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AUSTRALIA’S LEADING INDEPENDENT MEDICAL PUBLICATION I www.australiandoctor.com.au

30 SEPTEMBER 2016

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BROKEN HEART

THE LAST POST

Professor Max Kamien on the invisibility of deafness Opinion, page 34

A rare cause of liver failure Grand Rounds, page 16

Will faxes finally fade away? News, page 3

WorkSafe scheming Insurance agents employing dirty tricks to avoid payouts PAUL SMITH INSURERS have been accused of distorting doctors’ clinical reports on injured workers to prevent payouts for their rehabilitation. An investigation into the running of Victoria’s WorkSafe scheme uncovered a range of dirty tricks used by insurance agents in dealing with claims. They included shopping around for independent medical examiners (IMEs) who were likely to deliver

assessments showing that workers were fit to return to work. According to Victorian Ombudsman Deborah Glass, who published her inquiry report this month, vulnerable people were harmed as a result of cases being deliberately delayed or cancelled on flimsy medical pretexts. In one case, a woman took her own life after losing medical treatments for a stress disorder caused by workplace sexual assault

and harassment. One of her children told the inquiry: “While my [mother] was cut off from their medical expenses ... we struggled to keep up with them. “Her treatment was denied, and the sheer stress and anxiety caused her to get worse, and I watched her lose all hope. “My mother proceeded to commit suicide ... [A few days later], I received letters ... stating that every program had been approved and her

medical expenses reinstated. “I burst into tears and couldn’t look at them. “The help that the treatments could have given my mother is unimaginable … she may still be alive.” In all, five insurance companies operated as agents for the WorkSafe scheme — Allianz, CGU, QBE, Gallagher Bassett and Xchanging. Ms Glass said that under the scheme, the agents paid IMEs to carry out assessments on claimants so they

could make informed decisions about a worker’s entitlements, both compensation and medical services. However, some agents “doctor-shopped”, simply choosing IMEs on the basis that they were good for the terminations of payments. Another tactic used by the agents was to cherrypick the findings of the medical assessments, in some cases using just one line from an IME report to reject a claim. There were also cases where agents had failed to

RACGP revenue rises to $57m PAUL SMITH THE RACGP seems to be escaping the hard financial times endured by general practice, with more than $57 million filling its coffers during the past financial year. This is a 14% increase on revenue from the previous year — and a significant chunk of the money went into the college’s media and advertising budget. According to the college’s annual report, the RACGP spent $6.6 million on media and advertising in 2015/16, compared with $2.6 million the year before and just $366,000 the year before that. Although the college has not given a breakdown, much of the money would have gone into its ‘The Good GP’ campaign, which included prime-time TV advertisements designed to raise the

provide crucial background information about injured workers to IMEs when they were forming their opinions. An injured police officer wrote a complaint to Gallagher Bassett saying: “My issue is that you have only included half of the information on the referral provided by [my GP]. “By reading this full referral and not selectively removing elements that are detrimental to your justification, it can clearly be seen cont’d page 4

FIGHTING THE GOOD GP FIGHT

college’s brand awareness among the public. During the federal election, the college also launched its ‘You’ve Been Targeted’ campaign, a TV and social media campaign against the government’s decision to freeze GP rebates until 2020. The increase in revenue amid the Medicare freeze is partly the result of record membership numbers, now totalling 32,000. Some $27 million was generated by membership fees — $1420 a year for a full-time GP — and the payments non-RACGP members make to the college to collect and collate CPD points under its Quality Improvement and CPD (QICPD) program. The sums raised have risen by more than one-third in the space of two years. But the figures have reignited criticism

As Dr Frank Jones steps down as RACGP president this month, he speaks about leading the specialty in politically turbulent times. News Review, page 11

cont’d page 4

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ONLINE THIS WEEK australiandoctor.com.au TOP 5 RECENT HOW TO TREAT ARTICLES 1. Osteoarthritis of the hip 2. Bulimia nervosa 3. Hyperhidrosis and other sweat gland disorders 4. Cystic fibrosis 5. Strabismus in children

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Only half of younger GPs doing home visits CLARE PAIN ONLY a minority of new GPs undertake home visits or visit nursing homes, an Australian study shows. The survey of 212 GPs qualified for fewer than five years found that 48% undertook home visits and 41% visited nursing homes. The study also showed that those who had experienced visits as part of their training were five times more likely to do home visits, and more than 10 times more likely to do nursing home visits. The University of Newcastle researchers said this finding suggested that GP training would benefit from having a requirement for trainees to do some home and nursing home visits. “At present, there is no program-wide requirement in the Australian GP vocational training program for trainees to undertake nurs-

Home visits should be part of GP training, researchers say. ing home visits or home visits. Involvement of trainees in out-of-surgery practice is at the discretion of the supervisor or of individual practice policy,” they noted. “Financial incentives for trainees’ out-of-surgery consultations (with payment to practices and/or trainees) as well as compulsory requirements may be appropriate,” they added. However, study co- author

Conjoint Professor Parker Magin, a GP and senior lecturer in general practice, said any requirement for registrars to undertake visits would have to take into account the apprenticeship model of GP training and how different practices were organised. “I think there needs to be a dialogue between the regional training organisations and supervisors,” he

told Australian Doctor. The study also revealed that younger GPs were less likely to do home visits than older GPs, with 63% of doctors under 35 not visiting patients in their homes, compared with 18% of those over 40. “It may be that this represents an increasing reluctance of graduating cohorts of GPs to perform home visits. But it may be that the GP assumes a ‘fuller’ role within the practice over time,” the study authors said. The findings of the 2015 Australian study compare poorly with rates of home visits and nursing home visits globally, which a 2001 study put at around 90%. Family Practice 2016; online.

Q&A with Dr Bruce Willett, chair of General Practice Supervisors Australia. See: page 8.

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Pharmacists claim vax pilot a success MICHAEL WOODHEAD PHARMACISTS have brushed off GP concerns about in-store flu vaccinations, declaring last years program a success in reaching patients who would otherwise have been unimmunised. A review of a WA pharmacy-led flu vaccination program found that the 76 pharmacies provided 15,621 vaccinations, with no major adverse events and fewer than 1% minor adverse events. The pharmacies reported high customer demand for trivalent flu vaccination, for which they charged $20-30,

even though one in six of those who opted to pay were eligible for free immunisation from a GP because they were over 65. A high proportion of the pharmacy flu vaccinations were provided in regional and remote areas, which the Curtin University researchers said might be filling a gap due to low access to GPs in these areas. Some pharmacists reported that they had to overcome objections or negative attitudes from local GPs to provide flu vaccinations. Nevertheless, almost all pharmacies involved were

IMG pain is charitable INTERNATIONAL medical graduates who are paying thousands of dollars to the Australian Medical Council (AMC) may be surprised to learn they have in fact been donating to charity. Overseas doctors have long complained about the high cost of going through AMC exams and assessments in order to practise in Australia, estimated to cost around $7000. But it turns out the AMC is officially a charity rather than a bureaucracy, based on the “charitable benefits” it offers to IMGs, medical practitioners, students, schools and the general community in Australia. The AMC, a not-for-profit organisation that was awarded charitable status back in July

2014, receives around $16 million in examination fees a year from around 4000 IMGs. But its commitment to charitable endeavour has brought with it some legal wrangling. The council is currently in a battle with the ACT Revenue Office. The council claims it should get a $1.3 million refund on the payroll tax it paid from 2009-2013 because its charitable status should apply retrospectively. The Commissioner for ACT Revenue initially refused to consider the AMC’s application. However, the ACT Civil and Administrative Tribunal overruled the decision, in a judgement handed down this month. Antony Scholefield

‘The impact of [this pilot] will result in more fragmentation of care.’ — Dr Kruys chair of RACGP Queensland

positive about offering vaccinations and 85% said they would like to expand to offer other vaccines to customers. However, in Queensland, where pharmacists were recently granted an

expanded role to administer pertussis and measles vaccinations, doctors have warned that pharmacy vaccination schemes could erode the proven general practice model of care.

“The impact of patients presenting to pharmacies instead of general practice will result in more fragmentation of care, missed opportunities for screening and preventive health care,

unnecessary and non-evidence-based care, and possibly increased risk and wasted health resources,” wrote Dr Edwyn Kruys, chair of RACGP Queensland, in the magazine Doctor Q. Dr Kruys said there was little evidence to show that pharmacy programs were improving vaccination coverage rates in areas where there were gaps. There were concerns about conflict of interest and pharmacies using vaccinations as an opportunity for add-on sales of other products that may be unnecessary, he added. BMJ Open 2016; online.

Last post for faxes and letters THE RACGP has identified a new “national priority” to save patients from unnecessary death: eliminating faxes and letters from the working lives of GPs. In a position statement, the college calls for a paperless health system within three years, saying the lack of timely communication is putting patients at risk. The college believes many non-GP specialists have been slow to adopt secure messaging. This has left GPs with the job of having to upload hard copy information to their computer systems. In 2015, snail mail between a hospital consultant and a GP led to one death, when a cardiologist posted a letter to tell a GP that an elderly patient, who he had started on warfarin, would need monitoring. Even though the practice was just 100m from the hospital, the letter did not arrive for two weeks, during which time the patient died from a subdural haematoma after a fall. However, ditching faxes and letters could adversely impact general practice.

System compatibility is an issue, warns Dr High. An Australian Doctor survey of 551 GPs earlier this year found that more than 90% still used fax machines, and 35% thought it was the most effective and secure way to communicate. Dr Hilda High, a Sydney oncologist,

also warned that compatibility was an issue for specialists communicating with GPs, given the different messaging systems used. “It would require us signing up to Argus, Division Report, Health Link, Medical-Objects. Use of these systems varies across the suburbs of Sydney, let alone Australia. “Each has its own subscription, usually for over $100 that we would have to pay for.” She said her practice sent letters to GPs and specialists by fax. “Most receive the fax, like we do, as an eFax that is easily integrated into the patient record. This is effectively instantaneous and saves postage and trees.” Last month, new Australian Digital Health Agency CEO Tim Kelsey said it was time for a “bonfire of the faxes”, adding that their demise would transform healthcare, just as the digital revolution had transformed other industries. Antony Scholefield

‘You have to live with your patients and look at them across the dinner table’ Doctors of Australia celebrates the diversity and passion of those working at the heart of healthcare. Launched by Australian Doctor, the project includes a website showcasing GPs’ personal stories. Tasmanian GP Dr Eve Merfield shares her story:

www.doctorsofaustralia.com.au www.australiandoctor.com.au

I’VE worked on ships in the Russian Arctic and I’ve also worked in Antarctica — I’m ‘bipolar’, as somebody once said to me. Antarctica is an amazing place. There are a lot of scientists down there doing different things and they often need help counting penguins or tagging seals. I’m a keen gardener, so when I’ve been down there, I’ve looked after the hydroponics. It’s a different life, and being isolated with a small number of people has its own challenges. You have to live with your patients and look at them across the dinner table three times a day. There are small things too. For example, I ordered something online to come in on the next ship. The bank cancelled my credit card because they didn’t

recognise the place I was buying it from. I rang them and they said, ‘It’s alright, we’ll send one in the next post’. But that was in eight months’ time. I also had some major things happen on ships. I was on an icebreaker in a remote part of the Russian Arctic and we had a helicopter crash. Seven people injured with varying degrees of injury. There was me, as the passenger doctor, and a Russian doctor who normally looked after the crew. He didn’t speak any English and I didn’t speak any Russian, but we still managed to sort it out between the two of us.

If you would like to be a Doctor of Australia, please email: jo.hartley@ cirrusmedia.com.au

30 September 2016 | Australian Doctor |

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News

IPN gives me coordinated support for my practice Doctor Alan Wallace IPN Townsville Keen rower

GPs say hospitalisations not always ‘preventable’ CARMEL SPARKE BMJ The idea that preventable hospitalisations are the result of patients struggling to access primary care may be a myth. A study by the University of NSW tracked whether patients with preventable conditions had had access to quality primary care in the weeks and months before hospital admission. It found that almost onethird of the 8715 patients with conditions such as diabetes complications, angina, asthma and influenza had visited a GP in the week of their admission. Two-thirds of patients had seen a GP in the month before their admission, and 14% had visited their GP on the day of hospitalisation. “We have been hearing anecdotally from GPs that these people needed to be admitted,” said lead author Michael Falster, from

Hospitalised patients genuinely were sicker, says Mr Falster. the Centre for Big Data Research in Health. “And the fact that people admitted for preventable hospitalisations were accessing all these other types of health services, including GPs and EDs, at

rates higher than the general population, pretty much pointed to these being sicker patients, who really needed to use these services,” he added. Potentially preventable hospitalisations are used as

a measure of primary care success and failure. According to the Australian Institute of Health and Welfare, there were 600,267 hospitalisations in 2013/14 for the 22 conditions for which hospitalisation is considered potentially preventable, representing 6% of all hospital admissions. Mr Falster said his research findings, published in the BMJ, suggested that preventable hospitalisations could be used to identify sicker patients needing highlevel managed care, possibly through the new Health Care Homes reforms. The Federal Government wants to sign up 650 GP practices to the scheme next year. Each practice will receive block payments to fund care packages for voluntarily enrolled patients with multiple chronic conditions. BMJ online; 2016.

Chiros offering to correct breech pregnancies

1800 IPN DOC enquiries@ipn.com.au ipn.com.au

| Australian Doctor | 30 September 2016

the chances of caesarean birth. “Chiropractors should be not using the Webster technique or any other inappropriate breech correction technique to facilitate breech version as there is insufficient scientific evidence to support this practice,” the college says in a statement this month. The International Chiropractic Pediatric Association, an organisation based in the US, claims it has certified chiropractors, including about 150 chiropractors in Australia, to use the Webster technique. The association’s website says the technique is a “specific chiropractic analysis and diversified adjustment (sic)”. “The goal of the adjustment is to reduce the effects of sacral subluxation/

SI joint dysfunction. In so doing neurobiomechanical function in the pelvis is improved,” it adds. One Australian clinic based in Melbourne currently advertises the technique, saying its goal is to “improve biomechanical function which balances the pelvis and promotes optimal positioning of the baby in readiness for birth”. But RANZCOG said there was insufficient evidence for chiropractors to make any claims to patients about the benefits of chiropractic treatment that can reduce the risk of a caesarean birth. Australian Doctor has contacted the Chiropractic Board for a response. Antony Scholefield

Antibacterial laundry products trigger child skin rashes HOUSEHOLD antibacterial washing products are triggering severe skin rashes that can take weeks or months to resolve, dermatologists warn. Antibacterial laundry rinse aids containing the disinfectant benzalkonium chloride cause skin irritation that can lead to granular parakeratosis, according to Dr Aaron Robinson and colleagues at the Royal Children’s Hospital in Melbourne. In a case series of six children, aged 5-14, who presented with granular parakeratosis, they reported all had a history of exposure to benzalkonium chloride via their clothing after the addition of antibacterial rinse aids to the washing machine. The dermatologists said granular parakeratosis had

PHOTO: Australasian Journal of Dermatology

That’s why I choose to be part of the Independent Practitioner Network

CHIROPRACTORS are offering to correct breech pregnancies by manipulating the woman’s pelvis despite warnings from both obstetricians and regulators. The so-called ‘Webster technique’ originally came under fire from the Chiropractic Board of Australia in March, when it declared that no chiropractic intervention should be advertised as offering “treatment to the unborn child as an obstetric breech correction technique”. But six months later, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) says chiropractors are still advertising the unproven treatment on websites, along with claims it can help women avoid breech births and minimise

been seen predominantly in the axilla and was caused by household products such as antiperspirants, but the laundry rinse aids triggered eruptions over wider areas, including the torso, neck and legs. In most cases, patients’ skin eruptions resolved over 3-4 weeks, after cessation

www.australiandoctor.com.au

of the benzalkonium chloride exposure and treatment with emollients. However, in some cases, the eruptions persisted for months and were unresponsive to topical steroids. Dr Robinson and colleagues said only a small number of people

exposed to benzalkonium chloride developed granular parakeratosis, and this could be due to genetic susceptibility, resulting in disruption of epidermal lipids via filaggrin processing. Michael Woodhead Australasian Journal of Dermatology 2016; online.

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News

Why are younger GPs not doing home visits? Only a minority of recently qualified GPs are doing home visits and nursing home visits, a study has shown. Australian Doctor spoke with Dr Bruce Willett, chair of General Practice Supervisors Australia about whether GP training needs to change.

Australian Doctor: Should we be concerned that younger GPs are not doing home visits and nursing home visits? Dr Bruce Willett: I think it’s concerning, but it’s not a recent phenomenon. I think it’s been a trend over decades now. One of the reasons is that, until recently, registrars have been a scarce commodity. They could go to job interviews and refuse to do home visits or nursing home visits, but I think that’s beginning to change. Another reason is that it is not a training requirement.

You can progress through your training and never have done a single home visit or nursing home visit. In other countries, it is part of the requirements. And there’s been an attitude shift over the generations. Being a GP is now seen more as a job than a vocation. We don’t feel that same sense of responsibility as we once did and there’s less of the doctor as a ‘martyr’. And patients have less allegiance to particular practices and particular doctors. AD: Are home visits and nursing home visits an

important role for the busy GP?

cial disaster, but medically very useful.

Dr Willett: I think it’s an important part of the work of general practice, and as supervisors, we have perhaps been remiss in not insisting our registrars do this. There are established benefits from home visits in particular. You get a wider appreciation of who the patient is, and their family and home situation. You get a feel for hygiene, for example. You learn a lot about the patient by going to their home. It’s a finan-

AD: So remuneration is a factor in the low rate of home visits? Dr Willett: Remuneration is a huge issue for all GPs. If you bulk-bill patients — and you do, for most home visits because of the nature of the very unwell people who need them — it’s usually a loss-making exercise. When you consider you need to be paying for your practice to be running while you are at the visit, it’s not going to cover your practice costs.

The bulk-billing rate for a standard home visit is $63. Of course, you can’t charge for travel time or petrol. For a 15-minute home visit, you are generally going to be out of the practice for at least an hour, which compares very unfavourably to a callout for an electrician or a plumber. AD: Should there be a requirement to do visits as part of vocational training? Dr Willett: There are already so many complex rules for registrars now, I’m reluctant to propose another one. But it’s reasonable to discuss it.

Child meningitis deaths due to untreated bore water

In Brief

MJA People living in rural areas are being

Staff writers

warned that untreated bore water exposes children to the risk of rapidly fatal primary amoebic meningoencephalitis. Doctors have raised concerns about the rare but almost universally fatal illness, caused by amoeba such as Naegleria fowleri, following the death of a 12-monthold boy at Townsville Hospital. Clinicians at the hospital say the boy, who lived on a cattle homestead in North Queensland, died of fulminant disease within 72 hours of presenting at the hospital in early 2015. It is believed he contracted the amoebic infection from untreated and unfiltered warm bore water, which is an ideal reservoir for the pathogen. N. fowleri is thought to enter the brain when contaminated water is flushed into the nasal cavity during play with water hoses, swimming or showering. In the latest case, the boy received aggressive antimicrobial treatment, but quickly deteriorated and died after being transferred to hospital. The clinicians say the organism may be found in bore water sourced from the Great Artesian Basin. It had previously caused numerous cases of primary amoebic meningoencephalitis (PAM) until

‘[Remuneration for a home visit] compares very unfavourably to a call-out for an electrician or a plumber.’

| Australian Doctor | 30 September 2016

Maybe it would be better if it was ‘strongly recommended’ by the colleges. That would strengthen the hand of supervisors. Registrars don’t want to do visits, and it’s difficult to tell them to do something they don’t want to do. Also, some practices would struggle to provide visits for their registrars. They may not have a relationship with a nursing home, for instance. I think supervisors need to harden up and expect registrars to do this — and that includes me. Dr Willett spoke with Clare Pain.

Registrars’ salaries frozen

Organisms such as Naegleria fowleri flourish in bore water household water supplies were chlorinated in the 1970s. The three recent cases have occurred in children living on rural properties that still use warm or heated bore water via hoses, pipes and taps. “The presentation of an acutely unwell child with a history of bore water exposure and signs of meningitis or encephalitis should … prompt consideration of PAM as a potentially life-threatening diagnosis,”

doctors from Townsville Hospital wrote in the Medical Journal of Australia. The rare, but serious, infection poses a public health dilemma around persuading rural families to install household water treatment, as owners often take pride in the clarity and taste of their bore water, they said. Michael Woodhead MJA 2016; 205:325-28. www.australiandoctor.com.au

THE base pay for more than 3500 GP registrars will effectively be cut in real terms as a result of the Medicare freeze. The rate of pay is linked to Medicare item 23 — the level B standard consultation, which, because of the freeze, has remained unchanged since 2014. This means registrars’ base pay will remain at about $74,000 a year for a first-year registrar, $89,000 for a second-year and $95,000 for a third-year, plus superannuation. However, registrars can also take a percentage of their Medicare billing as bonus pay. Last week, General Practice Registrars Australia, the lobby group representing GP registrars, reached an agreement on the national terms and conditions for employing registrars with General Practice Supervisors Australia. The agreement, which will cover 2017/2018, was largely about “tidying up some of the wording” from the previous agreement, a GPRA spokesperson said.

Warning over false-negative CMV tests SOME patients may have had a false-negative test for CMV, pathology labs have been told, following a global recall of the Siemens assay kit in use between June 2015 and August 2016. The manufacturer says the chances of such an incorrect test result are “very low”. A review of more than 1000 tests undertaken by SA Pathology did not find any with a changed result, according to SA Chief Medical Officer Professor Paddy Phillips. The TGA has announced the product recall and categorised it as class II, stating “the product deficiency could cause illness, injury and result in mistreatment”.

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News Review

Fighting The Good GP fight

Dr Frank Jones has battled turbulent times as RACGP president. As he stands down this month, he talks with PAUL SMITH about what has been won and lost.

LOOKING back, the best insight Dr Frank Jones would have had of what was coming his way as RACGP president was in the few lines of text buried deep within the 2014 Federal Budget papers. It was in those papers that he would read an outline of a political intent that later resulted in a fullscale saga, with general practice fighting against repeated policy assaults designed to strip away billions in funding for the specialty.

The results were the first copayment horror, then the scrapping of General Practice Education and Training, and a time-pressured mass reorganisation of regional training for thousands of new registrars. Next came the mutations, with former Prime Minister Tony Abbott’s attack on six-minute “sausage machine” medicine, via a cost-cutting plan to re-engineer level B items — the standard unit of GP consults. That was ditched, along with a second botched co-payment plan. And then, obviously, the rebate freeze itself: the one surviving policy monster slowly sucking billions in government funding for GP care. As Dr Jones ends two years of leading the specialty (he steps down at this week’s RACGP annual conference in Perth), he describes his experience during these interesting times as “a fantastic adventure”. In person, Dr Jones has rarely been a misery monger and he offers an up-beat message on the

‘I WANTED TO RAISE THE PROFILE OF GENERAL PRACTICE AMONG STAKEHOLDERS AND PATIENTS, AND THAT OF THE RACGP AS WELL. PEOPLE MAY DISAGREE, BUT WE HAVE MADE SOME INROADS.’ — Dr Frank Jones, outgoing RACGP president

college’s achievements, as well as on general practice itself. The specialty stood united and it fought, he says. When it came to the copayment pledges, it won. “When I stood for president, I wanted to raise the profile of general practice among stakeholders and patients, and that of the RACGP as well. People may disagree, but we have made some inroads.”

www.australiandoctor.com.au

Line in the sand He adds: “We have defined who we are, what we are and what we stand for. We stand for patient quality care, cost efficiency in keeping people out of the expensive hospital system.” But it is also true that the road the college has taken, begun under his predecessor Dr Liz Marles, has been controversial. It has moved well beyond its focus on “education and training”,

its mantra of the past decade, and ventured into that hotly contested lobbying space, the traditional preserve of the AMA. In private, the college argument for this is based on democracy. Its membership numbers some 32,000, which makes the college believe it carries a greater mandate than the AMA (whose membership is believed to be around 7000) to speak on behalf of GPs. Publicly, the college, including Dr Jones, doesn’t put this so bluntly, saying instead that the college is a powerful voice made up of 80% of GPs to which governments now have to listen. The second issue of controversy is the means the college has employed in its expanded role. It has done less walking the corridors of power in Canberra, pressing flesh with ministers and schmoozing with the backroom party hacks, and focused more on broadcasting its message directly to the public. TV advertisements for its ‘Good cont’d next page 30 September 2016 | Australian Doctor |

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News Review from previous page

GP’ campaign — designed to bring the RACGP brand to the masses — were aired in prime-time slots during Master Chef and State of Origin games. Then came the second wave, the ‘You’ve Been Targeted’ campaign, run during this year’s federal election, which saw the college wage a media war against the Turnbull Government’s pledge to extend the rebate freeze into the next decade. Again, there were TV and social media adverts, featuring mothers worried about covering the cost of healthcare for their families.

ment they want — whether they want a government that cares about health.” It has been a bold stance, especially for an academic medical college, and one the college believes necessary when the government has so wilfully ignored the views of general practice. But when organisations encourage people to lay their votes elsewhere, politicians often take it personally. “I have a great personal relationship with [Health Minister] Sussan Ley,” Dr Jones says. “She is strong,

and listens. I’m sure some of the things we’ve done have not pleased the government politically, but we have to state our case on behalf of patients ... If anything interferes with the quality of care for our patients, we have to be in there batting for them.” He also says the college’s broader message of the past two years about the importance of general practice has finally ensured that the government genuinely understands “the best bang for the buck is in primary care”.

“I think everyone understands that, but unfortunately, they have not reacted in a positive fiscal manner to all our endeavours. The message has got through to most people. It’s just disappointing that the government has not put dollars where it should.” And this may be the problem. Because one argument you hear from some doctors — the noisy group who believe that general practice is enslaved under bulk-billing — is that the specialty will be the victim of the col-

High-priced advocacy The price tag for this public relations push was significant, somewhere north of $5 million — although the college has always refused to divulge the exact costs for reasons it has never shared. It is worth pointing out that the college can probably afford it. During the last financial year, its annual revenue, drawn mainly from education and membership fees, reached a staggering $57 million. It’s a sure signal the dark days 14 years ago, when the college nearly collapsed as a result of a membership exodus, are over. But is this spending worthwhile. Has it delivered? “Yep, yep. [Based on] our feedback from our membership and from the community, our profile has definitely improved, so we have a big tick from them,” Dr Jones says. “People are always interested in the money, I know that. The college council signed off a big budget for [the campaigns]. Going into the future, it will be a lot more focused and a lot more strategic. Success, he says, has been measured by the college with “internal research”, which means outsiders have to take the methodology and the results largely on trust. “The figures are really good, it basically sold itself [in terms of community perception]. We measured how many people recognise that a GP was a member of the RACGP, and we have good figures to say they have definitely increased. And we also have some figures showing they understand a little bit more about what general practice can offer them as a community.” He adds: “Our ‘Good GP’ campaign [has] achieved. It has put government on notice … [And it was also] a stepping stone to our ‘You’ve Been Targeted’ campaign [that] changed the face of electoral voting. “There is no question in my mind that it did sway [voters] about what govern-

| Australian Doctor | 30 September 2016

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‘I HAVE A GREAT PERSONAL RELATIONSHIP WITH SUSSAN LEY. SHE IS STRONG, AND LISTENS.’

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lege’s success in its co-payment battle. The campaign not only helped kill off the socially regressive versions of copayment that Peter Dutton concocted as health minister, it has also killed off the prospect of any government — Labor or Liberal — promoting a policy encouraging patients to contribute from their own pockets where possible because of the risk of eroding bulk-billing. Dr Jones says: “As the college of GPs, we have always said you should charge what

your skills are worth, we have always said that.” No, he doesn’t believe unfreezing the Medicare rebate — another battle still being waged — will be the answer to the current financial woes. And he is warning that GPs are already looking at charging gap fees to keep their businesses afloat. But he says ending the freeze would “give us some breathing space so we can get to the next step”.

The next step The next step for Dr Jones is

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Health Care Homes, which he describes as one of the college’s “big achievements” during his time as president. Having been pushed by the college, it now forms the government’s flagship health policy. Rolled out next year, it will mean chronic disease patients can voluntarily register with practices, triggering block funds from the government for practices to manage their ongoing care. “[The college issued] a brave vision statement [for health care homes],” Dr Jones says, referring to its ‘A Vision for a Sustainable Health System’, released in April last year. “No one else out there had any particular ideas … but the RACGP put the theoretical concept out there to debate and discuss.” The hope is that new funding mechanisms for chronic disease care will allow GPs to work according to what patients need, rather than to the restrictions of item descriptors. But it will herald the end of fee-for-service for chronic disease care. There is also a familiar problem: there are no new dollars for the 650 practices expected to take part in the scheme next year, just what appears to be recycled Medicare funds. Dr Jones is taking on this fight too, bluntly warning that unless ministers come up with $100,000 for each of these practices, the policy will flop and the political dream of reduced hospitalisations will not be realised. “It needs dollars to back it … and make it work,” says Dr Jones.

The future Despite the turbulence of his two years leading a specialty whose future is still far from clear, Dr Jones heads back to full-time practice in Mandurah, rural WA, feeling confident. He says morale is always variable among GPs, partly a result of general practice itself being such a “broad beast”. “The fact that we have increased recognition [of general practice] is a big tick and GPs like that. The fact that we are stuck in this freeze, that is still an issue for general practice and, from a practice owner point of view, the profitability of your small business is under threat because of various non-initiatives by the government. “There are some challenges, but all in all, general practice is in a healthy space. “I’m optimistic about the future because every country in the world now gets the fact that a strong primary healthcare system gives better outcomes.” 30 September 2016 | Australian Doctor |

AMGPR0105_FP_PA_R 2016-06-17T10:19:40+10:00

AMGEN Australia

Prolia is just part of our 25 years in Australia ®

Refer to full Product Information before prescribing: available from Amgen Australia Pty Ltd, Ph: 1800 646 998 or at www.amgen.com.au For information on Prolia® or to report an adverse event involving Prolia® please contact Prolia® Medical Information on 1800 646 998 PBS Information: Authority required (STREAMLINED) as treatment for osteoporosis. Refer to PBS Schedule for full information. Prolia® Minimum PI. INDICATIONS: Treatment of osteoporosis in postmenopausal women to reduce risk of vertebral, non-vertebral and hip fractures. Treatment to increase bone mass in men with osteoporosis at increased risk of fracture. CONTRAINDICATIONS: Hypocalcaemia. Hypersensitivity to denosumab, CHO-derived proteins or any component. Pregnancy and in women trying to get pregnant. PRECAUTIONS: Correct hypocalcaemia prior to initiating therapy. Monitor calcium in patients predisposed to hypocalcaemia. Adequate intake of calcium and vitamin D is important. Evaluate patients for risk factors for osteonecrosis of the jaw (ONJ); use with caution in these patients. Very rare reports of atypical femoral fractures. ADVERSE EFFECTS: Hypocalcaemia, skin infections (predominantly cellulitis) and pancreatitis. DOSAGE AND ADMINISTRATION: Single subcutaneous injection of 60 mg, once every 6 months. Ensure adequate intake of calcium and vitamin D. No dose adjustment required in the elderly or in renal impairment. PRESENTATION: Pre-ﬁlled syringe with automatic needle guard. Prolia® is a registered trademark of Amgen.

Refer to full Product Information for all these products below before prescribing: available from Amgen Australia Pty Ltd, Ph: 1800 803 638 or at www.amgen.com.au. For more information about these products below or to report any adverse event or product complaints involving any of these products below, call Amgen Medical Information on 1800 803 638 PBS Information: S100. Authority required. Treatment of anaemia requiring transfusion, defined as haemoglobin levels of less than 100 g per L, where intrinsic renal disease, as assessed by a nephrologist, is the primary cause of anaemia. Aranesp® Minimum PI. Indication: Anaemia treatment – chronic renal failure. Contraindications: Uncontrolled hypertension. Sensitivity to mammalian cell products, darbepoetin alfa or excipients. Precautions: Check iron status. Growth factor potential. Blood pressure (BP) may rise. BP should be controlled before initiation of therapy. To reduce the risk of cardiovascular & thrombotic events – use the lowest dose to gradually increase haemoglobin (Hb) which should not exceed 120 g/L & avoid Hb rise to exceed 10 g/L in any 2 week period. Hyporesponsiveness – evaluate for treatable conditions. If evidence of Pure Red Cell Aplasia (PRCA): discontinue treatment. With PRCA secondary to neutralising antibodies to EPO: Aranesp® should not be administered. Convulsions. Pregnancy Category: B3. Caution – breastfeeding. Drug interactions – no evidence. Adverse Effects: AEs – typical sequelae of CRF & not necessarily attributable to Aranesp®. Immunogenic potential. Rarely, allergic reactions – angioedema, dyspnoea, skin rash & urticaria. Very rarely, convulsions. Dosage & Administration: Either SC or IV. Aim: increase haemoglobin (Hb) to approach a target of not more than 120 g/L. Use lowest dose to gradually increase Hb. Hb rise should not exceed 10 g/L in any 2 week period. Correction of anaemia & maintenance of Hb: see full PI. Aranesp® is a registered trademark of Amgen.

PBS Information: Section 100 listed. Authority required. Refer to PBS Schedule for full Authority Listing. Neulasta® Minimum PI. Indication: Decrease duration of severe neutropenia & incidence of infection following chemotherapy. Contraindications: Hypersensitivity to E. coli-derived proteins, pegﬁlgrastim, ﬁlgrastim or excipients. Precautions: Rarely, splenic rupture. Sickle cell crises. Acute Respiratory Distress Syndrome in patients with sepsis. Glomerulonephritis – urinalysis recommended. Safety of concurrent administration with chemotherapy or radiotherapy not established. Not recommended within 24 hr of chemotherapy. Use in myelodysplasia or chronic myeloid leukaemia not established. Monitor for thrombocytopenia. Care in patients with organ impairment. Complete Blood Count before administration. Pregnancy Category B3. Caution: breastfeeding. Adverse Reactions: Usually associated with underlying malignancy or chemotherapy. AEs related to Neulasta: bone pain, arthralgia, myalgia, back pain, injection site pain. Dosage & Administration: Single 6 mg SC injection, once per chemotherapy cycle, ~ 24 hr after chemotherapy. Neulasta® is a registered trademark of Amgen.

PBS Information: Section 100 Listed. Authority required. Refer to PBS Schedule for full Authority Listing. Neupogen® Minimum PI. Indication: Decrease duration of neutropenia & incidence of infection following chemotherapy, myeloablative therapy in patients receiving bone marrow transplant & patients with severe chronic neutropenia (SCN) or HIV infection. Mobilisation of peripheral blood progenitor cells (PBPC) for autologous or allogeneic transplant. Contraindications: Hypersensitivity to E. coli-derived proteins, Filgrastim or any of the excipients. Precautions: Splenic rupture. Sickle cell crises associated with sickle cell trait or disease. Thrombocytopenia – monitor platelets. Abnormal cytogenetics in SCN patients. ARDS in patients with sepsis. Glomerulonephritis – urinalysis recommended. Not recommended within 24 hr of chemotherapy. Safety with concurrent chemo/radiotherapy not established. Use in myelodysplasia or chronic myeloid leukaemia not established. Monitor leucocytosis. Care with drugs that lower platelet count and in patients with potential inﬁltrating opportunistic infection & if organ function impaired. Complete Blood Count before administration & at regular intervals. Conﬁrm SCN diagnosis. Pregnancy Category B3. Caution: breastfeeding. Adverse Reactions: Usually associated with underlying malignancy or chemotherapy. AEs related to Neupogen: bone pain, arthralgia, myalgia, back pain, headache. With chronic administration, including SCN, splenomegaly. Dosage and Administration: Varies according to indication. Neupogen® is a registered trademark of Amgen.

PBS Information: Section 100 listed. Authority required. Refer to PBS Schedule for full Authority Listing. Nplate Minimum PI. Indication: Thrombocytopenia treatment in adult patients with chronic ITP who have had an inadequate response/intolerant to corticosteroids and immunoglobulins; Thrombocytopenia treatment in adult patients with chronic ITP who have had an inadequate response to splenectomy. Contraindication: Hypersensitivity to E. coli derived products‚ romiplostim‚ or any component. Precautions: Do not use in an attempt to normalise platelet count. Monitor platelets/follow ITP treatment guidelines on discontinuation - potential exists for recurrence or worsening of thrombocytopenia; serious life-threatening or fatal bleeding events have been reported. Increased bone marrow reticulin; examine peripheral blood smears/complete blood counts - if new/worsening morphological abnormalities/cytopenia(s), discontinue treatment, consider bone marrow biopsy. Thrombotic/thromboembolic complications; caution in patients with chronic liver disease. Theoretical potential to progress existing myeloid malignancies or MDS. Immunogenic potential. Pregnancy Category: B3. Caution breast-feeding. Safety and efﬁcacy in paediatrics not established. Adverse Reactions: AEs - headache, arthralgia dizziness, fatigue, bleeding, nasopharyngitis. Dosage & Administration: Weekly s/c injection with dose adjustments based on platelet count response; initial dose is 1 μg/kg, based on actual body weight; use lowest dose for ≥ 50 x 109/L, ≤ 200 x 109/L; see PI. Nplate® is a registered trademark of Amgen.

PBS Information: Authority Required (STREAMLINED). Refer to PBS Schedule for full Authority Information. Vectibix Minimum PI. Indications: Treatment of patients with wild-type RAS metastatic colorectal cancer (mCRC) (see full PI PRECAUTIONS – Laboratory tests): as first-line therapy in combination with FOLFOX. Efficacy may be influenced by patient performance status (see full PI CLINICAL TRIALS; PRECAUTIONS); as second-line therapy in combination with FOLFIRI for patients who have received first-line fluoropyrimidine-based chemotherapy (excluding irinotecan). Efficacy may be influenced by patient performance status (see full PI CLINICAL TRIALS); as monotherapy in patients after the failure of standard chemotherapy. Contraindications: history of life-threatening hypersensitivity reactions to panitumumab or any product component. Combination of Vectibix with oxaliplatin-based chemotherapy in patients with mutant RAS mCRC or for whom RAS status is unknown (see full PI PRECAUTIONS). Precautions: Assess risk-benefit prior to initiation in patients with ECOG 2 performance status. Monitor dermatologic reactions and soft tissue toxicity (severe or life-threatening reactions – modify, discontinue or withhold dose). Patients should wear sunscreen and a hat and limit sun exposure. Severe infusion reactions – stop infusion. Hypersensitivity reactions. Acute onset/worsening pulmonary toxicity – interrupt therapy and investigate symptoms. Monitor patients for the development of venous thrombolic events. Avoid combination with IFL chemotherapy or bevacizumab-containing chemotherapy. Acute renal failure if severe diarrhoea and dehydration. Monitor for keratitis or ulcerative keratitis. Monitor for hypomagnesaemia and hypocalcaemia prior, during and 8 weeks after therapy – replete electrolytes as appropriate. Determine KRAS and NRAS mutational status using a validated test in an experienced laboratory (see full PI Tumour Genetic Marker testing). May impair fertility in women. Pregnancy Category C. Caution: no breast-feeding. Paediatric safety and efficacy not established. Adverse Reactions: Skin and sub-cutaneous disorders including skin necrosis, gastrointestinal disorders, fatigue, infusion reactions and other hypersensitivity even >24hr after infusion, pulmonary embolism, electrolyte depletion, dehydration, keratitis and/or ulcerative keratitis. Dosage and Administration: 6 mg/kg by IV infusion once every 2 weeks until disease progression.

PBS Information: Authority required (STREAMLINED) as treatment for osteoporosis. Refer to PBS Schedule for full Authority Information. XGEVA® Minimum PI. Indication: Prevention of skeletal related events in patients with bone metastases from solid tumours; treatment of giant cell tumour of bone (GCTB) in adults or skeletally mature adolescents that is recurrent, or unresectable, or resectable but associated with severe morbidity; hypercalcaemia of malignancy (HCM) that is refractory to intravenous bisphosphonate. Contraindications: Pregnancy; hypersensitivity to denosumab, CHO-derived proteins or any product component; severe untreated hypocalcaemia; unhealed lesions from dental or oral surgery. Precautions: Correct hypocalcaemia prior to initiating therapy. Monitor calcium levels prior to initial dose, within 2 weeks of ﬁrst dose, and if symptoms of hypocalcaemia occur. Consider additional monitoring in patients with known risk factors for hypocalcaemia. Additional supplementation with calcium if hypocalcaemia occurs. Available data do not support use in multiple myeloma. Caution in patients with known risk factors for osteonecrosis of the jaw (ONJ); oral and dental exam prior to therapy recommended; maintain good oral hygiene during treatment. Avoid invasive dental procedures where possible. Do not use in patients with fructose intolerance. Hypercalcaemia observed following treatment discontinuation in patients with growing skeletons. Reports of atypical femoral fracture. Pregnancy Category: D. Use highly effective contraception during treatment. Caution breast-feeding. Safety and efﬁcacy in paediatrics not established. Adverse Effects: Hypocalcaemia (including severe symptomatic), ONJ. Dosage & Administration: Single subcutaneous injection of 120 mg once every 4 weeks. For GCTB and HCM, loading dose of 120 mg on days 8 and 15 of the initial 4-week treatment period. Supplement with calcium and vitamin D unless hypercalcaemia present. No dose adjustment required in the elderly or in renal impairment. Presentation: 120mg/1.7mL solution for injection vial. XGEVA® is a registered trademark of Amgen.

Amgen Australia Pty Ltd, Level 7, 123 Epping Road, North Ryde, NSW 2113. ABN 31 051 057 428. www.amgen.com.au. AUS4852 – Approved June 2016 S&H 06/16 AMGPR0087_AD_FP

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2016-09-22T08:46:58+10:00

Smart Practice Tech Talk Antony Scholefield

Drug-dosing company expanding to GPs

Staking a claim to 2046 FINANCE

There will be a huge increase in population, but no increase in the amount of land. TERRY MCMASTER

HERE will Australian property prices be in 2046? The 2016 Russell Investments ASX long-term investing report says in the 20 years to 31 December 2015, Australian property was the highest earning asset class and averaged 10.5% a year, including rent and capital gains. That’s an Australian-wide average: obviously most capital cities did even better. Australia faces a rising population, rising incomes and rising home aspirations. Australian cities are the best places in the world to live: Melbourne has won the Economist magazine’s nod for the “world’s most livable city” eight years in a row, and the other capital cities are not far behind. Our incomes are among the highest in the world and, despite the doom and gloom merchants’ best efforts, our economy is growing, and has just recorded an unprecedented 25 years of straight quarter-on-quarter economic growth, averaging about 3% a year.

ionable suburbs where doctors like to live. You should be buying more property. Your own home is a good starting point. Buy as much home as the bank will lend you. It is capital gains tax-free and pension assets test-free (and this will not change anytime soon). Over 30 years, your home will be a great investment. You should negatively gear an investment property or two. The tax benefit is worth a lot to a doctor on a high tax rate, and makes a good thing even better.

Property prices can and may fall some time soon. But effective investing looks past the short-term.

Think about helping your adult children buy a home. Gifts, soft loans and guarantees all have a place. Getting your children into a home even five years earlier than otherwise will save hundreds of thousands of dollars in loan repayments and non-deductible interest. It will be the best investment the family ever makes. If you are middle-aged or older and entering the property market for the first time, or have divorced and are re-entering the property market, think about an interest-only loan, and salary sacrifice extra super contributions earmarked for tax-free withdrawal on retirement, followed by repaying the tax-free cash off the home loan. This is effectively paying off the home loan via tax-benefited dollars, and means you get much more post-tax debt reduction bang for your pre-tax buck.

Negative gearing

Think long term So, what should you be doing on the property side of things? First, don’t forget that low interest rates fuel property price growth. Conversely, higher interest rates curb growth and even cause losses. Expect some losses in the coming years. Interest rates will not be this low forever. The key is to think long term — 30 years, not 30 days. Things become clearer and more certain in the long term. There will be a huge increase in population, but no increase in the amount of land. Prices will rise considerably across the board, and will rise even more considerably in the fash-

Best investment

Over 30 years, your investment properties will also be great investments. Think about buying a home for every child. If you have two kids, negatively gear two properties as a way of hedging your family against future home price increases. You buy the property at 2016 prices, not 2046 prices, and the tenant and the Australian Tax Office pay the loan off for you. This is much better than having your child buy the property at 2046 prices and then pay off the loan out of their after-tax income.

Think about buying your ideal “post-children retirement home” now, in 2016 prices, and renting it out as a negatively geared investment for 10-20 years before you finally move in. Property prices can and may fall some time soon. But effective investing looks past the shortterm and imagines what the world will be like in the long term, say 30 years down the track. My crystal ball says buy more property now.

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Mr McMaster is a solicitor and accountant who practises in Melbourne. The advice in this article is general and readers should seek expert advice before making financial decisions.

WHAT would you do with $2.6 million? If you’re a young, Brisbane-based company called DoseMe, you start expanding your software to make it useful for GPs. DoseMe uses a patient’s age, height and weight, plus extra information from pathology results, to calculate the right dose of a particular drug that should be administered to an individual patient. Founder Dr Robert McLeay (PhD), who is also the company’s chief technology officer, claims the injection of cash from two US investors will help the company to make the software relevant to primary care. “If you’re a GP and you’ve got a patient on warfarin and you’re having trouble keeping them in the therapeutic range, DoseMe takes the results of their [blood] test, either a point-of-care finger prick or a lab test, as well as the results of the doses the patient has previously been on. “DoseMe will then say ‘for the next two weeks, or the next month, the dose most likely to keep the patient in that range is 5mg daily’, for example.” The software, which is approved by the TGA, is linked to a database that works out the calculations for particular drugs. Part of making it useful for GPs involves adding new drugs to the database, says Dr McLeay. “Our primary market now is hospital doctors due to the drugs they are prescribing. That said, there are drugs in DoseMe that are applicable for primary care, such as warfarin. “We plan to expand that section of DoseMe and include some of the drugs that can be challenging for some patients, such as antipsychotics and antiepileptics.” Another part of the planned expansion involves integrating the software into the widely used GP practice management systems. “It’s a cliche, but doctors are really the busiest people. Giving them something else to learn is a challenge. It’s why we’re going down the path of integration,” explains Dr McLeay. “Giving a clinician another tool to learn is just giving them something else they need to do. They’ve already got a workflow, such as their current patient management system. “So we’ve got to not only give them a tool that works, but it’s got to also fit into a workflow that works for them.” DoseMe started out thanks to a $500,000 investment from entrepreneur Steve Baxter, known for his role on the TV show Shark Tank. St Vincent’s Hospital in Sydney, the site of a chemotherapy underdosing scandal, started using DoseMe in February 2016 as part of its efforts to make sure the mistakes weren’t repeated.

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Grand Rounds

Broken heart, broken liver THE AUTHOR

CARDIOLOGY

Cardiomyopathy is one of the few treatable causes of acute liver failure. Dr Eugene Teh is a general and acute care physician with Eastern Health, Melbourne.

HONDA, a previously well and independent 64-year-old woman, presented with a newly diagnosed, idiopathic, dilated cardiomyopathy and pulmonary embolism with an acute liver failure. This followed an uncomplicated, elective, laparoscopic cholecystectomy for calculi and chronic cholecystitis. Prior to her surgery, her LFTs were within normal range, and she was discharged home the day after her procedure. Within a week, Rhonda returned, complaining of worsening shortness of breath on exertion, paroxysmal nocturnal dyspnoea, nausea with epigastric pain radiating to her back, and bilateral swollen ankles. She did not have any chest pain, palpitations, dizziness, cough, fevers or rigors.

History

HAVE AN INTERESTING CLINICAL CASE? Please contact Dr Linda Calabresi at lindacalabresi@ cirrusmedia.com.au We pay $400 for each case and photos are encouraged.

Her past medical history was unremarkable, with no history of hypertension, diabetes, dyslipidaemia or ischaemic heart disease. She was an ex-smoker of 40 pack-years. Her only medication was occasional paracetamol. There was no significant family history.

Examination On physical examination, her blood pressure was 135/80, with a regular pulse of 100bpm and oxygen saturation of 98% on room air. Rhonda was afebrile and did not appear jaundiced. Cardiovascular examination revealed dual heart sounds, with a pansystolic murmur and an elevated jugular venous pressure of 5cm. There were coarse crackles in the bases of her lungs. Her abdomen was soft, with right upper quadrant

and epigastric tenderness, but no rebound tenderness. There was no palpable liver, spleen or flank tenderness. Lower limb examination revealed pitting oedema to mid-thighs, with no calf tenderness.

Investigation Investigations revealed elevated levels of serum transaminases and serum bilirubin, elevated INR and creatinine, consistent with acute hepatic and renal failure (see table). There had been no evidence of hypotension during her previous surgery or postoperatively. Other causes of acute hepatitis were excluded, including negative test results for vasculitis and an autoimmune screen, viral hepatitis A, B and C, Epstein–Barr virus, and cytomegalovirus. There were no potential hepatotoxic medications administered throughout her previous admission, except for paracetamol. Laboratory testing for Wilson’s disease and haemochromatosis were also negative. It was suspected that Rhonda might have had a hepatobiliary leak. Consequently, she underwent a CT abdominal angiogram, but this did not show any evidence of hepatic artery injury. The liver texture was normal, but the scan demonstrated prominent hepatic veins and inferior vena cava, consistent with hepatic congestion. She had an ultrasound of her liver, which was also suggestive of hepatic congestion but demonstrated a normal portal venous flow. Rhonda then had a CT pulmonary angiogram to

further evaluate her dyspnoea. The CT angiogram showed multiple, small, pulmonary emboli in both lower zones, and also demonstrated cardiomegaly. She was started on enoparin sodium and, subsequently, warfarin. Further investigation found Rhonda’s aminoterminal pro-B-type natriuretic peptide level was 12,129pg/mL (normal range <400pg/mL). A transthoracic echocardiogram confirmed the diagnosis of dilated cardiomyopathy with severe global biventricular systolic dysfunction and a left ventricular ejection fraction of 15%. An electrocardiograph showed sinus rhythm with a right bundle branch block, with no significant ST or T wave changes. There was no coronary artery disease as confirmed by a coronary angiogram, and a left ventriculogram confirmed severe left ventricular dysfunction.

Outcome The final diagnosis was of idiopathic dilated cardiomyopathy with cardiac failure causing acute liver failure.

CLINICAL AUDIT

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2016-09-22T09:49:37+10:00

Eye focus Dr Weng Sehu

Fundus photo of the left eye showing haemorrhage within the macula.

Fading vision TABLE. PATIENT’S FLUCTUATING LFTs PRE- AND POST-TREATMENT Preoperation

11 days post-op

14 days post-op

16 days post-op

23 days post-op

128 days post-op

Bilirubin (μmol/L) <22

ALT (IU/L) (5-40)

1785

3165

1964

315

AST (IU/L) (5-40)

1118

1863

559

ALP (IU/L) (30-120)

130

124

122

GGT (IU/L) (6-42)

144

141

122

Rhonda was started on frusemide, spironolactone and bisoprolol, with marked improvement in her symptoms. She subsequently had a biventricular pacemaker with an automated implantable cardioverter defibrillator and underwent a program of cardiac rehabilitation. Follow-up showed a return to normal liver

function after two months. Acute liver failure caused by heart failure is rare and is associated with a high mortality rate. In cases where the cause of acute severe liver dysfunction is not apparent, cardiac failure should always be considered. Cardiomyopathy is one of the few treatable causes of acute liver failure.

Ankle sprain App of the Week AN ankle sprain is a common presentation in general practice, and this app provides a good adjuvant for patients, once fracture has been ruled out and basic first aid applied. Not every patient can or will go to a physiotherapist, so this app is perhaps the next best thing.

It provides instructions on acute care, rehabilitation training and taping, while allowing the user to assess the function of their ankle, compared with a healthy ankle. The patient will then be in a much better position to determine if they are safe to resume full training or go back to sport.

This app has good, reliable information, which might well reduce the risk of re-injury.

Specifications COST: $2.99 COMPATIBLE WITH Apple devices REQUIRES: iOS 5.1 or later

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ROSE, 76, presents with a one-week history of decreased vision in her left eye. She is a non-smoker and does not have diabetes. She has a history of hypertension and is on an ACE inhibitor. Examination shows visual acuities of

6/8 in the right eye, and 6/15 in the left. Pupil reflexes are normal. BP is 160/95. Dr Sehu is a staff specialist at Sydney Eye Hospital and St George Hospital, a lecturer at the University of Sydney, and in private practice in Sydney.

THE QUIZ Q. True or false? The dilated fundus examination shows a retinal bleed in the central (macular) area. A. True. Q. What is the most likely diagnosis? a. Diabetic retinopathy. b. ‘Wet’ ARMD. c. ‘Dry’ ARMD. d. Trauma. e. None of the above. A. The answer is b. Even if this patient had diabetes, diabetic retinopathy is unlikely in view of the lack of other signs, such as microaneurysms, haemorrhages and hard exudates elsewhere. Dry ARMD is diagnosed in the absence of bleeding. There was no history of trauma. The patient’s age and the fundal appearance support the diagnosis of wet ARMD. Q. What is the most appropriate management of this patient?

a. Note the change and review in three months. b. Refer to an optometrist for new glasses. c. Refer to a cardiologist. d. Urgent referral to an ophthalmologist. e. Ambulance transfer to hospital. A. The answer is d. An ophthalmologist is likely to conduct tests to confirm whether there is fluid or blood in the retina, and determine the nature of this bleed. Q. Rose is diagnosed with wet ARMD. Which of the following treatments are likely to be recommended? a. An increase in medication dose of her antihypertensive. b. A diet high in leafy green vegetables and oily fish. c. A monthly intraocular injection of an antivascular endothelial growth factor. d. Specific dietary supplements.

e. All of the above. A. The answer is e. Wet ARMD involves the abnormal development of blood vessels in the macular region. These vessels are fragile and tend to bleed spontaneously initially, producing visual distortion before eventual visual loss. In the past, wet ARMD was treated with laser coagulation or photodynamic therapy, which was often destructive and could result in an initial worsening of visual acuity. More recently, injectable antivascular endothelial growth factor, which helps to slow or halt disease progression, has become the treatment of choice. This is in addition to lifestyle factors, such as smoking cessation, dietary changes, and management of chronic diseases such as diabetes and hypertension.

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Confidence from Evidence and Real World Experience* *Xarelto has evidence for its efficacy and safety profile for eligible patients from RCTs and real world studies in SPAF 1-3 and PE/DVT.4,5 Xarelto is the world’s most prescribed NOAC,6 with over 18 million patients treated across multiple indications.7,8

RCT=randomised controlled trial; SPAF=stroke prevention in atrial fibrillation; PE=pulmonary embolism; DVT=deep vein thrombosis; NOAC=non-vitamin K antagonist oral anticoagulant. Calculation based on IMS Health MIDAS, Database: Monthly Sales December 2015.

PBS Information: Authority Required (STREAMLINED). Refer to PBS Schedule for full authority information.

PLEASE REVIEW THE FULL PRODUCT INFORMATION (PI) BEFORE PRESCRIBING. APPROVED PI AVAILABLE AT WWW. BAYERRESOURCES. COM.AU/RESOURCES/UPLOADS/PI/FILE9466.PDF OR UPON REQUEST FROM BAYER AUSTRALIA LTD. Minimum Product Information. XARELTO® (rivaroxaban) INDICATIONS: Prevention of venous thromboembolism (VTE) in adult patients who have undergone major orthopaedic surgery of the lower limbs (elective total hip replacement, treatment for up to 5 weeks; elective total knee replacement, treatment for up to 2 weeks); 10 mg tablet once daily. Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and at least one additional risk factor for stroke; 20 mg tablet once daily (15 mg for patients with CrCl 30-49 mL/min). Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and for the prevention of recurrent DVT and pulmonary embolism (PE); 15 mg tablet twice daily for 3 weeks, followed by 20 mg tablet once daily. Xarelto 15 mg and 20 mg tablets should be taken with food. Tablets may be crushed and administered orally (mixed with water or applesauce) or given through gastric tubes. See full PI for details. CONTRAINDICATIONS: Hypersensitivity to rivaroxaban or to any of the excipients, clinically significant active bleeding, lesions at increased risk of clinically significant bleeding and patients with spontaneous impairment of haemostasis, significant hepatic disease which is associated with coagulopathy, dialysis or severe renal impairment with a creatinine clearance < 15 mL/min for Xarelto 10 mg or < 30 mL/min for Xarelto 15 mg and 20 mg, concomitant treatment with strong inhibitors of both CYP 3A4 and P-glycoprotein, Pregnancy, Lactation. PRECAUTIONS: Increased bleeding risk such as general haemorrhagic risk (see PI for list), bronchiectasis or history of pulmonary bleeding, renal impairment, hepatic impairment, surgery and interventions, spinal/epidural anaesthesia or puncture, patients with prosthetic valves (no clinical data), haemodynamically unstable PE patients or patients who require thrombolysis or pulmonary embolectomy, lactose intolerance. INTERACTIONS WITH OTHER MEDICINES: Care to be taken if concomitantly used with medicines affecting haemostasis; concomitant administration with NSAIDs, platelet aggregation inhibitors, other anticoagulants. ADVERSE EFFECTS: Please refer to PI for a complete list. Very common and common adverse reactions (≥ 1%) include post procedural haemorrhage, increased transaminases, gingival bleeding, constipation, diarrhoea, nausea, pyrexia, oedema peripheral, contusion, pain in extremity, headache, dizziness, haematuria, menorrhagia, epistaxis, haematoma, anaemia, rectal haemorrhage, fatigue and ecchymosis, haemoptysis, pruritus, conjunctival haemorrhage, abdominal pain, dyspepsia, gastrointestinal haemorrhage, syncope, hypotension, increased gamma-glutamyltransferase, tachycardia, vomiting, asthenia, wound haemorrhage, subcutaneous haematoma and rash. Less frequent but serious adverse reactions include: urticaria, hypersensitivity, hyperglycaemia, cerebral, cerebellar and intracranial haemorrhage, haemorrhagic transformation stroke, jaundice, eye haemorrhage, loss of consciousness, angioedema, allergic oedema, cholestasis, hepatitis and thrombocytopaenia. DOSAGE AND ADMINISTRATION: see INDICATIONS above. BASED ON PI DATED: 09 Nov 2015. References: 1. Patel MR et al. N Engl J Med 2011;365:883–91. 2. Camm J et al. Eur Heart J. 2015 Sep 1. pii: ehv466. [Epub ahead of print]. 3. Tamayo S et al. Clin Cardiol 2015;38:63–8. 4. Prins MH et al. Thrombosis J 2013;11(1):21. 5. Beyer-Westendorf J et al. Blood 2014;124:955–62. 6. IMS Health MIDAS, Database: Monthly Sales June 2015. 7. Calculation based on IMS Health MIDAS, Database: Monthly Sales December 2015. 8. Xarelto® (rivaroxaban) Product Information, 9 November 2015. Bayer Australia Ltd. ABN 22 000 138 714, 875 Pacific Highway, Pymble NSW 2073. Xarelto® is a registered trademark of Bayer Group, Germany. BAY3866/MR/L.AU.MKT.GM.12.2015.0386

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How to Treat PULL-OUT SECTION

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COMPLETE HOW TO TREAT QUIZZES ONLINE www.australiandoctor.com.au/cpd to earn CPD or PDP points.

INSIDE Vocal skill and vocal use Aetiology Examination Diagnosis and treatment Case studies

THE AUTHOR

A hoarse voice

DR JONATHAN LIVESEY ENT surgeon; voice specialist; director, Voice Connection multidisciplinary voice clinic, Sydney, NSW.

Introduction

HOARSENESS is very common and indicates a non-specific change in vocal quality. This may include vocal weakness, roughness, tremor, strain, altered or variable pitch, fatigue or breathiness. This may affect children or adults, though more often females than males. There are many causes of hoarse-

ness. However, persistence beyond one month requires ENT review. In order to produce the best voice, the following are required: • Good lungs and tracheal airflow (about 5L per minute). • A normal larynx. The vocal folds open and close at the frequency of the voice to convert a column

of continuous airflow into a column of puffs of air, upon which to essentially make a squeaking sound called the primal vocal tone. • Articulation by the tongue, palate, lips and pharyngeal musculature to modify the primary vocal tone to create words. • Normal sinonasal airway patency www.australiandoctor.com.au

for best vocal resonance. • Normal neurology. • Good hearing. • A healthy psyche. The frequency of the male voice is between 85Hz and 180Hz, females are between 165Hz and 255Hz, and children are 250-300Hz and higher. The cont’d next page

Copyright © 2016 Australian Doctor All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means without the prior written permission of the publisher. For permission requests, email: howtotreat@cirrusmedia.com.au

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How to Treat – A hoarse voice from previous page passage of subglottic air between the vocal folds (the glottis) has the effect of producing a ripple in the surface mucosa, called a mucosal wave, at the frequency of the voice. This all depends upon normal vocal fold structural integrity, with the surface mucosa loosely bound to the underlying tissue, although separated by Reinke’s space. It is common for many people to go to a party, talk over noise, drink alcohol and experience primary or secondary tobacco smoke. The next day, for a few hours, there is lowering of vocal pitch and dulling of the vocal tone due to loss of the mucosal wave by oedema within Reinke’s space. This resolves with time and voice use, so a normal voice returns. A focal lesion of the vocal fold or invading the mucosa causes both increased mass of the vocal fold and reduced mucosal wave. This results in a progressive lowering of vocal pitch, with dulling of the vocal tone and hoarseness related to poor glottic closure. All vocal difficulties are a consequence of the interplay of four issues: medical; vocal skill and vocal uses; psychological; and body/mind (see figure 1). A multidisciplinary clinic with ENT voice specialist, speech pathologist and psychologist can provide a thorough analysis, diagnosis and management program for the hoarse patient.

Ear, nose throat, neurological pathology

Reflux, asthma, endocrine

Intrinsic skill

Occupational/ lifestyle vocal loads

Medical issues

Vocal skills

Mood disorders: anxiety, depression

Vocal uses

voice connection

Compensatory patterns

Figure 1. The white circles with medical Issues, vocal skill and vocal uses, psychological issues and body/mind issues constitute the principal causes to be considered in hoarseness.

Psychological issues

Abusive behaviours

Body/mind Stress->body tension/muscle contraction

Maladjusted/ learned behavioural responses

Postural maladjustment, blocked energy

Vocal skill and vocal use EACH individual has a different intrinsic vocal skill. This is a combination of anatomy, physiology and cultural inputs. Some people seem to be able to talk perpetually without a problem, while others have voices that falter easily. Vocal use differs considerably from the professional voice user to the sports spectator, each of

whom can have hoarseness and dysfunction after use. Primary school teachers have three times the incidence of vocal problems compared with age/sex matched peers, while kindergarten teachers have six times the incidence of vocal problems. This is related to the sheer vocal load in a day’s work.

The mucosal wave has a vertical upward ripple of about 1mm. In a male, the mucosa on the inner border of the vocal fold will move from 8.5-18.5cm per second during speech. For females this could be from 16.525.5cm per second, and for a child much further. This may equate to the kindy teacher’s

mucosal wave moving at least 5km in a working day. This is a factor in females having a higher incidence of hoarseness. Teachers are rarely given any personal vocal care education despite voice being an essential tool of their trade. It is perhaps no wonder that use of a suboptimal vocal technique predisposes

to hoarseness in such voice professionals.1 It is said “the eyes are the window to the soul whilst the voice is the soul being heard”. Psychological issues, be they the normal everyday stresses or other factors, can have a profound effect on the individual and their voice, contributing to hoarseness.2

Aetiology MANAGEMENT involves taking a thorough history. What does the patient mean by hoarseness and when did it begin? Is there breathiness, excess drying of the vocal tract or hyperventilation due to increased glottal airflow? A strained and breathy voice suggests the vocal folds are being held apart inadvertently by the patient or by a lesion. Was there a precipitant like a cold, cough, fever, an illness such as tonsillitis or a period of excess voice use? Are the symptoms constant or do they vary throughout the day? Constant symptoms suggest a focal lesion while variability suggests poor vocal skill. Is the constantly hoarse voice deteriorating with time, suggesting a growing lesion? Has the patient had dyspepsia, dysphagia, dyspnoea, weight loss, haemoptysis, a persistent cough, any weakness in their body, felt a lump in their neck, a hiatus hernia, been a smoker or consumed alcohol? A past medical history of neck or thoracic surgery and general anaesthesia for other condi-

| Australian Doctor | 30 September 2016

Figure 2. Fungal infection: (A) epiglottis and (B) tongue base in an inhaled steroid user. tions may be relevant. Are there any other medical conditions affecting the patient or their family such as asthma, allergies, autoimmune disease (for example, rheumatoid arthritis, Sjogren’s syndrome), chronic fatigue, immune dysfunction, endocrine problems (particularly hypothyroidism, which may cause hoarseness), psychological or indeed vocal problems? Is there exposure to chemical

irritants at work or in the home? Many drugs (prescribed, overthe-counter or illicit) contribute to hoarseness or throat irritation. These include: • Inhaled corticosteroids for asthma or COPD. These can cause hypopharyngeal or laryngeal fungal infection (see figure 2), which results in hoarseness.3 • Anticoagulants, anti-inflammatories and some complementary www.australiandoctor.com.au

medicines will exacerbate any laryngeal bleeding secondary to vocal trauma from abnormal voice use or external trauma.4 • Antihypertensives may cause coughing.5 • Virilising agents (such as danazol and anabolic steroids) used in endometriosis and severe osteopenia will cause an irreversible male-type voice break in females.4

Medications for colds and flu, acne, psychiatric conditions, as well as diuretic medication all commonly cause airway dryness.6 Employment has a large part to play in hoarseness. It is rare for tertiary education to include any serious instruction on vocal skill development. Many jobs are very vocally demanding, such as teaching, childcare (formal or parenting), telephone work (call centres), reception work, sales and marketing, advertising, the law, acting, singing and medicine. There are businessmen who become hoarse and clear their throats when having to stand in front of the board to present information on a quarterly basis. Isolated people, like the elderly living alone, may not talk for days. When they do speak, it may be on the telephone, which always requires more effort to communicate than face-to-face interaction, where gestures and facial expressions are part of the exchange. Like all muscles, the vocal folds can be tight and painful from overuse or atrophied from cont’d page 22

292325_KOMBIXR431944_2016_BRAND_ADMR_FP_HR

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HbA1c CONTROL

1–3^

Sustained HbA1c lowering over 2 years in type 2 diabetes patients not adequately controlled on metformin alone1–3*†

Saxagliptin 5mg and metformin IR administered as separate components. †Comparable glycaemic control has been demonstrated between metformin IR and metformin XR.4 Bioequivalence of Kombiglyze® XR with coadministered saxagliptin and metformin XR tablets has been demonstrated.1

XR CONVENIENCE

Once-daily DPP4i+METFORMIN XR combination1

NOW PBS LISTED FOR

TRIPLE THERAPY

WITH SU5

Streamlined Authority Code Dual oral combination therapy: 5761. Streamlined Authority Code Treatment phase continuing: 5762. Streamlined Authority Code Triple oral combination therapy with a sulfonylurea: 5705. Refer to PBS Schedule for details of full PBS listing.

PBS Information: Authority Required (STREAMLINED). Type 2 diabetes. Refer to PBS Schedule for full Authority Required Information. WARNING: Life-threatening lactic acidosis can occur due to accumulation of metformin. The main risk factor is renal impairment, other risk factors include old age associated with reduced renal function and high doses of metformin above 2 g per day.

treatment with Kombiglyze XR ); renal impairment – assessment of renal function is recommended prior to initiation and periodically thereafter ( discontinue treatment if evidence of renal impairment is present ); change in clinical status in previously well controlled patient; impaired hepatic function; administration of iodinated contrast agent; hypoxic states; surgery; vitamin B12 levels; alcohol intake; *hypoglycaemia when used in combination with SU or insulin; *arthralgia ( continuation of therapy should be individually assessed in severe cases ); pregnancy ( category C ); lactation; use in elderly; not for use in children ( see full PI ). INTERACTIONS: Saxagliptin: No clinically significant interactions observed with metformin, glibenclamide, pioglitazone, digoxin, simvastatin, diltiazem, ketoconazole, rifampicin, omeprazole, aluminium hydroxide + magnesium hydroxide + simethicone, famotidine, or an estrogen /progestin oral contraceptive ( see full PI ). Metformin: Careful patient monitoring and dose adjustment of metformin and /or the interfering drug is recommended in patients who are taking cationic medications ( eg. amiloride, digoxin, morphine, procainamide, quinidine, quinine, ranitidine, cimetidine, triamterene, trimethoprim, or vancomycin ) that are excreted via the proximal renal tubular secretory system ( see full PI ). ADVERSE REACTIONS: Hypoglycaemia, URTI, urinary tract infection, headache, *hospitalisation for heart failure, sinusitis, gastroenteritis, vomiting, nasopharyngitis, abdominal pain, rash, blood creatine phosphokinase increased, hypertrigyceridaemia, anaemia, depression, anxiety, *hypertension; mild gastrointestinal symptoms, bronchitis, dyspepsia, back pain, peripheral oedema when used with TZD, taste disturbance; others see full PI. Post marketing experience: Acute pancreatitis, *arthralgia and hypersensitivity reactions with saxagliptin. DOSAGE AND ADMINISTRATION: One tablet ( 5mg / 500mg or 5mg /1000mg) or two tablets 2.5mg /1000mg once daily with the evening meal with gradual dose titration to reduce gastrointestinal side effects associated with metformin. For initial combination therapy start with one tablet 5mg / 500mg once daily. Patients with inadequate glycaemic control on this starting dose should further have their metformin dose increased to one tablet 5mg /1000mg or two tablets 2.5mg /1000mg once daily. The maximum dose is 5mg / 2000mg taken as two 2.5mg /1000mg tablets once daily. Tablet must be swallowed whole, and never crushed, cut, or chewed. PRESENTATION: KOMBIGLYZE XR 5mg / 500mg ( light brown ), 5mg /1000mg ( pink ) are available in blister packs of 7 and 28 tablets, KOMBIGLYZE XR 2.5mg /1000mg ( light yellow ) are available in blister packs of 14 and 56 tablets. DATE OF FIRST INCLUSION IN THE ARTG: 10 October 2013. DATE OF MOST RECENT AMENDMENT: 26 October 2015.

BEFORE PRESCRIBING PLEASE REVIEW FULL PRODUCT INFORMATION AVAILABLE ON REQUEST FROM ASTRAZENECA *Please note changes in Product Information. ON 1800 805 342 OR www.astrazeneca.com.au/PI HbA = haemoglobin A ; DPP4i = dipeptidyl peptidase- 4 inhibitor; SU = sulfonylurea; XR = extended release KOMBIGLYZE® XR ( saxagliptin /metformin hydrochloride extended release ). INDICATIONS: As an adjunct to diet and exercise to improve glycaemic control in adults with type 2 diabetes mellitus when treatment with both saxagliptin and metformin is appropriate. CONTRAINDICATIONS: A history of a serious hypersensitivity reaction to any DPP- 4 inhibitor. Hypersensitivity to the active substances or to any of the excipients of Kombiglyze XR; diabetic ketoacidosis, diabetic pre- coma; moderate or severe renal impairment ( creatinine clearance < 60 ml /min ); acute conditions with the potential to alter renal function; acute or chronic disease which may cause tissue hypoxia; during or immediately following surgery where insulin is essential, elective major surgery; hepatic impairment; acute alcohol intoxication, alcoholism; lactation. PRECAUTIONS: Not for Type 1 Diabetes or diabetic ketoacidosis. Has not been studied in combination with GLP-1 agonists. Lactic acidosis; serious hypersensitivity reactions; acute pancreatitis ( discontinue

References: 1. KOMBIGLYZE ® XR Approved Product Information. 2. DeFronzo RA et al. Diabetes Care 2009; 32:1649 –1655. 3. DeFronzo RA et al. Diabetes Care 2009; 58:A147, Abstract 547- P. 4. Fujioka K et al. Clinical Therapeutics 2003; 25 ( 2 ):515 – 529. 5. Pharmaceutical Benefits Scheme at www.pbs.gov.au. KOMBIGLYZE ® XR is a registered trademark of the AstraZeneca group of companies. Registered user AstraZeneca Pty Ltd. ABN 54 009 682 311. 5 Alma Road, North Ryde, NSW 2113. AstraZeneca Medical Information: 1800 805 342. 431944.022. WL292325. April 2016.

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How to Treat – A hoarse voice from page 20

limited use, either of which causes hoarseness. Primary or secondary neoplasia of the larynx, oropharynx, lungs, thyroid, mediastinum and lymphomas may all cause hoarseness. This may be directly or indirectly caused by damage to the recurrent laryngeal nerves, lungs or upper aerodigestive tract. Neurological conditions includ-

ing stroke, Parkinson’s disease, and MS may all cause hoarseness by central and/or peripheral effects on motor control of breathing, the larynx, the articulators or by vocal fold paralysis. Viral infections may cause a mononeuritis of a recurrent laryngeal nerve with vocal fold paresis or paralysis. There is often spontaneous recovery after a period of breathy hoarseness with a bovine cough — a non-explosive

cough by a patient who cannot close their glottis. This is probably much more common than we know because of underreporting. Spasmodic dysphonia is a neurological condition of unknown origin that causes breathy, strained and difficult speech (botox can be part of a treatment regimen). Trauma to the neck and larynx during sport or in a motor vehicle accident may cause hoarseness

and possibly airway comprise by oedema, haemorrhage or serious anatomical disruption. Endotracheal intubation or surgical instrumentation of the upper airway, or immediate post- operative coughing in recovery, may rarely cause such damage. An inhaled foreign body or caustic substance may cause hoarseness. In the multidisciplinary voice

clinic, the speech pathologist and psychologist make their enquiries but that is beyond the scope of this article. Vocal self-assessment by the patient is important with the Voice Handicap Index or Singing Voice Handicap Index providing a quantifiable measure of function. Use of the Computerized Speech Lab (CSL) enables quantification of many vocal parameters.

sinuses, upper airway and larynx are viewed with a per-nasal flexible fibreoptic laryngoscope, with a high-definition distal chip camera (see figures 3 and 4). A standard, constant white light is used. This allows assessment of the health of the laryngeal tissues and inflammation related to reflux or other conditions. The patient speaks, performs sounds

as directed by the speech pathologist, and then sings. Laryngeal movement is observed for symmetry and degree of laryngeal antero-posterior (AP) squeeze or constriction by the arytenoids (figure 5) or medial squeeze by the false folds (figure 6). Such inappropriate techniques usually contribute to hoarseness. A strobe light, at one or two cycles

per second difference from the vocal frequency, slows the apparent movement of the vocal folds. This allows assessment of the symmetry and integrity of both the mucosal wave and true vocal fold movement during phonation. The degree of closure of the true vocal folds — be it full, partial, incomplete or hourglass — is relevant to vocal function and qual-

ity (figure 7). Narrow band light will show altered vascularity as may occur with neoplasia. Highdefinition recording allows review with the patient and for them to take a recording with them, which greatly benefits the performer. For some patients, electromyography is helpful for analysing vocal fold muscle innervation or re-innervation after nerve dysfunction.

Examination THE examination in the multidisciplinary voice clinic starts as the patient is introduced. The voice is listened to, noting vocal quality for roughness, strain, pitch and breathiness. The general ENT examination begins with the ears and hearing. The nose is sprayed with topical anaesthetic and nasal decongestant to numb and open the nasal airway. The nose,

Figure 5. Antero-posterior constriction of larynx: (A) normal. (B) severe causing hoarseness known as muscle tension dysphonia. Figure 6. Plicae ventricularis – overtightening of the false vocal folds.

Figure 3. Voice clinic laryngeal examination.

Back wall of pharynx Arytenoid

Trachea True vocal fold False vocal fold Right side

Epiglottis Figure 7. (A) Incomplete glottic closure causing whisper. (B) complete glottic closure and normal voice on biofeedback.

Figure 4. Laryngeal anatomy at laryngoscopy in clinic.

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Diagnosis and treatment THE raspy-sounding voice with a history of fluctuation is suggestive of muscle tension dysphonia (MTD). Adding a breathy sound suggests nodules or a lesion. Throat-clearing and coughing indicates laryngeal irritation probably associated with reflux. Such conjecture precedes accurate diagnosis by laryngoscopy, stroboscopy and discussion in a multidisciplinary voice clinic. For a few patients, microlaryngoscopy, possibly with a biopsy, under general anaesthesia is required, at which time definitive treatment may be appropriate.

Box 1. Lifestyle changes for reflux9 Acid reflux into the larynx and throat is often referred to as ‘laryngopharyngeal reflux’ or LPR. Symptoms of acid reflux into the larynx may include laryngitis, hoarseness, sensation of a lump in the throat, post-nasal drip, chronic throat clearing, excessive throat mucous, sore throat, cough, laryngospasm (spasm of the throat), and/or throat pain. 1. Leave three hours between eating and bedtime so you do not go to bed on a full stomach. 2. Reduce intake of the following, particularly in the evening: tomatoes, pastry, fatty foods, red meat, chili and spices, caffeine, carbonated drinks, alcohol, tobacco. 3. Avoid coughing and throat clearing: swallow, sip water or have a soother instead. 4. Elevate the head of your bed with a telephone book or brick. 5. Avoid tight clothing, overeating and excess weight.

Common diagnoses Simple overuse and inappropriate vocal use most often cause hoarseness. The majority of people have no idea how to use their voice efficiently. We are all self-taught. Even trained teachers, singers and actors have rarely had training in how to use their everyday speaking voice efficiently. For the majority of hoarse patients, reassurance, explanation, diagnosis, cessation of coughing and throat clearing, reflux management, speech therapy and possibly psychotherapy is curative. Specific lesions require definitive surgical management. These include biopsy and excision of focal lesions, KTP laser to papillomata or low-grade malignancies or laryngoplasty. More significant neoplasia requires greater surgical or chemoradiation therapeutic involvement via the multidisciplinary head and neck clinic. The voice that deteriorates with use then recovers with rest is usually due to poor vocal skill. The laryngeal muscles are inappropriately tight (see figure 5). This is known as muscle tension dysphonia. This may be exacerbated by prolonged vocal straining such as talking over background noise while working or socialising in a pub, club or sporting event. For teachers/lecturers the voice may deteriorate throughout the working week, and recovering over the weekend just in time for resumption of work. Aphonia or dysphonia from a URTI may also be the precipitating cause with a suboptimal vocal technique being adopted. Throat clearing and coughing can contribute. Speech therapy is essential to educate people in efficient use of their voice. There is discussion about common vocal misuse and abuse, vocal hygiene advice, vocal techniques and exercises. When someone hums, that is the correct vocal pitch for them with placement of the voice forward in the face rather than down in the throat. The use of the voice during a 24-hour period across different activities is important for people to comprehend. It is important to avoid throat clearing and coughing, which contribute to hoarseness. This may be habitual or related to medication. Engaging in good vocal hygiene and voice habits/techniques is essential. When hoarse, people often alter the way they use their voice by whispering, altering their pitch so speaking lower than normal or holding their voice back. This greater muscular effort, with laryngeal constriction,

tributes to hoarseness, laryngeal and throat irritation, tickle, sense of phlegm, globus sensation, the need to cough or throat clear and the sense of a ‘post nasal drip’.8 There is a multitude of symptoms not immediately attributable to reflux, particularly in individuals who may never have dyspepsia. After an upper respiratory tract infection has resolved, the cough may persist for months. I think this is an ongoing laryngitis exacerbated by coughing, throat clearing and reflux. Hoarseness is a component. Management of hoarseness must include consideration of reflux with explanation of the relevance for voice care. Box 1 shows the ‘Lifestyle changes for reflux’ that should be discussed with all voice patients. It is paramount to ask patients to stop coughing and throat clearing, in addition to implementing antireflux measures. Some patients benefit from a PPI, although this only prevents acid production. Non-acidic reflux persists. Antacid with alginate tablets chewed after meals and before bed coat the oesophagus, protecting it from irritation by reflux. This can assist in overcoming symptoms and facilitate cough avoidance. Exclusion of Helicobacter pylori is important. It is also important to consider a gastroenterological opinion.

Vocal nodules

Figure 8. (A) Bilateral vocal nodules secondary to a laryngeal constriction seen in (B) with posterior glottic gap (air gap) between vocal folds.

Figure 9. (A) Vocal fold polyp in a female singer at rest and (B) when singing with a large glottic gap causing a strained and breathy, hoarse voice. causes hoarseness. Inappropriate voice use also includes grunting, shouting or using strained voices. Speech therapy also provides tools for voice care next time there is a similar vocal challenge. The nature of how a hoarse voice fares during the day helps diagnosis. Voices irritated by reflux tend to improve through the day as they warm up and become less affected by the nocturnal, recumbent reflux. The patient may report indigestion, heartburn or reflux — however, often they do not. There may be coughing, throat clearing, a sense of

phlegm, lump or tickle in the throat. These non-specific symptoms are often highly suggestive of silent reflux which contributes to hoarseness, and requires consideration during any management regimen.

Vocal inefficiency One type of vocal inefficiency is plicae ventricularis (figure 6) where inappropriate overuse of the false vocal folds causes a tight and pressed voice that fatigues easily. This is more common in the elderly and may contribute to a weak and reedy voice.7 Speech pathology

is very important. Isolated individuals with a very low vocal load throughout their week need to talk or sing more. This may be through community groups or choirs, talking and singing to themselves or an animal at home. This is not easy to implement as most people associate talking to oneself as inappropriate, particularly in public. Yet laryngeal muscles need use for conditioning and good vocal function.

Reflux There is certainly an oesophageal reflex triggered by reflux that con-

If someone with muscle tension dysphonia keeps pushing their voice, they progress from a strained and breathy voice to one that is rough as well. The AP constriction causes opening of the vocal folds posteriorly with excess air escape producing a breathy voice with loss of the higher frequencies. Singers are particularly aware of this change. Continuation causes overload of the vocal fold at the junction of the anterior 1/3 and posterior 2/3 of the vocal folds where the tissues thicken to form bilateral nodules (see figure 8). This can be compared with the callus produced on a foot by the overload associated with an ill-fitting shoe. Speech therapy teaches a more efficient vocal technique to deconstrict the larynx, which closes the posterior gap. The vocal load is then more evenly distributed along the length of the vocal folds, and the nodules resolve as the mucosa is able to recover. Surgery is very rarely required. Speech therapy is the key.10

Vocal fold polyp A vocal fold polyp occurs due to vocal trauma and overuse (figure 9), such as may occur with singing, shouting or coughing.11 These are prevalent in singers, teachers, other voice professionals and the shouting public. Excision is required to normalise glottic closure. Again speech therapy is essential to normalise vocal efficiency and quality.

Vocal fold paresis or paralysis Vocal fold paresis or paralysis presents with a breathy voice and possibly dysphagia. Some of the causes are noted above. Video documentation and CT scan from skull base to diaphragm cont’d next page

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How to Treat – A hoarse voice Figure 10. Bilobed granuloma of left vocal process.

from previous page

are essential in order to exclude pathology along the course of the recurrent laryngeal nerves in the neck or chest. Idiopathic cases require speech therapy and up to 12 months for spontaneous recovery. Some compensation does take place with the contralateral vocal fold crossing the midline to close the glottic gap, which can be curative for some. However, some people are unable to wait that long with a poor voice, so vocal fold injection with collagen gives three to four months reprieve.12 This may be repeated if required. Electromyography helps assessment of reinnervation. If dysphonia persists for 12 months then a formal laryngoplasty under general anaesthetic with medialisation of the paralysed fold with a Gore-Tex or a silicon implant should be very effective.

Figure 11. Reinke’s oedema of the right vocal fold.

Fungal laryngitis Diligent mouth washing or gargling following use of inhaled steroid treatment should prevent hypopharyngeal infection (see figure 2). However, the vocal folds cannot be rinsed. Use of a spacer and deep, silent inhalation so the vocal folds are widely apart reduces the risk of steroid deposition on the vocal folds. Alternatively, the use of a pro-drug like ciclesonide, which is only activated in the lung, is far less likely to cause fungal laryngitis. Diagnosis is made on visual inspection and noting consists of white lesions with an erythematous border (figure 2). Fungal laryngitis may be treated with nystatin, fluconazole or amphotericin. Salmeterol xinafoate and fluticasone propionate have, in my experience, caused temporary or permanent hoarseness.13

Figure 12. Extensive papillomata of glottis and supraglottis; very weak, breathy, hoarse, poorly projectable voice and restricted airway.

Vocal process granuloma The vocal process from which the vocalis muscle arises is part of the cartilaginous arytenoid. Chronic irritation of the process will produce an inflammatory reaction with overgrowth of tissue to produce a vocal process granuloma. In figure 10 this is bilobed where the contralateral vocal process inserts during phonation. These benign lesions are caused by reflux, coughing and poor vocal technique with a tight laryngeal posture. They are not very common. In turn they cause laryngeal irritation with coughing and dysphonia. There may be unilateral throat pain. Management is not easy. Excision under general anaesthetic often causes recurrence because of surgical trauma and ongoing irritation. The use of oral steroids, antibiotics, anti-reflux measures and avoiding irritants like coughing, throat clearing and smoking enable slow resolution of these lesions over many months. Speech pathology is important to optimise vocal efficiency and so reduce laryngeal tightness.14

| Australian Doctor | 30 September 2016

Recurrent respiratory papillomatosis is an uncommon condition with papillomata of the airway. Human papilloma virus (HPV) is the cause, with HPV 6 and 11 — the cause of genital warts — being most prevalent. It is thought infection occurs from the female genital tract at birth or through oral sex.15 These papilloma viruses very rarely cause malignant change. Diagnosis is by laryngoscopy, biopsy and histology. This article will discuss only laryngeal pathology. Laryngeal papillomata present because of vocal, swallowing and airway difficulties including coughing and sleep apnoea. Asthma or chronic bronchitis may be mistaken for recurrent respiratory papillomatosis. Puberty is often associated with a relief or remission from this condition in children. There is no cure for recurrent respiratory papillomatosis (figure 12). Management is very difficult with frequent, and at times rapid, recurrence of papillomata, requiring regular surgical management under general anaesthesia. This may mean surgery on a monthly basis, particularly for children, or with longer time intervals for adults. On occasion a tracheostomy is required to maintain an airway although this disrupts the tracheal mucociliary escalator and papillomata can spread into the trachea or bronchi, which can be fatal. Treatments include cold steel excision, microdebridement, CO2 laser or KTP laser. The green light of the KTP laser has been a game changer since green light is solely absorbed by red. This enables targeting of the haemoglobin-filled capillary loops that supply the papillomata, with very little damage to adjacent tissue. This limits scar formation found with other treatments, particularly since repeated surgical management is required. Virus particles may also reside in the adjacent normal-looking laryngeal mucosa producing papillomata in apparently normal areas with time. Adjuvant therapies with injection of interferon and cidofovir have been tried though with little documented success as yet. Vaccination with HPV vaccine will be another game changer for this condition.

Drug side-effects Adjustment of drugs (for example, cardiac and psychiatric) by the GP or specialist may reduce hoarseness, as part of a multidisciplinary approach.

Hearing

Reinke’s oedema The slow deterioration in vocal pitch and quality of the smoker who also talks to excess may be due to marked swelling within Reinke’s space of the vocal fold (figure 11). This can be sufficiently large to cause airway compromise including sleep apnoea. Management is cessation of

Recurrent respiratory papillomatosis

Figure 13. Sinus CT scans showing opaque, polyp and mucus-filled sinuses with a deviated septum (left) and healthy, patent sinonasal tract after surgery (right). smoking and speech pathology, neither of which is at all easy. Often individuals are reassured by this benign diagnosis and require

regular review. Malignant change is very uncommon. In the event of severe airway compromise or unacceptable vocal www.australiandoctor.com.au

quality, surgical excision is possible. Re-occurrence is common since the smoking and excessive talking often continue unabated.

Presbycusis, with or without hearing aids, further distorts auditory feedback and can exacerbate vocal difficulties. People report they dislike the sound of their voice and this may contribute to some compensatory voice use patterns that are inappropriate and fatiguing, causing greater laryngeal tightness. Optimising hearing may include aural toilet for wax removal, drainage of middle ear effusions (possibly with grommets) or hearing aids for conductive or sensorineural hearing loss. In loud environments people raise the volume of their own voice cont’d page 26

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How to Treat – A hoarse voice from page 24

in order to hear themselves rather than to be heard. This is the Lombard effect and contributes to vocal overloading.16

Sinonasal health Nasal care with nasal saline douching and a topical steroid spray for obstruction or antihistamine for sneezing is good primary care management. Septoplasty, turbinoplasty and/ or functional endoscopic sinus surgery may have a role to play

in management of hoarseness secondary to chronic mouth breathing, snoring, sleep apnoea or recurrent infective laryngitis from a sinus origin. All these cause laryngeal irritation and may contribute to hoarseness from airway drying, reflux and throat clearing. Asthma tends to be improved by greater nasal airway patency to improve cleaning, warming and humidification of inhaled nasal air. There may be a reduction in need for inhaled medication as a result (figure 13).17,18

Children The history is important since a child hoarse since birth suggests a congenital or birth-related pathology, possibly related to intubation. Airway patency and reflux are very relevant. Some may require laryngoscopy under general anaesthetic to fully assess. A small number will have recurrent respiratory papillomatosis. Most children have a muscle tension dysphonia secondary to excessive and loud voice use at home in a large noisy family or at school. Some may develop nodules.

A small percentage of boys have puberphonia where the voice doesn’t break despite having all other secondary sexual characteristic including an Adam’s apple.19 Most often hoarseness and puberphonia are a consequence of poor vocal skill and usage and a lack of knowledge, as with vocal disorders in adults. Education through speech therapy is usually effective for a great proportion of children’s hoarseness. The other medical conditions in this article require consideration, if only for exclusion.

Conclusion HOARSENESS is very common and has a wide variety of causes of both laryngeal and extralaryngeal origin. Persistence of hoarseness beyond one month requires ENT review. The multidisciplinary voice team will consider medical, vocal skill, vocal usage and psychological factors in their diagnosis. Medical education and treatment, speech therapy and counselling, if appropriate, form the best management protocol for the individual with a hoarse voice.

Case studies Case study one DIANE, 32, has a cold with severe cough, which renders her aphonic. The best voice she can achieve is a whisper, which persisted for seven weeks until she attended the voice clinic. She reports being exhausted by the end of the working day because of the muscular effort of whispering. She is hyperventilating to keep up with the excessive outflow of air during whispering and consequently is light-headed. Diane is also feeling parched from excessive drying of her airway. At laryngoscopy it could be seen that her larynx was normal though with incomplete glottic closure, hence the whisper and excess airflow (figure 7). Speech therapy, with the laryngoscope in place, allows Diane to close her glottis and achieve a normal voice. Diane watched the laryngoscopy on the monitor, which helped her see how her laryngeal function changed to produce a normal voice. Further sessions of speech therapy will reinforce correct voice use.

logical counselling. He is able to return to full-time work rapidly, partly as a result of quick intervention and support through the multidisciplinary team approach. This illustrates the impact of loss of voice on identity.

Case study three

Figure 14. Haematoma and polyp of left vocal fold from vocal trauma causing loss of pliability of vocal fold with markedly reduced vocal quality and durability.

Case study two Jake, a 35-year-old musical theatre performer doing eight shows a week had a URTI with ear infection, blocked nose and sinuses. He is unable to perform because of vertigo, reduced hearing and loss

of vocal resonance in his sinuses. Antibiotics, oral steroids, a PPI and symptomatic care enable him to recover over five days. He also has a crisis of identity as he is unable to perform. He greatly benefits from speech therapy and psycho-

Sally, a 44-year-old mother of three and marketing executive has a vocal overuse injury in early December. She is unable to rest her voice because of work and family commitments over the festive and holiday seasons. She presents four months later with a strained, breathy voice, throat clearing and severe throat pain. She is unable to maintain a conversation as a result. Laryngoscopy demonstrated a unilateral vocal fold haematoma and polyp (figure 14). Surgical excision of the lesion and speech therapy allow a return to work after a fortnight’s rest. Psychological counselling enables planning for a better work/life balance with an associated reduction in stress.

Online resources Laryngology Society of Australasia www.lsanz.org.au Australian Voice Association www.australianvoiceassociation. com.au Vocal handicap index bit.ly/2abrZqU Singing voice handicap index bit.ly/2aolyE5

Instructions

How to Treat Quiz

Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes by post or fax. The mark required to obtain points is 80%. Please note that some questions have more than one correct answer.

A hoarse voice — 30 September 2016 1. W hich THREE lights are beneficial in laryngeal examination in the voice clinic? a) White. b) Blue. c) Strobe. d) Green. 2. Which THREE symptoms are principally related to silent reflux? a) T hroat clearing and coughing. b) Throat tickle. c) P ost nasal drip sensation. d) Hyperventilation. 3. Which ONE is not relevant in voice care? a) P oor asthma control. b) Presbycusis. c) B arometric pressure.

d) Nasal obstruction. 4. W hich THREE are required for an optimal voice clinic assessment? a) A generalist ENT specialist. b) Video stroboscopy. c) An integrated multidisciplinary team. d) Radiological services available. 5. I n which TWO conditions is surgical management essential? a) Vocal polyp. b) Muscle tension dysphonia. c) Laryngeal papillomatosis. d) Reinke’s oedema. 6. W hich TWO asthma management modalities may be useful in management of the hoarse voice?

GO ONLINE TO COMPLETE THE QUIZ

www.australiandoctor.com.au/education/how-to-treat a) Use of a spacer with an inhaler. b) A deep and noisy inhalation for full lung penetration. c) Medical/surgical optimisation of the nasal airway. d) Regular dental care. 7. Which ONE is required for the management of vocal nodules? a) Surgical excision. b) Occupational therapy. c) Speech therapy. d) A paediatrician. 8. Which THREE may result in a fluctuating hoarse voice? a) Use of a quiet, measured vocal tone 24 hours a day. b) Whispering post URTI.

c) Throat clearing and coughing whenever possible. d) Being an educator. 9. W hich THREE types of medication may contribute to hoarseness? a) Cardiac medication. b) Anticoagulants. c) Diuretics. d) The oral contraceptive pill. 10. W hich TWO social factors are unlikely to cause hoarseness? a) Social isolation. b) Careful use of voice including warming up and down. c) The sports fanatic. d) Strict management of antireflux lifestyle changes.

CPD QUIZ UPDATE The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2014-16 triennium. You can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.

Next week

how to treat Editor: Dr Claire Berman Email: claire.berman@cirrusmedia.com.au

Next week’s How to Treat explores the role and complications of oestrogen deprivation in the management of breast cancer. These effects can have a significant negative impact on quality of life and treatment compliance, and cause immediate and long-term health consequences. The authors are Dr Sabashini Ramchand and Dr Mathis Grossman, both from the department of endocrinology, Austin Health, University of Melbourne.

| Australian Doctor | 30 September 2016

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Therapy Update

The latest buzz on malaria TRAVEL MEDICINE

Although malaria rates worldwide are falling, it remains high on the radar for non-immune travellers. PROFESSOR NICK ZWAR

A L A R I A remains a major cause of disease and death worldwide. The WHO’s most recent World Malaria Report estimated there were 214 million cases of malaria and an estimated 655,000 deaths worldwide in 2015.1 There is some evidence that this may be an underestimate of the death rate, with a report in the Lancet estimating 1.24 million deaths in 2010.2 The good news is that, according to the WHO, between 2000 and 2015, malaria incidence rates (new malaria cases) fell by

37% globally, and by 42% in Africa. During this same period, malaria mortality rates fell by 60% globally and by 66% in the African Region. Sub-Saharan Africa remains the most malariaaffected region. However, malaria can also occur much closer to home, including in our near Pacific neighbours of Papua New Guinea, Vanuatu and the Solomon Islands.

Who is most susceptible? Children under five are particularly susceptible to malaria illness, infection and death. In 2015, malaria killed an estimated 306,000

Malaria can also occur much closer to home including in our near Pacific neighbours of Papua New Guinea, Vanuatu and the Solomon Islands. under-fives globally, including 292,000 children in the African Region. Each year in Australia, 600-800 cases of imported malaria are reported and it is estimated that approximately 1.5:1000 Australian travellers develop malaria.3

Non-immune travellers from malaria-free areas are very vulnerable to the disease. This includes people who have grown up in malaria areas and then moved to malaria-free countries. The partial immunity to malaria that results from

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repeated exposure wanes within a year of cessation of exposure.

Prevention ‘ABCD’ Prevention of malaria is summarised by the WHO into the ‘ABCD of malaria prevention’.3 A — be Aware of the risk, incubation period, possibility of delayed onset, and the main symptoms. B — avoid being Bitten by mosquitoes especially between dusk and dawn. C — take antimalarial drugs (Chemoprophylaxis) when appropriate, to prevent infection from developing into clinical disease. D — immediately seek

Diagnosis and treatment if a fever develops one week or more after entering an area where there is a malaria risk and within three months (or, rarely, later) after departure from a risk area. Personal protective measures against malaria can be summarised as “less bites, less risk”.

Taking precautions Travellers should be advised to take precautions to minimise their exposure, including avoiding being outdoors between dusk and dawn, sleeping in screened or air-conditioned accommodation (preferably both), cont’d page 29

30 September 2016 | Australian Doctor |

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Guidelines advise all patients with asthma to carry a reliever containing a rapid onset ß2-agonist at all times. For patients on Breo Ellipta , that would be salbutamol e.g. Ventolin . ®

®2

Breo® Ellipta® is indicated for the regular treatment of moderate to severe asthma in patients (≥12 years of age) who require a medium to high dose ICS with a LABA.1 Prescribers should note that 100 mcg of fluticasone furoate (FF) is a medium dose of ICS and 200 mcg of FF is a high dose of ICS. To minimise the adverse reactions, inhaled corticosteroids should be used at the lowest dose that maintains symptom control.1 ICS = inhaled corticosteroid; LABA = long acting ß2-agonist. References: 1. Breo Ellipta Product Information. 2. National Asthma Council Australia. Australian Asthma Handbook, Version 1.1. National Asthma Council Australia, Melbourne, 2015. Website. Available from: http://www.asthmahandbook.org.au. Accessed July 2016.

Before prescribing please review PBS and Product Information available in the primary advertisement in this publication. For full product information please contact GlaxoSmithKline Australia Pty Ltd. PO Box 18095, Melbourne, VIC 8003. ABN 47 100 162 481. For information regarding a GSK product or to report an adverse event, please contact Medical Information on 1800 033 109. Breo®, Ellipta® and Ventolin® are registered trade marks of the GSK group of companies. Breo® Ellipta® was developed in collaboration with Innoviva. AUS/FFT/0030/16f(1) Date of Approval: September 2016 S&H GSKBR0090-AD-SA

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Therapy Update from page 27

wearing long-sleeved clothing, avoiding perfumes, and using effective insect repellent. Effective repellents include DEET (N,N-diethyl3-methylbenzamide) and Picaridin (piperidine derivative). DEET is widely used and effective, but may damage fabrics and there is a need for caution in using high concentration on young infants. Picaridin comes in a 19.2% preparation, which provides similar protection to DEET and is less irritating but there is individual variability in effectiveness. Chloroquine resistance is common in malaria risk areas where many Australians travel, so the choice of chemoprophylaxis is usually between doxycycline, mefloquine and atovaquone/proguanil. Each has their pros and cons, and individual assessment is needed to advise on which to use.4 Doxycycline has the advantage of being low cost but needs to be continued for four weeks after leaving the malarial area. This has implications for adherence, and a small number of patients experience adverse effects, such as gastrointestinal problems, or skin reactions, including photosensitivity. Mefloquine is an effective option, but its use is low given the concerns with neuropsychiatric adverse events. Atovaquone/proguanil has the advantage of being associated with a low rate of adverse reactions and, as it acts as a causal (active

Another suggestion put forward for discussion and research is the idea of a pre-travel-only course of atovaquone/proguanil aimed at improving compliance in the short-term traveller. against liver forms of the parasite), rather than suppressive form of prophylaxis, it does not need to be taken for as long a period after leaving the malarial area.

Dosing regimens There has been considerable discussion and debate in the travel medicine community

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about whether a shorter dosing regimen is effective, as it would be likely to improve uptake and adherence. This is important as most of the travellers who contract malaria have not taken any drug prophylaxis or have failed to adhere to the suggested regimen.5 Though Australian data show increasing use of

atovaquone/proguanil, one of the barriers is cost, as a pack of 12 tablets costs more than $60. The TGA-approved dosing regimen for atovaquone/ proguanil (both adult and paediatric forms) states that prophylaxis should start 1-2 days before entering a malaria-endemic area, and be continued daily until seven days after leaving. Leshem, et al, studied the effectiveness of an optional short prophylactic course where Israeli travellers to sub-Saharan Africa were offered the choice of the standard regimen of the anti-malarial prophylaxis or ceasing atovaquone/proguanil one day after leaving the endemic area. Of the 485 people studied, 421 (87%) opted for

the short course.6 Telephone follow-up 1-6 months after the travellers’ return did not identify any cases of malaria and no cases from the study participants were found in the Israeli Ministry of Health malaria registry. The study has a number of limitations, including low risk of exposure in some of the regions visited, uncertainty about whether the medicine was taken as advised and possible recall bias. Nonetheless, it provides some evidence to help inform practice. Other, even more radical, dosing regimens have been suggested including a weekly dose. This suggestion is based on the pharmacokinetics of the atovaquone/proguanil combination, specifically a long blood schizontocidal effect. This regimen has been examined in a human challenge study, but not, as yet, in studies in travellers.7 Another suggestion put forward for discussion and research is the idea of a pre-travel-only course of atovaquone/proguanil aimed at improving compliance in the short-term traveller.8 Clearly, shorter courses and alternative regimens for atovaquone/proguanil are popular subjects for research, but until there is conclusive evidence of benefit, caution is needed before adopting such strategies. However, if the likely alternative is a traveller not taking prophylaxis at all or failing to adhere to the standard recommended regimen, then consideration

on an individual basis is warranted. ● Professor Zwar is a GP and professor of general practice at the University of NSW, Sydney. He has a PhD and participates in primary care research.

References 1. WHO World Malaria Report, 2015. See: bit.ly/1NV8u7g 2. Murray CLJ, et al. Global malaria mortality between 1980 and 2010: a systematic analysis. Lancet 2012; 379:413-31. 3. WHO. International Travel and Health 2012. See: www.who.int/ith/en/ 4. Yung A, et al. Manual of Travel Medicine. 3rd edn. IP Communications, Sydney, 2011. 5. Robinson P et al. Imported malaria treated in Melbourne, Australia: epidemiology and clinical features in 246 patients. Journal of Travel Medicine 2001; 8:76-81. 6. Leshem E et al. Effectiveness of short prophylactic course of atovaquone/proguanil in travelers to sub-saharan Africa. Journal of Travel Medicine 2014; 21:82-85. 7. Deye GA et al. Prolonged protection provided by a single dose of atovaquone/proguanil for the chemoprophylaxis of Plasmodium falciparum malaria in a human challenge model. Clinical Infectious Diseases 2012; 54:232-39. 8. Shanks GD, et al. Drug free holidays: pre-travel versus during travel malaria chemoprophylaxis. American Journal of Tropical Medicine and Hygeine 2008; 77:1-2.

Breo® Ellipta® is indicated for the regular treatment of moderate to severe asthma in patients (≥12 years of age) who require a medium to high dose ICS with a LABA.1

For further information regarding Breo® Ellipta®, including full device use instructions, please refer to the Product Information and visit www.breoellipta.com.au. ICS = inhaled corticosteroid; LABA = long acting ß2-agonist. Reference: 1. Breo Ellipta Product Information.

PBS Information – Restricted Beneﬁt: Asthma Patient must have previously had frequent episodes of asthma while receiving treatment with oral corticosteroids or optimal doses of inhaled corticosteroids. Patient must be 12 years or older. Note: This product is only indicated and PBS reimbursed for maintenance therapy.

PLEASE REVIEW FULL PRODUCT INFORMATION BEFORE PRESCRIBING. The Product Information can be accessed at http://au.gsk.com/media/266962/breo-ellipta_pi_005_approved.pdf

Breo® Ellipta® (fluticasone furoate/vilanterol trifenatate) Minimum Product Information. Indications: Asthma: Regular treatment of moderate to severe asthma in patients requiring medium to high dose inhaled corticosteroid (ICS) combined with long acting ß2-agonist (LABAs). Chronic Obstructive Pulmonary Disease (COPD): symptomatic treatment of patients with COPD with a FEV1<70% predicted normal (post-bronchodilator) in patients with an exacerbation history despite regular bronchodilator therapy. Breo Ellipta is not indicated for the initiation of bronchodilator therapy in COPD. Contraindications: Severe milk-protein allergy or hypersensitivity to any of the actives and any excipients. Precautions: Long acting ß2-agonists (LABAs) as a class can be associated with an increased risk of asthma death. Patients using Breo Ellipta should not use another medicine containing a LABA (e.g., salmeterol, eformoterol, indacaterol) for any reason. Cannot be used to relieve acute symptoms of asthma or COPD (short acting ß2-agonists should be used for acute attacks). As with other inhalation therapy, the possible occurrence of paradoxical bronchospasm immediately after dosing should be treated with short acting ß2-agonists. As with sympathomimetic drugs, Breo Ellipta should be used with caution in patients with cardiovascular disease. As with all sympathomimetic amines, Breo Ellipta should be used with caution in patients with convulsive disorders or hyperthyroidism. To minimise adverse reactions, ICS should be used at the lowest dose that maintains symptom control. ICS should be used with caution in patients with active or quiescent tuberculosis infections of the respiratory tract; systemic fungal, bacterial, viral, or parasitic infections; or ocular herpes simplex. An increase in pneumonia has been observed in patients with COPD. Beta-adrenergic agonists may produce significant hypokalaemia in some patients, which has the potential to produce adverse cardiovascular effects. Beta-agonist agents may produce transient hyperglycaemia in some patients. Other: fertility, pregnancy (category B3), lactation. Interactions: Beta-blockers, P-glycoprotein inhibitors, CYP3A4 inhibitors, sympathomimetic medicinal products, monoamine oxidase inhibitors, tricyclic antidepressants. Adverse Reactions: Very common: headache, nasopharyngitis. Common: URTI, bronchitis, influenza, oral candidiasis of mouth and throat, oropharyngeal pain, sinusitis, pharyngitis, rhinitis, cough, dysphonia, abdominal pain, arthralgia, back pain, pyrexia, muscle spasms. Fractures and pneumonia in patients with COPD. Dosage: Prescribers should be aware that 100 mcg of fluticasone furoate is a medium dose of ICS and 200 mcg of fluticasone furoate is a high dose of ICS. Asthma: (Adults and Adolescents ≥ 12 years): 1 inhalation once daily (100/25 mcg or 200/25 mcg). In patients whose asthma is well controlled and stable the Breo Ellipta dose may carefully be down-titrated to the lowest strength of Breo Ellipta. The next step should consider the cessation of Breo Ellipta and transfer to an appropriate inhaled corticosteroid containing regimen. COPD: 1 inhalation once daily (100/25 mcg only). Breo Ellipta 200/25 mcg is not indicated for patients with COPD. Specific patient population: Elderly patients: due to limited data in patients with asthma aged 75 years and older, Breo Ellipta 200/25 mcg is not recommended. Moderate to Severe Hepatic Impairment: once daily maximum dose of 100/25 mcg. Min PI v3.0. For full product information please contact GlaxoSmithKline Australia Pty Ltd. PO Box 18095, Melbourne, VIC 8003. ABN 47 100 162 481. For information regarding a GSK product or to report an adverse event, please contact Medical Information on 1800 033 109. Breo® and Ellipta® are registered trade marks of the GSK group of companies Breo® Ellipta® was developed in collaboration with Innoviva. AUS/FFT/0030/16f(1) Date of Approval: September 2016 S&H GSKBR0090-AD-PA

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30 September 2016 | Australian Doctor |

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Gut Feelings

The healing power of words

Guest Editorial Emeritus Professor Stephen Leeder

ULLING yourself and your personal identity back together after a relationship break-up can be a bit like assembling a piece of IKEA furniture, argues a humorous article in the New Yorker titled, ‘How to put your Sëlf together’. The piece warns that leaving your Sëlf unattended during this emotional time of reassembly “can result in injury, error, or poetry”. It made me think about poetry and medicine, and how it can help doctors express their feelings over traumatic experiences. The language of poetry links to art, drama, sculpture and music, especially to song. It enables feelings of love and loss, of ecstasy and sadness, not otherwise easily expressed. Poetry can help us express our deep feelings when patients, family or friends suffer and die. It enables these feelings to be explored, articulated and shared without the heavy transactional processes of prose. Poetry can also enable the expression of achievement — liberation, cure, safe birth, the lifting of depression — things that are not enumerated in key performance indicators that tend to reflect processes and financial efficiency expectations of the clinician. It can help share an elemental connection to love and happiness that bypasses the bureaucracy of measurement and computation.

| Australian Doctor | 30 September 2016

Further, poetry can reveal deep things about the poet and his or her subject, which he or she may find difficult to share otherwise. Not all doctors are extroverts, not all express their feelings openly. They may be more comfortable speaking from behind the veil of poetry. It is a mistake, however, to think that poetry is simply random jottings that require little effort. In fact, it is an art form that carries its own discipline like learning a musical instrument.

through 10 or more degrees, allowing the light to diffract into new colours, astonishing the reader with their novelty. Take the first stanza, and especially its brilliant last line of his poem The Sharping Stone: “In an apothecary’s chest of drawers, Sweet cedar that we’d purchased second hand, In one of its weighty deep-sliding recesses impression. I found the sharping stone that was to be

Not all doctors are extroverts, not all express their feelings openly. They may be more comfortable speaking from behind the veil of poetry. I have benefited from being a member of a poetry writing group, which meets each week with an expert tutor to share poetry and critique each other’s efforts. I have come to enjoy the way poetry makes me consider and savour each word. It is rich in metaphor, analogy and simile, and light on description, depending more on evocation, suggestion and impression. The great Irish poet Seamus Heaney had a brilliant talent for turning words, like diamonds, www.australiandoctor.com.au

Our gift to him. Still in its wrapping paper Like a baton of black light I’d failed to pass.” Poetry allows me to search my mind for interpretations of events and people that are not immediately obvious. Others might access these insights through meditation, but for me, sitting at the laptop with no more than the germ of an idea of the poem and then watching it emerge, expands my understanding of those events and people.

The Scandinavian Nobel laureate poet Tomas Tranströmer suffered a devastating stroke in 1990, leaving him hemiplegic and without speech. His recovery was gradual and never complete, but he returned to playing the piano with his left hand. He also returned to writing short poems. I wondered about his experience — lived as it were from the inside. So I wrote a poem, beginning with the confusion and disorientation of the acute phase of his cerebrovascular accident, as he might have experienced it. I tried to use his voice, his style, for this purpose. One snippet of this quite long poem, The Stroke of One, reads: In a flash my spirit was caught like a fish in a net, my flesh pulled and spun through an unfamiliar deep. I do not claim that this poetic exploration was helpful to anyone, least of all Tranströmer, but I feel differently about the stroke experience as a result. May be it will make me better understand the impact of strokes in others, or in myself, if I were ever to suffer this fate. Professor Leeder is Emeritus Professor of Public Health and Community Medicine at the Menzies Centre for Health Policy and School of Public Health, University of Sydney. You can read more of his poetry at stephenleeder.blogspot.com.au

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2016-09-22T09:53:55+10:00

Let’s get serious about sleep Your Views EDITOR The causes of many common sleep disorders are very amenable to general practice management, such as weight loss, sleep hygiene, alcohol and drug use, education etc (‘MBS review targets “sleep disorder businesses”’, 13 September, australiandoctor.com.au). Sleep specialists are useful for more difficult or unusual cases. However, GPs are perfectly placed to initiate diagnosis and management of most conditions rather than refer immediately. The idea that only a specialist (in any field) can provide competent advice is a fallacy debunked by Professor Fred Hollows’ training of non-ophthalmologists. Plus, many doctors develop special interests in conditions outside their core fields. The art is to recognise our limitations and seek help — something many humans find challenging. The committee report about sleep studies recommends that GPs provide the initial management, and refer for complicated cases, plus improving the support and resources to GPs. Dr Sam Hutson Geriatrician, Sunshine Coast

EDITOR I work in a small town, and I refer patients for a home-based sleep study because the nearest ‘sleep lab’ is 2.5 hours away.

Besides, if you are anything like me, you can’t easily fall asleep in a new bed either. So many patients prefer this option. All the referrals I do are formally assessed by the company organising the sleep study, which conducts a phone questionnaire that, along with my referral letter, is vetted by a specialist. There has been an increase in the number of home-based sleep investigations because of increasing GP awareness of the condition. This is better than having sleep-deprived motorists crash into oncoming traffic. Let the MBS taskforce committee members try living in Condobolin — without an airport, without ‘visiting specialists’, but with floods, broken

internet and poor phone connections — and let’s see how happy they then are to make such recommendations. Residents here don’t even have the time for a hernia operation, let alone see a sleep specialist face-to-face. Dr Muhammad Umer Shehzad GP, Condobolin, NSW

Have your say All letters should contain the sender’s title, address and daytime phone number. Letters should be exclusive, no more than 250 words and may be edited. Letters should be sent to: Fax: (02) 8484 0800 or email: mail@australiandoctor.com.au

EDITOR I grumbled to a patient about a cardiologist demanding a new referral, when I had already provided a continuing referral for the same problem. The patient mentioned this to the cardiologist, who rang me up in the patient’s presence, and berated my stance. He virtuously claimed his policy was merely so “the patient had a higher rebate”. I brought up this topic when I met Federal Health Minister Sussan Ley, to point out areas that could be targeted for cost savings, rather than picking on quality GP practice. By the way, the patient asked to change cardiologists. Dr Maureen Fitzsimon GP, Logan, Qld

(6 big changes mooted for MBS items, 12 September) With regards to the new MBS item proposed for a postnatal attendance at six weeks after birth, for a mental health assessment ... where I work, the receptionist books a 15-minute consult for the mother’s six-week postnatal visit, and a separate 15-minute consult for the baby’s six-week visit plus vaccination. There is no time for an additional mental health consultation as per the proposed changes. Sorry, but the new mother will have to return on another day.

wonder no one is interested in uploading summaries to their stupid website, which will probably be hacked or blocked like the Census website was.

Dr Grub

Why do we need a new obstetric item number for a six-week postnatal check, which pays exactly the same as item 36 does? Similarly, with the 2713 mental health consultation — why not just charge a 36? Why have these extra numbers to confuse things? Reduction in overservicing with colonoscopies would help free up space for those waiting for follow-up of a positive FOBT. Bring it on. Similarly, rationalising the timing of follow-up bone

Dr Greg

How about we all refuse to do Centrelink forms? They are a ‘low-value item’ after all. Just tell the patients: “Take this to your local MP’s office, and get them to certify it for you.” rural GP

Doctor-patient ills

densitometry scans makes sense. The evidence supports much longer intervals. A bit of evidence on skin checks would help rationalise that area too. Dan Ewald

Reading by proxy (Free gift for million-dollar Health Minister, 9 September) There is an intriguing anomaly in the list of publications cited. Why does Sussan Ley pay for her copies of the Corowa Free Press? This may be the last of the ‘bulk-billed newspapers’, that has just seen the light. lhadnesorg

In Sussan Ley’s defence, are there not people in her

department who read medical magazines such as Australian Doctor and brief her? If the health department does not have personnel reading medical opinion, then that would really be a worry. Hypocrites GP

‘Low-value’ forms (Government to investigate e-health PIP failure, 15 September) After holding meetings with stakeholders, Sussan Ley ignores what was said. She claims much of our work “isn’t of much value” while continuing to send us Centrelink, and now NDIS, forms to be filled out. No

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Dr Elizabeth Kaiko GP, Raymond Terrace, NSW

No time for more

— Professor Deborah Saltman AM @Deborah Saltman

Editor: Jo Hartley (02) 8484 0741

EDITOR I rang up Medicare for advice on a procedural item interpretation (‘Doctors could be forced to take Medicare exam’, 12 September, australiandoctor.com. au). I was told they could not advise me because, essentially, they would then have to take the responsibility for its use. They just repeated the wording in their rules, which was ambiguous — my reason for calling them in the first place.

FROM THE WEB

“Health insurance a misnomer ... it is neither about health nor insurance.”

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Rules minus responsibility

Letters

TWEET OF THE WEEK

Australian Doctor team

(The dying GP who became a ‘heartsink’ patient, 6 September) As a doctor in my 50s who was previously healthy, I developed congestive heart failure, which turned out to be the result of myocarditis. I was not diagnosed for months — partly because I didn’t want to make a fuss, and partly because I was never properly examined. I think it was assumed I would know what was wrong (I didn’t), and nothing was done until I presented with severe oedema and all the other signs of CHF. Be careful if you treat doctors — they should be treated as you would treat anyone else, that is, with a proper history, examination and investigation.

The views expressed in this publication are not necessarily those of Cirrus Media. Australian Doctor is an independent publication serving the needs of Australia’s general practitioners. It has no affiliation with any medical organisation or association, and our editorial content is free of influence from advertisers. Australian Doctor is sent free to full-time GPs in private practice and certain prescribing and staff specialists. It is available to other readers on subscription for $390.00 pa including GST. Overseas rates apply. Phone (02) 8484 0666. Average Net Distribution Period ending March 2016 18,126

Australian Doctor is published 48 times a year by Cirrus Media, Tower 2, 475 Victoria Avenue, Locked Bag 2999, Chatswood DC, NSW 2067 Ph: (02) 8484 0888 Fax: (02) 8484 0800 Email: mail@australiandoctor.com.au www.australiandoctor.com.au (Inc in NSW) ACN 132 719 861 ABN 80 132 719 861 ISSN 1039-7116 © Copyright 2016 www.cirrusmedia.com.au Printed by Offset Alpine, under ISO14001 Environmental Certification.

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2016-09-22T08:48:10+10:00

Guest Views DR PAM RACHOOTIN

OPINION

The travelling sickness Patient holidays are no picnic for doctors.

‘H

OW are you?” I asked a friend. I was surprised by the reply. “Well, I’m off to the US next month, and will be travelling in India at the end of the year.” ‘I travel, therefore I am’, seems to be the new man-

tra for baby boomers. For a GP, this travel bug contagion demands skills in travel medicine. I enjoy advising people on how to stay healthy overseas. What I don’t relish is a surgery consult followed by banter that reveals the patient is taking off to an exotic loca-

tion the next day, without any medical forethought. Or worse, patients who have been told by their travel agent that “no immunisations are required”. Having survived their departure, the next hurdle is receiving communications from abroad when they have

run into problems. I remember several harrowing calls to the tune of “Don’t tell Mum, but I have a terrible burn”, or “I need you to book me in to a hyperbaric oxygen chamber on my return”, or “Since the accident, I can only breathe if I get down on the floor on

Think beyond statin monotherapy

Patients with primary hypercholesterolaemia not at LDL-C target on:

all fours. What do you think that means?” On the traveller’s return, the unsuspecting GP is particularly vulnerable. Invariably, your patient has picked up the latest virus on the long flight home and generously offers to share it with you. These people virtually roll off the plane into the surgery and cough in your face, guaranteeing you a nasty infection without the benefit of a holiday beforehand. Meanwhile, I wonder what pleasures realistically await the modern-day tourist, with pressure from social media guiding their every move. Exploration and serendipity seem to play no role in the travel experience. The important thing is not to miss out on anything.

These people virtually roll off the plane into the surgery and cough in your face.

atorvastatin

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10/20mg

10/40mg

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PBS Information: Authority required (STREAMLINED). Patient must be on maximally tolerated statin dose before switching to statin and ezetimibe combination therapy. Refer to PBS Schedule for full authority information.

Before prescribing, please review the Product Information. The Product Information can be accessed at www.msdinfo.com.au/atozetpi Minimum PI for ATOZET. Indications: as adjunctive therapy to diet in patients with primary hypercholesterolaemia where use of a combination product is appropriate in those patients: not appropriately controlled with atorvastatin or ezetimibe alone; or already treated with atorvastatin and ezetimibe. Patients with homozygous familial hypercholesterolaemia. Contraindications: hypersensitivity; myopathy secondary to other lipid lowering agents; active liver disease; unexplained persistent elevations of serum transaminases; pregnancy; lactation; fusidic acid; fenofibrate (gall bladder disease only). Precautions: Liver function: monitor liver enzymes before treatment and periodically when clinically indicated; high alcohol use; history of liver disease; moderate-severe hepatic insufficiency (not recommended). Myopathy/rhabdomyolysis: interrupt therapy in severe acute infection, hypotension, major surgery, trauma, severe metabolic, endocrine and electrolyte disorders, and uncontrolled seizures; renal impairment (monitor CK); cyclosporin – avoid; consider lower doses and monitor for signs/symptoms of myopathy when co-administered with erythromycin, clarithromycin, HIV protease inhibitors (alone or in combination), niacin, azole antifungals, colchicine, certain hepatitis-C protease inhibitors, fibrates other than fenofibrate (not recommended). Anticoagulants (warfarin, fluindione, coumarin derivatives: monitor INR), haemorrhagic stroke; endocrine function (elevated HbA1c and fasting serum glucose); interstitial lung disease (discontinue); women of childbearing potential (ensure adequate contraception); children; driving and operating machinery. Pregnancy: Category D. Interactions: CYP3A4 inhibitors e.g. erythromycin/clarithromycin, protease inhibitors, itraconazole, diltiazem, grapefruit juice (>1.2L per day); CYP3A4 inducers e.g. efavirenz, rifampicin, phenytoin; digoxin; oral contraceptives. Other interactions – see above. Adverse events: dizziness; headache; coughing; dyspnoea; abdominal distension; constipation; diarrhoea; dyspepsia; flatulence; gastritis; nausea; muscle spasms; myalgia; fatigue; malaise; blood CK increased; influenza; depression; insomnia; sleep disorder; dysgeusia; paraesthesia; sinus bradycardia; hot flush; abdominal discomfort; abdominal pain; stomach discomfort; acne; urticaria; arthralgia; back pain; muscle fatigue; muscular weakness; musculoskeletal stiffness/pain; pain in extremity; asthenia; oedema; ALT and/or AST increased; ALP increased; GGT increased; liver function test abnormal, weight increased; hyperkalaemia; bronchitis; sinusitis. Others – see full PI. Dosage: one ATOZET tablet daily (any time of day). Starting dose 10/10mg or 10/20mg once daily, adjustment after 2 weeks if required. HoFH: 10/40mg or 10/80mg daily. No dosage adjustment required for renal impairment or mild hepatic insufficiency. Not recommended in children, moderate-severe liver dysfunction. Take ≥2h before or ≥4h after bile acid sequestrants. Other co-administrations: see full PI. Overdosage: symptomatic and supportive measures should be employed. Based on PI approved 21 January 2015. References: 1. ATOZET Approved Product Information, 21 January 2015. Copyright © 2016 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, U.S.A. All rights reserved. Merck Sharp & Dohme (Australia) Pty Limited. Level 1 – Building A, 26 Talavera Road, Macquarie Park NSW 2113. CARD-1190058-0000. First issued July 2016. Bloe Agency MSD12677A_AD.A4

Conveniently, everything has been predetermined by those who have gone before. These days, travellers consult their smartphone to find where to drink the best cup of coffee. They are blind to the many wonders they could see if only they looked up from their phones. And don’t get me started on cruise passengers. I met some semi-retired friends from Wisconsin, passing through Sydney on a five-star cruise. They were ecstatic that I was flying in from Adelaide to see them and expressed their delight to some of those on board, who seemed to have misconceived idea of my GP earning power. “Gee, she must be really wealthy to fly over,” remarked one passenger. “What sort of jet does she own?” In my youth, I was seduced by the lure of travel. What a revelation to experience different cultures. Then I realised how superficial the tourist experience was compared with actually living in a foreign land. One’s life could be permanently enriched by learning a new language, being employed and productive, and making new friends. To see the world in a grain of sand, now isn’t that the trick? No immunisations required. Dr Rachootin is a GP in Adelaide, SA.

| Australian Doctor | 30 September 2016

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ASPC0031_AUSDOC_FP 2016-09-20T13:53:01+10:00

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2016-09-22T08:49:03+10:00

Guest Views EMERITUS PROFESSOR MAX KAMIEN

OPINION

A shout-out for the deaf Deafness is not a visible disability like a pair of crutches.

CCORDING to the Australian Bureau of Statistics, one in five people over 60 have a socially significant hearing loss. I am one of them. I sometimes fail to answer a question addressed to me, and I interrupt a companion’s

story that I think has finished when it hasn’t and miss the punchline of a joke. Thus, I sometimes appear preoccupied, rude or demented. This distresses my wife, who, in early old age, now loves me for my mind. Deafness, like many types of blindness, is invisible.

Others are not as helpful as they usually are when you have a visible disability, such as a plaster cast or a pair of crutches. Background noise is the real killer. Especially contemporary music that is dominated by a booming syncopated bass sound, which is

reflected off the hard surfaces found in coffee shops and restaurants. It not only masks my remaining hearing, but the reverberation gives me a headache and a sense of disorientation. In these surroundings, my hearing aids magnify the noise and have to be turned off.

My polite requests to turn the volume down, or preferably off, are usually refused on the grounds of ‘ambience’ or by the assertion that the other customers like it, even when there are no other customers. My declaration of deafness and the evidence of my hearing aids only rarely softens their stance. One waitress pointed to a sign. “If the music is too LOUD Your’e too OLD” (sic). My opportunistic surveys of customers in cafes and restaurants find that most would prefer to be able to hear each other. That is generally why people go to these places. But the wait-staff are young and they are the ones who choose what they, rather than their older customers, like. At my 80th birthday party, I insisted there be no background music. My guests

Making even a temporary change to accommodate a listener who they know to be deaf is difficult for most people.

Confidence from Evidence and Real World Experience* *Xarelto has evidence for its efficacy and safety profile for eligible patients from RCTs and real world studies in SPAF1-3 and PE/DVT.4,5 Xarelto is the world’s most prescribed NOAC,6 with over 18 million patients treated across multiple indications.7,8

RCT=randomised controlled trial; SPAF=stroke prevention in atrial ﬁbrillation; PE=pulmonary embolism; DVT=deep vein thrombosis; NOAC=non-vitamin K antagonist oral anticoagulant. Calculation based on IMS Health MIDAS, Database: Monthly Sales December 2015.

BEFORE PRESCRIBING PLEASE REVIEW PBS AND PRODUCT INFORMATION (PI) IN THE PRIMARY ADVERTISEMENT IN THIS PUBLICTION. References: 1. Patel MR et al. N Engl J Med 2011;365:883–91. 2. Camm J et al. Eur Heart J 2015. Sep 1. pii: ehv466. [Epub ahead of print]. 3. Tamayo S et al. Clin Cardiol 2015;38:63–8. 4. Prins MH et al. Thrombosis J 2013;11(1):21. 5. Beyer-Westendorf J et al. Blood 2014;124:955–62. 6. IMS Health MIDAS, Database: Monthly Sales June 2015. 7. Calculation based on IMS Health MIDAS, Database: Monthly Sales December 2015. 8. Xarelto® (rivaroxaban) Product Information, 9 November 2015. Bayer Australia Ltd. ABN 22 000 138 714, 875 Pacific Highway, Pymble NSW 2073. Xarelto® is a registered trademark of Bayer Group, Germany. BAY3866/AD/L.AU.MKT.GM.12.2015.0386

remarked on the wonder of going to a reception and not having to shout at each other. I can only conclude that the ubiquitous provision of loud, unmelodious pop music in restaurants and public places is another form of Australian mindlessness similar to the demand for sickness certificates for acute, self-limiting viral infections. By the time a person reaches adulthood, their speaking habits are neurologically hardwired. Making even a temporary change to accommodate a listener who they know to be deaf is difficult. Only one of my usually perceptive friends has been able to accomplish the task. He always sits in front of me, articulates clearly and speaks a little slower than usual. In contrast, my multitasking wife often speaks to me from the next room or with her head in the fridge. We deaf are a sizeable, silent and therefore neglected group of disabled people. Our needs are unlikely to be met without concerted political action. ● Professor Kamien is a Senior Honorary Research Fellow at the University of WA.

| Australian Doctor | 30 September 2016

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2016-09-23T10:47:20+10:00

This Week PIC OF THE WEEK

QUOTES OF THE WEEK

US Broc Brown, pictured with grandmother Joy (left) and mother Darci in Jackson, Michigan, has reached a record-breaking height of 2.3m and is still growing. Broc, who was the world’s tallest teenager before becoming too old for the classification, is growing at the rate of 15.4cm a year. If he maintains that rate, the 19-year-old could easily surpass the current tallest man, Sultan Kosen, who stands at 2.48m. Broc has Sotos syndrome and was told he would not outlive his teenage years, but doctors are now confident he will have a normal life span despite his condition.

“They were able to derail the discussion about sugar for decades.”

Primary care is now about bums on seats Journal Talk Michael Woodhead

AS well as Borat, Kazakhstan has also given us the WHO Alma Ata Declaration that first put primary healthcare at the centre of health systems. This 1978 vision of having multidisciplinary, locally focused healthcare services has been taken for granted for so long that we are in danger of seeing it whittled away under the guise of promoting competition, efficiency, “customer focus” and targets. That’s the warning contained in an article about the impact of “neoliberal” management strategies on primary care in Australia. Writing in Social Science and Medicine, Professor Fran Baum and colleagues at Flinders University, Adelaide, describe the changes witnessed by health practitioners and managers working in primary care since 2008. The era after the global financial crisis has seen a growing emphasis on cost-containment, outsourcing and “managerialism”.

According to the study based on interviews with primary care practitioners and managers, this has resulted in a shift from providing comprehensive, communitybased approaches to health to a focus on measurable activities in selected areas. As a result, primary care providers say they have had to drop a lot of their health promotion and community-based disease prevention activities to concentrate on providing acute care services. In this new mean-and-lean era, there is no place for health advocacy or addressing the social determinants of health at the local level, the authors say. No more funding for local health support groups or transport services, and less engagement with the community through education and collaborative projects. “We were told no more committees, no more partnerships with school and local government,” said one practitioner involved in a domestic violence prevention network. New “slash-and-burn” management

strategies have also meant short-term contracts for staff and programs, taking attention away from long-term health outcomes, they add. The neoliberal approach has forced practitioners to justify funding by showing short-term improvements in easily measurable throughputs, rather than meeting long-term goals. “The government funds bums on seats, episodes of care,” said one manager. “It’s all about numbers … you’re just like a widget, churning through people like a factory worker,” said another practitioner. Which brings me back to Borat, whose most notable legacy has been the ‘mankini’. It leads me to wonder if an acceleration in neoliberal healthcare delivery is going to have a similar ‘mankini’ effect, leaving certain areas of primary care (that are difficult to measure) largely uncovered and unsupported by funding — all in the name of “improved performance”? Social Science and Medicine 2016; online.

SNAPSHOT

AN AVERAGE DAY IN AUSTRALIAN HEALTHCARE

381,000

GP consults

616,000 246,000

pathology tests conducted

24,000

specialist

20,000 hospital emergency

79,000 consultations 27,000

applied health services provided

27,000 hospitalisations

departments

Reference: Australia’s health in brief, 2016, Australian Institute of Health and Welfare.

AMA president Dr Michael Gannon says the SA Government’s bill before Parliament to legalise assisted death would be far more difficult to implement than many realise.

“I wouldn’t think that an outbreak [of pertussis] like this would have happened in Australia for many years.”

“We found that drinking a glass of beer helps people see happy faces faster.”

visits to community mental health services presentations at public

1900

“Is it a service that is provided in public hospitals?”

AMA WA president Dr Andrew Miller responds to the news that a Perth primary school has had 29 pertussis cases in six months.

Almost 400,000 GP consultations are logged every day across the country, according to a new report.

prescriptions dispensed

Professor Stanton Glantz, from the University of California in San Francisco, claims his research team uncovered internal sugar industry documents that show the industry paid scientists in the 1960s to play down the link between sugar and heart disease, and promote saturated fat as the culprit instead.

Professor Matthias Liechti, from Basel University Hospital in Switzerland comments on his study on beer and sex.

people admitted for elective surgery in public hospitals MAZ

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2016-09-23T14:52:01+10:00

Classifieds For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

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| Australian Doctor | 30 September 2016

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NSW

Name your days and hours of work. Paid travel time. Provider number, GP level indemnity insurance and unconditional registration essential.

Call Practice Managers Celeste or Riley for more information or email to request an email information pack.

d.warner@jwhealth.com.au GS Search: Julie Warner Health KIN MS O U BO LOC www.jwhealth.com.au G 7 KIN201 JW_Health TA

• Good remuneration is on offer including support for relocation, accommodation and travel.

GP-owned practice (Dr Kirsten Baulch MBBS FRACGP).

Contact Dennis for a confidential discussion

VR GPs wanted for flexible, casual, fun work doing GP-based and community vaccinations. Opportunities in all States and Territories.

NSW 594132_16_09_16

• Very supportive of GP’s with special interests such as skin health and cosmetic medicine.

$125 per hour

NSW 594231_30_09_16

associate or partner? Practice management, Are you seeking to front to back transition out slowly? Free practice Love 3-6 months market appraisal sabbatical leave? Need a dentist, Need Full time, Part locum or dental staff? time VR or non VR? GPs from UK: we Are you seeking an have a London office

NSW 593554_16_07_22

Considering selling or buying a practice?

Exciting career opportunity in great clinic located in Jerrabomberra • Great variety of work with general practice, medical assessments, injury management and skin screening.

NSW 594237_30_09_16

Canberra GP’s Required (VR, DWS & IMG Opportunities)

NSW 594239_30_09_16

Practices wanted Australia wide

NAT 594193_23_09_16

Advertise your locum positions on medicaljobs.com.au now

jobs

NAT 594141_30_09_16

Need a holiday?

AD_037___30SEP_16

2016-09-23T14:52:01+10:00

For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

We have a number of exciting opportunities for GPs to join our dynamic and well-established practices throughout New South Wales: • Blacktown

• Liverpool

• Brookvale

• Mosman

• Glendale

• Orange

• Hammondville

• Shellharbour

• Hinchinbrook

• Upper Mountains

NSW 594219 30_09_16

GP Opportunities – NSW Doctor George Quittner IPN Mosman Trail blazer

CO CON

We work with GPs across Australia to deliver the highest levels of patient care. By partnering with IPN, you will have the support you need so that you can focus on what’s important, your patients. View all of our GP opportunities at ipn.com.au/doctors

NSW 594161_23_09_16

• Negotiable working days and hours plus excellent remuneration on offer. • Pathology, pharmacy, podiatrist, physiotherapist and dentist onsite. • Close to Hornsby Hospital and exclusive private schools. P: 02 9476 3644 - Practice Manager E: balmoralstmed@ozemail.com.au

MERRYLANDS 2 FT GPs REquiRED

NEWCASTLE (EdgEWorTh) FT/PT gP - Vr • 75% / Guaranteed weekly $4000 first 3 months • DWS area • Experienced nursing and support staff • Friendly modern practice, non-corporate • Coastal area close to Sydney and Hunter Valley

• VR GP to replace outgoing GP. • Very busy med centre with F/T nurse, allied health, Path and Specialists. • $150/hr or 70% • Locum work also available.

P: 0420 605 619

FT or PT - the choice is yours! Waterfront Practice. Flexibilty, work the hours you want. Experienced Nursing and Administration support. Modern Accredited Practice. Allied Health and Pathology collection on site. 65% of billings

TEM

Central Coast Vr General PraCtItIoner Monday - Friday 8:00am - 5:00pm

NSW 594112_16_09_16

Full time / Part time No After Hours 80% with minimum guaranteed P: 0424 164 863

P: 4971 6663 / 0432 748 736 - Lauren Seal E: swanseachannelpractice@hotmail.com

P: 02 4954 3222 Natasja E: admin@newcastlemedical.com.au

Penrith / CamPbelltown area DwS Vr GP

• To replace outgoing GP • Very busy medical centre with F/T nurse, allied health, Pathology and Specialists. • $150/hr or 70% • Locum work also available.

SwanSea FT/PT gP

NSW 594069_09_09_16

NSW 593718_07_10_16 NSW 594111_16_09_16

Excellent remuneration Modern appealing facilities Accredited, fully computerised practice Practice nursing support Flexible hours (no A.H) Partnership a possibility

Marrickville, Bankstown, Burwood area vr GP

Gynaecology Centres Australia requires doctor (VR or non VR) to administer IV Sedation to women undergoing surgical termination of pregnancy. Training provided. Possibility of additional work available at Hurstville. Paid per case with minimum. Approx $180-220/hr. P: 0412 394 502 - Meaghan E: info@gcaus.com.au

P: 0405 570 708 - Emma 0411 833 828 - Dr Subrata Banik

P: 02 9890 7755 - Jane E: office@pbbhealthcentre.com.au

P: 0401 140 966 E: GPneeded@optusnet.com.au

• Full support of RN’s, administrative staff and practice manager.

• • • • • •

Permanent/FT/PT or Locum. Locum period: 13 Dec 2016 - 20 Jan 2017 GUARANTEED $5,000-$5,500/Week. Fully Accredited, Modern, Busy, Teaching, Quality Practice. Open 7 days. Mixed Billing. Nurse / Allied Health / Pathology Lab. Computerized Medical Centre.

Wollongong IV SEDATIonIST

NSW 594176_23_09_16

Established since 1993, we are well known in the area and have the patient base to match.

Bay Healthcare Rockdale and Hurstvillle Town Medical Centre. FT/PT GP needed for modern, accredited and Computerised Centres “PracSoft and MD3”. Flexible hrs, Excellent remun and Conditions. Great earnings and weekends available. DWS after hours and Chinese Speaking GPs are welcome.

NORTH PARRAMATTA PT/FT VR GP RequiRed

Strathfield dOCtOrS Needed

NSW 594145_16_09_16

GP Required for busy, accredited, medically owned bulk billing practice in Hornsby.

Rockdale and HuRstville Ft/Pt GP needed

NSW 594087_09_09_16

P: 0424 771 220 / 02 9755 9676 - Dr Jenny E: familycaremp@gmail.com

P: 02 96718500 - Vivian E: vivian@blacktownfamilymedical.com.au

NSW 594048_09_09_16

Hornsby Vr GP rEQUIrED FUll TImE / ParT TImE

Fairfield Family Care Medical Practice • Accredited practice • Flexible working hours, parking space • 75% gross billings • Small friendly family practice • Nurse support • Fully computerised and modern

NSW 594096_16_09_16

P: 0412 224 979 E: jlas375982@gmail.com - Dr. Jacob

• To start ASAP • Eligible Non-VR and IMG Welcome to apply • Able to work evenings up to 10pm and weekends 9-5pm • High %, Busy, accredited, computerized, • RN support, allied health, specialist, xray, pathology onsite

FairField PT/FT GP required

NSW 594135_16_09_16

For A Busy Well Established DWS Practice Fully Computerized And Accredited. With Full Time RN, Pathology And 6 Allied Health. Excellent Top Remuneration.

Blacktown cBD GP REQUIRED

NSW 594117_16_09_16

Raby Full Time/PaRT Time VR GP (Dws also aPPly)

PR &S

ipn.com.au

NSW 594051_09_09_16

enquiries@ipn.com.au

NSW 594036_09_09_16

1800 IPN DOC

Allied Health and Nursing support. 80% of billing and hourly rate. Not DWS area. P: 0403 534 486 E: mail@hopehealth.net.au

With view to partnership after 1 year • Flexible Hours 75-80% • Practice Nurse and Allied Staff in Clinic • Specialist Surgeon, Gynaecologist and Cardiologist on site • Practice in good location, backing onto the train station and adjacent to shopping centre. P: 0411 085 909

DWS CampbelltoWn area Full time Vr Gp VR General Practitioner needed to join a team of experienced doctors and friendly staff. Fully accredited and computerized practice. On site registered nurse, physiotherapist, psychologist, dietitian and pathology. Next to shops. 75% and bonuses. P: 0466 029 838 - Dr Tran E: hdrtran@gmail.com

www.australiandoctor.com.au

LINDFIELD FT/PT DocTor rEQUIrED Established busy mixed billing practice, Fully computerised and accredited, Non-corporate and nursing support, Allied Health and pathology onsite, Friendly staff and 3 minute to station, Parking space and excellent remuneration. P: 0410628033 / 02 9880 7688 - Dr David Yu E: david_zq_yu@hotmail.com

Strathfield ft/Pt Vr GP required • • • • • • •

Albert Rd Medical Centre Huge Potential Suburb 4 GP rooms RN on Site 70% gross billing Minimum $150 per hour Chinese/Korean/Indian/Arabic speaking

NSW 594091_09_09_16

Merrylands Practice needs 2 Full Time GPs

NSW 594187_23_09_16

Busy, fully computerized, accredited teaching practice.

OR NEED TO CHANGE LOCATION

NSW 594165_23_09_16

Thornleigh/PennanT hills Vr gP required

NSW 594178_23_09_16

HAVE YOU COMPLETED YOUR FRCGP?

P: 0409 237 868 E: albertrdmedical@bigpond.com

30 September 2016 | Australian Doctor |

2016-09-23T14:52:01+10:00

Classifieds

l l

jobs

Bridgeman downs Vr generaL PraCTiTioner Required for a busy, friendly, non-corporate family practice in pleasant Northern Brisbane. Great opportunity for those wishing to relocate to Brisbane and walk straight into a large patient base. Terms Negotiable. Fully computerised. Full Time Nurse support

GP WANTED

P: 07 3166 9653 E: admin@bridgemanfamilypractice.com.au W: bridgemanfamilypractice.com.au

Great opportunity to join us in PARADISE at our Airlie Beach Practice

● ● ● ● ●

l l l l l l

Best consult room views in Australia!

Overseas trained doctors, Permanent Residents or 457 sponsorship

l l

Busy well established Practice – Large existing patient base

QLD 594033_09_09_16

QLD

GP Wanted – Caboolture

Caboolture Super Clinic, Now Open, is looking for GP’s to join our brand new state of the art facility offering multi-disciplinary medical services to the local population. Base contractual remuneration of $300000 per annum Comfortably earn between $300000-$400000 per annum, when adding additional service payments Full-time or Part-time positions with no lock-in period Appointment System - see 3-4 patients per hour Long standard consultation times (spend over 20 minutes seeing your typical patient) Work with specialists, nursing and allied health professionals Radiology and Pathology services onsite Extensive administrative and practice nurse support to facilitate health assessments and management plans Develop your clinical area of interest with dedicated multi-disciplinary specialist clinics Optional opportunities to perform minor operations with training available by Consultant Surgeons if required Opportunities for research, education and teaching with University collaboration and academic titles Pharmacy and Gym onsite opening soon

Excellent long standing Nurse and Administration support

Send Applications to: cabsuperclinic@gmail.com 0458 670 791 (Leeanne Dixon)

Email today for more details – recruitment@iig.com.au or call Cherie / Wendy on 07 4035 8004

GENERAL PRACTITIONER POSITIONS AVAILABLE

QLD 594080_09_09_16

QLD 592646 16_07_08

For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

QLD 594221_30_09_16

AD_038___30SEP_16

VR GP (FRACGP) positions available for our expanding Springfield Clinics • • • • • • •

Our Clinics are well Established in Modern Facilities Doctor owned and operated Busy well Established Bulk Billing Practices Accredited Family Practices Nurses, Pathology & Allied Health onsite Friendly Staff Open 7 Days a week

CONTACT:

ckammholz@stellarmedical.com.au

An exciting opportunity has arisen for an enthusiastic and committed GP to join the dynamic and well-established Central City Men’s Clinic in Brisbane, QLD. We are looking for an experienced practitioner with a keen interest in treating men’s sexual health problems. You will be part of a unique, modern, caring and friendly clinic that delivers quality healthcare.

Contact Fiona James on 0447 006 846, or email fiona.james@ipn.com.au

The Central City Men’s Clinic is part of IPN Medical Centres, the largest operator of medical centres in Australia. 1800 IPN DOC enquiries@ipn.com.au ipn.com.au

| Australian Doctor | 30 September 2016

www.australiandoctor.com.au

QLD 594210_30_09_16

Men’s health GP wanted for Brisbane clinic

QLD 594123 16_09_30

QLD 594131_16_09_16

North BrisBaNe (BurpeNgary) Ft or pt gp required Busy mixed billing practice experiencing growth due to high patient demand. Ideal work / life balance half way between Brisbane and Sunshine Coast. Fully accredited with opportunity for weekend work and evenings if desired. • • • •

Principal Doctor Owned Nursing and Treatment Room Support Rehabilitation Gymnasium & Courtesy Bus Extensive Allied Health Support and Visiting Specialists • Mixed Billing • High percentage and bonus after 3 months • DWS P: 0422 996 508 E: sharon@thehubmedicalcentre.net.au

AD_039___30SEP_16

2016-09-23T14:52:01+10:00

Both are mixed billing, MD software and good remuneration.

ESSENDON F/T Or P/T Vr GP rEQUIrED Busy established practice in modern facility. Private billing. Allied Health and Pathology onsite. Open 7 days but no obligation for weekend work. Excellent proven staff with full nursing support. Competitive remuneration and flexible hours offered

RESERVOIR GENERAL PRACTITIONER VR NON DWS

We have 2 new clinics and 1 established. Our Preston clinic offers extended hours and the Northcote clinic has a LGBTIQ focus. Centrally located, allied health and nursing services support the clinics. Please contact us if you have an interest in sexual health, complex care, family medicine and refugee health. We offer flexible, family friendly sessions in an exciting and interesting environment. P: 03 8470 1182 - Kath O’Donnell E: kathleen.odonnell@dch.org.au

• Small procedures theatre

• High earning capacity

• Visiting Specialists • GP Obstetrics; GP Paediatrics; VMO available at local base Hospital

• Fully accredited; fully computerised

P: 03 5382 0011 - Rob Phillips Practice Manager E: r.phillips@listerhouseclinic.com.au

CO CON

P: 03 87902111 - Julie or Neecia E: info@parkhillmedical.com.au

MOUNT MARTHA GP REQUIRED • GP required for our medical centre.

BENTLEIGH GP REQUIRED GP required for our medical centre.

• Fully computerised.

• Friendly staff.

• Busy location.

• High percentage remuneration.

P: 0416 355 042 - Joe

We have two of our GPs retiring, one at the end of September and one at the end of December.

VR FRACGP or NON VR

Earn up to $500 P/A

We are committed to the team with the following onsite: Practice Manager Nurse Manager and onsite nurses Pathology Physiotherapist Podiatrist Psychologist Mental health nurse Pharmacy

DWS - Full Time In the City of Casey, Victoria Requirements: •

Must have Full AHPRA Registration as a medical Practitioner (Specialist / General Registration)

A great opportunity exists for an experienced General Practitioner to join Balwyn Central Medical. Our team of Doctors aim to deliver good quality, affordable healthcare to all. We are a GP owned practice, modern and purpose built with on-site pathology, pharmacy and full time nursing support. We are seeking applications from General Practitioners with general registration who are committed and will uphold the standards in place to provide outstanding healthcare’ Our practice offers flexibility, diversity of clinical presentations, attractive remuneration, a fully computerised system and a great team environment.

PLEASE CONTACT Phone: 0401 477 860 - Arun Email: admin@bcmedical.com.au

VIC 594049 09_09_16_NC

P: 9478 2255 - Antoinette

» Modern bulk billing practice co-located with a Pharmacy. » Open 7 days, Full / Part Time positions with flexible rosters. » Excellent support from experienced clinical and admin staff. » After hours role 457 visa sponsorship and excellent remuneration is offered

•

Multiple Locations

•

Part Time / Full Time -

• •

If you are interested and would like more information please contact the Practice Manager.

BALWYN

TEM

General Practitioners

The practice is involved with APCC Collaboratives, Pen Tool, Board member and Accreditation surveyor.

AFTER HOURS GENERAL PRACTITIONERS REQUIRED FOR

PR &S VIC 594063_16_09_16

We are currently seeking an enthusiastic, committed long term Full/Time, Part/Time VR GP to join our busy accredited practice.

• • • • • • • •

VIC 594194_23_09_16

VIC 593834_19_08_16

• Varied and busy Practice

VIC 594073_16_09_16

For Established Successful Busy Practice. Located In Busy Shopping Complex In Berwick. Open Seven Days Large Patient Base. RN Support Pathology On Site With Pharmacy Next Door. Immediate Start With Excellent Remuneration.

• Fully supported with Nurses & Admin

•

Fellowship with the Royal Australian College of General Practitioners (FRACGP), College or Rural and Remote Medicine (FACRRM) or Vocational Registration (VR)

Bulk Billing Practice

With Immediate Start

The Offer: •

Excellent earning potential.

•

Full and Part Time positions available.

•

Opportunity to learn how to maximise billing. Nursing support.

If This Suits You...

Please forward your resume to fhmc.williamsondyllis@gmail.com or call 03 9799 6299 or 0413 535 288 for further information.

Doncaster Ft/Pt Vr GP requireD Computerized clinic with RN, Pathology and Pharmacy on site. 65% gross 70% after hours DWS ok P: 0408 718 979 - Michael E: lilithomp@gmail.com

www.australiandoctor.com.au

Carnegie Vr general PraCtitioner • • • • •

VR GP required urgently, Bulk Billing. On Site: Pathology and Pharmacy. 70%, Flexible Contract Option. Immediate Start. Fully accredited, excellent support, Practice Nurse, GP owned practice. • Growing Practice with fantastic earning potential. P: 0403 532 896 / 0438 854 732

HAWTHORN Are you the doctor for us?

VIC 594022_02_09_16

Darebin Community Health seeks VR GPs for our clinics. We are well established with 42 years of service to the community of Darebin.

• Large, modern, teaching Practice

VIC 594146_16_09_16

BERWICK P/T F/T GP REQUIRED

We are a family friendly, fully computerised practice and offer commitment to GP and flexibility with hours.

Preston/northcote Vr GPs

Horsham is a large regional city located on the Western Highway, midway between Melbourne and Adelaide, close to The Grampians and Mt Arapiles, and services the population of the Wimmera. Horsham has outstanding facilities and sense of community. Great sporting opportunities, top rated golf course, café culture, theatre, art gallery and other cultural pursuits.

VIC 594118_16_09_16

VIC 593903_02_09_16

P: 0402 260 459 - Bronwyn E: practicemanager@doctorsofnorthcote.com

Lister House Medical Clinic in Horsham, Victoria is seeking a full time or part time VR GP.

• Team environment

VIC 593809 12_08_16

VIC 594093_09_09_16

Dynamic Inner-City Northcote Practice. This is your opportunity to join a vibrant, familyoriented and progressive practice. Doctorowned, private billing clinic with strong team dynamic and exceptional development opportunities. Well supported with RN, On-site Pathology and Allied Services.

VIC 594140_16_09_16

NORTHCOTE P/T DWS AFTERHOURS GPs

GP Required In Horsham, Victoria

P: 03 9546 9222 / 0419 884 675 - Theresa Tran E: springvalehealthcare@gmail.com

P: 0477 009 985 - Jim Hacquoil E: jh@eastbrooke.com.au W: www.eastbrookemedical.com.au

jobs

To relieve a Long Time Associate going to retire. In Springvale on Main Road. • A busy, long established and Accredited • Medical Practice. • Modernised, equipped and fully computerised. • Flexible Hours and Sessions. • Ancillary health care on site: • Practice Nurse (RN1) • Psychologist • Physiotherapist • Pathology • Audiology • Earning 100% income • Low % Service Fee

P: 0497 312 930 E: Smithbro@bigpond.net.au

VIC

Springvale F/T or p/T Female vr gps

VIC 593596 12_08_16

For our clinics in Woodridge and Kangaroo point in Brisbane. Supervision can be provided for GP training and new fellows.

QLD 594240_30_09_16

Woodridge / Kangaroo Point (BrisBane) Vr / non-Vr gP required

VIC 591058 30_09_16_NC

For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

Are we the practice for you?

P: 03 9819 4044 - Carmel O’Toole W: www.medicaljobs.com.au W: www.healthandwellness.net.au

30 September 2016 | Australian Doctor |

2016-09-23T14:52:01+10:00

Classifieds VIC 593776 16_08_12

Doctor owned and operated Friendly staff Full nursing support Experienced management team DWS Available VR/Non VR F/T P/T Flexible working conditions 457 Sponsorship

Good Renumeration (negotiable) P: 0414783494 E: edenrisefc@y7mail.com

POSITION AVAILABLE

Cheltenham

VR GENERAL PRACTITIONER

VR GP URGENTLY needed for Medical centre in WESTFIELD SOUTHLAND. High percent of gross billings and minimum. No lock in contract or restrictions.Offers flexibility. Free ALL DAY parking. Full nursing support. Pathology onsite. Grateful and appreciative patient base. Please contact Dr. Cora Wong.

VIC 594225_30_09_16

DWS area Flexible days and hours 65% gross and 70% after hours Onsite pathology and Nurse support

Leigh Stevenson: 0425 728 495 Dr Gary Braude: 0403538258 or email CV to leigh@myclinicgroup.com.au

Corryong Medical Centre - Upper Murray Health & Community Services.

A great opportunity exists for an experienced General Practitioner to join Lakes Boulevard Medical. Our team of Doctors aim to deliver good quality, affordable healthcare to all. We are a GP owned practice, modern and purpose built with on-site pathology, pharmacy and full time nursing support. We are seeking applications from either restricted or unrestricted General Practitioners who are committed and will uphold the standards in place to provide outstanding healthcare. Opportunities are also open for VR GPs interested in locum work. Our practice offers flexibility, diverse work, attractive remuneration, a fully computerised system and a great team environment.

PLEASE CONTACT Phone: 0401 477 860 - Arun Email: admin@bcmedical.com.au

Full Time / ParT Time DocTor requireD

For a fast growing Practice on the coast. Friendly, family practice. VR 70% of billings Non VR with general registration week nights and weekends from 65%

E: dr.mike80@gmail.com - Dr Michael Gendy rafik.mansour@wcfp.com.au - Dr Rafik Mansour

| Australian Doctor | 30 September 2016

• • • • • • •

VIC 594227_30_09_16

Attractive remuneration Salary/split billing options Relocation package Car and accomm. benefits Practice support provided Autonomy in model creation Brilliant lifestyle opportunities

• DWS

Interested? For further information please contact Maxine Brockﬁeld, CEO P: 02 6076 3200 E: maxineb@umhcs.vic.gov.au W: www.umhcs.vic.gov.au

Wantirna Sth and WheelerS hill GP PoSition available • • • • • • •

P: 0438 931 120 - Rosey E: roseypanelli@seymourmedical.com.au W: www.seymourmedical.com.au

360 Health + Community is looking for GPs to fill key community roles in Broome and Dampier/Wickham.

jobs

• Accident & emergency skills an advantage

• Annual and study leave allowances

Loyal community Teamwork & integrity Pathology, psychology, podiatry onsite Visiting medical specialists & telehealth Travel and Aviation medicine Professional administration and nursing support

Practice by day. Holiday the rest.

UMHCS is a multi-purpose service with a newly renovated primary care centre. It has a co-located hospital and residential care facility. On site allied health services and visiting specialist compliment the health care of the community. You and your family will be warmly welcomed into the Upper Murray.

• Australian GP experience

• Housing assistance

Rare opportunity with vibrant non-corporate practice in a beautiful rural setting one hour north of Melbourne. Are you an experienced and compassionate general practitioner who values diversity of practice and quality education? Join the senior teaching group and discover how good general practice can be. Established, busy mixed-billing practice. • • • • • •

• AHPRA Registration

• RRMA5

SEYMOUR FRACGP GP DWS

Access Medical Group Busy, Doctor-owned, modern Practice. Doctor-centred, non-Corporate. Flexible working conditions. After hours available but not required. High grossing – 65% of billings. Xray, pathology, nursing support.

western suburbs GP required • • • •

DWS available 457 Sponsorship available Pharmacy, pathology, radiology onsite Great remuneration

P: 0424 190 155 / 0405 557 589 - Practice Manager E: practice.medical14@yahoo.com.au

ScoreSby, Melbourne Medical conSulting rooMS / officeS for leaSe With a prime visual location, on a busy intersection, shopping centres close by and public transport right outside the door, this modern medical centre has the potential for multiple usage. Comprising of:

P: 03 9887 0211 - Julia

WA 594050_16_09_09

» Modern bulk billing practice with a Pharmacy onsite. » Open 7 days, Full / Part Time positions with flexible rosters. » An expanding patient base, full book from day one! » Excellent support from experienced clinical and admin staff. » Allied health and Pathology Services onsite.

VIC 594047_09_09_16

VR GENERAL PRACTITIONERS REQUIRED FOR SOUTH MORANG

• • • •

Located in Corryong in the picturesque Upper Murray. Join a team of 2 GPs, Practice Nurse and allied health staff with onsite pathology and radiology services. The practice is fully accredited, computerised and has mixed billing. Established client base with attractive salary package with a negotiable guaranteed income period.

To apply, or for more information contact the manager: (03) 9363 0954 or jobs@activemedicalcentre.com.au

P: 0402 762 673 / 0417 681 567 E: info@lilydalemedical.com

Tarneit Werribee Village Werribee Central Bacchus Marsh Prahran Hoppers Crossing Mulgrave Glen Waverley Balaclava Elsternwick Seaford CBD Melbourne Camberwell

FULL TIME GP REQUIRED

Computerised and Accredited Practice

• • • • • • • • • • • • •

Applicants can call: • 70% of billings • DWS location • GP owned • Patient-focused team Active Medical is seeking a VR • Well equipped rooms General Practitioner to join our team • High profile location at our practice in Caroline Springs. • 30 mins from Melbourne Ongoing full time position available, CBD and Airport conveniently located in a high • Modern practice exposure area adjacent to a major • Experienced team of shopping centre. Division 1 nurses and This position would ideally suit a VR GP support staff looking to join a highly experienced • Onsite radiology, pathology team focused on quality patient care. and allied health GENERAL PRACTICE 30 MINUTES FROM MELBOURNE IN A DWS LOCATION

P: 0402455664 E: cora.wong@myhealth.net.au

LiLydaLe VR / NoN VR doctoR

VIC 592072 16_07_01

24.06.16

Locations are:

• • • • • • • • • • • •

15 consulting rooms Generous Waiting Area Permit for 10 medical practitioners Significant signage 31 car spaces Lift access Staff Kitchen Separate building with 6 rooms has a permit for a radiology practice Fully accredited and computerised with practice management software Total land area 2,325 square metres Long standing medical practice but endless possibilities Available now

P: 0417 357 715 - Gurdip Aurora

TODAY!

www.360.org.au/regionalGP www.australiandoctor.com.au

VIC 594243_30_09_16

Onsite pathology and Allied health support

E: xyz73625@hotmail.com

MY HEALTH MEDICAL CENTRE_STD LOGO

GP’S WANTED IN MELBOURNE CLINICS

Fully computerised and RN support

www.6minutes.com.au/Nutritionupdate

VIC 594109_16_09_16

PMS 021

Full Time /Part Time VR General Practitioner needed for a busy Family Practice with immediate start

VIC 594229_30_09_16

PMS WARM RED

FT/PT VR/Non for established practices Computerised medical centre Large Chinese population Allied health Pathology onsite Full nursing support 75% billings first three months support $150p/h

VIC 594244_30_09_16

PMS 3302

• • • • • •

BERWICK VICTORIA FT/PT VR GP

VIC 594213_30_09_16

VIC 594143_23_09_16

Preston and Bundoora GP required

VIC 594211_30_09_16

For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

WA 594183_30_09_16

AD_040___30SEP_16

AD_041___30SEP_16

2016-09-23T14:52:01+10:00

VR GPs

jobs

Playford Family Medical, Playford Town Centre Shop 16, 297 Peachey Road, Munno Para.

TAS Full time or part time hours available GP required due to high patient demand No contracts - non corporate Modern purpose built practice Mixed billing practice Excellent nursing and admin support Immediate start available

l Wages and hours are negotiable l Pathology, Allied Health services and Practice nurses on site.

08 8284 0010

manager@playfordfamilymedical.com.au

l Modern Practice

TAS 594082_09_09_16

• • • • • • •

FOR 593737_30_09_16

MEDICAL PRACTICE

l Open 7 days a week

For more information contact Sophie (Practice Manager)

jobs

Hobart Vr General Practitioner

l Flexible working conditions

BLACKTOWN LOCATION SHOP/OFFICE JOB TITLe Job Description vent. Udi Blacktown Healthcare hasomnit shop millupt front office atecum quia dolorest availablecum for tenancy and isommoluptate located within parciendem estotaturCentre. alignis qui apero con Westpoint Shopping repeadion nectinc totartem doluptaati nectinc totatemfor doluptat 200 characters Perfect Medical Specialist and Allied Health Services. P: 02 9787 8473 / 0419 029 012 E: fakeperson@fakecompany.com.au P: 0411 835 438 W: www.fakecompany.com.au E: meditechcorp@hotmail.com

FOR 593933_23_09_16 NC

SALE / LEASE

• RRMA 6 + DWS 475 kms West of Brisbane • SCALING DISCOUNTS APPLY • Practice for sale due to relocation to the UK • This large Practice was newly refurbished in Sept 2015 and is set up for a solo GP to move straight in and take over the patient base. • State of the art equipment • 4 consultations rooms • Large treatment room • Rental: $2,500 per month • Pathology pay $1890 a month • Lease is coming to an end and the landlord is happy to renew it. • Asking $80,000 ONO If you are happy with our service referrals are always appreciated E: Linda.allatt@jwhealth.com.au

Sydney, Melbourne & Brisbane BUSINESS PARTNER (SHAREHOLDER) NEEDED 20% ownership of brand new large medical centre within a Major Shopping Centre Turn key business solution - Franchise model ( we provide the back-end support with experience of running 30 successful medical centres) High Personal Gross billing. You have control over the business

PR &S

Excellent “group negotiated” subleases with pathology and allied health services Good long term passive income Low risk and low level of entry - ONLY $20k required to purchase 20% stake of the business! Extremely high return of your investment

P: 0418 181 444 - Dr Alex Andric

FOR 593922_26_08_16

l Great location and huge earning potential

SA 594089_09_09_16 NC

For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

Current Locations available:

COURSES & CONFERENCES

Chadstone Shopping Centre (Melbourne), Southland Westfield Shopping Centre (Melbourne) Bayside Shopping Centre (Melbourne) Warringah Mall (Sydney) Liverpool Westfield (Sydney) Chermside Westfield (Brisbane)

OUT NOW!

Be your own boss and build your future with us!

THE AUSTRALIAN DIPLOMA IN DERMATOLOGY The Australian Diploma in Dermatology

hr@myhealth.net.au

Apply online: www.myhealth.net.au/careers (select local Partner for new site)

TEM

Full details of the course are available at www.myskinconsult.com It is conducted by Dr Ian McColl, a Fellow of the Australasian College of Dermatologists

PRACTICAL PROCEDURES

W: www.myskinconsult.com

Intensive Course in Clinical Hypnosis for GPs & Psychologists

COU 593185_16_07_08

The Australian Institute of Dermatology is now taking applications for the 2017 Diploma course. Following a weekend Meeting on the Gold Coast in Feb 2017 the course is conducted online over 28 weeks, with weekly video teleconferences. It is particularly useful for doctors wishing to become the experts in their practice in the diagnosis and management of skin diseases.

Dr James Liang 0411 511 022 | Dr Stephen Ong 0422 115 370 | Kylie O’Sullivan 0419 780 538

COU 593787 12_08_16

Medical ebooks from the source you trust www.australiandoctor.com.au/ebooks

)

SKIN CANCER WORKSHOP

with meditation, CBT, NLP and Quantum healing

By Dr Muthukrishnan • Healing the Healer 27,28 August in ALMS 80 pts Sydney • In 6 ALMs with 240 Cat 1 points approved by the RACGP 27, 28, 29, & 30 October 2016 Surfers Paradise P: 02 9879 4350, 02 4736 6900, 0417 661 135 F: 02 4736500 E: rmoothoo@gmail.com

www.mindpowerwithhypnosis.com

MELBOURNE 22 October Royal Australasian College of Surgeons SYDNEY 29 October University of Technology BRISBANE 3 December University of Queensland 9.00am – 5.00pm

Strictly limited places for the ALM, so book early

www.education.australiandoctor.com.au

www.australiandoctor.com.au

30 September 2016 | Australian Doctor |

2016-09-23T14:52:01+10:00

Classifieds For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au

Aims

Enrol now in Practical Dermoscopy, a new course developed and delivered by the Australasian College of Dermatologists.

Practical Dermoscopy consists of online modules, a virtual outpatients’ clinic and a one-day face-to-face workshop in Brisbane on Saturday 26 November 2016.

COU 594188 16_09_23 NC

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Australia has the highest rate of skin cancer in the world and the vast majority of this is treated within general practice. Crucial to management of skin malignancy is accurate diagnosis. Dermoscopy allows the detection of clinical features invisible to the naked eye and has been well shown to increase the diagnostic accuracy of users. In Practical dermoscopy , GPs put dermoscopy theory into practice and develop a thorough understanding of how dermoscopy can be used to diagnose and manage patients with skin cancer.

Course components • Online modules • Virtual clinic • One-day face-to-face workshop

For further information: www.dermcoll.edu.au

COU 594029_30_09_16

| Australian Doctor | 30 September 2016

www.australiandoctor.com.au

AD_043___30SEP_16

2016-09-23T14:52:01+10:00

For bookings contact Classifieds Manager • Phone: (02) 8484 0732 • E-mail: GPClassifieds@cirrusmedia.com.au -

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CO CON

PR &S

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7/09/2016 12:24 pm

www.australiandoctor.com.au

30 September 2016 | Australian Doctor |

EARN

10 CAT2 RACGP CPD POINTS

SMART PRACTICE LIVE 2016 SEMINAR SYDNEY // 5 November // The Four Seasons Hotel MELBOURNE // 19 November // Sheraton Melbourne Hotel 9.00am – 3.30pm Or join a live WEBINAR from anywhere in Australia on 5 November

Staying abreast of clinical advances is one thing; staying on top of a thriving practice without burning out is quite another. In this must-see seminar, you’ll walk away with top tech tips, cuttingedge clinical, financial and legal practice boosters, and the building blocks of a sustainable business-life balance. It’s the firm foundation every GP needs.

5 PILLARS FOR WORKING SMARTER

FINANCIAL

TECHNOLOGY

5 golden rules to achieve financial security

The increasing role of technology

MEDICOLEGAL Avoiding medico-legal minefields

PERSONAL

GENOMICS

The changing role of GPs

How genomics will change the way you practice