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E-POLL & EVENTS
10 Celebrity Spotlight:
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for Children 31 Duchenne MD
NEWS & VIEWS
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6 Editorial: â€˜Yes Ministerâ€™ 8 Hero of Our Times 12 Have You Heard? 20 No Room for
Bad Behaviour 22 Kidsâ€™ Pain Unit
CLINICAL FOCUS 3 Antinuclear
Antibodies: Old Test Through a New Lens 7 Congenital â€˜Holeyâ€™
Hearts: Atrial Septal Defect %S-VJHJ%0STPHOB
32 Parent Queries
Risky Business 26 Childrenâ€™s Complaints .T.JDIFMMF4DPUU
37 Nutritional therapy
40 Obstructive Sleep 1SPG)BSWFZ$PBUFT
LIFESTYLE 42 Alan Charters Prize .S1FUFS.D$MFMMBOE
44 Kitchen Confidential (SBOU(SFZMJOHGSPN +BNJFT*UBMJBO
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45 Wine Review:
29 Poor Bear the Brunt
Cape Grace Wines
33 Leading the Herd
46 John Howard:
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39 Mental Tune-up Online
27 Empowering Kids
Next rum D Doctoraskfast Bre
36 Referred Leg Pain
38 Health InfoNet Review
21 Bonded to the Bush
26 Growing Up is
38 Action Can
35 Clostridium difficile
40 Beneath the Drapes
25 Question of Equality
28 Investing in Property
18 Doctors Drum
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Shrine to Winton 47 Conversations
with Ghosts 48 Funny Side 49 Competitions
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MEDICAL FORUM MAGAZINE 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email firstname.lastname@example.org www.mforum.com.au
ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury email@example.com (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam firstname.lastname@example.org (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) email@example.com Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) firstname.lastname@example.org Journalist Mr Peter McClelland email@example.com EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward
IMGs need support Dear Editor, I was enjoying reading Staying On: Choosing Rural Medicine [May] and praising the efforts of those who go remote until I got to the part that said: “As a colleague in Broome said, 'there are doctors who do medicine to get out of their country’. It's used as a platform to emigrate." As someone who appreciates the stress and sacrifices IMGs make to migrate, especially those from war-torn areas, these comments definitely do not motivate. No one can know in six years, which is the average time to graduate from medical school, what the situation will be and start planning from the outset to emigrate. Leaving your country and loved ones is never an easy decision. It takes about $30,000-$50,000 to migrate and settle – all before your first pay cheque comes in, that in itself is stressful, not to mention the pressure of exams etc. Until there is a way of measuring commitment and reasons for studying medicine, I would say let doctors be supportive of their colleagues. Many IMGs I know are actually stressed and demotivated because of the attitude of some so-called supervisors. I urge doctors to support each other, especially the junior ones and especially the IMGs, some of whom are refugees fleeing war. I respect their efforts and understand that coming to this wonderful country of ours is never that easy.
Name and address supplied
SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reﬂect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemniﬁes the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN 2 Thinking Hats
Joke A physician says these are actual comments made by his patients (predominately male) while he was performing their colonoscopies: 1. “Take it easy doc; you're boldly going where no man has gone before!” 2. “Find Harold Holt yet?” 3. “Can you hear me NOW?” 4. “Are we there yet? Are we there yet? Are we there yet?” 5. “You know in Tasmania we're now legally married.” 6. “Any sign of the trapped miners, chief?” 7. “You put your left hand in; you take your left hand out ...” 8. “Hey! Now I know how a Muppet feels!” 9. “If your hand doesn't fit, you must quit!” 10. “Hey doc, let me know if you find my dignity.” 11. “You used to be an executive at James Hardie, didn't you?” And the best one of them all ... 12. “Could you write a note for my wife saying that my head is in fact not up there?”
Laughter the best medicine Dear Editor, Re: Make Yourself Right at Home – loved it! Thank you to anonymous columnist who no doubt brought a smile to the face of all who read it. On a busy day in a busy practice, you just gotta keep your sense of humour alive! We all see some fantastic things in the course of our jobs, but when someone writes it down from such a tongue in cheek perspective, it sort of adds weight to the insight. A daily challenge for a Practice Manager is ensuring high staff morale in a busy and, at times, stressful work place. A laugh on the job is a sure-fire indicator of good staff morale.
Ms Jane Reid, President AAPM (WA) www.aapm.org.au/events.aspx ED. We had a lot of feedback about our anonymous correspondent’s funny, sharp insights. One wrote: “We often discuss in the rooms that we think there should be a page for extraordinary things that happen in the rooms ... for instance: t 1BUJFOUCPPLFEGPSJOJUJBMDPOTVMUXJUIB1BJO Medicine consultant. Rings day of consultation to say they have another engagement so will be sending a friend instead that “knows all about my back pain” t .ZDIJMEJTIBWJOHBOBOBFTUIFUJD XIFO I come for the pre-op do I need bring him XJUINF t )VTCBOEBOEXJGFIBWFBQSPDFEVSFPOUIF same day. They each receive a gap invoice from the anaesthetist. Husband rings... “Why do we have to pay two gaps – we XFSFJOUIFBUSFPOFBGUFSUIFPUIFS And the list goes on... Another wrote: “Spot on! You might also include revealing the presence of: t BTFDPOEPSUIJSEDPOEJUJPO PGXIJDIUIF doctor has absolutely no knowledge) t BWBSJFUZPGOFXTZNQUPNT JOTQJUFPGUIF Dr conducting a system review and search the relevant negatives) 85% of the way through the consultation.
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Antinuclear antibodies: an old test through a new lens Almost 60 years ago, we discovered that patients with systemic lupus erythematosus (SLE) had a factor in their serum that bound human cell nuclei and was therefore called â€˜antinuclear antibodyâ€™ (ANA). We now know ANAs represent an array of different antibodies that bind a number of possible proteins within cells, such as SSA or double stranded DNA. However, ANA screening is still based on microscope visualisation of this binding, using a technique called indirect immunofluorescence.
Improving ANA testing The patientâ€™s serum is incubated on a type of clonal cancer cells with large nuclei, washed and fluorescence-tagged antiimmunoglobulin G antibodies are added, revealing the patterns of cell-bound ANA. Despite newer alternative measuring methods, indirect immunofluorescence remains the gold standard for ANA testing. However, visual readings raise the possibility of inter-observer variability, for which precision and accuracy in testing is assured by having two independent assay readers, and vigorous and constant quality assurance measures. Long hours in a dark room examining patterns of green fluorescence can be a physically demanding aspect of ANA testing for laboratory scientists. One exciting innovation in laboratory immunology is image capture and recognition software that now enables some automation. Clinipath Pathology uses Image NavigatorTM, an automated microscope that captures images of autoantibody immunofluorescence slides and separates the images into controls and possible positives and negatives for presentation as digital images. Laboratory staff can then screen out negative samples more efficiently and assign to positives the patterns of binding for specific autoantibodies (e.g. SSA, Smith, RNP), each with more specific disease associations.
A recent study compared Image NavigatorTM to conventional fluorescent microscopy for over 3000 ANA tests in three major laboratories in the United States and Europe; overall agreement between the two methods was 98.7%, with improved reproducibility of ANA results between readers and from run-to-run for the same individual(1). The system reduces repetitive aspects of tests that have low complexity, while still allowing higher determinations by the human eye and brain (both still far superior to technology for complex pattern recognition).
Clinical context important While new technology can improve the sensitivity and reproducibility of ANA testing, the well-established limitations in the specificity of ANA testing are worth reiterating. There are around 150 different nuclear antigens that bind ANAs, however, only a minority are well characterised and have established disease associations. The remaining antigen-antibody reactions may not be clinically relevant. A recent US study aimed to determine the clinical utility of ANA testing in a â€œreal worldâ€? setting, where tests were generated by a heterogeneous group of medical providers and laboratories and 232 patients with positive ANA were referred to a specialist service(2). The positive predictive value of an ANA result in this particular cohort was only 2.1% for SLE and 9.1% for any ANA-associated systemic disease (Sjogrens disease, Mixed Connective Tissue disease and Scleroderma spectrum disorders). No disease was identified in patients with an ANA<1:160.
Dr Mina John, Clinical Immunologist & Immunopathologist
associated connective tissue diseases less likely. Multiple studies show low titre ANA is prevalent in some common organ-specific disorders such as autoimmune thyroid disease or celiac disease, and even in the general healthy adult and pediatric populations. A high rate of low-titre positive ANAs means that where the clinical probability of a particular disease is very low, a positive test does not strongly predict disease. In fact, inappropriate ANA testing and the consequent low titre false-positives can lead to unnecessary follow-up testing, patient anxiety, and inappropriate treatment. Only presentations with at least a moderate suspicion of an ANA-associated disease should prompt testing. If a pathogenic antibody is indeed present in such patients, a contemporary immunology laboratory is unlikely to miss it. If patients are selected appropriately, it remains an extremely useful way to exclude or suggest potentially progressive systemic autoimmune diseases, which require specific management. References 1. E.S. Hoy, B. Stoeck. Automated fluorescent microscopy shows strong correlation with conventional reading of antinuclear antibody tests. Kenes CORA, April 26. BCTUSBDU 2. Aryeh M. Abeles, Micha Abeles. 5IF$MJOJDBM6UJMJUZPGB1PTJUJWF Antinuclear Antibody Test Result. The American Journal of Medicine 2013, 126
However, the most common reason for an ANA in this study was diffuse body pain, and most of these patients were subsequently diagnosed with fibromyalgia on clinical grounds. Other common reasons for testing were unilateral knee pain, chronic lower back pain, and unilateral hip pain, all presentations that make ANA-
Patriarchy the problem Dear Editor, I was interested in reading Talk About a Revolution [July] and would like to suggest that a Minister for Menâ€™s Interests in not the answer. The male-led White Ribbon Day Campaign held a recent conference, (MPCBMUP-PDBM1SFWFOUJOH Menâ€™s Violence Against Women, focusing attention on what is a shattering issue in our society that results in devastating costs to individuals, communities and the nation. Alarming statistics show that nearly one in three women experience physical violence and one in five women experience sexualized violence over their lifetime (ABS, 2006). WA Police attended 44,000 violence in the home calls in 2012 (WA Police, 2013). It is the single biggest health risk to women aged between 15-44 years (Access Economics, 2004). However, we also know that violence against women and children is highly under-reported. The World Health Organisation recent report, Global and Regional estimates of violence against women: prevalence and health effects of intimate partner violence BOEOPOQBSUOFSTFYVBMWJPMFODF , highlights the importance of challenging social norms that support male authority and control over women and sanction or condone violence against women; reducing
levels of childhood exposure to violence; reforming discriminatory family law; strengthening womenâ€™s economic and legal rights. The underlying cause of domestic and family violence is the use of power and control to intentionally harm a victim by a perpetrator. In over 90% of cases the victim is female and the perpetrator male. Anger management programs fail to address the deliberate and systematic use of abuse and violence that underpins domestic and family violence The Womenâ€™s Council for Domestic and Family Violence Services is keen to forge links with progressive menâ€™s groups who take a proactive role in working with and challenging other men to change violencesupportive attitudes and behaviours (towards each other, and in particular, towards women and children). The challenge ahead is to dismantle the oppressive patriarchal structures and systems that allow violence against women and children to continue.
Angela Hartwig, CEO Womenâ€™s Council
Mentally ill need community support Dear Editor, RE: .BLJOH.FOUBM)FBMUIB1SJPSJUZ [July], I agree with Professor Allan Felsâ€™ comments, particularly those regarding the immense contribution families and carers make to the lives of people living with mental illness.
The Commission is progressively building home- and community-based supports, in addition to essential hospital and clinical services, so that people with mental illness are better supported to live a contributing and enjoyable life. This starts with recognising the importance of stable and affordable accommodation, which is often lost when a person becomes unwell and experiences an extended hospital admission. Accommodation options are being developed with packages of care and support to help people stay well and/or re-enter the community. Step-up/step-down options are available to manage transient periods when support needs are fluctuating. The new Joondalup sub-acute service is a good example of this. Improving mental health outcomes also means building on the crucial role GPs play in holistic healthcare and the destigmatisation of mental illness. Professor Fels says there is an acute shortage of resources and his analysis has been backed up by the Stokes Review here in WA. It is imperative that there is stronger support for families and carers, improved coordination of service delivery and better connection between the states and the commonwealth so that every mental health dollar is maximised. Eddie Bartnik, WA Mental Health Commissioner
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A Dog Chasing its own Tail
s journalists go, I’d be the first to admit I’m no blue heeler; more the friendly spaniel kind, ever optimistic that my patient persistence will be rewarded with a great story. I still believe you catch more flies with sugar than you do with vinegar. Many would disagree and lately I’m inclined to review my position. The main case in point is my persistent but totally unsuccessful attempts (emails began at 4.11pm on February 27, interspersed with hopeful phone calls) to have the Health Minister comment on queries we raised in letters he and his Chief of Staff sent to obstetrician Dr Marcus Rumpus in June last year. You may need reminding after all this time. Here’s the gist: It was all about reproductive services at the new Midland public hospital, for which the Health Minister chose St John of God Health Care as administrators, knowing certain services wouldn’t be offered because of SJGHC’s religious codes of practice. Medical Forum had heard from concerned medicos whose very reasonable questions were, if not SJGHC at the public hospital, what services, where and by whom?
Dr Hames to Dr Rumpus: “There is a very small number of procedures that SJGHC is unable to deliver including contraception, termination and sterilisation […] The required procedures that cannot be delivered by SJGHC will be delivered by other service providers on the MHC site. Planning for the best delivery model is currently in progress.” Dr Hames’ CoS repeated the statement in another letter a couple of months later. To give credit where it’s due, SJGHC has never shrunk from talking to us. Both CEO Dr Michael Stanford and Midland’s Director of Medical Services Dr Allan Pelkowitz, have willingly commented but not divulged specific details. However, perhaps unintentionally, Allan set the cat among the pigeons with his statement in the April edition of Medical Forum when he said “Patients will not be disadvantaged in any way because the State has already committed to fund the reproductive servicess we will not provide, in other facilities in the Midland area.”
of Houdini (“caretaker conventions hamper our ability to seek advice”); after the election, a settling-in period for the change of media adviser; then days of ambulance ramping and general mayhem (“busier week than expected, sorry”); and away sick, flu, sorry. It did go on longer but even I’m getting bored telling the story. At last, July 10, a short statement bounces into the inbox. “The Department of Health is continuing to investigate the best delivery model for those services that cannot be provided by SJGHC as a Catholic Health Care provider.” Specifically, what services? Those we highlighted? And where? I’m sure a blue heeler would know what to do. O
By Ms Jan Hallam
4DBOUIF23 with yyour mobile device for the Midland Health Campus story
You can see the Minister’s dilemma, can’t you? Now consider mine within this snapshot of ministerial media dealings: During the election campaign the “caretaker” line was used with the deftness
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Congenital 'holey' hearts: Atrial Septal Defect Atrial septal defect (ASD) accounts for about 10% of congenital heart disease. The three types, in order of frequency, are Secundum, Ostium primum and Sinus Venosus ASDs (see Fig 1). ASDs cause left to right shunting at an atrial level, resulting in right atrial and right ventricular dilatation with excessive pulmonary blood flow. Additionally, there is varying AV valve incompetence (ostium primum ASD) or partial anomalous venous drainage (sinus venosus ASD). Left untreated, the excessive pulmonary blood flow may result in pulmonary vascular disease many years later.
QFig 1: ASD types: Secundum ASD, a defect in the mid-portion of the atrial septum; Ostium primum ASD, affects the lower atrial septum, associated with abnormal atrioventricular valves, particularly the left; and Sinus Venosus ASD, juxtaposed to the connecting veins, either superior involving the SVC and right pulmonary veins or inferior near the IVC and coronary sinus. (Adapted from Boston Children’s Hospital.)
Common presentations Unless the ASD is very large, most children present with an asymptomatic heart murmur. Seldom do large ASDs result in failure to thrive in infants or exertional intolerance in older children. Congestive cardiac failure due to ASD is rare. The classic signs are fixed, wide splitting of the 2nd heart sound and an ejection systolic murmur at the left upper sternal border but never loud enough to cause a thrill. A common misconception is that the murmur is from the flow across the atrial septum but, as the flow across
the septum is unrestrictive and literally cascades across the defect, there is no turbulence to create a murmur. The turbulence comes from the excessive flow across the pulmonary valve, hence it is typical of a pulmonary flow murmur. The fixed and wide splitting of the 2nd heart sound is from delayed pulmonary valve closure due to the longer ejection time for the volume overloaded right ventricle. The “Mother” of all septal defects is the atrioventricular septal defect (AVSD), due to failure of fusion of the endocardial cushions. The complete form is associated with both an ASD and a ventricular septal defect (VSD) as well as a common atrioventricular valve and presents like a large VSD with pulmonary hypertension. Sometimes the deficiency of the septum is so great it can create either a common atrium or a functionally univentricular heart! The incomplete form, also known as the ostium primum ASD, is the combination of an ASD with division of the common AV valve in to left and right components but no VSD. The result is an ASD with AV valve regurgitation, usually left, so there may be the clinical features of mitral regurgitation as well as ASD. The AVSD is commonly associated with chromosomal abnormality, particularly trisomy 21. Echocardiography is best to define the defect and any associated structural abnormalities, as well as the haemodynamic consequence of the atrial shunt (see Fig 2).
Management options Management depends on the ASD size and type. Small defects, regardless of type, do not need treatment. Small secundum ASD may close spontaneously in childhood but sinus venosus and incomplete AVSD never close. However, there should be no evidence of RV dilatation or pulmonary hypertension if the defect is small. An exception for intervention would be suspected paradoxical embolus causing cryptogenic stroke. Surgical or percutaneous device closure may be considered to avoid further stroke.
Dr Luigi D'Orsogna MBBS, DRCOG, FRACP Paediatric Cardiologist. Luigi D'Orsogna trained in Paediatrics at the Children's Hospital in Vancouver, Canada and Princess Margaret Hospital in WA. Thereafter, he completed a fellowship in Paediatric Cardiology at the Children's Hospital in Boston and Harvard Medical School. He is a visiting cardiologist to PMH and is director of the Fetal Medicine Service at KEMH, and his private practice covers all aspects of general Paediatric Cardiology.
QFig 2: Apical 4 chamber echocardiogram systolic view of complete atrio-ventricular septal defect showing ASD and VSD component with common AV valve closed.
Even moderate to large secundum ASDs may either close or become significantly smaller during early childhood. Therefore, conservative management is appropriate in infants and toddlers with any type of ASD unless there is associated failure to thrive, which is uncommon. If the ASD remains significant by 4 to 5 years of age, elective closure can be undertaken with minimal risk. The presence of RV volume overload is an indication for closure of ASD in children and adults regardless of age, except if there is significant pulmonary hypertension due to irreversible pulmonary vascular disease. Closure of sinus venosus ASD and incomplete AVSD can only be done safely with surgery due to the proximity of vessels and the AV valves. Transcatheter ASD closure is an alternative for significant secundum ASD unless the defect is very large and/or the patient is small, say <14kg. The risk of infective endocarditis is negligible with ASD except after surgery or transcatheter closure when prophylaxis is recommended for six months after.
Every Generation Needs a Hero Dear Marvel Comics Talk about lucky breaks. Just when it seemed that you'd completely lost touch with modern kids because â€˜powâ€™ and â€˜whamâ€™ couldnâ€™t compete with decapitating people by Playstation, Hollywood came to your aid. You get a brand revival and screen writers get more time to snort cocaine. But did you really think it through? What could possibly go wrong with having Robert Downey Jnr as a role model? Now our children are becoming wired adrenaline junkies with the emotional stability of a MasterChef contestant whose soufflĂŠ has dropped. Some will inevitably end up in the justice system, heading down the slippery slope to becoming lawyers. Just look at the current crop of superheroes. Weedy and bespectacled, they hold down mundane jobs until transformed by an overwhelming compulsion to feel Lycra hugging their gluts. Is it a bird? Is it a plane? No â€“ itâ€™s a Mardi Gras float. What's more they're all over-achievers. Not only does this set the bar way too high for this generation, but as a parent I don't want to have to bust a gut to look good either. Also Marvel, you clearly haven't noticed that we have become a risk-averse society since you started peddling your wares in
the liberal 1950s. I hope you lie awake at night worrying about how many kids have skinned their knees trying to emulate their favourite superhero, or needed counselling on being told that they couldn't really fly. I'm sure your legal department does. Luckily, Iâ€™m prepared to save your bacon with a fresh new superhero that won't lead kids into anti-social behaviour, unrealistic expectations or dubious sartorial choices. Meet (ta-da) Sofaman! Admittedly, his superpowers are at the lower end of the range. You wonâ€™t see him leap tall buildings, or even walking much, but heâ€™ll astound you with his
bladder control. He's been known to down 20 tinnies during a one-day Test without having to get off the sofa to break the seal. No wussy tights-wearing either. Sofaman pulls on his underpants over his underpants; a wise move for anyone who fears that their superpowers might fail them in an anxious moment. Sofaman lives on the edge â€“ he may not dice with death exactly, but he certainly risks elevated blood pressure from a high sodium diet. The storyline is a quest to uncover the past trauma that fuelled his aversion to salad, illustrating the dark side that lies in all of us. Sofaman wonâ€™t battle evil villains either, because itâ€™s judgemental, socially inappropriate and he really canâ€™t be arsed. Ingeniously, he sends them amusing YouTube links from his iPhone to distract them from building weapons of mass destruction. Those uber-villains all love a funny cat! I'm willing to sell the screen rights, but I want a say in the casting. I feel Sofaman should be played by a relative unknown. Here in Australia we have a fresh talent pool of people with the grotesque physique and minimal vigour required for this role. And it would be good to see our retiring politicians gainfully employed at last. Yours Sincerely, Wendy Wardell
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Did You Hear the One About... It’s fitting that in the child health issue we talk to comedian Shane Bourne, who makes out a living out of having fun like a kid. Comedian and actor Shane Bourne was born to be in show biz. The thrill of the spotlight pulses strongly through the veins on both sides of his family, but his stage debut at the age of eight at a primary school social was still a shock to him and his mother. “I was a reasonably reserved kind of kid, not precocious at all, but I found myself on stage during this talent contest doing the Elvis Presley song Hard Headed Woman with all the moves. Everyone started screaming, which I thought was pretty good.” “But what really hooked me on show biz was my dad.. He had moved to the Gold Coast in 1956 56 just before its boom and set up a band which played the Beer Garden on Surfers Paradise six days a week. My brother and I would visit him and there he was in a Hawaiian shirt, surrounded by girls in bikinis, nis, singing, playing and cracking jokes, kes, what’s not to like?” The man who ho has been a part of the Australian entertainment ent landscape for decades – coming to national prominence on Channel 9’s Hey, Hey It’s Saturday then showing he had dramatic acting chops in the medico-legal drama MDA and the movie The Great Mint Swindle (playing Detective Don Hancock) – will be in Perth next month for a star turn in the family musical, Chitty Chitty Bang Bang. He has to compete with a flying car but as the tantrum-throwing, teddy-toting Baron Bomburst, he will certainly get his 15 minutes in the spotlight and a few laughs to boot. “The Baron has the villainous self-deluded thing going but he’s really a spoilt child, stealing toys and throwing tantrums – I can’t wait to get on stage! I was rehearsing the part at home and I thought, wow this is cathartic. Instead of putting your argument calmly and wisely, you can just throw yourself down and kick your legs.” Making people laugh is Shane’s great love, mostly because he loves a laugh himself. His first big break came when he was 21 and he had just thrown in his safe job in advertising to take a stand-up gig at a seedy pub in St Kilda. “The George Hotel was run by a mate of Dad’s and he needed a stand-up between 10
QThe cast of Chitty Chitty Bang Bang. Inset: Shane Sha Bourne
the burlesque acts of his show, My Bare Lady. It was a complete disaster. The first thing I heard from the stage was ‘Piss off you poofter’ but it didn’t faze me, I was in show biz.” “I didn’t have a specific direction, I just wanted to be in the entertainment industry and stand-up comedy, while it might be the hardest route, it’s the quickest. You don’t have to study, you just get booed and have things thrown at you, but you learn fast if you’ve got something.” “I jumped at any job. I even worked at the piano bar of Wrest Point Casino when I was in my 20s. I play a bit of piano, nothing like my brother who is the real musician, but I learnt 30 tunes, pulled out my dinner suit and headed to Hobart.” “I got into such trouble. I didn’t realise that people would come up and ask for requests. I think I played Elton John’s Song for Guy for about an hour and a half because I didn’t want to waste any of my other songs.” “The gig didn’t last long, just long enough for the Reception staff to wonder ‘is this guy for real’ and to fall madly in love with a young dancer from Perth. It was pretty serious because I flew over in the middle
of a Perth summer just to see her. I was on the beach for half an hour before getting sunstroke and fainting over dinner with her parents.” “The romance didn’t last – the distance was a big thing, and the climate obviously.” Never saying no has meant that we’ve seen Shane on shows like Cop Shop and The Sullivans to the hilarious improvisation comedy show Thank God You’re Here but while the credits are long the entertainment industry is fickle. “Sometimes I stop and wish I was a lawyer or a stockbroker – a guy who’s done the same job all his life because this industry blows hot and cold, and it’s always hard to get used to that, but knowing that it’s in my blood is a grounding thing.” O
By Ms Jan Hallam
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Have You Heard? over the Mentally Impaired Accused Act [Search Margaret Doherty at www.medicalhub.com.au].
Good policy? Adolescent lock-up Late in June, the WA Government introduced legislation to impose mandatory jail sentences on children (16 years +) and adults convicted of assaulting youth custodial officers, even though Corrective Services Minister Joe Francis admitted the frequency of such assaults was “relatively low”. Youth and mental health advocates have cried foul. Mental Health Carers Arafmi has lobbied to have those with mental impairment exempt. The legal fraternity is always uncomfortable with mandatory sentencing laws – they take away magistrates’ and judges’ discretion to sentence on merits, and there is the murky concept of politicisation of the judiciary to counteract. Arafmi says training youth and adult custodial officers in how best to deal with people with mental illness is more appropriate. This proposed legislation comes hard on the heels of intense lobbying
Disabilities and footy WAAFL has launched Integrated Football for people over 16 years with an intellectual disability to encourage involvement in community football, either playing or supporting coaches. High Wycombe, Kingsway, Lynwood Ferndale, Fremantle CBC and Warnbro clubs are participating and can cater for those with higher needs [Greg Gilbee on 0419 934 382]. With around 70 kids in six teams involved so far, another grade of competition has been created within the main league. Separately, 100 amateur sporting and non-profit groups are set to receive defibrillator packs from St John Ambulance and Lotterywest ($2900 each) – offer closes August 16; see Heart Start Giveaway website.
CF drug approved The press release announced Australian approval for Kalydeco™ (previously ivacaftor), said to be the first medicine to treat the underlying cause of cystic fibrosis, in this case a particular mutation of the cystic fibrosis transmembrane conductance regulator gene (1800 known mutations). USA FDA approval in January 2012 and US$75m for development from the US Cystic Fibrosis Foundation has helped. Efficacy outside the 8% of cystic fibrosis patients in Australia with the G551D mutation (n=250) is unknown so TGA approval is for those aged six or more with this mutation. Not PBS listed, The West Australian has carried stories of parents lamenting the $25,000 per annum drug cost. In his interview with Medical Forum last December, Prof Steve Stick said economics meant ivacaftor would probably never be trialled in young children where it has the greatest potential; he said only a 20% restoration of function would alleviate a lot of CF problems.
The numbers game Australian Institute of Health and Welfare reports cover many things. One said 201112 new medical indemnity claims and closed claims in the private sector (~1750 in both cases) exceeded the public sector (~1300 in both cases); 54% of closed claims were for less than $10,000, compared with 41% for $10-500,000 and 5% for $500,000 or
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more. A report on prisoner health confirms Medical Forum’s story with the deputy director of Prison Health Services Dr Cherelle Fitzclarence, that inmates leave jail healthier; at the time of incarceration 32% reported a chronic disease with 20% testing positive to both Hepatitis C and B, and 80% were smokers. And the latest report on the National Bowel Cancer Screening Program continues to show low uptake; 38% in 2011-12, then 35% of 930,000 invitations in 2012-13.
an environment of high demand and long waiting times. Meanwhile both RANZCO and ASO members are jointly launching Queensland Supreme Court action with respect to the Optometry Board of Australia's decision (endorsed by AHPRA) to allow optometrists to independently diagnose and manage glaucoma. Patient safety is at stake, they say.
Vax for the taxman From 1 July, one of two bacterial meningitis (meningococcal C), one pneumococcal, and a varicella vaccine will be compulsory for Family Tax Benefit Part A and childcare payments, according to the national register. Someone has crunched the figures – although we don’t have a vaccine against meningococcal B, and only 200-250 people are affected every year nationally, the serious permanent disabilities this infection causes are costly.
picture pict pic p cttture o of
Austral a’s children
HEALTH & DISABILITY CHILDREN IN AUSTRALIA INJURY IS A LEADING CAUSE OF DEATH OF CHILDREN
THE MOST COMMON INJURY HOSPITALISATIONS WERE:
4.3 MILLION 455% CHILDREN IN 2011
OF CHILDREN AGED 6
ACCC eyes fee agreements The ACCC proposes not to allow members of the Australian Society of Ophthalmologists (ASO, representing 60% of eye surgeons) to reach fee agreements for ophthalmic services provided within shared practices. With only 812 practising ophthalmologists, most in major cities, the ACCC is concerned price agreement might force higher prices for patients in
51% HAD DENTAL DECAY boys
LAND TRANSPORT ACCIDENTS
Got you covered AAPM has entered a partnership agreement with Avant to aid its Practice Manager members nationwide. Avant has a Dedicated Practice Indemnity Insurance Policy that includes cover for failure of practice protocols, breaches of patient privacy by staff, or errors by unsupervised staff, or where a patient sees multiple doctors. Avant is promoted by AAPM as a trusted adviser, with tools for training and education and Avant Practice Manager Scholarships will be launched in early September. O
OF CHILDREN HAD
LEVEL OF 7% SOME DISABILITY
51% BOYS COMPARED WITH
CHILDREN WERE OVERWEIGHT OR OBESE
MOST CHILDREN ACHIEVE ABOVE 200,245
THE MINIMUM STANDARD FOR READING AND WHILE NUMERACY OF CHILDREN LIVED IN COUPLE FAMILIES
INDIGENOUS NATIONAL CHILDREN
CHILDREN BORN OVERSEAS
HEALTH & DISABILITY
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EXPANSION OF EATING DISORDER SERVICE THE HOLLYWOOD CLINIC IS OFFERING A NEW DAY PROGRAM FOR PATIENTS WITH EATING DISORDERS. THE DAY PROGRAM WILL SUPPLEMENT THE EXISTING INPATIENT SERVICE AND IS DESIGNED TO TREAT THOSE PATIENTS WHO MEET CRITERIA FOR AN EATING DISORDER BUT ARE NOT SO PHYSIOLOGICALLY COMPROMISED THAT THEY REQUIRE INPATIENT TREATMENT. IN ADDITION, ACCESS TO THE PROGRAM WILL HELP FACILITATE EARLY DISCHARGE FROM THE INPATIENT UNIT, ENABLING PATIENTS TO RETURN HOME TO THEIR FAMILIES. According to the National Eating Disorders Collaboration evidence review published in 2010, the lifetime prevalence of Anorexia Nervosa is between 0.3%-1.5% and for Bulimia Nervosa between 1-2 %. From the 1990s to the 2000s, the prevalence of eating disorders has doubled for men and for women. Dr Eileen Tay, Director of the Eating Disorder Program at the Hollywood Clinic, states that in spite of the increased prevalence, treatment services for eating disorders remain inadequate and inconsistent in Australia. “The aetiology of the various eating disorders is complex as it is with most psychiatric disorders. The unique diﬀerence with eating disorders is that it is both a physical and psychological disorder. There are wide ranging eﬀects on multiple systems in the body and psychological complexity is another hallmark of this group of patients which may contribute to lifelong disorder. This latter group is increasingly recognised nationally and internationally and is referred to as Severe Enduring Eating Disorders (SEEDS). We are seeing increasing numbers of patients in this group”, said Dr Tay. “If diagnosed early and addressed in a professionally robust way, most patients can avoid hospitalisation and learn how to manage and/or recover from their condition in the long term. In the ideal world we would also be providing family support groups and 14
conducting research but our current focus is on the clinical needs of this patient group”. To respond to this need in a more comprehensive way, the Hollywood Clinic’s new Eating Disorder Day Program is based on a recovery model and aims at improving overall functioning. The program is suitable for patients with a minimum BMI of 15, who are medically stable and meet criteria for Anorexia Nervosa, Bulimia Nervosa and Eating Disorders Not Otherwise Speciﬁed (EDNOS). Co-morbid DSM V Axis II disorders, as well as signiﬁcant and regular current self-harm and substance abuse, are exclusion criteria for the program. The program is available daily, from Monday to Friday. Patients should be 16 years or older. Referred patients will be assessed for suitability to participate in the program by the Program Co-ordinator, Psychologist Dr Fiona Cartwright. “The program provides experientially-based group therapy that addresses disordered eating behaviours, cognitions and feelings through actual experience in real settings,” said Dr Tay. The goal is to empower patients to reﬂect on and change cognition and behaviour over an extended period of time within a supportive framework. This new ﬁve day program is a ﬁrst in WA”. At the program’s core is a series of cognitive behavioural therapy and process groups. These groups focus on some key psychological aspects in the treatment of eating disorders such as enhancing motivation for change and developing self-eﬃcacy, goal setting and planning around high-risk situations, increasing cognitive ﬂexibility, and improving daily functioning and encouraging valuebased living. Therapy groups are complemented by other experiential activities that include therapistsupported food preparation, meals and outings to food-based settings, and in-situ post-meal distress management and skills coaching.
Patients also have access to group dietetic review and information, and to individual dietetic assessment, support and review. “We have designed the program around a multidisciplinary team approach,” said Dr Tay. “While an individual treatment plan is drawn up for each patient, the multidisciplinary team will ensure a comprehensive approach to the range of factors that maintain eating disorders. “Collectively, the team creates the conditions conducive to improving mood, behaviour and overall quality of life. We see the GP as an essential part of the team, to ensure the ongoing medical management of patients. The team meets on a weekly basis and will provide feedback to the referring GP. This may be a challenging group of patients to work with but they are also a very rewarding group of patients to care for provided treatment teams have suﬃcient support and supervision to sustain the necessary work that has to be conducted in a compassionate, nonjudgemental yet medically appropriate manner. We are also very fortunate in being co-located with Hollywood Private Hospital which provides additional medical support via our physician colleagues when required”. The Hollywood Clinic is also planning some information sessions for the community and GPs in the future, not just regarding eating disorders but also with respect to the other expanded and/or new services available at the Clinic.
To refer patients or to find out more about the program, please contact: Program Coordinator: Fiona Cartwright Tel: 9346 6817 or 9346 6801 Email: email@example.com
A multidisciplinary team including consultant psychiatrists, psychologists, dieticians, clinical nurses and art therapists ensures a comprehensive approach to addressing the range of factors that create and maintain eating disorders.
Dr Eileen Tay: Director of Hollywood Clinic’s Eating Disorder Program Dr Tay graduated from The University of Western Australia in 1987 and trained as a general practitioner, obtaining her FRACGP in 1994. In 2000, she commenced psychiatric training, and subsequently worked in general adult and child & adolescent psychiatry across the Perth metropolitan area. She obtained the FRANZCP in 2006. Apart from eating disorders, Dr Tay’s other clinical interests include mood and anxiety disorders and PTSD, and she has a psychotherapy practice as well. Dr Tay is an accredited College supervisor with the Postgraduate Training Program in Psychiatry and she provides individual and group psychotherapy supervision to psychiatry registrars. She is a member of the WA Section of Psychotherapy and the WA Faculty of Forensic Psychiatry.
Hollywood Clinic Expansion The Hollywood Clinic is currently undergoing expansion. A new wing will add another 30 beds to the existing 40-bed in-patient facility. All new rooms will be single rooms with ensuite bathrooms. The redevelopment will also include a gymnasium, doctors consulting rooms and staﬀ rooms. A new dining room will accommodate 120 day and in-patients, including participants in the new Day Patient Eating Disorder Program. The new wing has been designed to create a warm and friendly setting that promotes wellbeing by incorporating an internal courtyard, large windows to allow natural light in and access to gardens. It is scheduled to open early 2014.
Computer-generated image of the Hollywood Clinic expansion
Hollywood Private Hospital Monash Avenue NEDLANDS WA 6009 Telephone: 08 9346 6000 www.hollywoodprivatehospital.com.au medicalforum
Health and Human Rights Helping those who have lost everything is a way of life for Dr Annie Sparrow, who will be in Perth in October to discuss the plight of refugees of the Syrian conflict. Perth-trained paediatrician Dr Annie Sparrow is no stranger to the horrors and deprivations of refugee camps and the traumatised lives of those who seek shelter in them. For more than 10 years, her human rights work has taken her from the Woomera Detention Centre in South Australia, to Afghanistan, Darfur and Chad. This month she will be working among the estimated 1.5 million Syrian refugees living in camps in Jordan and Lebanon looking for what she says is the missing link between health and human rights to force the humanitarian crisis back on the UN Security Council table. “We can count the number dead in this two-year civil war – conservatively, that’s about 93,000 – but to quantify human suffering is much more difficult. So I want to look at health outcomes – the return of childhood diseases, outbreaks of pneumonia, or flu, easily treatable or preventable illnesses that are now killing people when they wouldn’t have two years ago.” “Quantifying the conflict in terms of health outcomes is an apolitical demonstration of the moral imperative to keep the Syrian borders open so that humanitarian assistance can help the 3 million displaced people inside the country.” The targeting of civilians is no new thing when it comes to war, but the Syrian
QDr Annie Sparrow examines a baby in a Chad refugee camp
people have borne a heavy penalty in this increasingly bitter conflict between the Assad Government and the Opposition with almost complete destruction of what was a comfortable middle-income nation with a well-functioning health system. “There is a measles outbreak at present because children have not been vaccinated over the past two years; women are reporting serious reproductive health problems; there is a deterioration of chronic health conditions such as diabetes and renal disease; all because people don’t have access to medications,” Annie said. “We understand that several hundred doctors have been killed and hundreds of health workers have been jailed or detained, which is a clear violation of what we call medical neutrality, and hospitals, clinics and pharmacies have been bombed, the transport system is in tatters and normal life and work has been destroyed.” “These fundamental violations of civilians’ human rights have a direct and devastating impact on physical, emotional and psychological wellbeing.”
QShowering any way she can 16
The journey that has led the New Yorkbased, 42-year-old from first world paediatric emergency departments in Perth and London to barely resourced treatment tents on the edges of war zones began more
than 10 years ago when Annie was doing sessions at the Woomera Detention Centre in 2002. “I worked alongside Tirana Hassan, a young lawyer from Adelaide, who now works for Human Rights Watch [Annie’s husband Ken Roth is executive Director of HRW] and we often talk about Woomera and compare it to other places we’ve been – Somalia, Afghanistan, Sudan or Chad. All these were miserable places, but nothing was as miserable as Woomera in terms of conditions under which people were held.” [Woomera Detention Centre was shut down in 2003 after a hail of protest.] She told The West Australian last year that seeing those children in Woomera failing to develop, and babies being born in such a punitive environment, she understood for the first time what human rights really meant. “There were 13-year-old boys sewing their lips together out of despair, trying to mutilate or even hang themselves, 10-yearolds wetting the bed because they were so depressed and traumatised. When they bring you a teenage boy in handcuffs, hysterical because his visa has been refused, no one at medical school tells you how to deal with that in a human rights sense.” She told Medical Forum that it was at this heart-stopping moment when her research medicalforum
QDr Annie Sparrow with President Obama
on the relationship between health outcomes and human rights violations began. Annie will be a keynote speaker at the WA Transcultural Mental Health and Australian Refugee Health Conference in Perth at the end of October. Apart from sharing her insights, it will give her a chance to catch up with her family â€“ her brother Phillip and his wife Julie and their children, who have recently returned from 10 years working on development projects in Afghanistan, and sister, GP Louise Sparrow. But in the meantime, thereâ€™s a case to mount for cross-border humanitarian
QDr Annie Sparrow Chad refugee camp
assistance and support for the host countries of Lebanon and Jordan. This is an essential part of her life now. Her work with husband Ken in Human Rights Watch is complemented by her teaching work at the Mt Sinai Global Health Centre and as they raise their five-year-old son together, she has her late mother Joyâ€™s words ringing in her ears. â€œItâ€™s always easier for me to visit these places because Iâ€™m the one who always gets to leave. I have always tried to get as close as possible to the people Iâ€™m trying to help. A doctor is in a special position to provide direct care. Thereâ€™s an additional level of trust or confidence
bestowed on doctors, which means we hear stories that people need to share; awful things have happened to them, often they are the worst things that can ever happen.â€? â€œBeing there and listening and providing care and doing what you can is something special. Itâ€™s something I learnt from Mum that when Iâ€™m feeling sorry for myself, and wonder how can I take it, I look at what other people are going through and think, right they are much worst off so buck up, grin and bear it.â€? O ED. The WA Transcultural Mental Health and Australasian Refugee Health Conference will be held at the Duxton Hotel on October 31 and November 1. www.transrefugee2013.com.au
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"Doctors – The Care Factor" Doctors Drum Giving Doctors Voice The sun may have been a bit slow to get up for the second Doctors Drum breakfast in June, but the 50 hardy docs who attended were not. And they were rewarded with a stimulating discussion by six members of the panel on the varied and complex aspects of caring within and by the profession. ABC’s Russell Woolf kept the session bowling along and the panel – Critical Care Registrar Dr John Zorbas, GP Dr Helen Wilcox, cardiologist Dr Mark Hands (Western Cardiology), consumer advocate Ms Michele Kosky, Labor health spokesperson Mr Roger Cook and lawyer Mr John Pitman (Slater & Gordon) – grasped the topic with enthusiasm and raised some vital issues from their different perspectives.
Patient care, care in the health system, care for good health-care policy, care for the team, colleagues and oneself in an environment where doctors were expected to do more and more with less and less were real challenges to the altruism which motivates the vast majority of practitioners. Advanced Healthcare Directives (AHDs) emerged a big conversation starter, which affects all branches of the profession – from ICU, the operating theatre to the GP surgery and even the courts. Strands of the discussion went from levels of treatment, to organ donation to the need for educated and informed community debate on end-oflife issues as well as health system costs. One panellist said: “When we say caring, people only think of the curing potential of
any treatment we have. But caring is much, much more than that.” Several panellists referred to the need for public debate on AHDs – “The only time people confront these issues is around a poorly crafted or poorly informed debate around euthanasia.” Three of the six panelists declared they had their own AHD in place. Caring for colleagues and individual doctor’s own health was another can of worms. The crux was that doctors look out for each other, professional colleges could be resources and resilience training at medical school was important, but these measures were not foolproof. One of the panellists added that while doctors were pretty good at caring for each other, particularly if they worked in groups,
QClockwise below: Drs Jenny Elson, Jenny Fay, Ms Susanna Wolz; Dr Helen Wilcox and Glenn Bradbury; Dr Fiona Middleton and Dr James Latto
QThe Panel: Dr John Zorbas, Michele Kosky, Mr Roger Cook, Drs Helen Wilcox and Mark Hands and Mr John Pitman
We are in the thrall of how clever we are in terms of medical science. We are going to have to come to some decision about the sustainability of life and how much we are prepared to pay for that.
What I think we are very poor at as a profession is looking after the impaired doctor. It is a very stressful situation – stressful for the doctor who is impaired, and stressful for his colleagues to watch and manage.
DOCTORS DRUM Giving Doctors Voice www.doctorsdrum.com.au 18
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TOPIC: GPs & Specialists: Partners in What?
what the profession was not good at was looking after the impaired doctor. â€œIt is a very stressful situation for everyone. Thereâ€™s no real formula for looking after them. Invariably it ends sadly, in trouble. We need to address this issue in a more upfront way.â€? The lawyers in the room brought the legal responsibilities to the fore. If others know of a doctorâ€™s impediment to practice and say nothing, then they expose themselves to prosecution. That said mandatory reporting created real problems for the whistleblower. â€œThere is a lot of stigma around about being an impaired doctor and even more stigma for the person who makes it public. Until we take that away, it will continue to be a problem,â€? one said.
For the consumer advocate on the panel, the matter of professional caring was a heart and head matter â€“ a balance between objectivity and care. â€œWhat matters to h patients is how they are communicated with and what meaning is given to their illness. You can care too much. Patients donâ€™t need your emotions, they need your technical expertise and your kindness.â€? The forum was brimming with platforms for greater and wider conversations â€“ the role of doctors as advocates, not just for their patients but for the system, where the health dollar should be spent about keeping government policy less about politics and more about outcomes. The discussion could have gone on all day. O
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QClockwise from far left: Dr John Alvarez and Dr Jamie Blair; Dr Mirek Kanik, Ms Jenny Heyden and Dr Joe Kosterich; Dr Karen Prosser; Drs Shelley Davies, Elena Ghergori and Karen Moller; Dr Denis Cherry, Ms Jan Hallam, Ms Jenny Heyden and Mr Brad Potter; Mr John Pitman, Mr Roger Cook and Dr Mark Hands.
Have we got the wrong language, we talk of an insatiable demand for health care â€Ś really it is an insatiable demand for illness services
News & Views
No Room for Bad Behaviour How to help a colleague to overcome impairment is not as hard as it sounds. Planning, leadership and respect are the keys. attributes that allow us to create effective teams. We need to communicate clearly and effectively, be aware how our performance impacts on others’ ability to do their jobs and, above all, it’s about respect and self-regulation.”
The personal and professional dilemma created when a colleague shows themselves impaired to practise was a heart-felt topic raised at the recent Doctors Drum breakfast. The lack of a fair, stepped response puts enormous pressure on everyone involved.
“The vast majority of professionals are awesome and it’s important to know that most of that relatively small percentage of physicians who have problems will get better if we have the courage to address our professional awkwardness in dealing with them.”
It is an area that Dr Gerald Hickson, a paediatrician and professor at the Vanderbilt University School of Medicine in Nashville, Tennessee, knows well. For 20 years he and colleagues have been working on developing a peer-review system to promote disclosure of medical errors and address behaviours that undermine a culture of safety. He spoke to Medical Forum about some of his findings before the start of an Australian speaking tour, including a free seminar in Perth on August 23. “I think it is an awfully important topic to be discussing because it is a real and significant problem. There is the challenge of knowing how to appropriately address this colleague. We have not been well trained in this – we, as a profession, are conflict averse and tend to look the other way when we know there is a problem.” “Ultimately it’s about doing the right thing for our patients while maintaining our professional commitment to each other, and that takes personal courage. But it’s also about having a defined plan so that the medical leadership is equipped and prepared to address these challenges when they come up. And they come up all the time.” Leadership and planning are the crucial elements, Gerald says, to make what seems an overwhelming and complex dilemma, fair and procedural. However, even after 20 years of working on this across the US health system, he admits there’s still a way to go. “I’m a paediatrician, an ultimate optimist, but I’m also realistic. When we started this pilgrimage 20 years ago, we began by addressing the most senior positions in our system. We did that because of an experience I had with a medical student. I had given a lecture about professionalism and I thought I’d done a nice job when this very bright Vanderbilt medical student tugged me on the sleeve and said ‘I hear all you’re saying, but this is not what we’re seeing’.” “Unless we take on and engage our most senior, we are creating moral distress for the learner because how can we go in and say, ‘we want you to behave this way but we 20
QDr Gerald Hickson
The whole issue is about respect – respect for the patients we serve and the people we work with. There is no question that medicine is a stressful profession with a lot of anxieties and that can make us less than pleasant to work with some of the time. want you to ignore what you’re seeing.’ Peer review needs the support of our most senior physicians.” “Leadership commitment doesn’t mean a leader who says, ‘I don’t want these behaviours to occur’. Leadership commitment means that when you identify someone who is not functioning as a good team member, they are given a fair opportunity to reflect, to develop personal insight and to self-correct. If they don’t do it, then leadership means a willingness not to blink and to hold those people accountable even to the point of ultimately removing their privileges or their ability to practice.” “This is about changing culture and it’s simpler than we think. The whole issue is about respect – respect for the patients we serve and the people we work with. There is no question that medicine is a stressful profession with a lot of anxieties and that can make us less than pleasant to work with some of the time.” “But it doesn’t matter how bright we are, or our ability to do complex surgery, what is most important are those behavioural
Gerald’s US research has found drug and alcohol abuse and mental health, including early cognitive dysfuntion, account for some doctors’ impaired function but the largest subset by far are people who behave badly and inappropriately. “This is the group we often fail to deal with even though they are the easiest to deal with. These individuals are just not particularly self-reflective, they have bad behaviours modeled by their mentors. They are aggressive, inconsiderate, rude, they don’t appropriately do documentation, they don’t follow evidence-based practice.” “Like other impaired doctors, they need identification and the right level of progressive intervention by individuals who are comfortable to do that. While some early events may seem trivial, we believe that at the most local level possible, they need to be shared in an informal, respectful way that gives the individual the opportunity to try to do the right thing – and most do, our research shows more than 75% respond.” “But the process inevitably separates those who are able and willing to change and understand we have a new heightened level of professional accountability, and those who can’t. In the US, 4% of physicians are identified for intervention and of that 4%, 75% self-regulate. Half of the remaining 25% will return to practise as full professionals, the other half doesn’t for one reason or another.” “For the vast majority of people we deal with there is great success. There is no reason not to move forward, but we collectively have to make that decision.” O
By Ms Jan Hallam ED: Dr Hickson will be speaking at a free seminar at 6pm on August 23 at the University Club, UWA, as part of Avant’s 120th anniversary celebrations. Register at www.avant.org.au/Events medicalforum
Bonded to the Bush Dr Penny Wilson is a rural ‘conscript’ by choice but wonders about the wisdom of a decision made at the threshold of her formative years.
n 2001, at the age of 17, I was one of the first medical students to take up a Medical Rural Bonded Scholarship (MRBS). The deal was payment of $20,000 a year during medical school in return for six years of rural service after fellowship.
I didn’t actually sign on the dotted line until I was 18, but if I had decided to pull out of the MRBS after starting the course, I would have lost my place at university and my medical career would have been over before it began. So once I had accepted it I was essentially locked in for the next 16 or more years. Although I intellectually knew what the scholarship involved, I really don’t think I had the maturity to fully understand the psychosocial implications of that decision and I can’t help but feel that my younger self was somewhat taken advantage of. It’s now 13 years down the track and I have finally come to the end of years of training to become a GP obstetrician. I’ve recently commenced my rural return of service, working as a locum travelling all over the country in the hope of finding a place I’d like to settle down in for the next few years. I’m waiting to see if the benefits of the scholarship outweigh the costs. I don’t mean to sound ungrateful; I was very glad to have had the scholarship during my university years. I didn’t come from a wealthy family so it allowed me to focus on my studies and live reasonably comfortably. It also influenced me to pursue some fantastic rural medicine opportunities such as the John Flynn Scholarship Scheme, fifth year Rural Clinical School and a rural rotation in my internship year. As a result of these experiences, I have an overwhelmingly positive attitude towards country practice. I believe it can provide an interesting, challenging and rewarding career pathway and wish that it was perceived that way by the profession as a whole rather than it being stigmatised as an inferior option that people need to be coerced into doing. My experiences of the past few months since starting my rural service have only reinforced my positive view and I’m confident that I will emerge a broadlyskilled doctor who can cope with anything. However, I still feel uneasy about the fact medicalforum
QDr Penny Wilson performs a caesarian and, inset working for RFDS
that I have to do this and that if my life circumstances change and I want or need to return to the city, I could not do so without major penalties. I would be required to repay the scholarship amount but, more importantly, would lose my Medicare provider number – and therefore be unable to undertake clinical work – for up to 12 years. That's a pretty big stick. My biggest concern has always been the potential impact on relationships and family. Alas, disclosing my mandatory six years’ rural service has been met with a less-than-enthusiastic response by the few serious partners I've had along the way. More recently I had the heartbreaking situation of a relationship ending largely because it was time for me to head bush, when the other person was tied to the city by his work commitments. The scholarship also has some frustrating career implications. Any rural training done as a registrar does not count towards the return of service period, which is a significant disincentive. Allowing registrars to tick off some of their rural time during training would encourage registrars to train more appropriately for the type of work they will do as fellows. For GPs, this would include acquiring the emergency skills which are fundamental to rural practice and hard to get exposure to as a metropolitan GP registrar. Of course,
MRBS GP trainees can always chose to undertake rural training via the FARGP or ACRRM pathways but this would increase their rural commitment to eight years or more, with no recognition of the additional service. What’s more, the ability to increase and maintain skills after fellowship is limited by a maximum of two weeks of metropolitan up-skilling per year. Thankfully, the return of service requirements are fairly flexible, with participants only required to work part-time (an average of 20 hours a week each month, for a minimum nine months a year) to fulfil their obligations. I don’t see why that flexibility couldn’t be extended to allow us to use some of the time to work in metropolitan areas if it helped us gain or maintain a specific skill set. For example, allowing me do a couple of caesarean lists a month at a local metropolitan hospital would help me keep my surgical skills sharp and benefit the rural communities I serve. Having a Medical Rural Bonded Scholarship has given me many benefits over the years but its restrictions continue to cause anxiety. Do I think I made the right choice in signing up? The jury is still out. Ask me again in five years’ time. O
News & Views
Calls Grow for Kids’ Pain Unit Medical Forum discovers that about 30,000 WA children and adolescents live with pain but have no dedicated, multi-disciplinary unit to help them. The campaign to establish the state’s first paediatric pain unit is beginning to hot up. Chairman of the Statewide Pain Services of WA and WA director of the Australian Pain Society, Dr Stephanie Davies, says that WA has fallen behind the major states, despite rapid population growth in the past five years. “WA joins the Northern Territory, Tasmania and the ACT as the only states without a paediatric pain unit. NSW has three while Victoria, Queensland and South Australia each have one,” she said. This is despite an estimated 2.3% growth in 2011 of children and adolescents between the ages of 0 and 19 to 569,695. This figure will grow (mostly in the 0-4 age group) to 588,548 by 2016. “About 18% of the Australian adult population has ongoing pain, defined as day-to-day pain in a three-month period. In children and adolescents, the figure is about 15%. What people haven’t realised is that pain is almost as common in children and adolescents as it is for adults, with about 6% of children and adolescents having significant persistent pain [or 30,000 children].” If only 5% of those 30,000 children have complex conditions that require a multi-disciplinary pain unit, this would be 1500 children across WA who are currently unable to access a tertiary paediatric pain service. “So across all the ages, the incidence of pain is remarkably similar. But while there are three dedicated adult pain units in WA, based at Fremantle Hospital, SCGH
this was not the dominant group.
“There are some really good specialists, physios, OTs and psychologists at PMH who are doing the best they can for the children referred with complex medical conditions and there is some access to a multidisciplinary approach in some cases but it’s not consistent.” However, Stephanie says there is an even bigger issue for children whose medical conditions aren’t considered to require a tertiary referral. “For an adult in the same situation, they can be directly referred to a pain unit without necessarily going through a rheumatologist, or orthopaedic surgeon or a neurosurgeon. Half of our referrals to the Fremantle pain clinic are from GPs. This isn’t possible for children – it’s really an issue of equality.” Last month, pain consultant Dr John Quintner and OT Jane Muirhead started a five-month multi-disciplinary education and self-management pilot program for 50 children with funding from Telethon7. The Kids Overcoming Pain Education (KOPE) [See May’s Medical Forum] will be evaluated and provide much-needed data. “It’s an absolutely fabulous first step but if it’s going to continue, it has to be funded and, sadly, under Medicare, group sessions and multi-disciplinary care are just not covered, which is why I think a pain unit needs to sit under the state umbrella as a tertiary service,” Stephanie said. Medical conditions that would warrant such a service include cancer, but Stephanie said
“Most would come under the banner of musculoskeletal. For many kids and adolescents it’s almost like a hypermobilism, the extreme of which is Ehlers Danlos Syndrome. EDS is genetically determined but there are a lot of children who have hypermobility-like patterns of movement and pain who don’t test positive to the genetics of EDS.” “The other major groups are neuropathic pain and juvenile rheumatoid arthritis which encompasses inflammatory pain, also, recurrent abdominal pain, migraine and headache. ” There appears to be strong support for a pain unit among PMH clinicians though funding is, as always, a bone of contention. “If 6% of children have significant pain, that’s nearly 30,000 kids and families with disrupted lives. There’s a social cost to that.” “If untreated the majority of children with significant pain tend not to do very well at school. We are reducing their ability to find a productive path into the workforce and their pain will continue.” “Studies over the past seven years at Fremantle are tracking outcomes. Certainly a lot of people report less pain and improved function after we do this multidisciplinary intervention, and some do indeed return to the workforce, which is in line with all the randomized controls.” “But for children and adolescents, the structure is not there to say that is that case. But it would certainly be the expectation.”O
By Ms Jan Hallam
Specialists were polled this month on various aspects of paediatric pain and if they considered a dedicated pain clinic was required, with 72 responses.
The percentage of children with ongoing pain is said to be slightly less than the adult population. Do you think a dedicated Paediatric Pain Clinic, run on similar lines to the three adult pain clinics, is needed in the public health sector in WA?
and RPH, there’s no dedicated multidisciplinary pain unit at PMH.”
Would you have any misgivings about establishing such a Childhood Pain Clinic?
(22 responses in 72 results) ED: Views ranged from an “essential service” to suspecting “someone is looking for a cause”. Among those who thought there was a need for a paediatric pain clinic, the emphasis was on a multidisciplinary psychosocial approach. For one the issue is close to home: “I work at PMH and it is astounding that we cannot offer the same level of care that adults get. Children really do seem to be therapeutic orphans.”
It's a Question of Equality Julia Sutton’s teenage daughter has lived with pain for most of her life but it was only when she went to an adult pain clinic that she found relief.
s parents we want to comfort our kids and fix things, and usually we can. However, I learnt that fixing things isn’t always possible when my daughter developed a complex pain condition. We had our coping mechanisms. My daughter got used to being in pain. Still there were times – perhaps six episodes a year – where the pain was no longer manageable and we would take her to PMH Emergency Department. She felt she would die from the pain. (She has since been diagnosed with a rare metabolic condition.) PMH Emergency Department didn’t have a pain unit. More often than not we were given a couple of Panadol and sent home. After several bad experiences, attending PMH Emergency became our last – and most desperate – choice. On these occasions my daughter often felt dismissed, disbelieved and humiliated. It was difficult to participate in this cycle and
see the impact these experiences had on a teenager already struggling with a chronic health condition. Doctors and nurses are committed to helping people, and are used to being able to identify a cause and apply a treatment that makes a difference. What we noticed is that when these treatments did not work as expected, rather than looking further for the answer, the patient is disbelieved. Pain scenarios arising from chronic conditions are very different to pain scenarios associated with acute situations. Busy ED doctors are not in a position to identify or respond to chronic pain conditions, they don’t have the time or resources. A specialist pain unit would provide management for the more complex pain scenarios that may be less frequent, but no less real. Things changed dramatically when my daughter turned 17 and was referred to Fremantle Hospital. A pain crisis occurred and we attended Fremantle Emergency Department with very low expectations.
Our care surrounds you... medicalforum
What happened next took my breath away. My daughter was believed. A representative from the specialist pain team was called. Her pain was treated effectively and efficiently. My daughter was stunned and asked me why we hadn’t come to Fremantle all along. Why was the experience so different? Fremantle Emergency staff has access to specialists in complex pain, PMH Emergency staff do not. How does it come to pass that adults can access specialist pain expertise and children can’t? Children have less coping skills than adults and yet we offer them less support. This gap in service makes no sense and leads to enormous suffering and stress. PMH needs a dedicated paediatric pain team under the leadership of a specialist in children’s complex pain. Families need training in how best to support a child in complex pain – emotionally, in the administration of medications, and management of side effects. This is a resource our children deserve.O
Benefits Outweigh the Risks? Landscape architect David Smith underlines the strong connection between creative, three-dimensional outdoor environments and healthy psychosocial outcomes. “Everyone, adult or child, comes to Naturescape with their own script. We’ve designed a landscape that hopefully challenges and expands those narratives, one that allows an immersive and interactive experience and is markedly different from a conventional playground. A swing and a slide satisfy a physical need but do little to foster social and psychological strengths. This space develops those qualities and, hopefully, builds resilience in children.”
It’s not a picnic area and it’s definitely not a playground. The Rio Tinto Naturescape Kings Park – 60,000sq m of hidden thicket, creeks and trees – is a space specifically designed for children to engage with nature. According to its chief designer, David Smith, it’s an experiential landscape for children to extend themselves and push their boundaries. David underscores the point that his environmental design company, Plan E, has intentionally created a micro-world for children. It’s one that embraces similar problematic issues found within the wider horizons they’ll be stepping into as adults. “It’s a great challenge to allow children to be exposed to character-building risk while also maintaining appropriate levels of safety. Positive interaction with strangers and developing broad social connections without overarching monitoring are valuable skills to learn. As landscape architects, the Naturescape project prompted an exploration of how we can instil confidence and a sense of independence through the medium of creative play. In order to allow children to perceive their boundaries you have to let them have experiences that come close to those limits.” “There is an element of risk with Naturescape and I’m sure there are people who might say there’s too much bush, an excess of rocks and there’s bound to be snakes. We’ve designed it with the intention of setting some different challenges than
QMr David Smith
you’d normally find in an urban society.” “It’s a valuable and pertinent discussion and it begs the question, have current Australian standards for ‘safe’ play reduced it to something that doesn’t develop very much at all?” In a light-hearted reference to the medical profession, David expands on the balancing act between risk and reward. “Doctors should be thanking us because some of them will be getting a little extra work repairing broken arms. It’s a two-edged sword and some people might say it’s an unacceptable risk and others would counter by saying places such as Naturescape are absolutely essential to build confidence in children. Inevitably there will be a broken arm or two, but some would say that’s a rite of passage anyway.” The highly subjective interpretation of a creative space is something that David and Plan E value highly.
There’s been a long-standing association between Kings Park and Plan E. In fact, as David says, ‘if it’s happened in the Park over the last 13 years then we’ve been involved with it.’ “It’s been an amazing opportunity to have that level of consistency with a client such as Kings Park and Botanic Garden. They’re well aware that the area is a facility for the entire Australian community and that means we have to work across a broad range of design briefs.” “One of the projects we’ve worked on is the Place of Reflection, an area for people who’ve suffered loss in any form and are looking for a nature-based space for contemplation and healing. We’ve worked with a number of different groups in Perth embracing issues such as SIDS and posttraumatic stress linked with torture.” “We see ourselves as a catalyst in creating a three-dimensional landscape that mirrors what the wider community is trying to achieve.”
ll o P e
Health and Urban Living
Specialists were polled this month on Perth’s urban design with, 72 responses.
QMasterplan of the Rio Tinto Naturescape, Kings Park
In Medical Forum (August 2012) Professor Peter Newman from Curtin University spoke about ‘biophilic urbanism’ – creating a healthier Perth by bringing nature back to the city. David thinks Perth, particularly from a global perspective, is doing a pretty good job. “There’s a trend towards an ‘international’ style in the world’s major cities and I think that’s rather sad. The more I travel the more things are beginning to look the same. I went to Singapore recently and you couldn’t recognise it as an Asian city. Of course we have a few idiosyncrasies. Urban sprawl is a problem and the alienation of people in some of Perth’s more remote suburbs.
We’re very much a society shaped by our own geography.” He says his ‘top two’ urban locations are Cape Town and Paris. “The sense of space and the geography in Cape Town makes it a stunning place. Paris, of course, is an amazing city and I really used to enjoy Hong Kong but it’s become very much a Western city.” David is very clear regarding the role of a landscape architect and he’s equally emphatic about where his profession should draw a line in the sand. “I’m not a social engineer. We’re designers and we’re not here to shape or drive community expectations. It’s our job to listen to a client and transform their needs into a three-dimensional space.” “I’m not an expert on whether kids who play outside will grow up to be better citizens than those who sit in front of a screen. Would the world be a better place if Bill Gates hadn’t been a computer nerd? But I do feel that outdoor play is valuable for children and it’s important to make it as stimulating as possible.” O
A number of experts, writing in Medical Forum, have scored Perth comparatively highly as a ‘liveable city’. Given the known link between urban design and psychosocial health of inhabitants, how would you rate Perth? Highly favourable, a great place to live
Moderately favourable, could do better
Pretty average, there are better places to live
Poor, people would be better off leaving
Comments ED: Better public transport, including the development of light rail, dominated the responses from the 36 doctors who chose to comment, with more car-free bike paths a close second. Some called for higher density living within 10km of the CBD to stop the urban sprawl.
By Mr Peter McClelland
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Growing Up is Risky Business Cocooning children is creating â€˜risk illiterateâ€™ adults who are a danger to themselves and others. Griffin Longley wants common sense to prevail.
ou donâ€™t need to have grown up on Cloud Street, or in the pages of a Ginger Megs cartoon, to know that the experience of childhood has changed forever. But most of us know it has changed in the same kind of casual way we know petrol prices go up before the holidays, that apples donâ€™t taste like apples anymore, and that 90 per cent of all Hollywood movies are written by a dyslexic computer called Byron.
We know kidsâ€™ faces now seem to glow perpetually blue with the flickering of screens. We know that the parks are empty of kids on the weekends unless there is an adult present with a whistle in his mouth martialling them into half-backs and silly mid-ons. And we know it was different when we were kids. But we may not be aware that modern Australian kids spend less than two hours outside a day â€“ less than our maximum security prisoners. Or that only one in five Aussie kids have climbed a tree, and that measures of childhood creativity and executive function are falling faster than the Labor Party leadership. Childhood is becoming an increasingly indoor, sedentary, and isolated experience.
And that is a great loss, not just in terms of its effect on physical, mental and emotional health and development. It is also a loss in terms of its impact on the kind of fun our kids have and the opportunities we afford them to learn to interact with the complex, and yes, sometimes dangerous, world beyond their lounge room. The reasons for this change are many and complex. The rise of digital entertainment is part of it. As are our busy roads, our lack of unmanicured open spaces, our increasing desire to assess and measure childrenâ€™s â€˜outcomesâ€™, and our changing idea of what a good childhood looks like. And, critically, we have come to think that the important job of protecting our children is entirely an exercise in risk removal; that being a good parent/teacher/physician/ society is defined by the number of risks we can remove from childrenâ€™s experience. At its worst, this is a dangerous simplification. A kind of quarantining of experience that can undermine a childâ€™s excitement and interest in the world and lead to inactivity, inattention and an inability to assess and respond to risk when it inevitably arrives.
There is a real need to reinvest in the value of the sensible, graduated, risks that are part of what makes play exciting and valuable, and that form part of a deeper and more long lasting protection of our children. This is a point that has recently been taken up by the British Governmentâ€™s Health and Safety Executive (HSE) which regulates public safety in everything from playgrounds to nuclear power plants. Last year, after acknowledging a growing problem of â€˜risk illiteracyâ€™ in the British workforce, the HSE put out a position statement supporting a balanced approach to risk in the playground. The key messages are: t 5IFHPBMJTOPUUPFMJNJOBUFSJTL CVUUP weigh up the risks and the benefits. t 1MBZFOWJSPONFOUTUIBUMBDLDIBMMFOHF prevent children from developing their abilities. We canâ€™t turn the clock back to our own, sentimentally remastered childhoods, but we can bring a more common sense approach back to childhood. O &%(SJGGJO-POHMFZJT$&0PG/BUVSF1MBZ8"
Listening to the kids The Commissioner for Children and Young People Ms Michelle Scott has set about making it easier for children and young people to lodge official complaints. â€œ
e donâ€™t get many complaints from kidsâ€Śâ€? This was a comment I heard regularly when I began asking government agencies back in 2009 about the types of complaints they were receiving from, or on behalf of, children and young people.
Some believed that the absence of complaints indicated that children and young people had nothing to complain about. Sadly, inquiries into child abuse and neglect around Australia show that for too many the opposite has been true. Independent inquiries in Australia and internationally consistently cite the same reasons that children and young people give for not reporting abuse. These include not knowing how or who to complain to and fear of not being believed or other repercussions if they do make a complaint. 26
Children and young people, who are among the most vulnerable in our community, may experience a range of barriers to lodging complaints if they experience mistreatment or have concerns about services. Power imbalance is a major hurdle, as is a general fear of having their complaint dismissed and not taken seriously. Many children and young people report they donâ€™t know where to go to complain, or how to do so and that complaints processes appear too intimidating. More than ever we have a responsibility to ensure that children and young people know what to do when they have a grievance, and feel safe and empowered to complain. In 2009, I consulted with a number of children and young people to find out what issues and challenges they faced when
making a complaint, and what they needed to make the process easier. Their feedback was used to develop the commissionâ€™s complaints guidelines, published in 2009, Are You Listening? Guidelines for making complaints systems accessible and responsive to children and young people. The aim of the guidelines is to help government agencies make their complaints processes accessible and responsive to children and young people and those caring for them. I have recently revised and updated complaints guidelines which are available on the website at www.ccyp.wa.gov.au I encourage all agencies and businesses that deal with or deliver services to children and young people to use the publication to help them develop complaints systems that are more child-friendly. O medicalforum
Empowering Children to Say No Teaching children about their own personal safety is a powerful way to break the cycle of child abuse, says police officer and educator Andrea Musulin.
t is a sobering reality that in such an advanced society as Australia, the ongoing tragedy of child sexual abuse, child pornography and child exploitation occurs. Statistics clearly show that most children who are abused are abused by someone they know and trust and that most STIs in the country are in children.
It is a conservative estimate that 40,000 children will be sexually abused each year in Australia and most won’t tell anyone about it. What is becoming a major concern is that one third of all reports to authorities are incidents involving adolescent offenders, suggesting that a victim-to-offender cycle is occurring. While not all children who are victims of childhood sexual abuse go on to offend, we do know from research being conducted in Australian prisons that most who offend were offended against as children. Based on this knowledge, if we can save one child from becoming a victim, we have the capacity to save several hundred children in the future. There are two types of child sexual offenders – the fixated and the non-fixated offender. Fixated offenders can abuse up to 500 children in their lifetimes. Many of those children will repeat or re-enact the behaviour and abuse. It is estimated that one in four children will experience some form of unwanted sexual contact before they reach the age of 18. The issue of child sexual abuse appears so widespread that it is important to educate children at school, in the home and within the community on ways in which they personally can play a part in keeping themselves safe. Undeniably, early education is the first and best line of defence we can provide children as we know that in most of cases, but not all, the child is away from the primary care giver when the abuse occurs. The reason for this and why so many Australian children are being abused is because they lack the necessary information to resist, which I will explain later. The grooming process of an offender is so well orchestrated that children become easy prey. Then, once the offence has occurred, they feel they cannot disclose the abuse because the grooming process instils so much fear that it renders the child silent. medicalforum
QAndrea Musulin teaches a Protective Behaviours lesson
Children often prefer to suffer in silence than speak out and risk punishment, reprisals or other terrible things that might happen to them, their family or the even the perpetrator.
provided to them in many different forms and from many different sources. It is the knowledge that it is not OK to steal that creates the resistance and in most cases the child will refuse or tell someone about it.
It is extremely important that we empower children to apply the preventative strategies of The Protective Behaviours Child Safety Program. The program teaches children skills in a non-threatening and non-sexual way. It reinforces to them that they have a right to feel safe and if they don’t feel safe to speak about it to someone they trust.
If we apply the same model to sexual abuse where an adult or an older child asks a seven-year-old who has had no sex education and knows very little or nothing on the subject to participate in sexual game, that child will be more likely to agree. Without prior knowledge of the subject, it is harder for them to resist someone they know, trust, love or live with.
To best protect children from a young age we also need to deliver sex education at a level that is appropriate for their age. This is not to say we educate children about having sex at a young age, though for teenagers we definitely need to start having these conversations. We also need to talk to teenagers about pornography and sexualisation of females, particularly, but males as well. Sex education can be a crime prevention tool and needs to start around the age of six. An analogy is if a seven-year-old child is asked by an adult or an older child to steal something from a shop, they can resist based on a solid prior knowledge that stealing is wrong. This knowledge is
Protecting our children from sexual abuse depends on two things – education and empowerment. The sexual abuse of Australian children is becoming nothing less than a silent genocide and it is time we all take responsibility for protecting children. This includes those who are legally subject to mandatorily reporting incidences of child abuse and those who are not. We all have a moral responsibility to report and act on behalf of children. O ED: Andrea Musulin is a police officer and &YFDVUJWF0GGJDFSPG1SPUFDUJWF#FIBWJPVST WA and visits schools delivering Child Safety Education and Training. 27
The Golden West Location, location, location are the buzz words in real estate. But just like life, it’s a lot more complex than that. Three property specialists give a snapshot of the Perth scene. However, while price is an important consideration, David acknowledges that you can’t ignore location completely.
Real Estate Institute of WA (REIWA) President David Airey, Damian Collins from Momentum Wealth and Pindan’s Nick Shinner all agree that there are pockets of strong activity in the metro property market and the future looks reasonably optimistic.
“Our data is showing that most of the activity is happening in the $600-$800,000 range. You have to remember that WA still has the strongest population growth in the county and that means there’ll be ongoing pressure on the housing sector. This is already reflected in the trend towards multi-residential dwellings as Perth spreads further north and south. Premium locations are always going to be near the city and you only have to look at our freeways during peak hour to see that!”
David Airey underlines the point that when you’re looking at the economic topography of Perth, it’s too simplistic to focus on location, QDavid Airey location, location. “The Perth property scene is less about particular suburbs and more about priceranges. So a good question to ask is, ‘which price ranges are active and accessible’. It’s no secret that the premium property market has taken a bit of a dive so it’s a good time to be looking around if you’re a buyer.” “At the other end of the market there’s strong turnover in first-homes and that applies whether it’s a second-hand villa in Maylands or a new home in Baldivis. First home buyers make up about 22% of the market and it’s ticking along nicely.” David makes the point that about 10% of the market consists of investors and, at the moment, the lie of the land is rather flat.
“People looking to invest are a bit thin on the ground right now, and they remain unconvinced that Perth is the place to buy, so some are looking elsewhere.” About 70% of the market consists of ‘tradeup’ buyers. They’re people who already own a property and want something bigger, better or different. “Those approaching retirement fall within this group and they’re thinking about being closer to the beach, nearer to grandchildren and, in some cases, the city. The latter demographic may well be looking at a warehouse apartment in Northbridge or Perth.”
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Media reports concerning the rental market swing from upbeat to doom and gloom. Of course, the outlook depends on where you happen to be standing at the time. “Some investors, naturally enough, are looking for strong rental returns but it’s clear that rents have cooled and probably peaked. The vacancy rate has returned to normal levels and consequently there’s more competition between landlords and tenants. Rental returns are still relatively high and close to those in Melbourne and Brisbane.” The commercial property market is not REIWA’s prime focus nonetheless David makes a few observations regarding the CBD. “The commercial area is a bit soft and that’s probably linked with the downturn in the mining sector. There’s a flood of new properties in the city such as 140 William, Elizabeth Quay and Raine Square. The latter development added around 20% more floor space to the CBD alone.”
Damian Collins, studies Perth property from a number of angles. He sits on the REIWA Board, is a member of the Australian Institute of QDamian Collins Management and is an accredited mortgage consultant. “The supply side of the market is tightening with only 8600 properties for sale which compares with nearly 14,000 this time last year. A balanced market has about 12,000 properties for sale, so it’s safe to say that the current market is undersupplied.” Given this situation, it’s no surprise that prices are heading in a positive direction. “The March quarter saw a new median medicalforum
Poor Bear the Brunt
of $510,000 and that’s up 2% from the same period in December. Having said that, I don’t think the June quarter will see further rises in residential property.” “The areas within 10km of the CBD with the strongest sales activity include South Perth, Belmont, Bayswater, Bassendean, Victoria Park and Stirling. A hot-spot for first home buyers is the south-east corridor, places such as Gosnells and Armadale.” The rental market is ‘patchy at best’, according to Damian. “Vacancy rates have increased slightly to 3% which is symptomatic of a balanced market. The median rent sits at about $480 a week. Some areas are in high demand but the premium end is soft. From the tenants’ angle, low interest rates and high weekly rentals have encouraged them to look seriously at buying their own homes.” Commercial property exhibits strong demand, says Damian despite the question marks hanging over the resource sector. “The Perth CBD is fetching $835 per square metre for premium office space and the vacancy rate is about 5.7%. There has been a softening in demand, so the latter figure is likely to increase.” “There are high vacancies in the retail market which is really struggling. It’s bleak, with tenants in arrears and inflated rental prices.”
Nick Shinner, from Pindan, is upbeat about the Perth market. “The next 12 months look pretty positive due to the relatively reduced number of listings, low interest rates, increasing population and a strong local economy. Consumer confidence is positive with a general feeling that WA prices are on the rise.” “There’s certainly been an increase in sales volumes over the last 12 months translating to a 25% increase compared with a year ago. The other factor is the Federal election. Once that’s finalised and there’s a settling of the mining sector we believe the WA market will surge again.” “In fact, many experts are tipping Perth to be the next boom market.” O
By Mr Peter McClelland
Housing Affordability and Health 72 Specialists respond with their experience of the impact of Perth's high cost of living.
WACOSS says the health of the socially disadvantaged is adversely affected by the relatively high cost of housing/ rental. Do you have experience of someone from this disadvantaged group seeking help for a health problem made worse by financial stress? Yes
Comments ED: There were strong views on Perth’s cost of living with a number of the 36 specialists who chose to comment citing the affordability of housing as a serious impediment to good health. “For people who are not affiliated with the mining boom, Perth has become very unaffordable for housing, groceries and fuel. Public housing and better transport (more rail services & wider spread) would make Perth more accessible.”
WACOSS CEO Irina Cattalini says the lack of affordable housing leads to poor health for WA's most vulnerable.
estern Australians live in one of the wealthiest states in one of the richest nations at a time when the living standards of most of us have never been higher. Yet there is a pervasive myth within our community that we are all feeling the impact of rising living costs.
In fact, it is low-income individuals and households who struggle the most with the recent increases in the cost of living. They are at risk of slipping into poverty because they spend a much higher proportion of their income on essential items. The cost of these has increased compared with many luxury goods. The latter have fallen in relative terms thus benefiting higher income households who have greater disposable income. The lack of affordable housing is the most pressing issue facing low and fixed-income households. It is the biggest contributor to financial hardship and the most pronounced risk factor relating to family crisis. A significant contributor to the low rate of housing availability is the disproportionate growth in the WA population compared with the number of dwellings being built. Coupled with this, the dramatic increases in the cost of gas, electricity and water in recent years has meant that low-income households – who spend a greater proportion of their income on utility bills – are also feeling the pressure of the rising cost of utilities far more than other Western Australians. This is exacerbated by the fact that many low income families live in homes that are not energy efficient and, given their financial position, are unlikely to be able to afford the financial investment to install energy efficient alternatives. It’s well known that some low income earners put their health at risk by not heating their homes during winter in an attempt to keep costs down. Households under financial stress due to cost of living pressures are often forced to make difficult choices, such as balancing the nutritional quality of food against its actual cost as a proportion of a weekly budget. There is no doubt whatsoever that the purchase of less expensive, energy-dense foods is a significant factor linked to poor health outcomes. As a community we should be concerned by the risks that poor nutrition presents to children growing up in restricted income households. There are well-researched reports on physical and cognitive development under such circumstances and the impact on longer-term health prospects. Furthermore, there is strong evidence that dietary patterns and taste preferences established during childhood are likely to carry on into adulthood. The risk here is that children raised on a poor diet are predisposed to continue eating unhealthy foods even if their circumstances change. Poor diet has real, long-term consequences relating to the cost of chronic disease for our struggling health system. It is one example of how a broader social and economic factor such as housing impacts on health outcomes and access to health care.O
Knowing is One Thing... Prof Steve Wilton is edging toward a major breakthrough for those suffering some forms of muscular dystrophy, commercial realities permitting. so good to date, the FDA have approved dose escalation. Interestingly, they have discovered individual variations in affected boys, in their innate dystrophin production and response to treatment that suggest some cofactor or secondary gene is involved.
Early last year we interviewed Prof Steve Wilton PhD, now Director of the Australian Neuromuscular Research Institute at QEII, but the write-up stalled because of ongoing positive developments. Commercial realities sometimes hinder the adoption of discoveries that researchers feel confident will help patients with rare disorders.
If this compound (Eteplirsen) becomes a marketplace reality it will be the first genetic drug based on intellectual property developed in Western Australia.
These lessened for this group with the announcement in April last year that they had extended a licensing agreement with US biotech company Sarepta Therapeutics. This was to develop new treatments based on its research into Duchenne Muscular Dystrophy (DMD), offering new hope to boys who inherit this incurable musclewasting disease. The research won Profs Steve Wilton and Sue Fletcher the WA Innovator of the Year Award last November. DMD is caused by specific errors in the dystrophin gene that lead to drastically reduced production of the dystrophin protein, which Steve describes as an essential intracellular “shock absorber” for muscle fibres. Without this protein, muscle fibres become fragile and degenerate. Affected boys are usually confined to a wheelchair before age 12 and often succumb to the disease by age 30. To understand the basic innovations behind this research, you need a brief understanding of how the dystrophin gene encodes dystrophin proteins and the role of exons and introns, as Steve explains. “The first step in gene expression is to make an RNA copy, called a pre-message, and that consists of all the introns and exons in the gene. The exons code for the [dystrophin protein] amino acids and the introns are intervening sequences. The premessage cannot be translated [into the final protein] until all the introns are removed and the exons are joined or spliced together precisely.” “The dystrophin gene, which is large and complex, has 2.3 million bases [A,C,G or T] in a particular sequence. Just one change in the sequence can stop translation at that point, and production of functional dystrophin is lost.”
“The ongoing Phase IIB trial in Ohio indicates that boys continually treated with Eteplirsen are unequivocally making dystrophin and have maintained their same level of ambulation over 84 weeks. This result is unprecedented in the history of the disease.” With many more mutations in the dystrophin gene that can cause DMD, some treatments will have to be individualised, a cost barrier to development for what is a rare disease anyway. Steve estimates they potentially need 100 different ‘genetic drugs’ but many are now in the final stages of development. He clearly delights in applying research to clinical practice. QProf Steve Wilton
stability. In the milder form of the disease, Becker Muscular Dystrophy, the mutations are in the same gene but you end up with slightly shorter ‘shock absorbers’ which may be clinically normal. So what we are doing is taking a Duchenne boy and giving him the ability to alter the expression of his non-functional dystrophin gene so that he makes a Becker-like protein.” In effect, they are skipping the abnormal exon, hence the “exon-skipping” description of their technology. “We have developed compounds that can redirect the cell splicing to by-pass the abnormal exon so the induced dystrophin isoform provides strength and stability to muscle fibres. The compound that has been under clinical trial targets exon 51 to restore functional dystrophin in about 1 in 10 boys with DMD.”
The dystrophin gene has 79 exons. One or two are affected in the most common type of mutations in DMD.
Backed by favourable results in genetically engineered mice, then ‘proof of concept’ successful trials from injecting the compound into one foot muscle of affected boys, the developers are pushing on with Phase IIB clinical trials in the USA.
“We know that Duchenne is the most severe form of a disease where the ability to form a ‘shock absorber’ protein in cells is lost, proteins that give cells strength and
Given by intravenous infusion weekly, it is hoped that longer treatments with more significant doses will yield better clinical results – response and safety have been
“We have DMD boys and young men who are getting weaker and weaker and we have compounds that could potentially make a difference. Duchenne is one rare disease but the underlying strategy of splice switching can be applied to other conditions, such as Spinal Muscular Atrophy, the second most common autosomal recessive disorder and leading genetic cause of death in children under two.” “We are exploring other diseases where the same technology may be applicable – Parkinson’s, Huntington’s, cystic fibrosis, Alzheimer’s – the right candidate gene and target site have to be identified and then compounds must be made to alter disease gene expression.” “It’s been estimated that about 15% of all human mutations cause abnormal splicing or the processing of the gene messages. We have the ability to correct abnormal splicing, in these cases.” He says the DMD trial compounds can be made in sufficient amounts with the right production facilities but by his rough estimate, that will involve at least a thousand-fold increase in current production. O
By Dr Rob McEvoy
Parent queries on childhood vaccinations F
or young parents, the constant stream of health information creates a potential minefield that is challenging, particularly in the field of childhood immunisation. Never before has so much information (and misinformation) been so readily available. In 2010, adverse events with CSL FluVax renewed television, online and print media interest in the topic. Doctors are expected to be all knowing in a field that is rapidly changing, highly publicised and increasingly scrutinised.
“I was invited to a chicken pox party – isn’t it better to get natural infection?”
As a specialist in the field, I am frequently asked questions by both parents and colleagues. Some of these are easy to answer, some are much more difficult. I thought I would share some of the concepts I use when answering certain questions.
“With so many new vaccines, aren’t we overloading our children’s immune systems?” As a child growing up in the 1970s, immunisation was much simpler. We were given our triple antigen (Diphtheria, Tetanus, whole cell Pertussis vaccine), polio and measles vaccines; girls received their Rubella vaccine. In contrast, vaccinations on the 2013 national immunisation program for children protect against 15 vaccinepreventable diseases. Despite this increase in protection, the antigenic load in our current immunisation schedule is significantly lower than in the 1970s. Previous vaccines were relatively heterogenous mixtures containing many extra antigens that could not be removed by purification. Today, vaccinations are highly purified and contain limited numbers of antigens. The child’s immune system has millions of cells, each designed to uniquely react to a foreign sugar or protein. The volume of new antigens in immunisations is miniscule in comparison to all the foreign antigens a child is exposed to each day.
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“Why do some children get the disease despite being vaccinated?” Lifelong immunity is rarely achieved, whether by natural infection or immunisation. When infection following vaccination occurs, the illness is usually much milder. Breakthrough infections are very rare with some diseases (e.g. following either natural infection or two doses of measles vaccine). Immunity for some infections is short lived: immunity against pertussis (whooping cough), either by natural infection or immunisation, usually wanes after a few years. The only way to combat this is by regular boosters. Ensuring neonates and young infants are protected by immunising parents and the child as soon as possible, is paramount.
“What about herd immunity?” Having high immunisation uptake makes it more difficult for vaccine preventable diseases to circulate. This “herd immunity” effect is powerful but requires high uptake across the whole population. There are many areas in Australia where uptake is insufficient and outbreaks continue to occur. The most effective way to prevent outbreaks is by encouraging both individuals and the community to be vaccinated.
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“Why do you vaccines contain so many additives?” In addition to the immunising antigen, vaccines may contain adjuvants, preservatives and other residuals. Adjuvants, such as aluminium, increase the strength of the immune response. They have been used in vaccines since the 1930s and extensive research has demonstrated the safety of aluminium in these quantities. The volume of aluminium in vaccines is significant lower than many foods consumed by infants and young children.
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For many diseases, both immunisation and natural infection can protect against further infection. Natural infection is not without risks – that is why we offer immunisation. For chicken pox, 1 in 10 children will get a significant bacterial skin infection, 1 in 50 will develop pneumonia and 1 in 4000 will develop cerebellitis or encephalitis. For measles, 1 in 15 will develop pneumonia, 1 in 100 will develop seizures and 1 in 1000 will develop encephalitis, many of whom will die. The length and strength of protection following natural infection to some vaccine-preventable diseases, such as chickenpox, may be more robust than that observed following vaccination. This is not the case for all infections. And waning immunity following vaccination can be rectified, when needed, with booster doses.
Preservatives, including antibiotics (e.g neomycin), may be included in vaccines to prevent contamination. Thiomersal, a mercury containing preservative previously used in childhood vaccines, is not present in any of the vaccines on the National Immunisation Program for young children. Some compounds used in the manufacturing process, may be detectable in minute quantities. Formaldehyde, for example, is used to inactive viruses and toxins and may be detectable in vaccines. The human body produces formaldehyde as a necessary part of DNA and protein synthesis. A child has more than five times as much formaldehyde circulating in their body compared with the volume contained in vaccines. medicalforum
Leading the Herd
By A/Prof Christopher Blyth, Infectious Diseases Paediatrician, PMH. Tel 9340 8606
“So what about influenza vaccines?” Young children, the elderly and those with underlying medical conditions are greatest risk from influenza. Hundreds of West Australians are hospitalised with influenza each year and many die of influenza-related complications. Immunisation is the most effective way of preventing influenza. The effectiveness of influenza vaccines vary each year depending on the circulating strains. In general, an influenza vaccine will prevent 2 out of 3 children and adults from getting influenza. The significant adverse events seen in 2010 following immunisation with one brand of influenza vaccine (CSL FluVax) resulted in many losing confidence in influenza vaccination. It also highlighted the need for a comprehensive and coordinated vaccine safety system in WA. Western Australian Vaccine Safety Surveillance (WAVSS; www.health. wa.gov.au/vaccination/wavss.cfm) was created to identify, review and report adverse events following all vaccinations. The high number of reactions following influenza vaccination has not been observed in Western Australia since 2010 and public confidence in influenza vaccination is returning. It is recommended that young children, particularly those with with underlying medical conditions, receive influenza vaccination but should not receive the CSL FluVax. O Author declaration: no competing interests.
ll o P e
Vaccination and ‘Herd Immunity’
Of the 72 specialists who responded in our latest E-Poll, there was overwhelming support for this promotion of vaccination.
‘Herd immunity’ is said to decrease the circulation of some preventable viral infections in our community. All considered, should this be promoted by the profession as a reason for parents to vaccinate their child/children? Yes
Dr Katie Attwell, PhD, is taking the immunisation message to the vax sceptics.
octors, you have a problem. Some of your patients think you are on the payroll of Big Pharma, seeking to fill their children’s bodies with toxic chemicals, so they won’t let you immunise their children. Your problem is increasingly becoming everyone’s problem as vaccine-preventable diseases return. Perhaps you feel powerless to challenge the phenomenon of parents thinking they know your job better than you do. The Immunisation Alliance of WA seeks to support your professional integrity and protect public safety by promoting immunisation. We believe that a decline in herd immunity will have devastating consequences. We’re a not-for-profit organisation made up of parents and health professionals, funded by donations, the WA Health Department and industry. In 2013, we will be implementing the “I Immunise” campaign targeting low immunisation rates in the Greater Fremantle area. I proposed this campaign to the Alliance after realising that the informal “caring circle” I had joined after having a homebirth was a biohazard, putting my newborn son at risk of infectious disease.
advertisements, for a month-long campaign that will also target social and traditional media. A website will provide additional information. The posters feature beautiful, natural parents and list their credentials as breastfeeders, homebirthers, vegetarians, organic eaters and more, simultaneously stating their support for immunisation. The role models in the “I immunise” campaign will de-couple non-vaccination from ethical parenting practices. Please help us by displaying the posters when they’re produced; not just on your notice board but also in your treatment rooms. Talk to your patients about them, and don’t assume that all ‘alternative’ folks are anti-vax. Some may turn out to be our greatest supporters, and can be directed to the Alliance to get involved. The Alliance is conducting research as to the efficacy of the campaign, and its applicability for roll-out in Denmark and
Humans are herd animals. I was taught about cloth nappies by my homeQThe I Immunise posters that will be displayed in communities in Fremantle, birthing friends. I Denmark and Margaret River. was encouraged to home-birth by my natural-birthing friends. Margaret River. If you are in these areas These practices are packaged together to or greater Fremantle, please publicise this form a collective mentality and, ultimately, research to your patients who are concerned a stereotype. Unfortunately, not vaccinating about immunisation (see above). It is an is framed within this community as opportunity for them to have their views virtuous. Outsiders unwittingly buy into taken seriously. They will also be able to this stereotype; my fantastic GP and my advise us on how to best target local State MP both expressed surprise that the campaign. I was pro-immunisation. The “I Immunise” project can be The “I Immunise” campaign is a series contacted on 0421 925 775. Please ‘Like’ us of posters targeting the alternative on Facebook: Immunisation Alliance WA. community. These posters will be displayed Email us at email@example.com. We long-term in your surgeries, maternity welcome doctors in our Facebook group hospitals, child health clinics, schools, (and our committee) to help swimming pools, libraries and private counter misinformation. O businesses. They will also appear on billboards, bus shelters and newspaper 33
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Clostridium difficile infection
By Dr Oliver Waters, Gastroenterologist, Coastal Gastroenterology, Suite 41-42 Hollywood Medical Centre, Nedlands. Tel 6389 0631 www.coastalgastro.com.au
lostridium difficile infection (CDI) has been seen as a hospital or residential care facility problem but it is fast becoming a major health problem within general practice, with increasing rates of community acquired CDI and recurrent CDI. Greater understanding of the role of the gut flora in health and disease is leading us to develop new treatments as well as revisit old ones.
How big is the problem? 3% of the ‘normal’ population is colonised with clostridium difficile (c.diff) but hospital inpatients and residents of care facilities have rates of 25-50%. CDI is now the most common hospital acquired infection – approximately 0.7 cases per 1000 hospital bed days. In the last decade, community acquired CDI has emerged and now accounts for approximately 40% of all cases. Interestingly, people with community acquired disease have significantly less risk factors, they are younger (<65yrs), immunocompetent and less likely to have had recent antibiotics. Pregnant and peripartum women seem to be a significant at risk group – perhaps related to the fact that 50% of neonates are colonised with c.diff but seem to lack toxin receptors, so they shed spores but do not develop clinical disease.
toxin producing c.diff species may confer some protection. Antibiotic exposure is a key patient risk factor, with broad spectrum antibiotics conferring the greatest risk, but even metronidazole or vancomycin can precipitate CDI. Other risk factors include age > 65yrs, chemotherapy or malignancy, recent hospitalisation and gastric acid suppression. New risk factors are coming to light such as polymorphisms in genes linked with high IL-8 levels as well as an individual’s ability to mount an IgG response to the toxin.
Who should be tested? With no apparent benefit from treating asymptomatic carriers, laboratories generally only test diarrhoeal samples, and there is no need to check for eradication once CDI symptoms have settled.
The source of community acquired CDI is unclear. It is known to be a zoonosis and is probably a contaminate in some foods, so there is a great deal of suspicion around the use of antibiotics and modern farming techniques, but there is no proven link.
CDI is also a problem in inflammatory bowel disease (IBD) and so we recommend that CDI be excluded at the start of any flare of IBD. Luckily, the new GDH enzyme assay combined with rapid PCR testing now means a single stool sample is 98% sensitive, so multiple samples are no longer needed.
Why do only some individuals develop CDI?
What are the first line treatments?
There are both bacterial and host factors. C.diff is a gram positive spore forming bacillus and the spores are highly resistant to degradation. The bacteria can produce toxin A, toxin B (10-times more potent than toxin A), as well as binary toxin. The type(s) and amount of toxin produced is an important disease factor, and hypervirulent strains tend to produce large amounts of multiple toxins. Interestingly, being colonised with a non-
CLOSTRIDIUM DIFFICILE TESTING Do test stools of: t "OZQBUJFOUXJUIQFSTJTUFOUEJBSSIPFB t 1BUJFOUTXJUIGMBSFTPG*#% Do not test stools of: t "TZNQUPNBUJDQBUJFOUT t $IJMESFOZST t "GUFSTVDDFTTGVMUSFBUNFOUPG$%* NB. Testing a single sample is 98% sensitive (check with local laboratory)
As always, prevention is best. Good antibiotic stewardship has been shown to reduce CDI as has good infection control methods such as regular hand washing with soap and water (spores are resistant to alcohol hand rubs). The highly resilient c.diff spores have been cultured from patient rooms many weeks after a case of CDI has vacated the room. It has also been cultured from symptomatic patients’ toothbrushes. Consequently, a patient’s room and bathroom need a deep clean with bleach and toothbrushes should be changed during treatment. The seminal antibiotic trials showed that metronidazole and vancomycin had equal efficacy in mild to moderate CDI with vancomycin being more effective in severe disease. Metronidazile 400mg TDS for 10 days ($6) is first line therapy for economic reasons with 10 days of vancomycin 125mg QID ($200) held in reserve for severe disease or recurrence (about 25% of cases). A new antibiotic, fidaxomicin ($2500) has been approved by the FDA for use in CDI and has similar efficacy to vancomycin but with significantly less recurrence.
Do probiotics help? Possibly. Trials have shown mixed results and, really, there is only sufficient evidence for the use of Sacchromyces boulardii (1g daily for one month) for recurrent CDI, although recent college guidelines from the USA did not support probiotic use even in recurrent disease. Combinations of Lactobacillus acidophilus and Lactobacillus casei, and S. boulardii, and Lactobacillus rhamnosus have been shown to reduce rates of CDI as well as antibiotic associated diarrhea not caused by c.diff. However, a 2008 meta-analysis calculated that the number needed to treat to prevent one CDI would be approximately 210, even in hospitalised patients. Therefore, widespread use of probiotics cannot be advocated, but may be useful in very high risk patients or those who have had previous CDI. Having said that, bacteraemia and fungaemia have been documented in immunosuppressed patients taking probiotics.
Faecal microbiota transplant (FMT) The aim of any treatment of CDI is to restore the normal gut flora and you could describe the FMT as the ultimate probiotic. The first FMT for CDI was done in 1950s, but FMT went out of favour with the advent of new antibiotics. A recent trial from the Netherlands showed an 80% success rate for FMT compared to 30% for vancomycin in recurrent CDI. It is technically easy to perform and appears to be safe, but the major barrier seems to be the stigma for both patients and doctors. However, we will probably see more FMT performed for difficult to treat recurrent CDI.
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Declaration: the author has contributed to Medical Forum’s production costs. 35
An approach to referred leg pain
By Dr David Holthouse, Pain Neurosurgeon, Hollywood Private Hospital. Tel 9381 2422
any cases of referred leg pain resolve with conservative management. Imaging is usually required for radicular pain and MRI is the investigation of choice if referring for a surgical opinion. If imaging shows minimal or no compression then steroid injections, especially epidural/nerve sleeve injections, may be indicated. Motor weakness and cauda equina symptoms merit urgent referral.
What the history can reveal Dermatomal pain patterns and clues to underlying pathology are important to elicit. Within the pain history, these may raise concerns: t SBEJDVMBSQBJO XJUITIPPUJOHPSCVSOJOH components, suggests nerve entrapment or referred pain from facets or discs t BTTPDJBUFEOFVSPMPHJDBMTZNQUPNT TFOTPSZ or motor) suggest nerve compression t MPPLGPSSFMFWBODFJOBTTPDJBUFEHFOFSBM symptoms (e.g. weight loss, sweats) and previous medical history (e.g. back surgery, injections, or malignancy). t POTFUUIBUJTSFMBUFEUPUSBVNBDPVMEEFOPUF an acute disc injury or a facet joint sprain. t TMPXXPSTFOJOHXJUIQBJOPOXBMLJOH and relieved by rest or a flexed posture suggests degenerative spinal stenosis. Vascular compromise and peripheral neuropathy (e.g. stocking distribution sensory changes) are part of the differential diagnosis. A case could be made for observation if there is a short history associated with minor injury, without neurological signs. This is not so for severe pain, a history of a significant injury, bilateral symptoms or the need to clarify underlying pathology for occupational reasons. In todayâ€™s medicolegal world, most cases of presumptive radicular pain end up having some imaging.
The role of imaging This is usually required. While MRI is usually the most useful imaging, EMG, CT and plain radiography all have a role in specific cases. MRI will identify disc protrusion, sequestration, tumour, facet arthropathy, spondylolisthesis and more. MRI imaging should be performed on radicular pain that is: persistent (more than a month); severe; or associated with motor signs, significant sensory signs or other worrying systemic features. The only barriers to this non-ionising imaging modality are cost, availability, the presence of contra-indications (e.g. pacemakers), or claustrophobia. MRI is non-rebatable unless ordered by a specialist investigating radicular pain. As a result, the options for a general practitioner are limited and CT scanning has important limitations, particularly the imaging of soft 36
tissues and failure to pick up smaller disc protrusions, especially with foraminal disease. Plain films have a limited role in the investigation of radicular pain. If instability or spondylolisthesis is suspected, they can be invaluable. Standing AP and lateral lumbar views and/or lateral lumbar flexion and extension views can reveal much about spinal stability. Radicular pain can be associated with scoliotic deformities.
How accurate examination helps Often MRI shows multiple potential causes of radicular pain that only a good neurological examination can sort out. Depressed reflexes (ankle = S1 radiculopathy; knee = L4) or muscle weakness (great toe extension = L5; great toe flexion = S1; knee extension = L3 and L4; hip flexion = L2 and some L3) have classical associations. Sensory dermatomal disturbance can be useful â€“ classically we say, â€˜stand on S1, kneel on L3 and sit on S3â€™. The dorsum of the foot corresponds to L5 and, the lateral border to S1. The posterior thigh and calf is associated with S2. The lateral aspect of the shin is usually L5 and the medial aspect anteriorly L4. Pain radiating into these areas also provides a guide to the level involved. Sensory findings and pain can also be found in peripheral nerve problems such as tarsal tunnel syndrome or peroneal nerve compression syndromes. Clinical examination is different to pure dermatomal involvement; peroneal problems will not cause hamstring reflex pain whereas a L5 radiculopathy might, for example. EMG is also helpful to differentiate.
Ideas around management This is dependent on a good diagnosis. Once radiculopathic pain is diagnosed, management can be initiated. Conservative management usually involves reduced activities (especially lifting, running and weights) and the use of analgesics and antineuropathics. Paracetamol and antiinflammatories may help radicular pain but usually the opiates or anti-neuropathics are more effective. For mild-moderate neuropathic pain use paracetamol/codeine combinations in the first instance or perhaps low dose tramadol. If this is insufficient, for short term,
consider oxycodone PRN or short duration SR oxycodone. The naloxone/oxycodone combinations reduce the side effect of constipation and are less likely to be abused or sold. Either pregabalin or gabapentin may be added to reduce pain; start low and gradually increase because of potential neurocognitive side effects. If the pain is of sufficient severity and the patient is not currently a candidate for surgery, then steroid injections may be employed. The options are facet joint, nerve sleeve and epidural injections. These can be arranged through radiological practices relatively rapidly but selecting the correct location for initial injection is important. Generally, for radicular pain a combination epidural/nerve sleeve injection is best. For lateral discs however the nerve sleeve injection alone is probably better. Pain specialists also perform these blocks, usually under fluoroscopy. The principle advantage of pain specialists is that the patient is usually admitted as a day case to a hospital, which in turn enables sedation to be given and possibly larger amounts of local anaesthetic volume, allowing for a wider spread. The choice of steroid may also affect the result. Finally comes surgery. Against surgery are the absence of significant compression, a likely facet joint problem, medically unfit for surgery, extensive degeneration/scoliosis making open surgery less simple, patient preference, short duration of pain and a noted improvement already. Surgery is usually microdiscectomy. More significant disease may require a more extensive decompression (e.g. laminectomy), or even a fusion. The things that may influence the choice to move on to surgery early are large disc protrusion, severe pain, need to return to occupational fitness, failure of conservative therapy/ injections, the presence of cauda equina symptoms and patient preference. O Declaration: This clinical update is supported by an independent educational grant to Medical 'PSVNCZ)PMMZXPPE1SJWBUF)PTQJUBM
Nutritional therapy in chronic kidney disease C
hronic Kidney Disease (CKD) affects about 1.7 million Australians over the age of 25 according to Kidney Health Australia (www.kidney.org.au). Many doctors are unaware that nutritional therapy can not only help prevent CKD, but it can also reduce its rate of progression, decreasing patient morbidity and mortality.
Risk factors The leading cause of CKD is diabetic nephropathy. Other risk factors include: t t t t t t t
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It is recommended that adults with one or more risk factors are screened annually for CKD by checking estimated or measured glomerular filtration rate (eGFR) and/or proteinuria. For those with established CKD or at high risk, aggressive diet and lifestyle management should be instituted. This includes weight loss, smoking cessation and close diabetes control, as appropriate. CKD is one of the most potent risk factors for cardiovascular disease due at least in part to its effect on phosphate levels, promoting calcification and atherosclerosis.
CKD brings with it a two- to threefold increased risk of cardiac death.
Nutritional management of CKD All patients with CKD are best referred to a renal team that includes a dietitian for a comprehensive nutritional assessment. From Stage 3 (GFR 30â€“59 mL/min/1.73m2) dietetic reviews every 6â€“12 months are helpful, as are more frequent reviews for stages 4 and 5. Increased uraemia, as eGFR declines, frequently leads to malnutrition from anorexia, nausea, xerostomia and taste changes. Reducing uraemic toxin production through dietary manipulation can help. Contrary to popular belief, low protein diets are not indicated (KHA-CARI 2012) as the limited benefits of protein restriction are outweighed by the adverse effects of nutritional restriction. Dietary protein targets are aimed at 0.75g/kg body weight/ day and above.
By Jo Beer Senior Dietitian and Diabetes Educator. Tel 0403 938 747 Dietetic input can also assess and react if patient biochemistry is below optimum levels or above appropriate ranges e.g. sodium, phosphate and potassium. This is particularly valuable to the patient, as often they avoid some of their favourite fruits and vegetables such as bananas and potatoes (high in potassium) when there is no need as they are within ideal range. A case of â€˜donâ€™t fix until brokenâ€™. The use of an Enhanced Primary Care program (EPC) or private insurance are ways to ensure CKD patients receive the benefits of optimised nutrition through a renal dietitian (see www.daa.org.au). References on request
CKD FACTS: DIETARY INTERVENTION t .BOZSJTLGBDUPSTPOUIFJSPXO FH diabetes) require regular dietary attention. t $POUSBSZUPQPQVMBSCFMJFG MPXQSPUFJO diets are not indicated in CKD. t /VUSJUJPOBMUIFSBQZIFMQTQSFWFOU$,% and reduce its rate of progression.
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Fast Action Can Cure Stuttering The days of 'wait and see' when it comes to childhood stuttering are long gone. Speech pathologists say action is the key. Sabine Van Eerdenbrugh has a highly personal reason for her research focus on children who stutter. Her son began to show QSabine Van Eerdenbrugh signs of the condition at an early age and it wasn’t long before it was clearly affecting him. “Our son began to stutter when he was three years-old and one year later it was obvious he was becoming more distressed so we initiated treatment. I happened to see a young man as a patient who was struggling with a severe stuttering problem and it was devastating for him. It’s so important to identify this condition as early as possible.” “There’s a clear link between childhood stuttering and issues such as bullying, poor school performance and negative responses from peers. And in adults there’s a far greater likelihood, up to six to seven times, that they’ll develop an anxiety disorder.” “A few misconceptions about this condition have led to highly negative advice. Comments such as, ‘just think before you
speak’ or ‘speak more slowly’ are classic cases. It’s a motor-circle and there’s nothing the child can do about it. It’s important to reaffirm the importance of being an ‘interested listener’ and responding to what the child says and not how they say it.” The Lidcombe Program is a behavioural treatment developed at the Australian Stuttering Research Centre at the University of Sydney. It is centred on direct and positive comments by a parent or carer within the family home. “It’s important for GPs to know if a speech pathologist is Lidcombe-trained. It’s an evidence-based treatment with the backup of randomised control trials and a history of positive long-term outcomes. It’s the treatment of choice supported by a lot of research and used by 80% of speech pathologists in Australia.” “It’s a simple program conceptually and I’m doing a PhD developing an internet application. A lot of people have difficulties accessing treatment because of distance or a shortage of specialised clinicians. This online modality will give families more flexibility.” Penelope Cromack is the President of the WA Private Speech Pathologists Association with more than 30 years clinical experience.
“There’s a feeling among some GPs that children will grow out of it or that stuttering can be part of normal development. It’s not, and early referral QPenelope Cromack and treatment is definitely required. Sometimes it’s left too late and we’re left with trying to teach older children ‘control’ techniques rather than curing the condition.” “It’s crucial for GPs to refer to a speech pathologist, particularly if the onset is sudden and there are secondary symptoms causing distress. There’s an old attitude that nothing much can be done until the child turns three. That’s definitely not the case.” “Some people still think that speech pathologists focus on the way a person speaks. It’s a lot more than that, specifically areas such as symbolic language skills, comprehension, expression and broader literacy. If you struggle with spoken language then it’s likely that written language will be a problem, too.” O
By Mr Peter McClelland
A Fountain of Knowledge We were recently alerted that www. HealthInfoNet had updated its information on kidney disease among Indigenous people. A quick look later, and it was obvious that Prof Neil Thomson and his team at ECU have made some major improvements to the website, which in its words, acts as “a massive Internet resource that informs practice and policy in Indigenous health by making research and other knowledge readily accessible”. The question is how useful is it to junior doctors? We asked Dr Leanne Heredia, who has just entered her GP training, to ‘test drive’ the website from the trainee’s perspective: "Aesthetically pleasing and straightforward to navigate, the Australian Indigenous Health Info Net website successfully provides easy access to the evidence base, and is an invaluable resource for not only GPs but anyone wanting to gain insight into the health issues of Indigenous Australians. “Despite a somewhat busy index page, 38
headings are clearly marked and topics can be found quickly via a simple click or entry into the search engine. The content is comprehensive, relevant, current and well structured, with an additional “plain language” option for many topics. With links to external resources and reference lists, the user can dwell as deep into a health topic as their heart desires. “The ‘yarning groups’ provide a perfect forum for questions and health discussions among users. It is only in questioning that we identify shortcomings, which in turn act as catalysts for future research and improvements in health practices and policies. “As a GP registrar, I find the CPD portals particularly useful for health updates. Providing epidemiological information, they also take a multidimensional approach to health issues encompassing the physical, historical, socio-cultural and economic dimensions that impact on management, prevention and policies and strategies to reduce disease burden in our society.
“The website is a fountain of knowledge with up to date information that is instrumental in helping people to form a holistic understanding of Indigenous Health QDr Leanne Heredia issues, which in turn allows for a more informed and thus better approach to clinical practice.” O ED: HealthInfoNet receives its core funding from the Federal Government under Closing the Gap, and the web resource primarily reports on translational research with a population health focus.
IT in Practice
Mental Tune-up Online Medical Forum talks to one GP who uses a NFP online resource to help his anxiety patients, the This Way Up Clinic. Due to flagging medical resources, doctors are making more use of online help for patients. And so it is for many disciplines, from mining to entertainment venues. Always, the online resource has to be easy-to use, effective and a cost-saving for the user. Involvement of a mentor is a bonus, which brings us to Dr Tim Koh and his use of the This Way Up Clinic (TWUC) website to help his patients with mood disorders, particularly anxiety and depression. At first glance the website looks very patient and doctor friendly. For the older obsessivecompulsive doctor the website may look clunky and icon driven but that’s how they like it these days. “TWUC is a not-for-profit organisation run through St Vincent's Hospital in Sydney. They have been providing online CBT for several years and use the clinic to both treat patients and conduct research on this treatment.” “This style of treatment has some big advantages to traditional psychology services: it’s cheaper at around $50, patients with anxiety and social phobia in particular prefer it as there is no face-to-face interaction, no waiting rooms etc. and it provides ease of use by being available any time of day,” he explained. TWUC allows the doctor to take part in the referral process, by prescribing TWUC
for, rather than referring someone, and thereby receive updates of the patient’s progress. Both doctor and patient register online to use the module. “It does take a little bit more time but I don't mind. It gives feedback on whether the patient is following through with lessons and what their function is. Patient feedback is usually good.”
QDr Tim Koh
“This clinician option is useful in managing patients. The course supports doctors as it provides live data on the patient in terms of depression and anxiety scores.”
up fitness slowly by working on it regularly. Similarly the homework on internet-based cognitive behavioural therapy (iCBT) needs to be done repeatedly for it to kick in.”
What about patient compliance, which has always been an issue in mental health, in particular? “Patient uptake is mixed. I offer it to most of my anxiety patients. About 50% will take it up. About 75% of these will complete the course. I don't send patient reminders and usually see patients face-to-face during the course for feedback.” The patient learns coping strategies that they are expected to apply in real life, during which time they are locked out of doing more online.
The alternative approach is to hand over entirely to the TWUC psychological staffers who assist your patient without providing you feedback. Tim began using this website after it featured on SBS's Insight. He is unsure of TWUC security protocols, saying when TWUC provides clinical feedback it references the patient by their first name and the initial of their surname. “I have found iCBT to be a really useful tool. It definitely is not suited to everyone. It does require some practitioner up-skilling but it is well worth it for the outcomes.”
“Patients aren't bothered by a five-day lockout. I explain that CBT is like ‘fitness work for thoughts and feeling’, that you can't go to the gym once and expect to run a marathon the next day; you have to build
You can check it out yourself at https://thiswayup.org.au/ O
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Is this child obstructing during sleep? A
ustralian figures say only 0.5% of children between 12 months and 16 years have their tonsils and adenoids removed for obstructive sleep disorder/apnoea (OSD/ OSA). Yet 10% of these children snore and up to 3% have OSA. There is compelling evidence that OSA impinges significantly on the quality of life of these children, particularly neurocognitively and behaviourally, as much as asthma and rheumatoid arthritis. How can the family doctor detect children of concern who require further investigation and management? are snoring, struggling to breathe and obstructive apnoea. Remember, some children with gross adeno-tonsillar hypertrophy do not snore but have other concerning symptoms. In my experience if a parent has observed or reports: t t t t
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(Courtesy ABC National)
Children can have multiple presentations of sleep disorders breathing (SDB), from shortly after birth to adolescence. Known effects on behaviour and mental performance (e.g. educational) means it is no longer appropriate to dismiss large tonsils as healthy and not problematic, given that OSD/OSA has now far surpassed recurrent tonsillitis as the major indicator for adeno-tonsillectomy.
What parents can tell you that shouldn’t be ignored The three sentinel features of sleep disorders breathing (SDB) in children
the need for intervention in a child is clear. Moreover, 30-40% of school age children with SDB show tiredness during the day, inattention, behavioural issues and poor school performance. Other concerning symptoms include altered eating habits – dysphagia for meat and apple peel, living only on pasta or soup, or choking on solids. Or the child has ongoing enuresis (seen in up to 5% of children with SDB). Growth disturbance can show as failure to thrive in a child with SDB secondary to decreased growth hormone secretion in non-REM sleep stage 3 and 4, or obesity may be related to tiredness and inactivity.
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How to tell that varying T & A size will not put it right Tonsil sizes can be classified as grades 1 to 4 on oral inspection, preferably without a tongue depressor (see Figure 1): Grade I: taking a quarter of available space between lateral pharyngeal wall and uvula Grade II: half of the space, Grade III: nearly reaching the uvula, and Grade IV: touching (kissing) tonsils. We know the main structures that obstruct the upper airway in SDB children are the tonsils, adenoids and inferior turbinates – the later sometimes being so swollen as to resemble cherries. If there are enlarged inferior turbinates and grade III or IV tonsils, then lateral x-rays to assess adenoid size are not warranted. The airway obstruction occurs in series not in parallel. Tonsil size alone does not correlate with severity of SDB however. Also, in some groups with lax pharyngeal walls such as children with cerebral palsy, neurological conditions and Down syndrome, a grade II tonsil will be floppy and functionally will be a grade III or IV obstructing tonsil. Caution is also needed in the obese child, because the fat neck impinges on the upper airway and adeno-tonsillectomy only cures 10-25% of SDB (compared with 70-80% in the non-obese child with adeno-tonsillar hypertrophy alone).
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Some groups of children require special attention – those with Down syndrome, cerebral palsy and cranio-facial syndromes, and obese children. In my experience, children from Sub-Saharan Africa may have gross adeno-tonsillar hypertrophy and parents who are unable to effectively describe cardinal symptoms – getting parents to observe and film the sleeping child with a phone camera can greatly assist decision making.
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Physical findings that might cause alarm Rarely seen today are the gross complications of OSD/OSA and upper airway obstruction – right heart failure, cardiomegaly causing cor pulmonale and cardiac arrhythmias. Physical examination of the child may reveal a classic adenoid facies with a long face, open mouth, underdeveloped mid-face and orthodontic issues. There may be features of allergic facies with allergic shiners and turbinate hypertrophy. medicalforum
By Clin/Prof Harvey Coates AO, Paediatric Otorhinolaryngology Some children with chronic upper airway obstruction develop pectus excavatum, which can reverse with adeno-tonsillectomy. The child with gross adeno-tonsillar hypertrophy and failure to thrive, or significant obesity warrant special attention, as does the child with loud breathing at rest (â€˜Darth Vader breathingâ€™).
What to do when you decide to intervene? For children in the more severe range, with alarming physical findings, referral to a sleep pediatrician for urgent polysomnography is warranted or to an ENT surgeon for assessment and admission and urgent pre-operative sleep study. However, only 10% of children with SDB receive sleep studies and there are significant waiting times for the nonurgent cases. Home sleep studies are increasing. There is a strong relationship between the oxygen desaturation to 85% or less and significant OSA. However, oxygen saturation QFig 1: Tonsil size classification (adapted from episodes less than 92% can www.northcountyent.com) still be clinically relevant in the presence of a highly suspicious SDB based on history and clinical examination. O
X Dr Paul Cannell, Dr Hannah Seymour and Dr Simon Towler have been appointed Medical Co-Directors of Fiona Stanley Hospital, and Mr Christopher Whennan, Ms Janet Zagari, Ms Paula Chatfield and Ms Karen McMenamin are the Service Co-Directors. Ms Cheree Schneider is Nurse Director â€“ Acute Care Surgical and Ms Tammy Lynch is Nurse Director â€“ Womenâ€™s Children and Newborn. X Dr Johan Rosman has relocated from The Netherlands via Switzerland and NZ to RPH Nephrology Unit. Dr Abu Abraham, who has just finished doing a PhD in Melbourne has also joined RPH Nephrology (50% renal, 50% AAU general medicine). X Ms Leah Williams has replaced Ms Amy Felton as the Marketing, Membership & Events Officer at the RACGP WA Faculty. Leah returns to RACGP WA after several years working for the Royal College of Physicians in London. X University of Notre Dame paid tribute to academics in the Fremantle School of Medicine, Professor Greg Sweetman, Professor David Playford, Associate Professor Mark Fear, Dr Dianne Ritson, Associate Professor Alan Wright and Dr Michael Veltman, who received a Vice Chancellor's Award.
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Mersilene tape 5mm placed at internal os via a laparoscopic approach - anterior view.
In Australia, WAborn Ian McDonald FRANZCOG created a simpler cervical FHUFODJHPRGLĂ€FDWLRQ in 1957 whilst a Consultant at the Royal Womenâ€™s hospital in Melbourne. His purse-string stitch is inserted a little lower than the former, without any dissection and leaves the knot exposed. It can be tape 5mm placed at internal os removed at 37 weeks, Mersilene via a laparoscopic approach - posterior view. enabling vaginal delivery. These sutures are generally placed at 11-14 weeks gestation, DIWHU)76VFUHHQLQJZKHQWKHSUHJQDQF\LVFODVVLĂ€HGDV ongoing. Sometimes they are placed later as emergency procedures. However, in the Australian setting cervical cerclage has become controversial due to relatively high rates of failure due to cervico-vaginal infection, leading to chorio-amnionitis, and pre-term labour. More recently American studies have favoured inserting the suture via an abdominal operation, prior to pregnancy. At PIVET we have taken this a step further by placing the suture ODSDURVFRSLFDOO\DVDGD\FDVHZLWKIDYRXUDEOHEHQHĂ€WVDQG impressive outcomes.
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Out of the
Comfort Zone TThree young medical students from UWA put on their backpacks and headed off across the globe th UPFYQFSJFODFWFSZEJGGFSFOUTJEFTPGQSBDUJDFBOE U vie v for the Alan Charters Elective Prize in the process.
QLaura Buters in Canada.
Tom Christiner travelled to North West Bolivia, Laura Buters went to a remote town called Moose Factory in Northern Ontario while Helena Merrett packed her stethoscope and set out for Alotau in the Milne Bay Province of Papua New Guinea (PNG). The annual prize is named after Dr Alan Charters (1903-1996) who taught tropical medicine at UWA for many years. It’s awarded to the three Level 5 students who give the best presentation on their elective placement with a specific focus on social and public health issues. Tom emerged the winner of the 16th annual Alan Charters Prize and the happy recipient of $1000. “I left home after Christmas 2012 and flew into Lima, Peru. I then flew to North West Bolivia, a remote place called Rurrenbacque which is an hour’ss flight from La Paz and right on the edge of the Amazon jungle. It was tough and for the first six weeks I didn’t really understand what was going on.” “Perth’s a small pond and, like a lot of West Australians, I was pretty ignorant. I just assumed the doctor and nursing staff would speak English and none of them did!” “It was confronting to see how w basic it was compared with medi-42
cal care in rural WA. The clinic had no government funding, it was set up by an American physician to provide lowcost care and medication but the people were so poor they struggled to afford even that.” “The trip has definitely shaped me as a person. To see people who have so few options has really made me appreciate our medical system and opened my eyes to the world of volunteering and international aid. I’m leaning towards paediatrics and tropical diseases as a future specialty.” “If you’re comfortable travelling on your own it’s better than going with a larger group. It’s important to step out of your comfort zone. Having said that, if you don’t know the language you’re never going to learn it in six weeks but I’m pretty happy with my Spanish now. My prize money will go straight back into airfares for South America.” -BVSB#VUFST, one of two runner-ups, has had a life shaped by medicine. Her father is a Mandurah h GP and three uncles cles and an aunt are doctors.
“My placement was in an isolated First Nations community of indigenous Canadians about 700km north of Ontario called Moose Factory. There are no roads into the place and the only access is an aircraft in summer and an ice-boat in winter.” “It was only the second time I’d seen snow and I went on hunting trips and spent Australia Day dog-sledding. That was certainly the most unusual national holiday I’ve ever had!” “I went with my housemate, who’s also doing an Aboriginal Health specialty, and we worked in a 35-bed hospital almost in the role of junior doctors. There’s a maternity and general medicine ward plus a small paediatrics and ED facility staffed by eight doctors and an anaesthetist. There was everything from flu to hypothermia and broken legs from snowmobile accidents.” “Sadly, there’s quite a bit of alcoholrelated domestic violence due to the legacy of mission schooling. Canada very similar to has a ‘Stolen Stolen Generation’ Gener ours.” “The placement gave me an idea of g tthe bigger picture of iindigenous health. It’s important to see It successful programs s leading to better outle comes because this co area can be quite disar heartening. Aboriginal he health is an internationhea al issue and we should i be working with other countries to implement cou successful initiatives.” succ Tropic medicine Trop al doesn’t come much more does
remote than the Milne Bay Province of Papua New Guinea. )FMFOB .FSSFUU, who has a degree in physiotherapy from Sydney University, was pleased to find a connection between the UWA medical school and our nearest neighbour. “I’ve spoken with a lot of consultants here in WA who went to PNG in the 1970s and still go back and run health programs. I’d strongly recommend it to any medical student with an interest in tropical medicine. A lot of people who think about developing countries tend to seize on Africa and don’t realise that we have a country on our doorstep with a shared history of health partnerships.”
QWinner of the Alan Charters Prize Tom Christiner, who worked in Bolivia.
Develop your medical writing
“Both Australia and PNG benefit from that exchange and a medical placement is a great opportunity to contribute. I’d love to go back and do some more work on neonatal mortality.”
The Australian Medical Writers’ Association is celebrating its 30th anniversary at their annual conference in Melbourne this month, which is open to members and the public.
“PNG is the largest recipient of foreign aid through Ausaid. It’s no surprise to find that their health outcomes are pretty poor compared with ours, particularly in maternal and child health. The Alotau General Hospital has around 120 beds and a lot of people transfer in by boat from the islands in the D’Entrecasteaux Group.”
There are about 300 members from around Australia, New Zealand and South East Asia, including Medical Forum and other writers and editors who specialise in health and medical journalism. Doctors and other health professionals who are interested in writing and editing are also members.
“I wanted to go to the Highlands but realised that it probably wasn’t safe for me to be there on my own. In Alotau there were no problems at all and I was treated really well, particularly by the Melanesians. When I walked to the hospital through town I’d say hello to about 50 people!” O
sessions will explore new media, new publishing platforms and special health topics such as bowel cancer and mental health. Guest speakers include linguistic experts Prof Kate Burridge, public health physician Prof Simon Chapman and ABC journalist and academic Dr Gael Jennings. The conference will be held at Victoria University on August 22-23. To register go to www.medicalwriters.org O
This year’s themes is “Art and Science in Medical Writing” and conference
By Mr Peter McClelland
appreciated being able to serve customers on a more personal level and to work with interesting products to produce some creative dishes. 8IBUEJEUIPTFFYQFSJFODFTUFBDIZPVBCPVUGPPE BOEQFPQMF They opened my eyes to the potential of my job and helped me get to where I am now. The vastly different working environments taught me the many different ways of dealing with people and the ways I work with food. 8IBUXBTJUBCPVU+BNJF0MJWFSBOEIJTGPPEQIJMPTPQIZ UIBUNBEFZPVXBOUUPXPSLGPSIJTOFXSFTUBVSBOUJO8" Iâ€™ve always wanted to emulate the way in which Jamie Oliver goes about food. He has an extraordinary approach to food and insists on using fresh and local produce to make even the simplest dish an amazing experience. The food itself becomes the real hero, where flavour is everything. I was very excited at the prospect of being a part of his venture here and bring something new to the Perth scene. )BWFZPVNFU+BNJF *GTP XIBUXBTIJTNFTTBHF UPUIFUFBN
10 minutes with... Grant Greyling
Unfortunately I havenâ€™t met Jamie yet, but we did receive an amazing message of encouragement from him in the opening weeks of the Perth restaurant, which was hugely motivating for the team.
Local chef (SBOU(SFZMJOH has worked on Barrow Island, funky suburban cafes and now is kitchen manager in food juggernaut Jamie Oliverâ€™s new Perth CBD restaurant, Jamieâ€™s Italian.
I oversee occupational health and safety, food service, team management, ordering as well as providing support for our Head Chef Lorenzo Schiaffini.
8IPXBTZPVSFBSMJFTUJOTQJSBUJPOJOUIFLJUDIFO My earliest inspiration for cooking came from my family â€“ both my mum and dad love being in the kitchen. Making food in our house would always be a memorable family affair. Watching Jamie Oliver in The Naked Chef when I was a teenager was also a source of inspiration. I remember thinking that Iâ€™d love to be able to cook for my family and friends like Jamie, and have that real passion and flair for food. 8IFSFEJEZPVUSBJO I did vocational studies at Churchlands Senior High School and I gained incredible insight into the real life and work of a chef. After high school, I started an apprenticeship at La Cascade Restaurant in Wembley and trained at Polytechnic College in Bentley. *CFMJFWFZPVSDIFGGJOHIBTUBLFOZPVUPTPNFJOUFSFTUJOH QMBDFT$BOZPVUFMMVTBCPVUUIFN One of the more interesting places Iâ€™ve worked was on Barrow Island as part of the Gorgon Project. While this was quite a challenging place to work, it was also a fantastic learning experience. I have also worked at Ingredient Tree in Wembley, which was a welcome change of pace. I really 44
5IFXPSEJTUIBUUIFSFTUBVSBOUJTJOTBOFMZCVTZGSPNUIF NJOVUFJUPQFOTJUTEPPST IPXEPFTUIBUUSBOTMBUFJOUIF LJUDIFO The kitchen is always pumping from the service line to extruders producing our beautiful fresh pasta every day. Our passionate chefs are always up and running â€“ they really make Jamieâ€™s Italian an amazing experience to work in. 5IFSFTUBVSBOUIBTPOMZCFFOPQFOBGFXNPOUIT XIBUT UIFNPTUQPQVMBSUIJOHPOUIFNFOVTPGBS A few of our signature dishes have led the way. The prawn linguine and, of course, the antipasto planks are probably the most popular as well as the Italiano Burger. )PXPGUFOEPFTUIFNFOVDIBOHF Our menu is seasonal, giving us the opportunity to provide everything that is in abundance and at its most flavoursome. 8IBUEPZPVEPXIFOZPVSFOPUCBOHJOHUIFQBOT I have to say that when Iâ€™m not working, Iâ€™m actually back in the kitchen at home with my family, testing and trying new dishes. The kitchen is where Iâ€™m happiest and being at home with my family making food and enjoying it with them is where I relax the most. O
by Ms Jan Hallam medicalforum
$BQF(SBDF$IBSEPOOBZ 5IF$IBSEPOOBZJTBTJOHMFWJOFZBSEXJOFGSPNUIFFYDFMMFOUTFBTPO (SBQFTXFSFQJDLFEJOUXPCBUDIFT QSPDFTTFEBOECBSSFMGFSNFOUFEPOMFFT GPSNPOUIT0BLXBTQSFEPNJOBUFMZPOFUPUXPZFBSTPMEBOEPOMZPG UIFXJOFXBTHJWFONBMPMBDUJDGFSNFOUBUJPO5IJTJTBDMBTTJDXJOFGSPNUIF area and has fine aromas of grapefruit and oak with a crisp, acid palate. Well balanced with excellent persistence and a wine with at least five years of cellaring potential.
By Dr Martin Buck
Sometimes the best things come in small packages. My case of Cape Grace wines included only three wines but what a powerful package. Cape Grace is owned by the family that once were one of the original South-West timber barons from Karridale. Robert and Karen RosserDavies purchased their Wilyabrup vineyard in 1996 and planted 7ha of vines.
$BQF(SBDF4IJSB[$BCFSOFU 5IJTCMFOEJTBO"VTUSBMJBOJDPOXIJDIGJSTUBQQFBSFEBSPVOEUIFMBUFTBT DMBSFU*UXBTUIFOSFTVSSFDUFEJOUIFTBOECZIBECFFONBEFCZ.BY 4DIVCFSUJOUPUIF1FOGPMET#JO" QSPCBCMZUIFNPTUBXBSEFE"VTUSBMJBOXJOF PGBMMUJNF5IF$BQF(SBDF4IJSB[$BCFSOFUJTBOVODPNNPOCMFOEGPSUIF region but it works very well. Fermentation is done separately in open fermenters BOEUIFOCBTLFUQSFTTFEJOUPUBOL"HFJOHJTJOPOFBOEUXPZFBSPME'SFODIPBL for nine months. This is still a young wine but with interesting funky characters BOECFSSZBSPNBT"GSVJUESJWFOQBMBUFXJUIBIVHFNPVUIGJMMPGCMBDLDVSSBOUTBOE SBTQCFSSJFTDPNCJOFEXJUIGJOFUBOOJOT4IPSUUFSNDFMMBSJOHJTTVHHFTUFEBOE UIJTNFEJVNCPEJFEXJOFJTSFBEZGPSDPOTVNQUJPOnow.
Located in the premier circle of Wilyabrup terroir, the potential for great wines was reached with their 2000 Cabernet Sauvignon winning best wine at the Sheraton Wine Awards. Itâ€™s quite an achievement for such a young vineyard to produce quality grapes.
$BQF(SBDF$BCFSOFU4BVWJHOPO .ZFYQFDUBUJPOTGPSUIF$BCFSOFU4BVWJHOPOXFSFIJHIBOE*XBTOPU disappointed. Once again open fermenters and basket pressing were used CFGPSFBHFJOHJOBNJYPGOFXBOEZFBSPME'SFODIPBL*UIBTBEFFQ crimson wine with aromas of eucalyptus, rich berries and cigar box oak all TXJSMJOHJOUIFHMBTT5IFSFJTBTPGU TNPPUI CFSSZGJMMFEQBMBUFXJUIBMNPTU perfect structure and seamless tannins. A cracker of a Cabernet and could be cellared for some time with further improvement.
Vineyard management is by sustainable viticulture and winemaking is under the current care of Mark Messenger, who has a great record of making quality Margaret River wines. Cape Grace keeps its production small and clearly concentrates on making quality and not quantity. The two iconic Margaret River varieties, Chardonnay and Cabernet, are handled extremely well from vineyard to winery.
WIN a Doctor's Dozen! Which Cape Grace wine is kept in aged French oak? Answer:
ENTER HERE!... or you can enter online at www.MedicalHub.com.au!
Karen & Rob - Cape Grace
$PNQFUJUJPO3VMFT One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closesQN "VHVTU To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.
E-mail: ......................................................................................................... Contact Tel:
1MFBTFTFOENPSF JOGPSNBUJPOPO$BQF(SBDFPGGFST GPSMedical ForumSFBEFST
BARD Actor John Howard canâ€™t wait to head West to work with the blossoming playwright Tim Winton.
theyâ€™re doing â€“ itâ€™s more than anyone else in the country.â€?
Tim Winton is a towering ďŹ gure on the literary landscape but heâ€™s a relative newcomer to the world of theatre. However, in three short years, heâ€™s managed to see two plays hit the Heath Ledger auditorium at the State Theatre Centre as well as seasons in Melbourne, Sydney and Townsville. His third and latest play, Shrine, premieres here with Black Swan Theatre Company at the end of the month.
3BUIFS UIBO B EBVOUJOH FYQFSJFODF +PIO says itâ€™s a bonus to have the playwright sit ting in at rehearsals. i*WF EPOF UIJT NBOZ UJNFT XJUI /JDL Enright and David Williamson; in the thea tre, the writer has the last say, which is why a lot of writers love writing for the theatre.â€? John is a deep thinker about his acting craft and the theatre in particular so itâ€™s not sur prising when he says he has put pen to paper himself. i*IBEBHPBUXSJUJOHQMBZTXIFO*XBTBTTP ciate director of Sydney Theatre Company but while people enjoyed the plays they EJEOUOPUJDFE*EXSJUUFOUIFN"TGPSPUIFS XSJUJOH * XSJUF QPFNT GPS NZ PXO BNVTF NFOU * BMXBZT IBWF CVU USVTU NF * EPOU SBUFNZTFMGBTBQPFU*TIBSFJUPO'BDFCPPL which is more than enough.â€?
The veteran Sydney actor John Howard was brought to Perth to lead a strong cast in 3JTJOH 8BUFS, Wintonâ€™s debut play, and he returns to Perth for 4ISJOF. Could he be the first great interpreter of Wintonâ€™s work? â€œHardly,â€? he scoffs. â€œHe has people queu JOH VQ UP JOUFSQSFU IJT XPSL * TQFOU B CJU of time with him during the rehearsals of 3JTJOH 8BUFS and it was interesting to see IJNBCTPSCUIFMBOHVBHFPGUIFBUSF*UIJOL heâ€™s learnt very quickly.â€? â€œWintonâ€™s stage writing has the same integ rity as his novels or other writing. He is able to, in seemingly ordinary but poetic language, get to the heart of the things XF GFFM SJHIU JOUP PVS CPOFT *O QFSGPSN ing 3JTJOH8BUFSGPSJOTUBODF *DPVMEOFWFS CFTVSFIPXPOBOZQBSUJDVMBSOJHIU*PSNZ character, Baxter, would react at any par ticular moment such was the depth of the emotional story, which lies through and underneath the words. Now thatâ€™s a very rare talent, no matter what kind of writing youâ€™re doing.â€? â€œ4ISJOF is a concerto on grief. Simply, my character Adamâ€™s son Jack runs into a tree one night and the shrine is one of those roadside shrines you see all around the world. Tim has a very intriguing way of mov ing the story around in time so characters 46
are better able to cope with the emotional issues at stake. So itâ€™s quite different to the other plays heâ€™s written.â€? â€œYet it still has that Winton style â€“ the ocean is present, itâ€™s always stormy in that Shakespearean kind of way.â€? As for establishing himself as a notable writ er for the theatre, John has no doubt. â€œHe is a prolific writer and heâ€™s of such qual JUZ UIBU * DBOU JNBHJOF UIBU IJT CPPLT BOE plays wonâ€™t be eagerly read or performed in UIFGVUVSF*UJTEJGGJDVMUGPSOFXQMBZXSJHIUT UPHFUEFDFOUBOEDPOUJOVFEQMBZ*UEPFTOU really matter how good they are.â€? i'SBOLMZ*UIJOLUIFZTIPVMECFHPJOHTUSBJHIU to London, Paris and New York because Tim has such a distinctive voice and in my view heâ€™s up there with Arthur Miller because of his ability to get to the marrow of peopleâ€™s experience of living. Not a lot of writers can do that.â€?
After his outing in 4ISJOF, movie fans can expect to spot him on screen in the new Mad Max movie 'VSZ3PBE, which he shot in Namibia last year. i*O B OVUTIFMM 'VSZ 3PBE is Mad Max but NPSFTP*XBTHPCTNBDLFEBUUIFUFDIOJDBM toys they had to use and the mindboggling logistics of the project. We would film in one part of the desert one day and in another part of the desert the next, literally NPWJOHBUPXOPGQFPQMFPWFSOJHIU*U XBTBNB[JOHwO
By Ms Jan Hallam
WIN For your chance to win tickets to see 4ISJOF, which opens at the Heath -FEHFS5IFBUSFPO"VHVTU UVSOUP Page 49
â€œKate Cherry and Black Swan should be commended for the number of new plays
Conversations with G H O S T S
Some of Australiaâ€™s best musicians interpret the wonders of poetry to create a night of creative magic. WA composer James Ledger was destined for the musical life â€“ creative parents, a piano in the house and a plastic recorder in primary school. He never envisaged a career path that would lead to sharing the stage with rock icon Paul Kelly and recorder virtuoso Genevieve Lacey but Conversations with Ghosts is a distinctly unique collaboration. i6TVBMMZ *N KVTU UIF DPNQPTFS XIP TJUT in his room and writes the music but itâ€™s such a great experience to be up on stage XJUI 1BVM (FOFWJFWF BOE B HSFBU CVODI of young musicians from the Australian National Academy of Music.â€? â€œThereâ€™s certainly no set trajectory for a composer in Australia and you have to put yourself in places where opportunities might pop up and sometimes that means leaving Perth and even Australia. Until quite recently my philosophy has been to TBZ AZFT UP FWFSZUIJOH *WF EPOF B MPU PG different projects, everything from small, DSB[Z FOTFNCMFT UP XPSLJOH XJUI TPMPJTUT and orchestras.â€?
those images of ice and snow in the Baltic region. So when the opportunity came VQ XJUI UIF $IVSDIJMM 'FMMPXTIJQ * XFOU UP &TUPOJB BOE TUBZFE XJUI &SLLJ4WFO PO a remote island â€“ thereâ€™s even a little bay called Surferâ€™s Paradis!â€? â€œWhat really caught my eye was the light, the completely different colour of the day JO UIBU QBSU PG UIF XPSME *U JOTQJSFE NF UP write an orchestral piece called $ISPOJDMFT XIJDI XBT QMBZFE CZ 8"40 *U XPO 0SDIFTUSBM 8PSL PG UIF :FBS JO XIJDI was gratifying.â€? $POWFSTBUJPOT XJUI (IPTUT brings together many different but overlapping talents. i*UT OPU KVTU BCPVU UIF NVTJD * UIJOL BVEJ ences will find the whole thing looks pretty JNQSFTTJWFPOTUBHF*IPQFUIFZMMFOKPZUIF melding of different styles and itâ€™s interest ing to see Paul Kelly doing something you donâ€™t expect. Heâ€™s immersed in this ensem CMF PG PSDIFTUSBM JOTUSVNFOUT BOE JUT DPNQMFUFMZ PVU PG IJT DPNGPSU [POF "OE * IBWFUPBENJUUIBU*HFUBCJUOFSWPVTXBML JOHPVUPOTUBHFCFDBVTF*EPOUEPJUBMMUIBU often, but it was a great experience for me.â€?
James is certainly not averse to pushing NVTJDBMCPVOEBSJFT*OIFXPOBQSFT tigious Churchill Fellowship and travelled to Estonia to explore new forms of musical expression.
â€œPaulâ€™s memorised these poems and the amount of words he can keep in his head is FYUSBPSEJOBSZ * UIJOL XFWF DSFBUFE TPNF thing quite different here and hopefully itâ€™s a rewarding experience for the audience. Theyâ€™ll certainly be hearing something they wouldnâ€™t normally expect from Paul Kelly.â€?
i*O * NFU &TUPOJBO DPNQPTFS &SLLJ Sven TĂźĂźr, who came to Australia to do a commissioned piece for the Australian Chamber Orchestra. We spent a lot of time UPHFUIFSBOE*EBMXBZTCFFODBQUJWBUFECZ
i"UUIFCFHJOOJOHCPUI1BVMBOE*XFSFXPO dering how on earth this was going to work. *NGSPNUIFDMBTTJDBMXPSMEBOEIFTBSPDL and roll musician so we were fumbling in the dark for a while. Heâ€™d send me a demo
UBQF *EFNCFMMJTIJUBOEJUXPVMEQJOHQPOH back and forth.â€? â€œWe wanted a strong link between the words of these wonderful poems, such as Kenneth Slessorâ€™s 'JWF#FMMT and Lord Alfred Tennysonâ€™s huge epic work *O .FNPSJBN. Thereâ€™s a persistent theme of bells and the symbolism harks back to the darker side of life.â€? *U MPPLT MJLF CFJOH B CVTZ GPS +BNFT Ledger and one of the projects has a dis tinctly medical touch. i*MM CF DPNQPTJOH B QJFDF GPS UIF 3PZBM Childrenâ€™s Hospital in Melbourne next year. *UT BMM QBSU PG UIF )VTI QSPKFDU XJUI NVTJD performed and recorded for children with cancer. The WASO will be playing a violin DPODFSUP UIBU *N KVTU GJOJTIJOH BOE UIFO UIFSFT B DIJMESFOT PQFSB GPS (POEXBOB Voices.â€? James reflected on the piece of music heâ€™d most like to hear if he was being wheeled into the operating theatre. i*U XPVME IBWF UP CF .PPOMJHIU from Benjamin Brittenâ€™s 'PVS4FB*OUFSMVEFT*UT an incredibly serene and visual piece and to IFBS UIF PQFOJOH NPNFOUT CFGPSF * EP[FE off would be wonderful.â€? O
By Mr Peter McClelland
WIN $POWFSTBUJPOTXJUI(IPTUT Perth Concert Hall, Sunday, September 8. For your chance to win tickets to see the show, turn to the competitions page for details. 47
QQTaking the easy road "(1JO5BTNBOJBXBTXBMLJOHBMPOHUIF beach. He kicked an old glass container and out popped a genie. 5IFHFOJFDVSTFEUIF(1TBZJOHIFIBE been discovered three times that week already, was tired of granting wishes and UIFSFGPSFUIF(1XPVMEPOMZHFUPOFXJTI so he had better make it a good one. "GUFSTPNFUIPVHIUUIF(1UPMEUIF genie that he had to fly to Melbourne for a conference and as he always became airsick could the genie see his way clear to build a bridge so he could drive over. "Look," the genie snorted, the water is too deep, the tides too strong and the waves too high. The amount of concrete and steel would only be equaled by the death rates PGUIFQPPSQFPQMF*XPVMEQVUUPXPSLPO it. No try again, something a little easier."
QQRed Tape in Biblical Proportions *OUIFZFBS UIF-PSEDBNFVOUP Noah, who was now living in Australia, and said: "Once again, the earth has become wicked BOEPWFSQPQVMBUFE BOE*TFFUIFFOEPG all flesh before me. Build another Ark and save two of every living thing along with a few good humans. You have six months UPCVJMEUIF"SLCFGPSF*XJMMTUBSUUIF VOFOEJOHSBJOGPSEBZTBOEOJHIUT
QQDonâ€™t Argue With a Woman 5IJTZFBSPMEXPNBOJTOBLFE KVNQJOH up and down on her bed, laughing and singing. Her husband walks into the bedroom. He watches her awhile then says, "You look ridiculous! What on earth do you think you`re doing?"
Six months later, the Lord looked down and saw Noah weeping in his yard â€“ but no "SL/PBIIFSPBSFE *hNBCPVUUPTUBSU the rain! Where is the Ark?"
4IFTBZT *WFKVTUCFFOUPUIFEPDUPSXIP TBZT*IBWFUIFCSFBTUTPGBOZFBSPME
5IF(1SFGMFDUFE UIFOTBJE5IF DPOGFSFODF*BNHPJOHUPJTBCPVUHFOFSBM practice and the way we work with HJWF NF UIF (PWFSONFOU$PVMEZPVHJWFNFUIF nd wherewithal to insight, understanding and LOPXJOH UIFSF XJMM FOTVSFUIBU*DBOSFUVSOLOPXJOHUIFSFXJMM erference with my be minimum practice interference ed. life enriched and rewarded.
"Forgive me, Lord," begged Noah, "but UIJOHTIBWFDIBOHFE*OFFEFEB#VJMEJOH 1FSNJU5IFMPDBMDPVODJMTBZT*hWFWJPMBUFE CZ MB CZMBXTCZCVJMEJOHUIF"SLJO my backyard and exceeding tthe height limitations. We had to go to the planning commission for a decision."
He says, "Yeah right. And what did he say BCPVUZPVSZFBSPMEBSTF
our you wanted on "Was that two lanes or four ied the genie. that bridge Doctor?" replied
""Then the council and We Western Power demanded a TIFE TIFEMPBEPGNPOFZGPSUIFGVUVSF cost costs of moving power lines and othe other overhead obstructions, to cle clear the passage for the Ark's NPWFUPUIFTFB*UPME them that the sea would be coming to us, but they would hear none of it." "Then the Environmental Protection Authority stopped work on the Ark until they'd conducted an environmental impact study on Your proposed flood." 5PNBLFNBUUFSTXPSTF UIF"50TFJ[FE BMMNZBTTFUT DMBJNJOH*hNUSZJOHUPMFBWF the country illegally with endangered species. So, forgive me, Lord, but it would UBLFBUMFBTUZFBSTGPS me to finish this ark."
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Suddenly the skies cleared, the sun began to shine and a rainbow stretched across the sky. Noah looked up in wonder and asked, "You mean you're not going to destroy the world?"
She starts laughing and jumping again.
"Your name never came up." she replied.
QQHeavenly enly KPIs A priest dies and d is waiting in line at the Pearly (BUFT"IFBE of him is a guy who's dressed in sunglasses, a loud shirt, leather jacket, and jeans. Saint Peter addresses this cool guy, â€œWho BSFZPV TPUIBU*NBZLOPXXIFUIFSPSOPU to admit you to the Kingdom of Heaven?â€? 5IFHVZSFQMJFT i*hN+BDL SFUJSFEBJSMJOF pilot from Sydney.â€? Saint Peter consults his list. He smiles and says to the pilot, â€œTake this silken robe and golden staff and enter the Kingdom.â€? Next, is the priest's turn. He stands erect BOECPPNTPVU i*BN'BUIFS#PC QBTUPS PG4BJOU.BSZhTGPSUIFMBTUZFBSTw Saint Peter consults his list. He says to the priest, â€œTake this cotton robe and wooden staff and enter the Kingdom.â€? â€œJust a minute,â€? says the good priest. â€œThat man was a pilot and he gets a silken SPCFBOEHPMEFOTUBGGBOE*HFUPOMZDPUUPO and wood. How can this be?â€? â€œUp here we go by results,â€? says Saint Peter. â€œWhen you preached, people slept. When he flew, people prayed.â€?
"No," said the Lord. "The (PWFSONFOUCFBU me to it."
Entering Medical Forum's COMPETITIONS has never been easier! Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS'MJOL CFMPXUIFNBHB[JOFDPWFSPOUIFMFGU
Concert: Conversations With Ghosts 4JOHFSTPOHXSJUFS 1BVM ,FMMZ QBZT USJCVUF UP UIF XPSLT PG poets W.B. Yeats, Judith Wright, Kenneth Slessor and Les Murray among others with a haunting song cycle in collaboration with composer James Ledger, recorder virtu PTP(FOFWJFWF-BDFZBOENVTJDJBOTGSPNUIF"VTUSBMJBO National Academy of Music. 1FSUI$PODFSU)BMM 4VOEBZ 4FQUFNCFS QN
Movie: Stoker Music: Symphony 5IF FWFSBCTPSCJOH 1JQF 0SHBO 1MVT TFSJFT DPOUJOVFT with organist Dominic Perissinottoâ€™s tribute to the Symphony XJUI FYDFSQUT PG NBKPS XPSLT CZ (MJOLB .BIMFS 3BWFM BOE 5DIBJLPWTLZ )FBS (MJOLBT PWFSUVSF UP UIF PQFSB 3VTMBO J :VENJMMB, the sublime "EBHJFUUP4FIS-BOHTBN from Mahlerâ€™s 4ZNQIPOZ /P UIF MPWF UIFNF GSPN 3BWFMT CBMMFU TDPSF of Daphnis et ChloĂŠ, and the mesmerising, melancholic Symphony No. 4 by Tchaikovsky. 4U1BUSJDL#BTJMJDB 'SFNBOUMF 4VOEBZ 4FQUFNCFS QN
Musical Theatre: Chitty Chitty Bang Bang 5IF GJMN CBTFE PO UIF CPPL CZ *BO 'MFNJOH JT CFMPWFE by generations of children and now the famous flying car swoops into the Crown Theatre with some of the coun USZTCFTUMPWFENVTJDBMUIFBUSFQFSGPSNFST 3BDIBFM#FDL David Hobson and funny man Shane Bourne, aboard. This JT B NVMUJNJMMJPO EPMMBS QSPEVDUJPO XJUI PVS GJOF GPVSGFO EFSFE GSJFOE IPMEJOH UIF (VJOOFTT 8PSME 3FDPSE GPS UIF most expensive prop in the history of British theatre. $SPXO5IFBUSF 4FQUFNCFS4FBTPO SVOTGPSUISFFXFFLT
Road Leads to Elder ton
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Be the first to see the world premiere of Tim Wintonâ€™s third play, 4ISJOF XJUI B TUBSTUVEEFE DBTU JODMVEJOH John Howard, Paul Ashcroft and Luke McMahon. Set in WA wine country, a privileged young man, Jack, is killed when driving friends back to Perth from his parentsâ€™ beach house, leaving a path of destruction in his wake. )FBMUI-FEHFS5IFBUSF "VHVTU 4FBTPOSVOTVOUJM4FQUFNCFS
5IJT QTZDIPMPHJDBM UISJMMFS GSPN 1BSL $IBOXPPL casts Australian actresses Nicole Kidman opposite Mia Wasikowska as emotionally unstable mother and bewildered daughter grieving the loss of their IVTCBOEGBUIFS 5IJOHT TUBSU HFUUJOH USJDLZ XIFO IFS GBUIFST CSPUIFS QMBZFE CZ .BUUIFX (PPEF comes to stay and mother and daughter begin to vie for his affections. *ODJOFNBTGSPN"VHVTU
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#FGPSF.JEOJHIUo.PWJF%S"TIMFZ*SJTI %S+BNFT-BUUP %S)FSUIB$PMMJO %S+BTPO8FMMT %S#FMJOEB8P[FODSPGU %S+PIBOB4UFGBO %S,XPL,FPOH-BN %S1IJMPNFOB'JU[HFSBME %S%BOJJ1BUFSTPO %S4IJI&SO:BP
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FOR LEASE MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to email@example.com NEDLANDS Medical Specialist Consulting Rooms Fully serviced rooms and facilities for Specialist Consulting are available t 4VJUF )PMMZXPPE4QFDJBMJTU$FOUSF 95 Monash Avenue, Nedlands. Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager, Suite 31 Hollywood Specialist Centre 95 Monash Avenue, Nedlands, WA 6009 Phone: 9389 1533 Email: firstname.lastname@example.org NEDLANDS Hollywood Medical Centre- Sessional suites available with Secretarial support if required. Please contact 0414 780 751 DAWESVILLE Opportunity for two GPâ€™s t TRN.FEJDBM$FOUSF t *OOFX4IPQQJOH$FOUSF t $PNQMFUJPO+VMZ t $BUDINFOUQFPQMF t 6OTFSWJDFEBSFB Ross on 0409 887 641
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MURDOCH/LEEMING Medical specialist consulting rooms. Your chance to secure a long lease in the Fiona Stanley precinct before the hospital opens and opportunities like this disappear. Three minutes from the hospital. Internal area of 125 sqm with onsite parking and adjacent to several other medical specialist and allied health practitioners. Excellent exposure opposite the Farrington Shopping centre. Contact Eric Rogers at Metway 0412 228 555 or 9228 2255 AVELEY Suitable for dental practice and/or allied health services (eg. Physiotherapy, Psychology, Podiatrist, Radiology etc). Medical centre located in the same building. Located in a fast growing community beside a shopping centre, close to secondary schools, primary schools, church and Child Care Centre. Contact: 0400 814 091 JOONDANNA New medical centre in Joondanna. Only 5km from CBD. Excellent position on Wanneroo Rd, with ample parking. Suit GPs and / or allied health. Pharmacy and pathology on-site. For further details, contact Wesley Williams Ph 0414 287 537 Email email@example.com SHENTON PARK Medical Rooms in Shenton Park for Lease. Newly furnishing premise with two medical consultation rooms available. The rooms are approved by local council for medical use. Premise is well located off Onslow Road. Ample street parking available. Suitable for medical practitioners or specialists to setup. Call Kevin on 0413 969 003 now! MANDURAH Mandurah Fully furnished rooms in large medical complex available for part or full time leasing. Within physiotherapy practice who supports multidisciplinary approach to treatment and 29 General Practitioners. Reception support available. Ideal for any medical professional looking to open their own practice or expand an existing practice. Email: firstname.lastname@example.org
FOR SALE WEST LEEDERVILLE CONSULTING ROOMS (stand-alone) Opposite SJOG t -BOEBSFBTRN t #VJMEJOHBQQSPYTRN Parking at front & rear (8 bays) 2 large consulting rooms, treatment room, reception, waiting room, separate admin and staff areas, basement storage Phone Carol Prosser 0421 397 593 Email: email@example.com
MEDICAL SUITE(S) 10 McCOURT STREET WEST LEEDERVILLE These well located 61sqm medical suite(s with two car bays each are located opposite St John of God Hospital and ready for immediate occupation. GORDON TUCKER R/E 0408 093 731 firstname.lastname@example.org NORTHERN SUBURBS 3-doctor Medical centre for sale Northern Suburbs Profitable, well established medical centre with Pathology, chemist, podiatrist and physiotherapy in complex Not a DWS area. Phone: 0488 222 238
LOCUM WANTED PERTH Locums / Associates wanted. Perth Medical Centre, Hay Street Mall. Busy accredited privately owned practice, private billing, flexible hours. Excellent remuneration for suitable candidates. Phone: 9481 4342 Mobile: 0408 665 531
RURAL POSITIONS VACANT ALBANY VR GP required to join our 4 Doctor, busy, friendly family practice. Full or Part time. We are Accredited, computerised, full nurse support, experienced Admin team. Excellent remuneration. Clinipath pathology on site. Phone Gaye - Practice Manager 9841 6711 Email: email@example.com
URBAN POSITIONS VACANT BAYSWATER Wanted General Practitioner (VR) F/T or P/T required within our friendly non corporate medical practice. We are a fully computerised, wellequipped, teaching, accredited general practice seeking an enthusiastic person to join our team with a view in assisting our growing patient load. We are a proudly independent practice which offers a friendly environment, flexible working hours, pleasant rooms, great staff, with wonderful patients. Email resume to: firstname.lastname@example.org or Fax: 9279 1390 GOSNELLS VR GP female preferred, afternoon sessions from 12 noon till 4pm. 70% of receipts. Please phone Patrick on 9490 8288 or Email: email@example.com
FREMANTLE Fremantle Womenâ€™s Health Centre requires a female GP (VR) to provide medical services in the area of womenâ€™s health 1or 2 days pw. It is a computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical and counselling services, health education and group activities in a relaxed friendly setting. Phone: 9431 0500 or Email: Diane Snooks - firstname.lastname@example.org or Dawn Needham email@example.com VR GP Required for NEW PRACTICE located in an ASGC-R2 location east of Perth. This brand new practice is the perfect opportunity for a GP to work in the inner regional area of Perth located approximately 45 mins from the CBD. This large community with no current servicing GPâ€™s is located next door to a busy pharmacy and can accommodate 2 full time GPâ€™s. Admin and nursing services will be provided along with pathology onsite. Relocation incentive may apply to this location. For more information please call 0419 959 246 or firstname.lastname@example.org HILLARYS Exciting Opportunity. Join us in our brand new General Practice located NOR. Non-corporate. We require a full-time or part-time GP for our practice. Hours to suit. No evening or weekend work required. The practice is fully computerised and well equipped. Private Billing and some bulk-billing. Full-time Nursing support. Pathology on site. Please contact Practice Manager on 9448 4815 or Email: email@example.com MT LAWLEY Edith Cowan University, Student Health Services, Mt Lawley campus. Part time VR GP with an interest in Womenâ€™s and Student Health required. Well-equipped medical centre, accredited, excellent work environment, Registered Nurse support, flexible work arrangements. For information: Dr Robert Chandler Phone: 08 6304 5618 E-mail: firstname.lastname@example.org BENTLEY GP VR needed for privately owned family orientated practice. 15mins from Perth CBD, AGPAL accredited, fully computerised using MD/Pracsoft. Private and Bulk Billing. Supported by clinical and CDM nurses operating from purpose built practice. We offer 65% of billings. Contact Alison on 0401 047 063
SEPTEMBER 2013 - next deadline 12md Tuesday 16th August - Tel 9203 5222 or email@example.com
medical forum BALLAJURA (Northern Suburbs) PERMANENT/PART TIME GP wanted (preferably female) for Ballajura Medical Centre. This is DWS practice with mixed billing, busy practice, nursing staff & Best Practice software. Lots of potential. Phone: 0488 222 238 Email: firstname.lastname@example.org CURRAMBINE Sunlander Medical Centre is seeking a General Practitioner to join our Mixed Billing Practice. Prime location 25 minutes from Perth CBD and 5 minutes from the beach. VR and non-VR considered. Full Time and Part time positions available. On-site Registered Nurse, Perth Pathology, and X-Ray dept. Dentist and Physiotherapist within office and we are located next to a Pharmacy. Contact: Sirov Maharaj on 0438 740307 or email@example.com NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. Ring Helen 9227 0170 MT HAWTHORN Mt Hawthorn Medical Centre, a noncorporate accredited long established practice situated in a fast growing inner city suburb of Perth, seeks a part time or full time VR GP to join this highly desirable practice. Fully computerised, Nurse Assistant. Phone Rose 9444 1644 NORTH BEACH Part time GP to join our GP owned practice 18 minutes north of the Western Suburbs. Flexible hours and mixed billing. An interest in either womenâ€™s health or menâ€™s health will assist our two existing GPâ€™s. A recent closure in a neighbouring suburb has increased the demand for appointments. On site pathology, psychologist and nurse support. Supportive allied services close by. Please contact Helen or David 94471233 to discuss or Email: reception.nbmc@ bigpond.com UNIVERSITY OF WESTERN AUSTRALIA, CRAWLEY VR GP required for our fully computerised, accredited, well equipped and newly renovated practice. Our busy centre is complimented with full time nursing staff, Mental Health Nurses, Physiotherapy and onsite Pathology and Pharmacy Sessions negotiable - no evening or weekend work required. Very friendly team, attractive remuneration and free, reserved bay parking on campus. Please contact Judi Hicks, Practice Manager, firstname.lastname@example.org or Dr Christine Pascott email@example.com Ph: 6488 2118
MOSMAN PARK Full or Part time GP wanted. A rare opportunity to join a friendly, noncorporate, fully computerised practice in Mosman Park. Hours and days flexible. Remuneration - 70% of gross billings. Tel: Jacinta on 9385 0077 DIANELLA Non Corporate practice requires F/T and P/T VR GPâ€™s to join 6 female and 1 male doctor team. Our newly extended, long established, accredited, fully computerised practice is supported with 4 excellent nurses and 5 very friendly admin staff. Our practice is mostly private billing and we offer excellent remuneration. Please contact Practice Manager on 9276 3472 Email: firstname.lastname@example.org MELVILLE Rare chance for happy and motivated GP to replace long-term colleague moving soon from our stable, unique & boutique private, 6 Dr, General Practice here in Melville. Great Staff, Nursing & Allied Health support. Confidential enquiries welcomed to Robyn (Mgr) Tel: 9330 3922 a/h 0417 920 525 Email: email@example.com SOUTHERN SUBURBS After Hours GPs - Perth Southern Suburbs Seeking P/T VR/non-VR GPs for AH services in our DWS UAN Practices SOR. Offering flexibility, mixed billing with high earning potential, and full admin support. Computerised and fully accredited. Essential criteria include: t ")13"3FHJTUSBUJPO t .FEJDBSF1SPWJEFSFMJHJCJMJUZ t &YIJCJUFYDFMMFOUDPNNVOJDBUJPO interpersonal skills displaying solid clinical experience. t 1SPWJEFFYFNQMBSZXPSLJOHSFGFSFODFT Please email EOI & CV to: firstname.lastname@example.org
WEST PERTH GP sessions available at our private-billing, accredited and fully computerised general practice. Our busy practice serves a young, professional demographic as well as providing specialist sexual health services. This represents an exciting opportunity for an enthusiastic practitioner to join our friendly team. Morning and afternoon sessions are available. Experience in family planning, sexual health and mental health would be an advantage. Contact Stephen on 0411-223-120 Email: email@example.com SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979
THORNLIE VR GP required for a fully accredited, computerised, non-corporate, rapidly growing practice. Nursing support available. No after-hours. Friendly support staff. Outer-metro Visa 457 Sponsors. 65% billings and retainer negotiable. Contact: 9267 2888 / 0403 009 838 Email: firstname.lastname@example.org BOORAGOON Enjoy clinical sovereignty at our Garden City Medical Centre. We require a Full time General Practitioner to provide their medical expertise to the community. The centre consists of ten consult rooms and a two bay treatment room. This multidisciplinary medical centre offers a supportive administration team, experienced nurses and a long standing professional Practice Manager. There is onsite Pathology, Pharmacy, National Hearing Specialist, Physiotherapy and Speech Pathology conveniently located onsite. For all confidential enquiries please contact email@example.com or on 0418 371 724 BULLCREEK Come and join us in our New General Practice located SOR. Non-Corporate Practice. We require a Part-time VR GP for our Surgery. Tuesday afternoon, Wednesday All Day, Thursday mornings and Friday Morningâ€™s available. The surgery is Computerised, Private and Bulkbilling. Practice Nurse available part-time. Please contact the practice manager Annette on 9332 5556
We make Aged Care work for GPâ€™s Medical Practitioners for Aged Care (MP+AC) is seeking doctors to join its team providing medical services to residents of various Residential Aged Care Facilities throughout the Perth metro area. Our efficient service delivery model maximises the doctorâ€™s earning potential. t 'MFYJCMFTFTTJPOT.POEBZUP'SJEBZ t (SFBUBENJOTDIFEVMJOHTVQQPSU t 3FNPUFMPHJOUPQBUJFOUSFDPSET t 3/QSPWJEFECZ.1 "$UPBTTJTUEPDUPS t #FUUFSVUJMJTBUJPOPGEPDUPSTUJNF t 1BZNFOUPGHSPTTSFDFJQUT t &RVJUZJOWPMWFNFOUQPTTJCMF For more information or confidential discussion about work options please contact Rollo Witton â€“ Chief Executive Officer - MP+AC Tel. 9389 8291 or Mobile 0417 921 632 or
75 PALMYRA Palin Street Family Practice requires a full or part-time VR GP. We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens. Earn 65% of mixed billings. For further information call Lyn on 9319 1577 or Dr Paul Babich on 0401 265 881
Australian Skin Cancer Clinics Specialise in Skin Health in Western Australia t $"//*/(50/ t -&..*/( .63%0$)) Great opportunities for experienced GPs to join these two busy Australian Skin Cancer Clinics. t 'MFYJCMFXPSLJOHIPVSTUPTVJU your lifestyle; t (SFBUFBSOJOHQPUFOUJBM t .PEFSOXFMMFRVJQQFEDMJOJD t 1SPGFTTJPOBMBENJOJTUSBUJPOBOE practice management staff; These are not DWS listed sites. For more information please contact Fiona James on 0447 006 846 or firstname.lastname@example.org www.ausskinclinics.com.au/ BEACONSFIELD Well established, niche family friendly practice seeking VR Female GP to work flexible days and hours. Fully computerised and accredited. Good mix of private and bulk billing. Please contact Practice Manager Linda on 9335 9884 or Email: email@example.com KINROSS KinrossÂ (DWS) is looking for a VR full-time GP. This privately owned and managed practice will offer up to75% billing to the right doctor. Various locations North, South available. Please contact Phil on 0422 213 360 Email: firstname.lastname@example.org QUEENS PARK Looking for GP VR to join our growing medical centre. Efficient, helpful admin staff and RN support. Mixed billing, excellent facilities, accredited and fully computerised. On-site physiotherapy, occupational health and pathology. Please phone Tim 9356 8993 Email:email@example.com Website: www.queensparkmedical.com.au
Reach every known practising doctor in WA through Medical Forum Classifieds...
SEPTEMBER 2013 - next deadline 12md Tuesday 16th August - Tel 9203 5222 or firstname.lastname@example.org
WOODLANDS P/T or F/T VR GP wanted to join happy, noncorporate, mainly private billing practice. Good mix of patients, no weekends or afterhours. Great location, RN support. Would suit female GP. Contact email@example.com or 9204 3900
MANDURAH - YOUTH HEALTH Peel Youth Medical Service is seeking a youth-friendly GP for 1 – 2 sessions per week. Exciting opportunity to work with young people, with a focus on mental and sexual health in a supportive practice. Flexible session times available. Contact Sharlene 9581 3352 Email: firstname.lastname@example.org
WHITFORDS GP - F/T OR P/T. We are fully computerised, well equipped, accredited practice. Friendly practice Nurse and admin staff to support at all times, including Careplan/ Health Assessment Nurse. Medical Centre has on site pathology and pharmacy. Please contact Jacqui, Practice Manager on 9307 4222 Email: email@example.com
Venosan Diabetic Socks FREMANTLE Part time or Full time (preferably VR) GPs wanted. ELLEN HEALTH is a doctor-owned and managed General Practice operating from two locations in port city of Fremantle. Well established patient base, offering a broad suite of services including nutrition and lifestyle, specialised pregnancy and midwifery care, community mental health nursing and skin clinic consultations. If you were to join our team we will offer you: t "HSPXJOHEBUBCBTFPG1SJWBUF Billing patients t "QSPGFTTJPOBMBOEEFEJDBUFE support team t "MJGFTUZMFUBJMPSFEUPUIFMPDBUJPO t )PVSTPGXPSLUPTVJUPVSCBMBODFE lifestyle approach - Practice hours are Weekdays 8am-6pm, Saturday, 8am-4pm - No after hours, on-call or hospital work required at this time t )JHIMFWFMPGFBSOJOHT Contact Practice Manager Bridie Hutton 0413 994 484 Email: firstname.lastname@example.org GOLDEN BAY PT female GP required. Fully computerised, DWS, private/bulkbilling, Fully accredited, Practice Nurse, onsite pathology. Contact: Sheelagh 08 9537 3738
The Magic of Silver for Sensitive Feet No Compression Silver Ion Therapy Contains the antimicrobial silver yarn Shieldex® which enhances a balanced foot climate. Tested and proven in controlling over twelve types of bacterial and fungal infections common on the feet and legs. t
Silver yarn - is permanent and cannot be washed out of the socks.
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Soft-Spun Cotton - Ultra soft cotton
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Sizes – available in 3 sizes (Small, Medium & Large).
Your WA Consultant – Jenny Heyden RN Tel 9203 5544 or Mob 0403 350 810
SEPTEMBER 2013 - next deadline 12md Tuesday 16th August - Tel 9203 5222 or firstname.lastname@example.org
medical forum Looking for work life balance? GP Opportunities Available in WA
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To find a practice that meets your needs, call:
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'PSBMMDPOĂśEFOUJBMFORVJSJFT QMFBTFDPOUBDU&TUIFS on email@example.com or 0418 371 724.
Ph: 9315 2599 www.thehealthlinc.com.au
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CVS are a leading cardiology practice that provides high quality diagnostic stress testing services. We are seeking medical practitioners who meet the following pre-requisites: Â‡ 5HJLVWUDWLRQZLWKWKH$XVWUDOLDQ0HGLFDO%RDUG Â‡ 0HGLFDO,QGHPQLW\,QVXUDQFH Â‡ /LIH6XSSRUW6NLOOVRUH[SHULHQFH Â‡ +LJKUHJDUGWRGHOLYHURXWVWDQGLQJSDWLHQWFDUH ,I\RXPHHWWKHVHSUHUHTXLVLWHVZHZHOFRPH\RXWRMRLQRXUWHDPRI VSHFLDOLVHG0HGLFDO3UDFWLWLRQHUV6WUHVV3K\VLFLDQV$VD6WUHVV3K\VLFLDQ \RXZLOOZRUNZLWKVWDWHRIWKHDUWGLDJQRVWLFHTXLSPHQWFRQGXFWTXDOLW\ VSHFLDOLVWWHVWLQJDQGLPSURYH\RXUGLDJQRVWLF(&*VNLOOV$QDWWUDFWLYH UHPXQHUDWLRQSDFNDJHZLOOEHRIIHUHGWRVXFFHVVIXOFDQGLGDWHVDVZHOODV H[SHULHQFLQJH[FHOOHQWMREVDWLVIDFWLRQDQGZRUNLQJFRQGLWLRQV CVS locations include: Joondalup, Karrinyup, Nedlands, Midland, Mt Lawley, Leeming, East Fremantle and Rockingham.
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Equipment Provided - WADMS is a Doctorsâ€™ cooperative Essential qualifications: s General medical registration. s Minimum of two years post-graduate experience. s Accident and Emergency, Paediatrics & some GP experience. sĂĽ sĂĽ sĂĽ sĂĽ
Fee for service (low commission).sĂĽ Non VR access to VR rebates. 8-9hr shifts, day or night. sĂĽ Bonus incentives paid. 24hr Home visiting services. sĂĽ Interesting work environment. Access to Provider numbers.
Supplement your income: Are you working towards the RACGP? â€“ we have access to provider number for After Hours work. Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.
Contact Trudy Mailey at WADMS
(08) 9321 9133
F: (08) 9481 0943 E: firstname.lastname@example.org www.wadms.org.au WADMS is AGPAL registered (accredited ID.6155)
3OHDVHSKRQH$GDP/XQJKLWRGLVFXVVRSSRUWXQLWLHVDW&96RQ 1300 887 997 or 0402 825 570 RUYLDHPDLOinfo@cvs.net.au
With a reputation built on quality ality of service, Optima Press has the WKH resources, the people and the e commitment to provide every client y client with the finest printing and value DOXHIRU for money. 9 Carbon Court, Osborne Park 6017 Tel 9445 8380
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. Procedural GPâ€™s and ofďŹ ce based GPâ€™s well catered for. Contact Dr Brenda Murrison for more details!
9791 8133 or 0418 921 073
SEPTEMBER 2013 - next deadline 12md Tuesday 16th August - Tel 9203 5222 or email@example.com
Sunshine Summit 2014