Medical Forum 10/15 Public Edition by Medical Forum WA

Time to Speak Up

t Taking on the Pollies t NDIS – Dollar Dazzlers t Help for Nepal t Clinicals: Simulation, Cannabis, JIA, PTSD, Cough & more…

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Editorial

Hitting the Campaign Trail On our cover is a doctor who attended the last Doctors Drum of the year discussing the topic, “Money for Medicine – Slicing the Cake”. He sounded fed up; fed up that the real and significant concerns of doctors for their patients (and for themselves) were being ignored by Canberra and fed up that the response was yet another round of meetings to discuss those concerns. So did we witness the birth of a new political party over breakfast? His rallying cry was loud, and it was heard. If doctors are not being heeded by the bottom-up method, then maybe it’s time to rip a page out of the books of the Car Enthusiasts Party or the Shooters and Fishers Party and take those concerns direct to the electorate. It’s feasible. Gather your supporters (no trouble there), find six Senate candidates tro (trickier, but the profession is not lacking (tr robust personalities with resilient egos), write ro a song sheet that sings out a simple clear message and make a noise to get a few m knees of those politicians in marginal seats k to t jerk in the desired direction. Ah, A but there’s the catch! A simple clear message from the vast vault of o concerns sweeping through primary care, hospital care, aged care, Medicare – c Ms Jan Hallam where is the common ground? When and where does this multi-faceted profession put aside its myriad inherent conflicts of self and professional interest for the sake of the common good? More pertinently, who or what is the common good? In a way that question is both too easy and too hard to answer. The patient is not a bad start but it’s a long way short of the complete answer. The Pharmacy Guild has ripped up the dance floor in Canberra with its one-stop solution to government – and has been rewarded with a $1b package. Doctor groups (and there’s a lot of them) come bearing an overload of complexities and get shown a representative advisory group, a multitude of committees or a parliamentary review before they exit through the gift shop. Now we can view this as a message to ‘keep it simple, stoopid’ but that would be an insult to the vast knowledge of the profession and a great disservice to the patients. And, most importantly, it is not addressing issues that need urgent solutions. Doctors are not dispensers of drugs, they

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MEDICAL FORUM

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are trusted partners in health and that brings us back to the issue of the patient. One of the messages that rang out loud and clear at the breakfast is that it’s time for some brutal honesty. Politicians, regardless of their brand, have to stop this three-year cycle of delusion and stop making promises WE can’t afford to keep just so they can continue to warm their seat in Parliament. If they agree to stop their self-interested behaviour, then doctors should follow suit. Taxpayers’ money and the dollars provided by the public through their private health funds are to pay for health services, not to give individuals a leg up into the BRW’s Top 40, particularly if the services provided fall well-short of the common good. And consumers need to know that the free health ride is pulling into the terminus. Our welfare system is a wonderful and precious thing. It stabilises our nation’s social and economic wellbeing but it is not an entitlement. If you can afford to pay, you pay. Those messages are pretty simple. What do we need next? Only a couple of weeks ago, a bloke spoke these words on the steps of Parliament House in Canberra: “We are living as Australians in the most exciting time. The big economic changes we’re living through, here and around the world, offer enormous challenges and enormous opportunities. And we need a different style of leadership. We need a style of leadership that explains those challenges and opportunities ... and how to seize the opportunities. A style of leadership that respects the people’s intelligence, that explains these complex issues and then sets out the course of action we believe we should take and makes a case for it. We need advocacy, not slogans.” Well that bloke is now Prime Minister. He hit the nail on the head, and so did Dr Frank Jones at the Doctors Drum Breakfast when he said we need leaders in health and we need to nurture the leaders of the future to steer the system through the “enormous challenges” and those “enormous opportunities”. So what is the simple message we should be taking to Canberra? How about honesty? With that simple message we need leaders of integrity to step out and speak out! Sign up here! See Doctors Drum Page 22-23

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

OCTOBER 2015 | 1

October 2015 14

Contents 16

FEATURES 14 Spotlight: Dr Tessa Kaminski 16 Trailblazer: Dr Brenda Murrison 18 Trek & Rescue: Dr Gaynor Prince 22 Doctors Drum: ‘Money for Medicine’ 51 White Water Thrills: Dr John Hilton NEWS & VIEWS 1 Editorial: Hitting the Campaign Trail 4 Letters:

6 12 19 21 24 31 41 48

AHPRA Process Falls Short Dr Roger Paterson No Natural Justice Dr Don Kane Making MyAgedCare Work Dr Frank Jones Report Response Balanced Mr Kim Snowball Stick to the Evidence Dr Elaine Bennett PhD TB Response: Department of Immigration and Border Protection Curious Conversations: Dr Jean Foster Have You Heard? Midland Ready Minus Fertility Ops NDIS: Number Crunching Southern Hospital Roles Family Way of Life Chronic Disease Survey Beneath the Drapes

LIFESTYLE 52 2015 Alan Charters Prize 54 Laugh Lines: Ms Wendy Wardell 54 Funny Side 55 Review: Palmer Wines Dr Martin Buck 56 Social Pulse: WIRF & SJGSH Ball 57 Theatre: Next to Normal 58 Opera: Faust 59 Competitions

See Page 22

MAJOR SPONSORS 2 | OCTOBER 2015

MEDICAL FORUM

Clinical Contributors

Dr Trevor Beer Merkel Cell Carcinoma, Virus & Sunlight

Dr Robert Davies Simulation the Perfect Practice

Dr Mal Washer Medical Cannabis

Dr Senq Lee Juvenile Idiopathic Arthritis

Dr Jon Laughnarne PTSD: Diagnostic Concerns

Dr Veena Judge Chronic Childhood Cough

Dr Kenji So Ulcerative Colitis

Dr Richard Carey-Smith Soft Tissue Tumours

See Page 25

Contact jen@mforum.com.au

A/Prof Christopher Pantin Mandibular Advancement Splints

Guest Columnists

Prof David Gilchrist NDIS â&#x20AC;&#x201C; Time to Get Real

A/Prof Sam Winter Identity Without the Knife

Ms Kate Jeffries Domestic Violence

Mr Nick Ramondo Power of the Mind to Heal

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Michele Kosky AM (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Mike Ledger (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM OCTOBER 2015 | 3

Letters to the Editor

AHPRA process falls short Dear Editor, Medical Boards have a reputation for being a law unto themselves. AHPRA WA state manager, A/Prof Robyn Collins (September, 2015), suggested otherwise when she outlined the appropriate process to follow if there was unhappiness about a medical board ruling. I have to say that I tried this complaint process earlier this year and was greatly underwhelmed. On behalf of members of a peer review group, I complained about media coverage of attention deficit hyperactivity disorder (ADHD) last December (“Drugged Kids” being The West Australian front page headline, shared with the Sydney siege no less) wherein Adelaide child psychiatrist, and well known ADHD critic, Dr Jon Jureidini denigrated local ADHD treatment efforts, suggesting “doctors were grossly overprescribing” stimulants such as Ritalin and dexamphetamine (when in fact underprescribing is closer to reality: the latest WA Health Department data show that about 1% of W.A. children were dispensed stimulant medication in 2013 , and NHMRC data show an ADHD point prevalence rate of 3-5%). Public denigration of doctors by doctors seems unedifying and unhelpful but not according to the SA Medical Board who dismissed my complaint (Dr Jureidini “does not have control over the information published”). On appeal to AHPRA’s head office in Victoria, the appeal was sent back to (wait for it) the SA Medical Board who not unsurprisingly dismissed an appeal against themselves. They did suggest appealing to the National Health Practitioner Ombudsman which I duly did – again the appeal was dismissed but only on the grounds that due process had been carried out correctly (they do not give opinions on the merits of a case). Out of desperation, I then appealed to the WA Medical Board who again dismissed my complaint but, to be fair, at least provided more cogent reasons for doing so. This was my first complaint to any Medical Board about another practitioner. I don’t think I will bother again. Dr Roger Paterson, Psychiatrist, Nedlands ED. Dr Paterson has provided, in confidence, relevant correspondence. We also invited Dr Jureidini

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.

to respond. This story illustrates how doctors are still coming to grips with changes. AHPRA must decide if a doctor’s conduct or behaviour is below that reasonably expected, or that public safety has been put at risk (the latter mostly). If either is thought to have happened, the matter is referred to the Medical Board to decide impacts on registration. While doctors arguing in the media may not be edifying or helpful in the eyes of some, doctors are now free to do this provided they show balance, don’t get personal and follow ACCC guidelines for health professionals (e.g. no patient testimonials). The community has decided – the safety and successful treatment of health consumers is more important than the feelings of some doctors, and they want more transparency in decision making. The overarching questions are does AHPRA deliver this and is it dealing well with the unreasonable or vexatious behaviours of the few?

September 3 & 4 are recommended viewing (see http://iview.abc.net.au/programs/lateline/). Don Kane, Chairman Health Professionals Australian Reform Association ED. DK is a retired Thoracic Physician living in Queensland. HPARA is a national organisation campaigning for a judicial inquiry to reform the regulation, administration and representation for its members.

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Making MyAgedCare work Dear Editor,

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No natural justice Dear Editor, Health professionals who are notiﬁed to AHPRA are denied due process, natural justice and the presumption of innocence. The abuse of mandatory notiﬁcation and sham peer review is used to disadvantage health professionals. A distinct lowering of the quality of indemnity representation for members has occurred since mutual indemnity funds were replaced by commercial insurance agencies. The performance of the indemnity providers is well below the level required to provide protection and justice for members. The insurers appear to be more interested in cost containment and revenue raising at the expense of the interests of members. The legal representatives engaged by the insurers enjoy a healthy income from their work at the expense of the members of the indemnity insurers. It seems that they are acting on instructions to curb costs rather than making an all-out effort to get justice for policy holders. The perception is the insurers and AHPRA are hand-in-glove rather than being adversaries. A multitude of cases far worse than that of Dr Antonio Vega Vega exists. He enjoyed a successful challenge of actions by AHPRA. The other cases have not enjoyed the quality of representation or success of challenge to the authority of AHPRA when they too have been patently denied due process and natural justice. The ABC’s Lateline programs on

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.

In response to member feedback regarding the recently launched MyAgedCare website (www.myagedcare.gov.au) and its online referral system for Aged Care Assessment Team assessments and Home Care Package referrals, the RACGP wrote to the Department of Social Services (DSS) to express a number of concerns. No option is provided to send referrals electronically that conforms to the national Secure Message Delivery (SMD) system standard. The closest that MyAgedCare gets to electronic communication is to give the option for GPs and other healthcare providers to fax through referrals, but the fax number is not clearly displayed anywhere throughout the website. Most general practices are heavily if not fully computerised and neither make nor keep any records on paper. The Government’s policy is to use electronic communications. To be useable in general practice, online methods of communication must link to or integrate with GP’s electronic clinical and administrative systems to eliminate the need to manually re-enter information that is already held in the GP’s electronic clinical and administrative system and/or in the government’s system. The RACGP recommends: så-Y!GED#AREåWEBSITEåBEåEQUIPPEDå immediately to receive referrals via

continued on Page 6

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4 | OCTOBER 2015

MEDICAL FORUM

By Dr Trevor W Beer Dermatopathologist

Major Sponsor: Clinipath Pathology

Merkel Cell Carcinoma, viruses and sunlight Melanoma is frequently cited as the most deadly skin cancer. However, Merkel cell carcinoma (MCC) is more lethal with mortality three times that of melanoma. Although uncommon, MCC is increasing in Australia and at 8% per year in USA. The highest reported rate is in Queensland (1.6 cases per 100,000 population) and work we performed locally shows that WA has one of the highest global incidences (0.8 per 100,000).

and ambient UV and frequent solar damage and related tumours in MCC patients. UV induced DNA mutations (such as CÆT and CCÆTT in the p53 suppressor gene) are common in MCC. Following PUVA therapy psoriasis patients have shown a 100 times increase in MCC.

Patients with MCC are frequently elderly with multiple medical issues. Because of the rapidly developing approach to the management of MCC, involvement of a multidisciplinary team (MDT) is desirable. Many patients are seen by numerous different clinicians during the course

MCC is twice as common in males with almost 94% of tumours seen in fair skinned individuals. Sun exposed sites are typically affected, but rarely MCC occurs at non-skin sites. Intriguingly, even at sites such as the larynx, tumours are still far more common in whites. There is a marked increase in MCC with age, 75% of patients being 65 or older. AEIOU. Merkel cell carcinoma often presents as a non-specific, sometimes ulcerated, red nodule. Although literature suggests that many are confused with benign lesions, this is not our experience in Perth, where the majority are thought to be basal cell carcinoma clinically. Occasionally, an astute clinician does recognise a MCC in vivo. The acronym AEIOU was devised to help identify cases clinically: Asymptomatic, Expanding rapidly, Immunosuppression, Older than 50, UV exposed site. Whilst nearly 90% of patients show three or more criteria, unfortunately they are non-specific features common to many neoplasms and lack sensitivity and specificity. Merkel cell polyoma virus. In 2008, a novel virus was discovered in MCC - Merkel Cell Polyoma Virus (MCPyV). This lead to a huge surge of interest in MCC. The virus is common in the environment and exposure to it from an early age is frequent, with increasing levels of MCPyV antibodies with age. However, only a mutated, integrated form can induce MCC. Interestingly, MCC is more common and occurs at an earlier age with immunosuppression. Overall, 80% of MCC harbour integrated MCPyV, but this figure is only 23% in some Australian studies where UV exposure may be a more important factor. Research we undertook in WA showed low viral prevalence but significant solar damage was almost universal. Ultraviolet light. The role of UV is supported by the predominance of MCC in white-skinned individuals, a linear relationship between MCC

Normal Merkel cells are mechanoreceptors, here stained brown in a hair follicle. Antibodies to CK20 highlight the malignant cells in MCC, helping to establish the correct diagnosis. (Inset) A large Merkel cell carcinoma on the leg. Photo courtesy of Dr Doug Czarnecki.

Diagnosis. Histopathology and immunohistochemistry are essential to conﬁrm the diagnosis. Antibodies to CK20 highlight normal Merkel cells (Figure 1) and stain the vast majority of MCC, assisting in differentiation from other tumours which may not be possible on routine sections.

of their disease and an MDT can provide an environment in which all information is collated and reviewed by a panel. Currently, this is not done consistently in Perth, and patients may beneﬁt from the development of an MDT approach similar to that provided by the WA Melanoma Advisory Service for melanoma.

Treatment. Complete surgical excision is the mainstay of treatment, but increasingly, additional radiotherapy is applied. If surgery is contraindicated or declined, good results have been reported using solely radiotherapy. Recent reviews suggest that chemotherapy has only a limited role and side effects may outweigh beneﬁts. Antiviral and immune stimulating treatments are being pursued in clinical trials with no unequivocal beneﬁts to date.

Prognosis. In WA, five-year cause specific survival we found to be 64%, very similar to the huge US SEER database (62%). Half of patients show metastases at diagnosis, with lymph nodes typically involved first. Survival is highly stage dependent. With localised disease, 86% of patients were alive after two years, compared to just 32% with distant metastases in one large study.

The US National Comprehensive Cancer Network has excellent guidelines on MCC management, available at www.nccn.org. A clinical excision margin of 1-2cm is suggested, but it is acknowledged that there is no evidence that margins greater than 1cm affect prognosis.

The rarity and aggressive nature of MCC demand a good understanding of its clinical features, and a coordinated, assertive treatment approach to ensure optimal patient outcomes. Comprehensive references available on request.

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OCTOBER 2015 | 5

Letters to the Editor continued from Page 4 electronic communication systems that conform to the national Secure Message Delivery system standard. så2EFERRALåFAXåINFORMATIONåTOåBEåDISPLAYEDåMOREå visibly. så4HEåOPTIONåTOåUPLOADåAåDOCUMENTåTOåTHEå online referral form be made available. så#REATEåANåOPTIONåFORåTHEå@MAKEåAåREFERRAL å form to be printed to PDF once completed online. This would enable the document to be added to the patient record in a clinical system. Dr Frank Jones, President, RACGP ED: It was reported this month that GPs have abandoned the website in droves and the issue was raised in Federal Parliament after RACGP made formal representation to the Minister. The DSS has said it will move to ﬁx the software problem.

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Report response balanced Dear Editor, From my perspective the response from the Australian Health Workforce Ministerial Council to my report as independent Reviewer of the National Registration and Accreditation Scheme was balanced and measured. While nine recommendations were approved for immediate implementation, a further 18 were either approved in principle or deferred pending further advice on alternative approaches. Essentially 27 of the 33 recommendations are under active consideration by the Ministerial Council. After consulting with over 1000 people, involved or interested in the regulation of Australia’s health professionals, and having received over 230 written submissions I am conﬁdent the ﬁnal report represents the

major issues facing the current scheme and the challenges to achieving the right level of regulation of our health professionals into the future. I put forward what I felt were the best actions but there are always other ways. Given the importance of establishing the right platform for good regulation into the future, taking some time to ensure the right approach is not unreasonable. Remember that the agencies involved in the National Scheme, including the National Boards, AHPRA and the Accreditation Authorities, only had four years to establish all of the governance and processes involved in regulating over 619,000 health professionals across 14 professions nationally. This was a massive undertaking which had some major teething problems early on. While there is still more work to be done, the foundations of a very effective national regulatory framework is now in place. Review findings and recommendations singled out the complaints and notification system as one area needing priority attention. Many of the issues raised concerning timeliness and poor communication came from both complainants and health professionals, including doctors. It also identified the importance of addressing the interface between normal complaint mechanisms about health and hospital services with notifications about professional conduct. An important outcome is that the Ministerial Council and those involved in the scheme have supported immediate action on the recommendations to improve this part of the national scheme for the benefit of both complainants and health professionals. Reporting back to Ministers on the issues raised by the report will ensure momentum for improvement is maintained. Further enquiries about the Final Report they can be forwarded to NRAS: Review@dhhs.vic.gov.au Mr Kim Snowball, Director, Healthfix Consulting

ED. The behaviour of AHPRA and Medical Boards has taken a recent hammering in the media, with accusations of bullying and poor judgement in pursuing complaints. To this we would add a lack of transparency. For example, we wondered if Prof Pearn-Rowe had been used as a panellist or expert witness since the Medical Board and AHPRA lost a case in 2013 (Editorial, August edition), but AHPRA would not disclose this information. AHPRA State Manager Robyn Collins has eventually responded to our earlier questions. Her response is partly paraphrased here: så !(02!åHASåNOåSYSTEMåFORålNDINGåOUTåORåBEINGåå notiﬁed if someone it investigates suicides. så !(02!åHASåAåLISTåOFå7!åPANELLISTSåCHOSENåTOåå investigate other doctors, which it only makes partially known and after investigations (in annual reports) – most panellists have been grandfathered across from the old Medical Board (*see below). så !(02!åANDåTHEå-EDICALå"OARDåDOåNOTåREADå Medical Forum because they are unaware of general concerns about a lack of impartiality. WA Medical Board (Medical Practitioners) Prof Con Michael AO (Chair); Dr Frank Kubicek; Dr Michael Levitt; Dr Michael McComish; Prof Mark McKenna; Dr Steven Patchett; Prof Bryant Stokes AM; Adjunct Prof Peter Wallace OAM WA Panellists 2013-14* Dr Turabali Chakera; Dr Andre Cronje; Dr Graham Cullingford; Dr Geoffrey Dobb; Dr Alan Duncan; Prof Mark Edwards; Dr Daniel Heredia; Prof Con Michael; Dr Devashish Roy; Prof Bryant Stokes; Dr Arankanathan Thillainathan; Dr Geoffrey Williamson

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Stick to the evidence Dear Editor, RE: Dr David Roberts clinical opinions on Attachment Parenting (August & September) continued on Page 8

Curious Conversations

The Power of Patients to Inspire Narrogin GP Dr Jean Foster would love to change the world, eat more vegetables and thinks her patients are pretty amazing. The quality I most admire in other people is… honesty. Everything else hangs on that – good relationships, self-reﬂection and, very importantly in our profession, the ability to admit when we’re wrong or lack the required skills. I really need to remember… the Serenity Prayer. Grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference. I waste too much time feeling bad about things I can’t change and should channel my energy into the things that I can.

6 | OCTOBER 2015

If I won $10,000 I would… build a free-standing composting toilet on our 20ha at Brookton. My poor brother has the unenviable job of emptying the chemical toilet, so a new loo would be great! One of my happiest moments in medicine was… when a patient brought in some pictures of his mother. He’d been put in a Christian Brothers home and, apart from the abuse, was actively obstructed in his search for family members. He’s such an amazing person and I’m continually in awe of how some of our patients cope. If I could go to one restaurant anywhere in the world it would be… the Restaurant at the End of the World, as long as I knew I could get back again! And lots of vegetables please – you can never get enough veggies! MEDICAL FORUM

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Letters to the Editor continued from Page 6 The knowledge and experience base in this area of ‘attachment’ has certainly expanded over the past two decades and Ngala has been working with university partners and practitioners to understand the application of theory in practice. Today there is solid evidence that the quality of the parent-infant interactions during the first years of life has a direct influence on the child’s later social, emotional, cognitive and physical development, while poor parental responsiveness and reflective capacity are considered risk factors for later adverse child development. The titles and article content in Medical Forum suggest “attachment parenting” is informed by attachment theory. In recent times “attachment parenting” has become synonymous with a brand of parenting that has lost its way. Those who follow the evidence base provided by neurobiology and attachment theory encourage and facilitate a bond to develop between parent and child that is based on mutual understanding and sensitivity to the signals each party contributes to the partnership. The articles connect a number of colloquial terms as examples of parenting informed by attachment theory. While it is not clear exactly what is meant by these terms, some of them are linked to evidence-based programs while others are popular but remain undefined and not accompanied by evidence. In addition, the articles suggest Bowlby’s theory of attachment is a stage theory in the same way Erickson’s theory of development is. Bowlby did not seek to explain the origins of mental and behavioural problems in adolescence as the result of disordered early parent-child relationships, rather he observed naturally occurring disturbances in relationships and, with his psychoanalytic

background and child therapy experience, began to wonder about the nature of a child’s ties with his mother. There are dangers in overgeneralised and broad sweeping statements which may suggest a misinformed base. We point readers to Ngala’s website www.ngala.com. au and that of the Australian Association of Infant Mental Health www.aaimhi.org for more information. Dr Elaine Bennett, Ngala Director Services & Research ........................................................................

TB response Dear Editor, Following on from Dr Astrid Arellano’s clinical update on TB, we asked the Department of Immigration and Border Protection what measures it took to screen for the disease. Here is its reponse: Permanent visa applicants undergo immigration health examinations to ensure that they are free from TB prior to migrating (usually a chest x-ray). This includes offshore humanitarian visa applicants who may also undertake additional screening prior to departure to ensure that no new health issues have arisen prior to their arrival in Australia. Irregular maritime arrivals and those seeking asylum onshore are also required to complete immigration health examinations as part of arrival and/or visa application processes. Immigration health examinations are also required to be undertaken by some temporary visa applicants based on a risk matrix – i.e. those arriving from higher risk TB countries or entering special environments (for example, schools, hospitals).

Signiﬁcant work has been done, in conjunction with international partners, to strengthen TB diagnostic and treatment capabilities overseas, particularly in higher-risk TB countries that are key source countries in terms of Australia’s migration and temporary visa programs. More than 800,000 visa applicants are screened via the above processes each year. Visa applicants found to have active TB as part of immigration health screening processes will not be granted a visa until they have been treated and declared free of TB. If inactive TB is detected, a visa can be granted, with most visa applicants in these circumstances required to sign an undertaking agreeing to report for follow-up monitoring and treatment if required to a State or Territory health authority after their arrival in Australia. Department of Immigration and Border Protection ........................................................................

We welcome your letters and leads for stories. Please keep them short. Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. Letters may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.

October Laughs

Never Cross a Nurse A big shot lawyer had to spend a couple of days in the hospital. He was a royal pain to the nurses because he bossed them around just like he did his staff. None of the hospital staff wanted to have anything to do with him. The head nurse was the only one who could stand up to him. She came into his room and announced, “I have to take your temperature.” After complaining for several minutes, he ﬁnally settled down, crossed his arms and opened his mouth. “No, I’m sorry,” the nurse stated, “but for this reading, I can’t use an oral thermometer.” This started another round of complaining but eventually he rolled over and bared his behind.

After feeling the nurse insert the thermometer, he heard her announce, “I have to get something. Now you stay JUST LIKE THAT until I get back!” She left the door to his room open on her way out. He cursed under his breath as he heard people walking past his door, laughing. After a half hour, the man’s doctor came into the room. “What’s going on here?” asked the doctor. Angrily, the man answered, “What’s the matter, Doc? Haven’t you ever seen someone having their temperature taken?”

We are allll here W h on earth th h tto h help l others; what on earth the others are here for I don’t know

- W. H. Auden

After a pause, the doctor confessed... “Not with a carnation.”

8 | OCTOBER 2015

MEDICAL FORUM

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Dr Michael Allen

MBBS, FRANZCOG, FRCOG

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MBBS, FRANZCOG

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MEDICAL FORUM

OCTOBER 2015 | 9

Incisions

NDIS – Time to Get Real It’s time to slow down the rollout of the NDIS while the Government and the community analyse the cost-beneﬁt ratios of the scheme, according to Prof David Gilchrist. There has been a gradually rising concern that the National Disability Insurance Scheme (NDIS) is too expensive. Increasingly policy setters, industry representatives and commentators are concerned about the viability of some disability service providers and the effect their demise would have on the most vulnerable people in Australia who rely on these necessary services and supports. Notwithstanding that many in the disability services sector have been calling for a closer examination of the costs and service demand prior to the full rollout of the scheme, until now their concerns have fallen on deaf ears. However, the issue is not really one of cost per se, but, rather, one of a lack of real data related to the true cost of service delivery and the likely demand for services. The establishment of the NDIS was undertaken in haste due to political pressures and no real data was collected in terms of these critical elements. The demand data used to underpin expectations was from the ABS and service user data. However, this data does not match the eligibility criteria used by the NDIS. Further, the likely true cost of service has not been examined at all.

raised via a Medicare levy and an estimation of state funds – is not linked in any way to the real costs and demand that is materialising now the scheme is being trialled. In this context, there has long been a discussion focused on the efficiency of the predominantly not-for-profit disability service sector. In short, it is expected that the marketstyle resources allocation system, which is what the NDIS actually is, will allow market mechanisms to force efficiency within these providers. The problem with this thinking is threefold. Firstly, as mentioned, a funding figure was not arrived at after reviewing true cost of service delivery and demand but, rather, it’s an estimate of the money available for this

The funding envelope of $22 billion... is not linked in any way to the real costs and demand that is materialising now the scheme is being trialled.

initiative. Secondly, there is actually no market mechanism, the NDIS sets the price it will pay. Thirdly, the problem we have regarding funding is not able to be identified as we do not actually have any plausible data showing the likely true cost of service. Therefore, until we understand the true cost, how can we develop a logical response? Clearly, better data will help us to quantify the problem and develop a set of solutions that will include local decision making (reinforcing the need for WA’s NDIS My Way model), better targeted money, more efficient disability service providers, and a step away from the one-size-fits all system currently being trialled. To achieve this, we need to include disability service providers in the solution development process and to slow down the rollout so that a more deliberate and cogent implementation can be undertaken that ensures the significant cost of the initiative is money well spent. ED: Prof Gilchrist is Director of Curtin University’s Not-for-Profit Initiative.

The funding envelope of $22 billion – arrived at after estimating the funding that could be

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OCTOBER 2015 | 11

Have You Heard?

Panorama winds up We’ve been alerted to a General Meeting of Panorama Health Network that was to be held on September 30 to wind up the company in the wake of its failure to secure its bid for the northern suburbs Primary Health Network. Its funding ceased on June 30 on the eve of the PHNs taking control of Medicare Locals, in particularly the Perth North Medicare Local. Its chair Dr Alistair Vickery was on leave and uncontactable at the time of publishing as was its CEO Ms Terina Grace. However, we have seen the not-for-profit’s financial statements which it enclosed in a letter to doctors in the catchment. It is recommending the assets of Panorama be rolled over to Black Swan Health Ltd, a service provision company based in Joondalup that, we’re told, has a similar board and executive make-up as Panorama. The meeting was also asked to agree to the appointment of a voluntary liquidator. Black Swan’s website is short of company information but its services continue PNML’s work in the area of mental health, diabetes, aged care and chronic pain management. We weren’t able to ascertain why the need for a new identity and offices but there is a lot of unknowns in this new landscape of primary health which will be the subject of more investigation.

at ConnectGroups. They have been working with the WA Health’s Chronic Health Conditions Network and have provided a comprehensive directory of relevant community-based support groups. That task is all but done with 235 services highlighted in the regions and 300 in the metro area. The directory is available online and in hardcopy. ConnectGroup ED Ms Antonella Segre also told us that the group had been funded to establish a pilot program where nurses in Fremantle Hospital will be resourced to give patients information about local support groups pertinent to their condition. Antonella said this was step one in a vision to allow support groups direct access to patients in hospital.

Pharma merger go ahead

Support groups in hospital play In this issue we report on the chronic conditions discussion paper, consultations and survey concluded last month (See P41). All the representative groups had their say along with 700 individuals across Australia … suspicions are that the rest of the 29,000 GPs didn’t know what had happened. Not so for the good folk

members showed 13% were already doing this. In rural areas in WA, nurse-run clinics with suitably credentialed nurse practitioners are well established. We predict that as people clamber to access services, nurse-led clinics will flourish to provide routine non-doctor care. Time-poor doctors and general practices will need to find time to collaborate, or be left out of the loop. While we’re on the subject of nurses their numbers have grown by almost 7% between 2011 and 2014, but not all are finding work in their field, according to the Australian Institute of Health and Welfare (AIHW). There were 353,838 nurses and midwives registered in 2014, compared to 330,680 in 2011, while 9100 were looking for work – 900 more than in 2011. In WA, there were 1061 RNs and midwives, up from 1037 in 2011.

Nurses roles, numbers expand It appears that APNA (representing Australian practice nurses) are gearing up for independent nurse-run clinics, separate to but integrated with the RACGP’s view of whole patient care and the ‘medical home’. A limited survey of 120

The ACCC in Australia will not oppose the $17b merger of US pharmaceutical companies Pfizer and Hospira, suppliers of both biologicals and biosimilars (‘generics’). The ACCC didn’t think this would lessen competition. The Pharmaceutical Benefits Advisory Committee (PBAC) can give generics, deemed as safe and efficacious, an ‘a’ flag PBS listing, which enables pharmacists to substitute the drug without the approval or knowledge of the prescribing doctor or the patient if the “nosubstitution” box on the script is not ticked. If a conversation between pharmacist and patient occurs it is usually around cost, for which the decision is a no-brainer. Inflectra (Hospira) and Remicade (Janssen-Cilag) are classic examples and PBAC recommendations include the quadrivalent flu vaccine, and long-

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awaited listings of gliptins, hepatitis C antivirals and breast and prostate cancer therapies. Now consumer hearings are part of PBAC deliberations, the July hearing heard the PBS spent $2.3b on biologics in 2013-14 (a 130% increase) with much less biosimilar biologics on the market than Europe. The latter’s availability will reduce health costs and consumer and professional campaigns to promote substitution are OK.

Hospital ‘events’ hot to handle Medibank Private and Calvary private hospital group over east secretly patched up their stoush over contracts – Medibank, like other health insurers, do not believe they should pay for (165 in their case) avoidable iatrogenic adverse events in private hospitals. Health Minister Sussan Ley said this was about improving medical procedures, accountability and safety for patients and not using patient welfare as a tradeable commodity. We heard of someone locally whose previously replaced hip was dislocated when the second one was done, perhaps one for the “independent clinical review process” Medibank wants. The insurer says other hospitals have adopted their list of preventable errors which would reduce costs to the Australian health system. We hoped to have a dialogue on this issue between St John of God Health Care and HBF. SJGHC boss Michael Stanford told Medical Forum in September last year that his group was in negotiations with HBF about “not funding ‘dysquality’” when preventable adverse events occurred in hospital. Both were initially keen but perhaps those negotiations took on a different tone in the wake of the Medibank-Calvary stoush and they later declined.

Licence to thrill We had a medical student write to us amazed at the amount of GPs’ time soaked up by patients, usually elderly, worrying about their drivers’ licences. She thought doctors were being coerced by the government to check on patients’ driving abilities and it was turning them off telling doctors about potentially serious ailments. We asked the Department of Transport if it was now mandatory for doctors to report if they thought their patients’ were no longer fit to drive. DoT’s response was: “There is no legal requirement on WA doctors to report unfit drivers… however discussing the matter sensitively with patients will help achieve better road safety outcomes…A licence holder is entitled to continue to drive as long as they hold a valid driver’s licence and meet the national standards for assessing fitness to drive…Doctors have protection from prosecution action for expressing, in good faith, an opinion formed as result of having carried out a test or examination in relation to a patient’s fitness to drive to DoT.”

Devolution moves on Keen readers of government notices will have picked up that the WA Health Service Boards were seeking interim boards to tide them over until mid-way through next year when new, statutory boards would come into being. Interim chairs would receive about $56,000

and members nearly $34,000. It is part of WA Health’s governance reforms which would see legislation passed to create boards which would oversee the health services and public hospitals within a networked area, rather than individual public hospitals.

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OCTOBER 2015 | 13

Spotlight

Life Without a Safety Net GP registrar Dr Tessa Kaminski has twirled through the air from Perth to Los Angeles. There’s a good chance she’ll be dangling from a chandelier near you. Dr Tessa Kaminski is a great believer in the serendipity of life and the importance of grabbing an opportunity with both hands. “I grew up doing acrobatics and gymnastics and also did singing Dr Tessa Kaminski and dancing shows around Perth so I’ve got a lot of contacts in that world. It’s very freeing and exciting all this flying through the air and there’s the music, the costumes and developing a theme for a specific performance,” she said “It’s a highly creative process from start to finish.” This strong background in performing arts as a young girl has morphed into high-wire theatrics that complements her career as a medical professional. “I like the combination of medicine with an intense physical activity and they reckon circus performers peak in their 50s so I’m going to be in the game for a while yet!” “I’ve learnt not to think too far ahead because all the plans I made when I was younger have been completely obliterated. I was studying theology and social justice at Notre Dame with a strong interest in serving others and my mum said, ‘Why don’t you give medicine a try?’ I didn’t think I was smart enough but I sat the GAMSAT and passed.” Tessa is a year into her term as a GP registrar at a practice in Ballajura. “I like the one-on-one aspect of being a GP and the appeal of medicine more broadly. It’s a vocation in which you’re serving the needs of others but it can be quite daunting, too. You never know what’s coming through the door and that can be a bit stressful.” “A few people have said that I shouldn’t put my medical career at risk by doing the aerials but we’ve got no idea what’s might happen every time we step out the front door. I reckon if it’s your time, it’s your time.”

14 | OCTOBER 2015

“I’ve done shows for companies such as Chevron, NAB, Bankwest and Australia Post. It’s basically when the corporate sector wants a bit of decoration! I’m also associated with the WA Circus School in Fremantle.” “It’s a busy time coming up, I’m booked to do the Murdoch SJG Ball and PMH have just asked me to do a performance on the same night. I might have to sprint from the Crown to the Hyatt to do both shows.” “Sometimes I do a double-act with a big, muscular male partner who also does the rigging for my show. His YouTube act attracted attention and both of us are off to do Britain’s Got Talent early next year.” Tessa has even seen the bright lights of Hollywood from her perch high above the crowd. “My cousin was living ving in Hollywood and knew someone who o put on shows and events and I got the e call. I ﬂew in for a one-night performance, ance, met people such as Paris Hilton and d Snoop Dog and then jumped on an aeroplane oplane and came home. It felt like a dream!” “I don’t even have a business card and all this stuff’s happening!” ing!” It hasn’t all been plain lain sailing for Tessa and there were a few glitches litches in the early days. “I used to get a little le bit of stage-fright but I’m a more seasoned ed performer now and it does lessen as you ou learn more about the whole process. I did have a scare a few years ago when en I was a bit too gung-ho g-ho and that reminded me just how importantt it is to be aware of yourr own boundaries.” “You need to think about performing when you’re really tired or stressed, and the he same goes for practising as a doctor.” ctor.” t ”

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OCTOBER 2015 | 15

Trailblazer

Necessity the Mother of Invention Building a new practice from scratch is a daunting task, just ask Bunbury GP Dr Brenda Murrison, who has built three practices in the past eight years. Holidays are a tricky thing for Dr Brenda Murrison because she spends a fair bit of them thinking about work! In a way, that’s understandable as the past seven years have been driven by developing her blossoming primary care business.

Wheatbelt before moving to Geraldton in 2000. Here, alongside clinical practice, she took on the task of establishing the Geraldton branch of the Rural Clinical School, a joint venture between the University of Western Australia and Notre Dame University.

Back in 2008 she was running an evidencebased weight loss clinic when she could no longer ignore the critical shortage of GPs in her hometown of Bunbury.

“I was the first doctor on staff there. It was an amazing opportunity to do something very different,” she said. “It wasn’t just teaching, it was about setting up the school. So it was about employing staff, setting up the office, finding houses to buy for the students.”

“There was just a desperate need in this community at the time. People were waiting three to six weeks to see a GP – it was fairly awful,” Brenda said. So dire was the need for GPs that patients were walking into her weight loss clinic and pleading to see a doctor. Eventually Brenda decided to take a leap of faith and set up her own practice. Tackling the red tape It was, of course, much easier said than done. New premises were needed and, along with a multitude of other tasks, Brenda also had the unenviable task of applying to the Federal and State Governments for the District of Workforce Shortage and Area of Unmet Need classifications that would allow her to recruit international medical graduates. “I had a business mentor helping me a bit and he asked a prominent retired local surgeon for his advice. He basically advised me to go and work for another local practice. But you just have to keep going and you need to ignore the naysayers.” The first iteration of Brecken Health Care opened its doors in 2010 in the heart of Bunbury but Brenda’s business model proved so successful that by 2012 she was looking for a bigger home. After a long and frustrating search she decided to build one. When asked about her formula for success, Brenda, 43, is quick to say she doesn’t have one, beyond thorough due diligence and just “working extremely hard and never ever giving up”. However, her past roles and experience have all given her a good grounding. Understanding of the bush She arrived in WA from Scotland in 1998 and spent her first two years working at various practices in the Great Southern and the

16 | OCTOBER 2015

She took on a similar role in establishing a second branch of the RCS in Bunbury when she moved there in 2007. However, a few years in and she became “sidetracked” by

A lot of people absolutely fear ownership because they think they could lose money – and they are right, they absolutely could.

her own Brecken Health Care project, which is probably more accurately described as a health hub. On the top ﬂoor of the purpose-built premises is the general practice, which currently employs 18 GPs, ﬁve physiotherapists plus business and administration staff. Several independent health professionals also lease rooms within the practice, including psychologists, occupational health physicians, cardiologists, speech therapists and dermal therapists. Downstairs other health professionals – such as opticians and dentists – have established themselves. In a landscape increasingly dominated by corporate providers, Brenda laments the fact that too few GPs are taking the leap into practice ownership. “I think it is a shame that there are so many corporates – I think they can take the care factor out of general practice. A lot of people absolutely fear ownership because they think they could lose money – and they are right, they absolutely could. That risk for many people is too much for them to get beyond.”

Dr Brenda Murrison

Taking the business leap After Hours is a case in point. Brenda helped set up the Bunbury After Hours Clinic, which was initially to have had six GP owners, yet by the time it opened there were only two because of the fear it might make a loss. However, the business model was sound and there were steady funding streams via the State Government and then from the Medicare Locals. But government policy is ﬁckle. Federal funding changes, which took place in July, have made the clinic unviable and now much of the after-hours work has been taken inhouse by the Brecken doctors. So keen is Brenda to see more GP owners that she is always looking for ways to share her business knowledge and experience with others, by way of joint ventures. At present she and Dr Glenn Fernandes are partners in the St Clare Family & Occupational Practice in Albany. “He wanted to set up by himself and needed someone with administration and business experience to help him,” she said. “I think doing it jointly with somebody who has the experience in practice management and business development can take away the fear and make you more comfortable making that jump.” “It’s something that I expect I will be doing more of in the future, and I like that idea.” With a health hub, an after hours clinic and a joint practice to run, it is easy to wonder just how the rest of Brenda’s life ﬁts in. When asked about her husband and three children, Brenda is very clear that they are her “number one priority”. So while she does take work home, there is always time for the soccer run, the hockey practice and the piano lessons. “I think it is about being aware of the role you are playing at the time. So when you’re mum, you’re mum; when you’re a wife, you’re a wife; when you’re a doctor, well sometimes you’re a doctor or a mentor or a friend. If you can manage that you can manage the work-life balance.”

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Feature

When a Trek Becomes a Rescue Emergency physician Dr Gaynor Prince was in Nepal when the devastating earthquake struck earlier this year and was able to lend an expert hand.

walk but, understandably enough, it was difﬁcult getting any information.” The location wasn’t the only piece of luck for Gaynor because one of her travelling companions had a particularly impressive CV.

Dr Gaynor Prince

Just after midday on the April 25, 2015, the earth moved for four dramatic and tragic minutes in the landlocked, desperately poor nation of Nepal. Dr Gaynor Prince, a SCGH emergency physician who says she thrives on a challenge, suddenly found herself in the middle of a 7.3 magnitude earthquake. Gaynor had travelled to Nepal to attend an emergency medicine conference. Her skills would be put to good use.

this conference but one of the presentations discussed the fact that they were due for a big shake because the last major earthquake occurred in 1934. So after that I was deﬁnitely thinking about it.” Though Gaynor had been to Nepal previously, she was unfamiliar with the area she found herself in. Safe shelter a priority

“When the earthquake hit I was in a small monastery village called Tyengboche near Everest Base Camp. It’d been snowing, we’d been walking for about three hours and I was looking forward to some hot soup. I had the cup in my hand and it ended up all over the table. Everything was shaking violently and I wondered what the hell was happening!”

“I didn’t know the terrain very well but Tyengboche turned out to be a good place under the circumstances. It was on a small hill in the valley and that slight elevation provided some degree of safety. Everyone was shocked and scared. We got out of the building quickly because there’s no mortar in the walls and each rock vibrates at a different frequency. When the middle rocks start popping out of the walls, it’s not a good idea to be inside.”

“The possibility of a disaster like this wasn’t at the forefront of my mind when I left Perth for

“It was important to ﬁnd out where the epicentre was so we’d know which way to

18 | OCTOBER 2015

“I happened to be with a doctor from the UK who is a reservist in the British Army and specialises in major incident planning – the perfect guy for the situation. We didn’t know anything about the rising death toll and we were concerned about landslides so we decided to stay overnight in a tea house made of wood. After another 6.8 aftershock, we stayed one more night.” Panic stations and consequences “Then we trekked for six hours to a Himalayan research centre at Pheriche and by the time we got there the helicopters had been going in and out all day. That was dangerous in itself, people running around refuelling and an empty jerry can was sucked up into the rotors grounding one chopper.” “It taught me the value of standing back and thinking clearly, taking a moment to process information even in the middle of a major disaster.” Despite her hospital ED expertise Gaynor’s eventual role concentrated on logistics. “Most of the emergency physicians were situated at the main teaching hospital in Kathmandu while we focused our attention on the Grande Hospital north of the capital. They were evacuating patients due to a lack of shelter so we helped them set up a ﬁeld MEDICAL FORUM

News & Views

Midland Ready Minus Fertility Ops Last month’s Midland Health Campus open day attracted more than 2000 people from the Eastern Suburbs eager to have a look at the facilities at the new public hospital. Unlike state hospital projects, the St John of God project will open as promised on November 24 just as the doors of the Swan Districts Hospital close. The only blot on what appears to have been a seamless operation has been the continuing disquiet about fertility procedures that will not be performed at the hospital because they contravene Catholic doctrine. Gift of the Givers Kathmandu Hills

Medical Forum has pursued these issues through these columns since June 2012 when it became clear that the SJGHC-run hospital would not perform male or female sterilisations, contraception or terminations where Swan Districts did, leaving patients, especially women, adrift and the promised smooth transfer of services between the old and new hospitals less than perfect. Minister is pinned down It hasn’t been easy to get information from the Health Minister, Dr Kim Hames, who signed off on the contract, and it has taken Parliamentary Questions On and Without Notice to get some answers. What there won’t be is any backing down. So as of November 24 this will be the state of play: Marie Stopes Midland (MS) has received $1.2m in capital funding from the WA Government for a facilities upgrade to enable its staff to perform medical and surgical termination of pregnancy, contraception, vasectomy and tubal ligation. Igloo Labour Ward

hospital and my role was less hands-on medicine and more logistical in nature.” “After that I flew back to Kathmandu and joined up with a South African medical team called Gift of the Givers, a disaster relief foundation. They’d had experience in the 2010 Haiti earthquake and they put 80 people in Nepal within 48 hours. I worked with them up in the hills in a primary care health clinic when most of the acute needs linked with the earthquake were over.” Importance of primary health “In fact, just over a week after the disaster only about 10% of the patients we were treating had quake-related issues.” Despite the importance of a global and compassionate response, Gaynor is well aware of some of the inherent complexities associated with foreign aid in these circumstances. “It does raise some big questions: The ramifications of setting-up a primary health care service in a country that hadn’t had one before the disaster and the consequent expectations of the local people afterwards were two complex issues. I have to say I was a bit torn by all this, particularly given some of the behaviour of the Nepali government.” “Corruption is a problem and this aspect of politics directly affects the local people. There’s only one international airport and initially the Nepali government was taxing everything that came in by plane. At one stage they were only allowing tarpaulins to be off-loaded and they’re pretty ineffective against wind and rain. With the monsoon season just four weeks away it was pretty inadequate!” Post-disaster, Gaynor ponders on both the experience itself and the value for medical professionals in stepping outside their comfort zone. “I was a little bit flat and emotional when I got back but it was nice to get a good night’s sleep. It’s important for us as doctors to challenge ourselves and stretch our boundaries because it’s a catalyst for reflecting on the work that we do and going to developing countries certainly gives you a different perspective.”

A spokesperson from MS said that clients in the Midland catchment could access these publicly funded services with a GP referral “as a continuation of the services publicly available at Swan District Hospital”. The Minister said MS would receive $500,000 in recurrent funding (which was a continuation of the activity based funding rolled over from Swan Districts) for three years with two one-year extensions available. He added that hysterectomies would be conducted at Midland and KEMH as they “were not performed for sterilisation purposes”. Later-term abortions would be performed at KEMH on a state-wide basis. Potential role for Kalamunda Opposition Health spokesperson Mr Roger Cook quizzed Dr Hames on Notice if the Government had considered upgrading Kalamunda Hospital. He said it could have the potential to give greater anonymity to patients and greater security “(eg. people could be at Kalamunda presenting for any type of day surgery, whereas the Marie Stopes clinic is dedicated to providing contraception, termination and sterilisation services and regularly experiences protestors outside the front of the clinic)”. The Minister said that the Kalamunda proposal was examined but the capital cost to upgrade its procedure room was “far greater” than the Marie Stopes option. He added that Osborne Park Hospital was also considered and rejected on the same basis. Apart from cost, he said MS in Midland was a discreet facility and was more accessible than Kalamunda. Mr Cook criticised the Government for continually regurgitating the ﬁgure of only 200 patients a year affected by this policy change. “They are probably not including all the births at Swan Districts where mothers are offered contraception prescriptions prior to discharge. The contraception conversation is a normal one to have in most public hospitals post-delivery.” We are interested to hear from GPs in the catchment area as to what information has been provided by SJGMH and Marie Stopes regarding the referral processes for these restricted procedures. Email editor@mforum.com.au

By Ms Jan Hallam

By Mr Peter McClelland MEDICAL FORUM

OCTOBER 2015 | 19

The WOMEN Centre has assembled a team of practitioners. Maria Markus Perioperative Nurse Mel Mosey Midwife, Clinical and Research Nurse

Dr Paige Tucker Clinical and Surgical Assistant PhD Candidate

Dr Fred Busch Obstetrician & Gynaecologist

Dr Timothy Pavy Pain Medicine Specialist

Dr Paul Cohen Gynaecologist, Cancer Menopause Specialist Clinical Research Fellow

Dr Lesley Ramage Women’s Health GP

Dr Jason Tan Gynaecologic Oncologist

Dr Jeremy Tan General, Upper Gastrointestinal & Bariatric Surgeon

Helena Green Clinical Sexologist & Counsellor

Dr Stephen Lee Obstetrician & Gynaecologist

Kealy France Women’s Health Physiotherapist

Dr Clay Golledge Physician in Infection Management Sarah O’Sullivan Genetic Counsellor

Jackie Framjee Clinical Nurse and Ward Nurse, SJOG, Subiaco

Paula Watt Clinical Psychologist

Because no one person has all the answers. As respected as our Gynaecologic Oncologist is, he’s no Sex Therapist. Our OB/GYNs are skilled at delivering babies, but can’t coax mothers with PND to bond with theirs. Part of being a great doctor or health professional is realising when you need to call on the support of others, to ensure your patient’s total wellbeing. When you refer a patient to the WOMEN Centre, you’re making sure she will be cared for physically and mentally by a team that includes a Gynaecologic Oncologist, Gastrointestinal and Bariatric Surgeon, Obstetrician and Gynaecologist, Physician in Infection Management, Women’s Health GP, Pain Medicine Specialist, Physiotherapist, Psychologist, Sexologist, Genetic Counsellor, Midwives, Nurses and quality improvement/ research fellows. She can draw on as many, or as few, of our services as she needs.

Our dedicated Upper Gastrointestinal Surgeon will be on hand to assist should the cancer be metastatic and require extensive debulking to achieve nil macroscopic residual, which is the single most important prognostic factor in overall survival. If post-surgery issues arise, our Physician in Infection Management swiftly deals with them. Our experience has taught us that the beneﬁts of integrated care extend to every stage of a woman’s life. To reduce patient stress even further, our Administration team act like a concierge service, anticipating needs and seamlessly co-ordinating appointments. Whether it’s endometriosis, pregnancy or menopause, we don’t just manage the condition – we treat the whole person.

For cancer patients especially, this holistic Survivorship model is considered best practice and has been shown to improve quality of life.

9468 5188 admin@WOMENcentre.com.au Our Friendly Office Staff: Admin Support - Tammy Barrett-Izzard, Kelly Barrett, Annie Thomson, Barbara Ngarimu IT Admin / Apps Development - Jun Sato Corporate Affairs - Huey Lih Lim

20 | OCTOBER 2015

Suite 20, 2 McCourt Street, West Leederville, WA 6007

www.WOMENcentre.com.au

WOMEN stands for Western Australia Oncology, Menopause, Endometriosis and New mothers.

We offer treatment and support for:

• • • • •

Pregnancy and post-natal care

• • • •

Pap smear concerns

• • • • •

Risk reduction surgery for cancer

Cancers of the reproductive system Heavy periods, ﬁbroids, ovarian cysts Prolapse, incontinence and discharge Minimally invasive gynaecological surgery via laparoscopic or DaVinci Robotic approach

Endometriosis and chronic pelvic pain Sexual intimacy enhancement Complex medical conditions requiring contraception

Genetic Counselling Physiotherapy Psychology Issues arising from surgical and natural menopause

MEDICAL FORUM

Feature

Which Way the NDIS? The two WA trials of the NDIS have reached their one-year milestone but there is growing disquiet in some quarters of the sector. The NDIS trial figures for the final quarter of the 2014-15 financial year are in and the State Government has been quick to trumpet a resounding success for the inaugural year of the My Way trial in the South West. The Hills trial folk have to be content with a more subdued national report.

and stakeholders, it is becoming increasingly difﬁcult to talk about these things. The partisan nature of their commentary is just not helpful.”

For some in the disability sector, this competitive (almost combative) stance from the WA Government is not helpful for those with disabilities and their carers. They have a lot more to lose than State versus Commonwealth rivalry.

Long-term needs

So stepping away from the hype and wheeling the bandwagon to one side, what do the ﬁgures show?

“I think the WA Government has focused far too much on the system arrangements rather than getting their head around how we are going to resource this, whatever ‘this’ is. The scale of this reform is huge and every state is starting from a different place. Each jurisdiction must create the processes for the transition it needs depending on its existing resources and demographics.”

The underlying frustration of consumers and their advocates is that the NDIS is really the ﬁrst opportunity for a systematic approach to funding disability services.

“At the end of the day, no matter how they arrange the system, for our people, the critical issue is how to ensure that the system is resourced at a rate that meets the population need.”

Fourth quarter results My Way has 777 participants, the largest group (268) are those with an intellectual disability followed by 151 with autism and 108 with a physical disability. In the Hills there were 1199 participants, again dominated by autism and related disorders (479) and intellectual disability (202). The average cost of a My Way package is $26,014 with a median of $14,393 for a total cost of $17.9m. For those in the Hills trial average plan cost is $34,894 with a median of $23,210 and the total committed funds of $41.2m. The NDIS nationally cost nearly $953m. The WA Government said the My Way average plan cost was 30% lower than anticipated while the national report to COAG stated simply the scheme was within budget though added the average package costs were higher than expected because fewer low-cost participants had entered the scheme. As the reporting week unfolded, more concerned voices on a range of issues began to emerge. Service providers under strain Prof David Gilchrist from the Curtin Business School and an authority on the not-for-profit sector has written for Medical Forum (see P10) expressing his concern for the ability of service providers to continue to deliver services to meet an ever-increasing demand. He writes: “… a funding figure was not arrived at after reviewing true cost of service delivery and demand but, rather, it’s an estimate of the money available…Secondly, there is no market mechanism, the NDIS sets the price it will pay. Thirdly…we do not actually have any plausible data showing the likely true cost of service.” It also doesn’t do much for confidence that the report to COAG slips this line in: “Work is underway to implement an outcomes framework, which will allow the (National

MEDICAL FORUM

“There is great concern for people with complex needs on the long-term implications of the current pricing. There’s not so much bite now when service organisations have a bit of fat about but when it comes down to a funding regime that is strictly individualised for people with a range of clinical needs, there’s not a lot of room to get the price right.”

Disability Services Minister Helen Morton

Disability Insurance) Agency to report against scheme outcomes.” The NFP sector is calling for a delay in the rollout of the entire scheme until these issues are sorted out but this is cold comfort for those with disabilities who are not in the trial sites. A national campaign is calling for the full rollout … ‘Now!”.

That’s the message disability advocates are most keen to deliver – the experiences in the trial sites are much more nuanced than both reports indicate.

Consumer perspective

“In each trial site there are people who have great experiences and those who haven’t. We have to listen to all these conversations and distil that information but’s that’s difﬁcult to do in this environment.”

Disability advocate and CEO of Developmental Disabilities Council of WA Taryn Harvey was dismayed that the State Government sought to politicise the report.

“People’s expectations of the system are all different but everyone wants a system that meets their needs in a reliable, ﬂexible, responsive and timely way and one which treats them like a human being.”

“The greatest trauma for consumers and their carers is what they’re hearing in the media. They are not being consulted or asked for their input. It’s disappointing that the state minister decided to open the conversation with stakeholders on the front page of the newspaper.” “How can she be making these statements? We’re having a trial for a reason and there is a feeling in the community that the State Government is pre-empting the process.”

By Ms Jan Hallam

Participants with approved plans by primary disability

WA 1,199

Intellectual disability (including Down Syndrome) Autism Neurological (including multiple sclerosis) 28%

Developmental delay

40%

“A lot of really important issues are being raised as both these trials unfold and they need unpacking but in the present competitive environment between governments

Psychiatric (including schizophrenia)

11% 1%

Sensory

Cerebral Palsy

Global developmental delay

Other physical

6% 4% 0

The numbers in these charts will not add to 100% due to rounding.

OCTOBER 2015 | 21

Money for Medicine – Slicing the Cake This topic at the last Doctors Drum breakfast for the year spurred passion and frustration and a growing sense of required action both at the grassroots and policy levels. It was a fascinating discussion on September 10, with some startling insider insight into the workings of government, policy and practice and the panel’s expertise was brought to bear on a number of key issues. Limited money in the pot At election time, there’s money to spend, however, is it time for governments to say, we have limited funds, this is what we can offer you? With Australian health expenditure running at 9.4% of GDP (2013 World Bank data) and rising, there was no denying the cost issue, but is it a matter of cost savings or cost efﬁciencies? It was thought that much could be done by following the ‘choose wisely’ concept. Another view was that the community needed to get over the idea of entitlement; health was not a welfare industry not just because the country can’t afford it but because there are many individuals who can. There needs to be more honesty from all quarters, including the profession. The nation cannot afford self interest. Some of the solution discussed were: så &UNDåPATIENTSåTOåSTAYåWELL så 0ATIENTSåFUNDåTHEMSELVESåVIAåAåHEALTHå scheme så $OCTORSåREMUNERATEDåFORåACTIVITY åWITHåTHEå exception of diagnostic work, which by its nature takes time. Health expenditure must have a cap, was the insurer’s view, but that’s where value for money becomes vital. The evaluation must be rigorous to determine what value we’re getting for our health dollar. We need to look beyond the debate on the cost of hospital beds and look to what we get back. And when we know that, a way forward becomes clear. The solution can be found in diversifying funding sources but there must be better transparencies on outcomes. Waste, duplication & administration Ideas ﬂew thick and fast but there was consensus that we had a wasteful system with much room for improvement. The RACGP

in its submission to the PHCAG promoted patient registration... again. If consumers put the kybosh on it in the past it seems they might have a change of heart. On the proviso consumers had a choice to move doctors if personalities clashed, registration could reassure consumers on care, price-cost ratios and involvement in their own care. On the medical side, it would be a boon for treatment of chronic conditions though remuneration for the extra time should be considered in a structure that incorporated items for service/fee for service, enrolment plus some incentivised program. However, IT was seen as the vital cornerstone for change and there was genuine dismay that in the 21st century GPs and hospitals were so disconnected on the information highway – and there was little excuse. Privacy was dismissed as a cogent response. It was pointed out that with the rise of credit cards and electronic commerce, privacy in the conservative sense was dead and buried, so why make it the hurdle in the reform the health system?

There was even more dismay that WA Health had invested hundreds of millions in ICT and had accumulated so much patient data that it was inaccessible to clinicians – this was not only wasteful, precipitating repeat treatments but also cost precious minutes at critical times. These instruments, such as extensive and detailed databases, exist, they don’t have to be created and it’s unconscionable that they are not being used for the good of everyone. Quality and safety Another case of admin gone wild is the areas of quality and safety which one doctor described as completely overcooked. “There is no end to it. We have to recognise that medicine is inherently unsafe. Patients and doctors both understand that, none of us is stupid. The media has a lot to answer for in this area. If something goes wrong, there’s evidence to throw some other quality credentialing standardising regulation and it doesn’t work and it costs.”

Sponsored by:

Gallery of pictures now at www.doctorsdrum.com.au

22 | OCTOBER 2015

MEDICAL FORUM

Where to from here? So it came down to another question. In the prophetic words of one doc – “the whingeing and whining and the expectation that someone else can ﬁx the problem has a use-by-date... and it was a while ago.” Doctors are working harder than ever but in isolation and are not involved in designing the solutions for general practice. Politicians will listen to grassroots because their jobs depend on it. That’s where change will come.

The Panellists Dr Kevin Cheng, a Melbourne GP and head of integrated care at Medibank Private Dr Janice Bell, WAGPET CEO Dr Frank Jones, RACGP President Dr Michael Allen, fertility specialist Ms Michele Kosky, consumer advocate.

Gallery of pictures now at www.doctorsdrum.com.au

MEDICAL FORUM

OCTOBER 2015 | 23

Feature

Who Does What in WA Hospitals The opening of Fiona Stanley Hospital precipitated a reshufďŹ&#x201A;e of priorities in other metro public hospitals. In the ďŹ rst of two parts, hereâ&#x20AC;&#x2122;s the breakdown for the South Metropolitan Health Service. Fiona Stanley Hospital (783 beds) Aged care: Acute inpatient; orthogeriatrics; consultation liaison Cancer, haematology and palliative care: Cancer Centre, medical oncology, outpatient clinics and specialist pharmacy; breast assessment; haematology incl. bone marrow transplants; radiation oncology; palliative care Heart and lung services: Cardiology, diagnostic and interventional; state-wide heart and lung transplant; respiratory failure unit; advance lung disease service; sleep services Elective and emergency surgery: Incl. elective plastics; maxillofacial; dental and oral (emergency and elective); urology; ENT, vascular Emergency services and critical care: ED; ICU; Coronary Care; Metropolitan Trauma Service; State Adult Burns Unit General medical: Extensive for emergency, inpatients and outpatients; renal; incl. on-site dialysis and kidney transplants; endocrinology incl. specialist clinics; gastroenterology; immunology; infectious diseases incl. Hospital in the Home (HITH); sexual health (incl. 16-24 year-olds); dermatology; rheumatology incl. super-specialist rehab and outpatient clinics; hyperbaric medicine Mental health: For young adults, adults and older adults, incl. ED, mother and baby unit, psychiatric ICU Rehabilitation: Neurology and stroke incl. state tertiary neuro-rehab centre and acute stroke unit; spinal surgery; State Rehabilitation Service Women, children & neonatal: Maternity, neonatal; gynaecology (emergency and elective); paediatric incl. dedicated ED and visiting tertiary clinics

Bentley Health Service (199 beds)

Armadale Health Service (290 beds)

Fremantle Hospital (300 beds)

Aged care: ACAT; restorative, community rehab

Aged care: Inpatient and outpatient care; ACAT; restorative care

Critical care: ICU to support elective and planned surgery

Elective surgery

Elective and emergency surgery: General; plastics for minor trauma; vascular planned (low to moderate complexity); minor burns (in ED); orthopaedics (including major joint, upper and lower limb); urology (ED, elective and short-stay); ENT, including paediatric; anaesthesia and pain management

Elective surgery: General; plastics (hand procedures); vascular; orthopaedics incl. major joint, upper and lower limb; anaesthesia and pain management; ophthalmology incl. non-admitted patient review and eye condition management

General medical: Endocrinology incl. diabetes clinics; gastroenterology Mental health: Inpatient, outpatient and community for adults and older adults Neurology, stroke, spinal and rehabilitation: Rehab and stroke rehab Women, children and neonatal: Maternity for low-risk pregnancies

Emergency services and critical care: ED; ICU; minor trauma (serious trauma referred to RPH) General medical: ED; general admissions; renal medicine incl. on-site dialysis; endocrinology incl. diabetes clinics; infectious diseases; rheumatology; gastroenterology Mental health: For adults and older adults incl. emergency, inpatient, outpatient and community

Aged care: Geriatric and rehab

General medical: For inpatients and outpatients; endocrinology incl. diabetes clinics; sexual health services; gastroenterology Mental health: Inpatient and community for adults and older adults Rehabilitation services: General and orthogeriatric rehab

Palliative care Rehabilitation: Inpatient; RITH; community including day therapy Women, children and neonatal: Maternity and neonatal (low to medium acuity); gynaecology; paediatric

24 | OCTOBER 2015

MEDICAL FORUM

Feature

Rockingham General (242 beds) and Murray District Hospitals (15 beds)

Royal Perth Hospital (450 beds)

Aged care: Inpatient and outpatient; ACAT; restorative; RITH; community rehab including day therapy

Elective and emergency surgery: General; breast assessment; complex ophthalmology; orthopaedics; scoliosis, complex plastics; complex maxillofacial; complex dental and oral, (emergency and elective); urology; ENT (excluding major head and neck); complex vascular, anaesthesia and pain management

Cancer, haematology and palliative care: Cancer services, excl. radiation oncology and complex surgery, incl. medical oncology and chemotherapy; palliative care, haematology Cardiovascular, respiratory, thoracic and coronary: Some cardiology, excl. surgery; general respiratory, incl. chronic disease management Elective and emergency surgery: General surgery; plastics for low complex short-stay; minor vascular; minor emergency burns; orthopaedic surgery, incl. major joint, upper and lower limb; dental; urology; ENT incl. paediatric; anaesthesia and acute pain management; ophthalmology low complexity Emergency and critical care: ED, ICU, Regional trauma General medical: General medicine incl. Medical Assessment Unit; endocrinology incl. diabetes clinics; infectious diseases incl. HITH; renal clinic; rheumatology clinic, gastroenterology

Emergency services and critical care: ED; ICU; High Dependency Unit; Coronary Care Unit; State Adult Major Trauma Centre; neurosurgery (unplanned) General medical: ED; diagnostic and interventional cardiology; renal incl. on-site dialysis; endocrinology, incl. diabetes clinics; gastroenterology; haematology; immunology (incl. HIV); infectious diseases; neurology and stroke; sexual health clinic; dermatology; rheumatology; palliative care; inpatient aged care; respiratory Mental health: For adults and older adults ED: A leaked report from the taskforce looking into adult cancer treatment services have recommended the reinstatement of RPH’s cancer services because FSH is not coping with the volume of cases. The Minister said he would consider the proposal.

Mental health: For adults and older adults incl. emergency and community Neurology, stroke, spinal and rehabilitation: Excl. neurosurgery incl. a stroke unit Women, children and neonatal: Maternity and neonatal for lowto-medium risk pregnancies; gynaecology; paediatric incl. specialist clinics

2015 CHRISTMAS SUPPLEMENT MEDICAL FORUM'S

GREETINGS

Send Christmas greetings to your colleagues and clients in Medical Forum’s popular special Christmas Greetings Supplement. Deadline: Monday, November 9 • Acknowledge the support of colleagues • Extend goodwill to one and all • End 2015 in the spirit of the Christmas season Medical Forum’s Christmas edition is out on December 1

To lodge your greeting in Medical Forum’s Christmas Greetings Supplement Phone FORUM Jenny Heyden on 9203 5222 or email jen@mforum.com.au MEDICAL

OCTOBER 2015 | 25

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Guest Column

Identity Without the Knife WA’s Gender Recognition Act was written in 2000 but is now creating unnecessary anxiety for transgender people, says A/Prof Sam Winter.

There’s a new name for the State’s leading Ophthalmic Day Hospital.

Identification documents such as passports and birth certificates carry visible gender markers. Passports (administered federally) are relatively easy to change by a letter from a registered medical practitioner or psychologist. But birth certificates (administered at State level) are extremely difficult to change. With the exception of the ACT, all Australian states and territories require a trans person seeking to change their birth certificate to undergo gender reassignment. WA’s Gender Recognition Act of 2000 imposes as a precondition for recognition a reassignment procedure (medical and/ or surgical) to alter the genitals and other sexually differentiated physical characteristics. Some high-profile court decisions have chipped away at the edges but the Act remains unchanged. Indeed the relevant application form advises that only a person who has undergone surgery may apply. In Australia the birth certificate is in some ways the key identity document – for employment or to open a bank account as part of the ‘100 point’ identity criterion. If people can’t afford a passport (as many trans people can’t) there is no choice but to use a birth certificate, which not only identifies a person but also determines their legal sex. All trans people deeply desire to live and be accepted in their experienced gender and it can cause distress to be denied these things. True, many trans people are dysphoric about their sexual anatomy. For them surgery is a medical necessity. Hormones may be too. Gender affirming medical care can be life changing and, for the most distressed, life-saving. But not all trans people experience that need for hormones and surgery. Surgery can pose problems. For the old and unhealthy it may be illadvised on medical grounds. For all it is expensive. Medicare covers only part of the cost. Those without a good job are often unable to afford it. And birth certificates that ‘out’ trans people seeking employment reduce applicants’ chances in the workplace, feeding that vicious cycle. When trans people are pressured into surgery (or hormones) they may not want in order to access documentation that will enable them to lead their lives with dignity, respect and equality, then that is coerced treatment. When Governments say to trans people that they can marry their loved ones but only if they give up their right to bodily integrity, then that is coerced treatment. In these circumstances we delude ourselves if we think that there can be full and free consent to the medical procedures involved. Medical requirements for gender recognition have the capacity to turn gender affirmative treatment into medical abuse; indeed into cruel, inhuman and degrading treatment. The World Health Organisation and six other UN agencies plus a host of health and human rights groups are opposed to surgical prerequisites for gender recognition. A fair number of them take the same view on hormones.

In recognition of our expanded service area (the entire metropolitan area), our international-standard specialisation (‘Eye’ surgery) and our substantially increased scale (we’re a leading Western Australian day hospital), the Eye Surgery Foundation’s name has changed to Perth Eye Hospital. As the Perth Eye Hospital we continue to offer an unmatched team of world-class surgeons and support professionals. All with access to state-of-the-science technology and systems. We remain as passionate about providing patient care and comfort as we have been since our inception in 1987. To see everything we offer, simply visit pertheyehospital.com.au or call 9216 7900.

Countries across the world are discarding medical preconditions imposed for legal gender recognition. Some have gone all the way, entirely divorcing medical care (important for many, possible for some) from legal recognition (necessary for all). They have instead adopted a ‘Declaration Model’ in which trans people can change their legal gender status simply by completing a form. No hormones, no surgery. And no diagnosis either. At the moment the list is small: Argentina (2012), Denmark (2014), and Malta, Ireland and Colombia (2015). The list is sure to grow. Australia must be on it. References on request

MEDICAL FORUM

42 Ord Street West Perth 6005

OCTOBER 2015 | 27

Guest Column

Helping Violent Men A timely focus on the perpetrator is essential in addressing family violence, suggests Communicare WAâ&#x20AC;&#x2122;s Kate Jeffries. GPs are often the ďŹ rst port-of-call for perpetrators of family and domestic violence. And itâ&#x20AC;&#x2122;s not always easy to recognise the signs when it presents in a consultation room. But when it does, what can you do about it? Itâ&#x20AC;&#x2122;s a simple question but the answer is considerably more complex. Rosie Battyâ&#x20AC;&#x2122;s push to keep this issue on the agenda, the Royal Commission into Family and Domestic Violence and the National Plan to reduce Violence against Women and Children all have the same essential message â&#x20AC;&#x201C; the issue of Family and Domestic Violence requires the full involvement of the perpetrator. Itâ&#x20AC;&#x2122;s absolutely crucial to provide a holistic response if weâ&#x20AC;&#x2122;re to make any signiďŹ cant inroads into improving the safety of women and children. We need to provide effective services for the former, the latter and, most importantly, for the perpetrators. Alarm bells should probably ring when a male patient presents with anxiety, depression and relationship difďŹ culties combined with comments such as:

sĂĽ h) MĂĽARGUINGĂĽWITHĂĽMYĂĽWIFEĂĽALLĂĽTHEĂĽTIME v sĂĽ h3HEĂĽKNOWSĂĽHOWĂĽTOĂĽPUSHĂĽMYĂĽBUTTONS v sĂĽ h) MĂĽDRINKINGĂĽMOREĂĽTHANĂĽ)ĂĽUSEDĂĽTOĂĽBEĂĽANDĂĽ weâ&#x20AC;&#x2122;re not getting along very well.â&#x20AC;? sĂĽ h)ĂĽNEEDĂĽTOĂĽlNDĂĽSOMEĂĽWAYĂĽTOĂĽCONTROLĂĽMYĂĽ anger.â&#x20AC;?

Breathing Space Menâ&#x20AC;&#x2122;s Behaviour Change Program is a three-month residential program in Perthâ&#x20AC;&#x2122;s southern suburbs... There may, or may not, be a risk of family violence within such a situation but a few follow-up questions from a GP can help to provide a closer focus. sĂĽ h9OUĂĽMENTIONEDĂĽYOUĂĽAREĂĽlGHTINGĂĽAĂĽLOTĂĽ with your partner. Are you worried it may become unsafe for you or your family? sĂĽ h7HENĂĽYOUĂĽARGUE ĂĽDOĂĽYOUĂĽFEELĂĽYOUĂĽMIGHTĂĽ lose control?â&#x20AC;? sĂĽ h$OĂĽYOUĂĽKNOWĂĽTHATĂĽYOUĂĽCANĂĽGETĂĽSOMEĂĽREALLYĂĽ good support for this?â&#x20AC;?

Communicare runs Breathing Space Menâ&#x20AC;&#x2122;s Behaviour Change Program (MBCP), a three-month residential program based in Perthâ&#x20AC;&#x2122;s southern suburbs underpinned by a therapeutic community model and is the only one of its kind in the southern hemisphere. Itâ&#x20AC;&#x2122;s absolutely imperative, in some situations, to ensure the safety and well-being of women and children by removing the man from the home and providing alternative accommodation, intensive case management, individual counselling and group-therapy programs. Prior to entering the MBCP, Communicare also has the capacity to support men with issues associated with co-occurring mental health and substance abuse. ED: Last month the WA Government announced it would commit $34.5m to the Freedom from Fear Action Plan with the focus on the perpetrator. It will also address family and domestic violence, particularly in the Kimberley. Minister Helen Morton said the plan would include accommodation and support services, advocacy and counselling services, coordinated response services, domestic violence outreach services, and the Safe at Home Program.

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MEDICAL FORUM

Guest Column

Power of the Mind to Heal Clinical Psychologist Mr Nick Ramondo suggests that ‘the mind’ is an essential consideration in achieving healing and health. I never cease to be amazed at some people’s ability to use the power of their mind to achieve extraordinary outcomes that often defy rational explanation. While one person, under hypnosis, can plunge their forearm into freezing water and keep it there for more than a minute, others struggle to last more than 15 seconds. Or, even more astonishing, how a patient under hypnosis undergoes a thyroidectomy to the astonishment of a theatre full of surgeons but no anaesthetist! Recent developments in neuroscientiﬁc scanning and genetic mapping have enabled us to better understand the power of the mind and how people use this capacity to transform their sensory, physiological and emotional experiences. Research utilising these technologies has transformed longheld beliefs regarding the interaction of the brain with human experience and has led to exciting developments in neuro-genetics and epigenetics. We no longer remain enslaved to our biology and to an unalterable genetic destiny. Research has shown us that the brain is not only neuro-plastic across its life span but that one’s life experiences modify neuronal and

genetic development, and consequent human expression. Studies have demonstrated that, when a person is in a state of focused attention such as that induced by clinical hypnosis or mindful meditation, the brain can actually be altered through verbal suggestion. These developments have profound implications for both clinicians and patients. A reductionist model that seeks to diagnose dysfunction in the body or mind from a strictly biological perspective is a distinctly limiting model. It is particularly simplistic within the field of mental health and in the treatment of the most common presenting disorders to GPs such as anxiety and depression. To reduce a patient’s problem to a hypothetical biochemical imbalance is to miss the crucial point of how life experience interacts with, and modifies, neuro-biological expression. This leads to a critical question – how do we engage with patients to help them make more informed treatment choices and take them beyond just ‘popping a pill’? The medical profession generally, and GPs specifically, are in a wonderful position to guide patients towards better health and

treatment choices. Education across all levels is the key. First, medical training programs can focus on and highlight the latest non-pharmacological treatment options that utilise the power of the mind to effect change. There is strong evidence that clinical tools such as hypnosis and mindful meditation are effective in the treatment of a variety of commonly presenting disorders such as anxiety, depression, posttraumatic stress, anorexia nervosa, pain, alcohol abuse and other addictions. GPs can educate their patients that the mind, the body and life experience need to be considered holistically when formulating an understanding about the presenting complaint and its treatment. Second, GPs can (during their primary medical degree or through a CPD program) undertake clinical training that teaches them to use mindbased tools such as hypnosis and meditation to treat patients. This would be particularly useful for patients who may feel some stigma in being referred to a mental health professional. References: Contact the author at nramondo@dourohouse.com.au

“Why I recommend BreastScreen WA to my patients” Dr Steve Wilson, Bassendean GP It is a free service for my patients. Two radiologists review each screen independently. It is convenient with nine metropolitan clinics, one in Bunbury and four mobile screening units touring WA. BreastScreen WA is equipped with the latest digital technology. It has been shown when a woman’s GP recommends regular breast screening it is one of the main reasons women book their mammogram appointment. Please join me in recommending regular breast screens to all asymptomatic women aged 50-74 years old.

For more information, f to download the electronic referral form or to order your BreastScreen WA referral pad please visit www.breastscreen.health.wa.gov.au

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OCTOBER 2015 | 29

get your patient’s spine working Workspine’s team of hand picked specialists provide comprehensive occupational spine injury management under one roof. From pain management to surgery, cognitive therapy and rehabilitation exercise programmes, Workspine covers all aspects required for the successful treatment of work related spinal injury. Studies have shown that a comprehensive approach to spinal injury treatment results in better patient outcomes. Put an end to the spiral of endless referrals and self management and send your work related spinal injury patients to Workspine. We get spines working.

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WEMBLEY Suite 10, First Floor 178 Cambridge Street Wembley WA 6104 www.workspine.com.au MEDICAL FORUM

Feature

Medicine is a Way of Family Life Two peas from the same pod are now living in very different gardens – a generation apart with shared ancestry – Drs Wence and Tanya Vahala. Dr Wence Vahala He speaks Czech, is focused more on teaching than consulting since semiretirement early last year, and carries the legacy of his father. Dr Wence Vahala was only three years out of medical school when he joined his father Vaclav in his Bayswater general practice surgery in 1969. That’s where he stayed. “He was a single lone GP working 24 hours a day and unable to get help. I took a year off from hospital to help, and then stayed. The surgery had a bell phone connected to home so patients who arrived out of hours could ring you. There was a high level of loyalty so doctors saw sick patients no matter what and patients waited for their doctor where they could. It has become much more generic now.” His father’s earlier story provided a strong context to his life. “In 1950 we were in a German refugee camp, ﬂeeing Czechoslovakia. The UK took us on and Dad, who had been a GP in the Czech Republic, redid his exams, which he passed despite dreadful English. He met an Australian surgical registrar while working in hospital who told him a friend needed a GP in Bayswater. That’s how we got to Australia.” His father, who died at home aged 90, had survived Nazi occupation and left the country before Alexander Dubcek and the Soviet occupation of 1968. He told Wence that because people lacked cars in postwar Australia, they ran a branch surgery in Meltham. He said the goodwill he paid when he took over the practice was more than the cost of their home. The general practice ideas Wence has developed over the years reﬂect his experience in Bayswater, where the demographics of the area have changed but the 500 or so Czech-speaking patients have remained loyal. “In general practice you become adept at working with uncertainty because you see a lot of problems that are self-limiting and about to evolve. We see people at the earliest point and we have to navigate by not leaving investigation too late and knowing when it is still safe to watch.” He feels GPs have always been “lone wolves” because of their long hours and commitment to patients, which meant their world consisted of work plus a few friends or family. “I think we have had the golden years when it felt so rewarding to be a GP. The other side of the coin is you now have more free time to do other things.”

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He loves bush walking, which he now does three days a week. And the learning that comes from teaching inspires him, although he acknowledges he can never keep up. “One of the GP registrars during my recent teaching session was talking of their involvement with a dying friend. There were registrars there from the Middle East and India, where it is still normal in their cultures for people to look after best friends and family rather than leave it to strangers.” Until 25 years ago, he said GPs in Australia looked after their own families but a shift in ethical boundaries has changed all that. Wence has also seen general practice sizes grow from one or two doctors to four or six. He remembers the AMA and RACGP “fought tooth and nail” to block Medicare’s arrival in 1981, arguing that unnecessary consults would swamp GPs and there would be huge wait lists for procedures. “Now we ﬁght for no reduction in Medicare rebates like our lives depend on it!” he reﬂected. Dr Tanya Vahala This is the world into which his daughter, who describes herself as a ‘late bloomer’, launched her career in medicine after a stint coaching gymnastics. Now aged 31, she was born the eldest of three from Wence’s second marriage. “I had two things growing up, gymnastics and home, for which the surgery was a big part,” she said. In fact, the surgery was often the dropping off or rendezvous point for toing and froing from gymnastics and school.

and talk about medicine. I think the practice is his legacy, it was his Dad’s, and he’s seen generations grow up there. You would always hear nice things about him from patients being admitted through ED. I think it is very special.” “Dad is an amazing mentor and has an amazing capacity to connect with his patients and be very empathetic and know what they are trying to convey,” she said proudly. After her 2012 graduation, there followed residency and internship at RPH, and now she is at Fiona Stanley Hospital because it offers more in her chosen path of Critical Care. “When I went into med school I wanted general practice in the first two years but then one of my mentors exposed me to emergency medicine and I think it is more suited to my temperament – I like to get to a solution straight away.” (Dad told us his daughter “would find general practice uncomfortable because she needs a more defined set of circumstances.”) Now Tanya is hoping to get into a Critical Care training program. continued on Page 32

“On the days I didn’t have gymnastics I would wait the whole time and run around causing mayhem. The best part was the free jellybeans I would scrounge from Dad’s room. My Mum was a nurse who helped with the day-to-day running of the practice. So we were often there.” “As long as I can remember during childhood, I always wanted to be a doctor and remember destroying my dolls by injecting them with ﬂuids. I would bandage them up and write them prescriptions. I saw that Dad got a lot out of medicine.” Her gymnastics took her to Melbourne where she mingled with those interested in sports medicine, and noticed many moved from gymnastics to allied health careers. She came back to Perth, sat Year 12, then entered medical school at the ripe old age of 23 (much to her Dad’s excitement and relief, she said). “Every weekend we would go for a walk

This story started with bricklayer Paul who has been with the Bayswater practice, ﬁrst under Vaclav then Wence Vahala. He has strong connections with them both and spoke so glowingly, we had to investigate further, especially after he spoke of how these GPs would go the extra mile for their patients.

OCTOBER 2015 | 31

Feature continued from Page 31 “Like anything around medicine these days it starts to bottleneck around registrar level for training programs. Dual ED/ICU training is the goal at the moment. Surgery and its subspecialties have more of an ‘old boy network’ but in my path it appears to be more gender neutral.” Where she ends up is in the lap of the gods. Her boyfriend has a desire for rural general practice. And having kids may reshape everything, which is where her daily contact with her Mum may bear fruit. Three generations of the Vahala medical family

“Mum works very hard. She does post-op recovery nursing and was very supportive through medical school,” she recalls. “I think I’ve got the best job in the world. The biggest lesson is being patient. I’m not innately like that. There is so much to learn and you feel like you are never going to learn it all. I say to myself, just take a step at a time and enjoy each stage because you are only a student once.” The life balance discovered by Wence in semiretirement is already on Tanya’s mind.

Tanya, much later in her gymnastics career than the young girl who didn’t want her family around in case she made a mistake.

Wence at a recent GP conference

“I’m not all that great at keeping the balance – making sure it’s not all about medicine. You have to have something else outside of it to keep you happy, good family and friends to lean on when you’re tired and overworked or grumpy..”

By Dr Rob McEvoy

For the 1 in 5 adults who suffer from axillary hyperhidrosis, there is now a breakthrough non-invasive microwave technology to safely eliminate underarm sweat glands and provides a lasting reduction of underarm sweat Lasting and stable efficacy

Controlled thermolysis caused by precisely delivered energy

Strong safety proﬁle

Targeted energy delivery to the dermal-fat interface region

Focal Energy Zone created along interface, independent of skin thickness

Thermolysis at 60°+c

High patient satisfaction Minimal to no patient downtime TGA & FDA approved to treat excessive underarm sweat Recommended by the International Hyperhidrosis Society as second line therapy after topical antiperspirants

ąŗ Virtually all the sweat glands reside here

ąŗ Energy reﬂected due to electromagnetic properties in the interface ąŗ Energy intensiﬁed from constructive interference

ąŗ Hydro-ceramic cooling keeps Heat Zone at level of sweat glands ąŗ Cooling protects epidermis and upper dermis, which deeper tissue not affected ąŗ Lasting solution since sweat glands do not regenerate1

1 “The ontogenesis of sweat glands is only at the embryonic period, so no sweat glands are regenerated after birth.” Li H, Gang Z, et al. Antigen Expression of Human Eccrine Sweat Glands. J Cutan Pathol 2009: 36: 318-324

6 Short Street, Fremantle WA 6160 PHONE: (08) 9336 3066 | skinclinicfremantle.com.au

32 | OCTOBER 2015

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MEDICAL FORUM

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OCTOBER 2015 | 33

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MEDICAL FORUM

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OCTOBER 2015 | 35

Clinical Opinion

Simulation the Perfect Practice In 1964 Gus Grissom was given the job as command pilot on Gemini III making him the ﬁrst NASA astronaut to ﬂy into space twice. During the simulator training, Grissom undertook 20 normal launches, 46 aborted launches, 51 simulated booster failures and 211 systems malfunctions All this in preparation for a trip into the blackness of space that lasted just 4 hours 53 minutes.

practical and generic surgical skills using a variety of simulation models. Over the past decade the ASSET course has undergone various reﬁnements. The latest version comprises a series of online eLearning modules focusing on theory that must be satisfactorily completed prior to the two-day face-to-face skills laboratory-based course.

By Dr Robert Davies Urologist

The ASSET content has been made available only to RACS trainees but following the lead of other Colleges, and in response to the availability of questionable instructional content available on YouTube, we have recently opened up the ﬁrst ﬁve online instructional modules for public access. We hope that this initiative will mark out surgical skills as territory belonging to surgeons and reinforce the RACS as the Australian and New Zealand reference standard.

The NASA approach contrasts starkly with the historical model of surgical training, which has essentially relied on the use of public patients as training manikins. Somewhat provocatively, the surgical ‘learning curve’ was once deﬁned as ‘preventable injuries to patients that are a direct consequence of surgical incompetence’.

This subsequent component of the ASSET course delivers two days of face-to-face practical surgical skills training. There is a 2:1 participant/tutor ratio and the training is delivered in skills laboratories throughout Australia and New Zealand, such as the CTEC at UWA.

As surgeons and educators we recognised more than 15 years ago that we should be doing better than this. This led, amongst other things, to the development of mandatory surgical skills training for all RACS trainees.

The course is presented as a series of sequential modules. Each generic surgical skill is deconstructed on a video presentation before participants practise the techniques under supervision. A variety of low and high ﬁdelity simulations are used for instructional purposes.

The RACS initially adopted the Basic Surgical Skills Course (BSS) from the Royal College of Surgeons of England (RCS). With input from the RCS we later developed the Australian and New Zealand Surgical Skills Education and Training (ASSET) course. It was ﬁrst delivered in 2006 and its focus was on teaching

A central tenet is the One Safe Way concept. The ASSET committee recognises that there are always a number of equally acceptable surgical techniques that may be used to achieve the same outcome, but what we’ve agreed upon are single, safe techniques that can serve as a foundation for trainees to build on. This material needs to be accessible early in medical education so that students adopt sound techniques from the outset.

Using public patients for training is no longer acceptable and courses such as ASSET allow much of the surgical learning curve to be conﬁned to the skills laboratory under the supervision of experienced surgeons.

Doctors’ Service Awards – NOMINATIONS NOW OPEN Rural Health West will once again celebrate the achievements of outstanding and extraordinary rural doctors at the 2016 Rural Health West Doctors’ Service Awards. Wesfarmers provides the recipients of the following special awards with $5,000 to contribute towards professional development: z The Award for Outstanding Service to Rural and Remote Health z The Award for Extraordinary Contribution to Outreach Services z The Award for Remote and Clinically Challenging Medicine WA Country Health Service sponsor the following two awards: The Award for Above and Beyond – Community First z The Award for Outstanding Hospital Doctor

Key sponsor

Proudly sponsored by

Download a nomination form – scan the QR code or visit

www.ruralhealthwest.com.au/doctorsserviceawards 36 | OCTOBER 2015

MEDICAL FORUM

Clinical Update

Medical Cannabis Seriously ill patients in Australia currently use illicit cannabis for medical purposes. Often these are vulnerable people with late-stage cancer suffering pain and/or chemotherapy induced nausea, or children suffering epileptic seizures where existing treatments are less effective. These people and their carers are exposed to multiple risks – product produced with little or no quality control; no accurate standardisation or labelling of the ratio of cannabinoids in the particular strain for appropriate dosage; and potential criminal prosecution. Additionally, many patients administer cannabis using potentially harmful or inaccurate means such as smoking. This situation is completely unacceptable. International jurisdictions including Canada, Czech Republic, Finland, Germany, Israel, Italy, the Netherlands, Uruguay and 27 states of the United States permit cannabis for medical purposes. Barriers to overcome A regulatory framework must be implemented at a Commonwealth level to meet UN International Convention obligations. This process began with The Regulator of Medicinal Cannabis Bill 2014 introduced into the Commonwealth Parliament. It appears to have

MEDICAL FORUM

By Dr Mal Washer Company Director & Former MHR

bipartisan support. The Bill would establish a Regulator of Medicinal Cannabis to regulate the production and use of cannabis products for medicinal purposes in Australia. Hopefully the Regulator can be set up as early as mid-next year. Individual states and territories will then need to implement appropriate legislation. Some have, or are undertaking parliamentary inquiries into how such a system could be administered (TAS, VIC, NSW and ACT). Australian practitioners’ lack of knowledge will be a significant barrier. Criminalisation has inhibited research into the medical effects of cannabis. Scientific evidence (from increased global licit use) shows cannabis reduces distressing symptoms in a range of conditions where conventional medicines were ineffective or had unacceptable side effects. Clinical studies have shown that particular cannabinoids have efficacy for treating neuropathic pain, spasticity associated with multiple sclerosis, and nausea from chemotherapy. We would be naive to think that cannabis use is risk free. Evidence shows social, behavioural, educational and mental problems with frequent use by young people aged 15-25 but also that cannabis is not highly addictive like heroin, tobacco, and benzodiazepines.

As doctors we need to be driven by medical and scientiﬁc evidence not ideology in determining whether and what to prescribe. We must educate ourselves to ensure we enable those in our care to have an optimum quality of life. For many patients, medical cannabis could offer signiﬁcant relief from pain and suffering. We must work towards a future in Australia where physicians have all the tools available to provide the best care. Author competing interests: chair of AusCann Group Holdings, a potential supplier of medical cannabis. Questions? Contact the author mal@avowest.com.au

OCTOBER 2015 | 37

Introducing the

BACK2BONES Clinical Audit Program

40 QI & CPD Points The Back 2 Bones Clinical Audit has been designed to assist GPs in identifying and treating patients with osteoporosis at risk of a first fracture and patients with a history of fragility fracture.

This audit will demonstrate how early identification and treatment initiation of post-menopausal women with osteoporosis can reduce the risk of new fractures.

Visit www.back2bonesaudit.com.au to enrol This program has been developed with an unconditional educational grant from Amgen in collaboration with GSK. Amgen Australia Pty Ltd, Level 7, 123 Epping Road, North Ryde NSW 2113. GSK Australia Pty Ltd, Level 4, 436 Johnston Street, Abbotsford, VIC 3067.

38 | OCTOBER 2015

MEDICAL FORUM

AUS2916 Approved March 2015.

This organisation is an authorised provider of accredited activities under the RACGP QI & CPD Program.

Clinical Update

JIA: Kids get arthritis too By Dr Senq Lee, Paediatric Rheumatologist, Shenton Park Juvenile Idiopathic Arthritis (JIA) is complex and heterogeneous in presentation. â&#x20AC;&#x153;Juvenile Rheumatoid Arthritisâ&#x20AC;? and â&#x20AC;&#x153;Juvenile Chronic Arthritisâ&#x20AC;? were changed to JIA to avoid the incorrect supposition that kidsâ&#x20AC;&#x2122; arthritis was similar to adult rheumatoid arthritis. ClassiďŹ cation (based on articular, extra-articular and laboratory features) is useful for improving research, determining treatment, prognosis and likelihood of complications â&#x20AC;&#x201C; seven different subtypes are given. Uveitis risk varies with subtypes â&#x20AC;&#x201C; up to 20-30%, the risk being higher in patients who are ANA positive. Anterior uveitis is usually painless or asymptomatic, except in a minority of patients where it can be symptomatic and acute. Optometry/ophthalmology screening intervals vary with age, JIA subtype and ANA positivity. General considerations Exercise is crucial and recommended so that children/adolescents return to normal function, helped by ensuring arthritis is controlled. A gradual return to normal physical function is highly likely and achievable in most patients.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Prof John Yovich

Adjuvants for Poor-prognosis cases â&#x20AC;Ś which actually works? Currently in many IVF clinics around Australia, around 25% of treatment cycles are undertaken with adjuvant therapies â&#x20AC;&#x201C; GH, (Growth Hormone), DHEA (dehydroepiandrostene-dione), Melatonin or Testosterone.

The underlying causes of infertility causing couples to attend IVF clinics are numerous with respect to both male and female factors, but overriding all those is the factor of egg quality.

During initial treatment, deconditioning can risk injuries, fatigue and poor endurance. Physiotherapy is important to rehabilitation, often including a graduated exercise regime. Pain is inevitable in JIA ďŹ&#x201A;ares and if there is suboptimal control. During winter, seasonal viruses can trigger the immune system and cause ďŹ&#x201A;ares. A small proportion of patients (especially if inactive) develop chronic pain and/or fatigue - part of therapy is increasing cardiovascular exercise. Pharmacological treatments JIA treatment principles are similar â&#x20AC;&#x201C; generically, patients require anti-inďŹ&#x201A;ammatory therapy (NSAID, oral corticosteroids, intra-articular corticosteroid injections) with consideration of disease-modifying agents (DMARDs) if symptoms persist or recur. For example; sĂĽ /LIGOARTICULARĂĽ*)!ĂĽPATIENTSĂĽUSUALLYĂĽRESPONDĂĽWELLĂĽWITHĂĽORALĂĽ.3!)$ĂĽORĂĽINTRA articular corticosteroid injections and have the best overall prognosis sĂĽ 0OLYARTICULARĂĽ2&ĂĽPOSITIVEĂĽ*)!ĂĽPATIENTSĂĽUSUALLYĂĽHAVEĂĽSEVEREĂĽARTHRITISĂĽANDĂĽ poorest prognosis, hence are usually treated aggressively from onset, including greater cumulative use of corticosteroids and earlier DMARDs sĂĽ 3YSTEMICĂĽ*)!ĂĽUSUALLYĂĽPRESENTSĂĽWITHĂĽSYSTEMICĂĽDISTURBANCEĂĽ E G ĂĽFEVER ĂĽ rash, hepatosplenomegaly) and are treated more aggressively with corticosteroids and DMARDs. A higher proportion of these patients require biologic therapy to improve overall disease control. Methotrexate is a safe and effective ďŹ rst-line DMARD with LeďŹ&#x201A;unomide sometimes used, especially in methotrexate intolerance. Hydroxychloroquine and/or Sulfasalazine are still used as adjunctive agents in some.

Clinical Professor John Yovich

The molecular biology controlling the primordial follicle pool, the advancement of follicles into the selection process, the loss of follicles (with their oocytes) in the process of atresia as well as oocyte selection for maturation, is still rather poorly understood. Figure:SciGen pen for patient self-use, one of the GH preparations shown to improve pregnancy chances in PIVET research studies.

However many Molecular Biologists are working on this, including our researchers in the PIVET-Curtin collaboration. The main factor affecting egg quality is female age with 40 years EHLQJ D VLJQLĂ&#x20AC;FDQW Â´PLOHVWRQHÂľ DQG \HDUV EHLQJ DQ DOPRVW Â´FORVHG GRRUÂľ SRVLWLRQ +RZHYHU PDQ\ \RXQJHU ZRPHQ DOVR struggle in IVF programmes despite the generally excellent results nowadays for women under 40 years. The mechanisms underlying poor egg quality in younger women is sometimes linked to nutritional aspects and the bodyâ&#x20AC;&#x2122;s ability to counter adverse ROS (reactive oxygen species) effects.

With the advent of biologic agents (e.g. etanercept, adalimumab, inďŹ&#x201A;iximab, tocilizumab), patients have a greater chance of disease remission. These agents target speciďŹ c inďŹ&#x201A;ammatory cytokines (e.g. tumour necrosis factor, interleukins) and â&#x20AC;&#x153;switch offâ&#x20AC;? the inďŹ&#x201A;ammatory cascade, thereby decreasing inďŹ&#x201A;ammation/arthritis. Some DMARD and biologic agents are also efďŹ cacious for JIA-associated uveitis.

Therefore antioxidants, including Melatonin, are being explored along with DHEA (a sex steroid pre-hormone) and GH. The latter is because of its broad stimulation of many growth factors of which the important insulin growth factor IgF1 has been shown to be improved at PIVET, and associates with better egg quality in selected cases, particularly for younger women (under 35 years) and those with low body weight.

In Australia, only some biologic agents are TGA-approved or subsidised for JIA patients with speciďŹ c indications (e.g. polyarticular JIA not responding to standard DMARD therapy; systemic JIA patients with persistent systemic symptoms or arthritis). There are limitations:

We have shown that DHEA favourably improves androgen SURĂ&#x20AC;OHV EXW WKH RQO\ DGMXYDQW VR IDU VKRZLQJ VWDWLVWLFDO EHQHĂ&#x20AC;WV IRU livebirths, is GH.

sĂĽ 5NLIKEĂĽADULTĂĽRHEUMATOIDĂĽARTHRITIS ĂĽTHEREĂĽAREĂĽFEWĂĽBIOLOGICSĂĽAVAILABLE sĂĽ .OĂĽFUNDINGĂĽFORĂĽSPECIlCĂĽBIOLOGICSĂĽUSEDĂĽOVERSEASĂĽ E G ĂĽANAKINRA ĂĽ canakinumab in systemic JIA) sĂĽ #HILDREN SĂĽBIOLOGICSĂĽMUSTĂĽBEĂĽINJECTEDĂĽ SUBCUTANEOUSĂĽORĂĽ)6ĂĽINFUSIONS ĂĽ References available upon request. Author competing interests: no relevant disclosures. Questions? Contact the author on 9380 9484.

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NOW AT 2 LOCATIONS PERTH & BUNBURY

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

OCTOBER 2015 | 39

YOU ASKED US, WE LISTENED…

PERTH RADIOLOGICAL CLINIC NOW AT WEXFORD MEDICAL CENTRE, MURDOCH HOSPITAL Ground Floor, Wexford Medical Centre Barry Marshall Parade St John of God Hospital. Telephone: 9312 7800

OPENING OCTOBER 5TH 2015 Bringing our expert subspecialist reporting teams to you

40 | OCTOBER 2015 www.perthradclinic.com.au

Leaders in Medical Imaging MEDICAL FORUM

Clinical Update

PTSD: diagnostic concerns and neurobiology Originally described in soldiers returning from war, post-traumatic stress disorder (PTSD) can follow any traumatic event. A traumatised individual is someone who has “experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or threat to physical integrity of self or others” and gone on to re-experience symptoms relating to the trauma (flashbacks, nightmares), along with mood changes, avoidance symptoms and features of hyper-arousal – persistent symptoms that reduce functioning significantly. Affecting 5-10% of the general population, this is second only to major depression in Australia. Who gets PTSD? Possible trauma includes physical or sexual assault, serious accidents, extreme bullying and intimidation (school or workplace) and being diagnosed with a serious illness. High risk professions include police, fire officers, paramedics and prison officers. Psychiatric symptoms may stand alone. Some people self-present but others come because of family concerns. The initial presentation may be generic anxiety, irritability, social withdrawal, depressed mood or problems with an occupation – a more detailed history may uncover the re-experiencing symptoms and causative event(s). Can PTSD be predicted? Not with any precision. However, there are certain risk factors: female gender; low socioeconomic/ educational status; and a history of prior psychiatric illness. Multiple traumas also increase risk of PTSD: a cumulative effect over time. And not all types of trauma are equal e.g. sexual assault and interpersonal trauma from someone well known carries an increased risk. Resilience seems to stem from both genetic and environmental factors. Early nurturing relationships with parents lead to secure

By Dr Jon Laugharne Psychiatrist, UWA School of Psychiatry & WA Centre for Traumatic Stress

attachments that foster resilience against PTSD and other psychiatric disorders, later in life. The converse happens and trauma early in life can disrupt someone’s ability to self-regulate emotions and form sustainable healthy relationships – a more complex clinical picture than classic PTSD can develop.

PTSD, in response to traumatic reminders, and decreased medial prefrontal cortical activity. Those with PTSD have a limited capacity to regulate emotions by modulating hyperactive amygdalae using key prefrontal cortical regions.

Legitimate concerns

PTSD is treatable. First are psychological therapies. Current best evidence is for EMDR (eye movement desensitization and reprocessing) or a speciﬁc trauma-focused form of CBT (e.g. prolonged exposure).

An area of legitimate concern is the risk of over-diagnosing PTSD or medicalising normal stress responses after traumatic events. PTSD can be a “go-to” diagnosis in the medico-legal context, where there is potential symptom exaggeration and misdiagnosis. Specialist reports are preferred from at least two psychiatrists with expertise in PTSD, for more certainty of diagnosis and likely prognosis. A thorough assessment of effects on global functioning is particularly important. Another concern is whether diagnosis or treatment could dismantle coping mechanisms and lead to a worse outcome. Whilst some with mild to moderate symptoms choose to “soldier on” unattended, those that present usually do so because their coping mechanisms are starting to unravel, sometimes after many years. These patients should not be denied legitimate diagnosis and evidence-based treatment. Assessment and ‘treatment’ by clinicians who lack training or expertise, however, could do more harm than good: memories reactivated without proper reprocessing can re-traumatise the patient. Neurobiology of PTSD In recent years, neuroimaging has increased our understanding of the neurobiology underpinning PTSD. MRI structural brain changes in PTSD include decreased volumes of structures related to fear conditioning, including areas of the prefrontal cortex and the hippocampus. Functional neuroimaging via PET and fMRI has indicated increased amygdala activation in

Treatment is possible

Medications such as SSRI antidepressants are second line but are often used as adjunctive treatment. How each treatment impacts on the neurobiology of PTSD and other anxiety disorders is being investigated. In a review of the effects of psychotherapy and pharmacotherapy on brain structure and function in anxiety disorders, the authors’ principal conclusion was that psychotherapy tends to increase activity and recruitment of frontal areas (top-down effect), whilst pharmacotherapy decreases over-activity of limbic structures including the amygdala (bottom-up effect). Because the literature suggests that effective treatments for PTSD affect key brain regions thought to be involved, legitimacy is added to the medical diagnosis of PTSD. There is also hope that response to particular treatments can be predicted, based on pre-treatment imaging. In any event, the available effective clinical treatments are best delivered by appropriately trained clinicians. References available on request

Author competing interests: No relevant disclosures. Questions? Please contact author on jonathan.laugharne@uwa.edu.au

Inching Towards a Chronic Disease Plan In August, the head of the Primary Health Care Advisory Group, former national AMA President Dr Steve Hambleton, announced there would be nationwide consultation in chronic disease management as part of the Federal Government’s review of Medicare. An online survey was conducted from August 4 to September 3 with 1000 responses (255 organisations and 770 individuals) received and the PHCAG also held face-to-face consultations throughout the country, WA included. A Department spokesperson said about 50 people attended the brieﬁng in Perth and 20 in Broome. Certainly the institutions all got a guernsey – WA Health, RACGP, PHNs and AMSs – but if our own phone tree of local doctors is any MEDICAL FORUM

indication, most were completely unaware of discussion papers, surveys, national live webcasts or consultations. There is a wealth of material to be found at www.health.gov.au – search for Primary Health Care Advisory Group.

of success and perhaps it’s time that we start seeing some real results of the billions of dollars invested into Health ICT. What is needed now is the leadership to see it through.

For doctors in the ﬁeld, there is no mystery about the problems, though there does appear to be some crystallisation of the options for improvement put forward. There are the usual motherhood statements – better targeting and coordinated care, where that care should take place and patient participation and better pathways.

Then, of course, there’s the elephant in the room – payment models, which may not have necessarily been the goal of the PHCAG but certainly something that’s high on the Minister’s agenda. How much the Government is prepared to spend in order to save is a question that is on every concerned medico’s lips. The literature puts it extremely coyly: “Payment models: to best support service delivery and patient outcomes.” There is a long way to go.

However, the increased use of coordinated technology is emerging as the real determinant

The PHCAG is to report to the Minister by the end of the year.

OCTOBER 2015 | 41

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Clinical Updates

Chronic childhood cough - when to worry Cough is relatively common amongst children seeking medical review. Viral infection is the most prevalent cause; 6 to 12 respiratory tract infections per year is not unusual in the young child, especially those attending Day Care or living with older school age siblings. Mostly the cough is self-limiting (1-3 weeks) but occasionally it may be prolonged. Other causes need to be considered if a child has had a daily cough for over three weeks. Thorough assessment that includes history and examination helps determine if further investigation or referral is warranted. Causes of cough in children Upper respiratory tract infection (URTI) is the predominant cause of cough in children of all ages. Other causes may be age related and should be considered. Infants: cough may indicate structural abnormalities of the airways (e.g. vascular rings and trachea-oesophageal ﬁstula) or gastro-oesophageal reﬂux. Toddlers: consider foreign body aspiration, especially in the context of sudden onset in an otherwise well child. Children: Asthma often presents with cough, as does chronic rhinitis and they often coexist. A worsening of cough during exercise, in cold air, overnight, and in URT allergy situations may indicate underlying wheeze. Adolescents: Consider smoking and psychogenic factors. Assessment pointers Differentiate between recurrent (especially in winter, with back-to-back URTIs) from

By Dr Veena Judge Paediatrician, Subiaco

Management of a Persistent Cough > 3 Weeks YES Is history /examination normal?

Clues for common speciﬁc pathology

Request CXR Arrange for follow-up with Paediatrician

YES

Asthma Pertussis

continuous cough. “Do they cough every day?” Is the onset sudden (inhaled foreign body) or was there a viral prodrome? Is the cough paroxysmal and perhaps accompanied by a whoop sound (pertussis), honking and only during the daytime and never at night (psychogenic), or barking (croup)? Are there identiﬁed triggers? Inquire about other respiratory (atopy, wheeze, shortness of breath, exercise tolerance) and systemic symptoms (fever, failure to thrive, gastrointestinal, recurrent infections). Consider overseas travel or visitors (TB), animal contact, family history (cystic ﬁbrosis, atopy), and sidestream tobacco smoke exposure (50% of children with two smoking parents will cough). A productive cough is abnormal in children. Those under six may swallow sputum so it is only seen if vomited. Respiratory examination looks at sputum, chest shape, tachypnoea, wheeze/crackles, differential air entry, and clubbing. General examination looks for fever, failure to thrive and signs of atopy (nasal crease, eczema).

Ulcerative colitis: advances & trends Ulcerative colitis (UC) is increasing in incidence. Symptoms of mild to severe UC are generally diarrhoea (predominantly with blood), faecal urgency and abdominal pains (with fever and tachycardia in more severe cases). Severity is important in guiding management and can predict long-term outcomes, for which tests may help. Like Crohn’s disease, patients with UC can have extra-intestinal manifestations (Box 1). ‘Red flag’ test results for suspected flares of colitis are tests for anaemia, elevated inflammatory markers (CRP or ESR), low albumin. Tests for electrolyte imbalances, stool testing for faecal calprotectin (intestinal inflammation) and stool M/C/S to exclude infection (including Clostridium difficile toxin), are worth considering. Treatment success is usually defined as steroidfree clinical remission. Current treatments MEDICAL FORUM

Reassure & plan review: Consider psychogenic

include oral 5-aminosalicylate (5-ASA), topical therapy for proctitis (rectal 5-ASA; steroid enemas; or foam and rectal tacrolimus), thiopurines (azathioprine or mercaptopurine) and anti-TNF medications. Steroids (oral or IV) are used occasionally for ﬂares. Surgery (i.e. colectomy) may occasionally be needed if other measures fail. Other management considerations are listed in Box 2. Box 1: Extra-intestinal manifestations så -USCULOSKELETALå ARTHRITIS åOSTEOPOROSIS å osteopaenia) så %YEå UVEITIS åEPISCLERITIS så 3KINå ERYTHEMAåNODOSUM åPYODERMAå gangrenosum) så (EPATOBILIARYå PRIMARYåSCLEROSINGå cholangitis, fatty liver) så (AEMATOPOIETICå INCREASEDåRISKåVENOUSå and arterial thromboembolism)

Foreign body inhalation

Common management dilemmas With an otherwise well child (negative history and clinical findings), reassure parents and adopt a watch-and-see approach, with review in 2 to 3 weeks. Avoid overuse of antibiotics. Avoid sidestream tobacco smoke exposure. There is no evidence that OTC cough suppressants, decongestants or antihistamines help. Cystic fibrosis should not be forgotten; a chronic cough and systemic features (in particular, growth failure) warrants a sweat test. The flow diagram shows common scenarios. ‘Red flags’ for paediatrician review include: a systemically unwell child; weight loss or failure to thrive; and sudden onset, especially in a toddler (think inhaled foreign body).

Author competing interests – no relevant disclosures. Questions? Contact the author 9382 9462

By Dr Kenji So Gastroenterologist, Nedlands

Newer treatment options Vedolizumab was recently PBS approved for the treatment of UC (and Crohn’s). It is a gutselective integrin antagonist with no identified systemic immunosuppressive activity. It is a humanised monoclonal antibody that binds specifically to a protein known as ∂4ß7 integrin. It can be used in both anti-TNF naïve or failure patients. Its place will be refined as data on therapeutic drug monitoring, onset of action and other aspects of clinical effectiveness begin to accumulate. The success of faecal microbiota transplantation (FMT) in treating Clostridium continued on Page 45

OCTOBER 2015 | 43

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Clinical Update

Soft tissue tumours â&#x20AC;&#x201C; staying safe

By Prof Richard Carey-Smith, Orthopaedic Surgeon, Nedlands

Soft tissue tumours occur anywhere, may be benign, and affect all ages. Because malignant mesenchymal lesions are rare (1% of all adult cancers) and musculoskeletal symptoms are assumed benign, patients may face delays and errors in management that increase morbidity (including amputation) and mortality. Early recognition and multidisciplinary management of musculoskeletal tumours improves the likelihood of limb salvage with excellent functional outcomes in most patients. In 2014 Sarcoma care was centralised to SCGH/PMH and the State Sarcoma Service has rapid access clinics at both sites. Key points on assessment The history of the lump may be weeks to years. Changes in lumps that have been present for a long time are concerning, as is pain, although being pain-free is not necessarily a reassuring feature. Examination helps determine the relationship to skin/fascia and neurovascular structures. It is not possible to delineate lipomas from malignant or other soft tissue tumours on clinical examination alone. Due to their heterogeneous nature, lesions can be difďŹ cult to characterise. Any tumour either greater than 5cm, deep to the fascia, increasing in size, or painful should be considered malignant - size is the best single indicator. If there are multiple tumours, the risk of malignancy increases. MRI is the most useful imaging for soft tissue tumours. Ultrasound in skilled hands and CT can differentiate between fat predominant and other lesions. PET scans play a role in staging, occasionally to aid in biopsy, and restaging.

Axial T1 MRI of presumed â&#x20AC;&#x153;lipomaâ&#x20AC;? on backnote tumour is dark, unlike the subcutaneous fat that is bright.

Core needle biopsy is the mainstay of diagnosis, and should be performed/directed by a sarcoma surgeon following discussion of cross sectional imaging in a multidisciplinary meeting. The biopsy tract must be excisable at deďŹ nitive resection. Fine needle aspirate (FNA) is not helpful in the diagnosis of mesenchymal tumours. Key Messages sĂĽ 3OFTĂĽTISSUEĂĽTUMOURSĂĽAREĂĽCOMMON ĂĽANDĂĽ represent 1% of adult cancers. sĂĽ "ENIGNĂĽANDĂĽMALIGNANTĂĽSOFTĂĽTISSUEĂĽ lesions may feel the same on examination. sĂĽ %ARLYĂĽDETECTIONĂĽANDĂĽREFERRALĂĽTOĂĽ someone experienced in the management of sarcomas can result in better outcomes. sĂĽ 5RGENTLYĂĽREFERĂĽLESIONS ĂĽ CM ĂĽ increasing in size, deep to deep fascia, or painful. (Do not biopsy.)

Axial T2 MRI - subcutaneous fat has been suppressed; the sarcoma is bright.

Management overview Following diagnosis and completion of staging, large high-grade tumours usually receive pre-operative radiotherapy, followed by restaging and deďŹ nitive wide resection. This often leads to excellent functional outcomes, and amputation is rare. Low grade and small tumours may be managed with surgery alone. Chemotherapy plays a role in some tumours (synovial sarcoma, angiosarcoma), and in young adults/children. Prognosis is related to grade (features on microscopy) and stage (whether local or systemic). Effective multidisciplinary management often leads to cure.

Author competing interests: no relevant disclosures. Questions? Contact the author on 6389 0551

continued from Page 43

Ulcerative colitis: Box 2: Other management considerations sĂĽ )MMUNISATIONSĂĽSHOULDĂĽBEĂĽUP TO DATEĂĽ (live vaccines contraindicated in patients on immunosuppressant). sĂĽ 3URVEILLANCEĂĽCOLONOSCOPYĂĽFORĂĽ colorectal cancer (based on extent and duration of their disease). sĂĽ 3KINĂĽCAREĂĽANDĂĽSUN SMARTĂĽSTRATEGIESĂĽ for patients on a thiopurine (mercaptopurine or azathioprine) increased risk of non-melanoma skin cancers. sĂĽ 0SYCHOLOGICALĂĽFACTORSĂĽ DEPRESSION ĂĽ anxiety). sĂĽ "ONESĂĽANDĂĽOSTEOPOROSIS sĂĽ 0REGNANCYĂĽnĂĽDON TĂĽSTOPĂĽ any medications without gastroenterologist consultation. sĂĽ 0ATIENTĂĽSUPPORTĂĽGROUPS

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difďŹ cile infections has raised the possibility that FMT may be beneďŹ cial in treating inďŹ&#x201A;ammatory bowel disease. The results of recent studies have been underwhelming and conďŹ&#x201A;icting. Larger clinical trials (two underway in Australia) to establish both efďŹ cacy and safety are needed to establish the exact active ingredient/s in FMT, ideal donor and recipient, the best mode of delivery, and the best â&#x20AC;&#x153;doseâ&#x20AC;?. Patient self help Free patient management tools (developed by the Clinical Insights Steering Committee) are available through the Crohnâ&#x20AC;&#x2122;s and Colitis Australia website, www.crohnsandcolitis.com. au. These include information to distinguish from Irritable Bowel Syndrome and the Clinicianâ&#x20AC;&#x2122;s Guide to UC management (which looks at disease severity, red ďŹ&#x201A;ag symptoms and management options). â&#x20AC;&#x153;My Gut Feelingâ&#x20AC;?, a

patient guide for ulcerative colitis, is so patients can understand and take ownership of their disease, similar to an Action Plan for asthma.

Key Messages sĂĽ !NYĂĽ@REDĂĽmAG ĂĽFEATURESĂĽ ORĂĽUNSURE ĂĽREFER sĂĽ /RDERĂĽROUTINEĂĽBLOODSĂĽANDĂĽSTOOLĂĽTESTSĂĽ with a possible ďŹ&#x201A;are. sĂĽ &LARESĂĽ ANDĂĽPREGNANCY ĂĽAREĂĽBESTĂĽ managed in conjunction with a gastroenterologist. sĂĽ -OREĂĽTREATMENTĂĽOPTIONSĂĽAREĂĽ becoming available

Author competing interests â&#x20AC;&#x201C; no relevant disclosures. Questions? Contact the author 6389 0631

OCTOBER 2015 | 45

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Clinical Update

Mandibular advancement splints in OSA Oral appliances are a viable alternative to CPAP, in the right hands. Treatment options include CPAP, oral appliances or surgery (ENT or maxillofacial). Mandibular Advancement Splints (MAS), if properly managed, can achieve up to 95% effectiveness in relieving snoring accompanied by obstructive sleep apnoea.

By Assoc/Prof Christopher Pantin, Dental Sleep Medicine UWA

use of additional treatment such as NightShift positional modiďŹ cation. Other adjunctive treatments include maintenance of nasal airway patency (mouth breathing undermines successful treatment with MAS or CPAP), including novel interventions such as MaxAir Nose Cones. Predictive factors for MAS failure despite compliance

Where do MASs ďŹ t in? Compliance is a major factor inďŹ&#x201A;uencing recommendations. The â&#x20AC;&#x2DC;gold standardâ&#x20AC;&#x2122; of CPAP, has been shown to be less effective than MAS due to poor adherence. Studies looking at adherence using the 4 hours per night deďŹ nition for effective treatment showed 43% compliance with CPAP c.f. 76% with MAS â&#x20AC;&#x201C; this is replicated in many other studies although reliance on patient reports may be a confounding variable.

There are very few predictors of treatment outcome. However, numerous factors consistently indicate those likely responders to treatment â&#x20AC;&#x201C; lower disease severity, supine dependent OSA, younger age, female, lower BMI, and lower neck circumference.

The American Academy of Sleep Medicine suggests oral appliances as a ďŹ rst line treatment for patients who snore and who have mild to moderate OSA. They are also recommended for severe cases that have failed CPAP.

excessive day time sleepiness (EDS) as well as neurocognitive function. The most common measure of EDS is the Epworth Sleepiness Scale (ESS) and this improves in the majority of studies.

Measuring effectiveness â&#x20AC;&#x201C; lack of consensus

Interestingly, a study on neurocognitive function only showed improvement in some parameters i.e. vigilance/psychomotor speed, independent of the ESS â&#x20AC;&#x201C; AHI did not improve.

Outcomes for treatment can be measured different ways. EfďŹ cacy is traditionally measured by a reduction in the apnoea-hypopnoea index (AHI). Contemporary thinking looks at other measures of outcome success, such as the oxygen desaturation index (ODI) and additional health related outcomes. By moving the â&#x20AC;&#x2DC;goal postsâ&#x20AC;&#x2122;, outcome success also varies. For example in one study, 95% success was achieved using a 50% reduction in the apnoeahypopnoea index (AHI) with associated relief of symptoms, as measurement of treatment outcome. This was achieved in severe sleep APNOEICSĂĽ !()ĂĽ ĂĽWHOĂĽHADĂĽTHEIRĂĽ/!SĂĽTITRATEDĂĽ in a Level 1 polysomnograph (PSG) subsequent to subjectively driven self-titration for a period of time. Most studies show improvement in AHI, Arousal Index and SaO2. Numerous studies also assess

A multiparametric approach is now considered as the true guide to treatment effectiveness. The Mean Disease Alleviation measures efďŹ cacy and compliance, and hence effectiveness of treatment. Factors that impact on all interventions Many factor inďŹ&#x201A;uence the success of MAS treatment. The most signiďŹ cant is weight gain. Evidence suggests that a change in weight from fat gain can have signiďŹ cant effect on the severity of OSA as well as the efďŹ cacy of treatment, whether MAS or CPAP treatment for OSA. In addition to this, sleep position also signiďŹ cantly affects treatment outcome. Nonresponders to MAS treatment improve with

Latest trends are towards alternative objective methods of outcome prediction e.g. endoscopy, awake or drug induced sleep. A #0!0ĂĽPRESSUREĂĽ CMĂĽ( /ĂĽSUGGESTSĂĽAĂĽLESSĂĽ likely positive outcome for MAS therapy. The most promising predictive method is single night titration using RCMP (remotely controlled mandibular positioner). In one study, as well as correctly predicting 30/32 responders to MAS therapy, 20 of these may have been otherwise excluded due to the severity of their disease and excessive BMI and 5/29 predicted treatment failures were in fact responders. If patients want to try something again, whatâ&#x20AC;&#x2122;s their best option? Often success with MAS is dependent on the expertise of the clinician â&#x20AC;&#x201C; recent studies have shown that it is possible to increase the AHI by â&#x20AC;&#x2122;over protrudingâ&#x20AC;&#x2122; the mandible, and variations in splint design may also inďŹ&#x201A;uence effectiveness (but not efďŹ cacy). References available on request. Author competing interests: coordinator of Grad Dip in Dental Sleep Medicine UWA; provider of clinical services described at Absolute Snore. Questions? Please contact the author on christopher.pantin@uwa.edu.au

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www.healthnews.net.au OCTOBER 2015 | 47

TLH versus LSH: what does the evidence say? Hysterectomy is the most common surgical procedure performed in gynaecology and, in over 95% of cases, does not necessarily require the removal of the uterine cervix to be completed successfully. In clinical practice, however, fewer than 10% of gynaecologists offer patients the possibility to express a personal preference concerning the choice between total laparoscopic hysterectomy (TLH) and laparoscopic subtotal hysterectomy (LSH). Advocates of LSH suggest possible advantages including reduced recovery time, decreased risk of pelvic organ prolapse, and decreased risk of organ damage, in particular to the urinary tract. Opponents of LSH have suggested possible future risk of cervical malignancy and the possibility of ongoing cyclical bleeding. It is mandatory to counsel women to have regular pap smears after LSH. We are presenting a short summary of current evidence. In a study of 1,016 patients (Harmani et al 2009), most of the perioperative outcome measures did not differ statistically between the groups. However, the risk of serious complications was higher for TLH; specifically, urinary tract injury occurred more frequently in TLH. Conversion to laparotomy was also more common in TLH. The largest single-centre study (Wallwiener et al 2013) from January 2003 to December 2010 involved 1,952 patients and observed: Overall intraoperative and long-term complication rates did not differ significantly, but the short-term LSH complication rate was significantly lower (0.6 vs 4.8%). Spotting (LSH, 0.2 %) and vaginal cuff dehiscence (TLH, 0.7%) were long-term, method-specific complications.

såThe RACGP’s annual conference in Melbourne was a real WA-fest with major gongs being awarded to local doctors. Long-serving GP and educator E/Prof Max Kamien was awarded the College’s most prestigious honour, the Rose-Hunt Award for outstanding service. Max was one of the foundation professors of Community Practice at UWA in 1976. As well, the Collie River Valley Medical Centre was the recipient of the 2015 RACGP General Practice of the Year Award, acknowledged for its supportive culture, strong ties to its local community and high-quality training. And in another nod to rural practice in WA, Dr Cathryn Milligan, of Margaret River, is the 2015 General Practice Supervisor of the Year Award. s The Earbus Foundation of WA, whose patron is Prof Harvey Coates and CEO is Mr Paul Higginbotham, has been awarded a $4.8m contract from the Child and Adolescent Health Service (CAHS) to provide Newborn Hearing Screening Services at nine WA Private Maternity Hospitals. It is expected to cover the Peel, Metropolitan, Pilbara and South West regions. s Dr Daryl Kroschel is the inaugural medical director of Silver Chain’s Hospital in the Home service. He was previously deputy director of Cabrini Health’s HITH in Victoria. s West Australians on the recently announced NHMRC committees for 2015-2018 are Prof Peter Leedman (Research), A/Prof Daniel McAullay (Ethics and Research), Prof Steve Webb (Health Translation) and Prof Con Michael (Embryo Research). s The Australian Competition and Consumer Commission will not oppose Pﬁzer proposed $US17 billion acquisition of fellow US-based pharmaceutical company Hospira.

A French study (Gé P et al 2015) and an Italian study (Saccardi C et al 2015) seem to indicate an improvement on certain criteria in the evaluation of sexuality in the LSH group, in particular on the orgasm.

s Mr Peter House, regional sales manager for Caltex Australia, has been appointed a director of Breast Cancer Care WA.

A Canadian experience of 390 cases (Van Evert et al 2010) suggested that long-term complications such as cervical stump reoperation were higher in LSH group.

s The State Government and Lotterywest have granted the Lions Eye Institute $4m over the next ﬁve years for a new mobile service for rural and remote areas.

A randomised control trial with 62 patients (Berner Et al 2015) evaluating patient satisfaction and quality of life showed no difference between the groups. Currently there is vigorous academic discourse regarding the use of power morcellation and how this can be used with continued safety and efﬁcacy. We are currently exploring the use of so-called “inbag-morcellation” to continue to offer LSH to our patients. Bottom Line: At WA GynaeScope, we feel strongly about evidence based care for our patients. We continue to offer both TLH and LSH options to our patients and are counselling them appropriately.

Joondalup Private Hospital Suite 23, Level 2, Specialist Medical Centre (East), Shenton Avenue Joondalup WA 6027 Tel: (08) 6406 1801 Fax: (08) 6406 1802 www.wagynaescope.com.au

48 | OCTOBER 2015

s The UWA Science library has been renamed after Nobel Laureate Prof Barry Marshall, 10 years after he and Dr Robin Warren won the Nobel Prize for their discovery of the bacterium H.pylori and its role in gastritis and peptic ulcer disease. s Dr April Armstrong, from the Collins St Surgery Kalgoorlie is a ﬁnalist in the Start-up category of the 2015 Telstra WA Business Women’s Awards; Dr Kylie Sterry, from the Plaza Medical Centre, Kalgoorlie, is a ﬁnalist in the Entrepreneur category. s Primary Health Care founder Dr Edmund Bateman died last month after a year-long illness. Having started with one medical practice in 1986, Primary Health Care has grown into a $2.1b national concern. There are four PHC centres in Perth, one in Bunbury, Karratha and Boulder. Dr Bateman had stepped down from the board in January passing the leadership to former Qantas executive Mr Peter Gregg.

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50 | OCTOBER 2015

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Adventure

OVER, UNDER, SIDEWAYS, DOWN

Dr John Hilton has entered 17 Avon Descents and every one of them has given him plenty of thrills and spills.

It was two days of flashing paddles, hurtling through rapids, falling out of the kayak and getting back in again. The message that comes through loud and clear in Dr John Hilton’s account of his 17th Avon Descent is that it’s not for the fainthearted. “I started paddling in 1989, put my name down for the Avon where I came to grief at Emu Falls – one of the ‘Big Five’ rapids in the river – and my race ended there. But I came back the following year and made it all the way.” “After a 10-year gap I did it again with a psychiatrist friend, Peter Morton, and now I train six days a week and race all year-round. I’ve done the Murray Marathon in Victoria, the Fish River, Dusi River in South Africa and competed in the 2009 World Masters Games in Sydney. Marathon kayaking is a tactical and aggressive sport.” It can also be treacherous. Rocks and heads don’t mix “I had an anxious moment last year when I head-butted a rock six weeks before the race. An MRI confirmed no fracture or disc pathology but I did have a temporary C6 neuropraxia that had a significant effect on my strength for a while.” John, 53, gave Medical Forum a figurative ‘Go Pro’ view of his latest Avon Descent aboard (well, most of the time) his K1 kayak. “The gauges are rising and it has the makings

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Dr John the Avon HDilton in action du ring escent 201 5

of a good race. No rain at the start but a southeasterly breeze produces a chill factor instead of the usual 2C and fog. Kayak numbers are slightly down but there’s a lot of skill in the ﬁeld.”

For the ﬁrst time in living memory, the organisers are not playing the same old music over the PA … Chariots of Fire, Eye of the Tiger and We are the Champions.”

“At the outset, I take my ‘secret line’ down the concrete ramp, the boat starts to turn and I hit the bottom before spearing off into the grassy bank, losing 30 seconds. I focus on getting into a steady rhythm, avoiding the shallows and pegging back the guy in front of me. The river’s a complex maze of deep channels but I can feel the odd scrape on ‘coffee-rock’ outcrops.”

“Then the ﬁrst of 40 rapids, all with names! After Posselts it’s Superchute, I’ve done it a hundred times so I think this will be easy! I side-swipe a rock, the bow veers away and I end up facing diagonally upstream. The it’s Emu Falls and the Shredder, at the last moment I go right and get a good drop.”

“A double kayak passes me and I jump on his wash. I’m not feeling strong, the biting cold isn’t helping and I decide to do a short portage rather than crash down the line of a steep rock face. I get tangled in my drink-bag and I keep tipping, more fluffing around.” Into the drink “The tea-trees are coming up and I hope for a clean passage. As I was thinking about this I hit an eddy and fall in – bugger! It’s freezing and I lose all feeling in three fingers.” “Then a good run but, daydreaming, I hit a tree branch and I’m back in the water. Passing paddlers asked me if I was OK … I’m not, I’m furious and embarrassed! Soon I’m skimming down Leatherhead Rapid and into the pool for the finish line of Day 1 – 4 hours 35 minutes, 11th Kayak and 32nd overall.” “Sunday, very early alarm after five hours sleep, I’m planning the rapids. I tape my fingers, put my paddling shoes on and eat my last banana.

“I pick off a few smaller rapids as the sun rises and lights up the twinkling clumps of foam. Then it’s Bone Breaker, Raging Thunder, Accelerator and Moondyne – the last one is scary, the current slides me to the right and I drop vertically before landing upright. I pause to gather my senses.” “The crowds at Bells are good, I’m taking a nice line to avoid the rock island below but I hit it and slew into Devil’s Slide. I go over sideways and fall out.” “There is still 35 minutes of paddling, my body is trashed and I’m pufﬁng hard to clear the lactate as I cross the ﬁnish-line. My supportcrew, Frank and my wife, Claire, are there with food and ‘bubbly’ and rehydration begins immediately.” “It all hurts, but it’s a good sort of hurt!” John came 9th in the K1 class and is working towards the 2016 Avon Descent.

By Mr Peter McClelland

OCTOBER 2015 | 51

Feature

The Big World of Medicine Travel broadens the mind and also the clinical experience for ﬁve medical students whoo returned to recount their experiences for the Alan Charters Prize

Four final-year medical students travelled to all points of the globe and put pen to paper for the 2015 Alan Charters Prize. Another student told his story with a camera and took a prize-winning photograph. All five are firmly convinced that their elective placement will shape them both as individuals and as doctors. Colombo Binu Jayawardena was the eventual winner of the prize with his presentation, A Journey into the Not-So-CriminalMind.’ Binu, originally from Sri Lanka, returned to his birth country during a time of social and political change. “It turned out to be a very interesting elective, more by accident than design. My initial placement was in a large tertiary hospital that was similar to our system so I wasn’t being exposed to anything that was challenging.”

“I wanted to get a ‘fringe’ experience so I managed to talk myself into the hospitalAla n Cha rters Prize Finalists (fro wing of a maximum security prison. It was a criminal Ben Roestenburg, MC Dr Peter m left) Devaki Wallooppillai, Burke, Kieran Robinson and forensic ward and most of Binu Jayawardena. the patients were under court orders, both pre-trial and post-sentence. While I was there, a doctor was stabbed bed by a “I’m interested patient so it had its moments.” in how medical systems interact and, more speciﬁcally, improving the level of “Having said that, the drug problem in Sri Lanka communication between the city and the bush is minimal and there’s nothing like the issues we so that may be a longer-term career prospect.” have here with crystal meth.” “The country has come through a civil war and is undergoing a lot of social change so it is no surprise that there are patients in the hospital for purely political reasons. But the really interesting aspect is that the entire hospital, from catering to orderlies, is run by the prisoners.” As A for the future, Binu says his long-standing interest in mental health will be his beacon. in “I “ did my Bachelor of Science on depression. I’ll probably apply for psychiatry training because p it’s it a broad ﬁeld with lots of opportunities.” Kununurra K T future prospect of practising as a clinician in The tthe Kimberley region was a motivating factor for Devaki Wallooppillai. D “I “ loved my time at the Ord Valley Aboriginal Health Service in A Kununurra and I’d like to go back K there as a junior doctor. I chose t a local elective rather than head overseas because it’s easy to forget o that there’s a lot that’s not too th wonderful within our own health w system. And it’s important to see sy Aboriginal people within their own A context, too.” co

Prize winner Binu Jayawa rdena took thes pictures of his prison hospital placement. e 52 | OCTOBER 2015

“The doctors in the Far North need “T to have a wide skill-set and they don’t always have the luxury of being do able to refer to a range of specialist ab services. You certainly see a diverse se range of medical conditions with ra a llot of late presentations which is distressing because it means that the dis patient has been suffering for quite pa some time.” som

Durban Chris Lim worked hard to snap his prizewinning photo (above) in the Drakensburg Mountains in South Africa. Forget the technical and keep it simple, says Chris. “We couldn’t see more than five metres in front of us as we were scrambling up the hill and then the cloud cleared. Even so, the light wasn’t great and the photo’s a bit grainy. I took a few and that one was the best but I have to say I’m not a real photography buff.” “I’ve got a decent camera and putting it on ‘Auto’ seems to work better than fiddling with the settings!” Chris was based at the Addington Hospital in Durban. “It was a huge place with more than enough trauma to go around. It was right on the beach so you could watch the surfers falling off their surfboards and fracturing their ankles.” Unlike his colleagues, Chris’s elective was taken in early 2014 due to another highly appealing overseas trip. “I took a year off from medical studies and went to Oxford to do a Bachelor of Medical Science in Orthopaedics. It was a wonderful opportunity to see how the research process works.” Western Samoa Western Samoa is dot in the Pacific Ocean where time can sometimes stand still and Kieran Robinson returned with a love of the fa’a Samoan way of life. “I’d like to think I brought something back of their relaxed approach because it was a

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Feature

valuable lesson. I went with another medical student and the place ticked a lot of boxes. English is widely spoken, it’s a developing country with some medical conditions we don’t normally see here combined with a relative lack of early intervention and close management.”

“I love the science of medicine and applying it to the human body. Later in my career I’d love to do some work with MSF in developing countries.” Jakarta Ben Roestenburg is another medicoadventurer who decided to return from whence he came.

“Another attraction was the fact that the surf’s great and we’re both keen surfers!”

“Indonesia is close to my heart, I grew up there so I speak the language and it’s such a signiﬁcant neighbour for Australia. There were lots of opportunities for hands-on clinical exposure and it made me realise the importance of education for women and the link to improved maternal health.”

Ben Roestenburg working and with friends in Jakarta.

“That’s something that can lift the trajectory of a country.” “Indonesia established a new health system in 2014 and, like all broad policy, it’s not easy to implement. They have subsidised ised health care so it’s more affordable but they haven’t invested adequately in the infrastructure. There’s been a four-fold increase in presentations and the doctors are overwhelmed.” “Some of them are working 36-hour shifts – I did a couple and you’re pretty much incoherent towards the end.” Ben, 33 years-old and married with two young children, came to medicine from an engineering career.

Keiran Robinson with Tom Hendriks in bea utiful Samoa.

“There are certainly some transferable skills. As an engineer working in a team you learn to relate to people, handle setbacks and become

comfortable f bl with i h the h ups and d downs d off change. That’s useful right now! I’m in the last three months of my training and struggling to balance priorities and keep the family fed.” “I’ve got an internship at RPH beginning in January next year and leaning towards becoming a physician. I love the idea of treating the whole patient.

By Mr Peter McClelland Ed: The annual prize is named after Dr Alan Charters (1903-1996) a long-time teacher of tropical medicine at UWA. It is awarded to Level 5 students who give the best presentation on their elective placement with a speciﬁc focus on social and public health issues.

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OCTOBER 2015 | 53

Laugh Lines

The Social By Wendy Wardell

Butterfly Effect

tal number of daily tweets from the current 500 million down to around 120 and elevate the level of debate exponentially. Currently a pot plant with an attitude problem could be regarded as a shining beacon of intellectual reason.

The story goes that if you put enough monkeys in front of enough typewriters, they’ll eventually recreate the works of Shakespeare. The literary bar has been lowered to the point now that even a couple of alcoholically inconvenienced armadillos staggering over a keyboard could punch out a 140-character tweet. Words are sensitive yet powerful things. When the capacity to splatter them willy-nilly over the universe is given to the wrong people, the result, as we so often see, is offence, uproar and funding cuts to the ABC. If people were forced to at least spell their profanities correctly before being able to post them, it would reduce the to-

SINGLE V ENGAGED V MARRIED Three women were having a girl’s night out and talking about their men. The single woman said, “Last Friday at the end of the work day I went to Harry’s ofﬁce wearing a leather coat. When all the other people had left, I slipped out of it and all I had on was a leather bodice, black stockings and stiletto heels. He was so aroused we made passionate love right there and then!”

54 | OCTOBER 2015

Of course, social media can be a great tool for business, but, like a recipe for Fugu fish pie, it should be used with care and ideally, some knowledge. As medical professionals, tools like Twitter are something you might consider using to boost your profile. The problem, of course, is those niggles around patient confidentiality. Someone’s been busy in Smith Street! #STD #KeepItInYourPants People love anything visual, so Instagram is flavour of the month and it may be tempting to share a photo of anything particularly interesting you’ve examined recently. While this would certainly add some pep to the usual fare of selfies or breakfast dishes, even the most remarkable rash is unlikely to challenge the popularity of stars like Taylor Swift. On the other hand, it could give Susan Boyle a run for her money.

suming when you’re trying to get the hang of it, so should you decide to immortalise your exquisite stitching skills on Pinterest, remember to let the anaesthetist know beforehand, lest your canvas wakes up while you’re still trying to remember your log in. Bear in mind too that theatre lighting can be seriously unﬂattering when you’re taking a selﬁe with a trophy tumour you’ve wrestled from a reluctant host, so there is a plethora of other apps you can get to reduce those pink tones. Facebook remains ever popular for businesses and individuals alike, but the Medical Board considers it poor form to post photos of your full waiting room. There may also be a certain reluctance on the part of your customers to ‘like’ your page, particularly if you specialise in issues related to incontinence, sexual dysfunction or anything illuminating lifestyle choices their wife doesn’t know about. On the other hand, it’s clear that people have little reticence when it comes to sharing their opinions, and the absence of a clue is no obstacle to this. So you can still expect to receive pithy, if misspelled reviews of the work to which you have devoted your adult life, from someone who managed to Google their own diagnosis with their free hand while watching porn.

Social media can also be ﬁddly and time con-

The engaged woman giggled and said, “That’s pretty much my story! When Jack got home last Friday, he found me waiting for him in a black mask, leather bodice, black stockings and stilettos. We not only had sex all night, he wants to move up our wedding date!”

Where do you hide a $5 bill from a pathologist? Put it in direct sunlight.

The married woman put her glass down and said, “I did a lot of planning. I made arrangements for the kids to stay over at Grandma’s. I took a long scented-oil bath and then put on my best perfume. I slipped into a tight leather bodice, a black garter belt, black stockings and six-inch stilettos. I ﬁnished it off with a black mask. When my husband got home from work, he grabbed a beer and the remote, sat down and yelled, ‘Hey, Batman, what’s for dinner?’”.

How do you hide money from a primary care physician? Trick question. There isn’t any money in primary care.

MEDICAL MYSTERIES

Where do you hide a $5 bill from a plastic surgeon? You can’t.

WOODEN SPOONER My wife and I have split up because she said I’m more interested in football than her. It’s a shame because we had been together for 12 seasons.

Where do you hide a $5 bill from an anaesthetist? Put it in the operating theatre after 3pm. Where do you hide a $5 bill from a radiologist? Tape it to the patient.

MEDICAL FORUM

Wine Review

Palmer Classics in the Making

Palmer Wines was established by Stephen and Helen Palmer in 1977 on the banks of Wilyabrup River and as such are one of the pioneer vineyards in Margaret River. The initial plantings were of Chardonnay, Semillon, Sauvignon Blanc and small amounts of Cabernet Sauvignon and Merlot. They began receiving accolades for their wines – both white and red – in 2000. The current vintages have scored well in both national and international shows with many awards including a gold medal for their Chardonnay in the Les Citadelles du Vin in France. My last tasting of Palmer Wines was last year and they had a strong portfolio of wines and this tasting is no exception. Once again I am impressed and I think the Chardonnay is a new classic for Margaret River. By Dr Martin Buck

1. 2013 Palmer Reserve Chardonnay This is a focused and intense wine with a great Margaret River pedigree. A crisp, clean wine with aromas of French Oak, peaches, nectarines followed by balanced ﬂavours and restrained oak. I believe this is a very clever wine made by the very experienced Mark Warren, who has made a ‘new age’ chardonnay well suited to the new developing Asian markets. This is a highly recommended wine with good ageing potential but absolutely delicious at the moment. 2. 2012 Palmer Kracker Jack Shiraz Cabernet This is a softer style of Margaret River red. In the glass, the colour is a vibrant red and the aromas reﬂect some hot fruit and oak. There is a very silky palate of savoury fruit, blackberry and earthiness and a seamless blend of varieties. Certainly this is a great value wine with plenty of strong features and would be a great choice for Italian food.

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3. 2011 Palmer Merlot Once regarded just as a blending component, Merlot as a Margaret River varietal seems to be gaining more support. I enjoyed this as a stand-alone wine and it won’t disappoint those wine lovers who enjoy the varietals from classic Bordeaux blends. This is another wine big on alcohol, 14.9%, and has signs of age in the glass. Earthy and with hints of cigar box as well as black olives make this a mature, developed wine. The palate is warm, full bodied with aged plums and a fabulous, silky palate. I found this to be a quality, older Merlot and worth buying now at its peak.

.. or online at

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Wine Question: Which winemaker made the Reserve Chardonnay that Martin thinks so highly of? Answer: ...................................................

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, October 31, 2015. 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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OCTOBER 2015 | 55

Social Pulse

WIRF hosted two events keynoting University of Melbourne’s Prof Stephen Tong’s research into surgery-free treatments for ectopic pregnancies. The Stars Event feature presentations from Dr Kim Guelﬁ on gestational diabetes and Dr Matthew Kemp on preterm births. A cocktail party followed. The next day it was the turn of the ‘Rising Stars’ to present their ﬁndings from population screenings to pharmacological interventions in pregnancy.

1 WIRF’s ED Prof John Newnham with Dr Kym Guelﬁ (PhD) and Dr Peter Peeling (PhD) 2 Prof Stephen Tong, Prof Matt Kemp, Dr Yuichiro Miura and Dr Matt Payne

Women & Infant Research Foundation

3 WIRF Chair Prof Dorota Doherty and KEMH chief sonographer Ms Michelle Pedretti 4 Ms Diane Loh and Clinical nurse educator Ms Yen Kok 5 UWA’s Prof Yee Leung, Prof Stephen Tong, Mr Graeme Broadley and Prof Brendan Waddell 6 Ms Sarah Gorman, Ms Natalie East, Ms Teresa Warner, Prof Jan Dickinson and Ms Jenny Leverington

SJG Subiaco Hospital Ball

3 GP and aerialist Dr Tessa Kaminski twirled high above the heads of docs and nurses from SJG Subiaco at the annual hospital ball held this year at Crown. Head of Northern Hospitals Dr Lachlan Henderson reﬂected on the group’s achievements. 1 Northern Hospitals head Dr Lachlan Henderson 2 Ophthalmologist Dr Chris Kennedy 3 Anaethetist Dr Moira Westmore and Mrs Petrina Crostella

1 56 | OCTOBER 2015

MEDICAL FORUM

Musical Theatre Rachael Beck and Brendan Hanson

Next to Normal, Next to Brilliant It’s a rare and wonderful thing when a new show becomes the talk of the town. Black Swan’s last production of the year is set to be just that show. As the theatrical year draws to a close, Black Swan State Theatre Company, whose 2015 season has been widely applauded, is offering us with an absolute cracker. Next to Normal is a rock musical that has won three Tony Awards and the 2009 Pulitzer Prize for Drama – this is no slouch and BSSTC are putting some serious cards on the table in terms of talent and dollars. This story, which deals with a housewife’s deteriorating bipolar disorder and the ramiﬁcations on her and her family, is so superbly rendered by its authors Brian Yorkey (book and lyrics) and Tom Kitt (music) that it’s powerful and funny, light and dark, moving and illuminating and, by all accounts, unmissable. The small cast is top drawer with national musical theatre stars Rachael Beck, Brendan Hanson and Michael Cormick among the six players who are joined on stage by an eightpiece band. Brendan, who after a musical theatre career throughout Australia and Asia in hits such as Singin’ in the Rain and Les Miserables, has settled in Perth working as a writer, director, performer and a lecturer at WAAPA, said this production in Perth was only the fourth time Next to Normal has been mounted in Australia.

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“Musical theatre isn’t cheap to produce so it’s fantastic to bring this beautiful and clever production to WA. It is such a powerful show that explores mental illness in such a unique way.” “The arts has a fair bit of experience of mental illness. Elizabeth Gilbert (of Eat, Pray Love fame) has done a terriﬁc TED talk on the separation of genius from the genie. Before the Renaissance, we praised artists’ connections with the genius of God and the muses. Then we began calling artists the geniuses and that has poured on a whole lot of pressure and expectation, which has reached into all phases of society.” “I’m not surprised that mental health is becoming such a strong theme in our discourse. So many people face dissatisfaction in their lives that it can easily tip into an imbalance you have to work with every day.” “These become the stories people want to hear and Next to Normal handles these so deftly, people will laugh and they will recognise. I don’t think there’s a household in Australia now that’s untouched by mental illness. The musical doesn’t preach it honestly shows what a blight it is for a family to deal with it.”

that because music elevates the story out of the mundane. It is a heightened world where you can express so much more of what you’re feeling with music and lyrics than by spoken dialogue. That’s the gift of musical theatre. It unravels people and gets under the skin.” Brendan, who teaches his students every day the power of the art form, believes there is a new hunger for musical theatre. “Opera and musical theatre have emerged triumphant at times of great human stress and it’s much more than escapism, there’s something healing about music. Because there is this growing desire to look further and deeper at more social issues. This is what Next to Normal does so brilliantly. We are looking at the gritty underbelly of a family and exploring how they deal with this one big problem. I don’t know that you could go that far in straight theatre or ﬁnd an audience that would be willing to sit for 2 ½ hours without the music.” “This is not ‘show and tell’ musical theatre. The emotional shifts in the scenes make this very much three dimensional theatre.”

By Ms Jan Hallam

“It explores the depth, the sadness, the levity – and I think that’s really healthy. It can do

OCTOBER 2015 | 57

Opera

Teddy Tackles the Big Issues The versatile bass baritone Teddy Tahu Rhodes has steered through some challenging waters of late. Teddy Tahu Rhodes is at the fearless stage of his life and singing career and its opening him up to an extraordinary array of roles and experiences. From the glittering concert platform performing alongside musical theatre great Lisa McCune, tenor David Hobson and the new opera sensation Greta Bradman in Broadway to La Scala a few days ago to transforming into the beguiling agent of the devil, Mephistopheles, in Gounod’s Faust for WA Opera later this month, it’s the 49-year-old’s idea of a perfect singer’s life.

er he does to the point of inhabiting every character so six hours rehearsal is exhausting for everyone. We were all rung out but on the other hand he gives such freedom to create and collaborate.”

“I’m just happy to be working on exciting projects,” he told Medical Forum.

“Faust is itself a very different story to Don Giovanni. Despite its themes of doing deals with the devil, it is much lighter. It swings on the notion that people have the choice to do right or wrong. Mephistopheles is really only offering Faust temptation. He could say no and walk away.”

The adventure took him into unusually controversial seas last year when he took the title role of provocative opera director David McVicar’s production of Don Giovanni by Mozart. It apparently recreated a very dark world where the usually-portrayed lusty, bottom-slapping Don is transﬁgured into a bitter, misogynist who ﬂirts more with evil intention than the women he seduces. For lovers of the bubbling Mozart it was a bit too much to take; for others it drew on themes inherent in both the libretto and the music to create a production they’ll never forget. For Teddy, the Don is a character he’s played “dozens and dozens” of times but in some ways that experience was more of a hindrance than a help when it came to bringing McVicar’s visions to the stage. “I loved working with David, it was an extraordinary experience. It was also incredibly intense. He’s totally invested in whatev-

WA Opera’s Faust at His Majesty’s Theatre is another McVicar production but is being revived for the company by director Bruno Ravella. “Bruno has brought out the charm of this opera and creates a beautiful picture,” Teddy said.

This is the ﬁrst time Teddy has played the role of Mephistopheles and thinks it’s come at the perfect time in his career. “It’s wonderfully liberating to come to a role and be led by the direction without carrying any baggage from previous productions. I don’t have to think beyond the new things I’m learning. It’s a great role to play and best of all it’s the third role off the rank. The focus is on Faust (sung by US tenor Patrick O’Halloran) and Marguerite (sung by Australian soprano Natalie Aroyan), so that takes away a bit of the pressure and I can free myself up a bit. My role is to serve the other characters.” As Teddy gears up for the beguiling Mephistopheles, he ponders on where he will be 10 years from now. “All I know is standing up with an orchestra behind you is the most extraordinary experience and the joy of that never diminishes. If I am still singing 10 years from now, that’s what I want to be doing.”

By Ms Jan Hallam

58 | OCTOBER OCT CTOB OB BER ER 2015 20 01 15

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Movie: Bridge of Spies Steven Spielberg directs Tom Hanks, Amy Ryan and Mark Rylance among others in this Cold War spy thriller based on the true story of James Donovan, a lawyer who ﬁnds himself thrust into the centre of international politics trying to renegotiate the release of a captured U-2 pilot. In Cinemas, October 22

FEATURE

COMP

Movie: Mistress America Tracy is a lonely college freshman in New York and having a miserable time of it. But when she is taken in by her soon-to-be stepsister, Brooke – a resident of Times Square and adventurous gal about town – she is rescued from her disappointment and seduced by Brooke’s alluringly mad schemes. . In Cinemas, October 29

Movie: He Called Me Malala Malala Yousafzai captured hearts and imaginations when as a 15-year-old riding the bus to school in the Swat Valley of Pakistan she was shot in the head by Taliban gunmen who wanted to make her pay for speaking up for girls’ education. She miraculously survived, ﬁnished school and won the Nobel Peace Prize. This is her inspiring story. In Cinemas, November 26

Opera: Faust Acclaimed NZ baritone Teddy Tahu Rhodes returns to His Majesty’s Theatre for WA Opera as the beguiling Mephistopheles in Gounod’s grand opera Faust, which has been given an edgy makeover by controversial Scottish director David McVicar. Playing the title role is celebrated US tenor Patrick O’Halloran, who will make his debut with West Australian Opera. His Majesty’s Theatre, October 29, 31 and November 3, 5, 7, at 7.30pm; Medical Forum performance, October 29

Rock Musical: Next to Normal Don’t miss this Pulitzer and Tony Award-winning rock musical that has enthralled audiences on Broadway and will be seen in Perth for the ﬁrst time next month courtesy of Black Swan State Theatre Company. Diana Goodman is a woman in crisis – and the more her husband Dan tries to help, the crazier things get. Filled with music, fun and pathos! Heath Ledger Theatre, November 7-22, 7.30pm; Medical Forum performance, November 7

Movie: The Program

Was there ever a more spectacular fall from grace that cyclist Lance Armstrong? Director Stephen Frears (The Queen, Philomena) takes David Walsh’s whistle-hot expose Seven Deadly Sins and creates a spellbinding narrative ﬁlm documenting Armstrong’s cancer battle and then his amazing comeback blitz of the 1999 Tour de France. It seemed too good to be true. It was! This is the story of Walsh’s 13-year battle to reveal the truth which came to a crescendo when Armstrong was stripped of his seven Tour victories in 2012. In cinemas, November 19

Doctors Dozen Winner The winner of the Zonte’s Footsteps Doctor’s Dozen, Dr Jeff La Valette, is particularly well-credentialed. Jeff shares his name with a winery in France, although he reckons the wines aren’t as good as our own Margaret River variety. There’s a family reunion coming up in December and Jeff is looking forward to sharing a bottle of chilled Rose with his brother from Scotland. ED: We got Hollywood gynaecologist Dr Robyn Leake’s age wrong last edition, Sorry Robyn! She is 46 and going strong.

Winners from the August issue Musical Theatre – Lord of the Dance: Dr Tricia Charmer, Dr Rob Hendry Theatre – Extinction: Dr Jenny Elson, Dr Simon Machlin

Family Violence t Autism and Music t GP Expectations & e-Poll t Trailblazer in FASD t Clinicals: Childhood Arthritis, Diabetes, Feeding, Heart & Exercise, Parenting & Oesophagitis

Movie – A Walk in the Woods: Dr Paul Kwei, Dr Andre Chong, Dr Michael Hung, Dr Trixie Dutton, Dr Ian Walpole, Dr Yohanna Kurniawan, Dr Michael Bray, Mrs Jane Wong, Ms Tammy Barrett-Izzard, Ms Alison Carlisle li l Major Sponsors

August 2015 www.mforum.com.au

Movie – Maze Runner Scorch Trials: Dr Bill Thong, Dr Hock C Chua, Dr Sara Chisholm, Dr Donna Mak, Dr Christine Lee-Baw, Dr Suzette Finch, Dr Helen Clarke, Dr Alem Bajrovic, Dr Mik Parola, Dr Michael Armstrong Movie – Me Earl and the Dying Girl: Dr Dawn Barker, Mrs Maggie Juengling, Dr Mandy Croft, Dr Barry Leonard, Dr Alarna Boothroyd, Dr Ric Bergesio, Dr Max Traub, Dr Helen Slattery, Mr Michael Durell, Dr Clyde Jumeaux Movie –Pixels: Dr Simon Turner, Dr Ines Chin, Dr Lawrence Chin, Dr Amy Gates, Dr Linda Wong, Dr Divya Sharma, Dr Nai Lai, Dr Angeline Teo

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OCTOBER 2015 | 59

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RESIDENTIAL FOR LEASE

RURAL POSITIONS VACANT

WEST PERTH 'PS MFBTF BU $PMJO 4USFFU Medical Consulting Suite is now available for lease. Colin Street Day Hospital is situated on floor below. Furnished medical consulting suite includes:t TRN t DPOTVMUJOH TVJUFT t 5SFBUNFOU SPPN t 3FDFQUJPO 8BJUJOH SPPN t ,JUDIFOFUUF t 4UPSBHF SPPNT Y t VOEFSDPWFS DBS CBZT t #JDZDMF BOE TIPXFS GBDJMJUJFT JO CVJMEJOH Contact Marie Sheehan on 0411 738 809 Email: marie@csds.com.au

WELLARD )PVTF "DDPNNPEBUJPO UP 3FOU Male owner, non-smoker â&#x20AC;&#x201C; professional, seeking non-smoking working professional or couple to rent in newly built house. -BSHF N Y N #FESPPN QBSUMZ GVSOJTIFE room with built in robes. Own bathroom with separate toilet and vanity. Separate front TV room / Office for own use. Discuss laundry / kitchen/ food arrangements â&#x20AC;&#x201C; open plan living /dining. Ducted reverse cycle air-conditioning throughout house. Double lock up garage with some storage available. Secure. "QQSPY NJOT ESJWF UP 'JPOB Stanley Hospital. 5 minute drive to shops and train station. $275.00 single or $300 couple per week, JODMVTJWF PG JOUFSOBM CJMMT JODMVEJOH /#/ internet access. Terms maybe negotiable. "WBJMBCMF OPX Email Tim at tim@empyrean.wa.edu.au Mb: 0447 698 467

ALBANY t 4U $MBSF T JT BO FTUBCMJTIFE PDDVQBUJPOBM BOE GBNJMZ QSBDUJDF CBTFE JO "MCBOZ t 4NBMM GSJFOEMZ QSBDUJDF t 'VMM UJNF OVSTJOH BOE BENJOJTUSBUJPO support t 1BUIPMPHZ PO TJUF t 'VMM PS QBSU UJNF (1 XBOUFE UP KPJO PVS UFBN t 4QFDJBM JOUFSFTU JO TLJO XPVME CF JEFBM t $VSSFOUMZ OP %84 VOMFTT XJMMJOH UP XPSL in afterhours period t (1T OPU SFRVJSJOH TVQFSWJTJPO SFRVJSFE Please contact Practice Manager, Helen Williams: 08 9841 8102 Email: helen@stclare.com.au Or send your CV through and we will get back to you.

NEDLANDS Hollywood Medical Centre 4VJUF .POBTI "WF "WBJMBCMF GPS MFBTF OPX TR NFUSFT - Fully fitted DBS CBZ Contact Irene: 0409 688 339 or Email: irene.tay8@gmail.com NEDLANDS Hollywood Medical Centre - 2 Sessional Suites. Secretarial support available. Phone: 0414 780 751

BUSSELTON Suite 1/69 Duchess Street Busselton t &YDFMMFOU $#% MPDBUJPO XJUIJO NFEJDBM dental complex opposite Police Station/ Court House complex t "DSPTT UIF SPBE GSPN NBKPS 8PPMXPSUI complex t $PNQSJTFT PGGJDFT MBSHF XBJUJOH boardroom, reception, kitchen/ lunchroom, storeroom & 2WCâ&#x20AC;&#x2122;s. t "QQSPY GMPPS BSFB TRN Details: Len Mazga 0418 910 807 2VFFO 4USFFU #VTTFMUPO (08) 9754 1522 Email: mazga@iinet.net.au www.professionalsbusselton.com.au NEDLANDS Hollywood Specialist Centre. Two large furnished suites available with secretarial support. "WBJMBCMF PO B TFTTJPOBM CBTJT .POEBZ to Friday. Phone: Leon 0421 455 585 Or Gerry 0422 090 355

SHOALWATER Sessional and/or permanent rooms available at our brand new Shoalwater Medical Centre. Fully furnished and fitted out ideal for medical specialists and allied health practitioners. Full secretarial support if required. Fully equipped treatment room and procedure areas available. Experienced and friendly nursing and admin team. Located near both the Waikiki Private Hospital and Rockingham hospital. Please phone Rebecca on 08 9498 1099 or Email manager@sevilledrivemedical.com

MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. &NBJM HDGPSE !HNBJM DPN KELMSCOTT Room available for lease now "MCBOZ )XZ Reception staff, phone/fax/internet all inclusive Suitable for medical specialist or allied health service Contact Jo on 9390 8555 Or reception@akmd.com.au

Contact Jasmine, KBTNJOF!NGPSVN DPN BV UP place your classified advert

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 DBS CBZ QFS UFOBODZ Lease one or both rooms. For further details contact James Teh Universal Realty 0421 999 889 KBNFT!VOJWFSTBMSFBMUZ DPN BV BULLCREEK Specialist consulting room available at a very busy practice. For long-term or short-term use. Perfect for any professional. Furnished. Newly renovated. Contact Karuna 9332 0488 or admin_pm@bullcreekmedical.com

PRACTICE FOR SALE SOUTH of RIVER Great opportunity to own your practice. " VOJRVF PQQPSUVOJUZ OPX FYJTUT GPS B motivated GP to purchase a share or an entire practice in an under-serviced community south of the river. Please call 0412 839 977 for further information.

INTERSATE URBAN POSITION SYDNEY Campsie a busy inner west suburb of Sydney a city of cultural diversity. PG CJMMJOHT GPS UIF GJSTU NPOUIT BOE temporary accommodation provided. Looking for VR GPs with unrestricted provider number on a part-time or full time basis. 8JUI BMM "MMJFE )FBMUI 4FSWJDFT BOE RN support. Prefer Chinese speaking but not necessary. $POUBDU %S #FO "OH 0426 271 168 Or bhc2008@hotmail.com

PSYCHIATRISTS INVITED

URBAN POSITIONS VACANT GREENWOOD Greenwood/Kingsley Family Practice The landscape of general practice is DIBOHJOH BOE JU JT DIBOHJOH GPSFWFS "SF you feeling demoralised by the recent Federal government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? It doesnâ&#x20AC;&#x2122;t have to be this way!! Come and speak to us and see the different ways in which we operate our general QSBDUJDF #F QBSU PG UIF HBNF DIBOHFS Our practice is located north of the river. Sorry we are not DWS. Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion. WILLETTON )FSBME "WF 'BNJMZ 1SBDUJDF We are looking for a suitable full time or QBSU UJNF 73 (1 UP KPJO PVS GSJFOEMZ UFBN We are a small, non-corporate practice, fully computerised and accredited, with registered nurse support. *G ZPV XPVME MJLF UP KPJO VT Email: hafp@eftel.net.au or call 9259 5559 www.heraldavefamprac.com.au

SORRENTO "SF ZPV JOUFOEJOH UP TUBSU 1SJWBUF Practice? This is a sheer walk in! Part time, sessional or full time - all enquiries welcome. Furnished consulting rooms with secretarial support: "OOPJT 3PBE #JCSB -BLF 8" $VSSFOUMZ 1TZDIJBUSJTU B Psychologist work here Clinic is open 5 days a week 7 day pharmacy and GP surgery is next door 5 minute drive to St John of God & Fiona Stanley You are welcome to visit us or Phone Navneet 9414 7860 www.blsc.net.au

F/T or P/T GP for busy Sorrento Medical Centre, Normal/after hours available, we are like family, nurse & allied services on board, remuneration (70%-75%), Please call Dr Sam 0439 952 979

EAST PERTH 1 5 73 (1 XBOUFE UP KPJO East Perth Medical Centre for Holiday Relief/Travel/Corporate/ (1 $MJOJD 1SJWBUF #JMMJOH Call Dianne 9221 4242 WILLETTON GP VR required long term Full time or Part time 70-75% earnings Contact: 0412 346 146 ampmdoctors@westnet.com.au

NOVEMBER 2015 - next deadline 12md Thursday 15th October â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum HELENA VALLEY

General Practitioner FT/PT VR for privately owned general practice in Scott Street, Helena Valley. The well-established clinic is fully accredited and computerized with full time RN support. CJMMJOHT QJQ JODFOUJWFT Mixed billings. Please contact: pmanager@hvmc.com.au or call 9255 1161

CURRAMBINE GP clinic looking for a Full Time or Part Time GP for after-hours clinic. Female Full Time or Part Time position also available. New Purpose built medical centre, Great facilities, NOR, Non-Corporate. - Onsite nurse - Excellent Remuneration 4PGUXBSF #FTU 1SBDUJDF "DDSFEJUFE QSBDUJDF Call Michelle on 08 9305 3232 or Email resume to: shentonavenuemedical@outlook.com BEECHBORO (1 GPS #FFDICPSP #VTZ #VML #JMMJOH (FOFSBM 1SBDUJDF Requires VR GP urgently. 'MVFODZ JO "SBCJD PS 1FSTJBO EFTJSBCMF CVU OPU FTTFOUJBM PG CJMMJOHT Full admin support, Receptionist, RN, Prac Manager. In-house Pathology, Physio and Phycologist 6TFT #FTU 1SBDUJDF 4PGUXBSF Please email CV to practicemanager@hhmg.com.au

WEST LEEDERVILLE GP Addiction Medicine. #VTZ (1 "EEJDUJPO .FEJDJOF DMJOJD needs medical staff. The clinic is closely affiliated with an excellent team of psychologists, psychiatrists, community health staff and a private psychiatric hospital. Close contact with government agencies with excellent support. Good remuneration as all billing is mental health item numbers. Dedicated and experienced staff, a devoted patient population. Rewarding work in a stimulating environment. Flexible sessions to suit. Cambridge Clinic - Phone after BN 9388 2005

BULLCREEK/WANNEROO/ FORRESTFIELD 3FRVJSFE 73 OPO 73 (1 GPS #VMM$SFFL Wanneroo/Forrestfield Normal and after hours available. DWS location available and good percentage PGGFSFE /VSTJOH 1BUIPMPHZ BOE "MMJFE Health available. Contact 0401 625 712 or Email Waliadr@hotmail.com

COMO Want variety in your work? Special interest opportunities at the Well Men Centre in Como. Part time GPâ&#x20AC;&#x2122;s for our Perth Mole Clinic, Skin Cancer Screening Service and for our Holistic Health Management Programme. Call 9474 4262 or Email: wellmen@optusnet.com.au TWO ROCKS GP wanted for brand new, purpose built, privately owned and fully computerised medical practice in Two Rocks. %84 BSFB NJOVUFT GSPN UIF $#% VR preferred. #FTU 1SBDUJDF TPGUXBSF Generous billing percentage for the right candidate. For confidential enquiries contact 0415 684 926 or email mrobins@ormc.net.au

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology BOE "MMJFE TFSWJDFT PO TJUF Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979

CURRAMBINE Mole and Skin Cancer Clinic is looking for an experienced FT or PT VR doctor New Purpose built clinic with Great facilities, Non-Corporate, /03 "DDSFEJUFE 1SBDUJDF - Onsite Nurse - Rates Negotiable #FTU 1SBDUJDF TPGUXBSF Email your resume to shentonavenuemedical@outlook.com WHITFORD CITY URGENT, FT/PT VR General Practitioner required. Excellent remuneration minimum guaranteed income. State of the art general practice in the heart of Hillarys. Outstanding team, great admin staff support and excellent nursing. Contact Dr Rafik Mansour: rafik.mansour@whitfordcityfamilypractice.com.au

YANCHEP /PSUI PG 3JWFS %84 "SFB

Experienced FT GP required #VTZ DPNQVUFSJTFE QSBDUJDF /VSTF BOE "ENJO TVQQPSU Earn up to 70% of billings Flexible hours Non VR welcome to apply Enquiries to Phil: phil27bc@gmail.com

MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new non DPSQPSBUF QSBDUJDF XJUI GFNBMF NBMF General Practitioners. Sessions and leave negotiable, salary is compiled from billings rather than takings. Up to 70% of billings paid (dependant on experience). Please contact Jacky on 0488 500 153 or & NBJM UP KBDLZ TUFWFO!MJWF DP VL HAMILTON HILL " GFNBMF (1 SFRVJSFE GPS B DMJOJD JO B %84 BOE "0/ BSFB NJOVUFT ESJWF GSPN Fremantle. 3 Doctor GP Practice. Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or Send CV to eric@hamiltonhillfamilypractice.com.au

BUTLER Connolly Drive Medical Centre VR GP required for this very new, state of the art, fully computerised, absolutely paperless, spacious medical centre. Fully equipped procedure rooms and casualty, well-furnished consult rooms, pathology, allied health, RN support. "CVOEBOU QBUJFOUT %84 non-corporate. Generous remuneration. Confidential enquiries Dr Ken Jones on (08) 9562 2599 Tina (manager) on (08) 9562 2500 Email: ken@cdmedical.com.au

SHOALWATER F/T VR GP required for our brand new medical centre located in Shoalwater (DWS), Offering modern surrounds and fully computerised clinical software. We are a friendly, privately owned and run centre. " GVMM DPNQMFNFOU PG OVSTJOH TUBGG admin team as well as onsite allied health/specialists and pathology. generous remuneration offered Please phone Rebecca on 08 9498 1099 or Email CV to manager@sevilledrivemedical.com

HUNTINGDALE Our privately owned practice is located South of River in an area of DWS. We are looking for a full time VR G P to KPJO PVS GSJFOEMZ UFBN 'MFYJCMF XPSLIPVST available. 8F VTF #FTU 1SBDUJDF 4PGUXBSF IBWF modern equipment and full nursing support. 1MFBTF DPOUBDU %S 4JNPO #FSOT PO 9493 8333 or Email Simon.berns@srfp.com.au

"SF ZPV MPPLJOH GPS EPDUPST GPS ZPVS medical practice? "VTUSBMJBO .FEJDBM 7JTBT JT PXOFE BOE SVO CZ 1SBDUJDF .BOBHFST CBTFE JO 8" who have over 20 yearsâ&#x20AC;&#x2122; experience of the 6, BOE "VTUSBMJBO IFBMUIDBSF TZTUFNT We currently have a number of doctors XIP BSF MPPLJOH GPS QPTJUJPOT JO "VTUSBMJB We are able to assist practices with all paperwork involved including the migration process (if required). Please visit our website www.australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or "OESFB PO 0401 371 341. LANGFORD P/T or F/T GP position available Soon to be opened practice at Langford E-mail: contact@langfordfamilypractice.com.au JOONDANNA 8F BSF TFFLJOH B 73 (1 UP KPJO PVS GSJFOEMZ team on a part-time or full-time basis. New, state of the art medical centre. Flexible hours and billing. Percentage negotiable. Fully-computerised. Nursing support for CDMP. Please call Wesley on 0414 287 537 for further details.

DUNCRAIG & OSBORNE CITY Duncraig Medical Centre Osborne City Medical Centre Require a female GP â&#x20AC;&#x201C; would CF GVMMZ CPPLFE EBZ Flexible Mon to Fri hours. (after hours optional) Excellent remuneration. Modern, predominantly private billing practice. Fully computerised. Please contact Michael on 0403 927 934

BEECHBORO 1 5 PS ' 5 (1 SFRVJSFE UP KPJO MPOH established busy medical practice in #FFDICPSP Privately owned, 8 doctor practice with full nursing support. DWS and eager to replace recent GPâ&#x20AC;&#x2122;s departure back to Europe. Mixed billing. Generous terms. Confidential enquiries to manager@altonemed.com.au BERTRAM VR or Non VR GP required Part Time/ Full Time for our Two Practices in the Suburb PG #FSUSBN - Bertram Family Medical Centre 'VMMZ $PNQVUFSJTFE XJUI #FTU 1SBDUJDF Nurse Support and onsite Pathology. - Champion Medical Centre 0QFOJOH 0DUPCFS XJUI POTJUF %FOUJTU "MMJFE IFBMUI BOE POTJUF 1BUIPMPHZ (PPE 1BUJFOU CBTF #VTZ 1SBDUJDFT 3BUFT Negotiable, Privately Owned Contact Tricia on 9497 1900 for a Confidential Discussion or Email CV to: info@forrestroadgp.com.au

NOVEMBER 2015 - next deadline 12md Thursday 15th October â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum COMO Como Medical Clinic requires a full UJNF PS QBSU UJNF 73 (1 UP KPJO PVS friendly team. We are a small non-corporate, wellFRVJQQFE "(1"- BDDSFEJUFE BOE mainly private billing practice. You will be well supported by the owner-doctor and two practice nurses. Flexible working hours and holidays (school holidays available). 0GGFSJOH SFDFJQUT Please contact Linley Gray on 0417 978 574 for confidential enquiries.

MAIDA VALE We are seeking an enthusiastic VR/Non-VR GP for a FT/PT position. Our friendly practice is located in the Kalamunda Hills region. Purpose built, fully accredited and private billing. Excellent patient profile with full admin and nursing support. If interested please phone Peter on 9454 5544 or email to office@hillsfamilymedical.com.au CLAREMONT The Walk-in GP practice located in the trendy suburb of Claremont. 80% of billings. Looking for GPs for Saturdays and Sundays (DWS) Fully computerised with on-site pathology and RN support. Located in a modern complex with access to the gym and pool. For further information please contact %S "OH PO 9472 9306 or Email: info@thewalkingp.com.au (vacancies may be available for VR GPs on weekday PM sessions).

DIANELLA 1BSU UJNF 73 (1 XBOUFE GPS "GUFS IPVST Clinic. "DDSFEJUFE 1SJWBUF .FEJDBM $FOUSF XJUI BEKPJOJOH QIBSNBDZ (SFBU GBDJMJUJFT t &YDFMMFOU SFNVOFSBUJPO t 4PGUXBSF #FTU 1SBDUJDF Phone Terri 9276 3472 or Email resume: practicemanager@dianellamedical.com.au

56 Almadine Drive, Carine p 08 9448 7799 m 0401 815 587

www.gpwest.com.au

VR GPs wanted to join a friendly team Myaree Medical Centre seeks a full-time VR GP for our modern, expanding, south of the river practice. We are a private billing, non-corporate practice servicing a predominantly younger demographic. Our surgery is a modern, well equipped, purpose built facility. Our doctors have a special interest in skin cancer medicine as well as mainstream general practice. Excellent remuneration. Weekdays only, no after hours. Fully computerised, onsite pathology, physiotherapy and RN support "MM BQQMJDBUJPOT DPOTJEFSFE Confidential enquiries to Julia SFDFQUJPO !NZBSFFNFEJDBMDFOUSF DPN BV or 9317 8882 GOSNELLS "TICVSUPO 4VSHFSZ &TUBCMJTIFE VR GP needed part time. Ethical patient oriented practice 'VMMZ "DDSFEJUFE 1SJWBUF CJMMJOH 70% of billings. Fully equipped with nurse support. Email: angiesurgery@gmail.com PS DBMM "OHJF 0422 496 594

Okely Woodlake Village Newpark Medical Centre Medical Centre Medical Centre CARINE

ELLENBROOK

New Gumnut Medical Centre

GIRRAWHEEN

WANNEROO

contact Dr Kiran Puttappa kiranpkumar@hotmail.com

0401 815 587

GP WANTED â&#x20AC;&#x201C; BELMONT CITY MEDICAL CENTRE Ĺ&#x201D; #VTZ OPO DPSQPSBUF QSBDUJDF SFRVJSFT 'VMM 5JNF 1BSU 5JNF 73 (1 Ĺ&#x201D; 0O TJUF $IFNJTU 1BUIPMPHZ 1IZTJPUIFSBQZ %FOUJTU BOE (ZN Ĺ&#x201D; LN GSPN 1FSUI $#% PQQPTJUF #FMNPOU 'PSVN 4IPQQJOH $FOUSF

Ĺ&#x201D; PG SFDFJQUFE CJMMJOHT Ĺ&#x201D; &YDFMMFOU OVSTJOH TVQQPSU Ĺ&#x201D; "DDSFEJUFE BOE GVMMZ DPNQVUFSJTFE Ĺ&#x201D; (VBSBOUFFE IPVSMZ JODPNF GPS JOJUJBM NPOUIT

GP Superclinic @ Midland Railway Workshops General Practitioner (unrestricted VR) Wanted â&#x20AC;&#x201C; PT or FT Looking for a VR GP to work part time (minimum three days per week) or full time. 8F BSF CVTZ NPEFSO TUBUF PG UIF BSU GBDJMJUZ UIBU JT Ĺ&#x201D; 'SJFOEMZ DPMMFHJBUF UFBN FOWJSPONFOU Ĺ&#x201D; 'VMMZ $PNQVUFSJTFE Ĺ&#x201D; "(1"- "DDSFEJUFE BOE 8"(1&5 BDDSFEJUFE GPS UFBDIJOH BOE USBJOJOH Ĺ&#x201D; )BT NJYFE #JMMJOH Ĺ&#x201D; 0OTJUF QBUIPMPHZ QIBSNBDZ QIZTJPUIFSBQZ .FEJDBM 4VSHJDBM 4QFDJBMJTUT UP NFOUJPO B GFX Ĺ&#x201D; /VSTJOH 4VQQPSU Ĺ&#x201D; 0QQPSUVOJUJFT UP KPJO PVS 0DDVQBUJPOBM )FBMUI 5FBN Ĺ&#x201D; 1VSQPTF CVJMU CBZ USFBUNFOU SPPN BOE EFEJDBUFE IJHI UFDI QSPDFEVSBM VOJU GPS TQFDJBMJ[FE QSPDFEVSFT Ĺ&#x201D; *EFBMMZ MPDBUFE PQQPTJUF UIF OFX 4U +PIO PG (PE .JEMBOE )PTQJUBM OFJHICPSJOH EFWFMPQNFOUT JODMVEF UIF QSPQPTFE $VSUJO .FEJDBM 4DIPPM *OUFSOBUJPOBM #VTJOFTT )PUFM 'BOUBTUJD PQQPSUVOJUZ UP CVJME B MPOH UFSN DBSFFS BOE FTUBCMJTI USVTUFE SFMBUJPOTIJQT XJUIJO B OFX QBUJFOU CBTF

Ĺ&#x201D; %84 EPDUPST DBO BQQMZ GPS BGUFS IPVST BOE XFFLFOE TFTTJPOT Ĺ&#x201D; 'MFYJCMF TFTTJPOT BWBJMBCMF

Please contact Joy on 0421 119 443 or 0417 881 234 for more information

Metro Area GP positions available VR & Non â&#x20AC;&#x201C; VR Drâ&#x20AC;&#x2122;s are welcome to apply. Send applications to hr@betterhealthcare.com.au

All enquires are strictly conďŹ dential. Please contact Mark Riedel on 0412 526 913 for any queries or to arrange an interview.

NOVEMBER 2015 - next deadline 12md Thursday 15th October â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum GENERAL PRACTITIONERS REQUIRED Belvidere Health Centre (39 Belvidere Street, Belmont) Looking for something different? Are you seeking a ďŹ&#x201A;exible working environment? Our clinic offers the following opportunities to GPsâ&#x20AC;&#x2122; wanting to contract their services: Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D; Ĺ&#x201D;

(FOFSPVT SBUFT 'MFYJCMF XPSLJOH IPVST $MJOJDBM OVSTJOH TVQQPSU 'VMMZ DPNQVUFSJTFE TZTUFNT 7BSJFE DMJFOU CBTF 0O TJUF *SPO *OGVTJPO UIFSBQZ

%BZT DVSSFOUMZ BWBJMBCMF .POEBZT 5IVSTEBZT BOE 'SJEBZT For further information please contact Rod Redmond at (08) 9458 0505 or r.redmond@archehealth.com.au

HEALTH WATCH CLINICS MELVILLE / JANDAKOT / COTTESLOE General Practice )FBMUI 8BUDI $MJOJDT JT EPDUPS PXOFE BOE OPO DPSQPSBUF 5IFSF JT BO FNQIBTJT PO HPPE NFEJDJOF BOE OPU IJHI UISPVHIQVU HFOFSBM QSBDUJDF We require FT/PT male or female VR GP for our clinics.

We take care of you while you take care of others

See: www.healthwatchclinics.com.au Enquiries to: sherri@healthwatchclinics.com.au or (08) 9383 3435

ARE YOU WANTING TO SELL A MEDICAL PRACTICE?

We have vacancies in a wide range of locations: z z

Kimberley Pilbara

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South West Great Southern

Work in an Aboriginal Medical Service, a group practice or run your own practice. Visit our website www.ruralhealthwest.com.au or contact our friendly recruitment consultants for a confidential discussion. T +61 8 6389 4500 | E recruit@ruralhealthwest.com.au

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

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

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

NOVEMBER 2015 - next deadline 12md Thursday 15th October â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum

GP Opportunities - WA

Apollo Health is seeking local Drâ&#x20AC;&#x2122;s with an interest in : - Skin cancer - General family medicine - Walk in /Urgent care For our practices in Armadale, Cockburn and Joondalup FRACGP required, Relocation incentives available

If you would like to join our dynamic team please contact ofďŹ ce@apollohealth.biz

% '$$ & + % % &! "$ & & ! !) &)! &$ % !$ % * ! & & $ - Maylands Medical Centre - Parmelia Medical Centre % ) ! &! "" + IPN offers: , %!( $ &+ , "" - & ( % , ! $ ) #' "" % , '""!$& $! *" $ %& For all conďŹ dential enquiries, please contact Lucy Barker: ' + $ $ " ! ' With IPN, weâ&#x20AC;&#x2122;re looking after you.

Do you need a website or a refresh? Contact Thinking Hats today and we can help! hats@thinkinghats.net.au

VR GP full time or part time required for busy practice in Baldivis Established in 2011, this purpose built, non-corporate practice is RSHQ GD\V D ZHHN DQG RIIHUV *3ÂśV Ă&#x20AC;H[LEOH KRXUV WAGPET and GPA accredited practice with a rapidly growing SDWLHQW EDVH ORFDWHG DSSUR[LPDWHO\ NPV VRXWK RI 3HUWK ZLWK ':6 LI QHHGHG Pathology and psychology on site, with a busy pharmacy QH[W GRRU :HOO HVWDEOLVKHG &'0 FOLQLF *3 2EVWHWULFV DQG LQGHSHQGHQW PLGZLYHV 6SHFLDO LQWHUHVWV VXSSRUWHG PLQRU WKHDWUH WUHDWPHQW URRP DPSOH SDUNLQJ

2015 Christmas Greetings Supplement Medical Forum's

If you would like to join our friendly supportive team of doctors, nurses and admin staff please contact Sue Fegebank on 08 9523 6829 RU HPDLO \RXU &9 WR ULGJHPHGLFDO#JPDLO FRP

Send Christmas greetings to your colleagues and clients in Medical Forumâ&#x20AC;&#x2122;s popular special Christmas Greetings Supplement. Deadline: Monday, November 9 â&#x20AC;˘ Acknowledge the support of colleagues â&#x20AC;˘ Extend goodwill to one and all â&#x20AC;˘ End 2015 in the spirit of the Christmas season Medical Forumâ&#x20AC;&#x2122;s Christmas edition is out on Dec 1

To lodge your greeting in Medical Forumâ&#x20AC;&#x2122;s Christmas Greetings Supplement Phone Jenny Heyden on 9203 5222 or email jen@mforum.com.au

Your WA Consultant â&#x20AC;&#x201C; Jenny Heyden Tel 9203 5544 or Mob 0403 350 810

NOVEMBER 2015 - next deadline 12md Thursday 15th October â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au