers to move to ongoing employment would involve the following: 1. An eligible employee (or their union) must make the request for a secure employment arrangement with their employer in writing; 2. The employer must give the employee or their union a written response to the request within 21 days. If the employer refuses the request, the written response must include the reasons for the refusal; 3. Where an employer refuses a request for ongoing employment then an application can be made to Fair Work Australia who can issue a ‘secure employment order’. In deciding whether to make a secure employment order, FWC would consider a number of factors including the needs of employees to have secure jobs, and an employer’s capacity to use arrangements that are not secure in cases where this is genuinely appropriate to the needs of the business. For those practices that are not, for the purpose of the legislation, “small businesses” this particular amendment, if it were to pass and be implemented, would have significant potential impact on the manner in which staff is engaged on an ongoing basis. O ED: David Wenban is the Managing Director / Principal Legal Counsel of the Australian Health Industry Group. This is an edited version of his column in the AHIG’s February newsletter. medicalforum

Medicolegal Q&A

Tricky Scenario for Joe and his Marriage

Joe returns to his family in WA following a golfing holiday in Thailand and consults with his doctor for “personal stuff”. His doctor diagnoses a resistant strain of gonorrhoea and Joe discloses that he has had sex with his wife since returning from Thailand. Joe insists the doctor doesn’t tell his wife “because that will end it all and we’ve got young kids”. Where does the doctor stand legally?

Avant's Senior Solicitor Morag Smith answers the above question:

While Joe’s diagnosis and his test results are confidential, a doctor still has to take into account the health and welfare of Joe’s sexual contacts. Given Joe’s confirmation that he had sex with his wife, it is reasonably foreseeable that she could have been infected. However, you cannot disclose the diagnosis to Joe’s wife without his consent. Joe should be reassured that all the information he has provided during the consultation is confidential but he should also be informed that there is an obligation under the WA Health Act 1911 to report the diagnosis to the Communicable Disease Control Directorate, Department of Health, WA or, if Joe lives outside of the

metropolitan area, to the local Public Health Unit. Contact tracing is an important step in the treatment of any patient with an STI. The aim of contact tracing is to reduce the risk of reinfection as well the complications associated with an untreated infection. As the diagnosing doctor, it is your responsibility to counsel Joe about the risk of the infection being spread and the need for his wife to be treated, not only for her own health but to ensure that he is not reinfected. There are a number of resources available to doctors who are involved with contact tracing. In WA the Silver Book has guidelines on contact tracing (http:// silverbook.health.wa.gov.au) and the Australasian Contact Tracing Manual is also a useful resource (http://ctm.ashm.org.au).

Joe should be encouraged to look at a website developed by the Melbourne Sexual Health Centre (http://www. letthemknow.org. au/default.html) Q Ms Morag Smith that offers useful tips on how to inform a partner. If Joe persists in refusing to tell his wife about the STI, you should contact the Communicable Disease Control Directorate (or outside the metro area, the local Public Health Unit) and seek their advice. Finally, if you are concerned about management of this type of clinical scenario, contact your MDO for assistance. O

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Feature

CMO’s Pledge to Doctors Dr Gary Geelhoed is starting 2013 with some big challenges as WA’s new Chief Medical Officer but he has doctors firmly in the frame. to build more beds. To some extent, the Government has responded to that with the hospital building projects, but the 4-hour rule also showed that we had to be absolutely sure that we use existing beds as efficiently as possible. And clearly we weren’t.”

The news just before Christmas that WA leads the nation in reducing wait times in hospital emergency departments is the cherry that’s topped off a busy year for Dr Gary Geelhoed who has, since October 1, been settling into his position as WA Health’s Chief Medical Officer.

The next logical step in that sequence is to look at influencing the number of presentations at EDs.

As one of the key architects of the 4-hour rule, which has been subject to intense scrutiny both inside and outside the health system, its apparent success must be satisfying for this long-time emergency PMH clinician and former president of AMA (WA). It also tested his ability to navigate turbulent political seas while keeping frontline health practitioners and their patients at the forefront of policy. It’s a big time to be coming into the department with major projects including the Fiona Stanley Hospital and the new children’s hospital and the sudden resignation of Director-General Kim Snowball and the hunt for a replacement, but after 21 years at PMH he says he was ready for a change, though he continues to work there one day a week. His time as AMA president (he’s still on the federal council) has also helped prepare him for this public role, having given him a broader view of the system in which he has worked for so long. “There are issues you bat on about – lack of money, resources – then you think ‘well it’s an opportunity to influence and make a positive contribution’. All those things came together really when I accepted the CMO job.” While acknowledging the good times, with WA performing well compared to the rest of Australia, he also sees the challenges.

“It’s not just a simplistic thing about GP patients going to ED; that’s naive to look at it like that. What we’re now looking to do is to involve and invest in primary care because we all know it’s a growing ageing population.”

Q Dr Gary Geelhoed

“There is never enough money to do everything we want to do in health. My wife is a health economist so she’s probably influenced me about these things. Once a doctor could throw everything they had at a patient and wouldn’t spend that much, that’s not the case now. Doctors still want to do the very best for their patients but increasingly there’s a sense that there really is only so much money.” “And while we must look after that patient in front of us we also have a responsibility to think more broadly. How do we get the best for most patients; how do we make the most of the health dollar, such as it is.” “The 4-hour rule is a good example of where we stepped back and looked at the system and worked out how we could affect some positive change. Before that serious review, the answer to overcrowding was

“It used to be traditionally accepted that primary care is a Commonwealth responsibility but we all have to look at this and do it better. We can manage patients with chronic conditions in the community, which will not only deliver better patient care but also decrease the demand on our hospitals. That process has already started. We have met with Medicare Locals and the AMA and various other players. It’s good that a GP is the AMA president.” Gary said that the South Australia health system was ahead on this issue but he added that a lot could be learnt from within our own system, citing his own PMH emergency department which addressed what they termed “frequent flyers” with staff dedicated to liaise with patients and their GPs. “The system reduced presentations of these patients by almost 50% and they were probably given better care,” Gary said. “But there’s no magic bullet. Often it’s a case of saying this is our target, determine the things that are stopping it from happening, and then tick them off, one by one.” “Some things we’re doing already because

CMO on Pharma Sponsorship The CMO had some interesting insights into pharmaceutical sponsorship and the issues of transparency of accountability which it raises. Gary said it was important for doctors to keep up-to-date with what’s going on but there needed to be assurances that there were no undue influences, particularly from big businesses such as drug companies. “Things have changed from 30 years ago when, in simplistic terms, it was just understood that drug companies took you out to dinner and gave you pens. Over the years people have become much more suspicious; that this is very big business trying to manipulate markets.” “So while doctors should be informed about new product development, they should not be unduly influenced. That’s been the quantum difference from then and now. Current guidelines are much more 20

realistic and I think your average doctor now views it [pharma sponsorship] very differently to how they did in the past.” “The idea that you can only educate people by taking them to the best restaurant and serve them $100 bottles of wine is clearly crazy … but at the same time, hard-working doctors getting together in their own time to hear about a new product and are provided with a few sandwiches and a drink, that’s not unreasonable.” “But you can’t underestimate the importance of people networking and talking to peers … it’s probably the most important aspect of conferences. You come away energised with new ideas. It’s a bit annoying when it’s suggested that there’s something tainted about that.” “It is an important area but it has to be accountable and transparent – and useful.” O medicalforum

they’re self-evident but it is more a shift in emphasis. The broad principle is better communication with general practice. There’s a lot of rhetoric about trying to move chronic care back into the community, but not a lot is happening.” “In South Australia, hospital consultants work with GPs, who take over the care of patients, rather than have patients managed entirely in the hospital system.” “Richard Choong and I were on a panel recently talking about this issue. He said he sent his patients off to the hospital and he never saw them again. He said simply: ‘give me back my patients’. I think what he says is very true.” Workforce issues are the biggest stumbling block to the community care model with a chronic shortage of GPs stymying attempts to change rhetoric into action. However, Gary says that with the recent increase in intern places,

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The broad principle is better communication with general practice. There’s a lot of rhetoric about trying to move chronic care back into the community, but not a lot is happening

this could turn around quite quickly. If there’s a culture shock moving from the heat of an emergency department to the humidity of a huge health bureaucracy, Gary Geelhoed doesn’t show it. Perhaps it’s his years of experience in medical politics but one thing is for certain, he has his priorities. In a report in HealthView, the CMO said he was keen to promote research as an integral part of the health system. “There’s a tendency to think of research as an add on … especially when the money is tight, but medical systems that are regarded as getting very good results value research,” he said in that interview. On the day he spoke to Medical Forum, doctors at the coalface were very much on his mind. “When I took on the job, I saw my role as representing doctors. Basically we’re all here to do our best for West Australian patients and we certainly want to get the best out of our doctors. My predecessor Simon Towler did a wonderful thing to establish the health networks, which has senior clinicians looking at the system and taking a longer view and coming up with ideas of how can we do things better. I want to keep building on that. I’m now trying to find other ways to get senior clinicians involved.” “There is a bit of a disconnect (and probably always will be) between the bureaucracy and what’s happening in hospitals at the coalface. We’ve got to keep asking ourselves, ‘what are we doing here to make it better for patients in the hospitals?’. That’s the view I take as a senior doctor coming into this role and what I bring to the top table.” O

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By Ms Jan Hallam medicalforum

Christmas 2012

Celebrating 2012 Achievements gy Clinipath Patholoed with Clinipath users, staff and

e ouse was pack Dr Gordon Harlo Mosmanâ&#x20AC;&#x2122;s Tea H r function. CEO ea e with -y of op dsc en lth ea eir friends for th algamating H am to in go ill w rt that g with a move outlined the effo year, culminatin xt ne e th er ov ions ral operations. Clinipath operat eir expanded cent th r fo e bl ita su s into new premise

Q Dr Michael Watson, Mr Matt Boyle and Dr Carl Vinciullo

Q Ms Jenny Heyden and Mrs Sheila Harloe.

Q Prof Jon and Ms Sue Emery

Q Mr Yousif Yousif, Dr Adrian Jameson, Dr Fatin Wajdi, Dr Stuart and Mrs Rose Burton, and Dr Colin Stevens.

Q Mrs Elizabeth Treagus, Dr Tim Davis, Dr Ivan Treagus and Mrs Wendy Davis.

Q Ms Nicola Russell, Dr Harloe Gordon (CEO), Mr Kelvin Oh, Mr Bill McConnell and Ms Natalie Park

Q Dr Tim Cooper, Mr George Jones and Ms Penny Jones

Ear Science Institute Australia Ear Science Institute Australia celebrated the festive season and a busy 2012 with an elegant sundowner in the grounds of St Josephâ&#x20AC;&#x2122;s church, Subiaco, just next door to the institute. The ESIA board headed by Mr Graeme Jolley welcomed guests and supporters. Q Mr Graeme Jolley, Mr Peter Avery, Ms Deborah and Mr Victor Tana

medicalforum

SJOG Murdoch The rain threatened but this year held off for a return of the SJOG Murdoch lakeside marquee. Dr Peter Bremner received the Murdoch 2012 Doctor of the Year Award, having been with the hospital since it opened and MAC chairman for 10 years. Judging by the friendly banter that CEO Peter Mott dished out during the presentation, the friendships and dedication to patients are features of Dr Bremerâ&#x20AC;&#x2122;s relationship with the hospital.

Q Mrs Krista and Dr Greg Makin with Dr Shirley Bowen

Q Mrs Natasha and Prof William Hart with Mr Colin Keogh.

Q Dr Ross Keesing, Dr Fiona Sharp, Dr Shane Kelly, Dr David Russell-Weiss and Ms Jo Keesing.

Q The Bremner clan with waiter ducking for cover (l to r) Jon, Mrs Pauline, Dr Peter, Nick and Jeremy.

Q Mrs Ann and Dr Richard Gardner, with Mrs Geraldine and Dr Jacques Pretorius.

Q Father Joe Walsh and Prof Michael Quinlan

Q Mr Peter Millington, Prof Lyn Beazley and Ms Susan Andrews

medicalforum

Q Ms Claire Turton, Prof Marcus Atlas and Dr Kingsley Faulkner

Christmas 2012

Q Mr Chris Yates and Dr Genevieve Sadler

logy olog yâ&#x20AC;&#x2122;s Per th Patho op the crowd at Perth Pathan other busy

of s didnâ&#x20AC;&#x2122;t st ng the end f and Storm cloud m celebrati o fr welcome staf n io to ct it n fu Sm e as n m ay st h W ri Ch atmosp ere. r CEO a chance fo e convivial th as y w jo It . en ar to ye em and invite th supporters Q Dr Peter Heenan, Mrs Margaret Heenan and Dr Michael Armstrong

Q Dr Rini Roper, Ms Pak Chin and Dr T Chin

Q Dr Wayne Smit and Dr Karen Moller

Q Mr Leigh Richardson and Dr Patricia Dowsett

Q Dr Manal Rezkalla and son Marcus

Q Ms Yien Chin, Mr Damien Foy, Dr Rini Roper and Ms Pak Chin

R ACGPWA

ance the state had a ch GPs from around eer at ch ve sti fe e share som to catch up and W s A ian College of GP the Royal Austral s wa t ether. The even Christmas get-tog alvina M s M er P WA manag hosted by RACG Nordstrom. 24

Q Dr Mahinda Yogam, Dr Colin and Ms Barbara Hughes

Q Dr Denise Findlay, Dr Sally Edmonds and Dr Cherelle Fitzclarence medicalforum

Medical Forum

magazine

ered at ristmas rush gath e it in the pre-Ch ak ed to just m rn d tu ul co ns o tio wh sa Those sy year. Conver bu a te ith ra leb tfi ce blishing ou t, w Red Cabbage to imagine for a pu n ca u yo as , ng about anythi d. next year in min Q Out of focus focu again, Medical Editor Dr Rob McEvoy

Q Medical Forum Editorial Panelist Dr Joe Kosterich and Ms Michele Kosky and Dr Louis Papaelias (in background)

Q Terri Sedgman and Wardell Wendy provide welcome relief from the wallpaper

Q Jenny Heyden, winding down for 2012

Q Writer Peter McClelland admires wrist strength

Q Managing editor Jan Hallam tries her I talian hand gesture

Q Glenn Bradbury â&#x20AC;&#x201C; never a marketing dull moment

Q Dr Mithila Jayathilake and Dr Dinka Filipovic

Q Dr Penny Wilson, Dr Hanif Ibrahim, Ms Malvina

medicalforum Nordstrom and Dr Rasamogan Rasalingam

Q Dr Alistair Vickery, Dr Roslyn Carbon and Dr Peter Winterton

Guest Column

Doctors Crucial in Pension Process GP and member of the Social Security Appeals Tribunal Dr Mike Jones offers insight into the doctor’s role in application for the disability support pension.

s a GP, I know how time consuming filling out forms can be. Before I started working with the Social Security Appeals Tribunal (SSAT), I was like the majority of GPs who would groan about the red tape and bureaucracy. Forms would be filled out as quickly and as briefly as possible. What I didn’t know then was the importance and the weight given by agencies such as Centrelink and appeals boards such as SSAT to those reports. I have sat on appeals where applications have failed because of a lack of information in medical reports. It’s important to impress just what an enormous difference you can make to your patients’ lives by taking the application process for a disability support pension seriously. Doctors need to primarily concern themselves with the Centrelink criteria, which require that a person has a fully diagnosed condition; has undergone all

reasonable treatments and is now stabilised but with no real prospect for improvement at least for the next two years. Specialists are crucial players in this application equation because most disabilities that render a person permanently incapacitated for work have had some sort of specialist care. While some of the better GP reports I’ve seen include copies of scans and specialist letters, much of the time that supporting documentation is not there. In some cases, the patient has to go knocking on doors getting that information, which is pretty difficult for some of them. Patients can have unrealistic beliefs that they deserve the disability pension and this can place undue pressure on doctors. For instance there was an appeal from a man who had a heart condition and was unable to work. However, he was booked in for heart surgery two months’ later, he clearly had not come to the end of the line of his treatment options and his application was denied. One of my criticisms of the current Centrelink form is that it doesn’t give

doctors a clear idea of what will be useful information. It just lists a lot of questions. So I would like a better covering explanation to support doctors through the process. As a GP filling in those forms, I was never aware of the significance of the questions and the importance of my answers. I’m pretty sure that 99% of other GPs are the same. And while we all hate more red tape there are times when it is a necessary evil and it needs to be done properly because your patient’s future may depend upon it. O ED: Dr Mike Jones is a member of the Social Security Appeals Tribunal but the opinion expressed in this column are his own.

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Doc of The Swan

Putting a Smile of Their Faces Last year, money raised at the Doc of the Swan regatta went to several children’s support groups associated with Connect Groups. Childlimbs, an activity arm of The Spine & Limb Foundation, WA Special Families, a support group for families with children with special needs, and the Defence Special Needs Support Group.

were shared and in between the rain, some families even went on the rides and water slides at Adventure World. Overall the day was a great success with families saying they had an excellent day and are looking forward to catching up next year.”

possible, so from my family to yours, I thank you very much.

Medical Forum caught up with the coordinators of these groups to discover some of the uses this money has been put to work on. Q Fun at the Special Families Christmas Party Q Kids Ben Passmore, Amy Ralph, Josiah Kappert, Renuka Pantual with Brant Garvey & Sarah Potts.

Defence Special Needs Support Group From Marilyn Kench, the WA coordinator comes this report.

Q Marika, Henri & Jamaica Kappert with mum & dad

WA Special Families Anita Peiris of WA Special Families reports that funds were used to hold a Christmas party on November 24 for more than 50 adults and 70 children.

Childlimbs Sarah Potts of Childlimbs reports: “On November 4 last year, Childlimbs families braved the weather to attend the 2012 Living Loud Day at Adventure World. Despite it raining cats and dogs, families arrived early in the morning and set up their picnic rugs underneath a marquee. The families enjoyed each other’s company, the children were entertained by the photo booth and getting their face painted. The families were greeted by guest speakers from Princess Margaret Hospital, WA Paralympic Committee and WA Little Athletics. Stories and laughs

“Santa came to visit and handed out gifts to all of the children. The event was only possible thanks to Doc of The Swan funds. Thank you from all of the families who were lucky enough to attend (as we had limited places). Happy Memories to be Cherished Forever!” Anita passed on a message from Jodi Watterson, mother of Angel and Robert: “Through your support of WA Special Families my children were able to experience not only a wonderful night of fun but it allowed myself and my children a chance to forget about their medical problems for a few hours, and I thank you for that. Without your support these events would not be

"The Defence Special Needs Support Group is a non-profit volunteer organisation established to help Navy, Army and Air Force families who have a family member with special needs. DSNSG has many local support groups and more than 3000 families around Australia and overseas. The group provides support, information, assistance and advocacy for all ADF families who have a dependant (child, spouse or other) with special needs." "DSNSG has spent the funds raised from Doc of The Swan on producing emergency kits, which will help families plan for an emergency. The kit includes a folder; a car sticker to indicate that someone with a special need is present; a strip to go on a driver’s licence also alerting police and emergency services; documentation of all medication and routines required and who to call in an emergency. The kits will be primarily used for families who have the serving member deployed and families on the DSNSG Circle of Friends Respite Program. The emergency kit will be launched this month and trialled in WA." O

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Guest Column

Drug Policy Needs Debate Outreach worker Mr Paul Dessauer says the emotion needs to be removed in order to formulate a drugs policy that will work.

rug policy is a strange beast. Our existing drug laws are a product of accidents of our cultural history, and bear little relationship to the objectively-rated potential of each substance to cause harm to drug users or the broader community.

Criminal prosecution of drug users remains our default response to drug-related problems, although all evidence indicates that the severity of local drug laws, and the intensity of policing, has no relationship to per capita rates of drug use. Drug policy provokes strong sentiments, whatever the scientific evidence. The Needle and Syringe Program, probably the single most cost-effective public health intervention, remains one of the most controversial politically, both here and abroad. The majority of funds earmarked to reduce drug-related problems are spent on law enforcement and interdiction, when any economist knows that trying to reduce supply of a drug without effectively reducing demand is doomed to failure. The Rand Institute calculated the “return on investment” of drug treatment as seven times higher than that of drug law enforcement, yet Australia spends nearly 60% of our National Illicit Drug Strategy funds on police and Customs, with 17% spent on treatment, (and just 3% on harm reduction programs). A case in point: In 2007 Australia was host to the world’s largest ever “ecstasy” bust. Victorian Police estimated that these 15 million pills, weighing 4.4 tonnes, represented three quarters of Victoria’s annual

consumption of ecstasy. This seizure and the subsequent arrests were hailed as a spectacular success in the “war against drugs”. However during the following 12 months the availability of ecstasy in Victoria remained consistently high, the price of ecstasy did not increase and per-capita consumption of ecstasy was not affected. There was one observable change in Victoria’s ecstasy market post June 2007. The pills seized by Customs were quality MDMA pills, containing no adulterants. The locally pressed pills that flooded the market subsequently, typically contained active ingredients far more dangerous and neurotoxic than MDMA, (such as methamphetamine, ketamine, BZP, PMA and PMMA). It might reasonably be argued that this highly successful policing operation potentially increased, rather than decreased, the incidence of ecstasy-related morbidity and mortality in our community. Commentators, including Prof Geoff Gallop (Medical Forum, December issue) have drawn attention to Portugal’s 2001 decriminalisation of personal drug use. This experiment, by all objective evaluations, has proven a success. However, it is important to remember that use and possession of drugs remains illegal in Portugal; the offence is now an civil one, not a criminal one, (as long as the amount is judged to be less than 10 days’ supply for personal use). Under the Portuguese model, drug production, importation and trafficking remain offences. With less emphasis on policing personal drug use, more resources

are available to pursue the criminal syndicates that profit from drug prohibition. Most importantly, decriminalisation of personal drug use was just one plank of Portugal’s national strategy. It was accompanied by a vast expansion of harm reduction services, and by a doubling of public funds dedicated to drug treatment and drug prevention. It is the combination of decriminalisation and the expansion of harm reduction and treatment services that has delivered benefits to the people of Portugal. There is no magic solution to drug-related problems. They are complex, messy, human problems. However, it is clear to any objective observer that there are some "drug-related problems" that are largely a product of the interaction between the chemistry of the substance and the physiology or psychology of the user, and there are some 'drug-related problems' that are largely a product of the specific drug's legal and social status. The challenge is to pragmatically ask; 'What are the most effective ways of addressing these problems?' We should not be afraid to begin frank discussion of these issues in Australia. O ED: Paul Dessauer coordinates WA Substance Users Association Outreach Team. The WASUA is a peer-based, not-for-profit NGO that delivers a range of education, harm reduction, BBV and STI prevention, and drug treatment services in WA. References on Request

Are you a GESB Member? Les Conceicao – GESB Award Winning Financial Adviser RBS Morgans is pleased to welcome Les Conceicao as a Senior Financial Adviser to our Perth office. Les has over 13 years experience as a licensed financial adviser with over 5 years as a Senior Financial Adviser with GESB Financial Advice and is a multiple award winner of the GESB Financial Adviser of the Year. Following the recent closure of GESB Financial Advice, Les is available to assist you with your superannuation and retirement planning needs. Les has specialised knowledge to create tailored tax-effective strategies to maximise your benefits from: s¬'%3"¬7EST¬3TATE¬3UPER s¬'%3"¬'OLD¬3TATE¬3UPER Additionally, Les is also able to assist you to maximise benefits from Self Managed Super Funds and portfolio management. We help our clients achieve a secure and happy retirement. To make an appointment with Les, please call Marie on 08 6462 1989 or Les on 08 6462 1960. RBS Morgans Limited ABN 49 010 669 726 AFSL 235410 A Participant of ASX Group. A Professional Partner of the Financial Planning Association of Australia

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RBS Morgans Perth | 08 6462 1999 Level 20, 140 St Georges Tce Perth WA 6000 www.rbsmorgans.com/perth 29

Doctors Drum

"Doctors Never Had It So Good?" On February 27, Medical Forum is hosting the first in a series of lively breakfast discussions where you can network and throw some curly questions at our panel about a topic that’s close to your heart. Our first breakfast will be tossing around the idea that ‘Doctors /FWFS )BE *U 4P (PPE On the panel will be tertiary medical care buffs Dr Neale Fong (reformist) and Dr Michael Stanford (SJOG), newly minted Canning Vale GP Dr Shelley Davies, consumer advocate Ms Michele Kosky, lawyer Ms Karina Hafford and finance whiz Mr John Boyle.

Guaranteeing an entertaining morning the ev ents w ill be hosted by ABC radio’s Mr Russel l Woolf.

To kick off the discussion, we asked doctors in our latest E-poll to get some of the burning issues off their chests and to pose some questions for the panel. The response was magnificent and results, insightful (opposite and below). The floodgates opened… REWARDING “The joy and humour of treating our trusting patients will never change but red tape, accreditation and outside interference is throttling our profession. However, it is still the best job in the world. If you cannot find happiness in the art of the practice of medicine, you need help.” GOOD OLD DAYS “I don’t feel it is as enjoyable to practise now. Time constraints, constant criticism of fees and the fear of the ever-increasing risk of litigation do not allow one to relax. In earlier years it was possible to spend time with your patient, get to know the family and do home visits to strengthen that bond.”

Stimulating sample of comments by WA doctors on "Doctors Never Had it So Good?" RED TAPE “After just having worked ‘my butt off’ over Christmas/New Year, I'm not in the mood to agree. Certainly red tape and paper work detract from my work – some of it medico-legally driven.” “Doctors are increasingly considered 'nonessential' providers of medical service. We no longer provide patient care - except when the **** hits the proverbial fan.” “Doctors have always ‘had it good’. In some ways it is better with advances in knowledge and technology and in other ways worse with loss of the satisfaction of close caring of patients and loss of esteem.” 30

“We have much more powerful therapies now, and systems are better, but Medicine was more rewarding and less stressful back in the ’80s. Why is it so hard for governments to make sensible resource allocation decisions?” LOUSY “GPs are poorly paid for the training they have done, responsibility they carry and the huge administrative work they must do. They are painted by government as dishonest and unnecessary as their job could be done adequately by other "clinicians." What is there to attract someone to the profession?” TRUST “How can trust/respect for qualified doctors possibly exist when we are belittled and denigrated by the push to have nurse practitioners perform the roles and duties we have spent years studying, qualifying and specialising to provide?”

GEN Y “The Gen Ys just don’t get it! Money should be a side effect from the good practice of medicine not an end in itself.” “We have a sense of entitlement and yet keep taking the altruistic high ground. Most other businesses (we are classed as small businesses by the ATO) would vigorously compete, lobby and selectively market.” POOR PATIENTS I do think we could say 'patients have never had it so bad' particularly if you are part of a lower socioeconomic group. The gap between health services available to those who can pay and those that cannot is widening. The result is likely to be an increasingly dysfunctional society. LIFESTYLE “Have we moved so far towards "lifestyle first" in medicine that working three days a week and charging ridiculous gaps to cover not working the other two days is considered appropriate and fair? This also lets down colleagues and puts strain on rosters. I think that surgeons were previously overworked and appropriately paid but now work less for more pay. That’s great for us and our families, but not fair to patients, colleagues and the public system which cannot keep up. Why?” If you would like to attend the breakfast at Observation City on February 27, go to www.doctorsdrum.com.au to register or click on this QR code to be directed straight to the website. medicalforum

E-Poll: Doctors Drum A total of 248 medical practitioners responded within our five-day deadline. Thanks to all who took part – general practitioners 38%, specialists 43%, doctors in training 5% and other 14%. Winner of the wine prize was Dr PG. Please indicate how you align with the following statements. Strongly agree

Agree

Neutral

Disagree

Strongly agree

There’s been an increase in the trust the community has in doctors.

12%

37%

42%

There seems no end to dissatisfied patients these days.

36%

25%

30%

Our profession should more openly discuss abuse of power and position amongst our ranks.

14%

Medicine needs a more feminine approach and less ‘testosterone’!

51%

21%

14%

Increase your patients’ sense of security Our Silver Chain Alarm comes with a small water resistant pendant that is worn around the neck, so that help is always just the press of a button away. We also have a fall detector for your patients that are prone to falls and for those situations where they may not have time to press the pendant. Our experienced operators will answer your patient’s call 24/7, determine the appropriate response and will stay on the line until help arrives.

15%

36%

37%

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SC0556

Medical technology means doctors can achieve so much more for patients.

Yes................................................................................. 72% No ................................................................................. 13% Uncertain .................................................................... 16% .....................................................................................

Medical technology puts too much pressure on doctors to perform.

Yes................................................................................. 28% No ................................................................................. 57% Uncertain .................................................................... 15%

Future change I would support, in the main, is [multiple choices]

GP subspecialisation ................................................. 42% More part-time doctors ............................................ 38%

“Unplanned pregnancy & family planning services” Our experienced Dr Marie™ team provides caring and non-judgemental support and services.

Lifestyle before work ................................................. 35% Delegate work to Nurse Practitioners .................... 30%

Surgical & medical abortion on

Sharing more responsibility with non-doctors .... 21%

Contraceptive inserts

None of the above ...................................................... 28%

STI checks

Decision-based counselling g

Yes................................................................................. 52%

24 hour aftercare

No ................................................................................. 26% Uncertain .................................................................... 22%

DR0194

Vasectomy

Legal Red tape has 'killed' medicine (i.e. made it very unattractive)

Part of the Marie Stopes International global partnership Model pictured for illustrative purposes only

ED. Our E-poll doctors have offered up a series of questions for the panel and audience – we are busy selecting the best. See you at the breakfast!

8 Sayer Street Midland WA 6056 www.drmarie.org.au

Referrals and enquiries freecall 1800 003 707 medicalforum

Practice IT

Taming the Information Revolution Computers can enhance patient care but there’s lots to learn as Dr Rohan Gay has discovered at his Bayswater practice school and so on. In the same manner, letters to specialists and hospitals are much more comprehensive and useful.” Computer generated auto-fill forms – ACROD permits, medical alert forms, outpatient referrals, school asthma plans, etc. – are much faster, look more professional and reproduce easily.

Dr Rohan Gay says his practice’s highly customisable software Medtech 32 is a two-edged sword. Doctors use the flexibility to personalise patient data and handle recalls and reminders, but it takes a strong team approach and uniformity across the practice to deliver the software’s fullest potential. He and the practice manager are the go-to people for practice computing. “It is important to share broadly the Q Dr Rohan Gay same vision. So long as everyone has “We generate recalls for most of the the same aims in mind, doctors and staff screening items recommended by will see ways the computer can enhance the RACGP and as recommended for areas they are interested in,” he said. common medications. Relying on patient Good IT support is essential. Medical software training, network knowledge, blackout contingency, rebooting knowhow, installing printers, basic workstation troubleshooting, overseeing appointment and holiday schedules, and setting up new doctors are all in-house requirements these days. Then there’s the task delegation for computerised forms, billing matters, chronic disease plans, and data extraction and submission. “Surprisingly, it has been difficult to recruit doctors to assist with computer matters beyond the requirements of their immediate practice. Practising to a high standard and negotiating the overly complex MBS is hard enough, and there is just no incentive to step outside this role,” he suggested, adding that computerisation is probably scaring off doctors from becoming practice principals. However, well run computer systems are both a measure of success and a tool by which doctors can keep up with best practice, particularly for chronic diseases such as diabetes, hypertension, hypercholesterolaemia, COPD, etc.

appointments for scripts is very inefficient. We set recalls before scripts are due, and instruct the patient to make ‘diabetic’, ‘cardiovascular’ or ‘spirometry’ consults to receive their results. They are seen by the practice nurse for ECG, spirometry, BP, weight, etc. before seeing the doctor who then has all available data to manage the patient. In this way patient contact time is optimised, and more consultations meet the criteria for the better remunerated chronic disease items and service incentive items.” “In my opinion, general practice is about efficient delivery of care that makes a difference to people’s lives. Our chronic disease patients and mental health care patients, and any others who request it, have been given display books to slot in their health summaries results and specialist correspondence. We constantly receive favourable feedback from patients, hospital doctors and specialists, particularly in the context of emergency care and travel.” “Patients, especially mothers managing chronic conditions in their children, love printed instructions, consultation and tests records, and management plans for home,

It takes at least three hours to orientate a new doctor to their medical software, using dummy databases and patient records. A basic level of computer skills is needed. Modules for screening, chronic disease management, patient education, travel medicine, patient recalls etc. eventually become standard, along with introduction to clinical support material (websites). As a systems thinker, Rohan gives these things precedence: t 0WFSIBVMJOH UIF .#4 TP UIPTF TQFOEJOH time with patients are not penalised. t 3FDPHOJTJOH IJHI QFSGPSNBODF EPDUPST whether through computer, medical or teaching skills. t 'JYJOH DVNCFSTPNF 1*1T BOE 4*1T XIJDI are a disincentive to good, whole patient care. t %JTBTUSPVT TFDVSF NFTTBHJOH o OP standard protocol means practices struggle with half a dozen providers to obtain results and correspondence, and map these to patient records. t 5IF 1,* TZTUFN GPS TFDVSF .FEJDBSF access is cumbersome, limited and legalistically restricted – doctors are put off or forget. “We have an ethical obligation to practice the way should practice, rather than just the way we can. Computerisation is one way to bring ‘can’ and ‘should’ closer together. We have a greater ability to oversee, direct and coordinate patient care than ever before.” O

The PM Perspective Bayswater Practice Manager Cheree Matthews said recall systems remind both practice staff and patients, to the point that patients often ring before the reminder goes out! And when patients don’t follow-up a result, the system takes care of it. As well, recalls are ideal for chronic disease patients and their scheduled management plans. Q Cheree Matthews 32

With computers the work horse, all staff need to jump on and know how to ride. Plug and play is good for

most users, along with software shortcuts. However, management needs to be computer whisperers. As for doctors or staff becoming slaves to computers, looking at the screen not the patient... “Our patients deserve personalised care. Eye contact is very important as you will pick up things that may not be verbalised during a consult. Good practice is to set up your station with them side by side or have a swivel chair. Otherwise, they comment on their way out if you give the computer more time than them!”. O medicalforum

Guest Column

End of inner urban general practice? Dr Peter Winterton laments how inner urban practice, which he enjoys, is being forced out of business, mainly by rising costs.

eneral practitioners recently received a princely 70c more for a standard bulk billed consultation, which begs the question: How long can (1T XIP CVML CJMM TVSWJWF :FU CVML CJMMJOH rates have never been higher. There are two ways of interpreting this: GPs are stupid and not familiar with their worth; or many sectors of society cannot bare the true cost of their GP visit. GPs tend to be community minded, putting their patients before themselves. Unless there is drastic action, general practice may prove nonWJBCMF JO NBOZ JOOFS VSCBO BSFBT 8IZ The GP today is faced with a vastly more complex patient than even a decade ago. Medical science has achieved the impossible for many patients and chronic disease, debility and longevity are all on the increase. Todayâ&#x20AC;&#x2122;s patient has greater expectations, has often read Dr Google and attends with a treatment plan in mind.

To survive economically the GP is forced into clinically dubious summersaults, which have been given the euphemism of Enhanced Primary Care. It is note-worthy that almost all EPC items are bulk-billed, as no one in their right mind would pay for them. When the Government reduced the payment for such an item (e.g. the mental health care plan, item 2710) there was an outcry that standards would fall. What falls is the ability of the GP to offer adequate time for a consultation that should be a part of normal clinical practice, without three sheets of paperwork. As governments struggle to balance their budgets EPCs are easy targets. Raising the bar to qualify for a Service Incentive Payment is in the same territory, with reductions already in SIP for immunisations. Few inner urban areas are â&#x20AC;&#x2DC;areas of workforce shortageâ&#x20AC;&#x2122; yet it is nigh on impossible to find manpower. Because of this doctor shortage, sessional GPs demand and often receive 70% of gross fees when running costs mean few practices can really afford more than 60%.

Many sessional GPs have no experience in running their own practice and have false expectations as to their worth and what a practice can truly afford. Capital costs such as painting, computers, autoclaves, and a vaccine fridge are borne by the practice owner, which requires the practice to run at a profit and not just break even. The land on which inner urban practices stand has become increasingly valuable. Rent, land tax, council rates or land purchase costs all increase. Building codes have onerous parking provisions e.g. a 10 consulting room medical centre in the Town of Vincent needs 500sq m of parking. All this leaves the inner urban practice on the brink of extinction, which is catastrophic for patients and the health system. Inner urban residents will present more at public hospitals, with more expense and less humanity, continuity of care and cost efficiency. We need to see what is really happening in urban general practice and act before it is too late. O

WA Calendar of Events 2013 February

All Perth events TO BE AT &RASERS Kings Park. Bunbury venue to be advised.

Thursday 14th

Requirements of ePIP - ESeminar

Friday 22nd

Is your Practice Healthy? - full day event Will you survive standardisation of OH&S or a workplace audit? Bullying and harassment (receptionists welcome) and Compliance

April Thursday 11th

The effect of eHealth on your Business - ESeminar

May Wednesday 8th

Improve your Bottom Line - breakfast event #OST SAVING EFlCIENCIES s (OW TO IMPROVE YOUR BOTTOM LINE Interactive session

June Thursday 13th

Clinical Governance - ESeminar

August Thursday 8th

Managing my day, my practitioners, my project - ESeminar

Friday 16th

Toolkit for Women in Leadership - full day event including AGM $EVELOP IMPROVE THE SKILLS YOU HAVE s #ONlDENCE &INANCE ,EADERSHIP 2ELATIONSHIPS WITH YOUR STAFF s )DENTIFY YOUR LEADERSHIP STYLE

September Tuesday 24th to Friday 27th

National Conference (jointly presented with QIP) Sydney

October

FFor further f th information i f ti and d membership b hi please contact via email wa@aapm.com.au or visit www.aapm.org.au

medicalforum

Thursday 10th

Common ďŹ nancial miscalculations - ESeminar

Wednesday 23rd "UNBURY 7EDNESDAY TH (Perth)

Personal development and upskilling for receptionists - evening events 0ATIENT SCENARIOS OF DIFlCULT PEOPLE s )NTERACTIVE SESSION 2ECOGNISING THE SIGNS s -EDICAL LEGAL ISSUES s h0OPGUNv

November Thursday 7th

Effective strategic planning for your practice - ESeminar

Perth Radiological Clinic is pleased to welcome Drs Anuj Patel, Adrian Yoong, Helen Van Den Broeck, Ashley Bennett and Duncan Ramsay as new owners of the Practice. They join as equal equity partners in the ownership of Perth Radiological Clinic along with Drs Thornton Abbott, Richard Bessell-Browne, Martin Blake, Rudolf Boeddinghaus, Bill Breidahl, Tony Briede, Rodney Butler, Gavin Chapiekin, Brian Cleary, Stephen Davis, Michael Fallon, Kit Frazer, Kieren Gara, Rodney Greenberger, Susanne Guy, Roche Helberg, Sanjay Jeganathan, Susan Lamp, Joanne Lazberger, Martin Marshall, Mal McCloskey, Stephen Melsom, Andrew Patrikeos, Ramon Sheehan, Peter Shipman, Manoj Tharakan, Jacqueline Thomson, Rohan vanden Driesen, Sharon Winters and Eric Yau.

Perth Radiological Clinic is one of Australiaâ&#x20AC;&#x2122;s largest private radiology practices owned and operated by radiologists. This year, Perth Radiological Clinic celebrates 65 years of providing medical imaging services to the people of Western Australia.

www.perthradclinic.com.au 34

For more information about any of our services pleasemedicalforum visit our website.

X Dr Glenn Edwards has been appointed to the new role as St John of God Pathology’s National Medical Director.

BENEATHthe Drapes X Dr David Weisz, the chief executive of North Metropolitan Health Service, has been seconded to Fiona Stanley Hospital Commissioning as chief executive. By the time Medical Forum went to press, an acting CEO of NHHS had not been named. X The first three clinical positions at FSH have been announced. Dr Paul Mark has been appointed Director of Clinical Services. He was formerly Area Director of Medical Services for South Metropolitan Health Service. Ms Taylor Carter is Director of Nursing and Midwifery. Ms Carter has spent the past four years as chief nursing officer for Johns Hopkins Medicine’s International Division in the United Arab Emirates. Dr John Keenan has been appointed Medical Accreditation Lead. For the past two years, Dr Keenan has been Executive Director Medical Services for the North Metropolitan Health Service.

X Dr Rowan Davidson has resigned as Chief Psychiatrist with WA Health after more than a decade. He will be replaced by Dr Nathan Gibson. Dr Gibson was previously the Adult Program Director for the North Metropolitan Health Service and is the current Chair of the WA branch of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Dr Davidson will be a consultant at the Inner City Mental Health Service.

X Mr Willie Rowe has been appointed president of the Australian Federation of AIDS Organisations (AFAO). Mr Rowe had been servicing as vice-president of AFAO and had 13 years on the board of the WA AIDS Council. X St John of God Healthcare has appointed Ms Rita Maguire to the newly created position of group director workforce, a busy role with the Midland campus in the pipeline. Ms Maguire was previously human resources manager at Ramsay Health Care and has also worked in the public sector in WA.

X The Commissioner for Children and Young People, Ms Michelle Scott, has had a 12-month extension to her appointment. An extention was considered to be the most appropriate course of action in the light of recommendations made in the Blaxell inquiry which foreshadowed changes to the role and functions of the commissioner. In the meantime the contract process for the position will commence.

X Curtin University has appointed Prof Michael Berndt as the new pro vice-chancellor of health sciences. Prof Berndt was most recently director of the Biomedical Diagnostics Institute at Dublin City University. X Lee Parker is the new Sales and Marketing Manager for SKG Radiology

Surgeons Hit the Road CTEC has taken its basic surgical skills course to the Pilbara for the first time, where 13 doctors from Port Hedland and South Hedland – the Hedland Health Campus, Aboriginal Health Service and GP Trainees – spent two days improving their surgical prowess. Three consultant surgeons – Prof Jeff Hamdorf (CTEC director), Dr Dieter Weber (SCGH) and Dr Hairul Ahmad (private) – were volunteer teachers. The WA Country Health Service, CTEC, Royalties for Regions and Covidien (ex-Tyco Healthcare) were facilitators. A variety of animal tissues were used to simulate and none were ‘road kill’ that we know of! CTEC wants to do more workshops.O

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

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Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665 Certified to ISO 9001 Standard

Supporting Ophthalmic Teaching and Research

E: info@eyesurgeryfoundation.com.au 42 ORD STREET WEST PERTH WA 6005

Dr Robert Patrick Tel: 9300 9600 Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Angus Turner Tel: 9381 0802 Dr Michael Wertheim Tel: 9312 6033 35

Innovations & Trends

It’s mainly about blockage

oing into 2013, here are three things that carry special significance for vascular surgery.

Drug coated balloon angioplasty Plain angioplasty balloons are coated with paclitaxel which is an antiproliferative agent that inhibits restenosis due to neointimal hyperplasia, considered the ‘curse’ of plain Q By Dr Peter Bray, balloon angioplasty and stenting. The Vascular Surgeon standard technique is to perform a plain balloon angioplasty to achieve the vessel’s nominal diameter, and then the drug-coated balloon is inflated in the same area with the lipophilic paclitaxel being taken up by the vessel wall. The balloon is then deflated and retrieved. Stenting may be needed if a vessel dissects or recoils severely. Drug-coated balloons have advantages over stents as they can treat lesions across important side branches without losing flow to that branch, treat bifurcation disease, points of flexion or compression, and longer segments. Compared to drug eluting stents dual antiplatelet therapy is only necessary for 1 month rather than for 6 months or life. Drugcoated balloons are currently only used in Australia after TGA approval in selected cases (mainly in-stent restenosis). The delay in obtaining full approval and an item number means some private health funds and all private hospitals will not cover the cost of the drug-coated balloon. This is particularly frustrating because this is the most exciting new technology in many years, and will actually save hospitals and funds money by reducing reintervention, costly implants and the costs of dual antiplatelet therapy as well as preventing the incredible long-term costs of limb loss.

Endoluminal aortic aneurysm repair We have well and truly surpassed the initial aim of only treating selected infrarenal abdominal aortic aneurysms. We are now able to treat aneurysms or dissections of the aorta from the level of the coronary arteries to the iliacs. The main stent-graft used for this type of complex intervention was invented in Perth and is still manufactured in Australia and sent around the world. We have now performed at least three branched endoluminal aortic arch aneurysm repairs in Perth. This entails endoluminal placement of a branched stent-graft from the ascending aorta (just above the coronaries) to the descending aorta, with branches for the brachiocephalic trunk and left common carotid arteries which are then also stented. We routinely perform endoluminal thoracoabdominal fenestrated and branched repairs, using

“custom made” devices, or modular “off the shelf” devices for urgent cases. Standard endoluminal repairs are now done as same day admission with routine discharge on day three post-op, and no need for ICU. We now perform over 80% of AAA and TAA repairs endoluminally, and generally reserve open repairs for the very young or anatomically unsuitable cases, or country patients for whom travel is difficult for long-term duplex and x-ray surveillance.

Below the knee (BTK) interventions At vascular meetings around the world this has been heralded as the greatest advance in recent times. New technology has allowed us to treat small, calcified and tortuous vessels from a variety of access points. SAFARI (subintimal arterial flossing with antegraderetrograde intervention) is a technique where pedal vessels are punctured and blocked calf arteries recanalised from below. In Italy they have even performed retrograde punctures of digital vessels to re-establish the foot arcades for diabetic ulceration! New wires, crossing catheters, low-profile balloons and drug-coated balloon technology enables us to treat previously-thought-impossible lesions, achieving wound healing with durable patency and most importantly preventing limb loss. Drug eluting stents have also found their niche in focal BTK disease, where long-term patency has been achieved leading to earlier and sustained ulcer healing. These technologies come at a cost and the Private Hospitals and Health funds are at loggerheads over who should pay. This technology will save the limbs and lives of these extremely frail patients with critical ischaemia, and I predict will see the end of distal or pedal bypasses.

The future Multiple non-crushable, bioabsorbable, drug-coated scaffolds/stents are being developed and could become the “Holy Grail” in the treatment of occlusive peripheral vascular disease. O Declaration: No relevant author competing interests.

Respiratory medicine insights

e are currently grappling with the issue of solitary pulmonary nodules (SPN), particularly as it relates to screening for lung cancer. We do not have an effective screening tool but a recently published US study showed that low-dose CT screening drops the lung cancer mortality by 20%. Unfortunately the all-cause mortality did not change! Further 96% of all abnormalities found were not Q By Clin A/Prof cancer, producing a huge cost in subsequent Peter Kendall, HOD Respiratory Medicine, investigation. Fremantle Hospital, By stealth, the same is creeping into our Clinical Lead Health world, with CTs being widely performed Networks Branch and unexpected nodules being found. The public hospital system cannot cope with this workload and I would commend you to www.med.umich.edu/rad/res/Fleischner-nodule.htm for Fleischner Society guidelines on when to repeat the CT. 36

Respiratory Physicians should see enlarging nodules and those which are already "masses" or more obvious cancers. Perhaps research into exhaled breath volatile organic compounds as biomarkers of cancer will be more useful as it evolves. The overall reality, however, is that if a population stops smoking before the age of 30, we completely avoid the four-fold increase in mortality from all causes due to smoking. I know where my money is best spent. We have some new help in sorting out asthma from vocal cord dysfunction and within categories of asthma. Exhaled nitric oxide (FeNO) is becoming widely available as a marker for eosinophilic inflammation in the airways. When added to spirometry (expiratory and inspiratory flow-volume loops) and mannitol challenge testing, we are better able to make more accurate diagnoses. This is especially important when we are using / trialling anti-eosinophil and anti-IL-5 interventions. medicalforum

Developments in anaesthesia practice

Q By Clin Prof Neville Gibbs, Dept of Anaesthesia SCGH

naesthesia is an exciting specialty at present, for both researchers and clinicians alike. Long-terms trends include improvements in safety, expansion of services, and advances in pain management, with increased access to depth-of-anaesthesia monitors, videolaryngoscopes, and simulation since 2000. Against this background, several notable recent developments are Patient Blood Management (PBM), the use of Ultrasound Imaging, and SugammadexTM.

Due to the forward thinking of our Department of Health, WA has been at the forefront of PBM, both nationally and internationally. PBM aims to improve outcomes through its three ‘pillars’: optimise patients’ own red blood cell production; minimise blood loss; and extend patients’ tolerance of anaemia; thereby reducing the need for transfusion. Anaesthetists contribute to all three by detecting and correcting anaemia preoperatively, contributing to haemostasis intraoperatively through haemodynamic and pharmacological interventions, and optimising patients’ cardiac output postoperatively. A related development is the uptake of ROTEMTM technology, a laboratory analysis of secondary haemostasis that helps guide the appropriate use of coagulation factors and platelets. Another obvious recent change in anaesthesia practice is ultrasound (US) imaging to guide vascular access and nerve blocks. Its noninvasive nature and improved real-time imaging means that US now supplements or even replaces many techniques based on anatomical landmarks, so that many anaesthetists feel uncomfortable without it and a large proportion consider it a standard of care. US imaging requires new skills, and although its limitations are recognised, the probable associated improvement in efficacy and safety of a large number of blocks, has promoted regional anaesthesia use. Anaesthetist-performed limited transthoracic echocardiography (TTE) in the perioperative period is another important development, with many anaesthetists taking on a post-fellowship qualification in this area. TM

Sugammadex , a novel cyclodextrin, is the first agent capable of binding and completely inactivating a muscle relaxant (aminosteroid group only). It acts almost immediately and has an apparent wide margin of safety. These properties, far superior to the traditional neostigmine, allow anaesthetists to reverse even deep levels of muscle relaxation within minutes, thereby increasing the safety of muscle relaxant use. Although high cost limits its use in many centres to highrisk cases, the potential to reduce both anaesthesia turnaround times and the risks from subclinical residual neuromuscular blockade, may justify its wider use. References available on request. O Declaration: No competing interests.

There is increasing recognition of the co-existence of two common diseases, emphysema and pulmonary fibrosis of the Usual Interstitial Phneumonitis variety (syn. Idiopathic Pulmonary Fibrosis (USA) or Cryptogenic Fibrosing Alveolitis (UK)). Neither of these conditions is reversible and the resulting breathlessness is often profound, primarily because the gas transfer (DLCO) drops precipitously. Unfortunately we still have a prevailing belief system that oxygen relieves breathlessness, when it rarely does. Some palliative care literature mentions a "fan in the face" as relieving dyspnoea. It is worth looking at www.health.wa.gov.au/circularsnew/ attachments/418.pdf for those of you who don't have ready access to a Chest or General Physician to sort out home oxygen prescription. Silver Chain is currently working on systems to evaluate patients in their homes for initial and subsequent prescriptions along with the supervising physicians. O

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www.skg.com.au 37

Innovations & Trends

At the heart of fund raising

am sometimes accused of having an easy job. What could be more effortless than fundraising for Princess Margaret Hospital? Most people have spontaneous sympathy for sick children. And with many people in WA having visited PMH as parents, relatives, or perhaps as children themselves, we have the great advantage of relevance and nearly always associations of positive outcomes, wonderful staff and first-class facilities.

Notwithstanding the very generous government support of PMH, there is always more to be done. Trying to ensure that our relatively small and isolated WA community can hold its own in providing the most innovative medical equipment and facilities for our children is a constant challenge. So is attracting and retaining the world’s best medical teams and delivering financial support for ground-breaking research. The support for PMH Foundation may be great – but so are the demands. We operate in an increasingly competitive environment, with many other Not-For-Profits fund raising for other childhood and adolescent health issues. And the dynamics of fund raising are not only changing, but accelerating. These changes, for the most part, offer new opportunities, but they also demand that fund raising organisations like ourselves remain nimble and innovative. Three important community changes in WA are worth highlighting: t 5IF QSPNPUJPO PG B NPSF QIJMBOUISPQJD DVMUVSF CZ CVTJOFTT BOE civic leaders, with the creation of Giving West a clear signal of this dynamic.

Q By Mr Denys Pearce, CEO Princess Margaret Hospital Foundation

mountaineers participating. By locating it at the highly visible Woodside Plaza Building and promoting it as an opportunity for company groups as well as individuals to raise funds for a good cause through sponsorship of direct participants, we have involved far more people than ever before.

t 5IF TIJGU POMJOF EFMJWFSJOH JOEJWJEVBMT JNNFEJBUF BDDFTT UP much wider networks of friends and colleagues than ever before.

Further, by making it easy for participants to engage their own online communities of supporters, removing obstacles to giving by offering fast, trustworthy, online payment mechanisms, we have also been able to help participants tap into often very large networks of donors made available through Facebook or LinkedIn. Direct participant fees are becoming a less important source of funding for the event than the often very generous sponsorship they are able to attract through social media.

The impact of the third of these changes on PMH Foundation is particularly significant. Take an event like Urban Descent, where the amount raised was limited by the very small group of urban

In summary, innovation is a central driver for any charity to inspire the enthusiasm and generosity of participants and donors needed to support our shared vision. O

t 4QFDJGJDBMMZ HSFBUFS GJOBODJBM TVQQPSU GSPN NBKPS DPSQPSBUJPOT JO a variety of ways, such as matched giving (donating equal dollars to those raised by staff for charitable causes), promoting payroll donations, and providing financial and staffing support for specific projects.

Aged care: more innovation needed

e live in interesting times – too much change, and not enough innovation. The big change is relentless population ageing for a further two or three decades, and we have not yet worked out how to cope with it successfully. Last year a visiting US political economist and ex-Clinton government senior official, Prof Robert Reich, put it very well; “The retirement Q By Dr Penny Flett, of the Baby Boom generation is unfolding like CEO Brightwater Care Group a slow-motion train wreck”. We are not alone, if that is any comfort. Reich says the whole world is utterly unprepared for the economic and infrastructure impact of ageing. But for our medical colleagues, what innovations are afoot to cope with the increasing numbers of ageing people? Over the last few years, government has expanded funding for home care. While oftentimes this provides an alternative to moving into a nursing home, it means there are growing numbers of very frail and dependent old people staying at home. I doubt that GPs and the primary care system have fully appreciated the size of this need for good medical care, let alone developed an adequate response. 38

What good ideas are taking shape, to move us from our traditional but increasingly ineffective approach, to deal with this inexorably rising demand? I believe we must work much more closely with other health professionals. At present, we all work in parallel with each other, and have little real idea of what each other's skills are. What a waste of knowledge, and missed potential for much better outcomes (both clinical and economic!). One great example of innovation going on at my organisation is InterProfessional Education (IPE). This collaboration between Brightwater, UWA, and Curtin has students from all health professions learning together in our aged-care environment. Their response is overwhelmingly positive. Another example of working together more effectively is the three Nurse Practitioners who work with several GPs in our residential care and in-home settings. This is proving to be very successful for both GPs and patients. My abiding hope is that the experience of those students, GPs and Nurse Practitioners, not only works well for them but also really boosts confidence for others. Innovation is never easy, but it is critical for the future of Aged Care. O medicalforum

Cardiology on the move PIVET MEDICAL CENTRE Q Clin A/Prof Mark Hands

ecent developments in cardiology practice include percutaneous structural heart disease intervention, renal artery denervation for resistant hypertension, and minimally invasive mitral valve surgery. Locally, commencement of cardiothoracic surgery at SJOGH Subiaco is worthy of a mention.

Percutaneous structural heart intervention Expanding on closure of atrial septal defect and patent forum ovale, we now have these interventions: t 5SBOTBPSUJD WBMWF JNQMBOUBUJPO 5"7* 5IJT UFDIOJRVF EFMJWFST percutaneously via a catheter system an â&#x20AC;&#x2DC;artificial valveâ&#x20AC;&#x2122; to â&#x20AC;&#x2DC;replaceâ&#x20AC;&#x2122; a severely stenosed aortic valve, and is presently limited (invariably) to elderly patients with symptomatic severe stenosis, who are not suitable (due to accompanying co-morbidities) for open heart surgery. TAVI is not without risk (e.g. conduction abnormalities requiring pacemaker, stroke, residual aortic regurgitation). Worldwide, the technique is gaining popularity, so that as the technology and expertise improves it may become a viable alternative to open heart aortic valve replacement. t .JUSB$MJQTM procedure. The mitral valve (MV) leaflets are partially clipped together to reduce the degree of mitral regurgitation (MR). It is now performed in selected (usually elderly) patients with symptomatic severe MR who are not candidates for open MV surgery Its aim is symptomatic relief. Whilst the procedure can be tedious it carries a relatively low morbidity. t -FGU BUSJBM BQQFOEBHF -"" QMVHHJOH 5IF -"" JT UIF VTVBM source of emboli in patients with atrial fibrillation (AF). Via the femoral vein, the origin of the LAA is occluded by a device, isolating the appendage from the systemic circulation. The technique is applicable to patients with AF and moderate to high risk of embolic stroke whom, and for whom anticoagulation is contraindicated. For example, a patient with chronic AF, CHADS2 Score of 3 and taking warfarin for a (non-traumatic) subdural haematoma, has successfully undergone the procedure.

Renal artery denervation

Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

Medical Director Dr John Yovich

Top of the Wazza Again! â&#x20AC;Ś and Again! â&#x20AC;Ś and Again! The annual ANZARD report is released each November and this latest 2012 report independently details all outcomes of the 61,774 ART treatment cycles conducted in Australia and New Zealand for the year 2010, tracking every pregnancy outcome through to births by October 2011. 91.5% of ART cycles are conducted by 72 Australian clinics and 8.5% by 7 clinics in NZ. As part of the accreditation process all clinics are required to submit their data to the University of NSW and the ensuing ANZARD reports are available to the public on www. aihw.gov.au The overall results show a continuing rise in overall success rates (live births per cycle initiated) for both fresh at 18.5% and frozen at 18.1% per cycle. These rates are impressive given that the vast majority, 70% are from SET (single embryo transfers) so the multiple pregnancy rate has dropped to 7.9%. The results of individual clinics are once again reported in quartiles, so there are no league tables but each clinic can retrieve its own data from $1=$5' DQG Ă&#x20AC;QG LWV SRVLWLRQ Once again 3,9(7 Ă&#x20AC;QGV LWVHOI LQ the top quartiles for outcomes and is repeatedly the top clinic for frozen embryo success in the under 35 year group, considered the fairest for comparison. In that group almost all cases had SET and multiples were under 5%.

The renal arteries are catheterised by a radiofrequency catheter that is then used to ablate the renal artery sympathetic nervous symptom. This relatively simple technique, performed via the femoral artery, is presently applicable to patients with ongoing resistant hypertension despite taking three or more antihypertensives. A resultant 10-30mm Hg fall in BP over time is anticipated.

Cardiothoracic surgery This program at SJOGH Subiaco commenced October 2012 under two cardiothoracic surgeons and substantial cases have been successfully operated on involving coronary artery bypass grafting and/or valve replacement and repair. This includes the relatively new, minimally invasive mitral valve repair/replacement where access is via a 4-5cm incision on the right lateral chest wall rather than a median sternotomy. This facilitates rapid recovery and cosmetic advantage. It is anticipated that cardiothoracic surgery will help promote a percutaneous structural heart disease intervention program. Declaration: No competing interests

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Innovations & Trends

Paediatric ENT changes afoot

nnovation and technology inevitably leads to fundamental changes in healthcare delivery that challenge us. Such is the case in Paediatric ENT Surgery.

Suspected OSA: skip the sleep study before adenotonsillectomy? A sleep study (polysomnography: PSG) is the gold standard for the diagnosis of OSA versus Q By Dr Paul Bumbak mild sleep disordered breathing (SDB), prior ENT Surgeon to adenotonsillectomy in children. However, there is difficulty in obtaining such studies in Metropolitan Perth, especially in the public sector. So the recommendation is different. For otherwise healthy children: a history consistent with snoring, sleep restlessness, night terrors, daytime somnolence, behavioral changes, poor cognitive performance; and a physical exam consistent with adenotonsillar hypertrophy, with or without witnessed apnoea – if needed, proceed with adenotonsillectomy without prior PSG.

The Otolaryngologic Clinics of North America review says up to 80% of oropharyngeal cancers are now caused by HPV and key points were these cancers are more likely, when compared with non-HPV-related head and neck cancers, to occur in (i) whites (93% versus 82% in nonwhites), (ii) never-drinker/never-smokers (16% versus 7%), (iii) those with >six oral sexual partners over a lifetime (46% versus 20%), and (iv) those with a younger median age at cancer diagnosis (54 versus 60 years). Following the HPV-cervical cancer discovery, 100 subtypes of HPV have been identified. While two subtypes (HPV 16 and 18) cause 70% of cervical cancers, HPV-16 accounts for 90% of HPV-associated oropharyngeal cancers in males. The GardasilTM vaccine protects against these strains plus HPV 6 and 11 (causing genital warts). Although GardasilTM is free for girls/boys aged 12-13 as part of the National HPV Vaccination program, during 2013 and 2014 boys aged 14-15 years can receive this vaccine free as part of a “catch up” initiative. See www.hpvvaccine.org.au

Sophono Alpha 1 system for conductive hearing loss

Pre-operative PSG is recommended for medical co-morbidities (obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease or mucopolysaccharidoses), or where the need for surgery is uncertain or adenotonsillar size on examination does not fit the reported severity of sleep-disordered breathing.

The traditional Bone Anchored Hearing Aid (BAHA), developed by Cochlear® uses bone conduction to aid those patients with singlesided deafness, mixed hearing loss and conductive hearing loss. With a titanium abutment that is surgically implanted, and protrudes through the skin for attachment of a sound processor (hearing aid device), there is an ongoing concern of potential risk of infection.

Research: HPV-related head and neck cancers

Now Sophono Inc. has improved the BAHA concept (see www.sophono.com). There is no need for a titanium implant, as they use two magnets, which are implanted in the skull behind the affected ear to hold the external part of the bone-anchored hearing aid (the external processor) in place. So far, one implant has been performed in WA. O

A distinct subgroup of head and neck cancers caused by the human papillomavirus (HPV) has emerged in recent times, involving the oropharynx and in younger patients with little or no history of smoking and/or drinking.

Declaration: No author competing interests. References on request.

Infertility: Morphometrics and adherence

Q By Dr Simon Turner, Gynaecologist and Obstetrician, Hollywood IVF

mbryo and sperm selection are current topics of interest, following on the advances in infertility treatment before the turn of this century: controlled ovarian hyperstimulation with recombinant gonadotrophins and pituitary suppression alters the menstrual cycle to yield supernumerary ovarian follicles; 10-minute trans-vaginal oocyte aspiration under mild anaesthesia retrieves a mean of 10 oocytes; and a 70% fertilisation rate in the laboratory means that 7 cultured embryos are available for possible transfer into the patient.

In recent years, embryo selection protocols have improved using morphometric parameters, time lapse photography and metabolomic parameters. Collaboration between geneticists and embryologists has produced a selection technique known as comparative genomic hybridisation (CGH). Trophectoderm cells are removed from the developing blastocyst and analysed for aneuploidy [abnormal chromosome number], chromosome translocations and single gene defects on all 24 chromosomes. This ensures with 95% accuracy that only euploid embryos are transferred into the patient. Considering the aneuploidy rate of human embryos at 50%, this technique has been a change-wave for IVF treatment producing much improved implantation and live birth rates among women experiencing repeated implantation failure or pregnancy loss.

Another innovation is the use of the naturally occurring macromolecule hyaluronan during the latter stages of embryo development and embryo transfer – the cohesive strength of the molecule assists with the requirement of embryos to adhere to the endometrium after transfer. Fertility specialists are now less frustrated by seeing perfectly formed blastocysts fail to implant after being transferred, improving the chances of childless couples achieving their goal of nurturing a healthy baby. Evaluation of DNA damage in sperm is advancing beyond the traditional semen parameters such as volume, count, motility and morphology to determine the fertility status of the male partner. From recent research, the effect of reactive oxygen species (ROS) on the stability of sperm DNA helps determine the levels of DNA damage. Increased DNA fragmentation or damage (associated with lifestyle factors such as smoking, excessive alcohol and obesity) has been implicated in the elevated proportion of minor birth defects associated with intra-cytoplasmic sperm injection, performed in over 50% of IVF cycles where there is too few sperm available for successful sperm penetration of the egg vestments. Now, the selection of sperm with less DNA fragmentation can be done using a petri-dish containing solid state hyaluronan that mimics the outer layer of the oocyte – sperm with stable DNA are attracted to the medium and sperm with poor DNA integrity swim free. Further analysis of live birth outcomes are required to measure any improvement. Ed. Dr Turner acknowledges the assistance of senior laboratory people Itziar Rebollar and Hamish Barblett. medicalforum

Robotic assisted prostatectomy

he Da VinciTM surgical system allows remote laparoscopic surgery via a surgeon-operated computer consul adjacent to the patient. Advantages are said to be greater manoeuverability than the human hand, diminished tremor, and 3D vision for improved anatomical appreciation.

Robotic surgery is used in over 80% of radical prostatectomies in the USA (robotic assisted laparoscopic radical prostatectomy or RALRP). Australia is following this trend with 15 systems installed interstate and one in Perth. Given the costs involved, evidence of superior outcomes compared to open radical prostatectomy (ORP) or laparoscopic radical prostatectomy (LRP), have been important.

Q By Dr Justin Vivian, Urologist

In 2009, an analysis of outcomes in 77,616 men who underwent radical prostatectomy (RALRP: 63.9%, ORP: 36.1%) compared rates of blood transfusions, complications, prolonged length of

You can now prescribe exercise! stay, elevated hospital charges, and mortality. Overall, RALRPtreated patients experienced lower rates of adverse outcomes in all measured categories. However, other important outcome measures such as positive margin rates, or post-operative continence or potency were not measured and a RCT comparing RALRP to ORP is currently being performed in the Royal Brisbane Hospital to address these questions. Two randomised controlled trials have compared RALRP to LRP, both involving a single surgeon experienced in laparoscopic prostatectomy and moderately experienced in robotic prostatectomy. In both trials post-operative potency was better in the robotic group (80.0% vs 54.2%, p = 0.0202; 77% vs. 32%, P < 0.0001). In one of the studies, continence was also better (at 12 months the continence rate was 95.0% vs. 83.3%, p = 0.042). All other outcome measures were similar in the two groups. In Perth, there are two myths around the head down patient position (it is not harmful) and the older Da Vinci model in use (it is not inferior and instead adds 20 minutes or so to operating time). The costs of the Da Vinci system means that SJOG Subiaco charges patients a co-payment of $4500, which is covered routinely by some private health insurers and sometimes by others. O References available on request. Declaration: No relevant competing interests. Dr Vivian is one of five urologists performing robotic surgery in WA.

medicalforum

As part of our commitment to health of Western Australia the team at Obesity Surgery WA, is now offering exercise programmes at no cost. To enrol, we need a referral to our practice for exercise. Everyone gets a health review to check their suitability and will get a personal plan or get to join one of our group sessions. The service is open to anyone who needs a little help to get fitter, even if they are not considering surgery. < Mr Harsha Chandraratna Surgeon Jo Climo > Clinical Nurse & Exercise Co-ordinator

Obesity Surgery WA (08) 9332 0066 SUBIACO

MURDOCH 41

CLINICAL UPDATE

Update:Endoscopic ultrasound

By Dr AndrĂŠ Chong, Gastroenterologist SJOG Murdoch

ndoscopic ultrasound (EUS) combines ultrasonographic imaging during endoscopy. *O HBTUSPFOUFSPMPHZ &64 XJUI PS XJUIPVU GJOF OFFEMF BTQJSBUF '/" DBO QSPWJEF confirmatory or additional staging information.

EUS in diagnosis and staging of tumours Subepithelial tumours are growths under the epithelium of the gut, the aetiology of which cannot readily be determined by endoscopy alone. The differential diagnosis includes external masses (e.g. splenic artery aneurysm) or tumours arising from within the gut wall (e.g. carcinoid, leiomyomas). EUS assists in diagnosis by determining echogenicity, location in relation to the gut wall, and obtaining tissue diagnosis with FNA where indicated. Lung cancer/mediastinal lymph nodes: EUS FNA of mediastinal lymph nodes can assist in staging of lung cancer. When combined with endoscopic bronchial ultrasound (EBUS), a total â&#x20AC;&#x2DC;mediastinoscopyâ&#x20AC;&#x2122; can be performed, thereby obviating a mediastinoscopy. Another common indication is to obtain tissue diagnosis for unexplained mediastinal adenopathy (e.g. lymphoma, sarcoidosis). Oesophageal cancer: EUS provides the most accurate non-invasive imaging method for locoregional oesophageal cancer. It is indicated in patients with potentially resectable disease i.e. in whom a CT +/- PET scan has ruled out unresectable disease (T4/M1). Stomach cancer: In patients with nonmetastatic gastric cancer, T staging with EUS can help stratify patients suitable

for either curative endoscopic resection, surgical resection or neoadjuvant chemotherapy. Pancreatic masses and cysts: The close proximity of the pancreas to the stomach and duodenum makes obtaining EUS guided FNA of pancreatic masses safer and easier than a percutaneous approach. Indications for EUS FNA include differentiating between pancreatic adenocarcinoma, lymphoma, neuroendocrine tumours, metastases, chronic pancreatitis and autoimmune pancreatitis. A firm tissue diagnosis may prevent unnecessary surgery and expedite appropriate treatment. Pancreatic cysts, with a prevalence of 2-5% are increasingly incidental findings during improved imaging â&#x20AC;&#x201C; EUS FNA of cyst fluid for cytology and tumour markers is useful to ascertain malignant potential. Ampullary/Duodenal masses: EUS can be used to stratify which patients require surgery and those who may be cured with endoscopic resection alone. Cholangiocarcinoma: In selected patients with an extrahepatic biliary stricture with no definite diagnosis after an ERCP, EUS FNA can be used to obtain a tissue diagnosis.

Interventional uses for EUS The more widely recognised interventional procedures using EUS include coeliac

plexus blocks, drainage of pancreatic pseudocysts/abscesses and placement of fiducial markers.

Risks Risks of EUS are generally similar to routine upper endoscopy, including bleeding and perforation. Depending on site, the addition of FNA slightly increases the risk of pancreatitis, infection and bleeding. O

Q Pancreatic mass at the genu of the pancreas, adjacent to the portal vein confluence, as viewed by linear EUS. For FNA, a needle would normally be passed from the top right under direct vision.

Declaration: Dr Chong is currently the only provider of EUS at SJOG Murdoch

Pulmonary embolism: Your questions answered We had this request from a reader, who seemed to be focussed on competition between nuclear physicians and "low" radiation radiologists, as well as the actual clinical dilemma.

t "TTVNF UIF QSF UFTU QSPCBCJMJUZ BGUFS Wells or Geneva scoring) is low or moderate because if probability was high, immediate imaging is the preferred option to a D-Dimer test.

â&#x20AC;&#x153;Which imaging modality should a GP order in a suspected stable premenopausal female with symptoms suggestive of PE, with raised D-Dimer? Is it a CTPA [CT Pulmonary Angiogram] or V/Q [Ventilation/Perfusion nuclear medicine] scan ?â&#x20AC;?

Expert Comment Prof Richard Mendelson (consultant radiologist, RPH) & Dr Kay-Vin Lam (Consultant thoracic radiologist, RPH). 42

First, there is no simple answer, since there are several contingencies.

t "TTVNF UIF QSFTFOUBUJPO JT BDVUF OPU chronic. t "TTVNF UIF QBUJFOU JT OPU QSFHOBOU

t "TTVNF B QMBJO $93 IBT CFFO EPOF UP exclude more obvious causes of symptoms (pneumonia, pneumothorax, etc.). Assuming all the above and the GPâ&#x20AC;&#x2122;s continued management, the next step largely depends on the Radiology provider. The GP should not be â&#x20AC;&#x2DC;orderingâ&#x20AC;&#x2122; anything, but consulting with an imaging specialist instead. (In practice, what often happens is the patient is sent by the GP to an ED.)

Advantages of CTPA include the ability to diagnose alternative causes of symptoms and (usually) the likelihood that the study will be diagnostic even when there is co-existent lung disease. If a low dose CT protocol is available (which depends on age and type of scanner, the use of low dose scanning techniques, iterative reconstruction methods and the use of Bismuth breast shielding), CTPA would be the preferred choice. Total effective dose about 1.5 - 2.5 milliSieverts (mSv). If low dose CT techniques are not available or CT is contra-indicated (such as iodinated contrast medium allergy or renal impairment), then nuclear medicine ventilation/perfusion (V/Q) scanning should be considered. Total effective radiation dose about 1.0â&#x20AC;&#x201C;2.0 mSv, when low-dose protocols are used. medicalforum

Guest Column

No Flies on Him? Forensic entomologist Ian Dadour explains how creepy-crawlies move in when we move out, and some of the medicolegal ramifications.

n life we are surrounded by flies, who view us as large smelly mammals which in due course will provide a protein meal of some sort such as sweat, mucous and defecated products. We consider them a nuisance or pests. When we die, then we become a very large resource for flies, in the first wave, followed by beetles.

The flies that we see less of are blowflies, which tend to maintain a distance from us until we are dead, comatose, unconscious or, in the case of some humans, heavily intoxicated. There are also a smaller group of flies that will strike a live animal such as the sheep blowfly and other myiasis flies. Blowflies, depending on the species, either lay eggs or live larvae onto a corpse. This generally happens within an hour once dead. Blowflies are attracted to orifices, wounds and other moist locations such as between the fingers or toes, the armpits or any observable body crease. Insect material (generally immature, referred to as maggots) collected from the body is firstly identified then measured. The size of the maggots is a reflection of the insects estimated age. It is this parameter by which minimum time of death can be estimated. This is the underlying bread-and-butter reason for using forensic entomology â&#x20AC;&#x201C; to age insects to determine a post-mortem interval (PMI). With respect to time taken for carrion-eating insects to arrive on a body, there are two types

If low-dose techniques for both CT and V/Q scans are available, then radiation dose is not the major issue and CTPA would be the preferred option. O

of succession. The first is the breakdown of tissues by bacteria and this is overlaid by the second type of succession when different species of insects arrive dependent on the stage of decay. So, the presence of an insect known to be attracted only by a dry, decayed corpse indicates that the corpse has been dead for some time and has already passed through fresh, bloat and wet decay stages. This is generally dependent on the environment variables associated with the corpse especially weather factors, the most important being temperature and rainfall. Insects (other than flies) that feed on decaying flesh include beetles, wasps and moths, and because these arrive in succession by the time the last species arrives, the earliest arrivals are generally no longer present. In essence, contemporary forensic entomology is a crucial tool in providing a chronological â&#x20AC;&#x153;gold standardâ&#x20AC;? in the evaluation of postmortem intervals when insects are associated with a corpse and as a result of any investigation involving insects, a â&#x20AC;&#x153;FEâ&#x20AC;? will probably end up in a court of law to provide an opinion. Below is a list of the broader application of FE in the discipline of medico-legal entomology and includes: t %FUFSNJOJOH UIF MPDBUJPO PG XIFSF B human death occurred. t $BTFT JOWPMWJOH UPYJOT ESVHT BOE gunshot residues.

t 5IF NPWFNFOU PG WFIJDMFT BOE USBOTQPSU of remains. t 6SCBO FOUPNPMPHZ XIJDI JOWPMWFT DJWJM actions relating to insects and humanbuilt structures. t *OKVSJFT BGUFS EFBUI t *OTFDU CJUFT PS JOGFTUBUJPOT t /FHMFDU PG UIF FMEFSMZ TVDI BT GJOEJOH GMZ larvae in bed sores in aged care facilities, which HDWA classifies as neglect) t $IJME BCVTF F H B DBTF PG DIJME XIFSF UIF species of fly larvae inside the nappy on faeces showed neglect of 14 days whereas the blowfly larvae on the dead child gave a post mortem interval of 6 days. The child was malnourished.) t 'PPE DPOUBNJOBUJPO CZ JOTFDUT F H maggots in takeaway chicken dinners, alfresco dining, or in food at mine sites â&#x20AC;&#x201C; a female blowfly can lay an egg every second and some lay live larvae in 0.5 seconds, so turn your back for an instant and your food will be struck!). t 7FUFSJOBSZ BOE XJMEMJGF GPSFOTJDT One traditional technique that forensic entomologists have turned into a modern day treatment is maggot therapy. When antibiotics fail, many limbs have been saved by administering sterile maggots into gangrenous or necrotic wounds. O

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Q CTPA showing multiple bilateral pulmonary arteries extending into segmental pulmonary arteries (arrows).

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Adventure

Wild, Wet and Wonderful Dr Helga Weaving found an extreme way to get her name off the Christmas roster, she signed up to sail in the Sydney to Hobart yacht race. On Boxing Day 2012, ED consultant Helga Weaving sailed across the starting line in Sydney Harbour aboard the racing yacht, Finistere. Three days, twenty-three hours, thirty-six minutes and twenty-one seconds later she crossed the ﬁnish line in Hobart. “It was a surreal feeling and I had to keep pinching myself to believe I’d just done the Sydney to Hobart! It was a wonderful experience but it’s a cold, wet and hard race. The sleep deprivation didn’t worry me too much but there were times when I was sitting on the rails for six hours and thinking, ‘how much longer?’ Nonetheless, my work can be highly stressful and sailing gives me a lot back. It’s very important to me.”

This medico with a law degree embraces a career that is anything but one-dimensional. “I work as an ED consultant at Fremantle and, to a lesser extent, at RPH. I also do one day a week of Coronial liaison at the Department of Health and a shift every fortnight at the Sexual Assault Referral Centre (SARC). And there’s Schoolies at Rottnest as well. It’s good to have that variety because you’ll always have the occasional heart-sink day.”

I’d just done Schoolies at Rottnest so I’d had enough of people throwing up in buckets to last me a lifetime. Helga owns two boats, a Hartley 21 and an Etchell 30’ racer, and she’s never suffered from sea sickness. But she did get very wet on the trip south.

“I’m paying for it now, though. It seems like some sort of penance for going away. I’m working six days out of seven plus some double shifts!”

We used Ondansetron wafers but that didn’t stop some of the crew throwing up. 44

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â&#x20AC;&#x153;My wet weather gear wasnâ&#x20AC;&#x2122;t as good as some of the other guys and the mid-layers just didnâ&#x20AC;&#x2122;t keep me dry. Iâ&#x20AC;&#x2122;m very lucky, Iâ&#x20AC;&#x2122;ve never been sick on a boat but some of the crew used medication on the way down. We even used Ondansetron wafers but that didnâ&#x20AC;&#x2122;t stop some of the crew throwing up.â&#x20AC;?

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â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;d just done Schoolies at Rottnest, so Iâ&#x20AC;&#x2122;ve had enough of people throwing up in buckets to last me a lifetime.â&#x20AC;? â&#x20AC;&#x153;The race certainly isnâ&#x20AC;&#x2122;t for everyone and itâ&#x20AC;&#x2122;s very different from a leisurely sail around the buoys on the Swan River. Women are heavily outnumbered in the race and weâ&#x20AC;&#x2122;re definitely in the minority. Itâ&#x20AC;&#x2122;s a fantastic experience with some stunning scenery in the southern ocean and it shows you just what you can do.â&#x20AC;? O

By Mr Peter McClelland

Did You Know? Keel Boat Courses Royal Freshwater Bay Yacht Club (RFBYC) $495 (5 Saturday mornings) www.rfbyc.asn.au 9384 9100

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funnyside e Q Q The Billable Minute A doctor and a lawyer were talking at a party. Their conversation was constantly interrupted by people describing their ailments and asking the doctor for free medical advice. After an hour of this, the exasperated doctor asked the lawyer, "What do you do to stop people from asking you for legal advice when you're out of the office?" "I give it to them," replied the lawyer, "and then I send them a bill." The doctor was shocked, but agreed to give it a try. The next day, still feeling slightly guilty, the doctor prepared the bills. When he went to place them in his mailbox, he found a bill from the lawyer.

Q Q Piggy in the Middle Earlier this year, Winston lost his ear. Luckily, surgeons were able to replace the missing ear with a pig’s ear. They cut it to size to make it look more human before sewing it almost seamlessly into place. Weeks passed and Winston was forced to return to his surgeons. He complained bitterly, “Doctor, I keep hearing this strange noise in my ear and it’s doing my head in!” The doctor nonchalantly answered, “Don't worry; it’s just a bit of crackling.”

Q Q Poker Face A well-respected surgeon was relaxing on his sofa one evening just after arriving home from work. As he was tuning in to the evening news, the phone rang. The doctor calmly answered it and heard the familiar voice of a colleague on the other end of the line. "We need a fourth for poker," said the friend. "I'll be right over," whispered the doctor. As he was putting on his coat, his wife asked, "Is it serious?" "Oh yes, quite serious," said the doctor gravely. "In fact, three doctors are there already!"

Q Q Signs of the Times On a Plumber's truck: 'We repair what your husband fixed.' On another Plumber's truck: 'Don't sleep with a drip. Call your plumber.' In a Non-smoking Area: If we see smoke, we will assume you are on fire and take appropriate action.' Outside a Muffler Shop: 'No appointment necessary. We hear you coming.' In a Veterinarian's waiting room: 'Be back in 5 minutes. Sit! Stay!'

Q Q For Whom the Bell Tolls Upon hearing that her elderly grandfather had just passed away, Katie went straight to her grandparent's house to visit her 95-year-old grandmother and comfort her. When she asked how her grandfather had died, her grandmother replied, 'He had a heart attack while we were making love on Sunday morning.' Horrified, Katie told her grandmother that 2 people nearly 100 years old having sex would surely be asking for trouble. 'Oh no, my dear,' replied granny. 'Many years ago, realizing our advanced age, we figured out the best time to do it was when the church bells would start to ring. It was just the right rhythm. Nice and slow and even. Nothing too strenuous.' She paused to wipe away a tear, and continued, 'He'd still be alive if the ice cream van hadn't come along' .

In a Restaurant window: 'Don't stand there and be hungry; come on in and get fed up.'

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Wine Review

Hillsview’s Quest FOR THE BEST FRUIT

2011 Storm Bird Sauvignon Blanc This a very limey wine with some tropical hints. Some barrel fermentation has added a little complexity and the palate length is good. This is made with fruit from the Adelaide Hills and is a typical cool-climate sauvignon blanc, easy drinking and good value. 2010 Hillsview Cabernet Sauvignon This is from the Wine Maker’s Selection label with fruit sourced from Mudgee. The Cabernet is hot with 14.5% alcohol and a thin palate. Not a lot of varietal flavours, but would make a good, uncomplicated casual wine.

By Dr Martin Buck 2010 Hillsview Shiraz The shiraz is also from the Wine Maker’s Selection label with fruit sourced from Heathcote, which is one of my favourite red wine areas. It has a very interesting nose of deep, succulent fruit. Still a young wine and the tannins will certainly become better balanced with time. This is a good food wine.

Hillsview Vineyards are based in South Australia and produce a stable of wines from fruit sourced from the best wine regions in Australia. Their labels include Blewitt Springs and Storm Bird, which range from quafﬁng wines to premium drinking. Recent contractions in the wine industry have resulted in premium fruit becoming available at bargain prices and it is no longer necessary to have your own expensive vineyard. These wines represent a tour of the Australian wine regions with a variety of styles and complexity. None of the wines are expensive and provide good value for the consumer.

2008 Blewitt Springs Merlot Straight merlot is a style that is becoming less common but still has its virtues. This wine, with fruit form Maclaren Vale has a lot to offer on the nose with cigar box aromas and ample fruit. The palate is plump with jammy fruit and the tannins have settled. This is a wine ripe for drinking, well suited to meat dishes and my favourite of the reds. 2007 Storm Bird Cabernet Sauvignon This is a more full-bodied wine compared to the other reds in the tasting. Fruit has been sourced from the Central Ranges in Victoria. Plenty of aged aromas and a mature palate of balanced oak and fruit. Ready for drinking and will not require cellaring.

WIN a Doctor’s Dozen! Which is Dr Martin Buck’s favourite red wine area? 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, February 28, 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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Photography Competition

1st 2nd

the

Endless Summer

There are some easy and not so easy ways to cool off on a hot summerâ&#x20AC;&#x2122;s day and we, humans, have been known to go to extremes. Some of medico snappers share their summer memories â&#x20AC;&#x201C; from heading out at sunset in Derby in the cool of the evening to heading far south to the chill of the Antarctic.

3rd

First: Living in the Perth Hills as Dr Carol McGrath does, summer means keeping an eagle eye out for bushfires and also welcoming bush critters who head to her garden for a cooling off in her bird bath, just like this trio of New Holland Honeyeaters. Second: Dr Robert Davies captures the quintessentially summer festival, Sculpture by the Sea, at Cottesloe Beach, with this intriguing view of one of the artworks. He shot it on his Nikon D80, 1/10 f32 65mm ISO 100. Third: There are days in Derby, where you stay indoors until sunset. And when the fiery ball sinks into the ocean, people congregate at the town jetty to cool off and catch-up. Dr Susan Downes was there to capture the moment.

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Satire

The future's so bright… The threat of the Mayan apocalypse has faded into a year of other catastrophes, writes resident satirist Wendy Wardell. 2 In no particular order: 1. A boy’s holiday is not complete without a spot of beach fishing? Dr Tony Tropiano’s 11-year-old son Harrison was salmon fishing last month west of Shelley Beach at West Cape Howe. While it was a little too early in the season for salmon, Tony says Harry is developing the fishing passion similar to his brother, 22, who has just completed a Marine Biology and Commerce degree at UWA.

I'm so glad you're here to read this article, and quite honestly, even happier that I was here to write it, although it didn't go quite as planned. Originally I intended to give an in-depth analysis of the way the world would unfold in 2013 in science, society and politics, but started late. I didn't want my usual 10 minutes of painstaking research on Wikipedia to be for nothing, on account of Planet Earth being due to go belly up in some sort of cosmic catastrophe in December. Copy deadlines somehow appear less pressing when you've just blinked out of existence or the person next to you is screaming “Hey – what’s that enormous fiery ball that's hurtling towards us like an asteroid on a collision...” Suggested causes for our demise on December 21 included alien invasion or a devastating impact with a planet called Nibiru. Given our irritation at meterologists who somehow miss the impending arrival of heavy rain belts, the sudden appearance of a planet in our celestial rear view mirror would be a definite “What the?..” and represent a major fail for Astronomer I-spy, let alone Hubble telescopes. It's clear at least that an alien invasion has already started, and if anyone doubts this, then please explain Bob Katter to me. I really don't think that the mothership has been returning his calls for some time. Thanks to Bob though, we can now laugh off concerns about their being highly-evolved.

If Planet Earth isn't dealt a death blow by little green men or their larger red-necked cousins, then you could always put your money on the Zombie Apocalypse. At least they would find plentiful employment opportunities on the checkout at Bunnings where cold, dead eyes are just part of the uniform. “Flimsy pitchforks and cheap imported flaming torches? Aisle four.” Of course there are other much more likely ways for our planet to meet its end. Perhaps an errant North Korean missile with its ‘up’ and ‘down’ functions cross wired, taking out the core of the Earth like some sort of jihadist termite. A cataclysmic storm would be a hot favourite, although it may take a while for anyone in Melbourne or England to notice the difference. A fabulous boost for English dinner party conversation though. Briefly. Even if you're reading this from a still-rotating Planet Earth and not the luggage hold of an alien spacecraft, there are other interpretations. 2. The ever-watchful shark lookout at North Cottesloe Beach, preventing sharks from an unexpected Christmas snack, is Mr Clive Addison’s reflection on summer. 3. The ultimate summer cooloff is a trek to the frozen continent. Dr Gary Dowse sent this picture of the awesome coastal ice cliffs from a recent trek.

Some theorists posited that 2012 would mark the beginning of a transition in our society from one of shallowness and self-centredness to something deeper and more spiritual. While that got a few ‘likes’ on Facebook, it was drowned out by comment on Justin Beiber's new haircut. I do relish the idea of a new Utopian society populated by courteous road-users and footy players who read Haiku to each other instead of going the biff. However, I think a fender-bender with Nibirusians the more likely prospect. O

4. Augusta GP Dr John Williams is lucky to see sunsets at the mouth of the Blackwood River every night. He shares one with Medical Forum.

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Arts Preview

3 2 Take your seats for what the arts fraternity have in store in 2013 because it will take you all year to savour the delights on offer. 1. The Jersey Boys, 2. Perth Festival opening act Bombs Per Minute 3. The Spider routine in Cirque du Soleil’s Ovo. Picture: OSA Images,

As the city begins to tumble back into the working year, the landing is a lot softer when you have some choice theatre, music, ﬁlm and dance to look forward to and with the Perth International Arts Festival starting on February 8, none of us has too long to wait. This year, the festival opening will also kick off the centenary celebrations of the University of WA when the campus will be transformed into a sound and light show (check out centenary.uwa.edu.au for details). The following night the festival pulls out the big guns – literally – with Bombs Per Minute, an explosive melange of bells, drums and pyrotechnics from the company that staged the arrival of the Olympic torch 50

London Olympics. It’s taking at last year’s Lond place at Langley Park on Feb 9, gates open 6.30pm and it’s free. Medical Forum’s pick of the festival program: Theatre: Kate Grenville’s powerful colonial novel The Secret River is brought to the stage in a co-production between the Sydney and Perth festivals. Its pedigree is impeccable – director is Neil Armfield, writer is Andrew Bovell and movement choreographer Stephen Page (of Bangarra Dance fame) and the story is absolutely gripping. (His Majesty’s Theatre February 25-March 2.) Music: Can’t go past Philip Glass. Some reckon he is an eight-bar wonder, others think he’s a genius of the new age. It’s a terrific opportunity to find out in person. (Perth Concert Hall, February 16.)

Dance: Shiva Shakti ... Martial arts, yoga, aerial feats, classical and contemporary Indian dancing, plus one of Bollywood’s best-loved actresses, Isha Sharvani, performing it. Not a tutu in sight. (Regal Theatre, February 25-28.) Children: The House of Dreaming is a kidsonly event which offers them the chance to wander through an interactive labyrinth brimming with robots, live performers and projections. (ABC Perth Studios, suitable for 5-8 years.) The festival concludes on March 2 but there is barely time to draw breath before the two biggest commercial shows of the year hit town. At last Perth gets to see the musical that has had everybody raving – Jersey Boys, the story of Frankie Valli and The Four Seasons, opens at the Crown Theatre on

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Africa

Theatre

Shakespeare

T world has seen a lot of The interpretations of Shakespeare but in always room for something tthere’s h and exciting and that’s on the ffresh r ccards when Two Gents Productions bbrings its slant on Hamlet and Two Gentlemen of Verona to the New G Fortune Theatre (UWA) at the end of the month.

4. Black Swan’s Importance of Being Ernest by Oscar Wilde. Picture: Robert Frith, 5. Perth Festival House of Dreaming, 6. Perth Festival Philip Glass, 7. WA Ballet’s Onegin, 8. WA Opera’s Don Giovanni, 9. Simone Young for WASO

April 21. The story is gripping, the music is legendary and you’ll discover for yourself why big girls don’t cry.

of the Rings: Fellowship of the Ring (June 21 &22) while the audience sits back and watches the movies. Huge fun for all.

Also in April is the return of the greatest circus on earth – Cirque Du Soleil. These masters of acrobatics and contortion bring to Perth Ovo, which opens on April 14. Cirque veterans will know that there’s often wild and wacky staging associated with the company and Ovo is no exception – it delves into the world of insects. The bees are particularly amazing on the trapeze!

For the music lover who wants a little more dash than flash, Simone Young heads west on August 2 and 3, but this time, there’s no Wagner in sight. Expect a little Arvo Part, the Britten violin concerto and Shostakovich’s big fat No 10 symphony. Genius violinist Pinchas Zukerman, a giant of the instrument, will head to Perth in November 8 and 10 in a memory-making concert of Vivaldi, Mozart and Beethoven.

Our state arts companies have some tasty treats on their 2013 menu. West Australian Opera last year celebrated the diva, this year, it’s the boys’ turn. Expect the Romantic (La Traviata, from April 9), the Tragic (La Boheme, October 29) and the downright Bad (Don Giovanni, July 16) heading your way. The WA Ballet celebrates the arrival of its new artistic director Belgian Aurelian Scanella with a tribute to its outgoing boss, Ivan Cavallari, who has done some fabulous things with this company of dedicated young dancers. The highlight of the season will be WAB’s staging of the full-length narrative ballet, Onegin, from September 20. The West Australian Symphony Orchestra has some amazing firsts, coming up this year. In April and June it will be playing the soundtrack of two Hollywood blockbusters – Pirates of the Caribbean Curse of the Black Pearl (April 27) and Lord

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On stage at the Heath Ledger Theatre, Black Swan Theatre Company has a smorgasbord of golden oldies and cutting edge new drama. From the Importance of Being Ernest and Death of a Salesman to a play that is hot off the boards of Broadway, Other Desert Cities, which was nominated for five Tonys and the Pulitzer Prize. And don’t forget the kids – in fact Barking Gecko Theatre Company’s 2013 season has plenty to offer the whole family. The company, which has really hit its straps under the direction of John Sheedy, is taking on a young person’s version of Hamlet and a reprise of its standout 2012 hit Driving Into Walls. However, the unmissable show of the year is co-production with the Sydney Theatre Company of Colin Thiele’s classic Storm Boy. It opens at the Heath Ledger Theatre on September 21.O

The company is the tight trio of Zimbabwean actors Denton Chikura and Tonderain Munyevu and German-born director Arne Pohlmeier, who emerged from the acclaimed Market Theatre in Johannesburg. The trio explores Shakespeare from their particular cultural viewpoints and the results have created waves in theatre circles in the UK, especially at the home of Shakespeare, the Globe Theatre. Arne sees no cultural divide when it comes to interpreting the Shakespeare plays. The two Zimbabwean actors, who play all the characters, imbue the productions with an energy born from their own cultural roots with drumming and dancing playing a part, and their costume of orange overalls reflecting the clothes of Zulu workers. “Our starting point was to do Shakespeare in a South African style of storytelling with two characters performing the play. We are aware that we are two black Africans from Zimbabwe but you do also have to go beyond it,” Arne said. “You want to be truthful, you want to mine deeper.” “The thing is it’s all possible and what you have to do, whether you have a full cast or a two hander, is to invest in the characters. You also must invest in your relationship with the audience … that is the most important thing. If you are two actors performing an entire Shakespeare play, you need the audience to rally around the fact that there are difficulties but you’re going to surmount them by telling a brilliant story,” Arne said. Two Gentleman of Verona, February 26, 28, March 2 at 8pm; Kupenga Kwa Hamlet, February 27 March 1, 8pm; March 2 4pm, New Fortune Theatre, UWA. See the competitions page for your chance to win tickets.

By Ms Jan Hallam 51

Competitions

Entering Medical Forumâ&#x20AC;&#x2122;s COMPETITIONS has never been easier! Simply visit www.medicalhub.com.au and click on the â&#x20AC;&#x2DC;Competitionsâ&#x20AC;&#x2122; MJOL CFMPX UIF NBHB[JOF DPWFS PO UIF MFGU

Perth Festival: Shiva Shakti Daksha Sheth Dance Company unites traditional and contemporary Indian dance in a production of astounding beauty and incredible human skill. Featuring Bollywood actress and one of Indiaâ&#x20AC;&#x2122;s finest dancers Isha Sharvani, the performers explore the Kundalini Shakti [the divine spiritual power] present in each of us.. Regal Theatre, Feb 25-28

Movie: Lincoln (MA 15+) Movie: I Give It a Year The buzz is that this movie will scoop the upcoming awards season. Steven Spielberg directs Academy Award winner Daniel Day-Lewis in Lincoln, a revealing drama that focuses on the famous US Presidentâ&#x20AC;&#x2122;s tumultuous final months in office. In a nation divided by war and the strong winds of change, Lincoln pursues a course of action designed to end the war, unite the country and abolish slavery. Itâ&#x20AC;&#x2122;s unmissable. In Cinemas February 7

A romantic comedy from the makers of Notting Hill, Bridget Jonesâ&#x20AC;&#x2122;s Diary and Love Actually that charts the trials and tribulations of a young, mismatched couple in their first year of marriage. The ensemble cast of Rose Byrne, Rafe Spall, Simon Baker, Anna Faris and Stephen Merchant offer a fun ride through love, chemistry and compatibility. In Cinemas February 28

Theatre: Two Gentleman of Verona & Kupenga Kwa Hamlet

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Shakespeare gets all shook up with these fun, fast-paced interpretations by two brilliant Zimbabwean actors led by their German-born director. See the comedy and tragedy of the Bard with fresh eyes and renewed energy. There are tickets on offer to both productions. Two Gentleman of Verona, February 26 & 28; March 2 at 8pm; Kupenga Kwa Hamlet, February 27 & March 1 at 8pm and March 2 at 4pm. New Fortune Theatre

Movie: The Impossible A terrifying and emotional story based on one family's experience of the 2004 South-East Asian tsunami. The Impossible, starring Ewan McGregor and Naomi Watts, is a compelling account of perseverance and survival in the face of unimaginable disaster and chaos. In cinemas now

MEDICAL F ORUM

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MARCH 2013 - next deadline 12md Friday 15th February - Tel 9203 5222 or jen@mforum.com.au

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PROVIDING PRIMARY HEALTH CARE TO THE HOMELESS URGENTLY REQUIRES Íť 'Ä&#x17E;ĹśÄ&#x17E;Ć&#x152;Ä&#x201A;ĹŻ WĆ&#x152;Ä&#x201A;Ä?Ć&#x;Ć&#x;Ĺ˝ĹśÄ&#x17E;Ć&#x152;Ć? Ç Ĺ?Ć&#x161;Ĺ&#x161; &Z 'W Íť ZÄ&#x17E;Ĺ?Ĺ?Ć?Ć&#x161;Ä&#x17E;Ć&#x152;Ä&#x17E;Ä&#x161; EĆľĆ&#x152;Ć?Ä&#x17E;Ć?

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&Ĺ˝Ć&#x152; Ä¨ĆľĆ&#x152;Ć&#x161;Ĺ&#x161;Ä&#x17E;Ć&#x152; Ĺ?ĹśÄ¨Ĺ˝Ć&#x152;ĹľÄ&#x201A;Ć&#x;Ĺ˝Ĺś Ĺ˝Ć&#x152; Ć&#x161;Ĺ˝ Ä&#x17E;Ç&#x2020;Ć&#x2030;Ć&#x152;Ä&#x17E;Ć?Ć? Ç&#x2021;Ĺ˝ĆľĆ&#x152; Ĺ?ĹśĆ&#x161;Ä&#x17E;Ć&#x152;Ä&#x17E;Ć?Ć&#x161; Ć&#x2030;ĹŻÄ&#x17E;Ä&#x201A;Ć?Ä&#x17E;Í&#x2014; WĹ&#x161;Ĺ˝ĹśÄ&#x17E;Í&#x2014; 08 6102 2945 Ä&#x201A;ĹśÄ&#x161; ĹŻÄ&#x17E;Ä&#x201A;Ç&#x20AC;Ä&#x17E; Ç&#x2021;Ĺ˝ĆľĆ&#x152; Ä?Ĺ˝ĹśĆ&#x161;Ä&#x201A;Ä?Ć&#x161; Ä&#x161;Ä&#x17E;Ć&#x161;Ä&#x201A;Ĺ?ĹŻĆ?Í&#x2DC; ĹľÄ&#x201A;Ĺ?ĹŻÍ&#x2014; generalmail@mobilegp.org.au

Make a difference in the heartland of WA An opportunity exists for a general practitioner to become part of a medical practice in the Goldfields town of Leonora. Servicing a population of 1,500, you will have the opportunity to join an accredited, computerised practice. The position, which offers diversity, is flexible with the opportunity to work in a fly in/fly out capacity from Perth one week on/one week off or take a permanent role in the town. The package will include a salary of approximately $350,000, a fully furnished 5x2 house with pool and car. Hospital admitting rights are required as well as detention centre visits and some emergency work. For further information please contact Rural Health Select on 08 6389 4500 or email recruit@ruralhealthselect. com.au quoting RHWLEO1.

www.ruralhealthselect.com.au

Do you want to kill the pig? t The ClassiďŹ ed Advertisement section is your cost effective gateway to the medical profession in WA. t Reaches every known practising medical practitioner in WA. t The trusted, experienced and targeted way to deliver your message. Contact: Jenny Heyden RN Tel: 9203 5222 Mobile: 0403 350 810 Email: jen@mforum.com.au

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

MARCH 2013 - next deadline 12md Friday 15th February - Tel 9203 5222 or jen@mforum.com.au

Medical Forum CLASSIFIEDS 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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To find a practice that meets your needs, call:

Brad Potter on 0411 185 006

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

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Ph: 9315 2599 www.thehealthlinc.com.au

85% 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.

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

Equipment Provided - WADMS is a Doctorsâ&#x20AC;&#x2122; cooperative e Essential qualiďŹ cations: U General medical registration. U Minimum of two years post-graduate experience. U Accident and Emergency, Paediatrics & some GP experience.

UĂ&#x160;Fee for service (low commission). UĂ&#x160;nÂ&#x2021;Â&#x2122;Â&#x2026;Ă&#x20AC;Ă&#x160;Ă&#x192;Â&#x2026;Â&#x2C6;vĂ&#x152;Ă&#x192;]Ă&#x160;`>Ă&#x17E;Ă&#x160;Â&#x153;Ă&#x20AC;Ă&#x160;Â&#x2DC;Â&#x2C6;}Â&#x2026;Ă&#x152;Â° UĂ&#x160;Ă&#x201C;{Â&#x2026;Ă&#x20AC;Ă&#x160; Â&#x153;Â&#x201C;iĂ&#x160;Ă&#x203A;Â&#x2C6;Ă&#x192;Â&#x2C6;Ă&#x152;Â&#x2C6;Â&#x2DC;}Ă&#x160;Ă&#x192;iĂ&#x20AC;Ă&#x203A;Â&#x2C6;ViĂ&#x192;Â° UĂ&#x160; VViĂ&#x192;Ă&#x192;Ă&#x160;Ă&#x152;Â&#x153;Ă&#x160;*Ă&#x20AC;Â&#x153;Ă&#x203A;Â&#x2C6;`iĂ&#x20AC;Ă&#x160;Â&#x2DC;Ă&#x2022;Â&#x201C;LiĂ&#x20AC;Ă&#x192;Â°

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MARCH 2013 - next deadline 12md Friday 15th February - Tel 9203 5222 or jen@mforum.com.au

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