Medical Forum WA 10/14 Public Edition by Medical Forum WA

Gold Medal Medicine t Head, Shoulders, Knees & Ankles t Midland â&#x20AC;&#x201C; Going Public t GPs & Health Funds t Primary Care Research t E-Poll: Insurers in the Spotlight

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Contents

October 2014 23

FEATURES

LIFESTYLE

16 18 23 42

Trailblazer: Dr Moyez Jiwa, GP researcher GPs and Private Health Insurers Dr Michael Stanford on Midland Public Hospital Saving Gold Medal Knees Bali Off the Beaten Track

44 45 46

NEWS & VIEWS 3 4

12 27 28 30 34

Editorial: Out of Pocket Costs Letters: Fair Go for Caesars – Dr Donald Clark PHI: an Anaethetist’s View – Dr Hugh Welch Confusion Spooks Consumers – Dr Martin Whitely, PhD How Can Consumers Tell? – Ms Jenni Ibrahim Divide and Conquer – Dr Colin Hughes Where is Our Humanity? – Dr Elisabeth Wynne No Vaping; No Smoking – Mr Maurice Swanson Spirometry Training Essential – Dr Sally Young Central Referral Service Update Have You Heard? Technology Helping Kids Communicate Beneath the Drapes Spirometry Tips Kids’ Sporting Injuries

MAJOR SPONSORS medicalforum

46 47 48 48

Satire: May Contain Nuts Ms Wendy Wardell Felicity Kendal Makes Hay McLaren Vale Associates Wine Review Dr Martin Buck Social Pulse: SJG Subiaco Hospital Tribute Dinner and Ball Funny Side Competitions Funny Man Damon Lockwood Ancient Anecdote

E-POLL 3 17

e-Poll: Out of Pocket-Costs e-Poll: Insurers Woo GPs

Our Cover: WA’s Olympic Gold Medallist Hockeyroo Kellie White. Picture: Grant Treeby – Treeby Images

iss Don’t M rum ’s D Doctor r 29 Octobe

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

INDEPENDENT ADVISORY PANEL for Medical Forum Michele Kosky AM Consumer Advocate Mike Ledger Orthopaedic Surgeon Stephan Millett Ethicist Kenji So Gastroenterologist Alistair Vickery General Practitioner: Academic Olga Ward General Practitioner: Procedural

ISSN: 1837–2783

John Alvarez Cardiothoracic Surgeon Peter Bray Vascular Surgeon Joe Cardaci Nuclear & General Medicine Chris Etherton-Beer Geriatrician & Clinical Pharmacologist Philip Green General Practitioner: Rural Mark Hands Cardiologist

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Clinical Contributors

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

We ask Clinical Contributors to provide a phone number should a doctor wish to clarify a management issue.

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

DR SMATHI CHONG MALDI-TOF: Microbial Identification

ROGER 31 DR GOUCKE Barriers to non-drug therapy in chronic pain

GARY 32 DR COUANIS Managing Basketball Injuries

CARMEL 33 DR GOODMAN MRI in Knee and Back Pain

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au 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.

PAUL 35 DR JARRETT Dupuytren’s Contracture Update

DR JEE KONG 36 Oesophageal

REZA SALLEH 38 Severe Ankle Sprain

Manometry

DR CHRIS CHIN 39 Self-management of Back Pain

Guest Columnists DR JACINTA VU 40 Temporomandibular Disorders DR MICHIEL MEL 10 Time to Row Together

MR ROGER COOK 20 Women’s Services Not ‘Add-Ons’

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN Thinking Hats

DR KIM HAMES DR KEVIN NETTO PETER 21 Midland: 28 Exercise 30 DR WALLACE Lose Some, vs Injury Win More?

Buzz Out of Bees

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Editorial

By Ms Jan Hallam Managing Editor

One Gap too Far? Sept

Out-of-Pocket Costs Some stories uncork an army of genies, and our story last month about specialist fees, private hospitals and a consumer attempting to navigate through a headspinning array of item numbers, gaps, known gaps and possibly even tiny cracks hit nerves. Our e-Poll this month asked readers for some of their own experiences and not surprisingly, there was a flood of those as well, and high on the list were messages and phone calls resenting any perception that they were “only in it for the money”. One specialist was audibly upset that his 14-hour days should be reduced to such a simplistic notion. He was aggrieved that some health funds were making it almost impossible for him to stay afloat. One e-Poll respondent summed up the complexities: “It would be very helpful if Medical Forum ran an article on what the differing amounts different health funds pay specialists … if a surgeon wants to charge the patient a gap to account for the extra hours in theatre to do a complicated case of say $500, HBF pays nothing extra apart from the Medicare rebate to 100% of the schedule fee. They pocket the rest of the money they would pay the surgeon if the surgeon registers as a no gap provider. While Medibank Private and Bupa allow a $500 gap and the rest of the account will be paid as a no gap provider as the normal full amount.” We asked HBF to comment on this complaint with Executive General Manager of Health and Wellness, Ms Jennifer Solitario, replying that HBF’s no gap or known gap products gave members a higher level of certainty of their out-of-pocket costs and the fund achieved

The cost of private health care was under the spotlight in this month’s poll of doctors. Of the 146 respondents, 60% were GPs, 34% specialists, 2% DITs and 4% others.

Health consumers with private health insurance may face out-of-pocket expense following an episode of care in a private hospital. In your experience, where does most out-ofpocket expense come from? The hospital

14%

The specialist

24%

The laboratory

14%

The imaging provider

20%

Ancillary health (pharmacy, OT, physio, etc)

17%

Uncertain

10%

None of the above

better results than other insurers, for which WA specialists saw value. However, Ms Solitario said health funds weren’t qualified to judge the complexity of individual procedures and took their lead from Medicare. Where additional complexity resulted in a different item number it would guide the benefit funds pay. This discrepancy in the market place doesn’t make for happy camping and clearly causes deep emotions within the profession. For the consumer, who is unwell and facing surgery, it can be a totally bewildering experience. O

ll e-Po

Faced with elective ctivve surgery in a private rivate hospital, if a health consumer asks for your recommendation of hospital or specialist, is out-of-pocket cost to them usually a consideration? Yes

64%

23%

Undecided

Doesn’t apply

Comments It was a case of how long is a piece of string on the complex questions of private health insurance. As one GP put it: “No matter what your insurance policy, it is difficult to anticipate what and how much will be covered until the episode of care occurs.” It’s not straightforward for specialists either: “As a surgeon I am meant to provide informed financial consent which is now impossible because, although I, my anaesthetist and the hospital are “no gap”, the path lab, radiology, OT/Physio are not, so it is impossible to provide an estimate of fees.” “Radiology and pathology should be covered totally by a combined Medicare/private health rebate agreed fee.” One thought it could be simplified if private hospitals took on the responsibility of informing patients about out-of-pocket expenses and summarised by another: NO RULE FITS ALL O

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Letters to the Editor

Fair go for Caesars

Insurance: an anaethetist’s view

Dear Editor, The last two editions of your magazine carried articles attacking Obstetricians in general and high Caesar rates in particular. In a patriarchal sexualised society the control of young women’s bodies is never far from the surface – perhaps that is why the legitimate argument about Caesareans has become so nasty. The old-school model was midwife-only care, hardly any epidurals, long labours, lots of agricultural forceps deliveries and a Caesar rate of about 10-15%. This model produced outcomes which were good in Health Department terms – low cost and low mortality, but the model has been overwhelmingly rejected by the obstetric marketplace. Given a choice, most women want epidurals and a timely Caesar, preferably by their own doctor. And why not – most of the arguments against Caesar are contrived if not actually dishonest. With modern anaesthesia, a Caesar, especially an elective Caesar, is just as safe as an attempted vaginal delivery. A generation ago, progressive forces in our society fought for contraception rights and abortion rights. Now we seem to be fighting for ‘Caesar rights’! Dr Donald Clark, Mt Lawley

Dear Editor, I agree with the sentiment that private health cover is getting a lot more confusing – as medicos we are consumers as well as providers. I would like to clarify/comment on your article [Private Insures are Crunching the Numbers and Private Hospital Cover – A Consumer View, September] as it relates to anaesthetists. HBF (+ Medicare rebate) for any anaesthetic only covers about 50% of AMA rates. The proportion of AMA fees covered for most surgical item numbers by HBF (and other funds) is significantly greater. A lot of surgeons/proceduralists charge AMA rates (or higher) as a routine. Very few anaesthetists routinely charge even close to AMA rates – and many charge fund-direct fees (no gap) for many procedures, which is half AMA rates, or less, for many funds. To say in your article that anaesthetists are getting “100-300% top-up from private health funds” is a gross oversimplification. Anaesthetists are routinely charging a lot less than our training , expertise and responsibility should dictate, and we are poorly remunerated by Medicare and Health Funds compared to surgeons. Our patients are getting increasingly complex: older, more medical co-morbidities, more complex surgery and a lot more obese, with more complex and invasive monitoring/ventilation requirements and increasingly higher (often unrealistic) expectations from patients of a perfect outcome.

The problem for consumers with private insurance is complicated by anaesthetists being secondary providers. The surgeon is the primary care-giver and sees the patient in their rooms some time prior to planned surgery, where there is ample time to obtain financial consent. Most patients are reluctant to take time to see their anaesthetist in good time prior to their procedure, especially if the surgery is deemed to be routine (even if they have complex co-morbidities), so a lot of anaesthetic consultation takes place close to the planned surgery with little time to discuss the costs to the patient. Focusing on gaps in fees for some anaesthetics, without looking at the overall fee in comparison to the fee for the hospital stay or the surgeon, does not look at the root cause of the problem and grossly undervalues the level of training, experience and expertise required to provide an increasingly complicated specialist service. Dr Hugh Welch, Specialist Anaesthetist

Confusion spooks consumers Dear Editor, Your article [Private Hospital Cover - A Consumer View – September edition] demonstrates how complex, frustrating and potentially expensive it can be for consumers to navigate the health insurance gap payment

Continued on P6

Curious Conversations

Flying High A life well-lived is top of the checklist for MidWest Aero Medical Service’s Dr Stuart Adamson. I like the look of the world from 10,000’ because... every time I’m up there the view is different. Different seasons, different clouds, different sunlight. Sometimes it’s smooth as silk and others it’s rock and roll! I never quite know what it’s going to be like, but it’s always beautiful. And the best thing of all? You can’t see or hear a politician! 4

The one quality I most admire in people is… that rarest thing of all things – genuineness.

there’s Medicare’s contribution to global warming… don’t get me started!

My personal motto is... exactly the same as the 11th West Australian AIF Battalion – ‘DEEDS NOT WORDS!’

If I had the chance to bore holes in the sky for half-an-hour I’d love to be strapped into… something old, noisy and extremely powerful. I’m not too choosy – a Spitfire or Corsair would be wonderful! My 1948 Beech 18 with its two big radial engines sings a song to anyone with XY chromosomes but a Corsair with 1800 HP under the bonnet would be very nice indeed! O

The thing I most dislike about being a doctor is… Medicare. It’s a pointless exercise in bureaucratic waste. I fail to see how its mass of self-generated paperwork helps me provide better care to my patients. And then

medicalforum

By Dr Smathi Chong, Clinical Microbiologist

MALDI-TOF MS: An advance in microbial identification Most clinicians would not have heard of MALDI-TOF MS, a major advance in bacterial identification techniques over other current, century old traditional biochemical principles. It is a quantum leap forward in the microbiology labâ&#x20AC;&#x2122;s ability to rapidly and accurately identify the vast majority of clinically relevant bacterial isolates. MALDI-TOF MS is abbreviated from Matrix Assisted Laser DesorptionIonisation, time of flight mass spectrometry. With such a mouthful, even the abbreviation needs an abbreviation hence, MALDI. Its most basic application is to identify isolated bacterial colonies growing on an agar plate. A case of 19th century technology meets the 21st century. In the lab, patient specimens are still plated onto agar plates and incubated at least overnight. When there are visible isolated colonies growing, the scientist carefully picks a colony and applies it to a special plate where an organic liquid

matrix is applied. This plate is fed into the MALDI-TOF MS instrument where a laser beam repeatedly fires onto the bacterial colony. This irradiation produces charged particles, which â&#x20AC;&#x2DC;flyâ&#x20AC;&#x2122; through the reaction chamber and are detected on the other end. The time taken for particles to hit the detector and the mass of the particles represent the different ribosomal and other proteins of the bacteria and produces a pattern of peaks. This is then compared to a large database of known, previously characterized organisms to produce a match, giving an answer within minutes. Traditional biochemical identification methods generally take at least an overnight incubation or longer to reach a similar result.

What does this mean to the clinician? In a nutshell, improved speed and accuracy. Organisms difficult to separate from each other biochemically can be easily distinguished by MALDI. This will continue to improve over time as more bacteria are added to the database. Interim reports stating â&#x20AC;&#x2DC;Weird bug, watch this space while we scratch our headsâ&#x20AC;&#x2122;, will be replaced by â&#x20AC;&#x2DC;Weird bug, here it is!â&#x20AC;&#x2122; There are exceptions and limitations with the current commercial MALDI instruments. It is not able to distinguish between E. coli and Shigella, which are genetically closely related, but with very different clinical implications. The microbiology laboratory and its scientific staff have to be aware of these limitations so â&#x20AC;&#x2DC;traditional methodsâ&#x20AC;&#x2122; still have a place. Patient selection and collection of the best sample is still crucial to ensure quality of results. Bacterial cultures remain the first laboratory step. Even with new technologies and instruments, the old adage of â&#x20AC;&#x2DC;Rubbish in, rubbish outâ&#x20AC;&#x2122; still applies. A possible downside to this increased ease and rapidity of bacterial identification is the increased identification of previously â&#x20AC;&#x2DC;ignoredâ&#x20AC;&#x2122; organisms and those dismissed as contaminants or normal flora. The clinical microbiologist and clinician have a vital

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role to interpret the significance of identified and reported organisms.

Future developments These include expanding the database to more difficult organisms like fungi and mycobacterium, direct identification from clinical specimens, antimicrobial susceptibility and strain typing. Identification of bacteria from positive blood cultures is not mastered yet. For bacterial identification, PCR (polymerase chain reaction) has not achieved routine use and broad applicability in diagnostic clinical microbiology. One has to know what one is looking for. A successful example is in Neisseria gonorrhoeae and Chlamydia trachomatis PCR from genital samples in diagnosing STIs. Mainly because of its specific nature, a strength and limitation, one has to prespecify what one is looking for to be able to find it. Even multiplex PCRs looking for a range of expected organisms from a particular site or clinical sample is limited in its use. Other technological advances such as 16sRNA PCR and sequencing, which can identify a wide range of microorganisms, is not routinely available to most laboratories. It takes time even for highly trained scientists to perform and is still cost prohibitive for routine clinical specimens.

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Letters to the Editor Continued from P4 maze. This is particularly fraught for unwell patients who have to face confronting treatment choices with significant health and cost implications at a time when they are operating well â&#x20AC;&#x2DC;below their bestâ&#x20AC;&#x2122;. As you point out, against a background of rising costs leading to increased premiums and gap payments, an obvious challenge for the health insurance industry is delivering value for money. And added expense is not the only challenge. The opacity of the system with the fear of unknown costs to consumers exacerbates the problem. From a patientâ&#x20AC;&#x2122;s perspective, stress about the uncertainty of treatment outcomes must not be compounded by uncertainty about out of pocket costs. Patients are entitled to the same basic information that we all expect as customers; that is, the right to know what they are buying and how much it is going to cost them. Yes, there can be a degree of uncertainty for medical service providers â&#x20AC;&#x2DC;quotingâ&#x20AC;&#x2122; for a service. They canâ&#x20AC;&#x2122;t always know in advance how much time and effort they will expend in delivering their service. However, is that any different for many other businesses which are routinely expected to provide fixed quotes for work of sometimes unpredictable complexity? Similarly health insurers have a responsibility to provide comprehensible information to consumers so that they can make informed choices about â&#x20AC;&#x2DC;out of pocket costsâ&#x20AC;&#x2122;. It is in their own long-term best interest. Failure to provide transparent information will see many confused consumers, who would otherwise choose private health cover, default to the public system because of fear of the unknown. Dr Martin Whitely, PhD, Acting Executive Director, Health Consumerâ&#x20AC;&#x2122;s Council of WA

Consumers will go public Dear Editor, Your article on elective surgery and the complex financial and other relationships between health care providers, consumers, health insurers and Medicare [Private Hospital Cover - A Consumer View, September] confirms the experiences of many. We consumers are encouraged to make well-informed decisions about our health care and must manage our budget well, especially in later years of life when health care requirements increase but income is modest and fixed. It is nearly impossible to be sufficiently well informed in advance of incurring the expense. The information system would 6

appear to be broken. Few consumers would be confident and informed enough to persist in obtaining the kind of comparative cost information cited in the article. The complexity of the health care system is bad enough without the inexplicable charging practices, the difference across private insurers, different surgeons, anaesthetists, insurers, hospitals, whether in-patient or out-patient, etc. When consumers cannot take the risk of gap expenses breaking their budget, they will fall back on the public system, even when they have private insurance. This benefits private insurers greatly. Premiums collected without claims being made. And yet some surgical procedures are only available in the private sector, leaving the financially constrained consumer with little choice at all. And if the consumer is lucky enough to finally find a surgeon they feel comfortable with, that will usually determine the anaesthetist and hospital, for these are in effect largely chosen by the surgeon. Ms Jenni Ibrahim, consumer representative, West Leederville

Divide and conquer Dear Editor, What prompted the AMA to try and do a secret deal with the government on the co-payment? Surely the profession knows by now of the divide and conquer philosophy of governments. The lay response is greedy doctors who already earn $200,000 getting a $7000 pay rise with no savings to government. Yet the government are so desperate to get the measure through that General Practice has never been in such a position of strength. What we should be asking for is an all-ofprofession summit on the sustainability of general practice including the RACGP, the AMA, the rural docs and the Divisions or whatâ&#x20AC;&#x2122;s left of them. Deregulation of university fees means that most doctors will choose the high-paying careers rather than General Practice. Changes to GPET bring more uncertainty to registrars. The future is grim unless we argue for better productivity, training and remuneration. Dr Colin Hughes, Midland Family Practice

Where is our humanity? Dear Editor, I read with interest Dr Sarah Cherianâ&#x20AC;&#x2122;s column on children in detention [Is Anybody Listening?, August]. Australia was sending humanitarian aid to Kurds in northern Iraq, and is now also dropping weapons and ammunition. This decision was made without consultation with the Iraqi government, or indeed with the Australian people. As the wife of a Vietnam veteran, all war, terrorism, violence â&#x20AC;&#x201C; call it what you will â&#x20AC;&#x201C; horrifies me. We must, of course, support the military personnel involved, but how many more men and women and their families must suffer from the long-term pain of war before we learn to think, debate and consult before acting? There is no question that the Kurds in Iraq are in dire straits as are the Kurds in Iran. How many Australians realise that Reza Barati was a Kurd from Western Iran? He was killed in February by a rock to the back of the head while under the care of Australian government on Manus Island. On the very same day that as IS invaded Iraq, the Australian government sent an asylum seeker back to Iraq. No asylum seekers from Kurdish Iran, or Iraq will be settled in Australia under the current governmentâ&#x20AC;&#x2122;s rules. Why is there an apparent disconnect between the reality of war, and the arrival of asylum seekers on our shores? Where is our humanity? Where is the common decency and common sense? Has our country lost its moral bearings? Doctors, the great preservers of humanity, speak up. Dr Elisabeth Wynne, GP, retired, Wembley Downs

Continued on P8

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Letters to the Editor Continued from P6

No vaping; no smoking Dear Editor, I read with interest the report on e-cigarettes [What’s this Vapour Caper, August]. I point your readers to the World Health Organisation’s report published last month on the global rise of e-cigarettes, which urged regulation of their sale in the interests of public health. There is currently insufficient evidence to recommend e-cigarettes as an effective aid to smoking cessation, and there are concerns about whether they are safe to use in the short or long term. The Health Foundation recommends that e-cigarettes and their use should be regulated in the same way that we regulate conventional cigarettes: no promotion and marketing, consistent regulations in all states and territories, and their use should be prohibited in all smoke-free places. As your article mentioned, the Supreme Court of WA ruled against the proprietor of an online business selling e-cigarettes, on the basis that the devices resembled conventional tobacco products and therefore contravened the Tobacco Products Control Act 2006. The widespread use of e-cigarettes has the potential to undermine 40 years of work by doctors and other health professionals to denormalise smoking. Mr Maurice Swanson, CEO, Heart Foundation (WA Division)

foundations of ‘to standard’ practice of spirometry.

Genie, Zedmed, Medtech, Practix and Communicare).

It is a widely held misconception that knowing which buttons to push on a spirometer equates with knowing how to correctly perform spirometry. Nothing could be further from the truth. The skill of spirometry lies with operator knowledge of and ability to apply the international guidelines, not the spirometer – a tool that allows physiological measurement. At all times, the spirometry operator drives the performance of spirometry, no matter what model of spirometer is available.

t 8IJMF OP DMJOJDBM USJBHF JT EPOF CZ $34 incoming referrals are reviewed for both demographic and clinical completeness. Incomplete referrals now make up 15% of those received (down from 29% in the early months of operation), and take a median of 1.2 business days to reach a site, fully processed; while complete referrals take a median of 0.8 business days.

Knowledge of these minimum essentials underpins spirometry quality assurance as it impacts directly on accuracy and reliability of results obtained and reported. Key national and international professional respiratory representative bodies recommend training and education by health professionals who are skilled and experienced in spirometry guidelines and practice over in-house ‘word-of-mouth’ instruction. Formal initial training should be no less than one-day in length. The quality, and therefore the clinical utility of spirometry for our patients, starts with simply ensuring that the first principle of quality assurance is followed: appropriate staff training.

ED: See P30.

Central Referral Service update Dear Editor,

Dear Editor,

t 5IF TDPQF PG UIF $34 XBT LFQU OBSSPX initially due to the extensive volume of referrals a day (an average of about 750 for the planned ‘in scope’ referrals). While immediate referrals (within 7 days) are unlikely to be brought into scope due to the clinical urgency (please note the CRS does accept urgent [within 30 days] referrals), it is intended that other out of scope referrals will be reviewed and potentially brought into scope (Mental Health, Allied Health, Non-doctor led services etc), including Obstetrics.

Quality assurance for the entire practice of spirometry begins with initial formal education and training of staff. This is stipulated within the international guidelines and establishes the fundamental 8

t 5IFSF BSF NJOJNVN TUBOEBSET GPS information required from outpatient referrals. These standards are reflected in the fields of the referral template, and are listed in the ‘information for referrers’ booklet for those choosing to refer a patient using an alternate form. O

Dr Sally Young, Lung Health Clinic and ProHealth Training

Spirometry training essential In support of and as an extension to the information in the spirometry article [Spirometry – a quality measurement, September], it is important to draw attention to the often overlooked and undervalued education and training of staff. The single critical differentiating factor between whether spirometry is a useful clinical tool or an exercise in random number generation, where results are of limited to nil clinical value, is the knowledge and skill base of the staff responsible for performing the test.

t *NQMFNFOUBUJPO PG 4FDVSF .FTTBHJOH to enable a completely electronic two-way referral pathway for external referrers is under way. Functionality has been developed; incoming message functionality is now live, outbound message functionality is in test phase. Work is progressing to connect to all secure messaging providers that comply with National HL7 secure messaging standards.

After the story [Central Referral Service, June edition] the service, through the Health System Improvement Unit, has responded to some key points raised:

t 5IF XFCTJUF IBT CFFO JODSFNFOUBMMZ updated since last year’s GP workshop. Work has progressed to increase the existing availability of downloadable referral templates (Best Practice and Medical Director) to include other practice software applications (including

From the Editor Readers have asked about how we select Clinical Authors… Clinical authors are usually recruited by the magazine, in line with our editorial themes. They are asked to write on a subject we think will interest readers, at a digestible length. Most agree to help. All contributions are vetted by the medical editor to ensure adequate standards and coverage. We ask authors to declare any competing interests, in line with the profession’s desire for more transparency and accountability. We are not a peer-reviewed medical journal but we comply with current international disclosure rules anyway. It is important readers are aware of any perceivable conflict of interest, especially when we allow authors to give their considered opinion on management. Each author is asked to provide a contact phone number should a reader wish to clarify something. medicalforum

Incisions

Time to Row Together Being a doctor in a small country town should not be as isolating as people think, says Dr Michiel Mel.

’m passionate about being a GP in a small country town and am proud to say (in this day and age) that it is possible to provide quality general and emergency care almost 24/7, even when it means, at times, ‘you’re on your own’. However this performance can only be achieved with the right support – that is, customised to the GPs’ needs and tailored to their community. I’ve been working in my small town for 10 years, long enough to have a good understanding of the dynamics and behaviours of individuals, communities, hospital managers, staff and patients. In fact this fortunate ‘spider in the web’ position in such a small town makes a lot of things crystal clear. It is a fantastically enjoyable position to be in. However, in order to perform well in the hot seat, we all need help. What sort of help depends on a lot of variables: demographics of the community, business orientation, skill set, learning and management style of a GP (and all other allied health), work culture and so on. Unfortunately we don’t always get the management help customised to our needs.

Fortunately, in the small country towns with hospitals and surgeries, GPs are dealing with relatively small numbers of patients. It’s a very controlled environment, especially when as a GP you’re doing it with almost perfect continuity of care (one of the great fortunes of being a rural GP).

GPs should not have to be left to deal with a decision taken in an ofﬁce far away where there is little understanding of what’s is happening on the ground. However, this all appears a very risky environment for those sitting in office far away, who have to manage these situations from a distance. It is fair enough that government and managers of large organisations can’t ‘micromanage’ all that GPs do. Let’s face it: it’s inevitable that the voice of the individual GP in a small town gets lost.

It gets more frustrating when there are no clear inroads into the bigger system. I see too many people (not only GPs) who go ‘paddling their own canoes’ at significant cost of chemistry within our system. It’s not too hard to create more effective forums to solve the problems of nonimplementation. A forum can be as simple as a phone call. We should manage our communities together – managers AND local doctors jointly taking ownership. We need to give this partnership a fair chance to be effective. GPs should not have to be left to deal with a decision taken in an office far away where there is little understanding of what’s is happening on the ground. All factors that impact on our performance as doctors must be considered, so they can be addressed. This has to be done in a safe and effective management culture, so people are confident to speak out without fear. Surely this can be achieved for everyone’s benefit – even for those distant decision makers! O

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Have You Heard?

MDA Members Set to Vote

The proposed merger of MDA National (MDAN) and MIGA heads to its final hurdle with a vote of on October 11. The MDAN meeting, open to all members, will be held in Perth at 10.30am and video conferenced live to sites in Victoria, Queensland, NSW and South Australia. All members have received a 250-page Scheme Booklet, also available at www.mdanational.com.au, which MDAN President, A/Prof Julian Rait, said includes proper disclosure of the intended merger compliant with the regulatory regime, and contains all material information necessary for members to make an informed decision about the merger. On September 10, the president of AMA WA, Dr Michael Gannon, wrote to AMA WA members expressing his concerns about the merger. Among Q A/Prof Julian Rait those concerns, but not limited to them, were that a merger: t XPVME SFEVDF QFS DBQJUB OFU member assets; t XPVME QSFDJQJUBUF BO FČFDUJWF NPWF of Head Office from Perth to Adelaide; t DPVME OPU HVBSBOUFF TBWJOHT GPS .%"/ members and even the potential for them to contribute more than their fair share; t DPVME DIBOHF UIF XBZ DBTFT BSF NBOBHFE with a move away from medical input to a cases committee. Dr Gannon writes: “We have less than five weeks to have these concerns addressed. I ask that you entrust me with your vote and grant me your undirected proxy Q Dr Michael Gannon for the vote on 11 October.” A MDAN proxy voting form was enclosed with the email nominating Dr Gannon as the proxy. A/Prof Rait, whose comments are constrained by standard regulatory and judicial requirements which apply to merger communications, said that the directors of both MDAN and MIGA, as well as ‘independent experts’ have concluded that a merger is in the best interests of their 12

members. He said that he was concerned with inaccuracies in Dr Gannon’s e-mail and encourages all members to read the Scheme Booklet to ensure they are fully informed of the material relevant to the merger.

be reviewing the health bureaucracy. Written submissions should be emailed to nras.review@health.vic.

“Most importantly, members will continue to have access to high quality and local service from their medical indemnity provider,” A/Prof Rait said.

In Curious Conversations [August], Telethon Kids Institute (TKI) head Prof Jonathan Carapetis reiterated his long-held desire to find a cure for rheumatic heart disease. Well an announcement a couple of weeks ago put him one step closer. A collaboration between TKI, University of Auckland and the Murdoch Children’s Research Institute in Melbourne is focused on fast-tracing a vaccine and assess the most cost-effective treatments. The project is called CANVAS (Coalition to Advance New Vaccines Against Group A Streptococcus and is funded by the Australian and NZ governments.

Former President of both MDAN and AMA WA A/Prof David Watson told Medical Forum that he had been deeply involved with MDAN for the past 14 years, standing Q A/Prof David Watson down from the board just 11 months ago. He refuted AMA WA claims that MDAN’s focus would drift away from Perth.

All eyes on vaccine

A/Prof Watson said MDAN was no longer a state organisation but a national entity with offices all over the country; where once most members were from WA, 60% of its doctor membership now lived outside the state. This made MDAN a strong organisation. However, he said MDAN would always be anchored to WA because of its heritage and strong membership there. He denied that a merged organisation would move away from medical input in case management, and added that only the biggest claims went to Case Committees. Most are dealt with by case managers who are in regular contact with medical advisers, of which he was one. “I could talk to a case manager once a week. That medical influence is not going to change in a merged organisation.” A/Prof Watson said MDAN had changed enormously as an organisation over the years, but its core business of insurance and member support remains, and it is a good business. “However, businesses can’t stand still, or they will fail. This merger ensures a solid future.” Now it is up to the members to decide. O

National registration review

The review of the National Registration and Accreditation Scheme to be conducted by former Director General of WA Health, Mr Kim Snowball, is open for submissions. He has compiled a 120-page consultation paper, (available at www.ahmac.gov.au) flagging that the review would look into complaints and notifications, public protection, advertising, mandatory notifications, assessment of overseas trained practitioners and governance and cost of the national scheme among others. The paper poses 27 questions the review aims to answer. The review (and the reviewer) is not without its critics. One reader wondered how independent a former health bureaucrat could

O Biotechs’ bumpy ride We announced the recent IPO of local biotech Othocell was fully subscribed by its July deadline with Australian Super Investments taking the largest holding of 8.36%. It was a happy spot for what has been a volatile period for local biotechs, which collectively have lost about $37m in the 2013-14 financial year. While the balance sheets look a little scary, it hasn’t stopped confidence in the sector. In August, Admedus, which is producing CardioCel, a collagen cardiovascular scaffold developed by Prof Leon Neethling, opened its new bio-manufacturing facility in Malaga. The capital expenditure was necessary, it said, to meet the expected rising global demand. O

State seeks out primary care

Primary care is on everyone’s minds lately as the sector sails into another era of flux with Medicare Locals set to morph into a new entity still to be explained and the general pressure on health costs. The WA Health Department recognises the challenges ahead and is hoping to get input from those working in the area on key issues of integration and communications at a Primary Care forum on Friday, 24 October, at the University Club at UWA. It is hoped that GPs allied health, AMA, state health services, consumers, carers, and advocacy groups will attend. For information and to register, email healthpolicy@health.wa.gov.au or phone 9222 0200. O

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BOQS001115 08/14 13

Trailblazer

Proving that Primary Care Works How do you quantify what GPs do and then prove what they do works? Those questions drive the working life of primary care researcher Prof Moyez Jiwa.

The CEO of the National Health and Medical Research Council, Prof Warwick Anderson, wrote in The Conversation in July under the headline, With the right kind of research, we can reduce health-care costs, that by culling treatments which didn’t work or replacing expensive medical products for cheaper options without affecting outcomes, millions would be saved. It’s a statement loaded with significance and prompts big questions about medical practice and research and where common sense fits in. For one senior primary health researcher and GP, Curtin University Chair of Health Innovation (Chronic) Prof Moyez Jiwa, his work is all about bringing common sense back into the equation.

Cog in the medical wheel “I was lucky to have trained at Trinity College Dublin where I came under the influence of James McCormack – a good old-fashioned GP who had a major role in the curriculum of the college. He told us we would be trained to behave like automatons and we needed to understand the reasons why. He said: ‘You are there to support the industry that’s built up around medicine – the drugs, investigations, tests, surgery – activity that is driven by a biomedical model of healthcare’.” Moyez for his entire career as GP, first in Scotland, the UK and for the past decade in WA has been trying to show good reason why it is imperative to re-evaluate the way things have always been done. His work as a primary care researcher is focused on prevention and support of people with chronic diseases at the primary care level but that rarely attracts the competitive funds from bodies like the NHMRC. Such funding is a key measure of success for Universities. “About 2% of NMHRC money goes into primary care research, which is very translational. We don’t tend to research in the laboratory. Much of what we produce 14

is of more immediate benefit to the community.”

Cure, but in the meantime… Of course, all those working in the area of primary care research are aware of the bigger picture, where a cure for cancer, for instance, would change the scene dramatically.

WA Health is also ramping up its presence in the primary care space with the development of the Primary Care Health Network, which is seeking input from GPs later this month at a forum. [See P12.] The system is so weighed down, it’s time for action.

“But that is not going to happen, in my view, in the next 10-20 years, so we are left with treatments that may be curative but require on-going support of the patient . We have an ageing population developing complex conditions and becoming increasingly disabled by their condition and sometimes also by their treatment.”

“We’ve done a lot of research and now we need to apply it in a way that is agile, intuitive, creative and cost effective. The thing that will rescue Australia from the growing prevalence of morbidity is 10 minutes of uninterrupted time from someone who cares enough to give you their undivided attention.”

“The short-term solution must be solid evidence-based primary care practice to give the patient an early diagnosis, the right treatment pathway and support through the process.”

“What we don’t need to do is to interfere in that 10 minutes by creating payment structures which distract the practitioner and patient. GPs think all the time how they can improve that time with their patients and we need to harness this insight for the greater good so the system improves.”

“The role we GPs fulfil in society is as much a social role as a technical one. I know that for the majority of patients I see, there is very little I do that makes a technical difference to their health outcomes. But a lot of the interaction between doctor and patient helps them through their day, hopefully through their month and years in a way that has not yet been quantified.” “That’s why I find it so exciting to be working in this space. It has the potential to do an awful lot of good but also prevent an awful lot of harm.”

Commitment for primary care WA universities are all investing in primary care research. UWA has just appointed Prof Helena Liira as new Chair of General Practice. She comes to Perth from Finland in January and is apparently keen on GP involvement in medical research. Prof Tom Brett is at Notre Dame focusing on building research capacity amongst health professionals and disease burden from ‘multimorbidity’. GP Prof Moira Sim is at ECU.

Innovations push change “I’m a great admirer of [Ballajura GP] Dr Alan Leeb, who developed the Smart Vax app [see www.medicalhub.com.au] Alan is likely to find out before anyone else, if there was a bad batch of vaccine. That’s the kind of innovation I am excited about. It allows us to show people what will happen.” This showing, not lecturing, is the force behind several of Moyez’s own innovations – the smoking software, which aims to show young people what smoking will do to their faces; and the Future Me app, which aims to tackle obesity. His most recent research is in hospital discharge summaries where he put volunteer GP researchers and technology together in a unique way. “Time makes it difficult for GPs to be involved in research. Medicare doesn’t recognise research nor are GPs insured for it. Continued on P16 medicalforum

medicalforum

Feature

GPs and Insurers â&#x20AC;&#x201C; Romance in the Air? Private health insurers are increasingly ďŹ xing their gaze at the primary ary care space and overworked GPs are ďŹ rmly in their sights. If reaction to last monthâ&#x20AC;&#x2122;s discussion on private health insurers (PHIs) got people talking, this monthâ&#x20AC;&#x2122;s survey of the insurance industryâ&#x20AC;&#x2122;s wooing of general practice has already had sparks flying. Our September e-poll asked readers if they approved of amending legislation that would allow PHI to provide preventative health measures for their customers using GPS [see P17] and 66% of the 146 respondents said yes, or perhaps with conditions. The reaction would sober some politicians in Canberra who have been fighting a toothand-nail battle since March to put an end to â&#x20AC;&#x2DC;GP access trialsâ&#x20AC;&#x2122; by attempting to close loopholes in the Private Health Insurance Act 2007. Prime mover Victorian Greens Senator Richard Di Natale was mostly concerned that if these trials widened to common practice it would create a two-tiered system and the possibility of escalating health care costs. It is a concern shared by the national president of the AMA, A/Prof Brian Owler.

Medibank GP Access Trials Senator Di Natale referred specifically to Medibankâ&#x20AC;&#x2122;s trials in Queensland with IPN general practices which promised it members: t 4BNF EBZ BQQPJOUNFOUT XJUI DPOEJUJPOT

t 'FF GSFF DPOTVMUBUJPOT GPS NFNCFST XIP show their Medibank card at a participating clinic or who use the after-hours GP. t "Ä&#x2122;FS IPVST (1 IPNF WJTJUT

Medibank is all-systems go, with its executive general manager for provider networks, Dr Andrew Wilson, telling the annual Health Insurance Summit in July, that the insurer was in the process of creating a single service jointly funded by public and private payers which would enable â&#x20AC;&#x153;GP-led, system-wide coordinated care for high utilisersâ&#x20AC;?. â&#x20AC;&#x153;For high-need patients, we should move away from the â&#x20AC;&#x2DC;fee for serviceâ&#x20AC;&#x2122; approach and look at a payment per capita that encourages practitioners to work together and focus on the patient health outcome,â&#x20AC;? he is reported as saying. Some commentators are drawing links between Medibankâ&#x20AC;&#x2122;s GP initiatives with its likely privatisation â&#x20AC;&#x201C; something the insurer has denied and to be fair to Medibank, it is not the only insurance company with an eye on this potential gold mine. NIB trialled a three year study in 2003-05 in Brisbane focusing on â&#x20AC;&#x2DC;frequent flyersâ&#x20AC;&#x2122; after the insurer declared that 1% of their customers accounted for more than 50% of benefits. The figures are similar for Medibank Private (2.3% accounting for 49% benefits). There is a corporate imperative [with hopefully health benefits!] to prevent members from going into expensive hospital treatment.

government may be prepared to review the statute books. The Health Minister Peter Dutton told the Australian Private Hospitals Association national congress in March that if â&#x20AC;&#x153;insurers are prepared to work collaboratively with doctors and patients then we should welcome that developmentâ&#x20AC;?â&#x20AC;Ś it had the potential to â&#x20AC;&#x153;free up capacity for non-insured patientsâ&#x20AC;? and to â&#x20AC;&#x153;save a lot in human and financial terms... Why would we resist that?â&#x20AC;?

Government is listening

Not surprising there were plenty at the Health Insurance Summit who would agree and succinctly put by Sydney GP Dr Annette Carruthers, a non-executive director of NIB, who saw benefits all round for its strategy â&#x20AC;&#x201C; patients would not be hospitalised inappropriately, costs to the fund would drop with a flow-on effect on premiums, and GPs â&#x20AC;&#x2DC;would be rewardedâ&#x20AC;&#x2122; for collaborating in care planning.

For the first time in over a decade, the political stars are aligning giving the health insurance industry a genuine sniff that a

Comments from our e-Poll were divided with some welcoming the injection of capital private insurers would bring, not to mention

Continued from P14

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So we used simulation, which allowed us to test GP interventions or hypotheses in a safe environment.â&#x20AC;? â&#x20AC;&#x153;We have about 200 willing GPs and about 80 took part in this project and they really enjoyed seeing the patients [actors in this scenario] and testing hyoptheses in a safe environment where no de facto patients can be harmed. We focused on both the referral process and discharge process because for GPs those are big ticket items. And the outcomes of the randomised trial may be helpful to the integration of health service providers.â&#x20AC;? â&#x20AC;&#x153;Primary care has to wake up to the fact that itâ&#x20AC;&#x2122;s on the ropes and the only way to get off is to provide evidence that it can make a difference; provide evidence of the interventions that are likely to work and step up to the mark and provide leadership.â&#x20AC;? O

By Ms Jan Hallam medicalforum

Feature Sept

the equity after watching allied primary health getting remunerated by the funds for years. However, some doctors were deeply concerned about the gap between rich and poor widening even further.

HBF initiatives Medical Forum asked WA’s largest health fund, HBF, what its plans were, if any, in the GP space. Managing Director Mr Rob Bransby said it would continue “to support GPs by being active in preventative health – encouraging and supporting our members to take responsibility for their health.” While he would not elaborate, Rob added that the health was also in the early stages of implementing a program to provide additional resources to GPs to help them “coordinate and integrate care” for HBF members. Perhaps the last word should go to dentistry colleagues who made a submission to a Senate inquiry sounding a cautionary note to the medical profession about jumping too fast into arrangements with private health insurers. Australian Dental Association CEO Mr Robert Boyd Boland told the inquiry that dentists have been working with PHIs for years and GPs could find that patient choice would be eroded and clinical autonomy of practitioners undermined if PHIs were allowed to continue to enter into preferred provider arrangements. O

By Ms Jan Hallam

ll e-Po

Wooing GPs

Legislative changes could allow Private Health Insurers to provide preventive health measures for insured consumers, using primary care medical practitioners. Is this idea acceptable to you? Yes

41%

19%

Perhaps

25%

Undecided

15%

ED: of the 146 respondents, 60% were GPs, 34% specialists and 6% DITs and ‘others’.

Comments Of the 34 doctors who chose to respond, 43% of comments were critical of any Private Health Insurance intervention in general practice. Many expressed fear that it would send the Australian health system down the two-tiered US path. “Those who can afford private insurance are already the healthier half of the population. Further bias towards the well off in the

provision of services will increase the gap in health status between rich and poor. Within Australia we have the widest gap in life expectancy between different communities of any country,” wrote one. There was concern that if the system accepted private insurers into the market, why not others? “Corporates such as Woolworths and Coles will squeeze everybody else out of healthcare. Cheerio to the ‘family’ doctor as we knew it.” For another, such a move was yet another layer of bureaucracy. For others, it would be seen as a positive and long overdue. “It’s about time – how long have they been paying for homeopathy, naturopathy etc.?!” “Anything that can be done to improve care should be embraced,” wrote another. Most on this side of the fence were ready to embrace the change but many wanted checks. None wanted to see a reduced role for the GP in care. “The ‘insurance concept’ I support but it should be between the health care provider and the consumer.” O

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Feature

Midland Public – a Critical Test Case SJGHC’s ﬁrst toe in the WA public hospital water is not without its controversies. Added to the public vs private debate, religious ethics are shaping some of the health care agenda. As Group CEO of St John of God Health Care, Dr Michael Stanford has, for the past 12 years, been largely allowed to get on with the job. Midland Campus is a different ball game. Now ‘Catholic’ is added, with negative connotations for some, especially when public funds have to comply with minority religious views, not to mention the wider political arguments about the church’s role in the State. No wonder Michael sometimes feels caught in the middle as a non-Catholic himself. “We are doing everything the government has asked us to do. I know and have worked at some of the major Catholic hospitals over East. Some, like St Vincent’s are iconic. Here, there hasn’t been a church organisation involved with public provision before.” Like the State Government, he sees all the positives of St John of God Health Care involvement outweighing any restrictions that Catholic bylaws place on people working there. Nearly all will be employed by St John of God Health Care, not the State. “The church hierarchy won’t be running the hospital, it will be people like me and Lachlan Henderson, and you know a lot of the doctors who will work there – they are normal people. I have worked in for-profit, not-for-profit and public hospitals, and I can tell you, private not-for-profit is the place to be – we can make decisions and get on with it without constantly worrying about what the Minister is thinking. We just think about what is the right thing for our staff and patients.” He said about 10,500 people were effectively working for St John of God Health Care, though it doesn’t necessarily mean they are religious. “But we expect them to fit within our values, but justice, respect, hospitality, compassion and excellence – anyone in healthcare ought to be able to work with that value set.”

Contentious fertility issues No problem with that, we suggested, but what of the nitty gritty of Catholic bylaws that people have to sign on to, bylaws Medical Forum was refused access to by SJGHC? One gynaecologist from St John of God Subiaco Hospital said a Catholic couple were surprised they couldn’t get a lap steri done at the hospital. We also guess many Catholic women (10% at the last Census) are taking oral contraception. A spokesperson for SJGHC told us that while doctors at St John of God Midland Public 18

Q Dr Michael Stanford, Ms Tanya Plibersek, Mr Chris Palandri and Dr Kim Hames turn the first sod in 2012

Hospital will have an obligation to discuss all family planning options with patients, they will “generally direct the patient back to their GP”.

spokesperson added. “Our employees are required to behave in accordance with our Values and Code of Conduct as is required at most organisations.”

Recruitment of frontline people for Midland is under way and they are assuming about 25% of the people at Swan Districts Hospital will say ‘no thanks’ for various reasons. The new hospital is twice as big so more than half the medical workforce will come from elsewhere. Under the new bylaws, Michael believes they will attract doctors who want to work within those rules and there are plenty of alternatives for those who do not.

So once signed up, if a doctor believes it is in a patient’s best physical interests to be given contraceptive advice, they may face an accreditation review. The question might be, who does the doctor put first, him/herself, the patient or the Church?

Catholic by-laws Employees are required to sign up to the SJGHC by-laws [which includes the “Code of Canon Law and the teachings and traditions of the Catholic Church in relation to health care as set out in the Code of Ethical Standards published by Catholic Health Australia]. However, if they are deemed to have breached them, their accreditation would be reviewed “subject to principles of natural justice, including the right of appeal. No one is sworn to secrecy,” the

“There is some material that relates to our code of ethics,” Michael said. “But just like at our private hospitals, if you want to lease space or work with us, that’s the deal. It will be the same at Midland.” “I can understand someone who has had a baby, and under anaesthetic, with informed consent, they might not wish to have a fifth or sixth child, so that’s a potential downside for a small number of people. The question is, what’s the upside and is the upside worth the downside? And that was the State’s view in choosing us. I don’t have any qualms that there are maybe 200 pluses and maybe one minus.” medicalforum

Q Midland Health Campus model

Negotiations with Government “We were completely up front four years ago. Before the process started, we said if you ask us to do these things we won’t be part of the bid and were told ‘we aren’t going to ask you to do those things’. Why did they make that decision? I suspect they wanted two horses in the race and I know we were considered a better bid than Ramsay on a number of grounds, including economic, and the evaluation came up with us.” “The Minister said it was worth $1.2b to the State over the 20 years. I don’t know how he worked that out but he said it repeatedly so they must think we are going to provide a financial benefit. I’ve said that $1.2b is about the same as what the State is spending building the new children’s hospital – it’s not a small amount of money. We take the financial risk so if we are losing money we can’t go to the government with a begging bowl and say, can you please top us up. I think it was a selling point. We said we have our head office here in our home market, we can’t afford to stuff up.” However, this is not without precedence. Back in the 1970s, St John of God Subiaco had to seek a $22m government guarantee from the then Premier Sir Charles Court for its building program. Of course, the organisation has fundamentally changed since then, with its incorporation into St John of God Health Care Inc in 1989, which

brought all the SJG hospitals under the one umbrella organisation with strict governance. How Dr Kim Hames explains a $60m difference per year in bids, we are yet to find out. He did provide Medical Forum a brief statement of cost, below, and a brief insight into the decision-making process. So what is the best way to put out any fires over the Catholic ethos? “I think it will take two years of being up and running before the fires go out and everyone says ‘what a fantastic operator’, ‘great quality’, ‘we know what we get’, and ‘this is a great thing for Midland’. Until then, there will be people who will be a bit anxious about it and the unions, Labor, Greens and individual doctors will have their views.”

Midland, a done deal “The deal is done. The State’s not going to kick us out, and Labor’s not going to kick us out if they get in because they would have to pay us as much money as we have put into it. Why wouldn’t people give us the opportunity to demonstrate how great a public hospital we can be?” Maybe a lot of people still don’t know what the deal is? “The bylaws are not complicated. We were required to work our way through the hypothetical issues; for instance, what do you say if a girl who has just been raped comes to Emergency and doesn’t want to have the

child. I think there are about 24 potential things in that space, for which we and North Metro Health, for the Department, prepared information based on the real experience of all the Catholic teaching hospitals over East.”

Upfront with employees “What you said is right. We don’t want any doctors coming to work with us unless they are fully informed. We will have that information available to them. We haven’t started the recruitment of the general doctors but I think we have started recruitment of the department heads.” “We think the proper way to deal with it is with the individual doctors seeking to work with us. It’s between us and them because they are the ones who need to understand. Is it of media interest? Yes, but it’s a bit of a circus. Do I have to do cartwheels every time someone like Marcus Rumpus says ‘not happy’?What’s the point?” Sensing his frustration, we suggested people are naturally curious about what is going to happen in certain situations. They have never had to think it through, whereas he has. “Our medical director Allan Pelkowitz was the MD at Calvary ACT, which is a public and private hospital, so he has had six years of experience in exactly this environment and he is running all the recruitment for the medical department. He will be talking to everyone.” O

By Dr Rob McEvoy

Minister: Where the State will save Medical Forum asked the Health Minister Dr Kim Hames to elaborate on the estimated cost savings for the decision to give the Midland Public Hospital contract to a private provider. This is response below: “The $1.3 billion in estimated savings and risk reduction to the state was calculated inclusive of infrastructure, wages and other costs over 23 years, through St John of God’s role in the medicalforum

Midland Public Hospital compared with an estimate made at the time of signing the contract of what it would cost if the same services were delivered directly by the public sector.” The Minister’s office provided background which revealed the cost comparison was developed by accounting firm KPMG and the state’s project team based on the public sector comparator (PSC), which estimates the risk-

adjusted, whole-of-life cost of the project if delivered by the state. The PSC contained estimates for the costs and risks for the state for Midland Public Hospital infrastructure build, transition of services, provision of clinical services and ongoing maintenance and capital expenditure. O

Guest Column

Women’s services are not ‘add-ons’ Opposition Health spokesman Mr Roger Cook says the women of the Midland district will pay a price for the WA Government’s privatisation health policies.

he right of a woman to choose how she controls her fertility has been recognised for decades by the World Health Organisation as a basic requirement for health, wellbeing and quality of life. This has played a big part in enabling women to pursue educational and career opportunities and play an increasing role in society. Government has a responsibility to protect these rights. However, the Barnett Government has knowingly awarded a contract to build a major public hospital in Midland to St John of God Health Care, despite St John’s making it clear it will not provide contraceptive advice, reproductive services, sterilisation or terminations. SJGHC is a great organisation that provides high quality care in its private hospitals. It has done nothing wrong and has been utterly transparent about the services it will and will not provide. It is the government that has done the wrong thing and it will cost taxpayers in the long run despite its repeated claims that it will result in savings. If there are any savings, they are likely to

be offset by the expense of having to find someone else to design, finance and run a separate private clinic for the services SJGHC will not provide. Worse is the hidden cost to women who are denied services that should be routinely available when they go to a public hospital. We are told 250 patients a year will be affected by this decision but in the 2012/13 financial year, there were 1276 deliveries at Swan District Hospital. Every woman, whose delivery takes place at the Midland Health Campus, should be able to receive family planning advice, including surgical sterilisation, prior to discharge as it happens routinely at Swan District. This figure of 250 is based on a limited range of high-intervention procedures and does not include all the women who will not be able to access the full range of family planning services they receive now. Currently mothers attending Swan District have the benefit of ‘opportunistic medicine’ – that is, the opportunity to receive a range of treatments and advice while in the

hospital’s care. This opportunity in the area of contraception services will be lost at Midland Public Hospital. For some women whose social circumstances dictate, there is a low likelihood of them seeking that advice or treatment once they leave hospital. Women whose deliveries require a surgical procedure and who would also benefit from sterilisation at the same time will be forced to have a second procedure elsewhere, or attend another hospital to have their baby. This will inevitably put more pressure on hospitals such as KEMH. The contractual issues at Midland are an unfair imposition on the patient and staff of other hospitals. It is an insult that services recognised as fundamental to women’s health have not been actively planned for, and are being treated as little more than an add on. Delivering public health services that provide value for the taxpayer is important but this should not come at the expense of comprehensive and proper health care. O

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Guest Column

Midland: Lose Some, Win More? Health Minister Dr Kim Hames, was asked to respond to the controversy surrounding women’s services at Midland Public Hospital.

he Midland Public Hospital is the first new public hospital in the area in over 50 years. The project represents a $360m commitment by the State and Federal Governments to deliver an increased range of services for the people of Midland and surrounding areas, replacing the ageing Swan District Hospital which is due to close in late 2015.

The new health campus, managed and operated by St John of God Health Care, will have 367 (307 public, 60 private) beds and state-of-the-art equipment, increasing hospital capacity in the north-eastern suburbs by around 50 per cent, and providing 1000 jobs to cover the greater scope of services available. Importantly, there will be a significantly expanded emergency department and new intensive care facilities at the Midland campus, plus a coronary care unit and cardiology services. There will also be a new chemotherapy service, along with larger maternity, general surgery, mental health and rehabilitation services. St John of God Health

Care is also committed to providing ongoing teaching and training for students studying health care. Like the Joondalup Health Campus, Midland will operate as a public and private hospital, so private patients also have the option to be treated closer to home. While the Midland Public Hospital will offer more services and facilities than Swan District Hospital, the government acknowledges that there are a small number of procedures which St John of God Health Care does not provide at any of its campuses. The Department of Health is currently exploring options with regard to these procedures, to ensure patients in the Midland area have access to quality services, specialists and advice on contraception, sterilisation and pregnancy termination. We want the most feasible solution for all concerned, while preserving choice for patients and health care providers. To put this in perspective, Swan District Hospital on average each year performs approximately 200 contraception, sterilisation and pregnancy termination procedures, which

represents less than 0.7 per cent of the anticipated 29,000 inpatient admissions expected to be provided at Midland Public Hospital when operating at full capacity. Currently in Western Australia, over 90 per cent of pregnancy terminations are performed in private day clinics, with nearly all of the remainder undertaken at King Edward Memorial Hospital and in rural hospitals. It’s important to note that patients at the Midland Public Hospital will still have access to full information about family planning, and will be directed to a GP for additional advice, if needed. At the end of the day, the greater Midland area will be serviced by a new public and private hospital that offers reliable and greatly expanded health care services in an accessible location with modern, high-tech facilities and equipment. That means quality health care closer to home, and peace of mind for a lot of people in the north-eastern suburbs. O

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Feature

Saving Gold Medal Knees Five ruptured ACLs in the Hockeyroo squad have kept orthopaedic surgeons busy and prompted the team to turn to sports science for some sustainable solutions. The Hockeyroosâ&#x20AC;&#x2122; path to their next gold medal may seem like a straight line but for the players on the field there are rapid and frequent changes of direction with complex and potentially adverse bio-mechanical load patterns leading to career-threatening anterior cruciate ligament (ACL) injuries. The combination of effective surgery and a sophisticated training program helped one Hockeyroo make a speedy return to the Astro-Turf. The 23-year-old forward Kellie White has been capped on 89 occasions but there have been times when her future at an elite level was under a cloud. â&#x20AC;&#x153;From the age of 16 I had a few injuries that took me out of competitive hockey. They were mainly ankle issues but in 2010 I began having more serious knee problems. I was playing in New Zealand, sidestepped quickly and partially tore ligaments in my left knee. I played on and carried the injury for another two years but in 2012, just before the London Olympics, I ruptured my left ACL.â&#x20AC;? â&#x20AC;&#x153;It was a pretty devastating time and a hard slog during the recovery period. The rehab sessions required every movement to be exact and consciously monitored. I had to tick all the boxes to have any hope of career longevity.â&#x20AC;?

LARS benefits long-term As Kellie points out, a skilled orthopaedic surgeon is an integral part of the package in getting back out on the field. â&#x20AC;&#x153;Greg Witherow has been fantastic for me. He suggested the LARS procedure for my particular injury because, in his opinion, other treatment options might well prove to be a ticking time bomb. Greg felt my best option was a hamstring or patella tendon graft. I ruptured my knee on the 6th February, 2012, and I was in surgery three days later.â&#x20AC;? A new training program devised by sports scientists at UWA and specifically linked with the Hockeyroos is proving to be successful.

FACTS t "VTUSBMJB IBT UIF IJHIFTU SBUFT PG "$- JOKVSZ JO UIF XPSME t .PTU PDDVS EVSJOH B OPO DPOUBDU DIBOHF PG EJSFDUJPO PS VOTUBCMF MBOEJOH t "'- 4FBTPO LOFF SFDPOTUSVDUJPOT BOE "$- JOKVSZ SBUF DMVC

medicalforum

Q Mr David Edmonds (UWA Masters student), Ms Gillian Weir (PhD Candidate) and A/Prof Cyril J. Donnelly with wired up Hockeyroo, Anna Flanagan, at the UWA School of Sport Science, Exercise and Health.

â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve been working with Gillian Weir [see below] and it is producing great results. I started about 12 months after the ACL rupture when I was just beginning to come back into competition. I lacked confidence in my kneeâ&#x20AC;&#x2122;s ability to cope in those highpressure situations.â&#x20AC;? â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s been a massive improvement in my core stability and gluteal strength. My knee is as strong as itâ&#x20AC;&#x2122;s ever going to be and Iâ&#x20AC;&#x2122;m much more confident running on to the field.â&#x20AC;?

ACL ruptures prompt action PhD candidate Gillian Weir and her fellow researchers at UWAâ&#x20AC;&#x2122;s School of Sport Science, Exercise and Health building on 15 years of research into lower-limb injury prevention, began their association with the Hockeyroo

squad and team doctor Carmel Goodman in early 2013. Five members of the team suffered ACL injuries in one season, a much higher rate compared with similar sports such as soccer. â&#x20AC;&#x153;Hockey at the top level is played at a very fast pace. Itâ&#x20AC;&#x2122;s a non-contact sport, in fact around 60% of ACL injuries fall within that category, but thereâ&#x20AC;&#x2122;s a lot of side-stepping and cutting away from opponents. The knee is a highly complex joint with a lot of different load patterns occurring at the same time.â&#x20AC;? â&#x20AC;&#x153;In a squad of 30 players, five serious injuries is incredible! A more typical rate would be

Continued on P25 23

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Feature

development, is in general better able to handle this type of stress load.” Competition at Olympic level is intense so it’s vital that elite athletes have access to sophisticated strength and training programs.

Controlling movement “The research we’re doing focuses on a player’s directional changes during competition. We delved Q Hockeyroo Kellie White in action post LARS Procedure for a ruptured ACL into the literature, looked at the probable causes of Continued from P23 injury and found they were linked with the degree of control in the upper 1.33/team in a season so these are nightmare body and hip areas. We’ve had some positive figures but you do need to build in the results using different modalities that include gender factor. Females are almost six times balance, plyometric and resistance exercises more likely to rupture an ACL because the male body, at a similar stage of physical targeting the hip and trunk areas.”

“Following our hip and trunk focused training interventation, gluteal activation has increased by 30% which is vital for neuromuscular control and the forces exerted through the knee have been minimised. Essentially, we’re attempting to reduce the loads in the knee and transfer them to the hip.” “We’ve designed a program based around body-weight exercises so expensive equipment isn’t required. Another researcher is looking at injury minimisations at an amateur level and it will be designed for delivery via an online platform.” “As far as GPs are concerned it’s important they’re aware of the causal factors linked with the upper body and hip. Appropriate exercises and rehabilitation after an ACL injury is important but if it’s recurrent there may well be lingering biomechanical patterns that need to be addressed.” O

By Mr Peter McClelland

In the Eagles’ Nest Recently retired West Coast Eagle Dean Cox has had plenty of knocks in his 16-year career with the club but team doctor, Dr Gerard Taylor, has not had too many sleepless nights over the successful ruckman. “Long-term survival at AFL level is a combination of good genes, self-motivation, preparation and a dose of luck. I’ve been with the West Coast Eagles since 1988 and over the same period as Dean, in fact. He came into the team when Michael Gardiner was the number one ruckman. There was nothing

in a medical or injury sense that was particularly memorable in his early years,” Gerard said. “Dean’s a natural athlete with Q Dr Gerard Taylor excellent aerobic capacity. And he was in the fortunate position of never having had the type of injury that might have predisposed him to an early end to his football career.”

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“One of the most appealing things about my role is that there are no restrictions in the treatment regime. If a player needs to fly to the USA to see the best toe surgeon then that’s what happens. You can provide the ultimate level of care without concerns about costs or complications.” “The players are a captive audience, you’re always monitoring them and the follow-up works both ways. If they’re not fixed they come back and tell you!” O

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News & Views

Kids Finding Their Voice Technology has given children with complex needs a means to communicate and a Variety camp makes learning fun for the entire family. Just because someone struggles to speak doesn’t mean they have nothing to say. Speech pathologist Ms Kelly Savage and Julie Wright-de-Hennin, mother of eight year-old Sophia, sing the praises of the Motor Mouth Camp, which helps put young people on the path to improved language skills. “When you work with these children it’s apparent they have something to say and they often can’t show what they know. The camp is designed for school-age Q Kelly Savage children who are disabled and have complex needs. They require alternative ways of getting their message across and they do this by using Augmentative and Alternative Communication (AAC) aids and voice output devices,” said Kelly, who works at the Independent Living Centre (ILC) and is camp coordinator. “These kids have a range of issues from autism to cerebral palsy and other developmental or acquired impairments. The one thing they have in common is that they’re all using hi-tech speech generating devices.” The AAC industry produces a range sophisticated products but, as Kelly suggests, it’s important a device is a good ‘fit’ for the specific needs of the individual. “A lot of the children have iPads with specialised Apps. Many of them haven’t acquired literacy skills and they use a

Q Motor Mouth Camp is an annual event

symbol-based vocabulary to communicate. I’ve been working in this area for seven years and initially there wasn’t much choice. But now there’s been a real boost in Tablet technology, though some can’t use a touch screen and, fortunately, there have been huge developments in Eye Gaze equipment.” Kelly and her colleagues all look forward to the annual camp at Point Walter. “The Motor Mouth Camp is the highlight of the year for us. Not only is it great professional development but it also fosters a community of like-minded people. It’s fully funded by Variety [this year, iiNet has become principal sponsor], we all volunteer our time and there are always more people wanting to attend than the number of available places.” “I think that the majority of GPs are probably unaware of the camp and also may not be very well informed regarding the wider applications of AAC. The ILC is a good place to start for anyone struggling with these issues. We’re across all the funding schemes and provide a full range of services.” “We’re preparing these young people to take their place as independent members of the community and these devices help them produce speech.” Julie Wright-de-Hennin, her husband Steve, and their two children Sophia and Lily live in Dampier in North-West WA. Eight yearold Sophia has had no definitive diagnosis, is mostly non-verbal and uses a combination of signs and a communication device. “Sophia doesn’t fall into any particular category. Her condition has been described as ‘global delay’ which doesn’t mean much by itself and we’ve used the tag, ‘intellectual disability’ in order to get school support.”

Q Steve and Sophia Wright-de-Hennin

medicalforum

narrow down the diagnosis and we struggled with that for a while. And then we realised that the best thing we could do was focus on helping her live the best life she possibly can.” “Sophia uses Proloquo2go, which is an App on an iPad. We had been struggling to get her to use it because she would always find another way to communicate, usually by shaking her hand to indicate what she wanted. But it was important for Sophia to realise the potential power of this technology. A few sessions with a speech therapist at the Motor Mouth Camp and it became a lot easier for her.” The eligibility requirements are quite simple. Any school-age child who needs communication support using some sort of device can attend the annual four-day camp in early October. [The camp gets booked up early in the year, so forward planning is required.] “The children use a range of aids, everything from an iPad or a different computerised device to a picture book. There’s focused attention from one speech therapist for each family with the children communicating during a fun activity while the parents attend information sessions.” “There are even activities such as archery and canoeing for other siblings and they often go on to establish their own networks.” Julie is adamant that their remote location has been no barrier in obtaining support for Sophia, yet the benefits of Motor Mouth Camp are felt by the entire family. “It’s important to realise that you’re not alone and it’s so valuable to speak with other parents at the camp. It gives you a better perspective.” O

By Mr Peter McClelland

“We moved here from Canada when Sophia was five years-old. No one has been able to 27

Guest Column

Promote exerciseâ&#x20AC;Ś prevent injury The balance between exercise and injury is delicate, says Dr Kevin Netto, so goal setting and good management is crucial to maximise performance and beneďŹ t.

training. The only way to keep track of how training is going is to diarise what happens. Modern gadgets such as GPS and heart monitors usually come with software that allows training sessions to be downloaded, helping both the weekend warrior and the high level amateur athlete to monitor changes. Using a rating of perceived exertion can also be done â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s a little trickier but is quite accurate.

he onset of warmer weather brings a rush of blood, inspiring ideas of exercise, sport and enjoying the outdoors. So where do we start? In the age of litigation and duty of care, if we play a role in prescribing, facilitating, promoting or advocating sport and exercise, where do we start and what do we do? We know sport and exercise is good for health and well-being. However, risk is involved with participation, and statistics show once an injury is sustained, 25% do not return to active participation. So how do you keep safe? Here are a few tips for both the participant and anyone involved in prescribing, advocating or promoting sport or exercise. t (FU B QIZTJDBM PS NFEJDBM FYBNJOBUJPO before starting. At the very least, a pre-activity questionnaire should be administered because sport and exercise can put increased stress on the cardiovascular and musculoskeletal systems. Anyone at elevated risk due to pre-existing conditions should be screened and adequately managed. t Ä&#x2021;F OFYU TUFQ JT TFUUJOH B TPMJE HPBM *O my view, this is often missed. Why are you participating in sport? To get fit or lose weight is usually the answer. But what do you want to achieve? Run a marathon in under four hours? Goals that are clearly defined shape training. t " USBJOJOH QMBO OFFET UP CF MJOLFE UP UIF goal. Elite athletes and those who manage them have whatâ&#x20AC;&#x2122;s known as a periodised training plan. This usually incorporates

X Former MLA Dr Martin Whitely is acting executive director of the Health Consumers Council of WA, replacing Mr Frank Prokop. X Dr Alexius Julian is the Clinical lead of ICT Commissioning at Fiona Stanley Hospital. X Sixteen projects will share $3m in the second round of Telethon-Perth Childrenâ&#x20AC;&#x2122;s Hospital Research Fund grants. A/Prof Christopher Blyth, Prof Jack Goldblatt, Dr Nicholas Gottardo, Dr Rae-Chi

pre-season, games, major competition and tapering. Training levels are periodised to facilitate optimal adaptation and improvement while minimising injury and over-training. The main variables are generally intensity and volume. Intensity is a measure of how hard an exercise, drill or training session is. Any number of metrics can be used for this including heart rate or a rating of perceived exertion. Volume of exercise generally refers to how much exercise is performed. So, you could have training sessions that are high in intensity and volume (higher chance of injury) or low in intensity (lower chance of injury) or any combination of these. If you look closely at a training plan, you will see how these variables are manipulated for different goals.

t )ZESBUJPO JO UIF XBSNFS NPOUIT BOE nutrition in longer events is vital. Sports Medicine Australia has information on its website. Importantly, always practice what you intend to do at a competition, during training. Eating and drinking the appropriate amounts while exercising takes practice. t 1FSGPSNBODF FOIBODJOH ESVHT have made their way into amateur and recreational sport and exercise. We know these agents increase performance and optimise training gains (there are personal gains for those selling them too). Although the acute side effects of these drugs are well documented, whatâ&#x20AC;&#x2122;s unknown is the medium to long-term effects and this is where horror stories abound. The benefits of sport and exercise to an individualâ&#x20AC;&#x2122;s health far outweigh the risks of injury. With a sensible approach, most can keep injury free to enjoy what our bodies where designed to do â&#x20AC;&#x201C; move. O

t ,FFQ B USBJOJOH EJBSZ Ä&#x2021;JT TFFNT MJLF B pretty straightforward suggestion but the number of high-level athletes who donâ&#x20AC;&#x2122;t do this still astounds me. There is a strong link between injury and a sudden change in

ED: Kevin is Director of Research at Curtin Universityâ&#x20AC;&#x2122;s School of Physiotherapy and Exercise Science

Huang, Prof Peter Le Souef, Dr Andrew Martin, Prof Susan Prescott and Dr Claire Waddington were among the medical practitioners to receive funds for their various short-term research projects.

X The Mental Health Commission has awarded a $98,000 contract to Sankey Associates to conduct an evaluation of the Mental Health Court Diversion and Support Program.

X Asthma Foundation WA (AFWA) awarded $5m in grants for respiratory research: A/Prof Alexander Larcombe and A/Prof Benjamin Mullins (UWA); Dr Shelley Gorman and A/Prof Vance Matthews (UWA); Prof Peter Henry, Ms Tracy Mann and Prof Philip Burcham (UWA); Dr Kimberley Wang with Prof Peter Noble supervising (UWA) and Ms Robyn Jones with Prof Alan James supervising (SCGH).

X Former entertainer and Perth City Councillor Mr Max Kay and businessman Mr Michael Weir have been appointed to the board of Prostate Cancer Foundation of Australia (WA). X Dr Stuart Boland is the new president of Australian Senior Active Doctors Association (ASADA) replacing Dr Simon Strauss who will stay on the Executive and continue as website and newsletter editor. Stuart is former chairman of Avant.

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Perth Radiological Clinic adds Nuclear Medicine to its service at The Mount Hospital Mount Specialist Centre 140 Mounts Bay Road Telephone: 6228 6200 Imaging Services now available onsite : & & & & & & & &

Nuclear Medicine (fully comprehensive diagnostic service) MRI Low Dose CT Full field digital mammography Ultrasound and Colour Doppler X-ray Image guided injections and biopsy Interventional procedures

Please Note: Nuclear Medicine services at Subiaco clinic will transfer to The Mount site

www.perthradclinic.com.au medicalforum

Leaders in Medical Imaging

Guest Column

A Buzz Out of Bees Bees have accompanied Pinjarra GP Adj/Prof Peter Wallace most of his life and along the way a deep appreciation of these essential creatures has grown.

eekeeping was introduced to Australia by my namesake Captain Wallace in NSW in 1852. Within 50 years European bees had colonised the entire continent including Tasmania. It wasnâ&#x20AC;&#x2122;t so settlers could have honey on their breakfast but a serious economic matter of pollinating crops. Without the 500,000+ beehive across the country our $5b fruit and vegetable industry wouldnâ&#x20AC;&#x2122;t exist. I have been keeping bees since childhood and the income was helpful during university days. I have 25 hives scattered at various friendsâ&#x20AC;&#x2122; properties. Most management activities can be at my convenience although there are a few critical moments in the annual cycle. The main determinant is the queen â&#x20AC;&#x201C; a healthy queen, means a healthy hive. A queen can live 4-5 years though her egg production drops by 30% each year, so she is best replaced annually. I source my queens from a supplier who sends them by post. They come in small modified matchboxes with half a dozen nurse bees and a food source. Several dozen can fit into in standard, padded plastic postage bag and the package hums gently throughout the journey, though more noisily when shaken.

Q Adj/Prof Peter Wallace

This can transform a standard transcontinental delivery into a record Express Post. When it arrives, a rather breathless post office worker will ring and demand collection of â&#x20AC;&#x2DC;your dangerous packet at onceâ&#x20AC;&#x2122;. Once in possession of the buzzing but valuable package, there is a collective sigh of relief from the posties as if a live bomb had just been defused. Bees can develop a raft of diseases but because of WAâ&#x20AC;&#x2122;s strict quarantine laws we have the cleanest apiaries in the world. There are some nasty diseases that can wreak havoc but we donâ&#x20AC;&#x2122;t yet have the major debilitating parasitic and bacterial infections that exist elsewhere. Living with bees is a privilege and a wonder. A highly sophisticated pheromonal system, based on variants of oleic acid found in

vegetable oils, controls their physiology and behaviour. The dominant pheromone, QMP, is emitted by the queen and is her individual marker that permeates the whole hive. It suppresses egg-laying in the other 50,000 female workers and it enables identification of friend or foe at the entrance. Bees work best in an aura steeped in QMP. The alarm pheromone is another potent stimulant, which is released at the same time as a sting. Otherwise placid bees cruising around a beekeeper will become incensed and angrily hone in on the site of any sting. I well remember receiving several hundred stings whilst recklessly working on a hive wearing shorts. The stings were all within a diameter of 5cm on one leg. The faintest hint of DEET (the active ingredient of most insect repellents) swamps these pheromones and is a useful standby when things get out of control! O ED. Our interest in bees grew from a media release that alerted us to an epidemic that is killing billions of honeybees in Europe and North America. Thankfully, WAâ&#x20AC;&#x2122;s bees are in safe hands.

Spirometry Tips Talking with parents about childrenâ&#x20AC;&#x2122;s weight FREE, accredited, online course for health & community professionals in WA

By Respiratory Scientist Sharon Lagan

Did you know? Your spirometerâ&#x20AC;&#x2122;s inbuilt normals (also called â&#x20AC;&#x153;predicted valuesâ&#x20AC;?) for reporting are built on t FUIOJD EJÄ&#x152;FSFODFT XIJDI DBO WBSZ UIF SFTVMU VQ UP

t IFJHIU XJUIJO DN XIJDI NBLFT DIFDLJOH ZPVS NFBTVSJOH gauge crucial and not taking patient reported heights at face value â&#x20AC;&#x201C; men overestimate and women shrink!) t HFOEFS NFO IBWF MBSHFS MVOHT UIBO XPNFO PG UIF TBNF IFJHIU

Morbid obesity can affect your lung function. Spirometers that report % of predicted rather than give a LLN (lower limit of normal) may misdiagnose conditions as they donâ&#x20AC;&#x2122;t take into account natural decline with age.

1300 822 953 www.talkingaboutweight.org This online professional development resource has been developed for health and community professionals and is available FREE of charge across WA for a limited time. Developed by health and clinical psychologists, the course is accredited and endorsed by leading industry associations.

A joint Australian, State and Territory Government initiative 30

Kids can be tested from 4-5yrs of age but need extra encouragement to ensure spirometry is performed well. Your spirometry report shows the highest FEV1 and FVC from the best efforts, not the average, but the curve is from the effort with the highest FEV1 + FVC. A restrictive pattern, low FVC with normal/ high FEV1/FVC ratio, needs confirmation with more detailed lung function testing. In looking for a bronchodilator effect, remember it may not show for a variety of good clinical reasons, and significant is regarded >12% improvement in FEV1, coupled with an absolute increase in FEV1 of >200ml. Reliable results are all about proper operator training, correct spirometer calibration, and critical interpretation of reports. O medicalforum

CLINICAL OPINION

Barriers to non-drug therapy in chronic pain #Z %S 3PHFS (PVDLF 1BJO .FEJDJOF 1IZTJDJBO 4$() Tel 9346 3263

hronic or persistent pain that lasts for more than three months in any one year affects up to 20% of the Australian population. Associated with pain there is often significant disability. The efficacy of paracetamol, NSAIDs and opioids is clear when managing acute pain and cancer pain. Their value however in persistent non-cancer pain is limited. Evidence is also mounting against longterm (especially high dose) NSAIDs and in highlighting potential harms from long-term opioid use. The evidence for non-drug therapy in chronic pain is becoming stronger. Patient and community education, encouragement with self-management strategies, maximising physiotherapy led exercise, participation in psychological strategies and group-based multidisciplinary behavioural programs are the way forward. So, what are some of the barriers?

Medical barriers Doctors are very good at performing a biological or biomedical assessment by excluding red flags and then providing oral analgesics. Doing a socio-psychological

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assessment â&#x20AC;&#x201C; which requires appreciating its importance â&#x20AC;&#x201C; and formulating a management plan, however, takes time. Writing a prescription is easier than attempting motivational interviewing to change a patientâ&#x20AC;&#x2122;s expectations and behaviour.

use of team care plans (often involving physiotherapy and clinical psychology) for chronic pain patients. t (PPE TDSFFOJOH RVFTUJPOOBJSFT TVDI as StartBack and Orebro) for acute back pain can guide the prevention of chronic back pain. t &ODPVSBHFNFOU PG BOE CFUUFS GVOEJOH GPS long consultation item numbers for GPs.

Patient Barriers

t .PSF BDDFTTJCMF QBUJFOU GSJFOEMZ IBOEPVUT

Patients often have a biomedical view of their persistent pain expecting that medical practice can quickly improve them. Or they believe a diagnosis has not yet been found and they need further investigations.

t A)BOET PGG QIZTJPUIFSBQZ XJUI BDUJWF patient participation.

Most patients with persistent pain are passive in their approach to treatment, have many failed treatment approaches and present with co morbidities (often multiple).

Delivery of care barriers Public hospitals may not be the ideal place to offer chronic disease management; however, they often have the expertise. Accessing them often includes queuing on a wait list, travel (sometimes significant distances), parking issues and usually the requirement for multiple attendances.

Solutions t (1 FEVDBUJPO JODMVEJOH VQ TLJMMJOH JO

t 1BUJFOU FEVDBUJPO BCPVU AQBDJOH BOE HPBM settingâ&#x20AC;&#x2122;, and developing an understanding of the personality style of the patient â&#x20AC;&#x201C; identifying whether they have a boom and bust personality and then attempting change. t "O BDUJWF QTZDIPMPHJDBM BQQSPBDI involving the use of cognitive strategies. t 5IF QSJWBUF TFDUPS PGGFST HSPVQ CBTFE programs for post-traumatic stress disorder, anorexia and a variety of mood disorders but these often include admission to hospital, increasing costs. Private sector funding of day attendance group-based classes needs an advocate. O References available on request.

Author competing interests: No relevant disclosures.

CLINICAL UPDATE

Managing basketball injuries E

lite basketball requires tall, big-bodied athletes to be agile and explosive movements – a combination that risks injury to stabilising ligaments of the ankle and knee. Explosive accelerations, jumping and abrupt changes in direction can lead to acute muscle and tendon tears as well as chronic conditions such as Achilles and Patellar Tendinopathy.

Ankle sprains The commonest mechanism of ankle sprain is an inversion injury damaging the lateral ligament complex. The three lateral ligaments are, generally, highly resilient and even a complete rupture of the anterior talofibular ligament usually does extremely well with conservative management. Somewhat counterintuitively, immobilisation can harm longer term outcomes and, while a brief period of movement restriction may be required, the evidence tells us that early rehabilitation to regain range, strength and proprioception is appropriate. The key to managing inversion injuries lies in identifying when the injury is likely to involve more than just the lateral ligaments. Some common associated injuries and post-injury sequelae are listed in Fig. 1. The Ottawa Ankle Rules (Fig. 2) were developed as a tool for helping with that initial risk-stratification. Athletes often claim to be unable to recall the exact mechanism of injury but it is

INJURIES ASSOCIATED WITH LATERAL LIGAMENT ANKLE SPRAINS Avulsion Fractures t .FEJBM .BMMFPMVT t -BUFSBM .BMMFPMVT t -BUFSBM 1SPDFTT PG 5BMVT t #BTF PG UI .FUBUBSTBM Other Fractures t %JTUBM 5JCJB t %JTUBM 'JCVMBS t #J BOE 5SJ .BMMFPMBS 'SBDUVSFT t 5BMBS %PNF Osteochondral Injuries t 5BMBS %PNF t 5JCJBM 1MBGPOE Syndesmosis diastasis Peroneal Tendon dislocation Capsular Tears & Synovitis Anterior & Posterior Impingement Q Fig. 1 32

OTTAWA ANKLE RULES 1 Inability to weight bear four steps 2

Bone tenderness of any of the following: B %JTUBM DN PG QPTUFSJPS FEHF PG UJCJB PS GJCVMBS C 5JQ PG MBUFSBM PS NFEJBM NBMMFPMVT D #BTF PG UIF UI NFUBSTBM E /BWJDVMBS

Q Fig. 2

worth persisting. Inversion or eversion when an ankle is trapped in dorsiflexion increases the risk to the syndesmosis. Landing from a height onto the lateral aspect of the foot increases the risk of a 5th metatarsal fracture. Pain and swelling can impede initial assessment. Settle acute inflammation with compression, elevation, ice and NSAIDs and schedule review a few days later. Early diagnosis and intervention improves outcomes in syndesmosis diastasis but the window of opportunity is up to two weeks. If initial assessment suggests an isolated ligament injury then early active rehabilitation and physiotherapy is appropriate. There is limited use in applying machine-delivered modalities beyond the first 72 hours. As the initial risk assessment may not always be correct, give clear contingency advice from the outset. If initial assessment suggests a more complicated injury, or if the ankle has not progressed as expected, further investigation or referral is warranted. A displaced or intra-articular fracture, unstable syndesmosis or displaced chondral fragment is likely to require surgical review. A sports physician can conservatively manage most other complicated acute ankle injuries including avulsion fractures, non-displaced osteochondral injuries, bony contusions and impingement. Occasionally chronic synovitis can impair functional rehabilitation and an intra-articular corticosteroid injection may be appropriate.

Tendinopathies Degenerative tendon conditions arise from dysfunctional repair. The cycle of damage and repair is encouraged in sport to allow for positive adaptation. When damage exceeds healing capacity, tendons are forced to repair with a matrix of collagen that is less suitable to tensile loads, and causes pain under load. Again, it is counter-intuitive but true that tendons need exercise to achieve appropriate healing.

By Dr Gary Couanis Western Sports Medicine Tenocytes are sensitised to load and can remodel collagen appropriately. The type of load is critical: unaccustomed, explosive, plyometric and heavy eccentric loads are potentially harmful. Regular, sustained and controlled loads with combined moderate concentric and eccentric components are usually the only treatment that is needed in early and mild presentations. Severe and chronic tendinopathies are fundamentally different in that a paucity of tenocytes develops making the tendon less responsive to exercise-based rehabilitation. A wide variety of medical interventions have been used to stimulate tenocyte activity. There is currently very little consensus in the field of Sports Medicine as to the best modality to achieve increased tenocyte activity. The greatest success, however, is achieved by the clinician who is mindful that no injection therapy is a stand-alone treatment for tendinopathy and that instigating a more active healing/ remodelling process can only be successful when coupled with the appropriate exercisebased rehabilitation.

Muscle tears and contusions Acute phase management focuses on limiting the bleeding through ice (not heat), elevation, compression and avoiding NSAIDs. Protect damaged tissue by avoiding the trauma of direct impact (massage) or continued use (exercise). Controlled active movement beyond the first 48-72 hours reduces scar size and limits strength loss whereas early static stretching can have the opposite effect. Acute compartment syndrome is rare. Usually, even large haematomas don’t require draining unless there are complicating factors. Suspect myositis ossificans if there is poor early management, a persisting firm palpable lump or slow progression. It is usually visible on a plain X-ray at 2-4 weeks. It is not uncommon for a young healthy athlete with a calf strain to develop a DVT despite the absence of other risk factors. There are a variety of other basketball injuries to keep us busy, ranging from concussion to finger injuries. Fans of the sport will recall high-profile cases including an on-court posterior hip dislocation to an NBL star and a sickening elbow dislocation in one of Australia’s star players overseas. It certainly pays to have a well-stocked medical kit. O Author competing interests: No relevant disclosures. Reader questions, contact the author on Tel 9284 4511.

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CLINICAL OPINION

MRI in knee and back pain By Dr Carmel Goodman Sports Physician CMO WAIS

n increasingly common scenario in my practice is the patient with knee or lower back pain (LBP) presenting with the opening line: “I am just here for an MRI referral”.

Patients, and in particular elite athletes, believe an MRI is needed for accurate diagnosis and a management plan. A differential diagnosis is not acceptable and athletes can be extremely insistent they need an immediate diagnosis only achievable with an MRI. However, most patients with LBP have muscular or ligamentous pathology. Recent review articles demonstrate that in 95% of patients with LBP, no cause is identified and the majority are self-limiting. Even in those patients with symptoms and signs of disc or facet joint pathology, MRI does not influence my initial management plan. Recent well-conducted randomized trials of routine MRI, versus usual care without MRI, found no clinically meaningful benefits on outcomes related to pain, function, quality of life, mental health or overall patient rated improvement in LBP. Whilst “red flag” conditions have to be

excluded, these should be clinically obvious and constitute less than 5% of presentations.

No correlation At least 50% of the patients I see will have MRI evidence of lumbar disc or knee joint pathology, with no relationship to their current symptoms. Review articles show MRI evidence of disc degeneration in asymptomatic patients in 30% of 30- year-olds, 60% of 40- 60-year-olds and 90% of those over 60. Similar figures apply to facet joint changes. No MRI abnormalities are found in 50% of patients with LBP. Most with herniated disc improve conservatively, so MRI should be reserved for patients failing conservative management and who are realistic candidates for injections or surgery.

The downside of routine MRIs Patient knowledge of ‘pathology’ on MRI causes them to worry, focus excessively on minor symptoms, and avoid exercise for fear of causing more damage. Patients are ‘labelled’ and expect the treating doctor to ‘do something’. This can lead to unnecessary follow-up tests for incidental findings, and

unnecessary invasive procedures or surgery. Many studies show MRI within the first few months of presentation associated with a significant increase in referral for injections or surgical intervention. The most common cause of knee pain is patellofemoral joint pain, which responds extremely well to physiotherapy including a well-structured rehabilitation program. Some 40-50% of middle-aged and 60-70% of older patients have asymptomatic knee meniscal tears. Many acute tears will become asymptomatic or heal conservatively in 2-3months. Thus, early MRI to diagnose knee joint pathology and surgical referral is often unnecessary and counterproductive. I appreciate this advice is easy to dispense, but more difficult to follow through, particularly with elite athletes wanting to quickly return to training and competition. I find that ‘sticking to my guns’ and explaining my reasons, usually results in my opinion prevailing. O References available on request

Author competing interests: No relevant disclosures.

Author competing interests: No relevant disclosures. Reader questions, contact the author on Tel 9387 8166.

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News & Views

Kidsâ&#x20AC;&#x2122; Sport â&#x20AC;&#x201C; Risks v Rewards AFL and trampolining attract the most ED presentations at PMH and more boys than girls will feel sad and sorry for themselves.

However, the odds are good that heâ&#x20AC;&#x2122;ll be home for dinner with war wounds prominently displayed.

The latest Bulletin of WA Childhood Injury Surveillance, a publication partnership between PMH ED, Kidsafe WA and the Health Department, is illuminating.

t PG QBUJFOUT XFSF treated and discharged after presentation. t SFRVJSFE IPTQJUBM admission.

ealthy engagement in physical activity is a real plus for young children. On the down side there are potential risks. Injuries, some serious, will always occur.

Nationwide, about one million children every year are injured playing sport. Those aged between 10 and 14 run the greatest risk and roughly 50% of the injuries are regarded as preventable. At PMH between July 2012 and June 2013 there were 4580 sports injury presentations or 23.8% of total presentations at the hospital. A broader longitudinal timescale focusing on PMH ED (July 2008 - June 2013) paints a more complete picture. t DIJMESFO ZFBST XJUI sporting injury presentations (SIPs) t BHFE CFUXFFO BOE t .BMFT 'FNBMFT t PG JOKVSJFT XFSF VOJOUFOUJPOBM It may prove cost-effective for the parent of a boy who sees himself as the next Hayden Ballantyne or Nic Naitanui and also loves to have an occasional bounce on a trampoline to purchase a cheaper, long-term PMH parking permit. t "'- IBE UIF IJHIFTU OVNCFS PG SIPs (13%) followed by trampoline incidents(11%).

A spike in the numbers participating in highcontact sports during the colder months is reflected in a higher number of SIPs. Younger children, particularly, are learning new skills commensurate with a relatively elevated risk-factor. t .BZ BOE +VOF SFWFBM QFBL QSFTFOUBUJPOT 12.1% and 10.7% respectively. t 4BUVSEBZ BOE 4VOEBZ 4*1T BOE 21.3% respectively. Fractures were the most common sporting injuries (42.1%) followed by sprains and strains (20.7%). The number of concussion injuries is small but there was a slight rise from 0.15% to 0.20% over the five-year period. The main culprits? AFL (again) and cycling. Understandably, most children (85.8%) arrived at PMH ED due to parental (or other relativesâ&#x20AC;&#x2122;) concerns. The remainder are evenly split between GP referral (6.5%) and hospital referral 5.1% (includes metropolitan and

regional WA lacking paediatric expertise). The Injury Surveillance Report suggests that itâ&#x20AC;&#x2122;s important to have modified rules and equipment appropriate to the skill levels and physical abilities of the participants. AusKick, Minkey Hockey and Kanga Cricket are typical examples. Notwithstanding the risk of injury associated with sport at a junior level, itâ&#x20AC;&#x2122;s well-recognised that there are tangible benefits other than those linked with physical activity. Social and cognitive skills are an important aspect of childhood development and the reportâ&#x20AC;&#x2122;s findings would suggest that the rewards far outweigh the risks. O

By Mr Peter McClelland

Supporting Ophthalmic Research, Education and Overseas Projects

EYE SURGERY FOUNDATION Our Vision Is Improved Vision After 18 months of expansion, the Eye Surgery Foundation amalgamated two buildings and re-commenced surgical procedures. The new day hospital is twice the size â&#x20AC;&#x201C; four operating theatres, a dedicated Laser room with a Femtosecond Laser, two recovery rooms, large reception, and a spacious staff room. Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco Dâ&#x20AC;&#x2122;Souza Tel: 9258 5999 Dr Graham Furness Tel: 9440 4033

Dr Kai Goh Tel: 9366 1744 Dr David Greer Tel: 9481 1916 Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156 Dr Brad Johnson Tel: 9301 0060 Dr Chee Kang Tel: 9312 6033

Dr Jane Khan Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665 Dr Jonathan Ng Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600 Dr Rob Paul Tel: 9330 8463

Dr Vignesh Raja Tel: 9300 9600 Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Angus Turner Tel: 9381 0802 Dr Michael Wertheim Tel: 9312 6033 Dr Joshua Yuen Tel: 9301 0060

5FM & JOGP!FZFTVSHFSZGPVOEBUJPO DPN BV 42 ORD STREET WEST PERTH WA 6005 34

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CLINICAL UPDATE

Dupuytren’s Contracture P

ercutaneous needle fasciotomy and collagenase injection allows some patients with Dupuytren’s contracture a faster recovery with reduced morbidity compared to open surgery. Patients need to understand that Dupuytren’s Disease is an incurable genetic condition. Whilst it is possible to influence the nodules and contractures within the palm, some degree of recurrence is almost inevitable.

When is treatment indicated? The tabletop test is useful; if a patient can place their hand flat on a tabletop and the palm touches the table (negative table top test) no treatment is advisable. Once their palm no longer touches the table it is worth discussing treatment. Letting the contracture worsen beyond this point can make the end results less satisfactory. The exception to treatment for patients with a negative tabletop test is those who develop a painful tender nodule. Usually the tenderness resolves spontaneously over some months but, if the discomfort is severe, injecting corticosteroid is an option. This can reduce or resolve tenderness and may resolve the nodule.

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Open surgical treatments Standard treatment has been fasciectomy, removing the affected cords to allow the finger to extend. For most this works well but recovery is moderately long and some have thicker scars, taking longer to settle. New techniques make the fasciotomy skin wounds smaller reducing recovery time. Excision of the adipose layer over the tendon sheath and full thickness skin grafting can reduce the risk of recurrence but lengthens the recovery process.

Needle fasciotomy A hypodermic needle tip is used under local anaesthetic to percutaneously divide the Dupuytren’s cords in multiple areas allowing for correction of the contracture. It is especially good for contractures of the metacarpophalyngeal joint. Similar to a venepuncture wound, the tiny wounds heal within 1-3 days. Most people return to work the next day and patient satisfaction is high. Recurrence after fasciotomy is, however,

By Paul Jarrett Hand and Upper Limb Surgeon, Murdoch more rapid than after surgical fasciectomy, but the procedure can be repeated.

Collagenase injection Collagenase dissolves the Dupuytren’s cord and is good for both metacarpophalyngeal and proximal interphalyngeal joint contractures. A clinic procedure, patients return 1-4 days later for manipulation of the digit under local anaesthetic. Bruising and swelling can last up to four weeks. Compared to surgery, contracture correction is good, though slightly inferior, recurrence is slightly sooner but recovery is rapid and risks low. Rare complications are sensory loss, which usually resolves and tendon rupture (0.013%). Costs may be higher as collagenase is not PBS listed. Time off work on average is one day after percutaneous fasciotomy, three days after collagenase and nine days after open surgery. Good hand function returns rapidly for needle fasciotomy, within a few days for collagenase and within 2-4 weeks for most operations. O Author competing interests: No relevant disclosures. Reader questions, contact the author on Tel 9311 4636

CLINICAL UPDATE

Oesophageal function testing O

esophageal function testing measures pressures (high-resolution manometry, or HRM), bolus movement (multi-channel intraluminal impedance) and acidity (pH monitoring). This allows assessment of intraluminal bolus transit and the degree of gastric acid exposure in the oesophagus. Data obtained can be useful in evaluating patients with heartburn, dysphagia, non-cardiac chest pain and other extra-oesophageal symptoms such as chronic cough; and as a pre-operative assessment prior to antireflux surgery.

(classical achalasia), type II (achalasia with compression) and type III (achalasia with spasm), which guide whether pneumatic dilatation or surgical myotomy is the preferred treatment.

High resolution manometry HRM examines motor function along the length of the oesophagus â&#x20AC;&#x201C;upper oesophageal sphincter, transition zone, oesophageal body, and lower oesophageal sphincter (LOS). Simultaneous pressure recordings are obtained during swallow. This is done via a fine flexible nasogastric catheter containing closely placed sensors along its length. Most studies take 10 minutes and after initial patient discomfort during catheter insertion, the procedure is usually well tolerated.

Oesophageal Body Motility

Transitional Zone

LOS LOS Relaxation

Q Fig 1.Normal high resolution manometry with anatomical landmarks.

Assessment of LOS basal pressure and relaxation, propagation of peristaltic waves, integrity of peristalsis and bolus entrapment allows diagnosis and classification of an oesophageal motility disorder. Hypocontractile disorders (sclerodermalike oesophagus, achalasia, weak or failed peristalsis) and the spastic disorders (nutcracker oesophagus, jackhammer oesophagus, oesophageal spasm) can be diagnosed and managed appropriately. Achalasia is characterised by impaired LOS relaxation and aperistalsis â&#x20AC;&#x201C; about 40 new cases a year in WA. HRM also allows achalasia to be subtyped into type I 36

Q Fig 2.Type II achalasia. Impaired LOS relaxation with aperistalsis accompanied by panoesophageal pressurization.

HRM is frequently performed before anti-reflux surgery, and is recommended (American College of Gastroenterology 2013 guidelines) to rule out achalasia or scleroderma-like oesophagus, two conditions where anti-reflux surgery could worsen symptoms.

pH monitoring/impedance pH monitoring

By Dr Jee Kong, Consultant Gastroenterologist, Royal Perth & 4XBO %JTUSJDU )PTQJUBMT Reflux symptoms. Patients with erosive changes on endoscopy do not need to be further pH testing. However, in the absence of erosive disease, ambulatory pH testing is mandatory to evaluate patients who are PPI-refractory or have a GORD diagnosis in doubt, before proceeding to anti-reflux surgery. A normal ambulatory pH study in a patient with no reflux changes on endoscopy suggests functional heartburn, for which surgical outcomes are poor. Non-cardiac chest pain. Up to 60% of patients with non-cardiac chest pain have an abnormal pH study. If an empirical trial of PPI does not provide symptom relief, ambulatory pH monitoring is valuable in assessing these patients. Extra-oesophageal manifestations of GORD. These include laryngeal symptoms (chronic cough, globus, voice hoarseness) and atypical asthma. A dual-channel ambulatory pH study can help assess whether acid exposure is the pathophysiological process causing these symptoms. Lung transplant patients. Routine testing of lung transplant recipients is indicated to detect reflux. This is done using a pH-impedance catheter to detect acid and non-acid reflux. It is thought that reflux is one of the mechanisms causing bronchiolitis obliterans syndrome (BOS) which occurs in 50% of patients at five years. If abnormal reflux is detected, fundoplication should be considered. O

Ambulatory pH monitoring uses either a fine ED. Currently, Royal Perth Hospital provides nasogastric catheter or a wireless capsule, the only state-wide service for oesophageal with the pH sensor in the distal oesophagus. function testing. Continuous oesophageal pH measurements over 24 hours, coupled with impedance monitoring, allows detection of acid and non-acid reflux episodes. Author competing interests: No relevant disclosures. Reader questions, contact the author Gastroesophageal reflux disease (GORD) on Tel 9224 2179. is perhaps the most common disease encountered by gastroenterologists and also affects 10-20% of patients who visit their GPs. Given that >60% of patients with GORD have a normal endoscopy, ambulatory pH monitoring is the gold standard for diagnosing gastroesophageal reflux. Ambulatory pH monitoring documents abnormal acid exposure, reflux frequency and symptom-reflux Q Fig 3. Severe GOR. The distal oesophagus is exposed to acidic pH 70% of the 24 hour study period. association. medicalforum

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CLINICAL UPDATE

Assessment and management of severe ankle sprain U

p to 7% of workplace and 25-40% of athletic injuries are ligamentous ankle injuries. The majority involve the lateral ligament complex comprising anterior (ATFL) and posterior talo-fibular ligaments (PTFL) and an intervening calcaneo-fibular ligament (CFL). The most structurally important is the ATFL, which statically limits anterior translation and inversion of the ankle. Lateral ligament injuries occur mostly with the ankle inverted and plantar-flexed. A standard sequence of injuries occurs with initial tearing of the ATFL and with increasing violence the CFL followed by the PTFL. Patients generally present with a painful ankle and associated swelling and bruising, and possibly significant instability. Clinically it is important to determine the patientsâ&#x20AC;&#x2122; ability to walk and weight-bear and to isolate the maximal site of swelling and bruising. Examine the ankle in an anatomical sequence with palpation of the medial and lateral malleoli, sinus tarsi over the lateral ankle, base of the 5th metatarsal and throughout the midfoot to help exclude any associated injuries. The anterior draw stress test, optimally performed with the ankle held plantar-flexed and slightly internally rotated, evaluates lateral ligament instability (Fig. 1).

Q Fig. 1 Anterior draw stress test right ankle

Grading There is no consensus on grading but anatomic, clinical and radiological grading generally correlate well. Grade I injuries involve a sprain of the ATFL with some torn fibres, which are still functionally competent. Clinically there is mild swelling and point tenderness over the lateral ligaments, minimal bruising, no clinical laxity, and ability to weight bear. Grade II injuries involve a complete tear of the ATFL with a partial thickness tear of the CFL. Clinically this correlates with the patient weight bearing with some difficulty, moderate swelling and tenderness, associated 38

bruising and mild clinical laxity. Grade III injuries involve tears of the ATFL, CFL and PTFL. Clinically this correlates with more severe swelling, tenderness, bruising and gross clinical laxity.

Investigations The indications for performing an X-ray have been contentious. Ottawa guidelines were introduced in 1992 to emphasise the importance of clinical examination to determine the need for X-rays and have proven to have a sensitivity approaching 100%. X-rays are recommended for the following criteria: t 6OBCMF UP XBML GPVS TUFQT JNNFEJBUFMZ after the injury or in the examination room t 5FOEFSOFTT PWFS NFEJBM PS MBUFSBM NBMMFPMJ t 5FOEFSOFTT PWFS UIF CBTF PG UIF 5th metatarsal t 5FOEFSOFTT PWFS UIF NJEGPPU PS OBWJDVMBS Stress X-rays of the ankle are not generally recommended, being difficult to perform in the acute setting due to pain inhibition. Image quality is also dependant on radiographer experience. Varus talar tilting on a stress X-ray does not necessarily correlate to clinical findings and need for surgery. Ultrasound can be very useful to determine the integrity of lateral ligaments An MRI scan would be considered the gold standard, being the most Q Fig. 2 Intact ATFL accurate modality to detect highgrade tears of the lateral ligaments (fig. 2, 3). Associated damage such as chondral injuries can also be diagnosed. Radiological signs of ligament disruption do not determine the need for reconstructive surgery. Acute lateral ligament injuries are initially treated with rest, Q Fig. 3 Ruptured ATFL ice, compression and elevation. Studies confirm that rapid mobilisation and intensive physiotherapy for range of movement, strength and proprioceptive exercises lead to a much faster recovery irrespective of the grade of injury. Subsequently, it leads to a more rapid return

By A/Prof Reza Salleh, Orthopaedic Surgeon, Subiaco to sport and work, reduction in swelling and stiffness, and increased patient satisfaction. Splinting for up to two weeks with a Camwalker or support brace Q Fig. 4 Post traumatic may be required synovitis lateral recess for patients with severe pain and inability to weight-bear or severe functional instability. There is no scientific evidence to support casting.

Outcomes Few quality studies assess acute reconstruction of high-grade lateral ligament injuries but general consensus is that highdemand patients achieve a more reliable outcome with earlier surgical intervention. The only absolute indication for surgery in the acute setting would be associated pathology such as unstable osteochondral damage, loose bodies or peroneal tendon tears which, if extensive, will generally not heal with conservative treatment. The relative indication for surgery is a better functional outcome in patients with highactivity demands. Despite appropriate conservative treatment, 20-40% of patients may present with either pain or instability up to one year following the injury. Common causes of chronic pain after an ankle lateral ligament injury include posttraumatic synovitis or adhesion formation (fig. 4), chondral damage or associated pathology especially peroneal tendon tears. Differentiating functional from anatomic instability is important. Functional instability is significant instability of the ankle with no obvious lateral ligament laxity on examination. Generally caused by peroneal weakness or poor reaction time, recommended treatment is further rehabilitation. Anatomic instability is where ankle motion on an anterior draw stress test is beyond functional limits suggesting high-grade lateral ligament disruption. If such patients do not improve with further rehabilitation, surgery may need to be considered. O References on request.

Author competing interests: No relevant disclosures. Reader questions, contact the author on Tel 9382 9102

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CLINICAL UPDATE

Active selfmanagement of back pain

PIVET MEDICAL CENTRE By Dr Chris Chin, GP, Cockburn Medical Centre

ip Rib or Costo-iliac Impingement has been documented in the medical literature as the cause of pain at the iliac crest, rib tip pain in cricketers and patients with osteoporosis and loss of spinal height. This model can also explain musculoskeletal changes in patients with non-specific back pain (accounting for 95% of chronic back pain) enabling us to give more specific advice for selfmanagement, improving compliance.

Compressive forces occurring at the inferior margins of the 11th and 12th rib against the iliac crest can traumatise the origins and insertions of the quadratus lumborum, gluteal, iliopsoas and lateral abdominal muscles causing pain and muscle dysfunction. Peripheral nerves, which penetrate these muscles, may also become traumatised leading to peripheral sensitisation. Tractional forces at the lumbar sacral area may contribute to sacroiliitis, strain of the multifidus muscles and contribute to spinal degeneration. The easiest way to find evidence of Hip Rib Impingement is to examine the patient standing up. Palpate the inferior edge of the lower ribs and the iliac crest looking for corresponding tender areas and observe how much gap there is between the ribs and the iliac crest. A gap of 5cm. (two fingers) or less increases the likelihood of impingement. A history of pain exacerbated by getting out of a chair or bending forward is supportive.

Targeted advice Avoid exercises which cause Hip Rib Impingement such as lateral flexion, forward flexion, flexion and rotation and excessive hyperextension at the waist. More specific biomechanical advice may be required depending on the patientâ&#x20AC;&#x2122;s exercise pursuits. To avoid impingement, take a deep breath and hold it while changing postures such getting out of a bed, chair or car and with lifting, bending and going up or down stairs. Encourage sitting upright on higher dining or office chairs or fit balls and avoid low soft seating. Slow deep breathing, while walking on flat grass is the safest initial exercise program. Aim for 30-40 minutes, three days a week, starting with 10 minutes and increase by five minutes every fortnight. Schedule reviews to monitor progress and reinforce the message SUMMARY By applying the Hip Rib t &YBNJOF GPS UFOEFS NVTDMFT Impingement model in CFUXFFO UIF MPXFS SJCT patients with ongoing back BOE JMJBD DSFTU pain of unknown aetiology, we can safely promote t "WPJE QPTUVSFT PS NPWFNFOUT DBVTJOH JNQJOHFNFOU active self-management, reduce fear of movement, t 5BLJOH BOE IPMEJOH B EFFQ CSFBUI minimise the perpetuation, SFEVDFT JNQJOHFNFOU XIFO exacerbation and recurrence DIBOHJOH QPTUVSFT PS FYFSDJTJOH of persistent back pain and t "WPJE MPX VOTVQQPSUJWF TFBUJOH disability. O t 4MPX EFFQ CSFBUIJOH XIJMTU XBMLJOH PO GMBU HSBTT TUSFOHUIFOT DPSF BOE MVNCBS NVTDMFT

References on request.

Specialists in Reproductive Medicine & Gynaecological Services

ANDROLOGY NEWS

by Medical Director Prof John Yovich

Varicocele Ligation â&#x20AC;Ś renewed interest In 1955 W. Selby Tulloch, urological surgeon from Edinburgh and father of our very own Alistair Tulloch, published his excellent results in the BMJ on Varicocele ligation. Using the Palomo Ligation technique (high â&#x20AC;&#x201C; above the inguinal ring) he reported LPSURYHG VHPHQ SURĂ&#x20AC;OHV DQG SUHJQDQFLHV LQFOXGLQJ WZR FDVHV who previously had azo-ospermia! However, the Palomo operation along with other surgical methods performed within the inguinal canal, fell into disrepute by the 1980s as life-table statistical evaluation showed no improvement in Q Dr Darren Katz, above and below, using the VTI fertility compared ultrasound Doppler to identify the testicular artery. to no-surgical treatments. Cochrane studies twice panned varicocele ligation surgery. What I noted in Perth when setting up Fertility Services in 1980, was that most men who had surgeries had persistence or recurrence of varicoceles. However, the new data of Peter Shlegel and Marc Goldstein from Cornell University in New York has changed the picture and even Cochrane is revising its conclusions as the new data reveals EHQHĂ&#x20AC;WV 7KH QHZ WHFKQLTXH LV VXE LQJXLQDO RYHU WKH H[WHUQDO inguinal ring) and requires a microsurgical technique to identify the veins and preserve the testicular artery within the spermatic FRUG )XUWKHUPRUH FRPPXQLFDWLQJ YHLQV KDYH WR EH LGHQWLĂ&#x20AC;HG for ligation. 9DULFRFHOH LV LGHQWLĂ&#x20AC;HG LQ DOPRVW RI PHQ LQ VXE IHUWLOH VHWWLQJV EXW RQO\ DSSHDU UHOHYDQW Â˛ GLVSOD\LQJ VHYHUH VHPHQ anomalies, increased DNA fragmentation, reduced testicular YROXPH Â&#x2022; POV DQG UHGXFHG VHUXP WHVWRVWHURQH OHYHOV $OWKRXJK IVF with ICSI can overcome the fertility problem for many cases, WKH EHQHĂ&#x20AC;W RI YDULFRFHOH FRUUHFWLRQ FDQ EH ZLGH UDQJLQJ including long-term testosterone elevation and improved embryo quality in IVF.

NOW AT 2 LOCATIONS PERTH & BUNBURY

Author competing interests: Dr Chris Chin has received honoraria for involvement in educational activities provided by Pfizer. Reader questions, contact the author on Tel 9418 3722.

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

CLINICAL UPDATE

Mx of acute temporomandibular disorders T

emporomandibular disorders (TMD) involve the temporomandibular joints (TMJ), masticatory muscles and associated tissues. Specific signs and symptoms are usually self-limiting or fluctuating, with progression to chronic forms uncommon, especially with early treatment of acute TMD.

suggested by: mouth opening restricted to ~25mm and no increase with jaw stretching; asymmetrical jaw movements; and preauricular pain from TMJ capsulitis and/ or synovitis. An MRI of the TMJ will show TMJ disc displacement without reduction in the open mouth position as well as effusion, and occasionally bone marrow oedema.

Common risk factors for TMD include: t JOKVSZ CMPX UP UIF GBDF PS XIJQMBTI t UFFUI DMFODIJOH BOE HSJOEJOH t IZQFSNPCJMJUZ TZOESPNFT BOE t FNPUJPOBM TUSFTT

Arthritis. TMJ osteoarthritis presents as a tender TMJ, with fatigue and TMJ crepitation with jaw use. CT is the imaging of choice.

Once persistent and chronic TMD is established, associated anxiety and depression can perpetuate the problem. It is not true that dental malocclusion (so called â&#x20AC;&#x2DC;bad bitesâ&#x20AC;&#x2122;) can cause TMD.

Diagnostic subtypes There are three broad sub-categories: Masticatory myalgia. Painful masticatory muscles on palpation and with use. Patients complain of limited mouth opening (measured <25mm, but normal opening usually attained with jaw stretching). Disc derangement. TMJ displacement without reduction (i.e. closed lock jaw) is

A system for assessment Pain. Look for dull aching pain, with sharp pain when yawning, talking and chewing. Relieved by limiting jaw use and analgesics. Palpate the TMJ during jaw movement, looking for painful clicking or crepitus. Other. Ask about jaw clicking, popping or grinding, as well as history of jaw locking. Predisposing factors. Ask about nail biting, chewing gum, daytime and/or sleep clenching and grinding. Measure. Mouth opening of >40mm interincisal, is considered normal. Observe the lateral and protrusive movements of the mandible for pain, limitation or asymmetry. Palpate the masseter, temporalis and medial

By Dr Jacinta Vu, Oral Medicine Specialist, BDSc (Hons), DClinDent (Oral Med/Oral Path)

pterygoid muscles for tenderness.

Management As most acute TMD are self-limiting and improve with time, non-surgical treatment is almost always first line. Patient education centres around: reassurance about the self-limiting nature of TMD; avoidance of excessive jaw movements (e.g. yawning and opening wide, eating hard/ chewy foods); avoidance of aggravating habits (e.g. teeth clenching and grinding); and pain relief from ice/heat packs. NSAIDs and muscle relaxants are useful for short-term use (1-2 weeks) before tapering off. Gentle jaw stretching exercises aim to restore pain-free masticatory muscle and TMJ function. If jaw pain and dysfunction persist, referral to a specialist can result in occlusal splint therapy, intra-articular steroid injections, neuromuscular injections, specialised physiotherapy, CBT with a clinical psychologist or in refractory cases of TMJ disc displacement without reduction, arthrocentesis or arthroscopy of the TMJ. O Author competing interests: No relevant disclosures.

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Travel

f f o the i l a BBeaten Track Thereâ&#x20AC;&#x2122;s more to Bali than tourist-crammed streets and Bintang T-Shirts. Dr Carol McGrath found a little corner of paradise and is prepared to share the secret.

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Warning: May Contain Nuts

Humour

Laugh Lines

By Ms Wendy Wardell

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Words and Pictures by Dr Carol McGrath medicalforum

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Theatre

Making Hay Put together the witty words of Noel Coward, the perfect timing of sassy Felicity Kendal and Hay Fever will have you itching for more.

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S E T O U Q

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Q Simon Shepherd and Felicity Kendal

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By Ms Jan Hallam

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Wine Review

McLaren Vale: Bold & Beautiful

2012 Four Score Grenache 5IJT XJOF JT BMM (SFOBDIF BOE GSVJU JT TPVSDFE GSPN ZFBS PME WJOFT JO 'PHHP 3E QMBOUFE JO 5IJT JT B XFMM NBEF NFEJVN CPEJFE XJOF XJUI GBOUBTUJD GSVJU FYQSFTTJPO +VJDZ BSPNBT PG SJQF QMVNT BOE DIFSSJFT BSF BCVOEBOU *U T CFFO NBUVSFE JO B NJYUVSF PG BHFE 'SFODI BOE "NFSJDBO PBL SFTVMUJOH JO TPGU UBOOJOT BOE KBNNZ GSVJU GMBWPVST "O FOKPZBCMF (SFOBDIF XJUI B MPU PG SFHJPOBM DIBSBDUFS BOE TVJUFE UP TIPSU UP NFEJVN UFSN DFMMBSJOH

By Dr Martin Buck

2010 Backbone GSM #VJMEJOH PO UIF HSFBU TPVSDF PG (SFOBDIF GSVJU UIF #BDLCPOF (4. JT BOPUIFS XJOF XJUI MBSHF EPTFT PG SJQF GSVJU GMBWPVST *U T CVJMU PO B CBTF PG (SFOBDIF BOE DPNQMFNFOUFE CZ TIJSB[ BOE NPVWFESF XIJDI XFSF BMM NBEF BT TFQBSBUF XJOFT CFGPSF CFJOH BTTFNCMFE UIFO BHFE GPS B GVSUIFS ZFBS JO PBL " GVMM CPEJFE BMDPIPM OJDFMZ CBMBODFE XJOF XJUI VQGSPOU CFSSZ DIBSBDUFST BOE UPBTUZ PBL BSPNBT *U DPVME CF DFMMBSFE GPS UIF NFEJVN UFSN

McLaren Vale is sometimes considered the poor cousin of the Barossa wine region but it has a fantastic reputation for hot-climate XJOFT BOE OFX WBSJFUJFT

2011 Renaissance 5IJT B #PSEFBVY TUZMF CMFOE PG NFSMPU DBCFSOFU TBVWJHOPO BOE QFUJU WFSEPU BOE OPU B DPNNPO TUZMF GPS UIF XBSN .D-BSFO 7BMF SFHJPO CVU OFWFSUIFMFTT JU JT B WFSZ BQQSPBDIBCMF XJOF "HBJO B MPU PG KVJDZ GSVJU DBSBNFM IFSCBM BOE UPBTUZ GMBWPVST BMM XFMM CBMBODFE 5IF QBMBUF JT GVMM XJUI HPPE QFSTJTUFODF "O JOUFSFTUJOH XJOF UIBU TIPXT IPX UIF SFHJPO DBO PGGFS B GFX TVSQSJTFT

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2012 Squid Ink Shiraz #PUI 4IJSB[ IFSF BSF CMPDLCVTUFS XJOFT BOE OPU GPS UIF GBJOU IFBSUFE 5IF 4RVJE *OL JT NBEF GSPN QSFNJVN GSVJU BOE NBUVSFE JO B CMFOE PG OFX BOE BHFE PBL +VTU UIF BQQFBSBODF PG UIF XJOF JT JOUJNJEBUJOH *U T B NBTTJWF CSPPEJOH EFFQ SFEEJTI QVSQMF XJOF JO LFFQJOH XJUI UIF OBNF 5IFSF BSF GBCVMPVT BSPNBT PG CFSSJFT TQJDFT CJUUFS DIPDPMBUF BOE WBOJMMJO PBL MFBQJOH PVU PG UIF HMBTT 5IF QBMBUF JT GVMM DPNQMFY BOE QFSTJTUFOU $FSUBJOMZ B XJOF UP CF BQQSFDJBUFE BOE XFMM TVJUFE UP NZ TJSMPJO TUFBL 2010 Giant Squid Ink Shiraz 5IF (JBOU 4RVJE *OL JT NBEF GSPN B TJOHMF QBUDI PG TIJSB[ JO B TNBMM CBUDI XIJDI JT BHFE JO OFX 'SFODI PBL IPHTIFBET GPS UXP ZFBST CFGPSF CPUUMJOH 5IJT JT B NVMUJ BXBSE XJOOJOH XJOF XJUI B TUSPOH QFEJHSFF *O UIF HMBTT JU JT BT PQBRVF BT TRVJE JOL BOE UIFSF JT SJQF CFSSZ TMJHIUMZ GFSBM BSPNBT BOE B GMBWPVS GJMMFE QBMBUF PG GSVJU BOE EBSL DIPDPMBUF *U IBT UJHIU GMBWPVST BOE GBCVMPVT QFSTJTUFODF " TQFDJBM PDDBTJPO XJOF

Senior Winemaker Campbell Greer

WIN a Doctor's Dozen! Wine Question: Which McLaren Vale wine comes from a single patch of vines? Answer:

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ENTER HERE! PS ZPV DBO FOUFS POMJOF BU XXX .FEJDBM)VC DPN BV 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, September 28, 2014. 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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Social Pulse

Benefit Ball

of God Subiaco Guests at St John to Ball were invited Hospitalâ&#x20AC;&#x2122;s Benefit m ite an g est but brin dress in their fin the d of the night to en e th to donate at . al pe Ap r te in lâ&#x20AC;&#x2122;s W St Vincent DePau

Q Dr Richard and Q M Mrs r Trish Clarke

Q Mrs Cathy and Dr Lachlan Henderson

Q Manager Perioperative Services Mrs Evelyn and Mr Jeremy Quinn with Deputy Chief Pharmacist Mr David McKnight

Q Prof Neville and Mrs Jaqueline Knuckey

te Dinner u b ri T o c ia b u S S JG Dinner at Medical Tribute

Q Mrs Cath Henderson, Dr Glenn Edwards and Ms Michelle Edwards

Q Ms Sayaka Oda and Dr Jason Tan

Q Dr Jo Colvin, Shanette and Greg Sims

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nial biaco held its bien at the hospital. St John of God Su ution of doctors rib nt co e ation th g in nour ised medical educ Crown Perth ho event also recogn â&#x20AC;&#x2122;s yed ar jo ye en is ts th es e, ardâ&#x20AC;&#x2122;. Gu For the first tim her of the Year Aw ac h Te ut n Yo so A at W W d id te with the â&#x20AC;&#x2DC;Dav ent by the talen nm ai rt te en ar ith ye eal w r of the a three-course m n Yeo was teache ysician Dr Roby ph l Prof Br yant , na in Re ch a. in str M Orche eon Dr David rg su to id pa s while tribute wa f David Watson. l physician A/Pro Stokes and genera

Q Award winners Prof Bryant Stokes, A/Prof David Watson, Dr David Minchin and Dr Robyn Yeo

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Q Dr Greg and Krista Maskin, Dr Marian Bahemia and AMA President Dr Michael Gannon

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Competitions

Entering Medical Forum's COMPETITIONS is easy! Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' link (below the magazine cover on the left).

Movie: Pride Pride JT CBTFE PO UIF USVF TUPSZ PG B 8FMTI NJOJOH DPNNVOJUZ TUSVHHMJOH UP NBLF FOET NFFU EVSJOH UIF NJOFST TUSJLF XIFO IPQF BSSJWFT XJUI UIF VOMJLFMJFTU PG BMMJFT o B HSPVQ PG HBZ BOE MFTCJBO BDUJWJTUT XIP EFDJEF UP SBJTF NPOFZ GPS UIF NJO FST 5IJT SPVTJOH DSPXE QMFBTFS TUBST #JMM /JHIZ BOE *NFMEB 4UBVOUPO In Cinemas, October 30

Theatre: Hay Fever 0OF PG UIF 6, T NPTU QPQVMBS BOE FOEVSJOH BDUSFTTFT 'FMJDJUZ ,FOEBM JT IFBEJOH UP "VTUSBMJB JO UIJT IJMBSJPVT DPNFEZ PG CBE NBOOFST CZ /PFM $PXBSE 4IF TUBST BT +VEJUI #MJTT B SFUJSFE KFXFM PG UIF -POEPO TUBHF XIP JOWJUFT B ZPVOH TVJUPS UP IFS DPVOUSZ IPNF VOCFLOPXOTU UP IFS UP NFFU IFS IVTCBOE BOE DIJMESFO Regal Theatre, from November 13. Medical Forum performance, November 13

Opera: Il Trovatore 7FSEJ T *M 5SPWBUPSF 5IF 5SPVCBEPVS JT POF PG UIF NPTU QFS GPSNFE PQFSBT JO UIF SFQFSUPJSF BOE DPOUBJOT TPNF PG IJT NPTU QBTTJPOBUF BSJBT BOE JOTQJSJOH DIPSVTFT FYQMPSJOH UIF EFFQ JOUJ NBDZ PG IVNBO SFMBUJPOTIJQT CFUXFFO GBUIFST BOE EBVHIUFST NPUIFST TPOT BOE MPWFST 3FMBUJPOTIJQT BSF UFTUFE BOE JO UIF FOE EFTUSPZFE JO UIF OBNF PG SFWFOHF His Majestyâ&#x20AC;&#x2122;s Theatre, 7.30pm, October 30 (Medical Forum performance); season continues until November 8

Movie: Decoding Annie Parker "OOJF 1BSLFS MPTFT IFS NPUIFS BOE TJTUFS UP CSFBTU DBODFS BOE CFDPNFT SFTFBSDI TDJFOUJTU .BSZ $MBJSF ,JOH T NJTTJOH MJOL UP IFS UIFPSZ PO HFOFUJDBMMZ JOIFSJUFE CSFBTU DBODFS #BTFE PO B USVF TUPSZ "OOJF FNFSHFT BT SFMFOUMFTT B TPDJBM DBNQBJHOFS BT ,JOH CFDPNFT BO FNCBUUMFE SFTFBSDIFS GJHIUJOH UIF TZTUFN In Cinemas, late October

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Doctors Dozen Winner PVOE UIF 5IFSF T B CJSUIEBZ KVTU BS Keating TP DPSOFS GPS GP Dr Kate CF QPQQJOH UIF TDSFX DBQT XJMM %PDUPS T PO UIF 8FTU $BQF )PXF UF QBSUJBM RVJ P T XI F %P[FO ,BU CPEJFE GVMM UP B DIBSEPOOBZ BOE B T UP B POH CFM SFE JBO 8FTU "VTUSBM E BOE GPP PE #BMJOU (SPVQ XIFSF HP U PG KFD TVC MBS PQV B Q BZT XJOF JT BMX DPOWFSTBUJPO

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47 47

Theatre

y r e v E h t a e Br There is not a minute to lose in Damon Lockwoodâ&#x20AC;&#x2122;s schedule. The actor/comedian/playwright/writer/ magazine editor â&#x20AC;&#x201C; and father of two young boys, â&#x20AC;&#x201C; is on a tight turnaround. Q Ben Elton and Damon Lockwood prepare for Gasp!

When Damon Lockwood spoke to Medical Forum he was between rehearsals for Neil Simonâ&#x20AC;&#x2122;s Laughter on the 23rd Floor, which was Black Swan State Theatre Companyâ&#x20AC;&#x2122;s winter laughter machine, and promoting Ben Eltonâ&#x20AC;&#x2122;s rework, Gasp! â&#x20AC;&#x201C; BSSTCâ&#x20AC;&#x2122;s spring release that opens at the end of 0DUPCFS 5IBU T OPU B CBE TDPSF o TUBSSJOH JO UIF XPSLT PG UXP PG DPNFEZ T NPTU DFMFCSBUFE XSJUFST %BNPO XIP IBT NBEF B OBNF GPS IJNTFMG BT B DPNJD BDUPS BOE TUBOE VQ DPNFEJBO IBT BMXBZT CFFO B XSJUFS BOE PWFS UIF QBTU TFWFSBM ZFBST IBT GPVOE SFBM USBD UJPO XJUI IJT QMBZT o I (honestly) Love You BOE Horsehead IJT TBUJSJDBM NPCTUFS UBLF IBWF CPUI IBE JOUFSOBUJPOBM PVUJOHT JO *UBMZ &EJOCVSHI BOE /FX :PSL i-BTU ZFBS XBT HSBUJGZJOH UBLJOH I (honestly) Love You UP CPUI UIF &EJOCVSHI 'SJOHF BOE /FX :PSL XIFSF XF HPU TUBOEJOH PWBUJPOT w IF TBJE

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By Ms Jan Hallam ED: Gasp! by Ben Elton opens at the Heath Ledger Theatre, October 25 to November 9.

Ancient

Anecdotes

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From: Inventum Novum, by Leopold Auenbrugger. 1761. 176 761. 1. I here present the reader with a new sign which I have discovered isco is c vveered rreed for for detecting fo detect de dete tect te ctin tin ng diseases dise di dis seases a ses as es of of the the chest. th ch ches hesst. t. heereby h rebyy, according re accoordin ac acco rd din ing to to the th hee character chaa rraact cter er of of the th he This consists in the percussion of the human thorax, whereby, particular sounds thence elicited, an opinion is formed off tthe hee iinternal h n er nt ern rn naa l sst state taatte of of the th hee ccavity. aavvit ity. t yy.. In In making maki ma a king k ingg ki public my discoveries respecting this matter I have been actuated act ctua tua uate ated tteed neither neiitth ne heer by by an a n itch iittch h for foorr writing, wri rittiingg, nor nor no a fondness for speculation, but by the desire of submitting ng ttoo m myy bbr brethren reetthr hren en tthe he ffruits he ruitts of ru ruit of sseven even ev en yyearsâ&#x20AC;&#x2122; eeaa rsâ&#x20AC;&#x2122; rsâ&#x20AC;&#x2122; rs observation and reflection.

medicalforum

medical forum FOR LEASE MURDOCH Wexford Medical rooms for lease. Phone: 0410 786 007 MURDOCH Brand new Medical Suite for Lease at the new Wexford Medical Centre. 106sq m, complete fit-out and ready to lease. Please contact: reception@ccwa.net.au

BUSSELTON Suite for lease 1/69 Duchess St Busselton t &YDFMMFOU $#% MPDBUJPO XJUIJO NFEJDBM dental complex opposite Police Station/Court House complex t $PNQSJTFT PGGJDFT MBSHF XBJUJOH boardroom, reception, kitchen lunchroom, storeroom & 2WCs. t "QQSPY GMPPS BSFB TRN Details: Trevor Frusher 0417Â 177 211 104 Queen St, Busselton (08) 9754 1522 e: trevor@profsbsn.com.au www.professionalsbusselton.com.au NEDLANDS Hollywood Medical Centre â&#x20AC;&#x201C; 2 Sessional Suites. Available with secretarial support if required. Phone: 0414 780 751 MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email your interest to admin@sleepmed.com.au WANNEROO Specialist rooms available If you are looking for a consulting room to see patients in Wanneroo, we have rooms available Mon-Fri, from 8am-12pm, or 1pm-5pm, at 771 Wanneroo Rd, Wanneroo $150 + GST per 4-Hour Session. Friendly, professional reception staff to welcome your patients. For further details Contact Practice manager Jody Donaldson Email: jsaunders.wthc@gmail.com or Phone: 9405 1234 Tuesday or Wed between 9.30am-1.30pm NEDLANDS HOLLYWOOD MEDICAL CENTRE Two new, large, professional, well-presented consulting rooms within specialist suite at Hollywood Medical Centre Full/part time lease or sessional basis available Available furnished or unfurnished Shared reception, office and patient waiting area Please contact Michelle/Emma on 08 6389 0244 for further details Or email: Info@perthcolorectal.com.au

APPLECROSS Applecross Medical Group is a major medical facility in the southern suburbs. Current tenants include GP clinic, pharmacy, dentist, physiotherapy, fertility clinic and pathology. Both the GP clinic and pharmacy provide a 7-day service. The high profile location (corner of Canning Hwy and Riseley St, Applecross), provides high visibility to tenants in this facility. A long term lease is available in this facility â&#x20AC;&#x201C; with the current layout including 4 consulting rooms, procedure room and reception area. Would suit specialist group, radiology or allied health group. Contact John Dawson â&#x20AC;&#x201C; 9284 2333 or 0408 872 633 MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: cford@cyllene.uwa.edu.au NEDLANDS Available now. Use of rooms at Chelsea Village on M T W only. Easy parking. Nicely appointed examination room would suit nonprocedural eg medicolegal examinations or paramedical. You open up, have sole use when required, then lock up. Occasional use or long term. Flat $275 per day use. Contact Dr Peter Burke 0414 536 630 MURDOCH Consulting room for lease at the new Wexford Medical Centre, Murdoch. Well lit, spacious sessional consulting rooms for lease. For further information please contact Murdoch Specialist Physicians on 9312 2166 or email us at admin@murdochspecialistphysicians.com.au

FOR LEASE OR SALE MURDOCH An attractive suite at SJOG Murdoch Medical Clinics. This fully self-contained, recently vacated suite is 47sqm and has a reception area, kitchen, and consulting room. Rent: $18,500 plus outgoings pa. For a long term tenant, suite reconfiguration would be considered. Please contact 0407 192 227

FOR SALE BUSINESS & PREMISES Plastic Surgery Business & Premises Prominent West Perth Location Well-established Plastic Surgeon looking to phase out and hand over the reins. Premises are spacious, well appointed & fully equipped. Stable staff and systems in place. Contact â&#x20AC;&#x201C; Brad Potter â&#x20AC;&#x201C; 0411 185 006

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

GENERAL FOR SALE

URBAN POSITIONS VACANT

EMG Machine (Keypoint Medtronic) portable. Fully computerised (Toshiba), complete with cart, printer and all necessary software. Used minimally ie. as new Cost $28,000 Sell $12,000 Phone 9381 9934 or 0431 369 292

GREENWOOD Greenwood/Kingsley Family Practice The landscape of general practice is changing, and it is changing forever. Are you feeling demoralised by the recent Federal Government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? *U EPFTO U IBWF UP CF UIJT XBZ Come and speak to us and see the different ways in which we operate our general practice. Be part of the game changer! Practice Associateship would be considered for the right applicant. Our practice is located north of the river. Sorry we are not DWS. Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion.

PRACTICE FOR SALE ALBANY Private Psychiatric Practice A great opportunity to live and work in scenic Albany by taking over an established private practice. Providing private psychiatric care for Great Southern Region (Population: approximately 50,000) Good supportive network of skilled General Practitioners sharing in the care and management of Psychiatric patients. No private hospital and patients needing inpatient care are transferred to Perth. No after-hours work. Peer review groups with Psychiatrists working at Public Mental Health. Phone Felicity: 9847 4900

PSYCHIATRISTS INVITED

BIBRA LAKE - Psychiatrist wanted Are you intending to start Private Practice? This is a sheer walk-in! Part time, sessional or full time â&#x20AC;&#x201C; all enquiries welcome. Furnished consulting rooms available at: Bibra Lake Specialist Centre, 10/14 Annois Rd, Bibra Lake WA 6163 Currently 4 practising Psychiatrists and clinic is open Tuesday to Friday 7-day pharmacy and GP surgery next door are added advantages. 5 minute drive to St John of God and upcoming Fiona StanleyHospital. Phone Navneet 9414 7860

RURAL POSITIONS VACANT ALBANY t 4U $MBSF T JT B OFX GBNJMZ QSBDUJDF based in Albany t 4NBMM GSJFOEMZ QSBDUJDF t 'VMM UJNF OVSTJOH BOE administration support t 1BUIPMPHZ PO TJUF t 'VMM PS QBSU UJNF (1 XBOUFE UP join our team t 4QFDJBM JOUFSFTU JO TLJO XPVME CF JEFBM t $VSSFOUMZ OP %84 VOMFTT XJMMJOH UP work in after-hours period t (1T OPU SFRVJSJOH TVQFSWJTJPO SFRVJSFE Please contact practice manager Belinda Elliott Tel: 9841 8102 Email: belinda@stclare.com.au Or send your CV through and we will get back to you.

ASCOT Part-Time VR GP required for our well established Accredited Privately Owned Friendly Family Practice in Redcliffe. We are fully computerised, using Best Practice software. Nurse is support available. Non DWS area. Please call â&#x20AC;&#x201C; 9332 5556 NORANDA Female GP required for a fully accredited, fully computerised, privately owned practice in Noranda. With on-site dentist, podiatrist and physiotherapist. Hours to be discussed with owner of the practice. Please contact our friendly team on (08) 9276 8526 or phone 0412 260 491. Alternatively you can email at: brgp@iinet.net.au SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979 MANDURAH Mandurah coastal lifestyle 40 minutes from Perth. VR non VR doctor required short term or long term. No weekends or after hours. Good remuneration. Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist and orthotics. Contact practice manager Elaine 9535 8700 Email: elaine@mandurahdoctors.com.au MINDARIE GP required for our busy privately owned practice in Perth Northern Suburbs. VR or Non VR Generous remuneration package available Fully computerised Nursing and clerical support available Onsite pathology and allied health Please contact us via email: mkmc@iinet.net.au or Call Dr Melad Benyamine either Before 9:00am or After 6:00pm on 0412902522

NOVEMBER 2014 - next deadline 12md Wednesday 12th October - Tel 9203 5222 or jen@mforum.com.au

medical forum

WEST LEEDERVILLE Great Lifestyle! Part time (up to full time) VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: glenstreetpractice@iinet.net.au or call Jacky, Practice Manager on 9381 7111 / 0488 500 153 PALMYRA VR doctor required for full/part time work. We are a friendly, private, non-corp practice situated in Palmyra. Our surgery is accredited with modern facilities and has fantastic doctors, nurses & reception staff. If you would like to join us please email your CV to helen@leeuwinmedical.com.au KELMSCOTT Expressions of Interest Vocationally Registered General Practitioner Wanted South of the River Temp/Perm position Email CV to armitage@highway1.com.au

YOKINE Part-Time VR GP required for a small privately owned practice in Yokine. Female GP preferred to help our existing female GP. Family friendly practice with nursing support and a lovely team of receptionists. Our GPs have full autonomy. Private billing. Fully computerised. Accredited. On-site pathology. Allied health rooms attached next to the practice. Excellent remuneration is offered to the right applicant, but we are not in an area of need. Please contact Jayne Jayne@swanstsurgery.com.au or Dr Peter Cummins peterc@swanstsurgery.com.au for further information.

PERTH CBD Full and part time VR GPS to join our busy inner city practice located in the Hay Street Mall. Non-corporate, mainly private billing, accredited, fully computerised with full admin and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates Please contact Debra on 0408 665 531 to discuss or Email: drogers@perthmedicalcentre.com.au KINGSLEY Fantastic opportunity. A modern state-ofthe-art, paperless clinic. 100% private billing. Flexible hours & your choice of patient case load, treat the patients you want. Email resume & cover letter to km@kingsleymedical.com.au www.kingsleymedical.com.au

Expression of Interest General Practitioners A Great Opportunity for those looking to practice diverse medicine in a supported environment Are you ready for a challenging career? Benefits: t 0QQPSUVOJUZ UP QSBDUJDF EJWFSTF medical care to an ageing population t (FOFSPVT QSPGFTTJPOBM development opportunities t 'MFYJCMF XPSLJOH BSSBOHFNFOU o BO opportunity to choose your hours t 8PSL XJUIJO B NVMUJ EJTDJQMJOBSZ UFBN t /VSTJOH "MMJFE )FBMUI BOE administration support t 4VQQPSUJWF DPMMFHJBUF UFBNT t *OUVJUJWF FMFDUSPOJD QBUJFOU management system Life Style Opportunity Join our multi-disciplinary team of dedicated health care professionals at Southern Cross WA, a Not-for-Profit organisation providing aged care services for over 50 years. The organisation successfully ventured into mental health care over ten years ago and is now growing our medical and health care business. The General Practitioner will be an JOUFHSBM QBSU PG 4PVUIFSO $SPTT $BSF T OFX service offering. Some details of the role: t 1SFEPNJOBOUMZ XJUIJO 1FSUI Metropolitan area t $IPPTF ZPVS IPVST GSPN BN UP QN Monday to Friday t 'VMM UJNF PS KPC TIBSF t PG UIF CJMMJOHT PS IPVS whichever is greater Clinical Area of Practice Geriatric medicine, palliative care and mental health management in the following settings: t 3FTJEFOUJBM DBSF t 3FUJSFNFOU WJMMBHFT t $PNNVOJUZ t *O IPNF DBSF Requirements: t 'VMM "VTUSBMJBO .FEJDBM 3FHJTUSBUJPO with AHPRA and FRACGP t &MJHJCMF UP BQQMZ GPS .FEJDBSF Provider Number t $PNNJUNFOU UP BDIJFWJOH CFTU client outcomes within a multi disciplinary team t &YDFMMFOU PSHBOJTBUJPO BOE communication skills I would like to hear from you to discuss this rewarding position further. Please call 1300 669 189 or send your resume to Hakeem at hkhan@scrosswa.org.au KARDINYA Non-corporate General Practice presents opportunity for VR P/T GP to join an exceptional team. Well managed, long established 5 doctor practice offers a comprehensive CDM program with 3 RGN support along with onsite pathology and podiatry. Enquiries to Practice Manager on 0419 959 246 or practicemanager@kelsomg.com.au

MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new non corporate practice with 2 female & 1 male General Practitioners. Sessions and leave negotiable, salary is compiled from billings rather than takings. Up to 70% of billings paid (dependant on experience). Please contact Jacky on 0488 500 153 or E-mail to jacky-steven@live.co.uk

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity for FT/PT doctor in a State of art clinic, inner-metro, Nursing support, Pathology and Allied services on site. Private billing. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979 Email: o_takla@yahoo.com

JOONDANNA We are seeking a VR GP to join our friendly team on a part-time or full-time basis. Flexible hours and billing. Fully-computerised. Privately-owned practice. Pathology collection on site. Please call Wesley on 0414 287 537 for further details. CANNINGTON Southside Medical Service is an accredited practice located in Cannington area. We are a family practice and offer mixed billings. We have positions for a GP to join 3 GPs currently working. It is a well-positioned practice, close to the Carousel Shopping Centre. Phone: 9451 3488 or Email: practicemanager@southside.com.au

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

MINDARIE Harbourside Medical Centre is looking for a GP preferable VR FT/PT, Accredited medical centre, onsite pathology, fully equipment and nurse, utop70% billing. Contact 0417813970 or mmutahar@ harboursidemedicalcentre.com.au <Australian Medical Visas Logo> Are you looking for doctors for your medical practice? Australian Medical Visas is owned and run by 2 Practice Managers based in WA, XIP IBWF PWFS ZFBST FYQFSJFODF PG UIF UK and Australian healthcare systems. We currently have a number of doctors who are looking for positions in Australia. We are able to assist practices with all paperwork involved including the migration process (if required). Please visit our website www. australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or Andrea on 0401 37 1341.

MANDURAH Full time VR GP required for busy established, accredited practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed by 10 doctors and 4 experienced Registered Nurses. Relocation fees are negotiable Generous remuneration, no DWS please. No on-call. Contact Ria 9535 4644. Email: Mandmedi@wn.com.au

NURSING POSITION VACANT WEMBLEY DOWNS Casual Practice Nurse Ocean Village Medical Centre in Wembley Downs requires a casual practice nurse (RN). Modern fully computerised private and bulk billing practice. We are a non-corporate practice. Contact anthony.lau@ovmc.com.au for more details

WANTED TO BUY OR LEASE GP PRACTICE REQUIRED Looking to buy or lease. *O 1FSUI T OPSUIFSO TVCVSCT 1-3 doctor practice. DWS Area. Call Eric on 0469 177 034 or leave a message

Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. * full-time/part-time/sessional * medical systems and secretarial support * adjacent to Fiona Stanley Hospital More information phone: 9366 1802 or email: diane.car@sjog.org.au

NOVEMBER 2014 - next deadline 12md Wednesday 12th October - Tel 9203 5222 or jen@mforum.com.au

medical forum ARE YOU WANTING TO SELL A MEDICAL PRACTICE? Skin Cancer and Cosmetic Clinic As WAâ&#x20AC;&#x2122;s only specialised medical business broker we have sold many medical practices to qualiďŹ ed buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible. We are committed to maintaining conďŹ dentiality. You will enjoy the beneďŹ t of our negotiating skills. Weâ&#x20AC;&#x2122;ll take care of all the paper work to ensure a smooth transition.

To ďŹ nd out what your practice is worth, call:

Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au

in Joondalup seeks an enthusiastic committed doctor to replace one of our female doctors, who is departing after several years. We are a very busy, state of the art clinic with a largely private billing clientele. You will have experience and qualifications in Skin Cancer Medicine (essential), and an interest in cosmetic medical procedures. Training in the latter can be arranged if desired. The successful applicant will inherit a very busy, largely private billing practice of skin cancer and cosmetic patients. Significantly above average income can be achieved for the right candidate. In addition, we have a very pleasant working environment with modern CBD premises, weekly lunch meetings at local restaurants etc. Website: www.moleclinic.com.au Enquiries to Emma on 9301 1825 or by Email to ozdoc123@gmail.com

RADIOLOGIST WANTED

Brand New, State-of-the-art p Medical Centre opening August 2014

GPâ&#x20AC;&#x2122;s â&#x20AC;&#x201C;Joondalup, weekend w work, DWS , guaranteed minimum income of $180 an hr Cand Candidates didates must have FRACGP or equivalent. TThis hiss ssuperclinic up uperclinic up is lo oc located in a DWS area. To ďŹ nd out m more contact: ofďŹ ce@apollohealt ofďŹ ce@apollohealth.biz | 08 6142 9275

FOR LEASE

Medical Suite for Lease Long term lease available 38 Arnisdale rd Duncraig (Opposite Glengarry Private Hospital) Ĺ&#x201D; High Quality ďŹ t out Ĺ&#x201D; 150m2 Ĺ&#x201D; Large Reception ( 2 person) and waiting room Ĺ&#x201D; Practice managers office Ĺ&#x201D; 3 Consulting rooms Ĺ&#x201D; 1 Treatment room Ĺ&#x201D; Full Kitchen Ĺ&#x201D; Large Conference room Ĺ&#x201D; Avaliable from Dec 1 2014

Call Dr Cliff Neppe 9203 7600

SKG Radiology is a highly recognised private Radiology group, providing imaging services at 20 locations throughout Western Australia. We are seeking a dedicated and enthusiastic Radiologist with FRANZCR qualiďŹ cations or equivalent to join SKG Radiology. To be successful in this role you will need expertise in the areas of: Ĺ&#x201D; General, CT, Ultrasound, Image Guided Procedures and Mammography. Ĺ&#x201D; A Fellowship in Subspecialty areas of radiology is desirable. SKG Radiology offers an attractive salary package, beneďŹ ts and excellent working conditions. Please forward your Curriculum Vitae via email to: Julie Rogers, Executive Assistant to the CEO, SKG Radiology. Email: julie.rogers@skg.com.au

Our busy, well-run clinic requires part-time GPs for ongoing sessional work; working with domestic, international students and staff. t 'MFYJCMF TFTTJPO UJNFT BWBJMBCMF .POEBZ UP 'SJEBZ t (SFBU PQQPSUVOJUZ UP XPSL JO B WJCSBOU EZOBNJD FOWJSPONFOU XJUI EJWFSTF OFFET t 8F PGGFS OFX QSFNJTFT BOE DBO TVQQPSU ZPV XJUI B UFBN PG FYQFSJFODFE OVSTFT QTZDIPMPHJTUT BOE GSJFOEMZ BENJOJTUSBUJWF TUBGG t &YDFMMFOU SFNVOFSBUJPO PG CJMMJOHT oCVMLCJMMFE BOE QSJWBUF BOE GSFF SFTFSWFE PO DBNQVT QBSLJOH BWBJMBCMF "O JOUFSFTU JO BOE FYQFSJFODF XJUI XPSLJOH XJUI ZPVOH QFPQMF NFOUBM IFBMUI TFYVBM IFBMUI BOE USBWFM IFBMUI JT FTTFOUJBM 1MFBTF DPOUBDU -JTB $SBOmFME 5FBN -FBEFS .VSEPDI )FBMUI BOE $PVOTFMMJOH 4FSWJDF PO PS email l.cranďŹ eld@murdoch.edu.au

NOVEMBER 2014 - next deadline 12md Wednesday 12th October - Tel 9203 5222 or jen@mforum.com.au

medical forum Venosan Diabetic Socks

Southern Suburbs GP required for after-hours & weekends Non-VR Dr’s encouraged to apply. Send applications to hr@betterhealthcare.com.au

The Magic of Silver for Sensitive Feet No Compression Silver Ion Therapy Contains the antimicrobial silver yarn Shieldex® which enhances a balanced foot climate.

WANNEROO

Specialists rooms available – If you are looking for a consulting room to see patients in Wanneroo we have rooms available Mon-Fri from 8am-12pm or 1pm-5pm at 771 Wanneroo Rd Wanneroo. $150 + GST per 4 Hours Session. Friendly, professional reception staff to welcome your patients.

Tested and proven in controlling over twelve types of bacterial and fungal infections common on the feet and legs. t

Silver yarn - is permanent and cannot be washed out of the socks.

Keeps feet cooler in the summer and warmer in the winter

Comfort for The Patient

For further details Contact Practice manager Jody Donaldson Email: jsaunders.wthc@gmail.com or Phone: 9405-1234 Tuesday or Wed between 9.30am-1.30pm

Soft-Spun Cotton - Ultra soft cotton

Fully cushioned foot and fully cushioned sock

Comfortable for arthritic patients

Flat Seam Safety No noticeable seams due to hand-linked toe section. This reduces chafﬁng and blistering that could result in infection and skin ulceration.

Non-restricting cuffs

– avoids restriction of circula-

tion.

Colours – available in Silver (essentially a white sock with Silver yarn) & Black.

Sizes – available in 3 sizes (Small, Medium & Large).

Your WA Consultant – Jenny Heyden RN Tel 9203 5544 or Mob 0403 350 810

NOVEMBER 2014 - next deadline 12md Wednesday 12th October - Tel 9203 5222 or jen@mforum.com.au

medical forum 7 Day Medical Centre &MMFO )FBMUI GPSNFSMZ &MMFO 4USFFU 'BNJMZ 1SBDUJDF IBT SFMPDBUFE UP UIF IJTUPSJD #FBDPO 5IFBUSF PO UIF DPSOFS PG 8SBZ "WFOVF BOE )BNQUPO 3PBE JO 'SFNBOUMF DP MPDBUFE XJUI QIBSNBDZ QBUIPMPHZ BOE BMMJFE IFBMUI %PDUPS PXOFE BOE NBOBHFE &MMFO )FBMUI JT B NVMUJEJTDJQMJOBSZ UFBN TUSJWJOH GPS FYDFMMFODF JO IFBMUI DBSF Limited opportunity remains for GPs and specialists to join our large BOE IBQQZ UFBN &ORVJSF UPEBZ o ZPV UPP DBO FOKPZ UIF FBTF BOE DPOWFOJFODF PG GVMMZ TFSWJDFE SPPNT HFOFSPVT OVSTJOH TVQQPSU BOE UFSSJmD GBDJMJUJFT 8F BSF QBSUJDVMBSMZ TFFLJOH EPDUPST XJUI FYQFSUJTF JO TLJO DBODFS PDDVQBUJPOBM IFBMUI BOE "GUFS )PVST (1 TFTTJPOT Call practice manager, Amber Kane, on 9239 0200 or email practicemanager@ellenhealth.com.au

ARE YOU READY FOR A CHANGE? We are looking for specialists and GPâ&#x20AC;&#x2122;s to join the expanding team! Tenancy and room options available for specialistâ&#x20AC;&#x2122;s. Procedural GPâ&#x20AC;&#x2122;s and ofďŹ ce based GPâ&#x20AC;&#x2122;s well catered for. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

GP Opportunities in WA Available Now

Looking for a rejuvenating change in your career? Due to continued growth, IPN is currently looking for GPs for opportunities within our Medical Centres. As a valued GP, you will enjoy freedom, ďŹ&#x201A;exibility and clinical sovereignty, with a busy patient base. Each centre is run by a Practice Manager and the team is supported by a Business Manager.

Stimulate your career today! supportive, Join oin n IIP IPNâ&#x20AC;&#x2122;s supp ortive, collegiate network and a d discover ďŹ&#x201A;exibility and work-life balance ba ance for you. To make a conďŹ dential onďŹ dential enquiry about GP Opportunities pportunities in WA or to ďŹ nd out more, contact Craig on:

0427 744 097 craig.coombs@ipn.com.au mbs@ipn.com.au Supporting Better Medicine www.ipn.com.au NOVEMBER 2014 - next deadline 12md Wednesday 12th October - Tel 9203 5222 or jen@mforum.com.au