Medical ForumWA 09/13 Public Edition

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Perth Pathology

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CONTENTS

33 Spinal Cord

FEATURES 9

Celebrity Spotlight: Nathan Charles

12

Trailblazer: Prof Harvey Coates

20

How Secure is Your Surgery?

Research " 1SPG 4UVBSU )PEHFUUT

34 Addressing Non-

Urgent KEMH Backlog %S 7JDLJ 8FTUPCZ

9

42 Social Pulse –

Doctors on the Town

NEWS & VIEWS 2

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8

Editorial: Groups that Love Us Back

10

Have You Heard?

14

Ongoing Childhood Research

15

Community Action on FASD

19

PCEHR: One Year On

22

Health Apps Challenge

23

Avatars in Health

24

Practice Tip

28

Stigma Ends With a Handshake

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30 Don’t Gamble with

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Support Group: Arafmi

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E-POLL EVENTS 17

20

30 Doctors Drum

Breakfast 41

40 Dr Ken Collins:

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44 Blue Man Group

People Behind the Frontline Services

44 Dr Tony Barr,

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Practice Accreditation

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Your Say on D-G of Health

LIFESTYLE

'EyeT' apps

Confessions of a Pedal Pusher

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29

Approaches to Chronic Cough

pain

DoH: ‘Leavers’ and Liquor Licensing

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Congenital ‘Holey’ Hearts: Patent Ductus Arteriosus

38 Injections for ‘hip’

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28

Sunlight and the Eye

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GUEST COLUMNS

25

Spitzoid Tumours

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38 Conference Corner

24

7

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35 Beneath the Drapes

16

CLINICAL FOCUS

42

sculptor 45 Wine Review:

Swooping Magpie %S -PVJT 1BQBFMJBT

46 The Funny Side 47

Storm Boy

48 WASO and WAYO 49 Competitions

1

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

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

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website.

Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

The support of all advertisers, sponsors and contributors is welcome.

Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reflect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended.

All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

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

GRAPHIC DESIGN 2 Thinking Hats

Letters

Coercion not the answer Dear Editor, It was Mencken who wrote, "For every complex problem there is a solution that is simple, neat, and wrong". When it comes to workforce and workforce distribution, the problem is complex and we have seen plenty of simple, neat, and wrong solutions. Bonding medical students (Bonded to the Bush, August 2013) through the medical rural bonded scheme (MRBS) might be simple and neat. Is it wrong?

From an ethical point of view, I'm concerned about who we are bonding. At 17, I was a bonded student teacher because that way my parents could vaguely afford so-called free university education. Had there been bonded rural medical student places, would I have taken one of those instead? Yes, I would have.

But just as Dr Wilson points out, I didn't much understand or consider what the bond might mean in practice in several years' time.

From a workforce point of view, I'm concerned about the effectiveness of bonding. Over two decades, and from both sides of the equation, I've seen registrars wangle in and out of all sorts of commitments, and I've seen them released as well – usually for good reasons. History has shown us that forcing registrars to go where they do not want to go, simply does not work.

Rural peak bodies have come to the same conclusions. Rural posts want doctors who want to be there.

From a training point of view, I'm concerned about the message bonding sends about rural practice. It doesn't do justice to the amazing work rural doctors do every day of their own unfettered will, or to the attractiveness of rural life and practice.

At WAGPET, we are able to fill our rural quota with competent doctors and meet our target rural and remote distribution without enforcing a compulsory rural component.

However, are bound relationships any worse than freely chosen ones? Partners must invest in any relationship to make it mutually beneficial.

For instance, bonded students could be offered top-pick clinical rotations at all stages of their education and training. They could be given a mentor, holiday paid positions that count towards their rural obligation, extra courses and opportunities to work beside those who have walked before them.

This is some of what WAGPET is working on with its partners WACHS, Rural Health West and the Rural Clinical School in the WA Rural Practice Pathway. It's what WACRRM did more than two decades ago, also without bonding.

We can make it as easy and enjoyable to train in rural as in urban areas, with persuasion rather than coercion. It's not just about picking rurally minded students early and making sure we don't lose them. It's also about providing a safe, quality, rewarding career for all, in places where doctors – whatever their background or early intentions might be – are most needed.

In pragmatic terms, I doubt the mechanics of the MRBS align with the kind of mutually respectful relationship I describe above. They are instead, in my view, rather draconian and punitive as well as illogical. I agree with Dr Wilson that registrar training should count towards the return of service period. Vocational training is an apprenticeship program, and doctors are providing clinical services during these years.

The Mason report addressed the various levers and programs dedicated to building rural health capacity and expressed ambivalence towards the MRBS as it currently stands. On reading the report, it is clear there are no neat or simple solutions to complex problems.

Harder and more important questions like models of care and perverse incentives and unintended barriers must be addressed. Let's hope whoever holds the reins after September 7 asks those who know that. Doctors like Dr Penny Wilson.

Dr Janice Bell, CEO WAGPET More letters P4

Star

Joke A bloke starts his new job at the zoo and is given three tasks.

First is to clear the exotic fish pool of weeds. As he does this a huge fish jumps out and bites him. To show who is boss he beats it to death with a spade.

Realising his employer won’t be best pleased he disposes of the fish by feeding it to the lions, as lions will eat anything.

Moving on to the second job of clearing out the Chimp house, he is attacked by the chimps who pelt him with coconuts. He swipes at two chimps with a spade killing them both. What can he do? Feed them to the lions, he says to himself, because lions eat anything.

He hurls the corpses into the lion enclosure.

He moves on to the last job which is to collect honey from the South American Bees. As soon as he starts he is attacked by the bees. He grabs the spade and smashes the bees to a pulp. By now he knows what to do and throws them into the lions cage because lions eat anything.

Later that day a new lion arrives at the zoo.

He wanders up to another lion and says "What's the food like here?"

The lion says: "Absolutely brilliant, today we had Fish and Chimps with Mushy Bees."

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3

Letters Continued from P2

Role of agencies

Response

Dear Editor, A small number of doctors providing locum services to public hospitals are having their terms of employment manipulated, and perhaps compromised, by locum agencies that dictate the terms and conditions under which they are being employed.

This happens even if you are using an incorporated private practice company (Pty Ltd Contractor). The use of Agencies for locum employment stands in the way of open and transparent negotiation between employer and service provider.

These agencies may also have conditions that favour them and must be agreed before they will act for the medical practitioner.

Direct independent negotiation between doctor and hospital over conditions of service is discouraged. Are the agencies and public health system looking after each other’s interests to the detriment of the locum medical practitioners?

I would be very interested in the experiences and opinions of other locums.

Dr Michael Marsh

On any one day we provide locum and longterm contracts across all districts and regions in every state and territory.

I hope the below answers the statement (see left) at least in a general sense.

Firstly locum agencies are usually paid a fee based on the percentage of the total remuneration of a medical practitioner. It is against our commercial nature to not lobby and negotiate for the best possible terms for medical practitioners. We also deal with thousands of contract negotiations a year so we are best placed to know the medical industry and market and the most favourable terms and conditions at that time.

Despite the terms and conditions that locum agencies use, there is a huge element of trust imparted to practitioner and client.

For example, our terms and conditions have a further involvement clause – by no means are we suggesting we be privy to verbal conversations between ‘employer’ and practitioner but unfortunately it is not uncommon that after a first assignment the terms are discarded and the agency

by-passed for future assignments. The time, money and years of networking, referencing, credentialing, telephone calls, emails, advertising and marketing which go into agencies establishing a trusted network of practitioners and clients is substantial and has to be protected, to an extent.

Locum agencies are now more than ever open and exposed to a myriad of legal responsibilities with recent legislation change in Work, Health and Safety. We as the agency are just as exposed as the ‘employer’ and can and will be treated as one and the same when it comes to non-compliance, fines and criminal prosecutions. Our compliance at this agency is particularly stringent along with our contract terms and we insist that these are completed before allowing practitioners to work. The safety and protection of doctors, clients and patients is of equal and paramount importance to us.

To enable further comment and discussion it would be interesting to hear the exact terms and conditions or scenarios that are causing concern. Please do not hesitate to contact us further.

Terry Cornick, Manager, General Practice & Medical Imaging, Charterhouse Medical

Send in your letters by September 10 to editor@mforum.com.au

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Editorial Letters Continued from P4

IMGs are valued Dear Editor, Rural Health West is the rural health workforce agency for WA, focused on recruiting and supporting health professionals in rural and remote areas. In the last financial year, Rural Health West placed 43 general practitioners into rural communities, a large percentage of whom were International Medical Graduates (IMGs).

The 2012 Minimum Data Set Report and Workforce Analysis produced by Rural Health West indicated that of the 741 currently practising rural general practitioners, 51.8% had obtained their basic medical qualification overseas.

Regarding the letter (IMGs Needs Support, August 2013), Rural Health West acknowledges that these doctors provide much needed services, and contribute significantly to the health and sustainability of rural and remote communities. We are committed to supporting our valued IMGs by providing access to high quality clinical and professional orientation; education and training support based on individual need; as well as a family orientation to assist them in settling into their new life.

We acknowledge the courage of many of these families in choosing to move to Australia and start a new way of life, and we

aim to provide as much support and care as possible, both prior to and after their arrival.

Ms Belinda Bailey CEO, Rural Health West

We must benefit from our research Dear Editor, Thank you for raising awareness of the groundbreaking muscular dystrophy research being undertaken

by Profs Steve Wilton and Sue Fletcher (Knowing is One Thing… August, 2013).

Their exon-skipping approach to possible treatments for those with muscular dystrophy and other so-called ‘rare diseases’ holds world-wide appeal.

For many years, Muscular Dystrophy WA has assisted in funding this research. We are excited to review the promising results of the Ohio Phase IIB trial of Eteplirsen of boys with Duchenne muscular dystrophy (DMD). Obviously, we are impatient for Western Australians to have access to trials and/or treatments emanating from WA research. As Prof Wilton identifies, the inexorable and unrelenting progression of the disease means that the boys and young men with DMD become weaker, day by day.

The Phase IIB trial is demonstrating a slow-

down in the progression of the disease and it can be postulated that earlier intervention with Eteplirsen will have a longer lasting and more profound outcome than if treatment is delayed.

The licensing agreement with Sarepta Therapeutics provides us with hope that capacity can be increased to the requisite scale to allow Western Australians to benefit. Government support and funding is paramount – both here in Australia and overseas.

We need to ensure that we are ‘trial-ready’ and ‘treatment-ready’. Following relentless campaigning by Muscular Dystrophy WA and other muscular dystrophy support and advocacy groups, the Australian National DMD Registry was launched here in November 2010. The Registry collates an individual’s gene sequence and clinical information about their disease. This information will assist clinicians in quickly identifying patients suitable for trials of therapeutic strategies. Other neuromuscular disease registries have since commenced.

These national registries were developed and are coordinated by the Office of Population Health Genomics, Department of Health WA. Many muscular dystrophy initiatives have commenced here in WA. Western Australians must be given the opportunity to benefit from them.

Mr John Gummer, CEO , Muscular Dystrophy WA

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medicalforum

Spitzoid Tumours S

pitzoid tumours encompass Spitz naevi, spitzoid melanoma and atypical spitzoid tumours. The distinction between Spitz naevi and melanoma remains one of the most difficult areas in the field of dermatopathology.

The Spitz nevus, originally described

by Sophie Spitz in 1948, is a benign melanocytic lesion that shows histological nuclear and cytological pleomorphism and is therefore prone to misdiagnosis as a melanoma.

Spitz naevi usually present as a solitary rapidly growing pink, red, brown or black dome shaped papule or nodule in children, adolescents and young adults, most frequently on the head, neck and extremities (fig 1). The size of the lesion stabilises after an initial phase of rapid growth (in contrast to the slow continuous growth of melanomas). Spitz naevi rarely occur in elderly patients. The incidence of Spitz naevi in adults, however, is probably understated.

Agminated Spitz naevi present as multiple Spitz naevi in a single area and rare cases of widespread eruptive Spitz naevi have been described. Reed naevus is regarded as a pigmented spindle cell variant of Spitz naevus. Heavily pigmented Spitz naevi and pigmented Reed naevi can be clinically mistaken for melanoma.

Dermoscopy of pigmented Spitz and Reed naevi may show the globular pattern

(central pigment surrounded by large peripheral globules) or starburst pattern (central pigment surrounded by radiating peripheral streaks or globules).

Spitz naevi are benign, have no capacity for metastasis and rarely recur even when the lesion is assessed as incompletely excised histologically. The management of Spitz naevi is controversial. Some centres recommend wider excision if the histologic margins are not cleared while others recommend clinical follow-up for adequately sampled but incompletely excised lesions.

Spitzoid melanomas refer to: 1. Melanomas showing striking histological similarities to Spitz naevus but having other histologic features that are readily recognisable as malignant on careful examination.

2. Lesions with histological features of classical Spitz naevus but which later develop nodal or distant metastases.

Despite their histologic similarities, Spitz naevi and spitzoid melanomas are biologically unrelated. The majority of spitzoid melanomas arise in adults and tend to be larger than Spitz naevi (>1cm). Their prognosis is similar to that of other forms of melanomas of the same tumour thickness.

Infrequently, they occur in prepubescent children and adolescents. These lesions are often misinterpreted as benign because of the reluctance of pathologists to diagnose

Q Fig 1. Image courtesy of Dr Philip Singh

By Dr Minh Lam, Consultant Dermatopathologist melanomas in children and the difficulty in diagnosis.

Often their malignant behaviour is not realised until metastasis has ensued. A subset of those that occur in children and adolescents may represent a distinct clinicopathological entity. Some small studies show that spitzoid melanomas in children have a more favourable prognosis than in adults. In these cases, the lesions have potential for lymph node metastasis but low potential for distant metastasis.

Atypical spitzoid tumours (aka spitzoid tumour of uncertain malignant potential) are lesions that have histological features intermediate between Spitz naevus and spitzoid melanoma and are not easily classified as benign or malignant by histologic examination. This is not a specific entity but an expression of diagnostic uncertainty.

There is no single histologic criterion for malignancy. Histologic features favouring malignancy include ulceration, size greater than 10mm, asymmetry, expansile nodule, pushing deep margin, impaired maturation, poor circumscription, excessive mitotic activity, deep mitoses, atypical mitoses, and necrosis. The threshold for the diagnosis of atypical Spitz naevus can vary between pathologists and different centres.

The clinical appearance of an atypical Spitz tumour is usually no different from a classical Spitz naevus. Other clinical characteristics such as lesions in older patients, a new lesion developing in the elderly, and the presence of solar damage favour melanoma. Atypical Spitz tumours require complete excision and regular review of the patient.

Genetic testing may provide the means to more accurate diagnosis of Spitzoid tumours in the future. Comparative genomic hybridisation has shown that the majority of Spitz naevi do not have any chromosomal aberrations and about 20-25% of Spitz naevi have a gain of chromosome 11p. This is in contrast to melanomas, which show multiple chromosomal gains and losses. A high rate of BRAF gene mutations is reported in common naevi and melanomas whereas BRAF gene mutations are infrequent in Spitz naevi.

Heenan Lam Skin Pathology Part of Perth Medical Laboratories P/L (APA): Independent, Pathologist Owned and Operated.

Contact Phone: 93863500 q 'BY 93863511 q 26 Leura St Nedlands WA 6005 medicalforum

www.heenanlamskinpathology.com.au

7

Editorial

Groups That Love Us Back This month, our prize for Research That Is Patently Obvious goes to people at UWA who said they found that adults who walk their dogs make more friends when they enter a new neighbourhood and the increase in physical activity is good for them. These startling revelations were presented to the International Association of Human-Animal Interaction Organisations in Chicago, thanks to funding support from a pet food company and a confectionary bar manufacturer!

Sponsors aside, anyone who has picked up smelly dog poo, dragged two marauding dogs away from each other, or had their every command ignored by a dog under the influence of hormones, will testify to the value of human groups around a common interest. You see dog groups in local parks after work, dogs illegally playing in the sandpit with children, or bouncing around waiting in vain for some parent to throw the ball. Instead, the adults continue to talk to each other until dark.

So it is for music groups, new mother groups, sports groups, craft groups – it’s all about sharing companionship around a common interest, from which lasting friendships often flow. Shared moments cherished for a lifetime.

It’s only until you get to Type A people like doctors that groups get more intense.

The photography people will attest to doctors buying up the shop so they can use the latest and greatest to capture the perfect shot – the same reason they join photography groups. Cyclists often get the million dollar graphite bike, treat the Tour de France like a religion and love donning the Lycra for a group ride. Whatever the group, there appears to be an element of doctor vs. the challenge.

And because we are so absorbed by our work, there are a zillion professional groups for which recreation often takes a back seat. It’s outcomes-focused and evidence-based instead. Some say there is a price to pay for the trust people put

in us and the altruism and caring we are expected to show. Does that mean we have to work harder and smarter to keep up?

But hold on a minute. The hallmark of doctors, the thing that distinguishes them from other professions like lawyers, engineers, boilermakers, pilots, policemen, is the humanity in what they do. This hungry child needs to be fed.

That’s precisely what we had in mind when we started the Doctors Drum breakfasts. Not so much to get an outcome, as to stimulate ideas around issues of humanity. No one wants to get up around dawn to be part of a discussion unless the topic grabs them, or the group does. I’m glad to say I think both are contenders.

It’s a mighty thing we can do, even without our canine friends. O

By Dr Rob McEvoy

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Celebrity Spotlight

Banging Down the Door Elite rugby union and Cystic Fibrosis aren’t normally mentioned in the same sentence but Nathan Charles from Western Force proves they are not mutually exclusive.

Nathan Charles is one of the first names ames to go down on the team sheet in thee Super Rugby season. In 2012 he wass the le only player to run on for every single is game. Despite having Cystic Fibrosis ralia at (CF), Nathan has represented Australia schoolboy level and competed at thee Under 20s Junior World Championship.

“I was diagnosed as a baby using thee sweat at test but having this condition hasn’t stoppe stopped ped me from being incredibly active. Myy parents encouraged me to play a lot of sport and as a youngster I was always outdoors playing laying T-ball, football and swimming. I had d a go at everything and that was good for myy lungs.”

“Having CF didn’t affect me much at all and, to be honest, I didn’t understand nd what it was. I just thought my life was normal.” rmal.l” However, there were times when thee reality reaa liity t of living with CF just couldn’t be ignored. nored.

“I’d have to take a few tablets and use se the nebuliser. That became noticeable when, like all young kids, I’d stay at a friend’s nd’s house and they’d ask me what the nebuliser ebuliser was all about. Sometimes I would get et a bit embarrassed about that but it never prevented me doing anything I wanted to do. I just refused to let it control my life.” defined Nathan, 24, is well aware of the significant role the world of medicine has played in his life.

It’s important not to be by this illness. You have to be disciplined and positive and I just won’t let CF run my life.

“I remember going to the clinic at Westmead Children’s Hospital in Sydney as a youngster. I also know that my parents tried to keep me out of hospital as much as possible because they were worried about the risk of infections.”

“My condition is well managed now and I go to Sir Charles Gairdner Hospital once every three weeks. I’m quite fortunate because I’ve got a milder case of CF, I don’t have to take pancreatic enzymes and I’m able to digest food easily and put on weight.

I don’t really fit the mould of the ‘typical’ CF person.”

The issue of drugs and sport is always contentious and rarely out of the news.

Nathan underscores the importance of knowing your own body and acknowledges the importance of a supportive medical team.

“The medication I take isn’t performance enhancing but, if there were any overlaps, I could apply for exemptions. You get to feel the changes in your own body and it’s a case medicalforum

of being proactive when you’re competing at this level. It’s all about following the correct protocols and procedures. There’s a great medical team here at Western Force, they’re on top of all that and it’s never been an issue.”

“It’s important not to be defined by this illness. You have to be disciplined and positive and I just won’t let CF run my life.”

There have been a number of significant advances in the treatment of CF, including lung transplants. But Nathan cautions against a sense of false hope.

“It’s fantastic the work that’s being done but it can be a bit like looking at Fool’s Gold.

You can get yourself excited thinking there might be a cure someday but if you keep focusing on that there can be a tendency to let life just slip past. I’m not hanging on by a thread so I don’t feel dependent on finding anything really groundbreaking.”

and funds f nds for research into the disease as a National Ambassador for Cystic Fibrosis Australia. That’s certainly opened my eyes to how some other people live their lives with this condition. Genetic counselling is much easier now with modern technology and it would certainly be good to limit the number of people who suffer from CF.” With a recent win against the NSW Brumbies the fortunes of both the Western Force and Nathan Charles are looking positive.

“I’ve always wanted to play for the Wallabies. It would be fantastic to pull on the yellow jumper, particularly in a World Cup. There’s a time limit in professional sport and you have to make the most of the opportunities. Rugby is certainly what I love to do!” O

By Mr Peter McClelland

“I do as much as I can to raise awareness 9

Have You Heard? to travel to major centres to have their medicals. A spokesperson for MHS said this was not the case. The company had only reviewed providers to assess them on the quality criteria and on the demand for services.

IMGs and bush medicine Last edition we had one doctor’s anonymous letter in support of the uprooting of IMGs and a Guest Column from Dr Penny Wilson, uncertain about her earlier decision to become one of 4500 students on a 10-year bonded recruitment to rural practice. The federal parliamentary report Lost in the Labyrinth (2012) looked at issues around our current national reliance on the 8460 IMG doctors working under the 10-year moratorium, many in rural areas but most in cities and large towns.

The RDAA and AMA have not favoured the moratorium as a way of getting doctors into the bush. Also arising from the report was the lack of opportunity for IMGs seeking registration in Australia to undergo clinical examinations. The Australian Medical Council (AMC) has just opened a test centre in Melbourne with facilities that match those of major teaching hospitals. It’s expected that the test centre will eventually take over all testing from the hospitals.

DSM-5 controversies The recent update of DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) after a 20-year gap, has sparked some controversy that we are medicalising normal behaviours so the medical industry (psychiatrists in particular) can treat accordingly. Things such as bingeeating disorder, hoarding disorder, and disruptive mood dysregulation disorder in kids reportedly have too-low thresholds.

Medical Forum received The Book of Woe by psychotherapist Gary Greenberg for review, billed as an expose of the psychiatric profession’s bible, and how human suffering has been turned into a commodity. For example, the author suggests the politics behind mental health classification of autism, ADHD and bipolar disorder has been linked to an unhealthy relationship with pharma companies and other parts of the medical industry. Given that escaping slavery and homosexuality were once classified as mental illnesses, it makes an interesting read.

Growing up male Pain perceptions change As part of Pain Week in July, Arthritis and Osteoporosis WA put on a inter-disciplinary workshop, Making Sense of Pain, around health professional engagement with people in pain. Before the workshop, participants were asked to complete an online questionnaire to encourage them to reflect upon their own beliefs and attitudes towards people in chronic pain. At the start of the workshop, they were given a case-study based on an actual patient with chronic pain and answered several questions around their management of that patient. This process was repeated at the end of the two-day workshop and the comparison of responses demonstrated that the majority (78%) of the participants had changed their practice towards evidencebased care. The first day was challenging discussion led by pain physicians, psychologists and physiotherapists. Day two was practical, putting skills into practice while being aware of inadvertently stigmatising and stereotyping patients.

[See p28 for our report on stigma with Prof Patrick Corrigan]

It’s a health hazard, or that’s the news from the team at the Australian Institute of Health and Welfare. In it's report into the health of Australian males 0-24, it comes as no surprise that the major cause of death was vehicle accidents with three times more males likely to die like this than females.

Also concerning was that 43% between the ages of 14 and 19 were at risk of injury from drinking too much alcohol over the past year; 6% in this age group smoked daily which was less than the 8% of girls who smoked; and of all chlamydia notifications among males, 53% of them came from males aged 15-24. The news is not so rosy for guys over 25 with obesity figures tipping 31% and 66% with a waist circumference that put them at risk of chronic disease.

It just leaves us holding our breath for the next 50 years.

Doctor to the Rescue

Visa medicals go walkabout

No room for bullying

A reader wrote into our website at www. medicalhub.com.au with concerns that Medibank Health Solutions (MHS), as providers of immigration medicals for the Department of Immigration, had stopped offering the service through approved GPs in country towns. Our correspondent thought that people would now have

Research conducted by Avant reveals that 44% of Australian doctors admit to outbursts of disruptive behaviour.

That’s interesting when you compare it with the 78% who say they’ve been on the receiving end of verbal abuse and physical intimidation. Dr Gerald Hickson, a US expert in disruptive behaviour

10

amongst doctors, has just completed a series of seminars around Australia, including Perth, discussing the issue. It’s a ‘no-brainer’ that the treatment and welfare of patients is directly affected by how medical practitioners interact with each other. A strained conversation (or worse) with a colleague followed by a difficult consultation with a demanding patient and ‘tell someone who cares’ comes to mind.

The Patient Advocacy Reporting System (PARS) in the USA suggests that there’s a direct link between positive interaction between doctors and better patient outcomes. And there’s a financial bonus – you won’t be paying for your lawyer’s next Porsche!

Travelling in an aeroplane is never the most relaxing pastime. Airborne medico Dr Ken Harvey became so incensed reading an advertisement in both the Virgin Voyeur and the Jetstar Traveller that he actually wrote a letter! The object of his derision was a ‘scientifically proven’ claim by Scala Fat Blaster Garments that a new patented technology called Active Bio Crystals embedded in tight-fitting underwear would melt away those pesky muffin-tops and cellulite. Apparently the wonder crystals emit Far Infra Red Rays (FIRRS). POW! No more fat! Unsurprisingly, the Therapeutic Goods Advertising Complaints Panel found in favour of Dr Harvey. O

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Trailblazer

Hearing is believing The world of paediatric ENT is full of amazing possibilities and Prof Harvey Coates wants to be there to watch it all unfold.

It only takes five minutes of being in the company of paediatric ENT surgeon Prof Harvey Coates to realise that it will take more than a ‘significant birthday’ and the barely mentioned ‘R’ word to slow him down. His conversation is bubbling with excitement as he explains breakthroughs in otolaryngology and what they will mean for thousands of children, many of them Aboriginal, and many struggling to meet developmental milestones because of hearing loss.

When Medical Forum caught up with Harvey last month, the third edition of the Aboriginal and Torres Strait Island Ear Health Manual had just been published, supported by Telethon7 Foundation. He and a team of ENT specialists, including A/Prof Kelvin Kong, Dr Alastair Mackendrick, Prof Francis Lannigan, A/Prof Shyan Vijayasekaran and Dr Paul Bumbak, as well as audiologists, speech pathologists, researchers and health workers, collaborated on the manual, which Harvey says will help health teams keep up to date on the management of middle ear disease.

Harvey coordinates about 16 trips to the Kimberley each year by specialists from around the country; such is, he says, the collaborative nature of the paediatric ENT community.

“What we see in the Kimberley is basically disease of poverty; of overcrowding, poor diet or no running fresh water, lack of general hygiene and access to medical treatment. But also, if there isn’t a feeling among parents and grandparents that a runny ear is a significant problem because they’ve had it themselves for a lifetime, then all these things coalesce to form social determinants for ill health.”

The man who has dedicated more than four decades to research and treatment of ear disease knows all the responses there is to have – from better housing to washing hands, but it could be simpler than that. “There’s a GP in Alice Springs who tells anyone who’ll listen that he can cure chronic ear disease if he gives each child an orange a day – not Vitamin C but real oranges. It makes sense. These children are eating the least expensive food, which is full of carbohydrate and sugar.”

“Groups such as the EON Foundation encourage communities to produce their own food and I reckon this is the way to go. It’s much better to give kids fresh fruit than to give them antibiotics.” Harvey has long seen the benefit of mobile and flexible 12

Q Prof Harvey Coates has dedicated four decades to improving Aboriginal children's ear health.

solutions to apparently insurmountable problems, with the ear buses a perfect example. Two buses sponsored by Variety WA, travel through the Metropolitan area and South-West examining vulnerable children's ears and putting them on the appropriate treatment pathways and the Earbus Foundation of WA is planning three more ear buses for rural and remote WA. It is hoped that a surgical bus will hit the road in the next 12 months that will enable procedures such as adenoids, grommets and myringoplasty to be performed in remote regions.

“We rely on dedicated community nurses, Aboriginal health workers and teachers on the ground to pick up ear problems early.

It’s not an easy fix and that’s why the idea of having buses going out to these kids works so well. However, we now know that by the time children reach school age, we’ve really missed the bus in terms of hearing loss. The battle for Aboriginal children and for most kids with ear disease is won or lost in the first couple of years of life. If you don’t get their ears in good shape, many of these kids will have runny ears by 3-6 months of age.”

“Establishing the newborn hearing screening program was a real milestone.

WA was the first to do a large scale trial – with a few bumps along the way – but now it’s gone national. Over 95% of Australian children have hearing tests at birth. That means we can pick up permanent hearing loss within days of birth and if it’s acted on within the first six months, their language

development will be the same as a hearing child.”

While the frustration has left some of his colleagues exhausted, or burnt out, Harvey takes a sip of the glass half full and smiles.

“There is so much happening that’s exciting, like the tissue engineered myringoplasty, a collaborative project with Prof Gunesh Rajan and PMH colleagues, which will cut the operation time to 7-8 minutes; the national research project to see the effect of adenoidectomy with or without grommets being run by our colleagues in Queensland, WA and NT.” “The translational work of Professors Deborah Lehmann and Fiona Stanley at Telethon Institute for Child Health is being developed by groups such as Prof Jenny Blackwell and Dr Sarra Jamieson who are looking at the genetics of otitis media in a remote WA town; our group, with Dr Ruth Thornton and A/Prof Peter Richmond, from the Vaccine Trials Group at PMH, have discovered the first bacterial biofilm in an Aboriginal child with chronic middle ear disease. This is a world-first which medicalforum

will have a big impact on the treatment of otitis media with potential treatments such as DNAase. Our team has also found that the bacteria responsible for Otitis media are present within the cells of the middle ear mucosa and the adenoids and the tonsils.” For a man who has dedicated much of his waking hours to disadvantaged children’s hearing, he acknowledges that without the support of his wife Lyn and his own two children, he would not have had the career he has.

“I’ve spent a lot of time working. I’d go away on weekends for Lions, leaving the family behind, and I have some regrets about that.

The young wives now wouldn’t tolerate that.

Men are more hands-on with their children and that’s wonderful. My generation was different … I guess we were trying to get things up and going and lead by example.

I couldn’t say, ‘OK, you guys, spend the weekend testing hearing in Geraldton while I stay at home. People I’ve worked with like Fiona … we’ve all done the same.”

Having grandchildren now gives Harvey the opportunity to catch up on some of the things he missed. “Sunday is their day and we spend wonderful time together.” As one of the pioneers of his specialty, he is in a unique position to be able to look forward and back and draw conclusions. He said his collaborations with Sydney colleagues Victor Bear and the late Ted Beckenham in the mid1980s were vastly significant.

“I met them in 1986 at the old Melbourne Children’s Hospital and we formed the genesis of the paediatric otorhinolaryngology study group which was the first sub-specialty group in the field. We were accused of being a secret society, but we just felt that we wanted to be open and honest about our results … what worked and what didn’t work.”

“That group has gone through several incarnations and now is Australian and New Zealand Society of Paediatric Otolaryngology (ANZSPO). It’s a strong and vibrant group that is part of a wider international community. I’m very honoured that a number of them are coming to Perth next year for a meeting festschrift and to help me celebrate my 70th birthday.”

But banish any thought of the R word. While regular surgical lists might be retiring the man at the wheel is not … at least not before he has finished his DM, established an Aboriginal clinic in the northern suburbs, got a surgical bus on the road and lobbied for more resources for otitis media.

In Harvey’s own words: “It’s been a wonderful journey and it’s not finished yet.”O

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13

News & Views

Justifying Ongoing Child Research in WA Reputations, competitive funding, and attracting career researchers are some of the things occupying the mind of TICHR head Prof Jonathan Carapetis.

The Telethon Institute for Child Health Research launched its new strategic plan a couple of months ago. The 500 or so staff and researchers linked to the Institute operate within an increasingly competitive environment. Community benefits are now a marker of their success. After a year in the job, Prof Jonathan Carapetis told Medical Forum blic he could not compete with the public profile his predecessor Prof Fiona Stanley.

health issues, being judged on our ability to make a difference, engaging collaborators such as community, supporting the organisation’s greatness and raising the dollars.”

“Number one is doing research that makes a difference. We have a new research strategy team and are working closely with PMH, so I’m confident that in the next 12 months

Similar efforts are likely in respiratory and infectious diseases and that brings us to what attracts researchers to Perth.

“The Institute judges itself on how it makes tangible benefits for child health and wellbeing. That’s incredibly different to most research institutes and that alone motivates researchers.”

“Fiona is revered and unique and stands nds on her own. At this time it would be a mistake al, to build a profile around an individual, ange when we are trying to showcase the range of talent we have. Yes, I need a public profile and I play a role in some of thee advocacies but there are a whole lot off fantastic people here.”

“The other thing we are pitching is the unique environment in Perth; a single tertiary hospital that has incredible community support. Telethon demonstrates how individuals want to support child health research. I don’t know any other place in Australia that gets that sort of community engagement.”

“I see my role as someone who starts conversations and then brings other researchers on board as needed. I deliberately try to work behind the scenes cenes talking to some of the politicians and d other influential people in the community about the Institute’s plans.”

“We are recruiting people now by saying if you come here you will be able to do stuff you can’t really do anywhere else because you have access to a significant population, a single tertiary hospital, fantastic resources like date linkage, and incredible prospective cohorts such as the Raine, and you will work in an terrific collaborative environment. It’s that combination of factors and the Perth lifestyle that you don’t get in many other places.”

He acknowledges that as a relative unknown, nknown, letting people know he has a slightly different way of doing things takes some ome time. The yearly reliance on grants and nd philanthropic Telethon funds is both a reality and a dilemma.

“The Institute needs NHMRC grants – in many ways our life blood – which also bring credibility because they are competitive and peer reviewed. I was able to bring the Menzies School of Health [in Darwin] the highest success rate in the country for grant applications, so we are working on those strategies here. As well, there is community engagement; looking at more diversified community funding and raising our profile.”

He said time-limited grant funding can dictate what happens too much.

“We as an Institute want to take some of that responsibility so people don’t have to tailor their research around where their next grant is coming from. One of my challenges is to build that safety net.”

When we interviewed him a year ago, Jonathan was big on translational research – making sure clinicians were involved in research that brought community benefit.

This hasn’t changed.

“Our strategic plan was launched a couple of months ago – identifying the important 14

The Institute judges itself on how it makes tangible benefits for child health and wellbeing. That’s incredibly different to most research institutes...

Q Dr Jonathan Carapetis

Maintaining the relevancy of childhood research is one strategic aim he personally embraces.

you will see a whole lot of new faces involved with the Institute, including clinicians.

We will also be building a program of work around research areas that includes government and community strategies. The whole idea is to not just rely on researchers to figure out how we put research into action.”

“I do the equivalent of half a session a week in infectious diseases at PMH. I love it and it keeps me in touch,” he said, adding that his research projects in the Northern Territory are still being overseen by him, with rheumatic heart disease in Aboriginal children one of his pet projects.”

In that regard, WA’s small, young population necessitates the need for national and international collaborations for research success. He said that brain tumour research in children, featured by Medical Forum last year, is a perfect example.

When the Institute takes up premises at the new children's hospital in 2016 he sees the rubbing of shoulders with more clinicians as a positive.

Last February, the Institute hosted the biggest ever meeting of brain tumour researchers from around the world to share ideas, data and tissue samples – as Jonathan put it, “a joined-up vision to get a global strategic plan to defeat childhood brain cancer”.

“We will be operating as part of the broader community so people don’t look at the Institute as an ivory tower and the people who associate with us will include doctors at the hospitals, bureaucrats, and people out at clinics.” O

By Dr Rob McEvoy

medicalforum

Feature

FASD and a Town that Won’t Give Up In 2007 Fitzroy Crossing became a dry community after lobbying by a determined group of women. Now those same women have turned their attention to FASD. Fitzroy Crossing in the mid-2000s was in constant mourning. The town had experienced 13 suicides in 13 months, family violence and child abuse was commonplace, and alcohol abuse was at the heart of it. It was a town in crisis.

Something drastic had to change and two Aboriginal women, June Oscar and Emily Carter, decided to take the matter into their own hands and lobbied and succeeded to have alcohol restrictions imposed in Fitzroy Crossing in 2007.

institutions have dealt with young people with FASD. It resonated instantly with the judiciary which has stated that it will work with researchers to translate those findings into new protocols so that those working in these areas are trained to identify people with FASD. “A qualitative approach has the power to tell a story, the power to measure what you see,” Dr Mutch said at the time. “FASDaffected offenders are vulnerable when they are questioned by police and in the courts.

They may look normal but they don’t behave as such.”

There was, of course, fierce opposition from drinkers and the alcohol industry.

“Before the restrictions, there was total chaos in the town and community. It was difficult to see the good things and stay positive. Families were struggling with the basics. People weren’t getting enough sleep, children were being dumped while parents went out drinking and there was great sadness because there were deaths that were preventable,” June Oscar told Medical Forum.

“That’s six years ago now, and I’m not saying that that’s all been fixed, but the town is more caring, calmer. People who work in Fitzroy are reapplying to stay. More businesses have opened. The restrictions are not a silver bullet and we have a long way to go but they have given us some space so that we can build on what we have achieved so far and focus our attention on all the aspects of the alcohol issue. We have proven that we can make the hard decisions with good leadership but it requires our resilience.”

June is CEO of the Marninwarntikura Fitzroy Women’s Resource Centre and the focus for her and the team is now Foetal Alcohol Spectrum Disorder (FASD), which she says will be an issue that needs to be faced for the next 70 years.

“It’s so important to keep FASD in the spotlight because it risks dropping off the radar despite its challenges being everpresent. The question is how do we do that without running the risk of people turning away, saying ‘we’ve heard enough about that’. But we can’t ignore that alcohol abuse and FASD are a large part of the reality for our entire country and we have to keep people informed.”

June said that the past 12-18 months have seen some significant developments that have flowed from November’s Federal Parliamentary inquiry into FASD. For

medicalforum

In order for some people to be treated equally before the law, they had to be treated differently, but without a specific diagnosis, they cannot have alternative sentencing under the law, she said.

For June Oscar, FASD is a daily reality.

Q Ms June Oscar

starters, $20m has been committed to research. The inquiry also gave parliamentarians the chance to visit Fitzroy Crossing to hear from its residents.

“They came to Fitzroy Crossing and attended the annual women’s meeting where they were received and heard our women’s point of view. That was important.”

“There is also a growing network focusing on FASD and our community is linking with research being done because we need evidence to keep putting pressure to bear on politicians so that the findings and recommendations of the inquiry are not forgotten.”

Fitzroy Crossing is also participating in the Lililwan research project through Sydney’s Westmead Children’s Hospital and the George Institute for Global Health, where the community has designed the parameters of the research, as well as the Telethon Institute.

“Through research we can represent to Government the truth of the impact alcohol is having on our children. From that we hope good policy will grow.”

In May, WA paediatrician Dr Raewyn Mutch and colleagues from the Alcohol, Pregnancy and FASD Research Group at the Telethon Institute for Child Health Research released results of a survey which revealed 85% of staff in the police force, corrective services and WA’s legal

“There is a growing awareness of FASD in our community. The truth is always a challenge to hear but there has been a change there too. People genuinely want to know so they can make informed choices and decisions but there is still a long way to go.”

However, she warned against the alcohol industry which she said was ever watchful and ready to counteract any community or government initiative to reduce consumption.

“It’s difficult to deal with an industry that is self-regulating and has its own rules, which means we must keep working to raise awareness of the damage the misuse of alcohol has on everybody. This is a cradle to grave issue and the alcohol industry needs to be working more closely with us – governments and communities alike – because we are the ones picking up the pieces.”

She also appealed to the medical community to take some time to discover the complexities of the problems from an Aboriginal community perspective.

“We need visiting doctors to understand the issues. Some doctors seem to come at it from their own interest and priority. It’s an attitude really. The problem is complex it is not superficial or affecting just one aspect of health. They need to understand what the community is trying to do.” O

By Ms Jan Hallam

15

Guest Column

DoH: 'Leavers' and Liquor Licensing Exuberant young leavers and alcohol fuel the media each year. Mr Tony Spicer RN from the Health Department explains our response to this event and more.

T

not a decision-maker in the liquor licensing process, but under section 69 (8a)(8b) of the Liquor Control Act 1988, the EDPH is able to review, monitor and investigate liquor licence applications throughout the State in terms of risk of alcohol-related harm or illhealth. Common myths about the EDPH’s involvement in licensing matters include:

he prevalence of alcohol-related harm and ill-health within the WA community is becoming increasingly prominent. The facts are sobering. In 2010, there were 15,775 alcohol-related hospitalisations in the WA public health system, consuming 80,227 bed days and costing taxpayers in excess of $100 million.

1. The EDPH objects to all new liquor licences; and

Each year, South-West communities are inundated by graduating high school students attending rite of passage “Leavers” celebrations. Historically, communities were ill-prepared for the impact of these celebrations, with major strains being placed on small, regional Emergency Departments (ED) and local GPs. Since 2007, the Department of Health has worked closely with WA Police, St John Ambulance, Drug Arm, and the Baptist Church to create a safe and attractive environment for school leavers, while at the same time, minimising and managing the impact of Leavers celebrations on local community resources.

2. The EDPH opposes all applications for Small Bar licences.

The reality is that the EDPH has only intervened on five applications for new Small Bar Licences since they were introduced in 2007, and has only intervened in 16.8% of liquor licence applications received in the past five years.

This initiative has undoubtedly assisted in reducing the risks of alcohol-related harm in youths, and eased the pressures on local hospitals and GPs.

The creation of medical zones, where a doctor, together with nurses, counsellors and paramedics are on scene to provide medical assistance and counselling services, has proved successful. For example, in 2012 there were 109 Leavers-related ED presentations to Busselton Hospital over the two-week Leavers’ period. The medical zone treated 248 patients over 48 hours.

The emergence of liquor licence applications for non-traditional venues, such as hairdressing salons, provides many challenges to the Department of Health about how to minimise alcohol-related harm linked to the availability of alcohol.

Since 1998, the Executive Director of Public Health (EDPH) has possessed statutory powers to make representations to the Licensing Authority on matters of alcoholrelated harm and ill-health. The EDPH is

Health involvement in liquor licensing or targeted youth programs provides important expertise and adds value to the mix of organisations working to make a difference. With parliament now reviewing the Liquor Control Act 1988, it is a timely reminder that issues of alcohol control require special consideration, particularly when the cost is not just in dollars to the health care system, but to the well-being of the community. O Ed. The author acknowledges assistance from Ms Naomi Hendrickson (Drug and Alcohol office) and Dr Revle Bangor-Jones (DoH).

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E-Poll

On the Booze Bandwagon Medical Forum asked specialists last month for their views on young people’s consumption of alcohol and what could be done about a problem that impacts on all of society.

ll o P e

Alcohol and Young People

Q

How aligned are you with the public stance taken by our professional bodies over young people and alcohol? Please respond to the following statements?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Alcohol overuse is behind unnecessary violence and antisocial behaviour.

79%

20%

0%

0%

1%

Greater restrictions on alcohol availability are needed for those of legal age.

26%

32%

17%

21%

4%

Attitudes need changing through more education, rather than prohibition.

56%

35%

4%

4%

1%

We should be more concerned that alcohol overuse is a symptom of alienation amongst young people.

15%

38%

22%

17%

8%

Underage drinking is primarily a parental, not community, responsibility.

18%

34%

11%

36%

1%

What You Had to Say There were some powerful opinion being expressed by the 23 of the 72 specialists who chose to comment. All but one believed extreme action was warranted: “Alcohol is a legal drug. It is responsible for the cost of a major part of our health care, judicial system, society (sickness leave) and suffering in families. I state frankly here that I am of the opinion that after smoking, alcohol should be banned as it causes more and widespread damage than smoking. It is incredible that a liquid which kills so many people and hurts our society is sitting in shops for a few dollars. In 25 years we will look back in shame. Alcohol should be illegal.�

And others believed alcohol has become the ‘new tobacco’ and we should treat it in the same way we have tackled the health issues around tobacco. “Make excess drinking a stigma for adults rather than something to brag about,� wrote one. Another doctor said parents needed help to raise their children and this was a social issue and solutions should be multifactorial. “All public health initiatives to reduce alcohol-related harm should be considered. This includes public education, restrictions on alcohol advertising and sales, penalities for alcohol-related offences such as drink driving, individual and targeted health promotion, brief intervention and alcohol treatment services. Community attitudes influence parental and individual behaviours and therefore, health promotion to the general community about the harmful effects of underage drinking and prenatal alcohol exposure is important.�

ll o P e

Alcohol in pregnancy

Q

Do you think that as a profession, we have been slow to promote ‘no alcohol’ in pregnancy for fear of putting the “guilts� onto mothers who have already had affected children?

Yes

No

Uncertain

49%

37%

14%

medicalforum

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Comment

Just for the Record It’s been a rocky first year for the Patient Controlled Electronic Health Record and it doesn’t look like smooth sailing ahead.

It’s almost a full-time job keeping up with the bubble-over events at the National E-Health Transition Authority (NEHTA).

The mass resignations of key clinicians last month including the head of the clinical leads, Dr Mukesh Haikerwal, sparked all manner of rumours about the roll out of the PCEHR, which has just ‘celebrated’ its first anniversary in July.

The health informatics magazine Pulse+IT reported talk of disquiet from the clinical leads team about the lack of clinical utility of the PCEHR and the sidelining of clinical input into its functionality several weeks before the walk-out.

In his official statement posted on the NEHTA website, Dr Haiwerwal, who has been involved with the project since 2007, said it was the right time to step away “with the eHealth system now in its current place and moving into a different phase.” In just the barest hint of disquiet he added that he had been assured that healthcare providers, peak bodies, consumers, vendors and other key stakeholders would continue to be consulted.

Also walking out the door was RACGP e-health standing committee members Dr John Bennett and Dr Nathan Pinskier, Dr Jenny Bartlett and Melbourne GP Dr Chris Pearce, who was reported as quitting because he wanted to do research.

Robin's Lab The Robin Warren Clinical Skills Laboratory at Adelaide Uni exemplifies two things: how everyone lays claim to a Nobel Laureate (Robin graduated MBBS from Adelaide Uni in 1961); and how medicine has adopted simulation as a teaching method. The Adelaide School of Medicine still has an undergraduate intake and the Robin Warren Lab teaches 1st and 2nd Year students (about 350 in all), basic history taking and physical examination skills using real people acting as surrogate patients. The new facility offers a less crowded and more personalized teaching environment, more a mirror of the planned Royal Adelaide Hospital and School of Medicine due to open in 2016. Downstairs from Robin's Lab is the high end simulation lab that uses mannequins to teach resus, anesthetic and suchlike bioskills to undergrads and postgrads. Both facilities are also used by the School of Nursing. medicalforum

in place and working well, it will be so much better for patient care.

As of August 19, there were 726,967 registered PCEHRs. As of August 13 there were 15, 610 clinical documents, including Shared Health Summaries, Discharge Summaries, Event Summaries and prescription and dispense records, uploaded in the PCEHR system. There were 5427 Shared Health Summaries where a doctor has contributed information for other health care providers.

Midland GP Dr Colin Hughes, who has been working in remote communities in the Northern Territory, says the electronic record is up and working and is “fantastically useful where new patients enter a community. All hospital records plus health summaries are available to the clinician.”

However, he added that his city practice is not using it and won’t until incentive payments are worked out to compensate GPs for their time and cost.

This month Medical Forum spoke to a number of GPs. Geraldton GP Dr Edwin Kruys is an outspoken critic of the PCEHR in its present form. He has a quiz on his blog (http://doctorsbag. wordpress.com) as a way of alerting fellow clinicians about what he sees as some of the contractual and privacy pitfalls.

Other GPs approached gave big shrugs of their shoulders. One said: “Essentially the PCEHR is in trouble as GPs are not engaged. After the meeting I am less likely to start doing at my practice.”

Then there are those, like Kalamunda GP Dr Mike Civil, who think that the current upheaval is worth struggling through because ultimately, when the right system is

Another said “The whole concept is great but I personally have misgivings about privacy, ownership and fine details of modus operandi : if 2 and 3 level care is not on board then it’s a waste of time.”

So as the second year rolls on, it’s clear that there is still a long way to go to win the trust of clinicians and a bureaucratic takeover of the rollout is not going to help that in any shape or form. O

By Ms Jan Hallam

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19

Practice Security Feature

IT Revolutionising Practice Zero Day Vulnerability, Ransom Ware and Remote Access – medical practice has become a hi-tech minefield.

As medical practices become larger and more sophisticated their computer systems often struggle to keep pace.

State-of-the-art IT is complex and expensive and, unless efficient system protocols are implemented, valuable information can be compromised.

Medical Forum, with the help of an IT specialist and three practice managers, plunged headlong into the black hole of medical cyberspace.

Liam Gale, who heads up Aviso IT, is an experienced computer expert with a great deal of experience in the medical sector. He stresses the importance of protecting against data corruption and highlights the potential Q Liam Gale pitfalls of remote access. And he has a few things to say about ‘passwords’ as well, “I’ve seen examples of systems that have been looked after by an ‘IT expert’ who is the ‘nephew of the boss’. While they may have a keen interest in computer technology they often have a blasé attitude to security and data protection. Invariably, they don’t have a good disaster-recovery system and some don’t even have a functioning uninterruptable power supply (UPS). You can easily have problems if the system isn’t 20

shut down properly and that can wreak havoc with database systems.”

“As far as security goes there are still practices whose anti-virus (AV) systems are either not working or not current. Some use free AV and that’s okay, but it’s generally not as good as the software you pay for, which isn’t expensive. There’s potential for security breaches if AV and anti-malware systems aren’t functioning because Spyware or Trojans can create holes for hackers with malicious intent.”

“I come across a lot of weak passwords, everything from leaving it blank to actually using the word, ‘password’. We had one practice that allowed open remote access to their systems. Their password was blank, their user name was ‘administrator’ and anyone could’ve gone logged on and done whatever they wanted. They were surviving on dumb luck!”

Liam suggests a few simple actions to make IT systems more secure.

“Lock down remote access. Either restrict it or, if it’s not needed, don’t allow it. It’s easy to limit it to specific remote internet addresses (such as the practice manager’s home internet connection) and you can also set up Virtual Private Networks (VPNs) that provide more secure remote access.

Windows updates are important because they patch vulnerabilities in the software that could be exploited by hackers.”

“You can have as much protection as you

Their password was blank, their user name was ‘administrator’ and anyone could’ve gone logged on and done whatever they wanted. They were surviving on dumb luck!

– IT expert Liam Gale. like but you might still be susceptible to a Zero Day Vulnerability. That’s where a weakness has been discovered but hasn’t been patched which means it can be targeted. It’s this sort of situation where a verified backup system with an offsite component is crucial. A GP practice in Queensland had all their data encrypted and then were sent demands via Ransomware to unlock their system. Cases like these pop up all the time but usually you don’t hear about them. They’re too embarrassing!”

Keith Symes, the practice manager for The Surgery – Middleton Beach and The Surgery – Spencer Park (both in Albany) spoke with Medical Forum hard on the heels of a major Q Keith Symes power outage. The repercussions were minimal and a reflection of significant capital and personal investment in the development of a sophisticated IT system with good technical backup.

“A large section of the town was without medicalforum

power for about an hour so that meant no lights, internet, software, phones out in both surgeries and doctors back to manual operations. Because of the size of our system – two locations and up to 26 users – our UPS is only there to allow a graceful shutdown.”

“The way the service comes back up and reconnects is crucial. In the above case everything was fine except our mail server.

It’s an old Unix machine and has problems rebooting so we got our network engineer to sort that out.”

Despite being in Albany, Keith maintains they’re not unduly disadvantaged when it comes to technical assistance. The same can’t be said for the speed and stability of their internet connection.

“It doesn’t happen often but I’m occasionally here on weekends reconfiguring the system with the IT expert. We use Alpha West, an Optus company with a Bunbury head office and a local Albany service guy. They can log in remotely and get most things done.”

“The significant disadvantage we have is the internet. Compared with Perth’s wider band-width and faster speeds we’re pretty much at the end of the line down here.

We can’t wait for the NBN, or its Liberal equivalent!”

Keith suggests that being reasonably techsavvy is an integral part of a practice manager’s job description.

“If you have a problem it’s good to have some idea how to get the system up again.

We had an incident recently when the Apple server decided to stop running Genie and I was able to fix that one. The RACGP guidelines are helpful and when I first came here I used them as a basis for ticking everything off. It’s also important to have a checklist for staff when things go wrong.”

Louise Bray steers the IT command module at Hollywood Medical Centre for vascular surgeons Peter Bray and Stefan Ponosh.

“We certainly don’t believe in IT for its own sake. For us, it’s being able to connect with our referring doctors and patients in the most efficient way without losing that personal touch. As a surgical practice our doctors aren’t ‘in-rooms’ for much of the time and they also travel to the Great Southern region so they need good access to patient information.”

“IT systems need ongoing review to make sure they’re a good fit with our clinical and administrative processes. We’ve got a great working relationship with our IT expert and he’s a key member of our team.”

“We also work with a management consultant and part of that process involves assessing if we can make better use of our IT systems. There’s no way we’re going to allow our software to dictate the way our practice functions.” medicalforum

Security is a major issue with any IT system and Louise appears to have all bases covered.

“I think the major risks and vulnerabilities are web-based and we go to great lengths to ensure our system is protected. We’ve got firewalls in place, good password security and the surgeons have remote access via laptops so they run AV software, too.”

“We have nightly off-site backups and ‘read-only’ copies so that our surgeons can use them if they’re unable to access the network.”

Rachel Hadlow has come up through the ranks at Third Avenue Surgery, Mt Lawley and has witnessed significant developments since the days of the ‘paper’ office.

“I started in reception 11 years ago and have been Practice Manager for the past two years. I’ve seen big changes, everything from increased staff size to more sophisticated software. It was pretty much paper files back then and we rarely operate that way anymore.”

“All our documentation is scanned and put on an electronic record, pathology comes in electronically and letters from specialists are scanned into the Q Rachel Hadlow system. We’re also looking at online bookings and I think that a lot of surgeries will be doing the same.”

“We go through the results from our system expert and implement the required changes.

The UPS gives us about 90 minutes of emergency power but we still print out the appointment lists the night before just in case.”

“All the doctors’ computers run from the Server so that increases the security aspect and reduces the risk of viruses. We closely monitor the system and can remove anyone who logs on who shouldn’t be there. The RACGP guidelines set out the security standards and we were at the Fourth Standard at our last accreditation. We’re well set up for e-health, too. Mind you, I’ve only ever had one patient ask about it.”

“We have moments of initial panic when things go wrong. It’s probably true of all of us that you don’t realise how much you rely on IT until it goes down.” O

By Mr Peter McClelland

10 STEPS TO A GOOD NIGHT’S SLEEP 1. Avoid generic usernames and use strong passwords.

2. Good Backup system including an offsite component.

3. Internet Firewall with Unified Threat Management.

4. Clear Internet usage policy for staff.

5. Network anti-virus, anti-malware and antispyware protection.

6. Physical security of premises and/or server equipment.

7. Redundancy on primary storage system.

(RAID) 8. Regular updating of operating systems (manual or automated).

9. Lock down Remote Access.

10. Uninterruptable Power Supply (UPS).

Source: Aviso IT

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Technology

Keep it simple... and useful While the world is grappling with eHealth a young medical student has gone back to basics with some sound common sense.

Einstein said ‘When the solution is simple, God is answering’ well in the case of medical student Martin Seriveratne’s awardwinning health app concept, iResident, a choir of angels was thrown in for good measure.

The fifth year Sydney University medical student used his experience on the wards – trailing behind consultants’ entourages and trying to decipher his resident’s notes – to create this brilliantly functional app which won this year’s HISA Health App Challenge and $8000 grant to help its development.

“I looked at this sheet of scrawled notes with all these different tasks to do for each patient and it struck me that it was such an inefficient system and I thought that a simple app which got the interface right would be enormously useful.”

“I’ve shown the video to a variety of people in the medical food chain. The interns in particular are really positive towards the idea. They keep saying, get it out for next year’s intern allocations because they would really use it. The consultants have been really positive as well because they realise where the mistakes get made and they’re usually at the grass roots level where a first term intern out of university is given a million jobs to do and ends up forgetting a few of them – or can’t read their writing on the sheet.”

“There is no electronic tracking system and that’s the niche iResident is trying to fill. And it affects everyone on the team – nurses, physios, social workers. I can see it happening. I always wonder how the nurses remember what to do. At least the intern is writing things down, but nurses are getting regurgitated information and all they can do is nod politely and say yes.” iResident is pure concept at this stage. Cost for Martin, whose undergraduate degree was in physics, is a difficult bridge.

Outsourcing can cost anywhere between $20-$30,000, so Martin is keen to work with some of his student programmer mates, who had worked previously with him on his ServeAid app which is now commercially available.

Q Medical student Martin Seriveratne and HISA CEO Dr Louise Schaper

“Technically speaking, iResident isn’t super-complicated because it’s really a checklist interface, which will hopefully sync across a number of tablets on the ward. So there’s no great degree of technical innovation it’s just making the interface suitable to an Australian junior doctor setting.”

While he hasn’t heard officially, the judges loved the concept because it was easily achievable, practical and there wasn’t an obvious existing competitor.

HISA CEO Dr Louise Schaper said the organisation received 47 applications for the challenge, which was open to all comers as long as the app was not commercially available.

“I was one of the judges so I was only privy to the short list but I didn’t see anything that wasn’t interesting. Some ideas were very formative and others were more developed but they all had value for the people they were designed to help.”

Second prize of the challenge went to an app created by a team from CSIRO’s Australian e-Health Research Centre to help Type 1 diabetics manage their medication routine. While third prize was a game app called Game On, designed by Dr Keith Joe, Emergency physician Prof Arthur DeBono and designer Cameron Rose, which aims to demystify hospital for young patients and engage and guide them through various departments and procedures.

Louise said that the Health Apps Challenge would be bigger and better in 2014 and urged those bubbling with ideas for useful health apps to start thinking now.

Perhaps the winner of this year’s challenge has the secret of success.

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“I just drew directly from my clinical experience and devised an app which offered a practical solution that was feasible and achievable,” Martin said.

However, time is his biggest problem now.

“The medical pathway is a bit of a conveyor belt so after med school next year I’ll do my internship and start using scribble sheets of paper, myself, but longer term my interest is in health care apps and med-tech and how to optimise work flow in hospitals.” O

By Ms Jan Hallam ED: The winning apps can be viewed at https://hisa.site-ym.com/page/awardsEntrants

22

medicalforum

Innovation

Seeing the You, You want to Be An app developed by Curtin University’s Prof Moyez Jiwa creatively uses an avatar as a motivation tool for people to lose weight.

The obesity epidemic shows no sign of slowing up. In fact, most medicos suggest that everything that has been tried so far – from laparoscopic banding to healthy lifestyle programs – has gained little traction. Dr Moyez Jiwa, Professor of Health Innovation at Curtin University and a practising GP, has developed an app called Future Me linking self-image with personal motivation.

“The concept behind this stems from a Canadian study on smoking and ‘photoageing’, which shows that when you appeal to a person’s self-perception you can actually change behaviour. Our appearance is extremely important to us because it’s a physical and psychological reality. When it’s presented in the form of a simulated image it can be a strong motivating factor.”

“We thought this idea might be useful in treating obesity, so we developed our own software which takes a photo of someone’s face and creates an avatar according to individual measurements such as height, weight and general body shape.

You can even use the colouring from the face to create an ethnically appropriate representation.”

“By manipulating the avatar using inputs such as amount of exercise over a certain time-frame and kilojoules consumed you can see a realistic picture of how you will look in three or six months-time. Future Me gives you a glimpse at what you’ll look like if you do what you say you’re going to do.”

There’s no debating the fact that there’s a strong generational aspect to having an avatar as a new best friend, rapidly twiddling your thumbs and living a significant portion of your life in a virtual world.

“This technology is very appealing to young people, both females and males. You only have to walk into any gym to see lots of young men pumping iron. But we haven’t given up hope that an older age-group will be interested in this application. We’ve got trials planned under the auspices of the Peel Health Foundation, we’re also working with Weight Watchers Federation WA and we hope to be reporting on a pilot study by the end of this year.”

Perth’s geographical position can be a catalyst for novel approaches to entrenched, and seemingly intractable, social issues such as obesity.

medicalforum

Q Ms June Oscar Q Prof Moyez Jiwa

“This is a project funded ed iverrsity entirely by Curtin University and I think part of thee reason reaason for that is that we are an isolated i city. We have to be imaginative magin native in developing our careers areers as doctors and solvingg probl problems lems in ways that aren’t necessarily necessaarily traditional.” ng ideas and “I like the concept of taking eas and applying insights from different areas them in a clinical setting. We’re looking at user-friendly devices in the treatment of ADHD, the rehabilitation of stroke patients and a mattress that measures a baby’s blood pressure without using wires. We’re not hoping to change the world in the next five years but it won’t be long before this technology is in most people’s hands.”

A simulated image can be a strong motivating factor.

“The use of digital technology can only accelerate in a healthcare setting. For example, last year a 22-year-old doctor won an award for designing an App that’s used in the diagnosis of malaria.”

Moyez suggests that social norms play an integral part in the uptake of new technology.

“Medicine is an inherently conservative profession and, at times, it’s slow to embrace change. I don’t think we use technology as much as we could in clinical practice. I’m very happy to Google in front of my patients, in fact I had a woman with impetigo and it was useful to show her images of the condition.”

“It will be interesting to see what happens with PCEHR. There are obviously issues surrounding security and the potential for patients to withhold information. Any of those could result in litigation and who wants to end up in court to test that!”

“But there are also technical challenges with PCEHR. It’s going to involve some complex technology because it will have to link up with a lot of other clinical systems.” O

Mr Peter McClelland

23

Guest Column

'EyeT' – a Personal View Ophthalmologist Dr Steve Colley provides a personal perspective on his own ‘light bulb’ moment when it came to using technology to enhance his practice.

T

hese days we all walk around with computers that double as mobile phones or eBook readers.

These devices are able to leverage significant extra functionality through the use of Apps or programs that can be downloaded or bundled with the device, such as web browsers or email readers.

So, what if you came up with an idea for a program to make your phone or tablet even more useful? There are a couple of options: you could search the Apple or Android store to see if someone has written a program already, or you could write your own.

As an ophthalmologist, cataract surgery is a central part of my practice and any method of obtaining better outcomes for patients is eagerly embraced. Dealing with corneal astigmatism (“rugby-ball shaped” corneas) has become much easier with the advent of

Q Fig 2. eyeSnellen on the iPhone and iPad

smartphones. It begged the question, why not write my own?

This resulted in EyeToric (fig 1), which uses a simple graphical interface and vector mathematics to provide on-the-fly lens predictions based on a patient’s astigmatism and the surgeon’s wound position.

My most recent App, eyeSnellen (fig 2), is more broadly applicable to GPs and specialists alike and was written in response to the paucity of useful eye charts Q Fig 1. Eyetoric on the iPhone available on the App Store.

By using an iPad or iPad-mini as the eye powerful toric chart and an iPhone as a remote control, a intraocular lenses portable and accurate vision chart is readily to counteract available. the astigmatism at the time of surgery. Online calculators The key to the utility of the eyeSnellen App is its ability to automatically calibrate the have been released to help this process, but distance to the iPad which adjusts the size they require an internet connection and of the letters, numbers or pictures on the are not particularly user friendly when it chart and the brightness of the chart (based comes to the smaller screen size of most

on room illumination) by using the iPhone camera.

The eventual aim is to deploy the eye chart in public hospitals and throughout remote WA. I have written a test application called Lens Transposer with a short article describing how to code the application which is available at eyeapps.com.au.

Quite apart from clinical examination and surgical aids such as the above programs, the use of smartphones and their integration into medical practice is up and running. Medical imaging, telemedicine, online journals and practice billing software are areas where smartphone and tablet Apps are already part of the landscape. There will be a double flow-on effect for medical professionals embracing this technology: streamlined service delivery for patients and improved small business operation.

The only limiting factor is a lack of imagination. O

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medicalforum

Guest Column

People Behind Frontline Services Health Department Chief Health Officer Dr Tarun Weeramanthri says those supporting frontline services are essential to any team effort.

A

s a university student, I occasionally worked at Subiaco Oval on the gates for football matches, collecting money and opening the turnstiles. Not as glamorous as playing, perhaps, but I was happy (they paid me) and so presumably were my employers (I handed over the takings).

When discussion about ‘frontline services’ in government comes up, I often think about football teams.

Eighteen players plus the interchange bench are all that get on the field but behind them stands a diverse group of ‘backroom staff’, who are often recognised for their essential contribution to the success of the 18. Coach, trainers, physios, ground staff, administration and marketing – the list goes on.

In sport, you don’t disparage those who don’t play as somehow not contributing to the success of the team. Everyone’s contribution is valued. It’s a team on the field, and a wider team off the field. Of course, management always considers how

many backroom staff is needed to fulfil tasks but that’s no different in concept from managing your team list.

I believe the same should be true in health.

Anyone who works inside a hospital knows it is a team effort. Yes, the doctors and nurses have most contact with patients but others have critical frontline roles (e.g. allied health workers), and others have critical backroom roles (e.g. records staff, laboratory staff, radiology technicians, pharmacy, information technology, catering, cleaning, administration, payroll etc.).

And a whole health system is more than hospitals. In public health our clients are the public, and our services include managing disease outbreaks, mitigating an A-Z of environmental risks (from asbestos in the home to zoonotic diseases), organising screening programs (for breast, cervical and bowel cancer), and working in partnership to promote good health and prevent chronic disease.

All these could and should be considered

frontline services but think what lies behind each of them. Take immunisation services as one example. The physical injection is the end point of a complex process.

Maintaining the cold chain, ordering the vaccines, training providers, monitoring for adverse events, compiling evidence for effectiveness, securing funding, and creating strategies to target high-risk groups all take dedication and expertise from backroom staff at every step.

Working inside the Department of Health in East Perth, I get to see a slightly different group of backroom staff, working in the best traditions of the public service on a range of essential tasks, from legislation, to finance, to performance, to activity-based management – ensuring value for money, public accountability and transparency.

So, yes, always consider whether we have the right balance of staff to serve the public but in so doing, don’t equate frontline with essential and assume backroom is somehow non-essential. Without the person at the gate to collect the money, the football team could not survive.O

smithcoffey

medicalforum

25

perth clinic bigger and better On the 1st of July 2013 Perth Clinic celebrated its 17th birthday and in those 17 years it has experienced many changes, the most signiďŹ cant being that of increasing its patient capacity from the original 56 beds to 100 beds. Perth Clinic’s contribution to mental wellness in Western Australia has been an integral and essential component of this private Psychiatric Hospital.

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Perth Clinic has created a culture which aims to strengthen and promote the mental wellness of patients and the enhancement of well being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her family / community. We provide treatment and therapy for a wide age range from 14 to 90 plus, with a focus on inpatient therapy and day patient therapy.

Patients are allocated to therapy groups according to their diagnosis and after discussion with their Psychiatrist, their needs at that time.

The Hospitals mission is to provide

In an ever changing world with an increasing population Perth Clinic has grown in stature in providing the best care possible to individuals with varying mental health problems.

individual treatment planning and

patient outcomes that are exemplary, outcomes that our entire team can be proud of. Perth Clinic is a health system here to serve the people of not only Western Australia but people from all over the world and with over 45 Consultant Psychiatrists accredited to the service; it is uniquely positioned to have a profound impact on the health and wellbeing of the people to whom they provide services for.

Our Hospital provides a broad range of inpatient and day patient services for people experiencing mental health concerns. With a strong focus on proven effectiveness of treatment outcomes, we aim to provide the best in psychiatric care to ensure that patients get better faster. medicalforum

Perth Clinic provides over 20 differing forms of group therapy, each program tailored around the complex problems that patients face on a daily basis. These groups include:

liaising with GP practices, Emergency Departments, patients and the on-call Psychiatrist. They can also provide advice on other services and alternative options of treatment.

¬

The Admissions Manager is available from 8am to 4pm Monday to Friday. Referrals made outside of those hours will be dealt with by the Duty Nurse Manager or the Hospital Coordinator.

s s s s

¬ s ¬ s ¬ s ¬ s

Mood and Anxiety Management Interpersonal / Relationship Therapy Alcohol and Drug Treatment Therapy for Adolescents and Young Adults Cognitive Behavioural Therapy (CBT) – Day and Evening Programs Art Therapy Dialectal Behavioural Therapy (DBT) Mindfulness Skills

Perth Clinic also offers individual therapy as well as group therapy programs.

With a modern, well equipped ECT suite the clinic also provides Electro-convulsive therapy for patients with depression.

As a General Practitioner there may be times when you would like a specialist Psychiatric opinion regarding the management of a patient, or times when you feel that referral for ongoing care / therapy is required. There are a number of ways in which you can refer to one of our Accredited Psychiatrists; through our acute admission service, via the first available outpatient appointment service or direct to a particular Psychiatrist.

ACUTE ADMISSION SERVICE This service is provided by Perth Clinic and a team of accredited Psychiatrists in providing admissions for patients who are going through an acute episode of mental illness and have not been seen by a Private Psychiatrist in the previous 12 months. One Psychiatrist is on call daily between the hours of 8am and 7pm Monday to Friday.

HOW TO ACCESS THE ACUTE ADMISSION SERVICE In order to access the Acute Admission Service you will need to telephone Perth Clinic on (08) 9481 4888 and ask for the Admissions Manager. The Acute Admissions Manager is responsible for

Information that would be helpful when referring a patient through the acute service would include: ¬ s Patient’s name and date of birth ¬ s Patient’s address and telephone numbers ¬ s Patient’s Private Health fund and membership number ¬ s Details of the presenting problem and any diagnosis history ¬ s Whether the patient has seen a Private Psychiatrist in the past ¬ s Any alcohol or illicit drug use ¬ s Suicide risk and / or history of aggression ¬ s Physical problems The more information the on-call Psychiatrist has about a patient, the easier it will be for them to make a decision regarding admission.

Once the Admissions Manager has this information you will be asked to fax a referral letter to (08) 9488 2977.

Once the referral is received and a Health Fund check has been carried out, the referral will be discussed with the on-call Psychiatrist. If the patient has full health insurance and the Psychiatrist accepts the referral, then the patient will be contacted to organize an appropriate time for admission, usually the same day or the following day. The referrer will also be contacted and informed of the outcome. If the referral is not accepted by the on-call Psychiatrist, then the Admissions Manager will contact both the patient and referrer to explain why it was not accepted and give advice about alternative options.

If a patient only has basic Health Insurance cover then the Admissions Manager may be able to advise on an alternative option.

It is advised that a patient does not wait in the GP surgery once a referral has been made as the process could take several hours due to the Psychiatrists consulting throughout the day. The patient will be contacted via telephone.

OUTPATIENT SERVICE If your patient requires an Outpatient appointment with one of Perth Clinic’s accredited Psychiatrists then a referral will need to be faxed to (08) 9488 2977 stipulating an Outpatient appointment.

The referral should be addressed ‘Dear Doctor’ and ‘for the attention of the Admissions Manager’. Information on the patients presenting problem and past history should be included in the content of the referral.

Once the referral has been received it will be faxed to the Medical Suites for the first available appointment and the referrer will be notified that the referral has been received. If the referral is accepted by a Psychiatrist then the Administration staff at the Medical Suite will telephone the patient with an appointment date and time. The referrer will be informed of the outcome.

Please be advised that it could take between 4 to 6 weeks for an appointment.

For any further information please contact: Kathryn Turner, Admissions Manager on (08) 9488 2973.

We would also be interested in your opinion on how Perth Clinic could assist your GP Practice and would welcome feedback on the referral process.

Hospital Address: 29 Havelock Street, West Perth WA 6005 Phone: (08) 9481 4888 Website: www.perthclinic.com.au medicalforum

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News & Views

Stigma Ends with a Handshake Prof Patrick Corrigan was spreading the word to local groups last month on how to reduce the stigma of mental illness and there was a message for the medical profession.

WA’s Mental Health Commission hosted a series of talks on reducing stigma of mental illness with distinguished US psychologist and researcher Prof Patrick Corrigan Q Prof Patrick Corrigan from the Illinois Institute of Technology last month. He spoke to Medical Forum to urge health professionals to take the issue seriously.

“What’s sobering is research that suggests that GPs endorse the stigma of mental illness and unintentionally discriminate against these patients. There are repeated studies that suggest if a GP knows that a person has a psychiatric diagnosis they are less likely to refer them to specialties, labs or surgical care. So the evidence is that GPs, like lots of people, will respond to people with mental illness differently to others.”

Research published last month from the

University of Melbourne puts this in an Australian context and while health professionals (518 GPs, 506 psychiatrists and 498 clinical psychologists) have less stigmatising attitudes to people with mental illness than the general public, there is still work to be done in combating stigmatising attitudes among GPs. “In the US there is a campaign with GPs and our veterans administration and the message is simple: when you have a patient with mental illness provide the same standard of care," Patrick said.

He said that personal contact with mental illness was more effective in breaking down stigma than education.

“GPs who encourage people who are out and recovered from their mental illness to tell their stories is a positive way to challenge those myths of mental illness.

Having contact with a person with lived experience is much more effective.”

And these stories should not only be heard

by GPs but also employers and landlords

who may discriminate against a person with mental illness.

“Stigma in mental illness is similar to stigma to being gay and lesbian because they have all been in the closet at one time and viewed as broken and sick. What the gay community has taught us is not to educate our children about the genetics of gay, but demonstrate the courage of gay men and women who come out and tell their stories.”

“It’s the same kind of thing with mental illness only when you think about it statistically there are far more people with serious mental illness that there are gay people. So it could have a huge impact on the population if those with mental illness came out and tell their story.”

“But the reality is, good intentions only go so far and people with mental illness also have political rights, so the more they can organise themselves, the more likelihood their actions will translate and have impact.” O

Changing Times, But Nothing Changes PIPs and accreditation standards are not keeping up with the demands of modern general practice, says Kalgoorlie practice principal Mr Tim Spokes.

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ur practice in Kalgoorlie has, for the past eight months, been working meticulously through the fourth edition RACGP accreditation guidelines.

Planning began a good two years earlier because we wanted to get it right.

With registration, came excellent online support, but there were some hard cold facts to face as we rapidly became aware that the standards focused on GPs and not so much on nurses, midwives or allied health professionals. That’s not unreasonable, one may think, after all they are formulated by RACGP. However, the number of nurses, midwives and allied health workers employed in general practice has grown exponentially.

The lack of GPs, the growing need for and a multidisciplinary approach to chronic disease management and incentive payments have all seen a jump in demand for nurses and other health workers in general practice.

However, changes to the PIP system have seen some knock-on effects.

The abolition of the immunisation incentive payment is one; reductions to the asthma

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care incentive and item numbers that could be applied to specific nursemanaged treatments such as wound care and dressings, all but abolished. If you expect the wages of nurses to be met by the incentive program, think again! There are also the associated costs of insurance, continued education and superannuation.

Don’t get me started on the paperwork.

GPs working FTE are in short supply and, in our region, disastrously short supply.

The dichotomy is “Areas Of Unmet Need” (which attract a payment to GPs) are reclassified so that these areas may only be a short bus, train or taxi trip from the CBD or the beach. The end result is a medical system under significant strain and general practices at breaking point.

Now let’s revisit the RACGP standards and the survey process. If you thought the clinical notes of your nurse or allied health carer would be surveyed, you will be disappointed. If the activity does not directly involve the GP it will not be allowed in the survey review.

It seems the RACGP standards assume all patients entering a general practice are there to see a doctor. While it’s true there is little monetary reward from consults that do not involve the doctor in some manner, patients are being cared for by other capable and credentialed professionals.

Like it or not, general practice is a health care business but one that I’d like to think functions “to a set of standards that encompass all health care professionals and processes.”

With the change in incentive payments that can only be accessed through RACGP standards accreditation, which does not recognise nursing and allied health care, I am left to conclude that Medicare and RACGP are two editions behind practice and do not reflect current trends or even match standards of hospital accreditation, which encompasses the action of all staff.

For general practice, there is less and less reward from the PIP, making accreditation questionable and a costly venture in an already fragile economic climate. O medicalforum

Guest Column

Confessions of a Pedal Pusher The health benefits of cycling are just one of the attractions of the sport for urologist Jerard Ghossein who shares some of the rules of the road.

W

hen I was 14, I had a serious bike accident. Coming down a very steep and narrow road, my dodgy brakes gave way and I came flying off my bike down a steep cliff. I was lucky to be alive. I wasn’t wearing a helmet, I did need a few sutures but at least my brain remained intact because I went on to finish medical school.

It wasn’t until 24 years later that I hopped on a bike again – this time with a helmet and functioning brakes! Sitting on that saddle, feeling the wind on my face (not my hair, that’s long gone), I felt liberated. That was it, I was hooked. A whole new world opened up – carbon frames, fast wheels, energy drinks, and of course … the Lycra.

I joined a cycling club and after my first group ride, I quickly learnt the rules: t &OTVSF UIF DPMPVS PG ZPVS -ZDSB NBUDIFT the bike and drink bottles t /FWFS XFBS ZPVS TVOHMBTTFT VOEFS UIF helmet straps t 5IF -ZDSB IBT UP CF BT UJHIU FWFO JG JU interferes with your circulation,

NO NEED TO SHOUT I have always had a severe hearing loss and struggled in everyday situations, even with hearing aids. At 36, I decided to get a ‘bionic ear’ from the ESIA Implant Centre. The day my implant was switched on was life changing. It was incredible to hear new sounds. Of course I didn’t know what half of them were, and I had to spend a few weeks learning to adjust.

Now, I can hear my girls talking in the next room.

My confidence has skyrocketed and work is reaping the rewards - especially as I can now use the phone.

I have only one regret - that I didn’t do it sooner.

Brett Paton.

medicalforum

t /FWFS TIPX TJHOT PG TVGGFSJOH PS GBUJHVF (hence the polarised sunglasses), t /FWFS BENJU UP BOZ TFDSFU USBJOJOH t "CPWF BMM LFFQ ZPVS MFHT TIBWFO BOE silky smooth. t *U JT BDDFQUBCMF JG OPU EFTJSBCMF UP PXO multiple bikes and spend most of your free time cleaning and maintaining them.

Group riders might be viewed as a bunch of poseurs overcrowding coffee shops on a Saturday morning, sipping coffee in their bright Lycras. That’s mostly true! But being part of a club is much more than that. It is about developing new friendships, learning to ride in a peloton and training hard to avoid the humiliation of getting dropped.

Waking up before 5am for a ride and driving hundreds of kilometres to get to a race become the norm.

Cycling is becoming an increasingly popular sport in Australia and especially amongst doctors. As a urologist, I am often asked the inevitable questions.

Effect on PSA? Research is conflicting. Some studies show no effect, while some report

a 9-10% increase in PSA when recorded within one hour of cycling activity. Cycling abstinence of 48 hours is recommended before testing PSA. Hematuria? More commonly seen in runners and triathletes but also cyclists.

Believed to be due to repeated micro trauma to the bladder and kidneys and correlates directly with exercise duration.

Perineal pain and numbness? This is due to compression of the pudendal nerve and its perineal, scrotal and vulvar branches, from prolonged riding. Numbness is reported in as high as 60% of riders but most resolve within minutes of getting off the bike. Chronic perineal pain, also reported, is associated with age (>50), body weight, cycling history (>10years), and frequency of training (>3 hours/week).

Erectile dysfunction? This is reported in 13-20% without this necessarily being causal but an issue that led some manufacturers to design a saddle aimed at reducing perineal pressure.

It is worth investing in a comfortable saddle and a good pair of cycling shorts. O

I can hear whispers since my cochlear implant.

Brett Paton, 40.

Who is suitable for a cochlear implant?

Patients with severe or profound hearing loss could benefit from a cochlear implant – especially if they find hearing aids ineffective.

What is the ESIA Implant Centre?

ESIA Implant Centre specialises exclusively in implantable hearing technology. Our experienced team of surgeons, implant audiologists, a radiologist and psychologist work with your patient to find the right solution for their hearing loss.

We can treat your patient through either the public or private health system and we’re with them every step of the way – from the initial

consultation through to long term hearing management.

To learn more, call (08) 6380 4944 or email implants@earscience.org.au today.

www.esiaimplants.com.au

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Infection Control

Don’t Gamble With Gonorrhoea Emerging antibiotic resistance is scaring the profession and government, with high community stakes – and gonorrhea is a good example.

Medical Forum received an attentiongrabbing media release from the inaugural Gram Negative ‘Superbugs’ Meeting by the Australasian Society for Infectious Diseases (ASID). It was titled “Extensively-drug resistant gonorrhoea invading Australian cities: a matter of when, not if”. We asked PathWest’s Dr David Speers to give us the WA perspective on some of the claims.

Q Dr David Speers, Clinical Microbiologist Pathwest

The first claim is that it was only a matter of time before multiresistant (XDR) strains of gonorrhoea hit our shores, according to sexual health experts.

“N gonorrhoeae is a bacterium with significant genetic recombination potential that allows rapid acquisition of resistance determinants from other bacteria, including commensal Neisseria species,” David explained, adding that resistance to firstline oral antibiotics was worldwide, with only a few isolated pockets of penicillin susceptible N. gonorrhoeae remaining in the world.

“More recently the concentration of third generation cephalosporins required to inhibit growth in the laboratory has been rising and resistance to the oral third generation cephalosporin cefixime, used extensively overseas, has occurred. Now several strains resistant to ceftriaxone have been detected in France and Japan.”

Such resistant N. gonorrhoeae strains are expected to spread, with some multi-drug resistant varieties already in Australia.

“The remote regions of WA, especially the Kimberley, have some of the highest rates of gonorrhoea in the world, as does the Northern Territory. However, in WA the pattern of resistance is different between gonorrhoea contracted locally in the remote regions – Kimberley, Pilbara, Goldfields and Midwest – which is usually more susceptible, and that acquired outside of these regions. The mining towns in the remote regions are at risk of introduction of more resistant strains due to the large number of workers who commute from outside the region,” he said.

He said XDR N. gonorrhoeae, the strain resistant to ceftriaxone, is most likely to enter Australia through one of the major cities. Uncomplicated gonorrhoea acquired in the more remote regions of WA most often can be treated with oral combinations of amoxycillin, probenecid and azithromycin (ZAP packs). Gonorrhoea from the more populous regions of WA (Perth, Southwest, Wheatbelt, Great Southern regions), interstate or overseas is more likely to be penicillin-resistant and should be treated with combination ceftriaxone and azithromycin.

Speakers at the Gold Coast conference pointed to labs moving away from culturebased methods to diagnose gonorrhoea, which reduces the ability to detect antimicrobial resistance. Having to rely on clinicians to identify patients who fail treatment makes it difficult to contain the spread of a resistant strain in time.

David confirmed that WA has also moved to a combination of culture and nucleic acid amplification tests for N. gonorrhoeae detection.

“To combat the reduced proportion of culture diagnoses and hence the susceptibility results available, we have

undertaken molecular antimicrobial resistance surveillance of non-culture specimens to monitor for the development of penicillin resistance in the remote regions of WA where ZAP packs are used for uncomplicated gonorrhoea,” he added. Since 2011, a move to dual therapy (combined oral azithromycin/ ceftriaxone injection) has been one response to emerging cephalosporin resistance.

“August bodies in the USA and UK now recommend ceftriaxone combined with azithromycin as first line therapy, to help reduce the likelihood of the development of ceftriaxone resistance. It is hoped the azithromycin, which also shows activity against most N. gonorrhoeae, will ‘protect’ the ceftriaxone as it is harder for bacteria to become resistant to two antibiotics simultaneously than to one.”

Will Australia soon face a high proportion of more difficult-to-treat cases, with expensive social implications? While oral treatment of gonorrhoea in Perth, and the Southwest, Wheatbelt, and Great Southern regions of WA is not an option, David believes the judicious use of combination oral therapy in remote WA regions can continue to meet the WHO target of 95% effectiveness with some clinical vigilance.

Ensuring the adequacy of STI services in vulnerable communities will help prevent an explosion of resistant strains within these populations.

“All states routinely screen all N. gonorrhoeae isolates for resistance. WA is the only state performing remote region routine molecular antimicrobial surveillance from non-culture specimens.”

ASID leaders and others are pushing for an Australian equivalent of USA’s Centers for Disease Control and Prevention, to do this and coordinate any response. O

DOCTORS DRUM Giving Doctors Voice

Have your say at the next Doctors Drum Breakfast Thursday, October 31, 2013 Rendezvous Hotel (It's FREE but seats are Limited)

TOPIC: GPs & Specialists: Partners in What?

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BOOK NOW go to

www.doctorsdrum.com.au medicalforum

CLINICAL UPDATE

Sunlight and the eye S

unlight, famously in Australia, delivers one of the harshest UV loads on earth and can affect the eye in numerous ways. Obviously chronic sun exposure can be negated principally by wearing sunglasses, and all on sale in Australia are Cancer Council approved.

By Dr Dru Daniels Ophthalmologist

year. Cataract surgery is the most common elective operation in the Western world and represents the most significant operation in terms of improved quality of life and costeffectiveness for outcome.

Cataract

Cataract is an ageing of the native eye lens resulting in reduced visual acuity as well as symptoms such as glare, ghosting and sometimes monocular double vision.

Sunlight certainly plays a significant role in cataract formation, although it is a multifactorial condition in which increasing age, trauma, steroid use, diet and some systemic diseases are factors.

Overall prevalence of cataracts in Australia is over 10%, with more than 100,000 operations for cataract performed each

One of the most concerning eye diseases associated with sunlight exposure is agerelated macular degeneration, which is becoming more frequent. Sunlight and ultraviolet light contribute to free radical damage in the macula, which is the vital element of the retina subserving central vision and acuity.

Choroidal melanoma

Loosely, macular degeneration is often described as wet or dry. Dry macula degeneration prematurely ages the macula, with a chronic slow reduction of vision. Wet macular degeneration can superimpose on the dry type, resulting in acute visual deterioration. Modern intravitreal treatments can partially restore or preserve vision for the wet type of macular degeneration, whereas the dry type (which is more common) has less successful treatment options beyond maintenance of a good diet or supplements.

Pterygiums, which are a benign growth of tissue often nasally on to the cornea, are particularly common in Australia and have a direct relationship to the degree of UV exposure. A relatively simple removal under local anaesthetic has a recurrence rate of less than 10%; the main reasons for removal are constant irritation, visual disturbance because of globe distortion, significant

Macular degeneration

encroachment on the central cornea and appearance.

Several sun-related tumours affect the eye.

It is a little known fact that melanoma can occur inside the eye as well on the external structures such as the lid and conjunctiva.

A choroidal melanoma is often silent until late presentation with visual obscuration or symptoms such as flashes and floaters. This is one reason why these symptoms need a full-dilated examination on presentation.

Prognosis is often quite reasonable for melanoma involving the eye.

Other tumours, including basal cell carcinoma and squamous cell carcinoma, are often found regularly on the eyelids requiring often complicated reconstruction so removal early is the preferred mode of treatment.

Declaration: Perth Eye Centre P/L, managing the Eye Surgery Foundation, supports this clinical update through an independent educational grant to Medical Forum. Author – no competing interests.

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

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Dr Nigel Morlet Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600 Dr Jo Richards Tel: 9321 5996

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Dr Stuart Ross Tel: 9250 7702 Dr Angus Turner Tel: 9381 0802 Dr Michael Wertheim Tel: 9312 6033 31

CLINICAL UPDATE

Congenital ‘holey’ hearts: Patent Ductus Arteriosus

By Dr Luigi D’Orsogna, Paediatric Cardiologist, Western Cardiology.

Tel 9346 9300

T

he ductus arteriosus is the fetal vascular channel connecting the pulmonary artery to the descending aorta so that most of the blood from the right ventricle flows directly into the systemic circulation. Postnatal closure of the ductus arteriosus starts with the newborn’s first breath and functional closure evolves in the first 24 hours with anatomic closure usually completed within two weeks. If it persists, the patent ductus arteriosus (PDA) may be isolated or associated with other congenital heart disease.

Clinical presentations: The pathophysiology and clinical manifestation of isolated PDA relates to the size of the PDA and the pulmonary vascular resistance (PVR), as this influences the amount of left-to-right shunting. The large PDA with low PVR causes excessive pulmonary blood flow resulting in left atrial and ventricular dilatation, which may lead to cardiac failure. If the PVR remains elevated, as may occur with lung disease in the newborn or associated congenital heart disease, there will be little shunting even with a large ductus.

As the PVR decreases over several days in the normal newborn, a large PDA will present with signs and symptoms of excessive pulmonary blood flow. The newborn gradually develops increasing respiratory effort, which may affect feeding.

The peripheral pulses are bounding because of the large pulse pressure from lower diastolic pressure due to flow into the lower-resistance pulmonary circulation

Support Group

during diastole. The praecordial activity is increased, the heart sounds are accentuated and there is a continuous machinery-like murmur over the upper left sternal border.

Hepatomegaly with congestive cardiac failure from excessive left ventricular volume overload may develop over a few weeks.

The small or moderate PDA will usually present as an asymptomatic heart murmur.

This is typically a harsh continuous murmur over the left upper sternal border with normal heart sounds and the pulses are normal if the PDA is small or bounding if moderate.

Investigation: Echocardiography is the best investigation for the diagnosis, the assessment of the size and shape of the PDA and the haemodynamic effects of the left to right shunting such as pulmonary hypertension and left heart volume overload.

Management: Initially, the newborn with PDA can be managed conservatively as

However, it still remains a place where carers come together to learn, to share, and to know that they are not alone. In particular, it helps carers find information about entitlements and law and provides them with support via contact with others in similar situations, counselling and education.

Support and other services are free to carers, including information, counselling, support groups, respite and recreation, carer peer support, Outreach indigenous 32

the ductus may close spontaneously over several weeks. If it persists, then elective transcatheter closure can be undertaken at approximately one year of age with minimal risk. Transcatheter PDA closure is the treatment of choice for small and moderate PDA. It can be performed safely with minimal morbidity and virtually no mortality in all infants >8kg as a same-day procedure. Surgical closure of the PDA is usually reserved for the large ductus in symptomatic newborns and young infants <4kg. This is also a low risk procedure but involves left thoracotomy or a thorascopic approach.

Declaration: Western Cardiology has contributed to the production costs of this clinical update. No author competing interests.

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rafmi was formed in 1976 when there was next-to-nothing by way of official support for carers of people with mental health issues. Today, Arafmi WA has grown into an organisation that supports more than 2000 carers each year. It has become a strong voice for carers of people with a mental illness. It is regularly consulted about Government policy and service implementation affecting carers.

Q Lateral view of aortogram with PDA (arrow).

programs, advocacy, childcarer support, education and school holiday services.

Q CEO Mike Seward

Membership is free and members are provided with a weekly online bulletin, quarterly newsletter and website.

Arafmi has good contact with some medical practitioners Q Mr Lee Tatet and hospitals, who have given positive feedback, but is keen to promote a better awareness of its services to doctors.

It is a goal of the group that the role of carers is better understood by governments, the medical profession, the media, the

AT A GLANCE: ARAFMI Membership: Several hundred. 20 staff and over 70 active volunteers Main Source of Funds: WA Government; annual budget $3m Contact person: Lee Tate Email: lee.tate@arafmi.asn.au Website: www.arafmi.asn.au Arafmi offices: Perth, 9427 7100; Hillarys/Whitfords, 9427 7100; Fremantle, 9427 7100; Midland, 9427 7100; Mandurah, 9427 7100; Rockingham, 9427 7100; Broome: 9192 5860; 9193 5800; Carnarvon, 9941 2803; South Hedland, 9172 3960 and 0437 616 806

police and ambulance sectors and the public. This is happening, particularly with increased federal and State funding, and focus on overcoming stigma in mental health. O medicalforum

Research

Sci-Fi, or a New Hope?

A/Prof Stuart Hodgetts, Director of the Spinal Cord Repair Lab at UWA, gives us an overview of stem cell research in spinal cord injury.

A

widely adopted strategy to treat spinal cord injury (SCI) involves transplanting cells directly into the injury site. The rationale for this is that donor cells may â&#x20AC;&#x153;transdifferentiateâ&#x20AC;? into neuronal and/or supportive glial populations that contribute either directly to regeneration, or act indirectly by inducing beneficial host responses such as remyelination and a reduction in secondary injury damage.

With 26 current clinical trials using stem cells for SCI (http://clinicaltrials.gov) in various stages of completion, there has been much hype about this strategy but, if one is brutally honest, with very little clinical efficacy so far. Most recently, the termination of Geronâ&#x20AC;&#x2122;s Phase 1 clinical trial using human embryonic stem cells and the over-rapid growth of â&#x20AC;&#x153;stem cell tourismâ&#x20AC;? clinics that â&#x20AC;&#x153;promise to deliver, but never deliver on their promiseâ&#x20AC;? have heralded a scepticism about stem cell transplantation strategies for SCI. Of course, this undermines decades of hard experimental work and the significant genuine advances that have been made towards a therapeutic goal.

Funded by the Neurotrauma Research Program of WA, the Spinal Cord Repair Laboratory (UWA) focuses on adult stem cell transplantation strategies, mainly using multipotent mesenchymal precursor cells (hMPCs) isolated from bone marrow. In our rat model, we found that hMPCs isolated from SCI patients promote marked functional (locomotor) and morphological improvements following acute and chronic SCI. Indeed, these cells are currently being used clinically for SCI around the world with some success.

Although researchers have so far been unable to confirm if donor hMPCs are wholly responsible for improved function, there remains momentum in the field to identify potential new donor cell candidates. One emerging candidate is the Induced Pluripotent Stem Cell (iPSC) which involves reprogramming adult differentiated cells back to an embryonic stem cell phenotype (the â&#x20AC;&#x153;gold standardâ&#x20AC;? â&#x20AC;&#x201C; believed to provide consistently better outcomes after SCI). While iPSCs have not yet been used in any extensive SCI study, they hold much promise but are not without safety issues (teratoma-forming potential). It is hoped to generate clinical grade iPSCs using TGA-approved facilities already in use with our hMPC therapy and with technological advances in recent years there is good evidence that clinical grade iPSCs are achievable within a few years.

While we can direct donor stem cells to adopt many different phenotypes (in vitro), a major hurdle is providing the correct cues to control this process after transplantation into a completely different and reactive SCI environment. Equipping the cells with the correct â&#x20AC;&#x153;languageâ&#x20AC;? to navigate these environments successfully over the long term will be critical, since all acute injuries eventually become chronic. As most success has come from adopting ways to treat acute injuries in animal models, it just may be that making the chronic injury acute once more (e.g. by surgical or enzymatic debridement of the glial scar) will maximise therapeutic success using the optimal donor cell type.O

medicalforum

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILTY NEWS

Medical Director Dr John Yovich

International Conferences â&#x20AC;&#x201C; ESHRE â&#x20AC;Ś keeping up and in-touch

Dr John Yovich, Consultant in Gynaecology, Andrology & Reproductive Endocrinology Medical Director, PIVET Medical Centre In the 1980s contingents of medical researchers from America, Europe and Asian countries travelled to Australian centres, including PIVET, to learn the art of applying the new reproductive technologies into effective clinical services. $OWKRXJK WKH Ă&#x20AC;UVW ,9) VXFFHVV RFFXUUHG LQ (QJODQG LQ LW ZDV in Australia where the technology was swiftly adapted and applied to treat a range of fertility disorders with consistently reproducible outcomes measured as livebirths per treatment cycle initiated. PIVET published more than 200 articles on these developments.

So too was Australia the leader in developing strategies to minimise the sometimes lethal side-effects such as OHSS (ovarian hyper-stimulation syndrome), high-order multiple gestations, pre-term deliveries, ectopic gestations and ovarian torsion complications.

Australia also pioneered a nation-wide accreditation system which now also embraces New Zealand and reports annually as the ANZARD independent and reliably complete database. We have shown that every complication can be virtually eliminated whilst maintaining the principle of ovarian stimulation to maintain optimum live-birth rates.

The Australian impetus for frontier research in reproductive medicine has been overtaken by overseas centres nowadays and we learn mostly at the highly-regarded ESHRE meeting and workshops, this year held in London during its warmest ever July. None-the-less there are still some bright sparks from Australia, including PIVET which has recently published its own outstanding results in a highly-rated international journal - Follicle recruitment determines IVF productivity rate via the number of embryos frozen and subsequent transfers; Stanger & Yovich, RBM Online 2013.

NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY

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

33

Guest Column

Addressing non-urgent KEMH backlog

By Dr Vicki Westoby KEMH Liaison GP

B

y June 2012, around 1100 women were waiting for a â&#x20AC;&#x2DC;category 3â&#x20AC;&#x2122; outpatient appointment at King Edward Memorial Hospital (KEMH); that is, nonurgent clinical problems â&#x20AC;&#x153;with limited functional impairment that should be seen within six monthsâ&#x20AC;? such as a HRT problem, infertility or dyspareunia.

Waits of between two months and two years (with many over a year), meant patients could deteriorate while waiting.

The extensive waitlist also increased demands on outpatient clinics with more pressure on staff. Wait times at the six metropolitan secondary gynaecology services (Joondalup Health Campus, Swan Health Service, Osborne Park Hospital, Kaleeya Hospital, Rockingham General Hospital and Peel Health Campus) were often significantly lower for similar problems. KEMH staff investigated.

Internal review A Clinical Service Redesign project investigated the mismatch between demand and capacity and examined potential corrective measures, aiming to reduce the Category 3 waitlist 25% by June 2013.

Overall aims were:

t "DDFTT UP RVBMJUZ IFBMUI DBSF JO B timely manner, t 3JHIU QFSTPO SJHIU QMBDF BOE t " TUBOEBSEJTFE QSPDFTT GPS SFGFSSBMT

Around 50 women attending KEMH gynaecological outpatient clinics identified key priorities as: appointment access; getting specialist care closer to home; and better communication including timelines for appointments.

As a tertiary service, the main focus of KEMH is both urgent or semi-urgent (Category 1 and 2) problems, as well as women with multiple and/or complex medical problems. However, a review of 1100 referrals showed less than 10% of referred women had complex co-morbidities. And only 11% resided within the KEMH catchment area, compared with 72% at other tertiary adult hospitals (Category 3 patients).

Key stakeholders were asked why they thought the majority of non-urgent referrals to KEMH were for women living a significant distance from KEMH and why there were such relatively high levels of low complexity patients.

The likely root causes were identified as:

34

t *OBEFRVBUF TUSBUFHJD QMBOOJOH GPS womenâ&#x20AC;&#x2122;s health. t 1SPCMFNT XJUI BDDFTT UP OPO UFSUJBSZ services. t -BDL PG USVTU CZ (1T BOE XPNFO JO other health services.

What did GPs think?

An opt-in survey of GPs around non-urgent gynaecology referrals yielded 70 responses, with the assistance of metropolitan Medicare Locals and WA General Practice Network. (Online responses took 6.5 minutes average, 78% of respondents were female with 47% under 50 years, and nearly half (48%) had over 20 yearsâ&#x20AC;&#x2122; general practice experience.)

Questions related to confidence in managing common gynaecological conditions, knowledge of gynaecology services available at secondary hospitals, what constitutes a Category 3 referral, and knowledge of Clinical Priority Access Criteria (CPAC).

Key Findings from the survey are shown (see right).

Project outcomes The Category 3 waitlist was reduced by 51% by June 2013, when 565 women were still waiting for outpatient appointment at KEMH. Around 60% of this improvement was due to active list audit (some nonurgent referrals were redirected to another service; some came off the list because they had accessed help elsewhere; or problems had resolved, including cases where women waiting for tubal ligation attended the antenatal clinic instead!)

After meetings with KEMH Executive and representatives from North Metro Area Health Service Clinical Planning and Redevelopment, it was agreed that wait times for Category 3 gynaecology outpatient appointments should be similar across the metropolitan area, regardless of which hospital.

For the future, referring doctors need more information about what gynaecology services are available at secondary hospitals, the referral process to access these, the triage categories used by the Department of Health (Category 1, urgent, seen within 2 weeks; Category 2, semi-urgent, seen within 1 month; and Category 3, routine, seen within 6 months), and CPAC guidelines (see www.gp.health.wa.gov.au/CPAC/speciality/ women.cfm).

KEMH remains committed to providing womenâ&#x20AC;&#x2122;s health education for GPs in

metropolitan and regional areas. The future vision is: â&#x20AC;&#x153;KEMH will only see Category 3 gynaecology patients from within the KEMH postcode catchment OR those with co-morbidities that exclude them from other sites.â&#x20AC;? O Ed. The author acknowledges the assistance of Barb Lourey (Health System Improvement Unit KEMH), and Linda Sinclair and Hannah Moss (NEAT Health reform).

KEY SURVEY FINDINGS (N=70) Barriers to referring to a secondary hospital: 73% uncertain about services available at secondary sites; 54% unsure about referral processes; 43% more DPOGJEFOU JO SFGFSSJOH QBUJFOUT UP ,&.)

What constitutes a Category 3 referral?: 90% of GPs were unfamiliar with relevant clinical conditions (see Fig 1) and there was confusion about whether â&#x20AC;&#x153;Category 3â&#x20AC;? meant most or least urgent.

Use of CPAC guidelines when referring: 87% did not use them (and of these people, 13% said guidelines were not easily accessible, and 9% said they needed further training in their use).

Participation in womenâ&#x20AC;&#x2122;s health and gynaecology CPD: 91% attended an event at least once per year and 23% attended 4 or more times per year; 76% were interested in attending more.

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FIG1. CATEGORY 3 CONDITIONS Defined in the CPAC guidelines (2006), as a clinical condition with limited functional impairment that should be seen within 6 months of referral. Common examples of Category 3 referral conditions: Thrush Ovarian cysts >5cm under the age of 50 years Incontinence, prolapse Dyspareunia Premenstrual syndrome Dysfunctional uterine bleeding (normal Hb) Sterilisation Amenorrhoea Infertility Vaginal agenesis Hirsutism, galactorrhoea Symptoms or problems with HRT

medicalforum

X Dr Jonathan Purday has been appointed medical director of Bunbury Hospital’s new Intensive Care Unit. He has moved to Bunbury from Exeter in Britain where he had more than 30 years’ experience in intensive care medicine and anaesthesia. He leads a medical team that includes two intensive care consultants, Dr Anupam Chauhan and Dr Ravi Krishnamurthy.

X Rural Health West Chairman Mr Ian Taylor has resigned his position after completing his maximum number of years’ service in the role. Former Speaker of the Legislative Assembly, Mr Grant Woodhams, is the new chairman.

XWAGPET received 218 applicants (88 for its rural pathway and 130 for its general pathway) to start GP training in 2014. Not all applicants met the WAGPET benchmark, so exact numbers to be offered a place in each pathway is still being negotiated.

X Director of Nursing at St John of God Midland Public and Private Hospitals, Mr Jeffrey Williams, has been appointed Adjunct Associate Professor for the School of Nursing and Midwifery at The University of Notre Dame Australia.

XDr Randy Beck has been appointed CEO of Primary Care WA. X Curtin University dietitian and researcher Professor Jane Scott has been made a Fellow of the Dietitians Association of Australia.

X Dr Michael Levitt has retired from his post as Director of Medical Services at St John of God Subiaco after seven years.

He continues to practise privately at the hospital.

X General surgeons Dr Robert Goldman and Dr Ravi Rao have joined the Mercy Medical Centre.

X Perth-based technology group Titan ICT Consultants have been signed by WAIMR to design and built the IT systems for two new medical research facilities at the QEII Medical Centre and Fiona Stanley Hospital. The new facilities will house 800 researchers once fully operational.

X The Health Department of WA has recently awarded a contract worth $400,000 to Australian Associated Press to provide an electronic media monitoring and clipping service. The contract also includes the electronic delivery of media releases to WA media outlets.

9 NOVEMBER 2013 SPORTS MEDICINE

CONFERENCE

THE UNIVERSITY CLUB OF WESTERN AUSTRALIA Registration Opens August 2013

An educational meeting for the general practitioner, registrar and physiotherapist with an interest in sports injury and the management of those who exercise.

Contact Conference Secretariat Jo Maguire conference@ perthortho.com.au

PERTH ORTHOPAEDIC & SPORTS MEDICINE CENTRE 31 Outram Street, WEST PERTH T: +61 92124200 F: +61 94813792 www.perthortho.com.au

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35

CLINICAL UPDATE

Procedural options for varicose veins

By Dr Peter Bray, Vascular & Endovascular Surgeon, Fellow Australasian College of Phlebology, Nedlands.

Tel 9386 4377

V

aricose vein treatment has progressed dramatically over the last 10 years and endovenous treatments are likely to become mainstay treatment of varicose veins in the future, but this doesnâ&#x20AC;&#x2122;t hail the end of other treatment modalities. No single modality has perfect results in every situation or is complication-free. Common to all successful treatments is comprehensive patient assessment, setting of realistic goals and a quality venous duplex study.

Venous Duplex Ultrasound: precision is everything In traditional management of varicose veins, a venous duplex scan identified incompetence at the saphenofemoral or saphenopopliteal junctions, with surgery the option if present, otherwise treatment was with sclerotherapy. With modern management, venous duplex must be comprehensive and performed by an experienced vascular sonographer. While the main purpose is to identify the site of incompetence â&#x20AC;&#x201C; deep or superficial veins (saphenous trunks, tributaries, or perforators) â&#x20AC;&#x201C; a quality venous duplex should also demonstrate vessel calibre, tortuosity, depth, nearby nerves, thrombus and aberrant anatomy, all of which impact significantly on treatment selection. A quality duplex study is central to successful planning of treatment.

Treatment Modalities Surgery Saphenofemoral junction ligation and stripping of the great saphenous vein (GSV) is highly effective, and current techniques have greatly reduced morbidity.

It is performed as an inpatient procedure under general anaesthetic. Subfascial ligation treats perforator incompetence.

Surgery still requires 1-2 weeks off work.

Bruising, swelling and postoperative pain are common but settle with time; and major complication of DVT is rare with appropriate prophylaxis.

Recurrent varicose veins previously led to re-do surgery, which is rarely necessary today (thereby reducing the risk of major vascular and neurological injury, chronic lymphoedema and wound complications). Instead, quality venous duplex in combination with sclerotherapy or endovenous laser ablation can effectively manage most recurrences.

Endovenous Laser Ablation (EVLA) This is becoming the preferred treatment for saphenous vein incompetence by many vascular surgeons, as a sterile â&#x20AC;&#x2DC;walk in - walk outâ&#x20AC;&#x2122; office-based procedure.

Following local anaesthetic infiltration along the saphenous trunk, percutaneous access to the lumen of the vein is obtained by a needle puncture and then laser energy 36

used to heat and obliterate the vein lumen.

Currently, EVLA is mainly used for reflux in the above-knee segment of the GSV. Ablation of the below-knee GSV is avoided because there is a higher risk of saphenous nerve injury. Likewise, EVLA of the short saphenous vein (SSV) can be done successfully but the procedure has a higher risk of sural nerve injury if precautions are not taken. EVLA of perforators and major tributaries is not currently commonplace.

matting and superficial ulceration are specific complications associated with microsclerotherapy, but can be minimised by careful patient selection and phlebologist experience. O

EVLA is essentially painless, the patient typically returns to work the next day, and wears a compression stocking for two weeks. Major complications are rare but include DVT and nerve injury (thermal).

Phlebitis can occur, but rarely needs treatment and usually settles with time.

/P USFBUNFOU NPEBMJUZ JT QFSGFDU &BDI IBT its pros and cons and all have a varying risk of recurrence (progression of disease following all treatments) or recanalisation &7-" PS 6('4

Lasers have continued to evolve. Studies have shown that the new 1470nm wavelength lasers ablate the vein with less energy, pain and staining than older 980nm predecessors. Initial comparisons with radiofrequency ablation (RFA) reported less pain with RFA, but was based on older lasers and new RFA. Large randomised trials favour the newer lasers with respect to pain, staining and durability of results, and a wider range of veins can be treated due to smaller and more adaptable laser fibres.

Sclerotherapy The advent of ultrasound guided foam sclerotherapy (UGFS) means sclerotherapy is no longer confined to spider and reticular veins and varicosities not related to saphenous vein reflux. UGFS is now accepted as an effective treatment for major tributary incompetence, perforator incompetence, and recurrent varicose veins. It can be used to treat even saphenous incompetence in selected cases.

Microsclerotherapy is still the optimal treatment for surface varicosities (spider and reticular veins).

Sclerotherapy takes about 30 minutes, does not require time off work, and a well-fitted Class II compression stocking is as critical as the injection itself, and must be worn for two weeks afterwards.

Major complications are rare but include DVT, anaphylaxis, migraine and stroke.

Phlebitis and skin staining can occur and the latter may time to fade but can be avoided by correct case selection. Venous

CHOOSING APPROPRIATE TREATMENT

t 4BQIFOPVT JODPNQFUFODF DBO CF USFBUFE XJUI &7-" PS TVSHFSZ XJUI BMNPTU JEFOUJDBM results. Certain anatomies (revealed by a quality venous duplex study) determine which technique is best. o .PTU TBQIFOPVT USVOLT DBO CF USFBUFE XJUI &7-" PS TVSHFSZ CVU SJTL PG GBJMVSF BOE DPNQMJDBUJPOT XJUI &7-" JODSFBTF JG UIF USVOL JT PG FYUSFNF DBMJCSF UPSUVPVT PS TVQFSGJDJBM o 4VSHFSZ JT QSFGFSSFE JO JTPMBUFE TBQIFOPGFNPSBM JODPNQFUFODF BTTPDJBUFE XJUI BO FOPSNPVT BOUFSPMBUFSBM UIJHI WFJO USJCVUBSZ PS XIFSF FYUFOTJWF QIMFCFDUPNJFT BSF SFRVJSFE PS B (" JT JOTJTUFE PO t 1FSGPSBUPS JODPNQFUFODF BOE SFDVSSFOU junctional varicose veins are now routinely treated with UGS or endovenous ablation, in experienced hands. t 5SJCVUBSZ JODPNQFUFODF JT CFTU EFBMU XJUI utilising UGS but patients concerned about intravenous sclerosant can be treated with day case or ambulatory phlebectomy. t .JDSPTDMFSPUIFSBQZ JT TUJMM UIF PQUJNBM treatment for spider and reticular veins that are symptomatic or cause cosmetic concern.

When a patient has access to all treatment modalities they can expect the best technique for their pattern of disease (taking into account personal preference), otherwise: i8IFO UIF POMZ UPPM ZPV IBWF JT B IBNNFS FWFSZ QSPCMFN TUBSUT UP MPPL MJLF B OBJMw "CSBIBN .BTMPX

Declaration: Author competing interests: No relevant disclosures.

medicalforum

CLINICAL UPDATE Dr Ivan Ling, Respiratory & Sleep Physician, SCGH & Cardio Respiratory Sleep (CRS), Suite 15, 95 Monash Avenue, Nedlands.

Tel: 1300 130 930 www.sleepcrs.net.au

Approach to chronic cough P

atient distress and healthcare costs go hand-in-hand with chronic cough, one of the most common symptoms in general practice. In outpatient respiratory services, management of cough can account for up to 40% of all cases. Chronic cough (that is, persisting beyond eight weeks) has a wider variety of possible causes, whereas acute cough (<3 weeks) is most commonly due to respiratory tract infections. Many doctors will have difficulty diagnosing and treating patients with chronic cough; management can be challenging, and evidence-based guidelines recommend a systematic approach to clinical assessment and trials of therapy 1, 2

Common causes A cause can be identified in 75-85% of adults with chronic cough, for which more than 85% are accounted for by asthma, upper airway cough syndrome (UACS, includes concept of â&#x20AC;&#x2DC;post nasal dripâ&#x20AC;&#x2122;), GORD, and ACE inhibitor use. Initial history and physical examination often suggest one or more of these possibilities, towards which a trial of treatment may be directed.

Key questions Duration of cough establishes chronic vs. sub-acute vs. acute. Diurnal variation in symptom severity may help point to certain causes (e.g. GORD), as does exacerbating factors (e.g. posture for GORD, cold air/ exercise for asthma) and associated symptoms such as heartburn (GORD), shortness of breath (lung or cardiac disease), wheeze (asthma), sputum production (infection), facial pain (sinusitis), and rhinitis.

Other key questions involve detection of â&#x20AC;&#x2DC;red flagsâ&#x20AC;&#x2122; which include features such as haemoptysis, smoking history >20 pack years, current or ex-smoker with altered/ new cough (malignancy), progressive shortness of breath (lung or cardiac disease), substantial sputum production (chronic infection), and systemic symptoms such as fever and weight loss (malignancy, infection).

Strong causative links A history of atopy (atopic dermatitis, allergic rhinitis) prompts consideration of asthma, and further specific history (wheeze, shortness of breath, exacerbating factors) and testing (spirometry) may be directed as such.

Chronic symptoms of facial pain, pressure or fullness associated with nasal blockage or purulent discharge is suggestive of chronic sinusitis.

Haemoptysis in the absence of acute infection is frequently associated with malignancy, the suspicion of which is raised by the presence of a significant smoking history and age >50 years.

Sputum production and fever prompts consideration for chronic infection and medicalforum

possible bronchiectasis. Tuberculosis remains one of the most important health problems worldwide â&#x20AC;&#x201C; questions regarding close contact exposure and travel history may reveal clues.

Diurnal and weekly variation in symptoms with worsening after workplace exposure suggests occupational association (e.g. asthma), which can be difficult to recognise. Occupations at particular risk are those with exposure to organic or chemical dust/fumes. Establishing the diagnosis can be challenging, and proper serial PEFR measurement can be very helpful.

Heartburn and regurgitation suggest GORD. However, severe gastrointestinal symptoms (e.g. haematemesis, dysphagia, odynophagia) act as prompters to consider serious underlying conditions (e.g. malignancy) and specialist referral.

Most helpful tests Chest X-ray and spirometry are helpful in excluding serious underlying disease (e.g. interstitial disease, emphysema, heart failure) and may help confirm asthma.

Blood tests are probably of limited value but may be helpful in identifying underlying infection (WCC, inflammatory markers) or allergy (IgE, RAST).

If cough is productive, sputum microscopy and culture can be considered if initial treatment is unhelpful. Further tests such as full lung function (parenchymal lung disease) and bronchial provocation (asthma) can be helpful in selected circumstances, and may be appropriately recommended in discussion with a respiratory physician.

Management and when to refer Initial evaluation often suggests a cause of chronic cough, for which treatment can be trialled (cessation of ACE inhibitor, bronchodilators for asthma, proton pump inhibitors for GORD, and intranasal steroids and antihistamines for allergic rhinitis). When less common conditions are suspected, further investigation may be warranted (e.g. CT chest and full lung function if examination and spirometry suggest interstitial lung disease).

Specialist referral may be considered when: t 5SJBM T PG USFBUNFOU IBWF CFFO unsuccessful.

t 5IFSF JT TVTQFDUFE VOEFSMZJOH PS TFWFSF lung disease (e.g. malignancy, interstitial lung disease, COPD). t 4ZNQUPNT BSF TFWFSF BOE PS debilitating. t 5IFSF JT VODFSUBJOUZ BCPVU EJBHOPTJT Further reading: Australian guidelines for the management of chronic cough (CICADA: Cough In Children and Adults: Diagnosis and Assessment) were recently updated and are recommended1.

References: 1. Gibson PG, Chang AB, Glasgow NJ, Holmes PW, Katelaris P, Kemp AS, et al. CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian cough guidelines summary statement. The Medical journal of Australia. 2010; 192: 265-71.

2. Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006; 129: 1S-23S.

SUMMARY: CHRONIC COUGH t $ISPOJD DPVHI JT DPNNPO DPTUMZ BOE detrimental to patient wellbeing. t PG JEFOUJGJBCMF DBVTFT BSF EVF UP BTUINB 6"$4 (03% BOE "$& JOIJCJUPS use. t " GPDVTFE JOJUJBM BTTFTTNFOU VTJOH history, examination, chest X-ray and spirometry can help exclude many serious underlying conditions with high confidence, and direct a trial of treatment toward one or more conditions. t A3FE GMBHT GPS TFSJPVT DPOEJUJPOT JODMVEF haemoptysis, smoking history, progressive shortness of breath, substantial sputum production, fever, and weight loss. t 'BJMVSF UP SFTQPOE UP POF PS NPSF USJBMT of treatment directed at more common conditions should prompt consideration of alternative diagnoses and specialist referral.

Declaration. Author: No relevant competing interests.

This clinical update is supported by an independent educational grant to Medical Forum by CVS-CRS. 37

CLINICAL UPDATE

Injections for ‘hip’ pain

I

can't walk, my leg/hip/pelvis hurts too much," is a patient comment that raises the possibility of three common conditions that may be crippling your patient and which can respond dramatically to local injection. These three problems can coexist. One memorable evening I injected all three, enabling a 70-year-old lady to walk out of the ED singing for joy. She had been brought in on a wheelchair by her family, unable to walk for weeks despite conservative management.

Gluteus medius bursa: The pain for the most common condition may refer to a number of areas around the hip or pelvis but is characterised by a dramatic increase when weight bearing on one foot on the affected side or during the swing phase of walking. Gluteus Medius is a major stabiliser of the hip. How do you find it?

Facing your patient while they are laying on their good side with the upper sore leg flexed at knee and hip, place your thumb and little finger on the greater trochanter and the anterior superior iliac spine, respectively (see Figure 1). Extend your index finger over the rounded muscles and press down. This is usually the area of gluteus medius tenderness, found with just a little exploring. Pressing a little

deeper into the muscle finds the point(s) of maximum tenderness, which correspond with the attachments and body of the muscle. If pressure reproduces your patient's pain, quietly celebrate, because a simple injection of 5ml of local anaesthetic with 2ml of Kenacort A10 into the point[s] of maximum tenderness enables your patient to walk pain free, much to their joy.

Meralgia paraesthetica: This is caused by entrapment of the lateral cutaneous nerve of the thigh as it emerges from the abdominal wall under the crook of the anterior superior iliac spine. This is more common than you may think and is often not declared by the patient as it is more of a nuisance than disabling. A simple injection of 1-2ml of local anaesthetic and steroid will give some initial numbness (hence pain

Q "Figure 1

By Dr Michael Eaton, RDA (WA) President, Rural Locums Many of us do not have the luxury of referring patients for ultrasound-guided joint injections because we practise in impoverished or remote areas, or patients prefer us to do it and trust us to do joint injections safely, efficiently and/ or cheaply. Patient benefits are quick and professional satisfaction comes from providing a simple and often highly effective treatment.

relief) and help reduce the swelling causing the entrapment. If preferred, topical antiinflammatory cream can be trialed first.

Trochanteric bursitis: This is the third and easiest to find problem-causing ‘hip’ pain.

Easily felt even if your patient is carrying many excess kilos, this responds well to injection when topical and conservative treatments have failed. With the patient lying on their good side and the upper thigh exposed, insert the needle vertically at the point of maximal tenderness and gently advance it until you either feel the outer wall of the bursa "pop" or you reach the bone. If the latter, withdraw a centimetre and inject gently (there should be no resistance) the 5ml of local anaesthetic mixed with 20mg (2ml) of Kenacomb A10.

Conference Corner

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

Surgical & medical abortion on Contraceptive inserts STI checks Vasectomy Decision-based counselling g DR0194

24 hour aftercare Part of the Marie Stopes International global partnership

Dates: Venue: Website:

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

Dates: Venue: Website:

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

Dates: Venue: Website:

National Environmental Health Conference September 24-26 Parmelia Hilton www.eh.org.au/events

Dates: Website:

WA ANZCA Meeting Bunker Bay October 11-13 www.anzca.edu.au/events

Date: Venue: Website:

Rural Health West Fremantle Conference October 19 Fremantle www.ruralhealthwest.com.au

Dates: Venue: Website:

Model pictured for illustrative purposes only

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

Dates: Venue: Website:

National Conference on Incontinence October 23-26 Crown Conference Centre, Perth www.continence.org.au/pages/national-conference-onincontinence.html WA Transcultural Mental Health and Australasian Refugee Health Conference 2013 October 31-November 1 Duxton Hotel, Perth www.transrefugee2013.com.au

Referrals and enquiries freecall 1800 003 707 38

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39

Philanthropy

Never Stops It may have been a few years since Dr Ken Collins saw more than 60 patients in a day, but his work in retirement centres around giving.

After a busy career as a suburban GP, Ken Collins became even busier as a Director of the International Board of Rotary. The job took him all over the world and encompassed everything from raising funds for cleft palate and cataract surgery in developing countries to putting magnifying microscopes into WA primary schools.

“I can’t claim much credit for the microscope project. My wife, Di has done most of the work for that – I’m just a helper.

She heard Professor Lyn Beazley [WA Chief Scientist] speak at the Karrakatta Rotary Club about her passion to give every primary school child access to this technology.”

“They’re simple instruments, magnifying 60-100 times with a slide underneath and costing around $15 each. We bring them in from China and distribute them to other Rotary clubs who then present them to primary schools around WA. We’ve just ticked off the 300th school, so that’s about 9000 microscopes for budding scientists.”

40

whatever you want as long as it’s legal!’

I was interested in pharmacy but ended up doing medicine in Adelaide, joined the RAAF and ended up at Pearce as the Chief Medical Officer. After that I had a long career as a GP in Langford.”

It was a case of ongoing bureaucratic intervention that prompted Ken to embrace a somewhat early retirement.

Although the siren call of Rotary played its part.

“In the 1970s I was seeing between 90-100 patients a day and being congratulated by the Health Department for being such a hard-working GP. By the mid-90s I was told that if I saw more than 60 patients per day I was over-servicing!

That’s when patients started crowding into the public hospitals because I wasn’t the only GP working hard and suddenly we were told we couldn’t do that anymore.”

Ken, who comes from a long line of market gardeners, had an early interest in science. Initially he was heading for a career in pharmacy and then detoured towards medicine.

“I was getting letters from the Health Insurance Commission telling me I’d done this number of short, medium and long consultations and prescribed the following medications. The last line was ‘you’ve cost the government this amount of money.’ It was very disheartening so, at the age of 64 with a bit of working life still in me, I said ‘that’s it!’ Mind you, a big part of that decision was tied up with my appointment to the International Board of Rotary.”

“My father had no choice but to leave school and go into the family business of market gardening. I didn’t want that so, thankfully, he said to me ‘you can do

“Medicine can be a hard life. We used to deliver babies back then and some nights you didn’t see your bed but were still expected to front-up at 8.30am and

pretend you’d just had eight hours sleep.

None of our children has gone into medicine, I think they saw the hours I worked and ran in the opposite direction!”

“There were some high points in my medical career. I was recognised by the AMA with an award for Outstanding Service to Medicine and in 1994 I received an OA for Service to Public Health in Australia.”

The transition into retirement can be a daunting process, particularly from an all-consuming profession such as medicine.

“Rotary has been a real blessing. I joined in 1967 and back then there wasn’t much support for families in difficulty. If a husband left the family and the wife couldn’t work some people really struggled so we’d organise food hampers and holidays. As a GP in the Langford area I saw this sort of thing every day.”

“Rotary’s signature project is the eradication of polio. That started in 1985 and it’s raised close to $240m to buy vaccines. We’ve reduced the number of cases from around half a million in 150 countries to less than 250 in five countries.”

“I’ve been heavily involved because both my brother and I had polio back in the 1940s. It was pretty mild and only affected my right arm but I’m beginning to feel the effects of post-polio syndrome because the damaged nerves have degenerated faster than the nondamaged ones.”

medicalforum

Who Wants to be the D-G

E-Poll

ll o P e

We’ve all read the problems the State Government is having on finding the right person for the post of Director-General of Health. So we decided to give the HR department a helping hand by asking readers in last month’s E-Poll for their opinion on the qualities needed for the job.

Completing this sentence, "The right person for WA's Director General of Health position needs to have..." 72 specialists responded as you would expect experienced anatomists to do.

Some opted for thick skin; some for enlarged male genitalia (which could be tricky if they choose a woman); several thought extra brainpower from rocks and tin whistles while another was writing a referral for neuropsychological assessment as to why they would want the job; others thought guts and heart.

Large animals also figured prominently, with elephants leading rhinoceroses 4:2, perhaps elephants’ superior recall tipped them over the line.

A couple of readers thought the chosen one might need some supernatural help from a magic wand or an enchanted amulet and if they weren’t readily to hand, try “the wisdom of the Dalai Lama and the energy of Richard Branson”.

For many, experience mattered – medical administration, politics, epidemiology and health economics. Add a background in health management or clinical medicine, “concern for the continuum of health care, not just hospital care, the ability to stand up to the bean counters in order to drive reform, and ensure an adequate budget to fund future health services for a growing population.” Easy!

The applicant also needs “broad insight into the deficiencies of the health service and excellent communication skills” while being “an independent thinker who will not be compromised by political pressure groups.”

At a recent Medical Forum Doctors Drum Breakfast, the issue of caring for fellow practitioners was a catalyst for robust discussion. Ken sings the praises of Rotary as an opportunity for doctors to be both socially engaged and to enjoy the camaraderie of working with fellow clinicians.

Understanding the complexities of the health system would also help. “This can ONLY be gleaned from actually studying, qualifying and working as a hospital doctor to a senior level BEFORE taking on the role of DG of Health. This is far superior than having someone who only pretends to understand.”

Other qualities required are courage (because it’s contagious), patience (because it will be sorely tested) a ridiculously hard work ethic (because you’ll need it) and a carefully packed parachute.

Should be easy to find someone!

“I’m always bumping into colleagues at Rotary events. Paddy Ramanthan and Bryant Stokes are members, Rob Pearce is our current President and Grant Buxton runs our bowel screening project. You can do as much or as little as you wish, from travelling overseas as a volunteer to raising money. We do everything from collecting superseded hospital beds and sending them to developing countries to funding eye surgery in India. The latter procedure is done by local doctors and the lens and suture material costs around $15.”

“Some of the older clubs are steeped in tradition and, realising that younger people aren’t necessarily attracted to sitting around singing 100 year-old songs, we’ve formed Rotaract for 18-30 yearolds. It’s more like a cocktail club, you can drop in on the way home from work and it’s all over by 7pm. I’d recommend the Rotary organisation to everyone.” O www.facebook.com/freshwaterbayrotary www.rotary.org

By Mr Peter McClelland

medicalforum

41

Social Pulse

s detail l i a m E r of you tion to func rum. l a i c so mfo @ r o t i ed om.au c

Apple founder Steve Jobs once famously said: “I think we’re having fun” and just to prove it, Medical Forum has started a regular social page showing our readers doing just that. While there’ll be no paparazzi sneaky shots or idle tattle in Social Pulse, we reckon it’s a good chance to show that we are all more than our work. Let us know if you have an upcoming social event by the first of every month by emailing Jan Hallam at editor@mforum.com.au

Q Dr Jim Brown (left) from rural general practice in Nyngan, NSW (population 1500), with Dr Iain McIntyre, who works with 12 aged care facilities in Adelaide.

Q Geraldton contingent (l to r) Dr Aubrey Francis (sailboard exponent), Dr Ana Abraham, and Dr Bertel Bulten take a break between sessions.

Q Esther Mortimer (right) from IPN recruitment is looking for Australian-trained doctors to work in their 200 or so national practices, particularly the 32 practices in WA. IPN recently acquired ALMS in WA. She is pictured talking to Dr Antonina Volikova, ex-SKG and currently out of the workforce.

GPCE PERTH Scientific program producer Ms Nikki Drummond said the inaugural GPCE conference in Perth under Reed Medical Education seems to have been a successful satellite of the bigger eastern states annual events. They were worried that the only weekend available to them at the Perth Convention Centre fell into the school holidays but this seems to have resulted in a healthy contingent of GPs and others from rural general practice. By mid-morning the conference sessions were full. Official figures are still under wraps by press time.

Although 2013 is the final year in the triennium for accumulating required CPD points, and the program almost covered total points required, this did not appear to be a major drawcard among the delegates Medical Forum spoke to.

Q Dr Laura Osborn (left) pictured with Dr Daisy Hamilton-Baillie. Both are from the UK, with Laura working as a medical registrar at Peel Health Campus and Daisy doing her RMO rotation at King Edward. Both have their sights on entering GP training at the end of this year.

Q A chance to catch up with friends – Dr Beng Tan (left) from Candlewood Medical Centre and Dr Wei Hong Chua from Kingsway Medical Centre. Both were not chasing CPD points but keen to update their knowledge, which Beng pointed out doubled every five years.

In fact, two doctors from interstate said the GPCE conference was simply a chance to update in important areas – aged cared and rural general practice in their case – and a chance to see Perth for the first time.

42

medicalforum

Social Pulse

FLIGHT OF FANCY AT SJOG SUBIACO BALL

Q Dr Donald Ormonde and with nurses from the Endoscopy unit,

Q (Left to right Nurse manager of Day Surgery Services Ms Margaret Knowles, Deputy DON Ms Sarah Hession and gastroenterologist Dr Paul Laidman; Mr Graham Cullingford and Dr Michael Stanford; Acting CEO of SJOG Pathology Mr Michael Hogan and Medical Director Dr Glenn Edwards.

Guests brought their passports to adventure when they rocked up to the SJOG Subiaco annual ball at the Perth Convention and Exhibition Centre. Almost 500 doctors, allied health professionals, staff and sponsors began the journey at the Bellevue Ballroom for a taste of Asia, complete with Lion Dancers and Asian canapés. After the short stopover it was off to Spain with flamenco dancers and guitarists tantalising almost as much as the tapas. The night ended in a a funky bar in New York, where guests soaked up the river views, relaxed on sofas, indulged in a candy buffet and danced to the funky DJ beats.

Spotted were Group CEO Dr Michael Stanford and wife Sally, CEO of SJGSH Dr Lachlan Henderson and wife Cathy, ophthalmologist Dr Chris Kennedy and wife Victoria, gastroenterologist Dr Donald Ormonde, surgeon Dr Harsha Chandraratna and wife Wendy Smith and SJOG pathology head Dr Bridget Cooke.

Q SJOGSH CEO Dr Lachlan and Cathy Henderson

TIME AND SPACE SJOG heavyweights gathered for the opening of Murdoch Hospital’s new standalone Endoscopy Unit, which is part of the extensive hospital redevelopment project. The unit is in full-swing with feedback positive from staff and patients alike. Spotted at the launch were Group CEO Dr Michael Stanford, acting Murdoch CEO Mr Colin Young, Director of Nursing Adam Coleman and Dr Glenn Edwards from SJOG Pathology.

REMEMBERING AT BETHESDA After almost 70 years, it’s important to remember where you came from and that’s what staff past and present did at the first Bethesda Hospital Remembrance Day. The Premier Colin Barnett launched the commemorative booklet, Our Beginnings, chronicling the role of the Churches of Christ, past staff and board members to the development of the hospital. Former matron Ms Joyce Brand, who took over from inaugural matron Beryl Hill, contributed much to the book.

Among the awards to be present by Mr Barnett was recognition to Ms Penny Collin, an Enrolled Nurse who has been associated with the hospital for 43 years. Also at the function was Bethesda CEO Ms Yasmin Naglazas.

Q Premier Colin Barnett with former matron Ms Joyce Brand and awardwinner Ms Penny Collin at the Bethesda Remembrance Day.

medicalforum

43

Musical Theatre

Turning

BLUE Breathtaking theatrics, pulsating music, one size fits all and it comes in just one colour â&#x20AC;&#x201C; BLUE!

Three bald and totally blue men crank up the tribal rhythms, pull out the PVC pipes and bring a whole new meaning to â&#x20AC;&#x2DC;live entertainmentâ&#x20AC;&#x2122;. Phil Stanton, one of the three co-creators of the Blue Man Group, tells Medical Forum that theyâ&#x20AC;&#x2122;re trying to fuse the ancient with the modern and bring people together in a surreal explosion of light and sound. â&#x20AC;&#x153;Drumming is a way of expressing a tribal past within the context of our modern world and all its advanced technology. One of the RVFTUJPOT XF SF BTLJOH JT AXIBU SFNBJOT human during all the technological change we see around us?â&#x20AC;?

i8F SF BMTP JOUFSFTUFE JO comedy and poking fun at UIF MJWFT XF SF MJWJOH *G XF can make ourselves laugh, we think we can probably make other people laugh as well.â&#x20AC;?

commentary on modern technology and human behaviour. The Blue Man is silent, MJLF $IBQMJO BOE ,FBUPO CVU IF T B MPU NPSF UIBO B NPEFSO DMPXO )F T B QBSU PG BMM PG us and something magical occurs when we come together and play like this. Blue Man Group is a catalyst for that to happen!â&#x20AC;?

*U T WJTVBMMZ TUVOOJOH VMUSB modern musical theatre and the audience at Crown Theatre, Burswood, will be asking the same question as fans all around the world. Why blue?

â&#x20AC;&#x153;The core creative spark comes from our /FX :PSL CBTF 8F IBWF OJOF EJGGFSFOU ensembles in the USA and one in Berlin.

8F SF B QSFUUZ UJHIULOJU HSPVQ BOE UIFSF T a lot of creative cross-pollination. It takes a while to learn the characters because UIFSF T OPU B MPU PG GBDJBM BSUJGJDF BOE DMPXO BOUJDT *U MPPLT TP VOOBUVSBM ZFU XF SF USZJOH to portray real people.â&#x20AC;?

i5IFSF T QSPCBCMZ OPU B SFBMMZ HPPE BOTXFS to that! It was an intuitive decision and it just seemed that this particular blue has a TVCMJNF BOE CFBVUJGVM RVBMJUZ 5IFSF T BO element of seriousness to it and it has a UPVDI PG UIF DMPXO UPP *U T HPU BO VOOBUVSBM versatility, a little bit of PT Barnum combined with a more sombre note. A minor key, if you like?â&#x20AC;? i*U T JOUFSFTUJOH CFDBVTF B MPU PG USJCFT painted themselves blue for ceremonial rituals. We were also attracted to the work PG 'SFODI BSUJTU :WFT ,MFJO BOE IJT CMVF monochrome paintings. But really we just TBJE AXPVMEO U JU CF GVO *U T XPSLFE GPS VT BOE XF SF BMXBZT HPJOH UP CF CMVF QVU it that way.â&#x20AC;?

5SJCBM EBODJOH BOE 'SFODI QBJOUFST BSFO U the only driving forces behind the Blue Man Group, as Phil Stanton points out. â&#x20AC;&#x153;Charlie Chaplin and Buster Keaton are huge influences with their bizarre social

This is one show that traverses geographical and cultural boundaries with consummate ease. â&#x20AC;&#x153;People react to the performance in remarkably similar ways. From the very beginning we never saw the Blue Man Group as parUJDVMBSMZ "NFSJDBO *U T NVDI NPSF VOJWFSTBM than that and the humour comes from the situations we all find ourselves in as human beings.â&#x20AC;? O

Mr Peter McClelland

WIN Blue Man Group opens at Crown Theatre Burswood on October 12. For your chance to win tickets, turn to the Competitions P49.

Show Your Artistic Side In the June edition of .FEJDBM 'PSVN, doctor-sculptor Tony Barr shared with readers his joy in developing his artistic talents. He described in glowing terms how his medical training â&#x20AC;&#x201C; the horrors of his anatomy classes â&#x20AC;&#x201C; has become a special part of his sculpting.

He wrote: â&#x20AC;&#x153;Sculpting life models, both head and torso, has plunged me back into this dark science with a new burst of energy and pleasure. The aesthetic of working with 44

silken like clay fashioning delicate parts of human anatomy to the sounds of soft music and good wine has given me insight into the public lives of the Greek gods.â&#x20AC;?

It got us thinking that among you, there is an BWBMBODIF PG DSFBUJWF UBMFOU BOE XF E MPWF to hear about your artistic endeavours, be it visual arts, music, theatre, writing, dance, as individuals or in a group â&#x20AC;&#x201C; let us know.

Contact editor@mforum.com.au

medicalforum

Wine Review

Magpie

SEASON

2011 Commonage Semillon Margaret River makes beautiful Semillon and this wine is no exception. Lovely and fresh bouquet rounded out by soft attractive oak barrel flavours. It is crisp and lively with a clean finish and will keep in the bottle but is so enjoyable now.

A very good food wine that would go well with fried squid or any light fish or chicken dish.

Dr Louis Papaelias

2012 Commonage Noble Sauvignon Blanc Botrytis affected and at an alcohol level of just 10.9%, this is reminiscent of a light-bodied Sauternes. Again, it is crisp and lively with complex sweetness.

Lovely to drink unaccompanied or with light cheese or fresh fruit.

Yallingup represents the northernmost part of the greater Margaret River wine region. To quote from Dr John Gladstones: “The area from about Abbey Farm Road northwards to Dunsborough has the unique advantage, for Western Australia, of facing north across Geographe Bay.

2010 Swooping Magpie Cabernet Merlot The fame of Margaret River rests upon the success of its Cabernet Sauvignon. So TVDDFTTGVM IBT JU CFFO UIBU JU JT OPX DPOTJEFSFE BT "VTUSBMJB T GJOFTU QSPEVDFS PG this noble Bordeaux variety. This particular blend displays all the right attributes one would expect – generous yet refined berries with a gentle underpinning of oak; attractive round to the taste with an earthy finish. Great with any meat or fullflavoured food. Like the Semillon it will keep but is very good right now.

This means that north easterly and northerly winds must come across the bay, resulting on average in slightly warmer nights, cooler days and higher relative humidities than in the more land dominated locations.”* Soils suitable for viticulture are mainly lateritic gravelly sandy loams. It is an area that is eminently suitable for wine production but is also highly sought after for its real estate potential and tourist development. It comes as no surprise that many properties in this area support thriving restaurants and tourist facilities in addition to their vineyards.

Swooping Magpie Wines is one such place, which judging from its many positive web feedback comments, provides a very hospitable and high quality food and wine service from its restaurant and cellar door facility. Based on what I tasted, this property serves up wines that are of very good quality at an attractive price point. My preferred wines showed fresh and youthful flavours. Wines that are enjoyable now and that would go beautifully together with the abundant local produce of the region.

The wines are labelled either as under the premium Commonage range or the lower priced “Kid on a Bike” range. Both groups had their strengths and weaknesses. My notes on the wines tasted are arranged in decreasing order of personal preference.

medicalforum

2008 Commonage Cabernet Franc At five years of age this wine shows a lot of youth and vigour. It had an attractive lifted bouquet which also had whiffs of green eucalypt. This wine certainly has the structure to keep in the bottle.

2009 Swooping Magpie Shiraz As is typical of the variety, this wine has the softness, spiciness and leather that make Shiraz such a popular choice among wine lovers everywhere. This is good, generous and flavoursome drinking that will not fail to please.

WIN a Doctor's Dozen!

What infection makes the Commonage Noble Sauvignon Blanc distinctive?

Answer:

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ENTER HERE!... or you can enter online at www.MedicalHub.com.au!

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

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Please send more information on Swooping Magpie Wines offers for Medical Forum readers.

45

funnyside e

Q Q 25 life truths 1. If you're too open-minded, your brains will fall out.

2. Don't worry about what people think, they don't do it very often.

3. Going to church doesn't make you a Christian any more than standing in a garage makes you a car.

4. Artificial intelligence is no match for natural stupidity.

5 If you must choose between two evils, pick the one you've never tried before.

6. My idea of housework is to sweep the room with a glance 7. Not one shred of evidence supports the notion that life is serious.

8. It is easier to get forgiveness than permission.

9. For every action, there is an equal and opposite government program.

10. If you look like your passport picture, you probably need the trip.

11. Bills travel through the mail at twice the speed of cheques.

12. A conscience is what hurts when all of your other parts feel so good.

15. No man has ever been shot while doing the dishes.

16. A balanced diet is a biscuit in each hand.

17. Middle age is when broadness of the mind and narrowness of the waist change places.

18. Opportunities always look bigger going than coming.

19. Junk is something you've kept for years and throw away three weeks before you need it.

8. There are 10 types of people in this world. Those that know binary, and those UIBU EPO U

20. There is always one more imbecile than you counted on.

9. When I heard that oxygen and magnesium hooked up I was like OMg.

&YQFSJFODF JT B XPOEFSGVM UIJOH *U enables you to recognise a mistake when you make it again.

5IF CBSNBO TBZT i8F EPO U TFSWF faster-than-light particles here.â&#x20AC;? A tachyon enters a bar.

22. By the time you can make ends meet, they move the ends.

11. A Buddhist monk approaches a hotdog stand and says: â&#x20AC;&#x153;Make me one with everythingâ&#x20AC;?.

23. Thou shall not weigh more than thy refrigerator.

24. Someone who thinks logically provides a nice contrast to the real world.

25. It ain't the jeans that make your butt look fat.

14. Never trust an atom. They make up everything.

&BU XFMM TUBZ GJU EJF BOZXBZ 14. Men are from earth. Women are from earth. Deal with it!

Q Q Be Not Afraid

Q Q Too clever by half 1. A photon checks into a hotel and the porter asks him if he has any luggage. The QIPUPO SFQMJFT i/P * N USBWFMMJOH MJHIU w 2. â&#x20AC;&#x153;Is it solipsistic in here, or is it just me?â&#x20AC;?

3. What does a dyslexic, agnostic, insomniac spend most of his time doing?

Staying up all night wondering if there really is a dog.

6. Pavlov is enjoying a pint in the pub. The phone rings. He jumps up and shouts: â&#x20AC;&#x153;Hell, I forgot to feed the dog!â&#x20AC;?

7. How many surrealists does it take to screw in a light bulb? A fish.

46

"O &OHMJTINBO B 'SFODINBO B Spaniard and a German are walking down the street together. A juggler is performing on the street but there are so many people UIBU UIF GPVS NFO DBO U TFF UIF KVHHMFS 4P the juggler goes on top of a platform and asks: â&#x20AC;&#x153;Can you see me now?â&#x20AC;? The four NFO BOTXFS i:FT w i0VJ w i4J w i+B w

A few minutes before the church services started, the townspeople were sitting in their pews and talking. Suddenly, Satan appeared at the front of the church. &WFSZPOF TUBSUFE TDSFBNJOH BOE SVOOJOH for the front entrance, trampling each other in a frantic effort to get away from evil incarnate.

Soon everyone had exited the church except for one elderly gentleman who sat calmly in his pew without moving, seemingly oblivious to the fact that God's ultimate enemy was in his presence. Satan walked up to the old man and said, "Don't you know who I am?"

5IF NBO SFQMJFE :FQ TVSF EP "Aren't you afraid of me?" Satan asked. /PQF TVSF BJO U TBJE UIF NBO "Don't you realize I can kill you with a word?" asked Satan.

"Don't doubt it for a minute," returned the old man, in an even tone.

"Did you know that I could cause you profound, horrifying, physical agony for all eternity?", persisted Satan. :FQ XBT UIF DBMN SFQMZ "And you're still not afraid?", asked Satan.

"Nope."

More than a little perturbed, Satan asked, "Well, why aren't you afraid of me?"

The man calmly replied, "Been married to your sister for 48 years".

medicalforum

Theatre

TAKING US BY

STORM Itâ&#x20AC;&#x2122;s an Australian classic that celebrates 50 years of weaving magic with a young boy, a grieving father and a cheeky pelican called Mr Percival.

John Sheedy was knee-deep in pelican feathers when Medical Forum spoke with him recently. The Artistic Director of Perthâ&#x20AC;&#x2122;s Barking Gecko Theatre Company was in Sydney preparing for the opening night of Storm Boy â&#x20AC;&#x201C; a historic collaboration with the Sydney Theatre Company.

This beloved book by Colin Thiele, celebrating 50 years this year, has been read by generations. The film was equally adored for its sweeping landscapes and heartfelt performances. Now John and Tom Holloway have adapted the book for the stage, with its premiere in Sydney followed by a season at the Heath Ledger Theatre at the end of the month. i8IFO * N DIPPTJOH XPSLT GPS #BSLJOH Gecko I look for stories that have stayed with me since I was a child, and 4UPSN #PZ DBNF TUSBJHIU UP NJOE *U T OPU KVTU UIF UBMF PG B CPZ T GSJFOETIJQ XJUI B QFMJDBO 5IFSF T a lovely simplicity to the story but also a deeper complexity, a melancholy undercurrent dealing with issues such as masculinity and grief.â&#x20AC;? â&#x20AC;&#x153;I like theatre that asks questions, creates conversations and provokes discussion.

And, of course, entertains audiences too!â&#x20AC;? &WFO XJUI UIF CFTU TUPSJFT JO UIF XPSME UIF shift from page to screen then on to the stage can be fraught with difficulties. â&#x20AC;&#x153;I always favour the book rather than the GJMN XIFO * N DPOWFSUJOH B TUPSZ GPS UIF theatre. There are so many wonderful rich EFUBJMT JO UIF XSJUUFO GPSN UIBU BSFO U BMXBZT captured in film. Mind you, 4UPSN #PZ was B CSJMMJBOU GJMN BOE * UIJOL UIBU T CFDBVTF UIF storytelling is so flawlessly simple.â&#x20AC;? â&#x20AC;&#x153;There are quite a few elements to this proEVDUJPO BOE JU T CFFO IBSE XPSL CVU XF SF having a lot of fun. The technical side is a challenge and the trick there is not to overcomplicate it.â&#x20AC;?

medicalforum

Perth is one of the most isolated cities in the world and Barking Gecko has shown UIBU PVS TUPSJFT BSFO U OFDFTTBSJMZ QBSPDIJBM Good theatre transcends boundaries and will delight audiences everywhere. i*U T KVTU HSFBU UIBU PVS XPSL JT CFJOH TIPXO in Sydney and Melbourne. Our teen show, %SJWJOH JOUP 8BMMT, had a season at the 0QFSB )PVTF BOE JU T UFSSJGJD UIBU UIFTF TUPries are given a larger life both over east and overseas.â&#x20AC;? i8F UIJOL JU T WFSZ JNQPSUBOU UP DSFBUF theatre that is sophisticated, not only in the program itself but also the broader aesUIFUJDT PG XIBU XF EP * N BQQSPBDIJOH UIF three-year point with Barking Gecko and XF SF JO B HPPE QMBDF UP LFFQ EFWFMPQJOH the company.â&#x20AC;?

4UPSN #PZ is, at its essence, a beautiful story. John Sheedy is absolutely unequivo-

cal that the cast members will do it full justice. â&#x20AC;&#x153;Two boys, Rory Potter and Joshua $IBMMPOFS TIBSF UIF MFBE SPMF BOE JU T B IVHF HJH GPS B ZPVOH BDUPS 5IFZ SF JO FWFSZ TDFOF and really lead the audience through the TUPSZ 1FUFS 0 #SJFO QMBZT )JEFBXBZ 5PN and Trevor Jamieson is Fingerbone Bill.â&#x20AC;? i5IFSF T TVDI B HSFBU MPWF GPS UIJT TUPSZ these guys are doing a magnificent job.â&#x20AC;? O

By Mr Peter McClelland

WIN Storm Boy opens at the Heath Ledger Theatre on September 21.

For you chance to win tickets, turn to Competitions P49.

47

Music

Summer Nights &

Fairytale Endings Mezzo soprano Fiona Campbell may live the pressures of a working mother, but when she performs, sheâ&#x20AC;&#x2122;s a world away and takes her audiences with her.

Sheâ&#x20AC;&#x2122;s played queens and fairytale princesses and even the odd prince, but when it comes to juggling the hardest act of all â&#x20AC;&#x201C; motherhood and an operatic career â&#x20AC;&#x201C; WA mezzo soprano Fiona Campbell is anything but a diva. â&#x20AC;&#x153;Any working mother knows that it takes a great degree of planning, organisation, good time management and a supportive IVTCBOE UP IBWF B GBNJMZ BOE B DBSFFS * WF DSFBUFE BMM UIPTF UIJOHT BOE * N WFSZ GPSUVnate to have a very supportive husband,â&#x20AC;?

Fiona said from her Perth home. â&#x20AC;&#x153;My children are 11 and 12, so in some ways now they are getting older it is getting easier but I still want to be there for UIFN BOE TPNF NPNFOUT * QIZTJDBMMZ DBO U * N OPU JO UIF TUBUF BOE DIPJDFT IBWF UP CF made. But the upside is they get to travel with me, so they get to see some great places, which is a real bonus.â&#x20AC;? â&#x20AC;&#x153;I was recently singing the title role of Cinderella with Opera Queensland and the

family came with me. We had a fantastic holiday but it puts a lot more pressure on me because I still have to sing every second OJHIU * N MJTUFOJOH UP UIF PUIFS DBTU NFNbers who just have themselves to worry about, complaining that they would never get out of bed before 10am.â&#x20AC;? i* N TBZJOH UP NZTFMG * LOPX XIP UIF QSJODFTT JT IFSF BOE JU T OPU NF w i*O UIF FOE JU T HSFBU UIBU UIF LJET DBO come to a show and understand the amount PG XPSL JU T UBLFO UP HFU UIFSF 5IBU T SFBMMZ important for them to see.â&#x20AC;?

Next month, Fiona sings, in front of a home crowd, one her all-time favourite song DZDMFT #FSMJP[ T -FT OVJUT E FUF [Summer Nights] with the WA Symphony Orchestra. i*U T POF PG UIF GFX TPOH DZDMFT GPS NF[[PT UP TJOH XJUI GVMM PSDIFTUSB *U T FYRVJTJUFMZ orchestrated with the most beautiful poetry. There is incredible intimacy contrasting XJUI UIJT IVHF PSDIFTUSBM TPVOE BOE JU T BMM in such balance. There are moments when you feel like the only person in the room and

PUIFS NPNFOUT XIFO JU T FQJD BOE SPNBOUJD *U T B DPNQMFUF KPZ UP TJOH BOE IFBS w Fiona will be the guest soloist in the concert that will mark distinguished UK conductor 1BVM .D$SFFTI T EFCVU XJUI 8"40 1BVM who is founder and artistic director of the Gabrieli Consort, will lead the orchestra in #FFUIPWFO T NBTUFSQJFDF 4JYUI 4ZNQIPOZ â&#x20AC;&#x201C; 5IF 1BTUPSBM â&#x20AC;&#x153;It will be a superb concert. These are some of my favourite pieces, so to be singing them with WASO in front of a home audience with a talent like Paul McCreesh JU T B SBSF BOE KPZGVM PQQPSUVOJUZ w O

By Ms Jan Hallam

WIN For your chance to win tickets to see Fiona Campbell sing with WASO BOE IFBS #FFUIPWFO T 5IF 1BTUPSBM symphony, turn to Competitons, P49.

Soaring the Heights When 19-year-old clarinettist Ben Pallagi steps out in front of the WA Youth Orchestra and its conductor Peter Moore at the end of the month, it will be as a soloist for the ďŹ rst time.

The winner of the Woodside Concerto Prize will play the Weber Clarinet Concerto No.2 BOE BT GBS BT IF T DPODFSOFE UIBU T QSJ[F enough. â&#x20AC;&#x153;The opportunity to play with the orchestra JT BMM * DBO UIJOL BCPVU SJHIU OPX * WF CFFO playing since I was seven, I just love the repertoire.â&#x20AC;?

48

The third year UWA music student has been QBSU PG UIF JNQSFTTJWF ":0 TJODF BOE music has been central to his life. He was home-schooled throughout his secondary education so that he could devote himself to music. Up until 2011 he was also playing piano and violin but the clarinet won out for the good reason that â&#x20AC;&#x153;it was the one I enjoyed the mostâ&#x20AC;?.

WIN

"U UIF TBNF DPODFSU 8":0 UBLFT PO UIF monumental Tchaikovsky Fifth Symphony. *U T B SBSF PQQPSUVOJUZ UP TFF UIJT BNB[JOHMZ talent band of young musicians.O

For your chance to win tickets to see 8":0 BOE TPMPJTU #FO 1BMMBHJ PO September 28 at the Perth Concert Hall turn to Competitions, P49.

medicalforum

Competitions

Entering Medical Forum's COMPETITIONS has never been easier!

Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' MJOL CFMPX UIF NBHB[JOF DPWFS PO UIF MFGU

Movie: Thanks for Sharing From the director/writer of 5IF ,JET "SF "MM 3JHIU comes a sharply comic and moving look at a haphazard family forged by a group people trying to navigate life, love and the emoUJPOBM MBOENJOFT PG /FX :PSL $JUZ XIJMF SFDPWFSJOH GSPN addiction. Mark Ruffalo, Tim Robbins and Gwyneth Paltrow anchor a stellar ensemble including pop star Pink (aka Alecia Moore) in her first film.

In cinemas from October 3

Theatre: Storm Boy Theatre: Blue Man Group A show first created 25 years ago by a group of three New :PSLFST BT B XBZ PG SFGMFDUJOH PO PVS HSPXJOH SFMJBODF PO UFDInology, Blue Man Group bang PVC pipes, dance and generally SFNJOE VT PG PVS QSJNBM PSJHJOT "OE UIFO UIFSF T UIF GBDU UIBU the three performers are blue, which has led to cult status in the US with the group being referenced in such TV shows as 5IF 4JNQTPOT "SSFTUFE %FWFMPQNFOU and 4DSVCT. Crown Theatre, October 12. Season continues until October 27

$PMJO 5IJFMF T DMBTTJD OPWFM XIJDI DFMFCSBUFT JUT 50th anniversary in 2013, has been adapted to the TUBHF CZ 1FSUI T #BSLJOH (FDLP BOE 4ZEOFZ 5IFBUSF Company for a night of exceptional family theatre.

The story of a young boy and his father retreat to the Coorong in South Australia after the death of their mother and wife and find solace in the landscape and a cheeky pelican called Mr Percival.

Heath Ledger Theatre, State Theatre Centre, September 21. Season continues until October 5

Music: WASO Gala Paul McCreesh, founder of the celebrated Gabrieli Consort 1MBZFST NBLFT IJT DPOEVDUJOH EFCVU XJUI 8"40 JO B glorious gala featuring mezzo soprano Fiona Campbell singing the beautiful and lyrical Berlioz song cycle, -FT OVJUT E Ă?UĂ? [Summer Nights] followed by the full-bodied, Beethoven Sixth Symphony, the ever-hummable, always thrilling 1BTUPSBM. Perth Concert Hall, October 11 & 12. Morning symphony on October 10 (minus Berlioz)

Music: WAYO

an, from Dr Miles Beam ia D gn os tic W es te rn Myaree, in y Patholog SVN he 'P told .FEJDBM 'FSNPZ E UF TJ WJ IBEO U BOE

&TUBUF TJODF ard to rw fo g in was look wines r ei th seeing how y iles is M d. pe lo n. In fact, ever ve had de rnet Sauvigno be Ca ew ed br di ge bo gara partial to a fullake their own few friends m r. ve year he and a Ri t re ga grown in Mar using grapes

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5IF 8" :PVUI 0SDIFTUSB JT POF PG UIF NPTU UBMFOUFE group of young musicians and they get together for this NPOVNFOUBM OJHIU XJUI 5DIBJLPWTLZ T 'JGUI 4ZNQIPOZ the keystone. Nineteen-year-old clarinettist Benjamin 1BMMBHJ UBLFT PO 8FCFS T GBNPVT DMBSJOFU DPODFSUP UP TIPX XIZ IF T KVTU XPO UIF 8PPETJEF $PODFSUP 1SJ[F Perth Concert Hall, September 28

Watching Fermoy Grow

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49

74

medical forum PSYCHIATRIST WANTED

BIBRA LAKE - Psychiatrist wanted Are you intending to start Private Practice?

This is a sheer walk in!

Part time, sessional or full time - all FORVJSJFT XFMDPNF Furnished consulting rooms available at: #JCSB -BLF 4QFDJBMJTU $FOUSF "OOPJT 3PBE #JCSB -BLF 8" &YJTUJOH QSJWBUF QTZDIJBUSJTU POF EBZ B week at this location.

EBZ QIBSNBDZ BOE (1 TVSHFSZ OFYU EPPS are added advantages.

5 minute drive to St John of God and upcoming Fiona Stanley hospital.

Phone Navneet 9414 7860

FOR SALE/LEASE

BULLCREEK Purpose built consulting rooms close to Fiona Stanley & Murdoch Hospitals.

"WBJMBCMF JNNFEJBUFMZ DPOTVMU SPPNT 2 treatment rooms with Ample parking.

Contact:   Brad Potter  -  0411 185 006Â

EAST PERTH Commercial premises on the corner of #FOOFUU 8JUUFOPPN 4USFFUT &BTU 1FSUI (SFBU &YQPTVSF XJUI OBUVSBM MJHIU UISPVHIPVU Suite doctors or specialists â&#x20AC;&#x201C; Available immediately.

Premises comes with 2 car bays.

Contact:   Brad Potter  â&#x20AC;&#x201C;  0411 185 006

MURDOCH Murdoch Specialist Centre, brand new stylish large rooms.

Please email you interest to admin@sleepmed.com.au

MURDOCH New Wexford Medical Centre â&#x20AC;&#x201C; St John of God Hospital 2 brand new medical consulting rooms available: t TRN BOE TRN t %VF GPS DPNQMFUJPO .BSDI t DBS CBZ QFS UFOBODZ Lease one or both rooms.

For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au NEDLANDS Hollywood Medical Centre- Sessional suites BWBJMBCMF XJUI 4FDSFUBSJBM TVQQPSU JG SFRVJSFE Please contact 0414 780 751 JOONDANNA New medical centre in Joondanna.

0OMZ LN GSPN $#% &YDFMMFOU QPTJUJPO PO Wanneroo Rd, with ample parking.

Suit GPs and / or allied health.

Pharmacy and pathology on-site.

For further details, contact Wesley Williams Ph 0414 287 537 &NBJM XJMMJBNT XFTMFZL!HNBJM DPN

WEST LEEDERVILLE Specialists Consulting Suite XBJUJOH SPPN PGGJDF DPOTVMUJOH SPPNT

Onsite parking. &BTZ BDDFTT UP GSFFXBZ Phone: 9380 6457

FOR LEASE NEDLANDS Medical Specialist Consulting Rooms Fully serviced rooms and facilities for Specialist Consulting are available t 4VJUF )PMMZXPPE 4QFDJBMJTU $FOUSF 95 Monash Avenue, Nedlands.

"OZ FORVJSJFT DBO CF EJSFDUFE UP Mrs Rhonda Mazzulla, Practice Manager, 4VJUF Hollywood Specialist Centre 95 Monash Avenue /FEMBOET 8" Phone: 9389 1533 &NBJM TVJUF IPMMZXPPE!CJHQPOE DPN AVELEY Suitable for dental practice and/or allied IFBMUI TFSWJDFT FH 1IZTJPUIFSBQZ 1TZDIPMPHZ 1PEJBUSJTU 3BEJPMPHZ FUD

Medical centre located in the same building.

Located in a fast growing community beside a shopping centre, close to secondary schools, primary schools, church and Child Care Centre.

Contact: 0400 814 091

SHENTON PARK Medical Rooms in Shenton Park for Lease.

Newly furnishing premise with two medical consultation rooms available.

The rooms are approved by local council for medical use.

Premise is well located off Onslow Road.

Ample street parking available.

Suitable for medical practitioners or specialists to setup.

Call Kevin on 0413 969 003 now!

MANDURAH Mandurah Fully furnished rooms in large NFEJDBM DPNQMFY BWBJMBCMF GPS QBSU PS GVMM time leasing.

Within physiotherapy practice who supports multidisciplinary approach to treatment and 29 General Practitioners.

Reception support available.

Ideal for any medical professional looking UP PQFO UIFJS PXO QSBDUJDF PS FYQBOE BO FYJTUJOH QSBDUJDF &NBJM FOIBODFQIZTJP!HNBJM DPN

FOR SALE

GREENWOOD

WEST LEEDERVILLE

GREENWOOD/KINGSLEY FAMILY PRACTICE In todayâ&#x20AC;&#x2122;s market where there is an oversupply of GPs, are you feeling frustrated that you have to work FYDFFEJOHMZ MPOH IPVST BOE XJUI MJUUMF take home income?

Are you pressurised to bulk-bill in order to stay afloat on todayâ&#x20AC;&#x2122;s competitive GP market?

"SF ZPV DPNNJUUFE UP PGGFS RVBMJUZ personalised services to your patients?

Are you to looking for likeminded GPs to work with?

Come and have an obligation free confidential chat with us.

"WFSBHF HSPTT CJMMJOH UP a day achievable for GPs who offer FYDFQUJPOBM TFSWJDFT UP PVS DMJFOUT $POUBDU %S $IBP 0402 201 311 or &NBJM TIFOZDIBP!IPUNBJM DPN 4PSSZ XF EP OPU IBWF %84 TUBUVT

CONSULTING ROOMS TUBOE BMPOF

Opposite SJOG t -BOE BSFB TRN t #VJMEJOH BQQSPY TRN 1BSLJOH BU GSPOU SFBS CBZT

2 large consulting rooms, treatment room, reception, waiting room, separate admin and staff areas, basement storage Phone Carol Prosser 0421 397 593 &NBJM GPSUF!BSBDI OFU BV

NORTHERN SUBURBS 3-doctor Medical centre for sale Northern Suburbs Profitable, well established medical centre with Pathology, chemist, podiatrist and QIZTJPUIFSBQZ JO DPNQMFY /PU B %84 BSFB Phone: Brad Potter 0411 185 006 MEDICAL SUITE(S) 10 McCOURT STREET WEST LEEDERVILLE 5IFTF XFMM MPDBUFE TRN NFEJDBM TVJUF T

with two car bays each are located opposite St John of God Hospital and ready for immediate occupation.

(03%0/ 56$,&3 3 & 0408 093 731 gtrealestate@iinet.net.au

LOCUM WANTED PERTH Locums / Associates wanted.

Perth Medical Centre, Hay Street Mall.

Busy accredited privately owned practice, QSJWBUF CJMMJOH GMFYJCMF IPVST &YDFMMFOU SFNVOFSBUJPO GPS TVJUBCMF candidates.

Phone: 9481 4342 Mobile: 0408 665 531

URBAN POSITIONS VACANT FREMANTLE Fremantle Womenâ&#x20AC;&#x2122;s Health Centre SFRVJSFT B GFNBMF (1 73 UP QSPWJEF medical services in the area of womenâ&#x20AC;&#x2122;s IFBMUI PS EBZT QX *U JT B DPNQVUFSJTFE private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical and counselling services, health education and HSPVQ BDUJWJUJFT JO B SFMBYFE GSJFOEMZ TFUUJOH Phone: 9431 0500 or &NBJM %JBOF 4OPPLT EJSFDUPS!GXID PSH BV PS %BXO /FFEIBN clinical-manager@fwhc.org.au

BALLAJURA (Northern Suburbs) PERMANENT/PART TIME GP XBOUFE QSFGFSBCMZ GFNBMF GPS #BMMBKVSB Medical Centre.

5IJT JT %84 QSBDUJDF XJUI NJYFE CJMMJOH busy practice, nursing staff & Best Practice software.

Lots of potential.

Phone: 0488 222 238 &NBJM DIJCJMJUJTN!ZBIPP DPN

FREMANTLE 1BSU UJNF PS 'VMM UJNF QSFGFSBCMZ 73

GPs wanted.

ELLEN HEALTH is a doctor-owned and managed General Practice operating from two locations in port city of Fremantle.

Well established patient base, offering a broad suite of services including nutrition and lifestyle, specialised pregnancy and midwifery care, community mental health nursing and skin clinic consultations.

If you were to join our team we will offer you: t " HSPXJOH EBUBCBTF PG 1SJWBUF Billing patients t " QSPGFTTJPOBM BOE EFEJDBUFE support team t " MJGFTUZMF UBJMPSFE UP UIF MPDBUJPO t )PVST PG XPSL UP TVJU PVS CBMBODFE lifestyle approach - Practice hours are Weekdays BN QN 4BUVSEBZ BN QN - No after hours, on-call or hospital work SFRVJSFE BU UIJT UJNF t )JHI MFWFM PG FBSOJOHT Contact Practice Manager Bridie Hutton 0413 994 484 &NBJM CSJEJF IVUUPO!FMMFOIFBMUI DPN BV GOLDEN BAY 15 GFNBMF (1 SFRVJSFE 'VMMZ DPNQVUFSJTFE %84 private/bulkbilling.

Fully accredited, Practice Nurse, onsite pathology.

Contact: Sheelagh 08 9537 3738 &NBJM $7 UP QSBDNBO!FGUFM OFU BV

OCTOBER 2013 - next deadline 12md Friday 13th September - Tel 9203 5222 or jen@mforum.com.au

medical forum BECOME PART OF THE BIGGER PICTURE! Long established and privately owned, Perth Medical centre is centrally located, accredited, fully computerised and privately billing.

We have recently renovated so come and join our team and you will be busy from day one.

We have an interesting and truly diverse NJYUVSF PG DMJFOUFMF ZPVOH BOE PME CMVF and white collar, travellers and residents.

You will have plenty of opportunity to develop an interest in whatever branch of practice you choose with the backup of a team of locally trained colleagues.

We also have a team of RNs leading our chronic disease management program.

We are a social group who support one BOPUIFS BSF GMFYJCMF XJUI IPVST BOE CFMJFWF in maintaining balance to avoid the rush hour, reduce your carbon foot print and keep fit; bus, train or cycle to work.

Check us out www.perthmedicalcentre.com.au Interested?

Call our practice manager &SJO PO (08)9481 4342 or %S 1IJM " ) 0411 108 883

CANNING VALE We have an opportunity for a happy, GSJFOEMZ (1 UP DBQUVSF B VOJRVF DPSOFS PG the market.

In an area of rapid growth, where GPâ&#x20AC;&#x2122;s are in short supply, we have a new purpose built practice that is waiting for you. *O $BOOJOH 7BMF XJUI 1BUIPMPHZ BOE %FOUBM POTJUF BOE BO BCVOEBODF PG BMMJFE health and specialists close by, a fully computerised practice is available for the right candidate Forward your interest to ahgpcvale@gmail.com or call 0416 022 721 MANDURAH .BOEVSBI DPBTUBM MJGFTUZMF NJOVUFT from Perth.

73 OPO 73 EPDUPS SFRVJSFE TIPSU UFSN PS long term.

No weekends or after hours. Good remuneration.

Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist and orthotics.

Contact practice manager &MBJOF 9535 8700 &NBJM FMBJOF!NBOEVSBIEPDUPST DPN BV GOSNELLS 73 (1 GFNBMF QSFGFSSFE BGUFSOPPO TFTTJPOT GSPN OPPO UJMM QN PG SFDFJQUT Please phone Patrick on 9490 8288 or &NBJM BTICVSU!IJHIXBZ DPN BV BEACONSFIELD Well established, niche family friendly QSBDUJDF TFFLJOH 73 'FNBMF (1 UP XPSL GMFYJCMF EBZT BOE IPVST Fully computerised and accredited.

(PPE NJY PG QSJWBUF BOE CVML CJMMJOH Please contact Practice Manager Linda on 9335 9884 or &NBJM DFOUSBMBWFOVFND!PQUVTOFU DPN BV

MANDURAH VR GP Required Ideal climate, white beaches, stunning golf courses.

Two hours from Margaret River, fifty mins from Perth CBD, excellent schools, no traffic jams. /PU %84 CVU HSFBU DPGGFF SPPNT with windows!

8F TFFL B 73 (1 UP KPJO PVS IBQQZ TVSHFSZ No on-call or afterhours in a purpose-built, paperless surgery.

'PVS MBSHF DPOTVMUJOH SPPNT UXP '5& nurses, clinical and practice managers to make the most of Medicare item numbers. &YDFMMFOU SFNVOFSBUJPO BOE DPOEJUJPOT JO 3" NJYFE CJMMJOH QSBDUJDF Sound too good to be true?

Come and see how good GP life can be.

4FOE $7 UP BDDPVOUT!NFUDFOJIFBMUI DPN BV PS DBMM 3PCJO PO 9586 2122.

HILLARYS &YDJUJOH 0QQPSUVOJUZ Join us in our brand new General Practice located NOR. Non-corporate.

8F SFRVJSF B GVMM UJNF PS QBSU UJNF GP for our practice.

Hours to suit. /P FWFOJOH PS XFFLFOE XPSL SFRVJSFE The practice is fully computerised BOE XFMM FRVJQQFE Private Billing and some bulk-billing Full-time Nursing support.

Pathology on site.

Please contact Practice Manager on 9448 4815 or &NBJM TND!XFTUOFU DPN BV

WHITFORDS GP - F/T OR P/T. We are fully computerised, well FRVJQQFE BDDSFEJUFE QSBDUJDF Friendly practice Nurse and admin staff to support at all times, including Careplan/Health Assessment Nurse.

Medical Centre has on site pathology and pharmacy.

1MFBTF DPOUBDU +BDRVJ Practice Manager on 9307 4222 &NBJM KNBSLPVMPPQ!JJOFU OFU BV

BAYSWATER 8BOUFE (FOFSBM 1SBDUJUJPOFS 73 ' 5 PS 1 5 SFRVJSFE XJUIJO PVS GSJFOEMZ OPO corporate medical practice.

We are a fully computerised, wellFRVJQQFE UFBDIJOH BDDSFEJUFE HFOFSBM practice seeking an enthusiastic person to join our team with a view in assisting our growing patient load.

We are a proudly independent practice which offers a friendly environment, GMFYJCMF XPSLJOH IPVST QMFBTBOU SPPNT great staff, with wonderful patients. &NBJM SFTVNF UP manager@walterrdegps.com.au or 'BY 9279 1390 MT HAWTHORN Mt Hawthorn Medical Centre, a noncorporate accredited long established practice situated in a fast growing inner city suburb of Perth, seeks a part time or full time 73 (1 UP KPJO UIJT IJHIMZ EFTJSBCMF QSBDUJDF Fully computerised, Nurse Assistant.

Phone Rose 9444 1644

NORTH BEACH Part time GP to join our GP owned practice NJOVUFT OPSUI PG UIF 8FTUFSO 4VCVSCT 'MFYJCMF IPVST BOE NJYFE CJMMJOH An interest in either womenâ&#x20AC;&#x2122;s health or NFO T IFBMUI XJMM BTTJTU PVS UXP FYJTUJOH (1 T A recent closure in a neighbouring suburb has increased the demand for appointments On site pathology, psychologist and nurse support Supportive allied services close by.

Please contact Helen or %BWJE 94471233 to discuss or &NBJM SFDFQUJPO OCND! CJHQPOE DPN

BULLCREEK Come and join us in our New General Practice located SOR. Non-Corporate Practice.

8F SFRVJSF B 1BSU UJNF 73 (1 GPS PVS 4VSHFSZ Tuesday afternoon, Wednesday "MM %BZ 5IVSTEBZ NPSOJOHT BOE Friday Morningâ&#x20AC;&#x2122;s available.

The surgery is Computerised, Private and Bulkbilling.

Practice Nurse available part-time.

Please contact the practice manager Annette on 9332 5556

BENTLEY (1 73 OFFEFE GPS QSJWBUFMZ PXOFE GBNJMZ orientated practice.

NJOT GSPN 1FSUI $#% "(1"- BDDSFEJUFE GVMMZ DPNQVUFSJTFE VTJOH .% 1SBDTPGU Private and Bulk Billing.

4VQQPSUFE CZ DMJOJDBM BOE $%. OVSTFT operating from purpose built practice.

8F PGGFS PG CJMMJOHT Contact Alison on 0401 047 063

PALMYRA

THORNLIE 73 (1 SFRVJSFE GPS B GVMMZ BDDSFEJUFE computerised, non-corporate, rapidly growing practice.

Nursing support available. No after-hours.

Friendly support staff.

0VUFS NFUSP 7JTB 4QPOTPST CJMMJOHT BOE SFUBJOFS OFHPUJBCMF Contact: 9267 2888 / 0403 009 838 &NBJM UIPSOMJFNFEJDBMDFOUSF!IPUNBJM DPN

1BMJO 4USFFU 'BNJMZ 1SBDUJDF SFRVJSFT B GVMM PS QBSU UJNF 73 (1 We, at this privately owned fully serviced computerised practice enjoy B SFMBYFE FOWJSPONFOU XJUI TQBDF and gardens. &BSO PG NJYFE CJMMJOHT For further information call Lyn on 9319 1577 or %S 1BVM #BCJDI PO 0401 265 881.

NORTH PERTH 7JFX 4USFFU .FEJDBM SFRVJSFT B (1 ' 5 PS 1 5 We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support.

Ring Helen 9227 0170

75 MURDOCH Murdoch University, Murdoch Contractor Positions â&#x20AC;&#x201C; part-time GPâ&#x20AC;&#x2122;s Murdoch Health and Counselling Service SFRVJSFT 73 (1T XJUI PXO "#/ GPS sessions per week; working with domestic and international students and staff.

This is a great opportunity to work in a busy and vibrant environment with diverse client needs. t 4FTTJPO UJNFT GMFYJCMF BOE OP BGUFS IPVST PS XFFLFOE XPSL SFRVJSFE t /FX QSFNJTFT XJUI TVQQPSU GSPN B UFBN PG FYQFSJFODFE OVSTFT psychologists and friendly administrative staff t &YDFMMFOU SFNVOFSBUJPO t 'SFF SFTFSWFE PO DBNQVT QBSLJOH is available &YQFSJFODF BT XFMM BT JOUFSFTU JO XPSLJOH XJUI ZPVOH QFPQMF NFOUBM IFBMUI TFYVBM health and travel health is essential.

Please contact: Bronwyn Williams, Manager Murdoch Health and Counselling Service on 9360 6330 or &NBJM # 8JMMJBNT!NVSEPDI FEV BV CURRAMBINE Sunlander Medical Centre is seeking a (FOFSBM 1SBDUJUJPOFS UP KPJO PVS .JYFE Billing Practice.

1SJNF MPDBUJPO NJOVUFT GSPN 1FSUI $#% and 5 minutes from the beach.

73 BOE OPO 73 DPOTJEFSFE Full Time and Part time positions available On-site Registered Nurse, Perth Pathology, and X-Ray dept. %FOUJTU BOE 1IZTJPUIFSBQJTU XJUIJO PGGJDF BOE XF BSF MPDBUFE OFYU UP B 1IBSNBDZ Contact: Sirov Maharaj on 0438 740 307 PS FORVJSJFT!TVOMBOEFSNFEJDBMDFOUSF DPN

MANDURAH - YOUTH HEALTH Peel Youth Medical Service is seeking a ZPVUI GSJFOEMZ (1 GPS o TFTTJPOT QFS XFFL &YDJUJOH PQQPSUVOJUZ UP XPSL XJUI ZPVOH QFPQMF XJUI B GPDVT PO NFOUBM BOE TFYVBM health in a supportive practice.

'MFYJCMF TFTTJPO UJNFT BWBJMBCMF Contact Sharlene 9581 3352 &NBJM TIBSMFOFI!HQEPXOTPVUI DPN BV MOSMAN PARK Full or Part time GP wanted.

A rare opportunity to join a friendly, noncorporate, fully computerised practice in Mosman Park. )PVST BOE EBZT GMFYJCMF 3FNVOFSBUJPO PG HSPTT CJMMJOHT Tel: Jacinta on 9385 0077 RIVERTON RIVERTON MEDICAL CENTRE is looking GPS B 15 PS '5 73 (1 Access to full-time practice nurse.

Fully computerised accredited practice.

Friendly working environment.

Pay negotiable.

3JOH %S 4PWBOO PO 0412 711 197 if interested.

OCTOBER 2013 - next deadline 12md Friday 13th September - Tel 9203 5222 or jen@mforum.com.au

76

medical forum

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

(SFBU PQQPSUVOJUJFT GPS FYQFSJFODFE (1T to join these two busy Australian Skin Cancer Clinics. t 'MFYJCMF XPSLJOH IPVST UP TVJU your lifestyle; t (SFBU FBSOJOH QPUFOUJBM t .PEFSO XFMM FRVJQQFE DMJOJD t 1SPGFTTJPOBM BENJOJTUSBUJPO BOE practice management staff; 5IFTF BSF OPU %84 MJTUFE TJUFT For more information please contact Fiona James on 0447 006 846 or fiona.james@ipnet.com.au www.ausskinclinics.com.au/ UNIVERSITY OF WESTERN AUSTRALIA, CRAWLEY 73 (1 SFRVJSFE GPS PVS GVMMZ DPNQVUFSJTFE BDDSFEJUFE XFMM FRVJQQFE BOE OFXMZ renovated practice.

Our busy centre is complimented with full time nursing staff, Mental Health Nurses, Physiotherapy and onsite Pathology and Pharmacy Sessions negotiable - no evening or XFFLFOE XPSL SFRVJSFE 7FSZ GSJFOEMZ UFBN BUUSBDUJWF remuneration and free, reserved bay parking on campus.

Please contact Sharon Almeida, Practice Manager, sharon.almeida@uwa.edu.au PS %S $ISJTUJOF 1BTDPUU christine.pascott@uwa.edu.au Ph: 6488 2118

We make Aged Care work for GPâ&#x20AC;&#x2122;s Medical Practitioners for Aged Care .1 "$ JT TFFLJOH EPDUPST UP KPJO its team providing medical services to residents of various Residential Aged Care Facilities throughout the Perth metro area. Our efficient service delivery model NBYJNJTFT UIF EPDUPS T FBSOJOH QPUFOUJBM t 'MFYJCMF TFTTJPOT .POEBZ UP 'SJEBZ t (SFBU BENJO TDIFEVMJOH TVQQPSU t 3FNPUF MPH JO UP QBUJFOU SFDPSET t 3/ QSPWJEFE CZ .1 "$ UP BTTJTU EPDUPS t #FUUFS VUJMJTBUJPO PG EPDUPS T UJNF t 1BZNFOU PG HSPTT SFDFJQUT t &RVJUZ JOWPMWFNFOU QPTTJCMF For more information or confidential discussion about work options please DPOUBDU 3PMMP 8JUUPO o $IJFG &YFDVUJWF 0GGJDFS .1 "$ Tel: 9389 8291 or Mobile: 0417 921 632 or &NBJM SPMMP!NQGBD DPN BV NORTH FREMANTLE Private Practice, Multi-specialist Centre PG &YDFMMFODF MPPLJOH GPS B 1SPDFEVSBM (1 15 73 /73

Commencing now, a rare opportunity to KPJO FYQBOEJOH UFBN PG NVMUJ EJTDJQMJOBSZ team members.

For confidential discussions please contact: &NBJM TDPUU!GBDFGPSXBSE DPN BV Phone: 9385 5544 www.therose.net.au

SOUTHERN SUBURBS After Hours GPs - Perth Southern Suburbs 4FFLJOH 1 5 73 OPO 73 (1T GPS ") TFSWJDFT JO PVS %84 6"/ 1SBDUJDFT 403 0GGFSJOH GMFYJCJMJUZ NJYFE CJMMJOH XJUI IJHI earning potential, and full admin support.

Computerised and fully accredited. &TTFOUJBM DSJUFSJB JODMVEF t ")13" 3FHJTUSBUJPO t .FEJDBSF 1SPWJEFS FMJHJCJMJUZ t &YIJCJU FYDFMMFOU DPNNVOJDBUJPO interpersonal skills displaying solid DMJOJDBM FYQFSJFODF t 1SPWJEF FYFNQMBSZ XPSLJOH SFGFSFODFT 1MFBTF FNBJM &0* $7 UP groupmanager@westnet.com.au QUEENS PARK -PPLJOH GPS (1 73 UP KPJO PVS HSPXJOH NFEJDBM centre in central, convenient location. &GGJDJFOU IFMQGVM BENJO TUBGG BOE 3/ TVQQPSU .JYFE CJMMJOH FYDFMMFOU GBDJMJUJFT accredited and fully computerised.

On-site physiotherapy, occupational health and pathology.

Please phone Tim 9356 8993 &NBJM BENJO!RVFFOTQBSLNFEJDBM DPN BV 8FCTJUF XXX RVFFOTQBSLNFEJDBM DPN BV KINROSS ,JOSPTT %84 JT MPPLJOH GPS B 73 GVMM UJNF (1 This privately owned and managed QSBDUJDF XJMM PGGFS VQ UP CJMMJOH UP UIF right doctor.

7BSJPVT MPDBUJPOT /PSUI 4PVUI BWBJMBCMF Please contact Phil on 0422 213 360 &NBJM QIJM CD!HNBJM DPN

WEST PERTH GP sessions available at our privatebilling, accredited and fully computerised general practice.

Our busy practice serves a young, professional demographic as well as QSPWJEJOH TQFDJBMJTU TFYVBM IFBMUI TFSWJDFT 5IJT SFQSFTFOUT BO FYDJUJOH PQQPSUVOJUZ for an enthusiastic practitioner to join our friendly team.

Morning and afternoon sessions are BWBJMBCMF &YQFSJFODF JO GBNJMZ QMBOOJOH TFYVBM IFBMUI BOE NFOUBM IFBMUI XPVME be an advantage.

Contact Stephen on 0411-223-120 &NBJM stephen@westperthmedicalcentre.com.au

SORRENTO 7 3 (1 GPS B CVTZ .FEJDBM $FOUSF in Sorrento.

6Q UP PG UIF CJMMJOH Contact: 0439 952 979 WOODLANDS 1 5 PS ' 5 73 (1 XBOUFE UP KPJO IBQQZ OPO corporate, mainly private billing practice.

(PPE NJY PG QBUJFOUT OP XFFLFOET or afterhours.

Great location, RN support.

Would suit female GP. Contact help@thewoodsmedical.com.au or 9204 3900

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

GPs Wanted - South Metro Multicultural Health Clinic (Belmont, 39 Belvidere Street ) Â&#x2021; Â&#x2021; Â&#x2021; Â&#x2021; Â&#x2021;

*HQHURXV KRXUO\ UDWHV )OH[LEOH ZRUNLQJ KRXUV &OLQLFDO DQG QXUVLQJ VWDII VXSSRUW 0RGHUQ ZHOO HTXLSSHG IDFLOLWLHV )XOO\ FRPSXWHULVHG

GPs Wanted - GP After Hours Clinics in Belmont, Armadale and Rockingham Â&#x2021; Â&#x2021; Â&#x2021; Â&#x2021; Â&#x2021;

*HQHURXV KRXUO\ UDWHV 0RGHUQ ZHOO HTXLSSHG IDFLOLWLHV )XOO\ FRPSXWHUL]HG DQG DFFUHGLWHG FOLQLFV 3ULYDWH DQG %XON %LOOLQJ RSWLRQV &OHULFDO DQG QXUVLQJ VWDII VXSSRUW For more information contact Liz Williams at 08 6253 2100 or l.williams@baml.com.au

OCTOBER 2013 - next deadline 12md Friday 13th September - Tel 9203 5222 or jen@mforum.com.au

medical forum Looking for work life balance?

GP Opportunities available in WA

Are you wanting to sell your medical practice?

IPN is currently looking for a Doctor to join our very busy, new, state of the art clinic to meet growing patient demand:

Beechboro Family y Practice We also have other GP opportunities available in Perth and surrounding suburbs.

IPN is a highly diverse and collaborative service provider.

You will enjoy:

77

As WAâ&#x20AC;&#x2122;s only specialised medical business broker we have sold many medical practices to qualified buyers on our books.

Your business will be packaged and marketed to ensure you achieve the maximum price possible.

To find out what your practice is worth , call:

Brad Potter on 0411 185 006

We are committed to maintaining confidentiality.

t Clinical sovereignty t Freedom & ďŹ&#x201A;exibility

You will enjoy the benefit of our negotiating skills.

t A busy patient base t Tailored business partnership

Weâ&#x20AC;&#x2122;ll take care of all the paper work to ensure a smooth transition.

t Modern, well equipped clinics t Support from experienced staff For all conďŹ dential enquiries, please contact Esther Mortimer on 0418 371 724 or email esther.mortimer@ipnet.com.au

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Ph: 9315 2599 www.thehealthlinc.com.au

www.ipn.com.au

Exciting New Opportunity for GPs in Perth Perth Metro location St Francis is a brand new medical centre PQFOJOH JO 4VCJBDP JO 4QSJOH Ă&#x17E; *U JT TUSBUFHJDBMMZ MPDBUFE XJUI B CSBOE OFX GJU PVU Ă&#x17E;8JUI B RVBMJUZ MFE GPDVT UIF NFEJDBM DFOUSF XJMM CF TUBGGFE CZ IJHIMZ FYQFSJFODFE /VSTJOH BOE "ENJOJTUSBUJWF TVQQPSU TUBGG backed by a strong marketing team. The medical centre will offer you the scope to rapidly build your practice whilst enjoying the opportunity to work as a key member of BO JOEFQFOEFOU GMFYJCMF BOE GBNJMZ GPDVTFE FOWJSPONFOU Ă&#x17E; 5IF NFEJDBM DFOUSF JT DMPTF UP LFZ IPTQJUBMT TVDI BT ,JOH &EXBSE T .FNPSJBM )PTQJUBM BOE 4U +PIO PG (PE 4VCJBDP Ă&#x17E; With pathology on site, 5 consult rooms, a 2 bed treatment room, continued education and development in specific areas of clinical interest will also be supported. Full time and part time opportunities are available with  competitive earnings.

Competitive Benefits Package 5IF NFEJDBM DFOUSF JT PGGFSJOH B HFOFSPVT XFMDPNF CPOVT JO SFUVSO GPS B NJOJNVN month commitment on a full-time contract.

Requirements Aside from enthusiasm for being part of a new practice in a location where you can walk to work, full and unconditional medical practitioner registration with AHPRA and '3"$(1 SFRVJSFE &WJEFODF PG $.& BOE NFEJDBM JOEFNOJUZ JOTVSBODF JT BMTP FTTFOUJBM For a confidential discussion contact Kerry Furler on 0414 532182.

85% take home,

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

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

Fee for service (low commission).sĂĽ Non VR access to VR rebates.

8-9hr shifts, day or night. sĂĽ Bonus incentives paid.

24hr Home visiting services. sĂĽ Interesting work environment.

Access to Provider numbers.

Supplement your income: Are you working towards the RACGP? â&#x20AC;&#x201C; we have access to provider number for After Hours work.

Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.

Contact Trudy Mailey at WADMS

(08) 9321 9133

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

OCTOBER 2013 - next deadline 12md Friday 13th September - Tel 9203 5222 or jen@mforum.com.au

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...come to the Sunshine Coast ar from Friday March 14th to an s Sunday 16th March 2014 and discover ing Cha inn mpio why your GP colleagues have given such a w nship d ar 18 h positive thumbs-up for past Bp Summit conferences.

Aw ole g olf c For the biggest and best Bp Summit yet – we’ve lined ours e up one of Australia’s finest conference venues at one of Australia’s most attractive resorts – all under the same roof and conveniently accessible from Australian capitals. Novotel Dare to learn the flying trapeze Twin Waters Resort. With eHealth front and centre for the Tours to Fraser Island or Hinterland nation as well as every GP practice as never before, we promise you a wonderful program of speakers, discussion and training at every level. If that’s not enough to get the adrenaline flowing, learning the flying trapeze is just B ring the one of the many diversions for you and your family at kids ; Tw Twin Waters – along with a host of other more in W ater traditional sun, surf and holiday activities. s ha sa S Call, write or email to register your interest kids ai club lo and we’ll send you the full program rk ay and booking details. ak &

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Sunshine Summit 2014 T: (07) 4155 8888, E: bpsummit@bpsoftware.com.au, www.bpsoftware.com.au