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May 2016

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Editorial

Can Venus Stop Revalidation?

Twenty years ago, I had the good fortune to be paid to study this beautiful painting below as part of a PhD project.

Agnolo Bronzino’s Renaissance allegory, Venus, Cupid Folly and Time, has us all pondering how much fun it must’ve been back in 1545 when Aggie was a boy.

This past month I have had cause again to gaze on its many layers for the seemingly unlikely connection with Female Genital Cosmetic Surgery (FGCS), which, growing evidence suggests, is becoming increasingly common (see p18).

The shock and awe of the statistics is not that plastic surgeons are being kept busy trying to ‘fix’ nature’s imperfections, but that the world must be full of such high anxiety that women with healthy genitals are choosing to have their labia minora incised, their clitorises snipped and their vulvas plumped because they are ashamed/horrified/dissatisfied (or all of the above) with themselves.

This ‘body-shame’ is not a modern phenomenon. Let’s return to the Bronzino and gaze wondrously at Venus’s mons pubis as have many before us. Not a whisker to be seen, in fact nothing to see at all – and this is the Goddess of Love, the paragon of all that is beautiful, alluring, sacred and desirable.

Given that Bronzino looked to the ancient Greeks and Romans for his artistic cues, we Venus, Cupid Folly and Time Agnolo Bronzino; National Gallery, London can account for at least the past 3000 years of female body shaming and that is just among the intelligentsia. The pornography industry goes back equally as far and has influenced a much bigger audience.

Now I can feel a rolling of eyes and an itch to turn the page because some of you can sense a feminist diatribe coming and you could be right. Some good old-fashioned hard stares are in order when you are writing the leader for the annual Women’s Issue.

However, an even more dazzling feat than just another drumbeating session would be to connect this powerful picture to

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MEDICAL FORUM

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

the culture of bullying in the profession. And also, perhaps, the Medical Board’s poorly thought-out push for revalidation.

In March last year, senior vascular surgeon Dr Gabrielle McMullin launched her book, Pathways to Gender Equality: The Role of Merit and Quotas, and told the audience: “What I tell my trainees is that, if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request.”

The irony was lost on a few, but for the vast majority it bore testament to the entrenched sexism and bullying values endorsed by the decades of silence from senior echelons of the profession.

It opened a hornet’s nest that stung a few Colleges into action.

RACS, pleasingly, because it was towards its fellows that the accusations were directed, were the first to conduct an inquiry and subsequently publish new guidelines.

Last month, a year on, AMA WA announced its survey of 1000 members that overwhelmingly supported the contention that bullying and sexual harassment is rife in the profession.

Has this horse at last escaped the clutches of the old boys’ network?

Let’s hope so, because if this enormous issue can be addressed maturely by the Colleges, so too can the equally painful and divisive issue of doctor competency.

Ms Jan Hallam

Revalidation is perhaps the bluntest of instruments to keep the medical workforce practising safely (see p24). Its CME components are already part and parcel of a doctor’s professional life and no manner of exams will weed out doctors who should be retired or sacked.

However, College networks that seek to maintain the high standards of their members are in a unique position to identify poor performers and to bring them up to scratch, slide them into retirement or cancel their fellowships. This is a professional issue and not one for the bureaucrats at the Medical Board or its crazed love-child, AHPRA. This is about equality and professionalism, not cronyism or misplaced loyalty. It’s about recognising Folly and Time’s winged chariot. There is a great opportunity here to avert an overwhelming disaster.

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

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

MAY 2016 | 1

May 2016

Contents

12

14

18

16

FEATURES 12 Profile: Kalgoorlie GP Dr April Armstrong 14 Spotlight: Jazz impresario Graham Wood 16 WA Health Service Reform 18 Female Genital Cosmetic Surgery 20 No Tax for Sugar NEWS & VIEWS 1 Editorial: Can Venus Stop Revalidation?

4

Jan Hallam Letters to the Editor: Health a Parallel Universe Dr John Rogers Zika Virus and the Olympics Dr David Rutherford Turf Battle Hurts Innocents Ms Samantha Jenkinson Court Wrangles Too Common Mr Chad Edwards-Smith Hepatitis C Management Dr Donna Mak Life and Death Decisions Dr Gerry Cartmel Docs – A Price on Your Head?

Dr Philippa Hawkings Swimming 365 Dr Sarah Cox

MAJOR SPONSORS

2 | MAY 2016

Perth Pathology

10 11 23 23 24 44

Have You Heard?

Beneath the Drapes Xenophon on Pokies Gambling: The Stats e-Poll: Revalidation, PHNs, Gambling, Test Savings An Ankle’s Tale

LIFESTYLE 46 Travel: Norfolk Island: 48 49 50 51 52 53

Dr Bruce Bridges Life After Baby Wine Review: Turkey Flat Dr Martin Buck Theatre: Angels in America Music: WASO Creations Funny Side Competitions

No Tax for Sugar Page 20

MEDICAL FORUM

Clinical Contributors

5

Dr Chanh Ly Lynch Syndrome

35

Dr Trenton Barrett Overactive Bladder

37

Dr Pam Quatermass Testosterone for Women

40

Dr Anjana Thottungal Informative Pelvic Scans

43

Dr Richelle Douglas Emergency Contraception – Ulipristal

45

Dr Sara Damiani App Review: My Dario

39

Dr Fred Busch Aneuploidy Screening: NIPT

Guest Columnists

8

Dr Matilda-Jane Oke Time to Sex-Up Education

27

Mr Geoff Diver Prevention for Mental Illness?

29

FIND US ON FACEBOOK & TWITTER! /medicalforumwa/

/medicalforumwa/

Ms Debbie Robinson New Party Puts Its Case

e-Poll

31

Dr Carol Pearce Open Mind on CM

P24 Your Say on Revalidation

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM MAY 2016 | 3

Letters to the Editor

Health a parallel universe Dear Editor, Consider a work place involving tens of thousands of Australian workers with one employer – by law – no one else is ALLOWED to employ them.

Consider that employer having the power to set your wage unilaterally, and reduce it annually or even halve it, at a whim.

Consider that employer having the power to ďŹ ne and sack you outside the process of law.

Consider an employer that can back-ďŹ ne you per job over a period of time without reference to any system of law and without any form of legal redress.

Consider the ACCC having no power to interfere with gross irregularities by the employer.

Consider an employer that does not pay superannuation, holiday pay or workers compensation and offers no payment towards ongoing education.

Consider a system where you cannot strike, or organise more than one person to correct pay anomalies without the ACCC coming down on individuals, ďŹ ning them tens of thousands of dollars.

Consider a system that can remove you from any payment if you accept a payment outside their guidelines.

Consider a system that operates in a parallel universe outside Australian Industrial, Commercial and Common law.

Consider the ATO not forcing an employer to recognise that it’s a major regular employer, when 80% of worker payments are paid directly through that employer; and that employer is not required to pay superannuation, long service leave and sick pay. Could a High Court challenge succeed to make the employer pay 30 years of unpaid superannuation plus ďŹ nes and interest?

Consider an employer than can double the local workforce PERMANENTLY with overseas workers (from countries that trained them and need them more than we do) into local poorly paid positions in areas of need, and areas of no need, to keep costs down?

Consider MEDICARE Dr John Rogers, Parkwood ........................................................................

Zika Virus and the Olympics

Remember to consider other differential diagnoses including Dengue, Chikungunya, Measles and Malaria if from a risk area.

Dear Editor,

Given the complexity of Zika Virus and also Yellow Fever requirements, advising general travellers as well as those going to the Olympics this year will be a challenge for us all.

With the Rio Olympics just around the corner in August, we have been receiving a lot of enquiries from GPs in regards to advice for travellers for Zika Virus, especially since it was found to be sexually transmitted, as well as mosquito borne. This notiďŹ able disease (>1 million cases in 12 months) has been declared a Public Health Emergency of International Concern (WHO) and was thought to arise in part following the World Cup 2014.

Although dynamic, here is a summary of the current facts. sĂĽ )TĂĽISĂĽTRANSMITTEDĂĽBYĂĽ!EDESĂĽMOSQUITOĂĽ LIKEĂĽ YF, Dengue, Chikungunya). Day-time urban mosquito sĂĽ (IGHĂĽRISKĂĽAREASĂĽINCLUDEĂĽ3OUTHĂĽANDĂĽ#ENTRALĂĽ America, Caribbean, PaciďŹ c nations. Also in South East Asia including Thailand (nine cases) sĂĽ &OURĂĽOUTĂĽOFĂĽlVEĂĽPEOPLEĂĽHAVEĂĽNOĂĽSYMPTOMS sĂĽ &EVER ĂĽRASH ĂĽCONJUNCTIVITIS ĂĽARTHRALGIA ĂĽ myalgia common but not diagnostic sĂĽ )NCUBATIONĂĽ ĂĽWEEKS sĂĽ 3YMPTOMATICĂĽTREATMENTĂĽONLY sĂĽ !SSOCIATEDĂĽWITH ĂĽ'UILLAINĂĽ"ARREĂĽ3YNDROMEĂĽ (24/100,000); Spontaneous abortion; Microcephaly Advice to travellers: sĂĽ 0REGNANTĂĽTRAVELLERSĂĽSHOULDĂĽAVOIDĂĽHIGHĂĽ risk areas, and use mosquito avoidance measures in other areas sĂĽ 0ROVENĂĽSEXUALĂĽTRANSMISSIONĂĽEVENĂĽWHENĂĽ asymptomatic WA Health Department says: sĂĽ !SYMPTOMATICĂĽMALEĂĽPARTNERĂĽFROMĂĽRISKĂĽAREAĂĽ use condoms for 4 weeks sĂĽ !SYMPTOMATICĂĽORĂĽSYMPTOMATICĂĽMALEĂĽ partner returning to pregnant partner to use condoms or abstain for duration of pregnancy. sĂĽ 3YMPTOMATICĂĽMALEĂĽPARTNER ĂĽORĂĽPROVENĂĽ:IKAĂĽ Virus, use condoms with non-pregnant partner for three months after diagnosis Testing through Path West includes: sĂĽ 0#2ĂĽBLOOD URINEĂĽ ĂĽDAYS sĂĽ 3EROLOGYĂĽ)G-ĂĽRISEĂĽ ĂĽWEEKSĂĽ ĂĽ)G'ĂĽATĂĽ ĂĽ weeks sĂĽ 2ESERVEDĂĽFORĂĽSYMPTOMATICĂĽTRAVELLERSĂĽANDĂĽ those where pregnancy is relevant and not just to avoid the above restrictions Useful link www.health.gov.au/internet/main/ publishing.nsf/Content/ohp-zikavirus

Dr David Rutherford, Travel Medicine, Fremantle ........................................................................

Turf battle hurts innocent Dear Editor, I read with interest NDIS Battle Lines Drawn (April edition).

People with disabilities, their families and carers are the ones caught in the crossďŹ re with this battle which sometimes feels more about State’s rights than building the best support system for people with disability.

The National Disability Insurance Scheme is about more than simply having extra money in the system from the Commonwealth. It is also about providing choice and control for people with disabilities in their own lives; consistency of the levels of support a person might get where ever they may live; and portability across Australia.

Whether the scheme is administered by the State Government in WA or by the National Disability Insurance Agency it is extremely important that people with disability are not disadvantaged in any way. This means that it must be absolutely clear that a person in WA will get a consistent interpretation of the eligibility criteria, and the reasonable and necessary criteria for funding when compared to people in other states. It also means that things like the appeals process should be the same, and data collection should be national.

Most importantly, people with disability, their families and carers must be asked what we want in the NDIS in WA. Having choice of how a person can manage their funding, and who they get support from is at the core of the principles behind the NDIS, which must be seen in practice. This requires a system to be exible, and at this point in time I would say that neither State nor Commonwealth is showing the level of exibility required. continued on Page 6

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

The support of all advertisers, sponsors and contributors is welcome.

Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemniďŹ es the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

Advertisers are responsible for ensuring that

4 | MAY 2016

MEDICAL FORUM

Dr Chanh Ly FRCPA

Perth Pathology (Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 26 Leura St, Nedlands WA 6009 Ph 9433 5696 Fax 9433 5472

www.perthpathology.com.au There are 52 collection centres across inner and outer Perth, Mandurah, and Secret Harbour.

Please refer to the website for opening hours and addresses

Histopathology and Cytopathology. Since graduating from UWA in 2004, Chanh has worked in a range of medical and surgical specialties around Australia before commencing pathology training in 2009. Chanh joined the team in 2015 and is enthusiastic about independent pathology practice. His interests include dermatopathology, gastrointestinal, breast and gynaecologic pathology.

Lynch Syndrome: Familial Cancer Risk

Hereditary non-polyposis colorectal cancer (HNPCC) was used by Henry T Lynch in 1985 to describe a familial cancer syndrome (see March edition). The term Lynch syndrome (LS) is preferred in genetic circles. The deďŹ ning characteristic of LS is an autosomal dominant predisposition to cancer attributable to germline mutations in mismatch repair (MMR) genes resulting in microsatellite instability (MSI).

Table 2: Revised Bethesda Criteria Tumours from individuals should be tested for MSI in the following situations 1

Colorectal cancer (CRC) diagnosed in a patient less than 50 years of age

2

Presence of synchronous or metachronous colorectal or other HNPCC-associated tumours, regardless of age

3

CRC with MSI-high histologic features (Crohn-like lymphocytic reaction, mucinous/signet cell differentiation, or medullary growth pattern) diagnosed in an individual less than 60 years of age

4

Colorectal cancer diagnosed in one or more ďŹ rst-degree relatives with an HNPCC-related tumour, with one of the cancers being diagnosed under the age of 50

5

Colorectal cancer diagnosed in 2 or more ďŹ rst- or second-degree relatives with HNPCC-related tumours, regardless of age

MSI associated tumours With LS prevalence about 1:440-1000, Table 1 compares cancer risks in LC patients AGEDĂĽUNDERĂĽ ĂĽCOMPAREDĂĽTOĂĽTHEĂĽGENERALĂĽ population.

Management guidelines

Table 1: Comparative LS Cancer Risks

The management of LS patients is still evolving.

Cancer type

General population risk

Lynch syndrome Risk

Mean Age of Onset

Colon

4.8%

5282%

44-61 yrs

Endometrium

2.7%

2560%

48-62 yrs

Stomach

<1%

6-13%

56 yrs

Ovary

1.4%

4-12%

42.5 yrs

Hepatobiliary tract

<1%

1.4-4%

Not reported

Urinary tract

<1%

1-4%

~55 years

Small bowel

<1%

3-6%

49 years

Brain

<1%

1-3%

~50 yrs

Sebaceous tumours

<1%

1-9%

Not reported

References on request.

Who should be tested?

Since genetic testing is expensive and timeconsuming, clinical and pathological criteria have been developed to identify high risk patients for further molecular genetic testing.

In Australia it is the Revised Bethesda criteria (see table).

Periodic colon examination detects CRC at an earlier stage, leading to a 63% reduction of the risk of CRC and to a signiďŹ cant reduction in mortality. Currently, colonoscopy every 1-2 years is recommended in LS patients and their relatives beginning at age 20-25 years or 2 to 5 years before the earliest diagnosis in the family. Prophylactic colorectal resection is not recommended but patients with CRC are offered segmental resection or subtotal colectomy. There is medical evidence that tumours with high MSI are relatively resistant to certain medications (5-ďŹ&#x201A;uorouracil).

Surveillance of the endometrium and ovaries may lead to the detection of premalignant lesions and early endometrial cancers but the data is still unclear. Prophylactic hysterectomy and salpingo-oophorectomy may be an option for women who have completed childbearing.

The efďŹ cacy of surveillance for cancer of the stomach, upper gastrointestinal tract and urinary tract is unknown.

Aspirin chemoprevention is now standard of care for those with LS. Colorectal Adenoma/ Carcinoma Prevention Programme 2 (CAPP2), a randomised trial from 1999-2005, show a signiďŹ cant reduction in CRC and â&#x20AC;&#x153;substantial protectionâ&#x20AC;? against other LS associated cancers.

Perth Pathology General Pathologist / Managing Partner: Dr Wayne Smit Histology / Cytology: Dr Michael Armstrong Dr Tom Grieve Dr Jason Lau Dr Chanh Ly

Dr Tony Barham Dr Peter Heenan Dr Stephen Lee

Infectious Diseases (Microbiology): Dr Laurens Manning Haematology: Dr Rebecca Howman Laboratory Director: Paul Schneider Providing phone advice to clinicians and a comprehensive range of medical pathology investigations, including: sĂĽ (ISTOLOGYĂĽ 3KIN ĂĽ') ĂĽETC sĂĽ #YTOLOGYĂĽ INCL ĂĽ0APSĂĽANDĂĽ&.!S sĂĽ (AEMATOLOGYĂĽ YES ĂĽWEĂĽDOĂĽLAB controlled INRs) sĂĽĂĽ"IOCHEMISTRYĂĽ INCLUDINGĂĽHORMONES and markers) sĂĽ-ICROBIOLOGYĂĽANDĂĽ3EROLOGY Professional personalised service from a non-corporate, pathologist owned and operated laboratory practice

Letters to the Editor continued from Page 4 We are hoping that the new WA Disability Services Minister will take the time to listen to people with disabilities, their families and carers, and remember this scheme must work for us.

Ms Samantha Jenkinson, Executive Director, People With Disabilities (WA)

så #ONSIDERåREFERRINGåTHEåCHILDåORåFAMILYåTOåAå psychologist if appropriate.

Doctors may also benefit from seeking guidance from their colleagues, or contacting their medical defence organisation for further advice.

Mr Chad Edwards-Smith, Head of Medical Defence Services WA, Avant

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

All-too-common scenario

Hepatitis C management

Dear Editor,

Dear Editor,

The issues raised by Doctors Caught in the Crossfire (March edition) for doctors dealing with children in family violence situations are very relevant. This issue is a common reason doctors call on Avant’s Medico-legal Advisory Service for assistance.

The appropriate steps will depend on each individual situation but here are some things to consider: så 4HEREåMAYåBEåAåMANDATORYåREPORTINGå obligation, which in WA only applies to reasonable beliefs of child sexual abuse, and reports can be made by contacting the Department for Child Protection and Family Support in WA (or the equivalent department in a different state or territory); så )FåINåDOUBT åDOCTORSåCANåMAKEåVOLUNTARYå reports or contact the Department for guidance on whether a report can or should be made; så $OCUMENTåTHEåHISTORYåANDåEXAMINATIONå in the child’s clinical records, but keep in mind those records may be subpoenaed or requested by the alleged perpetrator at some point so consider this when making your notes; så 3OMEåDOCTORSåTAKEåPHOTOSåOFåANYå injuries or record the consultation (with appropriate consent) to help address any dispute about what occurred or was discussed – these images and recordings are part of the child’s clinical records and should be kept with their file; så %NSUREåTHEåCHILDåISåINåAåSAFEåPLACEånå contact the police if the child is any immediate danger or ask for consent to speak to the child’s school and other treating doctors or care providers to help ensure their safety;

In response to Dr MacQuillan’s article about new hepatitis C treatments, Hepatitis C Game Changer (April), WA Health views the recent changes to availability of direct-acting antivirals (DAAs) as a huge opportunity to reduce hepatitis C transmission in the community by improving access to treatment for people with chronic hepatitis C. Anecdotal reports from GPs and Hepatitis WA indicates significant consumer demand for these treatments. To this end we are working with GPs, hepatologists, ID physicians, laboratories and the WA Primary Health Alliance on developing systems and resources to facilitate specialist review of GP referrals for approval to prescribe DAA treatment for patients with chronic hepatitis C. The Silver Book (Guidelines for managing STI and BBVs ww2.health.wa.gov.au/Silver-book) now includes a revised chapter on hepatitis C including a referral form.

WA Health and the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine are providing free RACGP accredited CPD on hepatitis C management for GPs and primary health care staff. Contact paola.rosales@ashm.org.au or go to www. ashm.org.au/courses to register for either a two–hour seminar/webinar on Thursday May 26, 6.30pm-9pm (4 cat 2 points) or a fourhour workshop for potential S85 prescribers on Saturday May 28, noon-4.30pm (40 cat 1 points).

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

I think the only difference between me and the other candidates is that I’m more honest and my women are more beautiful.

Donald Trump

Life and death decisions Dear Editor, Last year I wrote suggesting the exploration of the benefits of early diagnosis and treatment of cancer of the prostate and all that entails is reflected in outcomes. From memory I recall figures giving a reduction in death from 4:1000 down to 3:1000 and questioned whether the price, in terms of physical and emotional trauma and monetary cost was worth this gain. Clarification would be helpful to many patients as the thrust is all on early diagnosis and then varying treatment modes.

I am not sure if the following comment is relevant but again we see the individual caught between the social powers of the law and medicine.

I refer to the case reported in the media of the decision of the Family Court of Western Australia to override that of the parents who wished to withhold further treatment of a five-year-old dying from a brain tumour based on their information that if surviving five years of traumatic treatment the child would still be left with severe intellectual impairment, hearing and visual disability and damage to the endocrine system requiring lifetime medication and the need of ongoing care.

This seems at odds with our current Australian culture which in an age of excellent and available contraception aborts over 20% of pregnancies in which abnormality is not in question. They wanted nature to take its course whereas termination of a normal pregnancy runs against nature. Surely the parents in this tragic no-win situation should get no recrimination if they opted out of all ongoing responsibility for this child.

Dr Gerry Cartmel, Bridgetown ......................................................................

Doctors – a price on your head?

Dear Editor, Attending the recent Doctors Drum breakfast and reading the article in the Medical Forum got me thinking about the situation in the UK where this issue is highly topical and junior doctors truly feel as though a price is being placed on their heads.

Over the last couple of years there has been a growing movement in the NHS towards a seven-day service. This concept is supported in principle given the correct resourcing is made available, which may prove difficult in the current financial climate2. In relation to

continued on Page 8

6 | MAY 2016

MEDICAL FORUM

Incisions

Time to Sex It Up? In a formative period such as medical school, the topics of contraception and abortion should not be such odd bed-fellows, writes Dr Matilda-Jane Oke. There are lots of things that medical students need to know and a limited time in which to learn them. And even more so in a condensed four-year postgraduate degree!

Inevitably, there will always be topics that aren’t particularly well covered.

I’m OK with that as long as there are good and sensible reasons underpinning what’s in and what’s out. It makes a lot of sense to learn more complex details relating to surgery and cosmetic medicine. But I don’t believe it’s a good thing that medical and surgical abortion, a topic I learned almost nothing about in medical school, falls into the ‘what’s out’ category.

A medical course that ignores abortion seems a tad irresponsible to me, particularly when you consider that one-in-three Australian women will have one. I guarantee that abortion will touch more lives than Fanconi Syndrome, a rare disease I spent one week focusing on in Problem Based Learning.

Doctors should have, at the very least, a basic understanding of how abortions are performed, where they are done, their pros and cons and how to counsel people in an appropriate manner. Without such knowledge, a large chunk of the population may well receive suboptimal care at a time when they’re highly vulnerable.

Unless we, as doctors, have a comprehensive understanding about contraception and abortion... we risk perpetuating a chain of misinformation that falls well short of best-patient care.

This is neither a phenomenon limited to Western Australia, nor even to Catholic universities. An article in Student BMJ refers to abortion as the ‘forgotten rotation’. An article in the Sydney Morning Herald entitled, ‘How Medical Schools are Failing to Educate Doctors in Abortion Care’, Jenna Price describes how many students receive no instruction regarding abortions and the potential ramifications of a basic lack of understanding relating to what is a relatively common procedure.

Contraception is another common presenting issue, and medical students should be taught a lot more about it. I’m surprised and disappointed in equal measure by the number of people who are unaware of the wide variety of contraceptives. Little wonder they have little understanding of how they actually work!

This is especially evident when it comes to Long Acting Reversible Contraceptives (LARCs). Despite being highly effective and AFFORDABLE åLESSåTHANå åOFåWOMENåINå!USTRALIAå use LARCs and discussions about them occur in only 15.4% of GP contraception consultations. The latter statistic is particularly concerning. With variable quality, school-based sexual education a lot of young people will learn about contraception and its intricacies in a GP surgery.

Unless we, as doctors, have a comprehensive understanding about contraception and abortion – and definitely more than a one-hour lecture at university – we risk perpetuating a chain of misinformation that falls well short of best patient care.

I appreciate that creating a medical course is a difficult business and it’s a very good thing that places exist where those interested can learn more. Thank goodness for Sexual and Reproductive Health WA! Meanwhile, the majority of the community is having sex. Shouldn’t we ensure that all future doctors learn more about it?

ED: Matilda graduated in 2015 with a School of Medicine Medal at UND. She blogs at www.matildawhitworth.com References available on request.

Letters to the Editor continued from Page 6 the concept the consultant and junior doctor contracts are being reviewed.

At the end of March 2016, the Government released the final draft of the junior doctor contract, which has led to more angst and dissatisfaction amongst the medical community.

The Doctors Drum discussion focused on ‘how doctors are valued by the government, the consumers and even the profession itself’1. If this question were to be asked in the UK today, it would be reasonable to presume, in answer to the first part, the response would be the government places little value on the healthcare and quality service provided by junior doctors.

Two of the key arguments highlighted by the British Medical Association (BMA) to support this include normalising Saturdays by removing penalty rates and freezing pay increments for trainees who voluntarily take time out of training to complete valuable research (in accredited training positions).3

Hunt, has responded to the financial concerns raised claiming that a majority of junior doctors will see an overall net increase in their salary with only 1% receiving a decrease with the introduction of the new contract4.

I am appreciative that here in WA the junior doctors are truly valued for their contributions to the WA health system Dr Philippa Hawkings, Fiona Stanley Hospital References 1 Doctors Drum. Doctors – A Price On Your Head?

Medical Forum. 2016 April:18-19 2 British Medical Association. Position Paper 7-day services. 2013 October 3 British Medical Association. The junior doctors dispute – in their own words. 2016 Jan 28. Available from: https://communities.bma.org.uk/bmaspace/b/ weblog/archive/2016/01/28/the-junior-doctorsdispute-in-their-own-words 4. Bennett A. Junior doctors strike: why are they taking action and how will it affect you? The Telegraph. 2016 April 6

Swimming 365 Dear Editor, I am impressed to see this well-structured program incorporating motivational achievable swimming exercise for type 2 diabetics, which could be extended to other chronic diseases, with a scientific lean, measuring outcomes. GP involvement as referral source or after self referral is welcomed.

The obvious physical benefits to their medical conditions can be documented, the other less tangible benefits to do with improved Mental Health and General Wellbeing are also a major attraction for such programmes.

Gaining a sense of achievement and social contact is the way forward for this type of program to achieve these aims, with retention being important for success. 365 Swimming is well placed to do this.

Dr Sarah Cox, GP Rockingham

The Secretary of State for Health, Jeremy ........................................................................

8 | MAY 2016

MEDICAL FORUM

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MAY 2016 | 9

Have You Heard?

Curtin starts hiring

Prof William Hart, Adj/Prof Janice Bell, Vice-Chancellor Prof Deborah Terry, Federal Minister for Education and Training, Mr Simon Birmingham, and Acting Chancellor Ms Sue Wilson

4HEå#URTINå-EDICALå3CHOOLåISåGEARINGåUPåFORåITSå å launch with key appointments being made. WAGPET CEO Dr Janice Bell has been appointed chair of the school’s external advisory board which will “provide critical input and guidance” to the faculty. Janice has been an adjunct professor at the university since 2012 and will now take a key role in developing the school’s direction. More appointments will be made to the board in the coming months. The foundation dean is Prof William Hart, who has fought long and hard and withstood stiff opposition from AMA WA to see the school finally win government approval.

Health Service Board Chairs

College self evaluates

Flu shots good for mums

On P16 we look at the WA health service reform which will be launched on July 1.

The names of board members of the five area health services were unavailable at the time we went to press but we can report the names of the board heads:

Reform is blowing through corridors everywhere. Last month the Royal Australasian College of Physicians released last month its top five low-value practices and interventions in 10 specialties – dermatology, endocrinology, genetics, geriatric medicine, haematology, infectious diseases, neurology, palliative medicine, sexual health and clinical immunology and allergy. Far better to take this critter by the scruff of the neck before the Government comes in with a sledgehammer.

Check it out at www.evolve.edu.au.

WA Health researchers, in collaboration with the Telethon Kids Institute, have discovered that pregnant women who receive the seasonal flu shot are less likely to experience a stillbirth than unvaccinated mothers. The retrospective study used records to examine nearly 60,000 local births between the 2012 and 2013 seasonal influenza epidemics. The cohort included 52,932 mothers who had not RECEIVEDåTHEåVACCINEåANDå åMOTHERSåWHOå had. The risk of stillbirth among vaccinated mothers was 51 per cent lower than the risk among women who had not been vaccinated.

As a result WA Health will broaden its flu promotion campaign this year.

så Prof Bryant Stokes (North Metropolitan Health Service), neurosurgeon; medical academic and former acting DG of WA Health så Mr Robert McDonald (South Metropolitan Health Service), former leadership roles with WA Police, Treasury and State Supply Commission; former chair of NMHS Governing Council så Deborah Karasinski (Child and Adolescent Health Service), CEO Senses Australia, former CEO Multiple Sclerosis Society, and experienced board member så Dr Neale Fong (WA Country Health Service), president of the Australasian College of Health Service Management and a former DG of WA Health så Mr Ian Smith (East Metropolitan Health Service), formerly held senior roles in WA Health including CEO of WACHS and SMHS; former chief executive of commissioning at Perth Children's Hospital

såPaediatric oncologist and Telethon Kids researcher Dr Nicholas Gottardo has been awarded a $400,000 Cancer Council WA Research Fellowship for his work on medulloblastoma. Dr Samantha Bowyer was awarded the Jackson McDonald Research Grant of $35,000 for her work on melanoma. The Cancer Council WA announced $4m in grants last month.

Yellow Fever alert The Federal Government is adopting the World Health Organisation (WHO) amendment to the International Health Regulations (2005) that the period of protection afforded by yellow fever vaccination, and the term of validity of the certificate, will change from 10 years to the duration of the life of the person vaccinated.

These changes will be implemented as part of the new Biosecurity Act 2015 that takes effect on June 16. Vaccinated individuals who are travelling to yellow fever-declared countries, and who are due to have a booster vaccination before June 16, are not required to do so for health protection purposes. www. health.gov.au

recently been ED of the WA Drug and Alcohol Office. såDr Michael Winlo has been appointed CEO of Linear Clinical Research, the clinical trials arm of the Harry Perkins Institute.

Michael is a graduate of the UWA medical school and has been in the US for the past six years.

såAt the recent elections of the Royal Australasian College of Physicians (RACP), Curtin public health academic A/Prof Linda Selvey was voted president of the Australian Faculty of Public Health Medicine. The new college president is Dr Mark Lane from the New Zealand branch.

såHBF CEO Rob Bransby has called off his move to the CEO’s job at Perth Racing.

Given the volatility of the private health insurance sector, it will be welcomed by many in the industry.

såMr Neil Guard is the new CEO of mental health NGO Richmond Wellbeing taking over from long-serving CEO Mr Joe Calleja who has retired. Neil has most

såMs Mary Macnish, the Manager, Health and Human services from AGPAL is now based at WAPHA’s Rivervale office.

10 | MAY 2016

såMs Clare Mullen is the new manager of the Perth North PHN.

Woollard charges dropped The WA State Administrative Tribunal has told the Medical Board of Australia to drop a complaint against former AMA boss Dr Keith Woollard because he would not be in a position to defend himself against amended and new allegations brought against him 10 years after the board’s initial complaint in 2005. SAT ruled critical events had taken place in the decade since the patient died, which meant Dr Woollard could not mount a defence. Australian Doctor reported that SAT also criticised AHPRA’s handling of the complaint, saying it had not explained or justified the delay in bringing the complaint, which was so prolonged it was unreasonable.

såNews of the deaths of retired ophthalmologist Dr Gordon Bougher and retired Aboriginal health physician and academic Prof Neil Thomson has reached us. Dr Bougher was a great supporter of the John Fawcett Foundation’s work in Indonesia and Prof Thomson helped establish ECU’s Australian Indigenous HealthInfoNet. såThe Australian College of Rural and Remote Medicine (ACRRM) admitted as Fellows WA’s Dr John Van Bockxmeer and Dr Cheryl Choong, from Queensland. såDr Casey Whife is the 2016 Cynthia Bantham Burn Research Fellow supported

by The Ian Potter Foundation. She will be investigating how neuroplasticity relates to burn injury rehabilitation.

MEDICAL FORUM

Have You Heard?

More sell-offs at PHC Last month we reported the board entrances and exits and share buy-ins at Primary Health Care, which by the way lost its court case to force Primary Health Networks to change their names. This month its news of it selling its Medical Director software to a private equity firm for $155 million. The sale should be finalised by the end of June. Takeover, perhaps, in the wind? PHC’s WA interests – eight medical centres, four imaging site and Western Diagnostic– will be watching and waiting.

NEW SPECIALIST MEDICAL CENTRE AT VASSE

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Room to move For those growing older who require EVLA laser treatment for varicose veins (most of which can be done in the doctor’s rooms), coverage by private Health Funds leaves much to be desired. If you use a private hospital’s theatre, staff, anaesthetist and a no gap surgeon you’ll face a relatively small payment thanks to health insurance. But perversely, if you want to avoid hospitalisation and a GA, the option of EVLA in the Doctor’s rooms can leave you over $3000 out of pocket and health insurance pays nothing.

­

The Grattan Institute sailed itself into tricky waters with a clumsy headline grab which for all the world sounded like GPs alone were failing their patients who had chronic conditions. Worse still, its report, Chronic failure in primary care, was released just three weeks before the Prime Minister announced the Government’s major reforms into chronic disease management, which neutralised the Institute’s position entirely. It may have made them look relevant to the friendly few for a few short weeks and it did get some national media, but the ideas in the report were not new and were superseded by the Government’s reform package, Healthier Medicare, which will give people with chronic conditions a health package coordinated by their GP. It also funds PHNs to smooth those health pathways.

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MAY 2016 | 11

Close-Up

The Big Wide World of Medicine Becoming a doctor at 37 has inspired and motivated Dr April Armstrong to not only heal the sick but to also make her mark in the business world.

April with GP trainee Dr Marzieh Farajian

Kalgoorlie GP Dr April Armstrong took a mighty leap of faith in 2002. The 31-yearold single mother of three girls, the eldest 12 and the youngest just three, was accepted into the UWA medical school after a decade of working in and around the ďŹ nancial and business sectors.

The path was anything but smooth. Having been raised in the Wheatbelt, April had decided to go to agricultural college and did not have the TEE required for university admission. So in her late 20s, with babies in tow, she returned to secondary school to do Years 11 and 12. The drive to become a doctor was strong. â&#x20AC;&#x153;I wanted a career that was interesting, varied, academically and socially challenging but also rewarding. I had worked in about 30 odd jobs before I was 30 where Iâ&#x20AC;&#x2122;d only stay for a few months because I got bored. Going into medicine, which was six years of full-time study plus two years to get there, was putting a lot of eggs in one basket,â&#x20AC;? she said. â&#x20AC;&#x153;But Iâ&#x20AC;&#x2122;ve never regretted it. Medicine is everything Iâ&#x20AC;&#x2122;d hoped. It opens a lot of different doors and offers endless career pathways once youâ&#x20AC;&#x2122;ve got your medical degree.â&#x20AC;?

Heading to the GoldďŹ elds Aprilâ&#x20AC;&#x2122;s tenacity and entrepreneurial spirit was on full display when she was scouting for an advanced DRANZCOG training site. She had put her name down for Swan Hills and Nickol Bay when she received a call from the MD of Albany hospital offering her a position in Kalgoorlie as there was a chronic shortage of / 'ĂĽDOCTORSĂĽTHERE â&#x20AC;&#x153;I had family connections in Kalgoorlie so off I went. I didnâ&#x20AC;&#x2122;t have a training place in the practice where I started so I took up an offer

12 | MAY 2016

to buy an established practice in the town with the understanding that the previous owner would stay on for 6-8 months to support me while I completed my training. I think I was the ďŹ rst GP registrar to own my own practice.â&#x20AC;? â&#x20AC;&#x153;Before I got my fellowship I bought a third share of a second practice in Mandurah.â&#x20AC;? â&#x20AC;&#x153;I have a good head on my shoulders for business and buying a practice from someone who had owned it for 18 years and would mentor me was a great opportunity to watch and learn.â&#x20AC;?

Practice in Kalgoorlie ticks all of Aprilâ&#x20AC;&#x2122;s boxes nĂĽTHEREĂĽISĂĽAĂĽGREATĂĽNEEDĂĽFORĂĽ/ 'ĂĽSERVICESĂĽANDĂĽ the medicine is challenging. â&#x20AC;&#x153;I love the continuity of care working in a regional community and the fact people say hello to you in the street. I have also built a successful business in 2½ years with 6800 patients on my books from a population of 23,000, that speaks for itself,â&#x20AC;? she said.

Head for business Her business acumen caught the attention of the judges of last yearâ&#x20AC;&#x2122;s Telstra Business Womenâ&#x20AC;&#x2122;s Awards. April won the WA Start-Up Award. Her move into Mandurah has made an impact. â&#x20AC;&#x153;Mandurah has always had a shortage of / 'ĂĽSPECIALISTSĂĽSOĂĽ'0ĂĽSPECIALISTSĂĽHAVEĂĽ picked up that role over the past 25 years.

The city is slowly diversifying and becoming MOREĂĽPOPULARĂĽFORĂĽSPECIALISTĂĽ/ 'SĂĽnĂĽ+ALGOORLIEĂĽ will probably never have the population base to attract many specialists. For both centres, HAVINGĂĽ'0SĂĽMOVEĂĽINTOĂĽTHEĂĽ/ 'ĂĽAREAĂĽISĂĽAĂĽWAYĂĽ of closing the gap and offering exceptional services with continuity of care.â&#x20AC;? â&#x20AC;&#x153;I can also refer GoldďŹ elds patients to Peel Health Campus and my Mandurah practice, either for direct or shared-care services.â&#x20AC;?

When Medical Forum caught up with April, a difďŹ cult feat in itself, she was waiting to board a plane in Brisbane to return home to Kalgoorlie after ďŹ nalising her accreditation with the Australian College of Rural and

Dr April Armstrong with practice manager Ms Nazum Saheb

Remote Medicine (ACRRM) to examine overseas trained doctors.

IMGs need our support She is well placed to comment on the role these doctors play in regional and remote WA. â&#x20AC;&#x153;There are only four Australian-trained GPs working in the GoldďŹ elds area out of a total of 36, so we really have a major issue with locally trained graduates coming out here to work. And that puts IMGs under pressure because they and their patients lose networking opportunities,â&#x20AC;? April said. â&#x20AC;&#x153;Having been trained in WA, thereâ&#x20AC;&#x2122;s a good chance that if I have to ring a city hospital, I will know the person who answers the phone just by going through the local training process. I also know who to call if I have a problem. IMGs, with all good intentions, donâ&#x20AC;&#x2122;t have that kind of network.â&#x20AC;? â&#x20AC;&#x153;They work very hard, their pay is substantially lower than locally trained equivalents, the conditions of employment are not regulated and nor is their training. Standards have improved over the past few years because of community pressure rather than professional inďŹ&#x201A;uence. Itâ&#x20AC;&#x2122;s not the IMGsâ&#x20AC;&#x2122; fault, itâ&#x20AC;&#x2122;s the fault of the system.â&#x20AC;? â&#x20AC;&#x153;We have two overseas-trained doctors in our practice, one from India the other from Iran.

I made a decision that I would employ IMGs who had a long-term interest in the viability of regional community medical practice. Both have taken on semi-specialist roles â&#x20AC;&#x201C; one in child health and the other in palliative and aged care, both areas of need within the region.â&#x20AC;? â&#x20AC;&#x153;And both doctors have proven their longterm commitment to regional WA. One has been in Kalgoorlie for three years and has started her family here and the other comes to us from ďŹ ve years in Karratha.â&#x20AC;?

The attraction for them, like April, is being a vital part of a community that needs them.

By Ms Jan Hallam

MEDICAL FORUM

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MAY 2016 | 13

Spotlight

Jazzing it Up A close brush with cancer has given Perth jazz musician Graham Wood a new appreciation for his artform and he wants to share it with everyone.

“2013 was a bad year for me. I was diagnosed with cholangiocarcinoma, an aggressive form of cancer more common in people over the age of 60. They removed half my liver, reconstructed my bile ducts and I spent a couple of months in hospital. And then it was another four months recuperating at home.”

students engage with new technology, it certainly nly gives them access to a mass of information.”

“I’ll be an outpatient for many more years to come.”

Jazz in the city

“There’s no history of cancer in my family. The doctors told me I was just bloody unlucky and it was one of those things that life dishes up.

It was a difficult time but I was looked after incredibly well at RPH.” Occupational hazards Graham’s PhD topic had a medical slant focusing on injuries linked with musical performance.

“I was interested in the pressures associated with playing a musical instrument and did some research on jazz pianists. It’s hardly surprising that problems such as tendonitis and thoracic outlet syndrome tend to crop up when you spend a lot of time sitting in a position that’s relatively unnatural.”

“When you’re playing piano the muscles in the hands and fingers are used in highly specific ways and it can be quite debilitating. Some people have to quit the instrument and that’s a real tragedy.”

When Graham’s not composing his own music he’s teaching others to do the same.

“I’ve taught jazz piano at WAAPA for quite a while and I’m Associate Dean of Teaching.

It’s an interesting and enjoyable role that embraces not just music but also the broader curriculum. It’s interesting watching young

14 | MAY 2016

“Nonetheless, you have to live with music in an intimate way if you want to have any hope of mastering it. You can have 160,000 songs on your iPhone but from a deep listening perspective most people can only fully absorb three or four albums.”

The month of June is particularly busy for Graham who, apart from his WAAPA duties, is the co-owner of Ellington’s Jazz Club and the brain-child behind the Perth International Jazz Festival. The funk and groove will embrace the city with performance spaces in Brookfield Place and Elizabeth Quay.

“We’re really focusing on appealing to a broad audience and some of the acts are just wonderful. The Yellowjackets from the USA are a well-known jazz fusion group; Hiatus Kaiyote is a neo-soul outfit popular with a younger crowd and Stu Hunter heads up a 10-piece band containing the crème de la crème of Sydney’s jazz musicians.”

“There’ll be more than 50 performances, many of them free to the public.”

Graham was a music student in the late 1980s through to the early ’90s and that’s reflected in his own jazz favourites.

“I’m always partial to some chilled-out Miles Davis, Oscar Peterson, Keith Jarrett and Herbie Hancock. And if I had to pick a ‘Desert Island Disc’ it would probably be Miles Davis’s Kind of Blue.”

By Mr Peter McClelland ED: The Perth International Jazz Festival runs June 3-5.

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MAY 2016 | 15

Feature

Health Boards Ring in the New Era The potential for real reform puts serious expectation on the five new health service boards so who will be sitting on them will make or break the grand plan.

The clock is ticking down the start of a new era in WA’s public health system.

On July 1, the five new area health services’ boards of governance will begin overseeing the smooth and safe running of our public hospitals.

But more is expected of this sizeable reform, which has required significant legislation to go through the State Parliament. The Deputy Director General of Health, Ms Rebecca Brown, spoke to Medical Forum to give readers some insight into the reasons for and the expectations of the changes.

This reform has been a long time in the planning, which has seen WA Health seek out other jurisdictions, especially NSW and Queensland, which have already undergone similar transitions, to discover what worked and what Ms Rebecca Brown didn’t especially in the start-up phase. The message delivered loud and clear was how critically important it was to find the right mix of skills and experience on the boards of governance.

“Getting the right calibre of people on the boards is vital. Research was clear on the importance of investing heavily in recruiting [in terms of time] and a rigorous induction process so the boards are set up for success,” Rebecca said.

Health professionals represented Legislation, which was introduced into Parliament in February, requires the composition of the six-to-10-member boards to include three health professionals (two must be practising) and others with broader skills from legal finance, HR, risk and audit, and previous board of governance and executive experience.

It looks like there’s a lot of homework involved with induction focusing on areas of public sector governance and auditing, health system mechanics and risk and safety issues.

While interim chairs are likely to be made permanent (see list P10), the final make-up of the boards was not expected to be finalised until late April after MF went to press.

Board remuneration down the line Remuneration details are posted on WA Health’s website – board chairs will receive

åAåYEARåANDåMEMBERSå

åWHICHå is consistent with WA public sector policies and guidelines.

Rebecca said appointment terms were up to three years with no more than three terms.

“It was considered the best time period to enable board members to perform a role effectively but also allow the board to be refreshed. Of course, we may consider staggering the first appointments so that boards don’t lose continuity. Obviously if a board member at any stage needs to step down, we will go through the same statutory process ending in a ministerial appointment.”

Legislation will establish the legal framework for the establishment of the South, North, newly formed East, WA Country and Child å!DOLESCENTåHEALTHåSERVICESåWHEREBYåTHEå boards will enter into a service agreement annually with the Director General (DG), This agreement will set out the funding each body will receive and how and what services they will deliver.

“There is still a relationship between the department and the boards, just as there is still a relationship between the department and the Minister and the boards and the Minister,” Rebecca said.

Who is ultimately responsible “In terms of where the buck stops, the DG has responsibility for the overall performance of the system by ensuring there is the right oversight and system direction, but obviously the Minister has powers to replace board chairs and members.”

“If a board is not performing, the DG can undertake inquiries, investigations and audits, as can the Minister, who can appoint an adviser or administrator. There are clear roles for the boards and for the DG, with legislation as a fall-back to give overall assurance for the effective operation of the system.”

Such a dramatic change in how health services are governed may seem like a massive cultural change, but Rebecca suggests it is more a case of logical evolution.

“If we reflect over the past 10-15 years, there

16 | MAY 2016

have been significant changes to the health system. The clinical services framework was and still is a critical building block of the system in terms of outlining what services are delivered where. The recent investment in infrastructure has been critical and this change to governance is the next stage of investing in how we run the business.”

“The health services themselves are very large now, and while they haven’t operated autonomously, they have come to recognise themselves as separate services, while the creation of East will bring a new identity there. The change is about giving a new level of governance and coaching to them all that will not only support the administrative teams but also the clinical community and the community more generally.”

Handing back some authority “We talk about the system, in its entirety, being too big for one person in Royal St to manage. This evolution will bring more autonomy and authority to the system.

Experience elsewhere suggests that complete transition can take a couple of years and all the CEOs have been kept informed because it’s their job to deliver services to the community every day.”

While the governance may be streamlined, the pertinent question is what will the changes mean for the consumer?

Rebecca said that it was an opportunity for better patient pathways between hospital and primary care.

“It is the key benefit of these reforms. Local boards can build those local networks and work with primary care in particular. Even within the boards’ composition there has been a strong focus to build on community networks. Patients in other jurisdictions have continued on Page 20

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MEDICAL FORUM

MAY 2016 | 17

Feature

Living in a Barbie World The increasing popularity among women to seek out genital nips and tucks is creating healthy business but is it a symptom of an unhealthy society?

No one seems especially surprised that female genital cosmetic surgery (FGCS) is becoming increasingly popular among Australian women, just take a look at this monthâ&#x20AC;&#x2122;s e-Poll on the topic â&#x20AC;&#x201C; nearly 60% of the 215 doctors responding to our survey are on the money.

We know from Medicare ďŹ gures that rebates for labiaplasty and vulvoplasty have risen from 640 claims in 2000-01 to 1565 in 2010-11 but these, of course, represent only those women whose doctors deemed the procedures a medical necessity. How many women went private is anyoneâ&#x20AC;&#x2122;s guess but anecdotally it is a signiďŹ cant number.

Survey asks why surgery A national survey with Australian Research Council funding is seeking some cause why so many women with healthy genitals are seeking to cosmetically modify them.

Dr Maggie Kirkman, PhD, from the Jean Hailes Research Unit, was part of the project which quizzed 5000 women from Perth to Penrith along with surgeons, nurses and beauty therapists about their views on their bodies and what they considered was normal or abnormal.

The researchers also analysed the portrayal of womenâ&#x20AC;&#x2122;s genitals on the internet and social media.

While a report is still a while off, Maggie said there was a long history of psychology surrounding genital cosmetic surgery and the research focused in on the psycho-social aspects. â&#x20AC;&#x153;Womenâ&#x20AC;&#x2122;s genitals have been an issue of ACADEMICĂĽSTUDYĂĽFORĂĽDECADES ĂĽ)NĂĽTHEĂĽ SĂĽ women were encouraged to explore their own bodies with some intimacy but it wasnâ&#x20AC;&#x2122;t for everyone and many women didnâ&#x20AC;&#x2122;t, nor could they see themselves easily. Then along came the era of the Brazilian wax and everyone could see everything about themselves and some were shocked at how genitals differed so extensively woman to woman.â&#x20AC;?

Female Genital Cosmetic Surgery

e-Poll

215 responses from GPs & Specialists Are you aware demand is increasing for genital cosmetic surgery among Australian women?

Yes

59%

No

30%

Uncertain

11%

The â&#x20AC;&#x2DC;Ipanema Effectâ&#x20AC;&#x2122;

Impact of pornography

While women have been removing body hair, including around genital areas in some cultures, since ancient times, the Brazilian has become a world-wide and routine treatment SINCEĂĽ ĂĽWHENĂĽTHEĂĽSEVENĂĽ0ADHILAĂĽSISTERSĂĽFROMĂĽ Brazil opened a salon in Manhattan.

It is these very qualities graphic artists employed in pornographic magazines are paid to Photoshop to marble Venus-like perfection. Womenâ&#x20AC;&#x2122;s magazines do their share of perpetuating the aesthetic with the vast majority of images depicting the female pubic area as ďŹ&#x201A;at or a smooth curve.

Perhaps, more potently, it has helped feed insecurities as to how an individual womanâ&#x20AC;&#x2122;s genitals did or didnâ&#x20AC;&#x2122;t conform to an aesthetically pleasing â&#x20AC;&#x2DC;normâ&#x20AC;&#x2122;. Just how that â&#x20AC;&#x2DC;normâ&#x20AC;&#x2122; is determined is as diverse and complex as it is longstanding.

The contemporary pornography industry is often cited as being one of the greatest inďŹ&#x201A;uences on shaping what it is considered the ideal set of genitals â&#x20AC;&#x201C; men are not excluded in this either.

The Hailes researchers, led by Ms Hayley Mowat and Dr Karalyn McDonald, published a paper in BMC Womenâ&#x20AC;&#x2122;s Health last year which asserts that the â&#x20AC;&#x153;Practice of FGCS appears to be underpinned by the desire for a particular homogenous genital aesthetic, namely a â&#x20AC;&#x153;tightâ&#x20AC;? vagina and â&#x20AC;&#x153;clean slitâ&#x20AC;? or â&#x20AC;&#x153;Barbie Dollâ&#x20AC;? vulva, in which the labia minora are not visible.â&#x20AC;?

And donâ&#x20AC;&#x2122;t think the Government doesnâ&#x20AC;&#x2122;t have something to say on the matter. Australian censorship and print publication guidelines dictate that the inner labia must not protrude beyond the outer labia.

So genital diversity has a problem on a number of fronts!

Maggie said that doctors, because they are card-carrying members of the world and are exposed to the same cultural discourses as their patients, often are unaware of genital diversity. â&#x20AC;&#x153;Plastic surgeons are signiďŹ cantly more likely than other doctors to regard larger labia minora as distasteful and unnatural,â&#x20AC;? she told Medical Observer. continued on Page 21

18 | MAY 2016

MEDICAL FORUM

Feature

Would a Sugar Tax Work Here?

The UK Parliament has just passed a Sugar Tax. Two UK public health physicians have been in Perth to discuss the idea here but it could be long time coming.

After the UK recently passed a Sugar Tax on soft-drinks, celebrity chef Jamie Oliver urged Australia to ‘pull its finger out’ and follow suit.

Prof Jeff Collin It’s a complex issue ranging from opaque entanglements within the commercial sector to a general reluctance at the government health policy level to rock the corporate boat.

Jeff Collin is Professor of Global Health Policy at Edinburgh University with a strong interest in global governance and the inextricable links between Big Business and its promotional strategies relating to tobacco, alcohol, food and beverages. Jeff was in Perth to talk to consumers and health professionals last month at the Telethon Kids Institute.

“The implications for public health policy relating to non-communicable diseases (NCDs) are wide-ranging and profound. In the modern world, particularly in developing countries, virtually every piece of legislation relating to the formulation of health policy has some level of engagement with the commercial sector.”

“Tobacco is a case unto itself because, even in this murky world, it has become something of a pariah industry. Nonetheless, there are strong conflicts of interest involving food, beverage and alcohol companies and their push to increase market share at the expense of positive health outcomes.”

Political pressure on governments “That degree of involvement ranges from the connections between Coca Cola and its research funding in Australia to British Tobacco (BT) as a major investor in

Uzbekistan. It’s interesting, to say the least, that BT has secured the right to veto any item of health legislation for the duration of the investment period.”

While Jeff concedes it can be a difficult task to wade through this moral quagmire, he argues that we can all learn by casting a critical eye at tobacco.

“Some of the lessons regarding models of health governance are transferable when you apply them to the marketing of sugar-laden drinks. In the UK debate on a Sugar Tax, the health objectives eventually prevailed over competing self-interests.” [A levy will be imposed on drinks containing more than 5g of sugar per 100 millilitres, albeit with a twoyear lead time, in an effort to reduce spiralling childhood obesity levels.]

“In an ideal world these unhealthy industries would have no role in the formulation of public health policy. Nonetheless, companies such

as Coca Cola, SAB Miller and Pepsi are seen as legitimate partners within the WHO. There needs to be a new approach in governing the commercial determinants impacting on these profit-driven diseases.”

“Uzbekistan is a case in point. Some of these companies are making significant inroads into developing countries where a lack of transparency, ineffective legislation and dubious partnerships with politicians creates greater levels of opportunity compared with Western countries.”

Prof Martin Caraher

“Nonetheless, we need a strong push for collaborative partnerships on obesity control measures in countries such as

Health Boards Ring in the New Era continued on From 16 reported performance improvement because local boards have a more direct focus on issues around patient safety and quality.”

“We’re hoping to see shorter emergency wait times, more innovative ways in delivering clinical care, reduction in clinical risk. We anticipate boards will set up committees to focus on these areas which will bring other expertise to their oversight of the quality and safety framework in our hospitals.”

“When we see these kinds of performance benefits that focus on the patient, we generally see improvement in financial performances.”

20 | MAY 2016

Royal St future So while the service boards get ready to enact the reforms, what will the team at Royal St be doing?

“The department will become system manager with strategic oversight, monitoring the performance of health services and setting policy directions for the medium and long term. It will also continue to provide a critical role in system assurance,” Rebecca said.

duplication between the department and the health services.

“Certainly the DG has been clear that if there is something that affects the delivery of health services, it will be performed in the health services, not in the department.”

This may lead to redeployment of some staff but staff losses are not anticipated.

By Ms Jan Hallam

She added that as the legislation settled, there was scope to identify and remove MEDICAL FORUM

Feature

Australia and the UK. The big picture remains a scary one.”

The commercial strategies embedded within the food and drink industry are sophisticated and well-targeted, says Prof Martin Caraher, current Healthway Research Fellow on secondment to Curtin University from City University in London. Martin has an interesting take on the populist approach, such as the recent Australian movie That Sugar Film.

“It’s a real problem if the issue is located, as some of these films tend to be, at an individual level of responsibility. It’s much more complex than that. There needs to be more recognition that a push for a Sugar Tax is less about the public health system acting as some sort of Nanny and much more focus on the fact that commercial interests wield an inordinate amount of influence.”

‘But there does need to be some level of protection at the public health level because the default position of the soft drink companies is insidious.”

Incentives vs penalties Martin expands on the analogy between the ‘carrot and stick’ and subsidies and taxes. He also makes the point that the former works well within a closed system, such as a school, while the latter need to have a clearly defined purpose that’s not aimed exclusively at the consumer.

“In Australia the GST isn’t imposed on fruit and vegetables and that’s a subsidy of sorts.

More specifically, any form of ‘carrot and stick’ is more easily implemented in a canteen or school tuck-shop. The ‘stick’ is applied to all sugary drinks within the UK school system where they’re banned but the Australian context is quite different. There are no school meals here, for example.”

Oliver has been successful in promoting debate on the Sugar Tax, which is now going to happen, but it needs to be supported by restrictions on food and beverage marketing, particularly on the way young children are targeted.”

Softly, softly slows impact “We’re also keen to see more detailed policy strategy. The Sugar Tax will push up the cost of a standard bottle of soft drink by 25p, which is not a lot. In fact, many would argue that it’s not enough and current arguments suggest that to make an impact the tax needs to be pretty significant. Global studies indicate that to be really effective you need to be talking in the order of 20%, which is also the figure recommended by the Obesity Policy Coalition (OPC) in Australia.”

“The figures from Brazil are interesting. A tax hike of 12% on sugary drinks in that country resulted in a decrease in consumption between 10-20%, and the latter figure was specifically from low-income communities.”

“And that’s significant because it’s the very demographic that accounts for disproportionately higher health costs.”

Martin, who has worked in the NHS public health system for 30 years, said the welfare concerns of the disadvantaged were important.

“In a negative sense we’re five years ahead of you, so the Sugar Tax is timely. But I’m noticing distinctly similar patterns such as the growing preponderance of highly processed foods in Australian supermarkets.”

Nutrition and Physical Activity Manager at Cancer Council WA Steve Pratt said the council strongly supported the introduction of a Sugar Tax in Australia.

“There is a ‘traffic light’ system in local schools that has an educative role but, generally speaking, there is less of the ‘stick’ in Australian schools compared with the UK.” Schools, soft drinks and free lunches in the same sentence? Enter, Jamie Oliver.

“It’s great that some of these food celebrities are raising the profile of this issue. But it’s also unsurprising that the formulation of effective policy is a little more problematic. Jamie

Steve Pratt

“There’s compelling evidence from countries such as Mexico and the US that it would have the dual benefits of raising revenue and reducing consumption of sugary drinks. It’s also been shown that a modest increase in costs associated with container

deposit schemes lead to a reduction in softdrink intake.”

The WA Labor Shadow Minister for Health, Roger Cook, applauds some of the potential benefits of a Sugar Tax. Given the sophisticated Roger Cook levels of lobbying that accompany this issue he questions the intestinal fortitude of the current government to make any significant changes.

“You could envisage two positive impacts if a Sugar Tax were imposed. First, a reduction in sugar consumption and that would have the flow-on effect of lessening the burden of diabetes and cardiovascular disease.”

“But, perhaps more importantly, a tax would provide more resources to improve the health literacy of the wider population. It’s so important that we continue to educate people about the importance of reducing the amount of sugar in their diet.”

“More broadly, I don’t think our political system is robust enough to deal with the impact of the lobbying that would flow from larger business interests. I don’t hold any great hope that we’ll have a Sugar Tax anytime soon.”

By Mr Peter McClelland

Sweeteners så MLåOFå"UNDABERGå'INGERå"EERå contains more sugar (10.8g) than Coca Cola. så 3OFT DRINKSåAREåTHEåLARGESTåSOURCEåOFå sugar (~20%) in children’s diets. så !Nå/0#åSURVEYåOFå!USTRALIANåSHOPPERSå revealed 85% supported a Sugar Tax if the revenue was used for childhood obesity programs. så /0#åESTIMATESåAå3UGARå4AXåCOULDå result in ~ 16,000 fewer cases of Type 2 Diabetes in Australia.

Living in a Barbie World continued on From 18 A quick internet survey of medical practitioners in WA who perform vaginal “rejuventation” shows a professional approach to educating women on what the procedures entail but they all start from the premise that something needs fixing.

Normalising surgery Maggie sees this as not only promoting FGCS but normalising its results.

“On YouTube there are videos posted by surgeons seeking patients with before and after galleries and dedicated online health message boards where opinions and experiences of patients are shared,” she said.

MEDICAL FORUM

The BMC report suggest that given many women’s reluctance to discuss concerns about their genitalia with their doctors, the anonymity afforded by the internet might make it an even more powerful reference point for those considering FGCS. In 2008, RANZCOG released a statement discouraging FGCS in the absence of good evidence and in 2013 the Australian Federation of Medical Women published a similar caution.

However, evidence alone will not change culturally welded values. Maggie recounts a sobering anecdote.

“There is a case study in the literature of a mother who took her prepubertal daughter to a doctor because one labia minora was protuberant. The child was referred to a surgeon and it was removed. At puberty the same happened to the other side. Here was a woman who has been socialised to believe women should not have visible genitals. We all exist in a strongly gendered society where there is a clear binary understanding of what men and women should be like and what roles they play.”

We haven’t come as far as we thought.

By Ms Jan Hallam MAY 2016 | 21

22 | MAY 2016

MEDICAL FORUM

Feature

Nickâ&#x20AC;&#x2122;s Pokies Fight Continues When the trail of destruction from poker machines led to the door of Senator Nick Xenophonâ&#x20AC;&#x2122;s legal practice, he decided to take decisive action.

The independent Senator for South Australia, Nick Xenophon, is well known for his stance on poker machines. Itâ&#x20AC;&#x2122;s an issue that propelled him into politics and it remains one of his key platforms.

Andrew Wilkie as a fellow-traveller on an anti-Pokie platform. We put forward a number of different proposals but we shouldâ&#x20AC;&#x2122;ve gone for a simple model such as limiting the stake of each pull to a $1 bet. The industry out-muscled us, thereâ&#x20AC;&#x2122;s a huge infrastructure of self-interest, and we didnâ&#x20AC;&#x2122;t get a very sympathetic ear from Tony Abbott.â&#x20AC;?

â&#x20AC;&#x153;I was literally minding my own business as a personal injuries lawyer in suburban Adelaide when I began to see more and more people coming into my practice who were suffering the consequences Nick Xenophonâ&#x20AC;&#x2122;s of the introduction of poker machines in clubs and hotels. There had already been problems caused by casinos and the TAB but they rose exponentially with the increase in the number of these machines.â&#x20AC;?

â&#x20AC;&#x153;There have been been some encouraging signs from Malcolm Turnbull but the poker machine lobby is incredibly powerful. A recent Productivity Commission report estimated that around 40% of poker machine proďŹ ts come from the proďŹ ts of problem gamblers.â&#x20AC;?

â&#x20AC;&#x153;The tipping-point for me was an individual who had a brain injury and problems with alcohol. He broke down in my ofďŹ ce when he told me heâ&#x20AC;&#x2122;d lost his entire compensation payout of $30,000 on poker machines. On some occasions he said he was so intoxicated that heâ&#x20AC;&#x2122;d ask staff to help him push the buttons.â&#x20AC;?

Nick says these stories are played out in doctorsâ&#x20AC;&#x2122; surgeries every day but also argues that medical practitioners have an important role to play.

â&#x20AC;&#x153;This is a predatory industry and itâ&#x20AC;&#x2122;s causing a lot of harm.â&#x20AC;?

Nick argues that politicians are part of the problem. He decided to join the political fray in the hope of effecting change from inside the system.

Politicians turn a blind eye h)NĂĽ ĂĽ)ĂĽRANĂĽFORĂĽAĂĽSEATĂĽINĂĽTHEĂĽ3OUTHĂĽ!USTRALIANĂĽ,EGISLATIVEĂĽ#OUNCILĂĽ largely to make a point. How can a government sit back and watch peopleâ&#x20AC;&#x2122;s lives being ruined in the name of entertainment? These machines devour $1200 an hour!â&#x20AC;?

â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s a litmus test for good government. If those holding the political reins are prepared to sacriďŹ ce their citizens on the altar of gambling then what else are they capable of? Weâ&#x20AC;&#x2122;re talking about depression, family break-up and suicide.â&#x20AC;?

â&#x20AC;&#x153;Doctors play a critically important part in identifying the problem and providing advice. But, sadly, only about 10-15% of individuals with a gambling problem ever seek assistance. Thereâ&#x20AC;&#x2122;s a program running in New Zealand in which GPs actively screen for this and it has been partially trialled here, too.â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ll always remember a conversation with a senior psychiatrist who said he was horriďŹ ed that â&#x20AC;&#x2DC;politicians would vote for something that increases the level of mental illness in the communityâ&#x20AC;&#x2122;. If any political group started talking about introducing poker machines in WA doctors should be at the forefront in resisting it.â&#x20AC;?

By Mr Peter McClelland

â&#x20AC;&#x153;Ten years later I entered federal politics with Tasmanian Independent

e-Poll

See p25

The Odds are Stackedâ&#x20AC;Ś Gambling, or its ofďŹ cial euphemism, gaming, has been around since Adam was a boy. And for the equivalent amount of time there has been some form of authoritarian control over it with varying degrees of success.

In WA, the Government has kept the pokies out of pubs and club but is controller of one of the stateâ&#x20AC;&#x2122;s largest gaming companies â&#x20AC;&#x201C; Lotterywest.

It is, of course a not-for-proďŹ t unlike its interstate counterpart, the Tatts Group, which is listed on the ASX. Last year, Lotterywest made $826.3m in sales, $463.4m went as payouts, while $282.9m went to the community including $121.6m to WA Health and public hospitals, leaving $80m on administration, of which marketing takes a sizeable chunk. Itâ&#x20AC;&#x2122;s a big business.

Where it becomes murky is when discussion turns to problem gambling or â&#x20AC;&#x2DC;gamingâ&#x20AC;&#x2122; and its link to poor health and social harm. There is mounting evidence that for those problem gamblers, often alcohol and substance abuse, family breakdown and unemployment follows.

So here are some facts: sĂĽ 4OTALĂĽRECORDEDĂĽEXPENDITUREĂĽ LOSSES ĂĽINĂĽ!USTRALIAĂĽREACHEDĂĽJUSTĂĽOVERĂĽ $19b in 2008-09, or an average of $1500 per adult who gambled. $12b of that was spent playing the pokies. (Australian Productivity Commission, APC) sĂĽ 4HEĂĽRISKSĂĽOFĂĽPROBLEMĂĽGAMBLINGĂĽAREĂĽLOWĂĽFORĂĽPEOPLEĂĽWHOĂĽONLYĂĽPLAYĂĽ

MEDICAL FORUM

lotteries and scratchies, but rise steeply with the frequency of gambling on table games, wagering and, especially, gaming machines. This is estimated to be about 4% of the Australian population. (APC) sĂĽ 0ROBLEMĂĽGAMBLERSĂĽLOSEĂĽABOUTĂĽ ĂĽAĂĽYEAR ĂĽ !0# sĂĽ 4HEĂĽSOCIALĂĽCOSTĂĽTOĂĽTHEĂĽCOMMUNITYĂĽOFĂĽPROBLEMĂĽGAMBLINGĂĽISĂĽESTIMATEDĂĽ TOĂĽBEĂĽATĂĽLEASTĂĽ BĂĽAĂĽYEAR ĂĽ !0# sĂĽ 0EOPLEĂĽWITHĂĽAĂĽGAMBLINGĂĽPROBLEMĂĽORĂĽATĂĽMODERATEĂĽRISKĂĽOFĂĽDEVELOPINGĂĽ ONE ĂĽVISITĂĽAĂĽ'0ĂĽ ĂĽTIMES ĂĽMOREĂĽTHANĂĽTHEĂĽGENERALĂĽPOPULATIONĂĽ ĂĽ times). (Victorian Responsible Gambling Foundation (VRGF) 2015 Study) sĂĽ ĂĽOFĂĽPROBLEMĂĽGAMBLERSĂĽDRINKĂĽWHILEĂĽGAMBLING ĂĽ 62'& sĂĽ ĂĽOFĂĽPROBLEMĂĽGAMBLERSĂĽHAVEĂĽDIAGNOSEDĂĽDEPRESSION ĂĽ 62'& The rise of online betting has thrown up its own set of statistics: sĂĽ !MONGĂĽNON PROBLEMĂĽGAMBLERS ĂĽ ĂĽWHOĂĽBETĂĽONĂĽSPORTSĂĽBETĂĽONLINE ĂĽ OFĂĽLOW RISKĂĽGAMBLERSĂĽ ĂĽBETĂĽONLINE ĂĽMODERATE RISKĂĽ ĂĽANDĂĽ PROBLEMĂĽGAMBLERSĂĽ ĂĽ 62'& sĂĽ )NĂĽ ĂĽ ĂĽOFĂĽLOW RISKĂĽGAMBLERSĂĽBETĂĽONĂĽSPORTSĂĽONLINEĂĽRISINGĂĽTOĂĽ ĂĽ in 2014; 30% of moderate-risk gamblers bet on sports online in ĂĽRISINGĂĽTOĂĽ ĂĽINĂĽ ĂĽ 62'& Communicare and Relationships WA both offer support services for problem gambling locally.

MAY 2016 | 23

e-Poll Feature

R is for Run! (and Revalidation) Revalidation struck a raw nerve with our 215 respondents of this month's e-Poll.

It's to be hoped the Medical Board listens.

In last month’s magazine we reported on the latest moves by the Medical Board of Australia to usher in a revalidation system for medical practitioners sooner than later. An ‘expert advisory group’ has been established and directed to report to the board by the end of the year on its preferred model.

“I valued the experience of Accreditation initially to prove to me that I was running a GP practice efficiently and…to an approved standard.

This was not the case on my 2nd and 3rd Accreditations (which I passed). This became less of a benefit to the practice and a more of an exercise to justify further Accreditation costs.”

Readers will know only too well how long this ‘spectre’ has been hanging over them. One of the reasons there has been such prevarication is that the Medical Board is trying to tackle two distinct problems with the one arrow – to keep doctors appropriately skilled and to identify incompetent or at-risk doctors. The first is addressed by the current system of CME and the second has been swept under the carpet and no one dares speak its name.

“Let a consensus of the profession decide not bureaucrats.”

General Practice accreditation has undergone similar discussions for the same reasons – a blunt instrument for different aims. Back in November 2013, GPs were asked if they believed that the majority of things required of practices undergoing accreditation were appropriately targeted to improve the quality of patient care – the entire point of accreditation; 53% said no while 16% were uncertain. This is an oft-repeated tale – what is said to promote patient safety and quality of care is wide of the mark. It is seen as more red tape, not meeting its goals and the result is doctors’ trust in the system is dented.

“Where are the examples that the standard of medicine needs improving? Has revalidation improved anything anywhere or is it a solution looking for a problem to solve? It is bureaucracy trying to prove its importance and it will not lead to an improvement in care.”

In this month’s e-Poll the vast majority of the 215 GPs and specialists did not think a revalidation scheme would improve standards.

What we’ve got, ’aint broke “Rather than revalidation, a better approach would be to ensure CME is completed in a more organised way with attached funding so that doctors keep up with the KPIs of Government…as well as the key components of the particular discipline.”

“I have just been through the time-consuming process of credentialling and I think revalidation will be another set of paperwork to plough through… I am involved in a College Maintenance of Professional Standards program and fail to see the need for revalidation.”

“Revalidation should be administered by the colleges, and required by the credentialing bodies.”

“Isn't CME the same thing? Every few years they change things by renaming it and we end up with committees to oversee the ‘new structure’ and charge doctors more for it!”

Do you think revalidation of doctors introduced by the Medical Board and enforced by AHPRA will improve the standard of medicine?

e-Poll

“Our colleges are leading the way: let's support their efforts, rather than duplicating them.”

Bureaucracy on steroids

Yes

14%

No

53%

Uncertain

33%

Comment When asked to comment, 86 doctors were eloquent in their choice of words (some we can print, some we can’t).

Here’s a selection: Systems, systems, systems “102,000 doctors in Australia. A quick calculation tells you that it will cost at least $10,000 per doctor per year (assuming 2 hours per week of data entry and process) in lost earnings. That’s a cool $1.02b per annum!

And will it identify the psychopaths or poor performers? Probably not!

Will it make the bureaucrats feel good? Yep. The 100 odd hours per year per doctor will of course be done in a doctor’s spare time; hence the bureaucrats will think it costs nothing. Hmm that’s two weeks per year lost to family time and time in the community. What a disaster.”

“The betting is it will cost us money and time, not produce any improvement in patient care but will be forced on us.”

“We are already doing accreditation every 3 years. CPD every 3 years.

You want to add another layer? What every 3 years?? Umm I might go mow lawns.”

“It will likely hasten retirement decisions. In some situations this is probably a good outcome. For medical services and practices relying on regular, experienced locums to maintain rural services and sustainable on call rosters for resident staff, it will likely be a bad outcome.”

“By the time we know whether it was worthwhile, we'll all be dead.

AHPRA enforcement is a very scary concept.”

24 | MAY 2016

“What, add another layer? For the money of course!”

“Until the colleges, who monitor performance at a peer level, can agree on how to ‘revalidate’ a doctor's capacity to perform after X years of practice, AHPRA should butt out. Yet again, bureaucracy and faceless men/women taking control of clinical governance and emasculating senior/experienced clinicians who should be the guardians of medical practice.”

“Why aren't the bloody lawyers similarly targeted?”

“It means that unless doctors submit to costly and regulated lectures and educational programs they cannot stay registered. Their wealth of experience is lost. 99% lose the opportunity of continuing to practise to catch out perhaps 1% who should retire for medical or other reasons. That's bureaucracy!”

“If AHPRA is involved there will be tears.”

“As a professional group we should not be handing over our credentialing to the bunch of morons known as AHPRA (or indeed any bunch of morons).

Bring it on “Would support a process where key domains are identified to reflect scope of practice and then clinicians could demonstrate lifelong learning and evidence of how they contribute, depending on where they are in their career.”

“Most doctors I have worked with in the past 35 years are good.

However, I could name who were hopeless or dangerous.”

“Doctors are good at getting around hurdles without jumping over them.”

“Some form is necessary to maintain high standards but it is a big challenge regarding how to do it effectively and not make it unacceptably onerous and potentially unfair. It is surprising to me how MEDICAL FORUM

e-Poll Feature

many doctors appear uninterested or unwilling to keep themselves up-to-date and as effective as they can be.â&#x20AC;?

still depends on ethical behaviour, which is difďŹ cult to measure and enforce.â&#x20AC;?

â&#x20AC;&#x153;It is essential. With OTD we see there is a huge gap in ethical behaviour and knowledge.â&#x20AC;?

â&#x20AC;&#x153;Medical students learn to jump the hoops to pass. Interns and residents learn the tricks to stay on top of the workload. Registrars learn to shut their mouths in front of their consultants. All doctors try to learn how to duck or manipulate the bureaucracy. Will revalidation improve the standard of medicine? Given the profession's history, I doubt itâ&#x20AC;?.

Wrong direction â&#x20AC;&#x153;If the aim is to weed out incompetent doctors, this will be as ineffective as CPD because it is not lack of knowledge but lack of perspective, insight and communication skills that are usually the problem.â&#x20AC;? â&#x20AC;&#x153;No amount of the current form of revalidation will make much difference to doctors who are poorly-trained in the ďŹ rst place. A lot

This monthâ&#x20AC;&#x2122;s e-Poll has canvassed a wide range of issues but we have been ďŹ&#x201A;ooded with responses to our questions on revalidation and Health IT, so many that we will publish the IT responses next month.

We had 215 responses to this survey and we thank all those who took the ďŹ ve minutes on average to complete it. The winner of our e-Poll wine prize is Dr DM.

WA Health receives $120m from the proceeds of gambling each year. Is this ethically acceptable to you?

Yes

41%

No

30%

Perhaps

20%

Uncertain

9%

ED: Nearly a half the doctors were relaxed about the amount Lotterywest feeds into the health system. Last year it made $826.3m in sales â&#x20AC;&#x201C; $121.6m of that was granted to WA Health and public hospitals. Lotterywest is a NFP statutory body and stands apart from its Eastern States counterpart Tatts Group, which is a private company listed on the ASX.

Are there cost savings to be made by restricting some tests and/or procedures (without damaging patient care)?

â&#x20AC;&#x153;Revalidation will entrench overservicing as everyone struggles to make sure they did not forget some obscure test or expensive new drug.â&#x20AC;? â&#x20AC;&#x153;I have experience in the UK of being revalidated. It is a waste of time and will not weed out unsafe doctors.â&#x20AC;?

The people that you know behind PHNs in Western Australia â&#x20AC;&#x201C; what is your overall perception of them?

Positive

6%

Negative

12%

Uncertain

28%

Don't know anyone

54%

e-Poll

ED: Given the big investment in time and money, this poor recognition of the PHN brand among doctors is not good news for the three local PHNâ&#x20AC;&#x2122;s managing company, WA Primary Health Alliance. When nearly 80% have little understanding of what PHNs aim to do, getting the profession behind them when it comes time to kick in the reforms they are expected to enact could be hard work.

These questions arose from the last Doctors Drum.

Attitudes vary around dividing up health funding for the global good. Please tick any of these statements if they align with your attitudes.

The 215 responders tapped in 863 responses. The percentages here represent the number of responses.

Growing bureaucracy, and shrinking health services for patients, is a worrying trend.

20.5%

-OSTĂĽDOCTORSĂĽFOCUSĂĽONĂĽIMPROVEDĂĽOUTCOMESĂĽFORĂĽĂĽ individual patients, not global changes to health systems.

Yes

66%

Duplication of services is proving very wasteful.

16.6%

No

10%

Present day doctors are ineffective in lobbying government, compared to other health groups.

12.1%

Perhaps

23%

When things go wrong in patient care it is often not the doctorâ&#x20AC;&#x2122;s fault.

11.2%

Donâ&#x20AC;&#x2122;t Know

1%

ED: In July 1998 we asked (by fax back then!) if doctor shopping and poor referral practice was leading to over-servicing of pathology tests when 86% answered in the afďŹ rmative. While the question comes from a different angle, it seems nearly 20 years on we havenâ&#x20AC;&#x2122;t come a very long way.

In July, the Primary Health Networks (PHNs) will have been in operation for a year. Do you know enough of what they aim to do?

Yes

No

Uncertain

15%

) MĂĽUNSUREĂĽWHATĂĽPATIENTSĂĽREALLYĂĽVALUEĂĽANDĂĽCANĂĽAFFORD ĂĽĂĽ

Honesty in communication between those involved directly in patient care is lacking.

6.2%

Doctors do what the main health insurer, Medicare, asks of them.

4.9%

Having more services will inevitably produce better outcomes.

2.3%

None of these statements reďŹ&#x201A;ect my point-of-view.

0.3%

Do you think compulsory pushbike helmets stop a signiďŹ cant number of people from cycling?

Yes

25%

No

59%

Uncertain

16%

ED: Despite a noisy campaign to make wearing bike helmets discretionary, as we explored in the April issue, most doctors are still on the side of precaution and safety ďŹ rst.

MEDICAL FORUM

MAY 2016 | 25

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MEDICAL FORUM

Guest Column

medical m medica edical

Where is Prevention?

Consumer advocate and parent Geoff Diver takes issue with a system that waits until people become ill before treatment is offered.

Studies have shown that one can present a patientâ&#x20AC;&#x2122;s notes to a psychiatrist in England, New Zealand, Australia and the US and get a different diagnosis each time. This is especially the case with bipolar, PTSD and Borderline Personality Disorder (a diagnosis which can be conjured by mixing a handful of disparate symptoms from a bucketful on the schizoid spectrum.)

There is also no doubt in my mind that there are â&#x20AC;&#x2DC;fadâ&#x20AC;&#x2122; diagnoses as pointed out by Martin Whitely (March edition). The ADHD/ADD spectrum springs to mind as does the inability of some GPs to separate sadness and grief, from clinical depression.

It is also my view that the prescription of anti-depressants in the absence of some formal psychiatric assessment and implementation of a mental health plan for individuals is not always helpful. At its simplest a mental health plan can be â&#x20AC;&#x2DC;to function reasonably normally within societyâ&#x20AC;&#x2122;.

Chief Psychiatrist Dr Nathan Gibson noted in the inquest into the deaths of ďŹ ve Fremantle patients, [one being the authorâ&#x20AC;&#x2122;s daughter] that disorders such as BPD can lead to â&#x20AC;&#x153;therapeutic nihilismâ&#x20AC;? from clinicians. I have heard some say of BPD suicides that â&#x20AC;&#x153;itâ&#x20AC;&#x2122;s not a case of if, but whenâ&#x20AC;?.

So the questions become â&#x20AC;&#x153;is the system letting people get ill and then treating the symptoms?â&#x20AC;? â&#x20AC;&#x153;Is the diagnosis a recognition of the symptoms and not the illness?

The issue of having a diagnosis at all is also an interesting one. It is common practice in adolescent mental health to not reveal a diagnosis as it labels the patient. While this may have merit, it does not let the patient or the carer conceptualise the illness and look for treatment options.

The diagnosis from the DSM5 is likely to affect the patient for a long time, maybe for life. It will also inďŹ&#x201A;uence (even if subliminally) the treatment options explored by clinicians and the amount of hope they hold for a recovery.

There may also be a case for a broader commentary on what language used by society and the professions in mental health. It was noted by a member of the Mental Health Advisory Council that the new Mental Health Act should more accurately be called the Mental Illness Act as it speaks more to the latter and doesnâ&#x20AC;&#x2122;t really address the former.

While pithy comments and clever semantics are common from professionals, I think it is the starting point for a community discussion as it inďŹ&#x201A;uences both the stigma of those entering the system but more importantly, how we address the cause of, and pathway from mental ill health. You may note that mental ill health is now the term and not mental illness.

I like the term â&#x20AC;&#x153;social and emotional wellbeingâ&#x20AC;?. Living well requires a suite of habits such as eating well, exercise and avoiding excessive drinking etc., social and interpersonal skills. It is almost impossible to be mentally unwell if you eat well, exercise (both by choice), engage socially and manage the relationships in your life.

So the questions become is the system letting people get ill and then treating the symptoms? Is the diagnosis a recognition of the symptoms and not the illness?â&#x20AC;?

The message of social and emotional wellbeing is especially important for marginalised groups such as Aboriginal, LGBTI, migrant and refugee communities. Like physical health campaigns, this would not only increase the wellbeing of recipients, but may actually cut costs at the therapeutic end.

MEDICAL FORUM

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MEDICAL FORUM

Guest Column

New Party Puts Its Case Orthopaedic surgeon Dr Tony Robinson and wife Ms Debbie Robinson have launched a new political party. Debbie who is standing for the Senate, explains.

Australian Liberty Alliance celebrated its official launch in Western Australia on October 20, 2015. The party is secular with a conservative philosophy and 20 key policy areas.

In a nutshell we stand for individual liberty, small government, Western values, social fairness and an integrated multi-ethnic society. We want to return Australia to the values of self-reliance and leave no legacy of debt to future generations. We welcome Australians from all walks of life as members.

We are aiming for the Senate at the next Federal election and will stand two candidates in each state.

The founders of the party are ordinary Australians and include my husband [WA orthopaedic surgeon] Dr Anthony Robinson, Ralf Schumann from Melbourne together with Susan and Andrew Horwood of South Australia. Our backgrounds are in medicine, health, business and information technology respectively.

Prior to the formation of the party, four of the founding members spent five years working with the Islam-critical group Q Society. Q Society was established in 2010

ALA is not a one-issue party.

However, any party that does not have a policy on Islam is out of touch with reality. to educate and raise public awareness about the problems associated with Islamisation.

We wrote submissions, lobbied politicians and organised public events. Eventually we realised our efforts were falling on deaf ears and a better way to effect change was through the political process.

ALA is not a one-issue party. However, any party that does not have a policy on Islam is out of touch with reality. We believe our leaders and intelligentsia are committing a serious disservice to this country by refusing to acknowledge there is a problem with Islam and multiculturalism. Europe is experiencing first-hand the effects of mass immigration and the lack of integration of certain groups into their societies.

A series of factors have contributed including political correctness, cultural relativism, a

declining education system, multiculturalism and biased media reporting. Combine the aforementioned with a loss of pride in our heritage, culture and values and it becomes a recipe for disaster.

The complexities were the catalyst to formulating the Manifesto. It took two years of meticulous preparation to organise this new political movement.

It’s vital, before it is too late, to discuss and address the problems in a civilised manner via the democratic political process, without fear of reprisal. We discuss every other religion and ideology, be it Communism, Fascism, Nazism, Christianity, Judaism, Buddhism and every other ism you care to mention.

The party continues to grow and has quadrupled membership since last October.

Following the Turnbull/Abbott leadership change, views on our social media site skyrocketed from 38,000 a week to 809,000 in 24 hours.

On a final note, Australian Liberty Alliance offers an alternative for disillusioned and conservative voters. Australians may be afraid to speak out – fortunately they are not afraid to vote.

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MEDICAL FORUM

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Guest Column

Keeping an Open Mind on CAM A greater understanding of Complementary Medicine is beneficial for both doctors and patients argues Dr Carol Pearce.

Defining Complementary Medicine (CAM) is far from straightforward.

It’s generally regarded as embracing all therapeutic approaches outside conventional medicine. However, as we all know, pinning down the latter isn’t easy either. There are regional and cultural differences, for a start. Acupuncture and herbal remedies are mainstream in China and homeopathic treatment and vitamin therapies are rebated by Government Medical Insurance in France. Switzerland now has five CAM modalities offered as part of publicly funded health care.

An increasing number of people here use complementary medicines. Statistics suggest that two out of three Australians regularly use a natural healthcare product and one in three rely on a CAM practitioner in preference to a GP. Interestingly, perhaps alarmingly, less than 40% of CAM users inform their GPs they’re doing so.

Despite warnings about the use of nutritional supplements, Script Wise reports that in Victoria alone more people died of prescription drug overdoses in 2012 than the number killed in traffic accidents. Similar

interactions with other substances and potential side effects.

Since 2000 NHMRC has provided more than $86 million in funding for scientific research into CAM in competitive peer-reviewed articles and the number of CAM studies are increasing.

statements have been made by the Center for Disease Control in the USA where, in a corresponding period, there were zero deaths from herbal or nutritional supplements.

Since 2000 NHMRC has provided more than $86 million in funding for scientific research into CAM in competitive peerreviewed articles and the number of CAM studies are increasing. In Pub Med, ‘Curcumin’ (Turmeric) now receives numerous hits and, although many of these relate to inflammation, many concern dementia, memory and neuroprotective effects.

Databases such as Hyperhealth Pro provide access to information on a wide variety of vitamins, minerals, herbs, amino acids,

I recently saw two women with longstanding irritable bowel syndrome. Both had been extensively investigated and undergone treatment with no relief. After using Probiotics they achieved symptom resolution within days.

I also saw a lady in her 40s with a long history of fatigue and poorly controlled depression, despite significant SSRI dosing. She reported significant improvements in mood and energy levels on a simple Multi-B capsule and her symptoms are now well controlled. A number of my patients with insomnia or restless leg syndrome have been helped by night-time magnesium and Riboflavin can be an effective migraine prophylaxis.

If we as medical practitioners gain more knowledge about CAM, particularly the readily available complementary medicines so many of our patients are using, we will be better placed to advise our patients regarding their efficacy and potential interactions.

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MEDICAL FORUM

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Clinical Update

Update: overactive bladder

By Dr Trenton Barrett Urologist, Nedlands

Overactive bladder (OAB) is a clinical syndrome characterised by urinary urgency, usually accompanied by frequency and nocturia. Common in both sexes (about 10%), prevalence increases with age, and it signiďŹ cantly impacts quality of life, particularly where urge incontinence occurs. OAB has been linked to suffering in sexual and marital relations, depressive illness and sleep disturbance.

Many patients feel that OAB symptoms are a normal part of ageing so it remains under reported with only 40% of patients seeking medical help.

There are recent advances in treatment for OAB, although the problem has been recognised for millennia (e.g. treatment of â&#x20AC;&#x2DC;urine which runs too oftenâ&#x20AC;&#x2122; was found in the Papyrus Ebers from Ancient Egypt).

Amongst the different options available to patients suffering from overactive bladder, no therapy is a panacea. A patient will often progress through multiple therapeutic options before reaching a satisfactory treatment plan.

It is important that all therapeutic options are made available so they can make an informed decision, which often comes down to the unique side effect proďŹ le of each therapy.

Diagnosis Exclude other disease processes that cause a similar syndrome or may contribute to symptoms; a thorough systematic history and examination plus a urinalysis narrows the differential considerably. A three-day bladder diary and ultrasound measurement of postvoid residual, are additional simple and useful tools. With abnormal urinalysis, cultures should be sent. Haematuria should prompt urological referral.

Generally, with no red ďŹ&#x201A;ags, cystoscopy, detailed ultrasound and urodynamics are not necessary in the initial workup.

Conservative and medical therapy Treatment is a therapeutic ladder, with pharmacological and surgical management following simple non-invasive interventions.

Tailor treatment to the particular patient, taking into account their degree of bother and expectations. Patients need to understand that OAB has no â&#x20AC;&#x153;quick ďŹ xâ&#x20AC;?.

Behavioural modiďŹ cation and pelvic ďŹ&#x201A;oor physiotherapy (â&#x20AC;&#x153;bladder trainingâ&#x20AC;?) are accepted ďŹ rst line therapy with similar efďŹ cacy to oral medication.

Medical therapy has traditionally revolved around anticholinergic (antimuscarinic) drugs, which treat OAB symptoms but have a high side effect rate (e.g. dry mouth and constipation) and poor long-term compliance.

Mirabegron, a Ă&#x;3-adrenoceptor agonist has restricted use for OAB under the PBS and works by activating receptors in the detrusor muscle to relax it and increase

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Image by OpenStax College - Anatomy & Physiology, Connexions

bladder capacity. It is as efďŹ cacious as the anticholinergics with less risk of dry mouth or constipation. Hypertension and tachycardia have been ďŹ&#x201A;agged as potential side effects but the actual magnitude of these effects is MINORĂĽ MMĂĽ(GĂĽANDĂĽ ĂĽ ĂĽ"0- ĂĽ-IRABEGRONĂĽ has proven efďŹ cacious in patients unresponsive to anticholinergics, providing another medial option in those who would have previously progressed to surgery. â&#x20AC;&#x2DC;Cutting edgeâ&#x20AC;&#x2122; interventions Intradetrusor injections of onabotulinumtoxin A (Botox) are an established and reproducible long term treatment for OAB. Injections can be delivered via ďŹ&#x201A;exible cystoscopy under local anaesthetic in the rooms or hospital. The effect lasts on average nine months and then the procedure needs to be repeated. There is a risk of developing elevated post void residuals that may predispose to urinary tract infections

Key Messages sĂĽ /VERACTIVEĂĽ"LADDERĂĽISĂĽhURINARYĂĽ urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of UTI or other obvious pathology.â&#x20AC;? sĂĽ 4HEĂĽDISORDERĂĽISĂĽCOMMONĂĽINĂĽBOTHĂĽSEXESĂĽ and is under reported. sĂĽ "EHAVIOURALĂĽANDĂĽPHYSICALĂĽTHERAPYĂĽAREĂĽ ďŹ rst line treatment, with pharmacology second and surgery third. Tailor treatment individually and offer all options. sĂĽ .EWĂĽMEDICALĂĽANDĂĽSURGICALĂĽOPTIONSĂĽ open up new therapy in patients previously refractory to treatment.

or even necessitate temporary intermittent self-catheterisation.

Peripheral Tibial Nerve Stimulation (PTNS) involves electrical current acting on the bladder delivered via an acupuncture needle to the posterior tibial nerve at the ankle. Done as an outpatient, this can be as effective as oral therapies, with minimal side effects.

Meta-analysis shows patients receiving PTNS are seven times more likely to report success than those receiving placebo. Therapy is intensive, requiring weekly stimulation sessions of 30 minutes for 12 weeks followed by a maintenance regime of sessions (on average monthly) to sustain effectiveness.

Sacral Neuromodulation (SNM) involves implanting a permanent â&#x20AC;&#x2DC;pacemakerâ&#x20AC;&#x2122; like device to deliver electrical current to the sacral nerves (S3) and bladder. Prior to implantation, a test phase involves a temporary lead and external stimulator for up to 14 days; response is assessed (about ĂĽRESPONDĂĽFAVOURABLY ĂĽANDĂĽONLYĂĽ those signiďŹ cantly improved are offered a permanent implant. About 90% of patients report satisfaction with the device with reasonable outcomes reported for up to ďŹ ve years; disadvantages are periodic battery changes (approximately every 5 years) and local complications relating to discomfort or infection. The implant contraindicates MRI and can be troublesome at airport security gates!

References available on request. Further reading: www.racgp.org.au/afp/2012/november/overactivebladder-syndrome/

Author competing interests: no relevant disclosures.

Questions? Contact the author on 1800 487 656

MAY 2016 | 35

Fertility, Gynaecology and Endometriosis Treatment Clinic

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www.fertilitynorth.com.au

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Clinical Q&A

Q: A:

Response by Dr Pam Quatermass Sexual Health Physician Nedlands

What role testosterone for low female libido?

It's often said that men don't need a reason to have sex, just a place.

By contrast, female sexuality is complex. To have a functional libido, a woman needs oestrogen levels over 600, testosterone in the top half of the normal range, normal thyroid function, blood count, iron and calcium levels, and not-too-high cortisol and prolactin â&#x20AC;&#x201C; any abnormality of these can cause a problem.

And that's before you consider whether she's tired, worried about money, work, privacy or the kids - relationship issues are another large can of worms.

Women in their 40s have only half the level of circulating androgens compared to their 20s.

Oophorectomising premenopausal women halves their ability to produce testosterone.

Australia is unique in having a testosterone cream formulated speciďŹ cally for women, daily administration of which mimics natural production. Studies by Prof Susan Davies from Monash have shown that appropriate dosage keeps testosterone levels within

the physiological range; the testosterone is aromatised to oestrogen within 24 hours.

Before prescribing testosterone, consider other causes of low libido/anorgasmia: medication (especially antidepressants, the oral contraceptive pill, anticonvulsants, spironolactone or cyproterone, beta-blockers and other antihypertensives, adjuvant chemotherapy for breast cancer, treatments for Parkinson's disease, colchicine, lithium and steroids), depression, an endocrinopathy, anaemia, diabetes or alcohol.

Testosterone levels should be estimated before starting treatment. Hormones should be assayed in the morning. Premenopausally, testosterone levels are highest in late follicular phase; in practice, it's better to measure in early follicular phase as perimenopausal women often demonstrate an abbreviated follicular phase.

Measurement is chieďŹ&#x201A;y to rule out androgen excess; there is no testosterone level which predicts low libido. Even women with levels in

Protecting WA mothers and their babies from ďŹ&#x201A;u and pertussis The World Health Organization identiďŹ es pregnant women as the highest priority group for seasonal ďŹ&#x201A;u vaccination. However, uptake INĂĽ7!ĂĽHASĂĽBEENĂĽSUBOPTIMALĂĽnĂĽONLYĂĽ ĂĽOFĂĽ pregnant women were vaccinated in 2014.

Improvements welcomed In December 2015, of 524 women, including 100 Aboriginal women, who responded to a telephone interview 60.6% said they had received a ďŹ&#x201A;u vaccine during pregnancy that year - a 39% improvement from the previous year. Pertussis vaccination was even better WITHĂĽ ĂĽOFĂĽWOMENĂĽVACCINATEDĂĽINĂĽTHEIRĂĽ third trimester. Over half the women (56.9%) who received trivalent inďŹ&#x201A;uenza vaccine (TIV) were vaccinated against pertussis on the same day. Considered separately, results in Aboriginal women were 56.9% and 65.2% vaccinated against ďŹ&#x201A;u and pertussis, respectively during pregnancy.

Your recommendation counts The most important predictor of vaccination uptake in pregnant mothers is recommendation by the antenatal care provider, with 80.5% of unvaccinated mothers reporting they would have been vaccinated if their doctor or midwife had recommended

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the mid-normal range may ďŹ nd testosterone cream beneďŹ cial.

Monitoring of levels is made difďŹ cult by lack of a formal protocol deďŹ ning the time between last use of cream and blood testing. Generally, test in the morning, approximately 24 hours after last application of cream. If the patient says it doesn't work, check her levels and ask her to bring in the tube of cream. I have found women who have been reluctant to use it after consulting Dr Google and ďŹ nding reports that androgens will give them a hairy chest and deep voice. Comparing the date of dispensing and the amount of cream remaining is a clue.

Conversely, women may request too-frequent repeats; testosterone is a mood elevator and energy enhancer.

References available on request. Questions?

Contact the author on pamq@highway1.com.au.

Prof Donna Mak Public Health Physician, Communicable Disease Control Directorate, Department of Health

it.1 The proportion of women who say they were recommended inďŹ&#x201A;uenza vaccine during PREGNANCYĂĽHASĂĽINCREASED ĂĽFROMĂĽ ĂĽINĂĽ ĂĽTOĂĽ ĂĽINĂĽ ĂĽ)TĂĽISĂĽHOPEDĂĽTHISĂĽlGUREĂĽ becomes 100% of antenatal care providers recommending inďŹ&#x201A;uenza and pertussis vaccines to all their pregnant patients.

Safety concerns allayed Women more commonly refused ďŹ&#x201A;u vaccine than pertussis vaccine because of safety concerns (38.3% vs. 12.4%), despite the excellent safety proďŹ les of both in pregnancy. )NĂĽ ĂĽACTIVEĂĽFOLLOW UPĂĽOFĂĽ ĂĽIMMUNISEDĂĽ pregnant women showed that: 10% reported a common, expected reaction (e.g. pain ORĂĽSWELLINGĂĽATĂĽTHEĂĽINJECTIONĂĽSITE ĂĽRASH ĂĽ ĂĽ REPORTEDĂĽFEVER ĂĽANDĂĽ ĂĽREQUIREDĂĽMEDICALĂĽ treatment for an adverse event. With the exception that women who receive pertussis vaccine are more likely to report local reactions, there was no difference in the safety proďŹ le of inďŹ&#x201A;uenza and pertussis vaccines given during pregnancy.2

(99.0%) during pregnancy. A recent WA study found there may be an additional beneďŹ t to vaccinating against ďŹ&#x201A;u during pregnancy â&#x20AC;&#x201C; a 51% reduction in stillbirth. This is in addition to protection against disease in the ďŹ rst six months.3 In 2016 make sure you protect vulnerable mums and newborns by offering ďŹ&#x201A;u and pertussis vaccination to all your pregnant patients and emphasise the beneďŹ ts of maternal vaccination to their babies.

References: 1. Regan et al. Trends in seasonal inďŹ&#x201A;uenza vaccine uptake during pregnancy in Western Australia: Implications for midwives. Women and Birth 2016.

DOI: http://dx.doi.org/10.1016/j.wombi.2016.01.009 2. Regan et al. A prospective cohort study assessing the reactogenicity of pertussis and inďŹ&#x201A;uenza vaccines administered during pregnancy.

Vaccine 2016. doi: 10.1016/j.vaccine.2016.03.084 3. Regan et al. Seasonal Trivalent InďŹ&#x201A;uenza Vaccination During Pregnancy and the Incidence of Stillbirth: Population-Based Retrospective Cohort Study. Clin Infect Dis. 2016. doi: 10.1093/cid/ciw082

Protecting the baby Nearly all women reported wanting to protect the baby as the reason why they RECEIVEDĂĽmUĂĽ ĂĽORĂĽPERTUSSISĂĽVACCINEĂĽ

MAY 2016 | 37

Clinical Update

Aneuploidy Screening: The NIPT

PIVET MEDICAL CENTRE SPECIALISTS IN REPRODUCTIVE MEDICINE & GYNAECOLOGICAL SERVICES

By Dr Fred Busch Obstetrician and Gynaecologist West Leederville

First Trimester Combined Screening (FTS) has served us well over the last two decades. The detection rate of FTS in older mothers is high. However, the false positive rate in women 35 and older is up to 22% leading in some instances to invasive diagnostic testing that can put an unaffected pregnancy at risk. Non-Invasive Prenatal Testing (NIPT) provides an important tool to improve detection rates of aneuploidy*, and reduce unnecessary invasive tests.

NIPT uses sequencing of cell-free DNA (cfDNA) in the maternal circulation from ten weeksâ&#x20AC;&#x2122; gestational age, speciďŹ cally the â&#x20AC;&#x2DC;foetalâ&#x20AC;&#x2122; fraction, thought to be derived from apoptosis of foetal placental cells.

It compares favourably with the FTS, which has an overall detection rate (DR) of 86% and false positive rate (FPR) of 5.6%.

NIPT performs less well for sex-chromosome aneuploidy with a DR for Turner Syndrome (45X0) of 90%.

Limitations of NIPT 4ESTĂĽFAILURESĂĽAREĂĽASĂĽHIGHĂĽASĂĽ ĂĽFORĂĽAUTOSOMALĂĽANEUPLOIDYĂĽANDĂĽ ĂĽFORĂĽ sex chromosome testing. The most common reason is insufďŹ cient FOETALĂĽFRACTIONĂĽCF$.!ĂĽ ĂĽOFTENĂĽDUEĂĽTOĂĽSUBOPTIMALĂĽSAMPLEĂĽCOLLECTION ĂĽ maternal obesity (reduced foetal fraction in up to 10.5% of women over 110 kg), and foetal karyotype. The foetal fraction is reduced in trisomy 18 foetuses but not euploid or trisomy 21 foetuses.

False-positive results are seen with placental mosaicism, demised twin, maternal mosaicism, maternal cancer (more than one aneuploidy on test), and transplant recipients. False-negative results are seen with conďŹ ned placental mosaicism and borderline low foetal fraction of 4-5%.

In twin pregnancies, data suggest NIPT performs well but not as well as with singletons.

The cost has reduced but is still relatively high, with no Medicare rebate.

Options in indeterminate test or no result The risk of aneuploidy may be as high as 23% in such cases. Options include repeating the NIPT (result obtained in 50-80% of cases), FTS, and diagnostic testing. Diagnostic testing should especially be considered when the NIPT was done for a high-risk FTS. It is important to consider diagnostic testing in the presence of ultrasound detected signiďŹ cant foetal anomaly even when the NIPT is low-risk.

There are no speciďŹ c current RANZCOG guidelines on who should be tested apart from that NIPT should be discussed as an option in the ďŹ rst trimester. It is important to, as best possible, convey the advantages and limitations of NIPT so that prospective parents can make their own decision.

Table: Performance of NIPT Detection Rate (DR)

False Positive Rate (FPR)

False Negative Rate (FNR)

Down Syndrome

98.6%

1% **

1.4%

Trisomy 18

95%

0.14%

5%

Trisomy 13

91%

0.14%

8.7%

by Medical Director PROF JOHN YOVICH

Ă&#x;- hCG level after IVF ... apart from pregnancy, what else can the test reveal?

0)6%4 ĂĽINĂĽ ĂĽWASĂĽTHEĂĽlRSTĂĽTOĂĽINTRODUCEĂĽTHEĂĽVERYĂĽSUCCESSFULĂĽ Cryotop technique of VitriďŹ cation to Australia; learnt ďŹ rst-hand from scientist Masa Kuwayama in Tokyo. After immersion into vitriďŹ cation solutions containing potentially toxic cryo-protectants ethylene glycol and DMSO along with sucrose, the embryo is cooled at a rapid -25,0000C/min as opposed to the previous slow-freeze method of -0.30C/min.

The results for frozen embryo transfers (FETs) have been outstanding such that PIVET has been â&#x20AC;&#x153;top of the wazzaâ&#x20AC;? from the ANZARD data for many years. In fact the FET pregnancy rates have now surpassed the fresh IVF-ET rates such that increasingly we favour cryo-preservation of the better quality embryos, especially at the blastocyst stage.

This works hand-in-glove with our move towards single embryo transfers (SETs) as a universal policy, regardless of age or number of procedures.

Embryos are set onto a Cryotop polypropylene strip, then sealed in a protective cover before loading into an individual patientâ&#x20AC;&#x2122;s goblet attached to a handling cane. This is placed within a canister which is then plunged into a Dewar vat containing liquid nitrogen at -196 0C.

From the FET programme we have noticed that the pregnancy TEST ĂĽPERFORMEDĂĽ ĂĽDAYSĂĽAFTERĂĽTHEĂĽEGGĂĽPICK UPĂĽ FORĂĽ)6& %4 ĂĽORĂĽ a matched day for FET, showed a signiďŹ cantly higher Ă&#x;-hCG LEVELĂĽ ĂĽ)5 ,ĂĽVSĂĽ ĂĽ)5 , ĂĽP ĂĽ7HENĂĽWEĂĽTRACKEDĂĽTHOSEĂĽ SET pregnancies to delivery we found that although both groups delivered at a mean of 38 weeks 5 days there was a signiďŹ cantly higher birthweight for the singleton FET infants GĂĽHEAVIER ĂĽ GĂĽVSĂĽ G ĂĽP ĂĽ4HEREĂĽWEREĂĽALSOĂĽMOREĂĽ infants weighing >4000g but not into the macrosomic range (>4500g). This difference persisted after adjustments for age, BMI, gestational diabetes, gender of baby and monozygotic twinning. We conclude that embryos from FET programmes have the same, if not better developmental potential in comparison to IVF-ET. This data is now in press with the journal Reproductive Biomedicine Online and I presented the ďŹ ndings at the ASPIRE meeting in Jakarta last month.

**Includes test failures that do not resolve after repeat testing ED. *Aneuploidy is when a person has one or a few chromosomes above or below the normal chromosome number. For example, three copies of chromosome21 is characteristic of Down syndrome, a form of aneuploidy.

Author competing interests: nil relevant disclosure. Questions? Contact the author on 9468 5188

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MAY 2016 | 39

Clinical Update

Informative pelvic scans

By Dr Anjana Thottungal Obstetrician & Gynaecologist specialising in Ultrasound SJOG Mt Lawley

CASE REPORT 1: 38-yr-old para1 woman referred for a pelvic scan with history of left iliac fossa (LIF) pain for four days (pain score of 5/10), starting from the 6th day of her periods.

Similar pain over the last three years; less severe and not sustained. H/O left salpingectomy for ectopic pregnancy three years previous and she thought the LIF pain was related to this previous surgery. She had no other pain symptoms or menstrual complaints.

A routine pelvic scan showed moderate adenomyosis, multiple small fibroids and a left ovary adherent to the uterus. Further careful assessment of the left uterosacral ligament revealed an endometriosis nodule and a possible bowel nodule adherent to the left uterosacral nodule. In addition, there was evidence of left hydroureter. Tenderness over this area mimicked the LIF pain she had been experiencing. A diagnosis of severe deep infiltrating endometriosis was made.

Sigmoid nodule

Sonovaginography and detailed assessment of her pelvis was done after bowel preparation, in order to map out all the endometriosis lesions, prior to any surgical intervention. At this scan, findings were confirmed with clearer views of the lesions. The bowel lesion involved the rectosigmoid colon, and with about 44 cm of the bowel traceable, there was also a larger bowel lesion involving the sigmoid colon. She had an endometriotic lesion on the pelvic sidewall obstructing the left ureter, with evidence of hydroureter. Ultrasound of the kidneys revealed severe hydronephrosis of her left kidney.

Hydroureter seen lateral to the uterus

CASE REPORT 2: 44-yr-old nulliparous woman referred for a pelvic scan with a long standing history of cyclical bowel symptoms; severe constipation for up to three weeks starting from the time of her periods, bleeding per rectum during periods. There was H/O dyspareunia for 20 years, worse over the past 10 years. She had no significant dysmenorrhea or any other menstrual complaints.

Pelvic scan showed moderate-severe adenomyosis and fibroid uterus with a large 10 cm posterior wall fibroid to the right of the pelvis. A large rectal endometriosis nodule was seen, perhaps infiltrating the rectovaginal septum and posterior vaginal fornix. Severe tenderness over this area mimicked her symptom of dyspareunia. The left ovary was non-mobile and tender. Findings were consistent with severe deep infiltrating DISCUSSION endometriosis.

Large rectal nodule

Complex lesion consisting of rectal nodule, rectovaginal infiltration and vaginal nodule

40 | MAY 2016

Sonovaginography and detailed pelvic scan (after bowel preparation) confirmed the above findings. A complex LESIONåWASåSEENåASåAåLARGEå CMå rectal nodule, and endometriosis of rectovaginal septum and vaginal wall. The vaginal nodule alone was 3 cm in size. Kidney ultrasound showed moderate left hydronephrosis, with involvement of the left ureter at the level where it crosses the uterine vessels. Interestingly, the rectal nodule, rectovaginal septum involvement and vaginal nodule were not reported on her MRI, possibly due to a large fibroid obliterating the Pouch of Douglas.

These case reports amplify two important aspects of management: 1. High quality initial pelvic scans can provide important detail in the diagnosis of the condition and eventual outcome of the patient.

2. Once severe endometriosis is suspected on a pelvic scan, further assessment with sonovaginography and bowel preparation assist in mapping out all the lesions, especially those involving lower bowel and ureters, which help to: så så så så

!SSESSåTHEåSEVERITYåOFåDISEASE 'UIDEåAPPROPRIATEåSURGICALåREFERRAL 0LANåTHEåBESTåTREATMENTå MEDICALåVSåSURGICAL )NFORMåTHEåPATIENTåABOUTåTHEåCOMPLEXITYåANDåRISKSå of surgery

The accuracy of transvaginal scanning is operator dependent, and some endometriosis lesions are easily missed at the initial pelvic scan.

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Dr Arockia Doss MBBS (Ind) MRCP (UK) FRCR (Lon) FRANZCR Interventional Radiologist

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Nedlands WA 6009 P 6389 2776 F 6389 2778

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MAY 2016 | 41

Clinical Update

Emergency contraception - ulipristal A new emergency oral contraceptive pill, ulipristal (ellaOneTM, HRA pharma) will soon be available in WA on script only. Familiarity with use is important, as conditions of use affect some patients.

Ulipristal can be used up to 5 days after unprotected sexual intercourse (UPSI). It is a good option in women who do not wish an IUD and do not need to “quick start” hormonal contraception (ie: are happy to use barrier methods for up to 12 days after EC administered). It also appears to be more efficacious than Levonorgestrel in obese women. Expense (approx $45-$50 retail) and initially being restricted to prescription-only are possible barriers. Levonorgestrel may still be a more suitable alternative for women who are breastfeeding, wish to quick start contraception, or who want to continue with their usual hormonal contraception. Copper IUDs are highly effective and would, ideally, be more accessible and readily available for women as a choice in emergency contraception.

Background. Emergency contraception (EC) gives women the option of preventing an unwanted pregnancy if they have had unprotected sexual intercourse in the previous five days.

By Dr Richelle Douglas Medical Director Sexual & Reproductive Health WA (ex-FPA)

an inadvertent pregnancy is reported.

Restrictions on use. These are pregnancy (contraindicated), allergy (known hypersensitivity to any of the excipients), liver disease (avoid if significant impairment), severe asthma (if insufficiently controlled by oral glucocorticoids) and breastfeeding (detected in breast milk up to 5 days after ingestion).

Hormonal contraception considerations. The benefit of LNG over ulipristal (UPA) is that hormonal contraceptives can be “quick started” following its use reducing the chance of pregnancy in that cycle. The effect of ulipristal in delaying ovulation is reduced by quick-starting a progestogen-containing contraceptive.

It is advised that women should use barrier methods/abstinence for 5 days after taking ulipristal. If hormonal contraceptive methods are commenced after 5 days, then the woman needs to be advised to use barrier or abstinence for a further number of days, depending on the method used (please see table).

Table: Contraception options after giving UPA on DAY 0 and waiting +5 days.

EC has been limited in Australia to Levonorgestrel (LNG) and the copper IUD. Due to limitations in access, the copper IUD is not widely used although it has the added advantage of providing an ongoing contraception.

METHODS (day UPA +5)

Requirement for additional contraception

Combined Oral Contraceptive Pill COCP (excluding Qlaira)

åDAYS

Mechanism of action. Ulipristal acetate (UPA) is described as a ‘second generation’ selective progesterone receptor modulator (SPRM). The first SPRM, mifepristone, is only licensed for medical abortion but is an effective emergency contraceptive too.

Qlaira (COCP)

+9 days

Combined vaginal ring/transdermal patch

åDAYS

Progesterone-only pill (POP)

+2 days

Progesterone-only implant or injectable

åDAYS

Ulipristal works by blocking ovarian progesterone signalling, resulting in ovulation delay and endometrial changes that make pregnancy less likely. In contrast to levonorgestrel EC, UPA delays ovulation even if administered in the advanced follicular phase when the mid-cycle rise in luteinising hormone (LH) has started (i.e. just before the woman ovulates).

However, neither drug is effective if ovulation has already occurred.

How effective is ulipristal? In studies, up to 85% of anticipated pregnancies can be avoided if ulipristal has been used, with superior effectiveness over LNG when administered both within 120 and 24 hours of UPSI. We know pregnancy risk increases with higher body mass regardless of the type of EC drug used – ulipristal, however, appears to be more efficacious compared to levonorgestrel in women who are characterised as overweight or obese.

Side effects and safety profile. The most commonly reported side effects are abdominal pain and menstrual disorders (irregular vaginal bleeding, premenstrual syndrome, uterine cramps).

Ulipristal does not interrupt an existing pregnancy. Limited data regarding pregnancy exposure to Ella-One do not suggest any safety concern. Advice can be sought from the manufacturer and a specialist if

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Surgical & medical abortion Contraceptive inserts STI checks Vasectomy Decision-based counselling 24 hour aftercare

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Checklist for Emergency Contraception så )SåTHEåCOPPERå)5$åAVAILABLEåANDåACCEPTABLE å)FåITåIS åITåMAYåBEå the best option. så )SåTHEåPATIENTåBREASTFEEDING å)FåSO åLEVONORGESTRELåMAYåBEåMOREå appropriate. så #ANåSHEåAFFORDåIT å,EVONORGESTRELåISåCURRENTLYåAåCHEAPERåANDå more available option. så )SåTHEåPATIENTåOVERWEIGHT å)FåSO åULIPRISTALåMAYåBEåTHEåMOSTå effective hormonal option. så )SåTHEåPATIENTåWILLINGåANDåABLEåTOåUSEåBARRIERåMETHODSåFORåAå week after the tablet wears off? Yes: ulipristal provides a higher efficacy at 5 days than levonorgestrel. så $OESåTHEåPATIENTåWISHåTOåCONTINUEåWITHåTHEIRåHORMONALå contraceptive without a break? If so, levonorgestrel may be more appropriate.

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Referrals and enquiries call 1300 003 707

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MAY 2016 | 43

News & Views

An Ankle’s Tale…After Surgery It takes a village to raise a child, so the saying goes, and when that child gets injured all hands on deck lead to better long-term outcomes.

It’s not uncommon to see AFL players back on the paddock in doublequick time after a serious sporting injury. The recovery time in the real world can be markedly different but good communication between health professional and patient can lead to positive outcomes.

When you’re young, fit and playing Division 1 basketball, life seems pretty good. That’s how 19-year-old Edward Harman felt just before he landed awkwardly on his right ankle in July 2015. The medical train chugged out of the station with Edward hopping down the aisle.

“I tried to dribble past another player, caught the side of his leg and when I landed my foot wasn’t flat. It really hurt for a minute or two, the pain died away but it was off to the Emergency Department at Sir Charles Gairdner Hospital.”

“Then it was eight days in hospital waiting for the swelling to go down before treatment started for a spiral break of my fibula.”

“The surgeon put in a steel plate that will stay there forever and a pin to stabilise the ankle that’s been removed. I felt a bit depressed during some parts of the rehab process, particularly when I ended up putting on about 13kg.”

Physio Chris Perkins and Edward Harman (left)

Start-Stop Rehab The physiotherapy began well, says Edward, but fell in a hole shortly afterwards.

“My first couple of sessions with Chris Perkins were great but then, after seeing someone else, I lost a bit of momentum in the recovery process. After getting back to Chris everything went well and I’ve recently played three games of social basketball. I’ll be getting back on the bike to train for the ProState Charity Cycle Ride later this year.”

“Getting really good orthotics helped me a lot, too.”

Chris Perkins is a specialist sports physiotherapist who numbers the Eagles and WAIS among his clients. He suggests that a holistic approach for both professional athletes and mere mortals is the best way to ensure a complete recovery.

“Edward presented to me about three months after surgery, he’d come out of a moon-boot and described his injury as a ‘rolled ankle’.

It was a bit more than that! His right foot had hit the floor laterally and damaged the syndesmosis so he ended up with an internal plate, a diastasis screw and a fair bit of anxiety and frustration.”

See the person “With someone in Edward’s situation it’s important to set goals, both short and longterm, and make sure that you apply good

44 | MAY 2016

overall management of the person and the injury. It’s critical that a patient feels they’re in control of the process and doesn’t end up lost and uncertain regarding the outcomes.”

“The professional athlete receives closely monitored follow-up, which may not always be the case out there in the real world. Often there’s not the same level of continuity but the importance of the basic steps to follow, such as what to do when the cast comes off, can’t be underestimated.”

Chris utilised other health professionals in Edward’s treatment and underscores the point that a flexible approach works well.

“I contacted sports podiatrist Paul Griffin and the orthotics he designed for Edward were a crucial part of the recovery. It’s important to think laterally for these treatment models. For example, some people can get on the bike early in the piece and others can use a pullbuoy in the pool.”

to diminish. Podiatry as a discipline is highly specific. Chris was looking to improve Edward’s range of motion and proprioception whereas my focus was on a longer-term strategy, particularly in relation to his severe pronation.”

Thinking outside the box “Edward had some significant mechanical anomalies in the lower limb that would have delayed his recovery.”

“We made some images using a 3D organic scanner and wrote a prescription for an orthotic that would change the function of the axes in the foot, ankle and lower limb. He wore it for a couple of weeks but we had to really push the limits in Edward’s case and increase the inner-angle.”

“I always try to use the least amount of interference as possible because it’s important that you don’t interfere with the natural movement.”

“It’s really only limited by the clinician’s imagination and the patient’s commitment.”

There are some real positives in a collaborative approach, suggests Paul.

Paul Griffin works with players from Perth Glory and is the current Chair of the WA Podiatry Association.

“My focus is on a multidisciplinary practice and I always learn something from the interaction. Edward’s ankle is a classic example. It was an injury that needed more attention than most and it was rewarding for us all to play a part in his recovery.”

“We’re rarely the first port-of-call when someone suffers a sporting trauma but patients such as Edward filter down to us when the acute phase of their injury begins

By Peter McClelland MEDICAL FORUM

By Dr Sara Damiani

Dario for Diabetics Clinical Usefulness

Developed By LabStyle Innovations â&#x20AC;&#x201C; a start-up company that aims to integrate chronic disease management and mobile devices.

Its Purpose Dario is an App that couples with a compact TGA-approved glucometer that can monitor blood sugar levels wherever you are, in six seconds. The pocketsized system (normally $60 â&#x20AC;&#x201C; currently on sale for $30) contains a glucose meter, disposable test strip cartridge and a lancing device. The app on your mobile device integrates with this blood sugar testing system via the earplug socket on your smartphone so no separate batteries are required. Those with diabetes can map in a personal logbook their blood sugars, see how exercise, diet and even a night on the hops can inďŹ&#x201A;uence blood sugar levels, map insulin use and generally have a better sense of control. It allows patients to learn about self-care and easily share their data with GPs and caregivers (via emailed pdf reports that include estimated HbA1C, average blood sugar, and number of hypos and hypers). It even sends hypoglycaemic alerts/location tags to loved onesâ&#x20AC;&#x2122; mobile phones. Users can also set alarms or reminders, estimate their HbA1c level and synch the app with RunKeeper.

Details $ARIOĂĽISĂĽFREE ĂĽ ĂĽ-"ĂĽANDĂĽAVAILABLEĂĽFORĂĽI0HONEĂĽANDĂĽANDROIDĂĽSYSTEMS ĂĽ The blood glucose system is cheap, TGA-approved and the glucose strips are available through pharmacies and under the National Diabetes Services Scheme.

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Ease of Use

This app is sleek and well designed with the patient in mind. It is simple to use and easy to navigate.

Although self-explanatory, it includes a thorough userâ&#x20AC;&#x2122;s guide. No internet connection required but it is linked to a website with more information and resources for diabetics.

Pluses Compact and easily integrated into everyday activities. Dario may improve compliance by showing patients how well they are managing their diabetes. The educational and ease-of-use aspects are a drawcard. The App is regularly upgraded based on user review. A recent update allows for more than one insulin type (see www.mydario.com).

Minuses A common review complaint is inaccuracy of blood sugar results requiring numerous repeat readings and test strips. A control solution is sold to check accuracy. If you receive a phone call while testing blood glucose you will have to repeat the test (Dario recommends testing in â&#x20AC;&#x2DC;ďŹ&#x201A;ight/do not disturb modeâ&#x20AC;&#x2122;).

Expansion of breast screening program to 74 years BreastScreen WAâ&#x20AC;&#x2122;s target age range is now 50-74 years of age.

West Australian women are actively invited to attend for free two-yearly screening mammograms at BreastScreen WA until they reach 74 years.

Online bookings are available for standard appointments at metropolitan clinics

www.breastscreen.health.wa.gov.au To ďŹ nd out what your practice is worth, call:

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Alternatively phone: 13 20 50

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

MEDICAL FORUM

Wendy Mae2016 Brown| MAY

45

Travel

Norfolk Island’s Rich Past and Uncertain Future

Down there is one of the rocks behind which the intrepid Captain Cook landed his wooden boat during his voyage of discovery

The here and now people on Norfolk Island, mainly the younger generations, are not much interested in the history of this island and it’s a pretty tempestuous one at that.

It starts with the English abandoning the island – its harshest penal colony (just count the number of gravestones belonging to Irish political prisoners) – before handing it to the remnants of the Bounty mutineers to resettle because Pitcairn Island, about half the size and 3800km north-east, was too small.

Families of note on the island – the ‘real’ Norfolk Islanders – take their relatedness to the five early settler families from Pitcairn very seriously. They revere their connection to the mutiny on the Bounty and Queen Victoria is a hero here. They also use the Norfolk language – a mixture of English and Polynesian – in their celebrations. The Republican movement is nowhere to be found on Norfolk.

Why Queen Victoria? She bequeathed the island to the Pitcairn settlers, who were a bit miffed when they did not get it stock and barrel as they had been led to believe.

Mind you, the French were cruising the seas, grabbing new territories for their government so the English had to be quick about it.

Today there is uncertainty in the local community over the island adopting the Australian welfare, health, immigration and tax systems where previously none, or local versions, had existed.

A younger couple holidaying from New Zealand commented that things in the community had "been let go" since they

46 | MAY 2016

A highlight might be a night that light up on queue – thi walk with bush poetry illustrated by various scenes s one Mum’s old laundry.

last visited two years ago. I think they were referring to the potholes in the roads, among other things; the island is surprisingly hilly, so think twice about hiring a bike.

Certainly, the airstrip is the island’s lifeline and was a big part of the World War II effort as New Zealand built planes then islandhopped them to the Japanese war zone, via Norfolk Island. The demise of the Norfolk air carrier created economic hard times for the community. Now, because the island is equidistant from Brisbane and Sydney, you get a jet flight each day from either Australian airports or Auckland.

At this time of uncertainty we suspect

cheaper packages will become available as the island relies on tourism to maintain its standard of living, and there are well-heeled people from out of town enjoying the mild climate and lifestyle. There is a lot to see, lots of tours to join, and countless walks. The people are friendly and look after you.

The only school on the island, which teaches the 350 children the NSW curriculum, goes to Year 12 and includes Norfolk language classes. (Incidentally, most of the prisoners under the British were teenagers!)

Plenty of family spirit can be seen amongst these school kids attending the swimming

MEDICAL FORUM

You can enjoy a High Tea breakfast with food and a view to die for, before sampling local liqueurs.

t tones ta kes up mos Cruising the gravesg how mutineers were of a day â&#x20AC;&#x201C; hearin yed as a lesson to prominently displa litical prisoners, and others, the Irish poperished too young, heaps of kids who ulloughs contribution less make Eileen McC potent.

carnival at Emily Bay â&#x20AC;&#x201C; home to the bottomless boat, salt house and lime kilns, and just a short hop to the Kingston townsite with its historical buildings, pier and four museums.

At the Syrius Museum we learnt that the First Fleet supply ship Syrius met its demise on the rocks without loss of life, caught by a wind shift. Remnants of the wreck that weren't salvaged at the time remained on the bottom

MEDICAL FORUM

Most of the Kingston townsite, minus most of the prisons, is preserved for the traveller â&#x20AC;&#x201C; with four museums worth seeing

of the sea until people from the WA Maritime Museum (with Batavia experience) dived in ĂĽANDĂĽ ĂĽ#ARRYINGĂĽBRICKSĂĽTHATĂĽWEREĂĽ the latest and greatest mobile phones of the times, on video we caught a glimpse of a younger Dr David Millar in the inďŹ&#x201A;atable.

so even today, tenders from visiting cruise ships cannot get ashore when it is rough and Islanders get paid for their produce but employment goes begging.

By Dr Bruce Bridges

There was whaling on Norfolk at one stage until the Russians ďŹ shed out the whales by lying about their quotas (or so the story goes). The island has no natural harbour,

MAY 2016 | 47

Families

And Baby Makes…Change

New research and professional programs show that there is life after baby…

The intense early days of life with the first baby have been examined in a research project designed to reduce and/or prevent postpartum common mental disorders (PCMD).

Prof Jane Fisher and Dr Heather Rowe from the Jean Hailes Research Unit have just published their findings on the What Were We Thinking (WWWT) program in BMJ Open in March where 400 families (mothers, fathers, infants) took part in a randomised controlled trial.

The title makes it sound a pretty happy-go-lucky project but it rigorously tested three interlinked components: så 0RIMARYåCAREåFROMåAå7774 TRAINEDåMATERNALåANDåCHILDåHEALTHåNURSE så 0RINTåMATERIALS åEASILYåACCESSIBLE åPLAINåLANGUAGEåINFORMATIONåINCLUDINGå worksheets for each learning activity and a short book (post trial an iPhone app has also been developed) så &ACE TO FACEåSEMINARåATå åWEEKSåPOSTPARTUMåFORåSMALLåGROUPSåOFå about five couples and their babies. The single-day program has two sessions – one focusing on infant behaviour management and the other on parenthood, which explores expectations; distribution of domestic and paid workload; support etc.

The shift of emphasis from the woman’s mental health to a broader focus on the relationship between mum and dad and the behaviours of the infant as being integral to the health of the entire family has produced some encouraging results.

The WWWT research has shown that the program can be reduce a new mother’s mental health problems by up to two thirds.

The study was funded by an NHMRC grant.

48 | MAY 2016

Here in the West we, of course, have Ngala. Medical Forum spoke to Director of Nursing and Manager of Family Services Ms Melanie Marsh who said some Ngala staff had been trained in the WWWT program. She thought it was a good, evidence-based program at a universal education level. However, it would be evaluated by the team to see if it complemented or duplicated existing programs.

Ngala has a range of services and programs for families struggling with adapting to baby, many of them free, which help both parents negotiate their changed lives and circumstances once a baby has come on board.

“There is also our helpline which gives timely access to trained staff seven-days a week. We find that service resonates. It gives strategies and support at crucial times. If there are people identified from the helpline who need extra help, Ngala can offer consultations and home visits, which can move to day or overnight stays if necessary. It is a layered approach,” Melanie said.

At all those interventions, it’s an opportunity for clinical staff to gauge parents’ mental state.

Melanie said there was constant demand for Ngala’s in-patient services but they were prioritised and she wanted to let doctors know that the service was always ready to respond.

“Doctors are key stakeholders and we would like them to know about the depth and breadth of services we offer. Ngala recently conducted a GP workshop on sleep and feeding and later in the year we will be talking to junior doctors at PMH. It’s a matter of letting them know what we can do to help their patients.”

MEDICAL FORUM

Wine Review

Turkey Flat

is Ageing Perfectly

Turkey Flats Wines are located in the spiritual heart of the Barossa in Bethany. The Schulz family have a connection with the property and vineyards going back to 1865 when the family built the original butcher’s shop. Fortunately for wine lovers the original Shiraz and Grenache VINESåSURVIVEDåTHEå'OVERNMENTåWINEåPULLåINå åANDåNOWåAREåTHEåBACKBONEåOFåSOMEåFABULOUSå red wines. In 1990 the current Schulz family members purchased the property and set about building a winery and cellar door as well as preserving the heritage vines. Winemaker Mark Bulman has been in charge since 2008 and is a self-confessed Grenache tragic. Turkey Flat Wines are a snapshot of the history of winemaking in Australia.

By Dr Martin Buck

1

2

1. Turkey Flat 2015 Barossa Valley White Here is a blend of the Rhone valley trinity of whites – Marsanne, Rousanne and Viognier. This medley of varieties is sourced from their Bethany and Stonewall vineyards, made in separate parcels using traditional Rhone techniques of wholebunch pressing, extended skin contact and then new French oak maturation. It’s certainly an interesting wine with a closed nose, hints of stone fruit and ginger, with a clean finish. For me, I prefer these varietals as stand-alone wines as the blends can be a little complicated.

3

2. Turkey Flat 2015 Rose Some of Australia’s greatest Rose wines come from this area and this wine is in that company. It’s a luscious, iridescent pink in the glass with unmistakeable strawberry, petal and confectionary aromas. Predominately Grenache but with a smattering of Shiraz, Cabernet, Mataro and Dolcetto, they all give complexity, big fruit and some spice. This is a standout Rose and perfect for a summer’s lunch of seafood or Asian dishes.

4

3. Turkey Flat 2014 Butcher’s Block The Barossa is the Australian home of Grenache, Shiraz, Mataro blend which was “borrowed” from the lower Rhone valley. The 2014 Butcher’s Block blend is predominately Shiraz and contains fruit from some of the oldest Australian vines. As you head to the cellar door, these vines are along the driveway – ancient, gnarled, convoluted but alive and producing irreplaceable fruit. Each of the components of this wine are made separately and assembled for the final blend based on the vintage. There are aromas of ripe berries, spice and some feral hints. Palate weight is medium with soft, subtle plummy flavours, medium tannins, good mouth-fill and persistence. A sensational GSM blend and very well priced.

5

4. Turkey Flat 2014 Grenache It is impossible for me to give an unbiased review of the 2014 Grenache as it is the wine that, for me, took Grenache to a new level. Made from low-yielding, 98-eight-year old bush vines, it is the pinnacle of Australian Grenache. This wine has a seductive nose of mocha chocolate, plums and berries with the intensity of a boxer’s punch; medium-bodied, with a complex palate of silky, fine tannins and spicy fruit. This is the best Grenache in Australia!

5. Turkey Flat 2013 Shiraz This Shiraz is another wine from heritage vines that claim to be the oldest in the country. And, again, it is a wine assembled from individually fermented parcels to create the final vintage. It has great intensity boasting dark, brooding fruit, cassis and feral hints. It’s not easy to find another Australian Shiraz with such historic components, intense fruit and pure pleasure.

WIN a Doctor’s Dozen!

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Wine Question: Which wine does Martin describe as having the intensity of a boxer’s punch?

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MEDICAL FORUM

MAY 2016 | 49

Theatre

on

’ s l e g n A … s g n i W It may be one of the 20th century’s great masterpieces but because of its epic nature it is not staged as much as its quality demands. Next month is your window of opportunity when Black Swan State Theatre Company stages Part 1 of Tony Kushner’s Angels in America.

Many West Australians will remember the two-part television series in 2003 starring Meryl Streep and Al Pacino. It won a string of awards and has haunted the consciousness of its viewers ever since.

But it’s always been a work for the theatre and veteran Australian actor John Stanton (recognised instantly from Crawford cop shows Homicide, Matlock Police, Division 4 and countless other TV shows) played the role of Roy Cohn in the Sydney Theatre Company’s premiere production in 1993 (just two years after the world premiere in San Francisco). He returns to the role for the Perth season.

“I was 20 years too young for the role then, which didn’t seem to matter because I’d never heard of Roy Cohn at the time, and I’m åYEARSåANDåAåBITåTOOåOLDå ATå åFORåITåNOWåBUTå that doesn’t matter either,” John told Medical Forum. “When Roy Cohn died at the age of 59 he was ravaged by AIDS and looked 20 years older than he was. So I figured who cares, it’s such a great role to play.”

Angels in America is an epic two-part play OFåABOUTå 1/2 hours long, though most often these days only the first part, known as the Millennium Approaches, is performed and is a self-contained work, complete with resolution.

It is a three-way story of intersections and crossovers, tragedy and despair, in the era of political conservatism of Ronald Reagan and, of course, the AIDS epidemic. Notso-far-above this chaos of life on earth, are the Angels of the title, they themselves abandoned and eager to find home.

Black Swan artistic director Kate Cherry, who will be directing this production, was present at the very first reading of the play in the early 1990s and thought that, in 2016, it would be the perfect play to celebrate the importance of life.

While John is harder to lure off his rural property in Castlemaine, Victoria, these days his distinctive, molasses bass voice is still in demand for voice over work and late last year he added the role of Dracula to his CV, He returns to a different sort of Satanic creature next month in Perth – be on your toes!

By y Ms s Ja Jan Hallam a a

This infamous Roy Cohn is no work of fiction but a devious and significant player in US conservative politics, post-war until his death in 1986. He was Senator Joe McCarthy’s legal adviser during the communist witch hunt in the 1950s and before that was the prosecutor in the controversial Rosenburg spy trial which led to the executions of Julian and Ethel Rosenburg on testimony that was later revealed to be a lie.

Cohn was spitefully homophobic while conducting a double life as a homosexual and John Stanton, while describing him as a “vile human being”, is excited to be bringing him to the stage once more.

“Everything Kushner has written here about Cohn is true. The dialogue, the scenes – everything is based on what is known about Cohn’s life. While Tony wrote the words, they are created from Cohn’s own life.”

50 | MAY 2016

Mr John Stanton

MEDICAL FORUM

Music

WASO

s t h g i e H e h t s t i H

When Asher Fisch first conducted the WA Symphony Orchestra way back in 1999 few would have thought he would be one of the most significant figures in the orchestra’s history.

He has now been principal conductor since 2014 and has overseen some significant moments – the lightbulb moments that build reputations and foster audience devotion. The first was the Beethoven series in 2014. By the time he launched the Brahms concerts, the players, orchestra and administration were in love with this hugely enthusiastic, charismatic figure.

Walking alongside him every step of the way has been the orchestra’s executive manager of artistic planning, Evan Kennea, who is the connecting tissue between an idea over coffee and 120 players blasting their hearts out in one of nearly 60 concerts WASO performs each year (excluding their commitments to the opera and ballet companies).

When Medical Forum caught up with Evan, he put aside his planning for 2018, which he said was well under way, to talk about a concert coming up next month with the exciting young Uzbek pianist Behzod Abduraimov. As a little insight into Evan’s working day, to make the June 3 and June 4 concerts happen began about four years ago when Behzod, at just 22, brought the house down at the Perth Concert Hall playing the Tchaikovsky piano concerto.

“We immediately invited him back but, as sometimes happens, his schedule clashed and we had to find the next opportunity to fix a date in his diary. He is such an exciting musician.”

engagement has become a permanent fixture for WASO, nurtured by a great conductor and an administration prepared to bring the world’s best to Perth to play with them and, in October, a case of heading off to play with the world. The orchestra will be touring China and participating in the Beijing music festival.

Ever present is Evan and his calendar. Filling it, however, is a collaborative effort of planning directors from other Australian and New Zealand orchestras.

“We meet up 3-4 times a year and help each other plan seasons. Not many overseasbased conductors or performers fancy flying to Australia for just one week, so we often use our collective influence to create three and four week tours.”

However, the principal conductor has the first say and Evan says he and Asher have a wonderful relationship.

“When Asher is in Perth, there is a lot of strategy planning. He has strong ideas about what repertoire he wants to conduct with the orchestra. His musical world is the German late-classical/romantic period so from Mozart to Wagner and Strauss. He brings such depth of knowledge and understanding of this repertoire to the orchestra.”

“So we start with that wish list and build outwards. But there is a lot of long-distance discussion with Asher when he’s not in Perth and interstate and international colleagues.

Who’s heard a good violinist or soloist? Which guest conductor is free and fabulous and so it goes.”

Eva n K ennea

What is apparent that in the past two years, Asher Fisch has flicked a switch that has transformed WASO from a good orchestra to a great one.

“Asher has incredible musicianship; he’s very skilful and he has a clear vision of what level he wants the orchestra to play at. But this growth is not as simple as Asher Fisch coming to Perth. He’s unleashed the orchestra’s inherent musicianship and confidence that will endure. There are such good players in WASO and he’s given them permission to let rip; to play together and listen to each other and feel music together.”

By Ms Jan Hallam

Behzod won the prestigious London International Piano Competition in 2009 at just the age of 18 playing Prokofiev’s third piano concerto.

“It’s a party piece for him. He plays it with such panache and freedom – he looks as if he is having a great time playing and that enthusiasm is transmitted to the audience.

People hang off every note. I’m sure Perth audiences will be impressed and moved by the Prokofiev.”

Evan said it’s not just the audience that lifts when these extraordinary musicians come to play with WASO. “Every person on the platform wants to match the soloist and when that happens, we are reminded of how lucky we are to have such talented people to share their music with us,” he said.

Behzod Abduraimov

This elevated level of

MEDICAL FORUM

MAY MA Y 2016 2016 | 5 51 1

rs â&#x20AC;&#x201C; reer and mothe Food, love, ca s. p ou guilt gr the four major

SHORT STUFF Tim Vineâ&#x20AC;&#x2122;s Zingers 1. One-armed butlers: they can take it but they canâ&#x20AC;&#x2122;t dish it out.

2. Black Beauty â&#x20AC;&#x201D; heâ&#x20AC;&#x2122;s a dark horse.

3. Velcro â&#x20AC;&#x201D; what a rip off.

4. Iâ&#x20AC;&#x2122;ve got a sponge front door. Hey, donâ&#x20AC;&#x2122;t knock it.

5. My mother used to beat me with a telephone. I was always on the receiving end.

6. I went to the doctorâ&#x20AC;&#x2122;s, he said, â&#x20AC;&#x153;Youâ&#x20AC;&#x2122;ve got hypochondria.â&#x20AC;? I said, â&#x20AC;&#x153;Not that as wellâ&#x20AC;?. ĂĽ)ĂĽSAID ĂĽh) VEĂĽGOTĂĽAĂĽRASHv ĂĽ(EĂĽSAID ĂĽh) LLĂĽBEĂĽASĂĽ quick as I canâ&#x20AC;?.

8. I went to the carpet shop. I said, â&#x20AC;&#x153;Do you sell carpets by the yard?â&#x20AC;? He said, â&#x20AC;&#x153;No, we sell them in hereâ&#x20AC;?.

9. I went to the butcherâ&#x20AC;&#x2122;s. He said, â&#x20AC;&#x153;I bet you 10 quid you canâ&#x20AC;&#x2122;t reach those two bits of meat.â&#x20AC;? I said, â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m not betting.â&#x20AC;? He said, â&#x20AC;&#x153;Why not?â&#x20AC;? I said, â&#x20AC;&#x153;The steaks are too high.â&#x20AC;?

10. Iâ&#x20AC;&#x2122;ll tell you what often gets overlooked â&#x20AC;&#x201D; garden fences.

11. So, I ate this chess set. It was horrible.

I took it back to the shop. I said, â&#x20AC;&#x153;This is stale, mate.â&#x20AC;? He said, â&#x20AC;&#x153;Are you sure?â&#x20AC;? I said, â&#x20AC;&#x153;Check, mate.â&#x20AC;?

12. I went down the local bakerâ&#x20AC;&#x2122;s. I said, â&#x20AC;&#x153;Can I buy a sausage roll?â&#x20AC;? He said, â&#x20AC;&#x153;Do you want me to put it in the microwave for you?â&#x20AC;? I said, â&#x20AC;&#x153;Yes, please.â&#x20AC;? And he came home with me.

MELBOURNE COMEDY FESTIVAL I spy with my little eye only about 10-15% of the things I can see with my fully grown eye. â&#x20AC;&#x201C; Joe Lycett I have no maternal instinct. Iâ&#x20AC;&#x2122;ve just never had the urge to â&#x20AC;Ś ruin my life. If I had a kid crying in the next room: â&#x20AC;&#x153;Mummy, thereâ&#x20AC;&#x2122;s a monster under my bed!â&#x20AC;? Iâ&#x20AC;&#x2122;d say, â&#x20AC;&#x153;Of course there is!

Thatâ&#x20AC;&#x2122;s where they live!â&#x20AC;? â&#x20AC;&#x201C; Jen Kirkman At schooI I was terrible at science, on my ďŹ nal year 12 biology exam in answer to the question: â&#x20AC;&#x153;what is the function of a cell wall?â&#x20AC;?

I wrote â&#x20AC;&#x153;to keep the rabbits outâ&#x20AC;?. â&#x20AC;&#x201C; Mel Buttle You know it's hot when mum walks around the house in her underpants and her adult children do not have the energy to be horriďŹ ed. â&#x20AC;&#x201C; Denise Scott

athy - CartouoisneiswtitC e G

Whenever I'm in England someone invariably says to me: â&#x20AC;&#x153;Oh you are Australian. We really don't think it's right what you people did to the Aborigines.â&#x20AC;? And I always reply, â&#x20AC;&#x153;Hang on, wasn't that you?â&#x20AC;? â&#x20AC;&#x201C; Greg Fleet Do you know what mums have way more of, than anyone else in the world? Containers. â&#x20AC;&#x201C; Jmac I've been to a psychic. I don't know why I get SO much judgment about it. I mean, I don't judge religious people. You might like to listen to a man talk about a man in the sky, I'd rather listen to a woman in a purple dress talk about me for half an hour. â&#x20AC;&#x201C; Celia Pacquola

Just remember life is not a race, itâ&#x20AC;&#x2122;s a dance, a dance in a room slowly ďŹ lling with bees. â&#x20AC;&#x201C; Asher Treleaven I wonder how long it will be â&#x20AC;&#x2122;til airlines aren't only charging for physical baggage, but for emotional baggage too? Not that it'd bother me. I'm ďŹ ne. Really. Just ask my dad. WHO'S NEVER THERE! â&#x20AC;&#x201C; Tegan Higginbotham Well my new show is about getting famous.

I'm trying hard but it's not going so well. In fact this is HOW unrecognisable I amâ&#x20AC;ŚI was at home in Perth over Christmas going for a jog (because this bikini body does not just happen) and a child on a bike knocked me over. I was on the ground and as if I couldn't get any lower his mum yelled out: "CALLUM! LEAVE THAT POOR LADY ALONE." Yep â&#x20AC;&#x201C; people don't even recognise I have a penis at this point. â&#x20AC;&#x201C; Joel Creasey You know who hates hipsters the most?

Bikies. Yep, â&#x20AC;&#x2122;cause 10 years ago they were the only guys with beards and tattoos.

Now it's confusing for them, they go to Brunswick/Newtown and they're like: â&#x20AC;&#x153;Is that a Comanchero or a barista?â&#x20AC;? â&#x20AC;&#x201C; Dave Oâ&#x20AC;&#x2122;Neil

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52 | MAY 2016

MEDICAL FORUM

Entering Medical Forum’s competitions is easy!

Competitions

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

Music: Behzod Abduraimov Plays Prokofiev Behzod Abduraimov won the 2009 London International Piano Competition as a teenager. Barely in his 20s he heads to Perth to play the electrifying third piano concerto of Prokofiev with the WA Symphony Orchestra.

Tchaikovsky’s Pathetique symphony is also on the bill.

Perth Concert Hall, June 3 & 4, MF performance June 3

FEATURE

Theatre: Angels in America Part 1 Black Swan has Tony Kushner’s landmark and award-winning play on offer and it’s a modern theatre classic. Set in 1985 in New York in the grip of the AIDS epidemic is explores the vicious politics and economics of boom and the deep-seated prejudice that went along with it.

Heath Ledger Theatre, May 28-June 19

Movie: Money Monster This is a taut, tense thriller with Jodie Foster directing George Clooney and Julia Roberts in a story of a bombastic TV huckster whose popularity has made him the money guru of Wall Street. But that kind of profile can be dangerous as an irate investor takes matters into his own hands.

In Cinemas, June 2

Movie: Independence Day Resurgence (3D) Aussie Liam Hemsworth leads a cast including Jeff Goldblum, Bill Pullman and Judd Hirsch in the sequel we had to have. This chapter has global catastrophe on writ large but alien technology could be the saviour of the planet.

In cinemas, June 23

Movie: Ice Age 5: Collision Course (3D) Scrat’s epic pursuit of the elusive acorn catapults him into the universe where he accidentally sets off a series of cosmic events that transform and threaten the Ice Age World (again). Another quest is called for and the regular crew of Sid, Manny and Diego head off to exotic climes.

COMP Movie: Hunt for the Wilderpeople The buzz for this New Zealand comedy is huge. It stars Sam Neill and is the offbeat story of a defiant young city kid who is fostered to live in the country with Bella and cantankerous Hec (Neill). When Bella dies suddenly, Hec and Rick head for the hills.

In cinemas, May 26

Doctors Dozen Winner This month’s Doctors Dozen winner, GP Gavin Leong, is the only one in his family who has an occasional tipple. It would seem that the assorted Nail Brewing beers will last quite some time. In his youth Gavin paid a visit to the Munich Oktoberfest and enjoys a refreshing ale at the 19th after a round of golf.

In cinemas, June 30

Winners from the March issue Movie – Eye in the Sky: Dr Monica Keel, Dr Hilary Clayton, Dr Ross Henderson, Dr Louise Sparrow, Dr Brett Baird, Dr Jane Weeks, Dr Leanne Heredia, Dr Michel Hung, Dr Ian Walpole, Dr Suzette Finch Movie – Wide Open Sky: Ms Tammy Barrett-Izzard, Dr Sayanta Jana, Dr Twain Russell, Dr Amy Gates, Dr Ernest Tan, Dr Sara Chisholm, Dr Norman Juengling, Dr Michael Armstrong, Dr Patrick Lai, Dr Belinda Lowe

Reform Make or Break? t Mental Health Frontiers

Movie – Kung Fu Panda 3 (3D): Dr Divya Sharma,Dr Eric Khong, Dr Angeline Teo, Dr Michael Light, Dr Clare Matthews, Dr Nai Lai, Dr Smita Samuelraj, Dr Trixie Dutton, Mr Ray Barnes, Dr Chong Kwah

t Private Insurance Trials t Clinicals: Back Pain; End-of-Life & More...

Movie – Spanish Film Festival: Dr Colin Stewart, Dr Bibiana Tie, Dr Paul Kwei, Dr Ade Kusumawardhanui, Dr Moira Westmore, Dr Mandy Croft Major Sponsors

March 2016

www.mforum.com.au

Opera – The Riders: Dr Sharyn Bennier Theatre – Picnic at Hanging Rock: Dr Diane Comley

MEDICAL FORUM

MAY 2016 | 53

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JU UNE 2016 201 0 6 - next nex extt deadline dead de aad dliine ne 12md 12m 2md d Monday Mond nday dayy 16th 16th 6th May Maay â&#x20AC;&#x201C; Tel T l 9203 Te 92 3 5222 522 222 2 or or jasmine@mforum.com.au jasmiine ne@m @mforum.com.au JUNE

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