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Editorial: Common Sense & Sensibility Letters: Halo Graft Caution – Dr Mark Hanikeri CEDARS – Dr Michael Watson Medicines Australia on ADRs – Dr Brendan Shaw Housing Affordability – Ms Irina Cattalini The Standard Consultation – Clinical A/Prof Peter Winterton Pressure on General Practice – Dr Michael Morley New Name, New Focus – Ms Elizabeth Chester Have You Heard? Celebrity Spotlight: Tex Perkins Diagnosing Autism Spectrum Disorders Beneath the Drapes Elder Abuse Conference

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Common Sense and Sensibility

By Ms Jan Hallam Managing Editor

but also quantitatively) was not only limiting the effects of essentially good programs but also a waste of valuable resources.

Canadian social worker Dr Michael Unger was in Perth a couple of months back as ‘thinker in residence’ for the Commissioner for Children and Young People. His field is building systems that help develop resilience in kids.

Then he said something that has really resonated. He challenged his audience to ask their child the name of their family doctor and who were the string of specialists they had seen and why were they seeing them.

When you reach a certain age, there’s a tendency to gather in flocks for some congregational shaking of grey heads and chanting in unison: ‘kids of today don’t know what tough times are!’ Some of the flock might shake their heads a little less vigorously and wonder ‘where did we go wrong?’ while others know that growing up has never been easy, even less so for the socially disadvantaged.

His argument was that we should invest in the programs we have and ensure they are sustained so that our children can engage in the process, make relationships with the service providers and get the very best out of them in order that they, and our community more broadly, will benefit.

Michael’s message was full of a commodity that’s really quite rare these days – common sense. He spoke eloquently of the efficacy of services to help vulnerable families but the lack of them is not the problem. Disconnection with consumers in the design of programs, replication and a woeful lack of follow-up (especially on a basic human level,

The two take-home points here are that, despite the fact that children may not have the final say in what is done to them, they deserve to be central in their own treatment. And, of course, the rarest of rare birds – the concepts of ‘sustained and sustainable’ need to be established and adhered to. We can no longer afford to throw money at a good idea that is here today, gone tomorrow.

Or worse, continue to throw money at a poor idea, recycle it and call it by another name. The danger of this new and difficult phase of the health-cost debate is the risk that existing fault lines created by health system fragmentation will widen. Politicians are calling the shots and creating division between the various parts of the medical profession at a time when cohesion is absolutely critical. The health system was created to serve the community. You, me, them… all of us, in fact. It is not an elite industry that serves itself, but an integral part of a well-balanced, resilient and productive society. In turn, society has re-invested a hundredfold into the health system. It’s mutual! The answers are probably terrifyingly simple, but sure as eggs, they won’t be easy. However, we will need visionary leaders; we will need advocates to stand up for all parts of the profession and those for whom it serves. We will, most of all, need resilience and common sense. O

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Letters to the Editor

Halo graft caution sounded Dear Editor, RE: Skin excision – the Halo Graft, May edition. Dr Denis Caragher puts forward a very nice argument for the use of this technique for the case in point; a large BCC on the leg with surgery performed under a local anaesthetic. As the Director of the WA Melanoma Advisory Service, I must object to the assertion, “Excision of melanoma can be done in this way, ensuring adequate excision margin”. Malignant melanoma is an aggressive malignancy that has the propensity to infiltrate locally within the tissues or lymphatics. The clinical guidelines on management released by the NHMRC suggest that a 10mm margin be applied to invasive lesions. Thicker lesions may require a wider margin. The author of the Halo Grafting technique (Sharad Paul) says the technique should not be applied for surgery after excision of malignant melanoma and specifically states, “We recommend this technique for nonmelanoma skin cancer excision sites of the lower limb when the defect cannot be closed primarily”. They go onto specifically state that “we do not recommend this technique for malignant melanoma because of the adjacent nature of

the donor site and the primary tumour” and I would strongly reiterate this to clinicians using this technique. The WA Melanoma Advisory Service does not support the use of the Halo Graft for the management of insitu or invasive malignant melanoma, and I would urge clinicians not to employ this technique for these lesions. Mr Mark Hanikeri, Plastic Surgeon ED. The article on Halo Graft technique was published in May – this is a good time to remind readers that there is only a 10-day window between one edition being published and the next edition’s deadline, should anyone wish to offer comment.

CEDARS a new beginning Dear Editor, The Children’s Equity Developmental Assessment Review and Support Centre (CEDARS) has been in existence for three years but has only recently become fully operational. Why has it taken so long? Fundamentally because, with limited human and financial resources, we had to redesign the entire developmental screening and triage model of care to make it a system that is parent and clinician friendly and scalable. This has been no small feat!

Central to the new model is the efficient use of questionnaires and IT to gather and deliver high quality information that satisfies the needs of parents and clinicians. Children’s Equity has worked with Brookes Publishing Company in the USA (which controls the copyright to the Ages and Stages 3 screening questionnaire) to modify its online screening tool to make it internationally friendly. This now makes it fully compatible with the CEDARS Centre screening program. In addition, we have developed a detailed parent questionnaire to provide high quality information on the issues that most concern them. It also carefully guides them to provide high quality information that is essential for clinicians to assess their child’s development and clinical history. Currently this in paper format but will soon be available online. No complex triage system can work without a care coordinator. What has been missing in child development is the equivalent of the ACAT nurse in Aged Care. We now have two child health nurse practitioners trained in child development, triage and support who will guide families into and through the labyrinth that is the current private and public child development system. They will also formulate information from the questionnaires (with a CEDARS Centre paediatrician) into a draft CDM and TCA

Continued on P6

Curious Conversations

Kicking Goals Telethon Kids Institute director Prof Jonathan Carapetis is a Carlton tragic but don’t ask him to sing the club song. If I could eliminate one ailment it would be… rheumatic heart disease. It stems from poverty and social injustice and it’s a tragedy that young people around the world are still dying from a disease of yesteryear. And that includes our own indigenous people. One of my most satisfying medical moments was... the government announcing in 2009 that it was establishing a National Rheumatic Fever Strategy. Their decision was based on research that I’d been involved with for more than two decades and it made the hard slog worthwhile. I’m not very good at… singing. Even though I have Welsh genes to complement the Greek 4

ones, my daughters never fail to let me know just how (un)talented I really am. The three people I’d most like to have around a dinner table would be… a quick-witted politician, maybe David Lange by a whisker from Paul Keating. (The latter loses points after his wisecrack that the best way to see Darwin is from 35,000 feet on the way to Paris). Sir Gustav Nossal – a great scientist and a delightfully entertaining individual. Aung San Suu Kyi to hear her inspirational stories of leadership against incredible odds. And I hope my Dad could come too because he’d love it.

Tony Abbott’s just said to you ‘Jonathan, we’re not going to spend billions of dollars on new fighter jets and we’d like you to allocate the money.’ After pinching myself to make sure I wasn’t dreaming I’d spend it on prevention more than cures. I’d put money into research to find solutions for tomorrow, more funding for health in developing countries and better education outcomes because it’s a really important determinant of health. If I could have one brief moment of sporting glory… I’d kick the winning goal in Carlton’s first AFL premiership since 1995. O


Western Cardiology

Resistant Hypertension Insights & Treatment Strategies Resistant hypertension is defined as ongoing elevation of systolic and/or diastolic blood pressure levels despite a treatment strategy which includes lifestyle measures, and at least 3 antihypertensive drugs, one of which must be a diuretic (if tolerated). The prevalence of resistant hypertension has been reported to range from 5% to 30% of the hypertensive population though true prevalence is probably less than 10%. Resistant hypertension is however associated with a high risk of cardiovascular and renal events. Recently, new treatment strategies for resistant hypertension (such as renal denervation) have prompted increased referral numbers to specialists and specialist hypertensive clinics worldwide and studies of this population have produced some new insights into this group of patients. The first insight is the fact that in many cases a majority of these patients do not really have true resistant hypertension. In many centres the commonest cause for resistant hypertension has been noncompliance with prescribed antihypertensive medication. Between one quarter and two thirds of referred patients from various centres were found not to be compliant with medication. A second group of apparently resistant patients subsequently found not to have true resistance were those with significant “whitecoat� effects. When these two groups of patients were excluded by careful assessment of compliance and out of office BP recordings, only a minority of patients were left who were deemed to be truly resistant. With these issues in mind an assessment and treatment strategy can be recommended for patients who are not achieving target levels of blood pressure despite multiple antihypertensive medications. t Some assessment of compliance now appears mandatory. This may involve pill counts, review of prescription history and information from partners etc.

t Out of office recordings should be mandatory before diagnosing resistant hypertension. These can be obtained with ambulatory 24-hour blood pressure monitors and in some cases with accurately recording personal BP machines. t Review of lifestyle issues. Factors associated with possible resistance include obesity, high alcohol consumption (including binge drinking) and high sodium intake (which may also antagonise the benefits of certain blood pressure lowering medications). Obstructive sleep apnoea has been reported to be a common concomitant of resistant hypertension. t Review of other agents that may elevate blood pressure. These include antiinflammatory agents, oral contraceptive pill, sympathomimetic nasal decongestants, certain psychotropic and antidepressant medications, Reductil, steroids, licorice and erythropoietin. t Consideration of secondary hypertension. Secondary hypertension becomes not uncommon in truly resistant patients. Assessment for hyperaldosteronism, renal artery stenosis, renal parenchymal disease, hyperthyroidism, pheochromocytoma etc should be considered. t Ensure adequate diuretic treatment. Thiazide diuretics should be mandatory in patients with apparently resistant blood pressure. As GFR declines Thiazides become less effective so when GFR is < 30, loop diuretics may be necessary for volume control and will need at least b.d. regimens due to short duration of blood pressure lowering action. t Ensure maximisation of dosages. Thiazide diuretics can be utilised at dosages above commonly used levels e.g. 50 mg or even more of Hydrochlorothiazide. Chlorthalidone is often considered to be more effective than Hydrochlorothiazide for blood pressure lowering.

Dr Steve Gordon Cardiologist

About the author Stephen Gordon is a graduate in medicine from UWA and trained in Cardiology at Sir Charles Gairdner Hospital and subsequently at the Beth Israel Hospital, Harvard Medical School, Boston. He practices in all areas of adult cardiology and has a special interest in echocardiography.

t Addition of further blood pressure lowering agents. If blood pressure is not controlled by the above measures then less commonly used agents can be added. These include beta blockers, Moxonidine, Prazosin, Hydralazine, Methyldopa and Clonidine. The combination of ACE inhibitor and ARB however ought be avoided. t Spironolactone and Amiloride. These agents have been found to be particularly effective as add on agents in resistant hypertensive patients. Even 12.5 mg or 25 mg of Spironolactone daily may have significant blood pressure lowering effects. These agents retain potassium and need to be used with caution and monitoring when other potassium retaining medications are being used and with particular caution in patients with renal dysfunction. t Interventional therapies. Renal denervation has become available as a potential therapy for resistant hypertension. Unfortunately a recent randomised placebo controlled trial did not show a benefit of renal denervation over medical therapy and the place of this intervention now appears uncertain. Other therapies are evolving including carotid baroreceptor stimulation, but require further evaluation and are not widely available. In summary, resistant hypertension is relatively common and may carry a poor prognosis. Many patients with apparent resistant hypertension may not be truly resistant when medication compliance and whitecoat effects are assessed and excluded. A majority of patients who are truly resistant can be improved with lifestyle measures, intensification of antihypertensive therapy and in some cases investigation for secondary hypertension.

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Letters to the Editor Continued from P4 document and provide this electronically to the familyâ&#x20AC;&#x2122;s GP. For further information or to request a referral please email info@childrensequity. com. (Acknowledgment: The CEDARS Centre is supported by donations from Ramsay Health Care). Dr Michael Watson, CEO and Medical Director, Childrenâ&#x20AC;&#x2122;s Equity Ltd

Medicines Australia on ADRs Dear Editor, Medicines Australia member companies record all serious and non-serious adverse events (AE) regardless of causality. The information provided is evaluated and used as appropriate to update the approved Product Information for doctors and Consumer Medicines Information for patients. It is mandatory for sponsors to notify of any serious adverse event report to the TGA within 15 days. It is important to note that the TGA has been monitoring adverse events data for many years and take appropriate actions when needed. Pharmaceutical companies take their responsibilities for reporting adverse events to the TGA very seriously. Last year, 48% of all adverse event reports actually came from pharmaceutical companies. Itâ&#x20AC;&#x2122;s important that doctors and consumers have access to reliable data about the safety of medicines.

Education of healthcare professionals about the importance of adverse event reporting and the framework for reporting will be an important activity to enhance understanding to achieve quality use of medicines. Although the total number of adverse event reports has increased by more than 20% in 2013 compared to 2012, the number of reports received from GPs decreased over the same period, further demonstrating the need for GP education. Monitoring and reporting of adverse events is one of the crucial areas where the contribution of healthcare professionals and pharmaceutical companies is particularly important for patient welfare. Dr Brendan Shaw, CEO, Medicines Australia ED: See the TGA response to Drugs, Doctors and Patients â&#x20AC;&#x201C; ADRs (July edition) on P34.

Look long-term for homeless solutions Dear Editor, Regarding Mobile Care for Homeless [July edition] the lack of affordable housing and the ongoing increases in the cost of housing is the most pressing issue facing low-income households in WA at present. Spiralling housing costs are also limiting the housing options for those wishing to transition out of social housing or the crisis accommodation system, resulting in increasing pressure on the public system and an increasing prevalence of homelessness.

These factors, coupled with the increasing numbers of â&#x20AC;&#x2DC;persons with no fixed addressâ&#x20AC;&#x2122; attending WA EDs, will no doubt be exacerbated by recent Federal and State budget decisions to cut or discontinue homelessness services and reduce the already low incomes of those on pensions and benefits. The recent Commission of Audit Report and budget decisions are concerning in that they resulted in: t 0OMZBPOFZFBSFYUFOTJPOUPUIF/BUJPOBM Partnership Agreement on Homelessness, which provides funding to programs that focus on prevention and early intervention to stop people becoming homeless; breaking the cycle of homelessness and improving and expanding the service response to homelessness (with no monies allocated over the forward estimates). t 5IFBCPMJUJPOPGUIF/BUJPOBM3FOUBM Affordability Scheme, which was the only federal scheme aimed at increasing affordable housing supply. Under the NRAS about 20,000 properties were built for the genuinely needy. These programs and services provide assistance to the most in need and vulnerable of our community. Homelessness has real, long-term consequences for the cost of chronic disease to our health system. Interventions such as Mobile GP and housing-first models (see recent Mission Australia research findings), whilst addressing immediate need, also focus on delivering sustained long-term health and accommodation outcomes. These in turn can result in more successful individual life outcomes and deliver greater social and economic benefits to society as a whole. Ms Irina Cattalini, CEO, WACOSS


Joke Dear John, I hope you can help me. The other day, I set off for work, leaving my husband in the house watching TV. My car stalled and then it broke down about a kilometre down the road and I had to walk back to get my husbandâ&#x20AC;&#x2122;s help. When I got home, I couldnâ&#x20AC;&#x2122;t believe my eyes. He was in the bedroom with the neighbourâ&#x20AC;&#x2122;s daughter! I am 34, my husband is 38 and the neighbourâ&#x20AC;&#x2122;s daughter is 20. We have been married 10 years. When I confronted him, he broke down and admitted that they had been having an affair for the past three months. He wonâ&#x20AC;&#x2122;t go to counselling and

Why men shouldnâ&#x20AC;&#x2122;t write advice columns Iâ&#x20AC;&#x2122;m afraid I am a wreck and need advice urgently. Can you please help? Sincerely, Sheila Dear Sheila, A car stalling after being driven a short distance can be caused by a variety of faults with the engine. Start by checking that there is no debris in the fuel line. If it is clear, check the vacuum pipes and hoses on the intake manifold and also check all grounding wires. If none of these approaches solves the problem it could be that the fuel pump itself is faulty, causing low delivery pressure to the injectors. I hope this helps. John

Importance of the Standard Consultation Dear Editor, In recent weeks there has been a lot of debate about the interpretation of the descriptors for Medicare items for health assessments and other EPC items. My question is â&#x20AC;&#x2DC;Do we need these items?â&#x20AC;&#x2122; When a patient attends a doctor, they invariably perceive they have a problem and want advice for that or a multitude of problems. For that they are willing, in the main, to pay. In the process of giving them the advice they seek, the artful doctor should use the opportunity to make inroads into preventive or opportunistic screening. Continued on P8





Letters to the Editor Continued from P6 We know patients are not willing to pay for EPC items and that is why no one in their right mind charges for them. Patients don’t mind getting the service, so long as someone else pays for it (i.e. you and me via Medicare using bulk billing). Medicare is giving us a clear message: these items are in the firing line, if not by complete obliteration then by stealth (less painful for government).

a lot of my mates, so I easily worked in many local hospitals in Accident and Emergency, obstetrics and gynaecology, rheumatology, and even neurosurgery!

The bulk of EPC items force us to practise Mickey Mouse medicine to survive and pay the bills. Now seems the time when we should go back to basics and demand that we are paid a fair fee for a standard consultation. Then we could afford to abandon these Mickey Mouse items and the five Medicare supported allied health services could be managed as for DVA patients.

So it was that I emigrated here with my family and have enjoyed general practice since. But in the last few years the politicians and colleges are seemingly affecting general practice, with many GPs only working parttime or giving up.

Patients don’t need EPC items, in the main, possibly with the exception of Mental Health items and, therefore, neither do doctors. What we should be fighting for is to give our patients time and advice for a fair fee. Clin A/Prof Peter Winterton AM, Mt Hawthorn

Every UK hospital employed Australian doctors learning specialties, passing exams and then returning home to work. They were also great to be with socially, which made Australia a great attraction.

To quote Mandurah GP Dr Frank Jones [Show GPs Some Respect, July edition], “I have felt for a long time that the Government and other specialist colleges look on general practice as the poor cousin.” Frank is correct. It’s a shame that, as ‘poor cousins’, we now do not respect the advice and attitudes of such as Nobel prize winners Barry Marshall and Robin Warren and IVF inventor John Yovich. Dr Michael Morley, Crawley

Pressure on general practice

New name, new focus

Dear Editor, At this time of retirement due to illness from my medical working life of 40 years (mainly as a GP in WA ), I enjoy reading Medical Forum WA, though it makes me worry about and sympathise with the changes the medical profession has to put up with. When I qualified in Manchester, England, in 1966, I wanted to become a practical GP like

an ambitious strategic plan focussed on increasing collaboration and translation and diversifying our funding. We think it’s a blueprint for a new kind of research institute that’s opening its doors to the community, practitioners, policy makers and funders as important partners. These collaborations will help shape the research agenda, work together to attract funding, and importantly, enhance how research is translated into more effective policy and practice. Already we have four new research focus areas that are cross-disciplinary collaborations: Early Environments, Brain and Behaviour, Chronic Diseases of Childhood and Aboriginal Health. The groups have been charged with coming up with the big research questions in their areas. And we have a new name and brand. When we did some market research it became clear that while many people knew something about us, many also confused us with other organisations and surprisingly few knew our name. While that’s not unusual for research organisations, for us it was a significant issue if we were to fulfil our strategic goals. We are now the Telethon Kids Institute and a tagline that tells the story of what we do: Discover. Prevent. Cure. Ms Elizabeth Chester, Telethon Kids Institute

Dear Editor, For more than 20 years the Telethon Institute has undertaken research and advocacy to improve the health and wellbeing of children and families in Western Australia and nationally. With the appointment of Professor Jonathan Carapetis as Director, the institute has embarked on implementing

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By Mr William McConnell Scientist in Charge of Biochemistry & Toxicology

Drug of Abuse (DOA) Testing Drugs of abuse, taken for non-medicinal reasons (usually mind-altering effects), can lead to physical and mental dependence and addiction. Performanceenhancing compounds are now included due to the increasing popularity of the gym culture (1). There is a direct link between drug intoxication and the increase in self harm and harm to others, with as many as 70-80% of cases associated with substances such as ethanol, heroin and cocaine (2). In Australia, DOA testing is covered by the AS/NZS 4308: (2008) quality standard. Drug testing laboratories need to be accredited to this standard to ensure reliable and legally defensible results. Each year, thousands of urine drug screens are performed in Western Australia, mainly for workplace surveillance or preemployment purposes. Positive drug tests are a frequent occurrence; in a recent investigation of almost 60,000 urine drug screens performed by Clinipath Pathology in Western Australia, approximately 12% tested positive for at least one drug class. Of these, approximately 20% were also positive for a second drug class.

Screening and confirmatory testing The initial screening is done using an automated immunoassay. It is important to note that false positive results may occur during the screening test as other substances may cross-react. Positive urine screening tests should be followed by approved confirmatory testing using mass spectrometry. Appropriate collection precautions ensure reliable results; routine check of urine creatinine allows detection of very dilute urines, which may indicate an attempt to mask recent drug use.

Specific drug classes Cannabis Cannabis is the most widely used DOA and is often the entry drug for the majority of users. With the trend internationally to legalise cannabis, social acceptance has led to an increase in use. Testing is

confirmed by the detection of 11-nor-delta9-tetrahydrocannabinol-9-carboxylic acid in the urine. This metabolite may remain positive for up to 6 weeks after last cannabis exposure in heavy users. Benzodiazepines Benzodiazepines are routinely prescribed for well-recognised conditions, however, they possess strong addictive properties. The majority of positive results are from legitimate medical use but it is important to confirm that laboratory results are consistent with the medication prescribed. Given the number of benzodiazepines in circulation it is not practical to screen for all in urine samples, and therefore only the more common drugs of this class or their metabolites are investigated. Opiates Opiates continue to be popular and are highly addictive. A positive urine opiate screen can be due to the presence of codeine, morphine, pholcodine, diacetyl morphine (heroin), 6-acetyl morphine (heroin metabolite) as well as other less common opiates. Codeine-containing medication is by far the most common cause of a positive urine opiate result. Codeine is available over the counter in Western Australia in various preparations, is readily metabolised to morphine and it is not uncommon to see very high levels of codeine and morphine in the urine of subjects using codeinecontaining medication. Heroin is rapidly metabolised with a half-life of only 9 minutes and confirmed by the presence of its metabolite 6-acetylmorphine. Oxycodone, buprenorphine and methadone are not routinely detected by the screening test and detection may require specific testing. Poppy seeds may contain morphine and codeine and therefore the consumption of food containing poppy seeds may lead to detectable levels of codeine and morphine in the urine. Amphetamines The amphetamine class of drugs includes a large and growing family

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of sympathomimetic amines. They continue to gain popularity fuelled by Rave and gym cultures. Pseudoephedrine is available over the counter although it is now more closely monitored as it is used in methamphetamine manufacture. Ephedrine is often seen as a metabolite of pseudoephedrine. Methamphetamine, BZP, MDMA and MDA are not present in prescription medications and their use is unlawful in Western Australia. Synthetic Cannabinoids In recent years, synthetic cannabis compounds have grown in popularity amongst drug users â&#x20AC;&#x201C; there are some 450 different compounds now available. Synthetic cannabinoids are not detected in standard drug screens but assays are now available to detect most commonly abused compounds. They are controlled substances in Western Australia.

0SBM'MVJE5FTUJOH Some drugs may be detected in oral fluid and this has become a preferred choice for Police roadside screening due to ease of sampling. Oral fluid testing has been dogged by technical issues and currently no screening assays comply with the relevant AS 4760:2006 standard. As a result, this form of screening remains a developing technology. The author acknowledges the assistance of Dr Sydney Sacks and Dr Jonathan Grasko in preparing the article. References: 1. Athletes cheat. Do you? Sydney Morning Herald, February 12, 2013 2. David J Nutt, Drug harms in the UK: a multicriteria decision analysis, Lancet Vol 376 November 6, 2010


Is Anybody Listening? Paediatrician Dr Sarah Cherian has concerns for the health and wellbeing of children kept in detention, and our professional image. The 2004 Australian Human Rights and Equal Opportunities Commission Inquiry into Children in Detention1 outlined the significant negative effects of detention on children. Subsequently, asylum children and families were released into community care. The recent influx of on-shore asylum seekers, has led to the resurgence of mandatory detention for children and families. They remain a hidden and predominantly faceless cohort reflecting the “no advantage” stance of “Operation Sovereign Borders”.2 Transferring children to Nauru is creating further alarm amongst health professionals and those advocating for refugee rights and conditions.3

Current policy in breach Current detention policy continues to breach the United Nations Convention on the Rights of the Child (UNCROC),4 of which Australia is a signatory. Distressing pictorial submissions from detained children on Christmas Island in 2014 clearly demonstrate the despair, sadness, trauma and grief experienced as a direct result of detention.5 In April 2014, there were 833 children <18 years in Immigration Detention Facilities/ Alternative Places of Detention (254 on Christmas Island), 190 in Nauru Offshore Processing Centres, 1490 children in Community Detention (105 in Perth) and 1827 on community Bridging Visas.6 The majority (66%) have been detained for at least 6-12 months, with 66% in community detention detained for 1-2 years.6 Refugee children do not choose to immigrate, lose parents and/or siblings, witness or be subjected to trauma and violence, nor leave their home, school and friends. No period of time in detention for a child is acceptable and deleterious effects of even “short-term” exposure can augment previous trauma, both inflicted and vicarious. Post-traumatic stress disorder, depression, anxiety, secondary nocturnal enuresis, aggression, sleep disturbances, nightmares and developmental regression have been commonly identified in paediatric asylum seekers.

Children’s complex needs Refugee and asylum-seeker children have complex medical, psychological, developmental and socio-economic needs in addition to the basic requirements of every child.7 National specialist groups have released frameworks covering screening, diagnosis and management of refugee health and resettlement issues.8-10 Additional barriers to provision of care 10

include language, financial constraints, transportation difficulties, cultural and gender-role differences, housing concerns, access to education and/or visa constraints limiting access to Medicare, work rights and reunification. At times, these may overwhelm families and take priority over perceived health needs.

Help to navigate the system Doctors have an important role in helping refugees negotiate their way through health and welfare systems. Most families do not acquire proficient English language skills within the first few years. Therefore, when consulting with refugee families, utilise professional interpreters, not family members or children. The Translating and Interpreting Service Doctors’ Priority line is available 24/7 (TIS National 131 450). Booking long consultations may be required to adequately address concerns. Specialist psychological and advocacy support services for refugees are provided by The Association for Services to Torture and Trauma Survivors (ASeTTS – 9227 2700). The Princess Margaret Hospital Refugee Health Service accepts referrals for recently resettled refugees or asylum-seeker children <16 years of age. Health care for children in detention is coordinated by the International Health and Medical Services (IHMS). If this was your child, would you find detention acceptable?

3 Procter N, Sundran S, Singleton G et al. Nauru Site Visit Report: 16-19 February 2014. Physical and Mental Health Subcommittee of the Joint Advisory Committee for Nauru Regional Processing Arrangements. 2014: p 1-56. (Accessed June 4 2014 at nauru-detention-serious-health-risks-to-children-revealedin-confidential-report). 4 Convention-on-the-Rights-of-the-Child/childfriendlycrc.aspx 5 sadness-and-fear-what-the-drawings-by-children-indetention-showed-us 6 detention/_pdf/immigration-detention-statistics-apr2014.pdf 7 Mutch R, Cherian S, Kemba N et al. Tertiary paediatric refugee health clinic in Western Australia: analysis of the first 1026 children. J Paediatr Child Health 2012; 48 (7): 582-587. 8 Australasian Society for Infectious Diseases Refugee Health Guidelines Writing Group. Diagnosis, management and prevention of infections in recently arrived refugees. Sydney, Australia: Dreamweaver Publishing Pty Ltd. 2009. 9 Zwi K, Raman S, Burgner D et al. Towards better health for refugee children and young people in Australia and New Zealand: the Royal Australasian College of Physicians perspective. J Paediatr Child Health. 2007; 43(7-8): 522-526. 10 The RACGP. Refugee and asylum seeker resources: at O

ED. To access these reference URLs online, o scan this QR code which wh will link you or go to and search “Cherian”

References: 1 Human Rights and Equal Opportunities Commission. A Last Resort? The report of the national inquiry into children in immigration detention. Sydney. Human Rights and Equal Opportunities Commission. 2004. (Accessed May 26 2014 at 2


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Have You Heard?

Healthscope raises capital

Mergers eye hospital market

Back in 2005, the ACCC took a close look at Healthscope’s purchase of the 90-bed Mount Hospital before giving the green light. The purchase was part of Healthscope acquiring 14 hospitals across Australia from Ramsay Health Care, which had agreed to divest these hospitals after it acquired Affinity Health (previously Mayne Health). Healthscope has since sold off its pathology interests to Clinipath in WA but lists 11 general practices still under its management here. Healthscope had floated on the ASX in 1994 but performed below expectations for investors, including administration of the public Modbury Hospital in South Australia. Healthscope has now lodged an IPO for a float worth up to $2.5 billion, with a similar amount raised from private investors. The company has been owned by US private equity firms since 2010, which is the same year Robert Cooke (previously Mayne Group) was appointed MD.

Mergers are the name of the game. In June we reported on Pfizer-Astrazeneca proposal and now, following the Zimmer-Biomet merger due to go through in March 2015, Medtronic has announced a $43.9 billion merger with Covidien, which will create one of the largest medical devices companies in the world. These multinationals have WA branches. According to GlobalData analysts, it’s mainly about driving hospital medicine. Suppliers can offer wider ranges of products (surgical and wound care mainly) at lower prices and there are tax advantages as Medtronic plans to relocate its headquarters from the US to Ireland.

Protecting Dr X The ACCC authorised the 17th edition of the Medicines Australia (MA) Code of Conduct from January 2012, with the expectation that more transparency about payments or other transfers of value from pharmaceutical

companies to healthcare professionals would ensue. MA has now submitted its revised Code (v18) to the ACCC and submissions closed August 1. MA wants to improve some things but also wants to stop reporting hospitality, transport and parking reimbursement, and venue costs. It says the naming of health professionals should be voluntary (citing Privacy Law), the reason the surgical audit stalled until the surgeons’ college made it mandatory. In October, 2012, our poll of 250 doctors in WA had the majority saying that declaring sponsorship of individual doctors would not wrongly damage their independence.

Disability in focus Those with disabilities in our community are waiting to see what is coming their way next. While the national insurance scheme is being worked out, here in Perth both people with disabilities and their carers were part of focus groups organised by the Disability Health Network. They are aimed at improving care coordination wherever people with disabilities contact the health system. Unfortunately, the demise of Medicare Locals has created uncertainty. Apparently there is a huge amount of health consumer interest in this topic and we hope to involve readers in its progress. So far, longevity of coordinators, hospital discharge planning and flexibility in coordination have been flagged.

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Psychosocial assessment overlooked WorkCover WA has just sent its report on the legislative review to the Minister for Commerce, Michael Mischin, and it attracted 66 submissions including doctor groups including State Wide Pain Services WA. The pain fraternity is disappointed by the apparent rejection of a routine assessment of psychosocial risk factors using the Orebro questionnaire. The Australian Pain Society submitted to WorkCover that it was the ‘bare minimum’ required for evidence-based management of work injuries. Given that the idea didn’t make the cut raises questions why a specific medical assessment and management strategy should be so contentious for stakeholders, particularly as it is standard in other states.

Sign of the Times In other Telethon Kids Institute news, for the first time, fundraising has become the institute’s biggest source of funds. Last year $8.9m came from donations, bequests and sponsorship (or 20.5% of its funding pie). Next biggest was competitive grants totalling $8.1m or 18.5%, previously the greatest source of income. The Institute also made $4m from commercial contracts and $7.5m from government contracts.

Hospital admissions and ADHD The chicken or egg debate has been fuelled by Telethon Kids Institute work showing a significant association between children later diagnosed with severe ADHD and higher rates of early childhood hospital admissions. Their findings showed a strong association between the rates of injuries and illnesses in the first four years of life – middle ear disease, tonsillar and adenoid disease, epilepsy, and more than twice the risk of poisoning. Sleep disorders, burns and respiratory diseases were also higher in this cohort (about 12,000 children).


MSA Hip System. Figures to December 2012, showed it suffered a cumulative revision rate of about 11% at two years. According to GOT, only four have been implanted in WA.

UK dying Bill’s first hurdle A bill to legalise assisted dying has passed its second reading in the House of Lords, where it was moved by Lord Falconer. It will now go to the House of Commons. The outcome of the Commons debate was not known by the time Medical Forum went to Press. The Bill has sparked heated debate both in the British Parliament and the community. Protesters on both sides of the divide are camped outside of the Houses of Parliament, exchanging swipes at each other. In Australia, all eyes are on euthanasia campaigner Dr Philip Nitschke, who faces deregisteration after he allegedly gave advice to a depressed Perth man on how to obtain drugs to end his life.

Preterm birth strategy Another hip in spotlight We wrote about the problems with metalon-metal hip prosthesis and the 2009 recall of the DePuy ASR J&J product implanted into an estimated 500 West Australians. This prosthesis was developed in Australia. The latest controversy is from another Australian manufactured product, this time by Global Orthopaedic Technology, which, after issuing a hazard alert with the TGA, has withdrawn from sale the femoral stem component of the

Hard on the heels of the research breakthrough by Prof Jeffrey Keelan that a new generation antibiotic – solithromycin – has potential to cross the placenta and kill infections responsible for many preterm births, the Women’s and Infants Research Foundation (WIRF) is sharing the info with clinicians. It is holding a ‘Stars Event’ on September 24 at 6pm at the UWA Club to explain its Preterm Birth Prevention Initiative, which it hopes will safely lower the rate of preterm birth in WA. Register at


Celebrity Spotlight

Tex Walks the Line He might have a dicky knee, but when veteran Australian rocker Tex Perkins puts on the Johnny Cash uniform of black, nothing holds him back.

He looks like Johnny Cash and he sounds like Johnny Cash and for Australian rocker Tex Perkins, he is Johnny Cash – at least for a couple of hours a night when he’s the Man in Black. Tex told Medical Forum that his passion for the Cash songbook went back to his very first band, a cow-punk outfit called the Dum Dums, which plied the pubs of Brisbane 30 years ago. “I had a strong connection with this music when I was 17 years-old, we played a lot of Johnny Cash numbers. And even before that I felt a close affinity with his song, A Boy Named Sue. You didn’t hear too many songs back then about a man with a woman’s name.” “All those lyrics about beer and blood were my first taste of the dark side. Johnny Cash was the first performer to prick my ears that there was something naughty going on.” Tex returns to Perth next month with the stage show, The Man in Black, which is a hugely successful tribute to the man and his music. Tex fans and those who give just a cursory listen to the Perkins’ songbook will notice a reverberation of intersecting tastes and interests. “I like the darkness and humour in these songs, they go hand in hand for me and I try to put a little bit of both in everything I do. I’ve been dragging some audience members around for 30 years and we’re all getting older now. I do a lot of different things from rock 14

and roll to acoustic dinner shows. The Man in Black pulls in ages from 18 to 80.” “It’s the sort of show you can take your Granny to, even with the drugs and violence in the lyrics. I do gett a bit worried about the annies sometimes. We used grannies to do a Sunday matinee show d I’d always pull back a step and or two and wouldn’t swear quite ite so much.” Thee Man in Black has d a stable line-up for had

many years including a female vocalist with a Masters’ Degree in speech pathology with a focus on voice and accent. “It’s a very settled group now. The musicians in the Tennessee Four are superb and the only problem with Rachel Tidd is that she sounds better than June Cash.” “Unlike the film Walk the Line, which was a pretty standard Hollywood approach, our show goes right up to his death. That’s important because he made a bunch of fantastic records in the last 10 years of his life and it was an incredibly important part of the Johnny Cash story.” If there are any Johnny Cash loving orthopods out there who want a brief brush with fame, here’s your chance. “I’ve been putting off a knee operation for years. I fell down a staircase in an inebriated state and damaged my anterior cruciate ligament. The stairs just happened to be inside a Boeing 747 on the way to London.” “I’m paying for it now, but I’m not all that energetic on stage anymore. It might seem like I’m doing a lot but it’s just sleight of hand. I’m 49-years-old and falling to pieces but I’ll be playing music to the day I die. I guess I may have to move to a stool one day.” O

By Mr Peter McClelland



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The Burden of Choice How does a family cope when a life-or-death decision has to be made for a six-year-old? J y explains. p Jeremy and Marina Keating know the agony all too well. Jeremy My wife Marina and I knew Fontine had a problem within days of her birth – a clinically insignificant problem that may ultimately have saved her life. The paediatrician on the maternity ward heard a sound that led us to Dr Luigi D’Orsogna who located a small VSD, explaining this was common, and would probably close on its own in the first year or two. A year later the VSD was still present so we returned again when Fontine was five. This appointment changed everything. The examination seemed to take longer than we remembered from previous visits and Marina sensed something might be amiss. Luigi explained that the VSD was still present, but more significantly, with Fontine’s now larger heart he had detected an anomaly of the coronary arteries. He was reassuring that the anomaly would probably prove to be minor, but firm that it should be investigated further. A few weeks later the CT scan confirmed the anomaly was both present and of the most worrying kind. Our beautiful daughter was now at risk of sudden death.

Information overload Like many parents with sick children, we quickly became experts on the problem, digesting all the information we could find. I am a dentist and Marina is a dietitian at PMH. We have a wide network of contacts in

Q The Keating Family

the medical field, including my closest friend who by fate is an adult cardiologist now living in Brisbane. For us this background would become both a blessing and a burden. Fontine’s anomaly was very rare so we could not draw on solid statistics to guide us. What’s more the medical community is divided on whether to monitor the problem or attempt surgical correction. Initially, we chose to monitor. In our eyes Fontine was a normal, happy, symptom-free five-year-old. It was easy to forget what lay beneath and tempting to ignore it altogether. How could we commit her to the trauma and risks of surgery when it seemed as if nothing was wrong?

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How safe is safe? The difficulty with monitoring a rare condition was there were no clear guidelines. Could she run safely for 10 seconds? Could she run safely for two minutes? What about the reported cases where death appeared to occur at rest? With very little science to draw on we began to wrap her in cotton wool. She watched her sisters’ run, jump and play while she was regularly chided for exertion. Six months slipped by and after many long nights of research and sometimes heated debate, Marina and I were leaning toward surgery. We agreed that a surgical consultation was appropriate and spent another couple of months deciding on with whom. Ultimately, we felt the safest hands were in Brisbane and flew to meet the surgeon. While in no way pushy, his recommendation was surgical correction.

The decision made Marina and I decided to proceed with surgery, referred to as ‘elective’, a term I hated as it felt to us as anything but elective. It was another four months between decision and surgery and time both dragged and raced. Normally firm in my convictions I was riddled with uncertainty. Sleep was broken, I became chronically unwell and terrible thoughts would intrude at random. Was this her last birthday, her last Christmas, her last meal? Over 12 months had passed before the day of surgery arrived. Fontine was now six. Marina and I spent the last couple of months attempting to prepare her without alarming her while at the same time trying to maintain a veneer of calm with our children and the world around us. As a father of three daughters, an innate part of me feels it is my job to protect them. In the final moments before surgery the idea of letting someone cut open the chest of my child screamed at me that we were making medicalforum

Infectious Diseases Consultant Q Fontine Keating and Dad Jeremy in the final minutes before her operation

the worst of mistakes. With no real understanding of what was about to happen, Fontine was smiling at me as I left her with the anaesthetist. I was unable to speak, hardly able to breath. The choice was made. The post script to this story is that the surgery was in January and Fontine continues to recover well. We think we made the right choice. O

Dr Luigi Dâ&#x20AC;&#x2122;Orsogna, paediatric cardiologist, comments on 'POUJOFTDBTF â&#x20AC;&#x153;Fontine had the relative rare but potentially lethal coronary artery anomaly known as Anomalous Aortic Origin of the Left Coronary Artery, second only to hypertrophic cardiomyopathy as a cause of sudden death in QDr Luigi Dâ&#x20AC;&#x2122;Orsogna children and young adults during or soon after exercise. Prevalence is about 0.2%, more commonly affecting the right coronary origin, when it is usually asymptomatic and more benign.â&#x20AC;? â&#x20AC;&#x153;In Fontineâ&#x20AC;&#x2122;s case, the origin of the left coronary artery was from the right aortic sinus with a slit-like orifice and an intramural course between the pulmonary artery and the aorta â&#x20AC;&#x201C; both presenting highest risk for her, such that symptoms may be absent until the first catastrophic event.â&#x20AC;? It is common for doctors to be asked by parents, â&#x20AC;&#x2DC;What would you do in our shoes?â&#x20AC;&#x2122; How did Luigi respond? â&#x20AC;&#x153;I was honest after the initial diagnosis and said I really didnâ&#x20AC;&#x2122;t know what I would do in their situation as the condition is quite rare and not often diagnosed as an incidental finding. It is much easier to recommend treatment in someone who has presented with symptoms!â&#x20AC;? â&#x20AC;&#x153;But I sourced as much information as possible from the published literature and discussed the case with a number of colleagues interstate and internationally. The consensus was that she should have surgery electively and I felt very comfortable with advising this.â&#x20AC;? â&#x20AC;&#x153;It was difficult to quantify for Fontineâ&#x20AC;&#x2122;s parents the exact risk of sudden death if left untreated. The risk of surgery is about 1%.â&#x20AC;? Fontineâ&#x20AC;&#x2122;s parents eventually went ahead with their daughterâ&#x20AC;&#x2122;s surgery. â&#x20AC;&#x153;The surgeon commented that at the time of the surgery she developed marked ST segment changes on her ECG as she underwent induction of anaesthesia with associated sinus tachycardia. As well, the orifice of the left coronary artery was tight when he explored it, so there is little doubt that she would have developed myocardial ischaemia at some point in the future and was very much at high risk for sudden, unexpected death.â&#x20AC;? Yes, he said, he would have made the same decision as Fontineâ&#x20AC;&#x2122;s parents, if she was his child. Luigi has set himself some rules for situations like this. â&#x20AC;&#x153;It is to be honest and frank with the parents when a difficult decision needs to be made. Empathy is very important and make sure that you have all the current and appropriate information for them to make an informed decision with you. This is very much a partnership with the parents, child and physician. Once made, it is very important to convey confidence and optimism in the decision.â&#x20AC;? This rare anomaly is not inherited so Fontineâ&#x20AC;&#x2122;s siblings are not at increased risk. O medicalforum

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Q Dr Janet Hornbuckle (arm raised rear left), skippers Fortuosity at the Doc of the Swan regatta in 2012.

Born to Solve Problems…and Sail There’s a lot of investment of every kind in the maternity sector, there’s also a lot of interests to juggle but it doesn’t daunt KEMH’s Dr Janet Hornbuckle.

There are few topics that provoke passionate debate more than the thing women have been doing for tens of thousands of years – having babies. The who, what, when and how have caused divisions in the maternity sector and, adding to the fizz, consumers are asserting more influence than ever before. One of those working to keep the system cohesive is Dr Janet Hornbuckle – Head of Obstetrics at the Women and Newborn Health Service and co-lead of the Health Department’s Women and Newborn Health Network. She is also a consultant in Maternal Fetal Medicine, treating women with the highest risk pregnancies and most precarious outcomes.

“The complexity and the co-morbidities of pregnant women now are massive, including obesity and diabetes – 10% of women who come here have a BMI of over 40. We have 1000 women a year who have pre-gestational or gestational diabetes, in 2004 there were 400.” When WA Health was writing the maternity policy framework in 2007, Janet was asked for her input and she jumped at the chance and was soon appointed co-lead for the Network. It is living proof that she can’t abide a problem without a solution. She also thinks that as a senior member of her profession she has a duty to lend her skills and experience to finding that solution, and policy formulation is an important element.

“I am always amazed at the pathology of pregnant women who come to our hospital. We have people who have had liver and renal transplants, strokes, who are paraplegic, tetraplegic, breast cancer survivors – there’s no such thing as a normal pregnancy,” she told Medical Forum.

“It is fascinating to be a part of the policy setting. I know some of my colleagues think it’s a waste of time and, frankly, that attitude makes me mad. Things have to change. We have seen the number of births increase about 9000 since 2004 – we’re looking at about 35,000 this year.”

A system under pressure

“The solution is obvious – not all these women can come to KEMH. A lot of effort is going into increasing the capacity of secondary hospitals with more O&G specialists being employed, mostly IMGs, because the locally trained O&G specialists

Janet arrived at KEMH in 2004, having decided to emigrate from Sheffield in the UK where she had done her general and specialist training. In those 10 years, she’s seen remarkable changes. 18

are not interested in working outside of their patch. That’s the upshot.”

The role of midwives Another change Janet champions is a greater integration of midwifery in obstetrics. “When I began working in Perth, I couldn’t get my head around how medicalised maternity care was. Obstetricians and midwives provide care together. I couldn’t do my job properly or at all without the support of many colleagues but particularly midwives.” “There are two poles in Perth – some obstetricians who think midwives are just glorified handmaids and some midwives who want to do whatever pregnant women want regardless of safety – we need to ensure we don’t push those poles further apart. The gap is closing, I hope.” “There has been a push for midwives to provide care across the maternity spectrum – through the ante-natal period into labour and birth then post-natal at home. So I did some research and investigated 13 models of maternity care for low-risk women including models where midwives were the main providers, with protocols and medical back-ups.” “It was as safe, and more cost effective than the medical model. Unfortunately there is a lot of resistance from the obstetrics fraternity, medicalforum

Trailblazer the patient has to come out of the private system into the public.”

which thinks that every pregnant woman needs to see a doctor. My take on it is that they may need to see a doctor but we have to be confident that the people we are working with have effective lines of communication and collaboration so that doctors’ practices are not threatened and patient access and safety is paramount.”

“My view is a VBAC is fine if it’s done in a facility with adequate monitoring and access to an operating suite, but not all facilities have that. It’s really about explaining the pros and cons and negotiating a mutually agreed plan.”

Sailing on

The home birth debate

If it’s not evident by now, Dr Janet Hornbuckle loves challenges and problem solving. In fact, she is a constant surprise to her mother, who thought that after three years, Janet would be off and looking for new challenges and horizons.

If that isn’t controversial enough, Janet and her Network co-lead A/Prof Graeme Boardley, who is Director of Midwifery, Nursing and Patient Support Services at KEMH, developed the Network’s home births policy and operational directives. “That caused a lot of friction between the obstetrics fraternity and the midwifery community. I was heavily criticised by my obstetric fellows for being involved in devising that policy – they didn’t want a home birth policy at all. But I saw there were women who were going to do it anyway and I felt it was my responsibility to make it as safe as possible.” “For those private specialists who accuse WA Health of not doing the right thing by writing a policy (that would save babies), I’d remind them of the Aboriginal and socially disadvantaged women to whom they provide no services. When specialists start insisting on the provision of appropriate services for these women, then I’ll listen to what they have to say about home births. Until then, don’t tell me our home birth policy should not be out there because it’s going to kill a baby.”

Too many caesareans? “Perhaps another question we could ask is, why is our caesarean section (CS) rate as high as it is.” “If 30% of women were supposed to give birth by CS, the human race would have

Q Dr Janet Hornbuckle

died out by now. Occasionally things can go wrong and women need assistance, very occasionally something catastrophic happens but usually you can sort it out.” Janet acknowledges that KEMH has 24-hour access to operating theatres that are able to have a woman in surgery in less than 10 minutes while other hospitals do not. “I can understand that if you don’t have access to a theatre, you might want to do a caesarean because it is a safe option and a planned CS is less risky than an emergency CS. But do you do loads of caesareans just because?” “If a woman came to me demanding a CS without any medical indication, I’d try to talk her out of it, or try to work out why she wants a CS because she is not taking the easy choice. Other doctors may not quiz so hard. It’s unusual for women to disagree with what their private obstetrician is recommending but there must be a few because we get some of them who have had a previous CS and want a subsequent vaginal birth (VBAC). Many private obstetricians won’t do that and

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“But the challenges and opportunities in WA keep coming. I’ll never leave. This is home now,” she said. And home comes with a ready-made ‘family’ – at the Royal Perth Yacht Club where she is a champion sailor and committee member. “Everyone at the club is so supportive. It’s the only activity where people can tell me what to do and I’m grateful for it! I sail a 36 foot racer cruiser called Fortuosity and race every Wednesday afternoon. Babies know not to be born on a Wednesday.” “My crew of six has an average age of about 70 but you wouldn’t know it; sailing keeps them young and they are a great group of guys who look after me. We came equal first in the summer series just gone and I sailed in my first ever ocean regatta at Geographe Bay. It’s important for me to have a life outside of work.” “I feel like I’m on holiday most of the time here in WA. I have a house near Fremantle that has beautiful water views – to the city, the harbour and the ocean. I have found my perfect spot.” O

By Ms Jan Hallam

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Caesarean Rates in WA Medical Forum explores the latest figures from the Health Department and also asks WA women their beliefs around repeat caesareans. Delving into this topic brings up a lot of important related issues, such as: obstetrical intervention services at private hospitals beyond caesareans; the compliance of health professionals with consumer wishes; decreasing skills amongst obstetrical staff; the influence of convenience and safety for consumer or obstetrician; the fact that over 92% of women have regional anaesthesia for any caesarean; hospital stay, post-op maternal restrictions and private health fund payments to hospitals; and the role of induction. We’re assuming that KEMH gets most of the ‘abnormal obstetrics’ in WA (e.g. diabetes), including women who want a VBAC (vaginal birth after caesarean), with little consumerism involved. The main questions appear to be: Do childbearing women anticipate the option of a vaginal delivery after caesarean? We asked 40 health consumers in a straw poll (see below). The vast majority thought a VBAC was an option. Yet 2011 figures say the chances are 18% if a woman is delivered at a public hospital like Armadale-Kelmscott or KEMH, or 1-3% if delivered at SJOG Subiaco or Murdoch. Put another way, a woman who believes she can have a vaginal birth after caesarean will be wrong 82-99% of the time. Are caesareans done for non-obstetrical and non-medical reasons? Anecdotally

the answer is yes, the point is the extent to which it happens and the role played by the medical profession (which was flagged by our poll of GPs last edition). This is difficult to determine accurately because neither obstetricians nor midwives are required to indicate the primary reason for caesarean. In the government’s Midwives Notification System, midwives include the reason for caesarean when reporting complications of labour and birth – 43% reported previous caesarean as a reason for repeat caesarean, information that might have been passed to the midwives by the patient.


“Some people think that if a woman has a caesarean for whatever reason, she can no longer have a natural birth under any circumstances. Other people think she can. Which do you think is closer to the truth?” Can have a natural birth: 85%; Cannot have one: 15%

Surveyed Consumer Demographics. Mostly middle-class women (females 65%) were surveyed in person. Age groups were 18-30 (45%), 31-40 (42%) and 41-50 years (13%). Around 60% gave ‘friends and family’ as their source of information, while 15% gave an ‘obstetrician’ and 15% gave ‘personal experience’. Responses according to gender were similar.


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Doctors’ comments on Caesarians in WA? Comments hinted at motivation, roughly in frequency order: t $POWFOJFODFTPDJBMEFNBOEoi*IFBS regularly of ‘convenience’ caesareans”, “patients demand them, obstetricians comply”, “lots of caesareans in the private sector are mother’s choice operations – not linked to medical or obstetric reasons, only personal ones”, and “too much mother and obstetrician convenience”. t %FGFOTJWFNFEJDJOFoiDBVTFJOBQQSPQSJBUF caesareans”, “probably the fault of the lawyers”, “for medico-legal reasons” t 'FBSoiUPPNBOZJOEVDUJPOTBOEPQTw  while another said “there are more IVF patients” t 0UIFSoWBHJOBMEFMJWFSZJTTFFOBT “messy, even in doctor patients” We laughed when one doctor referred to one private hospital as “Caesar Palace”. Supportive of caesarean One comment supported patient choice, while another said “you can plan on safe delivery and the time you want it” while another said caesareans are safe. A rural perspective: “As a country doc I see large numbers of patients booking caesarean sections for reasons of timing, especially rather than trialling VBAC” “There are no prizes for achieving a vaginal birth, particularly if any risk involved. All the incentives in the system are weighted in favour of the quicker and less stressful option. The risk of caesarean section is pretty low so it’s not rocket science to work out why this option is readily resorted to.” Legitimate reasons for caesareans “There has been a push to reduce these and allow babies to go too far overdue – I believe that 10 days over is the max and not drive oversized babies through borderline-sized medicalforum

pelvises. For the short-term gain this generally results in gynae problems later in life.” “With the older mums, more obese mums and larger distances, WA has a higher need for C sections.” Role of the obstetricians Five said obstetricians either had the best interests of mothers and babies in mind, were trustworthy, gave very good obstetrical care, or will choose LSCS on appropriate clinical criteria most of the time. Other comments were not so favourable.

“The caesarean rate in the private sector is inappropriately high, and in conducting informed consent of patients regarding elective caesarean, inadequate information about the risks is commonly given.” Vaginal birth after caesarean (VBAC) One of our e-Poll respondents said, “Far too high a caesarean section rate in private for all sorts of spurious reasons e.g. big baby with a trial of labour. Only place you can safely have a VBAC these days is KEMH and perhaps other smaller government hospital with rostered on doctors 24/7.” O

165 GPs offered these opinions (64% were male), also reported in the July edition Editorial.


Do you believe WA’s Caesarean Rate is appropriately linked to medical and obstetrical complications? Response

















Birth type No Previous Caes Last birth caesarean No Previous Caes Last birth caesarean No Previous Caes Last birth caesarean No Previous Caes Last birth caesarean No Previous Caes Last birth caesarean No Previous Caes Last birth caesarean

El-Caes 4% 55% 5% 49% 4% 71% 5% 70% 16% 78% 23% 82%

Em-Caes (1) 14% 27% 20% 33% 17% 23% 16% 23% 16% 19% 18% 17%

Total 1740 238 4582 1005 1120 167 1674 171 2848 754 1245 490

(1) We assume “emergency” caesarean involves a woman in labour who has medical or obstetrical contraindications to vaginal birth, but it could also include a woman who arrives in labour who has a prearranged caesarean for whatever reason. Source: WA Health Dept.


ll e-Po

Caesarean Rates


You answered ‘No’ to the last question. Where do you believe most inappropriate linkage occurs? Private Sector


Public Sector








ED: There were no significant differences in responses based on GP gender.




Child Health

Diagnosing Autism Spectrum Disorder An early diagnosis of ASD can be the difference between a lifetime of possibility and a lifetime of struggle – and help is out there. The diagnosis of a lifetime condition can be a daunting experience for the parent of a young child. Obtaining a defining medical opinion is often a lengthy and convoluted procedure. Wait-lists for relevant diagnosticians are long and then there’s the emotionally charged process of accepting and coming to terms with the clinical outcome. Inevitable questions arise. What does this mean for our child? What does this mean for our lives? It’s challenging for everyone and extends well beyond the sphere of the immediate family. Medical Forum spoke with three individuals who have extensive experience dealing with autism. Joan McKenna-Kerr (CEO of the Autism Association of WA), Kylie Cannen – mother of five year old Logan – and Prof Andrew Whitehouse all agree that the difficulties shouldn’t be disregarded but the positives far outweigh the negatives.

New treatment possibilities “Autism Spectrum Disorder (ASD) is just another way of being in the world. In the past it was portrayed as a tragedy and I vividly recall Q Joan McKenna-Kerr an image from a fundraising program in NSW about 20 years ago, where a child with autism was depicted hanging from strings attached to his arms like a broken puppet. The message is very different now,” Joan said. The condition encompasses a particularly wide spectrum and some parents can misinterpret the signs. “Most of the families we see in the early intervention program readily accept the diagnosis. We’re seeing better outcomes and it’s not the sentence it was once perceived to be. But there are parents who have difficulties coming to grips with a child who may be silent, withdrawn and living in a world of their own.” “There are varying degrees of severity including children who have good language skills and collect highly detailed information on a specific topic. Some parents perceive this as the behaviour of a gifted child.” “This can skew a realistic appreciation of the difficulties the child may struggle with. It’s so important that parents come medicalforum

to an acceptance of the diagnosis, get specialised help early and actually see the progress that a child can make.” “There’s a far greater understanding of language development, strategies for social interaction and the reduction of stress. Parents and families are absolutely crucial because they make the best therapists.”

Early diagnosis brings hope Kylie Cannen sings the praises of both the Autism Association and the merits of early diagnosis and intervention. Q Kylie Cannen with her five-year-old son Logan “It’s been 15 months since Logan’s diagnosis and he’s a completely different person now. We have a large extended family and they can’t believe how much he’s changed. There’s so much help out there, for both the child and the family.”

One of the frustrations for the Cannen family was the planning and sequencing of medical appointments. Demand for these services is high and, even with private health insurance, the cogs in the system often grind slowly. “There was a five-month wait to see a specialist and slightly longer for the child psychologist. I was the first to notice Logan’s behaviour, particularly his focus on order and routine and went to see my GP. As soon as I got the referral to the paediatrician I immediately booked the psych and the speech therapist.” “I am aware there are some who deny the presence of this condition. That’s sad because many of these children are then labelled as naughty. People are much more forgiving if they know a problem exists.” “A formal diagnosis was such a relief for me. It cost me around $2000 to get it but it’s a child’s life we’re talking about. Once you get the diagnosis there’s government funding of $12,000 until the child is seven for allied health costs.”

Skills to offer In Medical Forum [December, 2013], the Head of the Developmental Disorders Group

at the Telethon Kids Institute, Professor Andrew Whitehouse, described individuals with autism as ‘wonderful people.’

Q Prof Andrew Whitehouse

“I don’t think we emphasise enough the wonders of people with disabilities. They’re often treated as something of a liability when the opposite is true. No two people with this condition are the same. There’s a well-known saying amongst clinicians, ‘if you’ve seen one person with autism then you’ve seen one person with autism.’ It’s just so varied.” Andrew’s career direction was shaped by a formative experience as a young man. “A friend of my mother had an autistic son and as an undergraduate I’d go over and help. He was a wonderful young boy but it made my heart ache to see what they were going through. It would be a very rare family who didn’t find this diagnosis confronting in some way.” “Dealing with people who have autism can be such a positive thing. Not a day goes by that I’m not challenged by some preconception or belief regarding this condition.” O

By Mr Peter McClelland 23

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Guest Column

DCH Course Critique Having just completed his external DCH through Sydney Uni, GP registrar Dr David Adam gives insights to anyone thinking of taking this on.


very sick child cared for by professionals with access to an up-to-date, appropriate education in child health’ – that’s the vision of Sydney Children’s Hospital Network and Sydney Uni, and their instrument is the Diploma of Child Health delivered externally, through recorded lectures, assignments and tutorial groups. I joined paediatric residents, general practitioners and GP registrars in enrolling in 2013. The course is offered to doctors and nurses from 10 countries, and consists of 111 lectures, a couple of case reports, and a written and oral examination. I did not want to be left on the proverbial cliff when Princess Margaret Hospital’s own program was withdrawn (due to the burden of maintenance) in favour of supporting the Sydney offering. Motivation for participants I spoke to varied. GPs in regional and remote areas aimed to up-skill to reduce the number of children they sent long distances for consultations or transfers. Some RMOs felt it was important

for their CV. After a few years without formal study, I deluded myself it was a good refresher before starting my fellowship! The benefits of lectures online were clear. They fitted in around my roster and I could do a half, or three at a stretch. I could replay complex parts, although even on the third attempt, some endocrinology is impenetrable. Online meant they were available in Sydney, Geraldton or overseas, largely on an equal footing. My housemates were the only ones who complained if I attended in my undies! However, technology cannot mitigate a badly-delivered lecture. Although the material presented was good, the quality of the presentations was variable. Recordings exacerbated strong accents and coped poorly with animated delivery. Several speakers attempted to engage the small 0800 studio audience with varying success, and the long pauses, as they were put on the spot, were frustrating. The biggest challenge for participants, though, was keeping up – the flexibility

made it easy to fall behind during busy weeks, and the advantage of being able to replay a complex section of a talk meant that an hour’s lecture often took 90 minutes or more to undertake. Of those sitting the examination with me, less than half had managed to view all the content. I have done some online training through the Scouts Australia Institute of Training, covering leadership and planning skills. Less material was covered in greater depth. Each lecture was given as a series of narrated slides, advanced at the participant’s pace, with videos, assignments, and interactive exercises interspersed. In contrast, the DCH consisted of traditional lectures put online. This course (and others) would benefit from a similar approach to the Scouts, blending complex ideas with multiple methods and integrated assessment. I imagine this is more expensive to produce. The Diploma of Child Health is an accessible interesting course suitable for a wide range of practitioners, and is worth considering – but don’t underestimate the time commitment! O

X Mandurah GP A/Prof Frank Jones has been elected national president of the RACGP. X Ms Claire Allman has been appointed director of workforce at St John of God Midland Public and Private Hospitals. X CEO of Lifeline WA, Ms Fiona Kalaf, has joined the board of the Australian Institute of Management WA. X ASX-listed Perth-based Safety Medical Products is acquiring 3D Medical, the latter looking to integrate 3D printing and holography into medical practice. X The Australian Council on Healthcare Standards has appointed Dr Christine Dennis as CEO. She replaces Dr Lena Low. X Former AMA national president Dr Steve Hambleton is the new chairman of the National E-Health Transition Authority (NEHTA), taking over from businessman Mr David Gonski. X KEMH sessional sinologist and former Director of Medical Services, Dr Diane Davies, has been inducted into the WA Women’s Hall of Fame. X Endocrinologist Prof Tim Davis has been awarded the Australian Diabetes Society’s 2014 ADS-Kellion Award for his contribution to diabetes research.


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News & Views

Conference Airs Issue of Elder Abuse People working in the area of elder abuse say the issue needs to be putt on n. the public agenda in much the same way as child sexual abuse has been.


he abuse of the elderly is a hidden and highly sensitive issue with profound social implications. The Third National Elder Abuse Conference, Unlocking Solutions will be held in Perth next month and Medical Forum spoke with two key-note speakers, psychiatrist Dr Helen McGowan and former District Court Judge Antoinette Kennedy.

issue can contact them and they will advocate for them.”

Helen is the Clinical Director of the North Metropolitan Health Service’s, Older Adult Mental Health Program and a representative of the WA Alliance for Prevention of Elder Abuse (APEA).

“I think we’re going to find that the story of sexual elder abuse closely parallels the similar mistreatment of children. They’re both hidden social issues and it’s clear that the former is occurring with increasing frequency. The development of appropriate response protocols is critically important.”

“This is only the third national conference but there’s growing interest. These areas are complex, increasingly prevalent and difficult to research. They’re also inextricably entwined with one of the most vulnerable groups in our society.” APEA employs quite a broad-brushed definition of elder abuse. It includes any act that causes harm to an older person occurring within an informal relationship of trust. It’s a lot wider than criminal behaviour. Emotional abuse, parasitic behaviour, financial and physical abuse all fall within its parameters. “Most of the cases I’ve been involved with relate to financial exploitation. They’re often very sad and involve an older person’s resources being incorporated into the wider family. For example, the home is sold to build a granny flat which works well for a time. The potential for a marriage breakdown is always there and, if there’s a division of assets, there may be insufficient funds to secure a place in residential care”, Helen said. “Financial abuse is often complicated by the specific context. Frequently the person concerned would rather lose the money than jeopardise the relationship with their children. It can be highly distressing for all concerned and often requires the efforts of a number of specialised services to resolve these cases.” The theme of the conference, Unlocking Solutions, is in stark contrast to the often ubiquitous platitudes found in reports and official recommendations. Helen suggests that practical and appropriate responses are absolutely vital. “There are many complex modifiers when dealing with elder abuse. Clinically, we address it by establishing a relationship with Advocare which is the leading service provider in WA. Anyone struggling with this medicalforum

“It may well be that the police need to be involved, although many older people don’t want to initiate a formal process.” One of the subject areas at the conference relates to the sexual abuse of the elderly. Helen suggests there are parallels with ongoing investigations concerning children.

“The lower level cases are more nuanced. For example, how reasonable is it for a man to continue having sexual intercourse with his wife who suffers from dementia? And there may well be health problems stemming from this such as recurrent urinary tract infections.” “One aspect that’s worth noting is the mandatory reporting of child abuse. This has effectively resolved the ethical dilemma for clinicians regarding client confidentiality. Clearly, the same cannot be said in relation to the elderly.” “The one thing I’d say to GPs is that help exists. A good first step is to contact Advocare or the Older Adult Mental Health Service and that can be done without formally referring the case.” “Most people don’t deliberately set out to abuse the elderly. The coping mechanisms of carers can easily be overwhelmed.” As a former Chief Judge of the District Court of WA, Antoinette Kennedy has borne witness to the raw edge of life. She points out that Q Antoinette Kennedy legislation and the justice system are constantly playing catch-up with difficult and intransigent social issues. “The simple fact is that there’s no end to the sorts of things people do to each other. The legal system just can’t keep up. I was asked to launch a paper on Elder Abuse in 2011 and I was amazed at my own ignorance so I decided I would do everything I could to put this on the agenda.”

Q Dr Helen McGowan

our community will collapse in despair.” Antoinette relates one particularly sad case. “A man came before the court charged with manslaughter. He was intellectually disabled and when he was physical with his mother as a young boy there were no serious consequences. But he grew into a robust man and she was quite a frail 70 year-old, he pushed her and she tripped, hit her head and died.” “It was a tragedy. It left him without any support and his mother was dead before her time. We shouldn’t be shutting our eyes to this problem, particularly the situation with carers as they grow older.” The conference is an opportunity to open up discussion and reaffirm that elder abuse spans a wider range of behaviour than many people realise. “The first task is education and to place this issue out there in the public domain. We need to make this a talking point in the same manner as child abuse. It’s an increasingly ageing population and this is only going to get worse.” O

By Mr Peter McClelland ED: Third Annual Elder Abuse Conference September 3-4;

“It’s so important to underline the importance of social justice and unless we nurture it, 27


Tips on Reporting for Legal Purposes Writing a court report can be stressful. Slater & Gordon medical lawyer Ms Karina Hafford says a thorough balanced report can help all involved.


report request is likely if your patient is pursuing a claim for compensation following injury. The request may come from lawyers acting either for the injured person (plaintiff) or those alleged to have caused the injury (defendant). Your report will likely be seen by different people â&#x20AC;&#x201C; the patient, representatives of both parties, and the court or tribunal. Remember that: t 5IFQBUJFOUTTJHOFEBVUIPSJUZJTSFRVJSFE to avoid breaching patient confidentiality.

t "MUIPVHIUJNFDPOTVNJOH BTVDDJODU and objective report reduces your chances of being called to give evidence in court, and a prompt report can avoid prejudicing any claim. t 8JUIIPMEJOHBSFQPSUVOUJMZPVSFDFJWF a fee (or promise of same within a timeframe), is considered acceptable. Questions in the lawyerâ&#x20AC;&#x2122;s letter of instruction usually ask for responses under the following sections.

History and symptoms How much detail is a matter of your judgement. Exclude personal matters irrelevant to the issues. How the injury occurred is perhaps fundamentally important to the court but of relatively small relevance to a health professional. If you have no precise record of how the injury occurred, start by writing â&#x20AC;&#x153;A history sufficient

for the purposes of treatment only was obtained and the details noted as followsâ&#x20AC;Śâ&#x20AC;? You may have only recorded symptoms important for immediate treatment, in which case avoid misrepresenting your report as exhaustive by prefacing, â&#x20AC;&#x153;Symptoms recorded at the time of attendanceâ&#x20AC;Śâ&#x20AC;?

Examination findings Stay with observations you noted during clinical examination, knowing that courts understand it is neither possible nor appropriate to note every negative clinical finding. Indicate this by saying, â&#x20AC;&#x153;The significant clinical findings, which were recorded on examination, wereâ&#x20AC;Śâ&#x20AC;?

Tests and relevant outcomes Report comments such as â&#x20AC;&#x153;X-rays were unremarkable and within normal limitsâ&#x20AC;? can be argued in court, so it may be more helpful to either directly recite test reports or provide scanned results and state whether you have read them and agree with them.

Opinions as to prognosis Only give opinions when asked for specifically, and only if you could reasonably be expected to know, ensuring the opinion relates to a clinical issue. You may be asked about prognosis: the extent of permanent disability; the level of impairment; and whether the injury has stabilised. You may also be asked about the cause of a condition, and the patientâ&#x20AC;&#x2122;s capacity

Food is Medicine

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for employment or life expectancy. Avoid offering a general, non-medical opinion by ensuring answers are grounded on ascertained facts, not based on assumed circumstances. Take care over value judgements (e.g. â&#x20AC;&#x153;genuineâ&#x20AC;? or â&#x20AC;&#x153;malingeringâ&#x20AC;?) as these may be used to suggest you lack objectivity (and increase the likelihood of your court appearance).

Requests for original records A patient can request their notes under the Privacy Act. Always ensure there is a written patient authority. If you have concerns about providing notes (e.g. content may distress the patient), contact your professional association for advice. If notes are not provided, the patient can seek a court order or issue a subpoena for the notes. There is occasional debate about the status of correspondence from other practitioners who have treated the patient. Generally, a court will view this correspondence as forming part of your patient history if it contains material you have relied on to make clinical judgements. O

The Teachable Moment? Does an encounter with a drug counsellor have any lasting consequences for a young person brought into Emergency Departments after an episode of alcohol or drug (AOD) abuse? It was the subject of an initial assessment 10 years ago by UWAâ&#x20AC;&#x2122;s Prof Gary Hulse and Dr Robert Tait (now at the National Drug Research Institute at Curtin University) and back then it looked promising. The study was sparked by the improved outcomes of patients who were counselled when they presented at EDs with self-harm symptoms. The AOD research team identified a cohort of 55 adolescents (aged 12-19) with 236 repeat presentations and studied six cases in-depth and 12 months later followed them up to find improvement in their outcomes. Ten years on, the cohort and others will be followed up again, through a survey of HoD records that include inpatient and outpatient admissions, midwifery, cancers, accidents, injuries and death to determine if the intervention had lasting benefits. O

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Medical Marketplace

Changes in Dismissal Laws There have been changes to unfair dismissal laws. Here is a summary of some of the changes, though your MDO will have all the details. here are traps and pitfalls when it comes to the termination of employment. Itâ&#x20AC;&#x2122;s a complex process and, if not managed well, the consequences can be serious. Fairness is a subjective concept and often depends on where you happen to be standing at the time.


reason for termination must be â&#x20AC;&#x2DC;sound, defensible and well foundedâ&#x20AC;&#x2DC;. In a general sense there are only three valid reasons for an employer to dismiss an employee: t DBQBDJUZ QPPSQFSGPSNBODF


Unlawful Termination

And. if youâ&#x20AC;&#x2122;re an employer based in WA, thereâ&#x20AC;&#x2122;s an added layer of complexity compared with the rest of the country and it may impact on the determination of what is deemed to be a â&#x20AC;&#x2DC;fairâ&#x20AC;&#x2122; dismissal.

Itâ&#x20AC;&#x2122;s worth noting that summary dismissal should only be enacted if an employee has engaged in serious misconduct. This infers that continued employment during the period of notice would be both untenable and unreasonable.

Applying for a Remedy

It all hinges on the Constitutional Corporation (CC) classification; a private sector employer is subject to either state or federal jurisdiction depending on which side of the CC line they fall.

Employees in WA State legislation pertaining to unfair dismissal comes under the umbrella of the following criteria: t FNQMPZFEVOEFSUIFTUBUFTZTUFN t FBSJOHMFTTUIBO  IJHIJODPNF threshold) or covered by an award/ industrial agreement.

4VCTUBOUJWF'BJSOFTT In essence, an employer must ensure that any dismissal is procedurally and substantively fair. In WA there is a further caveat in that an employer must not exercise their legal right of dismissal in a harsh or oppressive manner.

Valid Dismissal If an employee makes an unfair dismissal claim it will be assesssed by a tribunal. The

One aspect that may be pertinent for a medical practice relates to the Small Business Fair Dismissal Code. Any dismissal from an organisation that employs fewer than 15 people must fall within the guidelines of the code.


of a trade union An application must be lodged within 21 days of the actual dismissal. The employee will incur a fee of $67.20 Both parties coming before the Commission must generally pay their own costs. However, an order may be made for either the employer or the employee to pay costs if the claim is deemed to be: t GSJWPMPVTPSWFYBUJPVT t OPSFBTPOBCMFQSPTQFDUPGTVDDFTT O

)*/54'03&.1-0:.&/5$0/53"$54 The paperwork may well be tedious but employment contracts protect both parties when disputes arise. If youâ&#x20AC;&#x2122;re asked to sign an employment contract then itâ&#x20AC;&#x2122;s not a bad idea to grit your teeth and wade through the legalese. Here are some likely targets for the yellow highlighter: t "SFZPVBOFNQMPZFFPSJOEFQFOEFOU contractor? The former have much stronger fiduciary duties to their employer relating to the use of confidential patient information. t "SFUIFDPOEJUJPOTGPSDPOUSBDU termination fair? Look at notice to be

given, penalities for early termination and other related areas. t *GBQBUJFOUTVFT XIPJOEFNOJGJFTXIPN If in doubt, check with your medical defence organisation. t "SFUIFSFQPTUUFSNJOBUJPOSFTUSJDUJPOT such as restraint of trade? Ideally, theyâ&#x20AC;&#x2DC;re designed to protect an employerâ&#x20AC;&#x2122;s legitimate interests but they must be reasonable and relate to geographical restrictions, former patients, and employee restraints.

Supporting Ophthalmic Research, Education and Overseas Projects

EYE SURGERY FOUNDATION Our Vision Is Improved Vision After 18 months of expansion, the Eye Surgery Foundation amalgamated two buildings and re-commenced surgical procedures. The new day hospital is twice the size â&#x20AC;&#x201C; four operating theatres, a dedicated Laser room with a Femtosecond Laser, two recovery rooms, large reception, and a spacious staff room. Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco Dâ&#x20AC;&#x2122;Souza Tel: 9258 5999 %S(SBIBN'VSOFTT Tel: 9440 4033


Dr Kai Goh Tel: 9366 1744 Dr David Greer Tel: 9481 1916 Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156 Dr Brad Johnson Tel: 9301 0060 Dr Chee Kang Tel: 9312 6033

Dr Jane Khan Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665 Dr Jonathan Ng Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600 Dr Rob Paul Tel: 9330 8463

Dr Vignesh Raja Tel: 9300 9600 Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Angus Turner Tel: 9381 0802 Dr Michael Wertheim Tel: 9312 6033 Dr Joshua Yuen Tel: 9301 0060


Guest Column

Creating a Safer Future for Children It’s nearly two years since Hon. Peter Blaxell handed down his report into child sex abuse in government-run student hostels. He reflects on its effects.


2. A single central agency (or ‘one stop shop’) independent of all other State Government agencies which will receive complaints by children of sexual abuse committed by any public official employed in those other agencies.

n 2011, I agreed to conduct a Special Inquiry on the failure of public officials to respond to allegations of sexual abuse at St Andrew’s Hostel in Katanning, but I also dealt with issues surrounding similar allegations at four other country high school hostels.

3. Staff employed in country high school hostels should become ‘mandatory reporters’ of sexual abuse under the legislation.

The evidence that I heard during the Inquiry was quite shocking. At Katanning in particular, countless young students (mostly boys around 14 years of age) had been systematically abused over a 15-year period up until 1991.

4. A review of the Department of Education’s curriculum for educating children about ‘protective behaviours’ in relation to sexual abuse.

The main perpetrator was the Warden of the hostel who was responsible for their care, and the varying sexual offences that he committed ranged from simple molestation through to repeated acts of anal penetration. Most offences occurred at night behind the locked doors of the dormitory block where the Warden and the boys all slept, and where he was free to pick and choose his victims. (It was a situation akin to a fox being locked up with the chickens.)

Community ignoring the signs A disturbing feature of the evidence was that this sexual abuse was able to continue for 15 years despite numerous occasions when any sensible adult would have suspected what was going on. However, he enjoyed high standing in the local community. The few individuals who did report their suspicions were not given a good hearing by people in authority. In most instances they were rebuked or warned about the risk of defamation proceedings, and for that reason did not pursue their concerns any further. In this regard the Hostel Board had essentially abdicated its responsibilities and handed complete power over to the Warden. He exercised total control over the students, and the few who did complain or cause him trouble were immediately expelled (usually on a false pretext that they had been caught stealing). A similar situation prevailed at St Christopher’s Hostel in Northam where for 14 years (between 1963 and 1977) there was systematic sexual abuse by the Warden of boys in his care.

Victims had nowhere to go The common factor at both hostels was that vulnerable young students found themselves trapped in a closed environment where their paedophile oppressor had almost total control of their daily lives. Because of their 30

5. A significant upgrade of the training program for voluntary members of the boards responsible for the operation of individual hostels (now known as ‘residential colleges’).

Government moves on report

Most offences occurred at night behind the locked doors of the dormitory block where the Warden and the boys all slept, and where he was free to pick and choose his victims. (It was a situation akin to a fox being locked up with the chickens.) shame about co-operating in what they knew to be wrong they could not discuss what had happened with their parents or others they knew. As there was no one else to turn to they felt they had no choice but to remain silent. These feelings of helplessness have had lasting impacts on some victims (who are now mature men aged in their 40s and 50s). For them it required great courage to come forward, disclose for the first time, and testify about the sexual abuse that they had endured. The Report of my Inquiry identified many shortcomings in the way in which government agencies dealt with complaints from children of sexual abuse more than 20 years ago. Most of these shortcomings have since been overcome, but in respect of those that remain my Report made the following recommendations: 1. The adoption of a more robust ‘multiple avenue’ model for complaints from hostel students which allows them to be made to an agency external to their hostel.

In response to my Report, the State Government has either, implemented or taken substantial steps towards implementation of recommendations 1, 3,4, and 5. In relation to my second recommendation the Government has identified the Commissioner for Children and Young People as its preferred organisation to operate the ‘One Stop Shop’. To that end, the Public Service Commissioner has carried out a review of the legislative amendments that will be necessary to give effect such a scheme. I am informed that the report of that review is with the Attorney General, and is likely to be tabled in Parliament this month. In my view, if all of the recommended measures are fully implemented, the Government will be doing all that it reasonably can to minimise the risk of future child sexual abuse by public officials. There is no conceivable system that could guarantee that such incidents will never occur again. So long as there are humans there will always be a few paedophiles in our midst, and some of them will have sufficient deviousness and cunning to gain access to potential victims. All that can be reasonably hoped for is that children in the future will be sufficiently educated and equipped to recognise dangerous behaviour, and that they will be aware of the means and be willing to take preventative action before any sexual abuse occurs. O


Guest Columns

Support Kids and Families The policy to remove Indigenous children into care needs to be re-evaluated, says Ms Dawn Wallam, and the community must have a greater say.


estern Australia has the second highest rate of Aboriginal and Torres Strait Islander (ATSI) child removal than anywhere in Australia. ATSI children make up just 5% of children in WA but comprise 49.5% of all children in out-of-home care. This is higher than the national average.

In WA, non-Aboriginal children are more likely to be removed from their families and placed in out-of-home care because of sexual and physical abuse while ATSI children are mainly removed because of emotional abuse and neglect. While sexual and physical abuse can be easy to define and identify, emotional abuse and neglect are not. The Department for Child Protection and Family Support in WA describes children who have experienced emotional abuse as presenting as “very shy, fearful or afraid of doing something wrong. They often display extremes in behaviour, are often anxious or distressed, feel worthless about life and themselves and have delayed emotional development”. These are also signs of trauma and racial discrimination – neither is necessarily attributable to the child’s current home

environment. The lack of independent professional advice from medical experts such as paediatricians and trauma specialists within the WA child protection system is problematic and can contribute to the high reporting and subsequent removal of ATSI children from their families. The second most common reason for ATSI child removal is neglect. While neglect is not a well-defined term, it is strongly associated with disadvantage and poverty. ATSI children, families and communities commonly experience appallingly high rates of unemployment, incarceration and homelessness. They have the highest mortality rate, lowest education attainment and lowest standards of health than anyone else in Australia. Many Aboriginal people live in communities in overcrowded housing, with no running water or sanitation, with little access to services and community support that most take for granted. Child protection systems cannot, by themselves, address many of the underlying reasons for the high notification of neglect in communities. It requires an across-government coordinated effort involving local, state and commonwealth governments.

It also requires that Aboriginal people, families and communities are engaged in the full process of designing, developing and delivering services aimed for them. Leading international and Australian research suggests that applying a public health model to care results in better outcomes for both children and their families. Despite the potential for long-term cost savings in other areas such as education, health and the judicial system, governments continue to spend a disproportionate amount on child protection and the removal of children compared to family support. In WA in 2013, $341.5m was spent on child protection and out-of-home care services compared to just $68.1m on intensive family support services. Adopting a preventative rather than a punitive approach will significantly reduce the number of ATSI children being placed in out-of-home care, it will break the cycle of trauma and loss and also create significant long-term cost savings for government. O ED: Dawn Wallam is a Noongar Elder, CEO of Yorganop and WA representative on the Secretariat of National Aboriginal and Islander Child Care.

The Play Emergency Our children need to get outside and learn from playing in the great outdoors, says paediatrician Dr David Roberts.


hild’s play – we generally use this label to describe something simple or inconsequential. But the past two decades have shifted our insight into child’s play, as we begin to recognise its social and developmental importance. What is certain is that child’s play is far from trivial.

Children in Australia are spending most of their recreational time inside, slumped on cushions, staring at a screen. High security prisoners get more sunshine than the average Aussie kid.

Two truths emerge First, children become dependent to the point of addiction; evidence the distress some suffer when the screen is forcibly withdrawn. Secondly, adults are also in denial; we know the electronic babysitter is dangerous, yet many gave a tablet computer for Christmas. medicalforum

One defining characteristic of this style of play is its authoritarian nature. It channels engagement into strict pathways and allows virtually no room for innovation or creativity. The long-term impacts of this are not yet understood. We do know there is an inverse correlation between time spent in unstructured outdoor play and rates of childhood obesity and mental and social dysfunction. Then there are the unmeasured consequences; the more general disconnection from the world outside and from other people. Research now highlights the importance of unstructured, unsupervised play outdoors to the development of children’s imaginations and social intelligence and their decision-making, conflict resolution and risk assessment abilities. A measure of this is ‘creative elaboration’, which declines in children whose opportunities to play have been limited by adult interference.

Back to basics Put simply we need to get our kids outside, climbing trees, negotiating the rules of a game and building great edifices of the imagination. There is value in allowing children time to themselves, time to play. Not filling their every waking moment, nor fostering their appetite to be entertained constantly. Boredom is a great driver of the imagination. Watch kindergarten kids at play, and recognise how important is the time spent negotiating the rules, setting out the boundaries of the game. This conversation is the basis of ‘democratic’ play. If they don’t agree, the game doesn’t happen. It is also a foundation of their social development. And to succeed, they must wield the most powerful tool we humans possess, our imagination. O


Medical Audiology Services

Hear the best you can!

Degrees of Hearing Loss and Expected Challenges By Andre Wedekind, Audiologist The degree or severity of hearing loss is defined by the threshold of hearing. Below is the most commonly used classification, which divides hearing levels into 5 broad bands of severity. We list some of the difficulties expected at each level, without amplification. The affected frequencies and the type of hearing loss (conductive, mixed or sensorineural) result in different communication challenges.

Degree of hearing loss Hearing Thresholds

Sound examples in this range Possible challenges and needs

Normal Hearing

Rustling leaves, clock ticking


Quiet speech, clicking fingers

This is comparable to lightly plugging both ears. The child has difficulty hearing soft speech or from a distance. Noisy settings like classrooms and playgrounds pose extra difficulty. Difficulties may be wrongly attributed to behavioural or attention problems

Normal conversational speech

This is comparable to wearing well-fitting earplugs in both ears. Approximately 50% of speech is inaudible. The child may understand conversational speech at close proximity, in quiet, when facing the speaker. Listening in background noise is very difficult. Obvious hearing difficulties are observed by teachers and parents. Speech-language development is affected in all children.

Telephone ringing, baby crying

Most environmental sounds are inaudible. There is no understanding speech without amplification. The child may have a heavy reliance on visual cues, even with hearing aids. Early intervention is required for speechlanguage development. Cochlear implants may be recommended.

Truck, chainsaw

The child’s natural hearing is not functional. Early intervention and cochlear implants are required.

Mild Hearing Loss

Up to 20dB HL

25 - 40dB HL

Moderate Hearing Loss 45 - 70dB HL

Severe Hearing Loss

75 – 90dB HL

Profound Hearing Loss 95dB HL

Modified from PHONAK

Unilateral hearing loss in childhood: Isn’t one ear good enough? By Dr Vesna Maric, Senior Audiologist, Medical Audiology Services Permanent unilateral hearing loss (UHL) refers to normal hearing in one ear and a hearing loss in the other ear ranging from mild to profound. Prevalence at birth is around 1 in 1000, and increases to 3 in 100 by school entry. As for bilateral hearing loss, the leading causes are prematurity, genes, infections, syndromes, noise and head trauma. Good binaural hearing is critical for sound localisation and hearing in background noise. For toddlers, this allows opportunities for incidental language learning during daily interactions with parents. For older children, it is additionally important in social communications, further language development and classroom listening. Despite research dating back to the 1980s identifying poorer academic performance in children with unilateral hearing loss, its significance has been downplayed by professionals and parents over the years. While many develop normal speech and language, there is now good evidence that UHL is associated with increased rates of grade failures, need for educational assistance, perceived behavioural issues, social and emotional problems and poorer self-rated quality of life. With earlier identification of hearing loss from neonatal screening programs and growing awareness of UHL, there is now a focus on treatments beyond preferential seating in the classroom. Amplification with conventional hearing aids is an option for mild to moderate losses. If no functional hearing is present in the affected ear, CROS hearing aids and bone conduction implants can be used to send information from the affected ear to the good ear. Such contralateral routing does not provide localisation or benefits in noise, but it does increase awareness of sound from the affected side. Children with a severe or profound hearing loss in one ear are starting to be offered the option of cochlear implants. Similarly to adults, early evidence suggests good integration of the electrical signal with natural hearing from the good ear, as well as benefits for listening in background noise and localisation.


51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: medicalforum

Guest Column

Training To Be a GP Dr Michael Christmass has just passed his FRACGP exam. He gives some insights before pursuing his interest in addiction medicine.


sort of fell into GP training. I thought critical care medicine was for me, spent two years working in ED, ICU and CCU, and liked the excitement and collegial approach. But in ED I missed the opportunity to become more involved with patients. I felt suited to ICU (time management deficiencies were less exposed here!) but the prospect of shift-work for at least five years became too daunting. With general practice I had the opportunity to see patients again and to understand ‘the person with the disease’, which I valued.

As a fulltime registrar my Basic and Advanced General Practice terms raced by in a blink. Plans for study went by the wayside early. I found spare time was spent staying back at work and occasionally turning up on weekends to finish ‘extras’ (e.g. referrals, care plans, correspondence). During the Basic Term [the first six months in general practice] I especially found it difficult to manage time and patient expectations (e.g. the shopping list!). I was repeatedly, inadvertently, cramming two to three consultations into one. My time management deficiencies were exposed! Thankfully, towards the end of my Advanced

Term I was asked to form a study group. This was the best thing that could happen to a habitual ‘study loner’. I stopped shifting deadlines and actually finished study summaries because others depended on me – make a plan, get started and ‘knuckle down’. Group study also helped my study balance, avoiding my usual habit of spending hours on topics of personal interest but failing to cover other, equally important, areas like viral hepatitis. Juggling work and study? I was always a bit sceptical about maintaining ‘work-life balance’ and have never been a great time manager (my wife agrees!). Study came from whatever was left after work and a regular feeble exercise program, with ‘time out’ for a few hours on the weekend. There were a few surprises along the GP registrar path. As mentioned, the speed with which the first 12 months passed was most unexpected. Initially, I was surprised to find the day more tiring compared to hospital-based work. This seemed related to the intensity of repeated presentations, one-on-one, managed alone. Patients with multiple problems and several comorbidities, the depressed or suicidal patient, children with behavioural problems, substance use disorders, forms and paperwork

(worker’s compensation, driving licence assessments, requests from lawyers) were all issues I found difficult to manage in 15 minutes. Despite excellent supervisors, those first few months practising ‘behind the closed door’ required significant adaptation. In hindsight, if I’d opted for a dedicated paediatric (instead of ‘mixed’ ED) and O&G terms, it would have been helpful. A plan of regular study during the year, with a registrar colleague for support, would have been another good idea. Finally, spending some time developing time management skills, before starting work in a busy GP practice, would have made life easier. It has taken me some years to finally get around to studying medicine. Thankfully, I can say I have no regrets to this point. Having people take me into their confidence is something I hope never to take for granted. The amazing experiences from simply ‘turning up for work’ in the last two years make general practice a wonderful vocation. O ED. As a married mature aged student Michael has a PhD in exercise science and was a professional tennis coach.


Problematic alcohol use By Ms Tara Sita (Education and Training), Holyoake. Tel 9416 4416


ith over 80% of adult Australians saying they use alcohol, consumption is prevalent. Problematic alcohol use and alcohol dependence are increasing, yet only a small proportion of these individuals seek treatment. Early identification and management of problematic use can reduce the risk of physical and mental health problems.

Identifying issues

goes for people with issues of family violence, problems at work or home, or even accidents. Assessing alcohol use can assist in planning treatment.

Assessment This is not only to identify problematic alcohol use, but also determine the impact, their attitude towards it and any perpetuating factors. There are several screening and assessment tools including:

There are many different ways that alcoholrelated problems might present or raise suspicions. These may involve physical and/ or mental health. Medical presentations where alcohol use should be considered and asked about include: hypertension, impaired liver function, tremor, red eyes, and cognitive impairment.


Those with anxiety and depression may have underlying alcohol use problems. The same

Brief interventions can help. It is important to assess the individual’s motivation to change


t $"(&2VFTUJPOOBJSF BOE t 4FWFSJUZPG"MDPIPM%FQFOEFODF Questionnaire (SAD-Q). All three are easily found online.

their drinking patterns. Ask questions that require full answers (e.g. “How do you feel about your drinking?” or “I wonder if some of your health issues might be related to your alcohol use – what do you think?”). More detailed answers inform possible interventions and lead to a discussion of the impact of their alcohol use. It can provide an opportunity for education on recommended levels of alcohol use, and the impacts on their health and life in general. Work with them to develop realistic longand short-term goals, followed up at regular appointments. Develop strategies to assist the patient achieve their goals, such as recognising triggers to alcohol use, switching to low alcohol drinks or counting drinks. Encourage them to deal with perpetuating lifestyle or social issues. Further available interventions include medications, specialised alcohol counselling, residential rehabilitation programs and detox programs (either in-patient or home-based) – see O

Interventions No author competing interests disclosed. 33

News & Views

TGA on ADRs Medical Practitioners, Home Hospital Silver Chain Group is a forward-thinking and innovative not-for-profit organisation with a purpose to build community capacity to optimise health and wellbeing. Following the merger of Silver Chain (WA) and RDNS (SA), in 2011, the Group is one of the largest community care providers in Australia, assisting people across WA, SA, QLD and NSW.


e sought comment from the Therapeutic Goods Administration over our story and e-Poll on the reporting of Adverse Drug Reactions (Drugs, Doctors and Patients â&#x20AC;&#x201C; ADRs) [July edition]. We asked the TGA a series of questions and here is its edited response.

Q: Can the TGA explain why there is such a high incidence of pharmaceutical reporting â&#x20AC;&#x201C; doubled since 2008? A: In part, this may have been the result of recent updating of TGA pharmaco-vigilance guidelines to clarify the requirements of sponsors. Sponsors have mandated requirements to report serious adverse events to the TGA. The majority of these reports come from health professionals and consumers who report these to the sponsor through consumer information lines or to pharmaceutical representatives. Health professionals, including pharmacists, GPs and specialists, may also choose to report directly to the TGA. Increases may also be part of a global trend.

Q: What ADRs would the TGA like see more reported? Silver Chain Home Hospital delivers non-emergency hospital level care to patients across the Perth metropolitan area 24 hours a day 7 days a week. The service enables eligible patients who would otherwise need to visit or stay in hospital, to be treated in the comfort of their own home. ABOUT THE ROLE:

The TGA particularly requests reports of: t TVTQFDUFEBEWFSTFFWFOUTJOWPMWJOHOFXNFEJDJOFT t TVTQFDUFEESVHJOUFSBDUJPOT t VOFYQFDUFEBEWFSTFFWFOUT JFSFBDUJPOTUIBUBSFOPUEFTDSJCFE in the Product Information) t TFSJPVTBEWFSTFFWFOUT TVDIBTUIPTFTVTQFDUFEPGDBVTJOH inability to work; admission to hospital; prolongation of hospitalisation; increased investigation or treatment costs; danger to life; birth defects; death.

We are seeking expressions of interest from vocationally


registered general practitioners interested in working with us in Home Hospital. Patients value the ability to remain at

ll e-Po

We asked 165 GPs about their awareness of reporting methods for Adverse Drug Reactions.

home with loved ones and in their familiar surroundings.

treatment at home.



I know of the â&#x20AC;&#x2DC;Blue Cardâ&#x20AC;&#x2122; paper form.


0Providing clinical leadership, advice and support to the

I know of the online reporting system at


I subscribe to emailed TGA safety alerts for products.


Be part of the multidisciplinary team that provides their

Home Hospital team in accordance with current professional and ethical standards and evidence based practice. 0Participation in mentorship and supervision for junior medical officers. 0Participation in the on-call roster.

How aware are you of the TGAâ&#x20AC;&#x2122;s Adverse Drug Reaction reporting methods? ethod ds??

None of the above


Doesnâ&#x20AC;&#x2122;t apply




ED: Only about 1 in 4 GPs subscribe to TGA-enabled alerts. BENEFITS: 0Ongoing professional development opportunities. 0Attractive remuneration on offer. 0Opportunity to work in a growing national organisation. 0Salary packaging benefits â&#x20AC;&#x201C; up to $15,899 per annum tax free. 0Free on-site employee parking.

You can make a difference. View the position description and apply online at:


Q: How can the TGA make reporting more convenient and better understood? Is it possible to have more linkage via GP desktop software? A: The TGA is undertaking a range of initiatives. Providing an adverse event reporting mechanism in medical software, particularly one that allows reports to be automatically populated from clinical record data, has been suggested as an important way of reducing the time required to find, complete and send reporting forms. The TGA has recently developed a web service for the reporting of adverse events. The web service is available to companies providing software to health professionals â&#x20AC;&#x201C; including GPs, hospital and community pharmacists, specialists and nurses. Interested parties should contact the TGA for further information. Guildlink is the first company to provide an integrated link to the web service from its community pharmacy software. O medicalforum

Your cultural lens An invaluable aid for health staff working with people from diverse cultural backgrounds


young man who recently returned from a holiday to Africa storms out of your consulting room in response to your offer of opportunistic STI testing.

A woman with genital chlamydia repeatedly refuses your advice about condoms and safe sex insisting that she does not have a husband or boyfriend. What’s WRONG with these patients? Or do you need to refocus your cultural lens? These are just two of the real-life scenarios in Your cultural lens au/ycl, an interactive, online education

By Prof Donna Mak, Communicable Disease Control Directorate, WA Health

resource in cross-cultural communication for sexual health and blood borne viruses. The need for this cross cultural education resource is highlighted by the fact that between the two five year periods 20032007 and 2008-2012, the number of WA HIV notifications acquired in sub-Saharan Africa and south-east Asia increased by 180% and 40%, respectively; in 2012 nearly 80% of hepatitis B notifications were acquired overseas (The Epidemiology of Notifiable Sexually Transmitted Infections and Blood-Borne Viruses in Western

Australia 2012. au/cproot/5640/2/stibbv_2012_annual_ report_parta.pdf) Your cultural lens comprises six interactive modules that illustrate the principles of effective cross cultural communication in clinical and health promotion settings. Developed by the Metropolitan Migrant Resource Centre and funded by WA Health, the resource was designed to build the skills and confidence of doctors, nurses, practice support staff, health educators and community workers to work more effectively with culturally diverse patients and communities. Each module features a situation asking you to choose one of two options for dealing with a realistic issue and then shows the consequences of each course of action. As shown in the accompanying screenshots, the resource is video- and picture-based with minimal reading required. Each module takes only 5-10 minutes to complete. Users can work through modules in their own time and in any order. Dr Aesen Thambiran, GP and refugee health doctor, said ‘Your Cultural Lens is a creative and innovative package which thoughtfully QDr Aesen Thambiran challenges our attitudes around cultural diversity and sexual health. Best practice is demonstrated through a series of short video vignettes. This is an invaluable aid for GPs and nurses working with people from diverse backgrounds. Five stars!’

LOG ON... Your cultural lens is FUN, FREE and might just give you a new perspective on your cultural lens. Log on at and give it a go! And when you’ve finished, please fill in the online survey to give us your feedback.




Fetal Alcohol Spectrum Disorders A

lcohol consumption during pregnancy can be associated with spontaneous abortion, stillbirth, low birthweight, preterm birth and fetal alcohol spectrum disorder (FASD*). Children with FASD may experience developmental delay, deficits in intellectual functioning and difficulties with learning, memory and attention; have poor executive functioning; and show deficits in social and adaptive functioning. These can lead to school failure, unemployment, substance abuse, mental health disorders, and trouble with the law. Early diagnosis, intervention and family support can help reduce long-term adverse effects, and ensure women are advised about effective contraception and not drinking alcohol in future pregnancies. The degree of harm to the fetus depends on the quantity, frequency, pattern and duration of alcohol exposure, maternal and fetal genetics, and the stage of development of the fetus when exposed. The Australian Guidelines to Reduce Health Risks from Drinking Alcohol Guideline 4 applies an evidence-based precautionary principle: â&#x20AC;&#x153;for women who are pregnant or planning a pregnancy, not drinking is the safest optionâ&#x20AC;?. In association with increased public and research interest in FASD, there has been a marked increase in diagnosis and notification of FASD to the WA Register of Developmental Anomalies. Aboriginal children are more likely to be diagnosed with FASD than nonAboriginal children, but there is no doubt that FASDs are under-diagnosed and underreported for both groups. Research in WA has found that women want to be asked about alcohol use in pregnancy

By Prof Carol Bower, Winthrop Research Professor, Telethon Kids Institute

'"4%,&:10*/54 t %PDUPSTXIPBDUUPQSFWFOU'"4%JO  PGGTQSJOHBSFMJLFMZUPSFEVDFMPOHUFSN demand on community resources. t "TLJOHXPNFOBCPVUUIFJSBMDPIPMVTF before and during pregnancy is a simple  XBZPGJEFOUJGZJOHUIPTFBUSJTLPG'"4% in offspring. t .PTUDIJMESFOBGGFDUFECZ'"4%EPOPUIBWF recognisable dysmorphic facial features. t 'VSUIFSSFTFBSDIXJMMBTTJTUJOEFWFMPQJOH effective models of prevention and diagnosis and translate them into policy and practice.

and expect health professionals to advise them about it, and yet fewer than half of WA health professionals routinely ask and inform pregnant women about alcohol use in pregnancy and its consequences. GPs were included in this survey â&#x20AC;&#x201C; 60% stated that they routinely asked pregnant women about alcohol use and 40% said they informed them about the consequences; 27% of surveyed GPs referred children to confirm a diagnosis of FAS.

What can medical practitioners do? ASK: all women about their alcohol use, using a screening test such as the AUDIT-C: ASSESS: and record the level of exposure to alcohol ADVISE: women wanting to become pregnant or already pregnant, that not drinking alcohol is the safest option. Women who drank alcohol before they knew they were pregnant or during pregnancy should be reassured that the risk to the fetus from low level drinking is likely to be low.

ASSIST: women to abstain from alcohol through support and brief intervention when indicated. ARRANGE: referral to specialist services, as indicated, for women with an alcohol use disorder. Doctors also need to consider prenatal alcohol exposure when assessing children with dysmorphic features, neurodevelopmental or growth concerns, and to refer them for further assessment if indicated. *The umbrella term, FASD, includes fetal alcohol syndrome (FAS), partial FAS (PFAS) and neurodevelopmental disorder-alcohol exposed (ND-AE). FAS is characterised by typical facial features (short-palpebral fissures, thin-upper lip and smooth philtrum), poor fetal and/or postnatal growth and central nervous system anomalies (structural and/or functional); a diagnosis of partial FAS requires some, but not all the characteristic facial features and poor growth is not required. ND-AE diagnosis requires specific neurodevelopmental criteria alone, based on structural anomalies (such as microcephaly), standard neurodevelopmental tests, and the number of domains affected. Diagnosis is ideally done by a multidisciplinary team. O ED. A good resource for FASD in indigenous people is

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News & Views

Strong Spirit Shows Promising Results Evaluations of an awareness-raising campaign for Foetal Alcohol Spectrum Disorder are showing promising signs that women are heeding the no-alcohol message. In 2010, the Drug and Alcohol Office received four years of funding through COAG to develop a suite of Aboriginal FASD prevention initiatives pulled together in the project Strong Spirit Strong Future: Promoting Healthy Women and Pregnancies. Ms Judi Stone from the Drug and Alcohol Office offered these insights. The project aimed to increase Aboriginal peopleâ&#x20AC;&#x2122;s awareness that the safest option for women who were pregnant, planning a pregnancy, or breastfeeding was not to drink alcohol. The project also aimed to increase human service professionalsâ&#x20AC;&#x2122; awareness and increase their capacity to provide culturally secure screening for alcohol use, and conduct brief interventions with Aboriginal women. A television commercial featuring Aboriginal entertainer Mary G, and three complementary radio advertisements aired in September 2011 with repeats being aired in 2012 to 2014. Small grants were provided to organisations to develop and implement localised health promotion activities which supported the â&#x20AC;&#x2DC;no alcohol in pregnancyâ&#x20AC;&#x2122; message. Training was delivered to over 670 human service providers via 36 one-day workshops. Around half the training participants were from non-metropolitan areas, most were female and about half were Aboriginal. The training incorporated culturally secure resources to support service providers in conducting screening and brief interventions. Resources included a screening tool (AUDIT-C) with brief advice; alcohol and breastfeeding fact sheet and booklet for health professionals.

Campaign outcomes Nine out of 10 women recalled the television campaign unprompted, according to the post-campaign evaluation. Nine out of 10 women stated they were aware that no alcohol during pregnancy was the safest choice, and most reported the message was both believable and credible, especially those with a child conceived or born since the campaign started. Three out of four women stated that they now believed that they shouldnâ&#x20AC;&#x2122;t drink alcohol when breastfeeding. Self-reported changes over the life of the campaign indicate that drinking during pregnancy has become more salient with most women reporting increased discussion and less drinking amongst their peers. Intentions regarding future behaviour around alcohol, pregnancy and breastfeeding indicated that over two-thirds of women intended not to drink alcohol while pregnant, and nearly three quarters intended not to drink while breastfeeding. Training was evaluated before the workshop and again three months later. Participants were asked about their confidence in conducting culturally secure screening and brief interventions with Aboriginal women. Results showed a 34%-55% increase in confidence three months after training. For example, understanding of the effects of alcohol during pregnancy increased from 49% before the workshop to 96% three months after; knowledge of culturally secure alcohol and other drugs models increased from 29% to 73%; and their understanding of harm reduction strategies increased from 42% to 97%. For more information contact Judi at O


PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services


by Medical Director Prof John Yovich

Testicular Microlithiasis â&#x20AC;&#x201C; â&#x20AC;&#x153;Stars by Nightâ&#x20AC;? â&#x20AC;Ś a reason for concern? PIVET has encouraged the wider application of male genitourinary ultrasound among the male partners in subfertile settings. With colleagues Anne Jequier and Nevile Phillips, we KDYHGHPRQVWUDWHGDQXPEHURIXQH[SHFWHGĂ&#x20AC;QGLQJVPRVWO\ ZKHUHFOLQLFDOH[DPLQDWLRQIDLOVWRUHYHDODQ\VLJQLĂ&#x20AC;FDQWVLJQV We have recently published on one of these, namely Testicular Microlithiasis in the journal Andrology & Gynecology: Current Research in April 2014. At PIVET we Ă&#x20AC;QGWKLVLQ of men but we are uncertain if this is selectively increased or not, as prevalence has not been reported in Ultrasound image of a testis showing extensive Australia. PLFUROLWKLDVLVWKHSRLQWVRIFDOFLĂ&#x20AC;FDWLRQUHSUHVHQW microliths in the testis, simulating the starry night sky. Several reports from YDULRXVFRXQWULHVVXJJHVWDWRSUHYDOHQFHEXWDQ $PHULFDQ$UP\VWXG\VKRZHGDUDWHRIKLJKHULQ$IULFDQ Americans and increased in association with undescended testes, hydroceles and varicoceles. It is higher with Downs 6\QGURPHDQGUHSRUWHGZLWK0F&XQH$OEULJKW6\QGURPH where cases may also show macro-orchidism. It has a known association with testicular cancer and may be a marker for this condition but was present in only 1 of 7 cases of cancer detected at PIVET. Of interest, it was a prominent feature in the ultrasound of testicular malignancy reported by Urologist Dr Jerard Ghossein in Medical Forum WA last month. The Urology Societies of Australia, UK and USA regard the feature as entirely benign but some North European countries recommend more active management with regular scans, testicular biopsy and some have even proposed therapeutic considerations. +RZHYHULQWKHOLJKWRIDUHFHQWĂ&#x20AC;YH\HDUIROORZXSVWXG\RQ asymptomatic American men with testicular microlithiasis, the concern has been down-graded with such men being HQFRXUDJHGWRVHOIH[DPLQHPRQWKO\DQGUHSRUWWR their GP if a testicular lump develops. PIVET now advises accordingly but also enables clinical and ultrasound review in 2 years at GP discretion.


For ALL appts/queries: T:9422 5400 F: 9382 4576 E: W:



Are WA Vaccines Safe? A lot of vaccinations are given to kids and adults. Major reactions are few, so surveillance has to be watertight and national to pick up early trends. The WA Vaccine Safety Surveillance website ( came into being in 2011, a response to the higher than usual adverse vaccine reactions to CSLâ&#x20AC;&#x2122;s influenza vaccine the year before and the perceived tardiness of health authorities to act. The website takes adverse reaction reports from health professionals and the public, collates and triages where necessary, and hopefully acts as an early warning system should problems recur.

WA health professionals have a statutory requirement to report adverse events following immunisation (AEFIs) to WA Health under Regulation 4 of the Health Regulations 1995. All AEFI reports are forwarded to the Therapeutic Goods Administration (TGA) daily, which can also receive reports directly. The public can report directly to both groups, and the TGA has kept an online Database of Adverse Event Notifications (DAEN) since 2012 (www.tga. Alternatively, a parent/guardian or a vaccinated person, can report an adverse reaction at after registering online or by downloading a two-page reporting pdf, filling out and faxing to WAVSS. First port of call for a report through the WA system is the WAVSS Clinical Nurse at the Rheola Street Central Immunisation Clinic. In assessing reported reactions, she requests medical records and speak to GPs and practice nurses. As well as reporting to the TGA she works with research groups at Telethon Kids and PMH. She discusses cases with the doctors at WAVSS via email and telephone and has a monthly teleconference where specialists from PMH, SCGH and RPH attend. It is hosted by the project officer for WAVSS from the Communicable Diseases Control Directorate (CDCD) at the Health Department. PMH has a monthly Adverse Event Clinic where a parent can get advice from a team of experts around future vaccination, and catchup vaccinations are given.

QVaccination Fridge

CDCD produces monthly reports of AEFIs (adverse events following immunisation) which look at such things as:

'"$54%*%:06,/08 t *O PWFS EPTFTPG/BUJPOBM Immunisation Program (NIP) childhood vaccines were distributed for use in children <5 years in WA. t 3BUFTPG"&'*JODIJMESFOZFBSTQFS   EPTFTWBSJFECFUXFFOBOE  "$*3CZWBDDJOF   t .PTUSFQPSUFE"&'*TBSFGFWFSPSMPDBM reaction â&#x20AC;&#x201C; with a small rate of possible severe reactions, careful review is needed to discern trends. t *O8" "&'*SFQPSUTWBSZCFUXFFOBCPVU  BOEQFSRVBSUFS BOEBSFIJHIFTUJO  UIFNPOUITPG.BSDI.BZ XIJDIDPJODJEFT  XJUIJOGMVFO[BWBDDJOFSPMMPVU.PTUSFQPSUT are by nurses, followed by GPs, then parents.

t UIFOBUVSFPGBOZTFWFSFSFBDUJPOTSFQPSUFE t UIFOVNCFSBOEEFNPHSBQIJDTPGQFPQMF in reports (e.g. childhood vs adult), t XIJDIWBDDJOFTXFSFJOWPMWFEXJUI which AEFIs, t UIFSBUFPG"&'*TQFSWBDDJOFBDDPSEJOH to national ACIR figures, t DPNQBSBUJWFGJHVSFTJOBHFHSPVQT PWFS the last 3-4 years, t UIFUZQFTPGBEWFSTFSFBDUJPOTSFQPSUFE (comparative years), and t WBDDJOBUJPOFSSPST The monthly report is seen by the WAVSS team to assist them review adverse events reported to the system. As such, it contains some historical information so that each month can be compared against baseline information. In short, there is plenty of information to draw relationships for an alert regarding a particular vaccine, whether new to the national immunisation schedule or not. The annual report is circulated beyond the WAVSS team. See: www. au/cproot/5660/2/ WAVSS_2013_Annual_ report.pdf O

By Dr Rob McEvoy QAEFI reports to WAVSS â&#x20AC;&#x201C; month and age group 38



ll o P e

Childhood Vaccination 165 General Practitioners (64% male) took time to give us their opinion on issues to do with childhood vaccination, all in news of late. Thanks.

Herd Immunity

Penalise Parents?

Just over 20% of young kids in WA are unvaccinated for different reasons, with about 2% of parents registered conscientious objectors. As far as you know, what percentage of unvaccinated kids is required before “herd immunity” breaks down and some infectious disease outbreaks are more likely as a result?















ED. First, GP gender did not significantly alter responses. Next, we realise this is a very vexed question, for which “depends” is a good response! Even the experts don’t agree. Dr Chris Blyth has attempted to explain (see below) – natural variations between infecting bugs, the longevity of vaccinations, age at vaccination, previous exposure to ‘natural’ infection, how exposure risk occurs, etc., can all play a part. Herein lies the Catch 22 – we would like to send simple messages to health consumers to vaccinate, yet at higher population vaccination rates, the medical answers may not be simple, and responding simply arms the antagonists.


Should parents who are conscientious objectors to the vaccination of their children still receive the Family Tax Benefit Part A end-of-year supplement of $726?







ED: This punitive measure has been suggested by proponents of mass vaccination campaigns.

Doctor Refusal


Should doctors be able to use ‘public health reasons’ to explain their refusal to co-sign the Conscientious Objector forms of parents who forgo vaccination for their children? Yes






ED. What’s good for the goose is good for the gander, it seems – GPs believe they should be able to apply a right of refusal too. Whether this is for professional, moral, or other reasons is irrelevant. It appears to be more of a case by-case consideration. A bit like pregnancy termination, we guess. It would be a matter of treating differing patient opinions with respect and to refuse openly.

About what proportion of kids must be unvaccinated before “herd immunity” breaks down and infectious outbreaks become more likely? Which infections?

What is herd immunity? Herd immunity most often refers to the protection of non-immune individuals as a result of being surrounded by immune individuals. High levels of immunity make it less likely that a susceptible individual will come into contact with someone who is shedding or colonised with the pathogen, thereby offering indirect protection. Which infections show this herd effect? For herd or indirect effects to be observed, immunity from vaccination or past infection must impact on transmission of infection. Herd effects are observed for many recommended vaccines including measles, mumps, rubella, pertussis, poliomyelitis, varicella, Haemophilus influenza type B, meningococcus and pneumococcus. In fact, much of the impact of childhood vaccines used today result from these indirect effects. At what point are herd effects observed? Even in regions with modest uptake (<50%)


of conjugate Haemophilus influenzae type B vaccination in children, a reduction in disease was observed in unvaccinated children, demonstrating the significant impact of these vaccines on nasopharyngeal colonisation and disease. In Australia and other countries, dramatic changes in pneumococcal disease have been observed in all age groups following introduction of conjugate pneumococcal vaccination in young children. What proportion of kids must be vaccinated to prevent outbreaks? There is an inverse relationship between the herd immunity threshold (the level of immunity required to prevent outbreaks) and basic reproduction number (Ro: the number of secondary cases generated by a typical infectious individual in a randomly mixing susceptible population). In other words, the more infectious the agent, the higher vaccination rates need to be to prevent infection. Measles and pertussis (both

have Ro > 12) require immunity rates to be as high as 95% to Response: A/Prof achieve sufficient Christopher Blyth, herd immunity Infectious Diseases to prevent Paediatrician, PMH. transmission. Less Tel 9340 8606 infectious agents (e.g. rubella, Ro ≈ 6-12; polio, Ro ≈ 5-7) requires lower rates of community immunity (approximately 85%), to prevention transmission. O References: Fine P, Eames K, Heymann DL. “Herd Immunity”: A Rough Guide. Clinical Infectious Diseases, 2011, 52 (7): 911-916. doi: 10.1093/cid/cir007 Plans-Rubio P. Evaluation of the establishment of herd immunity in the population by means of serological surveys and vaccination coverage. Hum Vaccin Immunother. 2012 Feb;8(2):184-8. doi: 10.4161/hv.18444.



Rotavirus disease R

otavirus has long topped the charts as the leading cause of severe gastroenteritis in children. Without vaccination, every child will get rotavirus disease by its 5th birthday, and many children more than once. Although most children recover over a few days, about one in five will need to see their GP, and one in 10 will be hospitalised. Prior to the rotavirus vaccine, rotavirus disease led to at least 115,000 GP visits, 22,000 emergency department visits and 10,000 hospitalisations every year in Australia.

Since introducing rotavirus vaccines into Australia in 2007 we have seen an enormous drop in the number of children suffering from rotavirus. Hospitalisations alone have declined 70%, with at least 7,000 fewer hospitalisations of young children a year. However some parents remain hesitant and are uncertain about possible risks of vaccination.

Intussusception One specific concern is the link between rotavirus vaccines and intussusception. This was a rare side effect of a now withdrawn rotavirus vaccine, Rotashieldâ&#x201E;˘. Trials of both Rotateqâ&#x201E;˘ and Rotarixâ&#x201E;˘ showed that these vaccines were going to be much less likely to cause intussusception. Wide-scale use of these vaccines has given us more specific data. In the first week after vaccination, approximately 7

to 10 extra cases of intussusception occur for every 100,000 infants vaccinated. In Australia, this equates to an extra 14 cases every year as a result of the vaccine â&#x20AC;&#x201C; far fewer than the 7,000 or more admissions for gastroenteritis averted. We still donâ&#x20AC;&#x2122;t know if these cases are truly â&#x20AC;&#x2DC;extraâ&#x20AC;&#x2122; cases or simply earlier presentations of infants that would have gone on to get intussusception at some point in the future, regardless, but the very small numbers of cases of intussusception allow us to reassure parents as they weigh up the benefits versus the risks from childhood vaccination in Australia.

Challenges still remain Each year, rotavirus still accounts for around half a million deaths in children under five, worldwide, with over 85% of deaths occurring in developing countries. Indigenous infants in Australia also still suffer from high rates of rotavirus. After three years of the vaccination program, rotavirus hospitalisations dropped by 29% among Indigenous infants compared to 65% for all Australian infants. Unlike for nonIndigenous children, no significant decline has been observed among Indigenous children aged 1-4 years old. Compared with >90% effectiveness among other children in Australia, the United States and Europe, rotavirus vaccination was 50-60% effective for preventing severe rotavirus among Indigenous children in the Northern

By Dr Claire Waddington, 1PTUEPDUPSBM'FMMPX Telethon Kids Institute

QTransmission electron micrograph of intact rotavirus particles.

Territory and in infants from Asia and Africa. Current research efforts are directed toward finding strategies which use these vaccines more effectively, as well as developing alternative rotavirus vaccines. In the interim, improving vaccine coverage will have an impact. O ED. The author acknowledges the assistance of Dr Tom Snelling, Scientific Director Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute.

Competing interests: Dr Snelling was an investigator on a study part funded by GSK, manufacturer of Rotarix TM

QChild being vaccinated




Improving Vaccination Surveillance By Dr Alan Leeb, GP, Principal of Illawarra Medical Centre


hen adverse events led to the 2010 seasonal trivalent influenza vaccine in children being suspended, this was a huge surprise to us at the Illawarra Medical Centre â&#x20AC;&#x201C; we believed we were in touch with our patients yet had no idea of the extent of the problem.

In response, we surveyed the parents of all 337 children immunised with influenza vaccine over the preceding two months. Surprisingly, 38% had suffered an adverse event following immunisation (AEFI) â&#x20AC;&#x201C; 20% had significant febrile reactions, three had pyrexial convulsions and eight were admitted to hospital. We then surveyed adults receiving the same vaccine and noted a 31% adverse event rate. Noteworthy, was the 10-day lag from suspicion of an AEFI to suspension of the program. A single brand of vaccine (Fluvax by CSL) was only implicated some weeks later.

Dr Sanjay Nadkarni Endovascular Specialist MBBS, FRANZCR, FRCR, FCP, MRCP, DA

Dr Sanjay Nadkarni wishes to inform that Endovascular WA has moved to new purpose built facilities for outpatient treatment of varicose veins. 221 Stirling Highway, Claremont 6010.

Australiaâ&#x20AC;&#x2122;s passive surveillance of adverse reactions relies on health providers and the public reporting suspected reactions to state or federal health authorities. There is no active surveillance of scheduled vaccinations.

Services provided include:

Surveillance is particularly important for seasonal influenza vaccines because they are released without clinical data to demonstrate safety â&#x20AC;&#x201C; safety of new vaccine strains is assumed, based on past experience.


General practices will give over 70% of all vaccinations and they have a duty of care to monitor for any adverse events. This is core general practice. Following this 2010 incident I have been working with software developer Ian Peters to come up with software that can actively monitor adverse events following any immunisation. SmartVaxTM uses SMS technology and existing practice software to message those who have been vaccinated (or their parents), asking if they reacted. Almost all patients receiving vaccination have mobile phones. Those who respond â&#x20AC;&#x2DC;Yesâ&#x20AC;&#x2122; are pointed to an online smartphone survey or we call them. High response rates are pleasing (e.g. > 85% for children, and >75% over 65 years), with 75% overall response to 7000 SMS messages sent since 2011. Responses are also prompt â&#x20AC;&#x201C; 80% within two hours (and we found that AEFI rates were similar in SMS non-responders.) This method allows a near real-time check on the reactivity of seasonal influenza vaccines, by brand, in both adults and children. And when the National Immunisation Program schedule was changed last year to include two combination vaccines at 12 months and 18 months of age, there was no sign of increased reactivity. This is most reassuring for doctors and parents, particularly the low reactivity of the MMR and MMRV vaccines, which had suffered bad publicity. We actively share information with our patients who respond positively â&#x20AC;&#x201C; they value our interest in any adverse reaction and it further reinforces the safety of immunisation. We are now working to enrol other practices to become part of a network for active surveillance. The Communicable Disease Control Directorate of the WA Health Department has been most supportive and we plan to share de-identified data as an early warning system for adverse reactions. O






All correspondence to PO Box 473, Claremont 6910 Phone: 9284 2900 Fax: 9384 5725 Mobile: 0410 407 044 Email: Parking available - Easy access Ramp access for disabled. Dr NadkarniĂĽREMAINSĂĽDIRECTORĂĽOFĂĽ)MAGINGĂĽ#ENTRALĂĽ ANDĂĽ3TERLINGĂĽ2ADIOLOGY ĂĽANDĂĽCONTINUESĂĽTOĂĽWORKĂĽASĂĽANĂĽ INTERVENTIONALĂĽRADIOLOGISTĂĽATĂĽ3IRĂĽ#HARLESĂĽ'AIRDNERĂĽ(OSPITAL Dr Nadkarniâ&#x20AC;&#x2122;s vision is to provide a comprehensive, minimally invasive vascular and interventional radiology service.




PMH Referral for thyroid disease

Clin A/Prof Aris Siafarikas. Dept Endocrinology & Diabetes, PMH. Tel 9340 8090


lmost 30% of referrals to the Dept of Endocrinology at PMH are related to thyroid conditions. Here we summarise helpful referral criteria and note that all referrals should include clinical notes, lab results and historical data on height and weight, if available.

Autoimmune thyroiditis/ hypothyroidism Findings

Pre-referral workup

Elevated TSH

TSH, free T4

Low free T4

Anti-Thyroglobulin Antibody

Clinical symptoms suggestive of hypothyroidism

Anti-TPO Antibody

Facts to remember t "MPQFDJBPSIBJSMPTTJOUIFTFUUJOHPGOPSNBMUIZSPJEGVODUJPOUFTUT (TFTs) does not indicate an endocrinopathy t $IJMESFOXJUI5SJTPNZPÄ&#x2122;FOIBWFBNJMEMZFMFWBUFE54) (hyperthyrotropinaemia) with normal free T4. Generally, referral is not needed unless there are positive thyroid antibodies, or rising TSH >10 mU/mL. t $IJMESFOXJUIQPTJUJWFUIZSPJEBOUJCPEJFTCVUOPSNBM5'5TNBZ never go on to develop hypothyroidism. The TFTs just need to be followed periodically and if abnormal, referral is appropriate.

If TSH is abnormal but <10 mU/mL and the free T4 is normal: Obtain thyroid antibodies and repeat TSH, free T4 in 2-3 months. Slight elevations in TSH (5-10 mU/ml) are common in obese children secondary to metabolic syndrome and obesity. No endocrine referral is indicated unless the thyroid antibodies are positive. If TSH rising to levels >10 mU/mL please refer

Autoimmune (Graveâ&#x20AC;&#x2122;s Disease)/ hyperthyroidism Findings

Pre-referral workup

TSH < 0.1 mU/ml

Current TSH, free T4, free T3

Elevated free T4, T3

Thyroid receptor antibody (TRAb)

Clinical symptoms suggestive of hyperthyroidism

Anti-Thyroglobulin Antibody Anti-TPO Antibody

Goitre Findings

Pre-referral workup

Asymmetric gland Increasing size or causing discomfort, palpable nodule

TSH, free T4 Anti-Thyroglobulin Antibody Anti-TPO Antibody Obtain thyroid ultrasound

Thyroid nodules There is a rising incidence of thyroid nodules in the paediatric population. Small nodules (<1.0 cm) with thyroid antibodies are less concerning. Solitary nodules or nodules >1.0 cm require an urgent referral to rule out thyroid cancer. A fine needle aspiration may be indicated. We suggest these baseline tests: TSH, free T4, anti-thyroglobulin and anti-TPO antibodies and a thyroid ultrasound. O

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Investigation and follow-up of UTI in children It is no longer common practice to extensively investigate all children after their first febrile UTI. The belief that vesicoureteral reflux (VUR) predisposes to recurrent UTI which in turn leads to renal scarring led to guidelines aimed at identifying VUR and preventing recurrent UTI and associated scarring. This involved costly and invasive diagnostic procedures, prophylactic antibiotics and long term follow-up. In 2007, the National Institute for Health and Clinical Excellence (NICE) published evidence-based guidelines that promoted a less aggressive approach to management of UTI in children. Since then, the American Academy of Paediatrics has updated their guidelines, other papers have favoured less radiological procedures and antibiotic prophylaxis and Australian doctors have responded appropriately. This response has included updated guidelines at Princess Margaret Hospital (PMH).

PMH recommendations Admit a child of any age who is acutely unwell with a febrile UTI; arrange ultrasound in all children aged less than 3 years who have had a febrile UTI. Patients with a suspected first UTI, not admitted, are followed-up by their GP within 2-3 days of commencing antibiotics. If UTI is confirmed, children less than 6 months old have both a renal tract ultrasound and follow-up at PMH; those over 6 months old should get an ultrasound through their GP.

TAKE HOME POINTS t 3FOBMUSBDUVMUSBTPVOEJTOPXUIF investigation of first choice, particularly if experienced sonographers are available. A MCUG is not recommended in all children following their first UTI. t A1SPPGPGDVSFVSJOFDVMUVSFTBSFOP longer recommended if the organism is susceptible to antibiotics given and there is clinical improvement. t 5IFGJSTUVODPNQMJDBUFE65*EPFTOPU require follow up. However, there should be a low threshold for suspicion with future febrile illnesses;  SFDVSXJUIJONPOUIT Risk of recurrence increases with each subsequent infection. t "OUJCJPUJDQSPQIZMBYJT UPQSFWFOU65* recurrence, is only beneficial in  (SBEFPSIJHIFS763 BOEPWFSVTFPG prophylactic antibiotics will increase rates of antibiotic resistance).

<6/12 age

>6/12 age

Ultrasound scan during acute infection

No, if responding No to treatment

Ultrasound is non-invasive, avoids radiation, and technological improvements mean that many renal abnormalities are detected antenatally. An MCUG assesses renal tract anatomy during voiding to detect renal tract obstruction, anatomical anomalies and VUR. Detection of higher grades of reflux is important, for which NICE advocates a more selective imaging of children with atypical UTI features. As an intraurethral catheter and radiation are involved, a MCUG on all children after their first UTI is no longer recommended. A DMSA scan assesses renal function through differential uptake of radioisotope in the kidney; an IV cannula and radiation are involved. The long term prognosis of renal scarring found on DMSA scan is unclear; some resolve over time, particularly in otherwise normal kidneys. With no literature consensus on monitoring renal scarring, the conservative recommendation is follow-up with annual blood pressure check.

PMH experience Children aged over 3 years only need renal tract imaging (i.e. a renal ultrasound) if the UTI is recurrent or atypical, that is (NICE classification), if associated with a severe illness, it fails to respond to appropriate antibiotic after 48 hours, involves nonEscherichia coli organisms, causes septicaemia or there is also a raised serum creatinine.

Imaging Imaging following UTI includes ultrasonography, micturating cystourethrogram (MCUG) and dimercaptosuccinic acid (DMSA) scan.

Typical Infections Intervention

By Dr Aggie Judkins, General Paediatrician. Tel 6162 1615

Atypical Infections <6/12 age

6/12 to 3yrs >3yrs




Ultrasound scan Yes within 6 weeks of infection





DMSA scan 4-6 months after acute infection







Consider if ultra- No sound abnormal




Antibiotic prophylaxis





A recent audit at PMH found that renal tract US by the PMH radiology service effectively excluded high grade (4 or 5) VUR and posterior urethral valves, decreasing the need for MCUG. A separate audit showed US excluded significant abnormalities found on DMSA, making repeat US an acceptable alternative to DMSA for monitoring renal scarring. More studies are required before extrapolating these findings to the general population. Amongst children admitted to PMH with a first UTI, Escherichia coli was the most common pathogen isolated (85%), followed by Klebsiella (7%), Proteus (2.5%), and Enterobacter species. (1.5%) The remainder were attributed to Pseudomonas, Citrobacter, Acinetobacter, Staphylococcus and Streptococcus species. Fifty one percent of the E. coli isolates were resistant to amoxicillin, 7.5% were resistant to amoxicillin/clavulanic acid and 19.5% resistant to trimethroprim. The majority were sensitive to third generation cephalosporins cefotaxime/ceftriaxone (99%), gentamicin (98%), nitrofurantoin (99%) and sulfamethoxazole (67.5%). Further Reading 1. National Institute for Health and Clinical Excellence.


Urinary tract infection in children. London: NICE, 2007. 2. American Academy of Pediatrics. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatr 2011;128:595â&#x20AC;&#x201C;610.

QTable 1. NICE Guidelines for UTI Management


References available on request

O 43

Real Estate

Brea t hing into Life Perth Is our love affair with the quarter acre block beginning to wane? As the urban sprawl becomes unsustainable eyes are turning to apartment living.

Perthâ&#x20AC;&#x2122;s urban sprawl has hurtled past the concrete and bitumen of Los Angeles and Tokyo combined. The toes of our metropolitan footprint nudge Yanchep and the heel sits ďŹ rmly in Mandurah. Medical Forum spoke with architect Colin Beattie from Curtin University and four representatives from the property sector to explore the concept of higher density living.

Colin Beattie

i.Z GPDVT JT PO A%FDBSCPOJTJOH 6SCBO %FWFMPQNFOU XIJDI JT QBSU PG B XJEFS research project run by the Curtin University Sustainability Policy (CUSP) Institute. I grad uated from Aberdeen in Scotland, made models of undersea mining equipment and XPSLFE JO -POEPO CFGPSF B NJEMJGF DSJTJT brought me to Perth,â&#x20AC;? Colin says. i* NFU 1FUFS /FXNBO <"VHVTU > BOE found there wasnâ&#x20AC;&#x2122;t much happening in the way of environmentally sustainable design. 44

There was little incentive for a developer to become involved in a more energy efficient medium to high density project.â&#x20AC;? The Australian dream of the quarter acre CMPDL  TXFFQJOH MBXOT BOE B UXPDBS garage is completely unsustainable, sug gests Colin.

Housing costs skyrocket â&#x20AC;&#x153;Perth has one of the lowest urban densi ties in the world yet the preferred model is still the single dwelling. And, added to that, Australia has the unenviable ranking of the UIJSEIJHIFTU IPVTJOH DPTUT JO UIF XPSME The city has grown massively in the last few years but it remains relatively unaffordable for people on average incomes.â&#x20AC;? â&#x20AC;&#x153;Perth is dominated by concrete, masonry and brick block which is expensive and inef ficient. Weâ&#x20AC;&#x2122;re doing research into higher density modular construction and the WA %FQBSUNFOU PG )PVTJOH JT MPPLJOH BU CVJME JOHVQUPVOJUTCBTFEPOUIJTNPEFMw Colin has a vision of a modern city with a NVDI NPSF BQQSPQSJBUF NJY PG NFEJVN UPIJHI EFOTJUZ MJWJOH DPNQMFNFOUFE CZ intelligent mobility options. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s well known that good public transport networks coupled with cycle paths have positive health outcomes. The expense of owning a car is only going in one direction, the least wealthy are being pushed to the

outer suburbs and weâ&#x20AC;&#x2122;re imposing costs on those who are least able to afford them.â&#x20AC;? â&#x20AC;&#x153;We need to increase the density of the city. A younger demographic might be more JODMJOFEUPQJDLVQPOUIFTFNVMUJVOJUEFWFM opments if they were more affordable. Weâ&#x20AC;&#x2122;re not advocating doing away with sub urban development, merely suggesting a shift towards a better balance of occupancy with lower energy consumption.â&#x20AC;?

Dealing with political resistance An undercurrent of political resistance to higher density living is not unusual and often linked with perceived social problems. Colin argues that thereâ&#x20AC;&#x2122;s plenty of scope for artistically creative built environments that address this issue. â&#x20AC;&#x153;It all comes down to good design, the actu al architecture itself. Sydney and Melbourne have some great examples and this vision has been embraced overseas. Perth has a

Itâ&#x20AC;&#x2122;s well known that good public transport networks coupled with cycle paths have positive health outcomes â&#x20AC;&#x201C; Colin Beattie medicalforum

Real Estate

to live in a modern city. Well located and high quality apartment living is an increas ingly desirable choice for many people in Perth. Itâ&#x20AC;&#x2122;s increasingly popular for medical investors to invest through their SMSF and apartments have the potential to offer a good return.â&#x20AC;?


kaleidoscope of wonderful design opportu nities,â&#x20AC;? Colin said.

Damian Collins

â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s been a recent rezoning amendment in Fremantle allowing increased residential development. Iâ&#x20AC;&#x2122;d like to see more people liv ing there and utilising the attractions of the main hub. It shouldnâ&#x20AC;&#x2122;t just be somewhere you go to buy a tourist souvenir.â&#x20AC;?

Damian Collins  .BOBHJOH %JSFDUPS PG Momentum Wealth, offers some specific advice and sings the praises of Melbourneâ&#x20AC;&#x2122;s urban landscape. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s crucial to look at supply/demand funda mentals. We rarely recommend apartments in larger complexes because they are often JO BSFBT PG MPOHUFSN TVQQMZ BOE JU EPFTOU take long to flood the market. Our research suggests that an investor is better off buying something with an inherent land DPNQPOFOUWBMVF QBSUJDVMBSMZXJUIJOBLN SBEJVTPGUIF$#%w

Nick Allingame

1JOEBOT %JSFDUPS %FWFMPQNFOU .BOBHFS  Nick Allingame suggests that the local real estate market has matured in the last five years and the move to higher density living presents opportunities for astute investors.

â&#x20AC;&#x153;I would hope that we start to resemble Melbourne with a vibrant city and suburbs. Not everyone wants to live in a house on a suburban block. Planning schemes and local

Travelling time a deal maker â&#x20AC;&#x153;Time spent travelling to and from work is an important factor in deciding where

Continued P46


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Real Estate

Continued from P45 councils need to work together to provide housing choice.â&#x20AC;? The ink is barely dry on MLG Realtyâ&#x20AC;&#x2122;s Inner City Apartment Market Report (Autumn   BOE JUT %JSFDUPS  Ms Cindy Lee, sounds a cautiously optimistic note and looks forward to a vibrant City of Perth.

Ms Cindy Lee

Moves in the market i5IFSF BSF QPDLFUT PG TIPSUUFSN PWFSTVQ QMZ QBSUJDVMBSMZBSPVOEUIF$#%XJUIOFBSMZ  OFX VOJUT DPNJOH PO UP UIF NBSLFU This will mean a fall in rental yields but it TIPVME CPVODF CBDL GSPN 'FCSVBSZ  onwards. It wouldnâ&#x20AC;&#x2122;t be a bad idea to lock in existing tenants or even offer a slight rental discount.â&#x20AC;? â&#x20AC;&#x153;The downturn in the resource sector, XIJDI JT  PG UIF $#% NBSLFU  IBE IBE an impact. On the positive side, the residen UJBM HSPTT SFUVSOT PG  XFSF DPNQMFUFMZ unsustainable and weâ&#x20AC;&#x2122;re seeing local pro fessionals renting and living in the city. :JFMET BSF BSPVOE  XIJDI JT QSFUUZ good.â&#x20AC;? â&#x20AC;&#x153;Speaking as a female the security of an apartment is wonderful. Itâ&#x20AC;&#x2122;s great to be able UP MPDL BOE EFBECPMU ZPVS EPPS BOE LOPX that the building is secure.â&#x20AC;?

RVBSUFSBDSFCMPDLKVTUJTOUTVTUBJOBCMFw â&#x20AC;&#x153;My advice to potential buyers is look at the â&#x20AC;&#x2DC;walk scoreâ&#x20AC;&#x2122;. Whatâ&#x20AC;&#x2122;s within walking dis tance? Is it close to transport nodes and an entertainment precinct? Iâ&#x20AC;&#x2122;d shy away from the large apartment towers. There are a GBS IJHIFS OVNCFS PG PXOFSPDDVQJFST JO smaller complexes and thereâ&#x20AC;&#x2122;s an emotional component linked with ownership.â&#x20AC;? O

Sven Robertson

makes the point that thereâ&#x20AC;&#x2122;s an element of TFMGSFHVMBUJPO XIFO JU DPNFT UP UIF RVFT tion of oversupply. He also argues that there are two distinct markets within the apart ment sector.

By Mr Peter McClelland


Influence of first-home buyers

â&#x20AC;&#x153;The vision I have for Perth can be summed up in one word â&#x20AC;&#x201C; Sydney! Elizabeth Quay will see the integration of the waterfront XJUIUIFDJUZBOEUIF$#%XJMMCFBUSVFEFT tination for work and play.â&#x20AC;?

â&#x20AC;&#x153;Because of financing requirements you IBWF UP QSFTFMM NPTU PG UIF TQBDF CFGPSF construction commences. Perth has the lowest level of apartment approvals in Australia yet more and more people want UPMJWFJOUIBUOFBSDJUZCFMU5IFSFTCFFOB QBSBEJHN TIJGU BNPOHTU GJSTUIPNF CVZFST  they donâ&#x20AC;&#x2122;t want to live in Alkimos and spend NJOVUFTESJWJOHUPXPSLw

Sven Robertson from Psaros Realty

â&#x20AC;&#x153;Once a city gets past a critical mass the


South Perthâ&#x20AC;&#x2122;s mo ost sttrikking riv verssid de landmark. Onee Ri On O Richardson ichardson h d iiss a prem premium miiu um m 13 sstorey tto ore rey y ap apar apartment artm ttmen entt complex with Swan River, Perth City and Park views. LABOUCHERE ROAD ME ND SS TR EE T







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Wine Review

SouthernGem A Great

2011 â&#x20AC;&#x2DC;Book Endsâ&#x20AC;&#x2122; Mt Barker Cabernet Sauvignon These wines represent some of the best value for money that I have seen in the market and is particularly evident in the Book Ends Cab Sav. This wine is from UIFJSUPQGMJHIUA4JOHMF7JOFZBSE4FSJFT XIJDIJTQSPEVDFEGSPNUIFCFTUGSVJU from the most mature vineyards. It displays a glistening garnet red colour, and enticing lively concentrated fruit aromas â&#x20AC;&#x201C; varietal Cab Sav at its best, showing cassis, some stewed rhubarb, and wonderful cedary oak. You know you are going to get something special on the palate, and indeed you do. There are concentrated long and lingering flavours of blackberry with a touch of menthol. The tannins are fine, firm and grippy, the acid giving a structural backbone. Eighteen months maturation in quality French oak has resulted in wonderful integration. I try to avoid international comparisons, but cannot help myself from comparing this wine to classified Bordeaux â&#x20AC;&#x201C; but at a fraction of the price. It ESJOLTXFMMOPX CVUXJMMHPGPSNBOZZFBST%FGJOJUFMZXPSUITPVSDJOHUIJTPOF

Dr Craig Drummond, Master of Wine

4JODFJUTCFHJOOJOHTJO 8FTU Cape Howe Wines has been an immense success. Local winemaker Brendan Smith originally set up the venture as a contract winemaking facility for local growers. Then in 2000, wines were released under the West Cape Howe label. After seven years at the helm Brendan sold the business to a partnership, and since then there has been continued formidable growth and success. This is of no surprise to me, as two of the partners [with whom I had involvement in my Great Southern years] are really talented and driven locals â&#x20AC;&#x201C; Gavin Berry, previously winemaker at Plantagenet Wines, and viticulturist Rob Quenby. .VDI PG UIF GSVJU DPNFT GSPN UIFJS IB Mt Barker Lansdale vineyard but they also source from across the Great Southern. This has to be a strength given the diversity of terroir, and spectrum of grape varieties across this immense region, which includes UIF TVCSFHJPOT PG .U #BSLFS  'SBOLMBOE  1PSPOHVSVQ  "MCBOZ BOE %FONBSL 5IJT USBOTMBUFT UP XFMM PWFS IB PG BWBJMBCMF vineyard. " GVSUIFS DPVQ XBT UIF QVSDIBTF JO  of the large Langton vineyard and winery <QSFWJPVTMZ (PVOESFZ 8JOFT> XIJDI NFBOU PQFSBUJPOT NPWJOH GSPN %FONBSL UP .U Barker, which I see as the focal point of this large wine region. West Cape Howe wines are widely distribut ed in the retail market, and can be purchased on Not surprisingly I note that a few of their wines have sold out till new season wines are available.


The next two wines are from the â&#x20AC;&#x2DC;Regional Rangeâ&#x20AC;&#x2122; â&#x20AC;&#x201C; Estate wines made with minimal intervention to achieve varietal ďŹ&#x201A;avour and regional expression. 2013 â&#x20AC;&#x2DC;Two Peepsâ&#x20AC;&#x2122; Albany Sauvignon Blanc Semillon This wine has undergone partial fermentation in oak, a technique that results in more texture, weight and complexity than seen when these varieties are vinified in OFVUSBMWFTTFMT)FODFUIFXJOFTIPXTNJETUSBXDPMPVS5IFBSPNBTBSFPGDJUSVT and tropical fruits. On the palate are flavours of lemon curd and ripe pineapple, with some background dried herbs. It shows the texture as expected, but bound tightly together by the clean acid of Sav Blanc. There are vanilla nuances from the oak exposure. This wine is rather delicious, and winemaking influence results in good compatability with food, and a further few years longevity. 2012 Frankland â&#x20AC;&#x2DC;Hannahâ&#x20AC;&#x2122;s Hillâ&#x20AC;&#x2122; Cabernet Merlot 5IJTIBTBWJCSBOUCSJDLSFEDPMPVS XJUITVCUMFGSVJUBOETQJDFPOUIFOPTF followed by rich, ripe flavours of redcurrant, mulberry and blackberry. There is a slight warmth on palate from alcohol, and tannins are firm and savoury. It relies on fruit ripeness and concentration with oak only subtly in the background. This is an honest, enjoyable wine for everyday consumption, and will also give a few more years.

WIN a Doctor's Dozen! Who is the current winemaker at West Cape Howe? Answer:


ENTER HERE!... or you can enter online at! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, August 31, 2014. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.



E-mail: ......................................................................................................... Contact Tel:


Please send more information on West Cape Howeâ&#x20AC;&#x2122;s offers for Medical Forum readers.



Laugh Lines

Geek is Good By Ms Wendy Wardell How is it that we bring into our airconditioned homes every electronic diversion in the Harvey Norman catalogue and then wonder why the kids arenâ&#x20AC;&#x2122;t outside entertaining themselves with an inďŹ&#x201A;ated bladder in 38 degrees, wearing four layers of UV-resistant clothing? At the risk of causing rioting in the streets (once the footy is over) why would we want our kids to aspire to be sports people any way? At the elite level they come across BT PWFSJOEVMHFE  OBSDJTTJTUJD BOE PGUFO unpleasant people. What values do team sports teach them PUIFSUIBOUIBUPGBXFMMBJNFEFMCPX JOWB sive index finger or a cheeky chomp when the refâ&#x20AC;&#x2122;s looking the other way? If sport cre ates such fine upstanding role models for kids to aspire to, someone please explain Sam Newman to me. The main message as far as I can tell is that if you become a sporting superstar you get to marry a human coat hanger. I bet those unions provide some deep, incisive EJOOFS UBCMF DPOWFSTBUJPOT  ZFBST EPXO the track. Social changes always fuel concerns about UIFOFYUHFOFSBUJPO/PEPVCUUI$FOUVSZ health advocates were worried that seven year olds were getting too fat to get up DIJNOFZT BOE CZ UIF T  IBSEMZ BOZ ZFBSPMETLOFXIPXUPIJUDIVQBIPSTF and buggy.

funnyside e QQDisorder in the Court The following quotes were taken from Electronic Medical Records dictated by physicians. They appeared in a column XSJUUFOCZ3JDIBSE-FEFSFS 1I% GPSUIF Journal of Court Reporting.  4IF IBT IBE OP SJHPST PS TIBLJOH DIJMMT  but her husband states she was very hot in bed last night. 5IFQBUJFOUIBTOPQBTUIJTUPSZPGTVJDJEFT  5IFQBUJFOUSFGVTFEBOBVUPQTZ  5IFQBUJFOUTUBUFTUIFSFJTBCVSOJOHQBJO in his penis which goes to his feet. 5. She slipped on the ice and apparently her legs went in separate directions in early %FDFNCFS 50

Humourist Wendy Wardell muses on what wonders our children could become if they werenâ&#x20AC;&#x2122;t pushed into playing kidsâ&#x20AC;&#x2122; sport. The world is the oyster of todayâ&#x20AC;&#x2122;s teen aged Sofa Loafer. We should learn to get over that slightly zombiefied expression and delve a bit deeper. Try visiting Supernova â&#x20AC;&#x201C; an annual event UIBUTCFFODBMMFEUIF(FFLT%BZ0VU5IJT is completely unfair as itâ&#x20AC;&#x2122;s actually run over two days. Everyoneâ&#x20AC;&#x2122;s dressed up as their favourite character â&#x20AC;&#x201C; and itâ&#x20AC;&#x2122;s pure escapist GVO 5IFSF JT OP KVEHFNFOU BOE OP HSPH fuelled hostility even when someone gets Coke spilled on their best Wookie costume.

the budding scientist who never got the chance to experiment on his sister because he always had to get up early for rowing? Bill Gatesâ&#x20AC;&#x2122; parents knew he was never going to make it as a basketballer, and Nelson Mandela didnâ&#x20AC;&#x2122;t just channel his unhappiness at the Apartheid regime into B NFBO TQJOCPXMJOH EFMJWFSZ +VTU UIJOL about it, had other parents focused on their kidsâ&#x20AC;&#x2122; latent talent for anything else whatso ever, Australia might even have been spared Warwick Capper. O

Here, kids of all ages share a common love of fantasy and imagination, queuing to get photos with their favourite actors and authors, who make a mint out of it. Sure, some of these kids may look a bit pasty and carry more weight than is maybe ideal. That can easily be remedied by par ents making them walk to the shops to get their own pizza and chips. Itâ&#x20AC;&#x2122;s still physically and mentally healthier than an VOEFS GPPUZ HBNF XIFSF your kid could get beaten up NJENBUDI CZ BO PQQPTJUJPO playerâ&#x20AC;&#x2122;s grandmother. What talents have been lost to soci ety through its obsession with sport? The hands of a potential con cert pianist that have instead been crushed inside boxing gloves or

 1BUJFOUXBTSFMFBTFEUPPVUQBUJFOUEFQBSU ment without dressing. I have suggested that he loosen his pants before standing, and then, when he stands with the help of his wife, they should fall to the floor.


 )FBMUIZ BQQFBSJOH EFDSFQJU ZFBSPME male, mentally alert but forgetful.


 #Z UIF UJNF IF XBT BENJUUFE  IJT SBQJE heart had stopped, and he was feeling better.

5IF QBUJFOU JT UFBSGVM BOE DSZJOH DPO stantly. She also appears to be depressed.

 1BUJFOU IBT MFGU IJT XIJUF CMPPE DFMMT BU another hospital. 5IF QBUJFOU FYQFSJFODFE TVEEFO POTFU of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room. 0OUIFTFDPOEEBZUIFLOFFXBTCFUUFS and on the third day it had completely disap peared.




Concert Drama


Vietnam Letters from young conscripts and regular army personnel who served in Vietnam form the basis of a new production that explores the tensions of the time.

As Australia edges closer to the centenary of the Gallipoli landing next year, expect to see a lot more theatrical re-imaginings of our nation at war. Next month a â&#x20AC;&#x2DC;concert dramaâ&#x20AC;&#x2122; that explores the impact of the Vietnam War on those who were sent and those left behind opens in Perth. Rolling Thunder Vietnam is the brain child of writer Bryce Hallett, who has used scores of interviews with veterans and their part ners, plus their letters from the front to DSFBUFBTOBQTIPUPG"VTUSBMJBJOUIFT BOE T #FUXFFO UIF NPOPMPHVFT BSF iconic songs of the era by rockers such BT 4UFQQFOXPMG  +PF $PDLFS  $SFFEFODF Clearwater Revival and Billy Thorpe. The music did so much to define the social tur moil and with such searing clarity. Bryce said the veteransâ&#x20AC;&#x2122; letters also revealed the tensions of a personal level.

Tensions of the time â&#x20AC;&#x153;They tell of the strained and loving rela tionships, the danger of combat, the rise PG UIF BOUJXBS QSPUFTU NPWFNFOU BOE UIF bittersweet homecoming. They are deeply personal stories, so I wanted the monologues between songs to be truthful and spare.â&#x20AC;? i5IF 7JFUOBN 8BS XBT UIF XPSMET GJSTU televised war. More than any other conflict


it produced some of the most popular and FOEVSJOHTPOHTPGUIFUIDFOUVSZ.PTUPG UIF TPOHT JO UIF TIPX BSF FTTFOUJBMMZ BOUJ war protest songs that brilliantly convey the rhythm, spirit and mood of the times. Many are epic in nature and the directness of the storytelling serves to bring a raw intimacy to the music.â&#x20AC;? 'PS ZFBSPME TJOHFSBDUPS ,JNCFSMFZ Hodgson (pictured above), this is her first major production since her graduation from the Brisbane Conservatorium of Music last year. While she is too young to have experienced the volatility of the era, she told Medical Forum that she had been singing some of the songs since she was a young girl because her mother loved them. â&#x20AC;&#x153;I had no idea where they came from or what they were about but now, with this production, and reading through the soldiersâ&#x20AC;&#x2122; letters and the interviews Bryce conducted has given me a new insight into XIBUXFOUPOJO"VTUSBMJBZFBSTBHPw

In their own words â&#x20AC;&#x153;These are authentic voices. Most of the dialogue is what the veterans told Bryce. The stories are peopleâ&#x20AC;&#x2122;s actual experiences.â&#x20AC;? ,JNCFSMFZ QMBZT 4BSBI  B DPVOUSZ HJSM XIP JT FOHBHFE UP +PIOOZ  XIP IBT CFFO DPO scripted. Their letters reveal the worsening DPOEJUJPOT JO 7JFUOBN BOE UIF DIBOHJOH

attitudes to the war back home. Sarah gets caught up with the protest movement and is torn between her loyalty to her fiancĂŠ and the politics of peace. â&#x20AC;&#x153;I only graduated from uni at the end of  TP CFJOH JOWPMWFE JO TPNFUIJOH MJLF this so early in my career is an absolute honour. To be a part of the creative process from the start, and seeing your character grow and develop and having a role in that JTSFBMMZDPPM w,JNCFSMFZTBJE And she scores some pretty big songs to boot â&#x20AC;&#x201C; for those who remember, try The Letter, Nowhere to Run and Killing Me Softly. â&#x20AC;&#x153;Theyâ&#x20AC;&#x2122;re really good songs and our musical director Chong Lim has assembled an awe some rock nâ&#x20AC;&#x2122;roll band. It will be a full on rock concert with heart.â&#x20AC;? Rolling Thunder Vietnam will open in Brisbane this month then heads on a national tour of the major cities, and in Perth for just three EBZTPO4FQUFNCFS BOE O

By Ms Jan Hallam




Amazing physical feats are delivered in a sumptuous and theatrical format taking the Cirque concept to new heights.

The extraordinary success of Cirque Du Soleil has created an array of entertaining spin-offs â&#x20AC;&#x201C; Australian producer Tim Lawsonâ&#x20AC;&#x2122;s Le Noir an exotic case in point. #JMMFEBTA5IF%BSL4JEFPG$JSRVF UIFEBSL mystery is perhaps in the intimacy the show manages to achieve even in theatres as big as The Crown at Burswood, in which it PQFOTBOEUIFFOEPGUIFNPOUI"DVTUPN CVJMU DJSDVMBS TUBHF XJMM HJWF B  EFHSFF view of the performance and will have some of the audience reflexively ducking as aerialists soar above them and balancing acts and skaters whizzing centimetres from their seats. $IPSFPHSBQIFS /FJM %PSXBSE TBJE Le Noir was more interested in exploring the different sides of being human rather than the more bizarre characters from other similar shows. â&#x20AC;&#x153;I was really inspired by the aesthetics of popular music and fashion shows so the




production has a more contemporary and edgy feel themed around the colours red (for passion), black (for mystery) and white (for purity). The costumes are glamorous but you could wear them out to dinner or a club.â&#x20AC;? Each act is different and itâ&#x20AC;&#x2122;s been Neilâ&#x20AC;&#x2122;s job to style and choreograph them all to create a cohesive and thrilling show. Medical Forum spoke to Mexican roller TLBUFS +FSPOJNP (BSDJB    XIP XJUI IJT "VTUSBMJBOXJGF +FTTJDB3JUDIJF  QJDUVSFE BCPWF IBWFDSFBUFEPOFPGUIFTIPXTUPQ ping acts in Le Noir'PS+FTTJDB JUIBTCFFO an epic transformation from dancer to elite roller skater in the space of just four years. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s been a lot of hard work. We didnâ&#x20AC;&#x2122;t have anyone training us or teaching us these techniques. We literally learnt this act through persistence, watching videos on YouTube and then trying it out. Weâ&#x20AC;&#x2122;d film ourselves and then appraise the video â&#x20AC;&#x201C; what worked and where we needed to change the routine.â&#x20AC;?

Before I got married I had six theories about bringing up children; now I have six children and no theories. â&#x20AC;&#x201C; John Wilmot

â&#x20AC;&#x153;Letâ&#x20AC;&#x2122;s just say there were many falls, bumps, scrapes and bruises along the way.â&#x20AC;? The pair met in St Nazaire, in France, when they were both working on a Norwegian DSVJTFTIJQ#VUXIJMF+FTTJDBXBTUIFOPW JDF +FSPOJNPIBTHSPXOVQPOSPMMFSTLBUFT â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve been roller skating since I was kid but UVSOFEQSPGFTTJPOBMJOEPJOHBDSPCBUJDT on skates in Starlight Express in Mexico. This QBSUJDVMBS BDU  UIPVHI  +FTT BOE * IBWF POMZ been doing for a little more than a year.â&#x20AC;? â&#x20AC;&#x153;We have performed the roller skating act in other cirque shows before Le Noir. I was in Cirque du Soleilâ&#x20AC;&#x2122;s Zumanity for six years before, but this is the first time weâ&#x20AC;&#x2122;ve put this â&#x20AC;&#x2DC;sexyâ&#x20AC;&#x2122; concept on roller skates.â&#x20AC;? â&#x20AC;&#x153;We donâ&#x20AC;&#x2122;t want the audience just to see two people spinning around doing tricks on skates, we want to make them feel the story we are portraying, to feel the rela tionship and the connection. This act is a continuous learning process and we are constantly developing it.â&#x20AC;? Many of the athletes are Cirque du Soleil alumni, so expect to see the best of bal ance, contortion, stamina, aerial artistry and CSFBUIEFGZJOHBDUTTVDIBTUIF$PMVNCJBO 8IFFMPG%FBUI O

By Ms Jan Hallam medicalforum


Entering Medical Forum's COMPETITIONS is easy! Simply visit and click on the 'COMPETITIONS' link (below the magazine cover on the left).

Movie: Wish I Was Here Written and directed by and starring Zach Braff (Garden State, Scrubs), Wish I Was Here is the story of a struggling actor, GBUIFS BOE IVTCBOE  XIP BU  JT TUJMM USZJOH UP HFU UIF BDU PG life together. No longer able to afford school fees, Aidan finds IJNTFMGIPNFTDIPPMJOHIJTUXPDIJMESFO BHFEGJWFBOE BOE learns the big lessons. In cinemas, September 11

Movie: The Little Death A dark comedy exploring the perverse lives of â&#x20AC;&#x2DC;ordinary peopleâ&#x20AC;&#x2122;, this film take audiences into the fantasies of a couple that often have unexpected and hilarious consequences. The Little Death explores why we want what we want, how far we will go to get it and who suffers in the wake of that fleeting glimpse of ecstasy. In cinemas, September 25

Circus: Le Noir â&#x20AC;&#x201C; The Dark Side of Cirque Le NoirNBZCFQPQVMBUFEXJUINBOZ$JSRVF%V4PMFJMBMVNOJCVU it presents an intimate and sophisticated take on the theme. The Crown Theatre will be transformed with a circular stage project ing into the auditorium. Expect incredible displays of balance, contortion, stamina, aerial artistry and death defying acts. Crown Theatre, August 28 to September 7, Medical Forum performance, August 28, 7.30pm

Concert Drama: Rolling Thunder Vietnam Rolling Thunder Vietnam draws on personal stories from the CBUUMFGSPOU JO 7JFUOBN BOE UFBNT UIFN XJUI UIF DMBTTJD TPOHT PGUIFTBOET4PNFPGUIFDPVOUSZTCFTUZPVOHNVTJ cal talent and rock musicians pull off songs by Steppenwolf, +PF$PDLFS #VGGBMP4QSJOHGJFME $SFFEFODF$MFBSXBUFS3FWJWBM  (MBEZT,OJHIU #JMMZ5IPSQFBOE5IF3PMMJOH4UPOFT Crown Theatre, September 12 and 13, Medical Forum performance, Friday, September 12, 7.30pm

Concert Drama: The Man in Black

Music: Requiem Itâ&#x20AC;&#x2122;s always a treat to hear the requiems of these great 'SFODIDPNQPTFST %VSVGMĂ?BOE'BVSĂ? BOERequiem, Pipe Organ Plusâ&#x20AC;&#x2122;s special event next month, you get to hear both from some of WAâ&#x20AC;&#x2122;s best musicians. St Patrickâ&#x20AC;&#x2122;s Basilica musical director, pipe organist %PNJOJD1FSJTTJOPUUP IBTKPJOFEGPSDFTXJUIDPOEVD tor Chris van Tuinen and the UWA Choral Society for these masterworks. Soloists include soprano +FOOJGFS#BSSJOHUPO CBSJUPOF5IPNBT'SJCFSH NF[[P TPQSBOP &WB.BSJF .JEEMFUPO QMVT WJPMJOJTU -VDBT Oâ&#x20AC;&#x2122;Brien and cellist Nick Metcalfe. St Patrickâ&#x20AC;&#x2122;s Basilica, Fremantle, September 21, 2.30pm

Doctors Dozen Winner Chin Obstetrician Dr Jason es win er Riv loves Margaret couple a got s heâ&#x20AC;&#x2122; now and The of reasons to smile. %P[FO ST DUP %P FQ %F F ,OF EJFE DPOUBJOT TPNF GVMM CP whites fted cra ly fine and s red good and thereâ&#x20AC;&#x2122;s a ver y open to up ing com son rea JGF JTX EI BO UIFDBTF+BTPO t child firs ir the ing ect exp are arrival in September and the nd to bou is er ght dau ir the of H QJO QPQ QT DB TFUUIFTDSFX


Aussie Rock legend Tex Perkins is a perfect fit for this celebra UJPO PG UIF MJGF BOE NVTJD PG +PIOOZ $BTI 3FUVSOJOH UP 1FSUI BGUFS B TFMMPVU TFBTPO JO   UIF )FMQNBOO "XBSEXJOOJOH The Man in Black JT B UFSSJGJD OJHIU PVU  OPU KVTU GPS UIF UPF tapping brilliance of the songs but for Texâ&#x20AC;&#x2122;s hugely entertaining performance. Regal Theatre, August 26-31, Medical Forum performance, Tuesday August 26, 7.30pm

FORUM $ 10.50








Major Sponsors

June 2014

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MANDURAH Mandurah coastal lifestyle 40 minutes from Perth. VR non VR doctor required short term or long term. No weekends or after hours. Good remuneration. Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist and orthotics. Contact practice manager Elaine 9535 8700 Email: SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979 WEST LEEDERVILLE Great Lifestyle! Part time (up to full time) VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: or call Jacky, Practice Manager on 9381 7111 / 0488 500 153 HILTON GP. Wanted / Sessional/ P/Time VR. GP. to join 25yrs established General Practice JOUIF)JMUPOBSFB(1T Accredited: Computerised with fulltime nurse support. Service growth potential. Contact Practice Manager on 9337 8899

YOKINE Part-Time VR GP required for a small privately owned practice in Yokine. Female GP preferred to help our existing female GP. Family friendly practice with nursing support and a lovely team of receptionists. 0VS(1TIBWFGVMMBVUPOPNZ Private billing. Fully computerised. Accredited. On-site pathology. Allied health rooms attached next to the practice. Excellent remuneration is offered to the right applicant, but we are not in an area of need. Please contact Jayne or Dr Peter Cummins for further information.

GOSNELLS GP wanted VR or Non VR. Corfield Doctors Surgery is looking for VR or Non VR GP to join the family practice. Would offer 70% of the income and state of the art surgery with Pathology on-site. Send your CV to Practice Manager TP 08 â&#x20AC;&#x201C; 9398 9898 BULLCREEK PT/FT VR GP required for Accredited, Privately owned, Friendly Family Practice Please call â&#x20AC;&#x201C; 9332 5556

SHENTON PARK Churchill Health Centre A part-time position is available up to 4 sessions per week for a GP with special JOUFSFTUJOXPNFOTIFBMUIDBSF and paediatrics. We have modern spacious consulting rooms and work in a friendly relaxed atmosphere with flexible working hours. We are a private billing practice so there is a guaranteed minimum income. For further enquiries or to lodge your resume please email â&#x20AC;&#x201C; Marie at NORTH BEACH Close to the beach! Opportunity for a P/T or F/T GP to join our privately-owned practice. Flexible hours and mixed billing. "OJOUFSFTUJOXPNFOTIFBMUIBO advantage. On site pathology, psychologist and nurse support. Please contact Helen or David 9447 1233 to discuss or Email: reception.nbmc@ CANNINGTON Southside Medical Service is an accredited practice located in Cannington area. We are a family practice and offer mixed billings. We have positions for a GP to join PUIFS(1TDVSSFOUMZXPSLJOH It is a well-positioned practice, close to the Carousel Shopping Centre. Phone: 9451 3488 or Email:

KINROSS VR or Non VR GP required for a privately owned medical centre in Kinross. *UTB%84MPDBUJPO Fully computerised practice. Excellent support available with onsite Pathology, physiotherapist, psychologist & podiatrist. Fully equipped treatment room with nurse support. Please contact on or call 9304 8844 GREENWOOD Greenwood/Kingsley Family Practice The landscape of general practice is changing, and it is changing forever. Are you feeling demoralised by the recent Federal government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? *UEPFTOUIBWFUPCFUIJTXBZ Come and speak to us and see the different ways in which we operate our general practice. Be part of the game changer! Practice Associateship would be considered for the right applicant. Our practice is located north of the river. Sorry we are not DWS. Please contact or 0402 201 311 for a strictly confidential discussion.

KALLAROO /PSUIPG3JWFSQSBDUJDFSFRVJSJOH")T GP to work Sundays, 8 â&#x20AC;&#x201C; 2, private billing, with nurse support. Contact Practice Manager 0488 963 749 Email

NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. Ring Helen 9227 0170.

MT LAWLEY ECU medical centre, P/T VR GP required well equipped, accredited practice, RN support. Caring for University community. No weekends or after hours. Flexibility of hours and days can be accommodated. Contact Dr Rob Chandler Email: Phone: 6304 5618

SEPTEMBER 2014 - next deadline 12md Monday 11th August - Tel 9203 5222 or

medical forum MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new non corporate practice with 2 female & 1 male General Practitioners. Sessions and leave negotiable, salary is compiled from billings rather than takings. Up to 70% of billings paid (dependant on experience). Please contact Jacky on 0488 500 153 or E-mail to NEW PRACTICE - Inner Northern Suburb Located in an inner northern suburb, approximately 5 mins from the CBD. In a prime location on a main road, with good exposure and ample parking at the front and rear. Also next door to a 7-day pharmacy. With recent retirements in the area, this is the perfect opportunity for an enthusiastic GP or group of GPs. Generous percentage offered and interest in ownership considered. Administrative and nursing services will be provided, along with pathology collection on-site. Call 0414 287 537 for details. NEDLANDS Fantastic opening for a VR GP who seeks work life balance. Next to UWA and Swan River in a busy shopping centre. FT or PT with 70% of billings for suitable candidate. Mostly private billing. Full accredited. Pathology onsite. FT Registered Nurse Allied health services next door. Call Suzanne on 08 9389 8964 or Email:

KARRINYUP St Luke Karrinyup Medical Centre. Great opportunity for FT/PT doctor in a State of art clinic, inner-metro, Nursing support, Pathology and Allied services on site. Private billing. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979 Email:

PERTH CBD Full and part time VR GPS to join our busy inner city practice located in the Hay Street Mall. Non-corporate, mainly private billing, accredited, fully computerised with full admin and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates Please contact Debra on 0408 665 531 to discuss or Email:

We make Aged Care work for GPâ&#x20AC;&#x2122;s Medical Practitioners for Aged Care (MP+AC) is seeking doctors to join its team providing medical services to residents of various Residential Aged Care Facilities throughout the Perth metro area. Our efficient service delivery model NBYJNJTFTUIF%PDUPSTFBSOJOHQPUFOUJBM t 'MFYJCMFTFTTJPOT.POEBZUP'SJEBZ t (SFBUBENJOTDIFEVMJOHTVQQPSU t 3FNPUFMPHJOUPQBUJFOUSFDPSET t 3/QSPWJEFECZ.1 "$UPBTTJTU%PDUPS t #FUUFSVUJMJTBUJPOPG%PDUPSTUJNF t 1BZNFOUPGHSPTTSFDFJQUT t &RVJUZJOWPMWFNFOUQPTTJCMF For more information or confidential discussion about work options please contact Caroline Claydon - MP+AC Mobile 0433 269 532 or Email:

ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? As WAâ&#x20AC;&#x2122;s only specialised medical business broker we have helped many buyers ďŹ nd medical practices that match their experience.

Duncraig Medical Centre Osborne City Medical Centre Require a female GP for both practices. Existing patient base. Flexible hours. Excellent remuneration. Modern, predominantly private billing practice with full time Practice Nurse. Fully computerised. Please contact Michael on 0403 927 934 Email Dr Dianne Prior:

NORANDA Female GP required for a fully accredited, fully computerised, privately owned practice in Noranda. With on-site dentist, podiatrist and physiotherapist. Hours to be discussed with owner of the practice. Please contact our friendly team on (08) 9276 8526 or phone 0412 260 491. Alternatively you can email at: SEVILLE GROVE Seville Drive Medical centre (AON/DWS) requires a Female GP, VR/Non VR to join our team. P/T or F/T. Privately owned and run centre, great clinical support team, allied health and friendly admin team. Please contact Rebecca on 08 9498 1099 or

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

NORTHERN SUBURBS General Practitioner wanted. An integrated health clinic in the northern suburbs is looking for a General Practitioner with a holistic approach to medicine to join our diverse team. The practice focuses on a holistic approach to health. We have a Holistic GP, Naturopath, Remedial therapies, Counselling, Yoga and Meditation within the practice. Practitioners work together based on the health interests of the patient. Hours are flexible and by negotiation. Must be licensed in Western Australia. If this approach appeals to you please send your expression of interest to

MANDURAH Full time VR GP required for busy established, accredited practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed by 10 doctors and 4 experienced Registered Nurses. Relocation fees are negotiable. Generous remuneration, no DWS please. No on call. Contact Ria 9535 4644 Email:

(Belmont, 39 Belvidere Street ) Â&#x2021; Â&#x2021; Â&#x2021; Â&#x2021; Â&#x2021;


GPs Wanted - GP After Hours Clinics in Belmont, Armadale and Rockingham

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ASCOT Part-Time VR GP required for our well established Accredited Privately Owned Friendly Family Practice in Redcliffe. We are fully computerised, using Best Practice software. Nurse is support available. Non DWS area. Please call â&#x20AC;&#x201C; 9332 5556

GPs Wanted - South Metro Multicultural Health Clinic

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SEPTEMBER 2014 - next deadline 12md Monday 11th August - Tel 9203 5222 or


medical forum Specialists – opportunity for easy private practice in Fremantle!

Ellen Health (Ellen Street Family Practice) will be moving from 59 Ellen Street Fremantle, to the beautiful old Beacon Theatre - 69 Wray Avenue (corner Hampton Road), Fremantle, co-located with pharmacy, pathology and allied health. Doctor-owned and managed, Ellen Health is a multi-disciplinary team, providing excellence in health care. We invite specialists to join the team, offering an instant referral base with our established general practice, and with the ease and comfort of fully serviced new rooms.

We are recruiting specialists and VR-GPs now. Enquiries to Dr Catherine Douglass 0421 520 767




Looking for dedicated GP’s and Specialists who love the South West and want to stay – move across to our state of art practice – we have oodles of space. You can have your own room. Excellent working conditions with limited after hours needed through Bunbury After Hours GP Clinic. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

GP Opportunities in WA Available Now

Looking for a positive change in your career? Due to continued growth, IPN is currently looking for GPs for opportunities within our Medical Centres. As a valued GP, you will enjoy freedom, flexibility and clinical sovereignty, with a busy patient base. Each centre is run by a Practice Manager and the team is supported by a Business Manager.

It's A August ugust already! Don't let 20 Do 2014 14 slip away without doing something s mething for you. To make a confidential onfidential enquiry about GP Opportunities pportunities in WA or to find out more, contact Aillinn on:

0467 804 050 Supporting Better Medicine SEPTEMBER 2014 - next deadline 12md Monday 11th August - Tel 9203 5222 or

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With a reputation built on quality of service, Optima Press has the resources, the people and the commitment to provide every client with the finest printing and value for money. 9 Carbon Court, Osborne Park 6017 Tel 9445 8380

Medical Centre in East Victoria Park, Western Australia Requires GPs for weekday work. Best possible terms offered. Earn 70% of billings. Best possible location, stand-alone site integrated with a pharrmacy and pathology, located next to the very busy Park Shopping Centre, ample free parking. This is a busy Medical Centre having easy access to all surrounding suburbs of Vic Park, Belmont, Bentley, Canning, and South Perth. (Non VR IMG doctors may also apply for afterhours and weekend work) Applying doctors have the ďŹ&#x201A;exibility to work sessions or full time.

Apply now. (Phone: 0411 87 6677) SEPTEMBER 2014 - next deadline 12md Monday 11th August - Tel 9203 5222 or


Medical Forum WA 08/14 Public Edition  

WA's Premier Independent Monthly Magazine for Health Professionals

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