Medical Forum WA 03/16 Public Edition by Medical Forum WA

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Editorial

Reform – Stopping All Stations Being a journalist is a privilege. That may come as a surprise to many who read that Forbes magazine has ranked it the worst career of 2015. After 40 years in the industry, you come to realise that Forbes is just another squawk in a raucous farmyard but it is exactly this cacophony of opinion that makes the job exciting – and career defining. Whose opinion is worth noting? After a lot more listening, whose opinion is worth reporting? What is my opinion? Am I sufficiently informed to have one? I am a subscriber to the more you learn, the less you know theory so I fight mightily to keep an open mind. Of course no one’s perfect and a hastily hatched idea can prove to be one of many red-faced moments in a long career. A couple of weeks ago a doctor asked me what was in this job for me. It made me think. I am not a glory seeker, nor do I particularly desire foisting my own opinions on unwilling or unsuspecting readers, but this is the editorial after all! So after years of listening to tens of thousands of machinations, frustrations and humiliations, mostly off the record, what’s in it for me – and you – is information. Journalists can’t say to a patient, this is what’s wrong and this is what we can do to improve it; they can’t make politicians do the right thing – whatever that is! What we can do is try to gather as much information as possible, tell our audience what we’ve found and perhaps, if we’re super-egos, draw some lines between the dots. This may, but mostly may not, spur the reader to dust off his or her democratic rights and assert their indisputable influence in our society. Perhaps, even, a call to arms? To enable me to sleep at night, I say to myself, I can only let people know when I think a train wreck is coming. I can’t push them out of the way. OK, so is a disaster on its way? That’s easy, there’s always a disaster waiting to happen. The fact we avoid so many of them is testament to the robust nature of our libertarian society and the checks and balances we have in place. This is going to be a big year in the history of our country and for the fortunes of our health system. The past 18 months, with a marked crescendo since Malcolm Turnbull became Prime Minister, the political narrative is reform; the political imperative is cost-cutting. The two are irritable and incompatible bed-fellows unless, of course, they mean the same thing?

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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

That really would be a disaster and a shameful loss of opportunity to create a better health system that will steer us to a sustainable future. May’s Federal Budget will reveal which way this Government will point the ship. We all know we’re heading to the polls, sooner rather than later. When you start with ‘everything on the table’ and then one by one (GST Brussels Sprouts and Lambs Fry g and reform Medicare) they are removed, an election is looming becomes a moveable feast. The RACGP last month released its pre-budget submission calling on the Government to lift the freeze on MBS indexation, fund 400 new intern community placements by 2020-21, make a $162.m investment over three years to pilot a GP-centred Medical Home model to 500 practices and commit $27m over nine years for a general practice research program.

Ms Jan Hallam

The GP college is just one of many interest groups putting their wish list to the government. The AMA’s list is both extensive and expensive, with the national president Prof Brian Owler insisting the Government “not retreat from its health responsibility”. The implication here is don’t touch health with that dirty scalpel of yours! However, the detail settles into a narrative of indexation of patient rebates, increased hospital funding and more training places as well as equally thoughtful ideas for reform. The information input from just these two organisations alone is vast. Clever, caring people wanting new models of care that will take the health system into this new challenging era with an element of resilience; clever, caring people who want to ensure that their craft groups don’t get trampled on; clever, caring people protecting their patch – or, the more daring of them, moving into someone else’s. More of the same, then. I hear the train a’comin’.

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

MARCH 2016 | 1

March 2016 14

Contents 18

FEATURES 14 Spotlight: Newspaper Cartoonist Dean Alston 16 Proﬁle: Dr Penny Flett 18 Mental Health Reform 24 Medicolegal: Dr Rod Moore 34 Lean Thinking at WA Health NEWS & VIEWS 1 Editorial: Reform – Stopping All Stations 4

6 8 10 27 29 33

Ms Jan Hallam Letters: Collateral Damage of Pell No-Show Dr Richard Sallie Best Practice & Experience Dr Fraser Brims & Dr Annette McWilliams Abortion and Population Decline Dr Colin Smyth Abortion Medical not Criminal Dr Kamala Emanuel Mental Health Support Ms Debbie Guest Curious Conversations Dr Peter Wutchak Meet the CEO: Ms Pip Brennan Have You Heard? PainHealth Website Impact of OTA Review Dealing with Family Violence

37 38 42 49

Rural Medicine Dr Fintan Andrews Primary Care for Frequent Fliers Beneath the Drapes Hospitals in the NMHS

LIFESTYLE 52 Ride for Youth Dr Phil Downing 54 History Inspires Book Dr Peter Burke 55 Nail Brewing Review: Dr Sergio Starkstein & 56 57 58 59

Dr Bradleigh Hayhow WASO has the Passion The Riders Hits High Note Funny Side Competitions

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Clinical Contributors

Dr Tony Barham Lesions of the Sebaceous Glands

Dr Max Majedi Complex Regional Pain Syndrome

Dr Sarah Pickstock Managing End-Of-Life Pain

Prof Eric Visser Chronic Lower Back Pain

Dr Tim Welborn Testosterone Revisited

Dr Mark Schutze Candidates for Back Injection

Dr Sara Damiani App Review: HealthDirect

Guest Columnists

Ms Kate Ryder When Death Comes a Knockin';

A/Prof Angela Alessandri Cultivating Positive Workplaces

Ms Nina Butler No Limits to Life

Dr Tim Smart Innovation – Cliché or Reality

Lean Thinking at WA Health Page 34

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), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM MARCH 2016 | 3

Letters to the Editor

Collateral damage of Pell No-show

Best Practice and Individual Experiences

Dear Editor, I recently saw a frail woman, in her 80s with an illness that meant continued work among Aboriginal people in WA’s North West was impossible and which necessitated her return to Victoria to be cared for by her Order. Since 1895, hundreds of young Catholic women have bravely left home at 18 or 19, made long, often dangerous and arduous journeys around the world, usually with little more than the clothes they wore, to spend their lives, as my patient had done, living in inhospitable circumstances selﬂessly caring for the sick often suffering untreatable (at the time) infectious diseases like tuberculosis, typhus and leprosy. The contrast with the recently departed Cardinal Pell—who’s taste for, and spending on, ﬁrst-class air travel, luxury accommodation and bespoke tailored clothing, drew recent sharp rebuke from the Pope— is stark. George Pell may have no regard for the victims of child sexual abuse or fear of the Royal Commission into that abuse but he (and the Church) should understand that it is the tradition of the true Catholic values of Thomas Aquinas—compassion, justice and respect—embodied by those courageous young nuns that he is currently spitting on and contemptuously destroying. Dr Richard Sallie, Hollywood ED: Richard’s letter to the Sydney Morning Herald offering his medical assistance to ensure Cardinal Pell’s safe return to Australia to give evidence at the Royal Commission made nationwide news. We asked him if he had anything more to add and he penned the above for Medical Forum. His deep feelings encompass compassion for the victims of child sexual abuse, their relatives and friends, and also to “decent hard-working people of faith” whose work and reputations may be tarnished by this sorry chapter of the Catholic Church’s history

Dear Editor, We read with interest the recent article (How lucky am I? February) detailing an experience of an asymptomatic early stage lung cancer detected by lowdose CT and treated with surgery. This is undeniably great news for the author. Individual experiences are powerful anecdotes in medicine and when considering best practice in screening for lung cancer we should remain cognisant of the current evidence and guidelines. Screening for asymptomatic disease is a population-based concept and with lung cancer it is only effective when a high-risk population can be identified.(1) Even then, the number needed to screen to save one life from lung cancer is ~255. The recent Standing Committee on Screening position statement highlights significant concerns that need to be addressed before Australia will formally endorse this practice.(2) Lung cancer screening is associated with harm. Up to 50-75% of scans performed on current or ex-smokers will identify a noncalcified pulmonary nodule of some size, of which the vast majority will be benign. In the National Lung Screening Trial the 3 lives/1000 saved was (partially) offset by significant harm (death or hospitalisation) in 3/1000 investigations performed as a result of ‘false positive’ findings.(3)

For this and others reasons, a screening program utilising CTs needs to be coordinated by an experienced multidisciplinary team of radiologists, pathologists, respiratory physicians and thoracic surgeons skilled in minimally invasive surgery.(4) Whilst it is fair to contend that the radiation from a low dose CT is now acceptably low, it is the radiation from unnecessary or incorrect follow-up scans, harm from biopsy and even unnecessary surgery for benign lesions that may still cause harm. In Australia, CT screening for lung cancer is currently neither accepted nor funded. Should clinicians have patients they feel may be at high risk we would encourage referral to the NHMRC-funded LungScreen WA project, examining the role of lung cancer screening in Australia commencing in mid-2016. Phone 1800 768655. Dr Fraser Brims. Dr Annette McWilliams References 1. Tammemagi MC, Church TR, Hocking WG, Silvestri GA, Kvale PA, Riley TL, et al. Evaluation of the lung cancer risks at which to screen ever- and never-smokers: screening rules applied to the PLCO and NLST cohorts. PLoS Med. 2014;11(12):e1001764. 2. DoH. Position Statement: Lung Cancer Screening using Low-Dose Computed Tomography. Canberra, Australia Department of Health, Australian Government, 2015. 3. Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. The New England journal of medicine. 2011;365(5):395-409. 4. Brims F, McWilliams A, Fong K. Lung cancer screening in Australia: progress or procrastination? The Medical journal of Australia. 2016;204(1):4-5.

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Abortion in Era of Population Decline

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Dear Editor,

I don't deserve this award, but I have arthritis and I don't deserve that either. Jack Benny

In the February edition of Medical Forum, there was an article on Abortion Law Reform. Almost as an aside, it quoted that the number of abortions per year had remained static at 80,000. In 2014, there were 299,700 births in Australia. A recent article in the Sydney Morning Herald (October, 2015) discussed

continued on Page 6

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The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reﬂect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

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Letters continued from Page 4 the declining birth rate in Australia over recent years. From the above ﬁgures, there were approximately 379,900 pregnancies in 2014 but 21% of them were aborted. This is an incredible and I believe tragic loss of potential Australians.

anyone experiencing mental health or life challenges and we are also introducing online counselling.

Dr Colin Smyth, Northam

In September last year we rebranded from Arafmi to Helping Minds to reﬂect our commitment to providing quality education, respite and support services. Our new tagline, ‘Helping You’ underscores that Helping Minds is here to support and understand carers and clients as they try and live their best life possible.

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www.helpingminds.org.au or 1800 811 747.

I ﬁnd it hard to believe that this fact is not mentioned when declining birth rates are being discussed.

Debbie Childs, Executive Director, Helping Minds

Mental Health Support

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Dear Editor, It is timely to advise your readers that we at Helping Minds (formerly Arafmi) offer help and support for both carers of someone with a mental health issue or who are themselves experiencing a mental health condition. The organisation was established in 1976, providing mental health services and carer support for 40 years in Western Australia. The majority of our services are free and focus on advocacy, understanding the mental health system, education, counselling and support, school holiday programs and respite. We have a professional and compassionate team of staff and dedicated volunteers who provide quality, conﬁdential support and services to children, youth, adults and families In order to help more people, we are now offering services online. This allows us to accommodate the busy needs of people and the fact that not everyone can get into an ofﬁce, or has access to support locally in their community. An online support program called Recovering Our Families is available now for

Abortion is Medical not Criminal

performing the abortion. While many women would turn to their GP for a consultation and referral even without this law, it imposes an extra cost and time burden that wouldn’t be necessary if no referral was needed (as in NSW and Victoria). It also has a gatekeeper effect, in practice enabling doctors with personal objections to abortion to hinder access by refusing to discuss or refer for abortion. It is not unheard of for women to see several doctors seeking abortion referral before being able to ﬁnd one who will refer them for a procedure that the majority of the population agrees should be up to her to decide. This is despite the fact that although the WA law explicitly prevents anyone from being obliged to take part in performing abortion, it doesn’t exempt doctors from providing information or referral for abortion. We don’t know how many women in WA continue unwanted pregnancies because of such obstacles to accessing abortion. But the potential is clearly there.

Dear Editor, I support the thrust of Caroline da Costa and Heather Douglas’ call (February) for consistent national abortion laws to improve access to legal abortion for women regardless of the state or territory they live in. Much more needs to be done to remove practical barriers for women to access abortions they seek (including improving public provision and expanding access to medical abortion). But legal obstacles are a signiﬁcant barrier to women accessing early, safe termination of unwanted pregnancy. It is still a crime in WA for a doctor to provide a woman with an abortion unless she has seen another doctor ﬁrst, to be given ‘appropriate counselling’ about the medical risks, and to be offered a counselling referral – all of which could and should be provided by the doctor

Victoria’s laws offer an improvement on WA’s in every regard. Their provision obliging conscientious objectors to refer their patients to a practitioner who does not object to abortion, and to perform abortion if needed to save the woman’s life, would particularly be an advance in WA. That said, it is important that any changes to abortion law don’t introduce any new restrictions on women seeking abortion. Rather than introducing laws to say when and where abortion can be performed, it would be preferable to follow the Canadian road and just remove all laws restricting abortion, allowing it to be treated as a medical matter, not a criminal one. Dr Kamala Emanuel, GP, Perth ........................................................................

Curious Conversations

Practice Makes Perfect The physics of cricket and golf are the things Collie GP Dr Peter Wutchak would love to master with surgical precision. One of the things I’m most proud of is… my practice and my team. They’re all absolutely wonderful and the recent RACGP award is a testament to their hard work. My wife and children are pretty wonderful, too. If I could say one thing to Dr Kim Hames it would be… don’t overlook the beneﬁts of General Practice in the delivery of health. The old adage that an ‘ounce of prevention is better than a ton of cure’ is so true. The cost-drain of the public hospital system is enormous and primary care will help to ease the pressure. One of the best mentors I’ve ever had was… my former partner, Dr Keith Meadows. He had great skills in surgery, obstetrics and

6 | MARCH 2016

anaesthetics and was the epitome of a procedural, rural GP. Dr Peter Wallace is also a great inspiration, he does wonderful work away from the consulting room and I share his philosophy of medicine. If I was forced to choose a career other than medicine it would be… engineering with a business focus. I ﬁnd the practical application of physics very interesting and I enjoy the ‘business’ side of medicine. If I could pick one sport to be exceptionally good at it would be… a toss-up between cricket and golf. Both sports are psychologically demanding and ask hard questions in different ways. To be honest, I’m a ‘sports nut’ and would happily be exceptional in any sport! ED: The Collie River Valley Medical Centre won the 2015 General Practice of the Year. The practice principals are Peter and Dr Jan Van Vollonstee

MEDICAL FORUM

Dr Peter Heenan

HL Skin Pathology Part of Perth Medical Laboratories P/L (APA):

Peter Heenan graduated from UWA and is internationally recognised for his expertise in skin pathology. Peter's extensive contributions to the field encompass diagnosis, teaching and research.

Independent, Pathologist Owned and Operated. Contact Phone: 93863500 q 'BY 93863511 26 Leura St Nedlands WA 6005

www.heenanlamskinpathology.com.au

Lesions of the Sebaceous Glands Sebaceous glands are present in the skin throughout the entire body except on the palms and soles, and are particularly numerous on the face and scalp. They release oily secretions (sebum) into hair follicles and subsequently onto the skin surface. Sebum moisturises and lubricates the skin and hair, and inhibits microbial growth. The most common skin lesions composed of sebaceous cells are benign, non-neoplastic conditions. Sebaceous neoplasms are relatively rare, but are of clinical importance due to their association with Muir-Torre syndrome (see below).

Sebaceous carcinoma

Muir-Torre syndrome

Sebaceous carcinoma is a rare but clinically important lesion. Most (75%) occur in the periocular region. Periocular sebaceous carcinoma may form a nodule similar to a basal or squamous cell carcinoma, but some cases clinically resemble blepharitis or a chalazion, potentially resulting in delayed diagnosis. Metastatic and mortality rates have been reported to be as high as 30%, although recent reports indicate a mortality rate of 6%.

Sebaceous neoplasms are usually sporadic lesions, but they are also an important feature of Muir-Torre syndrome (MTS). This is an inherited condition characterized by the combination of at least one sebaceous neoplasm and at least one visceral malignancy, the latter most often involving the gastrointestinal or genitourinary tracts.

Non-neoplastic lesions These are very common on the lip and buccal mucosa, consisting of 1 to 3mm yellow to white papules known as Fordyce spots. Similar papules occurring on the areola are known as Montgomeryâ&#x20AC;&#x2122;s tubercles. Sebaceous hyperplasia This typically presents as a 1 to 5mm ďŹ&#x201A;eshcoloured papule on the forehead or cheek of an adult. Not infrequently, it is mistaken for a basal cell carcinoma. Naevus sebaceus Q Fig1: Sebaceous adenoma from the groin of an 81 year-old female.

Sebaceous neoplasms Sebaceous adenoma (Fig. 1)

Demonstration of MSI requires molecular analysis by PCR. A more widely available technique is immunohistochemical staining for MMR proteins (Fig. 2). This method is not deďŹ nitive, as loss of MMR protein may occasionally occur in sporadic tumours; furthermore, some mutations may cause loss of MMR activity but still result in production of an antigenic (albeit non-functional) protein. Nevertheless, immunohistochemistry is a useful tool for detecting possible cases of MTS. We routinely stain sebaceous neoplasms using immunohistochemistry and recommend further investigation if there is loss of MMR protein expression. References available on request.

This is a benign tumour that essentially recapitulates the normal sebaceous lobule and consists predominantly of mature sebaceous cells. It presents as a tan, pink or yellow papule or nodule, usually on the head or neck of an older adult. Sebaceoma This tumour is also benign and is clinically similar to sebaceous adenoma. It is distinguished from sebaceous adenoma by a predominance of immature (germinative) sebocytes over more differentiated sebaceous cells.

MTS is a variant of hereditary non-polyposis colorectal cancer (HNPCC). It results from mutations within genes encoding DNA mismatch repair (MMR) proteins. The gene most commonly involved in MTS is MSH-2 (90% of cases). Abnormal MMR function results in a detectable genetic marker known as microsatellite instability or MSI. Microsatellites are short repeated sequences of non-coding DNA, the lengths of which are normally maintained during cell reproduction. Loss of MMR function, however, allows â&#x20AC;&#x153;slippageâ&#x20AC;? of DNA during base pairing to go uncorrected, resulting in an altered number of repeats (instability).

Ectopic sebaceous glands

This is a hamartomatous lesion, most frequent on the scalp. It consists of a smooth, waxy and hairless plaque, usually present at birth and becoming more raised and warty at puberty. Although sebaceous glands are usually prominent, naevus sebaceus also incorporates other skin structures including epidermis and hair follicles.

Dr Tony Barham Tony Barham graduated from the University of Newcastle and undertook his pathology training in Western Australia. Tony's interests include skin, gastrointestinal and gynaecological pathology.

Q Fig2: Normal expression of MSH-2 within the epidermis (brown staining) but loss of MSH-2 expression within the neoplastic sebaceous cells (arrow)

Incisions

‘When Death Comes a Knockin’…’ RN Kate Ryder has seen both in her work and in her own family how dangerous our health system can be and calls for change. Nothing can prepare you for the sickening and heart-wrenching moment on a plane to England when you realise that your mother is probably going to die as a result of negligent treatment by a locum GP, and that you had a chance to save her by calling an ambulance yourself from Australia.

I thought, like many of us, that I had the knowledge to keep my family and friends safe…I was wrong, and my mother died.

I will always remember the locum’s glib, throwaway comment ‘She was full up to her pelvic rim’ on that fateful Sunday evening when I spoke to him on the phone, and the ensuing silence when I asked him why he hadn’t sent her to hospital on the preceding Friday when he saw her, especially as he knew she had been constipated for ﬁve days and had diverticulitis.

was going to be ‘OK, now. The pain has gone. It was really bad, but it’s gone now…’ I will always remember that terrible moment when I realised that her bowel had already perforated. And I never will be able to forget lying down beside her on the ICU bed and holding her while she died.

Was he being dismissive in his silence? Did he think he’d done anything wrong? I will always remember silently blaming my father for not calling an ambulance when I asked him to, even though I knew he wasn’t the type of person to ‘make a fuss’. I should have also anticipated that he wouldn’t have wanted to offend the doctor by calling an ambulance himself. I will always remember my mother’s frail and thready voice trying to reassure me that she

As a nurse with over 20 years’ clinical experience and former Senior Investigation Ofﬁcer with the Health Care Complaints Commission (NSW), I thought, like many of us, that I had the knowledge to keep my family and friends safe from the pitfalls of the health system. I was wrong, and my mother died. I often think about that locum doctor and wonder if he ever thinks about my mother and the role he played in her distressing, preventable and untimely death. I am also

reminded of all the other clinicians who have been the ‘secondary victims’ of their own medical errors, as I am of mine as a nurse. In doing so, I am reminded of the old adage: ‘There by the grace…’ I’ve taken a different approach to the problems within our own health system, which recognises that patients themselves have an important and understated role in preventing medical errors. I have sought to empower them by writing what I describe as a ‘patient’s safety manual’, which informs patients of what they need to know to keep themselves safe from us all in the health system. It recognises that health practitioners are not perfect and that some of us are, at times, downright dangerous, and that we need patients to help us to help them. If we are to have any kind of chance of keeping our own family and friends safe inside the health system, then we have to work together to ensure the safety of all patients.

Meet the CEO

How Consumers Will Aid Reform Ms Pip Brennan was appointed ED of the Health Consumers Council of WA last year and it was a ‘coming home’ for the long-time advocate. “My ﬁrst paid health job, after eight years working in the museum sector, was as an advocate here at the council. Working alongside [former council ED] Michele Kosky and Maxine Drake, I learnt so much about advocacy. Like a lot of arts graduates, I have amassed a long and varied work history but I had done signiﬁcant work at the grassroots level around health consumer rep work and grant writing.”

ED position at HConC WA came up and in her own words “brought everything I’m interested together – advocacy, consumer representation and running NFPs.” The health sector is in a volatile state and Pip sees the obvious challenge for her organisation is the changing structure of the health department as of July 1 with devolution to four area health services boards – North, South, East and Country.

Pip has also seen the work from the other side of the complaints coin when she worked as conciliator at the Ofﬁce of Health Review where mediating between provider and consumer gave her a deeper perspective of the landscape. However, her interest in consumer support led her to running Midwifery WA which provided postnatal support services and antenatal education and inevitably a broader understanding of NFP fund-managing.

“We are working with the interim boards to discover how that structure is going to work. In the past we would take issues to the Director General who would decide to take them up or not. If he said yes, essentially it was job done. Now we will have to pitch to the various health services, which will mean we must spend a lot of time building up a number of relationships.”

After a year working for WACOSS researching outcomes-based contracting in Health, the

Will the quadrupling of work beneﬁt the consumer?

8 | MARCH 2016

“It’s the age-old question of Ms Pip Brennan centralisation versus localisation and there are difﬁculties in both. The potential opportunities for consumers are the more localised solutions to population and health needs. It could be a fantastic opportunity to close the gap on fragmented care once a consumer leaves hospital.” “Together with the parallel reform in primary health, with WAPHA as a single entity running the state’s Primary Health Networks, we could see some really big wins.” “But we have to wait and see. The actual personalities behind these reforms will make or break them. Having the right people on the bus is so important.”

By Jan Hallam

MEDICAL FORUM

MARCH 2016 | 9

Have You Heard?

AHPRA state of play AHPRA has recently released its annual report and, as its principal ‘shareholders’, you will probably like to know that it’s stayed nicely in the black the past financial year with a net surplus of $1.8m. Income (88.23%) was derived from registration fees ($150.4m) and 5% from application fees ($8.5m). In WA there were 10,246 registered medical practitioners with 419 notifications (4.1%); WA recorded an increase in notifications (781, across all registrants) from the previous year (750). There were 37 mandatory notifications issued

to WA doctors across three main categories – standards/impairment; alcohol or drugs; and sexual misconduct; while 554 were being actively monitored (343 for eligibility/ suitability; 55 for conduct; 74 for health; and 82 for performance). Some good news is that resolution wait-times are lower than the previous year.

Inquiry heat on AHPRA The AHPRA annual report shows the local ofﬁce has been hot on practitioners’ heels, second only to NSW for the number of

notiﬁcations. The agency’s national activity has come to the attention of the Senate Community Affairs References Committee, urged along by South Australian Senator Nick Xenophon, and it will be inquiring and reporting on the medical complaints process. It will look into the prevalence of bullying and harassment in the profession and the roles of the Medical Board, AHPRA and others in managing investigations into professional conduct. It also turns the spotlight on the National Law as it relates to the complaints handling process and there’s sure to be

He Can Still be a Hero A lot of words have been written since pop legend David Bowie died on January 10 but we found this blog – written as a thank you letter to the singer by Cardiff palliative care consultant Dr Mark Taubert – particularly moving. Mark had never met Bowie but was an out-and-out fan. More powerfully, from a medical point of view, Mark thanked Bowie and his courage to document his dying in his last album, Blackstar, especially the single and its video, Lazarus. It enabled Mark to open conversations about death and dying with his patients like nothing had done before. Discussions about dying a “good death” at home, symptom control, advance care planning, no-resus orders – all became easier through the ﬁlter of “what did Bowie do?”. For one patient they wondered together “who may have been around you when you took your last breath and whether anyone was holding your hand. I believe this was an aspect of the vision she had of her own dying moments that was of utmost importance to her, and you gave her a way of expressing this most personal longing to me, a relative stranger. Thank you.” http://blogs.bmj.com/spcare/2016/01/15/a-thank-you-letter-to-david-bowie-from-apalliative-care-doctor/

smithcoffey

10 | MARCH 2016

MEDICAL FORUM

Have You Heard?

plenty of doctor input into that one. The committee is expected to report on June 23.

Never let facts get in the way We have been told that under the current Medical Board and AHPRA, a patient can make a false complaint; it can be fully investigated, including unfavourable judgement by a medical expert, without the expert saying they lack speciﬁc knowledge in what you do; the MB can require you to do things to keep them happy (e.g. attend courses), based on this report; and a black mark remains against your name as long as the Medical Board wants.

Whistle while you wait … and wait

Stats all in together Our ears pricked up when we read in the national media that Bupa was going to name and shame individual high-rolling specialists. We thought it sounded too crystal clear to be that transparent. A Bupa spokesperson told us that it will use “aggregated claims data from its 4m members to help consumers understand the average for typical surgical procedures”. Not quite as ‘courageous’ as ﬁrst thought, however, the idea behind it is interesting. Bupa will begin publishing the average costs for common procedures, state-by-state, but not what individual surgeons charge, by the ﬁrst quarter of 2016 and it hopes this will create competition and drive down prices. Without consumer action that might be a long

What is going on at the PBS Authority line? We have had a second complaint from a local doctor about the length of time it’s taking to get scripts authorised. To paraphrase Oscar Wilde’s Lady Bracknell once is a misfortune, twice looks like carelessness. In November we reported a doctor’s complaint (described to us as “ridiculous delays” of at least five minutes) to the Department of Human Services. We reported faithfully its statement that, oops, “oneoff technical issue”, “normally very low wait times” and how about an average speed of answer of 42 seconds. This latest complaint reports unreasonably long delays “every day”, which have forced doctors in this particular practice to write scripts at home at night because the waiting time is less. They claim that in the past couple of months they have lost more than half an hour each day waiting for a phone authorisation. A department response to one of the docs at least acknowledged a problem “they are working on”. The official media response was a carbon copy of the first, except the average speed of answer has blown out to 47 seconds. Alarmingly the statement says the line has been operating normally even bettering its average speed of answer in January to 23 seconds. You can accept a one-off spot fire but when lightning strikes at the same place twice, the smoke alarm is well and truly ringing. At the time of going to press, Alan Tudge had just been sworn in as Human Services Minister. We will give him time to find his coffee cup then we will ask the politician to respond. If you have experienced problems, send us an email at editor@mforum.com.au.

continued on Page 12

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MEDICAL FORUM

MARCH 2016 | 11

Have You Heard? continued from Page 11 time coming but then again if private health insurance premiums rise as the companies hope, pressure might be applied from all sides.

Morton fights on She may have had a slap-down from her party but Mental Health Minister Helen Morton won’t lie down. She and Police Minister Liza Harvey announced a $6.5m trial that could make a significant difference to outcomes. Senior mental health clinicians will work with police in special teams to respond more effectively to callouts that relate to mental health and drug and alcohol incidents. Since 2007 the number of such calls has risen from 4766 to 17,498 last year and police figures show that 70% of welfare checks involve self-harm.

My DNA, Your Info Wow, is there anything pharmacies can’t do? Apart from dispensing statins, ﬂu jabs and anti-depressants, some pharmacies are now offering to test customers’ DNA. The myDNA pharmacogenomic test (which identiﬁes gene variations in enzymes) apparently can predict the correct medication and dose for an individual based on their DNA. The media release said 10,000 GPs and specialists have been asking patients to have the test done – if you’re out there, we’d love to talk to you. About 200 Chemmart Pharmacies across Australia are conducting the tests – 27 in WA are ready to go with another 47 interested. Analysis is being conducted by Clinical Laboratories and clinical interpretation by My DNA Life. We’re told 265 West Australians have already had the test.

Safe access zones in WA Abortion is an emotive and volatile issue. This month’s letters page is testament. It has come into sharp focus locally with the opening of the new SJG Midland Public Hospital and its refusal to perform such procedures for public patients on religious grounds. With the Midland Marie Stopes clinic now performing those terminations and contraceptive procedures with State Government funding, it has attracted the attention of the religious organisation 40 Days for Life, which was to start a Lenten prayer vigil outside the Dr Marie premises from February 10. The organiser Joanne Cicchini didn’t return our calls but the Australian CEO of MSI Alexis Apostolellis told Medical Forum that his organisation had petitioned for the introduction of safe access zones at all its sites and “zoning is critically needed for WA”. “Every woman has the right to access medical treatment without prejudice or harassment. Every staff member has the right to go to work without being shamed for doing so, particularly when their role is to support the health and wellbeing of others.”

WAGPET: all OK here There was an almighty brew-ha last month over the backlog of 15,000 provider numbers waiting issue for this year’s GP registrars. The Rural Doctors Association was in uproar. But the issue caused barely a ripple here in the West. According to WAGPET, the sole training provider in WA, there are “no problems here”! CEO Dr Janice Bell added that, in fact, fewer

12 | MARCH 2016

Dr Rohan Gay and Dr Elizabeth Gray

WAGPET announces its stars WAGPET has just announced its 2015 award winners with Dr Rohan Gay’s Walter Rd East practice named training post of the year. Readers will be aware of Rohan’s enthusiasm for GP training through these columns, now his students have given him the thumbs up. Registrars have been equally glowing of the practice staff, led by practice manager Cheree Matthews. WREPG has been taking GP registrars for 13 years with 23 graduates passing through its doors, including this year’s Registrar of the Year, Dr Elizabeth Gray. Elizabeth was nominated for her “exceptional care and follow-up both in and outside of practice hours, and her thorough and holistic approach to managing acute problems and chronic conditions, preventative health and screening tasks”. Her training adviser was Dr Wence Vahala who gave her a key bit of advice about general practice: learning to deal with uncertainty. It has resonated with her and powered her enthusiasm for the keystone of general practice – continuity of care. Dr Byron Manning won the Prevocational Community Medicine Award. The ADF doctor completed a 21-week Community Residency Program rotation in General Practice, Acute Medicine and Aboriginal Health at the Roebourne and Nickol Bay Hospitals.

Dr Byron Manning

slip-ups than usual (“and there are always a few”). With a turbulent year of policy change behind them, WAGPET’s business-as-usual approach seems to have protected it from the worst of transition vagaries.

Cat among the pigeons Nurse and consumer advocate and former investigator for the Health Care Complaints Commission (HCCC) in NSW Kate Ryder says another title of her book, Getting the Best out of the Health System, could also be known as

‘Setting the Cat Among the Pigeons’. Kate, who writes a guest column in this edition, has said that the book, which is aimed at health consumers and details the sometimes poor practices especially in hospitals that cause patients harm, has had a mixed reaction among colleagues, though generally received positively. Kate will be in Perth to speak at the Health Consumers Council’s Patient Experience Week on April 29.

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MARCH 2016 | 13

Spotlight

By the Point of a Pen It’s a part of thousands of West Australians' morning ritual – Alston and a cup of tea. The morning newspaper’s chief cartoonist, Dean Alston, is a kid at heart. The West Australian’s resident cartoonist likes to stir the pot and that’s exactly what Dean Alston has been doing for the past 25 years. Along the way he’s penned more than 13,000 cartoons and won a prestigious Walkley award. He reckons it’s the greatest job in the world. “I get to my desk just after midday, have a look at what’s going on and then we have an editorial news meeting at three o’clock. That gives me an idea what’s going into the paper on the following day and I’ll work on the main cartoon between 4.30 and seven in the evening.” “It’s just so enjoyable, there are different issues popping up every day and that means a huge variety of possibilities with the drawings. It keeps me thinking. There’s a bit of pressure heading towards deadline and it’s a good brain workout every day. I’m working with people who are bright, well-read and can write.”

and Opportunity Commission ruled that the cartoon made inappropriate references to Noongar beliefs but did not breach racial discrimination law. “It’s important to push boundaries and challenge political correctness. The latter is a cancer in our society and goes way too far sometimes. Alas Poor Yagan ruffled a few feathers and was a pretty difficult time, although the newspaper ended up winning the case.” “I tend to shy away from an ideological position when it comes to politics but you do need to have a point of view on some issues. And sometimes I do end up dancing on the borderline of slander.” Late last year Dean couldn’t resist yet another somewhat delicate ‘soft-shoe shuffle’. His ‘take’ on feminism raised more than a few hackles when six panels depicting ‘Camp Femdom’ portrayed a group of militant women declaring they intended to ‘shatter the

glass ceiling’, but not before they’d ‘sipped a latte, waxed and had their hair done.’ Nonetheless, there is one line he refuses to cross. “I don’t do lunches with politicians. In fact, apart from putting them in my cartoons, I don’t have anything to do with them.” Dean’s career had been creative and colourful and it would seem that Perth’s politicians will be in his cross-hairs for some time yet. “I stay pretty active, run three days a week and go to the gym on the other days so hopefully old age is still a fair way around the corner. I’ve had over two decades at The West and I must have drawn thousands of cartoons. The words, I don’t want to go yet will be on my tombstone.”

By Peter McClelland

“I’m here six days a week with Sunday my only day off and, as far as I’m concerned, I’ll be doing this forever. I’m going to die at my desk!” Dean has always been a bit of a larrikin and in his pre-cartooning days he was a part-owner of the Carine Tavern. “Some people say it was because I spent so much time in there but, in fact, I’d never been there at all. A partner and I bought the freehold, ran it for 14 years and then I sold my share, got married and went to England.” “I worked for British Gas in London and the Lands Department back here in Perth and brought a bit of unconventionality to both those places. I honed my cartooning prowess by painting pictures for tourist books and annoying people mercilessly. I’ve been lucky enough to continue in that vein.” “I also had the good fortune to have wonderful parents and to grow up near the Canning River, it was terriﬁc! As early as I can remember I was drawing and in the days before television I’d sit at our lounge-room table doing just that.” “And at school there’d be the occasional, ‘Alston… get out!’ because a drawing of mine would go around the room and end up at the front of the class. It was all good fun!” There’s often a cutting ‘edge’ to a cartoonist’s pencil and Dean Alston is no exception. In September 1997 a cartoon, entitled Alas Poor Yagan, landed both The West Australian and the cartoonist in the Federal Court. Accusations of racism were levelled at the newspaper and, indeed, the Human Rights

14 | MARCH 2016

The Artist by the Artist

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MEDICAL FORUM

MARCH 2016 | 15

Close-Up

The Quiet Revolutionary Transforming a couple of old-school nursing homes into a multi-faceted, ďŹ&#x201A;exible and successful organisation has been Dr Penny Flettâ&#x20AC;&#x2122;s lifetime achievement. Sometime in the middle of March, Dr Penny Flett will hand over her Brightwater CEO keys to Ms Jenny Lawrence after 29 years but donâ&#x20AC;&#x2122;t call it retiring. Not only does Penny think the term â&#x20AC;&#x153;sillyâ&#x20AC;? and â&#x20AC;&#x153;anachronisticâ&#x20AC;? but, as those who know her already understand, itâ&#x20AC;&#x2122;s also way off the mark. The work â&#x20AC;&#x201C; and passion â&#x20AC;&#x201C; will continue. â&#x20AC;&#x153;Brightwater is such a big and complex organisation. It encompasses aged care, disability, brain injury, health, research and teaching. When I think where weâ&#x20AC;&#x2122;ve come from when I ďŹ rst arrived 29 years ago â&#x20AC;&#x201C; those two big nursing homes that were the Homes of Peace â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s been a remarkable journey.â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m proud to be passing it on to someone who will be taking it further and a little sad because itâ&#x20AC;&#x2122;s the people who make an Dr Penny Flett organisation â&#x20AC;&#x201C; the people weâ&#x20AC;&#x2122;re here for and the people I work with. I shall miss all of them. This is a complicated business and a business of high worth but fundamentally itâ&#x20AC;&#x2122;s all about people and Iâ&#x20AC;&#x2122;ve learnt so much from them.â&#x20AC;?

market; or organising research, or tackling governments and sticking my neck out when things werenâ&#x20AC;&#x2122;t quite right; if I knew that I would have trembled at the knees and done something else.â&#x20AC;? â&#x20AC;&#x153;But you donâ&#x20AC;&#x2122;t know and that protects you and leaves your future open according to the opportunities that present themselves and my career has been wonderful. Brightwater has been a place where I dared to dream because I wasnâ&#x20AC;&#x2122;t constrained by what people usually expect of medicine and doctors.â&#x20AC;? The aged care sector has always had its challenges but never more so than the looming â&#x20AC;&#x2DC;baby boomer bubbleâ&#x20AC;&#x2122;, the challenges of which, Penny says, are evolving so fast that even the government has to confess it canâ&#x20AC;&#x2122;t plan successfully. â&#x20AC;&#x153;Personally I ďŹ nd that exciting in itself because it is down to human beings to devise what to do.â&#x20AC;? While Penny will take a step back from the frontline, she says sheâ&#x20AC;&#x2122;s eager to return to medicine and her clinical interests â&#x20AC;&#x201C; â&#x20AC;&#x153;things I have had to forgo for a long time.â&#x20AC;? Penny will in fact be hands-on at a facility she campaigned for and achieved 23 years ago.

Fears and opportunities

Ahead of the game

But it may not have been where she dreamed of being as a medical student four decades ago. Indeed, itâ&#x20AC;&#x2122;s a universe away.

â&#x20AC;&#x153;Developing brain injury rehabilitation programs was a dream. Most people didnâ&#x20AC;&#x2122;t understand that we were getting incredible results with brain injured people long after they had left hospital. Brain plasticity is the big thing now but weâ&#x20AC;&#x2122;ve been doing it for 23 years when there was not that much support for it.â&#x20AC;?

â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t think many of us knew where weâ&#x20AC;&#x2122;d end up. I didnâ&#x20AC;&#x2122;t think Iâ&#x20AC;&#x2122;d be running a complex business; or running a laundry in a competitive

Penny is of course referring to the Brightwater Oats St residential rehab facilities, which put interdisciplinary treatment at the forefront.

Does your experience of mental health leave you feeling hopeless?

â&#x20AC;&#x153;Oats St is a special place of huge courage. Iâ&#x20AC;&#x2122;m inspired each time I go there. How these people can ďŹ nd the courage to do what they do is a lesson for all of us.â&#x20AC;? Brightwater Oat St began when Penny came across a number of headinjured young people institutionalised at the Homes of Peace who were improving without treatment.

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â&#x20AC;&#x153;The medical wisdom of the day was that after a severe brain injury, if you didnâ&#x20AC;&#x2122;t make signiďŹ cant progress in the ďŹ rst six months, certainly after two years, that was it. I wanted to do something concrete.â&#x20AC;? So one thing led to another, and with some assistance from the Health Department, the then Health Minister Ian Taylor and others advocating, WA Health bought the old Oats St private hospital in East Victoria Park. Dream comes true â&#x20AC;&#x153;I wasnâ&#x20AC;&#x2122;t convinced at ďŹ rst â&#x20AC;&#x201C; it was very â&#x20AC;&#x2DC;hospitallyâ&#x20AC;&#x2122; and I didnâ&#x20AC;&#x2122;t believe these people had any chance to improve in an institutional setting, my organisation or any other. So Oat St was vastly remodelled into three

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16 | MARCH 2016

Oat St Painting

MEDICAL FORUM

Close-Up

a truly interdisciplinary team before anyone invented the term.” “We set out to give these people the chance to recover in a domestic environment where they were learning (and relearning) to do everything to get back in control of their lives. If it took two years or more, they were given the chance to let their brains recover and come to terms with that catastrophic thing that had changed their lives forever and learn to live again, from the ground up, and then to ultimately leave.” Age-old question On other reforms, Penny is supportive of the political shift to community and self-directed care but is also aware of the enormous task it will be to manage the sector’s new systems and business infrastructure.

Prof Lyn Beazley, Dr Penny Flett and one resident who has been helped by Oats St.

eight-bedroom houses; each with front doors and domestic scale living spaces. I then advertised for staff who could trust me, took away the uniforms and set up a rehab program where every person who came could set their own goals and we’d all set out to achieve them as a team.” “It was revolutionary. We had therapists of all kinds – physio, OT, speech, psychology, social work and care workers – all prepared to throw in their lot with us. We worked as

“We are fortunate to live at this time of immense medical, genetic and technical knowledge, but it is also creating disruption in a system that is already under pressure, so consumers and providers have to adjust. The marketplace is shifting like you wouldn’t believe – it is becoming a commercial marketplace where NFPs will need to carefully deﬁne what their roles are.” “But NFPs will continue to do a lot of what others won’t, so how we survive in a commercial marketplace is another challenge. Hospitals think they are the ones doing the acute care but by the time people come into nursing home care, they are very acute. The sooner we get together on that bridge between acute and long-term care, the better.”

People staying longer at home creates its own set of problems. Penny is not certain Australia has the necessary accommodation solutions for that yet. “People need to live in an environment that enables them. If that can be achieved they can successfully and happily stay at home longer without suffering the indignities of not being able to do things. The only sleeper in that scenario is loneliness and as a society we will need to react to that with a shift in values around ageing that encourages the elderly to be a vital part of the community.” Family ties With a move towards part-time work, Penny is looking forward to enjoying the next phase of family life with a new grandson already claiming time with Granma. “I want to have the time to enjoy and contribute to his childhood and there are a thousand other things I want to do. I love my quilting, and art and I’m determined to learn a musical instrument. I also want to spend time with my husband (former DG and pathologist A/Prof Peter Flett). We have both worked very hard in our professional careers, with not much time to spare, so we’re both looking forward to having some ﬂexibility to enjoy ourselves until we reach 100.” “In 2050, there are going to be 50,000 centenarians in Australia, and I aim to be among them.”

By Jan Hallam

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MARCH 2016 | 17

Feature

Time for Action on Mental Health The mental health train is at the station. The reviews and plans are done, now it’s a question of delivering services ... and ﬁnding the cash. The expectations in the mental health sector are high. The past 12-months have seen the talk – reviews, reforms, plans and promises – grow louder and the will for change in political circles stronger. While the rhetoric has not vastly changed, the strategy has.

In December, just a week after the federal announcement and a few days after the new WA Mental Health Act came into force, the long-awaited release of the WA Mental Health, Alcohol and Other Drug Services Plan 2015-2025: Better Choices Better Lives was released.

While politicians continue to say consumers must be at the centre of the mental health system, the Federal Government’s latest plans go some way to putting them there if all the cogs turn together.

It is a detailed and ambitious document that takes the rhetoric of consumer-centric care and transforms it into a stepped reform package that will reduce the number of acute beds in favour of funded community beds. Here, we have asked Dr Elizabeth Moore, Chair of the WA branch of the Royal Australian and New Zealand College of Psychiatrists, and Mr Adrian Munro, operations manager of NFP service provider Richmond Wellbeing to offer their perceptions.

Primary Health Networks will be tasked to identify the services required in the various local areas in their catchment and use the $350m the Federal Government will redirect to them to commission them. Prime Minister Turnbull and Health Minister Ley ﬂagged a ﬁfth national mental health plan when the reforms had a chance to bed down. It would require, they said, meaningful planning with the states to “ensure smooth integration of these new reforms and help provide a better pathway between the State-based, acute mental health system and the Federally-funded primary mental health system.”

From a political perspective, the real difficulty lies in not having a sound plan but with a State Treasury that has had the stuffing knocked out of it. Better Choices. Better Lives was developed by the Mental Health Commission and the former Drug and Alcohol Office with input from just about everyone who has an interest

in seeing improvements in mental health care. Commissioner Tim Marney, though, is a realist who knows exactly how government works – and how reality can bite. Take the latest political machinations that affect the Mental Health Minister Helen Morton! The plan outlines the investment required “to achieve the optimal mix and level of mental health, alcohol and other drug services in the short (by the end of 2017), medium (by the end of 2020) and long term (by the end of 2025) to best meet the identiﬁed needs of the population.” The rub is, however, while it pinpoints the types and levels of services required, it “does not predetermine who should fund or provide them. Implementation will be subject to the State's normal budgetary processes and, as is the case with current services, will require input from the private and not-for-proﬁt sectors and the Commonwealth.” All will be revealed at Budget time in May.

By Jan Hallam

The Plan is a Start By Dr Elizabeth Moore, Psychiatrist, Chair WA Branch of the RANZCP The WA Mental Health, Alcohol and Other Drugs Services Plan 2015-2025 (the Plan) values a person-centred, whole-of-sector approach to treating Dr Elizabeth Moore people with complex needs and clearly articulates the inability of the sector to meet the current mental health needs of our community. It emphasises the need for collaborative care and a recovery focus, which we would all support. The Plan is in three phases. By the end of 2017 (“preparing for the future”) the MHC aims to progress existing commitments and priority actions. By the end of 2020 (“rebalance the system”) the plan articulates a need to invest in the community and provide care in more appropriate places; and by the end of 2025 (“continuing the reform”) it concludes with growing all elements of the system and monitoring the reform pathways. So what are the positives? Firstly, there is a plan which can be examined.

18 | MARCH 2016

The Plan recognises the need for strengthening prevention and investment in children and youth, as well as (currently under resourced) services for people with highimpact, low-volume disorders. The ageing population needs are well recognised and build on the successful clinical models in WA. The Plan recognises that funding from all sources needs to be better coordinated – as does planning across all parts of the sector to get the most appropriate and efﬁcient services and the best outcome for patients and their families. The fact that the Plan is funder-and-provider neutral gives it ﬂexibility. The caveat is this should be linked with the Clinical Services Planning at the Department of Health (as the largest current provider of clinical services in the mental health space). The Plan also recognises the need for more sophisticated input, output and outcome measures so that any changes can be objectively measured The Plan used the National Mental Services Planning Framework and Tool (a key outcome of the Fourth National Plan), and as such has a more robust base for comparison with other States.

However, the Framework and Tool have some assumptions which can be challenged in the WA context and, as the Commission acknowledges, the impact of the current Activity Based Management (ABM) model for funding of mental health services (and the impending changes) have not been fully considered. For instance the Plan recognises the need for investment in Consultation Liaison (CL) services which have been shown to have significant positive outcomes but CL services are in limbo in the current ABM model. The implementation of the plan needs further clarification. The lack of growth of community (clinical) treatment services makes it difficult to understand how a shift to care outside of the acute hospital system will be realised without additional risk. The workforce requirements, both in volume and competencies, are yet to be fully articulated and I hope that the Clinical Reference Group and the Mental Health Network will have input into the planning in this area. Finally, the Plan will have regular review (which is a plus) and is an opportunity for us all to shape the future of mental health service delivery in our state.

MEDICAL FORUM

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Feature

Why Do We Have Faith in DSM5? By consumer advocate Dr Martin Whitely What is ‘mental illness’? Who is sane and who is mad? The answers have significant implications for thousands of Western Australians. Dr Martin Whitely Aside from the effects on the expectations of self and others, there are life-changing medical and legal consequences. Anyone deemed ‘mentally ill’ and at risk of illdefined ‘serious harm’ (including damage to their reputation) can be locked up and drugged against their will, despite having committed no crime. These serious medical, cultural and legal questions demand serious consideration. Yet without debate in the medical, legal and wider community, WA has outsourced the task of defining ‘mental illness’. Specifically, without parliamentary input bureaucrats have developed regulations supporting the recently proclaimed Mental Health Act 2014 that state “a decision whether or not a person has a mental illness must be made in accordance with the diagnostic standards set out in either the så International Statistical Classification of Diseases and related Health Problems [ICD] published intermittently by the World Health Organisation [WHO]; or så Diagnostic and Statistical Manual of Mental Disorders [DSM] published intermittently by the American Psychiatric Association [APA].” Discretionary loopholes Unless these regulations are amended by the WA Parliament, individual mental health practitioners will be able to choose whether they use the latest version of the ICD or the extremely controversial DSM5 when exercising their powers under the Act. Significant international organisations and countless prominent international psychiatrists have been critical of DSM5 as arbitrarily broadening the boundaries of mental illness and classifying normal human behaviour and emotions as disease. In April 2013, three weeks before DSM5 was published, the Director of the influential US National Institute of Mental Health (NIMH), Dr Thomas Insel, stated that DSM5 lacked ‘validity’ and that consequently the NIMH ‘will be re-orienting its research away from DSM categories’. The road ahead Another notable critic is Prof Allen Frances who on behalf of the American Psychiatric Association led the development of the DSM4, first published in 1994. Prof Frances identifies numerous changes in DSM5 that will add to the history of psychiatry which he believes ‘is littered with fad diagnoses that in retrospect did far more harm than good’. Frances wrote:

20 | MARCH 2016

1. Disruptive Mood Dysregulation Disorder will turn temper tantrums into a mental disorder… (adding to) the already excessive and inappropriate use of medication in young children. 2. Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the… resiliency that comes with time. 3. The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. 4. DSM5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs contributing to the already large illegal secondary market in diverted prescription drugs. 5. Excessive eating 12 times in three months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM5 has instead turned it into a psychiatric illness called Binge Eating Disorder. 6. First-time substance abusers will be lumped into the definition of long-term substance users. 7. DSM5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless over-diagnosis of internet and sex addiction. 8. DSM5 obscures the already fuzzy boundary between Generalised Anxiety Disorder and the worries of everyday life… (adding to) the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

9. DSM5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings. 10. DSM5 includes a proposal for Somatic Symptom Disorder. This new diagnosis will encourage a quick jump to the erroneous conclusion that someone’s physical symptoms are all in the head. Danger of over-diagnosis While criticising the proposals in DSM5, Professor Frances has identified that the DSM4 process he led inadvertently helped trigger three false epidemics. One for Autistic Disorder… another for the childhood diagnosis of Bi-Polar Disorder and the third for the wild over-diagnosis of Attention Deficit Disorder.’ He contends that the lesson of DSM4 should be that ‘every change in the diagnostic system can lead to unpredictable over-diagnosis’. While many of the criticisms of subjectivity of assessment of behaviours are common to both the DSM and ICD, the DSM generally contains less rigorous diagnostic criteria. Studies comparing diagnosis and prescribing rates for a range of psychiatric disorders using DSM and the equivalent diagnostic criteria in ICD have established that for the majority of disorders rates were significantly higher when using DSM. For the purposes of the Mental Health Act 2014 there is absolutely no need to have two alternate diagnostic frameworks. The ICD is sufficient and it covers the full spectrum of physical and mental illness. Having one genuinely ‘international’ diagnostic framework would deliver greater consistency in the application of mental health law and provide clearer guidance to clinicians applying the law. The disease-mongering inherent in the DSM5 can’t stand unchallenged. At stake is the ‘sanity’ of too many vulnerable West Australians. References on request

MEDICAL FORUM

medical m medica edical

Engagement is Vital Unemployment can affect young people's mental health in rural areas. Thereâ&#x20AC;&#x2122;s often tension between the complex needs of the individual and the â&#x20AC;&#x2DC;systemâ&#x20AC;&#x2122; when it comes to mental health suggests Dr Andrew Wenzel from Headspace Albany. When you factor in youth unemployment within a regional setting it becomes a multi-faceted challenge. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m keen to improve the breadth of opportunity in Albany because it can be pretty tough for the younger generation here. Headspace is strongly focused on making sure that young people are better informed about all aspects of mental health because it can be a complex system to navigate.â&#x20AC;?

Property values falling... How could this affect me?

Dr Andrew Wenzel

Sarah Wells MMgtFin, DipFinPlan, DipFMBM

Medical Finance Detective is committed to providing the medical community with access to information and education on banking DQG oQDQFLQJ PDWWHUV We will be running a Q&A series for the next few months, in the lead up to the Doctorâ&#x20AC;&#x2122;s 'UXP HYHQW LQ 0DUFK RI WKLV \HDU

Question of the Month:

â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s not easy to get good data on the unemployment rate in the Great Southern region. I think a lot of it is hidden and weâ&#x20AC;&#x2122;re certainly hearing anecdotally that many young people are disengaged from any form of training and are struggling.â&#x20AC;?

â&#x20AC;&#x153;A colleague has been asked by his bank to reduce his loan with them, by paying it down with some cash he has. This is due to the decrease in his property values. Could something like this happen to me?â&#x20AC;?

â&#x20AC;&#x153;As far as politics is concerned, the change to the Independent Living Allowance has meant that young people have to demonstrate that theyâ&#x20AC;&#x2122;ve been living independently for 18 months before they qualify for Austudy and that can make things more difďŹ cult.â&#x20AC;?

Good news for our client - he is in a position where he should never receive such a call. Their friend however, may need to consider the below and have a professional negotiate with the bank on their behalf. 7KH\ PD\ DOVR QHHG WR UHoQDQFH ZLWK DQRWKHU OHQGHU WR UHWDLQ WKHLU FDVK

Training close to home â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;d like to see some more educational opportunities for young people in Albany. UWA does have an increasing presence down here and thatâ&#x20AC;&#x2122;s positive because it allows students to study locally with family support.â&#x20AC;? Andrew has an open mind, touched with guarded optimism, regarding the new reform package for mental health announced by Minister Sussan Ley. â&#x20AC;&#x153;We really donâ&#x20AC;&#x2122;t know enough about it yet, thereâ&#x20AC;&#x2122;s a lot more detail we need to see. But I certainly hope that thereâ&#x20AC;&#x2122;ll be no nett loss of services, particularly with the work weâ&#x20AC;&#x2122;re doing because early intervention makes so much sense. The promised vision of Primary Health Networks designed to enhance the ability of local communities to have direct input into the services they require looks encouraging.â&#x20AC;? â&#x20AC;&#x153;The Federal Government is looking more closely at the beneďŹ ts of the Youth Connections program and we hope this will be an integral part of its reforms.â&#x20AC;?

When it comes to money - prevention is better than a cure! o o o o

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Indigenous concerns Andrew suggests that any legislative changes will have to address the entrenched difďŹ culties of â&#x20AC;&#x2DC;Closing the Gapâ&#x20AC;&#x2122; in relation to the health of indigenous communities. â&#x20AC;&#x153;We know that mental health issues are a real concern for Aboriginal people and that their suicide rate is much higher than the general population. Headspace has done a lot of work to raise awareness of the help thatâ&#x20AC;&#x2122;s available and there has been increased engagement in programs such as Follow the Dream that focuses on indigenous highschool students.â&#x20AC;? â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s always encouraging to see young people around town whoâ&#x20AC;&#x2122;ve been clients of Headspace in difďŹ cult times and are now living happier, more productive lives. The beneďŹ t of small, early interventions before a person gets stuck in unhelpful life patterns is vitally important.â&#x20AC;? Andrew has seen a distinct shift in the six years heâ&#x20AC;&#x2122;s been with Headspace. â&#x20AC;&#x153;Initially, we were seeing a lot of people with anxiety and depression but now weâ&#x20AC;&#x2122;re working with more complex health needs. If someone is stuck in a feeling of hopelessness itâ&#x20AC;&#x2122;s all too easy to self-medicate with alcohol and cannabis.â&#x20AC;? â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s really only us and State Mental Health down here but it needs to be said that Albany is quite well off compared with a town 50km down the road.â&#x20AC;?

By Peter McClelland MEDICAL FORUM

NO cross collateralisation - insist all loans are siloed or single security. Understand the products on offer - some products are secured by your entire property portfolio with the bank, even your family home! Check before you sell \RX PD\ oQG WKDW H[SHFWHG VDOHV SURFHHGV DUH retained by the bank to offset a drop in value on your portfolio. Maximise mortgage insurance waiver - when you purchase each SURSHUW\ HQVXUH \RX ERUURZ XS WR WKH PD[LPXP DYDLODEOH IRU LW V value). This minimises equity you need to use from other properties. Brokers protect you - lenders use many methods to value your SURSHUWLHV D EURNHU V UROH LV WR XVH WKHVH SROLFLHV WR SURWHFW \RX Ask questions - why has a particular product/structure been recommended? Often restructures are required due to incorrect setup, usually done for convenience or time constraints. This may cause XQIRUHVHHQ LVVXHV DW WD[ GLYRUFH RU VDOH WLPH Some products require annual income/asset reviews - check if this is the case for you. I have seen several cases where Doctors have been asked to repay loans, simply due to a brief change in circumstances. (YHU\RQH UHTXLUHV WDLORUHG EDQNLQJ DQG oQDQFH DGYLFH - ensure that the person assisting you has made all the necessary enquiries into your needs and provides a recommended plan to meet them.

If the above rings alarm bells for you, seek a second opinion. Feel free to contact me on 0411 725 525, or call Medical Finance Detective, on 9289 7777. sarah@ďŹ nancedetective.com.au medical.ďŹ nancedetective.com.au Greentree Holdings Pty Ltd as trustee for Dworcan Family Trust No. 2 trading as Finance Detective ABN 75 094 366 193, Australian Credit License No. 468920, Credit Representative Number 394105.

MARCH 2016 | 21

Feature

Change Needs Collaboration By Mr Adrian Munro, Executive Manager Operations, Richmond Wellbeing WA The release of the mental health and drug and alcohol 10-year plan provides WA with a unique opportunity to set the course for real and lasting change in the sector and the resources to tackle the bigger challenges which require a coordinated approach by all service providers over a sustained period of time. A key goal over the next 10 years is for NGOs to work more closely with hospitals and primary health care providers. As we manage more complex challenges, NGOs need to change the belief of what our role is. The hospitals have long been seen as the safety net for individuals in distress. Now NGOs must assume greater responsibility for working with hospitals to provide the best possible support for individuals and families. We must see ourselves as part of that safety net. The 10-year plan rightly states that the focus of support will continue to shift from the hospital to the community and this hinges on NGOs and hospitals working more closely together. The Mental Health Network can play an important leadership role here. Included in this connected approach must be a greater emphasis on the physical health and wellbeing of individuals and their families so an individual may receive support for their mental distress, as well as their diabetes, blood pressure or chronic pain. Australia has

Mr Adrian Munro

an excellent health care system; We just need to think more collaboratively, drawing other professions into care plans. The plan expresses a commitment to innovation, evaluation and research but it isn’t clear how this will be funded. I suggest that having a separate funding pool allocated to these areas will ensure that funding is quarantined for purposes that will increase our evidence base and facilitate exciting change in the sector. Evaluations will assist us to demonstrate the nett economic beneﬁt of our services and help build the business case for increased funding in the future. It will

also promote stronger ties between service providers and universities. As with all new plans, much of the success of the next 10 years will depend on leadership and that includes everyone, not just the MHC and the Minsiter. This plan will see some fantastic results if leadership is shown in the NGOs, hospitals, primary health care and the MHC. Every one of us needs to see this as our responsibility. Our focus is on the community we serve and seeing better outcomes for them over the next 10 years and beyond.

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

Jan 2016

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

Women may book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50 22 | MARCH 2016

MEDICAL FORUM

PERTH CLINIC WEST PERTH LOCATION Referring Patients the Simple Way With Perth Clinic’s new admission centre, referring a patient has never been easier. If a patient needs a Psychiatric admission urgently and is willing to be admitted as a voluntary patient, then ring the Admissions Manager on (08) 9488 2973 to discuss the referral and then fax a referral to (08) 9481 4454 requesting an inpatient admission. The referral should include: Patients details; Past history; Risk issues; Presenting problem/s;

Physical problem/s; Drug or alcohol use; the severity of this problem may or may not exclude them from admission.

The patient must have top hospital private health insurance that does not have restrictions on psychiatric cover. If they do not have this type of cover, it may be helpful if the patient contacts their Health Fund to enquire about upgrading their cover. Once the referral is received, the Admissions Centre will do the rest. The centre’s extra staff are able to process referrals more efﬁciently and electronic tracking ensures quick answers to any query. We will respond to you as soon as possible, but please be aware that not all patients will qualify and the more complex patients may take more time. The Mental Health Clinical Nurse triaging the referral will speak with the Psychiatrist regarding an urgent admission. The Admissions Manager also has a list of available Psychiatrists if admission is not necessary. Patients who are suitable to be referred to Perth Clinic are voluntary patients. If a patient is not willing to stay in the Clinic

or is involuntary, then the referral will not be accepted. Urgent admissions can be arranged if a patient is at risk of self harm to themselves or others; has adequate Psychiatric Hospital cover; and if they have not been seen by a Private Psychiatrist within the last twelve months. Perth Clinic admits male and female patients with various diagnoses with an age range of 14 years to 90 plus. The prevalent diagnoses treated at Perth Clinic are: Mood Disorders; Personality Disorders; Stress and adjustment Disorders;

Anxiety Disorders; Substance abuse Disorders.

The Admissions Manager will be able to clarify whether a patient is suitable and which Psychiatrists treat certain disorders. Some of the Psychiatrists also admit Workers Compensation cases, which can take extra time to organize as Perth Clinic is required to gain prior approval from the patient’s insurance company before they can be admitted. Patients may be given an outpatient appointment prior to admission. As a General Practitioner you may ﬁnd it necessary to refer a patient for a Psychiatric admission or an outpatient appointment. Let Perth Clinic Admissions Centre assist you with this process and either fax a referral to (08) 9481 4454 or contact Kathryn Turner, Admissions Manager on (08) 9488 2973 to discuss the referral.

CURRENT UPDATE OF ACCREDITED PSYCHIATRISTS AT PERTH CLINIC MEDICAL SUITES 33 Havelock Street Ph: 9488 2946 Fax: 9488 2954

21 Havelock Street Ph: 9488 2983 Fax: 9488 2994

2nd Floor, 46 Parliament Place Ph: 9486 5800 Fax: 9486 5888

3rd Floor, 46 Parliament Place Ph: 9389 2300 Fax: 9389 2399

Dr Lawrence Blumberg Dr Julia Charkey - Papp Dr Lynne Cunningham Dr Joseph Lee Dr Boon Loke Dr Raymond Wu

Dr Ian Assumption Dr Russell Date Dr Antony Davis Dr Ernst De Jong Dr Roy Kolnik Dr Manoj Kumar Dr Daniel Morkell Dr Dennis Tannenbaum

Dr Lindsay Allet Dr Rachel Allet Dr Johann Combrinck Dr Stella Fabrikant Dr Zlatan Golic Dr Mark Hall Dr Margaret Lumley Dr Rebecca Rhys-Maitland Dr Chandi Senaratne

Dr Anu Bagwe Dr Nick De Felice Dr Pei-Yin Hsu Dr Chun (Solomon) Ong Dr Jasna Stepanovic Dr Gordon Wang

“We Strive to Provide the Best in Psychiatric Care” PERTH CLINIC 29 Havelock Street, West Perth WA 6005 Phone: (08) 9481 4888 Fax: (08) 9481 4454 Website: www.perthclinic.com.au MEDICAL FORUM

MARCH 2016 | 23

Medicolegal

Nobody Loves a Fight, But… MDOs, like all organisations, have cost considerations but Dr Rod Moore, chair of MDA National, says the mutual is still on the doctor’s side. Swings and roundabouts. Not long ago, the Medical Board was accused of being too pally with doctors and this was damaging to health consumers. Now, federal senators are looking at how the new national legislation is leading to complaints by doctors of unnecessary harassment. AHPRA, whose job it is to apply the legal blowtorch to the bellies of doctors who might be misbehaving, is in the spotlight again.

Maybe that’s the point, we said; who decides what is in the members’ best interests?

Medical Forum has been pointing to the different ﬂaws in the system for some time, partly because good souls we know are given a hard time. Registration premiums are up, not down, and some people may be beneﬁting. We talked to the head of one Medical Defence Organisation (MDO), Dr Rod Moore, from MDA National to get his take on things.

Case by case considerations

We started with the observation that doctors are becoming more price-sensitive and less loyal to MDOs, much like the doctor shopping patients they experience. Rod said old-fashioned brand loyalty is diminishing and MDA has had to package things for the younger set. “There’s a portability between MDOs, which they are required to facilitate, which means [transferring] is not as complicated as it used to be. Doctors just need to be sure retrospective cover is in their policy,” he said, adding that retiring doctors have the federally administered run-off scheme. Responding to new frameworks The medicolegal framework has changed – AHPRA and the national scheme and the rising cost of defending vs the need to protect reputations. Discretion by MDOs remains a thorny issue. Rod said MDA liked to think its members’ reputations came ﬁrst. He said that MDOs now had a regulated insurance product. “There is no concept of discretion – you are required to provide what you purport to provide. The only matters excluded are proven sexual misbehaviour, fraud and criminal behaviour.” We said that’s not what we hear; that doctors are being encouraged to settle rather than defend. “We would never prejudice a member’s claim on the basis of the cost. Sometimes we would actively pursue a matter, when we could settle it more simply, because there are issues of reputation or professional interests with a need to prove a point to the litigant community. I’m at pains to point out that doctors are in fact shareholders in the business. This is a mutual and the organisation operates for the beneﬁt of its members.”

24 | MARCH MAR ARCH CH 2016 201 016 16

“There are some matters we would settle on a commercial basis because it makes sense to do so because there are weaknesses in the defence and it’s not judged worthwhile. If there is signiﬁcant feeling from the member to pursue a matter then we have done that on occasions, when our advice has been to the contrary.”

And who weighs up the risk and the cost of defending a matter? “The doctors sitting around a Cases Committee do so purely on the basis of standard of care. We don’t get involved at all in discussion regarding costs. The lawyers present the case history, the doctors look at the medicine and we make a decision based around standard of care. If it is deemed to be adequate then we will defend it. If it is inadequate we will look to settle on the best commercial terms.”

profession become fixated on a course of action when the external review of the matter would suggest there are weaknesses. It may be difficult to convince someone not to fight something that is essentially a losing fight.” “We would share de-identified expert opinion with them – we don’t want people to feel they have been judged unfairly by their peers or experts to feel they have been compromised. We would explain our point of view and if the member is aggrieved they have recourse to a member of the mutual board.” Intimidation vs legal assertiveness We hear that MDOs are becoming more averse to any risk, as the expense of defending grows. Intimidation by lawyers is a frequent complaint from doctors. But it works both ways in the adversarial legal world. Rod said MDA National had a very good hit rate in defending matters before the court (only five cases last year) which sends a message to the litigant community that MDA

But the problem, we suggested, is that even medical opinion is open to interpretation. “Yes, that’s why we have a broad range of people around the table and we will seek external expert advice, particularly in matters that are going to be litigated. So many things in medicine are a matter of opinion and we are faced with opinions from the other side that vary in quality. We try and select the best experts. There are well known experts on the plaintiff’s side that are perhaps giving an opinion based on where the next pay check is coming and not necessarily on the merits of the matter.” The Cases Committee considers cases from SA, WA, and NT, while a smaller Committee in NSW sits for the eastern seaboard. Lower value matters are delegated to non-medicos but every case has a medical manager. “So a member of the Cases Committee would give informal advice and go externally if need be. Say it’s $5000 for reimbursement of costs because something has gone wrong – we might make a decision to go ahead and pay that without getting external advice.” Some doctors say they are being told by their MDO that settling for a few thousand will make a claim go away. “That’s pretty infrequent and I would be very happy to discuss it with any disaffected member because that’s not the feedback we get. I can’t recall someone being browbeaten. Some members of the

MEDICAL ME MED M ED E EDICA DIC ICA CA C AL FORU F FORUM ORU O RU UM

Medicolegal

is conﬁdent when it defends, so a lot of matters settle instead. Does legal blufﬁng mean hundreds of vulnerable cases are prematurely settled, with or without payment to the complainant? In one way, this would be a measure of an MDO’s effectiveness for anyone assessing how an MDO goes in to bat for a doctor – outcomes vs perceived risk. To disclose would let the cat out of the bag but to not disclose is an ethical dilemma. Given that only 25% of member claims seek advice on ethical matters, maybe it is of low importance. When it comes to ethics, AHPRA investigations on behalf of the Medical Board (MB), feature strongly. Rod said these investigations had increased 30-40% and are now its biggest area of business. In low-value matters, where the plaintiff lawyer might decide the matter is not worth pursuing because any likely payout would not cover their legal fees, more patients seem to be encouraged to lodge a complaint with AHPRA, which must investigate (at no legal cost to the complainant). Common sense communication “This investigation is often overzealous and often entails miscommunications. If you could sit with the patient, doctor and an independent party that knows a bit about medicine, you could probably explain why the doctor did what he/she did or why the patient has got the bull by the horns. You would expect the MB would do that – settle matters with some common sense on an informal basis – but maybe the legislative ambit is restrictive?”

Why isn’t more consideration given to the differences between lawyers and doctors, particularly the trusting vs adversarial approach, or doctors making quick-ﬁre decisions on the back of limited facts vs lawyers waiting too long (it seems) to give a measured decision based on all the facts. “With all the millions of medical interactions that occur around the country, the fact that so few result, ﬁrstly, in adverse outcomes and, secondly, adverse outcomes proven to be negligent, is testimony to the quality of medical care in the country. But like any biological system, it’s imperfect. With a complex mix of biology and human interaction, it’s inevitable that things will go wrong. We’re here for when things go wrong.” “People shouldn’t practise as if every patient who comes through the door is going to sue them but practise medicine in the best interests of the patient. If you do that in a considered and conscientious way the risks are pretty low.” We suggested most doctors can be sued on the ‘medical records test’ and therefore be seen as a risk by an MDO.

Relationships are important Doctor-patient relationships are important. So are others related to claims management? “We try to develop close relationships with plaintiff lawyers, so you can point out the merits or not of a case. This is often helpful in settling matters quickly by reducing costs, when it is clear a matter has to be settled. We are pragmatic about that.” He is impressed with the passion in-house lawyers have for their members. “We understand that there are strong emotions from members to the whole litigation response. Even when they’ve done nothing wrong their reputation has been threatened and impuned.” “We could provide a bare bones insurance product – no support, settle matters more expeditiously on a commercial basis, and probably charge lower premiums but would members want that? We think what we run now, more whole-of-person care in a stressful time, is more important.”

By Dr Rob McEvoy

“We don’t believe that doctors being sued have impeccable records. I would be the ﬁrst to put my hand up and say if the clinical outcome from an episode of care had been adverse, my notes wouldn’t defend me. It’s more about how we practise medicine than how we record it – the only time it becomes an issue is when things go wrong.”

Is there a reason for that? The MB was previously criticised for being too pally with doctors and allowing wrong things to be done to patients for too long. “The pendulum has swung too far the other way, from our perspective. Many of these things are just errors in communication. Doctors are not squeaky clean; some of their behaviours leave a bit to be desired and can inﬂame the process. One bugbear is when doctors send off a vitriolic response to a patient complaint instead of an orderly temperate view – something that just pours petrol on the ﬁre. We encourage members to seek our advice in framing a response to patients. A more conciliatory response will often nip something in the bud.”

MEDICAL ME MED M ED EDICA IIC CAL F CA FORU FORUM OR ORU O RU RUM

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

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News & Views

Helping People Take Charge of Pain Empowering consumers to understand and treat their own chronic pain is the aim behind a locally-designed website that is attracting attention globally. Next month, the locally created and resourced painHealth website turns three. In that time painHealth has established itself as an important resource for people to gain information, resources and skills to manage their ongoing musculoskeletal pain. The website was developed by a consortia including people from WA Health, Fremantle Hospital and Health Service, Curtin University and UWA and A/Prof Helen Slater is led by A/ Prof Helen Slater, a clinical researcher and clinician at the School of Physiotherapy and Exercise Science at Curtin University, and pain medicine physician, Dr Stephanie Davies. It takes a holistic approach to consumers managing their own musculoskeletal pain. Number crunching When Medical Forum reported the website’s analytics in September 2014, the website had had a total of 2.54m hits, 135,003 total visitors with average of 238 a day while attracting people from 142 countries. Most recent data (16.2.2016) show its continued traction with over 5.3m hits from 407,884 visitors with an average of 371 visitors a day. The site is also accessed by users in over 140 countries, the most active being Australia (41%), USA (26%), UK (6%), China (5%), and Canada and Japan (both 3%).

Consumers take charge Spend 10 minutes on the site and it quickly becomes apparent that it seeks to communication with consumers in a personal and supportive way. The videos in which people recount their own personal pain stories are particularly effective. Here is the power of the multidisciplinary approach of movement, medicine, psychology and brain-training in action to empower consumers to become architects of their own pain management program.

“It would be really helpful to know who is using the site. Anecdotally GPs, other health professionals and pain medicine facilities around Australia have told us they really like painHealth and use it before they would use a resource (written for health professionals) because it is structured in such a straightforward way. Communicating with the patient is easier if we can use a shared resource and language: this means the information and skills can be used in two complementary directions.”

“We initially created three prototypes in collaboration with researchers from UWA’s computer science department in order to understand how people used the platforms. We evaluated that usage with an External Reference Group including consumers with persistent musculoskeletal pain and clinical experts in the ﬁeld. People gave the platforms scores and told us which prototype, in their opinion, worked better and why. There was a long list of elements to evaluate and from this we reﬁned the prototypes and built the website.”

“In the next stage of updating we will add the option of users indicating if they are consumers or clinicians and that way we can better characterise our audience. We will also extend the pain stories and pain management tools to include sections on sleep and workrelated pain.

“A lot of thought and scientiﬁc evaluation went into it but we were careful to build a website that was faithful to consumers’ feedback. We can map the usage and we know that those tools requested by consumers are being used.”

“We believe the website provides a blueprint for the emerging second wave of health care system development which looks to design care with consumers rather than for consumers. At the end of the day, the project’s aim is to connect with people and help them ﬁnd a way through their pain. It’s tough out there, particularly if you are in rural and remotes parts of Australia.”

“We have just updated the website and extended the resources and revised the evidence. As Phase 2 of this update, we will increase the data capture capabilities to discover more about the clinical proﬁle of the people using the website”.

Eyes to the future “We continue to future-proof the site so that users can access content on any platform. We know between 35-40% of people are accessing the site via their smart devices”.

The ﬁgures come as no real surprise to Helen and Stephanie who have both been working in the area for more than three decades. They knew there was a gap for consumers who wanted engaging, reliable, evidence-based, accessible information. At the time of its launch, painHealth was the only website for musculoskeletal pain in Australia geared towards the consumer. The content was informed by WA-derived quantitative and qualitative research studies, the outcomes of which informed the team what consumers wanted to help them manage musculoskeletal pain. “When we were developing the platform we wanted something that was practical, knowledge-based and skills driven. There are a lot of websites that have information, but not a lot that bring complex information together in a meaningful way and offer an integrated approach to pain management. This is central because pain is complex and often requires a multidimensional approach, not just one thing or the other,” Helen said.

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MARCH 2016 | 27

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News & Views

Breaking Down the Barriers DonateLife WA Medical Director Dr Bruce Powell writes that the review into the Organ Tissue Authority should encourage more conversations and increased trust. The first time I saw an organ retrieval, the donor was a 19-year-old boy who had died from meningitis, I was shocked and also inspired. The sudden horror, the realisation of the loss, as if a bystander at a terrible car crash, was hard to bear. I don’t remember his family at all, I don’t know why. Maybe there was guilt, submerged beneath his relative’s tears drowning the memories, making it possible for me to carry on as a doctor. I felt compelled to follow the donation through to its conclusion, so I went to theatre to witness the giving of the gift his family had agreed to. Their decision has affected me all my professional life. The harsh but amazing realities The team that took that dead boy’s organs was amazing, professional, precise, respectful and tough. It was what the situation merited, that one life must save many lives. Not a trade as such, more a passing of the baton from one existence that had run its course, to others that would be revitalized and redeemed. I tried not to dwell on the practicalities of the donation because it was a shocking thing to see. Like childbirth, it seemed necessarily brutal in its nature, clinical and painful to watch, yet fascinating and miraculous in its ultimate outcomes. The impact on my life has led me to the job of WA Medical Director for DonateLife. Twelve months is a long time in medicine and an eternity in donation circles. Whether it is the advent of new technologies such as the “Heart in a Box” TransMedics device with its amazing use in Donation after Circulatory Death (DCD), or the emergence of new infectious diseases such as the Zika virus to complicate donor suitability decisions, the scene is ever-changing. Defence a default position Given the high profile of donation stories and the traditional partisan approach to health as a whole, it is perhaps no surprise that DonateLife and the Organ and Tissue Authority (OTA) are often on the defensive. Expectations and demand are high and managing and satisfying them can be difficult. The conclusions of the Government’s recently released review of OTA were broadly sensible, logical and predictable. What is less predictable is the consequences of the change in CEO and the impact of the new governance committee.

Donations in the right direction The results for 2015 reveal that Australia achieved its highest ever number of donors (435), its highest number of transplants (1241) and we exceeded this year’s annual national target of 18.2 donors per million population. Crucially, Australia’s donation rate represents a 61% increase from 2009 and a growth rate that compares well with growth achieved by Spain (51%) and the UK (39%) at the same stage of implementing their respective reforms. In WA 44 donors consented to donation after brain death (DBD) and 10 consented to DCD. This resulted in 42 actual donations compared to 35 in 2014. So what does the community think of these results? From the media coverage, you’d be excused to feel confused. Are we the best, the worst, failing, succeeding? Are we wasting money or doing the best we can achieve, learning lessons and moving ever forwards? In WA we now have organ retrieval occurring in smaller hospitals that have attracted recent State investment. Fabulous new hospitals such as Rockingham, Joondalup and Armadale-Kelmscott now undertake organ retrieval thereby avoiding the need to transfer donors to a metro hospital.

As a fan of “destructive innovation”, I welcome the opportunity to reinvigorate the debate, no matter how painful that might be.

Our donation numbers are 20% better than last year and no doubt they can be better still.

So how did we do?

However, it must be always emphasised, DonateLife is simply a partner; the technical,

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Trust is the glue

professional and governance part of the team. Others such as our surgical teams, NGOs, government departments, entrepreneurs, corporate entities, individuals with passion and drive, all play their role. The vital component, the common denominator that ties them together, is trust. Without trust the sector is doomed to struggle with donation numbers and transplant waiting lists. DonateLife is merely a partner in this complex ecosystem, an honest broker if you like, guiding and mentoring, listening and empathising with the views of the WA community as to how they want their donation service to work. Once changes have occurred in Canberra, new leaders and faces will emerge at the donation table. DonateLife can then return to its area of expertise – sharing information with grieving families and helping to support them with the most difﬁcult decision they might ever have to make – agreeing to save others’ lives through the gift of donation. ED: The Ernst & Young review into the Organ Tissue Authority was released last month after sitting with the Government since early September. It reported that OTA management was generally sound but defensive. It recommended a new board of governance. The CEO Yael Cass has stepped down to be replaced by health bureaucrat Felicity McNeill in an acting position. While Ms Cass’s departure comes at the end of her ﬁve year contract, there has been no response from the department when asked if her resignation has anything to do with the release of the report.

MARCH 2016 | 29

ST. JUDE MEDICAL DELIVERING A BROADER RANGE OF THERAPY OPTIONS TO SERVE YOUR CHRONIC PAIN PATIENTS TARGETED SPINAL CORD STIMULATION (DRG)

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Peripheral Neuropathies2,3 Failed Back Surgery Syndrome (FBSS) with or without prior surgery8

CRPS of the Hand2

Neuropathic Groin Pain3 = !478 .+63/466.(5.< = +246(1 &(7)91(6 ))+77 = +6:+ 386(52+38 = !+6/5.+6(1 +6:+ +7/43 = $+78/)91(6 $467/43 #)648(1 !(/3

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CRPS of the Knee5 Peripheral Vascular Disease (PVD)9

Neuropathic Foot Pain6

Excerpt from approved document for use in Australia and New Zealand (Doc version no. SJM-NM-0914-0012(1) MK0105C-EN) References 1.

Espinet A. An Australian case series in chronic post-surgical pain (CPSP) treated with spinal cord stimulation (SCS) of dorsal root ganglion (DRG). North American Neuromodulation Society, 17th Annual Meeting, Las Vegas, December 5-8, 2013.

Liem L , Demmel W, Thoma R, Neumann H, Rasche D, Schu S. Spinal Cord Stimulation (SCS) of the Dorsal Root Ganglion for Chronic Pain of the Upper Limbs – A Multi-center Case Series. International Neuromodulation Society, 11th World Congress, Berlin, June 8-13, 2013.

Schu S, Gulve A, ElDabe S, Baranidhara G, Wolf K, Demmel W, Rasche D, Sharma M, Klase D, Jahnichen G, Wåhlstedt A, Nijhuis H, Liem L. A Retrospective, Multicenter Case Series of Spinal Cord Stimulation (SCS) of the Dorsal Root Ganglion (DRG) for the Treatment of Intractable Groin Pain. North American Neuromodulation Society, 17th Annual Meeting, Las Vegas, December 5-8, 2013.

Bürger K, Moser H, Nijhuis H, Liem L, Klase, D, ElDabe S. Neurophysiology of the dorsal root ganglion (DRG): A translational premise for neuromodulation in the treatment of chronic pain. International Neuromodulation Society, 11th World Congress, Berlin, June 8-13, 2013.

Van Bussel CM, Green A, Fitzgerald J, Moir L, Bojanic S, Aziz T, Sharma M, Huygen F. Treating a Challenging Patient Population of Complex Regional Pain Syndrome (CRPS) of the Knee with Spinal Cord Stimulation (SCS) of the Dorsal Root Ganglion (DRG). North American Neuromodulation Society, 17th Annual Meeting, Las Vegas, December 5-8, 2013.

Van Buyten JP, Smet I, Liem L, Russo M, Huygen F. Stimulation of Dorsal Root Ganglion for the Management of Complex Regional Pain Syndrome: A Prospective Case Series. Pain Practice 2014. ePub ahead of print

Fumero, A. et al., (2012) [Spinal cord stimulation for refractory chronic angina pectoris: 100 patients treated in our 12-year experience]. G Ital Cardiol (Rome). 12(9):599-605 [Abstract in English; Article in Italian]

Mironer E, Bernstein C, Masone R, et al. A Prospective Clinical Evaluation of a Rechargeable Implantable Pulse Generator (IPG): An Interim Analysis of Sustainability of Spinal Cord Stimulation for Chronic Lower Back Pain. Poster presented at: 2010 Meeting of the North American Neuromodulation Society; December 2-5, 2010; Las Vegas, NV.

Horsch S, Claeys L. Epidural spinal cord stimulation in the treatment of severe peripheral arterial occlusive disease. Annals of Vascular Surgery.1994; 8(5):468-74.

Brief Summary: Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions, potential adverse events and directions for use Unless otherwise noted, ™ indicates that the name is a trademark of, or licensed to, St. Jude Medical or one of its subsidiaries. ST. JUDE MEDICAL and the nine-squares symbol are trademarks and service marks of St. Jude Medical, Inc. and its related companies. ©2015 St. Jude Medical, Inc. All Rights Reserved. This is approved for Australia only. St. Jude Medical Australia Pty Limited. 17 Orion Road, Lane Cove NSW 2066 Australia. Ph: +61 2 9936 1200 SJM-ANZ-NM-0915-0001

30 | MARCH 2016

MEDICAL FORUM

Guest Column

Cultivating Positive Workplaces The cone of silence on bullying and harassment in the profession has been cracked open. A/Prof Angela Alessandri has a response to this ‘Dark Side’.

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

Recent media reports have highlighted the prevalence of discrimination, bullying and harassment in clinical medicine that have led to the establishment of the Expert Advisory Group to inform and advise the Royal Australasian College of Surgeons on the matter. Its ﬁnal report states that nearly 50% of College fellows, trainees and international medical graduates report being subjected to discrimination, bullying or sexual harassment. The importance of this issue to medical students was highlighted by the current AMSA president, James Lawler, at a recent national conference. He stated that along with mental health issues, bullying, harassment and sexual harassment were the biggest problems affecting medical students. A recent pilot study conducted in two Australian medical schools reported 74% of students experienced, and 83.6% witnessed, ‘teaching by humiliation’ during their adult clinical rotations. The Australian experience is not isolated. Mistreatment of medical students appears to be equally common internationally. In the US, two large studies (16 and 24 medical schools respectively) that surveyed third year medical students report high rates of harassment (42%), belittlement (84%) and mistreatment (64%). A recent systematic review and meta-analysis with the majority of studies from the US, Canada, Pakistan, the UK, Israel and Japan reported a 59.6% prevalence of medical student mistreatment.

They alone will not change the culture that has enabled bullying and harassment to reach such alarming levels. Clearly, there is an urgent need to address this ‘dark side’ of medicine more comprehensively in the medical curriculum including providing students with skills to effectively deal with negative behaviours. Notre Dame’s School of Medicine is meeting this challenge with a multifaceted approach including:

In recognition of our expanded service area (the entire metropolitan area), our international-standard specialisation (‘Eye’ surgery) and our substantially increased scale (we’re a leading Western Australian day hospital), the Eye Surgery Foundation’s name has changed to Perth Eye Hospital. As the Perth Eye Hospital we continue to offer an unmatched team of world-class surgeons and support professionals. All with access to state-of-the-science technology and systems.

så %STABLISHINGåAåLOCALåBASELINEåOFåWORKPLACEåBEHAVIOURSåBYåSURVEYINGå third-year students regarding their experiences in the clinical setting;

We remain as passionate about providing patient care and comfort as we have been since our inception in 1987.

så #ONSOLIDATINGåTHEåCURRICULUMåINåTHEåCLINICALåYEARSåWITHåWORKSHOPSåONå topics such as assertive communication, conﬂict resolution, developing resilience and practical approaches to bullying and harassment;

To see everything we offer, simply visit pertheyehospital.com.au or call 9216 7900.

så "UILDINGåONåTHEåPREVIOUSLYåINFORMALåDIALOGUEåWITHåSTUDENTSåBYå establishing a Positive Workplace Behaviours Working Group;

While the aim of these initiatives is to equip students with skills to improve their practice and experience of the medical workplace, it is recognised that they alone will not change the culture that has enabled bullying and harassment to reach such alarming levels. Notre Dame like any other institution or college involved in the training of health care professionals must review its own practices and model the humility, respect and compassion required to support the signiﬁcant cultural change that the Australian health care system urgently requires. References on request ED: A/Prof Angela Alesandri is a paediatric haematologist/oncologist and an academic at University of Notre Dame.

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42 Ord Street West Perth 6005

MARCH 2016 | 31

Guest Columns

Ability Unlimited Nina Butler describes herself as a writer, ‘polite provocateur’ and 'distinctly annoying' – in the best kind of way. I only did Human Biology up to Year 10 but I’m pretty sure that the average human body consists of organs and bones covered by a layer of skin. It follows then, that I’m not invisible. Or am I? I guess I can’t be entirely certain because I am vision impaired so it’s just about impossible for me to see my reﬂection in the mirror. What I am sure of is that I often feel completely overlooked by health professionals who direct their questions regarding my symptoms and medical history to the person sitting next to me. The latter will turn to me, I’ll tell them and my parent/carer/signiﬁcant other then tells the doctor. It’s a bit like Chinese Whispers minus the whispering. Have I mentioned I’m 31 years old? It is true that I do look a little different. I may even present in a wheelchair or attached to a walking frame and I may take a few moments to process what you’ve said. But I’m the one paying the bills and enduring the procedures so isn’t it only fair that I’m spoken to directly?

I’m the one paying the bills and enduring the procedures so isn’t it only fair that I’m spoken to directly? I assure you that, despite appearances, I understand what you’re saying. My condition, Incontinentia Pigmenti is rare. Never heard of it? Don’t worry, not too many people have. In fact, there are only a handful of us in Australia. It affects my skin, muscle capacity – I’m down to 20%, so they say – and I twitch occasionally. Some of us have vision and hearing impairments, and I’m one of them. I’m a hulking 159cm tall and weigh barely 45kg but don’t let that fool you. I’m not as delicate as I look.

lots of medical adventures. Everything from neurosurgery, two complete foot reconstructions, heart surgery to grommets and a tonsillectomy; the current tally stands at around 30 operations. I know the drill. I understand the need to err on the side of caution, I appreciate anyone who tries to minimise my pain and discomfort but, let me tell you, I have a high pain threshold. I can handle that biopsy with a local anaesthetic and needles don’t bother me at all. If I’m honest, I get a bit of a kick from the look of bemusement on a doctor’s face when I don’t even get close to ﬂinching. I often have to ﬁght the urge to say, ‘I told you so!’ The moral of the story? Two, I guess. You can’t judge a book by its cover and it’s unwise to make assumptions. ED: Nina’s blog, Inner Musings of a Funny-Looking Kid, can be read at https://ninimeany.wordpress.com

And that’s just as well because I’ve had

Turning a Cliché into Reality? SMHS Area Director Clinical Services (DoH) Dr Tim Smart looks at what sort of doctor will best ﬁt our future and lead innovation. Innovation in healthcare is a much touted aspiration commonly driven by politics, resource needs and commercial imperatives. We could argue the proliferation of acute care hospitals, overburdened appointment systems and rigid hierarchical professional and leadership systems hinder progressive change. Also both the focus on hospital services and the rationing of scarce resources are reinforced by a relative value unit reimbursement system. Where are the markedly improved services to beneﬁt the community? Clinicians require a fundamental cultural change and ownership of change before innovation is part of the reality. These concepts may seem disruptive but the current healthcare system is often dependent on innovation to address access to care, affordability and improved patient experiences. We must reduce the waste in energy expended on the intertribal warfare that has been part of healthcare since before the Crimean War. Innovative cultural change necessarily requires a redesign of healthcare services in form, process and delivery. Innovation is most often noted during times of recession or unplanned resource constraints.

32 | MARCH 2016

We must reduce the waste in energy expended on the intertribal warfare that has been part of healthcare since before the Crimean War. This is when leadership comes to the fore. There needs to be a renewed focus on the patient, their health needs and leadership by clinicians. For example, care that returns people to work more rapidly provides economic gains as does the expansion of day surgery. Over recent decades innovation has focused on technological, therapeutic and digital innovations. While there have been exponential changes in technology, processes and business models, at the same time we have seen escalating costs, reducing access to care and ever-increasing waiting lists. Patient safety concerns continue to rise as do clinical incidents.

trials, improved wearable technology, 3D printing, optogenetics, digestible sensors, nanorobots, personalised genomics and robotic assistants; Brian Honigman 2014). On the one hand, over-reliance on new technologies can become a cost burden to patients, third party funders or the public health system itself. On the other, the judicious and early use of new technology may reduce long-term costs by reducing later treatments in those who are older and live longer and for those prone to chronic disease. IT now allows us to disseminate knowledge and expertise to assist communities to manage health concerns and become more self-reliant, especially those in isolated locations. The health system requires innovation in service delivery and leadership – a broad focus that enables technology and therapeutics to integrate and replace many of the marginally useful systems we are all so comfortable with.

Technological innovation in healthcare is being developed (e.g. cell-phone technology, VC technology, microchip modelling of clinical

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News & Views

Doctors Caught in the Cross-fire Trying to protect children from family violence is not as easy for doctors as the legislators make it sound and there’s no clear answers in sight. Dealing with alleged familial violence and sexual abuse within an adversarial legal system can be fraught with potential problems for doctors. This is particularly so when child visitation rights are added to the mix. Dr Anita Manes argues that doctors should advocate more strongly on behalf of their patients. Family and criminal lawyer, Ms Sharon Auburn SC suggests that the medical profession treads carefully when venturing into a potential minefield. The Doctor “We’re taught in medical school that child abuse is quite prevalent, that it can be hard to detect and that we really need to maintain Anita Manes a high index of suspicion. I always thought that detection would be the most difficult aspect and it would be acted upon and a set of protocols followed that would be in the child’s best interests,” Anita said. “It seems pretty obvious that the Family Court, with its requirement for a high level of supporting evidence, fails some vulnerable young people when it comes to visitation rights.” “There’s always lots of scaremongering about paedophiles in the local park but we all know that 90% of these offences are familial. “It’s very concerning when you hear that a child is telling their mother that abuse is occurring, a GP and often a psychologist becomes involved and then an adversarial justice system hands the child back to the person who may well be the perpetrator. Then, if the mother doesn’t hand the child over for an access visit, she can end up losing custody.” Two articles in The West Australian by lawyer and advocate Hannah McGlade and investigative journalist Colleen Egan combined with a lecture by Dr Elspeth McInnes from the University of Adelaide prompted Anita to put pen to paper. “I found it very disturbing that this sort of thing was happening. I’ve been fortunate that I haven’t had to deal with too many cases such as this because it’s such a confronting issue. I’ve spoken with [Mt Hawthorn GP and former head of the Child Abuse Unit at PMH] Dr Peter Winterton who has worked in this area for 37 years and he agrees that there are still very real problems and that this sort of thing is not uncommon.” The crux of the matter, suggests Anita, is that some perpetrators and their legal

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representatives are expert at playing the system to their own advantage. “Everyone keeps saying that the best interests of the child are paramount but the rights of both parents in relation to access are open to interpretation and, at times, it’s difﬁcult to see where the priorities actually lie.” “I think we, as doctors, need to advocate more strongly for people struggling with these issues. We shouldn’t believe, as I once did, that the system will take care of these situations once they’re reported. We need to provide clear advice to our patients, expedite referrals and make sure our documentation is thorough and accurate.” The Lawyer

Sharon Auburn

Sharon Auburn SC has more than 20 years’ experience in family and criminal law. She sounds a cautionary note regarding doctors becoming involved in familial abuse cases.

“In my experience it is virtually impossible for a doctor to avoid being caught in the crossﬁre. The best a medical practitioner can do is to keep meticulous notes of all consultations because they can be the subject of crossexamination years later,” Sharon said.

We shouldn’t believe, as I once did, that the system will take care of these situations once they’re reported.

The decision to subject a child to an intrusive, evidence-gathering procedure can itself have negative ramifications for a concerned mother. “A mother who has a genuine belief that her child is being abused by the father is caught between a rock and a hard place. If the court finds she is making unfounded allegations and submitting the child to the distress of unnecessary medical examinations, she risks losing custody.” “Often a child is unwittingly caught up in the dispute and their behaviour reflects the anxiety and the tensions of the parents. It’s not entirely surprising that a child's account is often overly influenced by one parent.” “We suffer from a paucity of experts in this field who are prepared to attend court. Given the increasing frequency of these allegations more emphasis and resources need to be directed towards educating medical practitioners on how to deal with these complaints.”

By Peter McClelland

“Sexual abuse cases can be very hard to substantiate based on a medical examination and the results may well be equivocal. The difﬁculties are compounded by the lack of independent witnesses and an actual conviction can be quite rare.”

MARCH 2016 | 33

Feature

Changing Public Health for the Better Jason Micallef, Brodene Straw, Dr Alexius Julian and Dr Yvette Tan all want the same thing – improvements in the public health system.

Jason Micallef Manager of the Institute for Health Leadership

Brodene Straw Coordinator of the Medical Service Improvement Program

Public healthcare is a tricky beast. Timepoor practitioners need time to reﬂect and develop ideas for change and then there’s the old saying, ‘the pain of change has to be less than the pain of staying where you are’. Jeff Kennett suggested the reason there is so much despondency in the community is because people can’t hack the pace of change. The younger generation probably handle it better, which is why since 2012 the Health Department has asked junior doctors to be champions of change, with smaller changes at a local level with its emphasis on the Medical Service Improvement Program now running at 10 sites in 2016.

Dr Alexius Julian and Dr Yvette Tan - Junior doctors in a leadership role

time to do an extra case each session, so patients are less likely to face an unplanned cancellation. “Our theatre improvements have helped resolve long-standing inter-professional issues – surgeons vs anaesthetists vs nurses vs wards –realising that the processes were to blame, not their level of professionalism and commitment,” Jason said. Improved weekend decision-making In hospitals, weekend junior staff are less likely to make major decisions (e.g. discharge) unless they have a clear plan from the team. This has improved at one hospital by standardising weekend handover information.

Examples of changes for the better Mr Jason Micallef manages the Institute for Health Leadership in the Health Department and is keen to demonstrate both its usefulness and acceptance within the health system. Through the Medical Service Improvement Program, 85 projects have been undertaken since 2012. Here are three examples. Improving efﬁciency of an Emergency Theatre Everyone knows the knock-on effect of a bad start to the day. Theatres in tertiary hospitals are not immune. About 25% of cases were starting late, which is why effort is now going into preparing the ‘gold’ ﬁrst case – surgeon at the ready, case chosen the night before, people who need to be there are organised (from patient collection to anaesthetist), and kick-off is on time. As a result, there is less frustration and more satisfaction amongst theatre staff, with

34 | MARCH 2016

Consequently, junior hospital staff spend less weekend overtime reviewing notes and more time progressing the care provided and helping patients get home sooner. “Taking a simple policy approach doesn’t work unless root causes are identiﬁed and resolved. There is evidence that patients have worse outcomes after hours, so the beneﬁt of a clear weekend patient management plan is an important improvement.” Better coordination of plastics Changes at one site consisted of a smartphone for the on-call plastic surgical registrar, improved ED handover for plastic surgery injuries, improved integration and communication between hospital sites (even in the same health service), and a proposed weekend procedure area for plastics under local anaesthetic. Outcome: Reduced duplication, delays and frustration for patients and staff.

Aiming for what sort of change? “What we are trying to achieve is a culture of continuous improvement, not disruptive change that interrupts the delivery of services. In the public system we have to prove the value of the ‘spend’, especially in a time when every dollar counts and people can be more risk averse than normal. We also have structural and procedural barriers and silos in health care. Things get complicated when there are agreements around how money or staff activity ought to shift, which sometimes stalls innovative thinking.” “We’ve learnt from Canterbury Health Service in NZ (equivalent to one of our health services) that you can work across the silos but it takes a lot of commitment and political will. The Christchurch earthquake in 2011 certainly accelerated their thinking about having to do things differently.” “Smaller regular changes train staff to get together to talk about problem solving and thinking outside the box.” How do we get people to take it on? What about vision? How do we get people to believe the idea that saving money need not be about axing services? “Innovation is like a bank account. It’s a longer term investment but ﬁnding the money will always be a struggle. The Medical Service Improvement Program’s 85 projects have shown a cost-beneﬁt through better use of resources.” Brodene said good communication is the key to avoiding delays in decision making. This allows things to be lined up ahead of time. When we interviewed FSH’s Robyn Lawrence,

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Feature

she said that getting people to hold on to an overarching vision was difﬁcult. And people are not inspired by a cost-saving agenda. Is the common motivator the patient’s journey?

The leaders of the future

“Lean thinking is about operational and clinical outcomes – it’s about aligning process and staff activities to best deliver what the health consumer needs. Staff are driven by maximising the time clinicians spend with patients and not duplicating efforts. Our projects have demonstrated repeatedly that a great deal of clinicians’ daily activities add little value. Waiting for a referral, transfer, results, trying to ﬁnd patient ﬁles and documents, ordering unnecessary tests or having to reorder them– those things are expensive, they don’t assist the patient,” Jason said.

“Senior and junior doctors work together to ﬁnd out how to improve care and patient outcomes. Junior doctors, through the nature of their role, are required to work across silos and navigate processes whilst also being able to relate to the needs and direction set by their consultants. For this reason we believe that junior doctors have an integral role in improvement”

“We have to keep asking ourselves ‘why do we do it this way’ to uncover redundant practices and get to the nub of the problem. The team has to work out where they want to put their energy to collectively address the root problem. Often ‘low hanging fruit’ problems can be resolved with little actual investment but will make a profound shift in the patient journey.” We are all at different points on the conveyor belt as the patient moves through. If you get stuck at one point on the conveyor belt, reform at that one point won’t change the full process. It pays us to look left and right.

Jason said it makes sense to have clinicians leading change, which is where junior doctors come in.

“The best leaders empower those around them to make the best possible decisions, rather than they themselves leading the charge through the brick wall of the status quo,” Alexius added. Yvette agreed but added this observation. “The relationship between nurses and junior doctors has been taken to a new level though we are still improving the level of engagement with consultants – I think it’s a generational thing. We have some great champions but they have come into a role where they often remain focused on their own ﬁeld of expertise rather than the system as a whole

“Using an improvement process makes everyone stand back and ask: what are the needs of the patient? What adds clinical value? Who is the right person to deliver that care? What are the right times to deliver it and what is the cost? It requires strong collaborative leadership from our clinicians.” Yvette said the breaking down of silos of care is crucial. “The improvement methodology isn’t as important as bringing everyone together who has involvement in providing care. The best solutions reside in the collaborative efforts of those people.” Starting at the beginning Alexius said a curriculum was being developed for UWA and UND medical students who would be exposed to this different way of thinking at the undergraduate level. “We want doctors to graduate knowing their role in driving change and how to encourage leadership in others. As far as we know, WA will be the only jurisdiction where all local graduates will have those skills and understand their role as a leader."

By Dr Rob McEvoy

Everyone in the team is valued or important and it takes courage to challenge the status quo.

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MARCH 2016 | 35

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News & Views

Rural Training Improves Care in Broome The array of opportunities for young doctors couldn’t be more diverse than in Broome and for GP trainee Dr Fintan Andrews it’s been a fabulous ride. There’s little wonder that Rural Health West has enlisted the services of Broome GP trainee Dr Fintan Andrews as one of its ambassadors for the past two years. When he says he loves the work and lifestyle in the Kimberley town, it’s no public relations exercise. “Broome is a really nice place to live and work. This is my third year in the town. This time around, I’ve been here for 13 months. Previously I did a year of Rural Clinical School and half of my internship here,” he said. While the outdoors lifestyle is compelling – Fintan speaks enthusiastically about crabbing, fishing and cycling, which will see him do the Gibb River Road Mountain Bike Challenge for the second time in May – the work in all its diversity and complexity excites him. Being part of a community “Last year I did my first two terms of GP training at Broome Doctors Practice and I saw and did just about everything. Every patient has a story and discovering them was one of the things I most enjoyed about the work. You get to know the patients really well and you also get a deeper understanding of how the community works because you’re the person they come to.” Fintan has extended his GP training through RACGP’s Far GP program for a Fellowship of Advanced Rural General Practice, which has him back in the hospital environment in 2016. “Basically it’s training to make me more country specific. I’m doing half time in ED and the rest in obstetrics. Technically I’m training to become a GP Obstetrician.” “So while I really enjoyed the autonomy of care in general practice – so much so I’m sure to go back to it – I am enjoying working with a lot of doctors in the hospital environment.”

Dr Fintan Andrews has taken to life and work in Broome.

practising in Broome. It has had a really big impact on getting doctors into the country.”

“There’s a big contrast between the advantaged and disadvantaged in Broome. There’s a large homeless population and the obstetrics can been challenging with a lot of high-risk pregnancies which take a fair bit of extra care. We have a population group that is quite at risk. The same can be said of ED presentations as well. It’s not a traditional ED here because of the limited private-care resources in town, so the ED sees a lot of GP presentations as well.”

While WAGPET’s pitched battle to retain the Prevocational General Practice Placements (PGPPP) program failed last year, community residencies, even in their new form, continue to be a crucial part of workforce solutions in rural and remote centres and presenting an economic boost to the towns.

Young docs eye Broome

Culture of teaching and learning

While the challenges of the clinical work are ongoing in the Kimberley, Fintan reports that workforce issues are responding to a number of programs instigated by the likes of WAGPET, universities through RCS and Rural Health West.

“For work and life experiences, Broome has almost everything. There are great opportunities in such a different work environment. Over the past three years, I’ve seen the numbers of junior doctors increase and under Dr Casey Parker and Dr Nick Gilbert, the hospital has established a really good culture of teaching and evidence-based learning.”

“At the hospital I work with a number of doctors who did RCS here and are now

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Fintan can’t speak highly enough of the beneﬁts he has gained from his experiences in Broome.

“That process and quality of staff and doctors here means Broome hospital has a really good standard of medical care with mostly locally trained graduates.” The future is still a work in progress for Fintan, who, along with wife, Broome Hospital doc Dr Jonika Mosedale, still has some interesting medical hills to climb with his work towards becoming a GP O&G. 2016 is study year with fellowship exams in August and October and a Diploma of Child Health in the ofﬁng. Wherever he lands, Fintan believes his time in Broome has made him a better, well-rounded doctor.

By Jan Hallam ED Dr Casey Parker has an interesting teaching and sharing blog, BroomeDocs.com

MARCH 2016 | 37

News & Views

Primary care for the frequent fliers Better coordination of what exists, new service providers, and redefining roles – all without treading on toes. Can Medibank Private in WA pull it off? Medibank Private’s Head of Health Network Relationships Simone Williams checked with both Government and HBF, the two other parties to this agreement, before sending details of three Medibank Care Programs for WA – CarePoint, CareFirst and CareTransition. She wished to avoid any suggestion these programs were a form of managed care, having suffered the same criticism over East with the GP Access program, an 18-month pilot just for those with chronic health problems and private health insurance. Medibank Private says 2.2% of insured members are responsible for 35% all hospital and medical expenditure and they know a large portion of them live with one or more chronic conditions. It considers this trend is across the broader health system. GP Access, which ran in 26 GP practices in Queensland, ended in July 2015 because participants didn’t think it added value to their insurance and there was a perception that it created a two-tier health system rather than support universal health care. New programs more inclusive As they stand at present, Simone said two key points of the new programs were: så 4HEYåWEREåNOTåEXCLUSIVEåTOå!USTRALIANSå with health insurance but to anyone with chronic conditions who met certain criteria, in “a unique public/private funding model that is open to governments, Primary Health Networks and other private health insurers”. så '0SåLEADåTHEåPROGRAMS åREFERåPATIENTSåTOå them, and maintain sovereignty over all clinical decisions. The programs are aimed at preventing unnecessary hospital admissions by helping those with specified chronic conditions – chronic heart failure, COPD, osteoarthritis, type 2 diabetes and CVD – better selfmanage and improve their use of the health system, and use GPs and “their primary care teams” to take pressure off the health care system. CareFirst aims to change behaviours in those diagnosed with one of five chronic diseases. CarePoint aims to integrate care to these people and others with chronic and complex conditions. CareTransition is aimed at hospital discharge patients at risk of unplanned re-admissions. Where’s the evidence? International and Australian studies are being used to support the programs. The Wagner Model for Chronic Illness Care; international trials of 5000 patients showing coordinated care can reduce hospitalisations for heart

38 | MARCH 2016

failure by 25%; and two randomised trials by the University of Colorado involving 850 people who received the Care Transitions Program, which showed reduced hospital re-admissions. Independent evaluation will be provided by the School of Public Health and Community Medicine at the University of NSW and UWA. Where’s the money? Funding by “a unique and open public/private model” seems to involve the WA Health Department, PHNs and private health funds. The CareFirst and CarePoint programs are delivered within existing primary care practice “without disruption to existing workﬂow and processes”. This must mean calling in someone else to do some of the work while continuing patient-centric care through Medicare. Certainly, the health coaching and support offered to those with the targeted chronic illnesses must be an add-on to normal services, paid for by government or private health funds. The CareTransition program is currently being phased into a number of hospitals in Australia (WA is not stated) to support the GP in patient post-hospital care. CareTransition doesn’t say

how those “most at risk of unplanned hospital re-admissions” are chosen or by whom but says the program should improve recovery and ongoing care through better coordination and planning. New on the block is a “CareTransition Coach” who works with the patient to ensure that follow-up appointments with the GP are made and attended. Coordination the key Whether it is the patient’s or the health system’s fault, Medibank says those who need help most are often confused about where to get it. They hope that better coordination of health services will improve their health outcomes and cut overall costs. Given this ﬁnancial pressures from high users, interventions like these programs make good business sense. “If our members are healthier and out of hospital, we can reduce healthcare costs, curb premium increases and make healthcare more affordable for all,” Simone said. At a political level, if results are palatable and supported by the community, expect much more to come.

By Dr Rob McEvoy

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Clinical Update

By Dr P. Max Majedi, Pain Medicine Specialist, SCGH Pain Management Department

Complex regional pain syndrome CASE REPORT

She eventually underwent trial dorsal root ganglion (DRG) stimulation with stimulation of C6, 7, 8 and T1. The trial went for four weeks with 100% improvement in pain, complete reversal of the skin changes and full return of function.

This patient ﬁrst presented with a painful right thumb (dominant hand) with dystrophic and hyper pigmented skin changes. This was after a minor work-related accident with a small cut to the thumb. Soon after the cut she developed severe pain, swelling, redness and loss of function. It was treated conservatively. However, it rapidly worsened and started to get hyper-pigmented, with rapid loss of function and hypersensitivity to the dominant right hand. On presentation, she was being investigated for a potential infection of the thumb with reviews and skin samples by a dermatologist and numerous steroid and antibiotic treatments but to no avail.

She was eventually implanted with a full device and is currently using it effectively. Discussion

Q Fig1: Before DRG stimulation

The choice of this technology was based on science of DRG stimulation, which in some respects may offer neuropathic and nociceptive modulation. Although such intensive input is not required for the majority of patients, in selected scenarios, this approach is advantageous to ensure a collaborative model of care that is 100% patient-centred.

Her GP attempted to treat her with the standard analgesia and anti-neuropathic medication, all of which caused signiﬁcant side effects. He was doing ring blocks and cleaning of the hypertrophic tissue sometimes on a weekly basis. She was initially assessed medically and then by the multidisciplinary team including hand therapist, physiotherapist and clinical psychologist. She was treated with numerous trials of pharmacotherapy including lignocaine infusion with no results. By this stage there was talk of amputation by her treating surgeon given the aggressiveness of her condition. The workers’ compensation interaction had become adversarial and there was little support to fund ongoing therapy. She had several attempts at stellate ganglion blocks with some improvement. Eventually the decision was made to do a direct brachial plexus block with addition of steroids and clonidine to the local anaesthetic. This gave the best results, as conﬁrmed by her, the wound nurse and the hand therapist. However the results where short-lasting.

såDr Richelle Douglas is the new Medical Director at Sexual and Reproductive Health WA. s Former Commissioner for Children and Young People Ms Michelle Scott is the inaugural director of the McCusker Centre for Citizenship at UWA. She has also been appointed to the Anglicare WA board along with Ms Jenna Palumbo. s A/Prof David Watson and Dr Tim Cooper recently became Members of the Order of Australia for their contribution to the profession and the community.

42 | MARCH 2016

This case demonstrates a very complex pain situation requiring input from multiple disciplines within the one team without any commercial conﬂict of interest. As a team there were direct lines of communication and frank discussion about the issues. This allowed timely decision making all the way to the highend treatment such as spinal cord stimulation.

Q Fig2: Two weeks after DRG Stimulation

Then the medical treatment added pulsed rhizotomy to the brachial plexus, with pain control resulting for about four weeks. This continued for approximately one year, as her workers comp case was still ongoing with additional stressors and a number of other psychosocial confounders. Eventually, the decision was made for trial of a spinal cord stimulator once the workers’ compensation case was ﬁnalised.

s BGC Constructions has won the tender for the forward works of the $32 million upgrade of the Katanning Health Service. Main building works for a new ED, medical imaging and outpatient facilities are expected to start in mid-year. Next in line is Merredin, Cunderdin, Warren and Narrogin. s Perth-based Avita Medical has sold its respiratory business to a Victorian company for $2.47m to concentrate on US regulatory approvals for its ReCell autologous cell harvesting technology.

It also demonstrated some of the shortcomings of our current workers compensation system where some medical conditions are simply not treated adequately and aggressively enough, predominantly due to disease classification and absence of understanding of the socio-psycho-biological nature of persistent pain. Complex regional pain syndrome, in its most overt form, responds poorly to psychosocial stressors that invariably are part of the compensation-based medicine system, when the pain generator cannot be identified by scans and tests. In the case of this patient, her response is very clear and confirmed by several medical practitioners and allied health practitioners. Author competing interests: no relevant disclosures.

s The State Government through the Southern Inland Health Initiative is calling for applications for one-off grants worth a total of $19m to improve regional aged and dementia care. Details are on the Tenders WA website. s Geraldton Building Services and Cabinets has been awarded a $5.3m contract to build the Midwest Cancer Centre with work expected to be completed by the end of the year. As well as the $4.1m cancer centre, there will be a $1.2m renal consulting room.

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Clinical Update

Chronic low back pain: a practical checklist Affecting 10% of the population, chronic low back pain (CLBP) lasts at least three months and may radiate into the buttock, thigh, groin, flank or abdomen. Leg pain (referred from musculoskeletal structures) is associated in 20% of cases. True radicular leg pain (‘sciatica’) is far less common (5%). ‘Non-specific CLBP’, where no specific cause is identified, accounts for 80% of cases.

rant urgent MRI and symptoms warrant neurosurgical review. eview.

Specific causes (where a ‘pain generator’ is identified) include: internal disc disruption; facet or sacroiliac arthropathy; myofascial pain; cluneal neuropathy; ‘red flags’ such as a vertebral fracture, metastases or discitis (IVDU); other pathology (pelvic, visceral or renal disease, aortic aneurysm, shingles); and also pregnancy.

Inform patient about realistic outcomes mes and functional goals. Reassure aboutt imaging ﬁndingss (‘hurt doesn’t equal harm’). arm’). Encourage ‘demedicalisation’ of life, visit the PainHealth website and enrol in a pain program.

Triggers include work or sports-related physical activities (e.g. lifting, twisting, straining, repetitive tasks). Acute back pain becomes chronic in 20% of cases and risk factors for this transition include psychosocial stressors (‘yellow flags’), family history, spinal surgery, high BMI, lack of physical fitness, and smoking. Management requires a multimodal, multidisciplinary approach based on the checklist below. Are there “red flags’? Exclude T.I.N.T - tumour, inflammation (spondylitis), infection (discitis), neurological problems (root, cord, plexus) and trauma (fracture, lumbar instability). Examine for features suggesting radicular leg pain or central spinal stenosis (straight leg raise, slump test, neurological signs, claudication). Order an MRI or CT if concerned. Severe radicular leg pain or neurological

‘Yellow ﬂags’ are re the best predictors of CLBP LBP and disability (C.H.A.M.P.S): catastrophising, hyper vigilance, anxiety, sed, passive medically focused, coping, stress, substance/ ruse, smoking medication overuse, rk. and sick-of-work.

Useful analgesics (some used e off label) include paracetamol, tramadol, amadol, tapentadol, transdermal nsdermal buprenorphine, duloxetine or pregabalin (for or radicular pain), celecoxib b (pain ﬂare ups), and NSAID D gel. Physical therapies include de activitypacing, walking, g, exercises (strength and stretching, tretching, core-stability), ergonomics (e.g. workplace), acupuncture, upuncture, hot or cold packs and TENS.

Back injections – who is a candidate? Lumbar spine pain is a common presentation, which can be difﬁcult to diagnose and treat. Here are a few factors to consider when thinking about the myriad of therapies on offer, focussed on various types of injections. General considerations Exclude “Red Flag” conditions such as fracture, infection, malignancy, and cauda equina syndrome. Consider “Yellow Flags” which increase the risk of developing chronic pain and disability. The STarT tool is useful for screening (www. keele.ac.uk/sbst). These patients may not do well with injections. Consider referral to a Pain Medicine Specialist. Treat the patient, not the scans. Degenerative changes are extremely common on imaging studies, yet many people remain

44 | MARCH 2016

asymptomatic. Avoid injecting areas of abnormality, which don’t match the clinical picture. A “diagnostic” injection can often clarify which anatomical structure is the source of pain. The ﬁrst few hours after the injection represents the local anaesthetic phase so ask the patient how they felt immediately after the injection. Therapeutic beneﬁt duration can vary from days to months. During this time patients should focus on improved physical function (ideally guided by a physiotherapist) and lifestyle changes (e.g. weight loss, activity pacing, etc.). Injections should be used as part of a “package deal”. Common painful structures and injections Facet joints are responsible for back pain in

up to 50% of patients. Pain and tenderness tends to be well localised, and often worsens with extension movements. Pain may be referred to buttocks and thighs, but rarely below the knee. Facet joint injections are low risk and can provide short term relief. Blocking the nerve to the joint (medial branch of the dorsal ramus) has even better diagnostic utility. A rhizotomy (or neurotomy) can provide about 12 months pain relief in patients with conﬁrmed facet joint pain. Sacroiliac joints cause up to 15% of back pain and can be treated like facet joints (i.e. inject the joint and if needed refer for rhizotomy). Nerve root irritation and impingement causes mostly leg pain with neurological symptoms and signs (radiculopathy). A nerve root sleeve injection or epidural is appropriate and can provide 3-6 months beneﬁt.

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By Prof Eric Visser, Churack Chair in Chronic Pain Education and Research, UNDA and SJOG Subiaco

PIVET MEDICAL CENTRE SPECIALISTS IN REPRODUCTIVE MEDICINE & GYNAECOLOGICAL SERVICES

Antidepressants and clinical psychology for anxiety and stress (catastrophic thoughts, feelings of injustice and frustrations). Manage drug and alcohol problems, medication-overuse and smoking. Assist with injury rehabilitation and compensation claims. Identify specific pain generators (e.g. myofascial trigger points) and consider local anaesthetic (LA) injection, dry needling or physiotherapy. Cluneal neuropathy (10% of CLBP): Pain (often unilateral) in buttock and thigh, tenderness over superior iliac crest, altered toothpick sensation over buttock. Consider injection of LA and steroid over iliac crest (‘12 noon’) and pulsed radiofrequency treatment. Facet joints (20-40% of CLBP): L4/5 and L5/S1 joints implicated in 90% of cases, so imaging is unhelpful for diagnosis. If over 60, consider facet joint injections or medial branch (facet) nerve blocks of these joints (treat most painful side first), with follow-up radiofrequency treatments (‘rhizotomies’) if required. Radicular leg pain (90% L5 or S1 root) and central spinal canal stenosis (over 60, back and leg pain, claudication) are clinical and radiological (MRI/CT) diagnoses. Consider ordering a transforaminal epidural steroid injection (specifically NOT a nerve root sleeve injection) in the former, facet joint procedures (not epidural steroid) in the latter or surgical decompression if needed. Consider LA and steroid injection for sacroiliac joint pain. Review regularly and monitor response. References available on request

Author competing interests: Dr Visser has received honoraria for education or research funding support for the Churack Chair from BioCSL-Seqirus, Pfizer, Servier, Mundipharma, Janssen, Boston Scientific, Nevro and St Jude in the past five years. Questions – contact the author on 9400 9020.

By Dr Mark Schutze, Pain Medicine Specialist, Midland

Disc degeneration can cause localised back pain as well as radicular leg pain. An epidural injection (optimal technique is vital) can help for several months. Who does the injection can be as important as where and what is injected. Complex injections (e.g. rhizotomies, epidurals) should be done by those with expertise and training in this area. Pain medicine specialists can provide comprehensive assessment and management that goes beyond the injection.

by Medical Director PROF JOHN YOVICH

Can Lifestyle influence IVF outcomes? ... #2; effects of “broccoli index” Continuing the theme from the PIVET-Curtin collaboration and our recent publication in Reproductive Biology and Endocrinology (Firns et al, 2015), this article will focus on the benefits of a high fruit and vegetable (F&V) intake, euphemistically entitled the “broccoli index”. The work was initially documented in the 2003 PhD thesis of Dr Karen Joesbury from her studies at PIVET and which has recently been expanded in the Masters studies of Sarah Firns at Curtin University. It has enabled us to develop a clearer understanding of lifestyle influences on fertility and treatment outcomes. Our earlier report on smoking showed clearly negative effects for both males and females but working in different ways, and dependent on the length of smoking history (smoking years). Our data matched other reports. However, our studies on nutritional influences did not reveal a particularly clear picture and was not always Masters student Sarah Firns with PIVET consistent with other Medical Director Prof John Yovich reports, although nutritional studies are relatively scarce and much of the advice given to infertility patients is based upon assumptions rather than hard data. Our studies were based on meticulous diaries for the men and women in the lead-up to an IVF treatment and applied multiple logistic regression analysis to examine interactions between F&V intake and other lifestyle influences such as smoking (including serum nicotine levels), alcohol consumption, caffeine intake and stress effects. Our data showed that F&V consumption (as well as alcohol consumption) for both men and women had positive effects on fertilisation rates resulting in more embryos and a higher number of livebirths. The working hypothesis is that some lifestyle factors (such as smoking) induce chronic oxidative stress effects and this can be countered by an appropriate intake of anti-oxidants in F&V, particularly greens such as broccoli. These benefits can be enhanced by supplemental anti-oxidants according to some studies, and may even offset the damage induced by smoking which increases sperm DNA fragmentation.

NOW AT 2 LOCATIONS PERTH & BUNBURY Author competing interests: no relevant disclosures. Questions? Contact the author on 0403 786 878.

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

MARCH 2016 | 45

Pharmaceutical advertising removed, page intentionally left blank

Clinical Updates

Managing pain at life’s end Chronic pain is a huge problem, with 20% of us suffering it despite advances in medicine and many new drugs – a complex biological, social and emotional experience. In the elderly is often multifactorial (e.g. OA, osteoporosis, diabetic neuropathic pain, cardiovascular disease, post surgery, immobility, contractures) and may be exacerbated by loneliness, loss and general decline in quality of life (QOL). Malignancy may then be diagnosed in addition. All treatment needs to be in the overall context of other symptoms, QOL, and considering the presence or absence of advanced care plans, possibly with formal advanced health directives. Ideally good pain relief would come with no adverse effects such as drowsiness. We need to ask what does this person most want? Would they, for example, swap good pain relief for more drowsiness or even a shorter life? The basics still apply. Is the pain nociceptive or neuropathic (or both)? What are aggravating and relieving factors? Is it continuous or not and what impact is there on function mood and sleep? Most need a combination of medications,

By Dr Sarah Pickstock, Palliative Medicine Specialist, Silver Chain Hospice Care Service

simple analgesia plus opioids, both regularly and PRN. Keep it simple with only one opioid. Codeine containing medications are not recommended as it needs to be metabolised to morphine to provide analgesia, and tramadol commonly causes delirium in the elderly. Barriers to good pain control These can be patient, carer, family or staffrelated. They include fear of addiction, noncompliance communication difficulties (dementia and pain scale tools can help) and fear of side effects. Practical difficulties are staffing levels, doctor availability (especially after hours), and the turnaround time to re-do Webster packs. In my opinion ageing in place is a nice concept but often means very frail sick patients are without 24-hour RN support, and not getting the opioids they need, especially in terminal care. If we do not plan properly, pain relief is often not available, and for patients moving into the terminal phase (last few days of life) death will often not happen in their place of choice. The emergency department is not a good place to die. Consider drug administration route. Patches will still work when tablets can no longer be swallowed. Injections may be needed for pain, restlessness and secretions. These need to be charted in advance, the ampules

Testosterone revisited The Testosterone Leadership Symposium had some interesting points on testosterone use.

subnormal testosterone levels linearly (hypothalamic mechanism unknown).

Clear indications

Over one third of males with longstanding hypogonadism have no symptoms. Risk factors for testicular disease include cryptorchidism, trauma or torsion, delayed puberty, genitourinary infections, and infertility; pituitary diseases include tumours, cranial irradiation, and iron overload (haemochromatosis, thalassaemia major). Simple testicular examination will indicate Klinefelter’s syndrome (volume <4ml). Kallman’s disease (hypogonadotrophic hypogonadism) is associated with lack of sense of smell.

Testosterone therapy is clearly indicated for physiological replacement for true testicular or pituitary disease causing very low levels. Pharmacological therapy is sometimes offered when ‘functional’ low testosterone levels cannot be reversed by medical treatment; such treatment requires proof of efficacy. Primary hypogonadism should be identified by low T levels and high LH, and treated. Many cases of Klinefelter’s syndrome are not diagnosed in life (75% of cases identified at autopsy). For erectile dysfunction, testosterone has only a modest role in its cause and treatment, although it can affect libido. Ageing effects on testosterone The effect of age on testosterone levels is quite small. Low testosterone levels with mid-range LH levels are usually secondary to reversible conditions including central obesity and other components of the metabolic syndrome, severe obstructive sleep apnoea, and depression. In obese subjects with androgen deficiency (testosterone can fall 50-60%), significant weight loss improves

MEDICAL FORUM

Practical Help Call 1300 558 655 for advice from a palliative medicine specialist for patients needing palliative care 24-hours-a-day. For patients at home needing palliative care contact Silver Chain Hospice Care Service on 9242 0289 www.silverchain.org.au/wa. Fax referrals to 9444 7265. For advice, staff education and a palliative care patient consult in high level aged care facilities, psychiatric units, and prisons - contact Metropolitan Palliative Care Community Service weekdays 8-4 on 9217 1777 or MPaCCS@bethesda.org.au Patients on schedule 8 medication (opioids) for over 60 days require a WA Health Department authority to prescribe. See www.health.wa.gov.au/info

need to be available, and if a pump is required it needs to be there, working, checked and ready to go. Families and staff need to know if there is a plan and what it is. Author competing interests. No relevant disclosures. Questions? Contact the author on 9242 0242

By Emeritus Endocrinologist, Dr Timothy Welborn

Hypogonadism prostate cancer and increase the chance of progression and that testosterone administration in treated prostate cancer does not elevate PSA levels nor cause progression. T and BPH Serum levels beyond 8.7nmol/L testosterone have no added inﬂuence within prostate tissue. Lower urinary tract symptoms attributed to benign prostate hypertrophy are more likely related to metabolic syndrome factors (obesity) than to testosterone levels.

Cardiovascular Risk

Male Infertility

Statistical data is variable and insufﬁcient to apply a ‘black box’ warning (FDA and European Medicines Agency).

Male infertility affects 1:20 men but most cases (60%) are of unknown cause. Avoidance of testosterone therapy is important in infertility, prior to expert fertility assessment.

T and prostate cancer In prostate cancer, testosterone is essential for initiation of the neoplasm, but studies show that in patients with stable and welltreated local prostate cancer, testosterone replacement is safe. Evidence suggests hypo-androgenism may increase the risk of

ED. PBS changes require specialist authorisation of testosterone prescribing for androgen deﬁciency, with new blood levels deﬁning this. Prescription rates have risen and there is concern about direct consumer marketing.

MARCH 2016 | 47

A NEW CONCEPT IN UROLOGICAL CARE SPECIALIST CARE, MULTIDISCIPLINARY APPROACH, IMPROVED ACCESS FOR GPs

PERTH UROLOGY CLINIC - SOUTH Suite 23, Wexford Medical Centre 3 Barry Marshall Parade Murdoch WA 6150

1800 4 UROLOGY www.perthurologyclinic.com.au refer@perthurologyclinic.com.au Appointments available at Geraldton and Joondalup

PERTH UROLOGY CLINIC - NORTH Suite 15, Hollywood Medical Centre 85 Monash Avenue Nedlands WA 6009

We are proud to introduce PERTH UROLOGY CLINIC. With our complementary skills and collaborative approach we ensure that patients are seen promptly by a surgeon with training and interest in their particular condition.

ANDREW TAN

TRENTON BARRETT

JEFF THAVASEELAN

SHANE LA BIANCA

ISAAC THYER

AK HAMID

r A team of sub-specialised and dedicated urologists working with in-house renal physicians, sexual health experts, physiotherapists and urology nurses to achieve gold standard holistic care r Access to state of the art technology including MRI guided prostate biopsy, Robotic DaVinci surgery, Holmium (HoLEP) and GreenLight prostatectomy, intravesical Botox, sacral neuromodulation, and microsurgical techniques r Streamlined referral process to guarantee a quick appointment; same-day appointments available r 24 hour a day, 365 day a year support for our GPs and their patients Uro-Oncology

General Urology

Functional Urology

r Comprehensive Diagnostics

r BPH Diagnosis and Management

r Comprehensive Female Urology Service

r MRI Guided Prostate Biopsy

r HoLEP and Greenlight Laser

r Male Incontinence assessment

r UROLIFT

r 5NKPIU #TVKĆ&#x201A;EKCN 7TKPCT[ 5RJKPEVGT

r Renal Stone Management

r Video Urodynamics

r Laser Stone Surgery/ESWL/PCNL

r Botox, Sacral Neuromodulation

r Laparoscopic Pyeloplasty

r Andrology and Penile Curvature

r Vasectomy and Vasectomy reversal

r Erectile Dysfunction, Penile Prosthesis

r Prostate, Bladder, and Kidney Cancer r Testicular Cancer and RPLND r Robotic Surgery r Advanced Laparoscopy r Cystectomy / Neo-Bladder Reconstruction

Prostatectomy

and surgery

Please give us a call, or visit our clinics to discuss what we can offer your patients and your practice 1800 4 UROLOGY (1800 487 656) FAX 6225 2105

48 | MARCH 2016

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News & Views

Hospitals of the North Our survey of hospitals concludes with public hospitals in the North Metropolitan Health Service. As of July 1, there will be a restructure which will include the creation of the East Metropolitan Health Service. Sir Charles Gairdner Hospital (556 beds) Aged care: ACAT; acute care of elderly; Delirium Care Unit; short-stay rehabilitation (GEM) vascular and orthogeriatrics; outpatient clinics for memory, falls, osteoporosis, continence and general geriatric medicine Cancer, haematology and palliative care: All services located at the Comprehensive Cancer Centre: Medical oncology – inpatient, outpatient and clinical trials; Haematology Department – inpatient, blood stem cell transplantation, outpatient and supervision of home chemotherapy. Radiation Oncology Department – tertiary referral service; R & D programs; outpatient palliative care; multidisciplinary management of malignancies; prostatic brachytherapy; stereotactic radiosurgery; image-guided radiation therapy; intensity-modulated radiation therapy and malignancy. Palliative Care Service – medical consultations; outpatient; specialist nurse consultations; bereavement service; discharge planning; education and research. Cardiovascular Medicine: Management of elective and emergency acute and chronic heart disease conditions; inpatient and outpatient cardiology consultations; ECGs; echocardiography (transthoracic, transoesophageal and stress); pacemaker checks; Holter monitors; and exercise stress tests. The Cardiovascular Invasive Laboratory – provides a 24-hour on-call service, including a 24-hour primary angioplasty service; inpatient services for angiograms, angioplasty, electrophysiology studies and pacing device implants; multidisciplinary Cardiac Rehabilitation and Heart Failure Service. Cardiothoracic Surgery: Cardiac and Thoracic surgery including Coronary bypass and adult septal defect surgery. Respiratory Medicine: 28 beds and outpatients; bronchoscopy service with imaging facilities and High Dependency Unit (HDU); laser photocoagulation, airway stent insertion and endobronchial irradiation (brachytherapy); outpatient services including pulmonary rehabilitation. Pulmonary Physiology and Sleep Medicine: Extensive Sleep Disorders Clinic; inpatient service for ventilatory failure. Elective Surgery: General – colorectal, upper GI, breast and liver transplants. Orthopaedics – all forms including state sarcoma service; bariatric and renal transplants. Plastics; Ophthalmology; pain procedures; Cardiothoracic; urology; ENT including all related skull-base procedures and major head and neck surgery; neurosurgery; maxillofacial.

Q Sir Charles Gairdner Hospital

Emergency Surgery: All the emergency procedures for the above specialties including all of the sub-arachnoid haemorrhages. Emergency services and critical care: ED, ICU (23 adult beds) HDU (7 beds) General medical: Specialist Medical Assessment Unit for urgent admissions with complex care specialist and rehabilitation.

Osborne Park Hospital (205 beds) Aged care: Inpatient, Outpatient and Rehabilitation; stroke services; ACAT; Parkinson’s clinic; falls clinic, Day Therapy Unit. Elective surgery: ENT; gastroenterology; general surgery; gynaecology/obstetrics; neurosurgery, ophthalmology; orthopaedics; plastics; urology; vascular. Rehabilitation: Aged care, stroke and surgical. Women, children & neonatal: Obstetrics for women with low to moderate-risk pregnancies; Postnatal support services.

King Edward Memorial Hospital (168 beds/100 neonatal IC beds) Cancer, haematology and palliative care: Gynaecologic oncology, allied health & support. Elective and emergency surgery: Obstetric and gynaecological Emergency services and critical care: KEMH Emergency Centre provides care for women experiencing pregnancy and gynaecological emergencies. Mental health: 8-bed Mother Baby Unit (Women and Newborn Health Service). Women during pregnancy or with their babies 0-12 months may be admitted to the inpatient program. Women, children & neonatal: KEMH oversees about 6000 births a year, provides high-level care for over 3000 sick and premature babies and provides care for over 5000 patients with gynaecological conditions, including cancer.

Allied Health: Dietetics; medical imaging; occupational therapy; physiotherapy; podiatry; social work; speech pathology; pharmacy.

Joondalup Health Campus (468 public/146 private beds)

Kalamunda District Community Hospital (33 beds)

Emergency services and critical care: ED including dedicated paediatric unit; ICU; HDU; Coronary Care Unit

(From 1 July 2016 the hospital will form part of the East Metropolitan Health Service.) The hospital offers services including palliative care, sub-acute medical, endoscopy and allied health services such as physiotherapy. Services: Palliative care; medical general; occupational therapy; outpatients; pathology; pharmacy; physiotherapy; radiology; social work; speech pathology, endoscopy; care awaiting placement; chaplaincy/pastoral care.

Aged care: Acute and restorative inpatient; day therapy outpatient clinics.

Elective and emergency surgery: General; orthopaedics; urology; ENT; ophthalmology; plastic and reconstructive surgery; vascular surgery; spinal surgery; anaesthesia and pain management; bariatric; state-wide peritonectomy service.

continued on Page 51

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MARCH 2016 | 49

How does endometriosis affect your patient’s fertility? It is estimated that the percentage of women of reproductive age with endometriosis is 10-15%. However, in a population of women dealing with infertility, this proportion jumps to between 25% and 40%. We therefore believe that part of a responsible work-up of patients presenting with infertility is an assessment of the possibility of her having endometriosis. Common symptoms such as dysmenorrhoea and dyspareunia are indicative of a potential problem but their absence does not rule out the diagnosis. There remains considerable controversy regarding exactly how endometriosis affects fertility, as well as issues surrounding its natural history, pathogenesis, diagnosis, surgical treatment and fertility treatment options. In essence, endometriosis is often an inflammatory and scar-forming condition causing suffering among patients. Here, we look at a few ways in which endometriosis can affect your patient’s reproductive potential. There are four variants of endometriosis related to infertility. They involve the formation of endometrioma, superficial peritoneal deposits, deeply infiltrating endometriosis (DIE), and adenomyosis. These four variants have similar pathogenesis, but have varied presentations and need different clinical managements.

Q Endometrioma

Q Deeply Infiltrating Endometriosis

Q Peritoneal deposits

Q Adenomyoma

Ovarian endometrioma occur in 17-44% of patients with endometriosis. There are four different ways in which ovarian endometrioma may affect fertility: så In about 15-25% cases the mechanism involves anovulation. så Fibrosis leads to destruction of germinal epithelium resulting in abnormal rates of follicular development, premature follicular rupture and asynchrony in the oocyte maturation. så Histological data confirms inflammation and fibrosis of the surrounding ovarian cortex. så There is also increased tissue oxidative stress inducing oocyte apoptosis and necrosis. så Over-aggressive ovarian surgery can also reduce the ovarian reserve and compound the problem. The other forms of pelvic endometriosis have similarities in how they affect a woman’s fertility. These include: så Increased secretions of pro-inflammatory cytokines leading to impaired cell mediated immunity, and neo-angiogenesis. så Changes in the peritoneal fluid adversely affect the spermatozoa. så Affected tubal motility and fallopian tube egg pick-up mechanisms, especially where pelvic scarring is significant. så Negative effects on uterine receptivity and implantation due to altered endometrial gene expression. Co-existence of DIE and adenomyosis is associated with a 68% reduction in the likelihood of pregnancy. Endometriosis can also double the risk of miscarriage once the patient is pregnant. In addition, some couples are dealing with considerable sexual dysfunction related to pain, obviously affecting their ability to conceive. IN SUMMARY: Endometriosis is an inflammatory and scar-forming condition over-represented in the infertile population. Although many controversies exist, multiple mechanisms are at work that may reduce a couple’s fertility. Sometimes balancing the patient’s symptoms and her reproductive goals requires careful consideration. At WA Gynaescope we believe that anyone presenting with longstanding infertility, unexplained infertility, or any symptoms of endometriosis warrant laparoscopic assessment for endometriosis. Current evidence is in favour of a more surgical approach to these patients. Dr Sunny Baruah & Dr Gian Urbani Joondalup Private Hospital Suite 23, Level 2, Specialist Medical Centre (East), Shenton Avenue Joondalup WA 6027 Tel: (08) 6406 1801 Fax: (08) 6406 1802 www.wagynaescope.com.au

50 | MARCH 2016

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Hospitals of the North continued from Page 49 Outpatient clinics include cardiology, diabetes, gastroenterology, general medicine, haematology, infectious diseases, medical oncology, neurology, respiratory and sleep medicine and renal.

General medical: Extensive for emergency and inpatients; endocrinology; gastroenterology; infectious diseases; onsite dialysis; rheumatology; respiratory, neurology. Mental health: Emergency and adult inpatient, including 10 secure beds.

Mental health: Voluntary and involuntary adults and older adults, including emergency and inpatient.

Rehabilitation: General and orthogeriatric; neurosurgery and neurology

Women, children and neonatal: Maternity (low to medium risk pregnancies); gynaecology; paediatric (general medical and surgical for 0-16 years); neonatal service (Level 2A); antenatal classes and outpatient clinics.

Women, children & neonatal: Obstetrics; neonatology including level 2b Special Care Nursery; gynaecology; paediatric medicine and surgery. Q Midland Public Hospital

Heart and lung services: Cardiology; Cath Lab - diagnostic and interventional. Cancer, haematology and palliative care: Chemotherapy; haematology; palliative care

St John of God Midland Public Hospital (307 beds) Aged care, rehabilitation and stroke: Geriatric evaluation and management; acute stroke; stroke rehabilitation; inpatient adult rehabilitation; hydrotherapy pool; gymnasium Cancer care: Chemotherapy; medical oncology services; haematology; specialist pharmacy; medical and radiation oncology outpatient clinic. Heart services: Coronary Care Unit

Allied health: Inpatient and outpatient services in audiology, clinical psychology, nutrition and dietetics, occupational therapy, physiotherapy, podiatry, social work and speech pathology.

Elective and emergency surgery: General surgery including colorectal surgery; ENT; ophthalmology; orthopaedics; urology; vascular surgery; plastic surgery; gastroenterology and diagnostic endoscopy; paediatric surgery. Emergency services and critical care: ED (adults and children), Emergency Short Stay Unit and ICU (high dependency patient care provided from opening and intensive care for ventilated patients from 15 February, 2016). General medical: Adult inpatient and outpatient services across general and sub-specialties; respiratory function testing; comprehensive sleep service and endoscopy.

Outpatient: Cardiology; continence; diabetes; fracture clinic; gastroenterology; general medicine; general and colorectal surgery; geriatric medicine; gynaecology; haematology; infectious medicine; neurology; obstetrics; occupational therapy; medical and radiation oncology; orthopaedic; paediatric and neonatal medicine; clinical psychology; renal; respiratory; stomal therapy; wound management.

By Dr Sara Damiani

HealthDirect Clinical Usefulness Healthdirect Australia (HA) on directions from COAG developed the website. HA says 12m Australians search the internet for health and medical information each week, with 78% of those landing on overseas websites. HealthDirect attempts to divert some of this traffic to what it says is more clinically sound information appropriate to the Australian health system. From these attempts we have this app. It allows you to check your symptoms and receive advice on what action to take next, find a local health service, and search for information from Australia's leading health organisations. Details. Free, for androids and iPhones. A measly 29.03MB in size but it requires an internet connection. There is no companion website but the information search links you to websites said to provide safe, relevant and appropriate information; users can save web pages of particular interest (asthma, dehydration, haemorrhoids). Not password protected. Overview. The app looks nice and is easy to navigate (my 90-year-old grandma had a go!). The symptom checker excludes red flags and helps the user make an informed decision about what to do next – supportive care, GP in the next 24 hours, emergency now. This app may assist liaison between doctor and patient, and cannot be worse MEDICAL FORUM

Ease of Use than a quick Google search. Unfortunately the app does not allow the user to keep notes of their symptoms and does not allow autorotation, which means some websites that are not mobile device compatible appear tiny. Yes, the information is accurate and easy for all ages to understand. Pluses It has Australian Government quality assurance. To my knowledge, the only app that allows the user to enter their symptoms and make an educated decision about where and when to get treatment. It's as fast as your internet connection! The app helps the user ﬁnd health services anytime and gives directions. If allowed, it transmits latitude and longitude coordinates to emergency services. Minuses Not widely known so may not break the knee jerk reaction to search Google instead. Required internet connection is a problem in rural and remote communities; and emergency situations if you have run out of data allowance. Not all practices are included in the app's service ﬁnder. Users are not able to record their symptoms in the app.

MARCH 2016 | 51

Charity Ride

g n i Rid y a w h g i H e h t e f i of L

Ride for Youth sĂĽ 4HEREĂĽISĂĽONEĂĽYOUTHĂĽSUICIDEĂĽINĂĽ7! every week. sĂĽ 2IDEĂĽFORĂĽ9OUTHĂĽHASĂĽRAISEDĂĽNEARLY $13m since 2003. sĂĽ $ONATIONSĂĽWWW RIDEFORYOUTH COM AU DONATE sĂĽ WWW YOUTHFOCUS COM AU

The annual Ride for Youth has become a regular on Dr Phil Downingâ&#x20AC;&#x2122;s calendar but for him the focus remains the young people who need the help. It will be a six-hour bus ride to Albany for Dr Phil Downing and his cycling team before they don the Lycra and start the 420km trek back to Perth. But it wonâ&#x20AC;&#x2122;t hurt a bit! The annual charity, Hawaiian Ride for Youth, raises funds for its adolescent mental health programs ms and for Phil an opportunity to talk to teenagers about suicide, depression ion and self-harm.

Keeping the kids in focus

faceâ&#x20AC;&#x2122; scarring done using a cigarette lighter.â&#x20AC;?

â&#x20AC;&#x153;Some aspects of social media donâ&#x20AC;&#x2122;t make things easy for young people and itâ&#x20AC;&#x2122;s almost impossible to avoid. You can go online and learn how to tie a hangmanâ&#x20AC;&#x2122;s knot and there are even sites showing â&#x20AC;&#x2DC;smiley smiley

Ride for Youth isnâ&#x20AC;&#x2122;t all about the bike, either. Phil has a regular pit-stop on the way back to Perth speaking with and, just as importantly, listening to high-school students in rural towns.

â&#x20AC;&#x153;It will be the fourth time Iâ&#x20AC;&#x2122;ve saddleddup and, despite the physical challenge, ge, itâ&#x20AC;&#x2122;s becoming strangely addictive. The he ďŹ rst thing to emphasise is that itâ&#x20AC;&#x2122;s nott a race. The purpose is twofold, ďŹ rstlyy to increase the awareness of mental health issues and secondly to raise funds for services such as Youth Focus that help young people who are struggling.â&#x20AC;?

â&#x20AC;&#x153;I tell a ďŹ rst-person story of a co colleague who chose to take her own life. She was an anaesthetist and put life a drip in her arm and just went to sleep. I talk about making choices, sle the importance of developing resilience and start by saying, â&#x20AC;&#x2DC;if I res were alive today Iâ&#x20AC;&#x2122;d be 35 years-oldâ&#x20AC;&#x2122;. we It gets g their attention and you can usually hear a pin drop.â&#x20AC;? usu

â&#x20AC;&#x153;The increasing numbers of those affected is disturbing and, as a GP at the pointy-end of all this, I see it every day. I work in Hay Street Mall in the CBD and we deal with a lot of disenfranchised and marginalised people, the homeless in particular.â&#x20AC;? â&#x20AC;&#x153;I also had friends at school who committed suicide and Iâ&#x20AC;&#x2122;m the father of two teenage daughters so this is an area close to my heart.â&#x20AC;?

52 | MARCH 2016

â&#x20AC;&#x153;Thatâ&#x20AC;&#x2122;s the main reason I keep coming back. I normally ply my c ttrade one-on-one dispensing what I hope are pearls of wisdom and to do that in a large auditorium of 150 d yyoung people is quite different.â&#x20AC;?

Dr Phil Downing

â&#x20AC;&#x153;There are three separate pelotons on â&#x20AC;&#x153;Th the ride â&#x20AC;&#x201C; the Coastal route through Pemberton and Mandurah, the Inland Pem course that takes in Porongurup and cou the Wheatbelt W run through Katanning and Williams. Last year I spoke at Narrogin High School where there are a Narr lot of Muslim immigrants with problems

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Charity Ride

Dr Phil Downing's Perth Airport team in the Wheatbel t

such as language difficulties and gang rivalry linked with different backgrounds.” “This year I’m going to Pinjarra and I find this aspect of the ride very humbling. It really has been one of the highlights of my life!” Keeping the team motivated Phil is at the helm of the Perth Airport Team, which can require a complete Doctor Phil skill-set. “Six months of getting out of bed for earlymorning training rides can be hard to maintain so I have to make sure they’re not suffering too much. And some team members have experienced first-hand the tragedy of suicide so there can be an emotional component, too.” “I also help to coordinate the fund-raising. If an individual rider doesn’t reach the set target of $5000 it comes off your credit card, so it has the potential to be an expensive ride.” There are both positive and negative spin-offs for a 52 year-old embarking on a 700km cycling adventure. “I train on the bike in the morning and go kitesurfing in the afternoon so I’m losing weight, but it’s hard not to fall asleep by 7pm. I’ve had

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to open a box of antiinﬂammatories a couple of times but it hasn’t been too bad. Mind you, one year I broke my foot but still managed to do the ride in a thermoplastic c splint and another time the chain snapped and I broke my thumb.” “Thankfully, this year’s been relatively injury free.” .” Keeping him honest If Phil’s motivation ever ﬂags his patients are more re than willing to say, ‘get on your bike’. “I ride thousands of kilometres every year, including riding to work every day. If my patients don’t see my sleek and expensive mid-life crisis leaning against the wall they know I’ve caught the train and give me a hard time.”

“I’d say to all my colleagues out there, if you can’t do the ride yourself a donation would be much appreciated. Thank you Clinipath! It’s a good cause and even $1 towards a young person’s mental health has to be a good thing.”

By Peter McClelland

“It’s a Trek, complete with electronic gears. Although I have to say in my defence, my car is 12-years-old with a lot of kilometres on the clock.”

MARCH 2016 | 53

Writing

T mystery of one of WA’s early tragic heroes is the subject of two The bbooks written and illustrated by local doctors. Dream, was shortlisted for two prizes in 1996 – the prestigious Vogel award for young writers and the WA Premier’s Award.

Dr Peter Burke

“It was useful having a chronological deadline because you had to be under the age of 35 to enter a manuscript. I was working up in the Kimberley at the time.” Sharing the spirit

Travel medicine physician Dr Peter Burke’s latest book isn’t his ﬁrst and it probably won’t be his last. Wettening Auralia is hot off the press and tells the tragic story of CY O’Connor and the world’s longest pipeline between Perth and Kalgoorlie. It’s a genuine medical collaboration with illustrator, Gwelup GP Dr Claude Cicchini waving his magic pencil throughout the book.

“Wettening Auralia is self-published with an initial run of 1000 copies with proceeds going to Direct Action Ethiopia and WA Music (WAM), two really worthwhile local charities. The former does important vaccination work in Ethiopia and the latter has had real success in

“There’s a lot of very interesting and unexplored WA history out there if you care to rake over the coals. And it’s a good thing for us, as doctors, to keep our creative talents alive. I know many colleagues who are musicians, actors and writers and it’s important to pursue activities other than work,” Peter said. Power of the pen While he’s distinctly reluctant to call himself an artist, Claude applies his creative palette in many different ways. “I did some cover artwork for Peter’s first book that showed a pearl diver drowning in his suit with some crazy looking birds flying around and fish swimming past. It wasn’t used, unfortunately, because the publishers insisted on having their own graphic artist.”

“There’s a real fascination with this story because it’s a quintessential West Australian foundation legend,” Peter said. “It all happened in the early 1900s when WA was coming out of a mineral boom with a strong Premier ruling a state that couldn’t quite believe its own good fortune. And, just like now, the economy began to turn pearshaped and there was a strong feeling that everything was about to head south.” When WA’s Chief Engineer, Charles Yelverton O’Connor, rode his horse down to Robbs Jetty south of Fremantle in March 1902, dismounted, walked into the water and shot himself it was the culmination of a litany of vitriolic abuse by a weekend newspaper. Shadowy figures of history “The firebrand left-wing agitator and former editor of the Sunday Times, Frederick Vosper, was blamed for O’Connor’s death but he had a rock-solid alibi – he’d been dead for 14 months! There’s no doubt that Vosper had published some scathing criticism of O’Connor’s engineering expertise but the real culprit was the ‘Invisible Man’ of WA history.” “He was a rather intimidating fellow who ended up becoming WA Attorney General.” Peter’s first literary foray, The Drowning

54 | MARCH 2016

Aboriginal communities with some wonderful music coming out of places such as Wiluna and the Pilbara.” Peter’s latest publication is actually two books in one. Wettening Auralia falls within the genre of historical ﬁction and its companion volume, A Dangerous Gift, is a factual account complete with extensive endnotes. The latter also has a superb line-drawing of the ‘Invisible Man’ by Dr Claude Cicchini on the front cover.

“As a kid I loved drawing cartoons and I still do some sketching and design work. I also really like making things and I’m building my wife a ukulele. I’d love to reinvent myself as a luthier!” “I play bass guitar in a band, everything from Lou Reed to the Go-Betweens. We go by a number of different names, which just goes to show we’re not very good, but we have a great time playing at parties.”

By Peter McClelland

MEDICAL FORUM

Beer Review Nail Brewing has been producing craft beer since 2000 when it produced a pale ale poured from tap at Bobby Dazzler’s pub in the Perth CBD. Now both Nail and Feral both produce locally owned beer from their brew house in Bassendean. Before we launch into the beers, a few disclosures are in order. First, we are unassuming dilettantes with no great expertise in ﬁneries, thus we are unable to identify clover or anything fancy in the aroma of the beer. Second, we primarily drink Belgian beer, which unfortunately sets a very high standard for its antipodean cousins. Third, we are in favour of independent breweries, such as Nail Brewing.

By Dr Bradleigh Hayhow and Dr Sergio Starkstein

T he Beers

Clout Stout 2015 (10.5% ABV)

Nail Imperial Brown (8% ABV)

This is a Russian Imperial Stout released every year in very limited numbers (this year, only 700 bottles (750ml) were available nationwide). It is presented as a big black beer with rich malty ﬂavour and aroma; smooth and full bodied, to drink now or cellar for two years. This is the only beer we tried together, and although we did like it, we were somewhat disappointed as it did not distinguish itself from other decent but not great stouts.

Presented as a rich and strong Brown Ale, with fruity esters and a warming ﬁnish. This is a beer to drink after dinner during a cold and rainy night.

Presented as a US-style ale, with ﬂoral and citrus hop character and caramel ﬂavours. We both agree this is one to skip, but are biased by our entrenched lack of interest in American beers.

Classic Pale Ale (4.7% ABV)

Oatmeal Stout (6% ABV)

Presented as delicate, fruity and floral, with a touch of sweetness and mild bitterness. An easy-drinking classic Pale Ale. We agree that it drinks quite easily, but with a flatish finish and without much character.

Presented as one of Australia’s most awarded stouts it has a chocolateand-coffee malt character. We found it a pleasant beer that can be enjoyed even on a warm day. Perhaps this is the stout to choose for those not used to this style.

Golden Ale (5% ABV) Presented as full of tropical fruit character, bright and juicy, and packed with ﬂavour. In our opinion, this is the best Nail beer. Mango aroma is quite prominent and the initial ﬂavour is agreeable on the palate.

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Red Ale (6.0% ABV)

The Verdict Nail beers are above the average Australian beer, and we liked the low carbonation in all of them. Nevertheless, there is much to improve, especially in the ales. Nail is a young brewery, and no doubt we shall witness increasing quality over the next few years.

.. or online at

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Beer Question: Which Nail Ale has mango aromas?

Email Please send more information on Nail Ale offers for Medical Forum readers.

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 29, 2016. 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

MARCH 2016 | 55

Music

, e r o M e c n O n o i s s a P h t i W

WASO's symphonic might is scaled back to reveal the beauty, power and melancholy of Bach's Easter classic, St John Passion. When WASO’s 2016 season was announced last year it was accompanied by the news that its principal conductor Asher Fisch had signed on for another two years taking his contract to 2018. It was greeted with delight by all whose life has been touched by the orchestra – his enthusiasm, knowledge and experience have taken the orchestra’s music making to a world-class level. Asher Fisch is renowned for his Romantic repertoire as anyone who sat spellbound through the Beethoven weekend in 2014 will attest. But Medical Forum was drawn to the Baroque offering this year where Fisch will lead a trimmed-down orchestra and WASO Chorus with soloists in Bach’s St John Passion this month. As readers of the magazine will know, there is a healthy clutch of doctors in the Chorus – a fact that the choir’s vocal coach and acclaimed baritone Andrew Foote discovered. “I was taking one of the singers to rehearsal and chatting away to discover she was a respiratory specialist and was on call,” he said. Andrew has been the Chorus’s vocal coach for about two years and works with the Chorus director Chris van Tuinen to prepare it for concerts as diverse in 2016 as St John Passion to Mahler’s Resurrection to Mozart’s Requiem.

56 | MARCH 2016

“Not many symphony choruses have a vocal coach but it’s not unlike sporting teams which have specialty coaches. We had a list of things we wanted to work on over a threeyear period, which is now coming to bear fruit for some voice types. The past two years we have concentrated on the male singers.” “They are generally not as experienced performers as women for a number of reasons going back to school days. So we have focused on giving them conﬁdence and role modelling and we are happy with outcomes, especially the tenors. They are about 8-10 in number compared to 20 basses and 30 of every other voice type but they are holding their own and make a good noise now. So our next voice part to focus on will probably be the altos.” St John Passion is the older of Bach’s two surviving Passions (the other is St Matthew) and is based on the Gospel text of St John, chapters 18 and 19, and is traditional Easter music at its ﬁnest. While professional singers are brought in to sing the solo parts and arias, in Bach’s day they would have been members of the choir, and instead of performing for 1500 people in a concert hall, Bach ‘premiered’ his work at the Good Friday service at St Nicholas Church in Leipzig in 1724.

Andrew Foote Anne Russell, Paul McMahon, Andrew Collis and Richard Butler. The last time the oratorio was performed in Perth was in 1995 when Andrew performed in the same role. “I love this oratorio. It’s a masterwork – it’s technically brilliant and ﬁendishly difﬁcult but I love that challenge.” The 2016 season for WASO has plenty of highlights but for sheer magnitude, Mahler’s Resurrection symphony in April, with the full might of the orchestra and a Chorus supplemented by singers from UWA is hard to beat. Check the WASO website for more details.

By Ms Jan Hallam

Andrew will be performing out front of his Chorus proteges in the role of Jesus alongside other soloists Sara Macliver, Sally-

MEDICAL FORUM

Opera

Riding on a

WA Wave The first main-stage production for WA Opera this year is an exciting synthesis of local talent from all corners of the artistic landscape. WA-born composer Iain Grandage has adapted Tim Winton’s Booker Prize shortlisted bestseller, The Riders, for the opera stage while WA Opera’s artistic director Brad Cohen has programmed it with an extraordinarily talented cast of local singers and, of course, the opera ensemble from WASO. It couldn’t fit Brad’s remit for the opera company any more snugly – Australians telling Australian stories in the opera form. For those who are unfamiliar with The Riders, or who are perhaps scratching their heads wondering how this tale of abandonment and desperate searching set in three continents could find an operatic expression, may not fully appreciate the extent of Brad’s determination, nor of Iain Grandage’s theatrical savvy. Having seen and heard Iain’s scores for the stage play of Winton’s Cloudstreet and his soundscape for the 2000 Perth Festival production of Plainsong among a swag of other productions, there’s very little Grandage can’t do when bringing the drama of a text to a musical context. Of course abandonment and desperate longing are the wellspring of all good opera,

“ “I’ve done a lot of contemporary premieres iin my time and having a second go is particularly satisfying because you have p tthe beneﬁt of retrospection where you can identify shortcomings and make the c necessary changes for greater success n ssecond time around.”

Brad Cohen so the raw ingredients for a dramatic night at the theatre are present before a note is played. Brad spoke to Medical Forum before Christmas about bringing this revised version of The Riders to its ‘home town’. “I’m very keen to tell regional stories in our own voice, that’s why I was so keen to program The Riders. It’s a WA story from a great WA writer that’s been turned into a great WA opera by an exciting WA composer for a WA audience. It’s important that our company brings these works to WA,” he said. “The opera was trialled in Melbourne in 2015 and it needed some tweaking so it’s very important to give it this second airing. It’s a great piece with wonderful accessible music and packs a lot of emotional power.”

T fit Brad’s ‘local’ requirements, the cast is To entirely new. WA baritone James Clayton, e whose dramatic skills match his sonorous w vvoice, and local soprano Emma Pearson, who is the hot-right-now opera voice in Australia and Europe, bring powerful credentials to the a W WA Opera production. However, Brad’s vision is not so narrow as to fixate just on this opera. For him The Riders is symbolic of the artform’s capacity to be relevant in today’s digital society. “As soon as opera is seen as museum art then it will struggle to grow, but while operas like The Riders and many other great contemporary pieces are being written, we are in a really good place. I’ve been lucky enough to be associated with a lot of those important new operas and it’s this regeneration of the artform that we really want to achieve.” “If you make good work with good talent, audiences will want to come and see it.” The 2016 WA Opera season promises other gems. Mid-year sees Donizetti’s The Elixir of Love with another two WA-born opera stars Aldo di Toro and Rachelle Durkin in the lead roles in director Simon Phillips’ celebrated and iconically Australian production – red dirt an all. Then in October, a production close to Brad’s heart is Bizet’s The Pearl Fishers directed by Michael Gow and starring Emma Matthews (another West Australian who is Opera Australia’s leading soprano). When Brad took up the artistic directorship last year, he had two goals: first to renew WA Opera’s repertoire and secondly to connect more directly with the audience. With this special year of delights, we think he’s achieved both…with spades.

By Ms Jan Hallam

MEDICAL FORUM

MARCH 2016 | 57

ody, d tto be someb I always wante ve ize I should ha but now I real c. eciﬁ been more sp

FROM THE PROFESSIONALS… “Posh hotels have a turn-down service. I had never heard of this and there was a knock at the door and a woman said, ‘I’ve come to turn down your bed.’ To which I said, ‘Well many women have in the past. Why should you be any different?’”

BEST OF THE EDINBURGH FRINGE 2015 “I did a gig in a fertility clinic. I got a standing ovulation.” Tim Vine

Michael McIntyre

“Giving up smoking for 27 years is like wrestling a polar bear, in that it can make you quite tense.”

“I knew a transsexual guy whose only ambition is to eat, drink and be Mary.”

Dylan Moran

George Carlin

“I’ve got type 1 diabetes. Diabetes is the only disease where I’ve had to stop half way through having sex to have a Kit Kat.”

“A few decades ago we had Johnny Cash, Bob Hope and Steve Jobs. Now we have no Cash, no Hope and no Jobs. Please don't let Kevin Bacon die.”

- Lily Tomlin

Ed Gamble

“I did have a drinking problem: Southern Comfort tasted quite nice; ordinary Comfort tasted like fabric softener.” Milton Jones “My skin is the biggest organ of my body, despite what stereotypes would lead you to believe.” Dane Baptiste “Recently in court, I was found guilty of being egotistical. I am appealing.”

Bill Murray

“When my wife and I argue, we’re like a band in concert: we start with some new stuff, and then we roll out our greatest hits.”

“She said she was approaching 40, and I couldn't help wondering from what direction.”

Frank Skinner

“I was vegan for a while. I lost 6lb, but most of that was personality.”

Bob Hope

“Dubai is what would happen if you gave a 12-year-old a trillion dollars to redecorate his bedroom.”

Pippa Evans

“Who discovered we could get milk from cows, and what did he think he was doing at the time?” Billy Connolly “Women need a reason to have sex. Men just need a place.” Billy Crystal “Anyone can be confident with a full head of hair. But a confident bald man – there's your diamond in the rough.” Larry David “The guy who invented the first wheel was an idiot. The guy who invented the other three, he was a genius.” Sid Caesar

Dane Baptiste “I am the one in my family who does all the driving because my husband never learnt to drive – in my opinion.” Jo Brand “Abortion wasn't legalised in Ireland until 3075.”

Mark Nelson “The ﬁrst time I met my wife, I knew she was a keeper. She was wearing massive gloves.” Alun Cochrane “Clowns divorce. Custardy battle.” Simon Munnery

“My cat is recovering from a massive stroke.”

“They're always telling me to live my dreams. But I don't want to be naked in an exam I haven't revised for...”

Darren Walsh “Whenever I get to Edinburgh, I’m reminded of the deﬁnition of a gentleman. It’s someone who knows how to play the bagpipes, but doesn’t.” Gyles Brandreth

Red Button

“Joan Rivers got exactly what she wanted from that ﬁnal surgery – to stop ageing. Finally she nailed it.”

Marcus Brigstocke

“Jesus fed 5000 people with two ﬁshes and a loaf of bread. That’s not a miracle. That’s tapas.”

Aisling Bea

“I don't trust that man. Before he gave his business cards out, he shufﬂed them.” “If Pac-Man had affected us as kids, we'd all be running around in dark rooms, munching pills and listening to repetitive electronic music.”

Stewart Francis

Grace The Child

Katherine Ryan “After 50, you have to stop seeing your heart as a muscle and more as an unexploded bomb.” Hal Cruttenden

58 | MARCH 2016

MEDICAL FORUM

Entering Medical Forum’s competitions is easy!

Competitions

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).

Opera: The Riders Tim Winton’s celebrated novel set in Europe has been transformed into a compelling opera by WA-born composer Iain Grandage and brought to the opera stage by WA Opera’s artistic director Brad Cohen and director Marion Potts. Baritone James Clayton takes on the lead role of Scully and Emma Pearson his wife Jennifer who never gets off the plane to join him. His Majesty’s Theatre, April 13-16, 7.30pm

FEATURE

Movie: Kung Fu Panda 3 (3D) Who doesn’t love Kung Fu Panda? Now you can love it in at least three dimensions. Po's long-lost father suddenly reappears, which sees the pair embark on a journey to a secret panda paradise. Of course, the supernatural villain, Kai, creates unnecessary drama by killing off the kung fu masters but watch how Po kicks and chops his way through this one. In cinemas, March 24

Movie: Eye In The Sky Director: Gavin Hood Featuring: Helen Mirren, Aaron Paul, Alan Rickman, Iain Glen and Barkhad Abdi Helen Mirren is a London-based military intelligence ofﬁcer commanding a top secret drone operation from her remote location to capture a group of dangerous terrorists in Nairobi, Kenya. When things turn nasty, it starts looking like a political as well as humanitarian nightmare. This edge-of-your-seat thriller has plenty of spills – it is also one of the late Alan Rickman’s last ﬁlms. In Cinemas, March 24

Movie: Wide Open Sky This uplifting ﬁlm documents the power of a children's choir set up in a far western NSW. Kids travel far from their home to a music camp to prepare them for a big concert in Coonamble, where they only have three days to learn a demanding repertoire. Moving and funny, the ﬁlm reminds us why no child anywhere should grow up without music.

COMP Theatre: Picnic at Hanging Rock If you’re hearing Gheorghe Zamfir’s pan flutes at the mere suggestion of this classic Australian novel/film then you need to head to the Heath Ledger Theatre to see Tom Wright’s stage adaptation. You may or may not find out what happened to Miranda and her gaggle of school friends in the Macedon ranges but you will be entertained and thrilled by director Matthew Lutton’s vision. For the record, Paul Jackson has created the music for this production! Heath Ledger Theatre, April 1-17; Medical Forum performance, Saturday, April 9 at 2.15pm

Doctors Dozen Winner The winner of the Doctor’s Sparkling Selection from The Wine Thief in West Leederville, Dr Jenny Beale, is rather fond of a Pinot and plucked exactly that from the carton to hold in the photo. Jenny and her partner have a wedding anniversary coming up so the sparkling bubbles will come in handy. Jenny, a Senior Registrar in Obstetrics at KEMH, is planning further training in the UK later this year.

In Cinemas, April 7

Winners from the December issue Movie – The Revenant: Dr Andre Chong, Mr Ray Barnes, Ms Kellie Ashman, Dr Katherine Ng, Dr Bill Thong, Dr Pat Mulhern, Dr Mandy Croft, Dr Mathew Carter, Dr Robert McWilliam, Dr Steven Dorevitch Movie – The Belier Family: Dr Melanie Chen, Dr Paul Kwei, Dr Amir Tavasoli, Dr Simon Machlin, Mrs Jane Wong, Dr Andrew Toffoli, Dr Jennifer Martins, Dr Angelo Carbone

Calm Waters Our wish for 2016

Movie – Spotlight: Dr Wen Loong Yeow, Dr Michael Allen, Dr Donna Mak, Dr Cathy Kan, Dr Crystal Durell, Dr Beverly The, Dr John Masarei, Dr Linda Wong, Dr Bibiana Tie, Dr Max Traub t Parenting Under Ice t Medical Board Fairness t Midland Public Opens t Clinicals: Adrenal Fatigue, Travel Medicine etc t Christmas Greetings, Letters & Humour

DECEMBER 2015 Major Sponsors

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Movie – Carol: Dr Sue Bant, Dr Nasim Fahimian, Dr Henrietta Bryan, Dr Penny Wilson, Dr Ioana Vlad, Dr Geoffrey Hunt, Dr James Flynn, Dr June Sim, Dr Tricia Charmer, Dr Glenn Parham Movie – Youth: Dr Christine Lee-Baw, Dr Ruby Chan, Dr Moira Westmore, Dr Patricia Dowsett, Dr Yohana Kurniawan, Dr Julia Charkey-Papp, Dr Pillay Surendran, Dr Jenny Fay, Dr Clyde Jumeaux, Dr Andrew Christophers

MARCH 2016 | 59

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WEST PERTH For lease at 51 Colin Street Medical Consulting Suite is now available for lease. Colin Street Day Hospital is situated on floor below. Furnished medical consulting suite includes:t TRN t DPOTVMUJOH TVJUFT t 5SFBUNFOU SPPN t 3FDFQUJPO 8BJUJOH SPPN t ,JUDIFOFUUF t 4UPSBHF SPPNT Y t VOEFSDPWFS DBS CBZT t #JDZDMF BOE TIPXFS GBDJMJUJFT JO CVJMEJOH Contact Marie Sheehan on 0411 738 809 Email: marie@csds.com.au PERTH Fully furnished serviced office available. An opportunity for all Allied Health Professionals to rent rooms in Perth. Located behind nib stadium. Only a 10 minute walk from Perth train station. We have 2 rooms available. Growth area with a growing clientele base. Work alongside our General Practitioner Dr Charl du Plessis. HICAPS and EFTPOS facility. Please send expression of interest to reception@psmedical.com.au

93 INTERSATE URBAN POSITION SYDNEY Campsie a busy inner west suburb of Sydney a city of cultural diversity. 100% of billings for the first 3 months. Looking for VR GPs with unrestricted provider number on a part-time or full time basis. With all Allied Health Services and RN support. Prefer Chinese speaking but not necessary. Contact: Dr Ben Ang 0426 271 168 or bhc2008@hotmail.com

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URBAN POSITIONS VACANT PERTH Sessional rooms available at our Travel Doctor TMVC clinic in Perth CBD Fully furnished and fitted out ideal for medical specialists and allied health practitioners. Shared reception, waiting room and facilities. Close to public transport facilities. Contact: Rebecca 08 6467 0900 or Rebecca.Hultink@traveldoctor.com.au

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JOONDANNA We are seeking a VR GP to join our friendly team on a part-time or full-time basis. New, state of the art medical centre. Flexible hours and billing. Percentage negotiable. Fully-computerised. Nursing support for CDMP. Please call Wesley on 0414 287 537 for further details. NORTH BEACH North Beach Medical Centre needs a GP for two to three sessions to start with. Availability to work one morning from 8 am and one afternoon until 6pm is a must. There is a Body Logic Physiotherapy and Western Pathology on site as well. The desire to build a regular clientele basis for the long term is available, as the North Beach area has undergone a major building boom. We are willing to discuss associateship for the right applicant. Please contact Helen on 9447 1233 or 0417 282 900 AVELEY "WFMFZ .FEJDBM $FOUSF SFRVJSF B VR GP for both FT & PT. Well established practice. On site pathology psychologist and dietician. Fully accredited practice, computerised and with nurse support. WAGPET accreditation available as well. Excellent remuneration. Please Contact: 0400 814 091

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BANKSIA GROVE North of the River Family Practice is seeking a VR GP. Well-established team, accredited and fully computerised. Please Email: jags@perthgp.com.au

*RVQHOOV +HDOWKFDUH CENTRE

GOSNELLS GP required for Sundays Gosnells Healthcare Centre is a growing Bulk Billing Medical Centre situated in the Gosnells Central Shopping Centre. t 8F SFRVJSF B (FOFSBM 1SBDUJUJPOFS 73 or Non VR with General Registration) to start as soon as possible t 4VOEBZ IPVST BSF BN UJMM QN t (PTOFMMT JT %84 GPS (FOFSBM Practitioners t 5IF QSBDUJDF JT GVMMZ FRVJQQFE BOE computerised t 'PS GVSUIFS JOGPSNBUJPO QMFBTF DPOUBDU Joseph Ranallo on 0418 282 796 or at joe.ranallo@ppsportal.com.au

DAWESVILLE South of River (DWS Area) Existing GP leaving. Busy computerised practice, great billing. Take over established patient base from existing GP Nurse and Admin support. Earn up to 65% of billings. &ORVJSJFT UP 7JTIOV H@WJOV!ZBIPP DPN THORNLIE Opened January 2016 - New Thornlie 4RVBSF .FEJDBM $FOUSF 73 PS /PO 73 (1 SFRVJSFE 1BSU 5JNF Full Time. Fully computerised with Best Practice, nurse support and onsite Pathology, Allied Health. Rates negotiable. Privately owned. Contact Tricia on 9497 1900 for a confidential discussion or Email CV to: info@forrestroadgp.com.au or coastalgp@yahoo.com.au

PERTH VR GP Required t /FX NPEFSO t $PNQVUFSJTFE QSBDUJDF t /PO DPSQPSBUF FOWJSPONFOU Mixed billing practice Great location opposite nib Stadium. Growth area with a growing clientele base. Please send your application by email to: reception@psmedical.com.au HAMILTON HILL " GFNBMF (1 SFRVJSFE GPS B DMJOJD JO B DWS and AON area 5 minutes drive from Fremantle. 3 Doctor GP Practice. Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or Send CV to eric@hamiltonhillfamilypractice.com.au

SHOALWATER ' 5 PS 1 5 73 (1 SFRVJSFE GPS PVS modern state of the art medical centre located in Shoalwater (DWS), Offering modern surrounds and fully computerised clinical software. We are a friendly, privately owned and run centre. A full complement of nursing staff and administration team as well as onsite allied health, specialists and pathology. generous remuneration offered. Please phone Rebecca on 08 9527 2236 or Email CV to manager@shoalwatermedicalcentre.com

REDCLIFFE Ascot Medical Group Part-Time VR GP Wanted for friendly General Practice Non-Corporate Practice with Mixed Billings Accredited and Fully Computerised Sessions available: Afternoons and Saturday Morning (Alternate) Please contact Practice Manager on 9332 5556

CONNOLLY DRIVE MEDICAL CENTRE Doctors Needed Now Instant Goodwill Top Income DWS Phone: manager on (08) 9562 2500 Email: manager@cdmedical.com.au

WEST LEEDERVILLE 'VMM UJNF QBSU UJNF (1 SFRVJSFE GPS privately owned well established practice in West Leederville. Excellent patient base. Itâ&#x20AC;&#x2122;s a Private billing practice with excellent earning potential. Contact: sanjaykanodia2000@yahoo.com

Are you looking for doctors for your medical practice? Australian Medical Visas is owned and run by 2 Practice Managers based in WA, who have over 20 years experience of the 6, BOE "VTUSBMJBO IFBMUIDBSF TZTUFNT We currently have a number of doctors who are looking for positions in Australia. We are able to assist practices with all paperwork involved including the NJHSBUJPO QSPDFTT JG SFRVJSFE Please visit our website www. australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or Andrea on 0401 371 341. BULL CREEK MetroGP Part-Time VR GP Wanted for friendly General Practice Non-Corporate Practice with Mixed Billings Accredited and Fully Computerised Sessions available: Monday, Thursday and Saturday Morning (Alternate) Please contact Practice Manager on 9332 5556 PADBURY Padbury Family Practice Fulltime/Part-time GP wanted for friendly General Practice. Non corporate with mixed billings. Outstanding reception/Admin/ Nursing staff. Established patient base. Accredited and fully computerised Adjacent to physiotherapist/ Podiatrist, Psychologist and pharmacy. Please contact Jane Cuzens on 9401 7566

Reach every known practising doctor in WA through Medical Forum Classifieds

APRIL 2016 - next deadline 12md Wednesday 16th March â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

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FREMANTLE We are seeking an experienced VR skin cancer practitioner to join our newly established and expanding purpose-built skin clinic in the heart of Fremantle. Part-time initially with potential to increase in the future. Non DWS area. 4$$" RVBMJGJDBUJPOT QSFGFSSFE &ORVJSJFT UP (BJM 1SBDUJDF .BOBHFS PO 08 9336 3066 or via email gail.camporeale@skinclinicfremantle.com.au

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

*RVQHOOV +HDOWKFDUH CENTRE

THORNLIE GP POSITION AVAILABLE AND CONSULTING ROOM FOR LEASE ,.( JT TFFLJOH 73 /PO 73 (1 UP KPJO its Accredited Medical Practice Invitation is now extended to interested specialists for a consulting room to lease at our brand new surgery suite. There is huge need for all specialties in Thornlie and immediate surroundings. Allied health practitioners seeking a room to lease are welcomed. Contact the Practice Manager: 08 9452 2055 Email: forestlakes@kingdommedicals.com.au

GOSNELLS Full-time VR GP required. Gosnells Healthcare Centre is a growing Bulk Billing Medical Centre situated in the Gosnells Central Shopping Centre. t 8F SFRVJSF B QFSNBOFOU (FOFSBM Practitioner (VR) to start as soon as possible t $POTVMUBUJPO IPVST BSF OFHPUJBCMF t (PTOFMMT JT %84 GPS (FOFSBM Practitioners t 5IF QSBDUJDF JT GVMMZ FRVJQQFE BOE computerised with nursing support t .JOJNVN IPVSMZ SBUF PG QFS IPVS or 70% of billings t 'PS GVSUIFS JOGPSNBUJPO QMFBTF DPOUBDU Joseph Ranallo on 0418 282 796 or at joe.ranallo@ppsportal.com.au

PERTH F/T VR GP SFRVJSFE GPS PVS GSJFOEMZ privately billing, well established central city General Practice. We are fully computerised and AGPAL accredited. You will replace a F/T VR GP with an established patient base; predominantly a well-motivated young professional clientele. We are non-corporate so offer generous remuneration and sociable hours. We have full nursing support, on site pathology, physiotherapy, psychology and a chronic disease management program. The practice enjoys a diverse range of patients which has allowed us to develop special interests; such as sexual health, minor surgery and we have a travel medicine license. Bike storage and end of journey facilities on site. Check us out PERTHMEDICALCENTRE.COM.AU Call Dr Phil Downing 9481 4342 AH: 0411 108 883

KARRINYUP 4U -VLF ,BSSJOZVQ .FEJDBM $FOUSF Great opportunity in a State of art clinic, inner-metro, Normal/after hours Nursing support, Pathology and Allied services on site. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979

BYFORD VR GP Female/ Male GP Required Full â&#x20AC;&#x201C; Time or Part -Time Under New Management Privately owned well established modern practice located in Byford, 30 mins from CBD, DWS and area of need. Full admin, nurse and practice manager support. Onsite Pathology, Podiatrist, Dental and Pharmacy. Fully computerised accredited Practice. Excellent Remuneration. Please email: byfordfp@gmail.com GOSNELLS Ashburton Surgery. Established 2002. Female VR GP needed part time. Ethical patient oriented practice Fully Accredited. Private billing. 70% of billings. 'VMMZ FRVJQQFE XJUI OVSTF TVQQPSU Email: angiesurgery@gmail.com or call Angie 0422 496 594

Contact Jasmine, jasmine@mforum.com.au to place your classified advert

A unique opportunity exists for Doctors (individuals or groups) wishing to acquire their own practice or partner with an industry leader. s .EW SUBSTANTIAL STATE OF THE ART MEDICAL CENTRE DUE FOR COMPLETION MID s $73 LOCATION WITH RAPID POPULATION GROWTH LESS THAN MINUTES FROM CENTRAL 0ERTH s 4URNKEY OPERATION AS A STAND ALONE OR IN PARTNERSHIP

Ongoing business mentoring, management, legal and accounting support available. s -INIMAL STARTUP COSTS s 4O BE ELIGIBLE YOU SHOULD HAVE THE &2!#'0 AND !USTRALIAN RESIDENCY OR CITIZENSHIP

To ďŹ nd out more and for a conďŹ dential discussion contact Paul Rowe, Managing Director, 4HE "USINESS 3QUAD s 0HONE %MAIL PAUL THEBUSINESSSQUAD COM AU APRIL 2016 - next deadline 12md Wednesday 16th March â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum

Looking for a Part Time/ Full time VR GP to join the UWA Medical Centre team. Flexible hours, fully computerised, full admin and nursing support. Patient base Students and Staff of the University. Bulk billing for students, private for staff. Please contact Dr Christine Pascott or Sharon Almeida Phone: 08 6488 2118 Email: christine.pascott@uwa.edu.au ; sharon.almeida@uwa.edu.au

West Australia Sexual Health Clinic requires a part time VR General Practitioner to focus on male sexual health and androgen replacement. WASHC is Perth’s premiere medical centre devoted to sexual health dysfunction in men and women. We are a holistic practice with sexual dysfunction being a powerful motivator for patients to make health changes. Patient assessments include physical, emotional and relationship issues with sexual dysfunction often the calling card. WASHC staff have worked hard to create an excellent team approach with expert office staff, experienced sexual health doctors, urology RN with close support from Urologists and a Clinical Psychologist. Full training provided. For enquires please contact Dr David Millar on 93891400 Website: www.wasexualhealthcentre.com.au

GENERAL PRACTITIONERS REQUIRED DWS positions available in 4 locations!

Leaders in cardiology

STRESS TEST SUPERVISING PHYSICIAN CASUAL / PART TIME

Bunbury: Brecken Health Care - Join a team of 20 GPs Albany: St Clare Family and Occupational Practice – Join a team of 3 GPs Busselton: New site opening soon Eaton: New site opening soon Special interests are encouraged! Skin cancer Antenatal/postnatal care Walk in/urgent and after hours care Occupational Health Travel Medicine Procedural work encouraged Chronic disease management All our sites are fully accredited with AGPAL. Nurses, admin & allied health support as well as pathology on site. FRACGP or equivalent highly regarded but not essential. Flexible hours, Full time or Part time available.

For Further information please contact Dr Brenda Murrison 0418 921 073 or brenda.murrison@breckenhealth.com.au

Perth Cardiovascular Institute is one of the fastest growing private cardiac services in Australia, with a focus on providing outstanding patient care with an ethical, thoughtful and sustainable approach. Perth Cardio has invested in the best medical technology, high skilled staff and we value culture, teamwork and innovation and we are currently seeking an enthusiastic individual to join our team.

In the role you will: •

•

The ideal candidate will: •

• •

HOW TO APPLY: Send an application with a cover letter, resume and referee details to hr@perthcardio.com.au

Supervise patients undergoing Exercise Stress Tests and Stress Echocardiograms Be supported by a strong team of cardiac technicians, sonographers and cardiologists Be responsible for taking a lead in patient care in emergency situations Be able to undertake training to further your skills and knowledge in diagnostic testing Receive a salary that is negotiable and experience based

•

Have current advanced life support skills or be willing to undertake training Have interest in cardiology Be able to clearly explain procedures to obtain consent and reduce patient anxiety Have strong communication skills to document findings and interact with cardiologists

APRIL 2016 - next deadline 12md Wednesday 16th March – Tel 9203 5222 or jasmine@mforum.com.au

medical forum

ARE YOU WANTING TO SELL A MEDICAL PRACTICE?

p 08 9448 7799 m 0401 815 587

www.gpwest.com.au

As WA’s only specialised medical business broker we have sold many medical practices to qualiﬁed buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible.

Mundaring GP super Clinic

We are committed to maintaining conﬁdentiality. You will enjoy the beneﬁt of our negotiating skills. We’ll take care of all the paper work to ensure a smooth transition.

VR GPs wanted to join a friendly team opening in April 2016 DWS and AON and 70 % offered. State-of-the-art Medical Centre GP Owned

To ﬁnd out what your practice is worth, call:

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

contact Dr Kiran Puttappa 0401 815 587

kiranpkumar@hotmail.com

Venosan Diabetic Socks Metro Area GP positions availab av ab able le VR & Non – VR Dr’s are welco come co m to ap appl plyy. pl y. Send applications to hr@betterhealthcare.com.au

The Magic of Silver for Sensitive Feet No Compression Silver Ion Therapy Contains the antimicrobial silver yarn Shieldex® which enhances a balanced foot climate. Tested and proven in controlling over twelve types of bacterial and fungal infections common on the feet and legs.

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

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

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

Keeps feet cooler in the summer and warmer in the winter

Comfort for The Patient t

Soft-Spun Cotton - Ultra soft cotton

Fully cushioned foot and fully cushioned sock

Comfortable for arthritic patients

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

APRIL 2016 - next deadline 12md Wednesday 16th March – Tel 9203 5222 or jasmine@mforum.com.au