Medical Forum 07/12 Public Edition by Medical Forum WA

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Contents

Major Sponsors

FEATURES

GUEST COLUMNS

6 Alannah MacTiernan:

26 Give a Man a Shed

Power with Passion

Mr Gary Bryant

8 Michele Kosky: Heart,

31 Are Men Scaredy

Hands and Voice

20 Southern Inland

Health Initiative

24 Healthy Opinions –

Doctors Speak Out

NEWS & VIEWS 2 Letters:

Dr James Kent, Dr Richard Yin, Ms Lesley Brydon, Dr Colin Hughes, Mr Aram Hosie, Dr Lewis Blake

10 E-poll: Tackling the

big issues

14 Have You Heard 16 Meet the MF Team 16 Beneath the Drapes Dr Rob McEvoy

Conflict Resolution

32 E-poll: PCEHR

Failure: Common and Deadly

Dr Andrew Tan

41 Cognitive Bias

Modification – What Is It? Dr Rob McEvoy

43 Epidural Labour

Analgesia

Dr Navid Hashemi

Mr Peter McClelland

Care Project

30 Practice Management:

36 Diastolic Heart

46 Boys’ Toys

23 Collaborative Aged

Dr Rob McEvoy

CLINICAL FOCUS

LIFESTYLE

22 Peel Health Campus

29 More Than a Prostate

Big Stuff

Mr Grant Westthorp

of Benign Prostatic Hyperplasia

Ms Jan Hallam

Mr Peter McClelland

45 Helping Men with the

39 Medical Management

President Dr Steve Hambleton

Ahead

Mr Dean Dyer

Dr Chris Finn

9 AMA National

28 A Truckie’s Road

Cats?

48 Kimberley Stories

By Ms Jan Hallam

48 Finding Ways to Cross

the Cultural Divide

49 Wine Review:

Churchview Estate Dr Louis Papaelias

50 Ye Olde Boyes Toyes Ms Wendy Wardell

33 Backpackers and STIs

51 Funny Side

35 STEPS to Pain Relief

51 Photo Competition

44 Conference Corner

52 10 Minutes with

Xavier Pique

By Ms Jan Hallam

52 The Mousetrap 53 The Wild One 54 Competitions

COVER: RCS student Matt learning airway management from Esperance legend Dr Donald Howarth with his anaesthetic hat on.

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PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Letters to the Editor

End for Fee-ForService? 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

The debate in the medical literature continues about the relative merits of fee-for-service or salaried medicine but in Western Australia our public policy has been changed without any debate. A few years ago Osborne Park Hospital management was taken over by the Sir Charles Gairdner Hospital. The Medical Advisory Committee was replaced by a non-elected Surgical Services Committee and any community input into the hospital disappeared along with any ability to dissent. Surgeons from SCGH gradually took on more of the lists and recently two VMP surgeons lost their sessions altogether. The circumstance appears to be that the HDWA is deliberately replacing fee-for-service practitioners with sessional or salaried doctors. Why would we want to so radically change public policy and what is the evidence behind such a change? The suggestion is salaried doctors are less expensive. But full-time salaried consultants are paid a base salary of $160-236, 000, along with their 9% superannuation, 152 hours annual leave, 80 hours sick leave, 2 weeks CPD paid leave plus 1 week overseas paid leave p.a., penalty rates for call back and after hours, retain a 25% right to private practice (or a $94,000 salary boost if they forgo this), and have the tax benefits of salary sacrificing (see www.health. wa.gov.au/awardsandagreements). Try earning this on a fee-for-service (FFS) basis because I am working to capacity and can’t. The FFS doctor has to pay for many of these things plus extra for his rooms, secretaries, equipment, and insurance (workers’ compensation). At OPH doctors sessions have been replaced with doctors from the SCGH but the allocation of this public sector work was never advertised or subject to a competitive process. We all aspire to evidence-based practice so what is the evidence against FFS medicine? FFS medicine in a public environment does not lead to overservicing, prevented by the doctor’s ethics and the scrutiny of peer review. The AMA and our more astute administrators have arrived at the same conclusion – that FFS medicine leads to greater productivity and decreases the unit cost per case to the community. As far as productivity goes FFS medicine clearly leads to a higher volume of cases being completed with substantial reduction in waiting lists. Unfortunately the HDWA is staffed by career public servants who fail to understand the costs of running a practice. If we convert to a sessional/salaried model all of these costs will fall on the State Government. Fearfully, SCGH is now taking over the Swan Districts Hospital. Already at SDH, full-time anaesthetists have been imported from overseas and our locally trained anaesthetists are being excluded from lists. How on earth can government declare Perth an area of unmet need when our own graduates are being deprived of the opportunity to work? At the last surgical audit at Osborne Park an English locum surgeon had completed the most surgical cases.

And at the same time a Western Australian-born colleague lost his sessions at the hospital. There needs to be some explanations. If there are areas of unmet need, perhaps the HDWA should employ the doctors full time, with no right of private practice, so that they don’t turn up at other peripheral hospitals taking sessions from WA-educated doctors, and so they can concentrate upon the area of unmet need. If we continue down this path there is going to be a lot of disruption with community specialists closing their rooms, down-sizing staff and the community pathology and radiology services becoming less viable. If the Minister really supports Liberal economic theory it is a strange way to demonstrate it. It seems contradictory that he wants to socialise how doctors are remunerated but privatise the cleaning services at Fiona Stanley. Dr James Kent, General Surgeon ED: Osborne Park Hospital denied that it had changed its policy regarding engaging Fee-For-Service surgeons, when contacted by Medical Forum. A spokesperson said there was no basis to the claim that any surgeons are being favoured over other surgeons on the basis of their country of training. “Surgeons are accredited at Osborne Park on the basis that they have appropriate credentials for the procedures that they undertake. Lists are allocated in response to demand for particular specialist services, availabilty of staff to perform the list and training requirements.”

Pain and Suicide Risk Dear Editor, The recently published Suicide Prevention Australia Paper on Suicide linked to Chronic Pain and Illness, draws attention to the need for GPs and other health professionals to approach the treatment of such patients with understanding and to be aware of danger signals. The paper references a 2006 Australian study which found that 21% of people who died by suicide, experienced physical health problems that may have contributed to their death. Evidence suggests at least half of those who have chronic pain also experience depression, and thoughts of suicide are common. Left untreated, chronic pain can have a devastating impact on all aspects of sufferers’ lives. About 65% of people with chronic pain report interference with daily activities including sleep, sex, work, exercise and routine self-care, which can have a negative effect on relationships and lifestyle. Such patients are likely to benefit from the multidisciplinary pain management programs (available at Royal Perth, QE II and Fremantle Hospitals). However waiting lists at these hospitals often preclude people from timely treatment. One of the key aims of the National Pain Strategy is to make such programs available at primary care level. Many patients will be helped by early intervention and only where necessary, be referred to the tertiary pain clinics.

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Editorial In this regard, it is exciting to see the work being done at Perth North Metro Medicare Local which is delivering the STEPS (Self Training Educative Pain) Program developed at Fremantle Hospital Pain Unit, within the Medicare Locals services. In the West Australian context the absence of a dedicated paediatric and adolescent pain unit, as well as gaps in service for remote and rural populations echoes the finding of the “Waiting In Pain” MJA article April 2012 from the Australian Pain Society.

Fortunately, this situation need not be difficult to address. Building education into university courses, developing and promoting strong referral pathways, and ensuring ongoing professional developments through initiatives such as the Queensland Transgender, Sistergirl & Gender Diverse Health Conference would all go a long way to addressing the knowledge gap that exists and ensuring that all trans and intersex people, regardless of their age, can get care that is appropriate to their unique needs.

With suicide so strongly linked to physical health problems, it is imperative that GPs and other health-care professionals give the psychological and emotional aspects of pain and illness the attention they deserve. Lesley Brydon CEO Painaustralia

Knowledge Saves Lives Dear Editor, I was pleased to read the recent article “Care for Those Under the Rainbow” (June 2012) featuring some of the services that have emerged to provide appropriate health care and support to LGBTI young people. It’s encouraging that the unique needs of this group are increasingly being recognised and responded too. However, there is much more work to be done when it comes to meeting the needs of adult and older LGBTI people, for whom there are no specialised services in WA. This is especially so in the case of trans and intersex people. Research estimates the prevalence of transsexualism in the population to be around 1:500, while the prevalence of intersex conditions known from birth has been estimated to be 1:1500. Trans and intersex people thus constitute a small but substantial population, and yet the vast majority of medical practitioners have little idea how to provide appropriate care or where to refer such patients to. This can be particularly problematic for a person who is seeking to transition and does not know where the 'trans-knowledgeable' health professionals are. Research tells us that rates of mental illness and suicide are extraordinarily high among transsexual people, with a particular risk in the time before someone is able to access appropriate care and commence transition. Others will access hormones illegally and attempt ‘DIY’ procedures – all of which can carry considerable risk. The lack of knowledge and level of misconception among health professionals can therefore literally be a matter of a life and death. medicalforum

Aram Hosie LGBTI Health Alliance and WA Gender Project

Paper Linen Isn’t the Answer Dear Editor, The discussion around the use of paper linen in our hospitals highlights the need for a broader perspective about healthcare. While patient care remains a primary concern, individual health is also dependent on the health of our society and environment. The decision to use disposable sheets should not just be about patient comfort or economics. Limited short-term economic analysis of paper linen use will fail to capture the externalised cost ranging from the harvesting of trees through to waste issues

of incineration, landfill and methane production. These costs have a health effect that we will pass on to the community we serve. While there is limited Australian data on the footprint of Australia’s health system, we know that the NHS in the UK, with a comparable percentage expenditure of GDP, produces 3.2% of the country’s total carbon footprint. The environmental threat of climate change is now considered by many leading medical authorities as the single biggest threat to global health, and Australia will not be immune. Furthermore, there is clear evidence linking fossil-fuel combustion to many diseases including cardiovascular disease, strokes, cancer, asthma and chronic lower respiratory tract disease, primarily through air pollution. Data from the US places their public health burden of coal mining to be about $US75 billion per annum. The AMA position, as stated in their Climate Change and Human Health Paper, includes that doctors should: •

Support policies and practices compatible with a healthy and sustainable future,

•

Encourage the sustainable reduction of carbon emissions from health-care facilities and organisations, and act as role models for others in reducing emissions in their own practices.

It is time for the AMA to become engaged in this process and like our colleagues in the UK and other countries, advocate for the changes that they espouse. Dr Richard Yin More letters on P4

Cartoon Caption Competition Don’t leave all the fun to the cartoonists. Write the speech bubble and submit your witty suggestions to Medical Forum. The best entry will appear in the August issue of the magazine. So get your entries in by July 13. You can enter by emailing editor@mforum.com.au or via the competition page at www.medicalhub.com.au. Please include your name and the publication date in which the cartoon appeared.

Letters to the Editor

The Balancing Act

which ably supports the roster and gives a much better lifestyle to all the GPs. Dr Colin Hughes, Centrepoint Swan View Medical Centre, Midland

Dear Editor, I have proposed that the RACGP develop a policy on work-life balance and safe hours. Given the fact GPs are seeing lots of FIFO patients, it’s time we looked at our own conditions of service and remuneration in General Practice to give ourselves and our families a better work life balance. I personally only work 2½ days a week allowing me to take time off for rural locums and working in indigenous communities as well as time for grandchildren, ageing parents in Victoria and leisure and travel. I think back to early rural general practice when I was on call for all my mids and hospital patients 3 out of 4 weekends and every night during the week. Unless we develop such position statements we will not be able to argue for better remuneration and conditions and so perpetuating the rural shortage. Northam doctors have at last negotiated 12-hour rosters. Initially we were told we would never fill the rosters but thanks to Royalties for Regions we have been able to negotiate a $200 per hour on-call allowance,

ED: Dr Hughes proposes a policy of safe hours for GPs, particularly rural GPs, similar to those in the hospital sector. Some of his suggestions in his draft work-life balance proposal include minimum leave entitlements of 6 weeks annual leave; public holidays or, if worked, time off in lieu where GPs are expected to work or be on call in unsociable hours or hours in excess of 35 hours per week; 4 weeks emergency or family leave; and 12 weeks long service or sabbatical leave after 5 years. For rural GPs in isolated or small towns requiring 24-hour on-call should be entitled to a minimum of 10 weeks annual leave and 24 weeks long service or sabbatical leave after 5 years.

Work, Rest, Play Dear Editor,

specialist colleagues have some interest and involvement, directly or indirectly, with occupational medicine. However, few opportunities arise for doctors to attend meetings that provide practical insights and educational updates in the field. We need, at times, to manage the interface between occupational injuries, diseases and disorders requiring the provision of sound medical advice on the one hand and a return-to-work process to environments that may be remote, unfamiliar and hazardous. Frustrations frequently experienced can test the patience of any doctor. May I draw attention to the forthcoming annual scientific meeting of the Australian and New Zealand Society of Occupational Medicine (ANZSOM), to be held at the Abbey Beach Resort, Busselton from August 21 to 25, hosted by the West Australian branch of ANZSOM. The meeting attracts vocational assessment points. You can obtain further detail by visiting the website on www.anzsom.org.au/ASM_2012 Dr Lewis Blake, Co-Convenor ANZSOM ASM

I like to think that most of our GPs and a good number of their

Our strength is in our numbers.

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Spotlight

Politics, Passion and Making a Difference She’s feisty, outspoken and determined and for the Mayor of Vincent Alannah MacTiernan doing something is far healthier than sitting back whingeing. a young age that you can’t just complain about something. You have to get involved and do your bit. I don’t want to make myself out to be a Mary MacKillop, but I went to school in an old-fashioned Catholic environment and social engagement was very much part of the ethos.”

The former state Labor Minister, Alannah MacTiernan is now Mayor of the City of Vincent and she happily concedes that she hasn’t really left politics at all. She’s feisty, funny and passionate about making Perth a better place to live. And she’s convinced that healthy communities lead to happier and healthier lives. “If you think about politics as something that determines the allocation of a community’s resources then I’m still very engaged on a local level. But, having said that, I certainly don’t miss being in State Parliament. It’s not much fun sitting on the Opposition benches after you’ve had a stint in government. You’re not making important decisions anymore and that’s not very satisfying. What I really love doing is adding value to the community and making it a better place to live.” Whatever the public perception of our political masters, the job is not for the fainthearted. “The Perth to Mandurah railway line was like four years of being on the Somme and

The Perth to Mandurah railway line was like four years of being on the Somme and it certainly took its toll. it certainly took its toll. We were under complete and utter attack, but when we won the election in 2005 I knew there was a lot of public support and it became much less wearing after that. I felt confident that it was the right decision and that helped me stick with it.” The glare of the spotlight can be harsh, for family members as much as the public figure. “My children have grown up with me in public life but they’ve been pretty much isolated from those pressures. In any case, they’ve got their own lives now. Our son works as a planner at Curtin University and our daughter is working at a university in Holland specialising in eastern Indonesian languages.” Sometimes, as Alannah points out, being recognised for all the wrong reasons can have unpleasant repercussions. “I had a neuroma in my foot and it hurt like hell when I went to the gym. After 6

Social engagement doesn’t have to be all hard work, as Alannah’s new business venture opposite the Maylands railway station goes to show. “The Swallow Bar will have a French 1920s theme and it’ll also be the smallest bar in Perth. The two young women who are going to be running the place are both experienced chefs. It’s a beautiful heritagelisted building and there are a myriad of regulations that need to be dealt with. Being on the receiving end has clarified for me some of the reasons why people get so annoyed with the planning process.” n Mayor of Vincent Alannah MacTiernan

the ultrasound a doctor walked in with the needle and said, ‘I’m really going to enjoy doing this to you because I’m sick of your railway… every time I drive down the freeway it’s just so inconvenient’. And he wasn’t joking! I rang the head of the practice and he was horrified.” “My other horror medical story goes back to when I was giving birth to our first child as an excited 22-year-old. The paediatrician was a passionate anti-war campaigner and kept saying, ‘I don’t know why people are bringing children into the world… we’re going to have a nuclear war and everything’s going to be terrible.’ On a more positive note, my GP is absolutely wonderful!” Alannah’s own family background was instrumental in shaping her personal interest in social justice, equity and the courage to speak her mind. “Well, it is true that my mother had a picture of Fidel Castro on the kitchen curtains! She was a hardworking woman and keen for her children to have a better life than she did. My father had an absolute self-belief and great personal confidence. We were brought up in a working-class suburb in a large family so we got to see the world in a fairly raw state. I learnt to survive in a very robust environment and that’s always been an asset.” “I think a certain percentage of the herd is more predisposed to think about the plight of other people and I’ve always felt from

At the last federal election, Alannah ran unsuccessfully as candidate for the seat of Canning. “I wasn’t too disappointed because I went into it knowing I might not win. I felt that I owed it to the Labor Party, they’ve given me a lot of opportunities and I felt I was well placed to maximise our chances. We did get a swing back to us but it’s a shame we didn’t win because it would’ve made the government more stable. But it didn’t happen and you just have to get on with it.” So does the former Melburnian miss the bright lights of the east coast?

...you can’t just complain about something. You have to get involved and do your bit “God no, I’ve had the operation! I never go back to Melbourne and think, ‘this is home’. Perth’s a very inclusive society and there’s a real lack of pretentiousness here, although Melbourne does have better newspapers. One thing I would like to see here is a society a little less obsessed with the personal accumulation of wealth. But I’ve never found Perth boring. Boredom is a sign of something else, I think. And anyway, if you think things need to be more interesting, then get out there and make them more interesting!”l

By Mr Peter McClelland

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Feature

With Heart and Hands and Voice Michele Kosky has been calling a spade a shovel for the past 25 years of health consumer advocacy. Now she looks forward to a new chapter in her colourful life. This month, tireless health consumer campaigner Michele Kosky will, in her words, become a “very cool private consultant”. After 18 years as executive director of the Health Consumers’ Council of WA, the woman who has fearlessly fought for the consumer’s voice in the health system is stepping aside but she won’t be forgetting the constituency any time soon.

The council was supported by the then Health Minister Peter Foss, who wanted diverse voices in the health system. Now patients have voices in most debates and decision-making around health. “If there hadn’t been a great partnership with the Department of Health, we would have been bleating on the outside, and we’d still be doing it today. They have kept funding us and are welcoming and supportive of what we were doing.” And the love flows the other way with the Director-General of Health Kim Snowball commending her contribution to health policy and debate with her “knowledge, insights and dedication”.

“The new Australian Commission on Safety and Quality in Health Care has set standards for all Australian hospitals, private and public – how they partner with consumers is second on the list. The public sector probably does that quite well but I hope my skills will help the private sector to become more consumer-responsive.” “Whatever I do, it will be getting consumers involved and working with people in good faith and good humour – it’s is the best way n Michele Kosky to achieve results.” Michele has been part of the health consumer landscape for 25 years, beginning at the WA AIDS Council in 1987 during the HIV-AIDS crisis. “What a privilege it was to work there – it was the inspiration to go on to work with other health consumer groups in the community.” She cites the signing of the 1985 national strategy by all Australian state and territory parliaments a “bloody miracle” and a highlight of the AIDS campaign. “I don’t think it could happen in 2012. The leadership of (the then Federal Health Minister) Neil Blewett and the Commonwealth AIDs unit was magnificent. I had never before seen governments working together – and not scoring points.” “But what left a profound and lasting impression on me was witnessing the marvellous volunteer work – people with HIV caring for sicker people, knowing it was their fate as well. And these were young people caring for other young people and confronting their own destiny every day.” “It also struck me that there were people with HIV-AIDS who often knew more about their treatment and their illness than their doctors. They were highly educated and articulate and already a cohesive political force. Gay men know now to lobby to exert influence and it made me think of other groups of patients who didn’t have that opportunity because of the idea of a

partnership between patient and a medical practitioner wasn’t the way to go in the 1990s.” Michele cites the 1992 Rogers and Whitaker “duty to warn” High Court decision as the catalyst for change. “It’s the law that makes the changes in health not the medicine itself, and I think that’s an indictment on medicine. Medicine and nursing are the most noble of human professions – I’m a complete fan – but resistance to change is quite profound. And that High Court case must have been really hard for medical practitioners because it confirmed that people have a right to refuse treatment or surgery.”

It also struck me that there were people with HIV-AIDS who often knew more about their treatment and their illness than their doctors. They were highly educated and articulate and already a cohesive political force.

Her 18-year tenure at the consumers council has seen it grow from a two-person office to a staff of 10 with an advocacy unit that employs three but could keep 300 people busy. It has grown to 86 organisational members and about 640 individual members.

The health landscape is a vastly different place than it was 18 years ago with community members on many committees across the board and for Michele that’s just sound common sense. “There’s more wisdom and a greater understanding that services designed by the service users are of better benefit. But this didn’t happen just in health. By the early 2000s it was happening throughout consumer land – all big industries and sectors learnt the value of consumers’ contributions and their participation was something worth investing in.” If she has one regret as she prepares to depart the consumers council is that this message isn’t heard everywhere. “There are a number of contemporary health charities with a long tradition of fundraising and disease prevention in this state who do not involve consumers and people living with a particular condition in their decision-making and service design and I think that very regrettable.” “I feel a sense of failure that we haven’t been able to persuade them that it’s in their best interest to involve consumers.” Her simple wish list for health is that the patient is at the heart of the system. But if she had magic powers for a day, she’d go much further. “I’d wish for an integrated pathway of care between primary, secondary and tertiary care and for patients and families to understand fully what those pathways of care are and to be prepared. It’s like going on a journey, you have to have the right luggage and clothes. This endless confusion about who pays for what has got to stop.” “I’m a fan of the national health service – there may be a lot of things wrong with it Continued on Page 9

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Past Historic, Future Conditional The future is very much on federal AMA president Dr Steve Hambleton’s mind – Medicare Locals, e-health, primary care and AMA membership are some of the topics keeping him busy. Federal AMA president Dr Steve Hambleton was fresh from the national conference when he spoke to Medical Forum and he was forthright in his views on Medicare Locals, the state of general practice, e-health and the future of the association. First, he responded positively to the federal Opposition promise to abolish Medicare Locals (MLs) if the conservative parties n Steve Hambleton were elected to government. “The AMA has always complained that MLs were taking away from the divisions, which for 10-20 years have had a very good relationship with general practice. These MLs are not local and are taking GPs out of leadership positions. In New Zealand this model lost its way because it lost the connection with general practitioners and we don’t want to see that happening in Australia.” “The AMA supports a change because there’s a real danger of disenfranchising people at the top of primary health care.” Mining the archives, Medical Forum unearthed a story in the 22 August 1997 issue of Australian Doctor where Queensland GP Dr Hambleton as then president of the Australian Medical Centres Association wrote that morale in general practice was at an all-time low, workloads were at record high levels and remuneration was the opposite. So how have things changed 15 years on?

“In 1997 there was a huge dip in the bulk billing rate until Tony Abbott as Health Minister changed it around and started focusing on the future. One of these changes was to increase the rebate, which meant that every single GP in the country was remunerated. The second thing he did was to introduce a structured approach to chronic disease management which has changed the way we practice.”

“General practice has gone from episodic care, to a structural approach, to chronic disease management with the general practice managing plan and team-care arrangements, item numbers and creating a new paradigm which is an interactive proactive approach to CDM.” “With it has come recognition of general physician work. I think recognition is starting to return by the fact that health systems are judged on the quality of their primary care framework. General practice has an exciting future.”

Dr Hambleton was also upbeat about the future of the AMA, despite a report in the Medical Journal of Australia’s online InSight publication, which claimed that of the country’s 88,293 practitioners (AHPRA 2010-11 annual report) only 26,500 or 30% were members. “We often say we represent 100 per cent of individuals and only 50% pay their fees – the denominator is now bigger than that. We have to make sure that we grow with the times to make sure that we are embracing

the emerging profession. There are very good signs this is happening.” “Membership growth is now from the emerging profession and it’s a generation that will be better trained. They are more open and savvy and communicate easily and that will renew the AMA. Our penetration of the profession in the past decade has been static but there are signs that’s changing now. Students through to DIT; to state AMAs and local hospital issues – particularly given the teacher-training pressure that we will be facing; and others transitioning to retirement without losing that high-quality knowledge; they are the jobs for the AMA – to be relevant for the whole profession.” With the clock counting down to the PCEHR, Dr Hambleton said the AMA had asked the federal government for a PIP for the entire profession in the e-health area because the entire profession would need to be engaged. “Geriatricans, renal physicians, oncologists – specialists of all kinds – are going to need to produce a shared health summary because they will be the primary provider at some point in time. Item numbers to deliver e-health shouldn’t just be focused on general practice either because the rest of the profession will be engaged.” As to the clinical usefulness of the PCEHR? “It’s a matter of whether we’re mechanising what we do or whether are we are re-engineering. If we’re just doing what we did before but electronically there won’t be extra gains; if we’re going to do it a better way, we might see more gains.” l

Continued from Page 8 but it delivers good service to most people, though I think the Commonwealth should give the state all the health money.” Speaking up and getting the community talking has been her driving passion and for Michele it makes good sense. “The more voices commenting on health policy, giving feedback to government and letting the public know what’s going on, the better. A more informed community means better health care for everyone.” She counts a recent meeting between the chief executive of the national Consumer

Health Forum and the Prime Minister about the impact of delays of medications going on to the PBS as a measure of just how far health consumers and their concerns have come. “I take some pride in contributing to that and to seeing that consumer participation is a normal part of the working of WA Health, WA country health and some parts of the private and NGO sectors.” Michele says she’s now looking forward to building on those relationships, “having fun and wearing a very smart black suit”.l

By Ms Jan Hallam

medicalforum

Fact Box A snapshot of the work of Health Consumers’ Council WA in 2011 • 11 public forums were held • 914 consumers obtained information,referral and advice • 68 consumer representatives are currently placed on decision-making bodies • The Health Issues Group has 36 active members and addressed 15 health issues • 597 health consumers were assisted with complex health complaints 9

E-poll

Tackling the difficult issues Thanks to the 1,322 GPs, specialists and doctors-in-training who opened our emailed invitation for this edition’s E-poll. Of these, a pleasing 368 doctors (or 28%) spent a few minutes giving us their important opinion. We are delighted with the high turnout, which adds considerable weight to our figures. The ‘window’ was only 7 days, so again, thanks for giving us your valuable time (especially the growing number of doctors who use their smartphones or iPads!).

What are survey respondents do… General Practitioner

152 (41.4%)

Specialising

153 (41.5%

Doctor-in-Training

63 (17.1%)

Achieving work-life balance

Doctors attach importance to good work-life balance, usually between family/recreation and work commitments. Do you think you’ve achieved that? Total

Spec

DIT

Yes, most of the time.

33%

40%

31%

19%

Partly.

29%

31%

26%

30%

No but striving for it.

25%

18%

29%

35%

No and unlikely to in the near future.

12%

10%

12%

16%

Not applicable/ not concerned

Uncertain

But does the other half agree?

Would the closest person to you (relative/partner/spouse) agree with your answer to the previous question? Total

Spec

DIT

Yes

62%

64%

57%

70%

Perhaps

26%

22%

33%

21%

Uncertain

Doesn’t apply

ED. It is interesting to note that virtually all doctors have a sense of their work-life balance, with GPs putting themselves ahead of Specialists in achieving good balance. But more specialists are aiming that way. And the person closest to our high achieving doctors seems in strong agreement, most of the time. Doctors-in-training feel less successful in attaining balance and their spouse/ partners agree more strongly.

Back in August, we published similar results from 197 male specialists and GPs. Around 80% of doctors with children expressed regret that work commitments had not allowed them to parent enough (a lot of regret 41%, a little 39%). Only 19% had no regrets.

Chaperone attitude post-Durani

In the light of the Durani case and others like it, what do you believe is the most important role of a chaperone during intimate patient examinations? Total

Spec

DIT

Protect the patient.

64%

57%

70%

Protect the doctor.

22%

33%

21%

Protect both doctor and patient.

70%

Protect the profession from any bad publicity.

Other.

Undecided.

ED. On this question there was no significant divergence of opinion across the three clinical groups of doctors. As a sign of our changing times, it is good to see that mutual protection of patient and doctor is at the forefront of thinking, rather than just safeguarding the doctor’s position during intimate patient encounters. Virtually all the responses in favour of “protect the profession from any bad publicity” came from GPs.

Doctors with financial conflicts of interest

Do you know of an instance where a doctor is benefiting from patient referrals to a third party in which they have a financial interest (such as day hospital, laboratory, diagnostic service, etc)? Total

Spec

DIT

Yes

20%

15%

29%

11%

65%

69%

58%

73%

Uncertain

15%

16%

13%

16%

Medical Board appointments disclosure

Do you believe all doctors should be given the opportunity to comment (in private) on the selection of any other doctor to a Medical Board panel that investigates complaints against doctors? Total

Spec

DIT

Yes

58%

59%

58%

54%

10%

11%

10%

Uncertain

32%

30%

32%

36%

ED. It is interesting to note the uniformity of opinion on this important issue of transparency and accountability within the WA Medical Board. Of those who had formed an opinion, a striking 85% of our surveyed doctors wanted the opportunity to privately comment on doctors appointed to investigative Medical Board panels. There are arguments in both directions but opinion amongst doctors is firmly behind open disclosure. You have to ask why? We have contacted the Medical Board (AHPRA) for comment over recent weeks, with no result.

Dismantle Medicare Locals?

Do you agree with the Federal Opposition’s determination to dismantle Medicare Locals if they are elected to govern? Total

Spec

DIT

Yes

26%

41%

18%

16%

18%

15%

13%

Uncertain

58%

41%

67%

79%

ED. You would expect GPs would be most informed on this issue, given it directly affects them. It is interesting then that they have the highest proportion who agree with a decision to dismantle Medicare Locals. The AMA takes a similar line and, anecdotally, there is plenty of confusion over the final structure and function of Medicare Locals and how they will add value to our current system.

Continued on Page 12

ED. From these results we can say that 1 in 5 doctors are aware of this conflict of interest happening, specialists more so. The next question is what are those involved doing to declare their position to patients and referring doctors? We hope to explore this issue in a coming edition. See P12 for doctor's comments on this issue.

medicalforum

E-poll

Medicine's balancing act Continued from Page 10 Regarding third party referrals, here’s what some doctors said: Would we complain if a doctor owned shares in a pharmaceutical company and used one of their drugs? Until recently, this has been standard practice of most professions EXCEPT the medical profession. This is all of medicine! Surgeons refer to themselves. Cardiologists own echo machines … Private medical practice is about making the maximum amount of money from the patient Unless disclosed to the patient, such relationships can negatively impact on the good public standing. Thought it was common but that doesn't make it acceptable. This is one of the consequences of removing the responsibility for professional ethics from the profession. This behaviour is highly damaging to the profession’s reputation.

The whole issue of financial gain from certain referral patterns is a minefield. For instance, specialists referring to a hospital where they get rent reduction for their rooms. Sometimes the third party cross-investment associates with an improved clinical benefit for the patient. Rather interestingly, it's quite legal for a pharmacist to own a medical practice. No problems if no pressures; convenience to patient is important. It used to be known as unethical.

I have seen my supervisor doing it, so there was no way I would report it! Grossly unethical. Difficult to be "cut and dry" as some conflict of interest, however minimal, may always be there. Define the financial benefit. Is the financial benefit legal or illegal? Such practice occurs in all walks of life and business! But it doesn't matter if they do benefit as long as the referrals, tests etc were appropriate. Business ethics say this is OK, medical ethics says that it is not.

It happens all the time in both general practice and with Specialists! It could be a difficult ethical decision if the doctor does believe that the third party will provide (the best service). Interests MUST be declared – just as board members, financial advisers etc must declare interest. In rural settings this may have some credence, especially if there are no other services being provided.

If the service is competitive and the patient gets excellent care, I have no issue. Winner of the E-poll wine prize was KB

Please take this opportunity to (anonymously) tell us anything you consider important - about these issues or others? l

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Have You Heard?

Lawyers on the record

for iPhones only. Among the 42 general practices you can look up and phone direct, there are nine GP After Hours services aligned with hospitals and with longer extended hours than the rest, usually. Then you have AMA Find a Doctor, an iPhone app launched through Queensland AMA using the federal AMA’s national member list, where you can tap into your local AMA GP (which leaves around 60-70% of GPs off your radar).

The PCEHR is a moving feast (see E-poll this edition). Legal liabilities are the latest hurdle, with a suggestion that unless something is done, medical defence premiums might rise. Commentators seem to be saying that with added responsibility for security of the system, comes added risk, which is increased by more people having access to and ability to alter the PCEHR, including for nonmedical reasons. Will we see lawyers at 40 paces?

App-happy The android-iPhone ‘app’ deluge continues when it comes to locating a doctor. St John of God Healthcare have just launched their freebie, downloadable by searching ‘SJGHC Find a Doctor’, so you can search one of their specialists in VIC, WA or NSW using location, name or speciality. Getting into them might be another matter. You may have noticed a sticker on your Sunday Times lately, promoting the WA Health Department’s ‘GP After Hours’ app

More men on HRT A recent MJA article suggests promotion of ‘andropause’ or ‘male menopause’ has caused a significant rise in testosterone prescription, nine-fold over the past two decades to >$12m each year. This is small in comparison to say, oncology PBS costs. Qld wins the testosterone script stakes while WA has jumped 400% from a lowish level a decade ago. The author, Prof Handelsman

from Andrology Australia, suggested there is no evidence of deficiency rates increasing or improved diagnosis, so non-approved use is a candidate explanation.

Sex and the single fish Britain faces a £30bn bill to clean up rivers, streams and drinking water supplies contaminated by synthetic hormones from contraceptive pills. Drastic reductions in these chemicals, which have been linked to collapses in fish populations, are proposed in the latest European Union water framework directive. More than 2.5 million women who take oral contraceptives in the UK (or flush them down the toilet) are inadvertently defaecating ethinylestradiol (EE) into UK water systems, which researchers say is inducing intersex in freshwater fish. At very low concentrations, male fish reduce sperm production and fish populations dwindle. Canadians added EE2 into a lake until five parts per trillion were reached and fish populations suffered severe problems. In the UK, sewerage works close to waterways are the problem – so much for recycling! The EU has proposed 0.035ppt as a safe level but achieving that will by expensive. Pharmaceutical companies are lobbying hard.

The waiting game Everything seems urgent when you get cancer. Every day counts. So interest in wait lists for cancer surgery has been high since the federal government pasted figures at the MyHospitals website. At Freo Hospital the

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median wait during 2010-11 was three weeks for bladder, bowel and melanoma cancer. At RPH, while waits for bladder and bowel cancer surgery were the same, melanoma surgery happened two weeks earlier but kidney cancer wait was three weeks and breast, two weeks. At Charlies, most cancers were operated on within two weeks, with melanoma a week’s wait and bladder cancer, 8 weeks. Of course all these waits relate to after the specialist puts someone on the list. Time taken to reach the specialist is not given.

surveyed workers felt disclosing a mental health problem to their employer or manager worked against them, and that nearly half of all senior managers believe none of their workers will experience a mental health problem at work. If you come across a male patient who needs encouragement to take better care of their physical and emotional wellbeing, point them to The Bloke’s Book which covers a wide range of health and lifestyle topics and provides a directory of WA services, support groups and programs relating to men. A brilliant resource produced by the Men’s Advisory Network (MAN) (which has a resourceful website and a new CEO), and is available through them or online at www.man.org.au. See Guest Column on P31.

Parents’ voices heard

Working man’s blues A mental health consultancy group recently had Perth lawyers explain responsibilities for mental health in the workplace to a local audience. The press release said the Australian mining industry loses up to $450m a year due to mental illness-related workplace issues (absenteeism, attending while sick, and increase in physical injury), that 85% of

WA Health has allocated an extra $0.5m this year to boost Botox treatment for children with cerebral palsy after heavy lobbying by parents. Wait lists of 11 to 21 months were stalling treatment for more than 129 kids, with about 260 already on treatment that requires repeat doses. The money will go to paying for extra staff after the Health Department approved a “business case” for the extra expenditure.

Electioneering starts now Can anyone else smell an election in the air? To coincide with a visit to Karratha, the minister for regional development and contestant for the lower house seat of Pilbara Brendon Grylls put out a joint statement with

Health Minister Kim Hames trumpeting an extra $57.15 million for a new Karratha Health Campus taking the investment for a state-of-the-art hospital to $207.15m. What wasn’t heard over the trumpeting was the two-year delay announced by Treasurer Christian Porter. The new health campus will replace the ageing Nickol Bay Hospital and the Warambie community and population health centre.

Changes mooted for AMA AMA Federal Council has decided that more efficient development of public policy and responsiveness to membership will come from making the function of Federal Council exclusively about policy development and analysis, and streamlining governance of the AMA group of companies by reducing the size of the board. A discussion paper and state-by-state consultation will follow before a final position is decided at a November Council meeting. Federal AMA president Dr Steve Hambleton is now inviting comment from members.

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The Team

Medical Forum: Heart and Soul Someone once said they like Medical Forum because “it’s a magazine with attitude”. We think they meant courage in standing for something. That’s how we see it – inclusiveness, from within the profession, warts and all, shared experiences, people having their say – the sort of stuff that doctors value and can feel part of. In the age of information overload, it is important we filter out the flotsam, no doubt, like you do in your working day, before offering you independent, balanced commentary. We don’t chase headlines but we do challenge conventions, thanks to the many doctors who talk to us. So you can identify with the key players behind Medical Forum, here we are one recent Thursday. Terri – all-rounder “I guess we give a personal touch to everything we do and always try to support each other and make the magazine the best it can possibly be. And that’s so much easier when you’re working in a small team. (Whose turn to make coffee?)”

Glenn – ad-man “Some things here were new to me. I’m selling opportunities in a product that people value, respect and most importantly, read! An advert in Medical Forum is as much about informing and advising as it is about selling.” Peter - journo “There’s a great diversity of individual skills and interests within the world of medicine. And that means lots of fascinating stories to tell. I’m hoping to put those stories on the page in a way that will inform, engage, challenge and entertain.” Jan – boss journo

Rob – medico publisher “While I’m proud of Medical Forum’s place in the WA medical scene, it’s the people we have conversations with that really matter, along with the many doctors who want to listen in. We’re evolving too and the pace is faster than I really like!” Jen – nurse publisher “Having worked with a lot of doctors over the years in nursing, I’ve noticed how things are more on a business footing these days. But we all crave a familiar face as well as people we can relate to. Empathy is a valued item.” l

“For 35 years I’ve been telling people’s stories – the sad, funny, fascinating, informative, outrageous and frustrating. From every story comes flashes of insight. For doctors, science might be their tool but their humanity is the motivation, which is inspirational.”

Beneaththe Drapes u Winthrop Prof Colin MacLeod was presented with a Citation Award at the National Press Club, which recognises Australia’s top researchers who have had the highest impact in their fields globally. Prof MacLeod, who is Director of UWA’s Centre for the Advancement of Research on Emotion (CARE), said his strong record of citation reflected the fact that his work had helped bring together the two fields of cognitive psychology and clinical psychology. (See his Guest Column on p41.) u Health Solutions (WA), which operates the Peel Health Campus, has appointed Dr Aled Williams, the Director of Clinical Services at PHC, as an executive director of the board, and Dr Neale Fong as a nonexecutive Director. 16

u Curtin University has appointed Gippsland-based academic Prof William Hart as Foundation Head of Medicine, even though the proposed medical school is still awaiting the green light. Curtin’s Acting ViceChancellor David Wood said Professor Hart’s first task would be to lobby for federal funds. He will take up his new role on September 24.

Centre and the Telethon Institute for Child Health Research.

u A landmark study that found a ‘third wave' of asbestos-related cancer had emerged among home renovators has won the $10,000 Medical Journal of Australia/Medical Defence Australia National Research Award for the best research article published in the journal in 2011. The study was conducted by UWA’s School of Population Health, the WA Institute of Medical Research (WAIMR), the department of Respiratory Medicine at the QEII Medical

u Ms Dianne Bianchini has been appointed Chief Health Professions Officer of the Public Health and Clinical Services Division. Dianne has been head of the Social Work Department at Fremantle Hospital and has been actively involved in the reform process within the South Metropolitan Area Health Service.

u Prof Christobel Saunders, the Winthrop Professor of Surgical Oncology at UWA, and RPH orthopaedic registrar Dr Peter D’Alessandro, have received $10,000 travel grants as part of the Perth Convention Bureau’s Aspire program.

Continued on Page 19 medicalforum

From personal wealth creation to business asset acquisition.

Arthritis and connective tissue diseases specialist Dr Jack Edelman has first-hand experience of how sound private wealth management can aid mobility in business. When he and his wife Ann decided to invest in a Bunbury office for their private practice, they were able to purchase the property outright, thanks to the enormous growth of their self-managed superfund set up by Brad Gordon of Entrust. ‘Spreading out investments, Brad has never overexposed our superfund to a single investment, giving us complete confidence, consistent growth and increased security,’ says Dr Edelman. During the 2008 market decline, Brad placed the superannuation in a holding pattern while the market bottomed out. As a result, none of the investments suffered any redemption problems. ‘Brad ensured we avoided funds that had any liquidity issues or subsequently became frozen, and eliminated unnecessary spending by running the superfund in a very tax effective manner. So, when we needed money for the Bunbury practice there were no problems,’ he adds. To alleviate the headaches associated with compliance, Brad also carefully managed the investment documentation that is so vital to self-managed superfunds. ‘Ann and I have been able to relax knowing that Brad is taking care of the book keeping,’ he says. ‘It’s an even greater convenience knowing our office is owned outright and I can focus on looking after my clients.’

Entrust Private Wealth Management Pty Ltd Level 17, 140 St Georges Terrace Perth Western Australia 6000 Important Information. The circumstances described relate to a particular client and his particular circumstances, and are atypical. Investing in volatile and unpredictable markets car r y financial risks including the risk of loss of capital. Past per formance is not an indicator of future per formance.

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Telephone 08 9476 3959 Email info@entrustpwm.com.au Web www.entrustpwm.com.au AfSL No. 222152

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“Reclaim your

Beneaththe Drapes u Sonic Healthcare has bought rival pathology operation, Heathscope, for about $100 million. Sonic chief Colin Goldschmidt said the acquisition of Healthscope's NSW, Queensland and WA pathology businesses, which have a combined annual revenue of $105m but are understood to have operated at a loss, would be "value accretive". u Former Kalgoorlie-Boulder Deputy Mayor, Nola Wolski is the new Chair of the Governing Council of the new Northern and Remote Country Health Service. She is also the Chair of the Goldfields District Health Advisory Council. u Professor Geoffrey Dobb will lead the Governing Council of the new Southern Country Health Service. He is also the Director of the Critical Care Division and Head of Intensive Care at RPH and a Clinical Professor at UWA. u There’s movement at the station at the WA Country Health Service (WACHS). The new Acting Executive Director Medical Services is Dr Meredith Arcus; Nephrologist and consultant physician Dr Steve Wright is the new WACHS Renal Clinical Lead; Dr Garth Herrington recently commenced as the Emergency Medicine Clinical Lead; and the new directors of the Postgraduate Medical Education Unit are Dr Sarah Moore and Dr Monica Gope. Dr Gope also continues as an Emergency Physician at RPH. u Silver Chain has won the Organisation Award at the 2012 Excellence in Care Awards presented by the Aged and Community Services WA (ACSWA).

Reasons to Smile at North St Zoe Stevens, practice manager at North Street Medical Centre in Midland is the current AAPM Practice Manager of the Year. Zoe has been at the centre for the past 10 years, first working as a receptionist then working her way into her current role. Last year Zoe completed her Diploma in Practice Management. Continuing North Street's run of outstanding achievements, the practice has also been awarded the RACGP WA Practice of the Year. This year the practice also received a Primary Care Infrastructure Grant. l

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Hidden Cash

Waiting at the ATO"

Every year Medical Professionals like you pay thousands of dollars more than they have to in taxes... That is cash just sitting at the Tax Office waiting to be collected. We'll show you how! REVEALED AT LAST!! Australia’s Medical Tax Expert Shows How Thousands of Dollars Can be Reclaimed Each Year ... Information 95% of Doctors Simply Don’t Know! Get your copy of the “The Official Medical Professionals’ Guide To Legally Paying Less Tax….Guaranteed” including the Important Information Doctors Simply Don’t Know Report (valued at $197) but yours as a FREE GIFT! If you are one of the thousands of Medical Professionals who procrastinate each year over their tax returns, almost paralysed with the dread of getting it wrong and facing prosecution, while apprehensive about bleeding your hard earned money, year after year... Then this FREE Report was written especially for you. Australia’s leading expert on taxation for the Medical Profession has just finished drawing on his years of experience to painstakingly author this guide, designed to help you avoid this trap... This FREE report is ideal for any Medical Doctors, Medical Academics and all other Medical Professionals wanting personal help to stop the bleeding of hard earned cash and take away the worry of having to prepare their tax returns on time each year! Claim your FREE copy of “The Official Medical Professionals’ Guide To Legally Paying Less Tax….Guaranteed” (Valued at $197). Simply go to

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SIHI

Rural Boost is Getting Results Adequate rewards and better use of stretched resources is now making rural practice a more attractive option for many doctors. Esperance GP Dr Toby Pearn was recruited by the Southern Inland Health Initiative (SIHI) to reorganise the Esperance Hospital ED services. Too much fragmentation was burning out local GPs. Through various incentive payments and projects – a $565m Royalties for Regions funded program – SIHI aims to reduce community impacts from changing trends in southern rural medical practice. In this case, local GPs joined in to ensure ED services were operating 8am to 8pm every day. Better matching of community expectations with changing work conditions for doctors and others is designed to help rural practice thrive. Closer networking has been one favourable spin-off. “Most networking gets done as casual banter at the hospital each morning, when the GPs visit at 8am to review their inpatients and chat on the wards. But we also have monthly clinical reviews for both emergency and obstetrics, when we present difficult cases or adverse outcomes, and a monthly meeting to give clinical input to the hospital,” Toby explained. Of course, local GPs who ‘hold the fort’ at the hospital ED are taken away from surgery consulting, so patient handover has to be efficient. Outsiders also help.

“We have weekends when locum GPs come from Perth or elsewhere to cover our ED and give the local GPs a break. We find locums enjoy it so much they want to move down here permanently – it’s a good recruitment strategy!” The mix of medical skills among Esperance GPs covers most eventualities. The gathering of skilled GPs in major centres is one change rural general practice is undergoing, and another is improved access to outside help. Toby, who has advanced obstetrics training, explains. “Getting some emergency department experience is the best preparation for rural practice. The local GPs have a multitude of different skill sets, and are happy to be called if assistance is needed. There is always the phone, and specialists in Perth are generally very helpful, knowing the lack of local specialist services.” “Exciting developments include telehealth cameras and screens all over the country, and the plan for dedicated specialists in tertiary centres to liaise this way. There are also heaps of courses, such as APLS, ATLS, etc., for which rural doctors get grants to cover costs and forgone income while attending, as well as special grants for urban GPs to upskill before rural placements.”

The Town:

The Doctors:

• Population 14,281 (catchment 17,600)

• Four private general practices; 18 GPs.

• 720km south of Perth (8 hours’ drive, 1hour flight)

• 9 GP proceduralists (obs/anaes/surgical).

• Farming the main activity – wheat, barley, lupins and canola. Some mining and aquaculture. The Hospital: • Built in the 1960s for 3000 people. • Services: general admissions, cancer treatment, elective surgery, ED, obstetrics and OP services. • Southern Inland Health Initiative will boost health care, 24-hour ED and attract more private GPs. • Esperance Health Campus redevelopment in submission stage.

“It’s the incredible Esperance beaches, outdoors lifestyle and sporting opportunities, combined with the fantastic team of GPs who work together on all aspects of medicine. Work and play is never dull!” In fact, after 18 months in the town, there seems no downside for him or his family. “Well, when you say rural life, it conjures up images of living on a dusty farm, miles from anywhere. Many doctors in Perth think rural is anywhere outside of Subiaco. But we live in a suburban street, walking distance from the shops, an awesome leisure centre, schools, beach, excellent parks, and the best coffee shop in WA.” “My two-year-old son loves the local swimming pool, kindy gym, and scooting along the scenic foreshore footpath. My wife has many friends with young kids, who live just down the road and meet at the park for playtime. I play in the local hockey league, my wife plays in the squash pennants, and both clubs are big social scenes as well as competitive. We surf and kite-surf, and enjoy exploring the vast surrounding national parks at the weekends.” Professionally speaking, Toby has warmed to the challenge of rural practice.

Esperance Workplace Profile

• Major growth through the Royalties for Regions SuperTowns initiative.

Dr Pearn has worked in a number of rural WA locations, and taken on some advanced training, so rural practice was in his sights. But why Esperance, with a young family?

• Dr Graham Rowlands from Norseman participates in the Esperance ED roster and anaesthetics The ED: • 14-15,000 presentations per year. • Primary care problems, accidents/injuries (local abattoir), paediatrics, road and recreational trauma, tourists (grey nomad repeat scripts!) • 15 GPs on the ED roster. • 24hr cover, 12-hours on the floor (8am-8pm), 12-hours within 10 minutes travel.

“The variety and depth of medicine available here is huge. The patients do not want to go to Perth to see a specialist. It’s a two-day trip, so they want you to manage them the best you can, which can be challenging but rewarding at the same time.” “I enjoy taking on a new young couple, looking after them through pregnancy, delivering the baby, and then looking after the child as they grow. The continuity of care is complete. If a patient is ill you can admit them to hospital and look after them.” As the new doctor in town, he acknowledges his experience is short compared to the other “legend” GPs. “Dr Wally Byrnes is a true rural GP legend, and rightly held in great affection by the people of Esperance. He's been working hard here for more than 40 years and is still so enthusiastic, and so humble. He does it all – general practice, emergency,

medicalforum

SIHI

n Esperance obstetrics monthly review (l to r) Dr Wally Byrne, Dr Jen Graham-Taylor, Dr John Spencer, Dr Richard Clingen, Dr Wim Speelman, Dr Mike Mears, Dr Toby Pearn and the Midwives Anne, Angela and Lorraine.

anaesthetics, obstetrics, and surgery – for which there are many stories over the years” “Another legend is Dr Donald Howarth, the radio mad professor, and an enthusiastic tutor who mentors the GP registrars and rural clinical school students. He gives tutorials every morning over coffee in the local cafe before the ward round. He's always onsite when the proverbial hits the fan, to offer assistance and anaesthetic expertise, as well as reciting Banjo Patterson bush poetry to his patients while inserting epidurals for C-section.” It is the close connection to appreciative patients and the community feel that completes the satisfying mix for Toby. “The locals are so friendly and welcoming, obviously because they know they need more doctors in town! Compared to the anonymity of the city, it is nice. A simple thing that makes a big difference here is the lack of commute. The hospital, my surgery, and the surf beaches are all less than three minutes away from home; time to surf before work, home for lunch etc. There is so much extra time in the day!” Toby asked us to mention rural incentive payments. They all add up to a generous package and he said he is happy to explain how they work to any GP (Toby_pearn@hotmail.com).l

n Drs Louise and Toby Pearn with their children, Felix and Lucy.

Encouraging GP Responsiveness Northam, Narrogin and Merredin have all commenced initiatives under SIHI using a medical model inspired by Dr Felicity Jefferies who is Executive Director Clinical Reform within WA Country Health Service. Felicity worked as a rural GP for more than 15 years becoming CEO of Rural Health West, then on to WACHS. She has firsthand knowledge of the challenges of regional practice and the drivers behind the rural medical workforce. The new medical model aims to ensure a 24/7 emergency response from a medical practitioner in rural communities, while protecting the work-lifestyle balance of GPs and offering professional development. Moves are afoot to build GP numbers in the SIHI region through supportive networks, educational opportunities and appropriate remuneration. Rollout commenced in November 2011. Weekends where no medical services have been available in key locations such as Northam and Merredin are becoming a thing of the past.

n Louise surfing at Lucky Bay.

n Medical student David with Dr Richard Clingen and ED Nurse Penny

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Service Profile

Peel Health Campus – Boom Town Hospital As the urban sprawl follows our coastline, demands increase on smaller district hospitals, not to mention the health professionals who live and work locally. Peel Health Campus (PHC) in Mandurah is bang in the middle of one of the fastest growing areas in WA and just 35 minutes from the Fiona Stanley Hospital offramp. Caught between these two worlds since ‘morphing’ from the Mandurah District Hospital in 1999, the 120-bed hospital is WA government-owned but operated by a private company, Health Solutions (WA) Pty Ltd, which was established in 1997 and has a 20-year contract similar to Ramsay’s at Joondalup Health Campus. Our attention was originally drawn to PHC by an announcement that an ED physician exchange with Frenchay Hospital in Bristol, UK. Medical Forum discussed this arrangement and other things with Dr Aled Williams, Head of Emergency and Director of Clinical Services.

growing about 5.5% per annum and the health index growth is about 8% because the very young and elderly tend to be disproportionately represented. We need a bigger hospital, and that’s our big challenge.” “Getting medical staff is becoming easier because word has got out it’s a nice place to live and the city is filling up as well. We are building strong links to Fremantle Hospital with joint medical appointments.” It will be interesting to see what happens to GP support within the hospital. RACGP WA chair Dr Frank Jones has his practice across the road and until seven years ago doctors from his practice were providing ED coverage. Although some GPs still do ED sessions, they all have plenty of other work to do these days.

“It started off as a personal connection – Dr Paul Younge and n Dr Aled Williams, Director of Clinical Services I worked together 12 years ago in Nambour in Queensland and we A media release said several more have kept in touch. Frenchay Hospital is one emergency physicians from Bristol would of the prestigious hospitals in the southrotate through PHC to impart skills and west of the UK. I like the guys at Frenchay experience to both nursing and medical because they are keen on education, staff. It outlined that the 22-bed Emergency including developing simulator courses, Department, which saw more than 45,000 plus they are very efficient with things patients annually, is achieving governmentsuch as the 4 Hour Rule. It’s using their set targets, and has reduced inter-hospital experience in a more peripheral emergency transfers by 24% in the past year. department here, plus setting up training. Health Solutions must meet standards We are outside the Health Department as a set by the Department of Health WA sole operator of a health contract, so getting Licensing Standards and Review Unit and links with other places is important,” Aled report to the Government on a number of explained. His Welsh accent hinted at his performance indicators as a condition of UK origins. the licensing arrangements.

“People like Dr Willie Walker [who chairs the MAC] have been great stalwarts of the hospital over the years. One of the strengths I really like here is how the GPs are really involved, although less, as the young guys do not want to admit. The guys in their 40s and 50s are trying to hold on to that and I’m trying to encourage it. It’s good for continuity of care and engagement with the community and they bring something different to hospitals. Patients like having their own doctor look after them; they still have that model slightly at Armadale and I like it,” Aled said. Peel Health Campus also delivers more than 900 babies a year, has about 400 staff, performs more than 800 surgical procedures a month, and has oncology and renal dialysis services.”l

By Dr Rob McEvoy

“Our admissions are going up 10% per annum. It’s a decent sized emergency department that is comparable to Rockingham and Swan Districts,” Aled added. He has been in the PHC job for 10 years, having done his emergency medicine training at RPH, and knows well the growth pressure on services. “The big thing for us here is how we are going to cope with the demand. The population is n PHC now surrounded by development (circled). 22

n The patient entrance announces services on offer.

medicalforum

Primary Care

A Place for Nurse Experts in General Practice While some nurse practitioners strive for autonomy others see the value of collaborative work with local GPs. A research pilot in Mandurah may show the way.

r Frank Jones and his colleagues from Murray Medical Centre in Mandurah are setting out to prove that a Nurse Practitioner, in collaboration with local GPs, can significantly improve health care on offer. They have chosen aged care for their three-year demonstration study, and the fact that Frank is RACGP WA Faculty chair and ANU in Canberra is overseeing, has added extra weight. More than 40 people attended the recent launch, including the Mayor and Councillors, GPs, nurses from local aged-care facilities, and representatives from GP divisions, allied health, the local hospital and the AMA. “I saw an ad in The Weekend Australian and asked our practice manager to work up a case. We were the only general practice out of 30 applicants chosen to demonstrate the nurse practitioner role,” Frank explained before acknowledging one main motivation. He believes autonomous NP clinics may fragment care when there is a crying need to assist general practitioners to improve care. But both parties will need to change what they do, prove better outcomes, and adopt a different financial model. “Feedback at the moment is fantastic. The patients love it. But the bottom line is, are we going to improve patient care; does a nurse practitioner, appropriately skilled, add value to quality patient outcomes? That’s the question.” “Nurse practitioners have always had recognised skills within specific areas, say hospital medicine clinics. But this is generalism and it takes a GP 5 to 8 years to qualify for a fellowship, and more than 60% of patient presentations are undifferentiated. This was our great angst when we took on this project but we have developed about 18 clinical templates that define what the nurse practitioner’s responsibilities are from the diagnostic and therapeutic point of view. It’s done utterly in collaboration with experienced practitioners. It’s like defining bandwidths of care,” he said, adding that virtually all common scenarios in aged-care were covered. “At the moment, without a grant like ours, it would not be financially viable for any general practice in Australia to take on a nurse practitioner in this role because the MBS rebates are pitiful. That’s why the trial medicalforum

is so important. If it works, we can turn around and say, ‘look at this successful model, you have to increase rebates’.”

walls and just see your patients and get on with it, but there’s a broader picture out there.”

With respect to aged care, Frank and his GP colleagues at Murray Medical Centre are not breaking new ground. There are already

“Our practice has always looked for new opportunities and innovations to improve patient care. General practice has lots of opportunities if you let yourself think outside the square. Our core business is looking after our patients but we can improve that clinical care by delegating to others while we get on with the more complicated stuff, which is really the way things are going.” The Murray Medical Centre NP in the hot seat is Carol Jones, who currently sees about 100 aged care patients in local nursing homes, their own homes or at the surgery.

n Carol Jones RN and Dr Frank Jones field question at the recent launch

aged-care nurse practitioners operating semi-autonomously, but they are supported by providers such as Brightwater and Silver Chain. “Ideally, in our urban areas, wouldn’t it be nice if the larger nursing homes aligned with a particular practice and paid an honorarium to look after their patients for a year. That might cover costs.” “At the moment, most nursing-care facilities believe payment should be between the patient and the doctor. As you know the rebates are pitiful, and I do a lot of nursing homes, and I would make a lot more money sitting in my rooms.” While income is one aspect GPs like Frank are grappling with, their motivation, in most cases, has roots elsewhere. “We are beholden to our federal politicians, unfortunately. General practice is incredibly cost-efficient – we know we make a difference to our patients’ health; 83% of the population see us every year; and Australians have one of the best mortality and morbidity rates in the world. So we are doing something right. We inherently know we are doing a good job, as do our patients, but measuring that sometimes is problematic because it’s not black and white, like if we were cardiologists putting in stents.”

“It is very difficult for some people to get appointments with their own GP and to get access to health care, so hopefully this will broaden it. I’m very excited about the promotion of the collaborative model of care.” She said the partners and doctors at Murray Medical Centre were very supportive. “They refer patients to me and trust my judgment and know that if I need something I’ll ask for it. They are visionary in their approach to providing their patients with good care. We also need to prove this is a financially viable option.” l

Help With NP Arrangements Wearing his RACGP hat, Frank put in a plug for the Collaborative Care Agreement from the college, which he said was extremely useful to his practice in setting up their current NP arrangement. Medical Forum took a look and we agree, especially if it is a “living document” as Frank describes. The template agreement and explanatory guide covers important points such as responsibilities and agreed scope of practice, communication between NP and the practice, arrangements for ordering tests and sharing information in the patient’s medical record, prescribing, clinical alerts, how to set up after-hours and emergency care, and indemnity and patient consent. See www.racgp.org.au/ practicesupport/cca

“It’s very easy to lock yourself in your four

Feature

n Dr Robert Davies with his children

Healthy Opinions – Doctor’s Speak Out What are the challenges of being a man and a doctor in the 21st century? Medical Forum asked WA medicos about their lives, their work and everything in between. Mr Robert Davies is a surgeon with rooms at Western Urology in West Leederville. He’s married (well, he was before this interview) and has two children and a motorbike. First up, Robert talks about men and medicine. “The harsh reality is that men still bring to medicine, and surgery in particular, a commitment to a full-time career. Women have made significant inroads into the feminisation of the medical workforce, with all the benefits that come with that, but it’s still more of a struggle for them to integrate a career with their role as a parent.” Robert segues nicely into another observation on the gender wars. “One of the trickiest parts about being a ‘doctor’ and a ‘man’ is meeting the paternal parenting expectations of our modern wives.”

could be taller,’ he said ‘and a footballer’. His response was, I think, a measure of some sort of success.” “I’d definitely recommend medicine as a career for my son if that’s what he wanted to do, as long as he didn’t become a physician or an anaesthetist. He’s only eight years old and has an excellent insight into the work of a surgeon having accompanied me on ward rounds and watched surgical videos. I’d advise him to follow his own interests and make sure it suited his personality.” One last pithy anecdote from the surgeon humourist on father/son teamwork and work/life balance: “My son told my wife on one occasion that, ‘Daddy doesn’t like living at home … he’d rather live at the hospital.” Dr Richard Riley, a 56-year-old anaesthetist, said his career has been shaped by role models in the profession.

Robert expands on his unique parenting style. “My wife reads all the parenting books which I assiduously avoid. However, I did buy motorbikes for both my children. I also bought Dr Bruce Robinson’s excellent book, Fathering from the Fast Lane, and asked my son how I could be a better father. ‘You 24

n Dr Richard Riley

“I was lucky

enough to learn how some of the greats in anaesthesia, intensive care and surgery achieved their goals and, probably just as importantly, the sacrifices they had to make. Some of them paid for their success with personal consequences and this gave me some perspective on my own future.” “I’d still choose medicine if I had my time again but I would definitely avoid any time in administration. It’s taken time off my life and taken me away from my family.” Richard feels that most men aren’t really listening to important health messages, especially in rural areas where he is from. . “I’m not convinced they are. My sons appear to be equally ‘resistant’ to health messages and decided not to take up an offer to look at a road trauma victim on a tour organised by Sudhakar Rao, the RPH Trauma Surgeon.” And how does Richard look after himself? “I don’t have my own GP but I do think it’s important for all the obvious reasons, such as health-screening for age-related illness. And I don’t have regular check-ups either, with the exception of seeing a dermatologist for my sun-affected skin.” medicalforum

Dr Duncan Steed is a fulltime GP in his mid-60s practising in York and sees medicine still as a caring profession with a great deal of variety. “As my dear old Mum used to say, ‘If you are going to work in the health system, you’re better off being a doctor.’ Interestingly enough, none of my children ever asked the question about becoming doctors.” n Dr Duncan Steed

“As to my doctoring style, I try to give an optimistic view of life while trying to encourage people to make better health choices. I think men are listening more these days and are prepared to discuss health issues affecting them. Certainly, speaking with a GP is better than getting health information from the TV. Put it this way, you’d do a lot better with a glass of wine or a bit of poetry than taking Horny Goat Weed!” In the light of the Suhail Durani case, chaperones are a topical issue. “I’ve never used one, but I’d recommend all male GPs to have a chaperone present for intimate questions or examinations. And if a patient encourages sexual advances, beware! Flattering it may be, but it’s not normal behaviour.” Dr Tony Taylor is a retired surgeon who now teaches at UWA and Notre Dame and is in a position to make some interesting observations on the next generation of doctors. “The X and Y generations, particularly the latter, don’t seem to have the same commitment that we did. Lifestyle has n Dr Tony Taylor become a major issue and they’re looking at specialties that don’t entail getting out of bed at night. They want shorter working hours with high remuneration and I can’t blame them, that’s the way life’s going. At UWA the financial and business courses are more popular than medicine.”

he was ‘giving up medicine and going back to university to do computer studies’. They’re looking at lifestyle and they want a 9-to-5 office job with weekends off.”

Zak Snelson is a 21-yearold medical student in his first clinical year at UWA. Originally from the UK, he’s been in Perth for five years. He sees a distinct difference between the males and females in his course.

The competitive nature of medicine is an important “The latter seem to be much factor, according to Tony. better organised and spend “When you’re carving out a more time studying. They career as a specialist there’s also seem to have a very definitely a competitive different style of approaching element and doctors are the demands of the course starting to super-specialise n Medical Student Zac Snelson and it seems to work better at a much younger age. It’s than ours! Having said that, all about developing a niche there are some older male role models and if you combine that with three or four that I look up to and it’s not so much their doctors supporting each other, you can technical knowledge as their ability to live a build a decent lifestyle.” well-rounded life.” Dr Rohan Carter is a 41-year-old GP Registrar at Geraldton AMS. He began studying medicine as a mature-age student after working as a psychiatric nurse and ‘loves being a doctor’.

“I’d definitely recommend medicine as a career for my own son. The practice of medicine is a privilege, because we’re in a very fortunate position to give something back to people. We need to make sure we’re doing it for the right reasons, too. When medicine becomes all about money, that often gets lost.” Rohan has a message for young doctors coming through the medical system. “Make sure you’re well organised, get to work early and know your patients. And make sure you have a good mix of work and leisure and keep the two separate. I made a choice not to have many doctors as friends. It works well for me and has done since I was a nurse!” Like many doctors, Rohan says he hardly ever sees a doctor. “This probably isn’t a good look, but I would if I was concerned about my health.”

Zak’s generation has a suite of technology to turn to and is perhaps more comfortable with change..

“I think medicine can be quite rigid in some ways. For example, there’s some hesitancy in moving towards electronic records but there are some real advantages. Medicine, at times, isn’t as adaptive as some other professions.” “There can be an over-reliance on new communication technology which can, for example, lead to a shallower understanding of a particular condition. You have to be careful that the software doesn’t start telling you what to do, but overall I think it’s a plus.” Tim Loy is in the same UWA student cohort as Zak Snelson and agrees that their female colleagues are on top of the game and has some interesting things to say about older male doctors. “It’s interesting to look at some of the older male doctors, the ones I look up to are honest and caring with their patients and

“I was talking with one young guy who’d just finished his internship and I asked him what his plans were. He told me that

medicalforum

n Dr Rohan Carter his son

Guest Column

Give a Man a Shed

The time-honoured institution of a backyard shed as a place for men to retreat to has, says Gary Bryant, been reworked as a community space where men can connect with each other and themselves.

en’s Sheds are now recognised as an important community resource for men of all ages, which may account for their proliferation over the past two decades with more than 700 operating and more planned. In WA there are about 115 sheds operating or planned involving about 5000 men – some big with more than 100 members and some in small rural towns serving 6-10 men. The primary focus of a shed is to provide a safe, friendly and healing environment where men are able to work on meaningful projects at their own pace in their own time in the company of other men. There is nothing new about men gathering together in their own space to talk, share skills, swap ideas, solve problems or just discuss life in general. There’s nothing new either about men spending time in their backyard shed – it has been a retreat for generations of men. What is new is that men are combining these two activities in a communal space simply called a Men’s Shed. What is also new is how strongly men

You will also find tea bags, coffee mugs and a comfortable area where men can sit and talk. Some men come to be productive, others come simply to have a chat.

of all ages and backgrounds have embraced this concept. If you popped your head into one, you might see men restoring furniture, perhaps repairing bicycles for a local school, or making rocking horses, or fixing lawn mowers, or making cubby houses for a local charity. You might also see a few younger men working with the older men learning new skills and learning something about life along the way.

The activities of individual sheds are determined by the shed members – there are no rules governing what activities may be included, but there are rules that ensure a safe working environment. The common shed themes are men feeling useful and contributing to their community, learning and sharing new skills, reviving old ones, making friends, networking and generally becoming involved in life again. The impact the sheds have on the physical and mental wellbeing of participating men throughout Australia is profound and those benefits extend to their families and communities. This was recognised in the National Male Health Policy: Building on the Strength of Australian Males and was one of the few areas that received funding when the policy was announced in 2010. It recognised that: “Sheds are popular with older men as a way of establishing

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friendships and social networks, and engaging in purposeful activity, but men of any age and background, including men who are unemployed or experiencing depression or social isolation, are also attending. Men’s Sheds address social isolation, which has an impact on health, and also provide an important opportunity to raise awareness about health issues and services.” In a 2008 study, Men’s Sheds – a strategy to improve men’s health, it noted that sheds also helped delivery of targeted health promotion programs for older men – such as the recent Spanner in the Works? Campaign – and recommended that “Men’s Sheds should be recognised at local, state and national level as being integral to primary health care service delivery for men.” On many occasions health matters and particular experiences of members (either physical or mental) are discussed either during and/or after morning tea. One president reported that a member came to the shed one day feeling low and was overheard saying he wanted to “end it all”. The members rallied and that man is about today telling his story, taking part in the activities of the shed and making a positive contribution to the community at large. From another shed comes a story of a natter after morning tea which ended with one

man being urged by his friend not to put off a visit his doctor. That man was diagnosed with bowel cancer. He underwent extensive treatment and eventually returned to the shed well and raring to go.

the WA Department of Health and is affiliated with the Australian Men’s Shed Association. WAMSA is a charitable notfor-profit association and is registered as a Deductible Gift Recipient

The Western Australian Men’s Shed Association (WAMSA) is the state peak body that coordinates and disseminates information and helps men to set up new sheds. WAMSA receives funding from

The location and contact details of all existing and planned sheds can be found at http://wamsa.org.au/mapofwasheds.html ED: Gary Bryant is Executive Officer of Western Australian Men’s Shed Association.

What WA Doctors Say About Sheds GP Dr Richard Walkey has seen the practical benefits of Men’s Sheds for men in rural areas, first in Toodyay and more recently in Wongan Hills where he practices. He said that Men’s Shed offered men excellent support in a practical, nonconfrontational environment that wasn’t the pub and often recommended it to his patients. “I see many men who have come off the farm and moved into town who are at a loose end and the Men’s Shed gives them the chance to catch up with what’s going on.”

MHR for Moore Dr Mal Washer is the patron of the Joondalup Men’s Shed and sees the tremendous value it has for the men of the city. “Women are much better at networking than men. Men are more individualistic and when they retire, they’re often at a loss. Men’s Shed offers them a place to learn new skills, or simply going and sharing a cup of coffee and a chat. It keeps men connected and constructive and that benefits the entire community.”

He added that stress levels were high in rural areas right now, and having the Shed gave men a place and an opportunity to talk through some of those tensions.

Continued from Page 25 technically skilled. Some are quite dogmatic and not too good at accepting that there might be a degree of doubt. I tend to see all of them as untouchable geniuses and I think some of them quite enjoy that, but others are more humble.”

way we deal with that is quite different. The females tend to talk it through and while we men do that too, we sometimes get drunk and joke about it to deal with the stress.”

a kid in Kalamunda, they were GPs who did absolutely everything from surgery to anaesthetics to delivering babies. And, I thought, that’s what I want to do … they really impressed me.”

As for his own health, Michael says he tends to wait for ‘Red Flag’ Bunbury GP and “Regarding medicine as symptoms and doesn’t baby-boomer Michael a career from an Asian have his own GP. I plan to Comparti sees some perspective, I’m the first do something about that distinctions between n Medical Student Tim Loy doctor in our family and and it will definitely be a his generation and sometimes I wonder if it’s male because there are a lot young men entering something to be proud of. I more of them out there. I’ve the medical profession. And yes, n Dr Michael Comparti think my family is wondering how long it’s inherited a few doctors as there’s a degree of envy towards all going to take and what sort of doctor patients, it’s quite difficult their more relaxed lifestyle. I’ll become. Although my parents did say looking after a colleague because you’re not “They tend to see medicine as a job, which to me, ‘are you doing this because you your usual dispassionate self and I worry is a good thing because they’re more want to, or because you think we want you about that for the GP I end up choosing.” inclined to separate work from their private to?’ That was a relief because a lot of my As for his male patients, Michael says he’s lives. You come to work and then you go Asian friends are pressured to be engineers, seeing more men in their 40s and 50s. home, there’s a life outside medicine. I doctors or lawyers.” envy them but I think I’m stuck with the “But what worries me is this “One thing I have noticed is that quite a work ethic I’ve got and I don’t know how to commercialisation of life and you see it high number of medical students have had change. All that has impacted on my family in advertising for things such as erectile a serious illness. They’ve had both good but I still think medicine’s a fantastic career dysfunction. It’s turning ‘well people’ into and bad experiences and they bring that to with huge opportunities.” ‘worried people’. l their practice of medicine. We’ve seen some “My role models were Peter Anderton, By Mr Peter McClelland sad and confronting things already and the Dick Newnham and Jamie Jamieson. I was medicalforum

Men’s Health

Keeping His Eyes on the Road Ahead Martin Buckland has been driving trucks for 14 years. He talks to Medical Forum about health, drugs and life in the not-so-fast lane of the trucking industry. The combination of poorly paid truckies and tight driving schedules make headlines when things go horribly wrong. The media and some statistical analyses might paint a grim picture but, as far as Martin Buckland is concerned, it’s a great way to make a living. “I’ve been driving trucks since I was 26 years-old and I’m 40 now. It’s been great as an owner-driver, particularly in the last four years when there’s been plenty of work around. Some of the guys on wages are getting more than $35 an hour, so it’s pretty lucrative and they’re making a good living out of it. I own two trucks, both 125 tonne 500 HP Volvos that cost me around $135,000 each.” Martin’s done his fair share of both eastwest and North-West long-haul driving and dispels some of the more tabloid rumours regarding hitch-hikers, drugs and crushing deadlines. “I’d stop for anyone in trouble but I don’t generally stop for hitch-hikers. It’s annoying having someone in the truck, especially when you pull over and you’re trying to sleep. As for deadlines, the companies just want you to get the job done safely. And there’s absolutely nothing in those stories about young women hopping into trucks at roadhouses. Although I have to say one of the best things about driving a truck is perving at good looking women from the cab.” “I’ve done a lot of driving and I’ve never seen any drug taking. I know I look a bit like someone who does that sort of thing with my goatee and mullet but I’m very anti-drugs. When I was younger I saw a bit of marijuana around but I’ve never seen anyone snorting cocaine or popping pills to stay awake. The trucking community is like any other group of people. I’m sure there are areas where it goes on but if you don’t do it, you just don’t see it.” “You listen to 6PR and you hear about drugs and truckies but it’s all overblown. Most of my mates are truckies and when we get together all we do is a lot of whingeing. It’s a bit like an old hen-house.” Martin relates a story about a television program that painted a rather strange picture of the trucking life. “They had this guy in Darwin swearing and drinking Jack Daniels whiskey. Then they showed clips of a truck going through a deep puddle and crocodiles snapping

n Martin's Truck

followed by a guy lying under his truck with a snake crawling between his legs. It was ridiculous, it made us all look like clowns.” Martin talks about his own approach to looking after his health. “My wife and kids go to the doctor but I don’t go much and I’ve never had to go to hospital. The last time was probably a couple of years ago when my nose was bleeding all the time. I only go when I have to and I always go to a male doctor. I had my colon checked a couple of years ago and that was horrendous.”

And retirement? “I love being a truck driver! It’s a job you can do when you get older even though I wouldn’t mind retiring now. But I couldn’t afford my 40 foot boat if I did!” l

By Mr Peter McClelland

Fact Box • 235 truck drivers died on Australian roads, 25 in WA.

The issue of gender and medicine elicits some fairly common attitudes.

• 31 drivers a day suffered a serious injury at work.

“I’d be too embarrassed to go to a female doctor for a man’s problem. Anyway, I’d talk to my wife if I was worried. When I go to the doctor my wife usually comes in with me, they’re more used to it – they seem to go to doctors all the time.”

• The TWU estimates that each death cost $1.7m; each serious injury $408,000.

Increasing age is a factor, as Martin acknowledges. “Getting older is going to change things and that comes quickly sometimes. We have to do a medical every two years and looking around at some of the guys, I don’t know how they pass it. We’ve got a few older drivers and some of them lose their faculties a bit. I’ve seen them come in with a cup of pills, heart, diabetes and Viagra – all legitimate stuff.”

• 82% of drivers are ‘paid by results’. This has a strong link with fatigue and stimulant drug use. • 76% of drivers are not paid for waiting (loading/unloading) time. •

A TWU statistical projection suggests that a 10% salary increase would result in an 18.7% reduction in the crash rate.

Source: Transport Workers’ Union of Australia, 2007

medicalforum

Men's Health

More Than a Prostate

Connecting with men allows them to help us fix their male bits. But being male has many other consequences, as Medical Forum discovered from one expert.

r Alan Wright is a senior GP whose experience and teaching interest in men’s health extends to positions on the advisory board of Andrology Australia (Monash University) and with the School of Medicine at Notre Dame university. While Andrology Australia focuses on disorders of the male reproductive system we asked Alan to focus simply on ‘maleness’. “It’s complex. A lot of factors influence how men feel about themselves, such as their peer group. Some still have the alpha-male macho attitude, n Dr Alan Wright particularly towards women. At the other end of the spectrum you have men who see everyone as their equal, and this is the trend. However, macho men can be a worry to society when they indulge in antisocial behaviour,” he said.

Men, relationships and parenting He stressed it is not just men who have problems with antisocial behaviour but when the subject turned to domestic violence, he sounded concerned. “I don’t think we’ve really made too many inroads into this. What it says about how we raise boys is, basically, the macho image is perpetuated and the insensitivity is ingrained.” He talked about parenting, the growing lack of extended families, and current role models, especially for young boys. “I have concerns about young men – some of the risk-taking behaviour has increased. And for the fly-in, fly-out men, to be a good father you really have to be there. In many ways it falls on the older generation to be mentoring and passing on parenting skills. There are many public forums talking about men’s health which younger men of parenting age can’t attend. Perhaps the older men, who do, should be taking the message back to their sons.” “It’s important we focus on psychosocial stuff, which is probably going to be more important in the long term; how we bring our sons up, rather than their problems.” A doctor and a male In doctoring circles, he says men’s attitudes have changed and they are more comfortable in their own skin and women medicalforum

are seen as no threat with more entering the traditional work domains of men. It is worth noting there is only one male among eight women on the administrative team for Andrology Australia. “Within professional groups there are still some men who look at themselves as the alpha male and I guess we call them the bullies,” he added. While younger doctors like to compete, age mellows most male doctors. “Most of us would be reasonably satisfied with where we are because we have a profession that allows that – a lot of job satisfaction, despite mistakes and the little baggage you carry when things go wrong.”

“In order to enjoy life we need to be well and you have to engage in the management of your health and that sort of education probably needs to start early in schools. We are starting to promote wellness more.” “The arguments over prostate screening don’t help because they give the impression we are not quite sure about what we are doing. The whole prostate debate gets up my

Engaging male patients It seems harder to get men to manage their health but are doctors falling short, too? “Yes and no. A lot of it is down to us. Most men over the age of 40 attend their GP because of an injury or illness that prevents them from doing what they want to do. We treat but don’t do the other opportunistic things like cholesterol, sugar and BP checks.” Such opportunistic screening is difficult, whatever the health concern, and both doctor and patient are busy and distracted by other things. He said delays in seeking help should not be misinterpreted as lack of intent by men. “A study in South Australia looked at men’s illness behaviour. It wasn’t that they didn’t take things seriously but they took a different pathway getting to us because of what they were doing and the way in which they approach illness. Over the past 10-15 years, more men are seeing their doctors than before so the messages are getting through.” He picked the Movember movement and Check Your Tackle as great attentiongrabbing health campaigns. “Merv Hughes is a fantastic ambassador – he raises awareness and gets men to see their GP. Merv is a bloke virtually every man in Australia can relate to at some level – he can laugh at himself and at other people, and be both politically correct and incorrect.” Campaign focus counterproductive? However, Alan has major misgivings about the physical carve-up that targeted health campaigns encourage. He would rather see things lumped back together and each person involved in overall health management.

nose, even more now that we are starting to use the same ‘overtreatment’ arguments for mammography that have been used for prostate screening.” “Prostate cancer screening needs to be discussed with men and they need to be given the pros and cons. If they decide they want screening, they need it annually and have the result discussed with them – the PSA is the thinking man’s test because you have to interpret the number in the light of your other findings.” l

By Dr Rob McEvoy

Practice Tips

Solving problems with grace Tips to Informally Solve Problems within the Practice 1. Briefly outline the problem in a non-confrontational manner with all relevant staff. 2. Ask all relevant staff for ideas on how they think the problem can be solved. 3. Discuss and evaluate factors contributing to the problem. 4. Identify possible solutions/approaches that can be undertaken, including anything that specific individuals can contribute to or be responsible for.

Ensuring the Most Appropriate Hair Loss Treatment A leading medical expert on hair loss has raised concerns about the proliferation of promotions claiming that some surgical techniques represent a panacea for all hair loss conditions. International Society of Hair Restoration Surgery president Dr Jennifer Martinick is concerned the promotions may lure unwary patients towards unsuitable treatments. Patients conducting internet research will encounter a lot of material claiming the Follicular Unit Extraction (FUE) surgical technique results in better growth, a faster recovery phase and is less invasive. Although the FUE procedure results in no sutures and does have merits in certain circumstances, there is no scientific evidence to support the other claims. FUE is not superior to the more established and widely used surgical technique, Follicular Unit Transplantation (FUT). FUE and FUT represent different methods of harvesting the donor follicles for transplant and the results achieved are dependent on the skill of the doctor. FUE, which surgeons often perform with just one or two assistants, involves extracting follicles one at a time using a small punch. The major difficulty with FUE is the use of the small punch prevents the physician from being able to see through the skin and is often referred to as ‘blind harvesting’ of follicles. A consequence of this is limited quality control and a significantly reduced survival rate of the transplanted follicles. FUE harvesting does not produce the same results as microscopic harvesting and replanting of individual follicles that occurs under FUT. Dr Martinick says FUT involves removing a strip of permanent occipital hairs that are microscopically dissected by a team of up to eight technicians. The patient benefits through a higher survival rate of the transplanted follicles – a transaction rate of just two percent compared to a much higher percentage for FUE and healthier hair growth. The challenge for hair restoration physicians is that a major investment of time and money is required to train the large team of supporting technicians needed to conduct the procedure. The physician also needs a large bank of procedures to retain their supporting technicians on a full time basis. But, these challenges must be secondary to ensuring that the patient receives the most appropriate treatment for their circumstances. Hair loss patients must be counselled on the progressive aspect of their hair loss and treatment plans, which can only be devised by specialist physicians, must accommodate this.

5. Collectively decide on a specific action/s to be taken. 6. Record the outcomes of these discussions and the agreed action to be taken. 7. Fix a date to review the effectiveness of your solution. 8. Once a solution is achieved, document the procedure, if appropriate, in your Policy and Procedure Manual.

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Before prescribing, please review Product Information and PBS information in the primary advertisement of this publication. Further information is available on request from CSL Biotherapies Pty Ltd. CSL Biotherapies Pty LTD ABN 66 120 067 45 Poplar Road, Parkville, Victoria 3052 Australia. Reference: 1. Gardasil Product Information 2011.

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medicalforum

Guest Column

Are Men Scaredy Cats? The path to positive physical and mental health begins early for men, says Dean Dyer, President of the Men’s Advisory Network (MAN).

o bloody way, I’m not scared of anything mate!’ Therein lies the problem: we blokes think we’re rustproof. In fact, we fancy ourselves as ‘superheroes’ in some ways. The dreadful statistics on men’s health – both physical and mental – suggests that we’re not made out of stainless steel after all. Well, that’s a surprise!

So, what stops men seeking help earlier and leading happier and healthier lives as a result? Many men got pretty used to being told what to do and how to do it by an authority figure, particularly as they were growing up. There’s often a problem here, though, because sometimes the subtext of those messages was critical, punitive, shaming, blaming and chastising. And what that does is diminish or remove critically important responsibility and accountability. We’ve all heard the words, “I’m the authority around here and you need to listen to me. I know what’s good for you!” And we’re all-too familiar with this message

The Blokes’ Book, which is full of positive and encouraging messages for all West Australian men. It’s a great resource and covers such areas as physical health, mental health, crisis care, legal help, addiction and lots more.

about our masculinity: Suck it up, tough it out and get back out there and take one for the team. You’re weak if you don’t. That’s when we begin to realise that it’s not appropriate to reveal our emotions and that it’s not a good idea to admit we’re struggling. Why? Because it looks like a weakness. And then the ‘mask’ goes up and positive, healthy self-regard evaporates.

There’s also an excellent men’s health check questionnaire at the back of the book. This will assist men to get a simple snapshot of their health and prompt them to visit their GP on a regular basis and there are some useful contacts for GPs there as well. l

And so, for many of us, the journey to a disabling resignation in middle-age and consequent ill-health begins. So, what sort of things would help men to live longer and more self-fulfilled lives? Those in positions of leadership play an important role – it’s vitally important they mentor, guide and provide positive models of support. It’s important they encourage non-violent communication and selfempowerment, allow time for self-reflection and exploration of the world around them. With a good solid foundation it will be much easier to encourage men to manage all aspects of their health and well-being.

Fact Box • MAN: www.man.org.au • Orders for The Blokes’ Book: orders@man.org.au • MAN is located at 33 Moore St, East Perth, Tel: 9218 8044

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E-poll

PCEHR – Confusion Reigns The date for large scale PCEHR adoption into clinical practice seems to be receding. This is not surprising, given the level of ignorance and scepticism amongst doctors, who it is proposed will be the main users and drivers. Medical Forum has produced its own survey this edition. (See below). When the AMA posted its 26-page Draft Essential Guide to the PCEHR in April after a national survey in January, online comment was very mixed but mainly negative. Patients might be highjacked by doctors wanting to collect any PCEHR fee. AMA Guide too complex. PCEHR information deleted for poor reasons may create danger. No actual patient care improvement proportional to effort involved. A record that has to be verified is useless. The doctor, the nominated practitioner, cannot edit the patient

July 1 is the official launch of the Patient Controlled Electronic Health Record (PCEHR). Given the current state of readiness and your level of knowledge, indicate your response to these statements.

contribution, only his/her own. A variety of new medico-legal risks. And so on… Now it has come down to that great driver of health reform, money. AMA president Steve Hambleton is in talks with the Health Minister and PIP eHealth Incentive payments and practitioner costs are firmly on the agenda. Here’s how 368 local doctors responded to the Medical Forum E-Poll: You said: “I am looking forward to the PCEHR, but I figure that unless it is the only method of communication between health practitioners, it will end up out of date, incomplete and therefore useless. So, although it isn’t compulsory, if a patient has one, it should be the only vehicle for communication. I would have been happy to be the Nominated

Provider, except that I am not a primary care-giver, and therefore it would be inappropriate for me to take on that role.” “I haven't received any direct info from the government on PCEHR, so I don't have a clue how it is going to work. We are always the last to know!” “I think PCEHR is being introduced way too prematurely. I have enormous concerns about confidentiality. I am concerned the info will be inaccuarate, I am very concerned GPs will bear an enormous brunt of extra time to construct the records and bear the responsibility if the information is not accurate or used inappropriately. It will also cost the taxpayer an enormous amount of money for very little gain! Why are we not all more vocal about these points?”

The PCEHR will result in improved coordination of healthcare provided by different professionals.

I am confused about who is responsible for what in maintaining an accurate PCEHR patient record.

GP Spec DIT

The PCEHR will assist me in my care of patients.

Strongly Agree

6% 10%

Strongly Agree

36% 45%

31% 24%

Agree

30% 23%

33% 41%

Agree

41% 33%

43% 52%

Neutral

46% 46%

51% 38%

Neutral

16% 13%

20% 14%

Disagree

11% 13%

8% 10%

Disagree

Strongly Disagree 3%

GP Spec DIT

Strongly Agree

Agree

19% 15%

Neutral

41% 36% 48% 43%

Disagree

21% 26%

Strongly Disagree 12% 19%

18% 30% 19% 16% 8%

ED. More of the younger doctors (but still less than half) see the PCEHR as useful for patient care, while GPs have a more opposite view (ahead of specialists). However, the biggest percentage in each craft group is undecided.

Patients have already asked me for information about the PCEHR Strongly Agree

Agree

Neutral

13%

Disagree

29%

GP Spec DIT

Strongly Disagree 55% ED. Virtually no patients are asking doctors about PCEHR, with no significant variation across craft groups.

Strongly Disagree 6% 13%

ED. Enthusiastic doctors-in-training have skewed the ‘total’ results in favour, while most other doctors are undecided.

The PCEHR will reduce the unnecessary duplication of tests and/or treatment.

ED. Confusion reigns amongst doctors on this issue – in fact three quarters are confused.

I would take on the role of Nominated Healthcare Provider if asked by my patients.

GP Spec DIT

Strongly Agree

Agree

21% 28%

Strongly Agree

7% 11%

Agree

35% 27%

41% 40%

Neutral

36% 35%

38% 33%

Disagree

14% 18%

10% 14%

Strongly Disagree 7%

GP Spec DIT

12%

ED. Perhaps younger GPs more readily embrace the possibilities for IT to work for us?

14% 17%

Neutral

36% 39%

32% 38%

Disagree

20% 8%

26% 36%

Strongly Disagree 20% 17%

27%

ED. Only a third of GPs say they will help patients maintain their PCEHR, with even less enthusiasm amongst other doctors.

Tick any of these statements if you believe the PCEHR may present these problems for working doctors [multiple choices possible] Unless someone takes responsibility for accuracy and keeping the PCEHR up-to-date, it cannot be relied on.

55%

As a health management tool, its usefulness will depend on tracking when important information is changed or deleted.

44%

It may increase our workload without adequate remuneration for time spent.

39%

Difficulties for GP locum doctors moving between practices because they have different approaches to PCEHR.

15%

None of the above.

All of the above.

32%

medicalforum

Clinical update

Backpackers at risk of STIs N

early three-quarters (73%) of backpackers have sex during their stay in Australia. Of those who arrive here without a partner, 69% have sex and 46% have multiple sexual partners.1 Many backpackers who were single on arrival report inconsistent condom use (41%) and having unprotected sex with multiple partners (24%).1 Heavy and frequent alcohol consumption, use of illicit drugs and number of sexual partners were associated with STI risk among backpackers.1 1

By Dr Donna Mak, Public Health Physician, Communicable Disease Control Directorate

WA Health recently launched a campaign encouraging backpackers to: 1) practice safe sex, and 2) get tested for STIs if they have had unprotected sex. Condom vending machines will be installed in backpacker hostels and pubs in Perth, Broome and Margaret River. Backpackers from countries with which Australia has reciprocal health care agreements can access Medicare and the Pharmaceutical Benefits Scheme for the treatment of an illness or injury, which occurs during their stay and that requires treatment before returning home.2 These countries include: Belgium Netherlands Slovenia Finland Norway Sweden Italy

Malta

United Kingdom

Under the Health Act 1911, government health services (including public hospitals and regional public health units that provide clinical services) provide free assessment, pathology services and treatment for all notifiable sexually transmitted infections including syphilis, gonorrhoea and chlamydia.3 This also includes assessment and pathology tests for HIV and hepatitis B.3 See E-poll results.

Backpackers are at increased risk of STIs References

So if a backpacker presents to your practice:

1. Hughes K, Downing J, Bellis MA, Dillon P, Copeland J. The sexual behaviour of British backpackers in Australia. Sex Transm Infect 2009;85:477-482. 2. Department of Health, Western Australia. Operational Directive 0322/11, Reciprocal Health Care Agreements. www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12787 3. Department of Health, Western Australia. Operational Directive 0364/12, Provision of treatment of Medicare ineligible patients in WA Public Hospitals. www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12858

1. Offer opportunistic STI testing 2. Encourage safe sex and condom use 3. Refer them to www.couldihaveit.com.au/backpackers.asp

Backpackers in Australia are at increased risk of sexually transmitted infections because of [multiple choices possible]:

Total

Alcohol consumption at unsafe levels. Illicit drug use. Frequent sexual partner change. Having unprotected sex. [Uncertain.

63% 66% 46% 49% 76% 82% 79% 85% 14% 9%

Spec

This is what some doctors said about STI testing: DIT

60% 62% 43% 49% 66% 82% 70% 84% 23% 6%]

ED. The answer is all of the above. It is perhaps not surprising that the opinions of doctors-in-training and street-wise GPs were almost identical, while specialists thought these risk behaviours for STIs were less common (or they were uncertain).

“Access to STI testing should be free and independent of Medicare status, for epidemiological reasons.” “Free condoms should be made available at all public places.” “Managing STIs among backpackers should be proactive and responsive to reduce the spread to local young people.” Some thought the campaign was misdirected:

“How can the DoH push for less antibiotic prescriptions and then say we should hand out Backpackers, including those without travel insurance or Medicare access, scripts for Chlamydia Rx to people we have never can get free STI testing and treatment at [multiple choices possible]: seen?” Total “STIs in FIFOs is more likely to be problematic than via http://couldihaveit.com.au/onlineTesting.asp 9% Royal Perth Hospital Sexual Health Clinic. 26% Fremantle Hospital B2 Clinic. 19% FPWA Sexual Health Services. 19% Goldfields Public Health Unit, Kalgoorlie. 14% Pilbara Public Health Unit, South Hedland. 14% Midwest Public Health Unit, Geraldton and Carnarvon. 14% Any government hospital in WA. 21% Uncertain. 63% ED. There are high levels of uncertainty across all doctor groups as to where backpackers can get free STI treatment and testing. The correct answer is ‘all of the above, except the FPWA Sexual Health Service’. It is a good thing the Health Department is running an awareness campaign! As expected, specialists showed greater uncertainty (72%) than GPs (53%).

medicalforum

backpackers.”

And some expressed their confusion about who pays for what. “I find assessing the situation of visitors or people without cover for Australia very confusing. There needs to be clear guidelines for GPs.” “Medicare ineligible tourists have to pay $177 upfront to see any doctor at my local hospital. The free STI testing will not be taken up unless there is a well-publicised, easy and confidential way to ask for the testing.”

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medicalforum

Pain Management

Small STEPS, big strides for those in pain A new self-management program for chronic pain sufferers is making its mark.

treatment and management program for chronic pain devised by the Fremantle Pain Unit and being rolled out at Perth North Metro Medicare Local has attracted national attention with PainAustralia urging other MLs to jump on board. The manager of Self-Training Educative Pain Sessions (STEPS), pharmacist Kylie Birkinshaw, said the free service was being embraced by patients, their GPs and pain specialists and because it is the first of its kind, people were coming literally from miles around. “We’ve only been running since November and the feedback from the patients is very positive.” The Fremantle unit has seen significant benefits of its trial, with reductions in waiting times from >2 years to 2 months and reductions in cases requiring followup and surgery. Other benefits include an increase in improved physical function from triage at both 3 and 6 months, a reduction in pain disability in regards to function at 3 and 6 months and a reduction in average pain scores at 6 months. Dr Stephanie Davies, from the Fremantle Pain Unit, is one of the architects of the program. She recognised that effective pain management was a multidisciplinary approach involving medical and allied health and the patients themselves. “People in pain are become totally engaged in understanding the complex interactions,

n The STEPS pain team: psychologist Paul Knight, physiotherapist Brigitte Tampin, pain physician Dr Stephanie Davies, program manager Kylie Birkinshaw, EO of clinical services Stefanie Johnston and CEO Terina Grace.

and really appreciate entering discussions around neuroplasticity, the immune system, and the range of options that people can put into practice at their home, as well as discuss with their GP and other health professionals.” STEPS treats 10-12 people each fortnight from referrals from GPs and by word-ofmouth and is one of a small number of pain management programs in the country that is free and where people can get timely access to treatment.

sessions where they learn new skills to manage their pain. They return after four weeks for one-on-one appointments with a physiotherapist, a clinical psychologist and a pain specialist to review how the new skills have been implemented into their lifestyle. A pain management plan is then formulated and sent to the patient’s GP, who continues to manage the patient. “It’s not about throwing another drug at people, it’s about giving people skills and access to local health resources, and GPs are at the epicentre of that.”

“The evidence indicates that people who receive timely access to pain management go on to have lower pain levels, a quicker return to work and less medication usage,” Kylie Birkinshaw said. And most people were eligible for STEPS. After a triage session, which Kylie conducts, patients are required to attend two 4-hour

After a presentation to a PainAustralia conference in the Eastern State in April, there was great interest in the program from other MLs and Perth North CEO Terina Grace is looking to mentor other MLs wanting to run the program. l

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Clinical update

Diastolic heart failure: common and deadly D

By Dr Chris Finn, Cardiologist, Western Cardiology. Tel 9346 9300

iastolic heart failure (or ‘Heart failure with preserved ejection fraction’) is a frequent and under-diagnosed cause for presentation with exertional dyspnoea, particularly in older patients with co-morbidities such as hypertension or diabetes. Outlook is often poor, but there are effective treatments.

Heart failure symptoms, hospitalisations and death correlate not only with left ventricular systolic dysfunction, but also independently correlate with increasing degrees of LV diastolic dysfunction. The hallmarks of diastolic dysfunction – including impaired left ventricular filling and high left atrial pressure – may lead to heart failure with or without associated systolic impairment, and this partly explains the highly varied clinical status of those with similarly impaired LV ejection fraction.

Diagnosis of diastolic heart failure A high index of suspicion is important – prevalence increases with age and female gender, among diabetics and those with left ventricular hypertrophy due to hypertension or aortic stenosis. Exertional dyspnoea is typical, particularly as left atrial pressure increases with exertional tachycardia and hypertension. The chest x-ray and NT-pro-BNP blood test may be useful, together with echocardiography. Echocardiographic clues include left ventricular hypertrophy and a dilated left atrium, often in association with small left ventricular volumes, which further impairs left ventricular filling (see Image 1). Echocardiographic diagnosis is complex, however, and an array of described parameters may be used. One of the most useful is E/E’ (or ‘E over E prime’) – a ratio of the early diastolic mitral inflow velocity

n Image 1: Echo image typical of diastolic heart failure including left ventricular hypertrophy and left atrial enlargement [LVH: left ventricular hypertrophy; LA: Left atrium; Ao: Aorta; RV: Right ventricle]

(E) to the early diastolic mitral annular relaxation velocity (E’). This parameter correlates with left atrial pressure, and an E/E’ >15 is particularly predictive of high left atrial pressure (or high ‘filling pressure’).

Management Randomised controlled trials using the standard therapies for left ventricular systolic impairment have been disappointing, and to date no medical therapy has been shown to improve mortality. Nevertheless, medical therapy is often effective in improving symptoms, and potentially preventing hospitalisation. Fluid and salt restriction together with diuretic therapy may be effective for symptom relief. Diastolic heart failure patients tolerate tachycardia and hypertension poorly, particularly during exercise. Optimisation of resting blood pressure (<130/80mmHg) and a target resting heart rate of ~60bpm (or ~80bpm for atrial fibrillation) are generally accepted. Beta-blockers are the predominant rate-slowing agent used, and (based on the ‘CHARM-Preserved’ trial which showed some benefit with candesartan) angiotensin-receptor blockers are among the additional antihypertensives that can be recommended. Cardiac resynchronisation therapy and implantable defibrillators have not been proven to be of benefit for these patients. Western Cardiology contributes towards the publishing costs of this clinical update.

By Dr John Quintner

For a free consultation with a trained nurse please ask your patients to call 1300 787 055 or visit continenceandyou.org.au

The evils of physical overwork are often increased by admixture of labours which are not akin. This fact is frequently evidenced in the volunteer movement. To men already engaged in active out-door pursuits, volunteering may, for a time. Be harmless; but to those who are confined within doors all day, violent exercise at drill or on march, after the ordinary work is over, is most prejudicial. From: Diseases of Modern Life by Benjamin Ward Richardson, MD, MA, FRS, 1876.

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IVF clinics are not all created equal... Our figures prove it. Hollywood Fertility Centre means high success rates, understanding staff and individual care.

Dr Simon Turner

Dr Julia Barton

MBBS, FRANZCOG, FRCOG

MBBS, FRANZCOG

Dr Roger Perkins

Dr Bill Patton

MBBS, BSc, DA (UK), MRCOG, FRANZCOG

MBBch, BAO, DCG, DRCOG, MRCOG, MRCPI, FACGO, FRCOG

Prof Lincoln Brett BMedSc, BSc (Hon), MBBS, FRANZCOG

Visit www.hollywoodivf.com or call 9389 4200 medicalforum

*N EW IN D I AT IC O N

OFFER MALES PROTECTION TOO GARDASIL NOW INDICATED for the prevention of anal cancer, precancerous or dysplastic lesions*, external genital lesions and infection caused by HPV 6/11/16/18 in men up to 26 years.1

IF YOU DON’T RECOMMEND GARDASIL WHO WILL?

PBS Information: This product is listed on the National Immunisation Program (NIP) for 12-13 year old girls Refer to NIP schedule

Please review the Approved Product Information before prescribing.

REFERENCE: 1. GARDASIL Product Information 2011. MINIMUM PRODUCT INFORMATION: GARDASIL® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant vaccine] INDICATIONS: GARDASIL is indicated in females aged 9 through 45 years* for the prevention of cervical, vulvar, vaginal and anal cancer#, precancerous or dysplastic lesions, genital warts, and infection caused by Human Papillomavirus (HPV) Types 6, 11, 16, and 18 (which are included in the vaccine). GARDASIL is indicated in males aged 9 through 26* years for the prevention of anal cancer, precancerous or dysplastic lesions#, external genital lesions and infection caused by Human Papillomavirus (HPV) Types 6, 11, 16, and 18. *Immunogenicity studies have been conducted to link efficacy in females and males aged 16 to 26 years to the younger populations. CONTRAINDICATIONS: Hypersensitivity to vaccine, including excipients. PRECAUTIONS Febrile illness, impaired immune response, thrombocytopenia or any coagulation disorder. This vaccine is not intended to be used for active treatment. Routine cervical screening and detection and removal of cervical lesions should be continued in individuals who receive the vaccine. Syncope (fainting) may follow any vaccination, especially in adolescents and young adults. Syncope, sometimes associated with falling, has occurred after vaccination with GARDASIL. Therefore, vaccinees should be carefully observed for approximately 15 minutes after administration of GARDASIL. Use in Pregnancy (Category B2). GARDASIL is not recommended for use in pregnant women. Use in Lactation GARDASIL may be administered to lactating women. ADVERSE REACTIONS: Injection site (pain, swelling, erythema, bruising, pruritis), fever and very rarely, bronchospasm. All cause common systemic adverse experiences include pyrexia, diarrhoea, vomiting. Post-marketing Reports The following adverse experiences have been spontaneously reported during post-approval use of GARDASIL. Because these experiences were reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency or to establish a causal relationship to vaccine exposure. #Infections and infestations: cellulitis Blood and lymphatic system disorders: idiopathic thrombocytopenic purpura, lymphadenopathy. Nervous system disorders: acute disseminated encephalomyelitis, dizziness, Guillain-Barré syndrome, headache, syncope sometimes accompanied by tonic-clonic movements. Gastrointestinal disorders: nausea, vomiting. Musculoskeletal and connective tissue disorders: arthralgia, myalgia. General disorders and administration site conditions; asthenia, chills, fatigue, malaise. Immune system disorders: Hypersensitivity reactions including anaphylactic/ anaphylactoid reactions, bronchospasm, and urticaria. DOSAGE AND ADMINISTRATION Administered intramuscularly at day 0 and then at 2 and 6 months after initial dose. In clinical studies, efficacy has been demonstrated in individuals who have received all 3 doses within a 1-year period. Based on TGA approved Product Information of 21 December 2011.

# Please note change in product information. Product information is available from CSL Biotherapies ABN 66 120 398 067, 45 Poplar Road, Parkville, 3052, distributor for Merck, Sharp and Dohme (Australia) Pty Ltd. GARDASIL® is a registered trademark of Merck & Co., Inc., Whitehouse Station, NJ, USA. Thinking Australia® is a registered trademark of CSL Ltd.

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Clinical update

Medical management of benign prostatic hyperplasia B

Dr Andrew Tan, Urologist, Mount Medical Centre. Tel 9322 2435

enign prostatic hyperplasia (BPH) is a histological description of a condition that begins in most males from the age of 30 and leads to an increase in the size of the prostate over time. BPH can cause lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO). The decrease in quality of life associated with BPH is similar to that of other chronic diseases – 90% of men aged 45-80 years suffer some type of LUTS.

Aims of treatment While the primary goal is to alleviate bothersome LUTS due to prostatic enlargement, recent focus has included slowing disease progression and preventing complications associated with BPH. The type of treatment initiated depends on how bothersome the patients’ symptoms are and whether or not secondary complications of BOO (e.g. urinary retention, recurrent urinary tract infections, renal failure, bladder calculi) are present. Treatments for LUTS secondary to BPH range from behavioural and lifestyle changes through to pharmacological management. Surgery is indicated in those cases that are refractory to medication or where the condition has progressed to cause secondary complications.

Initial assessment and conservative management All men with LUTS require a relevant medical history and physical examination, including digital rectal exam. Laboratory tests include prostate specific antigen to exclude the risk of cancer and urinalysis to exclude infection. A useful way of assessing how bothersome symptoms are is to ask the patient to fill out the international prostate symptom score (IPSS) questionnaire. This questionnaire asks seven questions that are scored according to the frequency of symptoms, divided between

those to do with bladder storage problems (irritative symptoms) and those to do with abnormal bladder emptying (obstructive symptoms). An eighth question measures quality of life. Most patients seek medical attention because of irritative symptoms, particularly nocturia. Other causes of nocturia such as diabetes, excessive fluid intake, congestive heart failure and nocturnal polyuria, need to be taken into account. A frequency-volume chart, measuring fluid in and urine out over 24-hours, repeated 2- 3 times, is a useful guide. Decreasing the amount of fluid taken towards evening, cutting down on alcohol and caffeinated drinks and changing the timing of any diuretic medication to early afternoon can all be effective in decreasing nocturia. Assessment by a urologist is recommended for: abnormal digital rectal examination; haematuria; abnormal PSA level; recurrent infection; palpable bladder; history/risk of urethral stricture; or neurological disease raising possibility of primary bladder disorder.

Pharmacological management Medications useful in LUTS secondary to BPH are: • • • •

Alpha-blockers 5-Alpha reductase inhibitors Anticholinergics Plant extracts

Alpha-blockers: In patients unresponsive to lifestyle changes, the first consideration is alpha blocker medication. Smooth muscle in the bladder neck and prostatic region contains Alpha 1 a type receptors, and the alpha blocker medications licensed for treatment of BPH vary Take Home Points in their selectivity for these receptors. While • LUTS affect a large number of men as they age, and impacts efficacy does not seem on quality of life related to how selective • LUTS can be due to BPH, they are, more selective causing bladder outlet obstruction, agents carry fewer side as well as non-BPH causes. effects. Prazosin is • Initial work up for LUTS includes relatively non-selective, serum PSA and digital rectal whereas tamsulosin examination. The IPSS questionnaire and alfuzosin are more helps quantify symptoms. selective alpha blockers. • Initial medical therapy in Side effects commonly a patient with bothersome LUTs seen with alpha blockers due to BPH is an alpha blocker. are hypotension, syncope, • Complicated cases (see list) retrograde ejaculation can be referred to a urologist. and nasal stuffiness, and patients need to

See: www.usrf.org/questionnaires/AUA_SymptomScore.html

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be warned of ‘floppy iris syndrome’ if undergoing cataract surgery. These medications provide relatively immediate symptom relief but do not affect the progression of BPH, so the efficacy of alpha blockers may appear to decrease over time, if symptoms become bothersome again or if patients develop secondary complications of bladder outlet obstruction. 5-alpha reductase inhibitors (5-ARIs) such as finasteride and dutasteride act by reducing the conversion of testosterone to dihydroxy testosterone (DHT). Several well-designed studies have shown that 5-ARIs improve symptoms, slow progression, and lessen the need for BPH-related surgery in men with enlarged prostates (greater than 40cc). These medications are also an effective treatment in men with refractory haematuria due to prostate bleeding due to the suppression of vascular endothelial growth factor. Reported adverse effects include erectile dysfunction, decreased libido, gynaecomastia and retrograde ejaculation – some persisting despite cessation of the 5-ARI. While it takes several months for 5-ARIs to reach peak symptom relief, combining them with an alpha blocker can speed this up and more effectively prevent progression than monotherapy with either drug. Concerns that long term use of 5-ARIs increase the risk of high grade prostate cancer are under debate – is the relationship causal or related to improved detection whilst on 5-ARIs? Anticholinergics. Medications such as oxybutynin and toleterodine block the neurotransmitter acetylcholine. These agents are most appropriate and effective in men without an elevated post-void residual and when LUTS are predominantly irritative. Men with an elevated post-void residual of 250-300ml should not be treated with anticholinergic agents due to the risk of urinary retention. Plant extracts. Many patients are interested in taking dietary supplements marketed to relieve prostatic complaints. Most contain extracts of the saw palmetto plant and stinging nettle. Well-designed studies around the saw palmetto plant have failed to confirm a significant role in the management of BPH, other than a placebo effect. Further studies are currently in progress. Declaration: Dr Tan is on the Advisory Boards of GSK, CSL and Lilly. 39

Relief... from the most bothersome LUTS associated with BPH, including nocturia

1,2

References: 1. Flomaxtra (tamsulosin) approved Product Information. 2. abrams P et al. Br J Urol 1995; 76(3):325-336. LUTS: lower Urinary tract Symptoms; BPH: Benign Prostatic Hyperplasia.

PBS Information: this product is not listed on the PBS. For rPBS information refer to PBS Schedule.

*Please note changes in Product Information. Please review the Product Information before prescribing. MINIMUM PRODUCT INFORMATION: Flomaxtra® (tamsulosin HCl). Indication: For the relief of lower urinary tract symptoms (lUtS) associated with benign prostatic hyperplasia (BPH). Contraindications: Hypersensitivity to tamsulosin hydrochloride or any other component of the product; a history of orthostatic hypotension; severe hepatic or renal impairment; concurrent use of another alpha 1-adrenoceptor inhibitor. Precautions: Postural hypotension; myocardial ischaemia; dizziness; Intra-operative Floppy Iris Syndrome has been observed during cataract and *glaucoma surgery; exclude prostate carcinoma; *history of serious or life-threatening sulfa allergy; Pregnancy Category B2. Adverse Effects: abnormal ejaculation; priapism; dizziness. Dosage and Administration: one tablet (400 μg) daily, swallowed whole, taken on an empty stomach, or before, with or after food. Presentation: 400 μg tablets; 10s, 30s, *60s. Based on tGa approved Product Information 26 may 2006, amended 18 November 2011. RPBS Dispensed Price: 0.4mg (30) $5.80. Product Information is available from CSl Biotherapies Pty ltd, aBN 66 120 398 067, 45 Poplar road, Parkville, VIC 3052. Phone: (03) 9389 1911. Internet: www.cslbiotherapies.com.au. Flomaxtra® is a registered trademark of licensor, astellas Pharma Europe BV. manufactured by astellas. Distributed by CSl Biotherapies. thinking australia® is a registered trademark of CSl Biotherapies. DC-5005 10010.

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Research

Cognitive Bias Modification – What Is It? We all show bias, either towards or away from danger signals, at a subconscious level. Those biased ‘towards’ can run into problems emotionally, which is where CBM comes in.

he fly-in fly-out worker in Perth’s Qantas lounge runs through 15 minutes of cognitive bias modification (CBM) using an smartphone ‘app’ to assist him overcome his fear of flying. CBM is used to increase bushfire risk alertness and spur people into action where bushfire is a real threat. The agoraphobic’s 10 minutes of smartphone exercises in the carpark allows them to enter the supermarket. These scenarios may seem a bit far-fetched but phobias, addictions, depression and post-traumatic stress are just some of the conditions said to be amenable to this method. We asked UWA’s Prof Colin MacLeod for some insights into CBM. He is a psychologist and director of the Elizabeth Rutherford Memorial Centre for the Advancement of Research on Emotion at UWA. “CBM sits between two ideas. One is the idea that fear doesn’t have to involve thinking. For example, you can uncouple fear paired with a spider by repeatedly exposing someone to safe exposures until the fear is extinguished. This works well but not for everyone. “At the other extreme, from the 1980s, we seized on the idea that negative thinking might be the cause of depression and anxiety not a symptom of it and it led to cognitive behavioural therapies (CBT), which operate at the level of conscious thought. They are geared towards finding what particular type of thinking is making a situation threatening and to teach people ways to counter these thoughts, and replace them with more adaptive thoughts. It involves rational thinking. Both methods – extinction and cognitive behaviour change – can be used together.” “CBM falls in between these two approaches. We try to change the patterns of low-level information processing, the biases, and distorted types of memory and attention, to reduce the likelihood that these negative thoughts will occur. We take some of the principles of behaviourism – practice something until it becomes habitual – but we have people practise the processing of information in a way that affects the kind of thoughts they have. As an analogy, we are re-programming the brain.” Now, if you are getting lost, Colin has a good example, taken from the very method used to assess cognitive bias.

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“After this type of training, these people show much more resilience when put under stress. Early treatment studies carried out by independent research groups overseas blew us away – eight sessions across a twoweek period, with each session 300 trials in 20 minutes, producing very good treatment outcomes that were maintained for three months.” Colin said that like most types of intervention, there will be strong and weak responders, and the most effective clinical treatment for anxiety and depression will be to combine CBM with conventional approaches such as extinction and conventional CBT. At this stage, he cannot predict who will respond to CBM, or respond better to visual or auditory methods.

n Prof Colin MacLeod PhD

“We flash onto a screen images that are pleasant or threatening, for half a second each. The participant is asked to observe small probes or lines in these images, deliberately placed in certain places. When they see them they press a button and we measure how quickly. People with attentional bias towards anxiety pick up the probes more quickly when they are placed more closely to the threatening information, even though the images are flashed so fast they are not even aware there is an image.” “We know from this that attentional bias works before people are aware of where their attention is drawn to. In a bias modification task, the participants do the

Over time, patients start to develop attentional avoidance of threat…a pattern of selective processing that is the reverse to that associated with dysfunctional anxiety and depression. same thing but the probes always appear opposite, distant from the threatening stimulus. Over time, those patients start to develop attentional avoidance of threat. This reduced attention to threat shows on other tasks and with other materials, so we induce an effect, a pattern of selective processing which is the reverse of that associated with dysfunctional anxiety and depression.”

Effecting change at a non-conscious level has some sinister connotations, given previous debates over subliminal TV advertising. However, people make a conscious decision to use CBM. Colin said chronic pain, eating disorders and a raft of other health problems involve biases in processing information, automatically and subconsciously. Of course, CBM raises a lot of questions that will keep researchers going for years. Prof MacLeod will lead three teams of Transylvanian researchers in a longitudinal study. “Genetic and developmental factors will be explored, looking for genetic and cognitive precursors and predictors of anxiety and depression in adolescents; whether patterns are present before adolescence or whether it’s adolescence that gives rise to these biases in some individuals.” “We know there is a genetic disposition to anxiety but it only accounts for a fraction of the variance. When we expose people to dangers they can mitigate – such as in combat or when they have ill children – those kinds of life events can leave people more vulnerable to anxiety. If you are exposed to a threat you can do something about, your brain learns to monitor for that type of threat, and bugger the anxiety it causes. It’s like a preparedness.” He said such automatic bias in cognition can be all pervading in those genetically predisposed, probably due to altered brain chemistry. Normally, we learn to regulate our anxiety by selectively avoiding danger information and some people do that better than others. l

By Dr Rob McEvoy 41

21% of male patients with type 2 diabetes may have total testosterone <8 nmol/L, the current PBS threshold for treatment.1 Testosterone replacement therapy may reduce HbA1c levels, waist circumference and improve insulin resistance – this may help reduce type 2 diabetes patients’ cardiovascular risk profile.2,3 Blood tests may identify patients with low testosterone. For more information log on to www.bayermenshealth.com.au

Please review Full Product Information before prescribing. Full Product Information is available from Bayer Australia Ltd.

Testogel® (Minimum Product Information) Testogel is 1% testosterone gel. Indications: testosterone replacement therapy for male hypogonadism when testosterone deficiency has been confirmed by clinical features and biochemical tests. Dosage: 5 g of gel applied once daily about the same time preferably in the morning. Depending on clinical/laboratory response, the daily dose can be adjusted by 2.5 g steps to a maximum of 10 g of gel per day. Contraindications: Known or suspected prostate/breast carcinoma, use in women/children, hypersensitivity to testosterone or any ingredient. Precautions: Regular prostate monitoring. Patients with severe cardiac/hepatic/renal insufficiency, ischaemic heart disease, hypertension, epilepsy, migraine, hypercalcaemia. Risk of sleep apnoea. Testosterone transfer to others via skin contact, check periodically for polycythemia. Pregnancy Category D. Adverse Effects: reaction at the application site, erythema, acne, dry skin, changes in laboratory tests, headache, prostatic disorders, gynaecomastia, mastodynia, dizziness, paraesthesia, amnesia, hyperaesthesia, mood disorders, hypertension, diarrhoea, alopecia. For other events refer to full PI. PBS dispensed price: Testogel: 5mg (30 sachets) $95.12. Reandron® 1000 (Minimum Product Information) REANDRON 1000mg/4mL, solution for injection: Testosterone Undecanoate. Indication: testosterone replacement in primary and secondary male hypogonadism. Dosage: 1 ampoule injected i.m. every 10-14 weeks into gluteal muscle. The first injection interval may be reduced to a minimum of 6 weeks to achieve steady-state testosterone levels more rapidly. Contraindications: Prostate/breast carcinoma, hypercalcaemia accompanying malignant tumours, hypersensitivity to testosterone undecanoate or the excipients, past or present liver tumours, use in women. Precautions: Inject strictly i.m. and very slowly to avoid pulmonary microembolism. Regular prostate and haemoglobin/haematocrit monitoring. Patients with severe cardiac/hepatic/renal insufficiency, hypertension, epilepsy or migraine, bleeding or coagulation disorder. Risk of sleep apnoea. Adverse Effects: polycythaemia, diarrhoea, weight increased, leg pain, arthralgia, dizziness, increased sweating, headache, respiratory disorder, acne, pruritus, skin disorder, testicular pain, prostate disorder, breast pain, gynaecomastia, hot flush, injection site reactions including subcutaneous haematoma at the injection site. For other events refer to full PI. PBS dispensed price: Reandron 1000: 1000mg (1 ampoule) $147.41. References: 1. Grossmann M et al. Clin Endocrinol 2009; 70: 547-53. 2. Grossmann M et al. J Clin Endrinol Metab 2008; 93(5): 1834-40. 3. Kapoor D et al. Eur J Endocrinol 2006; 154(6): 899-906. Bayer Australia Ltd. ABN 22 000 138 714, 875 Pacific Highway, Pymble NSW 2073. ® Registered Trademark of Bayer AG, Germany. L.AU.GM.02.2011.0086. BAAN4176/MFM. 07/11.

PBS Information: Authority required. Refer to PBS Schedule for full information.

Clinical update

Epidural labour analgesia T

he pain of labour is alleviated by a number of things, from complementary therapies to pharmacologic methods. Of the complementary therapies, hydrotherapy, relaxation, acupuncture and massage show the most promise, while effective pharmacological methods include inhaled nitrous oxide, opioid drugs, local anaesthetic nerve blocks and epidural analgesia. Epidural analgesia has consistently shown to provide superior pain relief than all other methods.

Epidural rates Epidural use varies greatly from hospital to hospital in Australia and overall use has increased steadily since the 1990s. This may reflect such things as maternal preferences, the availability of anaesthetists and the obstetric or medical risk of the population within the hospital. In WA, 35.9% of the 20,167 women who gave birth vaginally in 2008 used epidural analgesia (see Table 1). Only 20.7% received no pharmacological analgesia. At King Edward Memorial Hospital, epidural pain relief is provided to approximately 43% of women in labour (KEMH Stork 2011). The private hospital epidural rate of 67% was nearly double that of the public hospital rate in NSW. Internationally, about 33% of women in the UK and 58% of woman in the USA use epidural labour analgesia. Table 1. Analgesia for Vaginal Births in WA (2008) Type of analgesia

No. of

% of

births

None

4182

20.7%

Nitrous oxide

4908

24.3%

Narcotic sedation

3207

15.9%

Epidural

7232

35.9%

Spinal

155

0.8%

Other

483

2.4%

Total

20167

100%

NB. Extracted from Midwivesâ&#x20AC;&#x2122; Notification System.

Failure rates The most comprehensive review of obstetric neuraxial failures is a retrospective analysis of 19,259 deliveries that demonstrated an overall failure rate of 12%. Of these neuraxial techniques, 46% became functional with simple manipulations.

Epidural vs combined spinal-epidural (CSE) analgesia Local anaesthetic and an opioid analgesic, injected into the lumbar epidural space via an inserted catheter, gradually diffuse across the dura into the subarachnoid space, acting on spinal nerve roots, spinal cord, and paravertebral nerves. With combined spinalepidural analgesia (CSE), a small gauge spinal needle is passed through the epidural needle into the CSF, prior to catheter insertion, and a low dose of both local anaesthetic and opioid injected. The spinal needle is then withdrawn and an epidural catheter inserted as usual (see Figure 1). CSE has become medicalforum

By Dr Navid Hashemi, Anaesthetist, Fremantle Hospital & KEMH

increasingly popular and is used routinely at many institutions for labour analgesia. At King Edward Memorial Hospital, 23% of neuraxial analgesia for vaginal births are CSE (2011).

Advantages in using CSE for labour? Advantages include faster onset of analgesia (<5min) compared with epidurals (20min) and a reduction in the total dose of local anaesthetic. In a Cochrane Review comparing CSE and epidurals in labour, there was no difference seen for maternal satisfaction, mobilisation in labour, modes of birth, incidence of post-dural puncture headaches or blood patch, and maternal hypotension. CSE resulted in less urinary retention than traditional epidurals but more women receiving CSE experience pruritus. A more recent high quality randomised trial showed superior satisfaction due to both the speed of onset and amount of mobility. Practitioners who frequently use the CSE technique for labour analgesia may also note another benefit â&#x20AC;&#x201C; if an epidural catheter is unintentionally placed into a blood vessel, the intrathecal injection of low-dose local anaesthetic and fentanyl gives analgesia for 60-90 minutes, while the catheter is removed and replaced.

Effect on labour and instrumental delivery rates? A recent Cochrane review found that epidural analgesia was associated with a longer second stage of labour. The use of epidural analgesia in labour does increase the risk of instrumental delivery in the nulliparous women. Women who used epidurals were also more likely to need their labour contractions stimulated with oxytocin. There is insufficient evidence to suggest that stopping an epidural late in labour lowers the risk of instrumental delivery or other unwanted outcomes.

Risk of Caesarean section? There was no evidence of a significant difference in the risk of caesarean section overall. The risk of caesarean section for foetal distress was increased, however.

Other adverse effects on the mother? Women receiving epidural analgesia are more likely to experience hypotension, motor blockade, fever or urinary retention. However, there is very good evidence that epidural analgesia in labour does not increase back pain after childbirth.

n Fig 1. CSE method compared. Reproduced with kind permission New England Journal of Medicine.

Effects on the foetus/neonate? Epidural analgesia reduces the risk of acidosis and does not appear to have an immediate effect on neonatal status as determined by Apgar scores at 5 minutes. It also reduces the risk of naloxone administration where repeated doses of maternal opioid have been required. Other benefits include improving uteroplacental blood flow in the compromised foetus (e.g. pregnancy induced hypertension, intra uterine growth restriction). It is useful in the premature, breech or multiple pregnancy to assist with a controlled birth.

Additional benefits for the mother? Epidural analgesia may benefit women with cardiac, respiratory, neuromuscular and neurological diseases for whom pain control may have significant safety benefits. Epidural analgesia will benefit women with severe preeclampsia, as an adjunct to antihypertensive therapy, to stabilise blood pressure. Epidural catheters initially placed for labour analgesia can be used for operative delivery in women who have significant risk factors for general anaesthesia e.g. difficult airway management or the morbidly obese. References available on request

Declaration: No competing interest 43

Conference Corner

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

Medical Director Dr John Yovich

My Precious Children Being involved in the generation of more than 20,000 IVF babies, I have maintained a “fatherly” interest in their outcome, particularly the early ones – “my” first in WA is age 30 years this year! Given the adverse medical and scientific climate for IVF in the 1970’s when I commenced this activity, I undertook a study with Paediatric colleagues Trevor Parry, Noel French and the late Freddy Grauaug on the “Developmental Assessment of Twenty IVF Infants at Their First Birthday”. This was the first such study in the World and was published in JIVET, 1986: 3: 253-257.

Dr Chantel Thorn at UWA School of Dentistry

On the basis of a range of studies evaluating their behaviour, locomotion skills, social interaction, hearing & speech, eye & hand coordination as well as general performance, we scored a general quotient (GQ) according to the Griffiths Developmental Scales for children. This was the first ever study to show that IVF children were perfectly normal.

Dates: Venue: Website:

National Early Childhood Intervention Conference August 9-11, 2012 Burswood Entertainment Complex www.eciaconference2012.com.au

Dates: Venue: Website:

Catholic Health National Conference 2012 August 20-22, 2012 Pan Pacific Hotel Perth www.cha.org.au/site.php?id=14832

Dates: Venue: Website:

ANZSOM Annual Scientific Meeting 2012 August 21-25 Abbey Beach Resort, Busselton http://www.anzsom.org.au

Date: Venue: Website:

Australasian Society of Clinical Immunology and Allgery (ASCIA) September 10, 2012 Perth Convention and Exhibition Centre www.allergy.org.au

Aged Care Better Practice 2012 Dates: September 13-14, 2012 Website: http://www.accreditation.org.au/education/better-practice-2012/ Dates: Venue: Website:

Early Childhood Australia National Conference October 3-6, 2012 Perth Conference and Exhibition Centre www.ecaconference.com.au

Dates: Venue: Website:

7th World Conference on Promotion of Mental Health October 17-19, 2012 Perth Conference and Exhibition Centre www.perth2012.org/maintheme.html

Dates: Venue: Website:

Rural Medicine Australia 2012 Annual Conference October 25-28, 2012 Esplanade Hotel www.acrrm.com.au/program-

OSIWA & Sportreat are now offering Platelet Rich Plasma (PRP) injections

Condolences to Gail & Len Thorn

With permission from Mum and Dad I can indicate that Chantel Thorn became an energetic and spirited personality who immersed herself in Aboriginal culture as well as graduating as a dentist from UWA. Sadly Dr Chantel Thorn died in March age 28 years from a sudden thrombo-embolic episode consequent to an acute knee injury secondary to sporting trauma. This occurred in Alice Springs where Dr Chantel commenced practice determined to improve oral services for aboriginal communities. Chantel’s obituary was written up in The West Australian on Wed April 18 as “Broken Dreams” – Vale Chantel.

NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY

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

What is Platelet Rich Plasma Therapy? Platelet Rich Plasma Therapy (PRP) is a promising solution to accelerate healing of chronic tendon injuries[1][2]. PRP technology was initially developed 20 years ago to aid with wound healing and is used in Europe for this indication so we are confident that it is a safe modality. Recently it has also been used extensively for cosmetic applications. Autologous blood is collected in a special tube approved for PRP harvesting when spun in a centrifuge the selector gel separates the red blood cells from your plasma. The low density fraction of this is then removed yielding a serum rich in natural healing growth factors. Sportreat now performs PRP procedures, guided by ultrasound for accuracy, for the treatment of chronic tendon tears, such as tennis elbow & rotator cuff pathologies. Initially the procedure may cause some localized soreness and discomfort due to the action of the growth factors. Sportreat - Phone 9438 2400 [1] Injection of Platelet-Rich Plasma in Patients with Primary and Secondary Knee Osteoarthritis: A Pilot Study Sampson, Steven; Reed, Marty; Silvers, Holly; Meng, Michael; Mandelbaum, Bert American Journal of Physical Medicine & Rehabilitation. 89(12):961-969, December 2010. doi: 10.1097/PHM.0b013e3181fc7ed [2] Wasterlain AS, Dragoo JL, Braun HJ. Platelet-rich plasma as a treatment for patellar tendinopathy: A doubleblind randomized controlled trial. Paper #60. Presented at the Arthroscopy Association of North America 2012 Annual Meeting. May 16-19. Orlando, Fla.

Steven Sampson D.O. www.orthohealing.com sport medicine

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Guest Column

Helping Men with the Big Stuff There’s a friendly ear and a some sound advice for men when Grant Westthorp takes the Wellness Road Show into country towns in the Great Southern.

n 2005 the Men’s Resource Centre (MRC) was established in Albany to provide health promotion and referral services in the Lower Great Southern Health District. It takes the message of mental and physical wellbeing to towns big and small, encouraging men to open up about themselves and to seek help. When the Wellness Road Show rolls into town, so too does a dietician and trained people from groups such as Relationships Australia, Palmerston Drug and Alcohol, 1Life and community health and parenting support groups.

Advertisements and posters alert communities though 60% of men come because their wives have seen the ads. The wives are usually our first contact. We stress that we’re not clinicians and that helps some people who might feel nervous about talking to a doctor to open up to us. Basic blood pressure and waist measurements are taken and then men respond to the 10 coping questions, which explore physical, emotional and spiritual ad-june-12-2012.pdfwellbeing. 1 12/06/2012There’s 3:18:11 PM (though non-religious) no

judgment. We just want men to come. At the end of the session men are encouraged to take the results to a GP and to establish a relationship. People sometimes just need someone to talk to. We’re finding now that a lot of people are struggling, they’re losing connection with each other. The pressure to buy – buy a house, a big TV, and all instantly – is putting a lot of strain on men and their relationships. And there’s always a constant stress on farmers from drought, floods or just isolation. We are also starting to see the effects of FIFO in Albany. There is more relationship breakdown and some kids are going off the rails when dad’s away. It’s a hard lifestyle to maintain and doesn’t always bring happiness. The MRC covers a wide area from Albany, west to Walpole, east to Esperance and north into the southern Wheatbelt and meet a diversity of people – in Katanning we met some of the town’s refugee population from the Sudan and Asia.

Department and there is also some corporate sponsorship. The pitstop wellness checks visit businesses, government offices, schools, sporting clubs, men’s sheds and prisons – there’s no country town too small. A few years back we started going to a small regional show in Cranbrook. In the first year we saw seven men, the next year those seven came back with a couple of their mates and this year that number had grown to 40. The MRC has recently joined an alliance with the Regional Men’s Health Initiative, which includes Wheatbelt Men’s Health in Northam, Midwest Health in Geraldton and Peter Mitchell in Broome’s Men’s Outreach Service. The long term benefit of the outreach is that the participants are encouraged to establish a relationship with a GP so a history can be built up. l

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Men's Resource Centre 65 Serpentine Road, Albany Phone: 9841 4777 Email: grant@mensresourcecentre.org.au

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email: info@lawleypharm.com.au 45

Boys' Toys Harley Davidson Fatboy Lo Dr Martin Buck, oncologist and Medical Forum wine writer, has ridden motorbikes since he was a medical student. He loves riding his 2012 model Harley Davidson Fatboy Lo through the Swan Valley – what he doesn’t like is sharing the road with motor-cars.

ily but in 1994 I bought a Harley Softail and joined a nomadic bike club called the ‘Nullaboys’. We’ve had great rides all over Australia and we’re still going despite old age creeping among us. A trip for the future will be a ride through the US in the Blue Ridge Mountains and Route 66.”

“I got my licence in Laverton while working for Poseidon Mines and rode a trail-bike to try and avoid boredom and alcoholic poisoning on the mine site. I gave it away when I started a fam-

“I’ve just bought the Fatboy Lo and couldn’t be happier. It’s a great performer and a really comfortable ride. My partner, Loraine has a Harley Nightster 1200 so we’ll be hitting the road togeth-

It’s a lot of money, but you’ll get a big bang for your buck! The carbon-fibre frame weighs about 1kg and the bike is designed, constructed and painted in Italy. It’s fast, a joy to ride and a thing of great beauty.

Boeing 737 Flight Simulator, Northbridge The Colnago C59 Racing Bike This bike, in identical colours, is the same model ridden by Team Europcar in the Tour de France. The C59 is top of the 2012 Colnago range, it’s a distinctly ‘high-end’ machine and you can choose your own colours and componentry. And if you’ve got your heart set on this one, the Colnago C59 with Super Record 11 Speed Gears will set you back a cool $12,000. 46

er. One of my best rides was from Port Arthur in Tasmania to Perth with the Nullaboys. It was a fantastic trip! But I have to say, wine tasting through Tasmania on a Harley Davidson can be a challenge.” “I haven’t had any close calls but I regard all car drivers as my nemesis. Riding the bike is a great thrill and a big stress release after a busy week. When I’m on the open roads out in the Swan Valley I don't have a worry in the world!”

Ever wonder what it feels like to take the controls of a commercial jet airliner? Well now you can find out in a 737 Flight Simulator. You can select from thousands of destinations around the world including Paris at dusk, a low-level pass over Rome or a take-off and landing at Perth International airport. And if you want to find out how steady your hand really is, how about having a go at an approach and landing into Hong Kong’s Kai Tak Airport? The HD visual system and curved screen replicates the real world outside the cockpit window and there’s no better feeling than putting the Boeing 737 right on the runway centreline. Just don’t forget to put the wheels down! Don’t laugh, it’s happened before.

medicalforum

Boys' Toys

WIN!! Leica Digital M9 Bunbury GP Charley Nadin is devoted to the world's finest cameras. “Like a lot of people, I started with a Box Brownie when I was 12 years old. Then I moved on to a Russian-made Zenith before heading further east into the legendary Japanese-built Olympus OM1. I thought I'd reached the pinnacle of camera craft with an M Series Rangefinder

Leica and a Reflex Leica. A combination of Leica lenses and Kodachrome film was absolute perfection.” “And then came the digital era. Leica won out again! A combination of Leitz lenses and the Leica Digital M9 produces unsurpassable image quality. And you can even ring the factory in Solms to talk with the craftsmen who build the cameras.”

see everything from Holdens and Fords to Mercedes, Porsches and BMWs. And it’s safe, legal and you can open the throttle as wide as you want.

Jet Ski – Yamaha FZS Supercharger This beautiful piece of machinery blasts through the water at a top speed of 85kph. It’s the latest model Yamaha – the FZS 1812cc

Be in the running to win a GOLD Family pass to the Australian Top Fuel Championship – Saturday night, December 1, PLUS be a passenger in the Police Drag Racing team on an 11 second 200kmh blast down the ‘quarter mile. A GOLD family pass includes admission for 2 adults and 3 children (5-15) to the Perth Motorplex for the Australian Top Fuel championship, reserved GOLD seating and pit paddock access. Courtesy Perth Motorplex.

Dragsters, Sprintcars and the Audi RS6 V10 TT You expect to see nitro-burning dragsters and Sprint cars blasting down the main straight at Perth Motorplex in Kwinana, but an Audi? Although this isn’t your ordinary stock-standard Audi sedan, it’s the only one in WA and it was the star of the show at a recent ‘Whoop Ass Wednesday’. How’s 195kph with a 70-year-old passenger in the front seat? The car’s owner, petroleum industry consultant John Kopcheff, wasn’t too surprised. The Audi cranked up a massive 558 horsepower (426kw) during a recent dynamometer session. And that’s not surprising either. Under the bonnet is a Lamborghini V10 fitted with 40 sodium-filled valves and twin fuel pumps and turbochargers. It’s a HOT car, so hot it needs seven radiators to cool it down. ‘Whoop Ass Wednesday’ runs every week from September to May, it’s ‘off street’ drag racing at its most spectacular. You’ll

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Supercharger and you can use it to charge out to Rottnest, as a wake-boarding fun machine or to tow-in surfers at Margaret River. A full tank of petrol will give you two hours with the throttle wide open and a lot more time on the ocean if you wind it back a little. It will set you back $18,490 (including trailer and warranty) but, when you open the throttle, work will be the last thing on your mind. l

By Mr Peter McClelland

Win a pair of Pearl Izumi Select Gel gloves ideal for road, mountain biking or casual cycling. Courtesy of Bike Force Joondalup. 8/162 Winton Rd, Joondalup. To enter, email your name, contact details and the competition you are entering to editor@mforum.com.au. One entry per reader. For other terms and conditions go to www.medicalhub.com.au.

Book Launch

The lure of the Kimberley Donna Mak explores how the Kimberley has become her spiritual home in the new book, Kimberley Stories. Anyone who has let the Kimberley get under their skin and into their heart, has a story to tell, so anthropologist Sandy Toussaint decided to compile them into a book simply called Kimberley Stories.

try to impose on them, and consequently they don’t follow them.” “I’ve had medical students who have gone up north who have said, ‘I actually learnt that for this person, the most important thing for him was the welfare of his cattle’. If you can understand that, then you can understand why he may or may not make decisions about his health.”

Among this wonderful anthology is a chapter written by Dr Donna Mak, of the Health department’s Communicable Disease Control Directorate Health. She writes movingly of her encounters in Fitzroy Crossing and Derby, first as a young medical student on a one-month placement and later as a community medical officer at Fitzroy Crossing from 1989 to 1993, and a regional public health physician based in Derby from 1995 to 2002. “I don’t do this sort of stuff normally. I’m not a writer … I did it because Sandy is my friend and she was persistent. And they are stories that need to be told,” Donna said. The common thread running through all the stories is a spiritual connection to the pindan and people of the Kimberley. Donna believes it is her spiritual home and if there is one thing she would like to share with young medical students is the magic they can find there. “If doctors can live there rather than just see it as a place to work, then it’s just wonderful. The trouble is a lot of doctors don’t and they miss out on all those wonderful fun things I did. They don’t allow themselves to fall in love with the place and the people and that’s really sad.” She says her immersion with the culture, language and spiritual dimension of the Kimberley enabled her to treat her patients

Donna’s story, Hong Kong to Fitzroy Crossing: The Road Less Travelled to a Familiar Place, touches on her Chinese heritage and the good luck that saw her move to Perth as a young girl and how the deep friendships she forged in the Kimberley have anchored her to this land.

n Dr Donna Mak

more effectively. “This is not just true for Aboriginal people but for everyone. If you are going to treat them properly you have to understand that about them. It’s just a lot more obvious when you’re working with people from a culture that is so different. “You notice it the same when you work with pastoral people or farming people. They have a different skill set to your own, different priorities and unless you understand them, you can’t make sense of the decisions that they choose to make and they can’t make sense of the decisions you

“I went back to my ancestral village in China with my father and with my children and my husband last year and I feel comfortable enough not to have to keep going back. I’m extremely grateful that through chance my family left China to go to Hong Kong during the Japanese occupation. I know other Chinese people who were in the same situation – they were equally smart, equally resourceful – and they crossed the border into countries such as Burma, Laos, Vietnam, It’s only through chance that my family’s journey was different.” Kimberley Stories, which has been published by Fremantle Press also features stories by Jimmy Chi, Stephen Scourfield and Steve Hawke among others. It will be launched in Broome on July 18 at the Broome Library.l

By Ms Jan Hallam

Finding Ways to Cross the Cultural Divide Staying healthy, for Aboriginal men, is as much a spiritual matter as an issue about the body and science. Aboriginal men in Broome have told n Prof David Mellor researchers from Deakin University that living between two cultures was, among other factors, contributing to their poor health status. Prof David Mellor, a member of the research team, said the study, which is asking Aboriginal men in Broome, Mildura and Melbourne what they think about their health, body image and health behaviours, was revealing that while healthy lifestyle messages were getting through, this wasn’t leading to action.

In Broome the researchers have been working with an advisory group from the Men’s Outreach Service, the Broome Men's Group, and the Broome Regional Aboriginal Medical Service. They conducted focus groups and then individual interviews with

40 Aboriginal men (about a third who were employed, a third who were unemployed and a third who were transient/homeless) aged between 18 and 35. “The men interviewed were aware that health was important and that they generally had poor health status. They also talked a lot about the issue of dealing with two cultures and trying to balance the messages they received from each culture about what was healthy.” Land, family and spirituality also emerged as vital facilitators of healthy behaviour. “These men didn’t see health as being simply about the body. A good lifestyle was facilitated by ‘lian’ (the spiritual part of existence) and they talked a lot about peers and role models and being role models.” The men were also frank about the nega-

tives of alcohol and drugs but looked to sport as an important incentive to improve their health. However, their views on employment were more ambivalent, with some acknowledging that while paid work gave them the resources to live a healthier life, it also interfered with precious family time. “The importance of traditional lifestyle can’t be understated. We see that really strongly in Mildura where people see themselves as being much more cut off from traditional activity – fenced off from the river where they used to fish and barred from properties to hunt. There are fewer of those kinds of barriers in Broome because people are much more connected and have greater access to their own traditional lands.”

medicalforum

On the Grapevine

Angels of Churchview

theWines

By Louis Papaelias

2007 The Bartondale Reserve Cabernet Sauvignon

The little Anglican church of St John the Baptist at the corner of Metricup Road and the Bussell Highway was for many years the signpost to the great vineyards of Wilyabrup. Nowadays this little corner marks the spot for a serious 100ha vineyard estate aptly named Churchview. The property was previously known as Bartondale Farm and it is the Bartondale name that today appears on the label of Churchview’s flagship wines. Spike Fokkema, whose family migrated from the Netherlands in the 1950s, established the property in 1999. It is situated on well-drained gravelly soils with a north-facing aspect. Careful attention is given to the viticulture and the winemaking, a fact that is supported by the numerous accolades it has received. Not surprisingly for the region, it is Cabernet Sauvignon and Chardonnay that shine best at Churchview. There is also a Marsanne wine in the portfolio, a variety I believe deserves more attention here in WA. It makes a food-friendly dry white that will age well. Having tasted a lineup of Churchview wines for this magazine a few years ago, I was keen to see how the wines had evolved, especially with a bit more vine age.

From a very good vintage this justifiably sits at the top of the pecking order. It’s a classic, refined Margaret River Cabernet – full, rich and complex with berries and fine tannins. This wine will be even better in 2-5 years, though will go on for much longer.

2010 The Bartondale Reserve Chardonnay A refined and well-crafted wine. Good tight structure but with generous fruit, this wine has an appealing bouquet of peach and fine oak nuances. It will obviously age for a few years but it is just beautiful now. Awarded a gold medal at the Small Winemakers’ Show. 2009 St Johns Cabernet Blend Made from 45% Cabernet, 27% Merlot, 19% Malbec, 9% Petit Verdot, its bouquet is slightly closed at present though it has good structure and balance. It’s flavour-packed but reticent in its youthful state but a couple of years’ bottle age will see the wine open up to reveal its true potential. 2011 Sauvignon Blanc Semillon With a majority of Sauvignon Blanc (75%) this wine shows spice and asparagus. Clean, crisp and fresh as a daisy. A good example of this famous Margaret River blend. Great summer drinking.

2009 St Johns Vintage Brut Faint aromas of Granny Smith add lift to this well-made bubbly. There is the restrained presence of autolysis – a feature of all good champagne and sparkling wine. With plenty of life and a clean finish, this is a good aperitif with the structure to accompany seafood and white meats.

WIN a Doctor’s Dozen! Which Churchview wine won a gold medal in the Small Winemakers’ Show? Answer:

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

Enter here!... or you can enter online at www.MedicalHub.com.au!

Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, July 30, 2012. To enter the draw to win this month’s Doctors Dozen, return this completed coupon to ‘Medical Forum’s Doctors Dozen’, 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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Name:

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Please send more information Churchview wine offers for on Medical Forum readers.

49 49

Satire

Toyes For Ye Olde Boyes Resident satirist Prof Wendy Wardell hurtles back to the future to a strange new world that is eerily familiar. There was a knock on the door of the hovel that rattled it in its rotten frame, reverberating through the cracked walls of mud and straw. Chickens flapped in avian panic around the tiny room. The door was opened by a dishevelled man trying to pick from his hair the remains of what panicking chickens leave behind.

on that operating system. You can upgrade to the bigger box just as soon as your gran's finished sleeping in it.”

The visitor at the door smiled and spoke. “The town crier said that you were selling some vehicles. I wondered if I could take a look?” The other man brightened and responded “G'day – yeah – the missus wants me to sell some of my toys to make some space for her sister, brother-in-law and thirteen kids to move in. They used to sell matches on street corners, but the Carbon Tax put them out of business. Come through to the garage, or as the wife calls it, the kitchen.”

“I can see you're quite a collector. Tell me about this one with the full leather trim,” said the visitor, patting a cow standing quietly chewing the cud.

A child was listlessly poking a stick at a hedgehog curled up defensively in a small cardboard box. “William,” said his father, “I told you that your Sonic game won’t work

“Kids,” he said to the visitor, casting his eyes heavenwards, “Unless they have the latest gaming equipment, all the other little buggers cleaning chimneys pay out on them. Anyway, here we are,” he said as they walked into a particularly pungent corner of the room.

The owner smiled proudly. “Had it since new, always reliable, four stomachs, fuel injected. Goes like shit off a shovel, quite literally,” he said, picking up a bucket. “Low CO2 emissions, but the methane can make your eyes water a bit first thing in the morning. I was going to get a Governmentsubsidised cork fitted as part of the Insulation Program, but I heard there were some shonky operators around. Apparently a few bovines went up like rockets when they got near a naked flame.”

“'It’s not bad for a Fresian,”' the visitor responded, a tad dismissively, “but I'm a Holstein man through and through. What else have you got?” “How about this one? Latest model – straight off the production line and it has all the most efficient environmentally-friendly features,” said the owner, pointing to a young mule. ''Oh – a hybrid vehicle,'' said the other man, appreciatively. “What's the performance like?” “Plenty of kick,”' the owner responded, rubbing a large purple bruise on his leg. “I've got a ride-on-mower too, if you're in the market.” “Victor?” queried the potential buyer. “We generally just call him the bloody goat,” the owner murmoured darkly, starting to suspect that this man was just a hoof-kicker. “So what exactly were you looking for?” “I was hoping to find something for my mother-in-law, low mileage and easy to maintain. I don’t suppose you’ve got a broom for sale?” l

These imports will be the end of our business

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n n Local hero

n n Short cuts

n n Believe it, or not

A world weary local GP sent this one in, told to him by a patient having an SCC removed from his ear. The patient swears it is true, from when he worked as a surveyor for a gold mining company in the middle of nowhere, between Southern Cross and Leonora. There is a middle aged hairy eastern European named 'Stavros' (to protect his minimal dignity) living feral in a rough bush camp out there, who decides to bring some joy to his life by investing in a blow up sex doll. Stavros picks it up from his PO Box and takes it back to camp where for the next few weeks enjoys his evenings getting his money's worth out of his ersatz companion. After 3 weeks he develops marked pain and a purulent discharge from his male member and heads to Kalgoorlie to see a GP.

I told the ambulance men the wrong blood type for my ex, so he knows what rejection feels like. I like Jesus, but he loves me, so it's awkward. I'm glad they invented emoticons, otherwise I wouldn't know what my dad was thinking. On having sex with men in their 40s: Generally much better, but you've got to rub their legs afterwards for cramp. Looking at my face is like reading in the car. It's all right for 10 minutes, then you start to feel sick. Whenever I see a man with a beard, moustache and glasses, I think, 'There's a man who has taken every precaution to avoid people doodling on photographs of him. The definition of bipolar? A sexually curious bear. My friend said she was giving up drinking from Monday to Friday. I'm just worried she's going to dehydrate. I like David Beckham. Most of us have skeletons in our closet. But he takes his out in public. Surgery is just stabbing in a courteous environment.

Judge to the jury: 'What possible reason could you have for acquitting this man?

"Doctor, I think I caught clap' The GP is naturally overjoyed and examines the affected organ. " Yep , you've got the clap Stavros, but here's the thing. I can cure it easily enough but more importantly we need to find out which working girl you caught it from. Having an unclean girl working in a brothel here is a big deal for authorities and the establishment. Now which girl did you catch it from Stavros?" "I not go to brothel' says Stavros. The GP sits back. " Stavros, you caught it from someone, now don't tell me bullshit , who have you had sex with?" Stavros looks embarrassed and looks at the floor and says " I caught from my blow up doll.' The doctor throws his head back laughing . "Stavros it is not possible to catch gonorrhoea from a blow up doll...not possible! Do you understand? "Not possible , are you sure Doctor?' "Absolutely sure" says the Doc. Stavros shuffles his feet and asks painfully..." What if I lend to someone."

n n Top Funnies from the

2011 Edinburgh Fringe 1. Nick Helm – I needed a password eight characters long so I picked Snow White and the Seven Dwarves. 2. Tim Key – Drive Thru McDonalds was more expensive than I thought ... once you've hired the car. 3. Matt Kirshen – I was playing chess with my friend and he said, 'Let's make this interesting'. So we stopped playing chess. 5. Sarah Millican – My mother told me, you don’t have to put anything in your mouth you don’t want to. Then she made me eat broccoli, which felt like double standards. 5. Andrew Lawrence – I admire these phone hackers. I think they have a lot of patience. I can’t even be bothered to check my OWN voicemails.

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n n Not another

blonde joke

A young ventriloquist is touring Sweden and, one night, he's doing a show in a small fishing town. With his dummy on his knee, he starts going through his usual dumb blonde jokes. Suddenly, a blonde woman in the fourth row stands on her chair and starts shouting, "I've heard enough of your stupid blonde jokes. What makes you think you can stereotype Swedish blond women that way? 'What does the colour of a woman’s hair have to do with her worth as a human being? It's men like you who keep women like me from being respected at work and in the community, and from reaching our full potential as people. 'It's people like you that make others think that all Blondes are dumb! 'You and your kind continue to perpetuate discrimination against not only blondes, but women in general...pathetically all in the name of humour!" The embarrassed ventriloquist begins to apologise, and the blonde yells; 'You stay out of this! I'm talking to that little sh*t on your lap!' Courtesy New Norfolk Men’s Shed, Tasmania

'Insanity,' says the foreman. 'What, all of you?'

On the Grapevine

funny side

As the golfer trudged towards the 19th hole he muttered: 'That was my worst game ever.' To which the caddy replied, You mean you’ve played before?' A fish goes into a bar, the barman asks 'What do you want?' The fish croaks, 'water”

n n The worst pick-up lines (so far) The Classics: You must be tired, because you’ve been running around in my mind all day. Hey I’m lost, can you give me directions to your house? Stand out from the crowd. Say Yes. If being sexy was a crime, you’d have life in prison. When God made you, he was showing off. The Different: Hi, my name is Doug. That’s “god” spelled backwards with a little bit of you wrapped up in it. (hold out hand) Would you hold this for me while I go for a walk? You’ll probably be asked to leave soon. You’re making the other women look really bad.

Best Face Forward A reminder to all photographers that entries into Medical Forum’s next photo comp closes on July 10. The theme is The Human Face. And while you set your camera to stun, check out the website for the inaugural Fremantle Portrait Prize (www.fremantleportraitprize.org. au) where entries close on August 1. Dr John Quinter, a keen member of the Fremantle Camera Club, is on the organising committee. He has also been blogging on the site with professional photographer Abigail Harman. Look up Image Empathy for some nice words and insight into the pain suffered by Ben Hogan who has chronic arthritis.

Kitchen Confidential

10 minutes with... Xavier

Pique

On July 14 everyone turns a little French for Bastille Day. For Xavier Pique, his little corner of France is his bistro, P‘tite Ardoise Bistro, in the city. Tell us about your childhood growing up in Normandy? Was there a strong food tradition in your home? XP: I was born in Lisieux, Basse-Normandie, where there is a mix of livestock farming, and apple cultivation from which cider and calvados are made. I visited my godmother often at her farm, helping around the place. At the age of 12, I moved to Rouen, 120km from Paris. In the summer holidays, I visited my grandmother in Nyons, in the south-east of France, which is famous for olives. I cooked with my grandmother and discovered a different style of cooking compared to the North. Food is important for my whole family.

What is your first food memory? What are the sights and smells you miss most about your hometown? XP: I remember every Tuesday I would have a blood pudding with mash potato and apple. And after school I would eat a baguette with chocolate bars made especially to put inside. I miss the smell of the bakery in the mornings.

Did you always want to be a chef? Who were your heroes as a young boy? XP: Originally, I wanted to be an orthodontist but I was told not to. I always had a passion for cooking. I was brought up to value cooking so my second choice of career was to be a Chef. I was inspired by Joel Robuchon and Paul Bocuse, two famous chefs who were on television when I was young.

Who was your first cooking inspiration? What did that person give you that you still hold close today? XP: My mother was my very first inspiration – she cooked quality meals every time. My father would be unhappy if there wasn’t a dessert prepared. Her meals were always enticing and interesting. She was passionate about her cooking and made it grow on me. After becoming a chef, I learnt that without passion, you won’t survive as a chef.

Where did you learn to cook and where has your food journey taken you? XP: I began my apprenticeship in a family-based restaurant and once I was qualified, I move to a fine dining restaurant called Chez Gill, where I worked with a young Michelin star Chef Giles Tournadre. After receiving the second Michelin star I moved to England to work for the famous Albert Roux and Pierre Koffman. Then, with my wife, Valerie, I moved to Canada and worked at the Hilton International Hotel. After seven years in Canada and having two children we decided to go to Sydney, where I worked at Four Seasons Regent Hotel. Then in 2000 I worked at the Olympic Stadium. We decided to leave the hectic Sydney lifestyle to come to Perth.

How long have you lived in Perth? What were your first impressions of the food scene here? And how has it changed? XP: I have lived in Perth for 10 years now. When we arrived, I thought there were very few fine-dining establishments, and a lot of Italian and Asian cuisine-based restaurants. French cuisine wasn’t really present and not many establishments that I could consider heading in the French direction at all. Recently, with top chefs entering the Perth scene, I believe the quality and standards have risen. French cuisine is becoming a trend here in Perth, with the growing number of establishments opening.

You were the executive chef at the former Sheraton Perth Hotel for a number of years, what spurred you to open your own bistro, P’tite Ardoise? Is it a family affair? XP: It had always been my dream to open my own restaurant. I wanted my own establishment to cook real food that I enjoy and that I thought other people would enjoy too. P’tite Ardoise Bistro is a truly family business. My wife,Valerie,works on the floor and my teenage sons help out when they can.

There’s a real buzz in the restaurant and tables often end up chatting to each other about the food – how do you create such an atmosphere? XP: We keep with the traditional French bistro style restaurant. The tables are close together, which encourages people to converse with their neighbouring diners. The restaurant atmosphere is warm and cosy, the service is friendly and attentive without being imposing and this all creates a homely environment. I didn’t want the restaurant to be pretentious at all.

How would you describe your menu? XP: Our menu presents French traditional elements with a small modern cuisine influence. I focus on lighter and healthier food by reducing the use of flour and making the majority of our dishes gluten-free. We use the best WA and Australian produce. Also we import obviously a lot of French products.

What is the one dish that reminds you most of home? XP: Hands down, it’s the Canard a l’Orange.

How will you celebrate Bastille Day on July 14? Are there special foods that are symbolic of the day? XP: I remember simply celebrating the day with champagne but with no particular food or dishes.

When you close your eyes what do you smell? XP: The smell of the wood in the cheminée. (chimney)

What would be your last meal? XP: A good old traditional French flan or a nice tarte au citron.

By Ms Jan Hallam ** P’tite Ardoise, 283 Beaufort St, Highgate. Open Tuesday-Saturday. Phone 9228 2008 52

Theatre

Caught in the Trap Diamond 60 jubilee is the magic number for both the Queen and Agatha Christie’s perennial whodunit The Mousetrap. That’s how long their respective reigns have spanned and neither show signs of slowing down. The play has been running continuously since it opened in 1952 with more than 24,500 performances so far. It is the longest running show (of any type) of the modern era and next month The Mousetrap hits the road for a special anniversary tour of Australia with a local cast – the first time it has been performed here. Medical Forum caught up with the Australian director Gary Young who has the nerve-wracking task of bringing this iconic theatre production to stage of His Majesty’s Theatre. “No pressure, is there! I haven’t seen the play, so when read it for the first time, I could see why it had endured. It is a disarming play that takes you by surprise. It’s really a superb attempt at exploring the psychology of murder and revenge.”

“I’m intensely aware of the Agatha Christie fans out there so I am going fairly traditional with its design and direction. What was paramount was the characters’ sense of isolation in that typical Christie kind of way and you couldn’t pull that off in a contemporary setting with mobile phones and computers.” “I also wanted this visit to the theatre to be a nod to tradition – not in a old-school kind of way but to revisit the 1950s charm of the work and for them to see clearly how Christie creates extraordinary events in ordinary situations and all the emotion that goes with it.” For a play to have lasted 60 years on the West End, there must be some magic, the initial cast for one thing, with theatre royalty Richard Attenborough and Sheila Sim (pictured above) taking it to early heights. The Australian cast will include Linda Cropper and Robert Alexander and WAAPA graduate Travis Cotton. The Perth season runs from August 14-26 at His Majesty’s Theatre. For your chance to win tickets to the show, go to www.medicalhub.com.au. l

By Ms Jan Hallam

Calling all wild ones When the open road calls, Dr Stuart Burton is ready to open the throttle of his Suzuki Bandit 1250. Now this mild-mannered medico is keen to share the thrill with like-minded biker doctors who would like a group ride on a regular basis. Stuart has ridden motorcycles off and on for 20 years, but the bug has really taken hold over the past 5 years since he’s learnt to tame the big two-wheel beasts. “I try to plan rides for Sundays and public holidays. I have been riding with a group of priests, which has been a lot of fun, but I thought it would be great to start a Docs Riding Club.” Stuart is planning a group ride on Sunday, September 2, and would be pleased to hear from doctors who would like to join him.

n Dr Stuart Burton with his beloved Suzuki Bandit 1250.

medicalforum

His phone number is 0417 832 590. l 53

Competitions

Entering Medical Forum’s

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

Theatre: Nutcracker on Ice Experience the drama of Tchaikovsky’s famous ballet with the dazzling prowess of the The Imperial Ice Stars in a memorable night of art, flair and breathtaking skill. Four-time figure-skating World Champion and dual Olympic gold medallist Evgeny Platov and dual World Champion Maxim Staviski lead a cast of world-class skaters in this production full of high-speed leaps and throws, and awe-inspiring acrobatics, coupled with the most graceful and sublime ice dancing. Tickets through BOCS. His Majesty’s Theatre, August 2-12

Kids’ Theatre: This Girl Laughs, This Girl Cries, This Girl Does Nothing Barking Gecko Theatre Company presents exciting modernday fairytale for audiences of all ages (6+) during the July school holidays. Three sisters are abandoned in a forest by their father. Facing an uncertain future, one decides to walk one way around the world, one decides to walk the other way and one decides to stay right where she is. It’s an epic tale about the search for happiness, self and a place to call home. Tickets through BOCS. Subiaco Arts Centre, July 10-21

Comedy: Judith Lucy – Nothing Fancy Judith Lucy is back! One of the country's most popular comedians is returning home for a new stage show, Nothing Fancy. As its name suggests, it's a no-frills, top-notch, unadorned night of stand-up. Forget the singing and dancing, just enjoy the gags about everything from internet dating and Lucy’s cockroach phobia to meditation (hear about her spiritual journey that morphed into a TV series) and terrariums. Tickets through BOCS. Octagon Theatre. July 26-29

Food Event: Mundaring Truffle Festival It’s truffle season and The Mundaring Truffle Festival celebrates the black fungus with spectacular long table lunches and cooking demonstrations. There’s a spectacular lineup of chefs, including Neil Perry, Guillaume Brahimi, Alain Fabregues, Iain Lawless, Marianne Kempf, Herb Faust, Emmanuel Mollois and Xavier Pique. MF has double entry tickets to be won for both days of the festival. Tickets through BOCS. Mundaring Truffle Festival July 28-29, 10am-5pm

COMPETITION WINNERS From May issue Tina Arena/WASO – concert: Dr Eric Khong A Royal Affair – movie: Dr Trixie Dutton, Dr Julia Charkey-Papp, Ms Sue Gilbey, Ms Glenda Butters, Dr Kylie Seow, Dr Hui Jern Loh, Dr Bibiana Tie, DrSwAmy Gates, itch to Be on automatic st Practice and swit ch SMS remind ers/replies Dr Helen Slattery, Dr Danelle England & Dr Helena Donnelly Your appoin tment remind the wash but er today’s patie cards may disappear in their jeans nts can’t forge pockets going t appointmen constant com ts when you through For just a few panion, their cents and virtu mobile phone remind them via the reply) in Bes ir ! t Practice can ally no effort, new automa tic SMS remind do much to e There’s no fas liminate the c ers (and confi ter, more strea rmation ost and disru ption o mlined system Benefits of SMS than BP SMS! f No Shows. in Best

Major Spons or

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• Integrates Practice Manag seamless ement Appointment moduly into the Best Practice Features Management le. • Interchan • Patients c geable Pr an be rem messages with a sinactice SMS templates allow t appointment on th inded within minut gle click. ailored eir Mobile phone. es of making a new • Complies with National Priva • Seamless two-way out system. cy standards of an confirm an appoint SMS communications, allows opt in or • Exclude S ment via SMS with Patients MS Appo a simple YES reply. to • SMS mes made within a cert intments reminders for Appo saging sim ain number of days intments time and money w plifies Patient comm • Practice a . llocated mobile num hile greatly reducin unication, it saves appointments. • Delivery r ber (additional cost g the risk of No Sh eports - C ow SMS (2 delivery repoonfirmation the Patient rece s apply) ived the rts = 1 SM • Only qual ity Tier 1 Australian S Credit). SMS Providers used .

Africa Umoja – dance: Dr Helen Clarke & Dr Lynette Spooner Cost Prepaid

• 1000 SMS credit s = $200 +GST • 2500 SMS credit (20c Per SMS) s = $400 +GST • 5000 SMS credit (16c Per SMS) s = $700 +GST • 10000 SMS cred (14c Per SMS) its = $1200 +GST • 25000 SMS cred (12c Per SMS) its = Practice allocated m $3000 +GST obile number = $50 (12c Per SMS) +GST Setup Fee / $300 +GST per year (subscrip

tion based)

The Celtic Divas – music: Dr Anthony Osbrough & Dr Carol Deller For more informat ion contact

3543_bp_SM

S_AD_MEDIC

AL_FORUM_

A4.indd 1

us: T: (07) 4155

8800, SMS:

0427 767 833

Doc of The Swan

M AY 2 0 1 2

After a smash hit on stage, The Sapphires hits the big screen with Deborah Mailman and Jessica Mauboy in the lead roles. This is an inspirational tale of a quartet of young, talented singers from a remote Aboriginal mission, which is catapulted to stardom in the 1960s. The Sapphires were billed as Australia’s answer to The Supremes. The film is inspired by the true story of writer Tony Briggs' mother and three aunts. The film received a 10-minute standing ovation at the recent Cannes Film Festival. Opens in cinemas, August 20

John Love has entered the Doctor’s Dozen competition on previous occasions but this is the first time he’s hit the jackpot. And, generous to a fault, the midwives at SJOG Subiaco will be sharing the Bellarmine spoils. “We tend to get most of the thanks, so I’m going to split the case with the midwives because they do a wonderful job,” he said. John prefers whites – a Sauvignon Blanc, in particular – and his wife is partial to a robust red. They have a few acres in Pemberton where the persimmons are thriving and truffles will soon emerge from the rich soil underneath the numerous oak trees planted by John and his family. A small slice of France in the South West – Sante!

MEDICAL F ORUM

Film: The Sapphires

Sharing the Bellarmine Love

or E: SMS@bp software.com.au

Charity Fun Sail 2012 • Drs Across Many Cult ures • Opiate Use Reflections • It’s All Abo ut the Horse • Going Cra zy for You

Prometheus – movie: Dr Colin Lau, Dr Max Traub, Dr Kar Chan Wan, Dr Bastiaan de Boer, Dr Germaine Wilkinson, Dr Tom Shannon, Dr Tuck Meng Chin, Dr Jason Chin, Dr Luciano Marino & Dr Jayasheerie Nadarajah 11/01/12 4:48 PM

May 2012

www.mforum.c om.au

2012 Young Artists – opera: Dr Ken Collins

medicalforum

Switch to Best Practice and switch on automatic SMS reminders/replies

Your appointment reminder cards may disappear in their jeans pockets going through the wash but today’s patients can’t forget appointments when you remind them via their constant companion, their mobile phone! For just a few cents and virtually no effort, new automatic SMS reminders (and confirmation reply) in Best Practice can do much to eliminate the cost and disruption of No Shows. There’s no faster, more streamlined system than BP SMS! Benefits of SMS in Best Practice Management

Features

• Integrates seamlessly into the Best Practice Management Appointment module.

• Interchangeable Practice SMS templates allow tailored messages with a single click. • Complies with National Privacy standards of an opt in or out system. • Exclude SMS Appointments reminders for Appointments made within a certain number of days. • Practice allocated mobile number (additional costs apply) • Delivery reports - Confirmation the Patient received the SMS (2 delivery reports = 1 SMS Credit). • Only quality Tier 1 Australian SMS Providers used.

• Patients can be reminded within minutes of making a new appointment on their Mobile phone. • Seamless two-way SMS communications, allows Patients to confirm an appointment via SMS with a simple YES reply. • SMS messaging simplifies Patient communication, it saves time and money while greatly reducing the risk of No Show appointments.

Cost Prepaid • 1000 SMS credits

$200+GST

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• 2500 SMS credits

• 5000 SMS credits

$400

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$700

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• 10000 SMS credits

$1200+GST

• 25000 SMS credits

$3000+GST

Practice allocated mobile number = $50

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For more information contact us: T: (07) 4155 8800, SMS: 0427 767 833 or E: SMS@bpsoftware.com.au