Medical Forum WA 11/15 Public Edition

Age-old Questions

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November 2015 www.mforum.com.au

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Editorial

Should Doctors Worry?

AHPRA and National Law now make it so easy to complain that our MDOs, which have moved across to insurance contracts that involve less discretion, are feeling the financial burden of defending members.

And national and state-based Medical Boards have changed their spots – they protect consumers only – and AHPRA lawyers, with limited experience in forensic investigation, are making a hash of investigating complaints. Both complainants and defendants say it takes too long and communication is lousy.

The recent Lateline program that pointed to the bullying of a neurosurgeon in Townsville highlighted how AHPRA can either knowingly or inadvertently contribute to the vexatious harassment of medicos through its investigations. Politicians say vexatious complaints may not be identified and dealt with early enough.

To make things worse, risk averse MDOs that know how expensive it is to defend a matter will suggest to or cajole doctors into paying complainants to go away rather than defend the doctor’s reputation, even if the risk is small. We hear this often from doctors who are licking their wounds.

Then you have ‘experts at 40 paces’, doctors who when it comes down to it, are either supporting or defending complaints and earn from it. Welcome to the adversarial world of AHPRA. Lawyers know that if you ask the right questions you can bias reports. Experts who perform well in the witness box will be kept on the books (although court appearances are relatively rare).

Does this leave the conscientious doctor waiting for their turn to come around?

We have been campaigning for the disclosure of panellists involved in investigations and to this we can add the Medical Board’s list of ‘experts’. Under National Law, AHPRA is obliged to use local panellists where possible. The National Board might have final say over selection but no doubt relies on local recommendations.

We need investigators, panellists and experts who are prepared to see both sides, not just hired guns for either party. Most of the current panellists (and we assume experts) have been grandfathered across when the National Law came in. So what has really

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

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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

changed, you might ask? Where is the transparency around appointments?

Say someone believes women are prepared to lie about sexual harassment or they have some other gender, religious, or political bias that is over the top, why not allow other doctors to identify these people before finalising panellist appointments? We don’t want a popularity contest but we don’t want cronies with hang-ups appointed either!

GPs practising on the fringes are more susceptible.

The RACGP has a view theyy should be generalists (GPs with special interests, or GPwSI) but the reality is someone has to adjudicate on the safety of these people should someone take a disliking to them – consumer or health professional. This is because it is not illegal for GPwSI to confine themselves to work in their special interest area but still Dr Rob McEvoy hold general registration.

We know of many GPs who do this.

To be really good in one area might mean you are less crash hot in others but provided you work within those limitations, patient safety is assured. Specialists do it all the time. Next month we hope to present one such case involving a general practitioner that brings into question the behaviours of some.

Meanwhile, this month enjoy the kaleidoscope of different opinions in our pages, as we help you celebrate the diversity of medical practice. That’s how it should be!

In this edition, these things caught my attention. The pinball analogy for our elderly parents (p8) is a good one. I didn’t know David Dicks’ father was a GP (p14). It’s two years since the Catalyst statins story, which didn’t do the profession any good (p21). I didn’t know you could detect cerebral palsy in babies (p39)? To Dr Andrew Robertson’s profile we can add he is still a Navy man in the Reserve Forces (p46). And this job has its perks – I got to thank James Morrison (p49) personally for all his inspiring jazz music over the years!

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

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

NOVEMBER 2015 | 1

November 2015 12

Contents 14

44

19

FEATURES 12 Trailblazer: Prof Helena Liira 14 Spotlight: Solo Yachtsman David Dicks 17 Ageism in Medicine 19 Palliative Care Update 44 Peloton for Prostate Cancer NEWS & VIEWS 1 Editorial: Should Doctors Worry?

4

6 6 10 16 21 23 25 26 27

LIFESTYLE 46 Clinical Senate – Where Are They Now? 47 Wine Review: Chateau Xanadu 48 49 50 51

Dr Louis Papaelias Social Pulse: SJG Murdoch Hospital Ball Jazz Great James Morrison Funny Side Competitions

Dr Rob McEvoy Letters: Travelling the Road Together Dr Hilary Fine Calling Budding Administrators Dr Sayanta Jana NDIS for Mentally Ill: Prof Malcolm Hopgood MDA National Election & AMA Alliances; PHN Committee Process Curious Conversations Dr Sue Taylor Have You Heard?

Organ Donations Statins Story Revisited What Purpose Standards?

PHC – Missing But in Action Home Hospital New MD Beneath the Drapes

Ageism in Medicine See Page 17

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Clinical Contributors

28

Dr Johan Janssen Statins and Risk Management

28

Dr Leanne Heredia App Review: MedicineList+

29

Dr Peter O’Sullivan Athlete Over-Treatment

31

Dr Ken Thong Targets for type 2 Diabetes

33

Dr Sarah Pickstock Humour at the End of Life

35

Ms Jo Beer Diet & Wound Healing

37

Dr Steve Ward Understanding Iron Storage

39

Dr Jane Valentine Early Diagnosis of Cerebral Palsy

HURRY LAST DAYS Deadline November 9

41

Ms Blanche Coyle Hearing Loss – Unseen Disability’

42

Dr Rita Malik Sub-acute Delirium

Phone Jenny Heyden on 9203 5222 or email jen@mforum.com.au

Guest Columnists

8

Mr Ray Glickman Pinball with our Parents

25

Mr Jacob Hollenberg High-rise Aged Care

26

Dr Judy Edwards Dementia Research Essential

27

Prof Kingsley Faulkner A Changing Climate

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

Letters to the Editor

Travelling the road together Dear Editor, What is it that reading about the Nepal experience for Dr Gaynor Prince (October edition) jerked my memory?

It reminded me how quickly our world experience can change as health professionals.

Kathmandu. The year was 1987. The day, Black Monday. The stock market had just crashed and suddenly it seemed that budget travellers were not quite who they appeared to be as they scoured the scanty newspapers for stock market reports. No internet or mobile phones.

I was enroute to a working holiday in Australia via the Asian Backpacker trail. My medical degree, my certificate of completion of vocational training for General Practice and a stethoscope were all stuffed at the bottom of my rucksack. I had adventures to do first.

Black was blacker for one. I arrived at the scene probably five minutes after the event and too late to use any of my medical skills.

He lay in a pool of blood in the middle of the street. Motionless and covered by a thin white sheet. The jump from the top of the building had probably meant instant death. I thought that somewhere in the world he had parents. It would be a while before they knew.

I was gutted by an inability to do anything after all those years of training learning to save lives.

I wandered quietly away to my nearby hostel.

Much later that day I had to walk past the scene again and he still was lying under a thin now dusty white bloodied sheet. Cars and cows were avoiding the ‘obstacle’, horns blaring, cows mooing.

Now years later I reflect on many miles of travels. I am a tourist, a carefree incognito traveller, a ski sports fanatic, a camper or intrepid trekker. I am on a plane, a boat, sitting at a bar or restaurant, on a beach, around a camp fire. Just one of the group. Laughing, celebrating life and having fun. Then someone gets injured or gets short of breath or a chest pain or crashes their car on the road you travel.

We all have our stories and different scenarios but what I have learnt is that there is no point hiding your identity. As humans we have a natural instinct to help those in distress and

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

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as doctors we have experience to make a difference to the outcome. We are always on call and what a privilege that can be to help… so long as we are not too late.

Dr Hilary Fine, East Fremantle

of preference can be submitted to WA RACMA by emailing the electronic application to me (Sayanta.Jana@health.wa.gov.au) before screening by a panel including potential supervisors.

Dr Sayanta Jana, Secretary, WA RACMA

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

Calling budding administrators Dear Editor, The Royal Australasian College of Medical Administrators (RACMA) WA branch commenced a ‘RACMA Observership Program’ earlier in 2015. Every year RACMA Fellows, Associate Fellows and Candidates in senior leadership positions will give opportunities to a limited number of junior doctors and medical students to gain exposure to medical leadership, health management and medical administration and observe a senior medical leader in action within the health system.

Priority will be given to those associated with RACMA, WA Health Institute of Health Leadership (IHL) Service Improvement Program, those intending to undertake the RACMA Fellowship Training Program and those undertaking Clinical Fellowship considering exposure to health leadership and management principles.

Two week placements are available (subject to availability of appropriate supervisors) at various sites such as SCGH, RPH, KEMH, PMH, FSH, North Metropolitan Health Service, South Metropolitan Health Service, WA Country Health Service, SJOG Midland Public and Private Hospitals, Hollywood Private Hospital, WA Department of Health – Office of Chief Medical Officer and Disaster Management Unit.

A resume with two referees and a cover letter outlining career intentions and core objectives to be attained from the proposed placement, proposed dates and top five sites

CORRECTION We reported in a prior edition that Prof Pearn-Rowe was paid $26,000 by the Medical Board for preparation of an expert witness report in 2013. This was incorrect and we apologise for any error.

(The correct figure was $23,017.50.)

NDIS for mentally ill ED. Last issue we looked at the NDIS after both trial sites had submitted their fourth quarter reports. There is disquiet in the disability sector that the NDIS is unsustainable for both NFPs and the taxpayer. The Royal College of Psychiatrists contacted us about their submission to the Independent Review of the NDIS that has been completed by Ernst & Young. The College President Prof Malcolm Hopwood writes: Dear Editor, The NDIS is a life-changing and life-saving innovation in health care but that is why it needs to be appropriately planned and implemented. People with impairment from mental illness or psychosocial disabilities need intensive support. This is currently provided in some cases by state-funded services which will cease when the NDIS is fully implemented.

Statistics from the National Mental Health Commission indicate that 690,000 Australians live with severe mental illness, including 65,000 people with severe, persistent and complex needs.

Yet the NDIS is scoped to support only 57,000 Australians who have a psychosocial disability.

We are very keen to hear from the NDIA what the plan is to support the broader group.

We hope that health planners have learnt the lessons of the past and remember what happened when accommodation facilities were closed in the 1990s without sufficient planning to ensure care for a large number of vulnerable people.

Based on their experiences at the trial sites in Victoria, South Australia, ACT and Queensland, Fellows of the College have also voiced several concerns about the trial implementation of NDIS services for some significantly disabled patients who appear to be missing out on support due to confusion about eligibility, as well relying on individuals being able to drive their own NDIS application.

We are pleased to hear that the NDIA is engaging Peer Workers to assist people with serious mental illness. ........................................................................

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News & Views

MDA National Election and AMA Alliances What impact will a partnership between an MDO and a political organisation have on doctors?

Dr Wenck (head of RACGP Advocacy), A/Prof Capolingua, Dr Robyn Napier, and Dr Paul Nisselle, which is half of the 10-member board.

With a 10% turnout likely (compared to just over 30% in the recent Perth Lord Mayoral elections), four of six candidates will be elected to the MDA Mutual Board on November 17.

The AMA presence in the elections is strong.

Standing for re-election are Dr Andrew Miller (VP AMA WA), A/Prof Rosanna Capolingua (AMA WA Council), Dr Robyn Napier (AMA Federal Councillor, AMA NSW Medical Secretary), and Dr Beres Wenck (past AMAQ President and Federal Councillor).

Fresh candidates in the MDA Mutual Board election are Dr Keith Woollard (past AMA president) and Dr Patrick Mahar (AMA member 2004-2010). Dr Keith Woollard indicated when standing at the last MDA election that a dispute with the Medical Board was a motivating factor for him to stand.

MDA National has struck recent deals with the Victorian and Queensland AMA, and is said to

be in negotiation with the AMA in the Northern Territory. MDA’s recent attempt to merge with MIGA in South Australia was unsuccessful but saw the intervention of AMA WA president Dr Michael Gannon calling for members to give the AMA their proxy.

Given the AMA has about 25% of its membership as GPs nationally, GP positions on the MDA Mutual Board are important and include Dr Rod Moore (current president),

We have heard but cannot confirm that MDA National in WA has more GP members than AMA WA. MDA National originated in WA so membership here is strong. The media releases from MDA announcing interstate AMA preferred provider arrangements talk partly of educational synergies. No doubt market forces of other sorts are at play as we understand all MDOs are finding it hard going under the financial burden that AHPRA and the new National Law have created.

The MDA election closes November 17 and members would have received candidate papers soon after October 23. It will be interesting to see if the expected 90% of GPs and Specialists bin their ballot papers on this occasion!

Primary Health Networks Recruitment Does racing to meet deadlines explain the PHNs’ committee selection process?

The WA PHNs gave just 12 days from notification for me to apply for the Clinical Commissioning Committee Primary Health Network North (a three-day extension to this deadline was notified late). The call to action from the WA Primary Health Alliance (WAPHA) talked of a “once-in-a-generation opportunity to contribute to and influence the delivery of primary health care in WA”.

I was apparently one of 150 applications that would be processed in two weeks.

The automated website response said: “We endeavour to establish our committees with representation across the following focus areas of Aged Care, Aboriginal and Torres Strait Islander health, eHealth, Population Health, Mental Health and Chronic Illness/ Conditions while ensuring we have an equal geographical spread.”

I was informed that if my nomination was successful I would be obliged to comply with WAPHA’s Information Management Policy. I asked to see it. The response, on nomination deadline, was that it hadn’t been written yet

and would be shown to selected candidates after selection was done.

I was told my application would be reviewed by the Nomination Remuneration and Governance Committee who would have final say. Members are Dr Marcus Tan, Ms Ann Russell-Brown, and Dr Damien Zilm. Their final say is after initial selection by the chair and GM of PHN North, Ms Russell-Brown and Mr Andy Barnes, respectively.

I understand the selection process was similar for the other two PHNs. If I’m successful I will feel somewhat ‘handpicked’.

By Dr Rob McEvoy

Curious Conversations

Broadening Horizons A fully examined life makes for a richer experience according to Dr Sue Taylor.

If I could live anywhere else in the world it would be… in a small Japanese country town. Our family’s learning the language and we love the positive social and ethical qualities of Japanese culture.

If I were able to go back and make another career decision… it would still be medicine. It’s a privilege to help people and be rewarded with their gratitude. But, looking back, I’m not sure I ever actually ‘decided’ to go into medicine.

The most critical issue we face as intelligent people… is the stewardship of our planet. Fossil fuels and all the other stuff we’ve ripped

6 | NOVEMBER 2015

out of the ground have put us in a very privileged position. We need to recognise the high costs of our wealth and urgently adjust our way of living.

It’s a matter of survival, morality and plain common-sense.

The ‘Women in Surgery Collective’ is important because… it’s given me a different perspective on the medical lifestyle. I’m not planning to take up full-time work in the foreseeable future and I think I’m a better doctor for the breadth of my interests. But I don’t think it’s useful to classify doctors too rigidly. At times I behave more like a ‘surgeon’ than some of my male colleagues.

I’m reading… a variety of Japanese language books. But other books are calling to me from the book-shelf and The Landscape Below: Soil, Soul and Agriculture is top of the pile!

MEDICAL FORUM

Incisions

Pinball with our Parents GPs need to become pinball wizards to help their elderly patients navigate the complex and often treacherous system, says Mr Ray Glickman.

Pinball is a good game. We just shouldn’t play it with our elderly population.

When an older person’s health deteriorates or when they suffer an acute event, they often feel like that little metallic ball hurtling out of control between the flippers: GP, hospital admission, care awaiting placement, hospital in the home, transition care, aged care facility, and the list goes on.

While consumer direction is taking root in the disability and aged care sectors, it is virtually impossible for older people to call the shots when acute intervention is required.

There must be some way we can create an environment where they feel more like the flipper and less like the ball.

The acute intervention pinball board is littered with those treacherous little holes we fall down every time. Some are due to the lack of system integration between commonwealth and state governments, acute care and aged care, and aged care and disability. Others arise from the multiple clinical handover points that confuse an often disoriented elderly person.

There are some positive systemic initiatives in play to plug the gaps. These include the transfer of all responsibility for aged care to the commonwealth, the development of e-health records and structures such as the residential care line that supports clinical staff in care facilities to avoid unnecessary hospitalisation.

However, the key role surely must rest with the primary health care system. This puts the planning and coordination function of the family GP front and centre in this game.

GPs see themselves as the coordinators of their patients’ care while they’re in the community. However, integrated patient care often falls down at the pre-admission and post-discharge handover points. Similarly, one wonders how effectively hospital diversion and transition/restorative care programs are used to minimise hospital admission or reduce re-admission.

This question is all the more important in relation to the elderly given the significant functional decline they often face as a result of hospitalisation. There are counter-examples,

of course, but from the aged care sector’s perspective, we all too often see GPs taking an ‘all care and no responsibility’ approach.

Instead of looking up the board and working hard to avoid the holes, they merely flip the patient to hospital. After that, it is so often out of sight out of mind until the patient is flipped back into the community, quite possibly illprepared to cope and with inadequate support to avoid the next flick back into hospital or an aged care facility.

We know that family GPs are over-pressured and under-resourced, but I throw the question out there: can our GPs do more to prevent the involuntary pinballing of the elderly? The same question goes for all the other players. It just seems to me that GPs can make the biggest difference.

Don’t flip out when you read this. It’s just a game. Or is it?

Ray is CEO of Amana Living, Chair of Aged & Community Services WA and a Director at Aged & Community Services Australia..

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NOVEMBER 2015 | 9

Have You Heard?

HBF feeling the heat A couple of weeks ago, HBF posted an $80m surplus, which is not bad going for any business but particularly satisfying if you are a member mutual. Digging deeper and the story becomes a little more complicated reflecting the turbulent 12 months in the private health insurance world. Competition is hot with the privitisation of Medibank Private and HBF has made some sharp business moves this year to protect and potentially grow its patch such as forming an alliance with a dozen or so smaller member mutuals and aligning with aggregator iSelect. HBF’s annual report shows its after-tax surplus is down from $122.8m on the previous year despite a 5.1% increase in contributions (up to $1.4b) while benefits shot up to $1.33b (a 7.3% increase). It’s been a tough year for other WA NFPs – RAC announced a $19.5m net profit down from $37.9m the previous year.

Phoenix rises With the arrival of the WA PHNs the former Medicare Locals (MLs) have been required to wind up and re-configure as primary care service agencies. Last month we heard about the EGM of Panorama Health (Perth North ML) where its members accepted all of the recommendations to wind up and roll over remaining assets to the new service company, Black Swan Health. We understand now that the funding bodies insisted on these corporate gymnastics for all companies associated with MLs. This certainly appears to be a waste of time, effort and money for all of those involved, particularly as these new service companies are doing essentially the same work as the old entities delivering primary care services for

GPs and communities. As well as Panorama becoming Black Swan Health, South Coastal ML has created the company 360, Fremantle ML has created One Healthy Community and Bentley Armadale ML, Arche Health.

WAGPET gets late nod The word went out at the end of September that nine of the 11 GP training organisations were signed up but decisions were pending for both WA and SA. What the delay was no one was saying which led to us to speculate that perhaps WAGPET was holding out for a better deal for its vocational GP training program which was jeopardised by the lack of MBS provider numbers. A new day dawned on October 21 when WAGPET announced it had reached “an in-principle agreement” to run the AGPT program for the next three years.

Interestingly its statement went on: “Work continues on completing the details of the agreement however we anticipate there will be minimal disruptions” for participants. We don’t know the gives and takes on this one but more hard-ball should be played to get the best deal for GPs. Meanwhile the government has also announced its GP training advisory committee which has two West Australians – RACGP president Dr Frank Jones and Kununurra GP Dr Siew-Lee Thoo.

GPs last to know With the opening of the Midland Health Campus just three weeks away (November 20), MF learnt via Opposition Health spokesman Roger Cook’s questioning of the Health Minister that GPs in the catchment were only being notified of referral processes for restricted

procedures (fertility) to the SJG-run hospital sometime after October 20 when Mr Cook received the official reply. That doesn’t give docs much time to get their heads around the grey zones of the contract. We can tell Midland GPs that if your patient is at MHC and requests a restricted procedure available only at Marie Stopes or KEMH, they will be sent back to you for the referral. Similarly, if a woman has delivered at MHC, she will have access to family planning information before discharge but “seek advice on options for contraception from their GP at their six week postnatal review”.

DrShop takes a stand Electronic script ordering has been interchangeable between eRx and Medisecure since January 2013. Realtime monitoring of script drug abuse, beyond Schedule 8 drugs, has been in the news lately, mainly because the profession and governments can’t get their act together to monitor and prevent drug deaths investigated by State Coroners (even though the ERRCD is funded under the Fifth Community

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Pharmacy Agreement). In WA, we have Heath Ledger’s memory (see ScriptWise website).

Now, a frustrated MediSecure has gone it alone and launched DrShop providing free to doctors info to pick up script misuse amongst patients, in real time. Other key software supporters are Medtech, Minfos, Medinet and Best Practice.

Once more, with feeling Someone has been in the RACS’s ear. Just ďŹ ve days after the surgeons’ college issued a media release, came an unreserved apology for failure to respond to serious sexual harassment allegations seven years ago, naming Sydney vascular surgeon Gabrielle McMullin and the help she sought for female trainees. The ďŹ rst media release was a fanfare of its Expert Advisory Group, set up to examine discrimination, bullying and sexual harassment within the college training program, and the release of its ďŹ nal report which will inform an action plan to be released this month. The later media release highlighted how the RACS needs to be more involved and “cannot rely solely on investigations undertaken in the workplace by hospitalsâ€? and admitted the educational programs it had set up since complaints ďŹ rst arose in 2008 had been ineffectual.

Kleenex gets a ushing CHOICE has presented Kleenex with a Shonky Award for its promoted ushable wet wipes because they don’t break down like toilet paper. They say water treatment services spend $15m per year to get rid of hundreds of tonnes of wipes clogging the system and consumers are paying big time when home plumbing falters. They don’t think companies should get away with claims that aren’t true.

Gong for Collie River Valley MC The Collie River Valley Medical Centre was named the 2015 General Practice of the Year at last month’s RACGP annual conference.

Practice principals Dr Peter Wutchak and Dr Jan Van Vollonstee were in Melbourne to collect the award. Peter was thrilled the efforts of his team were acknowledged. “We’re in a small rural, coal-mining town and we aim to provide high quality health care that evolves to meet the needs of the community.

We look after our staff in the same way.

Everyone, from the nurses to administration and reception, is very much in tune with each other.� Peter said the practice was committed to teaching with some former registrars returning to work in the practice. The group has recently opened a practice in Manjimup.

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NOVEMBER 2015 | 11

Trailblazer

Seeing the World with Fresh Eyes On the eve of her first anniversary as head of UWA’s SPARHC, Prof Helena Liira, offers some timely insights into the future world of primary care.

A year ago, Prof Helena Liira packed her bags from her home in Kirkkonummi, Finland, to begin a new chapter of her career as Head of the School of Primary Aboriginal and Rural Health Care (SPARHC) at the University of WA. Apart from the obvious weather contrasts between a country that experienced a record low of -35C and a country where the mercury has been known to soar into the mid-40s, Helena also can tick off some interesting differences in the way doctors, particularly GPs, go about their daily tasks in their respective home ports.

If the local landscape seems fragmented with two systems often working against each other, try the nationalised Finnish model of three funding systems where decentralised multidisciplinary health centres, funded by municipal governments, and occupational general practice are the heavy lifters.

“Public health outcomes are very good in Finland, but over the past decade, finances have become problematic and health centres are suffering with a number of doctors leaving for the private sector. There is universal care but the queues to see a GP are very long,” she said.

excited to be at the forefront of curriculum development and connecting the five centres of study under her remit.

Connections are the future Collaboration is a word Helena Liira uses a lot. As she talks, she moves to the white board where there is a spider’s web of interconnecting lines between the schools.

The strategy has been written and already there is action.

“It’s exciting putting it all together and goal setting. I’m happy with the process. It has been challenging, but it is working so far but it’s a good time for all this to happen.”

UWA is undergoing a rebranding which has put the student experience in focus in an era of tightening funds. The medical school is no exception. It’s well aware of the challenges ahead with funding an ever-present question mark as well as the prospect of competition from the newly announced ed Curtin Medical School which is expected d to take its first students in 2017.

“The first thing that really struck me about the Australian system was how strong the role of GPs was here. They are far more independent and as business owners they are masters of their own work.”

“I am also impressed with th WA Health Translation Network, which ich Prof John Challis is now leading after it was as established by cardiologist Dr Peter Thompson. ompson. Here is a consortium of all universities ities with the aim of making stronger casess for research funding. It’s a very good sign that all West Australian universities rsities are collaborating to form a united nited front in the very difficult area of funding.”

Ability to adapt to change

Speaking with one voice ice

The second was just how flexible and resilient GPs were to system change. One might add they have had plenty of practice!

“I would like there to be a united voice for primary health care research, esearch, so there is room for partnerships ships as well as competition. Of course se there will be competition but UWA is strong and we are well prepared for the future. Next year we will begin with a new sense of who we are, what are our ur most important goals and what we can do best together.”

“The Australian system was at first complicated for me to comprehend. It can be difficult to discover what’s going on and there are often changes. Medicare Locals were here for only three years and now they are replaced with Primary Health Networks but while there might be policy change, people take those changes so easily and service is not really disrupted.”

“In my country nobody has been able to change a thing! Everybody knows the system doesn’t work but nothing changes. So I admire this attitude here which embraces change.

People here are innovators and think outside the box, you can see that courage in medical research and in practice. The mindset is focused on being able to do things.”

As head of SPARHC, Helena has five centres of study to coordinate – the Rural Clinical School, General Practice, Centre for Aboriginal Medical and Dental Health, Emergency Medicine and the WA Centre for Rural Health and it’s to the strategic coordinating role that she has devoted her first 12 months. She is

12 | NOVEMBER 2015

However, Helena is impressed with the quality and resourcefulness of the students she has come across and has no doubt they will take those qualities into the workplace.

She has endeavoured to discover what kinds of workplaces they will be, which has meant meetings with community and professional groups and representatives from the WA Primary Health Alliance, and has clarity in areas that many who have been in the system for decades have failed to achieve.

“I’m a manager and a strategist and I’m also an outsider. I don’t have a political opinion I just see things as they are. People like to talk to someone who is neutral.”

By Ms Jan Hallam

While this attitude might mark her as “not from around here” she has a wonderfully liberated perspective which comes es from seeing something for the first time. me. Systems, courses, research, students and teachers need to complement each other – it is a lesson for the entire health system.

Her primary responsibilities ties are to help produce young doctors ctors capable of meeting the challenges of the future, while giving students a satisfying experience in the process. In this new university environment, the student wields an unprecedented degree of influence.

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MEDICAL FORUM

NOVEMBER 2015 | 13

Spotlight

Nine Months Before the Mast

A helicopter delivers David a replacement rigging bolt off the Falkland Islands during his solo sail around the world in 1996.

Having grown up sailing, solo yachtsman David Dicks says his 1996 circumnavigation was just a longer sail than normal!

David Dicks is now an accomplished helicopter pilot.

“My solo trip didn’t really feel like much of a big deal. I’d already done about 10,000 sea-miles and been half-way around the equator with John from the age of 13, so it really was just more of the same. It was pretty much one day after another and the distance to the horizon didn’t seem to change much.”

Not always plain sailing This childhood spent bobbing up and down on the ocean meant that multiple knockdowns, a bout of food poisoning and a critical episode of gear failure didn’t faze him at all during his voyage. But the prospect of having to give himself a shot of morphine was another matter entirely.

David Dicks with his young children.

A nine-month circumnavigation of the globe in the family yacht was just “more of the same” for David Dicks OAM. David was only 17 years old when he set off from Fremantle in February 1996. When he sailed home nine months later he became the youngest person to sail solo non-stop around the world.

A life aquatic began aboard the 34-foot sloop, Seaflight, which belonged to Dr Harold Dicks, David’s father.

“It was my dad’s boat that I took on the circumnavigation. He was a well-known Como GP and a keen sailor. Sadly, he died from a heart attack when I was only nine. Jon Sanders [a renowned WA solo-yachtsman who famously became the first person to circumnavigate the globe three times] took me under his wing. We did a lot of sailing together and he inspired me to have a go at breaking the record.”

14 | NOVEMBER 2015

“If I’d been facing the prospect of having to stitch myself up I would’ve been reaching for the butterfly clips first. I hate needles! Peter James, a GP who took over my dad’s patients when he died, gave me some advice on what to do if I knocked out a tooth or broke my leg.

But the worst that happened was that I got pretty sick early in the trip after eating some dodgy peanut butter and later on some bad tinned pineapple.”

“Actually, in the early days I suffered from seasickness quite badly and I remember a trip on the Leeuwin when I was 15 that turned out to be very unpleasant. It was a different sort of motion, a lot of slow rolling from side-to-side and I was very sick.”

a helicopter and I could’ve asked for fresh supplies at the same time but I didn’t.”

Shock of dry land “It was so nice being out there and, thankfully, even though I was pretty young I did appreciate it at the time. But it was a bit of a culture shock coming back to the rat-race.

Everyone wanted a piece of me and for a while it was like get me out of here!”

“I did some public speaking which gave me a bit of an income but after I while I shied away from all the media stuff. At one stage I had a gung-ho media-manager from Sydney and it was all pretty intense. I had one day with him doing the PR thing and that was more than enough!”

David is now 33, married with two young children and works as a helicopter pilot. The yacht is still in the family and he’s itching to get back on the boat.

“I don’t go sailing all that often now, I’m so busy with flying and family duties. I’ve just cracked 1000 hours on the chopper and my ultimate dream is to work in Search and Rescue. Learning to sail is a wonderful life skill and I hope to teach my kids how to sail. The family yacht will also help to keep them away from a computer screen for a while.”

By Mr Peter McClelland

An episode off the Falkland Islands put paid to one record the young David Dicks had had in his sights.

“I was a little disappointed that I couldn’t claim an unassisted circumnavigation due to a broken rigging bolt near the Falkland Islands.

They winched a replacement down from

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NOVEMBER 2015 | 15

Feature

Politics and Organ Donation Raising the organ donor rates is hard work. A political stoush and an unreleased government review has made it that much harder. the something like 40-50 potential donors who weren’t on the register, 50% became donors.”

In May, there was a mighty kerfuffle over organ donation rates that had the then Assistant Health Minister Fiona Nash calling for an independent review into the Organ and Tissue Authority’s (OTA) donation and transplantation program.

“These families all knew what their relatives wanted and went along with their wishes. But we can’t ever forget that families are making these decisions at a dreadful time and if they don’t have a clear idea of what their family member wanted, their default is usually no.”

It led to the resignation of media personality David Koch as chair of OTA’s advisory panel and a spray on national television with a few choice words directed at Ms Nash regarding the strength of her backbone to withstand pressure from what he described as a “rich lobby group” – that being ShareLife – “who basically want to take control of the reforms and take control of the money,” he said.

Since then the Federal Government has been mired in political turmoil. We have a new Prime Minister, a new Assistant Health Minister and a review (conducted by Ernst & Young) which has fallen off the radar. Our inquiries to the Department of Health elicited an eloquent fourword response: “still to be released”. OTA is, understandably, anxious to hear its findings.

“We need a culture change where that default position becomes yes.”

Making last wishes known However, Bruce said Donate Life’s first priority was to realise people’s wishes around organ donation, whether they be strongly for or strongly against.

Donate Life WA Medical Director Dr Bruce Powell

misinformation disseminated by the Minister’s office still rankled.

Getting the facts right

“When you work in Government and use public money, scrutiny is expected and welcome. However, at the time, Fiona Nash’s statement claimed that families of 37% of patients registered on the organ donation register (ODR) had refused consent. That is incorrect and has been acknowledged by Fiona Nash’s office as incorrect though the correction was not reported,” he said.

Medical Forum spoke to the WA medical director of Donate Life, Dr Bruce Powell, after the ruckus had died down but the

“In WA that number is about 5%. In 2013, there were 21 potential donors who were on the register, 19 of whom became donors. Of

It could be a case of quietly forgetting about a chapter that was less than edifying but as public money is at stake that wouldn’t be right given Ms Nash’s criticism of poor returns on considerable public investment in OTA (about $240m since 2008) is at the heart of the review.

“The essential thing is to make those wishes known. We never want to retrieve an organ from someone who doesn’t want to be a donor, neither do we want to miss an opportunity to retrieve from someone who does.”

“It’s about realising someone’s wishes and while we are aware of how desperately recipients need organs, they are not on our minds when we speak to families about donation. If that yields very few numbers because that’s what people in WA feel about donation, then so be it. So often we hear ‘patient centred care’ trotted out by agencies but you know what, that’s the creed we believe in.”

Roles for regional hospitals He said that retrieval was not tertiary work and Donate Life WA was investing heavily in secondary and regional hospitals to be ready to undertake them.

“If you happen to be in a hospital that doesn’t do organ collection but your family knows you want to be a donor, we can make that happen.”

“We were asked to attend Armadale hospital recently because the donor’s family understandably did not wish them to be moved to another hospital, so Armadale did its first retrieval. It was challenging, but it happened. It’s perfectly reasonable for any hospital with an ICU or critical care area to do retrieval. It removes a layer of trauma in an already traumatic situation that realises a patient’s wishes to be a donor.”

So why is the donor rate in Australia low in comparison to other countries?

Everyone has an opinion. ShareLife says on its website we are missing out because hospitals are not identifying potential donors and calls on the implementation of Global Leading Practice to be followed. It says OTA, which was charged in 2008 to reform donation

continued on Page 19

16 | NOVEMBER 2015

MEDICAL FORUM

Feature

Do Human Rights Have a Use By Date?

Is aged care in Australia steeped in ageism? Some doctors thinks so while others say the solution is always in front ont of you – the patient.

Physician and writer Dr Karen Hitchcock put the cat among the pigeons in her controversial article, Dear Life: On Caring for the Elderly in a recent issue of Quarterly Essay. The central thrust of her argument is that contemporary society is steeped in ‘ageism’. She suggests that the elderly are now often seen as a burden – “difficult, hopeless and homogeneous” – yet all of us would do well to remember that “they are our parents and grandparents, our carers and neighbours, and they are every one of us in the not-toodistant future.”

There are many who Nonetheless, Kathleen would agree with supports the central premise Hitchcock’s ageism of Dear Life and is also argument. Even a concerned with the increasing cursory glance at Dr Kathleen Potter use of other forms of commercial television mathematical modelling. and social media would suggest that there’s more than enough of it to “I think what Karen is trying to say is that’s it go around. Nonetheless, when she states that important to treat people as individuals. You “sometimes limits are placed on care that suits can’t just put in sweeping processes and the system rather than the person” a quick protocols based upon the latest algorithms. riposte from some commentators might go The latter is an increasing trend in medicine along the lines of well, that’s life… it happens and its dumbing things down. Next step, it’s all the time! the robots!”

Social justice and fairness “Human beings are far too complex to be There’s one medico, with extensive experience reduced to a simplistic equation.” in aged care and its use of medications, Elderly fight for treatment who doesn’t completely agree with Karen’s argument. Dr Kathleen Potter recently A case recently came to the attention of completed a research trial in the frail elderly Medical Forum that underscores the innate based in Dongara and Geraldton. complexity when it comes to serious decisionmaking in relation to the elderly.

“I don’t, in a broad sense, buy Karen’s argument regarding ageism because it’s It involves an elderly man, with mild cognitive actually reversed in some ways. There’s impairment residing in an aged-care facility. no disputing that the very elderly are a He developed acute pneumonia, was sent to highly vulnerable group but a lot of people hospital, treated and returned to the nursing in their 60s, the ‘baby-boomers’, are a home. His condition worsened and his GP powerful demographic. Many of them have (who wishes to remain anonymous) wanted accumulated a great deal of wealth and to send him back to the ED for admission and political power while those in the younger age further supportive treatment but that transfer bracket are struggling to get a foot in the door was blocked because he was said to be ‘not of the housing market.” for resuscitation’ and his care described as ‘palliative’.

“It’s a social justice issue and the concept of a fair redistribution needs to be addressed.

The GP told us: “They cited an Advanced Specifically, the best use of health resources Health Directive (AHD) that stated that the man and hard questions need to be asked about ‘declined intervention’. I’ve known this person the balance between giving a 90-year-old a for the best part of a decade, he doesn’t have valve replacement and child immunisation.” a terminal illness and he is ambulant and able to do many things for himself. He would have “Ultimately, it comes down to a financial difficulty understanding the complex nature equation.”

MEDICAL FORUM

of an AHD and it turns out that the form was signed on his behalf some years ago by a relative who wasn’t ‘next of kin’.”

“I’m really concerned that ‘Not for CPR’ on an AHD is being misinterpreted as ‘Not for Any Active Treatment’. I’m equally worried that ACDs, which essentially become a death warrant, are being signed by people with reduced capacity or by family members without proper legal authority.”

“Older people do get sick and they do need hospital treatment. They shouldn’t have to fight for it.”

Changing attitudes The satirical novel, The House of God and its elderly ‘GOMERS’ – Get Out of My Emergency Room’ has a contemporary equivalent, says Kathleen in our very own ‘Crumbles’, ‘Bed Blockers’ and ‘Granny Dumps’.

“That was our attitude as junior doctors, those terms were bandied about and I think Karen Hitchcock is right that the elderly are sometimes seen as a different species. It’s a difficult area because, while writers such as Karen and US surgeon Atul Gawende in Being Mortal argue that the elderly should have more autonomy leading to a ‘good end’, it’s impossible to accommodate everyone’s requirements.”

“We institutionalise the elderly because it’s cost-effective.”

“There’s room for improvement and it is one part of medicine we’re not doing particularly well. Maybe we see death as a failure of treatment rather than something that’s inevitable?”

By Mr Peter McClelland

NOVEMBER 2015 | 17

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MEDICAL FORUM

Feature

In It Together Until the End End-of-Life planning is perhaps the most important conversation in the life of a patient and a doctor but it needs to have support from the entire health system.

On the previous page there is the case study of a relatively healthy elderly man being rushed to hospital from his aged care facility with pneumonia. His Advanced Health Directive (AHD) stipulated no resuscitation and medical staff in the hospital took that to mean no treatment.

This next chapter of the palliative care story in WA explores some different stories that amount to a concerted effort by those working in the area to improve the inconsistent approach to end-of-life of life care delivery and ameliorate the disconnection between the primary and tertiary sectors so the patient (and their family) is not stranded in a no man’s land.

A recent report from the Australian Institute of Health and Welfare (AIHW) indicates that palliative care-related hospitalisations have risen by over 50% in the past decade with almost 62,000 palliative care hospitalisations in 2012-13.

Contributing to this increase were the changing patterns of disease, particularly the rising prevalence of chronic illnesses.

Unsurprisingly those over 75 years accounted for just over half of all palliative care hospitalisations while 10% were aged under 55 years; 56% of hospitalisations were for patients with cancer.

Governments show commitment Both state and federal governments appear committed to reshaping how people with a terminal illness are treated in the health system. In May, the Federal Government funded a raft of palliative care projects to the tune of $52m, many were in the area of education and training for the health workforce followed by support programs for the dying and their carers, and public awareness campaigns on end-of-life choices.

WA Health earlier this year used one of its

regular clinical senate debates to canvas the issue of planning for expected deaths in a clinical setting. A month before the debate, it sponsored a consumer focus group of 11 people (eight carers/consumers and three staff from the WA Cancer and Palliative Care Network (WACPCN) so the senate would be informed by real experiences retold by those who had lived them.

It was also empirically relevant. The Acting Director General, Professor Bryant Stokes, told the audience at the debate that “more than any other time in our history, most people die when they reach an advanced age and are more likely than past generations to know when they are going to die. Hence the opportunity for planning arises. Despite the fact that the majority of Australians (68%) want to die at home most die in hospital (50%) or residential care (15%).” continued on Page 20

continued from Page 16

Politics and Organ Donation practice along these lines, has failed because of an “inconsistent and incomplete approach” across the country.

There have been calls for an opt-out system, payment incentives (to cover funeral costs, for example), a refocusing on retrieval from cardiocirculatory death to brain death, even giving a registered donor some preferential treatment if they need a transplant. There is no consensus (or evidence) that these work.

Community must decide Bruce contends that improving the donor rates is a community issue.

“Spain is often held up as the ideal, (It has on average 33.1 deceased donors per million people while Australia has 19), why? Here people are still asking ‘do people take my organs when I’m not dead’ or ‘will you take my organs against my wishes?’, when you hear those questions it says we have a way to go

MEDICAL FORUM

to convince people that we’re a safe pair of hands, that we can be trusted.”

“The Spanish don’t ask those questions.

They have a culture that has developed over a period of time – it didn’t happen overnight – that gives them faith that when they see someone with the Donate Life badge on their uniform that person can be trusted to carry out the wishes of the donor.”

“This is a complex issue and OTA has worked hard to establish Donate Life’s work on legal, administrative and ethical grounds.

There’s been a lot of investment in getting the framework right. It’s not just about me going into a hospital and talking to families.

OTA welcomes scrutiny but it is complex work and when it is politicised as it has been, that makes it harder.”

“The community is our only source of organs and the worse part of these controversies is

that it damages people’s confidence in the whole system. To increase the number of donors and save more lives we must work to realise community wishes. We also need to be prepared to put everything on the table and tell the community that all health is a compromise.”

“What compromise is the community prepared to accept to increase the number of organ donations?”

By Ms Jan Hallam

WA Figures så )Nå åTHEREåWEREå åLIVEåDONORS så )Nå åTHEREåWASåAåRECORDåHIGHåOFå så 4HEREåISåNOåLIMITåTOåGOVERNMENTå funding for donor activity

NOVEMBER 2015 | 19

Feature continued from Page 19

In It Together Until the End Having ‘the conversation’ can no longer be left to the last minute.

Shaping the conversation So the focus of the group discussion was communication; how WA hospitals managed and treated patients and family at end-oflife, from diagnosis or decline to before the terminal care phase. Discussion was shaped by questions such as: sĂĽ 7HATĂĽISĂĽYOURĂĽDElNITIONĂĽOFĂĽAĂĽGOODĂĽDEATH sĂĽ 7HATĂĽINFORMATIONĂĽANDĂĽCONVERSATIONSĂĽWOULDĂĽ have been useful? sĂĽ 7ASĂĽTHEĂĽINFORMATIONĂĽAPPROPRIATE ĂĽTIMELY ĂĽ and respectful?

These frank questions to people living through these tough times produced equally frank and searing answers.

Communication breakdown A consistent narrative was the lack of communication with family when a patient found themselves in emergency and a lack of understanding or knowledge of the patient’s wishes.

“We recognised early on that if you don’t get all the different elements in place, the weak links will cause it to fall over,� Bill said.

Here are his and RPC’s four golden rules for a health service intending to introduce advanced care planning. Ensure that: sü 4HEü#%/üANDüTHEüEXECUTIVEüAREüONüBOARDü so they send a clear message to other executive staff and the ranks that advanced care planning and improving end-of-life care is a commitment. sü 4HERE SüADEQUATEüFUNDING ü5NLESSüIT Sü funded, nothing really works in health care. To improve end-of-life care planning you have to have staff who are paid and trained to do it, or who are rostered to put aside time to do it. There needs to be an education program for doctors and nurses so they know how and when to have a conversation with a patient and their family.

Without that conversation, advanced care planning won’t occur.

Respecting Patient Choices Dr Bill Silvester, director of Respecting Patient Choices (RPC) based at Austin Hospital in Melbourne, has travelled the country for the best part of a decade facilitating training for health professionals in end-of-life care.

The group has also been part of the Federal Government’s current training roll out where it has been funded to conduct advanced care training for 9000 nurses and 5000 GPs nationally.

RPC’s success is not rocket science but it is something our health system struggles with – a whole-of-system approach.

20 | NOVEMBER 2015

“The GP signed her onto palliative care and we were very happy about that, then the consultant said ‘it’s far too early, sign her offâ€? and hung up.â€? “Once we got to specialist palliative care, it was generally good, but the lead up to it in terms of end-of-life care, we felt we were ďŹ ghting.â€?

Then there were the persistent problems of communication: “Communication is so important. People are emotional and they may fail to understand the information. People (health professionals) can’t just blurt out the information. It needs to be a two-way conversation as the patient or family may not understand. I want health professionals to explain to patients and families, and then check they understand.� “The palliative care teams were good, the hospital consultants were not. It seemed that doctors were the best ones to give advice, but they were never there to give you the information.�

Research is revealing that AHDs are not properly understood by the medical profession.

There also have been calls for a national approach to standardise the law and documentation for end-of-life care as the needs of the growing ageing population will only exacerbate the cracks that already exist in the system.

Responses included: “Palliative care is associated with cancer, but palliative care is also to do with all lifelimiting illnesses. Many don’t understand that.� (Another added her impression that few health professionals felt comfortable talking to dementia patients and their carers about these issues.)

Dying is a human experience

One carer reected on how poorly she had registered her loved one’s AHD simply because she didn’t know what to do: “I should have given the AHD to all teams [health services they were accessing]. I might have been told [to do this], but I didn’t register it.

I should have known how better to spread information...The Nurse felt distressed about the decision of not wanting to go to hospital.

They need to listen to patients’ wants and for the patient to know how to communicate it.�

Researchers from the Australian Centre for Health Law Research at Queensland University of Technology said a major challenge was convincing doctors it was “worth the effort� to learn the complex law around end-of-life care, which differs between jurisdictions. They suggest training should begin at medical school and continue through internship and traineeship.

their experience there was a lack of general palliative care knowledge in both patients and health professionals. This included a lack of understanding what palliative care encompassed and when it was appropriate.

“Human determination and how [an individual] accepts their own pending death needs to be considered within palliative care‌it’s not just a medical experience‌it’s a human experience.â€?

Death is not a failure sĂĽ 4HEĂĽMEDICALĂĽRECORDĂĽSYSTEMĂĽISĂĽEFlCIENTĂĽANDĂĽ up to date, so when someone does an advance care plan it gets ďŹ led properly in the medical records and everyone knows where to look for it when urgent decisions need to be made in the middle of the night. sĂĽ 4HEĂĽPUBLICĂĽISĂĽEDUCATEDĂĽANDĂĽAWAREĂĽTHATĂĽ they can go to their GPs and asked for an advanced care plan.â€? “Advanced care planning should not be an optional extra, it is the right of every patient. It empowers the patient because they know their wishes will be respected and it then means they can concentrate on living as long as possible,â€? he said Building conďŹ dence Despite all the effort, it seems WA has a way to go before patients can feel this conďŹ dent and health professionals feel equipped to deliver this type of care. The consumer focus group reported to the clinical senate that patient-centred care was not always present with progressive life-limiting illness and from

Consumers and carers in the focus group repeatedly raised this theme, revealing a gap in health professional training on how to approach these sensitive issues, particularly when progressive life-limiting illness is present.

The report acknowledged that having the conversation with a patient and their family about death is one of the hardest conversations to have as a health professional, but it is essential and it seems it’s not happening early enough for consumers.

The consumer focus group insightfully concluded that many parts of the health system see death as failure. “A culture shift from this attitude is only possible through small incremental change, and raising awareness of palliative care may be the ďŹ rst step in addressing this cultural attitude. It’s a failure of the system, not individuals.â€?

By Ms Jan Hallam

MEDICAL FORUM

Feature

The Statin Story Revisited Two years ago the ABC Catalyst program aired its controversial two-part series of statins. So what was that really all about?

With 2.1m Australians taking statins in 2011-12, and three statins in the ‘top 10’ of dispensed drugs in 2010 at a PBS cost of $1.25b that year, there were many market forces at play when the ABC ran its two part series the Heart of the Matter – Cholesterol Drug Wars in October 2013. These programs suggested, amongst other things, that statins were overprescribed. After considerable protests, the ABC’s independent Audience and Consumer Affairs Unit acknowledged contrasting expert opinions but supported the accuracy of reporting, while accepting that Part 2 was not impartial. With some water under the bridge, we have got out our retrospectoscope.

Where does the NPS sit?

In June 2013, the NPS’s Australian Prescriber published an article, Statins in Older Adults, in which it said use of statins in people over age 65 was high (reportedly 40%), and: så #63åRISKåFROMåCHOLESTEROLåDECREASESåWITHå age (and inversely relates to stroke risk). så &ORåTHOSEåAGEDå åWITHåCORONARYåARTERYå disease, you need to treat 28 people for five years to save one life. så 0RIMARYåPREVENTIONåWITHåSTATINSåFORå#63å disease in older people is uncertain. Any benefit accrues over five years – no better than placebo in the first year - so the person’s lifespan is important. så 3TATINSåINåPEOPLEåWITHå#63åDISEASEå probably decrease recurrent ischaemic stroke but increase haemorrhagic stroke. så 3TATINSåDOåNOTåHELPåPEOPLEåWITHåDEMENTIAå and withdrawal in Alzheimer’s patients improves cognitive function.

They pointed to dose effects – 80% of lipid lowering effect occurs at half the maximal recommended dose. The risk of adverse effects of muscle symptoms over age 70 increases as does diabetes risk especially at higher doses.

In summary, the article said increased side effects and co-morbidities make statins a line-ball treatment in the elderly, particularly as circumstances change and frailty increases.

In response to following letters, the authors pointed out that most of their conclusions applied to fit elderly people as those with increased frailty were often excluded through co-morbidity, co-medication or impaired physical or cognitive function.

Three months after Catalyst, the NPS consumer online publication Medicine Wise under the heading Keep Taking Your Statins Benefits Outweigh Risks, said that consumers should ignore mainstream media reports that statins were overprescribed and only act if their doctor advised against statins. That is, if the alleged overprescriber suggests you continue with the drug, follow this advice!

MEDICAL FORUM

We could find nothing more on statin prescribing since from the NPS, which has a clear consumer focus.

On December 11 2013 the Heart Foundation waded in with an online publication of its survey of 1094 Australians who had been taking statins for at least three months. About 25% had seen their GP or health professional to discuss use of statins. About 22% had reduced their medication adherence, whether temporarily, and about 5% had done this with a history of a pervious heart event. A reported 9% had stopped statins since watching, reading or hearing about the show.

The CEO’s concern was around the 5% who might be at risk of another heart attack or stroke and might not survive. Then followed statements like “statins are life-saving” and “high risk patients who’ve stopped their medication”, concluding there are “potentially 55,000 Australians who have stopped their medication as a direct result of the catalyst programs”.

Not to let the facts get in way of a good story, Cathy O’Leary at The West Australian wrote the same day that 55,000 had stopped their statins, which could cause 2000 heart attacks and strokes. A noticeable point in the piece was that half had not consulted their GP when stopping their medication.

Why would they if they thought their GP was needlessly prescribing statins in the first place? Food for thought?

124 GPs gave us their opinion in early 2014

e-Poll

Do you believe statins are overprescribed in the elderly?

Yes No Uncertain

54% 22% 24%

Which of these online sources would you recommend as balanced independent advice for health consumers on the need for statin use [multiple choice]?

National Prescribing Service RACGP AMA Wikipedia Google scholar Other:

39% 28% 17% 4% 4% 9%

And what of lifestyle factors? In the Heart Foundation survey, 41% of respondents were obese, and 22% were smokers but 27% had increased exercise and 24% had changed their diet since the program. More food for thought?

Peter Kort’s story Peter Kort is a 66 year-old male, with high cholesterol and Type II Diabetes. His doctor prescribed Lipitor three years ago and the side-effects weren’t pleasant. Peter had also heard that statins weren’t too good for ‘Mr Wriggly’ and he wasn’t happy about that either. And he was also distinctly unimpressed with the lack of informed advice coming from his doctors.

“I didn’t know what was happening. I had constant pain in my legs, I was always tired and just couldn’t get comfortable in bed.

My haematologist, GP and the doctor I go to for testosterone injections didn’t say anything about statins, even when I told them about the problems I was having.”

“The doctor I see for my sexual health told me that it ‘wasn’t his area’ and his main concern was to make sure that Mr Wriggly stays alive.”

“I went to Europe for a holiday and when I told my mother-in-law how I was feeling she said, ‘it’s probably the statins’. I went on to Google and stopped taking Lipitor immediately. I told my GP when I came back to Perth, he sent me for a cholesterol test and he hasn’t got back to me so everything must be okay.”

“I’m on Metformin now and feeling a lot better. I don’t need to go for a ‘nanna-nap’ these days!”

NOVEMBER 2015 | 21

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We offer so much more than insurance and are committed to providing the highest quality personal service, support and advice.

I’m proud of our team across Australia who are here for you 24/7. ”

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To find out why, visit our website or call us on 1800 777 156 miga@miga.com.au www.miga.com.au Insurance policies available through miga are underwritten by Medical Insurance Australia Pty Ltd (AFSL 255906). Membership services are provided

by Medical Defence Association of South Australia Ltd. Before you make any decisions about any of our policies, please read our Product Disclosure Statement and Policy Wording and consider if it is appropriate for you. Call miga for a copy or visit our website. ©miga April 2015

22 | NOVEMBER 2015

MEDICAL FORUM

Medical Marketplace

Guidelines and Standards – What Purpose?

Without transparency and accountability, guidelines and standards become weakened and just a series of empty words.

In our July edition, in an article examining the governance of AGPAL (How Transparent is AGPAL?), we pointed to the potential conflict of interest for longstanding AGPAL board chair Dr Richard Choong and AGPAL’s implied endorsement of Health Engine through an AGPAL Partnership. We wanted the AGPAL CEO Stephen Clark to outline how his organisation dealt with potential conflicts of interest, amongst other things. He declined to comment.

Not deterred and seeking greater transparency, we approached each of the eight governing organisations listed on AGPAL’s website. The response from five organisations was primarily ‘no comment’.

We asked ISQua CEO Peter Carter to indicate if the transparency and accountability standards of AGPAL were worthy of ISQua endorsement.

He referred us to generalities in the accreditation documentation. QIP standards (owned by AGPAL) were re-accredited by ISQua this year.

When we last looked, Gary Smith on the AGPAL Board was an ISQua surveyor and Stephen Clark, CEO of AGPAL, was listed as an ISQua expert. So the two organisations have multiple links.

AGPAL CEO Stephen Clark appeared for the first time on the AGPAL website after we asked questions of ISQua.

We learnt that Dr Choong was an AMA nominee, that the National Association of Medical Deputising Services had ceased involvement with AGPAL four years earlier, and the representative for RDA endorsed Health Engine without looking at how she was (incorrectly) profiled by that provider.

We believe that standards and guidelines account for much more when they are accompanied by full transparency and accountability, especially for organisations like AGPAL that are entrusted with applying the RACGP’s accreditation standards to general practices and, in doing this, it says it places importance on its own transparency.

Representatives of the Australian Association of Practice Managers and Australian Primary Health Care Nurses Association occupy board positions and both organisations have partnership arrangements with AGPAL, which is a potential conflict that must be managed.

In our dealings with General Practices, it appears that the incentive payments from government that are dependent on successful accreditation are a major motivating factor for practice principals. But we are hearing more that practices feel the increasing red tape of accreditation and the costs of compliance make the financial benefits received ‘a line-ball’.

There are still no financials on the AGPAL website to reassure the 81% of GPs we surveyed (August edition) who considered it important that GPs were informed of how the accreditation fees AGPAL collected were spent. We could find no reference to this matter on the AGPAL website.

We have been told AGPAL spends 1,100 Euro a year as an institutional member of an Irish accrediting body ISQua. This body accredited AGPAL in 2013 for four years, including its governance and its application of accreditation standards.

Accreditation is ingrained in the psyche of most practice managers and GPs as a compulsory three-year cycle. The big question is do practice staff enjoy and welcome this yardstick of performance?

By Dr Rob McEvoy

Ethics by the book The NHMRC has recently released a Clinical Ethics Capacity Building Resource Manual to help organisations plan, develop and implement a clinical ethics service. It is user-friendly and takes a step-by-step approach so the development is inclusive and appropriate for each organisation.

It makes the interesting point that every decision in healthcare reflects values and principles and most of the time the values of patients, doctors, nurses, managers and others align. At other times, values conflict and that’s where doing it by the book can diffuse a lot of potential crises.

Whether or not there is conflict, ethically sound clinical practices and organisational cultures contribute to the overall quality of health systems, it writes. You can find a copy at www.nhmrc.gov.au/guidelines-publications/e114

Blurry picture of booze In a previous Christmas edition we pointed to a report that moderate alcohol was good for the heart. The same scientific forum has modified its stance on the risk of developing Type II diabetes mellitus, no longer saying it is reduced about 30% among moderate drinkers – they now think this inverse relationship only applies to women.

Apparently the meta-analysis allowed in too many studies of Asian men who have very different genetics to non-Asian men and polyphenols in wine (vs beer) and binge (vs regular) drinking may also have an influence.

It pointed to potential errors in trying to provide global guidelines across different populations.

MEDICAL FORUM

Opening 38 more private mental health beds to support the Perth community Marian Centre is an established private mental health hospital in Subiaco. We are proud to have played a significant role in helping Western Australians suffering with mental illnesses since 2006.

Now owned by Healthe Care Australia, we have undergone significant redevelopment works, boosting inpatient beds from 31 to 52, soon to be 69.

Immediate admissions are now available. For direct access to our experienced Admissions and Assessment Mental Health Nurse, please call 1800 540 388.

A 187 Cambridge St, Wembley WA 6014 Admissions and Assessment 1800 540 388 P 08 9380 4999 F 08 9338 3179 E mrn.reception@healthecare.com.au mariancentre.com.au

NOVEMBER 2015 | 23

24 | NOVEMBER 2015

MEDICAL FORUM

Guest Column

Living the High Life As We Age? How will the elderly be living in the future? Mr Jacob Hollenberg is working on some ideas for aged care provider Bethanie that reach for the sky.

With aged care undergoing significant changes and with more to come, aged care providers are considering how the future will look in terms of their built-form accommodation offering. From being a heavily regulated industry, aged care is heading towards a new era of deregulation while at the same time being urged by Government towards the concept of “ageing in place”.

Consumer Directed Care (CDC) has already changed the operation of Community Care Packages, where the care recipient effectively has control over their aged care support at home. It is only a matter of time until the CDC model makes its way into traditional aged care settings.

The impact of dementia and its specific care requirements is fast becoming a major design issue for new developments as is the advanced age of many people entering aged care facilities (ACF) because they are generally staying at home longer.

We also know that the future care recipients will have different expectations for their aged care experience. Baby Boomers are considered to possess a different value set from the preceding generation and will have higher expectations of and desires for their care.

They appreciate modern design and value accommodation that looks and feels like home. They expect personalised service that satisfies both their needs and wants at an affordable price, though some may be willing or able to pay a premium for it. They like the idea of ageing in place and would prefer to stay in their own home and be supported to live independently for as long as possible. Or if they are to move, they want a facility that somehow satisfies all of the above.

So what does this all mean for the future built form of aged care?

There are many interstate and international examples of care providers who are changing their thinking about aged care design. These forms of accommodation maintain a feeling of independence but also offer the security and peace of mind that comes with the availability of both clinical and hospitality support services. However, the WA market is limited in its experience of these models.

Designers must balance the desire of consumers to live in a place that feels like home, that embraces modern design while unobtrusively incorporating all of the functional requirements of in-home support services.

Affordability is another major concern across the housing market in Perth with many providers offering supported living models, but by virtue of their operational costs are prohibitive to the many. Despite the stereotype of Baby Boomers being the generation of wealth, many who will need care are unlikely to have valuable properties nor be able to afford to buy into one of these, mostly premium, new developments. Accessing appropriate aged care accommodation in the future may be a luxury available to the wealthy or those who can sell the family home to pay for the service.

Designers must balance the desire of consumers to live in a place that feels like home, that embraces modern design while unobtrusively incorporating all of the functional requirements of in-home support services.

implications of making an apartment or house function in terms of access, door widths, circulation and equipment such as wheelchairs, walking frames, gophers and hoists.

Then aged care providers must find an affordable way to deliver the necessary support services to facilitate ageing in place.

This gradual transition may eventually change what a licenced aged care bed looks like as the industry starts to design offerings that appeal to the consumer market.

Will supported-living apartments move to become a licenced care bed? Will we see the commercial housing sector develop agespecific housing designed for supported living or even eventually a future licenced care bed?

How will the average citizen afford the cost of support services either in their own home or in aged care accommodation at the time of their greatest need?

Broadly speaking the success of an aged care facility comes down to two key factors – the ability of the provider to deliver a quality care service and the ability of designers to create a built-form environment which satisfies the needs and wants of the the care recipient.

The challenge is striking the balance between designing accommodation that meets changing expectations of future care, deals with the increase in dementia-specific needs, fits the aged care funding framework and all the while maintaining a range of affordable options for universal access.

ED: Jacob is development coordinator at aged care provider Bethanie. He is a qualified town planner who has been involved in the planning and management of $250m of construction projects which will roll out in the next 10 years.

Adaptable housing standards are a good place to start in understanding the design

Missing but in action In last month’s magazine we surveyed the activities of hospitals in the South Metropolitan Health Service and inadvertently missed out the Ramsay-administered Peel Health Campus. So apologies to those doctors in the region, here’s what your hospital’s priorities are:

General medical: Acute medicine (inpatients and outpatients), renal (including onsite dialysis), rehabilitation (including general and orthogeriatric and outpatient day therapy), palliative care

Peel Health Campus (128 beds)

Women, children and neonatal: Maternity including specialist clinics and antenatal, neonatal, gynaecology (emergency and elective), paediatric

Cancer and haematology: Medical oncology, outpatient clinics, breast assessment, haematology Elective surgery: General (including some emergency surgery), orthopaedic, ENT including paediatric, urology, ophthalmology, gynaecology

MEDICAL FORUM

Emergency: Serving the Peel region

Heart and lung: Cardiology outpatient consulting, respiratory outpatient consulting.

Outpatients: A broad range of outpatient clinics from visiting medical practitioners

NOVEMBER 2015 | 25

Guest Column

Alzheimer’s Future Research We need medical and treatment breakthroughs for Alzheimer’s if we are to cope with the future demand, says Dr Judy Edwards CEO of the McCusker Foundation.

Currently 342,800 Australians are affected by dementia and Alzheimer’s disease and this is now the second leading cause of death in Australia. Around 1800 new cases are diagnosed each week with these figures set to rise as the population ages.

While the impact on affected individuals and their families is huge, there is also a significant cost to the community. The aggregated cost of medical, social and informal care in Australia in 2015 is estimated to be $US14b. Unfortunately to date there is no cure and few effective treatments. Research is therefore important to understand the disease and uncover treatments and preventative measures to lessen its impact.

The cause(s) of Alzheimer’s disease in most people is yet to be fully uncovered. In the rare early-onset form of Alzheimer’s, a genetic mutation is usually the cause. Late-onset Alzheimer’s is characterised by a complex series of brain changes that occur over decades. These changes are most likely underpinned by a combination of genetic, environmental, and lifestyle factors: the importance of any one of these factors may differ from person to person.

Advances in brain imaging techniques

allow researchers to see the development, accumulation and spread of abnormal amyloid protein, a hallmark of Alzheimer’s disease, as well as changes in brain structure. We now know that Alzheimer’s pathology begins to accumulate in the brain decades before symptoms actually appear, and these changes are being explored along with CSF and blood biomarkers. These findings will help to understand the causes of Alzheimer’s and make diagnosis easier and more accurate.

While Alzheimer’s disease research increasingly focuses on addressing the underlying disease processes, clinical trials remain essential to enable more effective management and treatment.

One potentially promising clinical trial, the preliminary findings of which were presented at the Alzheimer’s Association International Conference (AAIC) in July, utilises Aducanumab (Biogen) in prodromal or mild Alzheimer’s disease.

Aducanumab (BIIB037) is a monoclonal antibody targeting aggregated forms of amyloid beta protein in the brain. The results marked the first time an investigational drug for Alzheimer’s demonstrated a statistically significant reduction in brain amyloid plaque

burden as well as a slowing of clinical impairment in patients with prodromal or mild disease.

These promising early results need to be expanded and replicated in larger populations, and it is anticipated that Perth research sites will be involved in this expansion.

Non-drug therapies There is growing evidence that lifestyle choices such as staying mentally and physically active, eating a heart-healthy diet and staying socially engaged can slow cognitive decline as people age. Research also suggests that reducing heart health risk factors, such as high blood pressure and high cholesterol, may reduce dementia risk, and possibly even slow down the progression of cognitive decline in vascular cognitive impairment.

The high socioeconomic cost of Alzheimer’s and dementia is poised to place considerable burden on society in the coming decades.

If we are to ameliorate the effects of these devastating conditions, it is essential that research into factors which help to prevent or delay onset as well as treatment strategies is pursued.

References on request

Home Hospital Stretches its Wings Dr Daryl Kroschel headed west in July with his young family to become Silver Chain’s first full-time director of its Home Hospital service. As Deputy Director of one of the country’s most successful Hospital in the Home (HITH) services, Cabrini Health in Victoria, he’s been able to hit the ground running.

However, Silver Chain’s large government remit and the area covered makes the challenge a unique and exciting one.

“There are a lot of services being delivered in hospital that should be delivered in the community – estimates put the figure at around 20% of people who don’t need to be there so our mandate is to try and treat those people in the community from the outset.

Hospitals will more and more become the preserve for people who are acutely sick, so we are there to facilitate early discharge for those who can be accommodated in the community.”

From a governance perspective, Daryl said HH had worked hard to establish a sound structure with a medical, safety and quality committee that had policy and protocol oversight.

“The extent of the service here in WA makes Silver Chain’s Home Hospital (HH) unique in as far as it’s system-wide approach.

For a large part, this role is liaising with the hospitals to make the interface as smooth and as consistent as possible,” he said.

“Medical governance and ensuring patient safety is paramount and we have processes in place, especially around the deteriorating patient and particularly in the clinical handover.

We know this is an area of high risk for any health service but particularly when there are multiple services involved,” Daryl said.

The call on services such as Home Hospital will only grow in the future and Daryl told Medical Forum that Silver Chain held a contract with the State Government in terms of bed days.

There is also a representative body from various specialist disciplines including infectious diseases, respiratory, emergency, geriatrics, haematology giving input.

26 | NOVEMBER 2015

From an operations perspective, Daryl

said the HH was trying to grow its own medical workforce, which saw the recent announcement that Silver Chain would be offering an expanded Community Residency Program in 2016 for 60 junior doctors with 12 RMO positions over five rotations.

It’s a boost for all concerned – it offers junior doctors a foundation of community care which will reverberate throughout their career and the health system and it will give Silver Chain a flexible and expanded workforce across its hospice and Home Hospital services.

Daryl says GPs and nurse practitioners (NPs) remain essential ingredients but there is a move towards salaried staff rather than calling on those in private practice.

“The arrival of the RMOs will give us vertical integration in terms of structure so we will be able to define the key roles around GPs and NPs and have greater opportunity to get out and see more patients in their homes.”

“It’s been really great couple of months.

The service has grown immensely this year so the opportunity to be involved in a service that reaches right across the metro area is quite unique and that’s what’s drawn me here.

The equivalent doesn’t exist anywhere in Australia.”

MEDICAL FORUM

Guest Column

A Changing Climate The times may be changing, albeit slowly, suggests the Chair of Doctors for the Environment, Dr Kingsley Faulkner.

The environmental plight of the planet is patently obvious and the scientific evidence for climate change absolutely overwhelming. There are those who continue to deny the impact of human activity as the major contributor but their numbers are melting away at roughly the same rate as the Arctic icecap.

The earth is a fragile ecosystem whose wonderful biodiversity and habitability is critically dependent upon keeping its average annual atmospheric and oceanic temperature within a very narrow range. As human beings we function best within the narrow 36.5-37.2C range, we feel unwell just a degree either side of that and become dangerously ill should our temperature remain two degrees above or below.

The earth is becoming febrile. It is at real risk of developing overwhelming sepsis. If humans develop generalized sepsis the mortality rate rises by around 7% for every hour`s delay in initiating effective treatment. Yes, the biology of the earth is different to our own but the need for remedial action is urgent and delay will worsen the prognosis.

National governments have struggled and global forums have floundered in their attempts to take decisive action. Will the Paris Climate Change Conference, which starts later this month, breathe new life and bring new

såHolyoake CEO Ms Angie Paskevicius was named Telstra WA Business Women of the Year. Kalgoorlie GP and practice owner Dr April Armstrong won the WA Start-Up Award. CEO of the Multiple Sclerosis Society of WA, Mr Marcus Stafford, won AIM’s excellence award for NFP management. såSJGSH CEO Dr Lachlan Henderson has been elected chair of the WA Cricketing Association replacing Mr Sam Gannon.

Dr Henderson has been on the WACA board as deputy chair. såPerth respiratory paediatrician and cystic fibrosis researcher Prof Stephen Stick has been awarded the Richard C. Talamo Distinguished Clinical Achievement Award from the US Cystic Fibrosis Foundation. såDr Mike Civil and Dr Alan Leeb are the only representatives from WA on the new RACGP REC-Standards for General Practices. såProf Donna Cross, Prof Susan Prescott (both from Telethon Kids), Prof Wendy

MEDICAL FORUM

hope or will it join Copenhagen as a city of shattered dreams?

There’s one thing for sure, the global disillusionment with the political process has led to a vibrant and interconnected global movement of individuals and organisations demanding change.

It’s hardly surprising, with governments around the world dancing to the tune of the fossil fuel flute, that a divestment movement is now sweeping the world The rapid accumulation and dissemination of evidence regarding environmental harm and its impact upon the health of individuals has increased awareness, forged steely determination and sharpened strategies to address these problems.

Climate change modelling is now robust enough to predict that around 80% of known reserves of fossil fuels will need to remain in the ground in order that the earth`s average annual global atmospheric temperature remains no more than 2C above pre-industrial

Erber (UWA) and Chief Scientist Prof Peter Klinken were inducted into the Australian Academy of Health and Medical Sciences. såProf Peter Thompson has won the NHMRC’s Marshall Warren Award for the most exciting and innovative study – why some cholesterol plaques in the coronary artery become inflamed and cause coronary thrombosis. såFormer Curtin University professor and Ocean Reef GP now Assistant Dean at Notre Dame’s Werribee campus Prof Moyez Jiwa won the 2015 Peter Mudge Medal at the recent GP15 conference. The medal is voted on by delegates for the presenter whose original research has the greatest potential to influence daily general practice. såDr Graham Melrose is back in the corporate fray. The founder of the former biotech company Chemeq which crashed and burned in 2007 is planning a $5m initial public offering in Recce, a Bentley-based biotech working on a synthetic antibiotic.

times. It’s hardly surprising, with governments around the world dancing to the tune of the fossil fuel flute, that a divestment movement is now sweeping the world with rapidly increasing pace.

Universities, superannuation funds, charitable foundations, churches, corporations, individuals and even the sovereign Norwegian Pension Fund (US $8.4bn) have divested from fossil fuels or are in the process of doing so. Australian and overseas banks are increasingly reluctant to ignore the pressure to act responsibly and are refusing to fund new fossil ventures. Mainstream newspapers are beginning to take a lead and social media has become pivotal in driving this movement forward.

Shell has shelved its Arctic oil drilling ambitions and Rio Tinto and BHP are showing interest in renewable energy technologies. The economic viability of solar panels, solar thermal facilities, storage batteries, wind farms and other new innovative renewable energy technologies is indisputable.

Thankfully, the new government in Canberra appears to be listening. If it fails to act with sufficient vision, strength and effectiveness, then history will be as unkind to it as it will undoubtedly be towards the one that preceded it.

såAustralian Red Cross has won a $7.2m WA Government contract to provide residential and in-home nursing services for children with high medical support needs. såAvita Medical has received a $US16.9m commitment from a US government agency to fund a trial of its ReCell device. såEpichem, a fully-owned subsidiary of ASX listed PharmAust, has stepped up its anticancer drug development with the move to a new laboratory at Technology Park at Bentley. såA/Prof Ravani Duggan has been appointed deputy head of Curtin’s School of Nursing, Midwifery and Paramedicine. såThe TGA has issued a hazard alert for the VAOIS Total Shoulder Replacement System (available since 2010) due to revision rates over three times what is expected.

NOVEMBER 2015 | 27

Clinical Update

Statins and risk management A whopping twenty-year follow up of the West of Scotland Coronary Prevention Study has shown that treatment with a statin for ďŹ ve years provides a persistent reduction in cardiovascular disease outcomes over the course of two decades.

By Dr Johan Janssen Cardiologist Western Cardiology

Ezetimibe has shown to successfully decrease LDL cholesterol, alone, or in combination with other drugs. Long term outcome data, however, have been lacking. During a sevenyear trial, Improve-IT has studied the role of LDL lowering by simvastatin 40mg alone or

In this primary prevention study, the statin used was Pravastatin 40mg – one of the least potent in its class. People were started on the statin between the ages of 45 to 64 years.

Now, after 20 years the average age is 70 and coronary heart disease mortality was reduced by 27% and all-cause mortality by 13%.

The study shows that combining a nonstatin medication, Ezetimibe, with a statin (simvastatin), can reduce cardiovascular events especially myocardial infarction and ischemic stroke. However, the results should not be extrapolated to low risk patients nor to conversations regarding primary prevention.

In IBIS-4, high dose Rosuvastatin (20mg started, up-titrated to 40mg) was investigated in its effect on plaque burden, composition and phenotype in patients undergoing intravascular ultrasound of coronary arteries.

The 18-month study reduced atheroma volume signiďŹ cantly and there seems to be a correlation between the amount of atheroma and risk of developing an acute coronary syndrome.

Also, the need for coronary revascularization was reduced by 19%, and the occurrence of heart failure was reduced by 31%. The study demonstrated no effect on stroke and no increased risk of cancer.

Last, but not least, the biggest challenger for statins to date, Alirocumab and Evolocumab are once-a-month injectables to lower ‘bad’ cholesterol. These so-called PCSK9 inhibitors inhibit the liver from expelling ‘bad’ LDL cholesterol and have gained marketing approval in the USA.

Data analysis of the National Health and Nutrition Survey III, revealed no signiďŹ cant difference between fasting and non-fasting LDL cholesterol levels when it came to predicting all-cause and cardiovascular mortality (sensitivity analysis conducted at 5, 10 and 15 years of follow-up). At present, many guidelines for cholesterol management do recommend fasting (8 to 12 hours) blood draws.

The way I discuss prevention with patients will change, and I will not request fasting lipid studies anymore.

These ďŹ ndings, which were similar to those published in the Archives of Internal Medicine (2012) might lead to change of practice.

Fasting is inconvenient for the patient, and doing away with it would simplify patient risk assessment.

Ezetimibe combined with simvastatin, when given within 10 days of an Acute Coronary Syndrome (ACS). The combination showed about a one in 350 chance the patient could enjoy a 2-10% risk reduction in event rates with no mortality beneďŹ t in the long term. In stable patients (not in the setting of an ACS), adding Ezetimibe made no difference.

References available on request.

Competing interests declaration: nil relevant.

Questions: contact author on 9346 9300.

Western Cardiology contributed to production costs.

By Dr Leanne Heredia

MedicineList+ Clinical Usefulness

Ease of Use

Its purpose and who developed it. MedicineList+ provides a strong argument for throwing away the old hand-written medication list. It is aimed at patients, family and/or carers to keep track of medications – busy people or those on multiple medications. Active players in health care can use additional features such as a portable health record.

Created by NPS Medicine Wise, a not-for-proďŹ t evidence-based group.

Features of MedicineList+

Details. Takes up 18MB. Free. For iPhones and Androids (about 50,000 users at present). Alerts and most other features are fully functional without wiďŹ and even in ight mode. No password protection (crucial in emergencies). Contacts: medicinelistplus@nps.org.au or 02 8217 8700.

sĂĽ -ECHANISMĂĽOFĂĽACTION ĂĽREASONĂĽFORĂĽUSEĂĽANDĂĽSIDEĂĽEFFECTSĂĽAREĂĽAVAILABLEĂĽFROMĂĽ the consumer medicine information internet link (connects to CMIs on NPS website).

Overview. With a bright and modern look, the app is easy to use – a succinct step-by-step tutorial can be turned on to show users how to navigate through the app and its features.

sĂĽ 0RESCRIPTION ĂĽ/4#ĂĽANDĂĽCOMPLEMENTARYĂĽMEDICATIONSĂĽCANĂĽBEĂĽRECORDEDĂĽ manually or by scanning the packet barcode using the built-in scanner.

(Pharmacies have not come on board to assist consumers register dispensed prescriptions.) sĂĽ -EDICATIONĂĽDOSE ĂĽINSTRUCTIONSĂĽANDĂĽINDICATIONSĂĽCANĂĽBEĂĽRECORDEDĂĽANNUALLY

sĂĽ 2EMINDERSĂĽTOĂĽTAKEĂĽMEDICATIONSĂĽCANĂĽBEĂĽACTIVATEDĂĽPERĂĽMEDICATION ĂĽANDĂĽ manually disarming after each is taken provides a record of medications taken. sĂĽ 2EMINDERSĂĽFORĂĽWHENĂĽPRESCRIPTIONSĂĽAREĂĽNOTĂĽAVAILABLEĂĽ PHARMACIESĂĽHAVEĂĽ pulled out). sĂĽ !ĂĽMEDICATIONĂĽLISTĂĽCANĂĽBEĂĽEMAILEDĂĽASĂĽAĂĽ0$&ĂĽTOĂĽWHOMEVERĂĽFROMĂĽTHEĂĽ!PP

28 | NOVEMBER 2015

MEDICAL FORUM

Clinical Opinion

Athlete over-treatment

By Prof Peter O’Sullivan Specialist Physiotherapist Curtin University

Sporting people with non-traumatic musculoskeletal pain are perhaps one of the most ‘medicalised’ and ‘over-treated’ groups of patients. This is often driven by pressure from the athlete, the club, the coaching staff, the media and the health care professional, to get the athlete back to their sport as soon as possible.

Pain and imaging drives intervention There is a persistent belief that musculoskeletal pain in an athlete is caused by ‘tissue damage’ or ‘injury’. Easy access to imaging for musculoskeletal pain conditions commonly reinforces and validates this belief.

So called ‘abnormalities’, such as disc degeneration, disc bulges, annular ďŹ ssures, labral tears, rotator cuff tears and bursal thickening are highly prevalent in the pain-free population. On the basis of such imaging, invasive interventions such as injections and surgery are frequently prescribed.

This practice is in spite of evidence that imaging, while very sensitive to detect changes in tissue morphology, is a poor predictor of pain and disability, and efďŹ cacy for these interventions is limited.

Physical therapies such as massage, manipulation and needling are commonly prescribed to the treat the symptoms of pain in spite of only short term effects on pain and disability.

A need to look elsewhere In contrast, contemporary evidence supports the view that non-trauma musculoskeletal pain in athletes is closely linked to other factors such as training volumes, sleep deďŹ cits, emotional distress, co-morbid pain and nonspeciďŹ c health complaints (e.g. feeling run down and fatigued).

This highlights the complex interplay between physical loading, mental health, tissue sensitivity, allostatic load and immune system factors. Pressure to train hard, play hard and get back to sport often escalates this process.

An alternative approach So where does this leave the clinician dealing with an athlete with non-trauma musculoskeletal pain? Instead of referring them for MRI scan or ultrasound (which will invariably identify some abnormality), how about ďŹ rst enquiring about their stress load, training volumes, lifestyle habits, and screening for their mental health and general health, which may be far more revealing.

Reassuring them about the body’s resilience, and that pain does not equal damage, helps build their conďŹ dence. The pain they are getting may mean that tissue is sensitised and they need to back off a little, preserve their sleep, learn to relax, normalise the way they move, maintain healthy lifestyle habits and optimise their whole health.

There is evidence that these interventions are effective in reducing pain and disability in athletic populations.

While this may be a hard story to sell to the athlete and the coach – it is evidence based.

Changing athlete expectations requires cultural change amongst all involved. More is not always better – that is more treatment, more training, more massage, more imaging and more injections. Sometimes we need to back off to allow the body to restore its homeostasis and recover.

Further reading O’Sullivan P, Lin I, (2014) Acute low back pain: beyond drug therapy, Pain Management Today, 1:1:1-13.

O’Sullivan, (2015) Common misconceptions about back pain in sport: Tiger Woods’ case brings ďŹ ve fundamental questions into sharp focus, British Journal of Sports medicine, doi:10.1136/ bjsports-2014-094542 O’Sullivan P (2012) It’s time for change in the management of non-speciďŹ c chronic low back pain, British Journal of Sports Medicine, 46:224-227.

sĂĽ !REASĂĽPROVIDEDĂĽTOĂĽINCLUDEĂĽINFORMATIONĂĽTHATĂĽACTSĂĽASĂĽAĂĽPORTABLEĂĽHEALTHĂĽRECORDĂĽnĂĽMEDICALĂĽ conditions, allergies, emergency contacts, health card details, specialist details and investigations. No connectivity with other systems. sĂĽ 'RAPHSĂĽCANĂĽBEĂĽGENERATEDĂĽFROMĂĽRESULTSĂĽTOĂĽOBSERVEĂĽTRENDSĂĽANDĂĽPROGRESSĂĽ MODULESĂĽMADEĂĽ for INR, bp, height, weight, but can be customised). sĂĽ !ĂĽFREEHANDĂĽNOTESĂĽSECTIONĂĽALLOWSĂĽRECORDINGĂĽOFĂĽPOINTSĂĽFORĂĽLATERĂĽDISCUSSIONĂĽBETWEENĂĽPATIENTĂĽ and doctor (not used much). sĂĽ -ULTIPLEĂĽPROlLES ĂĽSOĂĽMOREĂĽTHANĂĽONEĂĽPERSON SĂĽMEDICATIONSĂĽCANĂĽBEĂĽONĂĽTHEĂĽONEĂĽPHONE Minuses sĂĽ .OĂĽWARNINGĂĽORĂĽALERTĂĽWHENĂĽANĂĽALLERGICĂĽMEDICATIONĂĽISĂĽADDEDĂĽTOĂĽTHEĂĽMEDICATIONĂĽLIST ĂĽ sĂĽ 4HEĂĽVALUEĂĽOFĂĽTHEĂĽ!PPĂĽFORĂĽDOCTORSĂĽRELIESĂĽONĂĽCONSUMERSĂĽBEINGĂĽACCURATEĂĽANDĂĽTHOROUGHĂĽINĂĽ their record keeping (built in barcode scanner helps). sĂĽ )NABILITYĂĽTOĂĽSYNCĂĽWITHĂĽOTHERĂĽDEVICES ĂĽSUCHĂĽASĂĽANOTHERĂĽPHONEĂĽORĂĽTABLETĂĽ E G ĂĽCARRIEDĂĽBYĂĽ separated parents). sĂĽ .OĂĽVISUALĂĽCUESĂĽOFĂĽCOLOUREDĂĽTABLETS Pluses Educates users on medications and facilitates better doctor-patient communication for this purpose.

ED: Medical Forum reviews Apps that tend to be: sĂĽ&REEĂĽTOĂĽHEALTHĂĽCONSUMERĂĽANDĂĽDOCTOR ĂĽWITHĂĽLOWĂĽCOSTĂĽIN !PPĂĽPURCHASES ĂĽIFĂĽATĂĽALL sĂĽ&ACILITATEĂĽCOOPERATIONĂĽBETWEENĂĽDOCTORĂĽANDĂĽPATIENTĂĽASĂĽAĂĽPARTĂĽOFĂĽMEANINGFULĂĽILLNESSĂĽMANAGEMENT

MEDICAL FORUM

NOVEMBER 2015 | 29

get your patient’s spine working Workspine’s team of hand picked specialists provide comprehensive occupational spine injury management under one roof.

From pain management to surgery, cognitive therapy and rehabilitation exercise programmes, Workspine covers all aspects required for the successful treatment of work related spinal injury.

Studies have shown that a comprehensive approach to spinal injury treatment results in better patient outcomes.

Put an end to the spiral of endless referrals and self management and send your work related spinal injury patients to Workspine.

We get spines working.

Dr. Andrew Miles FRACS NEUROSURGEON

Dr. David Holthouse FRACS INTERVENTIONAL PAIN SPECIALIST

Dr. Michael Kern FRACS NEUROSURGEON

Dr. Graham Jeffs FRACS NEUROSURGEON

Guardian EXERCISE REHABILITATION

EXERCISE REHABILITATION

wisdom health PSYCHOLOGY SERVICES

1800 WRK SPN 1800 975 776 MURDOCH Suite 77, Level 4 St John of God Wexford Medical Centre 3 Barry Marshall Drive Murdoch WA 6150 30 | NOVEMBER 2015

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

Clinical Update

Targets in type 2 diabetes that matter

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

By Dr Ken Thong Endocrinologist, Murdoch

The importance of glycaemic control in type 2 diabetes varies with different disease stages. Furthermore, we need to shift from a glucocentric treatment approach to one targeting beta cell function in early type 2 diabetes.

At diagnosis, insulin resistance and compensatory insulin secretion have been maximal for some years. Hyperglycaemia manifests due to signiďŹ cant beta cell function being lost (estimated 50-80%) and this continues downwards. Unfortunately, treatments such as sulphonylureas and insulin only treat hyperglycaemia (the symptom) rather than protect residual beta cell function (the disease). This results in a steady loss of beta cell function, escalation of diabetes therapies and ultimately insulin treatment.

No accurate measure of beta cell function is available in routine clinical practice. Hence, the early target of treatment is, contentiously, weight, since signiďŹ cant weight loss has been shown to arrest the progression of beta cell loss. Interventions discussed below also exert beneďŹ cial effects beyond mechanisms of weight loss. The ease of HbA1c control is a surrogate marker of response.

Trial evidence Lifestyle measures (mandatory and instinctively well accepted by patients) are the cornerstone of managing pre-diabetes and early type 2 diabetes.

In the Diabetes Prevention Program, lifestyle intervention aiming for at least 7% body weight loss delayed progression. Trial patients received intensive sessions rarely achieved in the real world so results of lifestyle intervention in clinical practice may be much less successful.

Injectable GLP-1 receptor agonists have been shown to restore beta cell function. A three-year study found twice daily exenatide improved beta cell function (insulin glargine did not). Improvement was lost if treatment stopped at two years, but sustained if stopped at three years. In another trial, patients on once-weekly exenatide had superior HbA1c results and weight loss than those on insulin glargine. PBS restrictions and the need for injection prevent wide-scale uptake of the GLP-1 agonists.

Thiazolidendiones (pioglitazone/rosiglitazone) expand adipocytes stores enabling storing away of toxic fatty acids. This improves beta cell function but causes weight gain. TZDs consistently show the most durable effects in glycaemic control compared with lifestyle intervention, metformin or sulphonylurea therapy. Unfortunately, potential weight gain, osteopaenia, macular oedema and uid retention are rarely acceptable.

In a study of patients with pre-diabetes and early type 2 diabetes (all on metformin), combining exenatide twice daily and pioglitazone (a beta cell approach), showed superior outcomes to sulphonylureas and insulin.

Early bariatric (metabolic) surgery has been unequivocally superior to drug therapies in “curing� early type 2 diabetes. Often too invasive for some patients, public hospital access also remains limited.

The choice of intervention/s should be tailored to the individual considering access and cost, with an honest discussion about their inadequacies.

Physicians should recognise that we are treating the beta cell not hyperglycaemia in early type 2 diabetes.

FERTILITY NEWS

by Medical Director Prof John Yovich

ANZARD Report 2015 ‌ Australia leads on VDIHW\ DQG HIÀFLHQF\ The recent ANZARD report from the National Perinatal Epidemiology and Statistics Unit (NPESU) of the University of New South Clinical Wales details the outcomes of all assisted Professor reproductive technology (ART: IVF and John Yovich FET; frozen embryo transfer treatments) undertaken in Australia and New Zealand during 2013 with every pregnancy tracked through to deliveries to October 2014.

This independent report shows that 71,516 ART treatments were undertaken, 93% within Australia, representing a small 1.9% increase over the previous year.

Most treatments utilised autologous oocytes with only ANZARD 2015 4.9% involving donor oocytes or embryos. There was an increasing rate of pre-implantation diagnosis (PGD) applied WR VFUHHQ WKH HPEU\RV IRU FKURPRVRPDO DQHXSORLGLHV RU VSHFLĂ€F gene deletions or mutations. This was almost 20% higher than the previous year and represents 4.4% of IVF cycles.

For IVF the average age of women was 35.9 years and for men was 38.3 years. For FET the ages of both men and women was almost 5 years higher. For initiated cycles the clinical pregnancy rates were 23.8% and livebirth rates 18.2% overall; for those under 30 years the livebirth rates for fresh and thaw cycles were 27.2 and 27.8% respectively but only 1.2% and 5.4% respectively for those over 44 years. Total deliveries reveals 13,939 babies born with 94.4% being singleton, a marked decrease in multiple pregnancies from the previous years.

7KH GDWD VKRZV VLJQLĂ€FDQW EHQHĂ€FLDO WUHQGV QDPHO\ PRUH EODVWRF\VW VWDJH WUDQVIHUV PRUH YLWULĂ€FDWLRQ IRU cryopreservation of blastocysts, 82.9%; and the increasing use of cryopreservation with reliance on FET cycles (32.5% for total and 44.7% for some embryos). The quartile distribution of results for all IVF clinics shows wide variations from the above averages and PIVET takes pride noting its highly favourable position for pregnancy and livebirth productivity rates where fresh and frozen transfers are added for each initiated cycle.

References available on request

Author competing interests – no relevant disclosures. Questions?

Contact the author on 9313 8830

NOW AT 2 LOCATIONS PERTH & BUNBURY

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

MEDICAL FORUM

NOVEMBER 2015 | 31

Fertility, Gynaecology and Endometriosis Treatment Clinic

When your patient’s family plan isn’t going to plan... Fertility North can help. z Cycle Tracking z Timed Intercourse z Artificial Insemination z Ovulation Induction z In-vitro Fertilisation (IVF) z Intra-cytoplasmic Sperm Injection (ICSO) (ICSI) z Pregnancy Monitoring z Donor Services z Sperm / Egg Freezing z Oncology Fertility Preservation z Egg Freezing for Social Reasons z Semen Analysis

Dr Vince Chapple

Dr Jay Natalwala

Dr Santanu Baruah

Dr Gian Urbani

Dr Megan Byrnes

Medical Director

Clinical Director

Fertility Specialist

Fertility Specialist

Fertility GP

Qualifications

Qualifications

Fertility Specialist Qualifications

Qualifications

Qualifications

Qualifications

MB, BS (London) FRANZCOG MRepMed

MB, BCh (UK) DRCOG FRANZCOG MRepMed

MBBS, MRCOG (UK) CCT (UK), CGES FRANZCOG

MBCHB, MMEd(O&G) FRANZCOG MRepMed

BMedSci, MBBS FRANZCOG MRepMed

MBBS, DRACOG FRACGP

Dr Jane Chapple

Suite 30, Level 2, Joondalup Private Hospital, 60 Shenton Avenue, Joondalup WA 6027 Phone: (08) 9301 1075 Fax: (08) 9400 9962 Email: admin@fertilitynorth.com.au

www.fertilitynorth.com.au

Fertility, Gynaecology and Endometriosis Treatment Clinic 32 | NOVEMBER 2015

MEDICAL FORUM

Clinical Update

Humour at the end of life

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

“I want to die at home,” he said at the consult’s start, “but I don’t think that my wife wants to wake up to that type of stiff.”

He was frail. Death was likely within a few weeks at most. Yet he talked openly and seemed keen to spare me, the doctor, the difficulty and distress of the situation.

Discussing dying remains a great society taboo.

As a society we continue to use euphemism to avoid the stark reality of death. We say with a giggle; ‘they have gone to a better place’, ‘kicked the bucket’, ‘shuffled off this mortal coil’, ‘checked out’, ‘passed away’ or are ‘pushing up daisies’. For a smile or laugh Google the great mass of phrases.

We must all develop a style that suits us, but that can adapt as needed. Honest, open, approachable. Communication skills are being taught at undergraduate and postgraduate level, emphasising this skill, and can be developed and improved. We cannot simply say that it’s not something we are good at and ignore it. It reminds us to focus on both verbal and non-verbal skills, remembering that ‘the more we talk, the less we listen’.

Where does humour fit?

It may be the patient’s way of raising a difficult topic but keeping it ‘light’, discussing prognosis, or mode or chosen place of death. They are trying us out, but also are often trying to make our lives easier as they recognise our discomfort. Families use it for the same reasons.

We use it in our teams, to lighten the load, to improve our coping. Often somewhat grim, and at risk of seeming inappropriate or insensitive to others we like to laugh.

The original Patch Adams pictured with an elderly (not a dying) patient in a USA hospital.

A GP may well use humour when they know their patient well, who they are, their history, and coping styles. What are they like? Do they like a joke and a laugh? Humour can be useful but may also cause offence, and when we don’t know a person well can be dangerous.

essential role of the GP in providing end-of-life care.

Sadly medical summaries tell us about disease not the person, and palliative care teams who provide much of the end-of-life care often receive late referrals leaving little time to make relationships. The message is less about humour than about relationships and the

For information visit www.cancerwa.asn.au/ professional/pascet.

The Cancer Council of WA is running communication skills workshops. Eliciting and responding to emotional cues.

Author competing interests: no relevant disclosures. Questions? Contact the author on 9242 0242.

Integrated care plan Bethesda Health Care has just signed a Service Level Agreement with Cancer Support WA to provide counselling, support and education to patients of the hospital’s Palliative Care Unit and their families.

The agreement will extend Cancer Support WA’s existing role at Bethesda, which already works with breast cancer and urological cancer surgical patients. Bethesda CEO Prof Yasmin Naglazas and Cancer Support CEO Ms Mandy BeckerKnox said patients would benefit from this integrative cancer care.

Cancer Support’s counsellors specialise in psycho-oncology and other aspects of complementary cancer care which supports the medical treatment and palliative care patients receive in hospital.

SafeStraw A volume limiting Drinking Aid Safely delivers around 1 tsp of fluids per suck.

Enteral Feeding Tube DeCloggers Clears tubes in as little as 2 minutes

Available from NL-Tec Pty Ltd

Tel : 08 9259 5100 info@nl-tec.com www.nl-tec.com

MEDICAL FORUM

NOVEMBER 2015 | 33

Dr Randall Hendriks = Dr Bernard Hockings = Dr Mark Ireland = Dr Ben King = Dr Donald Latchem Dr Allison Morton = Dr Mark Nidorf = Dr Vincent Paul = Dr Peter Purnell = Dr Pradyot Saklani = Dr Nigel Sinclair Dr Isabel Tan = Dr Angus Thompson = Prof. Peter Thompson = Dr Alan Whelan = Dr Xiao-Fang Xu

PRIORITY REFERRER HOTLINE

WHY CHOOSE HEARTCARE?

HeartCare Western Australia has a dedicated line that gives doctors access to our Cardiologists at anytime for assistance with Please note enquiries urgent cases and advice. for TEST RESULTS can The priority referrer hotline be made direct to enables you to contact a 9480 3029 HeartCare Cardiologist 24/7.

HeartCare Western Australia provides the referring GP and patient convenient, considerate and efficient services, including . Easy access to appointments, with minimal waiting times . The choice of sixteen well respected Cardiologists . Accessible regional locations for both testing and consultation . Accurate, reliable results available with minimal delay . Caring, well trained and informed staff

GP HOTLINE

NEWSLETTER UPDATES

NORTH OF RIVER 1300 4 HEART (1300 443 278) SOUTH OF RIVER 6332 2350

View heartcarewa.com.au/medical-professionals/newsletter to flip through our Quarterly Newsletters, designed with the busy GP in mind.

EDUCATIONAL MEETINGS

REFERRAL FORMS

HeartCare WA believes that to ensure best practice, the medical community needs to be kept up-to-date with any clinical and technological advances through ongoing education.

The HeartCare referral forms have recently been updated.

We can provide in a format that suits you and your practice, including: . Electronic Templates suitable for ALL Practice Software . A5 printed referral pads (blank or personalised with your details) . A4 blank referral sheets with locations & contact details included for you to overprint

Visit our website and Register Online NOW for any of our monthly educational meetings, including . Meet the Specialist, Rotating Dinner Meetings . Educational Presentation Dinner Meetings, CPD points offered . Webinars FOR FURTHER DETAILS ON ANY OF THESE EVENTS, OR TO REGISTER GO TO:

heartcarewa.com.au/medical-professionals/referrer-events or call Marketing & Relationship Manager Tracey Horsley on 0437 849 061

PLEASE CALL 9480 3000 TO REQUEST YOUR REFERRAL FORMS. An interactive pdf of our referral form can also be downloaded from our website at: heartcarewa.com.au/medical-professionals/referral-resources

heartcarewa.com.au 34 | NOVEMBER 2015

MEDICAL FORUM

Clinical Update

Diet and wound healing

By Ms Jo Beer Senior Dietitian and Diabetes Educator

defining energy and protein requirements in those over 65. Dietetic assessment also considers wound stage (inflammatory, proliferative or remodelling) and type of dressing used. For example, vacuum-assisted closure therapy increases protein loss, necessitating a higher protein intake.

Wound care is not only costly (an estimated $3 billion annually in Australia), chronic wounds can also have a huge impact on quality of life. Chronic wounds (those that fail to heal effectively in 4-6 weeks) are often associated with comorbidities, advanced age and poor hygiene. Optimising nutrition can reduce their incidence and accelerate healing, so that making nutritional assessment a standard part of a care plan can help elderly patients.

Diabetes significantly increases the risk of developing a chronic wound (e.g. lower limb ulcers). Complications of these are the commonest cause of lower limb amputation.

Up to one third of individuals admitted to aged care facilities have pressure sores, with more than 60,000 residents having chronic wounds (predicted to double by 2041).

Nutrition’s role in wound healing is not always fully appreciated. Wounds (even small lesions) impose significant additional metabolic demands with increased energy use, protein synthesis and catabolism. Suboptimal nutritional status may lead to protein energy malnutrition resulting in delayed healing, impaired wound strength and persistent chronic wounds.

Lower leg ulcer present for 4 months without improvement, using conventional treatment

After 2 weeks of L-arginine supplementation

Up to 80% of residents in residential aged care either are or are at risk of becoming malnourished, despite having access to nutritious foods. Compromised oral intake due to anorexia, alterations in taste, dysphagia, poor dentition, reduced cognition or manual dexterity all increase the risk of malnutrition.

Patients with wounds may benefit from regular, small meals and snacks, fortified with high energy and protein sources. There is no harm adding supplemental full fat milk, eggs, cream, butter or olive oil. Commercial fortification products can also help; whilst perhaps expensive, improved healing can reduce prolonged hospital stays, re-admissions, additional nursing care and degraded quality of life.

L- Arginine is an essential amino acid that enhances a number of pathways involved in wound healing and promotes protein synthesis. Dietary supplementation with L-arginine has been shown to decrease muscle loss and promote collagen synthesis, facilitating wound healing and increasing wound strength.

Optimising healing A dietitian can use validated clinical methods such as the mini nutrition assessment – the gold standard for identifying malnutrition,

Dr Sanjay Nadkarni M B B S , FRA N ZCR,FRCR,FCP ,M RCP , D A 221 Stirling Highway, Claremont 6010 T: (08) 92842900 F: (08) 93845725 M: 0410407044 To see a full list of services provided: www.endovascularwa.com.au | www.newlifeclinic.com.au

Dr Sanjay Nadkarni is one of Perth’s most experienced specialists in the minimally invasive outpatient management of varicose veins. The full gamut of cutting edge endovenous techniques including Endovenous Laser (EVLA) , Ambulatory phlebectomy, Ultrasound guided foam sclerotherapy and Microsclerotherapy are performed in our “walk in–walk out” purpose built Claremont clinic.

Author competing interests: nil relevant.

Questions? Contact the author on 0403 938 747.

PRE & POST LASER

PRE & POST PHLEBECTOMY

Endovascular WA is your “one stop shop” for the diagnosis (Doppler Venous incompetence studies) and management (Treatment, clinical and ultrasound follow up) of varicose veins.

Call our friendly reception staff on (08) 9284 2900 to book your consultation.

PRE & POST SCLEROTHERAPY

MEDICAL FORUM

NOVEMBER 2015 | 35

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‚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

36 | NOVEMBER 2015

MEDICAL FORUM

Clinical Update

Understanding iron storage Despite the vast quantities of iron in WA soil, we only absorb 5-10% of dietary iron.

Dr Steve Ward Many people are iron deficient (up to 20% Clinical Haematologist of young women) and require iron therapy.

Iron overload is also relatively common. It Nedlands helps to understand the genes and proteins involved in iron homeostasis and storage disorders.

Aspects of Fe metabolism Free iron is reactive and toxic but is safely transported by proteins such as haeme, transferrin or ferritin. The key players in controlling iron haemostasis are duodenal enterocytes, macrophages and hepatocytes together with the molecules hepcidin, ferroportin, transferrin and ferritin.

The hepcidin-ferroportin system is the main regulator of iron. It regulates iron flow from duodenal enterocytes, recycling from old red cells and recovery from storage sites (liver, marrow, macrophages). Ferroportin is the sole known iron exporter in humans. Transferrin transports iron in the plasma. Ferritin is the main storage protein for iron.

New BreastScreen WA clinic has opened in Wanneroo

The new site replaces the Joondalup Clinic and provides ample free parking, easy access to public transport and improved facilities for women with disabilities.

The Wanneroo Clinic is co-located with the GP Super Clinic in the Wanneroo Town Centre and in close proximity to the local library and Wanneroo Central Shopping Centre. This convenient and readily accessible location will promote mammography screening to women attending other services.

Hepcidin is the iron-regulatory hormone, exerting its effect via its receptor for ferroportin. Increased iron levels lead to increased hepcidin production. Hepcidin binds ferroportin and leads to degradation of ferroprotin and cessation of iron export from cells, and lower iron levels.

Low iron does the opposite, lowering hepcidin and increasing iron absorption and transport. Hepcidin is regulated by iron, and also by other factors, mainly inflammation (via IL6, JAK-STAT and other pathways), to increase hepcidin and prevent iron export from cells. Erythroid regulation of hepcidin occurs by unknown mechanisms.

The “anaemia of chronic disease” is now better understood, where iron is not made available to tissues or erythroid precursors. One mechanism is the inflammatory increase in hepcidin leading to a decrease in ferroportin. Iron is then sequestered in storage cells and is not available for erythropoiesis.

Similar findings occur in renal failure, as hepcidin is partly renally cleared.

The iron overload disorders of haemochromatosis (table 1) are dependent on mutations of the key iron regulatory genes. Currently we can only routinely assess HFE gene mutations.

Development of drugs to combat these mutations is in its early stages.

Hepcidin agonists may help haemochromatosis and iron overload in thalassaemia. Hepcidin antagonists may overcome the block to iron use in the iron-restrictive anaemias of chronic disease, malignancy and renal impairment.

Table 1: Gene mutations in haemochromatosis Hereditary Haemochromatosis Type

Gene mutation

Type 1 HH

HFE gene (C282Y homozygous or C282Y/H63D double heterozygous)

Type 2a HH

Haemojuvelin (HJV)

Type 2b HH

Hepcidin (HAMP)

Type 3 HH

Transferrin receptor (TfR2)

Type 4 HH

Ferroportin

It is important for women 50 years or over to have a FREE breast screening mammogram at BreastScreen WA every two years.

Once is not enough.

Book your appointment online at

www.breastscreen.health.wa.gov.au or call 13 20 50 Clinic locations: Bunbury, Cannington, Cockburn, David Jones Rose Clinic - Perth, Midland, Mirrabooka, Padbury, Perth City, Rockingham and Wanneroo.

Rural locations: Check your local media or the website for mobile screening unit visit dates.

SEP 2015

Clinical scenarios

Author competing interests: nil relevant. Questions? Contact the author on 6142 0970.

MEDICAL FORUM

NOVEMBER 2015 | 37

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Clinical Update

Cerebral Palsy: early diagnosis allows early intervention

By A/Prof Jane Valentine Head of Dept Paediatric Rehabilitation*

comprehensive study showed a sensitivity of 98% and specificity of 94% for absent fidgety movements and the diagnosis of CP.

Cerebral Palsy (CP) is an early brain injury for which early intervention is important.

How early should we intervene? Although the average age of diagnosis of CP is 19 months, most parents (>80%) say they suspected all was not right with their child before diagnosis. Moreover, because most interventions in children with CP are given after the age of two, this is after the estimated critical period for maturation of the motor tracts of the infant brain.

That is, intervention may be too late to be maximally effective.

Whilst over 60% of children who develop CP are born either prematurely or unwell, the majority of such children do not develop CP. Among premature infants less than 32 weeks, the CP rate in WA is only about 5%.

The challenge is to identify those at increased risk. Neonatal imaging and neurological examination can identify some infants with significant neurological impairment who could be targeted for early intervention, however not all will be identified.

GM and the challenge of identification General Movement (GM) assessment helps distinguish between infants at increased risk of developing CP and those at low risk.

‘General movements’ are distinct spontaneous movement patterns evident in babies before birth (from 9 weeks gestation) and after birth (up to 18 weeks post-term). The movements are spontaneous, occur without any external stimulation, and originate from central pattern generators in the brainstem. Heinz Prechtl, a developmental neurologist from Vienna and co-workers observed and categorised these spontaneous movements; although complex and variable, movements can be grouped

Use of a video record The GM assessment can be done by observing the baby as they lay in a natural situation, such as on a mat on the floor, or by watching a video of the child in that same situation. To provide an assessable video, the baby should be filmed lying on their back on a non-patterned surface, lightly dressed and in a calm state. The baby should not be interacted with or be sucking on a dummy, so their spontaneous movement can be observed.

Early identification of those at high risk for developing CP is important to inform parents, maximise neuroplasticity with early intervention and to evaluate early interventions, including the growing use of neuroprotective agents. into a small number of recognisable normal or abnormal patterns related to gestational age.

If the nervous system is impaired, GMs lose their complex and variable character and become monotonous and poor. Two specific abnormal GM patterns reliably predict later cerebral palsy: 1) a persistent pattern of crampedsynchronised GMs. The movements appear rigid and lack the normal smooth and fluent character. Limb and trunk muscles contract and relax almost simultaneously.

2) The absence of GMs of a ‘fidgety’ character – small movements of moderate speed with variable acceleration of neck, trunk, and limbs in all directions. Normally, they are the predominant movement pattern in an awake infant at 3 to 5 months. The most

Conclusion The combined use of GMs, neurological imaging and examination is highly predictive for cerebral palsy allowing an early targeted intervention to maximise neuroplasticity. A growing number of Australian therapists, doctors and nurse specialists have training in this assessment, with the aim of expanding its use in diagnosis so infants benefit from comprehensive early intervention.

References available on request

Author competing interests: no relevant disclosures. Questions? Please contact the author on 9380 2141. *The author thanks Dr Mary Sharp, Neonatal Paediatrician KEMH, for help in compiling this article.

Brain Power to Beat Pain Readers will be aware of the success of the STEPS program being run out of the now defunct Fremantle pain clinic and Medicare Locals. While the organisations may have faded away, the program has not.

Its chief architect, pain physician Dr Stephanie Davies, her GP husband Dr Nick Cooke (pictured left) and paediatric consumer advocate Ms Julia Sutton have collaborated to write a book which takes all the strategies of STEPS and reworks them into a program for self-management of pain.

Nick said Rewire Your Brain was introducing the concept of managing pain through a multidisciplinary approach of daily exercise, activity and understanding.

MEDICAL FORUM

“It explores how pains works, helps people to acknowledge how the pain makes them feel, whether that be a lack of sleep, anxiety, or lack of mobility. STEPS is a process where people can engage in their own pain management and the book is a resource that can be used at any time.”

Rewire Your Brain is heavy on strategy rather than science, though Nick emphasises that it is evidence based. However, it is a book to be used by anyone from the age of 12 upwards to help them be more independent with their pain management without recourse to drugs.

And there’s a market for such an aid with 20% of the population at any one time estimated to be suffering debilitating pain.

NOVEMBER 2015 | 39

Pharmaceutical advertising removed This page intentionally left blank

Clinical Update

Hearing loss – an ‘invisible disability’ Hearing loss is the second most prevalent disease affecting our nation and one of nine National Health Priority Areas (NHPAs). Hearing loss ranks ahead of cancer, diabetes, mental health and asthma. Yet it is often described as an ‘invisible disability’ because people can delay fixing their hearing loss by up to seven years, often reluctant to transition to wearing hearing aids. That’s why the role of the GP is critical.

By Ms Blanche Coyle Manager of Australian Hearing Bunbury & Mandurah

directionality of the microphones in their hearing aids, allowing them to avoid much of the surrounding background noise.

Automatic adjustment of audio settings, direct streaming from the television and taking phone calls are just some of the advanced features of the new technology.

For example, in the Blue Mountains Hearing Study 35.5% elderly participants were aware they had a hearing loss and sought help from their GP, yet only 6.4% of these people were referred for assistance.

The clunky hearing aids of the previous decades have been replaced with hearing aids that can be used underwater, tiny discreet (see image) aids that are almost invisible, and aids that enable better than normal hearing in both ears in certain situations.

Technology enriches hearing aids

Hearing loss helped in other ways

Hearing aid technology is rapidly advancing.

In fact, a new hearing aid that outperforms the hearing ability of a healthy human ear has been introduced by Australian Hearing.

A number of home appliances can amplify or augment sounds in ways that help those with poor hearing:

New technology also means users can use an App on their mobile phone to focus the

så 7IRELESSåANDåPORTABLEåDOORBELLSå

så !LERTINGåSMOKEåALARMS så &LASHLIGHTåANDåBEDåSHAKERåALARMåCLOCKS

så %XTRAåLOUDåTELEPHONEåAMPLIlERSå så 7IRELESSåHEADPHONESå åGREATåFORåLISTENINGåTOå the TV så 6IBRATINGåANDåmASHINGåPORTABLEåBABYå monitors What costs are involved?

There are many hearing services providers in Australia and depending on a person’s circumstances, they may be eligible for free or subsidised services. Australian Hearing provides subsidised hearing services under the Australian Government Hearing Services Program and supports a number of demographic groups including: så #HILDRENåANDåYOUNGåADULTSåUNDERå så 0ENSIONERSå så 6ETERANSå så !BORIGINALåANDå4ORRESå3TRAITå)SLANDERåPEOPLEå over 50.

Common Hearing Aid Barriers “They cost too much.” Hearing aids can be fully subsidised. If you purchase higher technology, expect 5 years’ use during which your daily life improves - an investment not an expense!

“They look too big” or “I don’t like the look of them.” These days hearing aids vary in size according to your hearing loss, and there are different styles and colours to suit. Some are completely hidden and most are very discrete.

“Hearing aids are a sign of ageing.” Sometimes aids are a kindness to those around you.

Asking people to repeat themselves and feeling like a bother can make you feel older. Hearing well and staying involved keeps you young. Baby boomers who are working later can have them fitted for their work.

“They don’t work when there is background noise.” True, some hearing aids don’t manage background noise well but some can give ‘better than normal hearing’. It depends on the technology you use, something an audiologist knows. Ask a lot of questions, see if a hearing aid will meet your expectations, and ask for a free trial.

“How will I be better off?” There are plenty of great stories of people who report significant improvement in their quality of life after being successfully fitted with hearing aids and partners often report more benefit. For some, they said it saved their marriage!

“What else is available to me?” There are many other devices to help with hearing difficulties, such as headsets for the TV - Australian Hearing can offer free counselling sessions that teach tips and tricks.

“I worry about losing them.” Hearing aids get listed under home and contents insurance, and for those who are fully eligible for government assistance there is only a small fee for replacement.

Dedicated GP hotline 1300 412 512 or www.hearing.com.au.

MEDICAL FORUM

The services include hearing assessments, hearing device fitting and maintenance and repair of hearing devices. Batteries are taken care of too. The more sophisticated hearing aids involve some out-of-pocket expense.

Australian Hearing referral The GP provides the patient with a signed Medical Certificate, then the patient contacts their local Australian Hearing centre to arrange an appointment. Patients call 131 797 to find the nearest location or visit www.hearing.com. au to find out about eligibility etc.

GPs with any queries call on the dedicated GP hotline 1800 776 631.

NOVEMBER 2015 | 41

Medical Audiology Services

Hear the best you can!

Cochlear Implants – Age is No Barrier

Andre Wedekind M.Aud.,M.Clin.Aud., BHSc (Physio)

Dr Vesna Maric AuD.,M.Aud.S.A.,M.Clin.

Aud.,BSc.(Hons)

The prevalence of hearing loss doubles for every decade of life during adulthood.

For those with signiďŹ cant hearing loss, conventional hearing aids may not provide adequate beneďŹ t to address the social, communication and cognitive deďŹ cits that arise from an inability to converse in person or over the phone. Candidacy for cochlear implantation is based on audiological and medical factors. Candidates must gain limited beneďŹ t from well-ďŹ tted hearing aids on standardised measures and be ďŹ t to undergo a 90 minute surgical procedure.

Traditionally, cochlear implantation was avoided for the elderly for risk of surgical complications and low outcomes. Experience over the past 10 years supports cochlear implantation in this age group for those who meet candidacy criteria.

Cochlear implants typically provide substantial improvements in communication for adults, but individual outcomes vary. For adults, formal selection criteria do not pose an upper age limit. Patients in their 80s and 90s are routinely implanted, with similar beneďŹ ts to younger adults in speech understanding and quality of life beneďŹ ts. Further, there is strong evidence of improvement over time with cochlear implant experience, similar to other age groups. For outcomes, one of the main predictive factors is duration of signiďŹ cant hearing loss – the longer the period of deafness prior to implantation, the poorer the prognosis. The duration of deafness is a more powerful predictor of performance than age itself, and it seems that the lower the percentage of life spent with a signiďŹ cant hearing loss, the higher the hearing outcomes post-implantation.

sĂĽ !GEĂĽITSELFĂĽISĂĽNOTĂĽAĂĽCONTRAINDICATIONĂĽ sĂĽ 0OST SURGICALĂĽCOMPLICATIONSĂĽAREĂĽRARE ĂĽMOSTĂĽCOMMONĂĽISĂĽ short-lived imbalance sĂĽ 3PEECHĂĽRECOGNITIONĂĽOUTCOMESĂĽINĂĽADULTSĂĽOVERĂĽ ĂĽAREĂĽ comparable to those of younger adults in some studies and slightly lower in others sĂĽ !NYĂĽDIFFERENCESĂĽINĂĽPERFORMANCEĂĽBETWEENĂĽOLDERĂĽANDĂĽYOUNGERĂĽ recipients are better accounted for by longer duration of severe-profound deafness before implantation When lower outcomes are reported based on age alone, they are thought to be due to reduced learning potential, neural plasticity and central auditory function, which is known to reduce with advanced age. Recently, signiďŹ cant attention has been placed on the potential preventative effects of hearing interventions, including cochlear implantation, for older adults in terms of dementia, poor general health and falls.

References available on request.

51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au

42 | NOVEMBER 2015

Clinical Update

Subacute delirium - a source of confusion

By Dr Rita Malik Physician in Geriatric Medicine, Nedlands.

Delirium is best described as a clinical syndrome characterised by uctuating decline in cognition, altered attention, concentration and disorganised behaviour. Rapid uctuation in symptoms, within minutes, is a feature. Comparing previous behaviours is important, by listening to family, carers and RACF staff. In the older person, because it is often the unusual presentation of something treatable, it is important to recognise; multiple conditions are often involved.

Undiagnosed, it can lead to other problems (e.g. injury).

Milder forms of delirium are more common and difďŹ cult to diagnose. The GP can encounter delirium in the community or in the care facility, such as a car accident or wandering in the community. It can result in an unnecessary hospital admission if missed. Simply working through a delirium screen may be all that is required.

It is relatively common (one in eight hospitalised patients). Many patients, especially the elderly, remain undiagnosed and undertreated. Doctor awareness of the possibilities becomes important.

Diagnostic method Careful history (pre morbid function) and examination are crucial, which will often suggest other assessments. There may be some underlying dementia and lack of self-care, which eventually become the focus of care.

For example, delirium that results in a hospital admission may be the ďŹ rst presentation of undiagnosed dementia. In each case the management is tailored to each patient’s problems.

The gold standard of diagnosis is a uctuating conscious state, cognition and arousal (hyper and hypoactive state). Mood lability and delusions, inattention evident through responses to questions, and language disturbances (e.g. incoherent conversation), are common.

A baseline mental state examination is vital as is bowel and bladder history.

Abnormal gait can put the patient at risk of falls.

Multifactorial causes.

In the elderly, presentations of common disorders are often atypical and present as delirium. Considerations include infection (UTI, pneumonia, sepsis), dehydration, drugs (sedatives, narcotics, anticholinergic, chemotherapy), constipation, metabolic changes (hypoxia, diabetes, acidosis, anaemia, malnutrition), falls (subdural haematoma, TIA, hip fracture), and underlying cognitive decline /neurodegenerative disorder (early dementia, Parkinson’s).

A quick tool for rapid detection of delirium is at www.the4at.com – based on the four A’s described by Professor Alasdair MacLullich; alertness, abbreviated mental test- 4 (what is your age, DOB, name of this place, and year?), attention level, and acute change or uctuation.

Electrolytes, dipstick of the urine, assessment of uid intake, bowel history, bladder scan (for high post void residual), baseline haematology (for infection and anaemia), and renal function tests are important; neuroimaging if indicated for suspected intracranial pathology.

Treatment guidelines Treat any causative factors (e.g. UTI, dehydration). Promote good orientation and encourage the sleep wake cycle, without excessive sedation by day and a regular routine. Avoid benzodiazepines and opioids and reduce polypharmacy. A relaxing environment with family is part of treatment.

Resolution of delirium may be slow (sometimes months).

Key Messages sĂĽ #OLLATERALĂĽHISTORYĂĽOFĂĽPREMORBIDĂĽFUNCTIONĂĽISĂĽUSEFUL sĂĽ 2APIDĂĽmUCTUATINGĂĽMENTALĂĽSTATEĂĽ WITHINĂĽMINUTES ĂĽISĂĽCHARACTERISTIC ĂĽ sĂĽ )DENTIFYINGĂĽDELIRIUMĂĽALERTSĂĽOTHERSĂĽANDĂĽISĂĽOFTENĂĽTHEĂĽlRSTĂĽVITALĂĽSTEP ĂĽ sĂĽ $IAGNOSISĂĽANDĂĽMANAGEMENTĂĽMAYĂĽPREVENTĂĽFALLS

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NOVEMBER 2015 | 43

Adventure

R O F N O R T E O C L E N P A C E T A T S O R P The annual bicycle ride to raise awareness of prostate cancer is an opportunity for doctors and patients to tackle cancer in a special way.

It’s a long stretch of bitumen between Perth and Margaret River and even longer on a bicycle but for urologist Dr Tom Shannon and radiation oncologist Dr Raphael Chee they were only too happy to don the lycra, swing a leg over their carbon-fibre racing bikes and join the peloton in the annual ProState Cycle Ride.

“This event is all about being with a group of people who’ve been affected by prostate cancer,” Tom said. “Some of my patients did the ride and one celebrated the two-month mark after surgery by lining up for the starter’s gun.”

“Doing 300km on a bicycle after you’ve just had your prostate removed is a great achievement!”

“I rode in the 2013 event when we went straight into a storm and I’ve ridden from Perth to Albany three times. I’ve also done some pretty serious mountains in France and Italy so the Margaret River ride is relatively flat in comparison.”

Lance Armstrong’s brush with testicular cancer was the catalyst for some hard questions regarding the possibility of a link between specific men’s health issues and long hours spent perched on a thin racing saddle.

Cycling and PSA “Men who ride bikes can rest assured that that it will have no effect on their PSA. You’d have to be doing something pretty silly to end up sitting on your prostate! The only possibility of a problem might be if you were sitting in a low crouched, time-trial position and most middleaged men aren’t going to be doing that,” Tom said.

“There have been huge advances in the diagnosis of prostate cancer using MRI but the big issue really is awareness. We can’t

44 | NOVEMBER 2015

Kim Ledger and Tom Sha nnon cure people if they don’t come to us and, unfortunately, a lot of what we see is at the advanced stage and it doesn’t need to be that way.”

Raphael, once a hard-core cycling devotee who hadn’t spent much time on the bike before heading south to Margaret River.

“The other important reason for linking the Margaret River ride to prostate cancer, apart from raising awareness, is to highlight the exercise component. There’s data suggesting that patients who engage in some sort of physical activity have lower rates of recurrence after a prostate cancer diagnosis. It would seem that the epigenetics are altered by getting the muscles moving, a shift in the expression of genes that may be involved in cancer progression.”

“I’d barely ridden for about four years so I was a bit apprehensive. In fact, I only managed to squeeze in three sessions before the ride. We’ve got two young children, aged four and two, so there’s not a lot of time to jump on the bike.”

“And apart for that, riding is very friendly on your joints and it’s a great feeling being out on your bike with your mates.”

This year’s ProState Ride was the first for

Facing the elements

“One of the guys in our group had only been on a bike for six weeks and hadn’t been on a roadbike before. He’d never even used cleats!”

“At the briefing they told us it would be wet and cold with 60km/h headwinds but apart from a bit of soreness in my lower back it was fine. It was very well organised with support cars and everyone in the team helping each other along the way. Many of the riders had pictures of

MEDICAL FORUM

loved ones on their bikes – fathers, grandfathers, uncles and brothers affected by prostate cancer.”

Raphael echoes Tom’s optimism regarding diagnosis and treatment of a disease that will have an impact on the 20,000 Australian men who will hear a diagnosis of prostate cancer in the next calendar year.

“There have been some developments in tests and treatments over the last 12 months and the PBS is approving new medications. The Prostate Specific Membrane Antigens (PSMA) test is quite new and highly sensitive. It picks up very small volumes of the disease that just aren’t evident on CT scans. We’ve also got much better radiotherapy equipment now so we’re able to treat with less toxicity even at higher doses.”

One area that does remain toxic is the relationship between cyclists and some motorists in Perth.

D r To m Sh a n n

on a n d D r R a

p h a el C h ee

“It does seem that a lot of behind the wheel in Perth don’t have a lot of patience and it’s getting worse. I do feel more nervous on the road and I’m always watching my back. On the other side of the coin, a lot of cyclists have little regard for the road rules and it drives me up the wall when I see that happening.”

“But I’ll still be lining up next year for the ProState Ride and I’m going to try to recruit some of my colleagues as well.”

By Mr Peter McClelland

Dr Raphael Chee at the start rt line

MEDICAL FORUM

T he Blu e Tea m TS

a nd R C le ft

NOVEMBER 2015 | 45

News & Views

Where Are They Now We found on file people from the 2003 inaugural Clinical Senate set up by WA Health as part of the Reid Reforms – remember those times – and wondered where are they now? The Senate was set up to provide clinical advice to government on a range of health services.

Only two have left WA – so much for the brain drain!

D r Si m on Tow le r

Dr Da vid Ru sse ll-Weisz

Dr Scott Blackwell now President of Palliative Care Australia and an Aged Care GP. Dr Simon Towler now Medical Co-Director FSH and Staff Specialist Intensive Care RPH Ms Heather Gluyas now A/Prof. Nursing Education at Murdoch University.

Mr Cameron Bracks now retired and on a farm at Burekup, WA Dr Mark Platell now a Senior Specialist, Clinical Governance RPH Dr David Russell-Weisz now Director General of Health, WA Prof Judith Finn now a Research Professor in the Prehospital, Resuscitation and Emergency Care Research Unit in the Faculty of Health Sciences at Curtin University.

Dr David de la Hunty now a VMP at Rockingham General Hospital and is an elected member on the MAC there.

Dr Christ obel Saun ders

Dr Christobel Saunders now a Surgeon at FSH, Head of Breast Cancer Research SJOG Subiaco, and holds various positions at UWA, RPH and the WA Melanoma Advisory Service.

Dr Mark Newman now Medical Co-Director, Surgical Division and Medical Director, Safety and Quality SCGH. Dr Rowan Davidson how Consultant Psychiatrist, Community Mental Health Service in the centre of Perth.

Dr Graham Jacobs now Liberal MLA for Eyre in the WA Parliament.

Dr David Mountain now a Specialist ED Physician, SCGH, and a UWA academic.

Dr David Andrews now a Cardiothoracic Surgeon at PMH and SCGH. Dr Mandy Seel now Director, Public Health at HDWA. Dr John Collis now a rural GP, Margaret River.

Dr Vasantha Preetham now MD of Health Integra Pty Ltd, and Practice Principle of Centro Medical Centre, Morley and Belridge Medical Group.

Dr James Flexman now Head Dept. of Microbiology and Infectious Diseases, RPH, PathWest Laboratory Medicine, and a Clinical Professor at UWA.

Dr Fraser Moss now Principal Medical Officer with DCS Health Services and provides clinical services for regional and metropolitan Aboriginal patients.

Dr Geoff Knight now an Intensive Care Physician and Paediatrician, SJOG Subiaco.

46 | NOVEMBER 2015

Dr David McGechie now Director Infection Prevention and Management, and Consultant Microbiologist FSH.

Dr An dre w Ro be rts on

Prof Teik Oh is Director Medical Services Mercy Hospital, and Board Member at Clinical Training and Education Centre (CTEC).

Dr David Henshaw now a Consultant Physician, General Internal Medicine at Noosa Hospital, Qld. Dr Neil Cock now a Consultant Psychiatrist, Great Southern Mental health Service, Albany WA. Dr Helen Wright now a General Paediatrician, PMH. Dr Judith Finn now a Clinical Epidemiologist and researcher with the Discipline of Emergency Medicine, UWA. Dr Andrew Robertson now Deputy Chief Health Officer and Director – Disaster Management, WA Health.

Dr Aaron Groves now Chief Psychiatrist, South Australia Health.

Dr Brad Power now an Intensive Care Physician SJOGH Subiaco Dr Peter Wynn Owen now Executive Director, Swan Kalamunda Health Service & NHMS Contract Management.

Dr Ralph Chapman now an ED and Primary Care Doctor, Broome Hospital

MEDICAL FORUM

Wine Review

Hard Yards Pay off

at Xanadu

The first influx of vignerons into Margaret River back in the 1970s had a significant proportion of idealistic doctors in its midst. Tom Cullity at Vasse Felix, Bill Pannell at Moss Wood, Kevin Cullen at Cullens and John Lagan at Chateau Xanadu all put in the hard yards to establish premium vineyards while keeping their medical practices running.

By Dr Louis Papaelias

There were no corporate dollars to fund expensive wineries full of state-of-the-art presses, tanks, fermenters and oak barrels. It meant leaving work on Friday to spend the weekend planting, pruning and vinifying until Sunday when it was back to the surgery for another week of medicine to foot the bill.

In Dr Lagan’s case at Xanadu it meant shuttling back and forth from Perth to Margaret River for years.

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1. 2014 DJL Sauvignon Blanc Semillon A 63:35 blend with 2% Muscadelle. Wild yeast fermentation. Attractively floral and fruity with grassy overtones. Clean with a crisp backbone. Lovely 12.5% 2. 2014 Chardonnay Barrel fermented on wild yeasts without malolactic fermentation. Ripe stone fruit aromas. Clean tightly structured wine with balance and length of flavour. 13% 3. 2013 Reserve Chardonnay Made from old vines and selected barrels. Again naturally fermented with indigenous yeasts in 35% new oak barrels. A quantum increase in quality.

An initially reticent nose that builds in the glass. Very fine on the palate with marvellous depth of flavour and complexity reined in with crisp minerality leading to an extra-long aftertaste. Gold medal standard 13.5%

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3

The vineyard was first planted in 1977, 4km from the town centre. The early wines showed promise and a reputation for quality cabernet sauvignon in particular was quickly established.

Fast forward to 2015 and Xanadu is amongst the top flight of producers in the Margaret River region.

Now owned by the Rathbone family, which is also involved with Mount Langi Ghiran and Yering Station in Victoria, the estate comprises 65ha of vines planted on free-draining gravelly loam. The wines produced are in the first division for quality. Impeccably grown and vinified with a host of accolades. For those interested in point scores the 2012 Reserve Cabernet and the 2013 reserve Chardonnay were rated at 98 and 97 points respectively by James Halliday.

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4. 2013 DJL Shiraz 31% of the fruit comes from Frankland and a touch of viognier added for aroma. Appealing nose of spicy berries and a touch of white pepper. Good richness with depth of flavour and fine savoury tannins. Lovely now but will keep. 14% 5. 2013 Reserve Cabernet Sauvignon 90% Cabernet, 5% Malbec, 5% Petit Verdot. Made from the best parcels of fruit, this wine was vinified in the traditional manner and spent 16 months in 50% new French oak. The malbec and petit verdot components round out and add to the intensity of the cabernet. Very fine aromas of cassis and sour cherry. Full and supple palate with firm but finely structured tannins adding to the considerable length of flavour. An outstanding example of fine Margaret River Cabernet and a joy to drink even at this early age. Will definitely mature and keep for 10 years 14%

.. or online at

www.medicalhub.com.au

Wine Question: Who was the founder of Chateau Xanadu?

Email Please send more information on Chateau Xanadu 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, November 30, 2015. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

Raph Chee setting off

MEDICAL FORUM

NOVEMBER 2015 | 47

Social Pulse

Doctors, executive and staff from St John of God Murdoch Hospital had a great night under the big top at their annual ball at the Crown Perth at the end of September. Popcorn and fairy floss were served while jugglers, acrobats and a ringmaster entertained guests in true circus style. A raffle and auction raised over $8000 for the hospital’s new Charity of the Year, PlusLife, the only bone and tissue bank in WA.

1 Dr Bridget Cooke, CEO John Fogarty and Richard Harris 2 Melanie and Dr Michael Halliday, Dr David and Caroline Borshoff

From the big top…

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3 Raelee Denniston and Dr Craig Schwab 4 Emma Lacey and Dr Michael Anderson 5 Dr Julie Dockerty and Lindsay Boyd 6 Aimee Freeman, Dr Andrew Miles and Nina Labus 7 Carey Williamson, Cat MacGregor, Dr Penny Yeung, Lorraine Moniz, Joanne Climo, Helen Timms and Malin Holmer

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In the October issue we ran a story on GP Dr Tessa Kaminski and her special circus talents.

She was performing at the St John of God Subiaco Hospital and we would like to thank the SJGSH PR team for those amazing pictures!

48 | NOVEMBER 2015

MEDICAL FORUM

Music

w o l B Com e

n r o H t a th

H etty Kate Live

A musical life has led jazz great James Morrison on a fabulous ride and Australia has been lucky he’s taken us with him.

Jazz trumpeter and musical polymath James Morrison is coming to town for A Journey Through Jazz with the WASO on December 2 and 3. There may be a spike in his blood pressure, and probably yours, when he hits those high notes long and hard!

“I do have regular medicals because I’ve got a pilot’s licence but, then again, I’m not usually playing the trumpet in the cockpit.

I’ve never had it monitored in the middle of a performance but I’m sure my blood pressure goes way up.”

“When I was younger, before I learnt to do things the proper way, I burst a blood vessel that made my nose bleed. It’s not uncommon, we jazz musicians suffer for our art!”

James readily concedes that the early days of jazz were inevitably linked with drugs, alcohol and a lot of self-inflicted suffering.

“It was often viewed as a rite of passage and part of being a jazz musician. Many of the greats such as Miles Davis and John Coltrane were junkies or alcoholics and a lot of younger musicians at the time wanted to be like them. But clearly you don’t have to get stoned to play great music and, in fact, it doesn’t help at all.”

“It was pretty incredible that they were so creative in spite of their drug taking.”

“Thankfully, it’s much less prevalent now and people are much more aware of their own health. Within the jazz fraternity it’s regarded as not a good road to even think about going down. But 30 years ago if I’d wanted to put a Big Band together and stipulated that no one had a

MEDICAL FORUM

drinking problem it would’ve been almost impossible.”

“Now it’s more about those same musicians having a glass of red wine with dinner.”

There’s a strong musical thread running through the Morrison genes. His parents played instruments, James started early and his own children have inherited a healthy dose of talent.

“I started playing the trombone when I was seven, heard a jazz band and was absolutely inspired. From that point on there was never any doubt about what I was going to do with the rest of my life.”

“Our three sons are all very musical. The oldest is studying computer science and plays for his own enjoyment while the younger two are at the Music Academy at the University of South Australia where I’m Head of School. I think I’m pretty clever to have bred my own rhythm section!”

One thing that James doesn’t suffer from, and never has, is performance anxiety.

“The first moment I heard jazz I thought, ‘that’s the coolest thing on earth, I want to do that!’ And to get nervous and tense just seems a totally inappropriate reaction to playing music. My whole life is about standing in front of people who are happy and want to have their spirits lifted. They want to be there, they want to enjoy themselves. Why would you be nervous about that?”

“In one of my first solo performances the slide on the trombone came off and flew into the audience. I was eight years old, it brought the house down with cheers and a

Ja me s M orriso n

standing ovation. I thought, ‘this is great… even when things go wrong they still love you!’.”

“On a more philosophical level, I do feel I’ve been very blessed. I could’ve been born with musical talent in a country where the most important thing was dodging bullets or finding something to eat. So it’s important for me to share the joy with an audience, it’s a nice feeling.”

What can the audience expect from a Journey Through Jazz with vocalist Hetty Kate and WA’s own symphony orchestra?

“Well, we’ll be moving from A-Z but we won’t be doing every single letter! It does give us two names to hang our hats on from Louis Armstrong to Joe Zawinul but the music will evolve from early Jazz to Swing and Bossa Nova.”

“Hetty Kate is a great young vocalist and sings across a wide range from Honeysuckle Rose to Be Bop. It’s going to be a lot of fun to play.”

By Mr Peter McClelland

NOVEMBER 2015 | 49

KILLING TIME A lawyer and a woman are sitting next to each other on the plane from Cairns to Perth. That’s a very long flight so in the end the lawyer decides to make some conversation and asks the woman if she would like to play a fun game. The woman is tired and just wants to take a nap, so she politely declines and tries to catch a few winks.

The lawyer persists that the game is a lot of fun. “I ask you a question, and if you don’t know the answer, you pay me only $5; you ask me one, and if I don’t know the answer, I will pay you $500.”

This catches the woman’s attention, and to keep him quiet she agrees to play the game.

The lawyer asks the first question. “What’s the distance from the Earth to the Moon?”

The woman doesn’t say a word, reaches into her purse, pulls out a five-dollar bill and hands it to the lawyer.

“THE END IS NEAR. TURN YOURSELF AROUND NOW… BEFORE IT IS TOO LATE.” As a car speeds past them, the driver leans out his window and yells: “Leave people alone, you religious nutters. We don’t need your lectures.”

From around the next curve they hear screeching tyres and a big splash.

Shaking his head, Father Patrick says: “Dat’s da terd one dis mornin’.”

“Yaa,” Sean agrees, then adds: “Do ya tink maybe da sign should just say: BRIDGE CLOSED

FACEBOOK FUNNIES As I walk through the valley of the shadow of death I say unto myself I SHALL NEVER...

USE GOOGLE MAPS AGAIN...

If you’ve had cats, the singles virus may already be inside you.

Now, it’s the woman’s turn so she asks the lawyer, “What goes up a hill with three legs, and comes down with four?” The lawyer uses his laptop, searches all references. He uses the Airphone; he searches the Net and even sends emails to all the smart friends he knows, all to no avail.

80% of my life is pulling percentages out of thin air and stating them as facts...

After one hour of searching he finally gives up. He wakes up the woman and hands her $500, she takes it a promptly goes back to sleep.

You know you’re getting old when you’re looking forward to some time off so you can have three doctors’ appointments.

The lawyer is going nuts not knowing the answer. He wakes her up and asks, “Well, so what goes up a hill with three legs and comes down with four?”

When I finish eating something I have to show my hands to the dog like I’m a blackjack dealer.

The woman reaches into her purse, hands the lawyer $5 and goes back to sleep.

You’ve reached the limitations of my medications.

NIP’N’DUCK

THE NEW GENERATION

In surgery for a heart attack, a middle-aged woman has a vision of God by her bedside. “Will I die?” she asks. God says, “No. You have 30 more years to live.”

Daughter: “Daddy, I am coming home to get married. Take out your cheque book. I’m in love with a boy who is far away from me. I am in Perth and he lives in New York. We met on a dating website, became friends on Facebook, had long chats on Whatsapp, he proposed to me on Skype and now we’ve had two months in a relationship through Viber.

Dad, I need your blessings, good wishes, and a big wedding.”

With 30 years to look forward to, she decides to make the best of it.

So since she’s in the hospital, she gets breast implants, liposuction, a tummy tuck, hair transplants, and collagen injections in her lips. She looks great! The day she’s discharged, she exits the hospital with a swagger, crosses the street, and is immediately hit by an ambulance and killed.

Father: “Wow! Really! Then get married on Twitter, have fun on Tango, buy your kids on Amazon and pay through PayPal. And if you get fed up with your husband...sell him on Ebay.”

Up in heaven, she sees God. “You said I had 30 more years to live,” she complains. “That’s true,” says God. “So what happened?” she asks. God shrugs. “I didn’t recognize you.”

QUICK THINKING

DIG IT! Archeologists were digging in a pyramid in Egypt when they found a mummy covered in chocolate and hazelnuts. They believe it to be Pharoah Rocher.

ALL IN THE LANGUAGE

A man, shocked by how his buddy is dressed, asks him, “How long have you been wearing that bra?” The friend replies, “Ever since my wife found it in the glove box.”

Sean is the vicar of a Church of England parish on the border of Northern Ireland and the Republic of Ireland and Patrick is the priest at the Roman Catholic Church across the road.

One day they are seen together, erecting a sign which says:

50 | NOVEMBER 2015

MEDICAL FORUM

Competitions

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

Entering Medical Forum’s competitions is easy!

Movie: Suffragette A stellar cast of Carey Mulligan, Helena Bonham Carter and Meryl Streep among others tell the story of the fledgling suffragette movement in 19th century Britain. After their peaceful protests urging universal suffrage fell on deaf ears, the women in the movement radicalised and their fight saw them risk everything.

In cinemas, December 26

FEATURE

COMP

Movie: Trumbo Bryan Cranston leaves behind his tortured Breaking Bad character Walter White to portray another tortured figure – but this time in a bio pic during the McCarthy witch hunt in Hollywood. Successful screenwriter Dalton Trumbo was blacklisted in 1947 and refused to name “suspicious” friends and was sentenced to a year in prison for Contempt of Congress.

In cinemas, December 26

Choral: Handel’s Messiah

Perth Symphonic Chorus (formerly Collegium Symphonic Chorus) hits the sweet notes of Handel’s famous oratorio Messiah on with soloists Sara Macliver (soprano, pictured), Sally-Anne Russell (mezzo-soprano), Richard Butler (Tenor) and James Clayton (Bass). This year, a people’s choir will join the team for a couple of the rousing choruses. If you’re interested, www.collegiumsymphonicchorus.com.au Perth Concert Hall, December 19th, 7.30pm

Movie: Hotel Transylvania 2 The Drac pack is back in a new monster comedy animated adventure. Dracula’s rigid monster-only hotel policy has finally relaxed, opening up its doors to human guests. But behind closed coffins, Drac is worried that his adorable half-human, half-vampire grandson, Dennis, isn’t showing signs of being a vampire.

In cinemas, November 26

Music: James Morrison & WASO A Journey Through Jazz features Australia’s favourite trumpeter James Morrison playing all the standards made great by the likes of Louis Armstrong, Ella Fitzgerald, Benny Goodman, Duke Ellington, Miles Davis and Herbie Hancock. With the backing of the full symphony orchestra conducted by Benjamin Northey, it will be a cool night of hot jazz.

Perth Concert Hall, December 3 & 4, 8pm; Medical Forum performance December 3

Doctors Dozen Winner There were some highly eclectic wines in the Wine Thief Doctor’s Dozen and Dr Michael Page, a Chemical Pathology Registrar at Fiona Stanley Hospital, was the happy winner. Michael says he’s entered on numerous occasions and is looking forward to sampling something a little different. A couple of the wines are so unusual they even have corks!

Winners from the September issue Music – Broadway to La Scala: Dr Olga Ward

Movie: Freeheld Based on a true story that made headlines in 2007, Julianne Moore is a New Jersey Police Detective whose world is shattered when she becomes terminally ill and government officials prevent her from assigning her pension to her loving partner, Stacie Andree (Ellen Page). With the help of fellow police officers and a larger-than-life political activism the fight begins to overturn that decision.

In cinemas, November 26

Comedy – Stand UP!: Dr Brendan Connor Movie – The Walk: Dr My Nguyen, Dr Jens Buelow, Dr Alem Bajrovic, Dr Sarah Chisolm, Dr Christine Lee Baw, Dr Esther Moses, Dr Geoff Mullins, Dr Wen Loong Yeow, Dr Chin Tuck, Dr Bibiana Tie

Safe In Our Hands? t Protecting Kids t Regulation & Accountability t Wine, Competitions & Travel t Clinicals: TB, Allergy, Sinusitis, Aspirin, Iron, Psychosis and More…

Major Sponsors

September 2015 www.mforum.com.au

Movie – The Martian: Mr Ray Barnes, Dr Brett Baird, Dr Nai Lai, Dr Trixie Dutton, Dr Alarna Boothroyd, Dr Lawrence Chin, Dr Jason Chin, Dr David Storer, Dr Simon Turner, Dr Cathy Kan Movie – Macbeth: Dr Cameron Britton, Dr Brad Power, Dr Greg Glazov, Dr Deker Scurry, Dr Peter Brockhoff, Dr Bastiaan de Boer, Dr Andrew Christophers, Dr Fiona Sluchniak, Dr Richard Riley, Dr Stanley Koo Movie – Blinky Bill: Dr Andrew Toffoli, Dr Astrid Valentine, Dr Wendy Sexton, Dr Jenny Philip, Dr Belinda Lowe, Dr Jim Gherardi, Dr Kym Silove, Ms Jo Marks

MEDICAL FORUM

NOVEMBER 2015 | 51

medical forum FOR LEASE

MURDOCH New Wexford Medical Centre – St John of God Hospital 2 brand new medical consulting rooms available: t TRN BOE TRN t DBS CBZ QFS UFOBODZ Lease one or both rooms.

For further details contact James Teh Universal Realty 0421 999 889 KBNFT!VOJWFSTBMSFBMUZ DPN BV MURDOCH Wexford Medical Centre consulting rooms available for lease.

Modern and well lit.

Secretarial support and IT system use available if required.

1MFBTF DPOUBDU "J PO 0410 786 007 PS FNBJM BQUSBO!KPJOUTXFTU DPN BV NEDLANDS Hollywood Medical Centre – 2 Sessional Suites.

Secretarial support available.

Phone: 0414 780 751

SHOALWATER Sessional and/or permanent rooms available at our brand new Shoalwater Medical Centre.

Fully furnished and fitted out ideal for medical specialists and allied health practitioners.

Full secretarial support if required.

Fully equipped treatment room and procedure areas available.

Experienced and friendly nursing and admin team.

Located near both the Waikiki Private Hospital and Rockingham Hospital.

Please phone Rebecca on 08 9498 1099 or Email manager@sevilledrivemedical.com

ARMADALE 3PPNT UP SFOU JO "SNBEBMF PO "MCBOZ )JHIXBZ OFYU UP 4,( 3BEJPMPHZ 8FTUFSO 1BUIPMPHJDBM %JBHOPTUJD BOE WFSZ DMPTF UP "SNBEBMF )PTQJUBM GPs and all specialists are welcome.

For further information please contact Wendy on (08) 9390 0001 or email BMJBUJ !IPUNBJM DPN GPS B TUSJDUMZ confidential discussion.

BUSSELTON Suite 1/69 Duchess Street Busselton t &YDFMMFOU $#% MPDBUJPO XJUIJO NFEJDBM dental complex opposite Police Station Court House complex t "DSPTT UIF SPBE GSPN NBKPS 8PPMXPSUI complex t $PNQSJTFT PGGJDFT MBSHF XBJUJOH boardroom, reception, kitchen lunchroom, storeroom & 2WC’s. t "QQSPY GMPPS BSFB TRN %FUBJMT -FO .B[HB 2VFFO 4USFFU #VTTFMUPO (08) 9754 1522 Email: mazga@iinet.net.au www.professionalsbusselton.com.au NEDLANDS Hollywood Medical Centre 4VJUF .POBTI "WF "WBJMBCMF GPS MFBTF OPX - 86 sq. metres - Fully fitted DBS CBZ Contact Irene: 0409 688 339 or email irene.tay8@gmail.com WEST PERTH 'PS MFBTF BU $PMJO 4USFFU Medical Consulting Suite is now available GPS MFBTF $PMJO 4USFFU %BZ )PTQJUBM JT 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 MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available.

Email: gcford56@gmail.com NEDLANDS Hollywood Specialist Centre.

Two large furnished suites available with secretarial support.

"WBJMBCMF PO B TFTTJPOBM CBTJT .POEBZ to Friday.

Phone: Leon 0421 455 585 or Gerry 0422 090 355

RESIDENTIAL FOR LEASE

RURAL POSITIONS VACANT

WELLARD )PVTF "DDPNNPEBUJPO UP 3FOU Male owner, non-smoker – professional, seeking non-smoking working professional or couple to rent in newly built house.

-BSHF N Y N #FESPPN QBSUMZ GVSOJTIFE room with built in robes.

Own bathroom with separate toilet and vanity.

Separate front TV room / Office for own use. %JTDVTT MBVOESZ LJUDIFO GPPE arrangements – open plan living /dining. %VDUFE SFWFSTF DZDMF BJS DPOEJUJPOJOH throughout house. %PVCMF MPDL VQ HBSBHF XJUI TPNF TUPSBHF available. Secure.

"QQSPY NJOT ESJWF UP 'JPOB 4UBOMFZ Hospital. 5 minute drive to shops and train station.

TJOHMF PS DPVQMF QFS XFFL JODMVTJWF PG JOUFSOBM CJMMT JODMVEJOH /#/ internet access.

Terms maybe negotiable.

"WBJMBCMF OPX Email Tim at tim@empyrean.wa.edu.au Mb: 0447 698 467

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

INTERSATE URBAN POSITION SYDNEY Campsie a busy inner west suburb of Sydney a city of cultural diversity.

PG CJMMJOHT GPS UIF GJSTU NPOUIT Looking for VR GPs with unrestricted provider number on a part-time or full time basis.

8JUI BMM "MMJFE )FBMUI 4FSWJDFT BOE RN support.

Prefer Chinese speaking but not necessary. $POUBDU %S #FO "OH 0426 271 168 or bhc2008@hotmail.com

URBAN POSITIONS VACANT SCARBOROUGH 4DBSCPSPVHI #FBDI .FEJDBM $FOUSF 1BSU UJNF (1 SFRVJSFE GPS "GUFS )PVST QN UP QN BOE XFFLFOE IPMJEBZ SFMJFG sessions. .JYFE #JMMJOH "UUSBDUJWF *ODPNF 1MFBTF DPOUBDU 4VF %FMMB #POB on 0413 646 154 Email: pracman@sbmc.com.au WILLETTON GP VR required long term Full time or Part time FBSOJOHT Contact: 0412 346 146 ampmdoctors@westnet.com.au

HELENA VALLEY

PSYCHIATRISTS INVITED

"SF ZPV JOUFOEJOH UP TUBSU 1SJWBUF Practice? This is a sheer walk in!

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

Furnished consulting rooms with secretarial support: "OOPJT 3PBE #JCSB -BLF 8" $VSSFOUMZ 1TZDIJBUSJTU a Psychologist work here Clinic is open 5 days a week EBZ QIBSNBDZ BOE (1 TVSHFSZ JT OFYU EPPS 5 minute drive to St John of God & Fiona Stanley You are welcome to visit us or Phone Navneet 94147860 www.blsc.net.au

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

Please call 0412 839 977 for further information.

85

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

HELENA VALLEY General Practitioner FT/PT VR for privately owned general practice in Scott Street, Helena Valley.

The well-established clinic is fully accredited and computerized with full time RN support.

60-65% billings + pip incentives.

Mixed billings.

Please contact: pmanager@hvmc.com.au or call 9255 1161

GREENWOOD (SFFOXPPE ,JOHTMFZ 'BNJMZ 1SBDUJDF The landscape of general practice is DIBOHJOH BOE JU JT DIBOHJOH GPSFWFS "SF you feeling demoralised by the recent Federal government proposal on changes to Medicare? %P ZPV GFFM UIBU ZPV IBWF UP LFFQ CVML billing in order to retain patients?

It doesn’t have to be this way!!

Come and speak to us and see the different ways in which we operate our general practice. #F QBSU PG UIF HBNF DIBOHFS Our practice is located north of the river.

4PSSZ XF BSF OPU %84 Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion.

DECEMBER 2015 - next deadline 12md Friday 13th November – Tel 9203 5222 or jasmine@mforum.com.au

86

medical forum

DIANELLA Part time VR GP wanted for "GUFS IPVST $MJOJD "DDSFEJUFE 1SJWBUF .FEJDBM $FOUSF XJUI BEKPJOJOH QIBSNBDZ (SFBU GBDJMJUJFT t &YDFMMFOU SFNVOFSBUJPO t 4PGUXBSF #FTU 1SBDUJDF Phone Terri 9276 3472 or Email resume: practicemanager@dianellamedical.com.au

WEST LEEDERVILLE GP Addiction Medicine. #VTZ (1 "EEJDUJPO .FEJDJOF DMJOJD needs medical staff.

The clinic is closely affiliated with an excellent team of psychologists, psychiatrists, community health staff and a private psychiatric hospital.

Close contact with government agencies with excellent support.

Good remuneration as all billing is mental health item numbers. %FEJDBUFE BOE FYQFSJFODFE TUBGG B devoted patient population.

Rewarding work in a stimulating environment. Flexible sessions to suit.

Cambridge Clinic - Phone after BN 9388 2005

COMO Want variety in your work?

Special interest opportunities at the Well Men Centre in Como.

Part time GP’s for our Perth Mole Clinic, Skin Cancer Screening Service and for our Holistic Health Management Programme.

Call 9474 4262 or Email: wellmen@optusnet.com.au MAIDA VALE We are seeking an enthusiastic VR/ Non-VR GP for a FT/PT position.

Our friendly practice is located in the ,BMBNVOEB )JMMT SFHJPO Purpose built, fully accredited and private billing.

Excellent patient profile with full admin and nursing support.

If interested please phone Peter on 9454 5544 or email to office@hillsfamilymedical.com.au CLAREMONT Growing GP practice located in the trendy suburb of Claremont.

PG CJMMJOHT Looking for VR GPs with unrestricted provider number on a part-time or full UJNF CBTJT 8FFLFOET BWBJMBCMF GPS %84 EPDUPST "# FYFNQUJPO

Fully computerised with on-site pathology and RN support.

Located in a modern complex with access to the gym and pool.

For further information please contact %S "OH PO 9472 9306 or Email: info@thewalkingp.com.au WEST LEEDERVILLE Full time/part time GP required for privately owned well established practice in West Leederville.

Excellent patient base.

It’s a Private billing practice with excellent earning potential. $POUBDU TBOKBZLBOPEJB !ZBIPP DPN

CURRAMBINE GP clinic looking for a Full Time or Part Time GP for after-hours clinic.

Female Full Time or Part Time position BMTP BWBJMBCMF %84 XFMDPNF New Purpose built medical centre, Great facilities, NOR, Non-Corporate.

- Onsite nurse - Excellent Remuneration 4PGUXBSF #FTU 1SBDUJDF "DDSFEJUFE QSBDUJDF Call Michelle on 08 9305 3232 Or Email resume to: shentonavenuemedical@outlook.com

SEVILLE GROVE 4FWJMMF %SJWF .FEJDBM $FOUSF JT TFFLJOH a hardworking and enthusiastic VR ' 5 PS 1 5 (1 UP KPJO PVS GSJFOEMZ professional team.

Our centre see’s 200-250 patients per day, we also have an onsite pharmacy, pathology, allied health and visiting specialists.

Full complement of GP’s, clinical staff and administration.

Percentage of billings based on experience, with annual percentage increase.

1MFBTF QIPOF 3FCFDDB PS %FCCJF PO 08 9498 1099 or Email CV to manager@sevilledrivemedical.com

MANDURAH Rainbow health, Mandurah Seeking VR and non VR GP’s for after hours and weekend shifts.

Non VR’s can avail VR rebates through RLRP program. /PO 73 T BMSFBEZ XPSLJOH JO "VTUSBMJB XJMM be given preference.

Contact: g_vinu@yahoo.com

DUNCRAIG & OSBORNE CITY Duncraig Medical Centre Osborne City Medical Centre Require a female GP. Flexible Mon to Fri hours. (after hours optional) Excellent remuneration.

Modern, predominantly private billing practice. Fully computerised.

Please contact Michael on 0403 927 934

BULLCREEK/WANNEROO FORRESTFIELD Required VR/non VR GP for #VMM $SFFL 8BOOFSPP 'PSSFTUGJFME /PSNBM BOE BGUFS IPVST BWBJMBCMF %84 location available and good percentage offered.

Nursing, Pathology and "MMJFE )FBMUI BWBJMBCMF Contact 0401 625 712 or Email Waliadr@hotmail.com LANGFORD P/T or F/T GP position available Soon to be opened practice at Langford E-mail: contact@langfordfamilypractice.com.au

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology BOE "MMJFE TFSWJDFT PO TJUF Privately owned.

Generous remuneration.

1MFBTF DBMM %S 5BLMB 0439 952 979

WHITFORD CITY URGENT, FT/PT VR General Practitioner required.

Excellent remuneration minimum guaranteed income.

State of the art general practice in the heart of Hillarys.

Outstanding team, great admin staff support and excellent nursing. $POUBDU %S 3BGJL .BOTPVS rafik.mansour@whitfordcityfamilypractice.com.au

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

MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a %JTUSJDU PG 8PSLQMBDF 4IPSUBHF Highland Medical Madeley is a new non DPSQPSBUF QSBDUJDF XJUI GFNBMF NBMF General Practitioners.

Sessions and leave negotiable, salary is compiled from billings rather than takings.

6Q UP PG CJMMJOHT QBJE EFQFOEBOU PO experience).

Please contact Jacky on 0488 500 153 or E-mail to KBDLZ TUFWFO!MJWF DP VL

MYAREE FT / VR GP required.

Private billing.

Excellent remuneration. %PO U XBOU UP CVSO PVU Work weekdays only.

Predominantly younger demographic.

Variety – skin cancer medicine as well as mainstream.

Confidential enquiries to Julia SFDFQUJPO !NZBSFFNFEJDBMDFOUSF DPN BV or 9317 8882

BERTRAM VR or Non VR GP required Part Time/ Full Time for our Two Practices in the Suburb PG #FSUSBN - Bertram Family Medical Centre 'VMMZ $PNQVUFSJTFE XJUI #FTU 1SBDUJDF Nurse Support and onsite Pathology.

- Champion Medical Centre 0QFOJOH 0DUPCFS XJUI POTJUF %FOUJTU "MMJFE IFBMUI BOE POTJUF 1BUIPMPHZ (PPE 1BUJFOU CBTF #VTZ 1SBDUJDFT 3BUFT Negotiable, Privately Owned Contact Tricia on 9497 1900 for a $POGJEFOUJBM %JTDVTTJPO PS &NBJM CV to: info@forrestroadgp.com.au

"SF ZPV MPPLJOH GPS EPDUPST GPS ZPVS medical practice?

"VTUSBMJBO .FEJDBM 7JTBT JT PXOFE BOE SVO CZ 1SBDUJDF .BOBHFST CBTFE JO 8" who have over 20 years experience of the 6, BOE "VTUSBMJBO IFBMUIDBSF TZTUFNT We currently have a number of doctors XIP BSF MPPLJOH GPS QPTJUJPOT JO "VTUSBMJB We are able to assist practices with all paperwork involved including the migration process (if required).

Please visit our website www. australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or "OESFB PO 0401 371 341

SHOALWATER F/T VR GP required for our brand new medical centre located in Shoalwater %84 0GGFSJOH NPEFSO TVSSPVOET and fully computerised clinical software. We are a friendly, privately owned and run centre. " GVMM DPNQMFNFOU PG OVSTJOH TUBGG admin team as well as onsite allied health/specialists and pathology. generous remuneration offered Please phone Rebecca on 08 9498 1099 or Email CV to manager@sevilledrivemedical.com

MINDARIE Harbourside Medical Centre is looking for a GP – preferably VR FT/PT. "(1"- BOE 8"(1&5 Onsite pathology, fully-equipped.

6Q UP CJMMJOH Contact 0417 813 970 or Email: mmutahar@harboursidemedicalcentre.com.au

HUNTINGDALE Our privately owned practice is located 4PVUI PG 3JWFS JO BO BSFB PG %84 We are looking for a full time VR GP UP KPJO PVS GSJFOEMZ UFBN Flexible workhours available.

8F VTF #FTU 1SBDUJDF 4PGUXBSF have modern equipment and full nursing support.

1MFBTF DPOUBDU %S 4JNPO #FSOT on 9493 8333 or Email Simon.berns@srfp.com.au

SORRENTO F/T or P/T GP for busy Sorrento Medical Centre, Normal/after hours available , we are like family, nurse & allied services on board , remuneration

1MFBTF DBMM %S 4BN 0439 952 979

DECEMBER 2015 - next deadline 12md Friday 13th November – Tel 9203 5222 or jasmine@mforum.com.au

medical forum JOONDANNA 8F BSF TFFLJOH B 73 (1 UP KPJO PVS GSJFOEMZ team on a part-time or full-time basis.

New, state of the art medical centre.

Flexible hours and billing.

Percentage negotiable.

Fully-computerised. /VSTJOH TVQQPSU GPS $%.1 Please call Wesley on 0414 287 537 for further details.

KARDINYA Non-corporate General Practice presents an exciting opportunity for VR P/T GP to KPJO PVS FYDFQUJPOBM UFBN Well managed long established 3 doctor QSBDUJDF XJUI DPNQSFIFOTJWF $%. program.

This is an excellent opportunity for a GP who wants to be busy and work as part of happy and well established team within UIJT 8"(1&5 BQQSPWFE QSBDUJDF %84 GPS BGUFS IPVST POMZ Enquiries to Practice Manager on 0419 959 246 or practicemanager@kelsomg.com.au WILLETTON )FSBME "WFOVF 'BNJMZ 1SBDUJDF We are looking for a suitable full-time or QBSU UJNF 73 (1 UP KPJO PVS GSJFOEMZ UFBN We are a busy, non-corporate practice, fully computerised and accredited, with registered nurse support.

Rates negotiable *G ZPV XPVME MJLF UP KPJO VT QMFBTF FNBJM Trish hafp@eftel.net.au or call 9259 5559. www.heraldavefamprac.com.au

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COMO Como Medical Clinic requires a full UJNF PS QBSU UJNF 73 (1 UP KPJO PVS friendly team.

We are a small non-corporate, wellFRVJQQFE "(1"- BDDSFEJUFE BOE mainly private billing practice.

You will be well supported by the owner-doctor and two practice nurses.

Flexible working hours and holidays (school holidays available).

Offering 65% receipts.

Please contact Linley Gray on 0417 978 574 for confidential enquiries.

HAMILTON HILL " GFNBMF (1 SFRVJSFE GPS B DMJOJD JO B %84 BOE "0/ BSFB NJOVUFT ESJWF from Fremantle. %PDUPS (1 1SBDUJDF 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 TWO ROCKS GP wanted for brand new, purpose built, privately owned and fully computerised medical practice in Two Rocks. %84 BSFB NJOVUFT GSPN UIF $#% VR preferred. #FTU 1SBDUJDF TPGUXBSF Generous billing percentage for the right candidate.

For confidential enquiries contact 0415 684 926 or email mrobins@ormc.net.au

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

www.gpwest.com.au

VR GPs wanted to join a friendly team

Okely Woodlake Village Newpark Medical Centre Medical Centre Medical Centre CARINE

ELLENBROOK

New Gumnut Medical Centre

GIRRAWHEEN

WANNEROO

contact Dr Kiran Puttappa kiranpkumar@hotmail.com

0401 815 587

GP WANTED – BELMONT CITY MEDICAL CENTRE Ŕ Busy non corporate practice requires Full Time/ Part Time VR GP Ŕ On site Chemist, Pathology, Physiotherapy, Dentist and Gym Ŕ 6km from Perth CBD (opposite Belmont Forum Shopping Centre) Ŕ 65% - 70% of receipted billings Ŕ Excellent nursing support Ŕ Accredited and fully computerised Ŕ Guaranteed hourly income for initial 3 months.

GP Superclinic @ Midland Railway Workshops General Practitioner (unrestricted VR) Wanted – PT or FT Looking for a VR GP to work part time (minimum three days per week) or full time.

We are busy modern state of the art facility that is: Ĺ” Friendly, collegiate, team environment Ĺ” Fully Computerised Ĺ” AGPAL Accredited and WAGPET accredited for teaching and training. Ĺ” Has mixed Billing Ĺ” Onsite pathology, pharmacy, physiotherapy, Medical & Surgical Specialists to mention a few Ĺ” Nursing Support Ĺ” Opportunities to join our Occupational Health Team. Ĺ” Purpose built 9 bay treatment room and dedicated high tech procedural unit for specialized procedures. Ĺ” Ideally located opposite the new St John of God Midland Hospital, neighboring developments include: the proposed Curtin Medical School, International Business Hotel.

Fantastic opportunity to build a long term career and establish trusted relationships within a new patient base.

Ĺ” DWS doctors can apply for after hours and weekend sessions Ĺ” Flexible sessions available

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

Metro Area GP positions available VR & Non – VR Dr’s are welcome to apply.

Send applications to hr@betterhealthcare.com.au

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

DECEMBER 2015 - next deadline 12md Friday 13th November – Tel 9203 5222 or jasmine@mforum.com.au

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medical forum

Cottesloe Part-Time VR GP Wanted This is a great opportunity in a great location. Having opened in March, we are growing strongly and are looking for a VR GP to help us on Fridays, with room to expand as we grow.

We’re a high quality, very innovative and unique practice combining the best of traditional family medicine with many extended services on-site. These include laser treatments, skin and cosmetics, DEXA Body Composition scanning and on-site psychiatrist, dietician and health coach. Full-time nurse support.

Predominantly private billing.

With great staff, patients and facilities, if you are looking for a long-term option in the Western Suburbs (which will give you many opportunities to avoid being tied to Medicare) we would love to hear from you!

Email Dr Richard Newton (richard@azuremedical.com.au) for a full description and brochure, or call the practice on 9286 9900 for more information. www.azuremedical.com.au.

Medical Specialist Acquired Brain Injury Location: East Victoria Park Part Time Brightwater Oats Street is looking for a part time Medical Specialist to join it’s interdisciplinary Rehabilitation team.

Oats Street is a state of the art purpose built rehabilitation facility for people 18 – 65 years who have experienced a moderate to severe brain injury.

Whilst supporting individuals across the full brain injury spectrum, the program has a strong focus on cognitive rehabilitation.

The team is comprised of allied health professionals, nurses and disability support workers with the sessional medical specialist (2 sessions per week) required to ensure medical governance of the 48 clients. The role also provides, as required, medical oversight of a transitional program for 12 people with complex disability at Marangaroo.

As a medical specialist you may have a background in rehabilitation, geriatrics or neurology and have had extensive experience within the acute hospital setting.

Remuneration will be in line with AMA guidelines and working days and hours are negotiable.

For further information please contact Tim Lo on 0438991375

www.brightwatergroup.com

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

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With a reputation built on quality of service, Optima Press has the resources, the people and the commitment to provide every client with the finest printing and value for money.

9 Carbon Court, Osborne Park 6017 } Tel 9445 8380

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

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F nt Medical etings Suppleme s Gre en Christma tact Jenny Heyd Con 5222 or .au 3 0 2 9 m on forum.co m @ n je email Your WA Consultant – Jenny Heyden Tel 9203 5544 or Mob 0403 350 810

DECEMBER 2015 - next deadline 12md Friday 13th November – Tel 9203 5222 or jasmine@mforum.com.au

medical forum

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GENERAL PRACTITIONERS REQUIRED Belvidere Health Centre (39 Belvidere Street, Belmont) Looking for something different? Are you seeking a flexible working environment? Our clinic offers the following opportunities to GPs’ wanting to contract their services: Ŕ Ŕ Ŕ Ŕ Ŕ Ŕ

Generous rates Flexible working hours Clinical nursing support Fully computerised systems Varied client base On site Iron Infusion therapy

Days currently available: Mondays, Thursdays and Fridays.

For further information please contact Rod Redmond at (08) 9458 0505 or r.redmond@archehealth.com.au

HEALTH WATCH CLINICS MELVILLE / JANDAKOT / COTTESLOE General Practice Health Watch Clinics is doctor owned and non-corporate.

There is an emphasis on good medicine and not high throughput general practice.

We require FT/PT male or female VR GP for our clinics.

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

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

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

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

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

To find a practice that meets your needs, call:

Brad Potter on 0411 185 006 Do you need a website or a refresh?

Contact Thinking Hats today and we can help! hats@thinkinghats.net.au

Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au

DECEMBER 2015 - next deadline 12md Friday 13th November – Tel 9203 5222 or jasmine@mforum.com.au