Medical Forum 02/15 Public Edition

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Editorial

Reviewing the Regulators The national registration system for doctors (and other health professionals) was designed to make things easier across State jurisdictions and cheaper for doctors. It was also meant to remedy criticism that Medical Boards did a better job of protecting doctors than health consumers. For serious cases, the new system would be more transparent (i.e. judicial via SAT) and responsive. Consumers would have a greater say, sitting on both SAT panels, and for lesser misdemeanours, panels that investigated complaints which related to the doctor’s health (e.g. impairment, or addiction), behaviour or skill.

Cheaper hasn’t happened. Costly State Medical Boards and AHPRA ofďŹ ces have remained, the bureaucracy has grown, and lawyers feature prominently. Doctors can discover when their MDO money runs out, they are on their own – and it is then too expensive to take things further through the courts.

Mud sticks. According to the National Medical Board’s annual report, in 2013-14 there was a 19% increase in notiďŹ cations (complaints serious enough to consider the public is at risk) which were directed at one in every 20 doctors BUT 85% of these came to nothing. Some might consider this a waste of money and resources, with unnecessary creation of stress.

Dr Rob McEvoy

T degree of unnecessary damage The d done to some doctors’ wellbeing and re reputation is a great concern. A doctor c be singled out for investigation can b the Medical Board, not because of by c consumer complaints but because a ‘ ‘colleague’ thinks there is a problem.

This initiative was set up to deal with the ‘bad’ and ‘sad’ doctors before they did too much harm. But if someone gets it wrong are they answerable?

Recent ďŹ ndings from the UK suggest we are not a hard-nosed lot when it comes to complaints; they can hit hard personally and professionally.

Damage to reputation depends a lot on how long the Medical Board and AHPRA take to investigate matters. Both have been criticised for the time taken to reach an outcome for a notiďŹ cation. According to its own KPIs, delays are commonplace, with Kim Snowball’s August 2014 Review saying: sĂĽ )NVESTIGATIONĂĽTOĂĽ#OMPLETION ĂĽ4ARGETĂĽ ĂĽWITHINĂĽ ĂĽMONTHSĂĽnĂĽ Result to date 59%

However, one aspect of responsiveness gets a tick – immediate action BYü-EDICALü"OARDSüINCREASEDü üFROMü ü THEü7!ü-EDICALü Board took immediate action 38 times) and nearly three quarters of these led to regulatory action – such as conditions, undertakings or SUSPENSIONüOFüREGISTRATION ü7HATüABOUTüTHEüREST ü4HEü3NOWBALLü2EVIEWü says health consumers complain that communication from AHPRA is too little, too late and overly bureaucratic and legalistic. It is less than they got under pre-AHPRA legislation.

Lack of transparency is concerning. The Medical Board publishes panel and tribunal decisions on its website and last year’s Board members are published in the Annual Report. But nowhere are the names of ‘approved’ panellists (those who judge others) published.

There are arguments for and against more transparency in this. One doctor on the list was surprised it wasn’t public.

Just like the workers’ compensation system, some will make a living from appearing as panellists or expert witnesses. The Medical Board has the discretion to offer a sanctioned doctor anonymity beyond the public interest. On the other hand, panellists are anonymous, without discretion. Complaints of cronyism are sure to follow (given our e-poll results in February 2013, below).

The MDOs talk of improved “timeliness in handling notiďŹ cationsâ€? and they want monthly publication of the regulators’ performance, much like the Queensland Health ombudsman, currently going it alone.

All these issues will get a wider airing at Medical Board and AHPRA – Friendly Fire? the theme for the next Doctors Drum forum (March ü4HINGSüLIKEüPROCEDURALüFAIRNESS üANTI DOCTORüVSüPRO PUBLICü stance, inuence of legal costs, rising registration costs, etc will LIKELYüBEüCANVASSED ü7EüLOOKüFORWARDüTOüYOURüATTENDANCE ü

AHPRA WA State Manager Robyn Collins. There are about 99,400 registered MEDICALĂĽPRACTITIONERSĂĽINĂĽ!USTRALIAĂĽ ĂĽWOMEN ĂĽ ĂĽAGEDĂĽOVERĂĽ ĂĽ WITHĂĽ ĂĽINĂĽ7! ĂĽOFĂĽWHICHĂĽ ĂĽAREĂĽSPECIALISTS Tel 1300 419 495 or see www.ahpra.gov.au

MB Panellist Appointments e-Poll How would you explain why the national Medical Board does not make known to the wider profession in WA, prior to appointment, which WA doctors are to be offered panel positions to investigate complaints against other doctors [n = 328 respondents]?

Uncertain

38%

Desire to hide ďŹ nal appointments from potential criticism

34%

sĂĽ %STABLISHMENTĂĽOFĂĽ0ANELĂĽ(EARING ĂĽ4ARGETĂĽ ĂĽWITHINĂĽ ĂĽMONTHSĂĽnĂĽ 2ESULTĂĽTOĂĽDATEĂĽ

Prevent people from trying to inuence panellists before or after appointment

34%

sĂĽ 0ANELĂĽ(EARINGĂĽ#OMPLETION ĂĽ ĂĽWITHINĂĽ ĂĽMONTHSĂĽnĂĽ Result to date 73%.

Fears of not being able to attract doctors to the panels

13%

4HOSEĂĽCONTROLLINGĂĽAPPOINTMENTSĂĽBELIEVEĂĽTHATĂĽNOĂĽ7!ĂĽ doctor has information detrimental to an appointment.

5%

Other

5%

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Mr Glenn Bradbury (0403 282 510) advertising@mforum.com.au

MEDICAL FORUM

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au

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

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

1

February 2015

Contents 10

44

18

25 FEATURES 10

Spotlight: Jonathan Holloway, Perth Fesitval Director Mr Peter McClelland

12 18 20 44

Gym Junkies Crossing the Line

NEWS & VIEWS 1 %DITORIALånå2EVIEWINGåTHEå2EGULATORS Dr Rob McEvoy

4

Letters: Let’s Focus on Good Medicine – Dr Colin Hughes

Art for Health’s Sake

Canberra’s ‘March of Folly’ –

Genetics Research – a Big Pond

E/Prof Max Kamien

Dr Rob McEvoy

Do Not Trust Dr Nitschke –

Social Pulse: Christmas 2014 – RACGP, Clinipath, Ramsay, SJG Murdoch and Subiaco Hospitals, Perth Pathology

Dr John Hayes

4

Retrieving Sick Babies – Dr Kirsten Thompson Curious Conversations: Dr Steve Colley

LIFESTYLE 40 Hockeyroos Beat the Jungle Blues 41 Rural Mental Health Hits the Road 42 Funny Side with Cartoonist Dave Freeman 43 7INEå2EVIEW å0LANTAGENETå7INES Dr Craig Drummond

50

14

Dr Rob McEvoy

16 23

Competitions

27

Our cover: SJG Murdoch ED’s Dr Sandor Csontos stands in front of Untitled, 2011, by Alison Riley of the Wangkajungka Language Group displayed inside the SJG Murdoch cancer centre.

Medical Marketplace: e: Cost Matters for Those with Cancer Have You Heard?

Medico-legal 1 ! å%ND OF ,IFEå Issues Beneath the Drapes

Gym Junkies kies Crossing the Line ge 12 Page

MAJOR SPONSORS 2

MEDICAL FORUM

Clinical Contributors

7

Dr Paul Glendenning Measuring Vitamin D

9

Dr Mark Hands Fractional Flow Reserve

29

Dr Sean Stevens Incidentiloma Dilemma

31

Dr Karen Simmer Neonatal Intensive Care

33

Dr John Boulton Kimberley Children

34

Dr Fraser Brims Absestos Care Progress

35

Mr Neil Keen Pharmacy Trends

37

Dr Neda Meshgin Community Cardiac Rehab

Next

DOCTORS DRUM March 26 See page 14

38

Dr Raphael Chee VMAT Radiology Trends

38

Dr David SoďŹ eld Urology Trends

Guest Columnists

8

Dr Frank Jones Time GPs Took Control

25

Dr Alex Thng GPs Maintaining Skills

26

Ms Devaki Wallooppillai Refugee Health

27

Dr Philip Morris Pharma Transparency

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

3

Letters to the Editor

$EARĂĽ%DITOR

Patients need to become health literate so they can demand better health care from their GPs. In the long term this is about improving health and cannot just be a debate about money but rather about productivity.

As a former Chair of the College of GPs I feel that journalists are totally misinformed about the need to promote longer consultations. There should be no such consultation as ‘just a script’.

The recent debacle over the 10-minute CONSULTĂĽHASĂĽLEFTĂĽAĂĽPOLICYĂĽVACUUM ĂĽ7EĂĽNEEDĂĽOURĂĽ profession to stand united with the College, the AMA, and Rural doctors speaking with ONEĂĽVOICE ĂĽ7EĂĽNEEDĂĽTOĂĽDEMANDĂĽAĂĽREVIEWĂĽOFĂĽ the sustainability of general practice and, yes, we need to revisit the time bands to promote better care.

"EECHĂĽRESEARCHĂĽSHOWSĂĽTHATĂĽCURRENTLYĂĽ ĂĽ of all consultations deal with just one item of service. This is because the current Medicare system promotes fast ďŹ ve-minute medicine where in many clinics if a patient asks for more than one item, e.g. their BP review plus a referral to a specialist they are asked to return on another day thereby generating another consultation and extra cost for the government.

It is ludicrous that I spend 20 minutes with a complicated old pensioner with diabetes, needing referral and investigations while attending to her skin infections, and I get far less than the guy who does three quick consultations in the same time.

Yet in terms of productivity that extra consult means time away from their business or work, travel costs etc. There is no such thing as “just a script�. A good GP will check your BP height and weight and tell your BMI, advise re diet and exercise. Check your family history for risk of cancer or diabetes. Offer you an annual check-up and arrange blood tests to check your medications are not causing side effects.

You should be counselled about smoking and alcohol use as well as screening for mental health problems.

Canberra’s ‘march of folly’

Let’s focus on good medicine

Research shows that longer consultations decrease the number of visits patients make to doctors, so predictions of longer waiting times is wrong. The RACGP should be promoting even longer time bands, properly remunerated of up to 15 minutes so that GPs can properly manage their patients’ health.

Dr Colin Hughes, Roebourne ........................................................................

of the common fee. It has also become as complex as the taxation system. It was ripe for the plucking and corporate style medicine, aka MINUTEĂĽMEDICINE ĂĽISĂĽTHEĂĽRESULT Interference from successive governments has been the cause and for a sensible ‘listening to GPs’ government, they should be the cure.

Time-based consultations, as practised by lawyers, accountants and plumbers are easily understood and are one of the ways that could achieve simplicity for patients, GPs and the ďŹ scal aims of government.

Messrs Abbott, Hockey and Dutton [add new Health Minister Sussan Ley] wish to curb corporate style general practice. Sadly their blunderbuss methods will also destroy good, patient-centred general practice. Old GPs will retire early and young medical graduates will not be attracted to it and will seek to enter speciality practice. It will not be long before we go down the expensive and medically inaccessible path of the USA. The only beneďŹ ciaries of this march of folly will be the historians who will compare our current ‘leaders’ to those who let the Greeks into Troy.

Prof Max Kamien, City Beach

$EARĂĽ%DITOR

The historian, Barbara Tuchman, has coined the phrase ‘The March of Folly’ to describe the actions of governments which are contrary to available evidence, common sense and are against the best interests of their constituents and themselves.

Medicare was a good idea when it paid 85% of the common GP fee. But it has been starved of funds and now pays less than 50%

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

Do not trust Dr Nitschke $EARĂĽ%DITOR

Condemned by the Beyond Blue chairman and suspended by the Medical Board, yet Dr Philip Nitschke qualiďŹ es as a “guest columnistâ€? in Medical Forum [November]. I am appalled!

7HENĂĽINTERVIEWEDĂĽONĂĽNATIONALĂĽTELEVISIONĂĽ (Crossing the line), Nitschke supported assisted suicide for healthy people over 50 who are “tired of livingâ€?. continued on Page 6

Curious Conversations

Keeping Both Eyes Open Falling asleep over a good book sounds like paradise to ophthalmologist Dr Steve Colley.

The most frightening thing I’ve ever done is‌ TAKEüONüTHEü"LACKü2UNSüATü7HISTLER ü!ü friend invited me for a month-long ski holiday while neglecting to mention that a certain level of skiing prowess was required. I’ve never been so bruised and battered in my life, but there was a sense of achievement in negotiating most of the slopes.

Three people I would love to have around a dinner-table are‌Stephen Fry, Hugh ,AURIEĂĽANDĂĽ"ENĂĽ%LTON ĂĽ)ĂĽABSOLUTELYĂĽLOVEDĂĽ Blackadder, QI is a deďŹ nite favourite as is the TV series, House MD ĂĽ"ENĂĽ%LTONĂĽISĂĽANĂĽAUTHORĂĽ

4

I really like and next in line is his latest tome, Time and Time Again.

I’m very happy with my specialty of ophthalmology because‌ I’m colour-blind and I’ve always been fascinated with the inner workings of the eye. Patients take their eye health seriously and treatments are constantly improving. Cataract surgery is incredibly safe and many people see better afterwards than they ever have.

One thing I’d like to achieve this year is‌ a good night’s sleep! Our two little children

have never been great sleepers and Kristen and I are completely worn out. The end is in sight as Alyssa (19 months) recently moved into her own bed.

If I could live in another country for 12 months it would be‌ Southern Italy. I did a walking tour on the AmalďŹ Coast a few years ago and couldn’t believe how beautiful it was. And the food is extraordinary! The only problem would be ďŹ nding work because I don’t think Italy is short of ophthalmologists.

MEDICAL FORUM

MEDICAL FORUM

5

Letters to the Editor continued from Page 4 As the leader of the euthanasia movement, Dr Nitschke has been running workshops around Australia selling suicide kits to people who are NOT terminally ill.

Nitschke’s role in supporting the suicide of a depressed Perth man, Nigel Brayley, shocked the nation and was extremely bad publicity for the euthanasia cause. Sunday Times journalist David Penberthy was highly critical of Dr Nitschke (Time’s up for Dr Death), pointing out that euthanasia had “changed� and was now an option for depressed, suicidal people. He accused Nitschke of “playing God�.

The euthanasia lobby has no intention of limiting euthanasia to the “terminally ill�. The public, media and politicians have not been told the truth.

Politicians do not trust Dr Nitschke – 18 failed State %UTHANASIAü"ILLSüISüTESTIMONYüTOüTHIS ü Dr John Hayes, Consultant Physician, Subiaco

Editorial Comment Readers have asked about Major Sponsors‌ Major Sponsors of Medical Forum MAGAZINEüWORKüWITHINüTHEü7!ü MEDICALüCOMMUNITY ü%ACHüSTRIVESüTOü offer something extra to the medical profession and is happy to be involved with this reputable industry publication.

Medical Forum was founded over 20 years ago by two people within the profession, and the improved quality and readership of the publication since then speaks volumes for all involved. )NDEPENDENCE üDEDICATEDü7!üFOCUS üANDü ethical behaviour are the cornerstones of the publication’s success. Major sponsorships are offered on that basis.

Dr Kirsten Thompson

Retrieving sick babies $EARĂĽ%DITOR

.%43ĂĽ7!ĂĽ THEĂĽ.EWBORNĂĽ%MERGENCYĂĽ4RANSPORTĂĽ3ERVICEĂĽ7! ĂĽPROVIDESĂĽMOBILEĂĽINTENSIVEĂĽ care for babies, as well as neonatal advice, support and education for clinicians in METROPOLITAN ĂĽREGIONALĂĽANDĂĽREMOTEĂĽAREASĂĽOFĂĽ7! ,ASTĂĽYEAR ĂĽ.%43ĂĽ7!ĂĽTRANSPORTEDĂĽOVERĂĽ ĂĽSICKĂĽORĂĽPREMATUREĂĽBABIESĂĽFROMĂĽTHROUGHOUTĂĽ 7ESTERNĂĽ!USTRALIAĂĽ THEĂĽWORLD SĂĽLARGESTĂĽRETRIEVALĂĽAREA ĂĽTOĂĽTHEĂĽTERTIARYĂĽNEONATALĂĽINTENSIVEĂĽ CAREĂĽFACILITIESĂĽINĂĽ0RINCESSĂĽ-ARGARETĂĽ(OSPITALĂĽORĂĽ+INGĂĽ%DWARDĂĽ-EMORIALĂĽ(OSPITALĂĽ 0-( +%-( ĂĽ!NYĂĽBABYĂĽINĂĽ7!ĂĽWHOĂĽISĂĽLESSĂĽTHANĂĽ ĂĽWEEKSĂĽCORRECTEDĂĽGESTATIONALĂĽAGE ĂĽBELOWĂĽ KGĂĽANDĂĽNEEDSĂĽMEDICALĂĽTRANSFERĂĽTOĂĽ0ERTHĂĽMAYĂĽBEĂĽELIGIBLEĂĽFORĂĽTRANSPORTĂĽBYĂĽ.%43 ĂĽ 4OĂĽREFERĂĽORĂĽDISCUSSĂĽAĂĽNEONATALĂĽPATIENTĂĽATĂĽANYĂĽTIMEĂĽ ĂĽDOCTORS ĂĽNURSESĂĽANDĂĽMIDWIVESĂĽ can call 1300 NETS WAĂĽ ĂĽ ĂĽ4HISĂĽINITIATESĂĽAĂĽCALLĂĽCONFERENCEĂĽWITHĂĽSENIORĂĽ neonatal doctors to ensure effective and consistent advice is given.

We welcome your letters.

Please keep them short. %MAIL ĂĽeditor@mforum.com.au (include full address and phone number) by the 10th of each month.

You can also leave a message at www.medicalhub.com.au.

Letters may be edited for legal issues, space or clarity.

)NĂĽCONJUNCTIONĂĽWITHĂĽTHEĂĽNEONATALĂĽTEAMĂĽATĂĽ0-(ĂĽANDĂĽ+%-( ĂĽ.%43ĂĽ7!ĂĽALSOĂĽOFFERSĂĽ education sessions, undertaken as outreach sessions as well as Perth based COURSES ĂĽ4HESEĂĽINCLUDEĂĽTHEĂĽ.EONATALĂĽ2ESUSCITATIONĂĽ0ROGRAMĂĽ .20 ĂĽTHEĂĽ3 4 ! " , % ĂĽ PROGRAMĂĽ FOCUSSINGĂĽONĂĽPOST RESUSCITATION PRE TRANSPORTĂĽSTABILISATIONĂĽOFĂĽINFANTS ĂĽAND ĂĽ INĂĽCONJUNCTIONĂĽWITHĂĽTHEĂĽNEONATALĂĽTEAMĂĽATĂĽ0-( +%-(ĂĽANDĂĽTHEĂĽ5NIVERSITYĂĽOFĂĽ7! ĂĽAĂĽ Graduate Diploma and a Masters in Neonatology.

Through these activities, we hope to help clinicians across the state feel more conďŹ dent and more familiar with neonatal resuscitation and stabilisation of newborns. !LLĂĽOFĂĽOURĂĽ.%43ĂĽ7!ĂĽGUIDELINESĂĽANDĂĽFURTHERĂĽINFORMATIONĂĽONĂĽOURĂĽSERVICE ĂĽEDUCATIONĂĽ program and recent research is freely available on our website, www.netswa.net.au.

Dr Kirsten Thompson, Neonatologist NETS WA

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

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MEDICAL FORUM

By Dr Paul Glendenning, Consultant Endocrinologist and Chemical Pathologist

Major Sponsor: Clinipath

Measuring vitamin D: Revised indications and new restrictions Vitamin D is an important hormone required for bone and muscle development as well as preservation of musculoskeletal function. Vitamin D has three main functions: to enhance intestinal calcium and phosphate absorption, inhibit parathyroid hormone production and promote formation and mineralisation of bone.

Recent changes regarding when to test for vitamin D deďŹ ciency by the Royal College of Pathologists of Australasia (RCPA) reect the primary importance of vitamin D in musculoskeletal health as well as emphasise those patients at risk of developing deďŹ ciency.

These test criteria have largely been adopted by the Department of Health and Ageing, resulting in more restricted indications for testing on the Medicare BeneďŹ ts Schedule.

Referring practitioners should be aware of these changes and to assist laboratories, provide relevant clinical details when referring patients for vitamin D testing.

The RCPA position statement in May 2013 clariďŹ ed the role of vitamin D testing in vitamin D deďŹ ciency, with guidelines for who should be tested and when to repeat testing. The recommendations, broadly consistent with current evidence, advocate testing those at increased risk of vitamin D deďŹ ciency and provide clinical indications (see Table). A subsequent review by the Department of Health and Ageing has led to changes in the Medicare BeneďŹ ts Schedule adopting these speciďŹ c indications for vitamin D testing.

Degrees of deďŹ ciency Although 1,25-dihydroxyvitamin D is the functionally active vitamin D metabolite, vitamin D deďŹ ciency is deďŹ ned according to the measured concentration of circulating 25-hydroxyvitamin D. sĂĽ -ODERATEĂĽTOĂĽSEVEREĂĽVITAMINĂĽ$ĂĽDElCIENCYĂĽ HYDROXYVITAMINĂĽ$ĂĽ ĂĽNMOL , ĂĽISĂĽ causally associated with osteomalacia and rickets in children. sĂĽ -ILDĂĽVITAMINĂĽ$ĂĽDElCIENCYĂĽ HYDROXYVITAMINĂĽ$ĂĽ ĂĽNMOL , ĂĽISĂĽ associated with hip and other osteoporotic fractures.

Correction of vitamin D deďŹ ciency and adequate calcium intake have been cornerstones of osteoporosis management.

Most evidence for fracture reduction with current anti-resorptive therapies has been from trials where participants were vitamin D and calcium replete, or if not, they were receiving adequate supplementation.

testing of 25-hydroxyvitamin D at the same laboratory, at the end of winter in patients who are concerned about fracture risk or falls is still appropriate management in 2015.

Repeat testing

Table: Risk factors for vitamin D deďŹ ciency

Repeat testing is commonly advised, because the nadir of parathyroid hormone suppression following supplementation with cholecalciferol (vitamin D3) can take at least three months and the response can vary between individuals. Consequently, repeat testing after three months is recommended in most guidelines.

ADULTS

In patients already taking long-term replacement (including when combined with other treatments such as a bisphosphonate) or who have a higher fracture risk, repeat testing annually at the end of winter may be helpful, especially if risk factors for vitamin D deďŹ ciency have changed. The Medicare BeneďŹ ts Schedule currently does not restrict the number of vitamin D tests performed annually.

Targets explained Surrogate measures indicate that a HYDROXYVITAMINĂĽ$ĂĽTHRESHOLDĂĽOFĂĽ ĂĽNMOL ,ĂĽATĂĽ the end of winter (to account for the seasonal nadir) is a suitable target for treatment.

Supplementation of patients at highest risk for fracture should aim to achieve above this target. Practitioners should pay attention to the measured amount of 25-hydroxyvitamin D but be cautious of quoted desirable limits reported by some laboratories.

The different threshold limits quoted by laboratories are not due to methodological differences but to differences in the interpretation of data from surrogate measures and to the use of overseas, rather than Australian, guidelines. At Clinipath Pathology we report the desirable limit recommended in Australian guidelines.

Recommendations Vitamin D is one of the most commonly requested tests. Cholecalciferol therapy is well tolerated, easy to administer and readily available in Australia. Replacement should be started when circulating levels of HYDROXYVITAMINĂĽ$ĂĽAREĂĽLOWĂĽ ĂĽNMOL ,ĂĽATĂĽ the end of winter) and when patients are at increased risk of falls or fractures. Annual

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au

3IGNS ĂĽSYMPTOMSĂĽAND ORĂĽPLANNEDĂĽ treatment of osteoporosis or osteomalacia.

Increased alkaline phosphatase with otherwise normal liver function tests.

Hyperparathyroidism, hypo- or hypercalcaemia, hypophosphataemia.

Malabsorption (e.g. cystic ďŹ brosis, short bowel syndrome, inammatory bowel disease, untreated coeliac disease, bariatric surgery).

Deeply pigmented skin, or chronic and severe lack of sun exposure for cultural, medical, occupational or residential reasons.

Drugs known to decrease 25-hydroxyvitamin D levels (mainly anticonvulsants).

Chronic renal failure and renal transplant recipients #(),$2%.

3IGNS ĂĽSYMPTOMSĂĽAND ORĂĽPLANNEDĂĽ treatment of rickets.

Infants of mothers with established vitamin D deďŹ ciency. %XCLUSIVELYĂĽBREASTFEDĂĽBABIESĂĽINĂĽ combination with at least one other risk factor.

Siblings of infants or children with vitamin D deďŹ ciency.

Incisions

It’s Time GPs Took Control As the Government slowly extricates itself from the ďŹ scal responsibility of health care, RACGP President Dr Frank Jones says the College has a plan for the future.

Investing in the health of your population makes sound economic sense. Investing time and effort into maintaining one’s own health also makes sense. Maintaining good health costs money.

Governments, worldwide, are struggling with evolving health demography and the associated ďŹ scal responsibility. Countries with a strong primary health system (general practice) experience improved health outcomes, provide better quality of care and population health outcomes, along with greater equity and at a lower cost.

GPs in Australia see about 85% of the population annually with referrals to secondary and tertiary care accounting for less than 5-10% of consults. However, in terms of comparative Government spending, general practice and hospital spending represents 15.5% and 84.5% respectively.

The ďŹ gures speak for themselves. The RACGP has been persistent in presenting the statistics to Government. It has been said they are HEARINGĂĽBUTĂĽNOTĂĽLISTENING ĂĽ7HETHERĂĽTHISĂĽISĂĽTRUEĂĽ or not, recent Medicare BeneďŹ t Schedule (MBS) changes have unequivocally targeted general practice.

The Government has said it wants to send a ‘price signal’.

7HILEĂĽATĂĽITSĂĽCOREĂĽTHEĂĽ2!#'0ĂĽISĂĽANĂĽACADEMICĂĽ college, patient quality care is being affected

and the vast majority of our members expect an enhanced advocacy role by the College.

Recent government reforms include a cut of $5 in the rebates for non-concessional PATIENTSĂĽ ĂĽYEARSĂĽANDĂĽAĂĽFREEZEĂĽONĂĽALLĂĽ'0ĂĽ-"3ĂĽ item numbers until 1 July 2018: the removal of THEĂĽPROPOSEDĂĽCHANGEĂĽINĂĽTHEĂĽ! "ĂĽTIMINGĂĽWASĂĽ sensible and welcome following pressure from the RACGP, GPs and their communities.

savings that could be generated in this area.

Instead it is general practice, the most costeffective sector of the health care system, which has been targeted.

The MBS rebate is a deal between the Government and the patient. It is the ‘bottom line’ the Government is prepared to invest in its community’s health needs. The message from government is loud and clear: ‘we have limited our ďŹ scal responsibility’.

7HEREĂĽDOESĂĽTHISĂĽLEAVEĂĽTHEĂĽFRONTLINEĂĽ'0

As usual, specialist costs and secondary and tertiary care have been immune from the health funding debate despite the known savings that could be generated in this area.

Our health system is complex, with much duplication and opportunities for improved efďŹ ciency. This is where our collective energy should be focussed. RamiďŹ cations of change need to be carefully debated.

As usual, specialist costs and secondary and tertiary care have been immune from the health funding debate despite the known

It is obvious we can no longer ďŹ nancially rely on a central Government subsidy scheme.

7HATüWEüNEEDüISüAüCOMPLETEüREAPPRAISALüOFüTHEü funding model for general practice, reecting the true cost of providing quality continuity of care for a changed demography. There needs to be a sustainable, cost-effective patient and practitioner quality driven system of primary health care.

The RACGP has developed an innovative, sustainable ďŹ nancial model, which will include item off services in addition to rewarding practitioners and practices for providing quality HEALTHĂĽCARE ĂĽ% HEALTHĂĽANDĂĽE CONSULTATIONSĂĽWILLĂĽ also become integral to the funding model.

Moving away from our almost total reliance on a Government subsidy program presents an opportunity for general practice to reinforce its position as central in the provision of health care in Australia.

Dr Rohan Gay, Walter Road East practice: “My photo of the 23 forms required to register one doctor, all addressed to Medicare. The number of forms has ballooned with every new SIP, PIP and immunisation incentive introduced; a co-payment will no doubt add one more form. I think the ill-considered co-payment debate obscures the bigger picture of the bureaucratic overload and perverse funding GPs labour under.�

8

MEDICAL FORUM

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What is FFR all about?

Dr Mark Hands Clinical Associate Professor (UWA), Interventional Cardiologist

About the author Fractional Flow Reserve (FFR) is a technique used in coronary intervention to measure the pressure difference across a coronary artery (CA) stenosis (narrowing) to determine the likelihood that the stenosis is flow limiting i.e. this then determines whether percutaneous coronary intervention (PCI) with stenting is required.

FFR is defined by the maximal achievable blood flow in a stenotic coronary artery divided by maximal blood flow in the same artery without stenosis. It is derived by dividing the pressure distal (Pd) to a stenosis by the pressure prior the stenosis (Pa) during maximal blood flow (Diagram 1).

Q Diagram 1

The Procedure The FFR wire has a pressure sensor located approximately 3cm from its tip.

During cardiac catheterisation through an angioplasty guide catheter the wire is passed across the lesion such that the sensor is distal to the stenosis being interrogated.

Maximal blood flow (hyperemia) is induced by intracoronary nitroglycerin (dilating the epicardial arteries) and intracoronary or intravenous adenosine (dilating the microcirculation). Simultaneous recordings of the pressure distal to the lesion (from the sensor on the FFR wire) and proximal (from

the guide catheter at the vessel origin) are measured and the FFR is instantaneously derived.

6TJOH UIF ''3 There is no absolute cut-off point at which the FFR becomes abnormal.

However clinical trials have suggested a cut-off point of 0.75-0.80 being clinically significant. Higher values indicate nonsignificant stenosis, whereas lower values indicate a significant flow limiting lesion requiring intervention. Notably, for any given stenosis the FFR is also affected by the amount of myocardium that is supplied by that stenosed vessel e.g. the FFR of a 70% stenosis supplying a large area of myocardium/ micro-circulation will be lower than a 70% vessel supplying only a small area of myocardium/microcirculation. Thus the FFR is truly measuring the functional significance of a coronary stenosis in-situ.

The decision to perform percutaneous coronary intervention (PCI) is usually determined on angiographic results alone.

In symptomatic patients we tend to perform PCI in patients with greater than 70% stenosis but not in those with a less than 50% anatomical stenosis. Intermediate lesions (i.e. 50-70%) present a ‘grey’ zone where FFR is particularly useful. In this group the FFR can discriminate who should be stented and who should not. Data suggests that patients with flow-limiting lesions do better with stenting, whilst those with non-flow-limiting lesions are better off with medical therapy regardless of the degree of the “anatomical� narrowing.

The DEFER Study (1) clearly demonstrated that PCI of a functionally non-significant stenosis (i.e. FFR> 0.75) is of no benefit to the patient. The Fame Study (2) evaluated the role of FFR in patients with multi-vessel

Dr Mark Hands graduated from UWA with Honours (Dux) and trained in cardiology at Sir Charles Gairdner Hospital and Brigham Women’s Hospital, Harvard Medical School. He is an interventional cardiologist in private practice at Western Cardiology (chairman), Clinical Associate Professor (UWA) and emeritus consultant cardiologist at SCGH. In addition to general cardiology and echocardiography his special interests include investigation and treatment of acute and chronic ischemic heart disease. Dr Hands’ interventional procedural skills include coronary angiography, angioplasty and stenting in stable angina and in acute unstable angina and acute myocardial infarction and cardiac pacing.

coronary artery disease. Patients with FFRguided PCI compared with angiographyguided PCI had fewer stents used and after twelve months the primary end point of death, non-fatal myocardial infarction and repeat revascularisations was lower in the FFR group (13.2% versus 18.3%), combined with shorter hospital stay (3.4 versus 3.7 days) and less overall procedural costs. The follow up FAME II Study (3) clearly demonstrated that FFR guided PCI improved outcome over medical therapy.

4VNNBSZ FFR measurement is now an integral and routine procedure in selected patients in the cardiac catheter laboratory. Used properly it is associated with less stenting, better outcomes for the patient and overall cost effective. Thus it is useful that general practitioners have at least a basic understanding of FFR. References (1) N.H Pijls et al. Percutaneous coronary intervention of functionally non-significant stenosis. 5 year follow up of the DEFER study. T.AmColl, 49(2007), 2105-11.

(2) P.A.L Tonino et al. Fractional Flow Reserve versus Angiography. Percutaneous Coronary Intervention.

NJEM 2009; 360 : 213-224.

(3) B. DeBruyne et al. Fractional Flow Reserve-Guided PCI Versus Medical Therapy in Stable Coronary Disease.

NEJM 2012; 367: 991-1001

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9

Celebrity Spotlight

Jonathan’s Giant Leap This year’s Perth Festival will be artistic director Jonathan Holloway’s last so he’s upsized the program with a some large and impressive acts.

No two cultural events are ever the same but Jonathan Holloway, the Artistic Director of the Perth International Arts Festival (PIAF) has a clear and singular vision – celebrate the extraordinary, which is why he has chosen The Phenomenal Journey of the Giants as his one of his standout swansongs at this year’s festival. “It sounds ippant but when I ďŹ rst came here as Artistic Director four years ago I was somewhat comforted by the fact that if the Festival did disappoint I didn’t really know anyone. The pressure has increased now I’ve got to know Perth a lot better and I feel a great sense of duty to deliver on a big scale.â€? “The Giants, a modern-day fable that will be played out on the streets of Perth, is a big part of that. It’s full of energy and passion and we just knew we had to do it!â€?

This will be Jonathan’s fourth and ďŹ nal Festival and, when it all began in 2012, he expressed a desire to ‘disrupt’ the city with the art of the unexpected. And now, looking back? “I’m really happy with the journey we’ve been on, given that you never really know where you’ll end up until the the celebrations have played themselves out. The aftershocks of a Festival take time to develop. Ideally, they mature with time and live in the memory as much as in the moment.â€? “Phillip Glass composed and played those AMAZINGĂĽ%TUDESĂĽLASTĂĽYEARĂĽANDĂĽTHEY REĂĽNOWĂĽ about to be recorded as a major new release.

That concert is now part of history and it’s left the musical world slightly changed. You just never know how far the ripples will run!�

Perth, by international standards, is a remote and somewhat isolated city. Jonathan reects on the ideal geographical space for a celebration of all-things cultural. “I think a festival changes according to the actual scale of a city. A city such as London, for example, tends to shape the particular events within a program. As a director you need to have an appropriate focus, ďŹ nd an audience and play to them.â€?

10

“My sense with Perth, and any city with a population of around 1.5 million people, is that you can engage the entire city and utilise the full gamut of artistic expression. Some cities need a big cultural event and Perth really beneďŹ ts from having a world class international arts festival, both geographically and in terms of year-round coverage.â€? “If PIAF didn’t exist someone would have to invent it!â€?

Jonathan is something of a peripatetic artistic gypsy and another relatively short-term tenure is rapidly drawing to a close. Does he ever get used to saying goodbye? “I’ve literally got nothing lined up for next year and, I have to admit, it’s more difďŹ cult to say farewell when you don’t know to whom you’re saying hello. Our two children have spent more than half their lives in Perth. It’s been home for them and they love it.â€? h7HENĂĽYOUĂĽCOMEĂĽTOĂĽAĂĽNEWĂĽCITYĂĽYOUĂĽDON TĂĽGIVEĂĽ a thought about leaving and then suddenly it hits you. It’s certainly an interesting way to live a life, and a slightly strange one.â€?

Festival Facts sĂĽ ,OTTERYWESTĂĽDONATEDĂĽ MĂĽTOĂĽ PIAF in 2014 sĂĽ 0)!&ĂĽISĂĽTHEĂĽLONGESTĂĽRUNNINGĂĽ international multi-arts festival in the Southern Hemisphere. sĂĽ )TĂĽATTRACTSĂĽMOREĂĽTHANĂĽ ĂĽ patrons in Perth and the Great Southern region.

PIAF 2015 runs from February 13 to March 7.

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11

Feature

Gym Junkies Crossing the Line The law is chasing the buyers and sellers of performance enhancing drugs in gyms across the country, but is it a hopeless case?

The Medical Board of Australia recently removed the accreditation of Dr Salim Ismail, a Perth GP who wrote tens of thousands of prescriptions for performance and image enhancing drugs (PIEDs) over a nine-year period.

Dr Carmel Goodman, Dr Carmel Goodman CMO at the WA Institute of Sport, notes that both the Australian Crime Commission (ACC) and Customs have detected a signiďŹ cant increase in the use and importation of PIEDs. “I became aware of this issue late last year in the wake of the ACC’s annual report. A detective attached to the taskforce spoke to us and expressed surprise at the increasingly HIGHĂĽUSEĂĽOFĂĽ0)%$S ĂĽPARTICULARLYĂĽWITHINĂĽTHEĂĽGYMĂĽ environment. There are anecdotal reports of individuals walking between exercise machines with eskies full of vials!â€? “And it’s not just recreational gym users either.

Some of these substances are becoming popular in anti-ageing clinics which are becoming major distribution points, both for their clients and for those who just want to bulk up.� “I don’t see this type of patient because I’ve made it very clear that I won’t have anything to do with steroids or growth hormones.

However, people are obviously presenting to doctors who are prepared to dispense this stuff or they’re sourcing it online. There would have to be GPs in Perth who are seeing the side-effects of these substances.â€? “The signs to look for, particularly with young men, are sudden mood swings, shifts in personality and higher than normal blood pressure.â€? “I don’t think the use of steroids and growth hormones is as prevalent in female bodybuilding but they do use the bulking-up, high CARBOHYDRATE HIGHĂĽPROTEINĂĽDIETS ĂĽ)T SĂĽIMPORTANTĂĽ to note that there are a number of legal supplements such as creatine that, using the correct regime, can increase muscle mass by up to 8kg.â€?

In a market where high illegal demand and strict legislative controls are uneasy bedfellows, nefarious activity is bound to ourish. h!##ĂĽINVESTIGATIONSĂĽSUGGESTĂĽTHATĂĽTHEĂĽ0)%$ĂĽ market is run by elements of the Italian and Russian maďŹ as which are moving away from heroin and cocaine and into illegal hormones and peptides. One of the attractive aspects is that if an individual is caught importing these substances the resulting penalties are much less severe. Backing up these ďŹ gures is the

12

fact that between 2009-10 Australian Customs reported an increase of about 300% in the DETECTIONĂĽRATEĂĽOFĂĽ0)%$S vĂĽ

“People need to realise that they have to keep taking them to reap the full beneďŹ ts and that’s risky and dangerous.â€?

“The ACC also reported that it has identiďŹ ed doctors in every State who are dispensing growth hormones to patients without a prescription, but access isn’t difďŹ cult. Young kids are getting them online and the products are quite cheap. There’s a speciďŹ c region in China that has around 1000 laboratories all focusing on this market.â€?

by Mr Peter McClelland

“There’s no control over any of these supplements. There’s no obligation for the manufacturers to list the constituent ingredients so consumers have no idea what they’re ingesting and even if a particular sample is tested there’s no guarantee the next batch will be the same.�

Johnny Allen, a 27 year-old personal trainer, competes in both state and national body-building competitions.

There are a number of different divisions designed to eliminate the Johnny Allen competitive advantage of 0)%$SĂĽBUTĂĽIT SĂĽFARĂĽFROMĂĽAĂĽLEVELĂĽPLAYINGĂĽlELD “I compete in what’s called the Natural Federation (NF) and, if you choose to do THAT ĂĽYOUĂĽAREN TĂĽPERMITTEDĂĽTOĂĽUSEĂĽANYĂĽ0)%$SĂĽ whatsoever. But even within that division e there’s no real way of knowing if people are bulked-up with chemical assistance.â€? “Due to the cost of testing, they certainly don’t screen everyone. I’ve never been tested! The critical thing is, in terms of competition, that unlesss you’re genetically blessed you’ll alwayss o struggle to match it with the guys who use steroids.â€? h4HEĂĽUSEĂĽOFĂĽ0)%$SĂĽISĂĽVERYĂĽCOMMONĂĽ among the younger guys. They’re easily inuenced, they want to get big ike straight away and they look at things like her human growth hormones as just another e supplement. They don’t appreciate the risks, they want THAT body and they want ITĂĽ./7 vĂĽ ch “I do use some basic supplements such E ASĂĽ7HEYĂĽ0ROTEINĂĽ0OWDERĂĽANDĂĽ#REATINEĂĽ Monohydrate but I stress to my clientss that roper they won’t get good results without proper preparation and training. Nonetheless,, if you put a famous bodybuilder on the labell of a ‘fat ere are burner’ or a ‘testosterone booster’ there huge proďŹ ts to be made.â€?

The Gym Facts Common Supplements sĂĽ 7HEYĂĽ0ROTEINĂĽ0OWDER sĂĽ #REATINEĂĽ-ONOHYDRATE sĂĽ "RANCHĂĽ#HAINĂĽ!MINOĂĽ!CIDS sĂĽ 0RE 7ORKOUTĂĽANDĂĽ&ATĂĽ"URNERĂĽ Compounds Steroids and Hormones sĂĽ 4ESTOSTERONE sĂĽ (UMANĂĽ'ROWTHĂĽ(ORMONE sĂĽ $ "OL ĂĽ4REN !CEĂĽANDĂĽ3TANAZOL WWW CRIMECOMMISSION GOV AU australian-crime-commission-annualreport-2013-14

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A dedicated team of professionals continue to provide expert medico-legal advice. The commitment to deliver the very best value to Members remains true.

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MEDICAL FORUM

13

Medical Marketplace

Dollar Matters for those with Cancer Cost-containment arguments are raging around cancer treatment services.

Here’s a run-down of some of the issues.

Treating cancer is an emotive issue, particularly if you are on the receiving end and hanging on to survival. Nowhere is the carve-up of the limited health funding cake under closer scrutiny. Cancer treatment signiďŹ es to some all that is wasteful about medicine – treating end-stage disease with little hope of a cure and at great expense, while preventive programs go begging. On the other hand, doctors are obliged to offer the best for the patients before them. It is how doctors, oncologists in particular, go about deďŹ ning ‘the best’ that has greatest impact.

In the November 4, 2013, edition of the MJA, Bruce Armstrong listed a wide range of cancers and trends in incidence and mortality.

He concluded that, overall, Australians were better at treating than preventing cancers because incidence was increasing while mortality was decreasing. He mentioned that THEĂĽ!)(7ĂĽHADĂĽESTIMATEDĂĽAĂĽ ĂĽSPENDĂĽ of $3.19b on medical and hospital care and pharmaceuticals for cancer and $0.22b on community and public health programs, mostly for screening, not primary prevention.

The annual trends in cancer rates are inuenced by how we deďŹ ne them (prostate and thyroid being the best examples) against clear-cut climbs in rates (e.g. liver cancer).

Better treatments appear to have lowered the mortality rates from Hodgkin lymphoma, cancers of the cervix, testes, tongue and uterine endometrium.

Or as one commentator put it, “InsufďŹ cient prevention keeps cancer rates upâ€?. This was some months before pointing to a 19% per annum increase (over 10 years) in PBS cost FORĂĽANTI CANCERĂĽDRUGSĂĽUPĂĽUNTILĂĽTHEĂĽ MĂĽ SPENDĂĽINĂĽ ĂĽ4HATĂĽEQUATEDĂĽTOĂĽ ĂĽPERĂĽ prescription, as new pricier drugs became available.

This is a challenge for all involved as most solid tumours, if still present after initial treatment, will not be cured by further expensive chemotherapy. ! 0ROFĂĽ-ICHAELĂĽ/RTIZĂĽFROMĂĽ30-'ĂĽ'LOBALĂĽSAYSĂĽ the Australian Government is now spending almost 30% of its entire drug budget on cancer drugs (only 1.5% of PBS scripts). The PBS oncology spend has recently grown by 14.2% units and 25% in cost.

He asks if the Australian taxpayer is getting value for money when less than 2% of the population is using almost 30% of the drug budget? This spend is occurring in private ĂĽANDĂĽPUBLICĂĽ ĂĽHOSPITALS ĂĽ%VENĂĽ with our ageing population, he has a point.

Government introduced cost efďŹ ciencies in

April 2012 through dose-speciďŹ c prescribing and dispensing of chemotherapy agents that are given by infusion or injection, mainly to prevent wastage and allow community pharmacies to dispense for community based oncology services.

In the report, Health system expenditure on cancer and other neoplasms in Australia 2008-09,ĂĽRELEASEDĂĽ$ECEMBERĂĽ ĂĽTHEĂĽ!)(7ĂĽ said cancer and other neoplasms ranked sixth in terms of estimated health system expenditure on chronic diseases, accounting FORĂĽ ĂĽOFĂĽEXPENDITUREĂĽONĂĽALLĂĽCHRONICĂĽ diseases. #ANCERĂĽRESEARCHĂĽFUNDINGĂĽINĂĽ7! ĂĽASĂĽWEĂĽ reported in 2011, is fragmented and largely dependent on medical lobbying, not necessarily the prominence of individual cancers in the community. How researchers lobby through their media releases has been recently criticised as over-inated. Project funding may be how things must happen in a State that lacks ‘critical mass’ but some overarching rationalisation is needed as much of the funding is from the public purse, for which piecemeal project funding can be focused around researchers’ careers as well as patient outcomes.

by Dr Rob McEvoy

Medical Board & AHPRA...

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“I thought the discussion was excellent. Great to get some insight FROMĂĽTHEĂĽPOLITICIANS ĂĽ7ELLĂĽDONE vĂĽ Dr Cliff Neppe “A very enjoyable breakfast and a welcome break from work. I enjoyed meeting new people and specialists I have referred to but never met. The panel were very impressive ANDĂĽ2USSELLĂĽ7OOLFĂĽWASĂĽGREAT ĂĽ)TĂĽWASĂĽVERYĂĽ useful for the GPs to vent their frustrations.â€?

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14

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Have You Heard?

involvement, duplication of services and information, low referrals from GPs to programs, and difďŹ culties in coordinating SERVICEĂĽPROVIDERS ĂĽ7HILEĂĽTHEREĂĽWEREĂĽOBVIOUSĂĽ successes among the many plans and detailed research (Curtin Uni mainly), getting people across diverse areas onto the same page was no easy task. And so we wonder if the fact that 39 of the 144 attendees from now disbanded divisions of general practice (or their rebadged “networkâ€? names) make a difference to getting things done.

Countdown for PHNs The January 27 deadline for applications to RUNĂĽTHEĂĽTHREEĂĽ7!ĂĽ0RIMARYĂĽ(EALTHĂĽ.ETWORKSĂĽ may have just passed but the four bidders, Panorama Health (PNML), the rural ALLIANCEĂĽ 37ĂĽANDĂĽ+IMBERLEY 0ILBARAĂĽ-,S ĂĽ "ENTLEY !RMADALEĂĽ-,ĂĽANDĂĽTHEĂĽ7!ĂĽ!LLIANCEĂĽ (representing the remaining Medicare Locals) will not know until March if their bids are successful. That doesn’t leave a lot of time to manoeuvre given that PHNs are expected to be up and running by July 1. Talk has it that the government has seen the light (a month of enlightenments, it seems) and that there will be a 12-month handover between PHNs and MLs, with the obvious alternative BEINGĂĽAĂĽSERVICESĂĽBLACKĂĽHOLE ĂĽ7HILEĂĽBIDSĂĽAREĂĽ conďŹ dential, anecdotally there is no talk of any commercial bidders (Bupa et al), leaving existing MLs bidding for other ML turf. If this is the case, that’s an expensive exercise (estimates of $150m) in deckchair shufing.

Now the PHN process is advanced, the Labor Party has indicated it will keep PHNs if elected. That might comfort the bidders, but, then, we’ve all heard that one before.

MDAN’s new leadership After the failed MDA-MIGA merger turmoil last year, MDA National has appointed Mr Ian !NDERSONü PICTUREDüBELOW üASüTHEüNEWü#%/ü leaving long-time incumbent Mr Peter Forbes

Networks history repeating? !RCHIVEDĂĽPAPERSĂĽFROMĂĽTHEĂĽ7!ĂĽ#HRONICĂĽ$ISEASEĂĽ Summit (May 14, 2010, organised by the (EALTHĂĽ$EPARTMENTĂĽANDĂĽ7!ĂĽ'0ĂĽ.ETWORK ĂĽ show Dr Simon Towler as champion of the cause, with over 50 models of care developed FORĂĽ7!ĂĽ(EALTHĂĽ SEEĂĽWWW HEALTHNETWORKS HEALTH WA GOV AU MODELSOFCARE ĂĽRELATINGĂĽ to chronic disease management. Various speakers highlighted lack of consumer

free to retire after 39 years at the organisation.

Mr Anderson has most recently been the #%/ĂĽOVERSEEINGĂĽTHEĂĽCONSTRUCTIONĂĽOFĂĽTHEĂĽNEWĂĽ $400m public and private hospitals at Midland for St John of God Health Care. The MDANMIGA proposal prompted concern from AMA 7!ĂĽTHATĂĽ-$!. SĂĽTRADITIONALĂĽ7!ĂĽFOCUSĂĽWOULDĂĽ SHIFTĂĽEASTĂĽIFĂĽTHEĂĽMERGERĂĽWENTĂĽAHEAD ĂĽ7!ĂĽ members need not worry on that score with Mr Anderson’s experience ranging from the Midland role, Director of Capital Management ATĂĽ.-(3 ĂĽ#%/ĂĽOFĂĽ3+'ĂĽANDĂĽGENERALĂĽMANAGERĂĽ of HBF, rooting him ďŹ rmly into the local health establishment. Dr Glen Power is the new -IDLANDĂĽ#%/

Local cells sell The past year has been a big one for local biotech Orthocell. Readers will remember the regenerative medicine company had opened its new facilities in Malaga and listed on the ASX in 2014 and before year’s end it announced it was partnering with Swedish biotech Bonesupport, which produces injectable bone substitutes. Together they hope to play a part in the $2.1b global bone graft and substitutes market. Speaking of markets, GlobalData recently reported last MONTHüTHATüTHEREüWEREüAüRECORDü üMERGERSü and acquisitions in the medical device industry in 2014, which has left the market smaller but with some powerful hitters. The biggest deal of the year was Medtronic’s $42.9 billion acquisition of Covidien, creating the world’s largest medical device company.

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MEDICAL FORUM

A whacky investment?

Despite no sign of legislative movement locally, 7!üINVESTORSüAREüAPPARENTLYüQUEUINGüUPüTOü be a part of medical marijuana company Phytotech Medical’s initial public offering.

Business News reports that Phytotech will accept $932,000 of oversubscriptions bringing its IPO to $5.9m. The company’s base is in Israel with sites in California and Uruguay, BUTüITSüEXECUTIVEüDIRECTORüISü7! BORNü2OSSü Smith. He said the ASX required Phytotech to procure legal opinion prior to listing, now it’s all systems go. The IPO comes at the time WHENüTHEü.37üGOVERNMENTüISüFUNDINGüTHREEü medical marijuana trials and the new Victorian Labor government is working to make good its election promise to legalise medical marijuana by the end of the year.

Prof Geoff Riley is reaping the reward of his passion for the Rural Student Recruitment Program with ďŹ ve Indigenous students and 44 rural students (from 23 country towns) graduating from the 57!ĂĽ-EDICALĂĽ3CHOOL ĂĽTHEĂĽLARGESTĂĽCOHORTĂĽINĂĽAĂĽSINGLEĂĽYEAR ĂĽ'EOFFĂĽSAIDĂĽ ĂĽMOREĂĽRURALĂĽMEDICALĂĽSTUDENTSĂĽ were expected to graduate this year. He’s picture here, from left, with Dr Janelle Jurgenson "UNBURY ĂĽ$RĂĽ$USTINĂĽ3PRIGGĂĽ .AREMBEEN ĂĽ$RĂĽ&RANCESĂĽ4OLMANĂĽ %SPERANCE ĂĽ$RĂĽ0IPPINĂĽ(OLMESĂĽ -INGENEW ĂĽ$RĂĽ%RINĂĽ3TAINESĂĽ +ONDININ ĂĽANDĂĽ$RĂĽ+YLEĂĽ&AIRCLOUGHĂĽ $ENMARK

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We really are getting old

Mental Health Commissioner Tim Marney made his biggest splash since taking up the role in February with the launch of the draft Mental Health Plan in December. Media reports headlined the closure of Graylands Hospital by 2025. Those who have seen the former Under Treasurer in action know he’s a doer not a sayer. The 131-page plan proposes a shift from expensive centralised hospital responses and looks to make treatment and support services accessible at the local primary care level. The plan is OPENüFORüCOMMENTüUNTILü-ARCHü üHTTPS CONSULTATION HEALTH WA GOV AU STRATEGY theplan-consultation.

This will come as no surprise to those in general practice, especially those working in Aged Care, but now there are stats to back ITĂĽUP ĂĽ4HEĂĽ7!ĂĽ'OVERNMENTĂĽANNOUNCEDĂĽTHEREĂĽ were a record number of centenarians in

ĂĽWITHĂĽ ĂĽLIVINGĂĽWITHĂĽTHREEĂĽlGURES ĂĽ7HILEĂĽITĂĽ offered a nice photo opp for the Premier, the ďŹ gures are a sober reminder that hard on the heels of those 72 living treasures is an entire boom generation waiting its turn (including the 0REMIERĂĽHIMSELF ĂĽ7HILEĂĽ7!ĂĽ(EALTHĂĽANDĂĽTHOSEĂĽ who work in the sector are already feeling the strain, the State Government is pushing money – most recently, $200,000 – into local governments to help seniors stay healthy and at home. In the meantime, if you have a Seniors Card, make the most of it.

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17

Feature

Art for Health’s Sake Visual art is playing a unique role in the caring and healing of patients in hospitals as witnessed at Fiona Stanley Hospital and SJG Murdoch.

Building or expanding an existing hospital is not just about steel, concrete and IT. For the established SJG Murdoch Hospital, its art collection is substantial and impressive.

Arts Manager Ms Connie Petrillo said its program began in 2005 as a tribute to the Sisters of St John and their tradition of holistic and compassionate healing within a hospital environment. “There’ve been many studies reinforcing the role that an exposure to art plays in modern healthcare, both in an acceleration of the treatment and rehabilitation process. It’s all part of therapeutic healing and it can reduce the length of time a patient stays in hospital and decrease the use of pain medication,�

Connie said.

The reaction to a work of art is always subjective and one person’s masterpiece is another’s postmodern disaster.

Emotional Response “The agship of the program is most deďŹ nitely the art collection. And, yes, sometimes they’re challenging but we’ve focused on works that are transcendent and visually stunning.

There’s no doubt that there are many different artistic tastes and consequent reactions to the display of art. But it’s important to present works of art that challenges a viewer; that’s a risk, but art should always have an element of risk.� “Art is a universal language – a picture paints a thousand words – and whether it nurtures or challenges it should always nourish the individual and, at the very least, act as a

Adrenaline: Janis Nedela’s Rush #2 (SJG Murdoch)

catalyst to pause and reect. The majority OFĂĽARTWORKSĂĽATĂĽ3*'ĂĽ-URDOCHĂĽAREĂĽBYĂĽ7!ĂĽ artists and that’s intentional because they reect the place and role of this particular hospital. There’s also a signiďŹ cant number by Indigenous artists and that’s an integral part of the hospital’s commitment to reconciliation and the celebration of a rich Aboriginal culture.â€?

4HISĂĽMONTH SĂĽCOVERĂĽSHOWSĂĽ%$ĂĽDOCTORĂĽ3ANDORĂĽ Csontos in front of Alison Riley’s evocative artwork that is situated in the hospital’s cancer centre. “It’s also a way of forging relationships with the local arts community and, hopefully, making sure the collection remains contemporary, innovative and inclusive.â€?

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“The focus was to develop artwork in an area of the hospital frequented by children so the style and theme were tailored to the needs of younger patients. It’s been a wonderful opportunity for young people to be involved in their local hospital and for some of the students it was the ďŹ rst time their work had been displayed.â€? “The most important factor in everything we do is the way we care for patients and the experience they have at Fiona Stanley. Having said that, it’s not often we build a new tertiary hospital and its design lends itself very well to the incorporation of works of art. And having this community engagement is a deďŹ nite plus.â€?

Calming: Phillip Cook’s Herne Hill (SJG Murdoch)

Connecting to the landscape

SJG Murdoch arts manager Ms Connie Petrillo. Artwork: Chris Hopewell

There’s a broader brief to the SJG arts program, both on a policy level and in practical terms. In fact, it has just issued a tender for $500,000 a complementary artwork at the entrance to the hospital. “The entire SJG Health Care Group has a ďŹ rm belief in the value of the arts within the health SECTOR ĂĽ7E VEĂĽJUSTĂĽESTABLISHEDĂĽANĂĽ!RTSĂĽ#OUNCILĂĽ to develop this area across its 18 facilities in Australia and New Zealand, which will include its pathology, home nursing, disability and social outreach services.â€?

Children in hospitals At the industrial-look FSH, the paediatric ward is turning to artists of the future. Local high-school students have created artwork, their younger counterparts have selected the winning pieces and they have been digitised onto wallpaper. It’s all designed to make a child’s stay in hospital a positive experience and it will be rolled onto the walls at FSH early this month.

3ENIORĂĽ%NGAGEMENTĂĽ/FlCERĂĽ,UCYĂĽ+IRWAN 7ARDĂĽ WASĂĽTHEĂĽCATALYSTĂĽFORĂĽTHEĂĽ7ALLPAPERĂĽ0ROJECT

The paediatric ward is on the eastern side of the complex and one good reason why, says the Head of Paediatric Services, Dr Janine 3PENCER ĂĽAĂĽLOTĂĽOFĂĽTHEĂĽARTWORKĂĽREFERENCESĂĽAĂĽ7!ĂĽ landscape. “There’s an amazing diversity in the art but we do look out towards the desert and there’s a distinctive native ora and fauna theme with emus and camel trains. A lot of the art will APPEALĂĽTOĂĽINDIGENOUSĂĽKIDS ĂĽ7E LLĂĽALSOĂĽHAVEĂĽ a montage of water scenes some of which were done by children who arrived here as refugees.â€? “It’s so important to make this area of the hospital friendly and child-centred and also bear in mind that a child’s perception of a hospital visit is very different from an adults.

There’s a lot of supporting literature about the intrinsic beneďŹ ts of art in the treatment and recovery, particularly where young children are concerned.â€? h7E VEĂĽUSEDĂĽAĂĽLOTĂĽOFĂĽMUTEDĂĽCOLOURSĂĽTHATĂĽWILLĂĽ suit age-groups from babies to 18-year-olds and there’s lovely painting of Busselton Jetty THATĂĽSHOULDĂĽAPPEALĂĽTOĂĽOLDERĂĽCHILDREN ĂĽ7E REĂĽ hoping that the art will provoke conversations between patients and staff.â€? h4HEĂĽWAITINGĂĽROOMĂĽATĂĽTHEĂĽ0AEDIATRICĂĽ%$ĂĽISĂĽ interesting with some very quirky pieces done

Ms Lucy Kirwan-Ward and Dr Janine Spencer from Fiona Stanley Hospital

BYü7!üARTISTü3HAUNü4AN ü(E SüDONATEDüAüLOTüOFü his work to the hospital, some of which can be a bit confronting for younger children but we’ve selected appropriate pieces.�

4HEĂĽ7ALLPAPERĂĽ0ROJECTĂĽHASĂĽBEENĂĽAĂĽWONDERFULĂĽ way to engage with the wider community, suggests Janine. And the broader ethos of embracing a slightly different approach will have positive spin-offs for medical professionals. “There was a lot of enthusiasm from the schools involved and we may well do this on a biennial basis. Fiona Stanley is an inspirational person and we’ve got a terriďŹ c opportunity to do things a little differently here.â€?

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Feature

Genetics Research – a Big Pond While the WA research community lobbies for more local resources, the reality is that some research requires a global view.

3OMETIMEĂĽINĂĽTHEĂĽFUTURE ĂĽ7ENDYĂĽBELIEVESĂĽ intentional modiďŹ cations of cultured cells will precede putting them into someone for therapeutic purposes.

Meanwhile, it seems that the more you investigate the more complex it gets, with more options appearing. If that’s the case, how can anyone focus attention on one particular problem? h)üCAN TüANSWERüTHAT ü7HATüWEüHAVEüHEREü is at least the blueprint of what is normal and that can be used as a reference point so if we are studying disease and looking at particular pathways we may well see there is an abnormality of transcription at some point.

7EüCANüTHENüCOMEüUPüWITHü a way of making a genetic alteration.�

Winthrop Professor Wendy Erber agrees you can’t get ‘big’ research done without international collaboration. In genetics, with so many genes involved in some disorders, plus the superimposed effect of epigenetics, you need huge patient numbers to search out relationships. The multinational research she has been part of was a huge logistical challenge with no therapeutic ‘magic bullet’ in view. “This was a massive piece of research WORKĂĽFUNDEDĂĽTHROUGHĂĽTHEĂĽ%UROPEANĂĽ5NIONĂĽ Framework to the tune of millions of euros. I was just a part of it, with the author list around ĂĽPEOPLEnĂĽITĂĽREQUIRESĂĽAĂĽMULTITALENTEDĂĽ team; many talents, many people, many organisations coming together to deliver a big discovery.â€?

0ROFESSORĂĽ%RBERĂĽISĂĽ(EADĂĽOFĂĽ57! SĂĽ3CHOOLĂĽOFĂĽ Pathology and Laboratory Medicine. “I’m a haematologist so I was involved with, @7HATĂĽCELLĂĽISĂĽTHAT ĂĽSOĂĽASĂĽTOĂĽSPEAK ĂĽPLUSĂĽTHEREĂĽ were cell biologists growing speciďŹ c cell types while geneticists were doing some of the clever sequencing. It really takes a big pool coming from different angles.â€?

The hematopoietic stem cells and others needed for this study were sourced from umbilical cord blood donations, where progenitor cells are in higher numbers.

4HEĂĽLARGEĂĽINTERNATIONALĂĽ",5%02).4ĂĽRESEARCHĂĽ project set out to characterise gene expression driving lineage choice. They sequenced RNA from eight hematopoietic progenitor populations representing major

20

Technological breakthroughs have underpinned much of the RESEARCHĂĽINĂĽGENETICS ĂĽ7HILEĂĽ these ďŹ ndings add to the explosion in health information, FORĂĽSOMEONEĂĽWORKINGĂĽINĂĽ%$ ĂĽDOĂĽ all these possibilities help their ‘here and now’ decisions with patients?

myeloid and lymphoid stages. They knew that the way RNA is Prof Wendy Erber processed varies, leading “I don’t see that this research to different protein drivers changes what we offer for the differentiation of PATIENTSĂĽINĂĽ%$ĂĽTODAYĂĽBUTĂĽITĂĽDOESĂĽGIVEĂĽUSĂĽMOREĂĽ progenitor cells into mature blood cells. The background information so we can develop same gene is expressed in different ways. new therapeutics for immunological or Different mature blood cells result. haematological disorders, or develop more Research complexity includes these ďŹ ndings: sophisticated diagnostics. As the news story always says, ‘in ďŹ ve years’ time’ there may sĂĽ ĂĽRELEVANTĂĽGENESĂĽANDĂĽ ĂĽ2.!ĂĽ well be alterations to methylation that we can transcripts, administer to patients with particular bone sĂĽ ĂĽNOVELĂĽSPLICEĂĽJUNCTIONSĂĽANDĂĽ ĂĽ marrow diseases that might turn off epigenetic differentially used alternative splicing regulation or transcription of particular genes events, in a very targeted approach.â€? sĂĽ ANĂĽISOFORMĂĽOFĂĽNUCLEARĂĽFACTORĂĽ) "ĂĽ .&)" ĂĽ regulates megakaryocyte maturation into platelets, sĂĽ COMPLEXĂĽFATINGĂĽEVENTSĂĽAFFECTĂĽCLOSELY RELATEDĂĽ progenitor populations.

Potential applications for patients with blood disorders, arising from this study, include new diagnostics and therapies for problems like leukaemia. Then there is stem cell transplantation therapy, regenerative medicine and discovering the genetic basis of rare inherited haematological and immunological disorders. “This piece of work has uncovered that every cell is born with the same genetic information.

But what then makes the decision that RNA is then generated and translated into proteins?

And you also have the epigenetics that sit on top of that, as checking mechanisms?�

7ITHĂĽTHISĂĽINĂĽMIND ĂĽRESEARCHĂĽINSTITUTESĂĽAREĂĽ popping up everywhere. They now have to market themselves to compete and attract THEĂĽRIGHTĂĽPEOPLE ĂĽ4HEYĂĽAREĂĽCOSTLY ĂĽ7ILLĂĽMARKETĂĽ forces impact on them? “Top-ight medical research is very pricey.

This was hugely expensive research across many organisations, all of them pulling together to generate this new knowledge.� “As part of this, I’m involved with regular teleconferences, sending emails and pictures to try and bring this together. There were two or three main drivers who may never had got their hands dirty, looked down a microscope or run a sequencer but they had to make sure all the people were pulling together to bring this to fruition.� She is referring to the main centres in the UK and Holland.

by Dr Rob McEvoy

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21

Q&A

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MEDICAL FORUM

Medicolegal Q&A

Q:

An elderly patient of mine doesn’t want me to treat her as she wants to die. What needs to be in place for me to comply with my patient’s wishes?

A:

Recent articles in the MJA1 have highlighted the dilemmas doctors face when end-of-life issues arise and there is a concern about the patient’s capacity.

Following amendments to the Guardianship and Administration Act 1990 7! åINå å patients have been able to plan the treatment they will be given in the event they are unable to make such decisions themselves. This is done by preparing an Advance Health Directive (AHD). AHDs are legally binding documents that outline what a patient does and does not consent to if specific circumstances arise. This includes the ability to consent to or refuse palliative care and lifesaving treatment.2 Patients may also have an enduring guardian WHOåISåAPPOINTEDåUNDERåANå%NDURINGå0OWERå of Guardianship. An enduring guardian is nominated to make decisions, including treatment decisions, if a person is unable to make such decisions themselves. The difference between an enduring guardian and an enduring power of attorney is that the

Response by Morag Smith, Senior Solicitor, Avant Mutual Group Limited

power of attorney’s authority extends only to financial and property matters.

If a patient says they do not want any active treatment for their condition, it would be reasonable to ask them or their carer if they have prepared an AHD or if they have appointed an enduring guardian. If they have, then ask for a copy of the relevant document to be kept within the medical record, including any e-health record they have registered for.

Once you receive a copy of an AHD, review it with the patient to ensure it applies to their current situation, including any new diagnosis and the treatment options available. Guidance on how to approach this discussion is set out INåAå7!å(EALTHåPUBLICATIONåONå!DVANCEå#AREå Planning. 3 If a patient has neither an AHD nor an enduring guardian, they can verbally outline their wishes to their general practitioner or treating specialist, who should document them. As well as explaining the pros and cons to the patient, and documenting this, it is also advised to provide a second opinion if possible, and

have a discussion with the family if the patient agrees. Soon after a patient verbally conveys their wishes, a capacity assessment should be conducted to ensure they understand the nature of the treatment options, the benefits and risks of each option and what it means if they don’t have treatment.

If all the relevant information is given, and the patient has made their decision freely and voluntarily, then they have the right to refuse treatment.

Patients who refuse treatment should be encouraged to discuss the decision with their family to reduce the risk of disagreements in the future.

References 1. “End-of-life legal warning”, MJA, 11.08.2014; “Consent, capacity and the right to say no”, MJA, 2014, 201(8) 486-488.

2. A Guide for Health Professionals to the Acts Amendment (Consent to Medical Treatment Act 2008 (WA) at www.health.wa.gov.au/ advancecareplanning/health_professionals/index. cfm.

3. www.health.wa.gov.au/advancecareplanning/ docs/acp_guide_health_professionals.pdf

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Guest Column

Maintaining Satisfying Skills Dr Alex Thng understandably wonders why the system discourages appropriate combined use of his anaesthetic and obstetric skills.

I am both a GP Obstetrician (DRANZCOG) and GP Anaesthetist, working in a rural hospital that delivers over 1100 babies each year. Within the busy four operating suites it is frequently difďŹ cult to ďŹ nd an anaesthetist to promptly place an epidural for women experiencing a painful labour.

I am in the fortunate situation where I can fulďŹ l both roles but the system doesn’t recognise this. Instead, I am forced to be one or the other, GP obstetrician or GP anaesthetist.

If I am only allowed to be a GP anaesthetist, I am fully accredited to provide pain relief by putting in an epidural but this then breaks continuity of maternity care when I handover this role to someone unfamiliar to the patient.

If I am only allowed to be a GP obstetrician, I continue maternity care but accept potentially prolonging her distressing pain while waiting (sometimes hours) for another accredited doctor to put in the epidural.

For some 10 years now, when I have opted to put in an epidural, I have also opted to ‘hang around’ often until delivery or beyond, unofďŹ cially and unpaid, to provide maternity backup while the other GP obstetrician who received the ‘ofďŹ cial handover’ often remained OFFSITE UNAVAILABLE UNENGAGED ĂĽ!TĂĽNOĂĽTIMEĂĽHAVEĂĽ I felt my focus on fetal and maternal vital signs has been compromised, quite the opposite, in fact.

7HEREüTHEüDOCTORüCANüFULlLüBOTHüROLESü PUTü in an epidural and continue maternity care) the patient is safer – the same doctor carries

the responsibility of the epidural armed with an unparalleled knowledge of the patient’s medical history and birth plan.

Dismissing the preferred GP obstetrician BECAUSEĂĽHE SHEĂĽOPTEDĂĽTOĂĽRELIEVEĂĽPAINĂĽBYĂĽ performing a low risk epidural is not logical and could be seen as potentially unsafe and less fulďŹ lling for the woman. After all, these complementary tasks are not conicting or distracting, and are appreciated by midwifes.

A routine labour epidural is not a potential ‘crisis’ that requires a second obstetrician, often there in name only.

Where the doctor can fulďŹ l both roles (put in an epidural and continue maternity care) the patient is safer This is not the only scenario where a procedural obstetrician and anaesthetist should be encouraged to utilise their combined skills to beneďŹ t patients and improve safety. Consider the situation when the single accoucheur performs a safe pudendal block and forceps delivery or performs a vacuum assisted delivery after uncomplicated epidural.

Of course, when things go wrong (e.g. obstetric convulsion or inadvertent total spinal block), assistance from a second pair of hands, triggered by a Code Assist is always SENSIBLEĂĽAND ĂĽIFĂĽPOSSIBLE ĂĽPLANNEDĂĽFOR ĂĽ%VENĂĽ

Les Conceicao (MBA MIR BA Grad Dip FP FFin AFP)

Senior Financial Adviser Authorised Representative 296710

08 6462 1999 | www.morgans.com.au/perth Level 20, 140 St Georges Tce Perth WA 6000

when complications occur, the solution is NOTĂĽTOĂĽDROPĂĽTHEĂĽCOMBINEDĂĽ'0ĂĽ/BSTETRICIAN Anaesthetist from obstetric care but to keep them meaningfully involved.

For all legitimate services by someone with both qualiďŹ cations, appropriate Medicare remuneration should apply.

Editorial comment Currently, Medicare and private health funds do not allow items for delivery and epidural to be claimed by the same doctor.

Dr Thng’s experience in his rural practice seems at odds with government initiatives supporting GP obstetricians, designed to overcome disincentives identiďŹ ed as barriers to procedural obstetric practice.

7ITHĂĽAROUNDĂĽONEĂĽTHIRDĂĽOFĂĽALLĂĽ!USTRALIANĂĽBIRTHSĂĽ in non-metropolitan hospitals where about half do not provide specialist obstetric cover, rounded GP obstetric care is critical, particularly for low-risk rural women. About 10 years ago, a looming crisis in the provision of rural obstetric services was predicted with existing GP obstetricians leaving the workforce and 71% of GPs with an obstetrics Diploma opting not to use it.

It seems ludicrous that GP obstetricians and anaesthetists are discouraged from maintaining all their skills, especially where no compromise to patient safety is obvious. Do we want deskilled, professionally isolated GPs who abandon their obstetric and anaesthetic skills, those that complement each other in particular, as well as abandon communitybased obstetric services?

GESB Award Winning Financial Adviser Les has over 14 years experience as a licensed ďŹ nancial adviser with over 5 years as a Senior Financial Adviser with GESB Financial Advice and is a multiple award winner of the GESB Financial Adviser of the Year.

Les has specialised knowledge to create tailored tax-effective strategies to maximise your beneďŹ ts from: ƒ GESB West State Super ƒ GESB Gold State Super

Additionally, Morgans offers the Wealth+SMSF Solution service which frees up your time by taking care of the establishment and complete administration of a SMSF. We also offer top class equities and securities research, enabling comprehensive management of your SMSF portfolio.

To make an appointment or discuss your needs, please call Les on 08 6462 1960.

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MEDICAL FORUM

25

Guest Column

Let’s Fight for All Devaki Wallooppillai is a medical student who is part of AMSA’s Crossing Borders for Health, which aims to improve the health of asylum seekers and refugees.

It’s very difďŹ cult to hear about the health of asylum seekers. One main reason for entering medicine is to improve health but the system does not allow this.

Doctors say the Immigration Department has attempted to lessen the perception of health problems within detention centres. A leaked document also says “IHMS [International Health and Medical Services] needs to ensure medical staff who do reviews are not against Offshore Processing Centres�.

The status of both refugees (those outside their country who cannot return for fear of persecution) and asylum seekers (those who have ed their country and applied to become a refugee for protection) is commonly talked about. Both groups have had to leave their country of origin over concern for their lives or safety and unless the situation improves there, it is dangerous to return.

Current Australian policy dictates that those who seek asylum be indeďŹ nitely detained, or relocated on Nauru and Manus Island, though approximately 90% of those who seek asylum are found to be genuine refugees.

Australia has international obligations to

protect the rights of refugees and asylum seekers regardless of route of arrival or visa status. In Australia, 13,750 asylum seekers were resettled in 2013-2014 (0.058% of the Australian population). Compare this with the ‘resettling’ of 309,582 babies born in Australia in 2012.

Taxpayers pay ten times the amount for offshore processing than they would for community processing.

Health professionals know that both access to quality care and a safe environment are important social determinants of health.

Australia’s current bipartisan policy for detainees does not provide this.

'REENĂĽANDĂĽ%AGERĂĽSHOWEDĂĽTHATĂĽPEOPLEĂĽDETAINEDĂĽ for 24 months developed new mental illness ĂĽTIMESĂĽMOREĂĽOFTENĂĽTHANĂĽTHOSEĂĽRELEASEDĂĽ within three months (with an absolute rate of >27% for those detained for >24

months, versus <1% for those detained <3 months). Newman et al showed that anxiety, depression, post-traumatic stress disorder, self-harm and suicidal ideation have resulted, with a prevalence of >85%.Between January 2013 and March 2014, amongst children in detention, there were 128 reported self-harm incidents.

Furthermore, detention costs more. Taxpayers pay ten times the amount for offshore processing (~ $400,000 each) than they would for community processing, with a total cost of $3.3 billion in 2013-2014.

Given these things, the AMA, RACGP, RACP and AMSA have all called on the Government to adhere to the international obligation to respect the health of all refugees and asylum seekers.

7EĂĽCOULDĂĽIMPROVEĂĽHEALTHĂĽBYĂĽHAVINGĂĽAĂĽ maximum time that can be spent in detention, improving mental health services and training for those in detention, and ensuring transparency in the processing of asylum seekers. As a soon-to-be doctor, I hope things will change.

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9791 3280 MEDICAL FORUM

Guest Column

ACCC and Pharma Transparency Psychiatrist Dr Philip Morris has been campaigning for six years for more transparency in pharma relationships with doctors. The ACCC might bring results.

Transparency and ďŹ nancial relationships between doctors and the pharmaceutical industry was a hot topic reaching a crescendo late last year when the ACCC held a pre-decision forum after it delayed authorising the new Medicines Australia Code of Conduct.

It is no small matter. Some doctors receive substantial gifts or â&#x20AC;&#x2DC;transfers of valueâ&#x20AC;&#x2122; from the pharmaceutical industry with a monetary value that can reach into the tens of thousands of dollars a year with the potential of further gift support in future years. Currently, these gifts are kept secret from public view.

Some in the profession donâ&#x20AC;&#x2122;t think this is a big deal â&#x20AC;&#x201C; it is a private matter between the doctor and the pharmaceutical company. Others are not so sure â&#x20AC;&#x201C; and I am one of the latter.

ConďŹ&#x201A;icts of interest obscured 7HILEĂĽTHESEĂĽGIFTSĂĽAREĂĽKEPTĂĽSECRETĂĽTHEREĂĽISĂĽ no way physician colleagues, professional associations, or medical colleges on the one hand, or patients and patient advocates, or the public on the other hand can check for conďŹ&#x201A;icts of interest in advice given by or the prescribing habits of physicians receiving these gifts.

For the past six years, I, along with others, have been campaigning for these gifts to be made transparent. The most recent opportunity was the application of Medicines Australia (MA) to have its Code of Conduct %DITIONĂĽ ĂĽAUTHORISEDĂĽBYĂĽTHEĂĽ!USTRALIANĂĽ Competition and Consumer Commission (ACCC).

Push for mandatory disclosure

No excuse for delay

Most participants at the public meeting agreed that the transparency arrangements should be mandatory. This new model would mean that any practitioner entering into an agreement with a pharmaceutical company involving a transfer of value or gift would do so with the understanding that the transfer of value would be made public as identiďŹ ed payments to that particular practitioner.

Timing of the introduction of these transparency arrangements was also hotly debated. MA wants the transparency aspects OFĂĽTHEĂĽ#ODEĂĽDELAYEDĂĽUNTILĂĽ/CTOBERĂĽ ĂĽ however, in my view, its reasons were not persuasive.

If a practitioner does not want the transfer of value to be made public then the practitioner is free to reject the gift.

Most participants at the public meeting agreed that the transparency arrangements should be mandatory.

At the pre-determination meeting, MA tried to argue that it was better if a practitioner gave consent ďŹ rst to have transfers of value made public. It then argued that if a practitioner accepted and used the gift, but later withdrew consent, the transfer of value should be kept out of sight.

Of course this â&#x20AC;&#x2DC;opt outâ&#x20AC;&#x2122; clause would make a mockery of the transparency arrangements.

Once the ACCC makes a ďŹ nal determination early this year, it would not take more than six months for MA companies and health care practitioners to be made aware of the new arrangements and to implement methods of compliance. Therefore a start-up deadline of no later than the end of 2015 should be acceptable.

MA will be required to set up a centralised repository or database for making public all transfers of value to individual practitioners.

This could take some time, perhaps up to two years.

In the meantime, MA companies could record transfers of value to individual practitioners on the MA website. This would make the information available to consumers (and their advocate organisations) and to clinicians (and their professional associations and colleges) when assessing conďŹ&#x201A;icts of interest arising from ďŹ nancial relationships between health care professionals and the pharmaceutical industry.

The ACCC determination is an important opportunity to make the relationship between health practitioners and pharmaceutical companies more transparent. I hope it is not a wasted one.

Dr Philip Morris is a medical practitioner in Queensland.

s St John of God Murdoch Hospitalâ&#x20AC;&#x2122;s %MERGENCYĂĽ$EPARTMENT ĂĽLEDĂĽBYĂĽDr Paul Bailey, has been voted top private emergency department in Australia for the second year running in Press Ganeyâ&#x20AC;&#x2122;s annual patient survey. s Dr David Blacker is the new Medical $IRECTORĂĽATĂĽTHEĂĽ7!ĂĽ!USTRALIANĂĽ.EUROSCIENCEĂĽ 2ESEARCHĂĽ)NSTITUTEĂĽ 7!.2) ĂĽMr Roger Hussey is its new chairman. s Prof Jeff Hughes from Curtinâ&#x20AC;&#x2122;s School of Pharmacy, has been awarded the 2014 Australasian Pharmaceutical Sciences Association (APSA) Medal. s Former Dean of Medicine at Notre Dame University Prof Gavin Frost is now Dean of %DUCATIONĂĽATĂĽ2OYALĂĽ!USTRALASIANĂĽ#OLLEGEĂĽOFĂĽ Medical Administrators in Sydney.

MEDICAL FORUM

s Kaleeya Hospital, sitting on 10,000sq m in %ASTĂĽ&REMANTLE ĂĽHASĂĽBEENĂĽSOLDĂĽFORĂĽ MĂĽTOĂĽ 3OUTHERNĂĽ#ROSSĂĽ#AREĂĽ 7! ĂĽWHICHĂĽPLANSĂĽTOĂĽ use the land for an aged care service and health facility. s Mr Chris Pickett, Dr Andrew Png, Mr Tim Shackleton, and Dr Damien Zilm have BEENĂĽRE ELECTEDĂĽASĂĽ7!'0%4ĂĽDIRECTORSĂĽFORĂĽ another two-year term. s The WA Country Health Service received a 0REMIER SĂĽ!WARDĂĽFORĂĽ%XCELLENCEĂĽINĂĽTHEĂĽ0UBLICĂĽ Sector for its emergency telehealth service. s The NHMRC and the ARC have announced AĂĽ MĂĽ$EMENTIAĂĽ2ESEARCHĂĽ$EVELOPMENTĂĽ Fellowships scheme. s Genesis CancerCare has opened at Fiona Stanley Hospital from February 2 inside the hospitalâ&#x20AC;&#x2122;s Cancer Centre.

s Dr Sayanta Jana ĂĽ%$ĂĽOFĂĽ-EDICALĂĽ3ERVICESĂĽATĂĽ +%-(ĂĽWILLĂĽBEĂĽREPRESENTINGĂĽ!USTRALIANĂĽ0UBLICĂĽ Hospitals at the Australian Medical Council. s Renal physician and hypertension specialist Prof Markus Schlaich has been appointed inaugural Dobney Chair in Clinical Research, AĂĽPOSITIONĂĽCO FUNDEDĂĽBYĂĽ57! ĂĽ20(ĂĽANDĂĽ20(ĂĽ Medical Research Foundation. s 4HEĂĽWINNERSĂĽOFĂĽTHEĂĽANNUALĂĽ7!ĂĽ(EALTHĂĽ!WARDSĂĽ include: RPH Medical Renal Transplant Unit (Director Generalâ&#x20AC;&#x2122;s Award); Operations manager State Cancer Centre Mr Thomas Tuchyna (Minister for Healthâ&#x20AC;&#x2122;s Award); painHealth website developed by Dr Helen Slater, PhD, and Dr Stephanie Davies %MPOWERINGĂĽ0ATIENTSĂĽ!WARD ĂĽBreastscreen WA online booking project (Consumers %NGAGEMENTĂĽ!WARD

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MEDICAL FORUM

Clinical Case Study

Incidentaloma dilemma: benign or signiďŹ cant risk?

A recent case started general practitioner Dr Sean Stevens thinking about the potential harms of medical imaging.

CASE REPORT

The GP viewpoint This case, where one thing led to another, may seem extreme.

And it can be argued that each uncovered lesion was of a size where further scanning was indicated.

However, I have

By Dr Sean Stevens General Practitioner noticed an increasing trend for suggested repeat imaging of what are very low risk lesions, particularly in the lung and the liver.

Yet suggested scans are not without their radiation risk and cost.

Guidelines do exist on the re-imaging of lowrisk lesions but they have a surprisingly slim evidence base behind them and US studies suggest most radiologists donâ&#x20AC;&#x2122;t follow them anyway!

As a GP I ďŹ nd it very difďŹ cult to â&#x20AC;&#x2DC;over-ruleâ&#x20AC;&#x2122; the written advice of a radiologist (which may be read by the patient), even if according to the guidelines the repeat scan is not needed, or is not needed so soon.

I have, in some instances, referred to a hepatologist or respiratory physician who usually agrees with me in ignoring the radiologistâ&#x20AC;&#x2122;s advice, although this second opinion obviously comes at extra cost.

How much responsibility does the radiologist bear in recommending further imaging and how do we engage them in discussion to manage this increasing problem?

The Radiologist viewpoint

By Clin/ Prof Richard Mendelson, Director of Diagnostic and Interventional Radiology, RPH

It is difďŹ cult to comment without knowing the speciďŹ cs of Dr Stevensâ&#x20AC;&#x2122; patient â&#x20AC;&#x201C; in particular the radiological appearances of the various â&#x20AC;&#x2DC;incidentalomasâ&#x20AC;&#x2122; because each needs to be dealt with separately, according to the organ in which they occur.

However, as a general comment, incidental lesions are a major increasing problem. They are a signiďŹ cant cause of â&#x20AC;&#x2DC;over-diagnosisâ&#x20AC;&#x2122;; follow-up imaging and other investigations may well shift the cost-beneďŹ t and risk-beneďŹ t ratios to adverse levels for the patient, as well as causing much anxiety for patient and doctor.

MEDICAL FORUM

This conďŹ rmed the 42mm lesion as a benign cyst but also detected a separate 39mm hypoechoic liver lesion, for which a multiphase liver CT was recommended.

As suggested, I arranged the multiphase CT that revealed the 39mm liver lesion was probably a haemangioma (for which repeat imaging in three months was recommended) and also detected a 58mm cystic mass in the pelvis. Sure enough, further imaging was advised and the recommended pelvic ultrasound showed the lesion was a complex ovarian cyst for which gynaecological review was advised.

Patient liver ultrasound.

Mrs LS, a 52-year-old lady undergoing ankle surgery, had post-op chest pain so her orthopaedic surgeon did a CT pulmonary angiogram. The CTPA showed no pulmonary embolus but uncovered a 42mm lesion in the liver, for which ultrasound investigation was advised. The orthopod, quite rightly, referred her back to me to follow up and I dutifully ordered the US.

Such is the concern that the American College OFĂĽ2ADIOLOGYĂĽPUBLISHEDĂĽAĂĽSERIESĂĽOFĂĽ@7HITEĂĽ Papersâ&#x20AC;&#x2122; on the topic and a complete issue of Radiologic Clinics of North America was dedicated to it (Issue No 2, 2011). The size of the problem is large; at least 5% of abdominal CT scans show incidental lesions, and thyroid NODULESĂĽMAYĂĽBEĂĽDISCOVEREDĂĽINĂĽUPĂĽTOĂĽ ĂĽOFĂĽTHEĂĽ adult population undergoing carotid Doppler ultrasonography.

As Dr Stevensâ&#x20AC;&#x2122; suggests, there is a paucity of data on the effect on patient outcome of â&#x20AC;&#x2DC;incidentalomaâ&#x20AC;&#x2122; discovery, even for some lesions that are malignant (e.g. renal cancers).

In my opinion, when a radiologist reports an incidental lesion, the report should provide THEĂĽREFERRINGĂĽDOCTORĂĽWITHĂĽmEXIBILITYĂĽOFĂĽHIS her subsequent options by using a variation of the wording â&#x20AC;&#x153;there is an incidental lesion (insert site and description) that is likely to be a (insert differential diagnosis). Further imaging is recommended, if clinically indicatedâ&#x20AC;?.

Such a report should be nuanced by what the radiologist knows about the patient, including: a) The likely diagnosis: benign versus malignant; indolent versus aggressive? In the case of, for example, adrenal or thyroid nodules, is the lesion functioning and will the patient require any non-imaging investigation? For obviously simple cysts â&#x20AC;&#x201C; such as liver or renal â&#x20AC;&#x201C; the radiologistâ&#x20AC;&#x2122;s REPORTĂĽSHOULDĂĽREmECTĂĽHIS HERĂĽCONlDENCEĂĽOFĂĽAĂĽ benign pathology.

Referral to a gynaecologist resulted in a laparoscopic oophrectomy, with the histopathology showing a benign cyst.

In summary, this patient had two CTs (with another pending) two ultrasounds, an operation, histopathology, and multiple blood tests, all with no pathology found.

This has come at a total cost of several thousand dollars, and ~18mSv of radiation (about eight years of background radiation) with another ~10mSv to come.

b) Patientâ&#x20AC;&#x2122;s age: why investigate an incidental lesion the patient will die with, rather than of? For example, thyroid nodules, even if non-benign, are likely to be indolent papillary tumours that have an excellent prognosis with low risk of progression. c) Symptoms and co-morbidities: is the lesion TRULYĂĽASYMPTOMATIC ĂĽ7ILLĂĽANYĂĽTREATMENTĂĽ be contra-indicated by the patientâ&#x20AC;&#x2122;s comorbidities, making follow-up imaging IRRELEVANT ĂĽ7ILLĂĽINVESTIGATIONĂĽDISTRACTĂĽFROMĂĽ the real cause of symptoms? d) The risks (and costs) of further investigation: compared to the potential beneďŹ t, is it justiďŹ ed? e) The patientâ&#x20AC;&#x2122;s attitude: are they willing to accept a small risk of missing an important lesion, or are they risk-averse? Do they want an answer â&#x20AC;&#x2DC;nowâ&#x20AC;&#x2122; or are they willing to WAIT ĂĽ7HATĂĽLEVELĂĽOFĂĽANXIETY ĂĽ2ELEVANTĂĽFAMILYĂĽ and social history.

Importantly, the report should stimulate discussion between referring doctor and radiologist (as imaging consultant), with, of course, appropriate involvement of the patient.

Interested readers are referred to the literature (above) and published guidelines, including those on thyroid, liver, adrenal, adnexal and RENALĂĽLESIONSĂĽONĂĽTHEĂĽ7!ĂĽWEBSITEĂĽh$IAGNOSTICĂĽ Imaging Pathwaysâ&#x20AC;? (www.imagingpathways. health.wa.gov.au)

29

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MEDICAL FORUM

Innovations & Trends

Neonatal intensive care As NICU Director at King Edward Memorial Hospital (KEMH), Prof Karen Simmer can say babies 28 weeks or younger have the best survival in the country, which includes low disability rates (cerebral palsy and low IQ). Standout achievements have been establishing the human breast milk bank (taken up nationally and internationally) and probiotic prophylaxis for premature babies, both greatly reducing fatal necrotising enterocolitis (NEC). As well, researchers working with lamb models have been able to introduce JET ventilation â&#x20AC;&#x201C; â&#x20AC;&#x153;a fabulous rescue treatment for those who would normally succumb to worsening respiratory problemsâ&#x20AC;?.

Probiotic use in preterm infants

Outcomes for kids later in life

â&#x20AC;&#x153;It reduces all-cause mortality and, INDEPENDENTLY ĂĽNECROTISINGĂĽENTEROCOLITISĂĽ .%# ĂĽ 7EĂĽALLĂĽKNOWĂĽTHATĂĽTHEĂĽHUMANĂĽMICROBIOMEĂĽHASĂĽ a huge impact on health and not surprisingly the preterm infant is no exception, particularly as they are so vulnerable to infection and frequently receive high-dose intravenous ANTIBIOTICS ĂĽ5PĂĽTOĂĽ ĂĽAREĂĽDELIVEREDĂĽBYĂĽURGENTĂĽ caesarean section, which doesnâ&#x20AC;&#x2122;t help as well.â&#x20AC;?

Premature babies do surprisingly well and most research has shown no effect but with the improvement in survival rates, researchers are now looking at adults who were born premature. â&#x20AC;&#x153;Socioeconomic factors and genetics seem to overwhelm any effect of being born premature but there are still concerns about rates of diabetes and high blood pressure. Mind you,

4HEĂĽTWOĂĽ.)#5SĂĽATĂĽ+%-(ĂĽANDĂĽ0-( ĂĽPLUSĂĽTHEĂĽ .%43ĂĽRETRIEVALĂĽSERVICEĂĽ SEEĂĽLETTERS ĂĽAREĂĽRUNĂĽ by the same people â&#x20AC;&#x201C; 30 beds at the new Childrenâ&#x20AC;&#x2122;s Hospital for babies with surgical conditions or retrieved from elsewhere and a BEDĂĽ.)#5ĂĽATĂĽ+%-(ĂĽMAINLYĂĽFORĂĽPREMATUREĂĽ infants.

Single rooms detrimental in NICUs How might design directly affect premature neonates in Perthâ&#x20AC;&#x2122;s new ICU? â&#x20AC;&#x153;Research is coming out that shows babies that spend formative months in a single room at a time their brain is rapidly developing, appear to have poorer outcomes with LANGUAGE ĂĽTHANĂĽBABIESĂĽNURSEDĂĽINĂĽ ĂĽORĂĽ BEDĂĽ PODS vĂĽSHEĂĽSAID ĂĽADDINGĂĽTHATĂĽ%%'ĂĽANDĂĽ-2)ĂĽ changes attest to the difference. â&#x20AC;&#x153;Obviously, you donâ&#x20AC;&#x2122;t want them in extremely noisy environments but some baseline level of chatter from parents, nurses and doctors in the room is probably important for brain development. That is, there is potentially an adverse effect from different amounts of sensory deprivation in the NICU environment.â&#x20AC;?

She said the worldwide push to have single rooms was something her NICU staff resisted, mainly because single rooms would be harder to staff and the babies and families would be isolated. â&#x20AC;&#x153;It didnâ&#x20AC;&#x2122;t really occur to us that the babiesâ&#x20AC;&#x2122; brains wouldnâ&#x20AC;&#x2122;t develop as well!â&#x20AC;? she stressed.

The compromise for the NICU at the new Childrenâ&#x20AC;&#x2122;s Hospital is about half will be single ROOMSĂĽANDĂĽHALFĂĽFOUR BEDĂĽPODS ĂĽ!TĂĽ+%-( ĂĽ where most preterm infants are cared for, nearly all their 100 beds are in ďŹ ve areas including 2-4 bed pods for the sicker patients, and the only single rooms are for nursing in isolation. Surprisingly, it is the spacing of cots and things like hand washing and staff vaccination that reduce opportunist neonatal infections, not use of single rooms. â&#x20AC;&#x153;I think itâ&#x20AC;&#x2122;s an important development. As a director of a huge intensive care unit, which is a nightmare to manage, it just shows you shouldnâ&#x20AC;&#x2122;t make changes without researching the likely impacts on your patients.â&#x20AC;?

MEDICAL FORUM

Prof Karen Simmer, Director of Neonatal Intensive Care, KEMH and PMH

She is referring to neonatal colonisation by probiotics in breast milk (BiďŹ do and Lactobacilli) and the birth canal during normal labour.

how we feed premature infants now has changed dramatically so previous methods that might lead to insulin resistance are no longer used.â&#x20AC;?

2ESEARCHERSĂĽINĂĽ7!ĂĽTESTEDĂĽTHEĂĽAVAILABLEĂĽ commercial probiotics and found them wanting, eventually going with a single strain used and researched by neonatal units in Japan, BiďŹ dobacterium breve, after Dr Sanjay Patole et al demonstrated that giving it to infants colonised their gut.

In this rapidly changing world, it is hard to look at long-term effects with consistency.

h3INCEĂĽTHEN ĂĽATĂĽLEASTĂĽ ĂĽ.)#5 SĂĽINĂĽ!USTRALIAĂĽ HAVEĂĽDONEĂĽTHEĂĽSAME ĂĽ7HENĂĽWEĂĽOPENEDĂĽTHEĂĽ lRSTĂĽHUMANĂĽBREASTĂĽMILKĂĽBANKĂĽ; =ĂĽOURĂĽ.%#ĂĽ rate was lower than anywhere else, and with THEĂĽPROBIOTICĂĽITĂĽREDUCEDĂĽFURTHER ĂĽ/VERALL ĂĽ.%#ĂĽISĂĽ about 2% now.â&#x20AC;?

Reference Pineda RG, et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. J Pediatr. 2014 Jan;164(1):52-60

â&#x20AC;&#x153;Sometimes it becomes unethical to keep studying babies, for example, the cooling trial to reduce after effects from birth asphyxia, which we know works.â&#x20AC;?

â&#x20AC;&#x153;Ongoing research is looking at multiple vs single strains, and live versus dead strains, so there is plenty of work to do. There is no patent applied to it but death is pretty COMPELLING ĂĽ7ITHĂĽ.%# ĂĽALLĂĽGRADESĂĽAREĂĽREDUCED v

31

PRC BACK IN THE HANDS OF ITS DOCTORS Perth Radiological Clinic was created in 1948 and is the longest established private diagnostic medical imaging practice in Perth.

The Practice lives up to its mantra “Leaders in Medical Imaging” being the first private practice in WA to introduce ultrasound, CT and MRI services to Perth.

Today it employs over 700 Western Australians including over 70 specialist doctors.

On December 16, 2014 the Practice again became fully owned by its Partnership of radiologists.

It operates independent of any commercial or corporate owners.

The assurance of independent ownership attracts young outstanding radiologists who seek the benefits of partnership.

A strong Partnership and ownership structure means Perth Radiological Clinic will continue to provide the best care for our patients and referrers.

LEADERS IN

www.perthradclinic.com.au 32

MEDICAL

IMAGING MEDICAL FORUM

Innovations & Trends

Kimberley Children were 422 defendants with 2491charges laid, and 97 referrals to the Youth Justice Service.

These ďŹ gures suggest about half Aboriginal boys were in trouble in one year, of whom one quarter fell into the Juvenile Justice system, or 10% of total.

A year ago, as a social justice initiative, the Kimberley Alternative Juvenile Justice Strategy was started through the ofďŹ ce of the Kimberley MLA Ms Josie Farrer (and is now being CONSIDEREDĂĽBYĂĽTHEĂĽ7!ĂĽ0ARLIAMENT ĂĽ The underlying vision is a shift in rhetoric from punishment to compassion, care and nurturing (kanyirninpa)1 for boys and girls within the juvenile justice system. The aim of the Strategy is to prevent children (aged 11-17 years) from being sent to detention in Perth in three ways:

By Prof John Boulton, Regional Adviser in Paediatrics and Child Health.

Pictured here with Dakota.

Paediatrics and Child Health comprise three interconnecting layers: the acutely ill child; chronic complex disease and disability; and advocacy for the socially disadvantaged children who bear the heaviest burden of morbidity. Innovations for the ďŹ rst and third aspects have targeted Kimberley children.

Tackling infections early Aboriginal children in their ďŹ rst years face a tenfold higher risk of post-neonatal and childhood mortality, with sepsis the leading preventable cause. The â&#x20AC;&#x153;Assessment and %ARLYĂĽ-ANAGEMENTĂĽOFĂĽTHEĂĽ5NWELLĂĽ#HILDĂĽ0OLICYvĂĽ was implemented during 2010 in Fitzroy Crossing and Halls Creek, and throughout the region by the end of 2011.

The aim was to avoid delays in treatment of sometimes fatal bacterial infections. A management plan that identiďŹ es risk, a low threshold for parenteral antibiotics, clear guidelines for observation in hospital, and home management by parents of low risk children were part of it. The ďŹ ve-year mortality audit before the programâ&#x20AC;&#x2122;s introduction in 30 June 2013, compared to after that date, showed a drop in Aboriginal infant mortality from 14.9 to 9 per 1000 (post-neonatal mortality fell from 8.2 to 4.9). More long-term follow-up is needed to establish reliability.

Aboriginal boys at risk 7!ĂĽ!BORIGINALĂĽBOYSĂĽAREĂĽTHEĂĽMOSTĂĽMARGINALISEDĂĽ group with respect to a life curtailed by allcause violence, cardiovascular disease in EARLYĂĽMID LIFE ĂĽANDĂĽINCARCERATION ĂĽ)NĂĽ7! ĂĽANĂĽ average 150-200 children and youth aged from 11-17 years are in detention â&#x20AC;&#x201C; over 80% are Aboriginal (and most come from the North 7EST ĂĽ"OTHĂĽAREĂĽTWICEĂĽTHEĂĽNATIONALĂĽRATE ĂĽ4HEĂĽ Kimberley has about 1000 Aboriginal boys aged 11-17 years (ABS data). In 2012-13 there

MEDICAL FORUM

1. Those who require detention are looked after in a school-like environment with a focus on education, behaviour, and life skills.

2. Those under supervision orders are looked after out-of-town on a station or outstation placement by trained Aboriginal mentors. ĂĽ%ARLYĂĽDETECTIONĂĽANDĂĽPREVENTIONĂĽMEANSĂĽ each child who comes into contact with the Juvenile Justice system is rigorously assessed for intellectual developmental delay (typically due to FASD) and for emotional damage from early life trauma;

they receive the same level of care as if they had been referred to the hospital neurodevelopmental assessment clinic because of behavioural and learning difďŹ culties at school.

This area may seem far removed from everyday practice but is an invisible stain on the nationâ&#x20AC;&#x2122;s conscience, and is denied in every State election when there is an auction amongst politicians as to which party can be toughest on youth crime.

As a child specialist advocating compassion for the individual child, three things stand out: the high proportion who have severe intellectual disability (typically FASD) or who suffer from the social and emotional effects of early life trauma; the absence of public advocacy on their behalf by people who are very vocal in criticism of refugee children being held; and the echo of juvenile detention from Australiaâ&#x20AC;&#x2122;s early days of settlement.

The Kimberley Alternative Juvenile Justice Strategy is an example of how we Child Health professionals have a role in social justice far beyond our clinics.

Reference: 1. McCoy BF. 2008. Kanyirninpa and the health of Aboriginal men. Aboriginal Studies Press.

ED: Prof Boulton is now an honorary research fellow at Telethon Kids Institute.

Radiation Oncology services opened at Fiona Stanley Hospital on February 2, 2015

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Contact Department of Radiation Oncology Cancer Centre â&#x20AC;&#x201C; Lower Ground Foor Fiona Stanley Hospital

(08) 6152 5998 www.genesiscancercarewa.com.au

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Fiona Stanley Hospital

33

Asbestos exposure â&#x20AC;&#x201C; progress in caring for patients

By Dr Fraser Brims, Respiratory Physician, Asbestos Review Program & Lung Institute of Western Australia Western Australia has one of the highest rates of asbestos-related deaths in the world due to the amount and type of asbestos mined and imported during the last century. Crocidolite (blue asbestos) mining in Western Australia, particularly at Wittenoom, and its widespread use has resulted in signiďŹ cant asbestos exposures to Australians since the 1950s. Chrysotile (white asbestos) was also mined elsewhere in Australia and all forms of asbestos were imported until all asbestos production and importation was prohibited in 2003.

Surveillance for asbestos effects 3INCEĂĽ ĂĽ7ITTENOOMĂĽWORKERS ĂĽ FORMERĂĽRESIDENTSĂĽOFĂĽ7ITTENOOM ĂĽOTHERĂĽ workers with a minimum of three monthsâ&#x20AC;&#x2122; occupational asbestos exposure, and people with radiographically conďŹ rmed pleural plaques have all been provided with annual surveillance. Prof Bill Musk and Prof Nick de Klerk commenced surveillance as part of a clinical trial to see if Vitamin A supplementation reduced the incidence of mesothelioma.

7HILSTĂĽTHEĂĽORIGINALĂĽSTUDYĂĽDIDĂĽNOTĂĽDEMONSTRATEĂĽ any beneďŹ t, asbestos health surveillance has continued as the Asbestos Review Program !20 ĂĽUNIQUEĂĽTOĂĽ7!ĂĽANDĂĽFUNDEDĂĽBYĂĽTHEĂĽ(EALTHĂĽ Department. It is run from the Respiratory Medicine Department of Sir Charles Gairdner Hospital.

The ARP objectives are to: (i) monitor the health of people exposed to asbestos, (ii) provide health promotion resources and advice, and (iii) improve understanding of the health effects of asbestos exposure.

Since 1990, over 4,300 people have visited the program at least once. Many attend annually (about 1200 people currently). Collaboration WITHĂĽTHEĂĽ5NIVERSITYĂĽOFĂĽ7ESTERNĂĽ!USTRALIAĂĽOVERĂĽ the years has meant that observations in this cohort have translated into world-renowned research and the SCGH clinic has unparalleled experience in managing mesothelioma and other asbestos related diseases.

More recently, new technology adopted by the ARP is impacting on clinical outcomes.

Use of new technology %XPOSUREĂĽTOĂĽASBESTOSĂĽRAISESĂĽTHEĂĽRISKĂĽOFĂĽ developing lung cancer by at least twofold (depending on dose) and the risk is

34

Recent ARP data suggests that about 7-8 of 1000 people exposed to asbestos in the past may have an early stage and potentially curable asymptomatic lung cancer and up to three of these 1000 may develop a new lung cancer in the next 12 months.

Figure 1. An ultra-low dose CT scan of a Stage 1a invasive adenocarcinoma (arrow) in a never smoker previously exposed to asbestos as a tradesman. (The entire CT scan conferred the same radiation as a routine PA and lateral chest x-ray.)

multiplicative with concurrent tobacco and asbestos exposure.

The National Lung Screening Trial (NLST) in the USA showed that annual screening with low radiation dose computed tomography (LDCT) reduced lung cancer mortality in highrisk current or ex-cigarette smokers by 20%.

In 2012, in response to these results, the ARP adopted LDCT as an alternative to plain chest radiography during its routine annual review.

The ARP LDCT program has been successful in identifying early stage lung cancers that are operable and therefore potentially curable (recently published in the American Journal of Respiratory and Critical Care Medicine). This is a very signiďŹ cant development because currently in Australia most lung cancers (80%) present when they are too advanced for curative treatments.

The use of low dose CT is critical â&#x20AC;&#x201C; many people have had signiďŹ cant exposure to known carcinogens such as tobacco smoke and asbestos, consequently additional radiation exposure should be managed very carefully. The latest CT technology and software now confers the same radiation dose as a PA and lateral chest radiograph (0.1mSv), with CT images capable of picking up a lung cancer just a few millimetres in size.

The challenges of running this program are great, not least how to manage very early stage lesions â&#x20AC;&#x201C; a rapidly changing ďŹ eld that requires a team approach from thoracic radiology, respiratory physicians and thoracic surgeons.

The initial results from the ARP LDCT program are hugely exciting because there may now be an opportunity to detect and effectively treat a potentially lethal cancer at an early stage, whereas there has been no effective treatment for any of the other common asbestos related diseases (i.e. mesothelioma, asbestosis, pleural plaques or diffuse pleural thickening) in the past.

ARP is funded by

Asbestos Review Program, in a nutshell sĂĽ %XPOSUREĂĽTOĂĽASBESTOSĂĽWASĂĽCOMMONPLACEĂĽINĂĽ!USTRALIAĂĽTHROUGHOUTĂĽTHEĂĽLATTERĂĽHALFĂĽOFĂĽTHEĂĽ last century with hundreds of occupations affected. Pleural plaques and other asbestos related changes are common incidental ďŹ ndings on radiology. New technology has recently produced exciting advances in managing individuals exposed to asbestos. sĂĽ !NYONEĂĽWITHĂĽSIGNIlCANTĂĽPASTĂĽOCCUPATIONALĂĽEXPOSUREĂĽTOĂĽASBESTOSĂĽ ĂŤ ĂĽMONTHS ĂĽOFĂĽFULL TIMEĂĽWORKĂĽ WITHĂĽASBESTOS ĂĽAND ORĂĽTHOSEĂĽWITHĂĽPLEURALĂĽPLAQUESĂĽCANĂĽPOTENTIALLYĂĽJOINĂĽTHEĂĽ0ROGRAM ĂĽ sĂĽ 4HEĂĽ!20ĂĽPROVIDESĂĽANĂĽEFlCIENTĂĽANDĂĽEFFECTIVEĂĽANNUALĂĽHEALTHĂĽhCHECK UPvĂĽFORĂĽPARTICIPANTS sĂĽ )TĂĽPROVIDESĂĽSUPPORTĂĽANDĂĽADVICEĂĽAROUNDĂĽISSUESĂĽRELATEDĂĽTOĂĽPASTĂĽASBESTOSĂĽEXPOSURE ĂĽ4HISĂĽ includes advice on smoking, diet and exercise, as well as understanding and managing the risk of developing an asbestos-related disease. sĂĽ !LLĂĽRADIOLOGYĂĽREPORTSĂĽ ANDĂĽINCIDENTALĂĽlNDINGS ĂĽAREĂĽPROVIDEDĂĽTOĂĽTHEĂĽPARTICIPANT SĂĽNOMINATEDĂĽ'0 #ONTACTĂĽ.AOMIĂĽ(AMMONDĂĽONĂĽ ĂĽ COUNTRYĂĽCALLERS ĂĽ ĂĽ ĂĽ ĂĽORĂĽ ARP@health.wa.gov.au. For clinical queries contact Dr Fraser Brims, ARP Clinical Lead on ĂĽORĂĽFRASER BRIMS HEALTH WA GOV AU

MEDICAL FORUM

Innovations & Trends

Pharmacy health trends

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

By Mr Neil Keen, Chief Pharmacist, Dept of Health Some pharmaceutical innovations build on current practices while others are novel approaches.

Continued Dispensing, a Commonwealth initiative, allows continuation of supply of lipid modifying agents or oral contraceptives for patients already under treatment â&#x20AC;&#x201C; a single PBS supply, when unable to obtain a prescription, once a year. In the 9 months since the service was switched on (September

ĂĽTHEREĂĽWEREĂĽ ĂĽCONTINUEDĂĽSUPPLIESĂĽFROMĂĽ ĂĽPHARMACIESĂĽINĂĽ7!ĂĽ ACROSSĂĽ participating States, 41% for the contraceptive pill).

PBS public hospital reform. Almost a decade ago, State and Commonwealth Governments agreed to replace the 2-7 day discharge supply of medications for public hospital patients (people ran out, poor adherence and readmissions) with the same PBS access as community patients. Initial uptake was by secondary metropolitan hospitals, then the new state-wide pharmacy IT system allowed some tertiary metropolitan HOSPITALSĂĽTOĂĽCOMMENCEĂĽINĂĽ ĂĽANDĂĽ7!ĂĽCOUNTYĂĽHOSPITALSĂĽINĂĽ ĂĽ/VERĂĽ the last few years, remaining metropolitan hospitals have joined, with PMH the most recent site (early 2014).

Statewide formulary.ĂĽ-OSTĂĽ7!ĂĽHOSPITALSĂĽMAINTAINĂĽTHEIRĂĽOWNĂĽMEDICINESĂĽ formulary â&#x20AC;&#x201C; approved and unapproved uses, prescribing restrictions and other clinical guidance â&#x20AC;&#x201C; particularly aimed at high cost and complex medications to provide clinicians a list of accepted, cost effective and FUNDEDĂĽTREATMENTS ĂĽ)NĂĽ ĂĽTHEĂĽ7!ĂĽ4HERAPEUTICĂĽ!DVISORYĂĽ'ROUPĂĽ 7!4!' ĂĽ set out to consolidate all current hospital formularies into one state-wide FORMULARYĂĽnĂĽTOĂĽIMPROVEĂĽQUALITYĂĽUSEĂĽOFĂĽMEDICINESĂĽINĂĽ7!ĂĽHOSPITALSĂĽANDĂĽPROVIDEĂĽ better consistency for patients and prescribers.

The National Residential Medication Chart (NRMC), a Commonwealth initiative, provides a standard national document to write prescriptions and keep track of medicines given to residents in care facilities. It reduces the administrative burden for all involved, so that a correctly written medication ORDERĂĽONĂĽTHEĂĽ.-2#ĂĽISĂĽAĂĽLEGALĂĽPRESCRIPTIONĂĽINĂĽ7!ĂĽANDĂĽALSOĂĽAĂĽVALIDĂĽ0"3ĂĽSCRIPT ĂĽ No longer is a separate PBS prescription required and orders on the chart can be valid for up to 4 months. Implementing the NRMC requires a number of major changes to workďŹ&#x201A;ow and staff practices by a care facility.

Medicines and Poisons Act 2014. Passed in July 2014, this is the SUCCESSORĂĽTOĂĽTHEĂĽAGEINGĂĽ0OISONSĂĽ!CTĂĽ ĂĽ)TĂĽPROVIDESĂĽAĂĽFRAMEWORKĂĽFORĂĽ controlling supply of medicines and poisons and requires people to be qualiďŹ ed and authorised as recognised health professionals or holders of a Government licence. Key changes embrace action against doctor shoppers, overseeing prescribed drugs of dependence, and newer technologies for the distribution of medicines. The next step is the drafting of supporting Regulations that will provide more detailed controls, and for which the Department will be consulting with health practitioners during 2015.

Reporting of Controlled Drugs. A real time system has the potential to provide clinicians with an up-to-date, complete and accurate picture of a patient use of opiates and other similar drugs. Such a system would improve transparency of medication history, support better clinical decision making, reduce inappropriate prescribing, limit potential for doctor shopping and assist in rapid identiďŹ cation of individuals at risk. A real time system is a high PRIORITYĂĽFORĂĽ7! ĂĽ4HEĂĽ#OMMONWEALTHĂĽHASĂĽBEENĂĽINVESTIGATINGĂĽANĂĽ%LECTRONICĂĽ 2ECORDINGĂĽANDĂĽ2EPORTINGĂĽOFĂĽ#ONTROLLEDĂĽ$RUGSĂĽ %22#$ ĂĽSYSTEM ĂĽBASEDĂĽONĂĽ the existing Tasmanian system.

Pharmacist Vaccination. 4HEĂĽ7!ĂĽ0OISONSĂĽ2EGULATIONSĂĽWEREĂĽAMENDEDĂĽ

by Government on 12 December 2014 allowing limited vaccination services by pharmacists, that is, supply an adult inďŹ&#x201A;uenza vaccine to someone without a prescription for immediate administration. The intent is to increase vaccination coverage, particularly those who do not normally seek annual IMMUNISATION ĂĽ4HEREĂĽAREĂĽABOUTĂĽ ĂĽPHARMACIESĂĽINĂĽ7! ĂĽ0HARMACISTSĂĽ will need to complete additional training through courses accredited by the Department of Health and maintain mandated equipment and meet standards for facilities to ensure privacy and patient safety.

MEDICAL FORUM

FERTILITY NEWS

by Medical Director Prof John Yovich

Growth Hormone (GH) effects on the oocyte â&#x20AC;Ś research from PIVETCurtin collaboration

By Clinical Professor Over recent years PIVET has formed John Yovich a collaborative association with the Department of Biomedical Sciences at Curtin University. Recently this has become formalised with the establishment of a Research Fellowship with 50:50 shared funding and commitments to a post-doctoral scientist with an established research record.

The association has proven PXWXDOO\ EHQHĂ&#x20AC;FLDO DQG KDV been rapidly productive with several high-level research publications, the latest being that undertaken by Honours student Brandon Weall working under post-Doc Ghanim Almahbobi. His work is entitled: A direct action for GH in improvement of oocyte quality in poor An M-I Stage oocyte with responder patients. It has immunoďŹ&#x201A;uoresent labelling for GH (with permission; N, nucleus; CP, been published in the journal cytoplasm) Reproduction (2015; 149, 147-154) which is prestigious, KDYLQJ D Ă&#x20AC;YH \HDU LPSDFW IDFWRU RI 3,9(7 KDV SUHYLRXVO\ SXEOLVKHG EHQHĂ&#x20AC;FLDO HIIHFWV XVLQJ *+ as a supplemental adjuvant in women categorized as poor prognosis within IVF programmes. Brandonâ&#x20AC;&#x2122;s study demonstrates IRU WKH Ă&#x20AC;UVW WLPH WKH SUHVHQFH RI UHFHSWRUV WR *+ RQ WKH KXPDQ RRF\WH 2RF\WHV UHWULHYHG IURP ROGHU ZRPHQ VKRZHG VLJQLĂ&#x20AC;FDQW decrease in the expression of GH receptors and amount of functional mitochondria (stained with Mito Tracker Red and Cytochrome c oxidase) when compared to those from younger patients. More interestingly, when older patients were treated ZLWK *+ D VLJQLĂ&#x20AC;FDQW LQFUHDVH LQ IXQFWLRQDO PLWRFKRQGULD ZDV observed in their oocytes.

We were able to conclude that GH exerts a direct mode of action via the enhancement of mitochondrial activity, enabling the improvement of oocyte quality observed in our previous clinical study. Other collaborative studies have been submitted and I will report them when published.

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

35

High Frequency Spinal Cord Stimulation for Low Back Pain

By Dr Thomas J Berrigan, Pain Medicine Specialist, SJG Subiaco

Severe low back pain continues to be a significant problem for Western societies.

This is despite new medical treatments, new drugs and advances in spinal surgery.

Published rates of between 10 and 40% of patients undergoing lumbosacral spine surgery experience persistent or recurrent pain known as the “failed back surgery syndrome (FBSS)”.

This is a challenge to pain management strategies. FBSS patients often fail to obtain lasting relief from a variety of therapies including repeat surgery, oral medications, nerve blocks and physical therapy. It is frequently accompanied by financial and personal stress, loss of employment and productivity, diminished self-esteem and depression.

Recently, researchers studied the effect of much higher frequencies (including 10,000 Hertz) in several animal models. They implanted micro-electrodes in the dorsal horn and measured the response in neurons to painful stimuli in the periphery.

Soon to be published is a prospective RCT of HF10 versus traditional SCS in about 200 patients. At 12 months follow-up both groups had improved but results were superior in the HF10 group for both axial back and leg pain and closely matched the Van Buyten study.

They found that, at 10,000 Hertz, neurons that are believed to transmit pain were, in fact, inhibited by this high frequency.

Implantation process

In 2013, Van Buyten published the outcome of a prospective trial of the clinical application of 10,000 Hz high-frequency stimulation (HF10) in patients with severe low back pain and failed medical treatment. Of the 83 patients enrolled, 88% had a successful trial and proceeded to full implantation of an HF10 device.

Trial electrodes are inserted into the thoracic epidural space under local anaesthetic and sedation. There is no on-table mapping and no paraesthesia evoked. The trial period is typically two to four weeks.

At least 50% reduction in pain is required and the patients must be satisfied with the result before implantation of the implanted pulse generator (IPG).

Spinal Cord Stimulation Spinal cord stimulation (SCS) has become an accepted treatment for FBSS. In 2004, Neurosurgeon, Richard North, reported on a trial of using spinal cord stimulation versus repeat lumbosacral spine surgery. Fifty patients with FBSS were selected for re-operation by standard criteria and randomised to either re-operation or spinal cord stimulation.

SCS patients had the best outcome. Likewise, Kumar (2008) found SCS to be superior to conventional medical management.

However, of note, patients were excluded if the chief complaint was low back pain in excess of radicular pain (hip, buttock and leg).

EU study pain scores at 24 months.

The reason for excluding patients with predominant low back pain was most likely the accepted lack of success in this group. It has been the experience of most practitioners who implant spinal cord stimulators that it is difficult to get paraesthesia into the axial area and also commonly axial stimulation was not sustained.

At 24 months the mean reported VAS score for back pain had reduced from 8.4 down to 3.3 and mean leg pain scores had reduced from 5.4 down to 2.3.

HF10

Complications were typical to all SCS systems and included pocket pain, wound infections, lead migration, loss of therapy effect, suboptimal lead placement and skin erosion.

However, the satisfaction rate was 88%. My own experience mirrors these results.

Recently, researchers studied the effect of much higher frequencies. Traditionally, low frequencies (approximately 100 Hertz) are utilised and this produces a buzzing, tingling sensation in the area of pain. If there is no paraesthesia, there is no pain relief.

36

Similarly, there were significant improvements in Oswestry Disability Index, sleep disturbance and opiate intake reduction.

Electrodes in typical position bridging T9-10 disc.

The batteries of the IPG must be charged daily via an antenna placed over the IPG which normally takes about 30 minutes.

I have also found this device to be effective in a limited number of patients with neck pain and thoracic axial pain. As yet, there have been no published outcome studies for these areas but it looks promising.

Article sponsored by Nevro Corp. No editorial input from Medical Forum.

MEDICAL FORUM

Innovations & Trends

HeartBeat: community cardiac rehabilitation Cardiac disease accounts for nearly half of all hospital admissions but Bentley Armadale Medicare Localâ&#x20AC;&#x2122;s (BAML) community-based rehabilitation, HeartBeat, has successfully decreased readmission rates and assisted people with lifestyle changes. The monitored exercise program has run for nine years, with favourable outcomes. Initially, while studies were being done, more stringent selection criteria applied but now any patient can be referred if they have IHD or are at high risk (hypertension, high cholesterol, overweight, positive FH).

Suitable patients also include those with AF or post-infarction, or following coronary procedures such as stenting, angioplasty or bypass. RPH also refers patients following a cardiac admission.

During the free seven-week program, group participants receive education and tailored EXERCISE ĂĽ/NGOINGĂĽINVESTMENTĂĽBYĂĽTHEĂĽ7!ĂĽ Health Department in this service allows the established beneďŹ ts of cardiac rehabilitation to be realised.

HeartBeat participants meet for two hours each week in community centres close to home such as Kelmscott, Bentley, Gosnells,

2IVERVALE ĂĽ7ILLETTONĂĽANDĂĽ"YFORD ĂĽ!PPREHENSIONĂĽ about exercise following a cardiac event is overcome in a supported environment supervised by an exercise physiologist. %ACHĂĽWEEKĂĽAĂĽHEALTHĂĽEXPERTĂĽEXPLAINSĂĽDIET ĂĽ medications and heart disease to reinforce messages given by the participantsâ&#x20AC;&#x2122; GPs, all of whom are kept informed of progress.

Safety precautions include clearance by the GP or the referring RPH doctor, and triage using registration forms that outline medical history, exercise restrictions and medications.

GPs have every opportunity to ďŹ rst stabilise a patient, with say unstable angina, before starting the program. Venues are checked to ensure proper ďŹ&#x201A;ooring, disability access, adequate ventilation, etc. Proper clothing and footwear must be worn by participants.

Two fully trained staff members are at every session with glyceryl trinitrate and an automated deďŹ brillator.

Invariably, feedback from patients is positive, so that HeartBeat is an important part of their recovery and health education.

HeartBeat has been assessed for the known beneďŹ ts from cardiac rehabilitation â&#x20AC;&#x201C; reduced mortality, cardiac symptoms and modiďŹ able risk factors and improved exercise tolerance

By Dr Neda Meshgin, Canning Vale Medical Cente

and psychological factors.

After ďŹ ve years, participants demonstrated signiďŹ cantly reduced hospital readmission rates for non-elective cardiac reasons.

Hospital bed days were also reduced for those who completed the program, measured over 12 months. Differences were maintained across age and gender.

This yearâ&#x20AC;&#x2122;s results from over 1000 patients ENROLLEDĂĽINĂĽ(EART"EATĂĽ ĂĽALSOĂĽ showed improvements in quality of life, cholesterol levels, and measured walking distance.

Plans are also being made to expand HeartBeat across South Metropolitan Perth to increase access to the program. Program information is available from BAMLâ&#x20AC;&#x2122;s Carol Chong 9458 0505, c.chong@baml.com.au or VISITĂĽWWW BAML COM AU (" ĂĽ Reference: Canyon SJ and Meshgin N. Cardiac Rehabilitation: reducing hospital readmissions through community based programs. AFP 2008; 37:575-577.

Author competing interests: nil relevant.

Readers can contact Dr Meshgin at dr.meshgin@canningvalemedical.com

Murdoch Hospital

Now in the heart of the South With internationally recognised expertise in clinical management and research, our cardiologists are leaders in their fields. From January 2015, Perth Cardio will open doors at its new south of the river clinic in Wexford Medical Centre â&#x20AC;&#x201C; Murdoch Hospital. That means, for patients in the south, world-class cardiology care just got a whole lot closer. Visit perthcardio.com.au to find out more.

LEADERS IN C ARDIOLOGY | ECHO | ECG | HOLTER MONITORING | ECHO | TOE | E XER CISE STRESS TESTING

MEDICAL FORUM

37

Innovations & Trends

VMAT: advances in radiation therapy

By Dr Raphael Chee, Radiation Oncologist

External beam X-rays became part of cancer management in the 1920s but use has widened in the past 30 years thanks to advances in computing and hardware technology. The aim is to improve therapeutic efďŹ ciency by maximising cancer control (better tumour targeting, dose escalation) and minimising toxicity for the patient.

VMAT (Volumetric Modulated Arc radiation Therapy) is part of that technological evolution, minimising damage to normal critical structures while delivering nearly all dosimetric endpoints that form part of 3D-Conformal Radiation Therapy (CRT) plans.

Beam modulation allows clinicians to shape the radiation dose to tumours whilst reducing dose to healthy tissue and sensitive organs. The beneďŹ ts are obvious.

VMAT is fast when using highly modulated beams: most treatments use ONEĂĽORĂĽTWOĂĽROTATIONALĂĽARCS ĂĽTWOĂĽMINUTESĂĽEACH ĂĽWHICHĂĽCUTSĂĽ ĂĽOFFĂĽ treatment times compared to 3D Conformal and Intensity Modulated Radio Therapy (IMRT); shorter treatment usually translates into patient comfort and targeting accuracy.

Figure 1 shows how VMAT can shape the high dose region (the thick red line) to match the shape of the target (the teal shaded area) whilst reducing the dose to the normal, healthy tissue, especially the parotids (charcoal grey organ). Standard conformal RT can still shape dose to a target but not to the same degree as VMAT, as seen in Figure 2.

Fig 1. VMAT plan. Note the ability for the dose to â&#x20AC;&#x153;curveâ&#x20AC;? around normal tissue structures.

Fig 2. 3D-CRT plan. Note extra dose to parotid and oral cavity. In addition, the dose coverage is less homogenous, with greater â&#x20AC;&#x153;hot and coldâ&#x20AC;? spots.

It is the improved targeting of cancers that makes Modulated Radiation Therapy (RT) the standard of care in the treatment of head and neck, PROSTATEĂĽ ESPECIALLYĂĽPOST PROSTATECTOMY ĂĽANDĂĽANAL VAGINAL VULVAĂĽCANCERS ĂĽ Head and neck RT allows clinicians to conserve parotid gland (salivary) function, which drastically improves quality of life for patients.

As experience grows with VMAT, different tumours in situations previously prevented by toxicity are being targeted. Figure 3 shows advanced distal oesophageal adenocarcinoma with bulky celiac and para-aortic nodes: â&#x20AC;&#x153;radical intentâ&#x20AC;? type treatment induced minimal grade 1 toxicities of fatigue and nausea; the postTREATMENTĂĽ&$' 0%4ĂĽSCANĂĽSHOWEDĂĽNEARĂĽCOMPLETEĂĽ response; in the 3D-CRT era, his treatment plan would have been â&#x20AC;&#x153;medium-doseâ&#x20AC;? palliation.

Fig 3. Advanced distal oesophageal adenocarcinoma with bulky celiac and para-aortic nodes

Trends in Urology Penile Cancer. The incidence of squamous cell carcinoma (SCC) of the PENISĂĽAPPEARSĂĽTOĂĽBEĂĽINCREASINGĂĽINĂĽ7!ĂĽ FROMĂĽ ĂĽCASESĂĽPERĂĽYEAR ĂĽOVERĂĽ the last 25 years), probably due to an increase in HPV-related cancers SUBTYPESĂĽ ĂĽANDĂĽ ĂĽANDĂĽAĂĽREDUCTIONĂĽINĂĽNEONATALĂĽCIRCUMCISION ĂĽ)NCIDENCEĂĽ MAYĂĽWELLĂĽREDUCEĂĽAGAIN ĂĽWITHĂĽTHEĂĽUPTAKEĂĽOFĂĽ(06ĂĽVACCINATION ĂĽ!ĂĽNEWĂĽ7!ĂĽ service aims to provide state-of-the-art management that seeks to cure cancer with maximum functional and cosmetic preservation of the penis: early referral and plastic surgical techniques are key. The introduction in 2014 of dynamic sentinel node biopsy of the groin completes the picture, minimising morbidity whilst enabling accurate staging and treatment of metastatic disease.

Urethral strictures. These affect males from birth to death. Causes include the delayed consequences of infant hypospadias surgery, trauma (including fall astride injuries, pelvic fracture, catheterisation and endoscopic procedures) and less commonly infection (gonnorrhoea, TB, and schistosomiasis). The concept that â&#x20AC;&#x153;dilatation is palliationâ&#x20AC;? remains as true today as when coined 150 years ago. Modern reconstruction for

38

By Dr David SoďŹ eld, Urologist, Palmyra

ďŹ t men usually involves free grafts (most commonly oral mucosa), with high success rates that bring a dramatic quality of life beneďŹ t. Radiationrelated strictures are increasingly common and can be very difďŹ cult to manage; new temporary removable stents have an emerging role in these patients or the elderly.

Surgery for male urinary incontinence. As surgical treatment of prostate cancer has climbed, so too has the incidence of stress urinary incontinence (SUI) in men, a rare condition otherwise. Between 5% and 15% of men will remain incontinent 12 months after radical prostatectomy and most of these can be improved surgically. For those with mild to moderate SUI (1-3 pads or up to 400ml loss per day) a variety of minimally invasive suburethral sling procedures are available and have high success rates (85-90%). For those with more severe SUI, artiďŹ cial urinary sphincters are very successful, although more complicated to insert and they require patient operation of the device.

The quality of life beneďŹ t is great in men who have already suffered considerable trauma through their cancer diagnosis and treatment.

MEDICAL FORUM

PRP - ACHILLES TENDON REPAIR* ACHILLES TENDINITIS & ENTHESITIS A 50 year old non smoking lady presented with two years of heel pain. She could walk pain free only for 5 minutes. She 1 - 1*,,$ */. 1 $"#. " $) ) ' & *! 4.) -- / .* $) .$0$.3 # # ) $ ")*- 1$.# #$'' - . ) $)$.$- '- 1# , ) +, 0$*/-'3 /) ,"*) *,.$-*) $)% .$*)- 2 ( .# -*) $*).*+#*, -$- ) *.# , *)- ,0 .$0 ( -/, - 1$.# )* , '$ ! # , 1 , )* ( %*, * (*, $ $.$ - # 1 - 0$- -/," ,3 / .* + , $0 ! $' ( $ ' ., .( ). # -*/"#. $). ,0 ).$*) ' , $*'*"$ ' *+.$*)- ) +, - ). .* , ., .( ). **. ) )&' $- $'$.3 ) 2 1 -

) 2 ($) .$*) .# , 1 - ( ,& . ) ,) -- . .# $)- ,.$*) *! .# #$'' - . ) *) 1$.# + $)!/' 3-!/) .$*) $ ")*-$- *! ' $4 #$'' - . ) $)$.$- ).# -$.$- ) " ) , .$0 #$'' - . ) *)*-$- 1 - ( . # /) ,1 ). $( " "/$ + , /. ) */- , " ) , .$0 ., .( ). $) '/ $)" /.*'*"*/- ' . ' . $ # ' -( .* .# affected portion of the Achilles as an outpatient procedure. $) , '$ ! -. ,. $) ! 1 1 &- . -$2 (*).#- +*-. ., .( ). !*''*1 /+ -# , +*,. 2 '' ). + $) , '$ ! ) 1 - ' .* 1 '& + $) !, !*, ) #*/, # # *(( ) ", +#3-$ ' .$0$.$ - . (*).# +*-. ., .( ). - *, $(+,*0 .* -*'/. $) , - *! +*$).- $(+,*0 ( ). # *).$)/ - 1$.# + $) , '$ ! ) ( $). $)- + $) !, .$0$.3 ' 0 '- # 0$)" 0*$ -/," ,3

90 FADI Score

Photo of heel - location of pain at the Achilles enthesis.

67.5 45 22.5 0

Above: Ultrasound at the insertion of Achilles shows calcific tendinitis, enthesitis and interstitial tears.

July 2013

December 2013

Pre and Post PRP Foot & Ankle Disability Index (FADI) shows an absolute improvement of 39.5 points (80% improvement) over 6 months.

WORLDâ&#x20AC;&#x2122;S FIRST REPORTS ON PRP FROM WESTERN AUSTRALIA

Doss A. Neotendon regeneration and repair of gluteus tendon tear at 1-year follow-up after ultrasound guided platelet rich plasma tenotomy [v1; ref status: http://f1000r.es/4pu] F1000Research 2014, 3:284 (doi: 10.12688/f1000research.5719.1) Doss A. Neotendon infilling of a full thickness rotator cuff foot print tear following ultrasound guided liquid platelet rich plasma injection and percutaneous tenotomy: favourable outcome up to one year [v1; ref status: indexed, http://f1000r.es/xz] F1000Research 2013, 2:23 (doi: 10.12688/f1000research.2-23.v1).

Doss A. Case Series Report: Ultrasound Guided Autologous Liquid Platelet Rich Plasma - A new treatment option for Complex Regional Pain Syndrome and Reflex Sympathetic Dystrophy? WebmedCentral ORTHOPAEDICS 2014;5(5):WMC004621.

Doss A, Trigeminal Neuralgia Treatment: A Case Report on Short-Term Follow up After Ultrasound Guided Autologous Platelet Rich Plasma Injections. Webmed Central Neurology. 2012

Dr Arockia Doss

MBBS (Ind) MRCP (UK) FRCR (Lon) FRANZCR (Syd)

Interventional Radiologist Suite 3, 55 Hampden Road Nedlands WA 6009 ph 6389 2776 fx 63892778

info@imageguidedtherapyclinic.com

MEDICAL FORUM

IGTC is a trademark owned by Shashi Pty Ltd. Any unauthorised use is strictly prohibited.

www.igtc.com.au

39

Mental Health Ashleigh Nels

a e l L y n ch o n a n d R a ch

Two WA members of the goldmedal Hockeyroos hope their recent trek along the rugged Kokoda Trail will be a catalyst to prompt more people to ask the simple question, R U OK? It was a hard slog through the jungle of PNG for Australian hockey players and ambassadors of the mental health charity R U OK?, Ashleigh Nelson and Rachael Lynch, but if they thought their hockey training gave them an advantage they had to quickly think again. The physical and mental demands associated with toplevel sport are relentless and, in Rachaelâ&#x20AC;&#x2122;s case, thereâ&#x20AC;&#x2122;s the added dimension of her professional responsibilities as a nurse at RPH.

40

Ashleigh, an occupational therapist and FORMERĂĽ7AGINĂĽLOCAL ĂĽHASĂĽBEENĂĽAĂĽMEMBERĂĽ of the Hockeyroos since 2008 and is ONEĂĽ OFĂĽ THEĂĽ TEAM SĂĽ LEADINGĂĽ GOALĂĽ SCORERS ĂĽ %LITEĂĽ %LITE hockey is a high-performance sport requiring iring high levels of ďŹ tness nonetheless the terrain ain in PNG tested every single muscle. â&#x20AC;&#x153;Kokoda was completely different to running around a hockey ďŹ eld. Thereâ&#x20AC;&#x2122;s a lot of impact going through your legs, the ground is uneven and slippery and you have to focus on where YOU REĂĽ PUTTINGĂĽ YOURĂĽ FEET ĂĽ 7EĂĽ WEREĂĽ WALKINGĂĽ FORĂĽ nearly 10 hours on most days and I donâ&#x20AC;&#x2122;t have fantastic knees!â&#x20AC;?

Ashleigh is well aware of the mental pressures linked with performing at an elite level and the inevitable selection disappointments associated with injury and loss of form. â&#x20AC;&#x153;As an OT I understand the importance of the mental processes involved in the ability to bounce back from injury. And, for us, we also have to contend with the vagaries of team SELECTION ĂĽ7EĂĽREALISEĂĽWE REĂĽNOTĂĽGOINGĂĽTOĂĽMAKEĂĽ every international tour but sometimes itâ&#x20AC;&#x2122;s difďŹ cult not to take it personally.â&#x20AC;? â&#x20AC;&#x153;Both Rachael and I are involved in fundraising work for R U OK? Thereâ&#x20AC;&#x2122;s a personal dimension as well with some family members and friends AFFECTEDĂĽBYĂĽDEPRESSION ĂĽ7E REĂĽALSOĂĽAWAREĂĽTHATĂĽ many athletes struggle with the transition from professional sport to everyday life. But the

Ashleigh N

elson a nd

R a ch a e l L

y n ch

Hockeyroos is a supportive group and we know how important it is to speak up if we see someone going through a difďŹ cult situation.â&#x20AC;?

As a nurse at RPH, Rachael Lynch sees the full gamut of human emotions while dealing with some forceful Type A personalities on a professional basis. The health sector is an environment combining both high expectations and outcomes with varying degrees of success. â&#x20AC;&#x153;My work situation is a little unusual because ) MĂĽNOTĂĽFULL TIME ĂĽ7ITHĂĽHOCKEYĂĽCOMMITMENTSĂĽ) LLĂĽ often have ďŹ ve or six days between shifts so I turn up nice and fresh and that can be a good thing because if youâ&#x20AC;&#x2122;re not on a supportive ward it can be a really tough environment.â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m looking after stroke patients at the moment and weâ&#x20AC;&#x2122;ve just moved to Fiona Stanley. Thereâ&#x20AC;&#x2122;s been a lot of teething problems with some big changes at the new hospital and some people are resistant to that. Itâ&#x20AC;&#x2122;s been pretty crazy at times but things are improving.â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m a full-time hockey player and part-time nurse but, having said that, Tuesday is always a big day. I do three hours training in the morning and then a seven and a half hour shift on

MEDICAL FORUM

Health Message ON WHEELS o Storn Petters

n

Storn Petterson knows how tough life can be, which motivates him to travel the countryside offering information and a laugh for those who are suffering.

Emerging from a childhood of emotional abuse hasnâ&#x20AC;&#x2122;t been easy for Storn Petterson and he still ďŹ ghts a daily battle with his demons. Storn doesnâ&#x20AC;&#x2122;t stand out in a crowd but his spectacularly spray-painted Commodore certainly does!

â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve put the cold, hard facts on my ute and trailer. Sadly, the statistics are there for all to see and when I pull up in a car-park Iâ&#x20AC;&#x2122;ll often get around 50 people come up and speak with me.

The number of men between the ages of 1544 committing suicide every week in Australia is now up in the high 30s.â&#x20AC;? â&#x20AC;&#x153;I was brought up in a household with alcoholic parents and a lot of mental and emotional abuse. It damaged me more than I ever realised. How does a seven year-old boy cope with his mother telling him to stick a knife in his fatherâ&#x20AC;&#x2122;s back when he walks through the door?â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve carried these things all my life and heavy drinking was a way of deadening the pain. I just wanted those early years to disappear.â&#x20AC;?

Storn is a ďŹ rm believer in the Alcoholics Anonymous (AA) program and it proved to be a springboard for turning things around. â&#x20AC;&#x153;A person has to be at absolute rock-bottom before theyâ&#x20AC;&#x2122;ll change. And I was. I had peripheral neuritis, delirium tremens and was a complete mess. Iâ&#x20AC;&#x2122;d just sit there crying and trying to work out what was wrong. A guy whoâ&#x20AC;&#x2122;d been through this saw right through me, heâ&#x20AC;&#x2122;d been sober for ďŹ ve years and I rang him every day for nine months.â&#x20AC;?

â&#x20AC;&#x153;It hasnâ&#x20AC;&#x2122;t been all down to AA. After nearly 30 years of dealing with this stuff I went to a doctor and he told me I had chronic depression. I replied, â&#x20AC;&#x2DC;whatâ&#x20AC;&#x2122;s that?â&#x20AC;&#x2122; Medication has helped me get my feet back on the ground.â&#x20AC;?

The former sign-writer uses his car and trailer as a gigantic billboard at community gatherings and rural ďŹ eld days. â&#x20AC;&#x153;I decided to do something different and step outside the square. People at intersections wind down their windows and yell â&#x20AC;&#x2DC;well done!â&#x20AC;&#x2122; and â&#x20AC;&#x2DC;good on you!â&#x20AC;&#x2122; The response from the public has been overwhelming. Iâ&#x20AC;&#x2122;ve funded all this myself but Iâ&#x20AC;&#x2122;m hoping to get some sponsors on board and register as a charity.â&#x20AC;?

Perhaps the strongest message from Storn and his mobile information kiosk is that depression and suicide need to be placed ďŹ rmly in the spotlight, particularly in a society that sometimes forgets the power of community. â&#x20AC;&#x153;The issues lying behind depression need to be spoken about openly and itâ&#x20AC;&#x2122;s important to remember that each personâ&#x20AC;&#x2122;s suffering is unique. It makes it doubly hard because itâ&#x20AC;&#x2122;s a tough society now and people arenâ&#x20AC;&#x2122;t as kind to each other.â&#x20AC;?

By Mr Peter McClelland

â&#x20AC;&#x153;I was a quivering wreck and he treated me with respect. He saved my life.â&#x20AC;?

THEĂĽ WARD ĂĽ )TĂĽ CERTAINLYĂĽ PUTSĂĽ THINGSĂĽ INĂĽ PERSPECTIVE ĂĽ 7HETHERĂĽ )ĂĽ GETĂĽ PICKEDĂĽ for the Hockeyroos, as far as the patients are concerned, is pretty inconsequential.â&#x20AC;?

To ask a simple question like â&#x20AC;&#x2DC;are you OK?â&#x20AC;&#x2122; might also seem fairly innocuous but, as far as Rachaelâ&#x20AC;&#x2122;s concerned, it can make the world of difference.

KARRINYUP HEALTH PROFESSIONALS PRIME LOCATION

â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve been an ambassador with R U OK? for three years. Itâ&#x20AC;&#x2122;s only a small organisation but I love the fact that itâ&#x20AC;&#x2122;s a question anyone can ask. You donâ&#x20AC;&#x2122;t have to be trained to listen to someone and, as we all know, mental health is such an important issue.â&#x20AC;?

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h7E REĂĽINĂĽAĂĽBETTERĂĽSITUATIONĂĽTHANĂĽSOMEĂĽOTHERSĂĽBECAUSEĂĽIT SĂĽAĂĽTEAMĂĽSPORT ĂĽ Nonetheless, itâ&#x20AC;&#x2122;s an intense, high-pressure environment and to be under the constant scrutiny of coaches and selectors can be overwhelming at times. You can be surrounded by lots of teammates and still feel lonely if youâ&#x20AC;&#x2122;re not having a good day.â&#x20AC;? â&#x20AC;&#x153;Girls love talking with each other and we probably do that more than the GUYS ĂĽ)NĂĽFACT ĂĽTHEREĂĽAREĂĽAĂĽCOUPLEĂĽOFĂĽPLAYERSĂĽFROMĂĽTHEĂĽ7ALLABIESĂĽWORKINGĂĽ with RUOK? and theyâ&#x20AC;&#x2122;re saying that their teammates need to speak up a bit more on these issues.â&#x20AC;?

Rachael echoes Ashleighâ&#x20AC;&#x2122;s thoughts on life after hockey. â&#x20AC;&#x153;The world of professional sport is pretty unreal and something of a unique situation. You do see some of our best athletes struggle when it all comes to an end and large salaries are part of that. Perhaps weâ&#x20AC;&#x2122;re fortunate that we donâ&#x20AC;&#x2122;t get paid a lot of money! It forces us to develop another career and become more rounded individuals.â&#x20AC;? â&#x20AC;&#x153;The transition will be easier for both of us.â&#x20AC;?

Aaron Antonas 0434 659 818 Medical Services

By Mr Peter McClelland

52m² to 1,085m² strata areas

Estimated completion early 2015

Opposite Karrinyup Shopping Centre

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MEDICAL FORUM

colliers.com.au 41

7ELL ĂĽWEĂĽHAVEĂĽTHEM ĂĽANDĂĽYOUĂĽCOULDĂĽHAVE vĂĽTHEĂĽ Manager replied.

No matter what amenity the Manager mentioned, she replied, â&#x20AC;&#x153;But I didnâ&#x20AC;&#x2122;t use it!â&#x20AC;?

The Manager was unmoved, so she decided to pay, wrote a cheque and gave it to the Manager.

The Manager was surprised when he looked at the check. â&#x20AC;&#x153; But madam, this check is only made out for $50.â&#x20AC;? @4HAT SĂĽCORRECT ĂĽ)ĂĽCHARGEDĂĽYOUĂĽ ĂĽFORĂĽ sleeping with me,â&#x20AC;? she replied. â&#x20AC;&#x153;But I didnâ&#x20AC;&#x2122;t!â&#x20AC;? exclaims the very surprised Manager.

THE HOTEL BILL An elderly lady decided to give herself a big treat for her signiďŹ cant birthday by staying overnight in one of Chicagoâ&#x20AC;&#x2122;s most expensive hotel.

h7ELL ĂĽTOOĂĽBAD ĂĽ)ĂĽWASĂĽHERE ĂĽANDĂĽYOUĂĽCOULDĂĽ have.â&#x20AC;?

DIVINE INTERVENTION A man suffered a serious heart attack while shopping in a store and was rushed to the nearest hospital where he had emergency open heart surgery. He awakened from the surgery to ďŹ nd a woman with a clipboard loaded with several forms, and a pen.

â&#x20AC;&#x2DC;But I didnâ&#x20AC;&#x2122;t use them,â&#x20AC;? she said.

â&#x20AC;&#x153;But I didnâ&#x20AC;&#x2122;t go to any of those shows,â&#x20AC;? she said.

The nurse came in a while later, picked up the urine sample bottle, looked at it and said, â&#x20AC;&#x2DC;My, my, it seems we are a little cloudy today.â&#x20AC;&#x2122;

Donâ&#x20AC;&#x2122;t mess with seniors!

The Manager appeared and forewarned by the desk clerk announced: â&#x20AC;&#x153;The hotel has an Olympic-sized pool and a huge conference centre which are available for use.â&#x20AC;?

h7EĂĽHAVEĂĽTHEĂĽBESTĂĽENTERTAINERSĂĽFROMĂĽ.EWĂĽ9ORK ĂĽ Los Angeles, and Las Vegas performing here,â&#x20AC;? the Manager said.

day at breakfast, I took the apple juice off the tray and put it in my bedside stand. Later I was given a urine sample bottle to ďŹ ll for testing. So you know where the juice went!

The nurse fainted... I just smiled.

4HEĂĽCLERKĂĽTOLDĂĽHERĂĽTHATĂĽ ĂĽISĂĽTHEĂĽ@STANDARDĂĽ rateâ&#x20AC;&#x2122; so she insisted on speaking to the Manager.

He went on to explain that she could also have seen one of the in-hotel shows for which the hotel is famous.

- Oscar Wilde

At this, I snatched the bottle out of her hand, popped off the top, and gulped it down, SAYING ĂĽ@7ELL ĂĽ) LLĂĽRUNĂĽITĂĽTHROUGHĂĽAGAIN ĂĽ-AYBEĂĽ)ĂĽ can ďŹ lter it better this time!â&#x20AC;&#x2122;

7HENĂĽSHEĂĽCHECKEDĂĽOUTĂĽNEXTĂĽMORNING ĂĽTHEĂĽ DESKĂĽCLERKĂĽHANDEDĂĽHERĂĽAĂĽBILLĂĽFORĂĽ ĂĽ3HEĂĽ exploded and demanded to know why the charge was so high. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s a nice hotel but the ROOMSĂĽCERTAINLYĂĽAREN TĂĽWORTHĂĽ ĂĽFORĂĽJUSTĂĽANĂĽ overnight stop without even breakfast.â&#x20AC;?

@ 7ELL ĂĽTHEYĂĽAREĂĽHERE ĂĽANDĂĽYOUĂĽCOULDĂĽHAVE vĂĽ explained the Manager.

Always forgive your enemies; nothing annoys them so much.

THE URINE SAMPLE One time I got sick and landed in the hospital.

There was this one nurse that just drove me CRAZY ĂĽ%VERYĂĽTIMEĂĽSHEĂĽCAMEĂĽIN ĂĽSHEĂĽWOULDĂĽTALKĂĽ to me like I was a little child.

She would say in a patronizing tone of voice, â&#x20AC;&#x2DC;And how are we doing this morning?â&#x20AC;&#x2122; Or. â&#x20AC;&#x2DC;Are we ready for a bath?â&#x20AC;&#x2122; Or, â&#x20AC;&#x2DC;Are we hungry?â&#x20AC;&#x2122; I had had enough of this particular nurse. One

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She asked him how he was going to pay for his treatment. â&#x20AC;&#x153;Do you have health insurance?â&#x20AC;? she asked.

He replied in a raspy voice, â&#x20AC;&#x153;No health insurance.â&#x20AC;?

The clarke asked, â&#x20AC;&#x153;Do you have money in the bank?â&#x20AC;?

He replied, â&#x20AC;&#x153;No money in the bank.â&#x20AC;?

Do you have a relative who could help you with the payments?â&#x20AC;? asked the charge clerk.

He said, â&#x20AC;&#x153;I only have a spinster sister, and she is a nun.â&#x20AC;?

The clerk became agitated and announced loudly, â&#x20AC;&#x153;Nuns are not spinsters! Nuns are married to God.â&#x20AC;?

The patient replied, â&#x20AC;&#x153;Perfect. Send the bill to my brother-in-law.â&#x20AC;?

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This offer gives an additional reason to review ones personal insurance cover in the event of death ,terminal illness or total and permanent disablement.

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If you have a joke you would like to share with colleagues, email editor@mforum.com.au

The material provided in this advertisement is provided for information only and constitutes general ďŹ nancial product advice. It does not take into account your personal ďŹ nancial situation, objectives and needs. Consequently before taking action on the information contained in this advertisement you should consider its appropriateness to your ďŹ nancial situation objectives and needs.

42

MEDICAL FORUM

a leader in quality

By Dr Craig Drummond Master of Wine

Consistent high quality production over the past 40 years CONTINUESĂĽTOĂĽPUTĂĽ0LANTAGENETĂĽ7INESĂĽATĂĽTHEĂĽFOREFRONTĂĽASĂĽONEĂĽ of our stateâ&#x20AC;&#x2122;s leading producers.

a procession of competent winemakers including Rob "OWEN ĂĽ *OHNĂĽ 7ADE ĂĽ 'AVINĂĽ "ERRYĂĽ AND ĂĽ CURRENTLY ĂĽ #ATHĂĽ Oates.

7HYĂĽ SOĂĽ GOOD ĂĽ ,EADERSHIPĂĽ ISĂĽ THEĂĽ lRSTĂĽ ELEMENT ĂĽ 4ONYĂĽ Smith has been truly visionary, establishing one of the ďŹ rst vineyards in the Great Southern region when he PLANTEDĂĽ VINESĂĽ ATĂĽ HISĂĽ HOMEĂĽ PROPERTY ĂĽ "OUVERIE ĂĽ INĂĽ ĂĽ &URTHERĂĽ PLANTINGSĂĽ FOLLOWED ĂĽ ĂĽ 7YJUPĂĽ ĂĽ 2OCKYĂĽ (ORRORĂĽ 1 (1988), Rocky Horror 2 (1997) and Rosetta (1999). His management skills, together with the high quality fruit from these well-chosen viticultural sites, and now the signiďŹ cant vine maturity, has led Plantagenet wines to where it is today. Tony still has some involvement in management.

The three wines tasted here are all from the premium range, wines only produced from the old original vineyard sites. There are also two other labels â&#x20AC;&#x201C; Omrah and Hazard Hill for which fruit is sourced more widely.

There is an old clichĂŠ, â&#x20AC;&#x2DC;You canâ&#x20AC;&#x2122;t make great wine without great fruitâ&#x20AC;&#x2122; though quality production is also necessary and this has been another strength of Plantagenet, with

Wine Review

Plantagenet Wine I have an incurable habit of keeping all my tasting notes â&#x20AC;&#x201C; now some 18,000 wines over 35 years and as I look through them, the Plantagenet wines have always rated highly. In particular, I fondly remember being invited to the wineryâ&#x20AC;&#x2122;s 30th celebration where a retrospective â&#x20AC;&#x2DC;verticalâ&#x20AC;&#x2122; tasting of 30 years of Rieslings, Shiraz and Cabernets was truly remarkable and demonstrated the wonderful ageing potential of these wines.

1. 2012 Plantagenet Cabernet Sauvignon Shows an attractive deep ruby colour with aromas of dense blackcurrant, fresh-cut timber, cedar and a touch of wood smoke. Leads on to concentrated ďŹ&#x201A;avours of blackcurrant, dark berries, with hints of clove. The tannins are ďŹ rm, dense, with an enticing briary edge which will quickly soften. Really lively acid gives a long, LINGERINGĂĽlNISH ĂĽ!NOTHERĂĽENERGISEDĂĽYOUTHFULĂĽWINE ĂĽWITHĂĽALLĂĽTHEĂĽRIGHTĂĽELEMENTSĂĽJUSTĂĽWAITINGĂĽTOĂĽEVOLVE ĂĽ%ASYĂĽTOĂĽDRINKĂĽ now but Iâ&#x20AC;&#x2122;ll be even keener to in another 10-12 years.

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2. 2014 Plantagenet Riesling Yet another terriďŹ c Riesling â&#x20AC;&#x201C; a leading Great Southern variety. It shows the hallmark lemon citrus characters with a background slatey minerality. Like all its siblings, it is clean and tight in its youth, with an austere edge currently, but the structure, fruit concentration will allow it to evolve into a wonderfully complex rounded toasty wine over the next 10-15 years. A must for the cellar.

3. 2012 Plantagenet Shiraz Plantagenet, in my opinion, is one of Australiaâ&#x20AC;&#x2122;s leading producers of this variety with many accolades, INCLUDINGĂĽ'OLDĂĽATĂĽTHEĂĽ$ECANTERĂĽ7ORLDĂĽ7INEĂĽ!WARDS ĂĽ4HISĂĽWINEĂĽISĂĽLOADEDĂĽWITHĂĽSPICYĂĽCHARACTERS ĂĽTHEĂĽNOSEĂĽ showing white pepper, cinnamon and cardamon. The palate is savoury, with blackberry, and that touch of black ink (a frequent element which makes me think of the wonderful wines of the Rhone). The tannins are ďŹ ne and penetrating, giving a great mouthfeel. This is another brooding youngster just waiting to grow into a sensational wine. I hope Iâ&#x20AC;&#x2122;m still able to taste it in 20 yearsâ&#x20AC;&#x2122; time!

WIN a Doctorâ&#x20AC;&#x2122;s Dozen!

Name Phone

ENTER HERE!

.. or online at

www.medicalhub.com.au

Email Please send more information on Plantagenet Wines offers for Medical Forum readers.

Wine Question: Which wine does Dr Craig Drummond think will develop over the next 15 years?

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, February 28, 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.

MEDICAL FORUM

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Social Pulse

Clinipath Pathology Clinipath Pathology celebrated a huge year, which saw it move into its new laboratory in Osborne Park.

So Christmas 2014 was a time to relax and enjoy the season at Mosmans.

1 Mosmans on the water 2 Dr Colin and Jan Stevens and $Rå&ATINå7AJDI 3 Matt Bogel, Dr Gordon Harloe and Justin Koleits 4 Dr Roger Hart and Dr Jay Natalwala 5 Dr Sally Price, Cheryl Jones, Kaitlin Gardiner and Dr Carol Pearce å *ENNYå(EYDENåANDå3HEILAå(ARLOE å 3ARAHå%CCLESTONåANDå$Rå"ARRYå,EONARD 8 Carol O’Connor, Vicki Halliday and Dr Susan Clarke åå !NNIEå7ARBURTONåANDå$Rå.ICHOLASå 7ARBURTON

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Ramsay Health Care 4HEå%DELWEISå$ANCEåGROUPåGOTåTHEå Ramsay party is thigh-slapping high spirits at the Crown at Burswood. å (OLLYWOODå#%/å0ETERå-OTT å-RSå3HARONå -OTT å*OONDALUPå#%/å+EMPTONå#OWANå and Dr Brad Jongeling å 2ICHARDå%DGE å$Rå0ATTYå!DAMS å$Rå#LIFFå Neppe and Lauren Neppe 3 Mr Barry Ashwin and Prof Desiree Silva 4 Ramsay State Operations Manager Kevin Cass-Ryall, Christine Cass-Ryall, Health Minister Dr Kim Hames and Stephanie Hames

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5 Dr Gregory Janes and Kate Smith å $Rå+AH ,IMå4AYåANDå)RENEå4AY å $Rå!RTHURå#RIDDLEåANDå-EGANå7RAITH å %CHOåDEå"ERGEå"ELLåRINGERS

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Social Pulse

RACGP Dr Tim Koh greeted College fellows for the ďŹ rst time in his capacity as NEWĂĽCHAIRĂĽOFĂĽTHEĂĽ7!ĂĽ&ACULTY ĂĽ4HEĂĽ friendly gathering saw GPs from around the city popping into the 7ESTĂĽ,EEDERVILLEĂĽ(1 ĂĽ $RĂĽ'EOFFĂĽ%MERY ĂĽ$RĂĽ0ENNYĂĽ7ILSONĂĽ and Prof Max Kamian ĂĽ $RĂĽ,AURAĂĽ#ATIJA ĂĽ$RĂĽ*ANSHEEDĂĽ7ADIA ĂĽ $RĂĽ'LENNĂĽ%DWARDSĂĽANDĂĽ$RĂĽ!LISATAIRĂĽ Vickery

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3 Dr Fazal Shabudin and Dr Mahinda Yogam ĂĽ -SĂĽ,EAHĂĽ7ILLIAMS ĂĽ$RĂĽ4IMĂĽ+OHĂĽ and Malvina Nordstrom 5 Leanne Cridland and Terina Grace ĂĽ $RĂĽ,EANNEĂĽ3HAW ĂĽ$RĂĽ.ABELĂĽ!L 3HISHACHIĂĽ ANDĂĽ-SĂĽ,EAHĂĽ7ILLIAMS 7 Dr Victor Lee, Dr Kong Liew and Dr Grania Murphy ĂĽ *OHNĂĽ,INEHAMĂĽ 57! ĂĽANDĂĽ-IKEĂĽ7ATTSĂĽ (SJG Pathology)

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Social Pulse

SJG Subiaco Subiaco medical practitioners enjoyed a night at the museum for their annual Christmas soiree.

No exhibits came to life!

1 Dr Lachlan Henderson and Cathy Henderson 2 Dr Randall Oates and Tracey Chen 3 Dr Stuart SalďŹ nger and Jade SalďŹ nger 4 Dr Michael Stanford and Sally Stanford

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Medical Centre Bentley, WA

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Fantastic opportunity for setting up a Medical Practice This is a rare offering to lease a fully furnished, purpose built Medical Centre opposite Bentley Hospital with Pathology and Radiology in adjacent location. Built in 1994, furnished and carpeted to the highest standards possible with a fully equipped minor surgery/treatment theatre. The theatre has 2 patient change rooms with bathroom facility, examination couch and sterilising facilities all provided.

FOR LONGTERM LEASE or SALE

' &,* &%*,#+ % )&&$* # ) ' + %+ . + % )&&$ ) % & 2 # + * . + ) * + * &) * ,) ' + %+ 2# * % *+&) + " + % % &.% # ,% )0 # + * . + ## # % % *+& "* ')&- &) / $ % + &% &, * + .% ' + %+ ) ' )" ) + %+ ) % ) /+ % * )&$

+& )$ # % &# 0*+&% +& ,) & * +, + + !,% + &% & # %0 1. 0 % 1. 0

* * . #" % # +0 . % # * )&,' & 1* ' # *+* &) ## #+ +& commence practice immediately with exceptionally reasonable leasing arrangements with an option to purchase the property at any stage of tenure. You will never have such a grand opportunity offered to you. Ideal for a group of 4.

Contact Dr Tony Taylor to view the opportunity of a life-time Tel: 0418 945 047 E: thuff@conceptual.net.au

MEDICAL FORUM

25 MILL STREET, BENTLEY WA 6102 47

Social Pulse

SJG Murdoch It’s been a big year for the team at St John of God Murdoch with the first phase of its redevelopment project coming to fruition in 2014, so there were good times to celebrate. Orthopaedic surgeon Dr Michael Anderson was named Doctor of the Year. å 3*'å-URDOCHå#%/å*OHNå&OGARTYåANDå Doctor of the Year, Michael Anderson 2 Dr Peter Nathan and Prof Ian Rogers 3 Cameron Gibson, Christelle Gibson ANDå$Rå!NDREWå7ILD 4 Boyd Milligan, Leanne Milligan and Dr Sue Ulreich å 'ROUPå#%/å3Tå*OHNåOFå'ODå(EALTHå#AREå Michael Stanford and Sally Stanford å !CTINGå.URSEå-ANAGERå+ARANå,ANE å Matt Taylor MLA and Nurse Manager Marie Condon 7 Health Minister Dr Kim Hames and Stephanie Hames

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Social Pulse

The ever-beautiful view of the city over Perth waters at Matilda Bay GREETEDåGUESTSåOFå$Rå7AYNEå3MITå the team. As the sun set timelessly on the leaping fish, the talk turned to the tide of change in the medical profession and the year that was.

Perth Pathology

1 Dr Annette Graebuer, Matalia Marias, $Rå7AYNEå3MIT å+ATå,AUåANDå$Rå*ASONå Lau 2 Susan Tai, Comira Almonte, Dr Helen $ONNELLYåANDå$Rå%ILEENå4AY 3 Matthew Rees, Dr Susanna Rodriguez, Riccardo Tutone and Dr Cynthia Innes 4 Dr John McAuliffe, Riccardo Tutone and Dr Colin Hughes

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5 Dr John Troy, Raylene Troy and Dr Robert Liddell å (ARSHå*AYATILAKEåANDå$Rå-ITHILIAå Jayatilake 7 Dr Christopher Quirk, Dr Alan Donnelly ANDå$Rå%NZOå!LMONTE 8 Dr Benjamin Sung and Lillian Sung 9 Dr Soon Tan, Dr Lee Meng and Voon Zue Voon

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Competitions

Entering Medical Forumâ&#x20AC;&#x2122;s competitions is easy!

Simply visit www.medicalhub.com.au and click on the â&#x20AC;&#x2DC;Competitionsâ&#x20AC;&#x2122; link (below the magazine cover on the left).

FEATURE

COMP Movie: Black Sea A suspenseful adventure thriller which centres on a rogue submarine captain (Jude Law) who pulls together a misďŹ t crew to go after sunken treasure rumoured to be lost in the Black Sea. As greed and desperation grip the men onboard, the hunt becomes a ďŹ ght for survival.

In cinemas, February 26

Movie: Selma Movie: The Second Best Exotic Marigold Hotel The wildly popular hit of 2014 has a sequel with most of the original cast (Judi Dench, Bill Nighy, Maggie Smith, Dev Patel minus Ralph Fiennes) re-assembling. This episode sees the elaborate marriage plans for Sonny develop into an extravaganza and the ever-complicated lives of the rich and elderly donâ&#x20AC;&#x2122;t get any simpler.

Be on the look-out for new arrival Richard Gere, who joins the residents for this entertaining romp.

In cinemas, February 26

This story of Dr Martin Luther King Jrâ&#x20AC;&#x2122;s struggle to secure voting rights for African-Americans comes as a 50th anniversary tribute to the famous campaign that culminated in the epic march from Selma to Montgomery, Alabama; an event which galvanized American public opinion and persuaded President *OHNSONĂĽTOĂĽINTRODUCEĂĽTHEĂĽ6OTINGĂĽ2IGHTSĂĽ!CTĂĽINĂĽ ĂĽ In cinemas, February

Movie: The Wedding Ringer

Winners from the November issue Music â&#x20AC;&#x201C; WASO Messiah: Dr Ruth Highman Aged Care Movie â&#x20AC;&#x201C; Serena: Dr Lydia Peter, Dr Andrew Christophers, Dr Kamlesh Bhatt, Dr Julia Charkey-Papp, Dr Penny Wilson, Dr Felicity Whitewood, Dr Clyde Jumeaux, November 2014 Dr Colin Lau, Ms Alison Carlisle, Dr Adeline Fong Movie â&#x20AC;&#x201C; Exodus: Gods And Kings: Dr Shelley Davies, Dr Eric Khong, Dr Robert Weedon, Dr Angelo Carbone, Dr Michael Parola, Dr Angeline Teo, Dr Melanie Chen, Dr Rachel Price, Dr Ines Chin, Dr Hertha Collin Movie â&#x20AC;&#x201C; A Thousand Times Goodnight: Dr Michelle Bennett.

Dr Andrea Harsanyi, Dr Amy Gates, Dr Kylie Seow, Ms Gabriella Tallman, Dr Farah Ahmed, Dr John D H Bell, Dr Helen Slattery, Dr Sara Chisholm, Dr Simon Machlin Music â&#x20AC;&#x201C; Collegium Symphonic Chorus Messiah: Dr Alison Stubbs Musical Theatre â&#x20AC;&#x201C; Thriller Live: Dr David Storer, Dr Harsha Chandraratna t Palliative Care, Deprescribing & IT

t Voluntary Euthanasia

t Primary Health Networks

Doug Harris is a loveable but socially awkward groom-to-be with a problem: he has no best man.

7ITHĂĽLESSĂĽTHANĂĽTWOĂĽWEEKSĂĽUNTILĂĽHEĂĽMARRIESĂĽTHEĂĽGIRLĂĽ of his dreams, Doug is referred to Jimmy Callahan, OWNERĂĽANDĂĽ#%/ĂĽOFĂĽ"ESTĂĽ-AN ĂĽ)NC ĂĽAĂĽCOMPANYĂĽTHATĂĽ provides ďŹ&#x201A;attering best men for socially challenged guys in need. Need we go on!

In cinemas, February 22

t Delirium, Osteoporosis, ACAT, Gout, Nutrition, Blood Cancers & Sleep

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Theatre: Dinner Moira BufďŹ niâ&#x20AC;&#x2122;s razor sharp satire draws some amazing characters, puts them around the table and installs a manipulative hostess and creates a dinner party to remember. Black Swan State Theatre Companyâ&#x20AC;&#x2122;s ďŹ rst main stage production of the year BRINGSĂĽ4ASMAĂĽ7ALTON ĂĽ2EBECCAĂĽ$AVIS ĂĽ3TEVEĂĽ4URNERĂĽ ANDĂĽAĂĽCASTĂĽOFĂĽ7! SĂĽBESTĂĽFORĂĽTHISĂĽWHIP CRACKINGĂĽBLACKĂĽ comedy.

Heath Ledger Theatre, March 14-29. Medical Forum performance, Saturday, March 14

Movie: Shaun the Sheep

Phot o

FUN 50

Start looking through your S holiday pictures because Medical M Forum will feature y your best photos in in the !PRILĂĽ%DITION ĂĽ$EPENDINGĂĽONĂĽ ! d demand, we will feature both landscapes and â&#x20AC;&#x2DC;people picsâ&#x20AC;&#x2122;.

S Send Best Holiday Shots to editor@mforum.com.au by e March 1.

From the creators of Wallace & Gromit and Chicken Run comes the anticipated big-screen debut of Shaun the Sheep. Life on Mossy Bottom farm has become rather dull, but when Shaun decides to take the day off and have some fun, he gets a little more action than he bargained for! Huge family fun.

In cinemas, March 26

MEDICAL FORUM

medical forum FOR LEASE

MURDOCH New Wexford Medical Centre o 4U +PIO PG (PE )PTQJUBM 2 brand new medical consulting rooms available: t TRN BOE TRN t DBS CBZ QFS UFOBODZ -FBTF POF PS CPUI SPPNT For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au MURDOCH Available now.

Suite in Murdoch Medical Clinic for lease or sessional use.

Well-appointed 16sqm consulting room, TIBSFE VTF PG MBSHF SFDFQUJPO XBJUJOH BSFB and tea room.

Rates available on enquiry $POUBDU *BO %PXMFZ 9366 1769 or: ian@flexphysiotherapy.com.au MURDOCH Wexford Medical Rooms for lease Please contact aptran@jointswest.com.au APPLECROSS Applecross Medical Group is a major medical facility in the southern suburbs.

Current tenants include GP clinic, pharmacy, dentist, physiotherapy, fertility clinic and pathology. Both the GP clinic and pharmacy provide a 7-day service.

The high profile location (corner of Canning Hwy and Riseley Street Applecross), provides high visibility to tenants in this facility.

A long term lease is available in this facility - with the current layout including 4 consulting rooms, procedure room and reception area.

Would suit specialist group, radiology or allied health group. $POUBDU +PIO %BXTPO o 9284 2333 or 0408 872 633 NEDLANDS Available now.

Use of rooms at Chelsea Village on M T W only. Easy parking. Nicely appointed examination room would suit non procedural eg medicolegal examinations or paramedical.

You open up, have sole use when required, UIFO MPDL VQ 0DDBTJPOBM VTF PS MPOH UFSN Flat $275 per day use.

Contact Dr Peter Burke 0414 536 630 MURDOCH NEW Wexford Medical Centre Attached to the St John of God Hospital, in vicinity of the Fiona Stanley Hospital.

Modern, newly fitted out medical consulting room.

4FTTJPOBM NFEJDBM EFOUBM SPPNT BWBJMBCMF Please contact wexfordmedical@outlook.com for more information.

MURDOCH Consulting room for lease at the new Wexford Medical Centre at Murdoch.

Well lit, spacious sessional consulting rooms for lease.

For further information please contact Murdoch Specialist Physicians on 9312 2166 or email us at admin@murdochspecialistphysicians.com.au PERTH CBD Medical room for rent in established Medical Practice in Perth CBD. Suitable for medical or allied health professionals.

For more information contact Dale on 0414 455 783 MURDOCH Brand new modern consulting rooms available for sessional lease at the new Wexford Medical Centre.

For more information: Email: reception@paragonsp.com.au or Call 0403 323 168 NEDLANDS Medical Specialist Consulting Rooms and Treatment Room t 'VMMZ TFSWJDFE DPOTVMUBUJPO SPPNT at Hollywood Specialist Centre t 4FDSFUBSJBM TVQQPSU oIJHIMZ FYQFSJFODFE long term staff t (FOJF TPMVUJPOT QSBDUJDF management software t 0OMJOF .FEJDBSF DMBJNT t 5FMFIFBMUI DPOTVMUBUJPO GBDJMJUJFT t 1BQFSMFTT QSBDUJDF TVQQPSUFE t 5SFBUNFOU SPPN o BWBJMBCMF GPS ambulatory procedures t "DDFTT UP )PMMZXPPE 1SJWBUF )PTQJUBM for inpatient care and theatre bookings supported t *OQBUJFOU CJMMJOH TVQQPSUFE Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager, Suite 31 Hollywood Specialist Centre 95 Monash Avenue, Nedlands, WA 6009 Phone: 9389 1533 Email: suite31.hollywood@bigpond.com.

MURDOCH New consulting suite including separate treatment room available in Wexford Medical Centre.

Full time or sessional basis.

Very reasonable rates.

Contact Dianne 0409 379 795

MURDOCH .FEJDBM $MJOJD 4+0( .VSEPDI Specialist consulting sessions available.

Email: cford@cyllene.uwa.edu.au NEDLANDS Hollywood Medical Centre 2 Sessional Suites.

Available with secretarial support if required.

Phone: 0414 780 751 MURDOCH 4+0( .VSEPDI .FEJDBM $MJOJD XJUIJO 4+0( )PTQJUBM t TRN PO TU GMPPS DMPTF UP MJGUT t 4FDVSF VOEFSDPWFS DBS CBZ t $VSSFOUMZ DPOTVMU SPPNT X XBUFS t -BSHF SFDFQU XBJUJOH SPPN LJUDIFO t 0OF PG POMZ GFX TVJUFT XJUI QSJWBUF 8$ t %VDUFE 3 $ BJSDPOEJUJPOJOH t "WBJMBCMF G GVSOJTIFE NJE MBUF +VOF The perfect suite for the medical specialist or allied health service where a private Toilet is required or preferred Frana Jones 0402 049 399 Core Property Alliance 9274 8833 frana@corepropertyalliance.com.au

GENERAL FOR SALE

H20 Massage Systems Unit Dry Hydrotherapy water massage unit for personal or business use.

Quatro wave therapeutic massage combines Hydrotherapy, Massotherapy for a gentle or deep massage.

User remains fully clothed for a hands free massage. $21,000.00 - Phone: 0416 152 345

POSITION VACANT MEDICAL SECRETARY SUBIACO Full-time Medical secretary required for General Surgical Practice in Subiaco Please email: missqualify@hotmail.com with your CV

PSYCHIATRISTS INVITED

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

This is a sheer walk in!

Part time, sessional or full time - all enquiries welcome.

Furnished consulting rooms available at: #JCSB -BLF 4QFDJBMJTU $FOUSF "OOPJT 3PBE #JCSB -BLF 8" Currently 4 practising Psychiatrists and clinic is open Tuesday to Friday 7-day pharmacy and GP surgery next door are added advantages.

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

Phone Navneet 9414 7860

RURAL POSITIONS VACANT ALBANY t 4U $MBSF T JT B OFX GBNJMZ QSBDUJDF based in Albany t 4NBMM GSJFOEMZ QSBDUJDF t 'VMM UJNF OVSTJOH BOE 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 Belinda Elliott Tel: 9841 8102 Email: belinda@stclare.com.au 0S TFOE ZPVS $7 UISPVHI BOE XF XJMM HFU back to you.

EXMOUTH Brand new premises available for entrepreneurial GP. Be the first private GP in town, with opportunity to focus on occupational and dive medicine as well as family practice.

Wonderful lifestyle with stunning scenery and wildlife to explore.

Contact draburkett@live.com

URBAN POSITIONS VACANT PRACTICE FOR SAL ALBANY

NEDLANDS Commercial Space for Lease Hampden Road ground floor street frontage location ideal for consulting rooms.

Well lit and spacious premises in excellent condition with lease term flexibility.

Approx 72 sqm + 2 secure undercover car bays.

Rental: $30,000 p.a + approx. $9,000 p.a outgoings Presents a variety of practice options.

Available now.

Please contact David Azzopardi 0418 924 950 Kempton Azzopardi Real Estate 9386 1988

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Private Psychiatric Practice A great opportunity to live and work in scenic Albany by taking over an established private practice.

Providing private psychiatric care for Great Southern Region (Population: approximately 50 000) Good supportive network of skilled General Practitioners sharing in the care and management of Psychiatric patients.

No private hospital and patients needing inpatient care are transferred to Perth.

No after hours work.

Peer review groups with Psychiatrists working at Public Mental Health.

Phone Felicity: 9847 4900 or email pietclaassen45@hotmail.com

CANNINGTON Southside Medical Service is an accredited practice located in Cannington area.

We are a family practice and offer mixed billings.

We have positions for a GP to join other (1 T DVSSFOUMZ XPSLJOH *U JT B XFMM QPTJUJPOFE QSBDUJDF DMPTF UP UIF Carousel Shopping Centre.

Phone: 9451 3488 or Email: practicemanager@southside.com.au RIVERTON RIVERTON MEDICAL CENTRE is looking for a Part-Time VR GP. Access to full-time practice nurse.

Fully computerised practice.

Friendly working environment.

Pay negotiable. Ring Dr Sovann on 0412 711 197 if interested.

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

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CANNING VALE 3BSF 0QQPSUVOJUZ $BOOJOH 7BMF Canning Vale Medical centre will have a room available from January 2015 for an established VR doctor wanting to relocate their practice to new rooms and join our team.

Full management services are provided by doctor owned practice operating for 15 years under the same management.

Continuous accreditation, finalist for "(1"- QSBDUJDF PG UIF ZFBS MBTU ZFBS full nursing support, computerised with referees available for suitable candidate.

Visit us at www.canningvalemedical.com.au Confidential enquires Dr. Neda Meshgin 0414 641 963 or dr.meshgin@canningvalemedical.com WEST LEEDERVILLE Great Lifestyle!

Part time (up to full time) VR GP invited UP KPJO MPOH FTUBCMJTIFE 8FTU -FFEFSWJMMF family practice.

Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired.

-PUT PG MFBWF GMFYJCJMJUZ XJUI TJY GFNBMF BOE one male colleague.

Email: glenstreetpractice@iinet.net.au or call Jacky, Practice Manager on 9381 7111 0488 500 153 CANNING VALE (SFBU 0QQPSUVOJUZ GPS QBSU UJNF PS GVMM time VR GPs. Modern, new â&#x20AC;&#x153;Queensgate Medical Centreâ&#x20AC;? opening in Canning Vale February 2015, PQQPTJUF -JWJOHTUPO TIPQT JO CVTZ MPDBUJPO Privately owned, 29 years of experience in the area.

0VUFS .FUSP (SBOU NBZ BQQMZ JG FMJHJCMF Flexible working hours, nurse support, friendly working environment.

For further information please contact: Dr Karen Majda - karenmajda@gmail.com or Dr Richa Singh richa_s@hotmail.com ROLEYSTONE 15 '5 73 'FNBMF (1 SFRVJSFE GPS a GP clinic in Roleystone.

A friendly and efficient working environment.

Well-equipped consulting and treatment rooms, fully computerised, accredited and busy practice.

Contact: practice.manager@roleystonefmc.com.au COMO Want variety in your work?

Special interest opportunities at the Well Men Centre in Como.

1BSU UJNF (1 T GPS PVS 1FSUI .PMF $MJOJD Skin Cancer Screening Service and for our Holistic Health Management Programme.

Call 9474 4262 or Email: wellmen@optusnet.com.au

GREENWOOD Greenwood/Kingsley Family Practice The landscape of general practice is changing, and it is changing forever. Are you feeling demoralised by the recent Federal government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? *U EPFTO U IBWF UP CF UIJT XBZ Come and speak to us and see the different ways in which we operate our general practice. Be part of the game changer!

0VS QSBDUJDF JT MPDBUFE OPSUI PG UIF SJWFS Sorry we are not DWS. Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion.

PERTH NORTHERN SUBURBS 1FSNBOFOU QBSU UJNF (1 XBOUFE Wangara Medical centre Busy practice, nursing staff, Best practice, pathology, podiatry and physiotherapy onsite -PUT PG QPUFOUJBM *U JT B %84 BSFB 0488 222 238 DIJCJMJUJTN!ZBIPP DPN ASCOT Part-Time VR GP required for our well FTUBCMJTIFE "DDSFEJUFE 1SJWBUFMZ 0XOFE Friendly Family Practice in Redcliffe.

We are fully computerised, using Best Practice software.

Nurse is support available.

Non DWS area.

1MFBTF DBMM o 9332 5556 SORRENTO 7 3 (1 GPS B CVTZ .FEJDBM $FOUSF in Sorrento.

Up to 75% of the billing Contact: 0439 952 979 CLAREMONT Growing GP practice located in the trendy suburb of Claremont.

80% of billings or $1000 a day whichever is greater.

-PPLJOH GPS 73 (1T XJUI VOSFTUSJDUFE QSPWJEFS number on a part-time or full time basis.

Fully computerised with on-site pathology and RN support.

-PDBUFE JO B NPEFSO DPNQMFY XJUI BDDFTT to the gym and pool.

For further information please contact Dr Ang on 9472 9306 or Email: thewalkingp@gmail.com

YANCHEP North of River (DWS Area) Experienced FT GP required Busy computerised practice Nurse and Admin support Earn up to 70% of billings Flexible hours Non VR welcome to apply Enquiries to Phil: phil27bc@gmail.com

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.

Abundant patients, DWS, non-corporate.

Generous remuneration.

Confidential enquiries Dr Ken Jones on (08) 9562 2599 Tina (manager) on (08) 9562 2500 Email: ken@cdmedical.com.au

THORNLIE Thornlie Medical Centre is looking for a part- time doctor to fill our growing multicultural practice.

We can offer: t GMFYJCMF IPVST t FYDFMMFOU SFNVOFSBUJPO t HSFBU UFBN FOWJSPONFOU t OPO DPSQPSBUF OP CJOEJOH DPOUSBDUT t 0VUFS .FUSPQPMJUBO "SFB (SBOU Applicable, ( 16km from Perth CBD) t GVMM UJNF OVSTJOH t NPEFSO CVJMEJOH XJUI TFQBSBUF TFDVSF parking for doctors.

The successful applicant should be: t 7PDBUJPOBMMZ 3FHJTUFSFE t .VMUJ MJOHVBM XPVME CF CFOFGJDJBM particularly with Chinese Dialects.

Please contact Donna: 08 9267 2888 03 FNBJM FORVJSJFT BOE $7 UP thornliemedicalcentre@hotmail.com

WEST PERTH

GOSNELLS General Practitioner (VR) required for Saturdays Gosnells Healthcare Centre is a newly established Bulk Billing Medical Centre situated in the Gosnells Central Shopping Centre. t 8F SFRVJSF B (FOFSBM 1SBDUJUJPOFS 73

for Saturdays t $POTVMUBUJPO IPVST BSF OFHPUJBCMF t (PTOFMMT JT %84 GPS (FOFSBM practitioners t 5IF QSBDUJDF JT GVMMZ FRVJQQFE BOE computerised t .JOJNVN IPVSMZ SBUF PG QFS IPVS or 70% of billings, whichever is greater. t 'PS GVSUIFS JOGPSNBUJPO QMFBTF DPOUBDU Joe Ranallo on 0418 282 796 or at joe.ranallo@ppsportal.com.au

BERTRAM South of River (DWS Area) Experienced FT GP required Busy computerised practice Nurse and Admin support Earn up to 70% of billings Flexible hours Non VR welcome to apply Enquiries to Phil: phil27bc@gmail.com

FREMANTLE Fremantle GP After Hours Clinic require GPs for evening and weekend work.

We are classified as an area of unmet need BOE UIFSFGPSF BSF BCMF UP FNQMPZ 05%T who qualify to work in this area.

We have ongoing vacancies and casual shifts available.

Generous hourly rate.

Please contact either Marina.

USFWJOP!'SFNBOUMF.- DPN BV PS '(1").BOBHFS!'SFNBOUMF.- DPN BV or 9319 0555

GOSNELLS Ashburton Surgery. VR GP needed.

Private billing. Flexible hours. 75% of billings.

3 Dr surgery. Fully equipped with nursing support.

Email: angiesurgery@gmail.com or Phone Patrick 0403 756 338 or 9490 8288

MANDURAH GP required for accredited, established friendly practice with FT RN support with a special interest in skin cancer medicine.

Coastal lifestyle only 40 minutes from Perth Contact mail@modernmedicalclinics.com.au

FT GP required for our friendly, accredited and fully computerised general practice.

The practice has been growing rapidly and we are moving into new premises with an extra consulting room.

We serve a young, professional demographic as well as providing specialist sexual health services.

This is an exciting opportunity for an enthusiastic practitioner to join our practice.

VR with experience in family planning BOE XPNFO T IFBMUI QSFGFSSFE Contact Stephen on 0411 223 120 Email: stephen@westperthmedicalcentre.com.au

WINTHROP Female VR Doctor required to join our busy private billing practice in an ideal location in Winthrop. Perfect for a long term commitment.

All requirements provided for, including full nursing support in a large medical centre.

Please contact Cathy on (08) 9310 4400 or email CV to admin@hatherleymedical.com.au

KARRINYUP St Luke Karrinyup Medical Centre (SFBU PQQPSUVOJUZ GPS '5 15 EPDUPS JO B State of art clinic, inner-metro, Nursing support, Pathology and Allied services on site.

Private billing. Privately owned.

Generous remuneration.

Please call Dr Takla 0439 952 979

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

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

medical forum BICTON Full-time and Part-Time VR GPs positions available for our well established "DDSFEJUFE 1SJWBUFMZ 0XOFE 'SJFOEMZ Family Practice in Bicton.

The practice has a well-established patient base, and offers an exciting opportunity for an enthusiastic practitioner to join our practice, with potential to own. t 0O TJUF QBUIPMPHZ BOE 1SBDUJDF /VSTF support, Radiology available across the road. t 6OJRVF NFOUPSJOH PQQPSUVOJUJFT available, and excellent support staff and facilities t 8F VTF #FTU 1SBDUJDF TPGUXBSF BOE BSF mostly a Private Billing practice. t 73 XJUI FYQFSJFODF JO XPNFO T IFBMUI preferred, but not required. t -FBSO NPSF BCPVU VT BU IUUQ CJDUPONFEJDBMDMJOJD DPN t "MM BQQMJDBUJPOT DPOTJEFSFE Contact Dr. Sam Messina on 9339 1400 Email: smess@iinet.net.au KINROSS 73 PS /PO 73 (1 15 '5 UP TUBSU "4"1 Privately owned DWS location practice.

Support available for those having interest in skin cancer, cosmetic mole removal, onsite 1BUIPMPHZ QIZTJP QTZDIPMPHJTU QPEJBUSJTU Practice open 7 days. Great rates.

Contact : sanjaykanodia2000@yahoo.com or call 9304 8844 WILLETTON Apsley Medical Centre Part-Time VR GP required for Accredited, Modern, Fully Computerised medical centre.

0O TJUF 1BUIPMPHZ 1TZDIPMPHJTU Podiatrist, and full time Registered Nurse.

Email : Brenda Haddow willetton@medicalcentral.com.au Mobile No: 0411 606 242

KARDINYA Kelso Medical Group SFRVJSFT 1 5 PS ' 5 male GP (DWS after hours only) This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest in CDM and minor surgical procedures.

-PDBUFE JO ,BSEJOZB XJUI POTJUF QBUIPMPHZ and allied health with growing patient base. $VSSFOUMZ TVQQPSUFE CZ (1 T BOE 3/ T www.kelsomg.com.au Please call 0419 959 246 for further information.

85

Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic.

GVMM UJNF QBSU UJNF TFTTJPOBM * medical systems and secretarial support * adjacent to Fiona Stanley Hospital More information phone: 9366 1802 or email: diane.car@sjog.org.au

KINGSLEY

Fantastic opportunity. A modern state-of-the-art, paperless clinic.

100% private billing.

'MFYJCMF IPVST ZPVS DIPJDF PG QBUJFOU case load, treat the patients you want. &NBJM SFTVNF DPWFS MFUUFS UP km@kingsleymedical.com.au www.kingsleymedical.com.au

MEDICAL SUITE â&#x20AC;&#x201C; For Lease LESMURDIE OR HIGH WYCOMBE 'VMM UJNF PS 1BSU UJNF 73 (1 T SFRVJSFE JO -FTNVSEJF PS )JHI 8ZDPNCF %84 "0/

- Privately owned with mixed billing - Nursing support - Fully computerised - Teaching practice - Allied Health - Special interest and skills supported - Hills location Contact Karin on 0438 211 240 or karintatnell@yahoo.com.au

South Terrace, South Perth Purpose built medical suite vacant and available now.

Reception / waiting / 2 consulting rooms (14.2sqm and 15.6sqm).

More information and inspection contact: Marcia Everett CEO/Director of Nursing South Perth Hospital 9367 0275

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

86

medical forum LOCUMS LOOKING FOR SOMETHING DIFFERENT - DISCOVER WA Ŕ Excellent private remuneration Ŕ (FSBMEUPO ENT Specialists with FRACS required.

(New graduates very welcome)

Apollo Health Cockburn Opening late March 2015 Apollo A polllo Health is openin opening in Cockburn so adding to its alr lrre dy established Armadale, Cannington lrea already and Joondalu Joondalup practices.

Th his new practice iis within DWS area.

This Op pportunity exists fo Opportunity for doctors to become fo ounda daati tio on membe on b rs of our dynamic team. foundation members If interested, we would love to hear from you. confidential chat with our medical To arrange a confidentia dire di rector please email: office@apollohealth.biz o director

We have run a visiting country ENT service for the past 8 years and we have clinics ready to be seen and lists ready to be operated on. There will be the opportunity to do both public and private lists.

We will supply you with ENT instruments and a flexinasopharyngoscope. We will arrange the booking for your consulting and lists get all the referrals in, do the billing/typing/keep the records and ensure follow-up/ongoing care. You will need your headlight and a laptop, specialist registration, provider and prescriber numbers, indemnity insurance for private work and you will need to be registered for GST. We will take the legwork out of it for you and provide you with all the relevant accreditation paperwork.

We will pay for return airfares within Australia and arrange and fund your airfare from Perth to Geraldton and your accommodation.

To help you make the most of your trip to Geraldton, and to make it as enjoyable as possible, we also include free kite surfing lessons.

Let us know your interest and availability and we will explain what we can arrange for you.

For more information on this exceptional opportunity to boost your revenue, please contact Tracy Heywood, Practice Manager, on 9382 4800. www.facialplastics.com.au

BALLAJURA General Practitioner VR / FRACGP Ŕ Large Medical Practice Ŕ Nursing Support Ŕ Theatre/Procedure Rooms Illawarra Medical Centre in Ballajura WA has an opportunity for a dynamic full time GP. The centre is a modern and welcoming facility featuring a 6 bay treatment area and two fullyequipped procedure rooms.

Co-located with a range of allied health services including Dental, Physiotherapy, Pathology, Psychology, Speech therapy, Diabetes education and on-site Pharmacy.

IMC is a mixed billing, UWA and WAGPET training practice with a strong focus on general practice research. Our GP’s have expertise across a variety of disciplines including dermatology, paediatrics, obesity and womens health.

Your patients will love the quality comprehensive care provided by you and your colleagues as well as the easeof-access to so many amenities and services.

Phone: Rory 9249 2033 or 9208 6400 Email: rory@illawarramedical.com.au

MARCH 2015 - next deadline 12md Thursday 12th February – Tel 9203 5222 or jasmine@mforum.com.au

medical forum

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ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience.

You won’t have to go through the onerous process of trying to find someone interested in selling.

Southern Suburbs GP required for after-hours & weekends Non-VR Dr’s encouraged to apply.

Send applications to hr@betterhealthcare.com.au

You’ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision.

We’ll take care of all the bits and pieces and you’ll benefit from our experience to ensure a smooth transition.

To find a practice that meets your needs, call:

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

SOUTH WEST REGION Opportunity for Owner Operator – OR – 4-6 VR GP’s Positions Vacant with Business Opportunities to work within the complex.

Brand new Health and Medical Complex being built in the South West region of WA - due for completion early 2016.

RADIOLOGIST WANTED

Our priority is NOT to manage the practice so this presents an opportunity for an owner operator.

The option would also be open for private practice GP’s to work within the centre, in a part time or full time capacity alongside other GP’s.

There is the option to purchase the premise (sub title) or lease the room in this idyllic location.

For EOI’s please contact Jarred Smith 0412 810 499

SKG Radiology is a highly recognised private Radiology group, providing imaging services at 20 locations throughout Western Australia.

We are seeking a dedicated and enthusiastic Radiologist with FRANZCR qualifications or equivalent to join SKG Radiology.

To be successful in this role you will need expertise in the areas of: Ŕ General, CT, Ultrasound, Image Guided Procedures and Mammography. Ŕ A Fellowship in Subspecialty areas of radiology is desirable.

SKG Radiology offers an attractive salary package, benefits and excellent working conditions.

Please forward your Curriculum Vitae via email to: Julie Rogers, Executive Assistant to the CEO, SKG Radiology.

Email: julie.rogers@skg.com.au

Produced right here in Western Australia!

Full Colour Personalised Practice Newsletter -RLQ RYHU VDWLV¿HG PHGLFDO SUDFWLFHV DFURVV $XVWUDOLD ZKR SURYLGH Health News DV D YDOXDEOH SDWLHQW VHUYLFH LQ WKHLU SUDFWLFH ,W DVVLVWV ZLWK DFFUHGLWDWLRQ DQG ZH GR DOO WKH ZRUN IRU \RX 9HU\ UHDVRQDEO\ SULFHG DQG D Free Trial Offer IRU WKRVH VWDUWLQJ RXW 6LPSO\ SKRQH -HQQ\ on 9203 5599.

MARCH 2015 - next deadline 12md Thursday 12th February – Tel 9203 5222 or jasmine@mforum.com.au

88

medical forum WOMENâ&#x20AC;&#x2122;S HEALTH GP Ĺ&#x201D; MonaLisaTouch (www.monalisatouch.com.au) Ĺ&#x201D; Potential for substantial remuneration Ĺ&#x201D; Prominent Practice in Subiaco

MonaLisaTouch An opportunity now exists for a self motivated GP with an interest in womenâ&#x20AC;&#x2122;s health and to be trained in a minimally invasive Laser procedure for menopausal women. You may have seen this procedure advertised recently on Today Tonight or Current Affair.

About the Practice & Facilities Academy Facial Plastics & Laser Specialist offers a range of cosmetic surgery, liposculpture, vaginal rejuvenation, wrinkle relaxers & dermal ďŹ llers, skin tightening, tattoo removal, Cool sculpting, IPL, peels & much more. We have a government licensed day twilight sedation hospital on-site. Our Practice is open 5 days a week, including 3 late nights, and is open alternate Saturday mornings.

Culture To ďŹ t into the culture of our innovative practice you must be a team player with a positive, proactive attitude. We supply an aesthetically pleasing environment, top of the range equipment and resources & a supportive team that excels in customer service!

QualiďŹ cations FRACGP Record of ongoing professional development Registration Indemnity insurance

For more information on this exceptional opportunity to boost your revenue, please contact Tracy Heywood, Practice Manager, on 9382 4800. www.facialplastics.com.au

ARE YOU READY FOR A CHANGE? We are looking for specialists and GPâ&#x20AC;&#x2122;s to join the expanding team!

Tenancy and room options available for specialistâ&#x20AC;&#x2122;s.

Procedural GPâ&#x20AC;&#x2122;s and ofďŹ ce based GPâ&#x20AC;&#x2122;s well catered for.

Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

Our busy, well-run clinic requires part-time GPs for ongoing sessional work; working with domestic, international students and staff. t 'MFYJCMF TFTTJPO UJNFT BWBJMBCMF .POEBZ UP 'SJEBZ t (SFBU PQQPSUVOJUZ UP XPSL JO B WJCSBOU EZOBNJD environment with diverse needs. t 8F PGGFS OFX QSFNJTFT BOE DBO TVQQPSU ZPV XJUI B UFBN PG FYQFSJFODFE OVSTFT QTZDIPMPHJTUT BOE GSJFOEMZ administrative staff. t &YDFMMFOU SFNVOFSBUJPO PG CJMMJOHT oCVMLCJMMFE BOE QSJWBUF

and free reserved on-campus parking available.

"O JOUFSFTU JO BOE FYQFSJFODF XJUI XPSLJOH XJUI ZPVOH QFPQMF NFOUBM IFBMUI TFYVBM IFBMUI BOE USBWFM IFBMUI JT FTTFOUJBM 1MFBTF DPOUBDU -JTB $SBOmFME 5FBN -FBEFS .VSEPDI )FBMUI and Counselling Service, on 9360 2664 or email l.cranďŹ eld@murdoch.edu.au

Mandurah VR general practitioner required for busy general practice in Mandurah, near Peel Health Campus.

Accessible via public transport and just a few minutes off Kwinana Freeway.

Private mixed billing group practice providing quality comprehensive family care for over 50 years to Mandurah and the surrounding community.

Our team features primary health physicians, specialists and allied health professionals.

Treatment room facilities, procedures room, skin clinic, travel clinic, nurse practitioner, practice nurses, reception, medical secretary, accounts, administration staff are here to support you.

Specialist, allied health services, pharmacy co-located in the same building.

The practice is open 7 days a week.

No DWS. To apply please email: manager@mmcmandurah.com.au

ality WKH e y client DOXH IRU

With a reputation built on quality of TFSWJDF 0QUJNB 1SFTT IBT UIF SFTPVSDFT the people and the commitment to provide every client with the finest printing and value for money.

9 Carbon Court, Osborne Park 6017 } Tel 9445 8380

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