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Keeping Things Above Board By the time this edition goes to press MDA National will have held its elections and Medical Forum will have held its Doctors Drum breakfast AHPRA & The Medical Board – Friendly Fire? The ﬁrst event, an election that barely gets 10% of MDA members voting, features a tilt at MDA Mutual Board by Dr Keith Woollard. In his manifesto, he mentioned that four AMA presidents pr had been unfairly dealt with by Medical Boards. Later, using the MDA member m list, Keith was able to send a request re for a proxy to defeat a motion to lim elections from ﬁve to three people. limit M MDA control from Adelaide and the re representative nature of the board were m mentioned.
Dr Rob McEvoy
T There were emails of reply from Acting C Chair Dr Rod Moore and Mutual Board m member Dr Andrew Miller both saying K Keith’s request was misguided as l limiting the Mutual Board in future to 10 members was more efﬁcient and was going to save members money. How much they didn’t say. Is this important?
In this edition we look at governance of Boards, including remuneration, because conﬁdence appears to have been shaken by events at Healthway and professional standards are important, particularly to doctors. We have written to a number of Boards with a health focus, asking them things like what governance safeguards they have to deal with conﬂicts of interest. Boards with different degrees of government involvement have been approached (see P8). The AGPAL Board didn’t answer our speciﬁc questions so we hope to hear more from them next edition. Few seem to want to divulge remuneration of board members. Should this be a matter for the public record, as it is for boards like Healthway where taxpayer funds are primarily used, and perhaps extend to not-for-proﬁts like St John of God Health Care, which escapes considerable taxes? Should board member appointments have a price signal so that anyone affected by their decisions can see the value-for-money status of each?
PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Mr Glenn Bradbury (0403 282 510) firstname.lastname@example.org
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If we take $140,000 a year as a benchmark (a Medicare Local’s remuneration for an advertised board member position), there is a lot of money being invested in some boardrooms. Someone paid to sit on three different boards could be keeping the wolves well away from their door. How people are appointed or elected to boards – selection on merit – is important to governance. We have assumed from our survey that impeccable board member proﬁles are one way organisations keep their ‘brand’ above reproach. Doctors might appreciate that full-blown professors are usually appointed on peer review of their academic, research or teaching achievements. WA is a small pond, so inﬂuence is easier to wield. You rely on the integrity of individuals and the surveillance of others to prevent misuse of power. The profession, like life, is full of different personalities, and you need to have a good radar to navigate through the movers and shakers, the progressives and conservatives, the altruistic and the self-servers, the whistleblowers and those who are simply hungry for change. For example, in the last month, Medical Forum and some lay media outlets received a series of anonymous emails from Reward Mining [email@example.com]. The writer, who liked the ‘f’ word a lot and appeared to have intimate medical knowledge, let loose with a string of allegations about the management of Fiona Stanley Hospital – tender rorts, software debacles, inappropriate equipment purchases, poor sterilisation, mismanagement, inappropriate staff responsibilities, wasting money, kick-backs, on it went. There was enough in the anonymous emails to keep a defamation lawyer in clover. FSH certainly has had its fair share of hiccups but whether they are an “outrageous waste of taxpayer money” and the result of “moronic decisions” remains to be seen. The more whistleblowers we have who are prepared to shed light on events the better, and they need protection. But they in turn, need to have hard evidence and be prepared to go on the record. These days, social media ensures the disaffected, vocal angry ones have a disproportionate voice, and other aspects of the story may never be pursued.
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18 FEATURES 8 Board Governance 14 Trailblazer: Dr Felicity Jefferies Ms Shannon McKenzie
Doctors’ Escape from Sarajevo Mr Peter McClelland
Medical Tattooing for Breasts Ms Jan Hallam
Women Take the Lead
NEWS & VIEWS 1 Editorial: Keeping Things Above Board Dr Rob McEvoy
Letters: Time to Tackle Sexist Culture –
Hospital Liaison GPs CVD in Indigenous Population
LIFESTYLE 44 Soothing the Savage – Wendy Wardell 45 John Fawcett Foundation 46 Travel: The City Time Forgot – Dr Ted Collinson 48 Funny Side 49 Social Pulse: Rural Health West Awards 50 WASO: The Four Seasons 51 Simply Wicked 52 Competitions
Midland Mess Unforgiveable – Mr Roger Cook
4 7 12 26 30 33 33
Thin Line of Dying Debate – Dr Phillip Noble Become a Label Watcher – Ms Claire Ward Curious Conversations: Dr David Soﬁeld The WA Specialist Clinic Have You Heard? Practising for Longevity Diabetes Self-Management Radiopaedia in the Picture Beneath the Drapes
Prof Karen Simmer Page 24
MAJOR SPONSORS 2
Dr Luigi D’Orsogna Heart Murmurs in Children
Dr Stuart Salﬁnger Ovarian Cancer Screening
Dr Jessica Yin Urogynaecological Mesh Complications
Ms Jo Beer PCOS and Diet
Dr Peter Nathan GP MRI Knee Items
Dr Carmel Goodman Menstrual Irregularities in Sportswomen
Dr Maria Garefalakis Contraceptives and Unscheduled Bleeding
“Dr Uber Itall” GPs, double your income!
Dr Jonathan Aleck Just Culture No Pie-inthe-Sky
Self-Management of Chronic Illness
Mr Ron Chalmers NDIS My Way
Benjamin Keely Help Stamp Out Abuse
INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Michele Kosky AM (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Mike Ledger (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM
Letters to the Editor Midland mess unforgiveable
That it then bungled and fudged its way to ﬁnd an alternative solution compounding the problems, is unforgivable.
Dear Editor, The Barnett Government’s decision to privatise the Midland Hospital was an ideological decision to see the hospital run by a private operator. Labor has always held the view that public hospitals should be delivered by the public, for the public, responding to the health needs of the community they serve in an open and accountable manner. The Barnett Government signed the WA taxpayers up to a contract whereby the contractor, rather than the public, would determine the scope of services to be delivered. This initial decision to privatise the hospital has set off a chain of subsequent decisions that have compounded the problems for Midland patients. Having discovered that the contractor would not deliver all services currently being delivered at Swan District Hospital (such as fertility services) the Government moved to establish a separate clinic, through yet another private operator, on the site of the hospital. No one was interested in building and running this new facility. Unperturbed by this latest set-back, the Barnett Government then appointed a local clinic, some distance away and even further removed from the hospital environment, to ﬁll the gap in services. With the initial decision to privatise, the people have lost their right to public service accountability. With the second decision it had lost in-house services, including opportunistic medicine such as counselling and treating patients before they left the hospital. However, with its third decision it has created a disjointed service totally removed from the hospital site. That the Barnett Government made the initial decision to privatise and curtail clinical services available to people was regrettable.
Mr Roger Cook, Opposition Health Spokesperson
a termination (Thursday). The days are not correct, but you get the drift and all this in front of a group of students as they lie naked except for a gown, on a trolley and awaiting examination.
There is no male equivalent to a clinic such as this.
Time to tackle sexist culture
The year was 1972, I hope things have changed.
Rather like men returning from war, none of us spoke of these things. It was only much later, well into my 30s, that I had the chance to discuss these issues with other female doctors and the experiences were all the same, and very wounding. We were all punished for nothing more than being female, invading a male space. Yes, we do get the message, just as intended.
I have never been subjected to the sexual behaviour of colleagues that senior vascular surgeon Dr Gabrielle McMullin described in the media last month, but every female medico has experienced a professional culture in which they were not welcomed. Most of my vintage (I’m 65) would have no more considered a career as a surgeon than climb Mt Everest without oxygen – there are some things that just aren’t worth the effort. I ﬁrst read Germaine Greer’s The Female Eunuch when I was 22, and was, at that time, surprised by a chapter headed, “Hate, loathing and disgust” referring to a male attitude in relation to the anatomy, sexuality and very existence of females. It was very confronting, and I had no wish to believe in it. I was as a student, privy to a conversation between male gynae registrars discussing whether or not they would eat a human placenta. The disgust they expressed was not about the placenta itself, but “where it had been”. I remained silent, and wondered why, of all the choices, they had chosen to be gynaecologists? I was told by a gynecologist as an RMO “never to believe anything a woman tells you”. This was passed on as we walked the corridor, by way of what? Useful information? Or the ultimate put down? I witness young women patients at KEMH seeking terminations being routinely put through a process of humiliation; booked for clinics where it was known that the consultant of the day would say no to all (Tuesday), make them beg and justify (Wednesday) or be given
I believed that by now, in 2015, things might have changed, but plainly they have not. Dr [Name Withheld], GP ED: Since the McMullin story broke, the Royal Australian College of Surgeons have established an advisory group to deal with concerns of bullying, harassment and discrimination. RACS President Michael Grigg said there was no denying that bullying and harassment occurred and the College had zero tolerance for this behaviour. The advisory group would review current reporting policies and procedures and would also review the gender balance within the specialty. It will be chaired by former Victorian Health Minister Mr Rob Knowles and a former Equal Opportunity and Human Rights Commissioner, Dr Helen Szoke, will be Deputy Chair. Chair of the Medical Board of Australia, Dr Joanna Flynn, is also in the group. In WA, the chair of the WA chapter of RACS, Dr Tom Bowles, said that he had spoken to several prominent female surgeons to ensure this was not commonplace here. The AMA has also written to every member to encourage reporting of sexually humiliating behaviour. ........................................................................ continued on Page 6
Living Life Loud Guitarist, surfer and urologist Dr David Soﬁeld has a full life outside of the consulting room and to his amazement, so do many of his colleagues. The most amazing guitar riff in the world is… the introduction to Oh No, Not You Again by the band Australian Crawl. I tried to work it out for 20 years and was recently taught it backstage by supremo rock guitarist Phil Ceberano and haven’t stopped playing it since.
One thing I’d like to achieve in 2015 is… to win an ARIA award for my new CD and take it on a national tour.
The thing I like most about medicine is… the people I meet who continually surprise me with the diversity of their interests beyond the world of work. I’ve met incredible musicians, artists, photographers and canoe-builders.
My last meal would be… Seafood Risotto at Sandrino’s in Fremantle.
If I could be someone else for a day I’d be… 11-times World Surﬁng Champion Kelly Slater. I’d love to see if what he does on a surfboard is actually possible!
Major Sponsor: Western Cardiology
Heart Murmurs in Children: Who needs a Clinic? The asymptomatic heart murmur is the commonest presentation for congenital heart disease in childhood. But murmurs are very common in children and most are innocent or physiological. Differentiating innocent from pathological heart murmurs primarily involves clinical assessment. It may seem obvious but innocent heart murmurs should only be diagnosed in asymptomatic children. One should be wary of the diagnosis in young babies as newborn assessment may be difďŹ cult because of faster heart rates and the presence of transitional circulation or persistent pulmonary hypertension. Therefore, any newborn with a persistent heart murmur should be assumed to have a pathological murmur. Commonest innocent murmers These are the Stillâ€™s murmur, the physiological pulmonary ďŹ‚ow murmur and the benign venous hum. The Stillâ€™s murmur has a characteristic vibratory or musical quality and is an ejection systolic heard throughout the praecordium but usually maximal at the lower left sternal border and apex. This is often heard in toddlers and young children but is uncommon in teenagers. The innocent pulmonary ďŹ‚ow murmur should be differentiated from pulmonary stenosis and an atrial septal defect. Valve stenosis is usually louder and associated with ejection click whereas an atrial septal defect has wide and ďŹ xed splitting of the second heart sound. Innocent pulmonary ďŹ‚ow murmurs can be heard at any age. The benign venous hum is a continuous murmur over the infraclavicular region in older infants, toddlers and young children when seated or standing but disappear when the child lies supine or with changing head position.
an innocent or pathological murmer, then an echocardiogram can be done if they are cooperative (usually by age 5). Alternatively, the child can be referred directly to a paediatric specialist. Use of referral clinics Generally speaking, all children with pathological heart murmurs and all children under ďŹ ve years with an asymptomatic heart murmur of uncertain cause should be referred to a paediatric cardiac service. A dedicated murmur clinic was established in the Childrenâ€™s Cardiac Centre (CCC) at Princess Margaret Hospital (PMH) in 2008 in an effort to reduce the outpatient waiting time for all new cardiac appointments. Referrals are triaged by a supervising cardiologist into three categories of urgency â€“ Category: 1< 30days, Cat 2: 30-60 days and Cat 3: >90 days. Cat1 are newborns and symptomatic infants and children, Cat 2 are usually asymptomatic infants, whilst Cat 3 are mostly asymptomatic older children and adolescents.
In the clinicâ€™s ďŹ rst year, the average waiting times for all new referrals to CCC reduced from 4.5 to 3 months for Cat 3 patients. But increasing demand has now resulted in Cat 3 waiting times reaching almost 12 months. In 2014, 86% of the referrals were assessed to be innocent whereas 14% had congenital heart disease conďŹ rmed on echocardiography. As of 2015, Heart Murmur Clinics outside PMH have been established to provide services to metropolitan and Southwest Western Australia (see below). These privately-run clinics have only two triage priorities: sĂĽ 0RIORITYĂĽĂĽĂĽDAYS ĂĽFORĂĽALLĂĽSYMPTOMATICĂĽ children, and all newborns and young infants regardless of symptoms. sĂĽ 0RIORITYĂĽĂĽ ĂĽDAYS ĂĽFORĂĽASYMPTOMATICĂĽ children and adolescents. These clinics provide early assessment by a consultant paediatric cardiologist who will continue to manage the patient, if needed. This should reduce waiting times and alleviate some of the demands on the CCC at PMH.
New to Western Cardiology in 2015 Dr Luigi Dâ€™Orsogna, in association with Dr Darshan Kothari at Western Cardiology, is pleased to announce the establishment of Heart Murmur Clinics in metropolitan Perth and the Southwest region. Conveniently located in Applecross, Midland and Subiaco, as well as Mandurah and Bunbury, these clinics provide for the prompt and efďŹ cient assessment of children with heart murmurs at relatively low cost. Priority is given to newborns and young infants and all children who are symptomatic. Simply tick the appropriate box under Paediatric Services in the Doctor Referral Form or call directly on 6263 4740. Q Dr Luigi Dâ€™Osogna
As asymptomatic heart murmurs are often an incidental ďŹ nding during examination for an unrelated problem, it is important to re-examine later, particularly if at initial assessment the unwell child had a hyperdynamic circulation. If the murmur persists but it is difďŹ cult to distinguish between
Visit www.westerncardiology.com.au 17 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services
Main Rooms: St John of God Hospital, Suite 324/25 McCourt Street, Subiaco 6008 5FMt$PVOUSZ'SFF$BMM Urban Branches: Applecross, Balcatta, Duncraig, Joondalup, Midland & Mt Lawley Regional: Bunbury, Busselton, Geraldton, Kalgoorlie, Mandurah & Northam MEDICAL FORUM
Letters to the Editor continued from Page 4
Thin line of dying debate Dear Editor, In his article Engaging in the dying debate (November edition) Dr Nitschke talks about engaging in the dying debate. I think he will ﬁnd that throughout written history many people, including doctors, have already engaged. Death is part of our existence that we have to accept. Suicide is also part of our existence and is available to all already. The problem with Euthanasia is that the proponents want others to be involved in their dying process, often in an active way. That is the problem. If someone commits suicide, leaves a note and involves no one else, then most people would say that is sad but soon forget about lt. Apart from police investigation and judicial acceptance that it was suicide, we all move on. It is the thin line between self-suicide, assisted-suicide and murder that is always the concerning problem. That is what the debate is really about. I will have nothing to do with assisted-suicide or murder. I am dedicated to life, not death. Dr Phillip Noble, Cockburn Central ........................................................................
Become a label watcher Dear Editor, Regarding the feature No Sugar-Coating the Truth (March edition), I agree that consumers need support to help them make informed, healthy food choices. People want to make healthy choices but are struggling due to a lack of knowledge and skills. Much of the confusion around food labels surrounds content claims on the front of the packets. While not untruthful, these claims have the potential to mislead consumers. Standard 1.2.7 of the Food Standards Code outlines the two types of content claims which are permitted on food labels: nutrient claims and health claims. Nutrient claims make a claim about the presence or absence of a nutrient in a food eg. “Good source of calcium”, and health claims connect that nutrient to a health condition eg. “Calcium is good for bone health”. Content claims can have what is termed a halo effect: the consumer makes an assumption about the healthiness of the whole food based on one feature of that food. More often than not, these assumptions are false; the healthiness of a food is not determined by a single nutrient. Excluding some speciﬁc cases, all packaged foods are required by law to display a nutrition information panel (NIP) on the back of the packet. The NIP displays the energy, fat, protein and carbohydrate content of the food per ‘serve’ and per 100g. The NIP may also include micronutrients such as sodium or calcium, as
April Laughs If 50 Shades of Grey were written by a man, it might read something like this: ‘How do you feel about using toys in the bedroom?’ she asked. ‘Fine,’ I said, ‘But I can’t see how we’re going to ﬁt a Scalextric in here.’ Her body tensed and quivered as she felt wave after wave ﬂow through it. I probably should’ve told her about the new electric fence. As I lay there on the ﬂoor, my naked body covered in treacle and whipped cream, I heard those inevitable words . . . ‘Clean up on aisle 3.’ ‘Are you ready to be tortured in a way only a woman can torture a man?’ she asked. I nodded nervously. ‘OK’ she said and ate half my chips. Her body trembled and shook.’I can’t wait any longer, do it now!’ she cried. ‘OK,’ I said and got the winter duvet from the airing cupboard.
applicable to the food. If people want to become more label-literate, I encourage them to learn how to read the NIP. Accredited Practising Dietitians can teach people what to look for in regards to speciﬁc nutrients and handy label reading wallet cards are available from LiveLighter. Information about label reading is also available on the Eat for Health website. Ms Claire Ward, Accredited Practising Dietitian ........................................................................
Editorial Comment Readers have asked about how we select Clinical Authors… Clinical authors are usually recruited by the magazine, in line with our editorial themes. They are asked to write on a subject we think will interest readers, at a digestible length. Most agree to help. Our medical editor ensures adequate standards and topic coverage. We ask authors to declare any competing interests, in line with the profession’s desire for more transparency and accountability, and in keeping with current international disclosure rules. It is important readers are aware of any perceivable conﬂict of interest, especially since we allow authors to give their considered opinion on management. Most authors agree to provide a contact phone number should a reader wish to clarify something.
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‘Harder!’ she cried, gripping the workbench even tighter, ‘Harder!’ ‘Alright,’ I said, ‘What’s the gross national product of Nicaragua?’ ‘I want it now against this wall!’ she ordered, ‘And keep it up as long as possible.’ ‘Don’t worry,’ I said, ‘I know how to put up a shelf.’
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The W.A. Specialist Clinic HISTORY The concept of a clinic of this nature was ﬁrst formulated by Dr Ram Tampi who started performing iron infusions at West Perth in the early 1990’s. The rapid and safe nature of the procedure led to a demand for iron infusions which has grown in an unprecedented manner and which has gained wider acceptance in the general medical community.
Inside the WA Specialist Clinic
In March 2014 the WA Specialist Clinic was fortunate to move into a brand new facility at 310 Selby St North, Osborne Park. At this time it was appropriate to change the name of the clinic from the West Perth Specialist Clinic to the WA Specialist Clinic. The clinic is now situated at the front of the new, purpose built, Clinipath Pathology laboratory. With excellent parking, a stylish reception and waiting area, the spacious clinic provides a new level of patient service and comfort. The facility houses 15 infusion bays with recliner seats, privacy curtains and the ‘wrap around’ nurse’s desk ensures patients are monitored at all times. The unit provides a large iron infusion service as well as chemotherapy, blood and blood products transfusions and other various infusion treatments e.g. for rheumatoid arthritis. The facility employs 5 full-time and parttime haematologists plus 5 registered nurses and a Clinical Nurse Manager. The clinic also employs two phlebotomists who provide an onsite blood collection service for the attending clinicians, with results often being available during the consultation. The collection staff also provide a by appointment
only service for patients requiring the more esoteric tests performed by the adjacent pathology laboratory. Private procedure rooms are also available for more invasive testing such as ﬁne needle aspirations and bone marrow biopsies, performed by the onsite pathologists. The facility also houses additional consulting suites for the onsite clinical endocrinologist, immunologists and microbiologists. Other procedures performed in the clinic include venesections (for haemochromatosis and polycythaemia), mantoux skin testing, synacthen testing and ECG’s.
Inside the WA Specialist Clinic
The clinic operates on a referral only basis and more information can be obtained by calling 08 9371 4530 or by emailing bookings@ clinipath.net. Cyndy de Wolde Clinical Nurse Manager WA Specialist Clinic
Clinipath Pathology, 310 Selby St North, Osborne Park
Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200
Patient Results: 9371 4340
For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at
Board Governance Watching Brief Codes of Conduct and managing conﬂicts of interest are the daily responsibilities of our health boards. Without good governance, public trust is at risk. When Medical Forum embarked on this select survey of governing boards of WA charities, NGOs and mutuals operating in health, it became clear just how different the organisations were from each other. Some are member owned, others are overseeing billion-dollar businesses, while others are community-based organisations. While impossible to compare apples with oranges, it is useful to explore how the boards govern and what safeguards are in place in areas such as transparency, remuneration and conﬂict of interest. The Healthway controversy is a timely reminder of the important role public perception and trust plays in the performance of our health boards, particularly for those organisations that invest taxpayer or donor money for the welfare of the community in which they serve. The Public Service Commission’s website is a font of information regarding standards and its guidelines on remuneration of boards and governance issues such as conﬂicts of interest are benchmarks. In the limited time available, we approached eight organisations representing communitybased, not-for-proﬁt, mutual and industry bodies: St John of God Health Care (SJGHC), Cancer Council WA (CCWA), Heart Foundation WA, MDA National, ConnectGroups, Bethesda Hospital, Lotterywest and AGPAL, all but AGPAL responded at least in part to our questions.
recorded in a register and the member is absent during all discussion on related matters. The board regularly evaluates its own performance and individuals are “carefully selected and evaluated on the basis of their performance.” Lotterywest
Is a State government authority reporting to the Premier, Mr Colin Barnett. It collects $797m in lottery revenue (7% to operating costs; 8% commissions to the 500 retail outlets; $271m community grants, remainder to winners). In his public comments during the Healthway controversy, Mr Barnett used Lotterywest as the model he prefers. It has a six-member Board of Commissioners appointed by the Cabinet on recommendations from the Premier for threeyear terms. Board members are remunerated under the matrices of the PSC. Declarations of events attended or beneﬁts received are made at each board meeting and recorded in the minutes. Conﬂicts of interest are dealt with as per PSC guidelines. The Minister (Premier) reviews all board positions and performances and he invites individuals to the board who possess the “appropriate skills”. “Good standing in business and the community is important.”
Is a religious-based NFP managing a national hospital and healthcare operation with an operating revenue of over $1b in the last ﬁnancial year. Its trustees select board members on the basis of “skills and experience from different backgrounds” – a detailed board proﬁle is available on its website. Members are from medical, business, legal and consumer backgrounds. Tenure is usually three years though it is at the trustees’ discretion. There is no maximum time limit. Board members are remunerated but no ﬁgure was provided to Medical Forum. A full ﬁnancial statement is online at the Australian Charities and Not-forProﬁt website (acnc.gov.au) where SJGHC says it discloses transactions of a related party nature. Conﬂicts of interest is the ﬁrst agenda item of every board meeting, such conﬂicts are
Is a member-owned mutual providing professional indemnity and supporting services for the medical profession. It has two arms – MDAN Ltd and MDAN Insurance Pty Ltd and is led by two boards – the mutual board and the insurance board. The mutual board currently has nine member-elected directors and one appointed director. Elections are conducted as per its Constitution and tenure is for three years. Voters must be members and be registered or retired medical practitioners. The majority of insurance board members including the chairman are independent. All of its directors are appointed by the mutual board. They must meet the Australian Prudential Regulation Authority requirements for a licenced general insurer. Members of both boards are remunerated at “commercially competitive”
Each was asked (abbreviated here): så (OWåITSåBOARDåISåSELECTEDåANDåTENUREåOFå members? så !REåBOARDåMEMBERSåREMUNERATED så (OWåBENElTSåANDåCONmICTSåOFåINTERESTåAREå addressed? så 4RANSPARENCY så 0ERFORMANCEåREVIEWåOFåBOARDåMEMBERSåIFå controversy arises?
rates “reﬂecting the contributions required”. Each board assesses the boards’ and individual directors’ performances against the constitution. Elected directors who remain eligible under the Constitution and the Corporations Act and their Board charters can only be removed by a resolution of the members of MDAN. Conﬂicts of interest must be declared at board meetings and that member may be required by the remaining directors to absent themselves from relevant parts of the meeting. Cancer Council WA Is a non-government agency with a charter to provide support and services to cancer patients and their families, fund cancer research and run cancer education and prevention programs. Funding is through community fund-raising, donation, sponsorship, income from retails outlets and government grants. It has 11 board members who are not remunerated. Board membership is by recommendation from CCWA’s Nominations and Membership Committee based on skills and experience to complement the board. If the board accepts a recommendation, that person is appointed for 12 months with a review at the end of that period. Each board member must formally agree to abide by the Code of Conduct which includes well-deﬁned conﬂict-of-interest guidelines and deﬁnitions, and precludes any member from “seeking or accepting any fee, favour, reward, gratuity or remuneration of any kind.” In addition a member must not use conﬁdential information obtained during a board meeting for personal advantage. Donors and supporters are able to request a copy of the Code of Conduct. Conﬂicts of interest are a standing item on the agenda and board members must disqualify themselves from any relevant discussion or decision. Performance evaluation occurs if need arises and action is based on the Code of Conduct. Public trust is crucial and strict observance of governance practices and procedures is paramount. continued on Page 10 MEDICAL FORUM
GPs, double your income! One outer suburban GP, who will be known only as Dr Uber Itall, took a fateful taxi ride recently and has arrived at a creative solution for general practice. “I can make more than a GP!” The taxi driver made this comment in response to the news item on the radio as we started our journey from Melbourne CBD to the airport. So I invited him to explain.
‘rebates frozen’ analogy nor did I pursue the targeting of just one type of taxi driver.
“Well at $32.05 for 19 minutes … Just watch the meter. Never thought I would be pulling doctors’ fees after never ﬁnishing high school.” Yes, I was now intrigued, so I continued the discourse and decided to do some impromptu anecdotal research. I also decided to employ a well credentialed Canberran technique of making some calculations on the back of envelope.
“Well we often have to put up with unpleasant clients ... Sometimes abuse ... Sometimes vomiting... (Noted). Also, recently, more competition with overseas taxi drivers...(OTDs, I thought).”
Indeed the ﬁgures did stack up on the taxi driver’s side – similar gross income, he had less overheads. In fact the corporate take-out was $150 per shift and, surprisingly, indemnity insurance, membership fees and upskilling fees did not seem to be a big issue. I guess we GPs won’t be paying our union fees anymore because our union has allowed the government to just target us for the cuts. I enquired about taking cash. “Of course, but always pay tax, and I often get tips.” This was accompanied with a wink and nod, presumably so I wouldn’t get the wrong idea. What about fare increases with inﬂation? The taxi driver looked at me as if he didn’t understand the concept, so I didn’t pursue the
It started to sound too good to be true, so I asked what the downsides of the job were.
Then suddenly, I had the Eureka moment. Combine GP work with taxi driving! Turning my envelope over, I jotted down a plan. 1. Patient requests a consult and a taxi ride. 2. GP attends patient offsite for a consult and then subsequent taxi service. 3. GP bills offsite visit. 4. GP delivers patient to destination and receives fare. 5. GP pays corporate body a nominal fee for booking the patient. Advantages are manifold and costs are greatly reduced. Now of course there are many blue sky opportunities here and with room running out on my envelope I jotted down: åså $6!åTRANSPORTåCONTRACTSååAåPATIENTåRECENTLYå told me of a $300 taxi fare incurred for hospital visit – this could be the government golden egg) så -AXIåTAXISåFORåFAMILIES
Board Governance Watching Brief Heart Foundation of WA Is the WA branch of the National Heart Foundation, an incorporated association which runs public heart health campaigns and funds research into CVD. It raises funds largely through public donation (67%, investments 11%, grants 21%). While it did not address the speciﬁc questions, its communications manager directed us to the WA branch’s annual report, which details speciﬁc governance issues. There are 13 members of the board. Two directors are appointed by the Cardiac Society of Australia and New Zealand and nine are member appointed. They are all independent, non-executive and act in an honorary capacity. Directors, other than the representatives of the Cardiac Society, are re-appointed annually. The longest serving director was appointed in 1998. The association has a Code of Conduct though the annual report does not speciﬁcally address the issues of beneﬁt or conﬂicts of interest. It does state, however, that it is the board’s responsibility to ensure that the Foundation retains its “independence from government,
så $ELIVERINGåMEDICATIONåFORåPHARMACIESå (opportunity to complete HMR and ﬁnally to invoice the pharmacies for a service) så "LOODåTAKINGåFORåLABSåPHLEBOTOMYåFEE så !DVERTISINGåFORåCARS så -AKINGåVEHICLEåAåMOBILEåOFlCE så '0åTAXISåFORåPOLITICIANSåINCORPORATINGåWINERYå tours så å-OBILEåSCANNERS Problems så 7OULDåHAVEåTOåGETåAå-EDICAREåRULINGå regarding history taking and driving. så 0ERHAPSåTHEå'0åCOULDåWEARåTWOåDIFFERENTå hats, so there was no ambiguity in which job he was doing, så 4HEåMAINåRISK åOFåCOURSE åWOULDåBEåIFåTHEå rebates were not indexed to the taxi fare schedule. Hang on, this has already been proposed with the rebate freeze until 2018. At least there would be the fare schedule keeping pace with CPI. Perhaps in the future the taxi role will predominate in the business plan. Suddenly, my driver said destination arrived. $68 on the meter + $10 taxes? I handed over $70 and said keep the change and no receipt. Everyone was happy. GP TAXI has been born! The future is brighter for all.
continued from Page 8
industry and other groups in determining health and other policies and recommendations”. It also must ensure the foundation complies with relevant legislation and regulations. Bethesda Hospital Is a not-for-proﬁt, religious-based 88-bed hospital. It has a six-person board including the CEO. A nomination committee appoints board members based on skill mix. A prospective member is interviewed by the board and the nomination is put to a vote. Board members are remunerated at a “rate that reﬂects the NFP status and size of the organisation”. A conﬂicts of interest register is maintained at every board and committee meeting, which is reviewed and recorded in the minutes. A board member absents themselves during relevant discussion and voting. Beneﬁts are set as formal policy (and decision) of the board and regularly reviewed. These minutes are available to the external auditor and accreditation agencies. Controversy involving board members would be reviewed case by case by the board as covered in the Constitution.
ConnectGroups Is an incorporated NGO, with community membership, that facilitates the development and maintenance of self-help and support groups in the community. It has an eightmember board which is by nomination. The board has the power to co-opt members for special purposes. They are not remunerated and gain no personal beneﬁt for being on the board. Conﬂicts of interest must be declared at board meetings and that member absent themselves for discussion and voting. The board runs a governance planning day when members’ performances are reviewed. ConnectGroups places importance of its board’s performance. “We wish to demonstrate that our board functions as effectively if not more so than corporates”, from both a funding point of view as well as an executive perspective. To register your comments, go to our website at www.medicalhub.com.au.
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Have You Heard?
New DG in a state of grace Perhaps the worst-kept secret in government circles: news on St Patrick’s Day that Dr David Russell-Weisz will take over as Director General of Health in August having overseen the opening of Fiona Stanley Hospital as its commissioning CEO. The Health Minister was his usual chipper self at the media conference conﬁrming the appointment. “Dr Russell-Weisz will preside over a largely reconstructed health system. As well as Fiona Stanley, we have new hospitals in Albany, Busselton and Kalgoorlie-Boulder and will soon open hospitals at Midland and Karratha as well as the Perth Children’s Hospital,” Dr Hames omitted to mention the HDWA searched for two years but were unable to ﬁnd anyone suitable outside WA. The Serco contract at FSH may gain the new DG’s early attention. Dr David Russell-Weisz
Pharmacy audit controversy
Prostaglandin window increases
The RACGP and the Consumers Health Forum based in Canberra have called for a full inquiry into the ﬁndings from the audit of the $15b agreement between the Federal Health Department and the Pharmacy Guild. The CHF is calling for a full and public inquiry into what it says is widespread and signiﬁcant failures of administration, which is wasting taxpayer money. It cites the Australian National Audit Ofﬁce’s investigation into the administration of the 5CPA, which found “persistent shortcomings”, including the unapproved transfer of $127m, and reallocation of $5.8m for a Guild-run program, without ministerial approval. The system, it says, hasn’t been evaluated in 25 years and it’s time it was. The 5CPA has been extended for another year, but it looks like Health Minister Sussan Ley will move to close loopholes and have widespread consultation next time round.
Early prostaglandin medical termination of pregnancy has increased from 49 to 63 days gestation with MS-2 Step (mifepristone, misoprostol) release on the PBS. After prostaglandin treatment, the choice is either none or surgical termination, so the new product allows an extra 14-day window for treatment at home, which the manufacturers say is good for rural women. Doctors were required to recertify to prescribe at www.ms2step.com.au.
Getting serious over FVROs Attorney General Michael Mischin will introduce Family Violence Restraining Orders (FVRO). Victims, usually vulnerable women, will ﬁnd it easier to get a FVRO: by reporting behaviour intended to intimidate, coerce or control (rather than prove an act of abuse); downgrading a magistrate’s discretion in issuing a FVRO; and asking courts to adopt
a risk management approach by listening to reports from government agencies and perhaps ordering compulsory counselling for perpetuators. Around 45,000 incidents of family violence were reported to WA Police in 2012, with a 250% increase in the last 10 years – a whole-of-community approach is needed because policing has failed in the past.
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Great when IT works... Many doctors would carry a Merlin dongle on their keyring, to communicate at 425 MHz radiofrequency with their home rollerdoor. Merlin is also big on medical device communication, including its Merlin@home RF remote monitoring (model EX1150) used by USA-based St Jude Medical to keep track of patients with a range of implantable deﬁbrillators and pacemakers by communicating via a bedside device at 402405 MHz. Data is transmitted securely online (Wireless USB Adaptor available) to Merlin. net Patient Care Network, where the patient’s clinician can log on and view. We received a TGA-St Jude hazard warning saying a glitch in the Merlin software (updated version 8 released in January and downloaded into model EX1150 without patient intervention) was probably causing an unintended software reset which led devices to enter back-up mode and return to default. Although no one was at risk, patients may be inconvenienced by vibratory or audible alerts, clinicians by emailed alerts – some implanted devices might need replacing. The joys of technology advances.
War on SPAM The Internet is a busy place for scammers. The Medical Forum server is now getting over 1000 SPAM messages each day. Sophisticated SPAM ﬁltering may interrupt legitimate communication between businesses. We’ve noticed that legitimate press releases from pharma companies either carry the altered words “pen*le” or “s*x” or
One ﬂu over the cuckoo’s nest Flu vaccination has suffered two delays this year. A mid-March jab frenzy became April 15 and now April 20 due to virus strain inclusion – inﬂuenza A H1N1 and H3N2-like virus, as well as the B/Phuket/3073/2013-like virus. For the ﬁrst time, pharmacies will be able to administer the vaccine, after last year’s Terry White trial. We did a count of the big national groups, which are all participating at selected locations on speciﬁed dates. There’s a lot! Friendlies pharmacies have signed up with HBF so if you have ancillary cover, the vaccine is free. The cost at other outlets varies from $9.99 to $20. However, the date hopping has left pharmacy websites poorly out of date so we hope mass chaos doesn’t reign, with the clock ticking perilously close to winter ﬂu onset.
they avoid them altogether. As more and more practices get their own domain email servers, and email ﬁltering moves from the ISP to them, legitimate medical communications can be chopped because they contain key SPAM words. The hard part is that the SPAM ﬁlter fails to notify the sender (telling a SPAMer you exist is not on!) or the recipient (because of the sheer volume) it has done this.
Team work recognised
Lions Outback Vision founder Dr Angus Turner who has been working in the North West for the past four years with a team of registrars, optometrists, orthoptists, nurses and liaison workers in indigenous communities. He has been a great champion of telehealth and multidisciplinary team work to tackle the challenges of closing the gap. Last month, the business world stood up and took notice when he was awarded the Business News 40under40 First Among Equals award.
Back in July 2013, we featured the work of
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Fighting for Country Folk and their Doctors As a young Geraldton GP, Dr Felicity Jefferies was angry at the raw deal many sick people in rural areas received. She has spent the past 20 years addressing the imbalance. A love of rural general practice and a desire to contribute has seen Dr Felicity Jefferies step into many roles during her career. From practice rooms to board rooms, she has been a long-standing advocate for the profession she loves. Though she was born and raised in Perth, Felicity has always had strong ties to the country – her mother was from Broome, her father from the Wheatbelt. Growing up, there were plenty of holidays in the country visiting family and friends. So when a career in medicine beckoned, so too did the country. Felicity spent her GP rotation in Northampton supervised by Dr Ron Hutchison, a rural GP who ran a solo practice. “Dr Hutchinson worked across the spectrum – anaesthetics, obstetrics, surgery and even acupuncture and hypnosis. It made me think about what I wanted to do when I ﬁnished training and general practice – rural general practice – really appealed,” she said. After completing her training, which included one hairy day as a junior doctor stafﬁng the local emergency department after a cyclone, Felicity followed her heart into rural general practice. She spent 15 years working as a GP in Geraldton and raising a young family. It was during this time that Felicity also became a
passionate advocate for rural general practice. A quick glance at her CV shows there is barely a rural GP body that she hasn’t been associated with. The Rural Doctors Association of WA, the MidWest Division of General Practice, the WA Centre of Rural and Remote Medicine (WACRRM) and later Rural Health West – her name is a common denominator. What motivated her to step into policy making and advocacy? Changing policy at the source “In the early 90s, country areas were really short of doctors. In Geraldton and other places we tried to recruit but we were just not getting any doctors coming to our towns, I worked a lot with patients with breast cancer and I would see these women, in such poor health, having to travel all the way to Perth to get the necessary treatment. You couldn’t help but see the raw treatm deal that people from the country got.” “A lot of the thinking from other doctors was ‘Well you just need to pay doctors more money to go out there’. But that just wasn’t true. Someone had to start saying these things, Som correcting the misconceptions. Someone corre needed to start speaking up about it. I thought I need could be one of those people.” Throu Throughout the 1990s and early 2000s, Felicity work worked on a number of projects aimed to boost and ssupport the rural GP workforce yet she also knew there was still much more that needed to be done. do A move to government – to the centre of decision-making de – came next. “I came cam to realise that the levers that needed to be pu pulled were with the State Government. [It] alone had the funds and the capacity to make a real difference d and in the end I decided I needed to go there and be a driver from the inside,” she said. s
Royalties for Regions zeitgeist She spent ﬁve years as the Executive Director of Clinical Reform at WACHS, overseeing a number of projects including the Southern Inland Health Initiative, which is often touted as something of her baby, The SIHI aimed to transform health services in the State’s south by tipping more than $560m into GP services, primary health care, hospital upgrades and telehealth services. For Felicity, the key was to preserve and support the models of health care that worked for rural areas, not replace them. “SIHI was about getting more resources to support the GPs already working there and helping them to achieve a better lifestyle, so that they would stay in the communities where they were needed.” Other initiatives included the Rural Practice Pathway (which now puts an extra 30 junior doctors in country areas each year) and the Emergency Telehealth Service (which last year won the Premier’s Award) were key. Sharing the doctor experience What did she bring to the table to see these services come to fruition? “What it meant to be a rural doctor and how they perceived WACHS. This changed behaviours and attitudes,” she said. But she is quick to add that she had two big advantages. Her timing was impeccable – the Royalties for Regions funding had just been announced and she was able to access funds for projects. And there was her team, a group of people who “were prepared to work through the bureaucracy to get things done”. While she admits that at times the bureaucracy drove her mad – the business case for funding more junior doctor positions had to be rewritten three times – she remembers WACHS as a place where “people really seemed to care about the work they were doing”. Why, then, did she leave? As she tells it, both she and her husband, Mr Kim Snowball, the then Director General of the WA Health, had both stepped into the government system with the idea that they would work there for three to ﬁve years. Both held roles with “24/7 demands” and after ﬁve years, both were looking for challenges that allowed for a better work-life balance. There was also emotional investment her role demanded. “You feel like you are responsible for all of the clinical services in the entire State, and you want to make sure every single one of them is responsive and is supported,” she said.
continued on Page 16 Dr Felicity Jefferies, the consultant and, inset, as the the Medical Director of WACCRM back in 2000.
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Fighting for Country Folk and their Doctors Today she and Kim head up HealthFix Consulting. As a Director, Felicity now lends her expertise to organisations across a variety of ﬁelds, from policy development to education and training. She has been involved in a review of the national registration and accreditation scheme and a review of the WA telehealth services. She is currently working on projects involving the WA General Practice Education and Training and Silver Chain.
workforce for the country, remains a pet subject. Just over a year ago she was commissioned to produce a report for Curtin University on the feasibility of a third WA medical school.
In regards to telehealth, Felicity has researched governance and business models for WA Health to ensure better access for rural patients to both private and public health services, while for Silver Chain she is helping to guide it through an expansion of its junior doctor placement program.
Any new medical school, she argued in the report, must commit to producing graduates predisposed to take up general practice in these areas – otherwise the investment would not be worthwhile.
“The work with WAGPET has included an assessment of the community residency program and its potential to expose more junior doctors to the rewards and challenges of general practice through early placements. I recently completed a review on the PGPPP in WA, which is highly regarded by supervisors, junior doctors and communities alike.” “At HealthFix I am choosing which issues to take on,” she says. “It’s hard sometimes because I am very conscious that there are still problems out in the country, but this time I am not the one charged with ﬁxing them.” Power couple Mr Kim Snowball and Dr Felicity Jefferies
Rural general practice, and getting the right
The report, titled Western Australia: A Sorry State for Medical Education and Training, estimated the State has a shortage of 950 doctors. It again highlighted that this shortage is more acute in rural and regional areas.
“While increasing the number of medical school graduates will help, what we also must do is make sure that they are going into the specialties and communities that need them the most. We need to make sure we are creating the workforce that the community needs, rather than leaving it to chance. We want to be able to get medical students into areas like general practice, because we know there is a need.” While she admits to missing the cradle-to-grave medicine of general practice, particularly telling a woman who has been trying to start a family that she’s pregnant, policy is her future. “I really do feel that I can make the bigger difference by doing what I am doing now.”
By Ms Shannon McKenzie
Photo courtesy Whe
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Taking care of Western Australian rural medical practitioners for 25 years Rural Health West offers a diverse range of programs so general practitioners can take care of their communities: Business and Practice Support Service z Locum Placement Service z Access to financial incentives
Contact us to find out how we can help you take care of others. W www.ruralhealthwest.com.au | T 08 6389 4500 | E email@example.com 16
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Escape from Sarajevo The Dedic family has been through trials of ﬁre to make their way to Perth and become the doctors they were always meant to be.
Grandmother Mrs Ismeta Cekro, father Pasko, mother Jasminka at Deila’s UWA Graduation
There’s a strong strand of medicine within the Dedic family and the story is set against the backdrop of one of the bloodiest chapters in the history of modern warfare. Pasko, Jasminka and their daughter Deila escaped the siege of Sarajevo to forge careers as doctors on the other side of the world.
Pasko’s Story “It was a terrible time in Sarajevo during the early stages of the war. I managed to get my family to Croatia and then on to Italy, they were terriﬁed by the bombing and there was no water or electricity and very little food. Everything was broken and trying to work as a cardiologist at the hospital consisted of a basic physical examination and checking a pulse.” “Looking back, it’s hard to imagine that this was medicine in the early 1990s!” “I managed to get out after spending two years working in the hospital and ﬁghting the Serbs. People were being killed every day and eight died in our block of ﬂats alone. It was difﬁcult to stay in touch with Jasminka, in fact we had to use short-wave radio but I never lost hope.” “To escape the conﬂict, you had to do it secretly because if you were caught you could be tried
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as a traitor. I was lucky enough to get a fake identity card stating that I was a journalist and ﬂew out on a French military aircraft. It was a mixture of happiness and sorrow looking out the window and leaving my country behind.” “I had some connections in Germany with the College of Cardiologists and my initial plan was for my family to join me there. But they were difﬁcult times, I couldn’t get residency and we all came to Perth. Suddenly, after being a cardiology consultant it was no job, no income and we didn’t speak much English at all.” “We were starting again, from below zero!” “I was offered jobs working in a restaurant kitchen peeling potatoes but was determined to get back into medicine. After passing the initial exams in 1998 I got a job as a junior doctor two years later at Hollywood. I’ll probably do a few more years in the public system and continue as a private consultant as long as my skills are needed.” “I like to think that cardiologists are like a good red wine, we get better with age!”
speak a word of English when I arrived and a neighbour would call out over the fence, ‘How are you?’ We all thought he was asking us if we were from Hawaii!”
“We were smuggled out of Sarajevo by some Jewish people and went ﬁrst to Croatia and then to Italy. My qualiﬁcations as a neurologist weren’t recognised and I couldn’t speak Italian so I worked in a nursing home. Having my mother with me was wonderful because she looked after Deila while I was earning money as a nurse.” “After passing numerous medical exams in Padua I applied under refugee status for a visa to come to Australia. There was a degree of reluctance because my mother had just been diagnosed with type 2 diabetes but my sister was here in Perth working as a doctor and that made things easier.” “As Pasko has said already, our English wasn’t good so we did some courses but the focus was on grammar and we needed conversational skills. So Dr Wally Knezevic kindly allowed me to sit in on some neurology consults and, after passing the clinical exams in general medicine, I started work at Hollywood in 2003.” “I call it my second home! Dr Leon Prindiville and Dr Jane Courtney were so wonderful, they’d put a new word on the table every day and helped me learn how to take a good patient history. Hollywood doesn’t just care for its patients, it also cares for its staff.” “I’m going to keep working for another four to ﬁve years and also continue my teaching at Notre Dame. The experiences we’ve been through have shaped us both as people and as doctors. We were so lucky to be accepted here and that’s given us a lot of dedication to our profession.”
“After ﬁnishing Year 12 I did the UMAT test and didn’t get in and then went to UWA on a scholarship and did an Honours Degree in Arts/Science. I applied to do medicine and ended up spending 10 wonderful years at university. I’m now doing my basic Physician training at SCGH and hope to get into the advanced program in 2016.” Precious memorie
s of Sarajevo
“I was asked at the GAMSAT interview why I wanted to do medicine and I remember saying that it stemmed from having a persistent feeling of helplessness as a young child and seeing people suffer and not being able to do anything about it.” “As a refugee I met a lot of people with very different stories and it’s been a constant reminder not to judge others too quickly. It’s so important to keep an open mind and I ﬁnd it interesting when I hear a doctor say that a particular patient is a poor historian of their own condition. Sometimes it’s the case of a doctor being a poor listener. If you spend a bit more time with a patient you can learn a lot.” The long tradition of medicine in the Dedic family includes Deila’s parents and extended family. Her path to medicine has been somewhat circuitous but a distinct career direction is very much in sight. “I’m 33 years-old now and deﬁnitely got into medicine the long way around. I couldn’t
“I prefer working in a hospital environment, the interaction with other specialties really appeals to me and I enjoy the pace and case load. I think my eventual area of focus will be endocrinology and immunology because it’s an intriguing combination with medicine heading in a strong molecular direction. There’s a lot of research going on and breakthrough therapies seem to be coming through at the genetic micro-level.” Deila makes an interesting point in relation to local specialist training linked with Perth’s geographical isolation. “We seem to be lagging somewhat over here, particularly in the exam preparation courses. There’s a deﬁnite Sydney/Melbourne focus, the physician training seems to be a lot more intense over there and examiners tend to be based in those cities.” “Having said that, coming to Australia was such a wonderful thing for all of us. We’ve been treated really well, everyone has been so friendly and the opportunities for a young doctor are just amazing.”
As told to Mr Peter McClelland
“For us, Australia is the best country in the world!”
Deila’s Story “I was 10 years old when I escaped from Sarajevo in 1992 with my mother and grandmother. Men weren’t allowed to leave and they had the choice of either ﬁghting the Serbian army or working in the hospital. So we had to say goodbye to my father and I didn’t see him for another six years.” “It wasn’t easy, particularly for my mother because we had no news from him for long periods and we didn’t know if he was alive or dead.” “Children often have unusual ways of coping with things, and what we’re talking about here is going out to collect water and hoping you won’t get shot. I can remember always being hungry and very anxious and stressed in the ﬁrst year of the war. We made multiple attempts to get out, eventually we left on a UN aircraft and I have no memory of that at all. I guess it was some sort of defence mechanism, a complete amnesia.” The siege of Sarajevo was a strong formative experience for Deila and it has clearly inﬂuenced her choice of career. Graduation day for Deila
Finishing Touch of a Long Journey It is not a widely recognised end point of a woman’s breast cancer journeyy but medical tattooist Ms Christine Comans is proud to play a vital role in the process. ss. The women who come to medical tattooist Christine Comans are at the end of one hell of a ride sometimes years in the making and not surprisingly, it is a hugely emotional experience for patient and therapist alike. Christine specialises in the tattooing of areolas, the last step for women who have been through breast cancer surgery and breast and nipple reconstruction and all the medical implications those procedures contain. “Cosmetic tattooing is the ﬁnal component to making the breast reconstruction complete and for many it can provide signiﬁcant psychological beneﬁts. These women have gone through a lot of trauma and are often quite nervous when they come to see me because they are so close to the end of what has been quite an emotional journey,” Christine said. Women embark on the process of areola tattooing with widely differing motivations. For some it is a destination after a rollercoaster journey through surgery, radiation, chemotherapy and reconstructive surgery; others see it as a necessary step in a process to make them whole again. But few think it will take them back to how they looked precancer. For most, it’s enough to embark on the procedure as cancer survivors and the tattooing procedure is the ﬁnal mark. Each individual will have their own views about their body image; some are certainly more robust than others, but for Christine,
The Patient’s Story Julia Lee, 37, of Woodvale, and her husband had been home just a week from a two-month adventure in the remote North caravanning with their two daughters aged ﬁve and three when she felt soreness and then a lump in her breast back in October 2012. “I went to my GP who ordered tests which came back with not so good news.” That bad news led to a two-year journey that every woman dreads. First her private surgeon performed a lumpectomy and removed three lymph nodes but tests showed that the margins were not clear and there were cancer cells in another lymph node. A further operation ensued but the surgeon was still unhappy and talk turned to mastectomy. “Mum came with me to an appointment and she wasn’t happy that talk revolved around taking my boobs off and making me a nice set of boobs. There was no talk about cancer anywhere else in my body,” Julia told Medical Forum. She was referred to Prof Cristobel Saunders at RPH.
the emotion comes from giving these women something they want and didn’t have before they walked through her door. “Although some patients are comfortable without having a nipple, and do not wish to have further surgery, others choose the nonsurgical option of cosmetic tattooing without reconstruction. This often allows me to use my skills to simulate the nipple areola without the contour of an actual nipple and is often referred to as 3D nipple areola tattooing. Still, the reconstruction of the nipple areola helps to put the ﬁnishing touches on the new breast after a long journey in reconstruction.” Christine usually sees patients three times. The initial consult is to discuss the tattooing procedure and the patient’s preference for colour and appearance and to simulate the expected outcome. “That initial visit also dispels any notion that this is a tattoo shop and eliminates the unknown. Often patients are quite nervous but once they arrive, you can see the relief on their faces. Generally, I will draw on the areola choose colours, discover if they have any sensation and discuss what will happen in detail. “The second visit is the tattooing procedure and how the colour takes depends on the individual’s skin, and where the skin has been grafted from. This visit is about getting colour in the skin and the next visit is more about adding the detail.”
“I had tests for everything and they came out clear but I decided to have a double mastectomy. I didn’t have genetic testing but I have an aunt and a cousin who have both had breast cancer and while I was told that it didn’t put me in a high risk category, I felt I was the one in eight women who got cancer once, I didn’t want to take the chance that it could happen again.” 2013 was a big year for Julia. She had a double mastectomy and implants with expanders were inserted followed by six months of chemotherapy. Two tumours had been discovered, one HR + requiring her to take Tamoxifen for 10 years and Herceptin for 12 months. Her girls watched as she lost her hair, but also in that year she painted the house and was an active school mum. “I don’t know whether it was my age or just because I had young children but I didn’t slow down. It just so happened I had already organised leave without pay for a year from my work as a high school teacher, because the kids were so little, so 2013 was devoted to getting well and being a mum.”
Ms Christine Comans
Christine tattoos the outline of the areola then ﬁlls in with the colour, even creating the impression of montgomery tubercules and milk ducts. She also feathers the edges of the areola to give a more natural look.
Later that year, her silicone implants were inserted and early 2014, her nipples were reconstructed. By the end of the year, Julia was booked in to see medical tattooist Christine Comans. Julia, now 40, is grateful to be alive and well for her daughters and her family. Her reconstructed breasts courtesy of RPH surgeon Dr Anna Goodwin Walters, are better, she says, than pre-mastectomy, which after breastfeeding both girls, were never quite the same again. However, she said she was never really fussed about her breasts or her body image after surgery and was spurred on to have the tattooing done by her mother, who wanted to see the end of the process. A big line under the whole traumatic episode. “Tattooing hurt, despite what the doctors said. When Chris was drawing the circles, I could feel that even though I had anaesthetic cream applied. The next visit, Chris applied the cream and sat with me chatting for more than half an hour to make sure the cream worked. That afternoon was a much better experience.”
“I see some very complicated cases and it’s important that I try to understand the types of surgery these women have undergone. None want to recreate who they were before cancer but I like my work to be as realistic, and look as good as it possibly can.” Wound healing is of particular interest of Christine’s. “It doesn’t happen often but occasionally a woman will be preoccupied with life and not take care of tattoo site. After seeking the expert advice from one of my referring doctors I’m trialling hydrocolloid moist wound healing patches. They seem to make life easier for the patients and help eliminate non compliance with aftercare.” “Really my role and what I do is just a small part of a big collaborative process. We all work in the best interest of the patients to achieve positive outcomes.” Christine sees many surgeons’ handiwork and believes West Australian women are well served with some very talented plastic surgeons, not least working in the public system. “The work I see coming out of SCGH and RPH is amazing.” “However, the journey through the medical system for these women is tricky, which is not necessarily anyone’s fault. It’s down to information overload and women having to make crucial decisions at a time when they are emotionally ill-equipped to do so.”
An example of Christine Coman’s work, pre and post-tattooing
“It’s the hand-holding process from one stage to the next that seems to be missing. By the time the woman comes to me everything has been done. They almost all say, if I knew at the beginning what I know at the end I wouldn’t have had this, or done that.” “While it is explained what will happen to them and they are shown medically how things will play out, often it’s not in the context of how they will feel or how they will look as a woman. It feels like their life is out of their hands and that’s scary.”
mastectomy, colour matching is necessary. The price is inclusive of all necessary consultations. It is not covered by private health insurance, though she and her mentor, Queenslander Tina Viney, who is CEO of the Aesthetics Practitioners Advisory Network – a professional standards body – will be working on plans to have the procedure government accredited. This is the ﬁrst step towards applying for health rebate registration.
By Ms Jan Hallam
Christine charges $550 for the tattooing of both breasts. Even in the circumstance of unilateral
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Cracking the Glass Ceiling This month we went out to seek women in leadership roles in the health sector and discovered far more than we could publish here. Here is a selection. THE CLINICIANS Dr Caroline Goossens Director of Clinical Services, CAMHS, CAHS How did you get here? In 2011, I was asked to become the Clinical Lead for CAMHS when the service was integrated into the CAHS. I held the position for a year, before being appointed Director. The biggest challenges? Maintaining my own energy and enthusiasm and bringing our committed workforce along Dr Caroline Goossens a very demanding journey. There have been huge shifts in both the health and mental health landscape, which has compelled CAMHS to undertake multiple change processes. I couldn’t survive without my executive team who have been extremely supportive. Dr Sarah Moore GP, Medical coordinator Rural Clinical School Busselton How did you get here? Passion! I realised early in my training that I wanted to be a country doctor who worked in general practice but could also deliver babies. I also learnt fairly early how much I enjoyed teaching and mentoring. I am fortunate to have a number of inspiring mentors who have given me the conﬁdence to put my hand up for roles Dr Sarah Moore and responsibilities I thought were beyond my capabilities. And without my supportive and loving partner and I don’t think I would be working in the dream job that I do today. The biggest challenges? Work-life balance – it has taken me a while to get this right but now I think I’m pretty much there. As a mum who wants to be there for her kids, a wife who wants to be there for her husband, a GP obstetrician who wants to be there for her patients, and a medical educator who wants to be there for her students, priorities are often competing. Making time for myself (meditating and practising yoga), has been one of the key ingredients to making sure I prioritise appropriately and stay true to myself and those I serve. Prof Shirley Bowen Dean of Medicine, University of Notre Dame How did you get here? Originally I trained as an Infectious Diseases Physician and then became CMO of the ACT. The latter was pivotal in developing an understanding of population health, leadership and management. Since then, I have had the opportunity to manage in Public Health and Hospital Management, both in the public and private sectors, while maintaining my clinical Prof Shirley Bowen skills. I have a passion for healing. I ensure the students see my personal passion for being a doctor. The biggest challenges? Like all busy people, executive, clinician or parent, the greatest challenge is to keep “all the balls” in the air! My biggest challenge is to ensure that while the Medical School continues to evolve, my family feels that I am present and centred to their needs as well. From a professional perspective, the School of Medicine Fremantle is soon to celebrate its 10th anniversary. As such, the focus of the School is now on sustainability and evolving to the next level.
Dr Helen Wilcox GP, Censor, RACGP; A/Prof General Practice, UWA
How did you get here? After completing Fellowship I became involved with both UWA and the RACGP. I took on larger roles coordinating education programs for new RACGP Fellows which led to becoming Censor. The biggest challenges? Imagining the future. Doctors live in a changing (professional) world. It is challenging to prepare today’s medical students for the GP workplace of ﬁve years’ time, let alone 10 or 15 years when they may enter general practice.
Dr Helen Wilcox
Prof Karen Simmer Medical Director, Neonatal Intensive Care Unit, KEMH and PMH, Prof Newborn Medicine, UWA How did you get here? I trained in different states and countries; specialist training as paediatrician and neonatologist, Fellow of RACP and Royal College of Paediatrics and Child Health (UK), PhD London, AMP Harvard University. Built a world-class team of academic clinicians in a large NICU to a prestigious NHMRC Centre of Research Excellence in 2013.
Prof Karen Simmer
The biggest challenges? Advocacy for equitable resources to care for young infants in WA and breaking down established silos. Standing up for what is right even if at a personal cost. Dr Anne Karczub Director Obstetrics at KEMH How did you get here? I’m a WA medical graduate, specialised in Obstetrics and Gynaecology. Worked in the country for 11 years (1992-2004, the Kimberley initially then 10 years in the Midwest). I was approached by WNHS executive in 2004 to consider position of Director of Obstetrics, which I accepted. Dr Anne Karczub
The biggest challenges? Funding, and consultant recruitment and retention! Chronic pressure on a health budget has many implications. Providing a quality service requires people who are committed to service delivery to patients, teaching and training at undergraduate and post graduate level and research. The ability to recruit and retain consultants depends on adequate funding and the ability to create job satisfaction. With a skilled and committed consultant group, all things become possible. Dr Amanda Frazer Senior Clinical Adviser, Health Reform, WA Health How did you get here? As a doctor providing clinical care for about 10 years, I became increasingly aware of the challenges faced by a sick patient to negotiate the complex hospital environment. I could see how communication, team work and the physical and technological environment shape the culture of a hospital and, in turn, impact on the patient. After completing post-graduate Law, I returned to health in a management and leadership role, which was an enormous professional challenge.
Dr Amanda Frazer
The biggest challenges? It’s so important to try to understand many differing points of view and make the best decision which balances the many elements.
Feature THE ADMINISTRATORS We still think of a powerful man as a born leader and a powerful woman as an anomaly. – Margaret Atwood
Ms Rebecca Brown Deputy Director General, WA Health How did you get here? My background is in ﬁnance, beginning my career as a graduate with Federal Treasury in Canberra and more recently with WA State Treasury. A year ago I was seconded to WA Health, tasked with improving efﬁciency and assisting with the ongoing reform of the health system. After a decade of analysing and providing advice about the system, I am now part of the system.
Ms Rita Maguire Group Director Workforce SJGHC Ms Rebecca Brown
The biggest challenges? The biggest challenge as a manager and leader is recognising that change is not one dimensional and that change takes time – it can’t be rushed. Ms Gail Milner WA Health Operational Director Innovation and Health System Reform How did you get here? My career started in nursing. After becoming a clinical specialist, I moved to management. I studied health management and leadership, which taught me about systems and health economics as well as human and industrial relations. It also made me aware that good management Ms Gail Milner could improve patient outcomes and care. Clinical knowledge is important otherwise it is only economics driving patient outcomes and safety. The biggest challenges? Inﬂuencing others … especially clinicians who rely on data and evidence. You have to have the evidence to lead change. Mentors are important, as is remembering that you are only ever as good as your team. Dr Margaret Sturdy CEO, Peel Health Campus How did you get here? I was a hospital medical ofﬁcer at Hollywood Repat in the late 1980s and early 1990s, and had taken a temporary admin role in 1993 with the Department of Veterans’ Affairs. I got to know the Ramsay team during the tender process for the privatisation and was very happy when I was offered a position as the medical administrator at the new Dr Margaret Sturdy Hollywood Private Hospital. I stepped into the Director of Medical Services role in 2001 and since June 2013 have been the CEO at Peel Health Campus. The biggest challenges? Maintaining a good humour, saying “yes” whenever I can, working out the win-win scenario, helping clinicians to understand the difference between “demand”, “want” and “need” and ensuring the needs are met. Doctors know what is needed for good patient care and are happy to work with administrators, so long as they are listened to.
Ms Chris Hanna
The biggest challenges? I like to harness the opportunities rather than dwell on the challenges. In this spirit, the greatest opportunity is embracing all the great things about this hospital. It has a rich history, which needs to be honoured, while working with staff to bring about change. It’s exciting.
The biggest challenges? Ms Rita Maguire Finding a sustainable balance between my family and my career. It takes personal reﬂection and an open discussion with your employer to create an environment where you can do both. For me, raising the next generation was very important. Ms Belinda Bailey CEO, Rural Health West How did you get here? Thirty-six years of working in the health care system, in both clinical and administrative roles – 18 of those years working in organisations that believe general practice is the corner stone of primary health care. A sense of humour! The biggest challenges? Understanding the needs of the rural health workforce when every region is so unique; the Commonwealth-State funding divide; and lack of consistency with health reform and policy direction.
Ms Belinda Bailey
Ms Susan Rooney CEO, Cancer Council WA: How did you get here? I have worked in a range of leadership positions in emergency services, health, disability services and aged care around Australia. I have been lucky to have had amazing mentors along the way and to work with remarkably dedicated and skilled people which have enabled signiﬁcant organisational changes, which have vastly improved outcomes for the people we served.
Ms Susan Rooney
The biggest challenges? The biggest challenge for CCWA is to grow the incredible support we receive from the community so we can increase our assistance for people living with cancer and fund more world class research and prevention strategies to keep us moving closer to a cancer-free future. Ms Diane Jones Deputy CEO, Joondalup Health Campus
Ms Chris Hanna CEO St John of God Mt Lawley Hospital How did you get here? My parents were my role models. From a very early age, dedication, goal setting and the thrill of achievement was passed on by them. Since then I have always sought out opportunities and seized them. Moving states was pivotal. You are shaken out of your comfort zone and have to get out and build strong networks.
How did you get here? My best career move has been working with talented people throughout my working life – people I liked and trusted and who believed in me, challenged and stretched me and counter-balanced my limitations. I’ve also taken opportunities that shook me out my comfort zone.
How did you get here? I started my career as a RN and completed subsequent studies in Midwifery, Critical Care and Health Management. I have been fortunate in having a varied career in leadership roles including Director of Nursing and CEO in predominantly private healthcare organisations across Australia. I originally held the position of Deputy CEO at Joondalup Health Campus (JHC) from 2004-2009 before taking up the role of National Director, Clinical Services at a Sydneybased health care company. I return to JHC in early 2013.
Ms Diane Jones
The biggest challenges? The ever-changing landscape of health service delivery is a constant challenge as demonstrated by the ever-increasing demand for mental health services in WA.
News & Views
The X Factor for Longevity Narrogin GP Dr Jean Foster has had her own chronic illness to cope with but it has been a deﬁning element to a career full of great experiences and even better relationships. There’s a lot to be said for putting a big X in your diary and making sure it stays there, according to part-time practitioner Dr Jean Foster. Serious health issues as a hospital resident shaped her approach to medicine and sparked a long-term commitment to fostering collegial and supportive GP networks. “I was diagnosed with Lupus when I was 26, seven years later along came Non-Hodgkin’s Lymphoma and then Myasthenia Gravis. All through my professional life, I’ve had to tailor work to match my capabilities and it’s changed the way I’ve practised medicine – for the better!” “As a resident back in the 1980s nobody took it into account if you weren’t able to function at one hundred percent. I got back after two weeks off sick and the attitude was that I’d made it tougher for them and ‘it was all right for some’. I felt like saying, ‘well you give Lupus a try and I’ll be happy to work full-time’. There was no real understanding of what it was like to have a chronic disease and very little leeway was given.” “Some of the work we do as doctors can be highly distressing and it’s important we look after ourselves. I’ve learnt the importance of carving out time for myself and one way to do that is to put a big X in the diary.” “You just have to say… ‘No, I’m sorry I’ve got something else on’. It’s so important to give equal priority to family and friends.”
and I know doctors who can’t afford to retire after working for 40 years.” “I became closely involved with the GP Divisions in the early days and their programs supporting local practices. We had things such as a speciﬁc list of doctors willing to see their colleagues as patients because that can be a difﬁcult situation. It’s a ﬁne balance, you don’t really want to see a friend but you do want a person who’s good.” “And as someone who’s had a lot of experience visiting doctors I know the value of having a wonderful colleague as a backstop.” “We also ran GP Wellness Weekends where doctors could bring their families and we’d have everything from archery, circus in a suitcase to guest speakers. I made some really good friends at those events.” “I remember one session, it was on CPR, and a GP was there who’d had a situation in which a patient arrested and did not survive. The doctor did his very best, but this person just didn’t make it and it was obviously very stressful. He needed to talk about it but hadn’t had the chance until that weekend.” “As the Divisions changed there was a shift from our own programs to more overarching policy imposed from on-high. In some ways that can be positive because you don’t get lots of different splinter groups reinventing the wheel. But there’s often a down-side when some really positive initiatives wither on the vine.”
The element of personal choice is high on Jean’s agenda, as is the value of establishing close professional networks to minimise stress levels and potential burnout.
Individual personality, Jean suggests, is a factor that has to be considered when it comes to shaping a career. She reﬂects on her own predilections and, in a more sweeping arc, the psycho-social landscape of those who practice medicine.
“I made a decision to live a simpler lifestyle. It made me realise that many people are locked into the belief that you must work fulltime and earn a certain amount of money. That’s sad,
“Every now and then I have to do some pruning because sometimes I get too involved and tiredness leads to health problems. I’m the
Professional networks are vital
sort of person who can’t half-do things so I’ve learnt not to spread myself too thinly otherwise I start feeling unwell.” “And when that happens I try even harder. It’s that perfectionist trait, great for getting the job done but not so good for staying healthy.” “There’s a certain thread that runs through medicine and it’s linked with doing things perfectly and a feeling that you’re indestructible. I’m sure it’s improved now, but when I was honest and admitted that I was ﬁnding it hard to cope, a consultant said, ‘no one else has ever said that to me’. It made me feel as though I were the only one with a problem.” The thrill of teamwork “Of course, later on I discovered that we were all struggling!” “I’m based in Narrogin now and working in Aboriginal health with a great practice nurse and a wonderful team of allied health workers, including physiotherapists, OTs, Aboriginal health team, a social worker and child health nurses all in the same building. We also have visiting specialists and I get a chance to liaise directly with them. My other job is in women’s health, also based in Narrogin but visiting the smaller surrounding towns as well. It’s a lot of fun and I know that sounds a bit strange when you’re talking about a Pap-smear clinic, but it’s because the country people are so friendly and welcoming!” “I’ve never had a salaried position before with paid holidays and annual leave so that’s a bit of a luxury. All my work is in the country so when I’m back in Perth, I see friends and look after my mother. She’s 88 and I don’t know how much longer she’ll be around so I want to make the most of it.” “At the moment it’s a nice balance!”
by Mr Peter McClelland
Just Culture is not Pie-in-the-Sky Dr Jonathan Aleck, who is A/Director of Aviation Safety at CASA, says the ﬁrst step to a just culture is an open reporting system and trust between all involved. ‘Just culture’ is an organisational norm that enhances safety and promotes learning by encouraging people to report unintended errors, without fear of punitive or disciplinary action, but which does not countenance wilful, deliberate or reckless conduct. A ‘just culture’ is an essential feature of an overarching safety culture. Its successful implementation depends on demonstrable support at the highest levels of management and an abiding commitment to openness, honesty and accountability on the part of everyone involved. ‘Just culture’ regimes are especially useful in environments like health care and aviation. Professionals in both ﬁelds routinely take critical decisions and actions, often under pressure, the outcome of which can have serious implications for people’s lives, health and safety. On the ﬂight deck as in the operating theatre, skilled members of specialist teams are collectively responsible for the safe and necessarily cooperative performance of demanding tasks, in circumstances in which
Reporting is not an end itself. The objective of any ‘just culture’ regime must be the maintenance and improvement of safety. Legitimately protective, remedial and corrective actions taken in response to reports are not, and should not be regarded as, punitive or disciplinary. mistakes can, and from time to time inevitably do, occur. Learning form one’s own and others’ inadvertent errors is one of the most effective ways of minimising the likelihood that such errors will recur in the future. To learn from what happened, however, one must know what happened, how it happened and, as far as possible, why. That is why an open reporting system is so important. Reporting is not an end itself. The objective of any ‘just culture’ regime must be the
maintenance and improvement of safety. Legitimately protective, remedial and corrective actions taken in response to reports are not, and should not be regarded as, punitive or disciplinary. The integrity of a ‘just culture’ regime is grounded in trust—amongst and between those who participate in the program, those who administer it and those whose health, safety and well-being may be affected by the conduct of those governed by it. Agencies responsible for ensuring appropriate responsive action is taken on the basis of reported information must be able to verify that ‘just culture’ processes are not being abused, circumvented or exploited to advance or protect interests other than safety. Patient, passenger and public conﬁdence in the proper and effective operation of ‘just culture’ principles in medicine and air transport alike is crucial to the continuing viability of the concept and its practice. ED NOTE: Dr Aleck was a guest presenter at Avant’s recent Risk IQ webinar: Crteating a just culture— supporting the disclosure of human errors and near misses: lessons from the aviation industry.
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Reporting directly to the State Marketing Manager, in this key role you will be responsible for doctor engagement and building links between the hospital and the general practice community through the promotion and introduction of specialists and hospital services.
4 Competitive pay & conditions 4 Free on-site parking available 4 Childcare facilities/before & after school care facilities 4 Enjoyable social events 4 Employee assistance program 4 Corporate private healthcare rates
Ideally, you will have previous experience in hospital/ GP liaison or a similar role in the Perth metropolitan :LSLJ[PVU*YP[LYPH area, and a strong understanding of the Medicare You will be able to demonstrate the following; referral system between GPs and specialists. Equally 4 An understanding of the medical community important is experience in marketing and business - in particular general practice; development, with the ability to think strategically 4 Excellent communication and interpersonal skills; and plan eﬀectively using marketing data and 4 Excellent IT, planning and organisational skills; information to fulﬁl the position requirements. 4 Sound administration and reporting skills; Flexibility around work hours can be arranged to 4 Driver’s license accommodate family/carer responsibilities if required.
/VZWP[HS7YVÄSL Hollywood Private Hospital is a modern, 660-bed, acute care hospital in Nedlands and enjoys a strong reputation for excellence in patient care. The hospital employs over 1,800 people and has more than 800 accredited doctors working across a wide range of medical specialties. Further expansion of Hollywood Private Hospital is underway and includes six more operating theatres, two new wards, a new kitchen and more parking bays. On completion of the project later this year, Hollywood Private Hospital will have 16 operating theatres and over 700 beds, making it the State’s largest private hospital based on bed size. For more information on the hospital visit hollywoodprivatehospital.com.au
To submit your application for this role, go to amazingcareers.com.au and click on Current Vacancies
For further information, contact Annie Palmer, State Marketing Manager WA, Ramsay Health Care, on (08) 9346 6664.
WA Tunes into NDIS My Way The NDIS trials in WA are in reporting phase after the initial six months. Results of the state-run trial are promising, says Dr Ron Chalmers. I am often asked to provide clarity about how the National Disability Insurance Scheme (NDIS) will be implemented in Western Australia, especially given WA is the only state or territory running two separate NDIS trials. This approach is a result of the State Government’s commitment our existing disability services model, which has been built on decades of experience and stakeholder consultation. It was important not to lose this investment by signing up to an untested national NDIS Model. Therefore, we now have two trials running concurrently, which started on 1 July, 2014 – the State Government’s NDIS My Way trial in the Lower South West (Cockburn and Kwinana will join on 1 July, 2015) and the Commonwealth Government’s National Disability Insurance Agency NDIS trial in the Perth Hills. During the two-year trial period, the two models will be independently evaluated to inform how the NDIS will look in WA, and possibly nationally, in the future. Just six months into ofﬁcial reporting, the key strengths of My Way NDIS is the support it offers people the way they want to be supported, as individuals with differing circumstances, needs and aspirations. It focuses on intensive planning, community connectedness and ﬂexibility. Central to this model are the local community coordinators, who establish working relationships with people with disability to create an individual’s personalised My Way
plan. We are already seeing how detailed and well considered plans can have positive outcomes. The NDIS My Way trial is working closely with the disability sector and other government agencies and since its inception there has been an increase in registered service providers offering highly individualised options. Of particular note is our partnership with the Mental Health Commission. Over 50 people with psychosocial disability have already been successfully engaged in the Lower South West trial. The medical fraternity has had an important role in this early success. GPs, hospitals, psychiatrists and service providers are recognising and embracing opportunities for people to be supported outside of clinical interventions and are making referrals to coordinators. Supporting people with psychosocial disability can have increased complexity, especially given the perceived permanence of the condition. We know that complementing existing clinical and medical supports with My Way planning can lead to improved outcomes. If you are working with patients in the Lower South West or Cockburn and Kwinana who you believe may beneﬁt from the addition of NDIS My Way supports, I encourage you to discuss the program with them. ED: Dr Chalmers is the head of the Disability Services Commission. For more information on the MDIS My Way trial, call 1800 996 214, www.disability. wa.gov.au
NDIS My Way Case Study: Ben White Ben White has a psychiatric diagnosis of schizophrenia and obsessive compulsive disorder (OCD). He also has an acquired brain injury. Due to bad dietary habits, Ben had ongoing weight and dental issues, and was under constant threat of eviction from his Homeswest unit because he wasn’t able to manage his psychosocial disability. His 73-year-old mother, who lives in Canberra, said Ben was just surviving and was dependent on her coming to the rescue every few months to clean his unit, organise medical appointments and pay bills. His mother was fearful about what would happen when she was no longer able to help her son ‘pick up the pieces’ on each of her visits and was fearful he would lose his accommodation and become homeless. In 2012, Ben was found eligible for My Way supports and services and he commenced his individualised plan in August 2013. Since then Ben’s quality of life has improved dramatically. His psychiatric diagnosis remains the same, but a support worker now helps him to remember his psychiatric appointments each month and reminds him to collect his medication. While a supportive friend is helping Ben get to bed each night by assisting him with his OCD behaviour. Ben has lost about 10kg thanks to improved exercise, cooking and dietary habits, continually reinforced by his support worker. Ben’s social circle has widened from the contact. According to Ben’s mother, the highlight of his My Way journey has been his ﬁrst solo art exhibition in the local library, where he sold most of the paintings he exhibited. This success has given Ben a huge boost of conﬁdence and a belief that he can have a worthwhile life.
A medical clinic dedicated to weight loss Based in Midland since 2011. Servicing the Perth Metro Area and country WA Ph: (08) 9467 4484 firstname.lastname@example.org www.dalehealth.com.au Services for all patients include: ' Free initial consultation ' Detailed assessment with a medical doctor and psychologist ' Individualised program ' Treatment team all located onsite ' Availability of virtual technologies to service remote patients & FIFO workers ' Core treatment team allocated per patient consisting of a medical doctor, psychologist and exercise physiologist
Suitable patients include: ' All overweight patients 14 years+ ' Overweight patients planning an operation or pregnancy ' Patients who persistently regain weight ' Patients with co-morbidities from obesity Dr Patricia Dale M.B., B.Ch., DipWomen’s Health Dr Shelley Kirkbright MB.,BS., FACEM Dr Alison Dale BPsych., M Psych (Clinical).,PhD Bryce Ridgeway B.Psych. Amy Douglas B.Psych.,P.Grad.DipForenSc. Kelly Rothwell B.Soc., Sci., M.A. (Soc. Sci.) Dr Rob Suriano B.Ec., B. App. Sc., PhD
Excellent proven results - with 80% of patients maintaining goal weight after a year of follow up. 28
Please Help Stamp Out Abuse Horriﬁc personal experiences have transformed Benjamin Keely into a passionate advocate for people with disability. Hello, my name is Benjamin Keely. I have spastic quadripeglia, otherwise known as cerebral palsy. I am also a disability advocate. Since the allegations of sexual abuse of people with disabilities in care, aired on Four Corners last year, I have been busy meeting and writing emails to politicians to call for a national abuse and neglect inquiry. Before I talk about the WA abuse and neglect inquiry, I would like to share my story to shine a light on the types of abuse and neglect that occurs in residential facilities. Five years ago, I was in institutional care, where I had carers looking after me 24/7 due to my disability. During my stay there, I saw and experienced things no one should ever have to see or experience. Carers would often forget my basic necessities such as giving me food and water. The medications I needed to survive were often forgotten, or wrong medications were administered to me. There were times when I was not given enough water or other times when I was given too much water. This imbalance caused acute dehydration and constipation. My chair was
I am writing this column, to let you know that acts of abuse and neglect happen every day to people with disability who live in institutional care. often soiled with urine and faeces, because no one checked on me or gave me sufﬁcient time on the toilet. The backrest and the side supports on my chair broke often, because the carers did not know how to operate the equipment appropriately. Sometimes I used to get Jevity which is a liquid nutritional supplement, which was meant to go into my feeding tube but it was often spilled all over my bed. Throughout my time there, I was under emotional distress, so much so that for a time I stopped eating. Most of the time, I would sit alone in my room and feel sorry for myself. I was also sexually abused on a semi-regular basis. I suffered from pressure sores due to the incorrect positioning of my back brace.
I have also witnessed acts of abuse and neglect, such as when clients fell out of their hoist and off their beds, or when clients were given the wrong medications, and had to have their stomachs pumped in the hospital. This all comes down to clinical mismanagement and a lack of training. I am writing this column, to let you know that acts of abuse and neglect happen every day to people with disability who live in institutional care. As doctors and health professionals, if you see signs or symptoms of abuse, neglect or violence, please act. Do not ever let a person’s communication style, challenging behaviour or chronic health issues get in the way of deciding if someone has been abused or neglected. I am working with Developmental Disability Western Australia (DDWA) and Samantha Connor from People with Disabilities Western Australia (PwDWA) on a local abuse and neglect inquiry to hear stories of people’s experiences with abuse and neglect in institutional settings. We want to create safeguards for people with disability these acts do not occur anymore.
New breast assessment centre opens at Fiona Stanley Hospital A new multidisciplinary breast assessment centre catering for metropolitan and rural clients from across Western Australia has opened at Fiona Stanley Hospital in Murdoch. Located on Level 1, the breast centre is a purpose-built clinical area with: VSDFLRXVFRQVXOWLQJURRPV DVSHFLDOLVHGEUHDVWVXUJHU\GLJLWDOJDOOHU\IRUYLHZLQJµUHDOOLIH¶ results following surgery GHGLFDWHGPHGLFDOLPDJLQJVHUYLFHV VSHFLDOLVHGFRXQVHOOLQJVHUYLFHV 7KLVQHZDVVHVVPHQWFHQWUHFRPSOHPHQWV%UHDVW6FUHHQ:$¶V existing assessment centres at Royal Perth and Sir Charles Gairdner Hospitals and the South West Health Campus in Bunbury.
Self-Management Rules, OK? Patient responsibility and a supportive team of health professionals are the not-so-secret ingredients for good self-managed care – but it’s the quality that counts. based programs and send a patient back to their GP who’s engaged, committed and empowered to ask questions that matter to them.” “It’s important to remember that people with Type 2 Diabetes are often living with cardiovascular and renal co-morbidities leading to potentially serious complications. The DESMOND model (Diabetes Education and Self-Management for the Newly Diagnosed) has been used in the UK for a number of years. It looks at this condition from a new perspective with the educator taking a step back from an overtly clinical role and instead promoting a pragmatic approach tailored around lifestyle and affordable cost.” Ms Deb Schoﬁeld and Ms Helen Mitchell
Effective diabetes self-management is less about a proscriptive ﬂow of information and more about a ‘person-centred’ model, according to health professionals Ms Helen Mitchell and Ms Deb Schoﬁeld from Diabetes WA. Current programs revolve around ﬂexible delivery, goal-setting and promoting the idea that the clinician is an important part of a team approach. Both Helen’s (General Manager - Health Services) and Deb’s (Manager – Diabetes Management Unit) core message focuses on the importance of individuals taking control of their own chronic condition. “Sometimes, as health professionals, we’re good at spouting long words and acronyms but that doesn’t mean much to the average patient,” Helen said. “We need to keep our language clear and simple, deliver evidence-
“There’s an emphasis on the importance of physical activity and highlighting just what individuals can do for themselves.” “In a practical sense we offer a six-hour education program which we call a ‘Diabetes Quickie’. It sets out all the available support mechanisms and that’s important because a chronic condition is debilitating, it’s with you every day and there’s a high correlation between diabetes and depression.” A recent E-Poll in Medical Forum suggests that while most doctors believe self-management is a good idea, just over half believe it would lead to better health outcomes. “Not all self-management programs accurately reﬂect their title. Some of them are basically just knowledge-sharing and done in an outmoded, didactic manner. There’s a strong analogy with medication. If these models are used properly they’re effective. It’s all about
Chronic Disease Management Patients with chronic diseases are encouraged to self-manage more – problems like asthma, diabetes, arthritis, etc. Do you think this is important?
Is this change in emphasis just political ‘code’ for not enough resources to go around? Yes
Under current circumstances, is more selfmanagement likely to lead to better health outcomes?
ED. To summarise, our surveyed doctors (n=189; 56% GPs, 34% Specialists, 10% DIT and Other) are very strong supporters of self-management of chronic ill health, and most believe this will lead to better health outcomes. Interestingly, about half with an opinion on this, suggest the self-management agenda is driven by a growing scarcity of resources for health consumers.
delivering and providing access to services that do what’s written on the bottle.” “There are other factors that can’t be ignored. A lot of people don’t take their medication regularly and, sadly, there’s an economic component to that. It’s not uncommon that a person will take a particular medication for a week and then switch to the other because they can’t afford both.” “And approximately 40% of respondents to the recent Miles Study stated that they’d never had any formal, structured diabetes education at all. A huge chunk of these patients probably never see anyone about their condition.” GPs can only do so much, suggests Deb Schoﬁeld. Good self-management programs provide informative options without overwhelming a patient and provide a tool-box of possible strategies. “People live with this condition 24/7 and only see their doctor for a small fraction of that time. It’s an impossible task for GPs to take full control of a patient’s condition whereas if someone has a good understanding of their illness and how to manage it we’ll see better outcomes.” “One of the most important aspects is behavioural goal-setting and an example of this is ‘Swimming 365’, which gives people access to a water exercise program run by a trained physiologist. We’ve recruited some participants and it’s a good example of individual empowerment. Based on the evidence, the best self-management models focus on the clinician as a facilitator of information and not necessarily the ‘expert’. It’s turning the usual power dynamic on its head, in many ways.” When it comes to Care Plans, Deb believes that they present a window of opportunity for a productive interaction between doctor and patient. “It’s vital that an individual makes informed decisions regarding their own condition. A Care Plan discussion is very useful in both ascertaining a patient’s expectations and shaping an appropriate level of engagement for both clinician and patient.” “A visit to the doctor can take various forms and there’s no doubt that people swing in and out when it comes to managing their disease. Sometimes it takes a critical event to sharpen the focus, deteriorating vision or an ulcer on the foot can be a strong motivator to loop back into good self-management.”
“As far as GPs are concerned I’d emphasise the use of allied-health team support and refer them to organisations such as ours. The upside will be a much happier and more engaged patient.”
By Mr Peter McClelland
the food I was eating and my exercise regime. By actually writing it down I was able to take control over the way I was leading my life. It’s quite Buddhist in a way, a sort of practical mindfulness.” “After the diabetes diagnosis I tried to keep it under control but I put on a lot of weight, I would’ve been 125kg at one stage. I didn’t completely ignore the condition and went to the doctor regularly but, looking back, I just bumbled along.”
The ‘old’ John Rando
“I really hit the wall in 1996 with a major stroke. I was in intensive care for over three months, lost my speech, couldn’t walk and my memory was pretty much gone. I couldn’t function at all and they told me I’d never get back to practising law.” “The discipline of keeping a health diary extends to all areas of my life and I must’ve ﬁlled 19 exercise books. My blood sugar and cholesterol levels are ﬁne, I’m down to around 80kg and it just goes to show that rather than relying on others to manage our own health it’s really up to us.” “We all have an obligation to look after ourselves.”
The ‘new’ John Rando
A Patient’s Story Criminal defence lawyer and musician John Rando freely admits that he didn’t pay much attention to the ‘red ﬂag’ of a Type 2 diagnosis in the late 1980s. It took a major stroke 15 years later to ring alarm bells and since then John has become something of a poster-boy for self-management. “I’ve become my own ‘health guru’ and it all started when I began to keep a daily diary of
Fact Box In WA in 2014 there were 10,600 new cases of diabetes which translates to 29 people diagnosed every day. www.diabeteswa.com.au Western Australian NDSS State Snapshot Data 31 Dec 2014.pdf Diabetes MILES Study www.diabetesmiles.org.au WA Framework for Action and Diabetes Services Standards www.healthnetworks.health.wa.gov.au/ docs/Framework_Action_Diabetes_ Standards.pdf
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News & Views
Keeping You in the Picture An army of radiologists work tirelessly to keep cutting-edge imaging information free on the internet to all doctors who use imaging in their practice. We’ve mentioned www.imagingpathways. health.wa.gov.au in the past – a resource for those wanting to choose the best imaging for a particular problem and minimise radiation for patients. But what if you are learning the radiology ropes and want to know all the intricacies which can fool us (see Dr Richard Mendelson on incidentalomas, February edition). The internet is the ideal visual medium for just that – www.radiopaedia.org is the radiologists’ Wikipedia. It is an open source and can be updated by any enthusiast with knowledge but it is still very much a work in progress for the many radiologists and trainees who go there. WA radiologist Yuranga Weerakkody has been an editor at the website since 2008. He oversees the evolving parts of the 7000 or so radiology articles, each at Dr Yuranga Weerakkody varying stages of completion and therefore quality. His interest started like many others when he was studying for part II exams and continues his involvement as he tries to hone his diagnostic skills. “It is useful for the radiologist within a particular sub-specialist area to develop and build content in their area as an online collaborative resource. It can then act an online workstation reference which can be constantly updated,” he said. Dr Frank Gaillard is the Melbourne radiologist who started the website in 2005 (again while studying for his RANZCR fellowship). There are about 30,000 registered users, 8 million pageviews a month, and about 1 million followers on social media outlets. “Our mission is to create the best possible radiology reference and teaching site and make it available to everyone, for ever, for free,” he said.
s Prof Moyez Jiwa has left Curtin University to take up the position of Associate Dean at the University of Notre Dame’s Melbourne clinical school and the chair in Health Innovation. s Former Deputy Executive Director of Health Consumers Council Mr Gio Terni has taken up a position as advocate at People With Disabilities (WA). s Prof Alistair Forrest has been appointed laboratory head in system biology and genomics at the Perkins Institute. MEDICAL FORUM
Radiopaedia is a sign of the times. Things are moving so fast in imaging that the old ways of publishing articles, sometimes four years after the event, just doesn’t cut the mustard any more. “We are a collaborative site, where individuals work and revise articles constantly. As such, each article is an evolving work, with often dozens of contributors,” he said suggesting we take a look at http://radiopaedia.org/articles/ meningioma/revisions as an example. If you do, clicking through to the article reveals a multitude of descriptive terms, linkages and dot points that will blow your mind. It is similar for most other areas of the website – evidence of people beavering away to ensure everything is covered – an endless task. “We have almost 7500 interconnected articles, covering all areas of Radiology practice,
s Ms Gemma Crawford from Curtin’s School of Public Health has been recognised by the Australian Health Promotion Association with it 2015 national emerging leader award. s Tax accountant Ms Cathy Broadbent has been appointed to the board of Diabetes Research WA. s Dr David Borshoff has been appointed Director of Anaesthesia and Pain Medicine at St John of God Hospital Murdoch. s Five doctors received outstanding service awards at the Rural Health West annual
supported by over 17,000 cases. The articles range in size from short deﬁnitional ones (e.g. enlocated) to lengthier ones on important and common topics (e.g. meningioma).” Why the website in the ﬁrst place? “There are enough inequities in health provision and education without adding access to information to the mix. Too many medical sites, journals and textbooks require expensive or elaborate subscriptions which make access to the information required to diagnose and treat our patients effectively very difﬁcult. We believe that such information should be as freely available as possible.” Radiopaedia.org targets all health professionals using imaging in their practice. It is owned by Frank and maintained by him and two non-medical IT partners.
By Dr Rob McEvoy
conference: Paediatrician Dr John Boulton (Broome), Dr Randolf Spargo (Newman, particularly Jigalong), Dr Daniel O’Donnell (outreach services, particularly Cocos and Keeling Islands), Dr Andrew Jamieson (Midwest hospital doctor) and Dr Phil Reid (Kalgoorlie). Dr Mal Hodsdon, a longserving rural GP Obstetrician, was presented with a Life Membership of Rural Health West. s Mr Bill Monro has replaced Mrs Roz Baker as chair of the Prostate Cancer Foundation of Australia.
Primary Care News
Hospital Liaison General Practitioners Over the past 20 years Western Australia has been fortunate to have a strong history of general practitioner (GP) representation within hospitals in the form of Hospital Liaison GPs (HLGPs). These HLGPs are funded for between five and ten hours each week. Their main focus is to: t QSPWJEFB(1QFSTQFDUJWFXJUIJOUIFIPTQJUBM t BTTJTUJODPNNVOJDBUJOHXJUIUIF(1DPNNVOJUZ t SFQSFTFOUHFOFSBMQSBDUJDFJOTUSBUFHJDQMBOOJOHBOEQPMJDZ development within the hospital t IFMQEFWFMPQDPMMBCPSBUJWFJOJUJBUJWFTJOWPMWJOHUIFIPTQJUBM general practice and other health care agencies including Medicare Locals t QSPWJEF(1SFQSFTFOUBUJPOPOTPNFIFBMUITFSWJDFBEWJTPSZ committees including the Central Referral Service and Outpatient Direct t BTTJTUXJUI(1FEVDBUJPO t BEWJTFUIFIPTQJUBMPOEJTDIBSHFTVNNBSJFT5IF)-(1TBTB group have been instrumental in assisting the development and roll-out of electronic discharge summaries. The HLGPs remain active in encouraging hospital staff to produce timely summaries. One of the key roles of HLGPs is to form strong relationships with the GP community. This is achieved through establishing effective communication between primary and acute care and providing timely information to GPs. The HLGPs also work at a hospital and speciality level to strengthen these relationships and facilitate effective processes for communication between the hospital and GPs. Queries from GPs regarding a patient or clinical service are directed to the relevant specialty registrar. If a registrar or speciality is unable to assist HLGPs can provide advice and support.
Collaborative Complex Care in Diabetesâ€™ Pilot 5IF8FTUFSO"VTUSBMJBO%FQBSUNFOUPG)FBMUI JODPOKVODUJPOXJUI )FBMUIBOE$PNNVOJUZ 4PVUI.FUSPQPMJUBO)FBMUI4FSWJDFBOE Western Australian Country Health Service are piloting a program to improve community-based treatment for complex diabetes patients. The program aims to improve patient outcomes and reduce fragmentation in diabetes management by improving capacity for integrated and multidisciplinary care in metropolitan and country settings. 5IFQSPKFDUJTCBTFEPOQSBDUJDFBOESFTFBSDIGSPN2VFFOTMBOE XIJDIIBTTIPXOUIBUBDPNNVOJUZCBTFE JOUFHSBUFENPEFMPG DPNQMFYEJBCFUFTDBSF EFMJWFSFECZHFOFSBMQSBDUJUJPOFSTXJUI BEWBODFETLJMMT QSPEVDFEDMJOJDBMBOEQSPDFTTCFOFGJUTXIFO compared with a tertiary diabetes outpatient clinic. Through the delivery of community-based care the program aims to SFEVDFEFNBOEPOQBUJFOUPVUQBUJFOUDMJOJDT SFEVDFQBUJFOUXBJUJOH UJNFT JNQSPWFIFBMUIPVUDPNFT SFEVDFGSBHNFOUBUJPOBOEJNQSPWF communication in complex diabetes management. The pilot will IBWFUXPQIBTFTQIBTFPOFXJMMMBVODIJOBNFUSPQPMJUBOTFUUJOH and phase two will be in a rural and remote location. The pilot will be evaluated to determine the applicability for broader implementation. 'PSGVSUIFSJOGPSNBUJPOPOUIJTQSPKFDUQMFBTFDPOUBDU)FBMUI and Community on (08) 6595 8900 or email@example.com. *OUIFOPSUINFUSPQPMJUBOBSFB )-(1TDPOUSJCVUFUPBNPOUIMZPOMJOF(1 )PTQJUBM#VMMFUJOJOGPSNJOHMPDBM(1TPGOFXQSPUPDPMT HVJEFMJOFTBOE issues relating to the GP hospital interface. If you would like to receive this regular update please contact Tara Trostl on tara.Trostl@panoramahealth.com.au or access it online at www.pnml.com.au/gp-hospital
Top Row (L-R) %S7JDLJ8FTUPCZ ,JOH&EXBSE.BUFSOJUZ)PTQJUBM 5&7JDUPSJB8FTUPCZ!IFBMUIXBHPWBV %S.BSFF$SFJHIUPO 1SJODFTT.BSHBSFU)PTQJUBM 5&.BSFF$SFJHIUPO!IFBMUIXBHPWBV %S%BWJE0MEIBN 4JS$IBSMFT(BJSEOFS)PTQJUBM 5&%BWJE0MEIBN!IFBMUIXBHPWBV Dr Monica Lacey Fremantle Hospital 5&NPOJDBMBDFZ!IFBMUIXBHPWBV Bottom row (L-R) %S$MBSF.BUIFXT 0TCPSOF1BSL)PTQJUBM 5&$MBSF.BUIFXT!IFBMUIXBHPWBV %S'BSJE5BCB+PPOEBMVQ)FBUI$BNQVT&HQMJBJTPOKOD!SBNTBZIFBMUIDPNBV %S+BDRVJF(BSUPO4NJUI 3PZBM1FSUI)PTQJUBM 5&+BDRVJF(BSUPO4NJUI!IFBMUIXBHPWBV Dr Marianne Wood Liaison GP Aboriginal Health 5&NBSJBOOFXPPE!IFBMUIXBHPWBV Fiona Stanley Hospital TBA
Ovarian cancer screening
By Dr Stuart SalďŹ nger, Gynaecologic Oncologist, KEMH & SJOG Hospitals
cancer disease stages, in a Phase II study of 150 ovarian cancers and 212 control samples. No data have been reported from prospective controlled clinical trials.
Approximately 1500 Australian women were diagnosed with ovarian carcinoma in 2014. The lifetime risk is around 1.5%. As the majority present with advanced disease (Stage 3-4), which has a 10-40% ďŹ ve-year survival rate, it is disproportionately represented in cancer deaths (900 p.a.). Early disease detection has proved difďŹ cult â€“ testing for ovarian cancer in asymptomatic women can lead to false reassurance (false negatives), unnecessary highly invasive procedures (false positives) and signiďŹ cant anxiety.
Other biomarkers are being developed, including gene microarray proďŹ ling technology either as a single marker, or in a panel of biomarkers, and often in combination with CA125. No results from prospective randomised trials in a healthy, asymptomatic population are available and there is no evidence for survival advantage using these markers for screening.
Screening trials not instructive The low incidence and prevalence results in high rates of false positives unless a test is extremely accurate. Data suggests that screening leads to a small increase in the number of cases detected but no impact on outcomes or survival.
The only proven preventive strategy for women with a genetic predisposition is risk reduction bilateral salpingo-oophorectomy (+/- hysterectomy), which removes 99% of the ovarian carcinoma risk and halves the risk of breast cancer in BRCA mutation carriers. The other strategy is the oral contraceptive pill, which halves the risk of ovarian carcinoma across all women taking it (not proven in mutation carriers). More recent discussion has revolved around removal of the fallopian tubes, which have been implicated as a potential source especially in BRCA gene mutation carriers. Whilst an attractive option without the risk of menopause there is no conclusive evidence that this is protective. Recommendations. The National Breast and Ovarian Cancer Centre 2009 national guidelines say screening is not indicated for asymptomatic women (see Figure 1). Screening in high-risk populations is controversial and lacks consensus.
The PLCO (Prostate Lung Colorectal Ovarian) trial showed no change in the stage of disease detected or survival with screening (US scan and CA 125 marker) and 15% of women who underwent surgery for a false positive ďŹ nding experienced a serious complication. WHO criteria for disease screening perfectly suit breast or cervical cancers, however ovarian carcinoma lacks a pre-invasive disease stage or latent period. Patients with early stage disease perform better but are difďŹ cult to identify with any screening test. The poor sensitivity and speciďŹ city of the tests is also a problem.
The harsh reality for surgeons is that the majority of women with ovarian cancer present with advanced disease (Stage 3-4)
Large-scale prospective clinical screening trials are in progress. Until ďŹ nal results are in, consensus is that women at average risk for ovarian cancer should not undergo screening. Available tests CA125, a low molecular weight glycoprotein, is neither sensitive nor speciďŹ c for early stage disease. It can be normal in 50% of women with early stage ovarian carcinoma or elevated by numerous benign conditions including benign cysts, endometriosis, ďŹ broids, PID and even normal menses. Whilst suggested to be a better predictor of disease in postmenopausal women, the PLCO trial data only showed a positive predictive value of 3.6%
Ultrasound, is effective in assessing ovarian masses, but not as a screening tool. Three large trials looked at Multimodal Screening; PLCO, UKCTOCS and a Japanese trial involving 68,557, 202,638 and 83,000 women. These showed some promise to a multimodal approach using CA125 and transvaginal ultrasound (TVUS). Repeat CA125 measurements over time increases the sensitivity and speciďŹ city of this approach. A Risk of Ovarian Cancer (ROC) algorithm incorporating serial measurements of CA125 is being further evaluated as part of the UK Collaborative Trial of Ovarian Cancer Screening trial. High risk women
Human Epididmys Protein 4 (HE4) has a similar sensitivity but higher speciďŹ city. It is more effective than Ca125 in classifying benign and ovarian masses. OvPlexâ„˘, a commercial blood test marketed for early detection of ovarian cancer, measures CA125 and four additional protein biomarkers. Unpublished company data reports over 90% sensitivity and speciďŹ city across all ovarian
National guidelines help in explaining to patients the lack of evidence for screening but unfortunately some still seek testing and discussing the pros and cons can take a lot more time than simply requesting a blood test and ultrasound. The signiďŹ cant downside and risks of screening asymptomatic women should be remembered. Highrisk women should be referred to appropriate genetics counselling and gynaecologic oncology services.
Women with a family history or genetic mutation predisposing them to ovarian carcinoma (BRCA one and two and HNPCC) present a challenge. No current data shows that screening is effective in this population either. Many doctors will screen with the proviso that screening has many pitfalls. Most women who develop cancers do so during screening intervals.
Risk Factors for Ovarian Carcinoma sĂĽ 'ENETICĂĽPREDISPOSITIONĂĽ ĂĽINĂĽTHEĂĽ absence of proven genetic mutation sĂĽ &AMILIALĂĽOVARIANĂĽCANCERĂĽSYNDROMEĂĽnĂĽ BRCA 1 & 2, HNPCC sĂĽ !GEĂĽnĂĽPOSTMENOPAUSAL sĂĽ 2EPRODUCTIVE%NDOCRINEĂĽDECREASEĂĽ risk â€“ pregnancy, OCP, breast feeding, tubal ligation/hysterectomy; increase risk â€“ infertility, endometriosis, ?HRT There is currently no evidence that any test, including pelvic examination, CA125 or other biomarkers, ultrasound (including transvaginal ultrasound), or combination of tests, results in reduced mortality from ovarian cancer. Author competing interests; no relevant disclosures. Questions? Contact author on 9388 3495.
By Dr Jessica Yin Urological Surgeon, Hollywood Private Hospital, KEMH
Urogynaecological mesh complications The management of pelvic organ prolapse (POP) and urinary stress incontinence (USI) can be very complex, especially in repeat cases. Treatment may involve the placement of transvaginal mesh. Recently there has been controversy surrounding the use of POP mesh (less for midurethral slings) with escalating publicity and litigation as a result of complications.
Rectal perforation occurs rarely with symptoms and signs being more obvious. Evacuation difďŹ culties like constipation, urgency, or dyschesia can occur. Fixation devices (such as tissue anchors) can migrate or erode into the urinary tract (with resultant UTIs, pain and haematuria) or into the vagina causing pain.
In 2011, the US FDA released a safety communication advising mesh complications were not rare. A review based on prospective studies to monitor efďŹ cacy and safety was initiated but they did not recommend withdrawal or restriction, yet use of mesh for these purposes has decreased about 50% in the USA since 2011.
Mesh sling eroding urethra April 15
In 2013, the Royal Australasian College of Obstetricians and Gynaecologists (RANZCOG) and the Urogynaecological Society of Australasia (UGSA) released a combined statement with guidelines for consent, training, safety and efďŹ cacy monitoring and patient selection (see www.ranzcog.edu.au and search â€œmeshâ€?).. Uncommon complications may include Urinary obstruction results from excessive tensioning of slings or anterior vaginal mesh, but in poor detrusor function (hypotonic bladders) normal tension may be relatively obstructive. Patients may experience hesitancy, slow trickling stream, intermittency, high residuals and double voiding. Incomplete emptying may result in increased UTIs with incomplete clearance after antibiotics. Erosion or extrusion of mesh is more likely with atrophic or irradiated tissue, diabetes, immune deďŹ cient states, or where there is excessive tensioning of slings and POP mesh. Slings
may erode into urethra or bladder leading to calciďŹ cation, recurrent infection, haematuria, and incontinence (usually profound and refractory to usual therapies). Mesh material may emerge in the vagina. This is usually ďŹ rst noticed by the patients sexual partner as it is coarse and prickly. It may be a source of chronic urinary infection and vaginal bleeding. Perforation of the bladder is ideally recognised during surgery, with a cystoscopy being obligatory. Immediately recognised perforation is usually not a major problem, requiring only repositioning of the trocar and a more prolonged period of catheterisation. If not recognised, patients may complain of lower pelvic or abdominal pain and distension, fever, rigors, frank peritonism if the urinary leak is intraperitoneal and a rise in creatinine may be seen. Late complications include ďŹ stula formation. Ureteric injury is a rare but devastating complication usually associated with the passage of a trocar attaching a mesh arm. Ureters can be obstructed leading to ďŹ‚ank pain similar to renal colic. A ureteric leak can present in much the same way as a bladder perforation with abdominal distension, pain and bloating. Infection is a frequent sequel.
Chronic pain from scarring and tethering of the mesh can be devastating. Pain can radiate to thighs, groins and buttocks. It is often impossible to remove all mesh once it becomes embedded and the attempt may further destroy tissue and lead to further pain and complications. Next steps The gynaecological community is reviewing the place for synthetic mesh to provide guidance in this complex ďŹ eld. In cases of recurrent prolapse where native tissue repairs have failed, mesh may be the only surgical option. In the case of SUI midurethral slings have become the â€œgold standardâ€? of surgical treatment with more durable results compared with older methods. It is important to not throw the baby out with the bathwater but maintain a vigilant eye on outcomes and complications. UGSA have established a database which mesh users are strongly advised to utilise in auditing their results. References available on request.
Author competing interests: No relevant disclosures. Questions? Contact author on T: 9389 1094.
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Contraceptive use and unscheduled bleeding
By Dr Maria Garefalakis, Medical Director, Sexual & Reproductive Health WA
Unscheduled vaginal bleeding (syn. breakthrough bleeding) occurs outside the expected withdrawal bleeding from the use of combined hormonal contraception (CHC) or the unpredictable bleeding that goes with other contraceptive methods. It is a common reason why women attend their GP.
After excluding other causes of bleeding (remember that implants can also be affected by liver enzyme inducing medications) and if there are no contraindications, a CHC can be used for a few months. She should expect a withdrawal bleed on stopping and will generally resume her earlier pattern of bleeding. If effective, an implant user may choose to continue using CHC for the duration of the implant.
Unscheduled bleeding is commonplace when a new contraceptive method is started, often settling without intervention. Such unexpected bleeding, although temporary, often leads women to discontinue their contraception. However, many women accept irregular bleeding that lessens over time but perhaps not frequent prolonged bleeding that does not settle (in particular, implant use) and obscures the woman’s menstrual ‘pattern’. Giving information about what bleeding might be expected can reduce concerns and encourage ongoing use of a contraceptive method. An excellent summary of expected bleeding with different methods (both in the ﬁrst three months and in the longer term) is included in the UK Faculty of Sexual & Reproductive Healthcare Clinical Guidance: www.fsrh.org/pdfs/ unscheduledbleedingmay09.pdf Things to look for For a woman using CHC who experiences unscheduled bleeding, ﬁnd out if inconsistent dosing may be a factor. If not, reassure her that her bleeding is not associated with lower CHC efﬁcacy and risk of pregnancy. Check for liver enzyme inducing medication (including St John’s Wort) as these can reduce the effectiveness of CHC (both oral and vaginal ring), progestogen only pills and implants. Alternative causes of bleeding include pregnancy, sexually transmitted infections and other genital tract pathology. Examination and investigation is guided by the clinical history, including risk factors. What to do If unscheduled bleeding persists after three months of oral contraceptive use and other causes are excluded, the dose of ethinyloestradiol may be increased up to a maximum of 35mcg or she may consider changing to the contraceptive vaginal ring or another method. There is little evidence that changing the type or dose of progestogen or changing to biphasic/triphasic pills will improve bleeding. Using CHC continuously (without the monthly hormone-free break) avoids withdrawal bleeding and other symptoms around hormone withdrawal, a CHC use that is regarded as safe for women. However, unscheduled bleeding is very common in early cycles and this usually decreases with time. One option for management of a woman who has had at least 21 days of continuous combined hormone use and then experiences MEDICAL FORUM
Other options include a short course of NSAIDs (e.g. mefenamic acid 500mg twice a day for ﬁve days) or, if bleeding is heavy, tranexamic acid (500mg twice a day for ﬁve days). If successful, these can be repeated monthly. There is limited evidence for the use of progestogen-only pills or early removal and replacement of an implant or hormonal IUD.
Take Home Points
a bleeding episode that lasts for more than four days, is to have a four day hormone free interval and then restart. Intrauterine devices and implants have the highest rates of efﬁcacy, satisfaction and continuation and these long-acting reversible methods and are being increasingly offered as ﬁrst line options. In addition to counselling about expected bleeding, it is recommended that women feel able to return if bleeding is troublesome as management options are available (“don’t wait until you’re completely fed up”) and they should be advised that they may have the device removed any time with rapid reversal. Family Planning Alliance Australia (http:// fpallianceaus.org/larc) has developed the helpful Guidance for management of troublesome vaginal bleeding with progestogen-only long-acting reversible contraception (LARC) which is available for download www.fpv.org.au/assets/FPAAguidance-for-bleeding-on-progestogen-onlyLARC.pdf
så 7HENåPRESCRIBINGåCONTRACEPTION å advise women about the expected changes to uterine bleeding, both initially and in the longer term. så !SåUNSCHEDULEDåBLEEDINGåWITHåNEWå combined oral contraceptive use tends to settles with time, changing to another COC type in the ﬁrst three months is not recommended. så 7OMENåWITHåUNSCHEDULEDåBLEEDINGå who are at risk for STIs (e.g. under 30 years old or change in sexual partner in the last 12 months) should be offered STI testing. Check out www.sti.guidelines.org.au. så ,ETåWOMENåWHOåCHOOSEåAåLONG ACTINGå reversible methods ‘LARC’ know that there are management options for troublesome vaginal bleeding.
Competing interests: As medical director at SRHWA, the author provides training for Implanon and IUD insertion and has been a past member of MSD and Bayer advisory committees. Questions? Tel 92276177 (ext 920)
Expressions of Interest Dr John Raven is retiring towards the end of 2015 creating a good opportunity for a Clinical Haematologist to open a practice in Bunbury. There is a busy and interesting work load. The district covers Harvey in the North, Augusta in the South and Wagin in the East. There are excellent pathology facilities and access to a good day-only oncology unit. Bunbury is suitable for solo or partnership practice or part-time or full-time, according to experience. There are two part-time haematologists in Mandurah and one on Saturday mornings in Busselton.
Further information available from Dr J L Raven Telephone: 9384 7860
Spinal Injections at Perth Radiological Clinic
Lumbar Epidural Injection
Injection under CT guidance (facet joint injection)
Facet Joint Injection
Nerve Root Sleeve Injection
Perth Radiological Clinic provides a comprehensive image-guided spinal injection service (including selective nerve root sleeve, lumbar spinal epidural and facet joint injections) at multiple sites across the Perth metropolitan area.
10 reasons to send your patients to us. 1. Training – interventional fellowship trained radiologists perform these procedures. 2. Experience – very experienced doctors with an impeccable safety record over many years (using nonparticulate steroid for all NRSI and lumbar epidural injections). 3. Assurance – electronic online storage of results that allows for the review of ALL relevant previous imaging to ensure that we do the correct procedure at the correct level and relevant to the patients’ symptoms. 4. Convenience – we offer spinal injections at the majority of our hospital and community locations across Perth resulting in shorter wait times for appointments.
8. Feedback – all patients are given a pain self-assessment tool after their procedure so feedback can be provided to their referring practitioner. 9. Supervision – all patients are closely supervised during and after their procedure. Strict protocols are adhered to in the unlikely event of a reaction. 10. Guidance – doctors will offer guidance about the appropriateness of referral for injection, following imaging ﬁndings.
Easy access at multiple sites means shorter wait times for your patients...
5. Patient comfort – injection under CT guidance minimises the length of the procedure and potential discomfort to the patient. 6. Safety – low dose CT is used for all injections ensuring the lowest possible dose of radiation to the patient. 7. Team approach – communication between the doctors and experienced technical staff to ensure the accuracy of injection site.
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PCOS: can diets help?
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
By Ms Jo Beer, Dietician, Revitalise
Dietary strategies There is no speciďŹ c â€˜PCOS weight loss dietâ€™. A Mediterranean style diet of whole grains, lean protein, fresh fruit and vegetables, with fats derived from plant and marine source is generally recommended. Fad diets (Paleo or 5:2) are tempting but not recommended. The Paleo diet lacks important nutrients from high ďŹ bre grains, cereals and dairy products. The 5:2 diet may have some positive effects on insulin resistance. It is not advisable for those at risk of disordered eating, since it can promote binge eating on non-fasting days.
by Medical Director Prof John Yovich
Ultrasound scans for male partners â€Ś is it worthwhile? Part 2
Diet and exercise to promote weight loss should be the ďŹ rst line of treatment in managing PCOS; even ďŹ ve to 10% weight loss reduces symptoms. Diagnosed in 15% of women of reproductive years, polycystic ovary syndrome (PCOS) is one of the commonest endocrine disorders affecting women. It is the leading cause of female sub fertility. Whilst the causes may be genetically linked, lifestyle inďŹ‚uences severity of symptoms. PCOS leads to an increased risk of heart disease, diabetes, mental health issues and eating disorders. Symptoms vary, with irregular or absent menstruation, acne and hirsutism, sub fertility or infertility.
Last month I presented a summary table from our recent publication detailing a 3-year study examining the relevance of routine genito-urinary ultrasound scanning of 1203 men attending with their partners for infertility management.
PCOS & Diet Dietary intervention, following a Mediterranean style diet with low GI carbohydrates and moderate protein coupled with regular exercise promotes weight loss in those with PCOS, which in turn leads to reduced morbidity and improved fertility. Sample Menu: B/fast â€“ 2 x soy and linseed toast + 1 x egg MT â€“ 4 x vitaweat crackers + cottage cheese Lunch â€“ Tuna wrap and salad AT â€“ Carmenâ€™s gourmet protein bar Dinner - 100 g protein + vegetables or salad
The DIOGENES project looked into the most effective diet for not regaining weight. A low glycaemic index (GI) carbohydrate plus a moderate intake of protein was most successful. It promoted early satiety, increased thermogenesis and a reduction in HbA1c and postprandial glycaemia. This equates to a daily intake of 45% carbohydrate, 25 % protein, and 30 % fat. Other studies have found that eating smaller portions of carbohydrate in the evening can assist in promoting initial weight loss (see menu sample). A speciďŹ cally designed eating and exercise plan is recommended, but only works if followed! Increasing compliance is aided with motivational interviewing, goal setting and self-monitoring via Apps such as CalorieKing, myďŹ tnesspal or Fitbit. Strong social support from family and friends and regular dietary follow ups with an accredited practising dietician are crucial for success. Some patients gain motivation from celebrity role models such as Posh Spice and Jools Oliver who have successfully managed their weight and both now have four children.
By Clinical Professor John Yovich
7KHGDWDVKRZHGWKDWVXFKPHQÂ´FRQFHDOÂľDVLJQLĂ€FDQWQXPEHU of lesions, some with major health implications. If one only scans WKRVHZLWKVLJQLĂ€FDQWVHPHQGLVRUGHUVPRUHWKDQRIOHVLRQV ZRXOGEHPLVVHGLQFOXGLQJFDVHVRIWHVWLFXODUFDQFHUDQG cases of microlithiasis. Other â€œsurprisesâ€? included a Grawitz renal cancer, a Leydig cell tumour which proved benign and a total UHQDOOHVLRQVRIYDULRXVW\SHV In this series almost none of these lesions were detectable clinically, neither by the Gynaecologist screening the men nor by the Urologist to whom the serious cases were referred. Such men with suspected serious lesions require a more conservative management approach rather than immediate orchidectomy DVWKHSRVLWLYHSUHGLFWLYHYDOXHRIWHVWVLVFXUUHQWO\RQO\DQG the progression period for both cancer and possible pre-cancer cases (microlithiasis) is unclear in this setting. The latter cases are offered long-term follow-up at PIVET. Even benign lesions are worth identifying for the reassurance YDOXH)XUWKHUPRUHWKHEHWWHUGHOLQHDWLRQRIWKHIUHTXHQWĂ€QGLQJ RIYDULFRFHOHV HQDEOHVLGHQWLĂ€FDWLRQRIWKRVHZLWKFOLQLFDO UHOHYDQFHFDVHV 3URJUHVVLQ$QGURORJ\KDVUHTXLUHG the realisation that semen analysis has very low predictive value for underlying SDWKRORJLHV in this series), and fertility clinicians should â€œclinically embraceâ€? the male partner as well as organise an ultrasound scan of the genitourinary tract. Fig 1: One of the 15 cases of cystic ectasia in the series of 1203 men.
References available on request Author competing interests; no relevant disclosures. Questions to the author please 0403 938 747.
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New GP MRI knee items and knee arthroscopy The introduction of the new GP knee MRI item has the potential to alter referral patterns to orthopaedic colleagues for potential knee arthroscopy; this has become more contentious in OA, in that the value of chondroplasty and other procedures to address articular cartilage damage are being questioned.
a haemarthrosis, and a locked knee will likely require surgery. MRI in this setting will determine whether there is a bucket handle tear of the medial meniscus, an ACL rupture, an osteochondral injury, or a combination of these. MRI then assists in planning surgery and outlining the prognosis, which can be very valuable to the patient.
The new MRI items are speciďŹ cally limited to episodes of acute trauma with either:
A more difďŹ cult decision is in the older patient with intermittent symptoms where acute on degenerate injury to the meniscus occurs in association with pre-existing or possibly new articular cartilage damage. The old concept of mechanical versus inďŹ‚ammatory symptoms is still very valid in these patients. Episodes of locking or catching or restriction of range of movement suggest mechanical impingement, which may be amenable to arthroscopy. Alternatively, symptoms of pain and swelling without mechanical features may be more inďŹ‚ammatory in nature and respond better to medications and exercise than surgery.
1) an inability to extend the knee suggesting the possibility of acute meniscal injury or, 2) clinical ďŹ ndings suggesting acute anterior cruciate ligament tear. I would suggest that suspected or conďŹ rmed anterior cruciate ligament (ACL) injuries be referred for orthopaedic review. While meniscal injuries often require surgery, some may be managed conservatively and the MRI scan can assist in these decisions. Clinical context of MRI use Essentially the MRI can help to determine the extent of meniscal damage, the extent of preexisting or new articular cartilage damage and whether there are any associated injuries or conditions which would alter the management such as loose bodies, ligament injuries, or synovitis. This information can be combined with the clinical history and exam to assist in determining the need for orthopaedic referral and probable arthroscopy. Obviously a spectrum of injury is possible and the young person with an acute injury,
MRI in patients with mechanical symptoms can help determine the likely source of symptoms. There may be an unstable meniscal tear, an unstable ďŹ‚ap of articular cartilage, a loose body, or a combination of these. Arthroscopy to remove the offending source of mechanical symptoms can often provide substantial relief even if there is established OA. If the MRI shows such a lesion but also widespread chondral damage then it may be better to delay arthroscopy especially if bone oedema is present. If MRI does not show these lesions in patients with mechanical symptoms then orthopaedic referral
By Dr Peter Nathan GP and Sports Doctor Murdoch
Case study 49-year-old male with past history of lateral menisectomy and low grade patella-femoral pain develops a new symptom of painful catching at the lateral patella border. Painful crepitus is elicited on examination. MRI conďŹ rms chondrosis but also an unstable chondral ďŹ‚ap at the site of his symptoms. This did not recover with conservative management for eight weeks. Arthroscopy was then performed to debride the unstable area that was causing mechanical symptoms.
could usefully be delayed and a physical strengthening programme advised under a physiotherapist or exercise physiologist.
Competing interests declaration: nil relevant. Questions? Contact the author on 9332 6000
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PRP*- NON SURGICAL GLUTEAL TENDON REPAIR GREATER TROCHANTERIC BURSITIS
Greater trochanteric bursitis is a common cause of postero-lateral hip pains typically occurring in women. Histology reveals degenerative tendinosis with tears of the gluteal tendons. Histology does not show bursitis. The natural history of this condition is favourable in most cases. However in some patients the condition causes *!&!1&+ !*!$!+0 &**!++!& !&+)-&+!'& ')+!'*+)'! !&"+!'& ' + ,)* )',& + $,+$ +&'&*&*,)!$)(!)'+ +&'&)'%%'&+)+%&+'(+!'&*(!'&)(),+&',*+)+ment for tendon tears using Autologous Platelet Rich Plasma (PRP) tenotomy under high resolution imaging control as an alternative to surgery. Case report: A 56 year old female presented with left sided greater trochanteric pain syndrome for many months. She was unable to walk on an incline and had night pain. Pre()',)$$!&!$/%!&+!'&+)-$(!&,$$!%!++!'&'(**!-+!- !(,+!'&&)*!*+,+!'&$+)*',&* '.+)'&)+!&$,+,*%!,*+&'&!&*)+!'&*1,) +&'+'%0'+ +)+)*0%(+'%*!%()'-.!+ !&*-)$.#* &"'0.$#!& '$!0!&+ !%)$0.!+ ',+$!%!++!'&+%'&+ *'$$'.,(,$+)*',&+ %'&+ ** '.&'+&'&+!**,*1,) .!+ '&+!&,)$!'(!&.!+ ',+$!%!++!'&!&,&+!'& Summary: Percutaneous PRP tenotomy is an option for the non surgical repair of Gluteal tendon tears that present as GTB pain syndrome/bursitis.
Fig 2: Post PRP tenotomy ultrasound at twelve month follow up shows reduced swelling of the tendon (bro! eration of neotissue (blue arrows).
Fig 1: Pretreatment Ultrasound of the insertional gluteus medius tendon shows degenerative tendonosis (broken red line) with an irregular full thickness tear (thin red arrows).
*WORLDâ€™S FIRST REPORTS ON NONSURGICAL REPAIR OF TENDON TEARS FROM WA Doss A. Neotendon regeneration and repair of gluteus tendon tear at 1-year follow-up after ultrasound guided platelet rich plasma tenotomy [v1; ref status: http://f1000r.es/4pu] F1000Research 2014, 3:284 (doi: 10.12688/f1000research.5719.1).
Doss A. Neotendon infilling of a full thickness rotator cuff foot print tear following ultrasound guided liquid platelet rich plasma injection and percutaneous tenotomy: favourable outcome up to one year [v1; ref status: indexed, http://f1000r.es/xz]. F1000Research 2013, 2:23 (doi: 10.12688/f1000research.2-23.v1).
Dr Arockia Doss
MBBS (Ind) MRCP (UK) FRCR (Lon) FRANZCR
Suite 3, 55 Hampden Road Nedlands WA 6009 P 6389 2776 f 63892778 firstname.lastname@example.org
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Oligo and amenorrhoea in sportswomen
By Dr Carmel Goodman, Sports Physician CMO WAIS
(not only at the lumbar spine, as previously thought).
The relationship between amenorrhoea, eating disorders and osteoporosis, ‘the female athlete triad’, was ﬁrst recognised in 1997. It was redeﬁned in 2007 as a syndrome of low energy availability, subclinical menstrual disturbances and low bone mineral density (BMD). Prevention and early intervention is the key to avoiding the more serious clinical endpoints of anorexia, amenorrhoea and osteoporosis.
Menstrual irregularities in elite athletes are relatively common.
The incidence of menstrual irregularities varies between different sporting groups. Up to 100% of elite gymnasts, ballet dancers and light weight rowers demonstrate some form of menstrual dysfunction, with lesser rates in team sports, swimming and cycling. The causes of menstrual cycle irregularities include nutritional factors (inadequate diet, low body fat/weight loss), “excessive” exercise, altered hormone levels and psychological stress, some or all of which ultimately result in hypothalamic dysfunction. This decreases GnRH release, decreased FSH and LH levels and ultimately menstrual dysfunction. Prior menstrual irregularities and delayed menarche may play a role in further disrupting the hypothalamic/pituitary axis.
more than 30%, LH pulsatility and GnRH is disrupted within ﬁve days. FSH and LH release is then affected and menstrual dysfunction can occur shortly after.
Identifying and treating amenorrhoea early is important to prevent reduced BMD from low oestrogen. About 70-80% of peak bone mass is gained during adolescent years peaking in the 20’s. After this, women lose 1% BMD per year until menopause. A young female athlete presenting with amenorrhoea, may have already failed to attain peak BMD, increasing the risk of stress fracture and premature osteoporosis.
This is often very difﬁcult to achieve in young athletes, so pharmacological interventions, such as the combined oral contraceptive pill (OCP) are trialled. Findings in this regard are controversial. I will trial an OCP, for at least 3 months, primarily to replete oestrogen. Early recognition, prevention and intervention using a multidisciplinary approach (which may include psychologist, dietician, endocrinologist or gynaecologist) with the GP playing a pivotal, co-ordinating role are the keys.
Recent studies have demonstrated that delayed menarche and increased duration of secondary amenorrhoea results in a signiﬁcant decrease in BMD at multiple skeletal sites
Factors at play Research shows that when energy availability (intake minus expenditure) is reduced by
It is important to assess any exercising female who has one of the triad components, for the others. History and examination determines whether further investigation is necessary. In primary amenorrhea (delayed menarche after sixteen years) or secondary amenorrhoea (no menstrual period for six months), investigations may include FBC, UEC, TSH, sex hormones, prolactin and bHCG.
Aim to restore menstrual cycling by increasing energy availability (increased calorie intake) and/or reducing energy expenditure (exercise).
Author competing interests: No relevant disclosures. Questions directed to author please 9387 8166
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Soothing the Savage
Escalating ﬁgures for road rage are just the beacon illuminating exactly how ticked off we all are with our fellow man. Having toyed for two thousand years with the Christian ideal of ‘love thy neighbour’ Perth has collectively voted for ‘punching the lights out of random passers-by’ and chosen to play the hate card instead. Apparently it’s a thin line. While we might think that we only turn gladiatorial behind the wheel of our Hyundai Chariot, we’re fooling no-one but ourselves. Even the few West Australians who aren’t high on a NUTRiBULLET of kale, Krispy Kreme Doughnut and methamphetamine have the everyday bonhomie of a grizzly bear undergoing a Brazilian wax. Look around your waiting rooms – you’ll see wrinklies prepared to take you out with their walking stick if you keep them waiting more than ﬁve minutes. It’s dangerous to even be nice to people. Smile at a stranger on the street and they react as if you’re about stick a poisoned umbrella tip in their thigh. The majority of us have homes, sufﬁcient food and an absence of people trying to kill us, so on a world view, we should be pretty high up the ‘quietly smug’ scale, leading to the possible conclusion that ﬂuoride in the water is inducing irrational rage. Or perhaps it is the conviction that everyone else is out to pull a number on us that makes everyone so antsy. Plumbers could
be to blame; in my experience they generally are all out to pull a number on us. (Understandable really – given their stock in trade; their sentiments towards human life and its processes aren’t going to be terribly warm and fuzzy.) We could consider putting different chemicals in the water. Go to Byron Bay and you’ll see motorists smile and stop for pedestrians who even vaguely look like they might want to cross a road somewhere at some future point in their lives. Sadly, in Perth it may be easier to legislate against the causes of violence than to stop the violence itself, resulting in a gamut of new offences. Police on the beat in Northbridge on a Saturday night will be on the lookout for the potential felonies of ‘driving a poofy car’ or ‘looking at me funny’. Charges may even be upgraded to ‘possession of a later model iPhone than mine’ or ‘causing affray by wearing the wrong shirt with those pants’.
In its digitally downloaded form, all that’s required is a little enforced manipulation of our playlists. Yes – we’re treading the path that U2 went down last year, but with much better content. Certain songs have the power to uplift and more importantly, to unite us all.
Prison is deﬁnitely not the answer though; it’s one place not to send people you hope will adopt a sunnier approach to life. Luckily though, I have the answer. Music.
Forget turgid national anthems imposing girtness upon us or folksy encouragements to sheep rustling. I challenge anyone on hearing Queen’s Bohemian Rhapsody to not stop what they are doing and falsetto along with ‘Scaramouche, Scaramouche, will you do the fandango?’ I have witnessed this song turn a restive, ticked-off mob into an arm-waving, fellow-man-loving bunch of pussycats. No doubt there are other songs with a similar power to placate, but the choice needs to be made with caution. Anyone plays Phil Collins at me and the ﬂuffy bunny gets it.
15-17 Renal Society of Australasia Conference
8-11 The Human Genetics Society of Australasia (HGSA) Annual Scientiﬁc Meeting
Crown Perth http://rsaannualconference.org.au
‘Rare Diseases and Indigenous Genetics’
Conference Corner APRIL 15-18 International Conference of Alzheimer’s Disease International Perth Convention & Exhibition Centre https://b-com.mci-group.com
MAY 4-8 Royal Australian College of Surgeons Scientiﬁc Congress Perth Convention & Exhibition Centre http://asc.surgeons.org
Perth Convention & Exhibition Centre www.hgsa.org.au
JULY 4-5 Aboriginal Health Conference Parmelia Hilton Perth www.ruralhealthwest.com.au
SEPTEMBER 17-21 Asian Paciﬁc Conference of Nephrology (APCN) & ANZSN ASM 2016
22-24 Australia and New Zealand Breast Cancer Trials Group Annual Scientiﬁc Meeting
Perth Convention & Exhibition Centre www.apcn2016.com.au
Venue to be conﬁrmed www.anzbctg.org/content/33/annualscientiﬁc-meeting
AMSA Global Health Conference
Crown Perth http://arinex.com.au/dietitians2015 13-14 Aboriginal Maternal and Child Health Conference 2015
26–27 General Practitioner Conference and Exhibition
Novotel Perth Langley Hotel firstname.lastname@example.org
Perth Convention & Exhibition Centre www.gpce.com.au
13-16 Dietitians Association of Australia (DAA) National Conference
a r o f E Y E P SHAR D E S O U O A G C The John Fawcett Foundation has been working on saving the sight of poor Balinese for the past 23 years with help from the medical profession.
What can $2250 buy you? A lot, if work by the John Fawcett Foundation in Bali is anything to go by. John is a well-known West Australian and the various eye groups that have supported him (e.g. Eye Surgery Foundation) over the past 23 years can attest to the innovative outreach eye care services the Foundation provides. It is the hinterland poor in Bali who beneﬁt big time. Talk about an amazing ‘bang for the buck’! Here is what a tax-deductible AUS$2250 for Adopt a Mobile Eye Care Clinic achieves in two days: så 9OUåCANåINCLUDEåANåEYEåCLINICåVISITåDURINGåAå Bali trip by travelling off the main tracks to see ﬁrst-hand the team in action så 2EMOVALå OFå ADULTå EYEå CATARACTSå INå THEIRå unique mobile theatre (40,000 so far overall, about 10 per clinic) så 3CREENå POORå VILLAGEå PEOPLE å CHECKå FORå infections and other blinding diseases (about 500) så 2EFRACTå ANDå (about 250 pairs).
with John Fawcett
nt cata ract patie
On the second day, post-operative checks are done on those who received surgery the day before and there is a visit to a primary school to screen about 300 children, and refract and issue prescription glasses to about 10 children. This is their Blindness Prevention Program.
så 4AILOR MADEåTRAININGåMATERIALS åPOSTERSåANDå other visual aids are distributed to participating elementary schools as part of school-based eye health care education. This education leads to word of mouth information dispersal which reduces blindness.
There are cultural barriers to overcome. Family elders must give permission. Hindu beliefs often attribute today’s physical illnesses to superstition or an act in a previous life. The elderly do not step forward because they feel less important and are more accepting of their lot. So, gentle campaigning is part of the philanthropic work.
“We try to accommodate the donors should they want to select a particular village and, to some extent, the date of the program to provide an opportunity should a donor be in Bali the day of the sponsored clinic. In this way they are able to see how their money is spent,” foundation CEO LeRoy Hollenbeck said.
You can invest just in the Blindness Prevention Program (a $750 donation). så #HILDRENå AREå THEå TARGET å ONå THEå BACKå of a mobile clinic visit. One or two nearby elementary schools are screened – refractive errors ﬁxed with free glasses and eye screening examinations for an estimated 300 school children. så ,OCALåGOVERNMENTåNURSESåAREåTAUGHTåBASICå skills on how to refract and examine eyes (and they help cataract surgery patients post-op).
Contacts LeRoy Hollenbeck, CEO of The John Fawcett Foundation, E: email@example.com Yayasan Kemanusiaan Indonesia (translation: Indonesian Humanitarian Foundation). Jalan Pengembak 16, Br. Blanjong, Sanur Bali 80228, Indonesia T: +62 361 270812 F: +62 361 287707 E: firstname.lastname@example.org W: www.balieye.org
Travel Preserved by its isolation, Lo-Manthang in Nepal is now feeling the relentless pressure of modern tourism. Dr Ted Collinson wanted to see this Shangri-la before it changes. Visitors are thin on the ground at LoManthang, the ancient capital of the farﬂung Mustang region of Nepal. The region was closed off to Westerners until 1964 when the French ethnologist, explorer and author Michel Georges Francois Peissel was granted permission to enter. Since then it has become a serious trekker’s destination, with permits still restricted. For those who do, the Tiji Festival in May is drawcard. Every year Lo-Manthang hosts the three-day Tiji Festival, which is one of the Himalayas’ oldest and most spectacular religious festivals. It dates from the eighth century having been brought to Lo-Manthang from Tibet by Guru Rinpoche at a time when the area was ruled by the King of West Tibet, who also ruled the Ladakh area of the Indian Himalayas. The festivals are Buddhist in nature, though their roots lie in the ancient pre-Buddhist BonPo religion, which incorporates animalistic features also seen in Ladakhi festivals.
nks prepa re Buddhist mo Festival for the Tiji
Painsta kin gw the monas ork retouching tery fresco esv
Tourism breaches the walls Lo-Manthang is a walled city that houses three monasteries, a monastery school and the King’s palace. It owes its survival to its isolation yet now this isolation is being challenged by the modern pressures which are so obvious in other parts of Nepal. A road of sorts now links Tibet to Lo-Manthang, which is only 50km from the Tibetan border, to the plains of Nepal. One of the reasons why I was so keen to see the Tiji Festival was my fear that this new access would change this ancient festival forever and I wanted to document it before it succumbs to tourism and development. Getting to Lo-Manthang requires an overnight stop in Pokhara and then an early morning ﬂight to Jomsom, half way up the western part of the
Annapurna circuit. It’s about the last safe stop before the winds make air travel tricky. From there it’s a ﬁve-day trek up the Kali Gandaki gorge to Lo-Manthang, initially following the gorge but then breaking out to the west to avoid an impassable section. From the passes there, at 4026m, you are treated to a panoramic vista of a complete North to South cross-section of the Himalayas. The Tiji Festival represents the myth of Dorje Jono, a Buddhist deity who is said to have saved his people from the vagaries of a drought brought on by his demon father. Dorje Jono and his retinue of ﬁercely masked companions perform a series of dances to repel the resident evil, eventually reducing the demon to a small cloth efﬁgy, which is then destroyed.
Tiji transforms the city The Tiji is a major attraction for the whole area and the local populace, the Lobars, dress up in their ﬁnest clothes and jewellery and the city takes on a carnival atmosphere. Underlying the festivity is the need for rain as Lo-Manthang is in a rain shadow and agriculture is fragile in this arid climate. The day before the festival, monks, dressed in their red headpieces, hold a ceremony in the main monastery. During my visit last year, I was able to obtain permission to ﬁlm. The frescoes were being repainted and an antique generator chugged away outside powering a few tungsten globes; just enough for photography. Dating from the 15th century, the monastery’s high roof was supported by massive tree trunks,
r-K ag beni On the Sa ma
making them all the more spectacular as trees are a rare commodity in Mustang. The festival is held in a small courtyard adjacent to the Royal palace and the audience is packed in, making photography extremely difﬁcult. Space given up was immediately ﬁlled by small children, leaving little room to juggle three cameras, tripod, lenses and ﬂashguns! Adding to the vagaries of the crowd was the inclemency of the weather – the rain gods were obviously taking heed of the festivities with showery periods causing problems for the ancient silk costumes and their wearers. The second day was fortuitously sunny and made the modern silk costumes used that day shimmer spectacularly in the light. More and more exotic masks were on display and
The Tiji sp
irits a re co njured
the general atmosphere was far more relaxed with a surprise appearance from the greatly revered and frail 80-year-old former King of Mustang. The climax of this day’s activities was the dispatching of the resident evil, which was whisked away by dancers sporting masks reminiscent of frilled-neck lizards. Access has beneﬁts Already there are huge changes affecting Upper Mustang; the road allows villagers to travel to markets inside China and also to reach the hospitals in Pokhara within a couple of days, whereas previously this would have taken a week. But Lo-Manthang struggles to keep up with the increasing inﬂux of visitors and it is a major challenge for the residents to protect their
of a nd headdress e m u st o c te ra The ela bo ck da ncer the Tiji peaco
culture, which has been preserved for so long because of its isolation. A relative of the King is building a modern-style hotel on the outskirts of Lo-Manthang and more and more visitors are taking the easy option of using four-wheel drives. Not only does this rapid entry do little to help altitude acclimatisation, it does nothing for tourists’ cultural sensitivities. Unfortunately I witnessed too many incidents of tourists disrespecting the Lobars and their culture. The Nepali are a resilient people and the Lobars have managed to defy outside inﬂuences for many centuries. I have every hope they will succeed but, if you want to see the Tiji in its original state, I would advise you to go soon.
Words and pictures by Dr Ted Collinson
For Fo F or m most off history, hi Anonymous was a woman. Anony An
- Vi Virginia Woolf
WRONG QUESTION … SHOP TILL HE DROPS A woman was in town on a shopping trip. She began her day ﬁnding the most perfect shoes in the ﬁrst shop and a beautiful dress on sale in the second. In the third, everything had just been reduced by 50 percent when her mobile phone rang. It was a female doctor notifying her that her husband had just been in a terrible car accident and was in critical condition and in the ICU. The woman told the doctor to inform her husband where she was and that she’d be there as soon as possible. As she hung up she realised she was leaving what was shaping up to be her best day ever in the boutiques. She decided to get in a couple of more shops before heading to the hospital. She ended up shopping the rest of the morning, ﬁnishing her trip with a cup of coffee and a beautiful chocolate cake slice, compliments of the last shop. She was jubilant.
A WOMAN BEARS IT ALL In this life, I’m a woman. In my next life, I’d like to come back as a bear. When you’re a bear, you get to hibernate. You do nothing but sleep for six months. I could deal with that. Before you hibernate, you’re supposed to eat yourself stupid. I could deal with that too. When you’re a girl bear, you birth your children (who are the size of walnuts) while you’re sleeping and wake to partially grown, cute cuddly cubs. I could deﬁnitely deal with that. If you’re a mama bear, everyone knows you mean business. You swat anyone who bothers your cubs. If your cubs get out of line, you swat them too. Everyone knows where they stand. You’re the boss, OK? If you’re a bear, your mate expects you to wake up growling. He expects that you will have hairy legs and excess body fat.
Then she remembered her husband. Feeling guilty, she dashed to the hospital.
Yep, gonna be a bear.
She saw the doctor in the corridor and asked about her husband’s condition. The lady doctor glared at her and shouted:
FAST AND FUNNY
‘You went ahead and ﬁnished your shopping trip didn’t you! I hope you’re proud of yourself! While you were out for the past four hours enjoying yourself in town, your husband has been languishing in the Intensive Care Unit! It’s just as well you went ahead and ﬁnished, because it will more than likely be the last shopping trip you ever take! For the rest of his life he will require round-the-clock care. And he will now be your career!’ The woman was feeling so guilty she broke down and sobbed. The lady doctor then chuckled and said, ‘I’m just pulling your leg. He’s dead. Show me what you bought.’
Mary, I’m just having one more beer with the lads. If I’m not home in 20 minutes, read this message again.
My name is Alice Smith and I was sitting in the waiting room for my ﬁrst appointment with a new dentist. I noticed his degree on the wall, which bore his full name. Suddenly, I remembered a tall, handsome, dark-haired boy with the same name had been in my secondary school class some 40-odd years ago. Could he be the same guy that I had a secret crush on, way back then? Upon seeing him, however, I quickly discarded any such thought. This balding, grey haired man with the deeply lined face was far too old to have been my classmate. After he examined my teeth, I asked him if he had attended Morgan Park Secondary School. “Yes, yes I did.” He beamed with pride. “When did you leave to go to university?” I asked. “1970. Why do you ask?” “You were in my class!” I exclaimed. He looked at me closely. Then the ugly, old, bald, wrinkled, fat-arsed, grey-haired, decrepit, bastard asked… “What subject did you teach?”
The Grim Reaper came for me last night, and I beat him off with a vacuum cleaner. Talk about Dyson with death. When I was in the pub I heard a couple of boozers saying that they wouldn’t feel safe on an aircraft if they knew the pilot were a woman. What a pair of sexists. I mean, it’s not as if she’d have to reverse the bloody thing! Local police hunting the ‘knitting needle nutter’, who has stabbed six people in the buttocks in the last 48 hours, believe the attacker could be following some kind of pattern.
If you have a joke you would like to share with colleagues, email email@example.com
Bought some rocket salad yesterday but it went off before I could eat it! A teddy bear is working on a building site. He goes for a tea break and when he returns he notices his pick has been stolen. The bear is angry and reports the theft to the foreman. The foreman grins at the bear and says “Oh, I forgot to tell you, today’s the day the teddy bears have their pick nicked.”
Rural Health West recognised the hard work of GPs and specialists who dedicate themselves to the care of people in rural and remote areas at their annual conference last month. [See Beneath the Drapes P33 for the Doctors’ Service Award winners]. The night also recognised those doctors who had spent the last 20 or 30 or more years providing health services to country communities. 20 or more years of service Dr Anthony Best, Busselton; Dr Erik Hagen RFDS; Dr Sharon Jackson, Denmark; Dr Alison Turner, Manjimup; Dr Olga Ward, RFDS, Dr Christine Jefferies-Stokes, Kalgoorlie; Dr Mark Smith, Bunbury; Dr Doreen Menezes, Geraldton
Rural Health West Awards
30 or more years of service Dr Raymond Clarke, Margaret River; Dr Michael Eaton, Dardanup; Dr Philip Green, Australind; Dr Clifton Parry, Mandurah; Dr Lorraine Smith, Bunbury; Dr Gerard Travers, Bunbury; Dr Antonio Tropiano, Mandurah; Dr Neil Wells, Bridgetown; Dr Gavan White, Bunbury; Dr Lee Ming Yap, Harvey; Dr Tom Cottee, Bunbury; Dr Charles Nadin, Bunbury 1 Ms Belinda Bailey and Ms Kelli Porter with seven medical students bound for rural locations. 2 Dr Mike Eaton and daughter Michaela 3 Pilbara docs Dr Kate Hill and Dr Gareth Taverner 4 Dr Suzie Grainger and Ms Belinda Bailey in front of a painting Suzie was inspired to create after a Karajini Retrieval Weekend. 5 Service Award Winners: Dr Mal Hodsdon, left, Prof John Boulton, Dr Randolf Spargo, Dr Philip Reid, the WA Governor, Ms Kerry Sanderson, Rural Health West Chair, Mr Grant Woodhams, Dr Andrew Jamieson and Dr Daniel O’Donnell.
5 Bethesda GP Education Night
Three surgeons who operate at Bethesda offered presentations of various aspects of fertility and women’s health to a group of about 50 GPs. Obstetrician/gynaecologists Dr Panos Maouris and Dr Tamara Hunter and general and bariatric surgeon A/Prof Sue Taylor included topics such as vasectomy reversals, fertility and pregnancy in overweight and obese women and laparoscopic surgery for endometriosis, adhesions and tubal blockage among others. 1 Dr Tamara Hunter and A/Prof Sue Taylor 2 Dr Georgina Pagey and Dr Jenny Hart 3 Dr Elena Ghergori and Dr Gerogina Pagey
1 MEDICAL FORUM
Strap in for the Fun Seasons Vivaldi’s Four Seasons come raining down on a droughtparched Perth audience in May.
The weather has been a topic of conversation for millennia: a chat over the fence between neighbours, the subject of every news bulletin and even heated debate in the parliaments of the world, everyone talks about the weather. For 400 years, the ‘Red Priest’, Antonio Vivaldi’s conversation over the weather has been played in school halls, concert halls and exam halls everywhere. This genius Venetian composer and teacher at a Venetian girls’ orphanage, created four concerti representing each season in all its colour, vivacity and purpose in our lives. The Four Seasons is perhaps the most loved and most-well known classical music suite of all time. But like a message in a bottle to be read by audiences down the ages, Vivaldi inserted pieces of his poetry above each season, giving us insight into his Venice of the early 18th century. Australia’s very own baroque specialist Paul Dyer, founder and artistic director of the immensely accomplished Australian Brandenburg Orchestra, will be heading to Perth next month (May 1-2), a little like a cyclone – such is the energy and enthusiasm of the man, to lead the WASO in a full-length rendition of Vivaldi’s masterpiece. His excitement for music making never seems to dim, and as he was speaking over the phone to Medical Forum, he bubbled with anticipation. Leading the symphony orchestra, a vastly different beast to his own baroque orchestra, was something to savour. w ““A symphony orchestra comes with its own sset of parameters and dynamics but what I’ve managed to do, from my previous conducting m encounters with WASO, is to work with a core e g group of players, so they know who I am and tthey know I’ll be a bit crazy. But they also know tthey can be free with me.” “ “The string players will stand for the performance, w which is quite a different experience for them but it’s also quite liberating.” b P Paul is also keen to work with one of the country’s up-and-coming violinists, Perthc born-and-based Shaun Lee Chen, who will b sshoulder much of the ﬁery soloist load.
th Pa ul Dyer at
“Shaun plays both modern and baroque violin, so he understands the demands of the instruments and the music. We want to bring something fresh to the Perth concert.” While the Four Seasons is perhaps one of the most recogniseable pieces of music, courtesy of its appropriation by every supermarket and lift owner in the world, Paul says because of its magnitude is not often played in its entirety. In his 25 years of immersion in baroque music, he’s only been involved in three full-length performances, including the recording on ABO’s ARIA-award winning album. “But that’s not to say I haven’t played separate seasons many times! But every time I play it, I discovers something amazing about the piece.” “When I was discussing an encore with ﬁrebrand 29-year-old Russian violinist Dimitry Sinkovsky last year, we thought of the last movement of Summer, which is notoriously fast and fun for the audience, but it was all a bit easy and predictable, so I suggested the ﬁrst movement of Winter and Dimitry leapt on the idea.” “He would turn it into a Siberian winter, he said. And that got me thinking about our individual experiences of the seasons and I rushed to talk to Shaun about this idea, sowing the seeds for him to examine his own responses to the seasons in Perth.” “Shaun is a keen cyclist, who experiences the seasons physically and intimately as he rides his bike. I want the audience to have a similar visceral experience when they listen to the music.” Also on the Perth program is Bach’s Orchestral Suite No. 4 and Rameau’s glorious Les Indes Galantes Suite. “Rameau and the French baroque are light years away from WASO’s symphonic language but it’s a sublime piece and I have enlarged the orchestra for it, so they will go crazy.” Be prepared, Perth, the crazy Dyer is back in town and in his words: “Music has to be fun.”
By Ms Jan Hallam
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!åNEWåWIZARDåANDåWHITEåWITCH å ALONGåWITHåAåFEWåOTHERåSPELLS åHAVEå BEENåCASTåFORåTHEåTHåANNIVERSARYå of Wicked.
Simon Gallaher burst onto our television screens as a young twentysomething piano man in 1982 with a show of his own and numerous guest appearances on others. He achieved the then-remarkable feat of making Gilbert & Sullivan cool when he transformed rocker Jon English into a pirate king and slipped on a pair of cabin-boy breeches himself to produce, direct and star in a critically acclaimed production of The Pirates of Penzance. They were the foundations of an enduring career on and off stage, which is set to continue from May 3 at Crown Theatre when he takes on the role of the Wizard in Wicked. But it hasn’t all been spotlight and applause and at one point in his career, Simon told Medical Forum, he was in danger of burn-out.
to put the understudy on. The mind can play funny tricks on you.” “My close friend Julie Anthony was a saviour at that time. She encouraged me to join her on a tour as a double act and the music, friendship and collaboration reawakened my joy in singing, playing the piano and performing.” “We toured the smaller towns like Esperance and Broome and because we weren’t young and busting to move on, we spent more time getting to know people and places. It was just what I needed.” Now 56, Simon said in the last couple of years, thoughts once again turned to retirement. In his words: “I was ready to sit down and eat good food, drink good wine and get fat.”
“I’d lost my nerve to be honest and there was a time a few years back when I just didn’t want to go on stage. In fact I was performing in Perth at His Majesty’s and I walked out on stage in a show I had done hundreds of times before, having no idea what my next line was.”
“That was until I was offered a couple of comedy roles in Hairspray and Spamalot (with Jon English) last year. I enjoyed myself so much that when a friend asked me what I was going to do with myself over the next ﬁve years, I verbalised the idea that I might like to reinvent myself as a musical theatre character actor.”
“I spent the whole show with my heart in my mouth anticipating lines and by the end of the night I was an absolute nervous wreck. I began
“Just 48-hours later John Frost rings up out of the blue offering the Wizard’s role in the 10th anniversary tour of Wicked. How could I say no?”
Wicked opens in Perth in May with not just a new wizard but also a new Glinda, the sparkling white witch. Perth-raised Suzie Mathers, who toured with the show throughout South-East Asia, replaces another Perth-born musical theatre star, Lucy Durack, in the role. Lucy is expecting her ﬁrst child. Coming to the role fresh, Simon says the Wizard is much more complex than the character we all know from the MGM ﬁlm.” “Wicked is a very clever show. It manages to weave its own story through the characters of Wizard of Oz and the result is so multidimensional. To be honest, it makes the movie look very ﬂat. Unlike Frank Morgan’s jolly old fellow in the movie, the musical’s wizard is much more complex, sinister and power hungry.” Before Simon hits the Crown Theatre, his Wicked debut in the 10th anniversary production kicks off in his home town of Brisbane – at the same time he directs a reprise of Pirates of Penzance to celebrate QPAC’s 30th anniversary. Leaving him to direct by day and perform by night. So much for retirement!
By Ms Jan Hallam
Entering Medical Forum’s competitions is easy!
Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).
COMP Movie: Boy Choir A troubled 11-year-old boy ﬁnds himself at a prestigious East Coast music school when his single monther dies. He clashes with the school’s demanding choir master (Dustin Hoffman), who sees the boy’s talent but struggles to ﬁnds ways to reach him. This inspiring drama co-stars Kathy Bates, Josh Lucas, Debra Winger and Glee’s Kevin McHale. In Cinemas, April 23
Kids Theatre: The 26-Storey Treehouse Andy Grifﬁths and Terry Denton’s best-selling book, The 26 Storey Treehouse, features his much-loved characters Andy and Terry, along with their friend Jill and the mysterious Hector Houtkop. And, of course, the since 2013 have been renovated to accommodate another 13 Storeys. And that means…more inventions – like the 78 ﬂavour ice-cream-dispensing robot and the brain bamboozling Maze of Doom (not to mention the self-inﬂating underpants). The 60-minute show is ideal for children between the ages of six and 11. Heath Ledger Theatre, May 12-17, 7.30pm. Medical Forum performance May 12 (family ticket for four)
Movie: Testament of Youth Testament of Youth is a powerful story of love, war and remembrance, based on the First World War memoir by Vera Brittain, which offers the rare perspective of that war from a woman’s point of view. A searing journey from youthful hopes to the brink of despair, it’s a ﬁlm about young love, the futility of war and how to make sense of the darkest times. You will also see some familiar faces in this one. In Cinemas April 23
Doctors Dozen Winner
Movie: Spanish Film Festival
The champagne corks have been popping in the Sowman household! With two 40th birthdays and a signiﬁcant wedding anniversary, the birth of a second child, Fellowship exams passed and the hanging of the shingle as an orthopaedic spinal surgeon, there’s plenty to celebrate in Dr Braad Sowman’s household. His father-in-law is Italian and still trying to perfect the perfect ‘red’ so pouring a glass or two of a Plantagenet Cabernet might provide some clues.
Winners from the February issue
Spanish-language ﬁlms from across Spain, LatinAmerica and beyond, feature in this year’s festival with something for everyone. From comic romances to foodie adventures and the passion of Latin dance, the sights, tastes and emotion come swirling onto the big screen. Full program details at www.lunapalace.com.au. Cinema Paradiso April 23-May 9
Music: Vivaldi’s Four Seasons Baroque specialist Paul Dyer leaves his own band, the Australian Brandenburg Orchestra, to head west to direct the WASO in Vivaldi’s iconic Four Seasons, with one of WA’s most virtuosic violinists Shaun Lee-Chen in the solo part. Also on the program is Bach’s Orchestra Suite No. 4 andRameau’s sumptuous Les Indes Galantes Suite. Dyer will direct the orchestra from the harpsichord. Perth Concert Hall, Friday, May 1, and Saturday, 2. Medical Forum performance Friday, May 1, 7.30pm
WA’s Rich Movie – Shaun the Sheep:å$Rå,INå#HAN å Medical Mix $Rå-ICHAELå,IGHT å$Rå.ICOLEå#OLE å$Rå#HRISTINEå -ARSACK å$Rå$AVIDå"RADFORD å$Rå*ULIAå+ERMODE å $Rå"ELINDAå,OWE å$Rå7EIå#HUA å$Rå*ESSICAå *OHNSON å$Rå,ISAå3URMAN Movie – The Interview: $Rå2IMIå2OPER å February 2015 $Rå"IBIANAå4IE å$Rå!NCYå*OHN å$Rå3IMONå&RENCH å $Rå-ICHAELå"RAY å$Rå7ENå,OONGå9EOW å$Rå"OEY ,ENGå,OY å ENG ,OY $Rå3ARAHå,ONGHORN å$Rå-ONICAå+EEL å$Rå$EVASISHå2OY Movie – Selma: $Rå(ELENAå$ONNELLY å$Rå4ESSAå9OUNG å$Rå#HRISTINEå,EE "AW å$Rå+ARENå-OLLER å$Rå"EVERLYå4HE å$Rå*OHNå4ERRY å$Rå-ICHAELå!RMSTRONG å $Rå#RYSTALå$URELL å$Rå0ETERå-ELVILL 3MITH å$Rå(ELENå-EAD Movie – The Second Best Marigold Hotel: $Rå%STHERå%U å$Rå)ANå3WINGLER å $Rå*OHNå7ILLIAMS å$Rå2ICå"ERGESIO å$Rå2UBYå#HAN å$Rå4UCKå#HIN å$Rå!NTONYå $AVIS å$Rå*ULIEå#OPEMAN å$Rå-ANDYå#ROFT å$Rå+EVINå+WAN #ONCERTånå$AVIDå(ELGFOTTåATå-UNDARINGå7EIRå(OTELå$Rå)ANå7OOD Theatre: Dinner: $Rå2USSELLå$ATE t )FBMJOH"SU,JNCFSMFZ,JET t *OOPWBUJPOT5SFOET t (1%VSFTT
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Theatre: Glengarry Glen Ross Kate Cherry leads a big boy cast in the Black Swan State Theatre Company’s production of the David Mamet classic about the art of making money and leaving your ethics and integrity at the door. Set in a Chicago real estate ofﬁce, characters slip and slide their way to their ﬁrst million while ensuring that their colleagues don’t. Witty, sharp and incisive, Glengarry Glen Ross is a modern masterpiece. Heath Ledger Theatre, May 23-June 14. Medical Forum performance, May 23
medical forum FOR LEASE
MURDOCH /FX8FYGPSE.FEJDBM$FOUSF â€“ St John of God Hospital 2 brand new medical consulting SPPNTBWBJMBCMF t TRNBOETRN t DBSCBZQFSUFOBODZ -FBTFPOFPSCPUISPPNT For further details contact James Teh 6OJWFSTBM3FBMUZ 0421 999 889 KBNFT!VOJWFSTBMSFBMUZDPNBV NEDLANDS Hollywood Medical Centre â€“ 2 Sessional Suites. Available with secretarial support if SFRVJSFE 1IPOF0414 780 751 CLAREMONT Rooms available on a sessional basis in a lovely, newly refurbished office in Claremont. Suitable for medical or allied health professionals. Has provision to do minor procedures. 8PVMEBMTPTVJUB1VCMJD)PTQJUBM%SXIP XJTIFTUPEPTPNFQSJWBUFXPSL 'PSGVSUIFSJOGPSNBUJPOQMFBTFDPOUBDU 1IPOF 9284 2900 &NBJMNBOBHFS!WJSDDPNBV NEDLANDS Medical Specialist Consulting Rooms and Treatment Room t 'VMMZTFSWJDFEDPOTVMUBUJPOSPPNTBU Hollywood Specialist Centre t 4FDSFUBSJBMTVQQPSUoIJHIMZFYQFSJFODFE long term staff t (FOJFTPMVUJPOTQSBDUJDFNBOBHFNFOU software t 0OMJOF.FEJDBSFDMBJNT t 5FMFIFBMUIDPOTVMUBUJPOGBDJMJUJFT t 1BQFSMFTTQSBDUJDFTVQQPSUFE t 5SFBUNFOUSPPNoBWBJMBCMFGPS ambulatory procedures t "DDFTTUP)PMMZXPPE1SJWBUF)PTQJUBM GPSJOQBUJFOUDBSFBOEUIFBUSFCPPLJOHT supported t *OQBUJFOUCJMMJOHTVQQPSUFE "OZFORVJSJFTDBOCFEJSFDUFEUP Mrs Rhonda Mazzulla, Practice Manager, 4VJUF Hollywood Specialist Centre 95 Monash Avenue /FEMBOET 8" 1IPOF 9389 1533 &NBJMTVJUFIPMMZXPPE!CJHQPOEDPN MURDOCH .FEJDBM$MJOJD4+0(.VSEPDI Specialist consulting sessions available. &NBJMDGPSE!DZMMFOFVXBFEVBV
MURDOCH 8FYGPSE.FEJDBM3PPNTGPSMFBTF 1MFBTFDPOUBDUBQUSBO!KPJOUTXFTUDPNBV MURDOCH /&88FYGPSE.FEJDBM$FOUSF Attached to the St John of God Hospital, in vicinity of the Fiona Stanley Hospital. Modern, newly fitted out medical consulting room. Sessional medical & dental rooms available. Please contact XFYGPSENFEJDBM!PVUMPPLDPNGPSNPSF information. MURDOCH Consulting room for lease at the new 8FYGPSE.FEJDBM$FOUSFBU.VSEPDI 8FMMMJU TQBDJPVTTFTTJPOBMDPOTVMUJOH rooms for lease. For further information please contact Murdoch Specialist Physicians on 9312 2166 or Email us at BENJO!NVSEPDITQFDJBMJTUQIZTJDJBOTDPNBV
FREMANTLE Sessional Room for rent in a Specialist Practice. Two rooms available, reception with waiting room. $BOCFVTFEPOBXFFLMZ GPSUOJHIUMZBOE monthly basis. Please contact Kylie (Practice Manager) on 9279 4333 or LZMJFND!XBWBTDVMBSDFOUSFDPNBVUP discuss the availability and session price NEDLANDS 3PPNTGPS-FBTF Hollywood Specialist Centre TRN GVMMZGVSOJTIFE &YDFMMFOUMPDBUJPOBEKBDFOUUP4$() $IJMESFOT)PTQJUBM)PMMZXPPE0XOFS will change layout to suit client 5 year lease negotiable Contact Dr Tim Cooper UJNDQS!HNBJMDPN PERTH CBD Medical room for rent in established Medical Practice in Perth CBD. Suitable for medical or allied health professionals. For more information contact Dale on 0414 455 783
FOR SALE BUNBURY Break Free! $FOUSBM#VOCVSZ 3BNTBZTU PQQPTJUF New SKG suites) Small dwelling with the potential PGPSNPSFDPOTVMUJOHSPPNTXJUI BNQMFQBSLJOH Disability accessible. #MPDLTRN 0GGFSTDJSDB Phone Jill 0414 972 116
BIBRA LAKE - Psychiatrist invited. Are you intending to start Private Practice? 5IJTJTBTIFFSXBMLJO Part time, sessional or full time - all FORVJSJFTXFMDPNF 'VSOJTIFEDPOTVMUJOHSPPNTBWBJMBCMFBU #JCSB-BLF4QFDJBMJTU$FOUSF "OOPJT 3PBE #JCSB-BLF8" Currently 4 practising Psychiatrists and clinic is open Tuesday to Friday 7-day pharmacy and GP surgery next door are added advantages. 5 minute drive to St John of God and upcoming Fiona Stanley hospital. Phone Navneet 9414 7860
RURAL POSITIONS VACANT ALBANY t4U$MBSFTJTBOFXGBNJMZQSBDUJDF based in Albany t 4NBMMGSJFOEMZQSBDUJDF t 'VMMUJNFOVSTJOHBOEBENJOJTUSBUJPO support t 1BUIPMPHZPOTJUF t 'VMMPSQBSUUJNF(1XBOUFEUPKPJO our team t 4QFDJBMJOUFSFTUJOTLJOXPVMECFJEFBM t $VSSFOUMZOP%84VOMFTTXJMMJOH UPXPSLJOBGUFSIPVSTQFSJPE t (1TOPUSFRVJSJOHTVQFSWJTJPOSFRVJSFE 1MFBTFDPOUBDU1SBDUJDF.BOBHFS 08 9841 8102 &NBJMBENJO!TUDMBSFDPNBV 0STFOEZPVS$7UISPVHIBOEXFXJMMHFU CBDLUPZPV
NORTH BEACH Close to the beach! 0QQPSUVOJUZGPSB15PS'5(1UPKPJOPVS privately-owned practice. Flexible hours and mixed billing. "OJOUFSFTUJOXPNFOTIFBMUIBO advantage. 0OTJUFQBUIPMPHZ QTZDIPMPHJTUBOEOVSTF support. Please contact Helen or David 9447 1233 to discuss or &NBJMSFDFQUJPOOCND!CJHQPOEDPN
CANNING VALE 3FRVJSFTBGVMMUJNFPS1BSUUJNF(1UPKPJO our privately owned, established practice of 18 years, to be busy from day one. t'MFYJCMFIPVST t$PNQVUFSJTFE 'VMMZFRVJQQFEBOE well-staffed t'VMMUJNFOVSTJOHTVQQPSU t8"(1&5BOE"(1"-BDDSFEJUFE t0VUFS.FUSPQPMJUBO"SFBBOE%84 t&YDFMMFOUSFNVOFSBUJPO 1MFBTFDPOUBDU%S.BSL1BMMPU %S,FO 8POH %S5FE,IJOTPFPS%S1BSBN Dhillon on 9456 0800 for a strictly confidential discussion, PS&NBJMQSBDNBO!SBONFEDPNBV PERTH NORTHERN SUBURBS 1FSNBOFOUQBSUUJNF(1XBOUFE Wangara Medical centre Busy practice, nursing staff, Best practice, pathology, podiatry and physiotherapy onsite -PUTPGQPUFOUJBM*UJTB%84BSFB 0488 222 238 DIJCJMJUJTN!ZBIPPDPN
URBAN POSITIONS VACANT
GREENWOOD Greenwood/Kingsley Family Practice The landscape of general practice is changing, and it is changing forever. Are you feeling demoralised by the recent Federal government proposal on changes to Medicare? %PZPVGFFMUIBUZPVIBWFUPLFFQCVML billing in order to retain patients? *UEPFTOUIBWFUPCFUIJTXBZ $PNFBOETQFBLUPVTBOETFFUIF different ways in which we operate our general practice. Be part of the game DIBOHFS 0VSQSBDUJDFJTMPDBUFEOPSUIPGUIFSJWFS 4PSSZXFBSFOPU%84 1MFBTFDPOUBDUTIFOZDIBP!IPUNBJMDPN or 0402 201 311 for a strictly confidential discussion.
Full-time and Part-Time VR GPs positions available for our well established Accredited, Privately owned, Friendly Family Practice in Bicton. The practice has a well-established patient base, and offers an exciting opportunity for an enthusiastic practitioner to join our practice, with potential to own. t 0OTJUFQBUIPMPHZBOE1SBDUJDF Nurse support, Radiology available across the road. t 6OJRVFNFOUPSJOHPQQPSUVOJUJFT available, and excellent support staff and facilities t 8FVTF#FTU1SBDUJDFTPGUXBSFBOE are mostly a Private Billing practice. t 73XJUIFYQFSJFODFJOXPNFOT IFBMUIQSFGFSSFE CVUOPUSFRVJSFE t -FBSONPSFBCPVUVTBU IUUQCJDUPONFEJDBMDMJOJDDPN t "MMBQQMJDBUJPOTDPOTJEFSFE Contact Dr. Sam Messina on 9339 1400 &NBJMTNFTT!JJOFUOFUBV
HELENA VALLEY (1'503153FRVJSFE Fully computerized and accredited modern practice with nursing and admin TVQQPSU8FMMFRVJQQFEUSFBUNFOUSPPN 0OTJUFQTZDIPMPHJTUT QPEJBUSJTUBOE pathology services available. Attractive remunerations and long term career opportunity. -PDBUFEJO)FMFOB7BMMFZ8" Email expression of interest to IFNDBEN!CJHQPOEOFUBV
MAY 2015 - next deadline 12md Monday 13th April â€“ Tel 9203 5222 or firstname.lastname@example.org
medical forum CANNINGTON Southside Medical Service is an accredited practice located in Cannington area. 8FBSFBGBNJMZQSBDUJDFBOEPGGFSNJYFE billings. 8FIBWFQPTJUJPOTGPSB(1UPKPJOPUIFS (1TDVSSFOUMZXPSLJOH It is a well-positioned practice, close to the Carousel Shopping Centre. 1IPOF9451 3488PS&NBJM SFDFQUJPO!TPVUITJEFNFEJDBMDPNBV PALMYRA 73EPDUPSSFRVJSFEGPSGVMMQBSUUJNFXPSL 8FBSFBGSJFOEMZ QSJWBUF OPODPSQ practice situated in Palmyra. 0VSTVSHFSZJTBDDSFEJUFEXJUINPEFSO facilities and has fantastic doctors, nurses & reception staff. *GZPVXPVMEMJLFUPKPJOVTQMFBTFFNBJM your CV to IFMFO!MFFVXJONFEJDBMDPNBV
CANNING VALE Rare Opportunity; Canning Vale Canning Vale Medical centre will have a SPPNBWBJMBCMFGSPN+BOVBSZGPSBO established VR doctor wanting to relocate their practice to new rooms and join our team. Full management services are provided by doctor owned practice operating for 15 years under the same management. Continuous accreditation, finalist for "(1"-QSBDUJDFPGUIFZFBSMBTUZFBS full nursing support, computerised with referees available for suitable candidate. Visit us at www.canningvalemedical.com.au $POGJEFOUJBMFORVJSFT Dr Neda Meshgin 0414 641 963 or ESNFTIHJO!DBOOJOHWBMFNFEJDBMDPN
-BOHGPSE.FEJDBM$FOUSFOPXIBTBO opening for t '5 #VML#JMMJOH(1DPNNFODJOH +VOF t '515GFNBMF(1PS(1XJUIBOJOUFSFTU JO8PNFOT)FBMUIDPNNFODJOH"4"1 t %STXIPXPVMEMJLFUPXPSLXFFLFOE sessions. t %84 t $MPTFUP1FSUI t 'VMMQBUJFOUMJTUXBJUJOH t )VHFEFNBOEGPS8PNFOT)FBMUI services t QBZXFFLEBZT This is truly a lovely multicultural Family Practice treating the full range of conditions over a range of demographics. $POGJEFOUJBMFORVJSJFTUP1.3JUB NBOBHFS!MBOHGPSENFEJDBMDPNBVPS 9451 1377
GOSNELLS Ashburton Surgery. &TUBCMJTIFE VR GP needed full time or part time. Fully Accredited. Private billing. PGCJMMJOHT 'VMMZFRVJQQFEXJUIOVSTFTVQQPSU &NBJMBOHJFTVSHFSZ!HNBJMDPNPS 1IPOF"OHJF 0422 496 594 MANDURAH (1SFRVJSFEGPSBDDSFEJUFE FTUBCMJTIFE friendly practice with FT RN support with BTQFDJBMJOUFSFTUJOTLJODBODFSNFEJDJOF $PBTUBMMJGFTUZMFPOMZNJOVUFTGSPN Perth. Contact NBJM!NPEFSONFEJDBMDMJOJDTDPNBV YANCHEP /PSUIPG3JWFS %84"SFB
&YQFSJFODFE'5(1SFRVJSFE Busy computerised practice Nurse and Admin support &BSOVQUPPGCJMMJOHT Flexible hours Non VR welcome to apply &ORVJSJFTUP1IJMQIJMCD!HNBJMDPN
VR GP Required for practice only 7 months old, located in an ASGC-R2 location east of Perth. This brand new practice is the perfect PQQPSUVOJUZGPSB(1UPXPSLJOUIF inner regional area of Perth located approximately 45 mins from the CBD. This large community with no current TFSWJDJOH(1TJTMPDBUFEOFYUEPPSUPB busy pharmacy and can accommodate 2 GVMMUJNF(1T Admin and nursing services are provided along with onsite pathology and podiatrist. Relocation incentive may apply to this location. For more information please call 0419 959 246 or BENJO!QQEHSPVQDPNBV Infinitive Health â€“ KWINANA Opening late April 2015 Full time GP for a family owned noncorporate medical centre. &OKPZXPSLJOHXJUIUIF$MJOJDBM Psychologist, Physiotherapist, Chiropractor, Nutritionist and Podiatrist in our patient based Centre. Call Kirsty on 0422 606 839 or &NBJMLJSTUFWFDFBSOT!HNBJMDPN
LEEDERVILLE (1GPSB(FOFSBM1SBDUJDFJO-FFEFSWJMMF Conditions negotiable. $PSSFTQPOEFODFJODPOGJEFODF QETWE!HNBJMDPN NEDLANDS 6OJRVF0QQPSUVOJUZ 8"4FYVBM)FBMUI$FOUSFSFRVJSFTBQBSU UJNF%PDUPSGPSoTFTTJPOTQFSXFFL days flexible. Founded by Dr Denis Cherry the Clinic is 8"TQSFNJFSFTFYVBMIFBMUIDMJOJDBOEUIF opportunity is available due to continued growth. Position covers all aspects of functional male sexual health along with preventive health measures. This is a most rewarding role for a Doctor wishing to engage with patients in a IPMJTUJDQBUJFOUQBSUOFSBQQSPBDI Full training provided. For more information please call Dr David Millar on 08 9389 1400 and through our XFCTJUFXXXXBTFYVBMIFBMUIDFOUSF com.au
NORTH PERTH 7JFX4USFFU.FEJDBMSFRVJSFTB (1'5PS15 8FBSFBTNBMM QSJWBUFMZPXOFE practice with a well-established patient base, computerised & accredited with nurse support. Ring Helen 9227 0170
BERTRAM 4PVUIPG3JWFS %84"SFB
&YQFSJFODFE'5(1SFRVJSFE Busy computerised practice Nurse and Admin support &BSOVQUPPGCJMMJOHT Flexible hours Non VR welcome to apply &ORVJSJFTUP1IJMQIJMCD!HNBJMDPN HAMILTON HILL "(1SFRVJSFEGPSBDMJOJDJOB%84BOE "0/BSFBNJOVUFTESJWFGSPN'SFNBOUMF %PDUPS(11SBDUJDF Part time or Full time doctor considered. Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or 4FOE$7UPBENJO! hamiltonhillfamilypractice.com.au
Fantastic opportunity. A modern state-of-the-art, paperless clinic. QSJWBUFCJMMJOH Flexible hours & your choice of patient case load, treat the patients you want. Email resume & cover letter to LN!LJOHTMFZNFEJDBMDPNBV XXXLJOHTMFZNFEJDBMDPNBV
OSBORNE PARK 0TCPSOF$JUZ.FEJDBM$FOUSF 3FRVJSFBGFNBMF(1 Flexible Mon to Fri hours. (after hours optional) Excellent remuneration. Modern, predominantly private billing practice. Fully computerised. Please contact Michael on 0403 927 934 &NBJM%S%JBOOF1SJPS EJBOOF!EVODSBJHNFEJDBMDFOUSFDPNBV
85 CANNING VALE (SFBU0QQPSUVOJUZGPSQBSUUJNFPSGVMM time VR GPs. Modern, new â€œQueensgate Medical Centreâ€? opening in Canning Vale 'FCSVBSZ PQQPTJUF-JWJOHTUPO shops in busy location. Privately owned, 29 years of experience in the area. 0VUFS.FUSP(SBOUNBZBQQMZJGFMJHJCMF 'MFYJCMFXPSLJOHIPVST OVSTFTVQQPSU GSJFOEMZXPSLJOHFOWJSPONFOU 'PSGVSUIFSJOGPSNBUJPOQMFBTFDPOUBDU Dr Karen Majda LBSFONBKEB!HNBJMDPNPS %S3JDIB4JOHISJDIB@T!IPUNBJMDPN KARDINYA Non-corporate General Practice presents BOFYDJUJOHPQQPSUVOJUZGPS7315.BMF GP to join our exceptional team. 8FMMNBOBHFEMPOHFTUBCMJTIFEEPDUPS practice with comprehensive CDM program. This is an excellent income opportunity for a male GP who wants to be busy and XPSLBTQBSUPGIBQQZBOEXFMMFTUBCMJTIFE team. &ORVJSJFTUP1SBDUJDF.BOBHFSPO 0419 959 246 or &NBJMQSBDUJDFNBOBHFS!LFMTPNHDPNBV MADELEY VR & Non VR General Medical 1SBDUJUJPOFSTSFRVJSFEGPS)JHIMBOE Medical Madeley which is located in a %JTUSJDUPG8PSLQMBDF4IPSUBHF Highland Medical Madeley is a new non corporate practice with 2 female & 1 male General Practitioners. Sessions and leave negotiable, salary is DPNQJMFEGSPNCJMMJOHTSBUIFSUIBOUBLJOHT 6QUPPGCJMMJOHTQBJE EFQFOEBOUPO experience). 1MFBTFDPOUBDU+BDLZPO 0488 500 153 or &NBJMUPKBDLZTUFWFO!MJWFDPVL DAWESVILLE 4PVUIPG3JWFS %84"SFB
&YQFSJFODFE'5(1SFRVJSFE Busy computerised practice, mixed billing Nurse and Admin support &BSOVQUPPGCJMMJOHT Flexible hours &ORVJSJFTUP7JTIOVH@WJOV!ZBIPPDPN
BUTLER Connolly Drive Medical Centre 73(1SFRVJSFEGPSUIJTWFSZOFX TUBUF of the art, fully computerised, absolutely paperless, spacious medical centre. 'VMMZFRVJQQFEQSPDFEVSFSPPNTBOE casualty, well-furnished consult rooms, pathology, allied health, RN support. "CVOEBOUQBUJFOUT %84 non-corporate. Generous remuneration. $POGJEFOUJBMFORVJSJFT %S,FO+POFTPO 9562 2599 5JOB NBOBHFS PO 9562 2500 &NBJMLFO!DENFEJDBMDPNBV
MAY 2015 - next deadline 12md Monday 13th April â€“ Tel 9203 5222 or email@example.com
medical forum KARRINYUP
St Luke Karrinyup Medical Centre Great opportunity in a State of art DMJOJD JOOFSNFUSP /PSNBMBGUFSIPVST Nursing support, Pathology and Allied services on site. Privately owned. Generous remuneration. 1MFBTFDBMM%S5BLMB0439 952 979
SORRENTO GP for busy Sorrento Medical centre. /PSNBMBGUFSIPVST 8FBSFMJLFGBNJMZ FT nurse, good remuneration. Please call 0439 952 979
GP with a passion for preventative medicine to join our boutique practice with a like-minded team of Health professionals. "SFZPVMPPLJOHGPSEPDUPSTGPSZPVS medical practice? Australian Medical Visas is owned and SVOCZ1SBDUJDF.BOBHFSTCBTFEJO8" XIPIBWFPWFSZFBSTFYQFSJFODFPGUIF 6,BOE"VTUSBMJBOIFBMUIDBSFTZTUFNT 8FDVSSFOUMZIBWFBOVNCFSPGEPDUPST XIPBSFMPPLJOHGPSQPTJUJPOTJO"VTUSBMJB 8FBSFBCMFUPBTTJTUQSBDUJDFTXJUI BMMQBQFSXPSLJOWPMWFEJODMVEJOHUIF NJHSBUJPOQSPDFTT JGSFRVJSFE Please visit our website www. australianmedicalvisas.com.au or contact +BDLZPO 0488 500 153 or Andrea on 0401 371 341
Â˜ Leading Preventive Health Clinic Â˜ Non-corporate state of the art practice in West Perth Â˜ Monday â€“ Friday, various hours of work: no after hours or on call Â˜ Exclusive clientele, excellent work environment Â˜ Excellent PC/Mac knowledge desirable as we operate a leading edge software package Please contact General Manager on firstname.lastname@example.org or (08) 6181 3590
Mandurah DWS VR general practitioner required for busy general practice in Mandurah, near Peel Health Campus.
SPECIALISTS ARE YOU LOOKING FOR SPACE IN BUSSELTON? Expressions of interest sought Convenient location Projected completion date early 2016 Both tenancy and sessional options available
Accessible via public transport and just a few minutes off Kwinana Freeway. Private mixed billing group practice providing quality comprehensive family care for over 50 years to Mandurah and the surrounding community. Our team features primary health physicians, specialists and allied health professionals. Treatment room facilities, procedure room, skin clinic, travel clinic, practice nurses, reception, medical secretary, accounts, administration staff are here to support you. Specialist, allied health services, pharmacy co-located in the same building. The practice is open 7 days a week. DWS. To apply please email: email@example.com
Produced right here in Western Australia!
Please contact for a conďŹ dential discussion firstname.lastname@example.org Full Colour Personalised Practice Newsletter
Southern Suburbs GP required for after-hours & weekends Non-VR Drâ€™s encouraged to apply. Send applications to email@example.com
-RLQRYHUVDWLVÂżHG PHGLFDOSUDFWLFHVDFURVV $XVWUDOLDZKRSURYLGHHealth NewsDVDYDOXDEOHSDWLHQW VHUYLFHLQWKHLUSUDFWLFH ,WDVVLVWVZLWKDFFUHGLWDWLRQDQG ZHGRDOOWKHZRUNIRU\RX9HU\ UHDVRQDEO\SULFHGDQGDFree Trial OfferIRUWKRVHVWDUWLQJRXW6LPSO\ SKRQH-HQQ\ on 9203 5599.
MAY 2015 - next deadline 12md Monday 13th April â€“ Tel 9203 5222 or firstname.lastname@example.org
GP Opportunities Available Now %VFUPDPOUJOVFEHSPXUI *1/JTDVSSFOUMZMPPLJOHGPS(1TGPS PQQPSUVOJUJFTXJUIJOTFWFSBMPGPVS8".FEJDBM$FOUSFT Non-DWS Positions
q,JOHTMFZ8PPEWBMF.FEJDBM$FOUSF q4VCJBDP4UBUJPO.FEJDBM(SPVQ q:PSL(FOFSBM1SBDUJDF q(BSEFO$JUZ.FEJDBM$FOUSF q/PSBOEB.FEJDBM$FOUSF DWS Positions
q#FFDICPSP'BNJMZ1SBDUJDF q8FMMBSE'BNJMZ1SBDUJDF q+VSJFO#BZ(FOFSBM1SBDUJDF q,JOHTXBZ.FEJDBM$FOUSF For all confidential enquiries please contact Tony Kimber on 0467 804 050 or Tony.Kimber@ipn.com.au
ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? Apollo Health Cockburn Opening late March 2015 Apollo p Health is opening p in Cockburn so adding to itss aalready lrea lr e dy established Armadale, Cannington and Joondalu Joondalup practices. Th his new practice iis within DWS area. This Op pportunity exists fo Opportunity for doctors to become fo oundati tion ti on members membe beers bers rs of our dynamic team. foundation If interested, we would love to hear from you. 7RDUUDQJHDFRQÂžGHQWLD 7RDUUDQJHDFRQÂžGHQWLDOFKDWZLWKRXUPHGLFDO GLUH GL UHFWRUSOHDVHHPDLOR GLUHFWRUSOHDVHHPDLORIÂžFH#DSROORKHDOWKEL]
As WAâ€™s only specialised medical business broker we have helped many buyers ďŹ nd medical practices that match their experience. You wonâ€™t have to go through the onerous process of trying to ďŹ nd someone interested in selling. Youâ€™ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision. Weâ€™ll take care of all the bits and pieces and youâ€™ll beneďŹ t from our experience to ensure a smooth transition.
To ďŹ nd a practice that meets your needs, call:
Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au
LOCUMS LOOKING FOR SOMETHING DIFFERENT - DISCOVER WA Ĺ”Excellent private remuneration Ĺ”(FSBMEUPO ENT Specialists with FRACS required. (New graduates very welcome) We have run a visiting country ENT service for the past 8 years and we have clinics ready to be seen and lists ready to be operated on. There will be the opportunity to do both public and private lists. We will supply you with ENT instruments and a ďŹ‚exinasopharyngoscope. We will arrange the booking for your consulting and lists get all the referrals in, do the billing/typing/keep the records and ensure follow-up/ongoing care. You will need your headlight and a laptop, specialist registration, provider and prescriber numbers, indemnity insurance for private work and you will need to be registered for GST. We will take the legwork out of it for you and provide you with all the relevant accreditation paperwork. We will pay for return airfares within Australia and arrange and fund your airfare from Perth to Geraldton and your accommodation. To help you make the most of your trip to Geraldton, and to make it as enjoyable as possible, we also include free kite surďŹ ng lessons. Let us know your interest and availability and we will explain what we can arrange for you.
For more information on this exceptional opportunity to boost your revenue, please contact Tracy Heywood, Practice Manager, on 9382 4800. www.facialplastics.com.au
WOMENâ€™S HEALTH GP Ĺ”MonaLisaTouch (www.monalisatouch.com.au) Ĺ”Potential for substantial remuneration Ĺ”Prominent Practice in Subiaco
MonaLisaTouch An opportunity now exists for a self motivated GP with an interest in womenâ€™s health and to be trained in a minimally invasive Laser procedure for menopausal women. You may have seen this procedure advertised recently on Today Tonight or Current Affair. About the Practice & Facilities Academy Facial Plastics & Laser Specialist offers a range of cosmetic surgery, liposculpture, vaginal rejuvenation, wrinkle relaxers & dermal ďŹ llers, skin tightening, tattoo removal, Cool sculpting, IPL, peels & much more. We have a government licensed day twilight sedation hospital on-site. Our Practice is open 5 days a week, including 3 late nights, and is open alternate Saturday mornings. Culture To ďŹ t into the culture of our innovative practice you must be a team player with a positive, proactive attitude. We supply an aesthetically pleasing environment, top of the range equipment and resources & a supportive team that excels in customer service! QualiďŹ cations FRACGP Record of ongoing professional development Registration Indemnity insurance
For more information on this exceptional opportunity to boost your revenue, please contact Tracy Heywood, Practice Manager, on 9382 4800. www.facialplastics.com.au
ARE YOU READY FOR A CHANGE? We are looking for specialists and GPâ€™s to join the expanding team! Tenancy and room options available for specialistâ€™s. 3URFHGXUDO*3ÂśVDQGRIÂžFHEDVHG*3ÂśVZHOOFDWHUHGIRU Contact Dr Brenda Murrison for more details!
9791 8133 or 0418 921 073
Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. GVMMUJNFQBSUUJNFTFTTJPOBM * medical systems and secretarial support * adjacent to Fiona Stanley Hospital More information phone: 9366 1802 or email: email@example.com
So relax, knowing the low dose technologies used in SKG x-rays and other diagnostic examinations ensure that you receive the smallest possible dose of radiation. Scan the code or visit thetruthbehindxrays.com.au to discover more.
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