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Editorial

Paying the Piper and Calling the Tune Is medicine all about the money? There isn’t a consultation, a procedure, a treatment, an initiative, a study, a new drug, a new gizmo, a management program or a research project described in these Days of Budgetary Anxiety that doesn’t come down to money spent vs money saved. On one level, that’s fair enough. The health cake is shrinking and those sums have to be done and with it greater accountability and elimination of wasteful duplication. But is there a loss of focus on what all those things mean to the individual and to the community? Has there been a conscious disconnection that the funds everyone is scrambling for belong to everyone? Should those funds always find themselves filtering through the same set of hands to be distributed selectively and then their largesse trumpeted? While the health tsars may look to W philanthropy as a budget top-up, surely ph the bulk of the money belongs to the th community. It would be nice every now co and again to have an acknowledgement an by those who win government contracts to ssay to the community how privileged they are to be entrusted with our money and a tthey will endeavour to provide the best sservice possible to enhance the lives of as many as possible. m

Ms Jan Hallam

As regular readers of Medical Forum, you A will have noticed the word transparency w has cropped up more than a few times in h recent editions. It’s going to happen again … if organisations are entrusted with our money, we are the ultimate stakeholders and we deserve to know the details of how it is spent.

The purpose of taxpayers’ money is not to create emperors and empires but to ensure all those health initiatives mentioned in the opening lines of this editorial reach those in the community who need them the most, with minimum leakage on red tape and bureaucracy. Do we need another board with an advisory group hanging on before people can use their expert knowledge garnered over 20 years of clinical experience? What cost do we put on sitting fees,

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Mr Glenn Bradbury (0403 282 510) advertising@mforum.com.au

MEDICAL FORUM

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

air fares, administration – oops, there goes 30% of the budget. This scenario is repeated time and time again. When governments are flash with our cash in the good times no one asks hard questions but when the belts tighten, and this is such a period and it’s unlikely to end any time soon, there has to be a different policy culture, one that is sustainable and immune from the political life cycle and free from fear and favour. This edition explores a raft of issues that inevitably comes down to money. GP After-Hours home visits are an example of a hotly contested sector that lives off consumer demand for flexibility, shorter GP clinic hours and, in all but one case, bulk billing. In the Eastern States, we hear there are up to 100 players. Here in Perth, there are currently four who hit the road after 6pm on weeknights and from noon Saturday. The PIP to GPs announced in the 2015-16 Budget will encourage surgeries to stay open for longer. The big test will be what impact, if any, this will have on the drive-in drive-out doctors. The next will be the Medicare review – the 2014 failed co-payment signalled the Government’s increasing anxiety over the costs of bulk-billing, so any changes could test the viability of this area of practice. One of the winners of the Budget, at least on paper if the sums come out right, is the Medical Research Future Fund. The Government is committed to get this show on the road, despite the stumbles of last year which linked funding to the co-payment. It seems a matter of national pride to keep the ‘best and brightest’ working on our shores and over the next four years, the research fund will benefit from cuts in other health programs. But, even so, the Budget papers have a cutesy way of putting it: “The savings from this measure will be redirected by the Government to fund other Health policy priorities or will be reinvested in the Medical Research Future Fund.” Perhaps not time to break out the bubbly just yet. Last month, WA universities collaborated on bringing together their best and brightest for the inaugural Science on the Swan scientific meeting. We went along to see what community benefits we can expect down the track from our investment. And that brings us back to the shrinking cake – and whether we can afford to have it and eat it too. The next Doctors Drum breakfast, Money and Medicine – Slicing the Cake, will be exploring just how that cake can be distributed fairly.

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

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

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May 2015

Contents 20

18

23

FEATURES 18 Trailblazer – Dr Nadine Perlen 20 Investing in Succession Planning 23 GPs After Hours 25 Science on the Swan

25 NEWS & VIEWS 1 Editorial: Paying the Piper and 4

Calling the Tune – Ms Jan Hallam Letters: Poor Process, Ordinary Outcome Dr Amro Labib

A Panellist’s View Prof Moira Sim

AHPRA Improving the Process

LIFESTYLE 44 New Times for Myanmar

Prof Con Michael & Adj A/Prof Robyn Collins

Too Slow, Too Stressful and Unfair

Dr Carol McGrath

47 48 49 50 51

Dr Tim Cooper

Wine Review: Smallwater Estate

After-Hours Dilemma

Dr Louis Papaelias

Dr Pam Quatermass

Social Pulse: MDA 90th Anniversay; Bethesda GP Ed Legends of Theatre

Cosmetics Need Review Where’s the Loyalty?

Mr Peter McClelland

Dr John Hayes

Dr Jayson Oates

SJG Subiaco Response

Australian Dance Theatre Competitions

Dr Lachlan Henderson

4

Curious Conversations: Dr Jodie Forlonge

14 16 27 40

Have You Heard? How Much Transparency is Enough? State Backs GP Training Beneath the Drapes

MAJOR SPONSORS 2

MEDICAL FORUM


Clinical Contributors

5

Dr Michael Watson Antibiogram 2014

9

Dr Mark Hands Cardiology: What’s On The Horizon?

32

Dr Matthew Scaddan Ankle Pain After Sprain

39

Dr Andrew Klimaitis Antihypertensives in the Elderly

40

Dr Astrid Arellano TB Testing Dilemmas

43

Dr Ronny Low US in Acute Abdomen

37

Dr Stefan Ponosh Angioplasty in Peripheral Arterial Disease

Guest Columnists

12

Dr Marisa Gilles Caring’s 100% Success Rate

20

Dr Cathie Bowen PhD Putting Your House In Order

29

Mr Rob Bransby NFP Insurers Shape Up

31

Dr Richard Yin Taking a Stand for the Planet

e-Poll

We polled doctors further on how complaints are handled. Go to P10-11 for what docs think about Medical Politics and their views on AHPRA or Medical Board Impartiality.

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

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Letters to the Editor

Poor process, ordinary outcome

complaints that would make the process more transparent and minimise the stress on doctors.

Dear Editor,

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

Dr Amro Labib, Endocrine Surgeon, Fiona Stanley Hospital

Having attended the Doctors Drum breakfast (Medical Board & AHPRA – Friendly Fire?) I wanted to share my experience with your readers. While I was working as a surgical trainee in Melbourne a few years ago at Box Hill Hospital, I received my only ‘notification’ from AHPRA to inform me that I would be investigated following a complaint from a patient`s daughter. Her claim was that I had given her wrong information about her mother and that she had to fly from Perth to Melbourne to see her mother ‘before she dies’. I reviewed the patient’s file and found that I had never seen this patient – ever! I was never involved in her care in any way, shape or form. In fact, at the time in question I was actually overseas at a conference for the entire length of this lady’s admission. I wrote to inform AHPRA of all these points and included the hospital roster which clearly confirmed that I was on conference leave when this incident happened. However, I also wanted to find out how my name came to be involved in this complaint. It turned out that this lady’s daughter had asked a nurse looking after her mother for the surname of her mother’s doctor and the nurse volunteered my name!

A Panellist’s view Dear Editor, There is a great deal of confusion about the roles of the Medical Board of Australia and the Australian Health Practitioner Regulation Agency (AHPRA) explained in the 2014-2015 Health Professional Agreement between the Medical Board of Australia and AHPRA (www. ahpra.gov.au/Publications/Health-professionagreements.aspx). How did I come to be on a panel? I recall responding to a call for expressions of interest many years ago. Conflicts of interest were a key issue dealt with during the training sessions for panel members. Being reported to the Medical Board is and has always been a slow process and a difficult experience – that is not new. Time is needed to assess each complaint, provide for natural justice (which means following a fair and proper procedure when making decisions), and where relevant gathering busy people for hearings.

There was no process from AHPRA to clarify the identity of the doctor before contacting me. As you can imagine, this issue caused me a huge amount of stress for a few months before receiving a letter from AHPRA 5-6 months later that basically said “thanks, you are off the hook now!” At no stage, have I received an apology.

The National Law, the complex role divisions between AHPRA, the Medical Board of Australia and the State/Territory Boards and the sacking of the Queensland Board have all led to confusion and concern amongst the profession and public. A means for people to complain is important. Taking complaints seriously and having transparent processes inspires public confidence.

I thought my story could be relevent when considering how AHPRA could better handle

How can we ameliorate the negative perception among medical practitioners?

Everyone would agree that prolonged cases are stressful for all concerned. We can ask questions of the Medical Board about the timelines for communication, investigation, hearing and resolution. How many cases are resolved in three months, six months or over one year and why some cases take longer than benchmark timeframes? Transparency is important and there is a lot of information on the Medical Board website. But dissemination of more information about the processes of panel appointment, panel training, and the management of conflicts of interest may be useful. We need to understand the role of the Medical Board. It has been established to protect the public, not us. For our protection we have our medical defence organisations and other medical organisations that we belong to. Now is the time to engage our organisations to ask the questions above. Prof Moira Sim, GP, Head of School of Medical Sciences (ECU), Member of Impairment Review Committee for Nurses and Midwives Board, Panel member for Medical Board, Medical Adviser for the Health and Disability Services Complaints Office. ........................................................................

Too slow, too stressful and unfair Dear Editor, I thought the title of the last Doctors Drum (Medical Board & AHPRA … Friendly Fire?) very apt. The meeting was well attended and the various stakeholders were well-represented. The take home message was that there are inherent problems with the current regulatory arrangement. AHPRA is unreasonably slow continued on Page 6

Curious Conversations

Clear for Take-Off SCGH intern and former Army Black Hawk chopper pilot Dr Jodie Forlonge lets her actions speak for themselves. I’ve always set the bar pretty high and the main reason for that is… there is always something to strive for – always. Medicine in the military really appeals to me because… I can represent my country and help people at the same time.

My biggest weakness is… I guess it would be that, at times, I can be very matter-of-fact. That does put people off occasionally. If I could live anywhere in the world for a year it would be… New York, New York. I love the people and the diversity is wonderful. So much to do, and so little time. ED: Dr Jodie Forlonge is a serving military officer in the Australian Army.

The book I’m reading at the moment is… A Long Way From Paradise, a book about a woman who survives the Rwandan Genocide.

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MEDICAL FORUM


By Dr Michael Watson Clinical Microbiologist

Major Sponsor: Clinipath

Clinipath Pathology Antibiogram 2014 Implications for Community Practice This article gives a brief overview of Clinipath Pathology’s 2014 Antibiogram and the implication for General Practice in Western Australia. Every year, the antibiotic susceptibility of common organisms are analysed and presented as antibiograms by Clinipath Pathology, which has a very wide geographic distribution within WA and processes large numbers of community microbiology samples. This makes it an ideal source of information to guide clinical practice of GPs in WA. Wound infections and communityacquired MRSA Staphylococcus aureus is the most common bacterial cause of skin, soft tissue and bone infections. The mecA gene of MRSA isolates codes for a new penicillin-binding protein that renders these bacteria resistant to flucloxacillin, cephalexin and amoxicillin/ clavulanate (Australian Therapeutic Guidelines first line agents for wound infections) and all other betalactam antibiotics. The prevalence of community-acquired MRSA has rapidly increased in Western Australia and the 2014 Clinipath Pathology Antibiogram now shows that 10% of all Staph. aureus isolates from community sources are MRSA. This makes it essential to obtain wound swabs for culture and sensitivity testing and therapy should increasingly be guided by laboratory antimicrobial susceptibilities. Erythromycin susceptible strains of MRSA are also sensitive to clindamycin, which is a potent agent for serious skin and soft tissue infections. Clindamycin is effective therapy for many MRSA infections and is available as an authority script in general practice. If the strain is resistant to erythromycin, it should be assumed to be resistant to clindamycin because although they are structurally different, they have the same target site and cross-resistance is very common. Cotrimoxazole is also a possible therapy for uncomplicated skin and soft tissue infections and Clinipath Pathology data suggest that the

vast majority of MRSA isolates are sensitive to this agent. Other agents for MRSA such as fusidic acid, ciprofloxacin and rifampicin may be suitable alternatives but they should always be used in combination because resistance to these agents is common if they are used as monotherapy. Resistant gonococcal infections Resistance of gonococcus to oral antibiotics is now very common. Resistance of gonococcus to ciprofloxacin is currently 37% and amoxicillin is 60%, which means they are no longer suitable as empiric therapy. Patients with positive Gonococcal PCR (but without culture results) should be treated with intramuscular ceftriaxone PLUS azithromycin (recently recommended to help reduce development of resistance). It is important to obtain a swab for culture (gel swab) in addition to PCR (dry swab) in patients with significant discharge or other symptoms of an STD, as empiric therapy for Chlamydia trachomatis (single dose azithromycin) or UTIs will affect our ability to culture gonococcus, making the strategy of culturing following positive PCR results less than optimal. Urinary tract infections and resistant Gram negative organisms E. coli and Klebsiella sp are the most common cause of urinary tract infections in children and adults accounting for over 75% of community isolates seen at Clinipath Pathology. In the past, these were invariably sensitive to antibiotics such as cephalexin and Augmentin. Currently approximately 5% of E. coli isolates from UTIs are resistant to cephalexin and Augmentin. Augmentin has the added advantage of covering Enterococcus faecalis, which is the third most common cause of UTI, accounting for almost 7% of all UTIs. Enterococcus is inherently resistant to all cephalosporins including cephalexin. Of concern is that 23% of isolates of E. coli are now resistant to trimethoprim, which makes this a much less

suitable choice for empiric therapy in 2015 in WA. Two new resistance mechanisms have emerged in the recent years called extended spectrum beta-lactamase (ESBL) and Inducible Chromosomal beta lactamase. These two types of beta-lactamase breakdown all beta-lactam antibiotics including penicillins and cephalosporin antibiotics (including 3rd generation cephalosporins) with the exception of the carbapenems (meropenem and ertapenem). In 2014, almost 3% of all E. coli isolates had the ESBL phenotype. ESBL isolates also have plasmids (circular pieces of mobile DNA) that often contain genes for resistance to aminoglycosides (gentamicin), fluoroquinolones (ciprofloxacin and norfloxacin) and cotrimoxazole, potentially rendering them virtually untreatable with any commonly available oral agent available in Australia with the exception of nitrofurantoin. Nitrofurantoin is only suitable for uncomplicated cystitis. A new drug called Fosfomycin is available as an oral agent but is currently only available through the TGA Special Access Scheme, making it impractical to obtain in the general practice setting. For those strains without an oral antibiotic choice, treatment with IV intravenous antibiotics is required and a good option for this is single daily Ertapenem as home IV therapy. Summary Multiply antibiotic resistant bacteria are now very common in the community setting in Western Australia. Choice of therapy should now be guided by microbiological investigations as the ability to reliably predict antibiotic effectiveness is rapidly disappearing. Judicious use of antibiotics will be essential to help prevent the further spread of these organisms in the community.

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au MEDICAL FORUM

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Letters to the Editor continued from Page 4 to respond to complaints. Due process must be followed but cases shouldn’t be delayed for three to four years before being heard. The gathering of data doesn’t take that long. A common theme was the enormous amount of stress that is experienced in waiting for a case to be heard. It also appears that there are many minor grievances that could be more promptly and probably more effectively dealt with by mediation at a local level. It is clear that the balance is in favour of the consumer and this should be redressed. Dr Tim Cooper, plastic surgeon, Nedlands ........................................................................

AHPRA improving the process Dear Editor, Dealing with notifications about registered medical practitioners is one of the core tasks of regulation. We need to assess and manage these in a way that is fair, transparent and effectively manages risk to patients when a doctor’s conduct or performance is unsatisfactory. We know that being on the receiving end of a notification is very distressing and confronting. There are things the Board and AHPRA are doing to improve the experience of practitioners and notifiers involved in the notifications process, while keeping our focus on patient safety. Last month, we took part in the Doctors Drum Q & A session, to listen to the views of WA doctors and health consumers regarding regulation and answer any questions. Hearing from consumers and doctors highlighted both how challenging the experience of a notification is for everyone, and how common issues can be seen from different perspectives. More detail about the work we are doing to make improvements is published in the April Medical Board newsletter, Update. Key issues we are working on include the time it takes for a notification to go through the process; the tone and clarity of our communication; the

need to better explain how the process works and why; and greater transparency about what information can be legally released.

complaints are dealt with is another key concern, and this is evident in the way Medical Board panels operate around the country.

The Doctors Drum session showed us clearly how important it is for the Board and AHPRA to work harder to explain to registered medical practitioners how regulation works in WA, and help them understand their legal and regulatory responsibilities. We are committed to engaging more directly with doctors interested in learning about the regulatory processes and answering their questions.

Under the National Law, panel members are selected by the Medical Board of Australia, and the majority of members of any particular panel (whether health, performance or professional standards) are medical practitioners. AHPRA explains what you need to know about panels on its website.

Continuing to work closely with Medical Forum is one way of doing this. We will also be engaging with a range of organisations locally that also work with the medical profession, so we can hear the views of doctors directly and answer their questions. The purpose of regulation is to protect the public. We need to make sure the system is accessible, responsive and timely. Working closely with the profession and the community will help us achieve this. Prof Con Michael, Chair WA Board of the Medical Board of Australia Adj Assoc Prof Robyn Collins, WA State Manager AHPRA ED: For the record, there were no health consumers at the Doctors Drum meeting, just a representative from the Health Consumers Council on our discussion panel. This letter arrived after we wrote to Adj A/Prof Robyn Collins asking for AHPRA to write something on medical assessment panels and expert witnesses – how they are chosen, how conflict of interest and transparency is managed.

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Panels and procedural fairness Dear Editor, Your recent articles (When confusion turns to anger and Medical Board & AHPRA … Friendly Fire? May edition) raise important points about the way complaints against doctors are handled. The concerns expressed by attendees at the Doctors Drum breakfast mirror concerns expressed in other parts of the country about transparency, communication and parity in timeframes, and are issues that we have also identified in assisting our members.

The panel decides its own procedure and is required to observe the principles of natural justice and procedural fairness. For it to do so, it is essential that panel members are well-trained about the application of these principles, as well as how to balance conflicting arguments and expert evidence. In a national scheme, panels should operate in a manner that ensures consistency of both processes and outcomes, no matter which state or territory you are practising in. The principles of natural justice and procedural fairness are integral to a robust decision-making process. Unfair processes adversely impact the outcome and undermine confidence in the complaints-handling system. It is vital that health regulators and the individuals who make decisions that impact on a doctor’s reputation and ability to practise, be independent and impartial, have the requisite expertise and follow a fair, consistent and transparent decision making process. Georgie Haysom, Head of Advocacy, Avant Mutual Group ........................................................................

After-hours dilemma Dear Editor, Can Medical Forum please advise on what is happening with afterhours home visit services? Who is behind the two new(ish) bulk-billing home visiting medical services, Dial-A-Doctor and GP2home? They have both been advertising quite aggressively through pharmacies and the latter advertises services in Brisbane, Melbourne, Perth and Sydney. Meanwhile, the Afterhours GP at St John of God Subiaco has closed, presumably because it is no longer viable. I can’t imagine how a

Lack of national consistency in the way continued on Page 8

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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.

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.

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Letters to the Editor continued from Page 6 bulk-billing home visiting GP service would be either, especially since [some] provide doctors with a chaperone. At a recent Medicare seminar there was talk as to whether the request for the service was received during surgery hours – something about a delay of at least two hours after surgery close to presumably stop rorting whereby a doctor simply saves up work until after hours to legitimise a different, more remunerative item number. It seems this service is morphing into a homevisiting GP-type service and patients have commented to me they would rather sit at home and wait for the GP to visit them than use our own in-house after-hours clinic at Hollywood Hospital. The issue of what constitutes an emergency is a vexed one and I’m unsure whether patients who said they have used this service would constitute an emergency; most of them would have been fit to go to a walk-in after-hours clinic. It seems another brick in the wall that will undermine the traditional role of the family doctor. In our own case we are linked to an after-hours clinic at Hollywood, which employs a small number of local GPs and enables patients to see their regular doctor after hours or a doctor who has access to their medical file. Until we get a system that enables us to access previous blood tests and imaging results (the PCEHR seems to have been shelved) it will be more efficient and costeffective to be seen by either your own doctor after hours or by another doctor who has access to your file and results. But if other providers are cherry picking the ‘good’ item numbers, it will both put Medicare costs up and erode the financial viability of the family doctor. It worries me that these new services are fragmenting primary care even further. Dr Pam Quatermass, GP, Claremont ED: This letter has prompted us to take a detailed look at the changing landscape of GP After Hours home services on P23.

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Cosmetics need review Dear Editor, Dr Sammer makes some very important points in her column, (Control the Cosmetic Cowboys, May edition). And I agree with her wholeheartedly. I guess cosmetic injectables could be done well and safely from a beauty salon by an appropriately qualified person. However, commoditisation of these injections has certainly led to flouting of the rules the TGA has for S4 drugs. Maybe what the public wants is what they have in the UK where neurotoxins (Botox) are not our equivalent of S4 and less regulated as to who and where they can be injected? Also the TGA seems to be very selective about how it enforces its marketing rules.

8

I am far more concerned about injectors – both doctors and nurses – ability to manage intravascular injection of cosmetic filler. Any person injecting these products must understand the vascular anatomy and the depths of injection that are safe or dangerous in the face. Then they must have protocols to ensure that if there is a problem recognised at the time of injection, or hours later, that the appropriate management is instituted. Although rare, instances of skin necrosis and even blindness have occurred from cosmetic injections into the face. The AHPRA consultation and options regarding cosmetic surgery is welcomed. Of course, it misses the real issues in many cases. Suggestions that anyone under the age of 18 requires psychiatric review prior to say an otoplasty seems excessive. Patients with cosmetic concerns don’t want to be labelled as having a psychiatric conditions just because they don’t want to be teased. The child psychiatry service is already overrun. I don’t see that they would want to see patients coerced because AHPRA says so. However, the demand for cosmetic medicine and surgery continues to grow and, as doctors, we need to keep reviewing how we provide the service in a way that benefits the patient. Dr Jayson Oates, Plastic Surgeon, Subiaco ........................................................................

Where’s the loyalty? Dear Editor, I have leased Medical Suites at SJG Subiaco since 1982. I have a great affection for SJG Subiaco, which has been a wonderful working environment where I have made many friends, from kitchen staff, cleaners, engineering staff through to Medical and Nursing staff. I was thus shocked to receive a notice from the CEO, Dr Lachlan Henderson, that my Medical Suite lease was not being renewed and I was given an order to vacate the premises.

sister commented that she could not believe that a Catholic Hospital could behave in such an unChristian way. SJG prides itself on its Mission Values. Loyalty is not one of them. Dr John Hayes, Consultant Physician, Subiaco ........................................................................

Response Dear Editor, Thank you for the opportunity to respond. SJG Subiaco has a busy ‘on-site’ Medical Clinic with a waiting list of doctors requesting tenancies, representing a broad range of clinical specialties. When leases come up for renewal, the hospital, as landlord, considers a range of factors. A significant factor, referred to by Dr Hayes, is the inpatient load of the doctor. Proximity to hospital beds is another factor and clearly relevant to specialists such as obstetricians who often need to urgently attend their patients. Physicians play a vital role at SJG Subiaco. Many physicians are involved with teaching medical students and junior doctors while maintaining a busy inpatient practice at the hospital. We are also indebted to those physicians who support our after-hours’ roster. It is necessary to afford these doctors priority space in the medical clinic as it becomes available. At the time of his lease renewal, I met with Dr Hayes to inform him of our decision in this context. Given the longevity of his tenancy, he was given a minimum of six months to find alternative premises. It was also noted that multiple tenancies were available in the SJG Subiaco precinct. Whilst it is regrettable that a long-standing tenant may have been inconvenienced by the operational needs of the hospital, I consider our process and the time offered to Dr Hayes to find an alternative as reasonable and fair. Dr Lachlan Henderson, ED Perth Northern Hospitals (including CEO of SJG Subiaco Hospital)

Prof. Simon Dimmitt, General Physician, received a similar notice. We are both regarded as being of insufficient economic value to SJOG as we do not admit many patients. I pointed out that I care for five of the SJG Sisters and generate $150K in business through SJG Pathology and have 30 admissions each year to the Ivy Suite. This resulted in a six-month stay of eviction. SJG Subiaco plans to purge the Subiaco Clinic of similar low-admitting Physicians, which comprise about 20% of all tenancies. I thus warn current Physician tenants to protest to the SJG Board of Trustees if you receive a similar eviction notice.

We welcome your letters. Please keep them short. Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. You can also leave a message at www.medicalhub.com.au. Letters may be edited for legal issues, space or clarity.

On moving to my new rooms at McCourt St Medical Centre, my first two patients were SJG Sisters whom I had not seen before. One

MEDICAL FORUM


Major Sponsor: Western Cardiology

Cardiology: What’s On The Horizon?

Dr Mark Hands Clinical Associate Professor (UWA), Interventional Cardiologist

About the author Novel treatment for hypercholesterolaemia Statin therapy is presently the mainstay treatment for hypercholesterolaemia, particularly in secondary prevention. Large randomised studies have demonstrated their unquestionable beneďŹ t in this group. However, a small proportion of patients are intolerant to statin drugs developing myalgia, arthralgia, abnormal liver function and in some perhaps mild cognitive dysfunction (reversible). In the future, such patients may well become candidates for regular subcutaneous injections of human monoclonal antibody directed against PCSK9.

intervention trials with the inhibitor: if positive, we can anticipate PCSK9 inhibitors perhaps within the next 2 to 3 years. New alternative to ACE inhibitor in heart failure LCZ696 is a new class of drug entitled angiotensin receptor-neprilysin inhibitor (ARNI), which includes moieties of Valsartan and Sacubitril. The PARADIGM-HF study randomised over 8000 patients with depressed left ventricular systolic function (predominantly class II and III heart failure) to treatment with LCZ696 or Enalapril on top of other evidence-based therapies.

The latter is a key regulatory enzyme produced in the liver and secreted into plasma as functional PCSK9. Extracellular PCSK9 binds to the LDL cholesterol receptors on the surface of the liver and other cells. This complex is then transported to the lysosome for degradation, thereby preventing the recycling of LDL cholesterol receptors back to the cell surface.

Patients who received LCZ696 compared with the ACE inhibitor showed a 20% fall in cardiovascular death or heart failure hospitalisation and a decrease in cardiovascular death alone over 2 to 3 year follow-up. Effectively, the trial suggests that LCZ696 doubled the survival beneďŹ t of Enalapril in this group of patients.

This reduces the concentration of LDL cholesterol receptors on the surface of the cells resulting in a lower LDL cholesterol clearance and thus elevated plasma LDL cholesterol and total cholesterol.

We await to see whether LCZ696 is adopted instead of ACE inhibitors or angiotensin receptor blockers in the treatment of chronic heart failure. If so, the name needs to change (I already have trouble remembering my car registration!).

Several pharmaceutical companies have now developed monoclonal antibodies directed against PCSK9.

Bioabsorbable “stents� (BRS)

Subcutaneous injections given 2 to 4 weekly have shown a reduction of LDL cholesterol by 40% to 60%, regardless of whether they are concurrently using statins. Interestingly, and perhaps importantly, reduction of lipoprotein(a) has been noted with the treatment. Presently, oral active inhibitor is not available. PCSK9 inhibitors may well become alternative or additional to statins for management of hypercholesterolaemia. Hopefully, this new intervention will result in decreased cardiovascular events. Presently, we await the outcome of several large controlled

These new vascular scaffolds made of polyL-lactide degrade over two years following implantation. They have a polymer coating that elutes everolimus over 30 days, to prevent restenosis. It is hoped that the end product is a stent-free, normal, remodelled coronary artery with normal endothelium, resulting in decreased cardiac events (including late thrombosis) and the artery amenable to bypass surgery if required in the future.

Dr Mark Hands graduated from UWA with Honours (Dux) and trained in cardiology at Sir Charles Gairdner Hospital and Brigham Women’s Hospital, Harvard Medical School. He is an interventional cardiologist in private practice at Western Cardiology (chairman), Clinical Associate Professor (UWA) and emeritus consultant cardiologist at SCGH. In addition to general cardiology and echocardiography his special interests include investigation and treatment of acute and chronic ischemic heart disease. Dr Hands’ interventional procedural skills include coronary angiography, angioplasty and stenting in stable angina and in acute unstable angina and acute myocardial infarction and cardiac pacing.

towards the BRS having less need for revascularisation and a decrease in angina rate. It is anticipated/hoped that the real beneďŹ t of bioabsorbable scaffolds will be realised in the two to three years after implantation. Based on the initial trial data the product has now achieved TGA approval in Australia and it is anticipated they will receive reimbursement by Health Funds making them more widely available in both the public and private systems in the second half of 2015.

The ďŹ rst completed randomised trial comparing BRS with metallic drug eluting stent has recently demonstrated similar outcome data at 12 months, with a trend

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e-Poll

Handling Dr Complaints – Slowly Getting There! Medical Forum has supported doctors who deal with the Medical Board or AHPRA, simply because we have heard many disturbing stories. As it turns out, our last Doctors Drum highlighted major deficiencies in communication, which the Medical Board and AHPRA are finally sorting out – their letters will be less confronting, more frequent when things drag on, more informative (e.g. explain their obligations under National Law, and why things are taking so long) and they will be seeking your feedback. Hopefully, they will listen. Interestingly, health consumers have similar complaints, so they should be winners too. ........................................................................ While communication is one thing, investigation of notifications is another. We believe good doctors want the bad ones weeded out but they don’t want to be part of a witch hunt or get buried in lawyers, politics or paperwork. The national Medical Board can respond to a complaint or act on the advice of the WA Medical Board to establish an assessment panel to either examine the health or performance and professional standards of a doctor. Health consumers are represented on panels along with medical practitioners. The Medical Board and AHPRA have undisclosed lists of doctors who are approved by them as panellists and probably as expert witnesses. Many of these people, we believe, were ‘grandfathered’ across when National Law first came in (2010). Their impartiality is as unknown as they are. Then we have expected biases of the legal assessors, chosen by AHPRA, possibly thrown into the mix. What Are Doctors Paying For? It is important this is sorted to everyone’s satisfaction as 42% of doctors in our survey thought panellists could lack impartiality to a serious extent. In fact, only one quarter of doctors we surveyed (n=195) were happy with the impartiality shown by AHPRA or the Medical Board in processing a complaint (with 36% unhappy and 39% undecided). Nearly all of those who were unhappy said they were concerned that unfairness will be seriously damaging to someone. Investigation is a very confronting experience. If someone is being investigated by a panel, either the panel or the person being investigated can opt for a more out-inthe-open State Administrative Tribunal (SAT) judicial hearing – the panel usually refers because it feels the evidence before it constitutes more serious professional misconduct.

10

What Fair Doctors Want

POINTS OF NOTE

Doctors we talk to appear to want an apolitical system of investigation that is fair and timely, and to be treated reasonably. Unlike the legal profession, their work is mostly built around trust and honesty. They do not want a return to the ‘good old days’ where those doctors with a political bent could influence what the Medical Board did.

så Impartiality in dealing with complaints is important. Just over one third (36%) think AHPRA or the Medical Boards impartiality is unacceptable, and 45% believe doctors sitting on panels that judge other doctors could seriously lack impartiality. Damage to someone is their main concern.

While this is a very difficult area for us to investigate, with arguments and counterarguments at every step, we cannot understand why the Medical Board would turn to arguably the most political organisation, the AMA, for its counsel (the national Board Chair met earlier this year with “senior leaders from AHPRA and representatives of the AMA” to workshop doctor complaints).

så What role for AMA WA? Lack of impartiality in the AMA may be a given, as the organisation is political, acting for about 4700 financial members in WA (mostly specialists and hospital doctors). Close association with the Medical Board or AHPRA in WA may not be desired by a significant proportion of doctors, nonmembers more so than AMA members (where there are proportionally more GPs).

Why? Our e-Poll responses raise a question mark over the AMA’s involvement. We asked WA doctors to reflect on experience over the years, and 9% of AMA members thought the AMA was part of any problem with Medical Board impartiality, and only 9% said there was no problem at all. With a higher proportion of non-members (30%) pointing to a problem with AMA involvement, and between 36-45% of doctors unable to decide either way, the AMA may worry at this apparent lack of endorsement. However, results suggest the AMA should be involved at some level – 9%-25% of doctors see them as part of the solution. GPs a Special Case GPs are a particular case. Only 26% are financial members of the AMA nationally yet they contribute over half of fees to AHPRA and the Medical Board. From our survey, proportionally more GPs than other doctors are not happy with AMA performance over Medical Board impartiality.

så Our solutions for improved governance: better communication; transparency of panel membership; training for all doctors in the fair discharge of their duties; apolitical steps to improve both the quality of complaint and people hearing the complaint; and KPIs linked to timeliness.

Politics & Impartiality 195 doctors responded to our e-Poll within the six-day time frame. We have made it much easier for those using mobile devices, for those thinking of taking part next time. Around 63% of respondents were male and 54% were financial members of AMA WA (8% preferred not to say).

According to the AMA WA website, WA GP members are represented by Dr Steve Wilson and A/Prof Rosanna Capolingua. How much both GPs and specialists relied on their WA experience alone in answering our questions is unknown as is whether results from our sample can be easily extrapolated to doctors as a whole. ED. The independent review by Kim Snowball, the National Registration and Accreditation Scheme (NRAS) Review, we anticipated would be released at the COAG Health Council meeting of Health Ministers in mid-April. Health consumers will not even see the Review’s recommendations before the Ministers again “discuss them further” in August. Is this politics at play?

MEDICAL FORUM


Smart people, bad decisions In your experience, what are main reasons why smart people make bad decisions (up to 3 choices)? Self-interest

22%

Poor self-awareness

15%

Think they can get away with it

13%

Blinded by success

13%

Surrounded by ‘yes men’

13%

Abuse of power

10%

Confusion

6%

Other

5%

Cannot say

3%

Medical Politics Are the problems at Fiona Stanley Hospital, including those reported by the media, beyond what you might expect from start-up ‘teething problems’? Yes

54%

No

32%

Uncertain

14%

Is your perception that the Minister for Health in WA can be easily inuenced by medical factions that lobby him? Yes

27%

No

27%

Uncertain

46%

WA Doctors on AHPRA or Medical Board impartiality

e-Poll

sĂĽ )ĂĽKNOWĂĽOFĂĽTHREEĂĽDOCTORSĂĽWHOĂĽSUICIDEDĂĽASĂĽRESULTĂĽOFĂĽBOARDĂĽNONĂĽIMPARTIALITY sĂĽ 4HEYĂĽDOĂĽANĂĽEXTRAORDINARILYĂĽDIFlCULTĂĽJOBĂĽBRILLIANTLYĂĽFORĂĽNOĂĽREWARDĂĽMONEYĂĽORĂĽTHANKS  sĂĽ )ĂĽHAVEĂĽBEENĂĽVERYĂĽSURPRISEDĂĽBYĂĽAĂĽCASEĂĽINVOLVINGĂĽAĂĽ-EDICALĂĽ#OLLEAGUEĂĽINĂĽ3!ĂĽWHEREĂĽ AHPRA appear to have been very lenient toward the doctor involved. Before a court, the outcome would have been very different. sĂĽ /NEĂĽOFĂĽTHEĂĽ!(02!ĂĽDOCTORSĂĽWASĂĽVERYĂĽBIASEDĂĽAGAINSTĂĽMEĂĽnĂĽTWOĂĽPATIENTSĂĽTOLDĂĽMEĂĽSHEĂĽ slandered me to them when they saw her for a consult and mentioned my name! She has never even met me. sĂĽ !(02!ĂĽSEEMĂĽTOĂĽGOĂĽWITHĂĽGUILTYĂĽTILLĂĽPROVENĂĽINNOCENTĂĽ4HEIRĂĽPROCESSĂĽTOĂĽCLEARĂĽSOMEONEĂĽISĂĽ onerous and lengthy. They should offer counselling to doctors. sĂĽ (AVINGĂĽRECEIVEDĂĽANĂĽUNSOLICITEDĂĽREQUESTĂĽTOĂĽREVIEWĂĽTHEĂĽPERFORMANCEĂĽOFĂĽAĂĽ'0ĂĽWHOĂĽWORKSĂĽ in a “special interestâ€?, on the basis that I have considerable experience in the ďŹ eld, I formed a favourable view of the MB as I am not a fellowship “specialistâ€?, just a peer. sĂĽ 4HEREĂĽISĂĽSUCHĂĽAĂĽPOORĂĽDEGREEĂĽOFĂĽTRANSPARENCYĂĽTHATĂĽWEĂĽAREĂĽLEFTĂĽTOĂĽFEARĂĽTHEĂĽWORSTĂĽ sĂĽ )NĂĽTHEĂĽ5+ ĂĽTHEĂĽEQUIVALENTĂĽTOĂĽ!(02! ĂĽTHEĂĽ'-# ĂĽHASĂĽBECOMEĂĽTHEĂĽVEHICLEĂĽOFĂĽPOLITICIANSĂĽ who seek to control medicine. Doctors have had no conďŹ dence in the GMC for over a decade. AHPRA is following a similar path e.g. re-validation, sudden increase recently in hearings. I feel that AHPRA will become more partial in the next few years. sĂĽ !(02!ĂĽTENDSĂĽTOĂĽBEĂĽUNDULYĂĽHOSTILEĂĽTOĂĽTHEĂĽDOCTORĂĽANDĂĽTHEĂĽDOCTORĂĽISĂĽNOTĂĽADEQUATELYĂĽ informed about progress of the complaint. sĂĽ 6ERYĂĽDIFlCULTĂĽTOĂĽGETĂĽTHEĂĽBALANCEĂĽOFĂĽFAIRNESSĂĽRIGHTĂĽFORĂĽBOTHĂĽSIDESĂĽ/NĂĽTHEĂĽONEĂĽHANDĂĽ)ĂĽ was staggered to hear of the specialist who now has a permanent record of ‘prior complaint’ from a patient he had never treated i.e. a blatant mistaken identity. On the other hand, the best way to protect the profession is not to protect every individual at any cost but to quickly cut loose those that are unscrupulous or disgrace the profession. sĂĽ !(02!ĂĽHASĂĽPURSUEDĂĽTWOĂĽCOLLEAGUESĂĽOVERĂĽEXCEPTIONALLYĂĽTRIVIALĂĽCOMPLAINTSĂĽYETĂĽTHEYĂĽTURNĂĽ a blind eye to quacks (chelation, multivitamin therapy, etc.)

Impartiality in Investigating Complaints Is the impartiality shown by AHPRA or the Medical Board in processing a complaint about a doctor, wherever it comes from, usually acceptable to you? Yes

25%

No

36%

Uncertain

39%

ED. There were no signiďŹ cant effects from gender or AMA membership on these responses.

You answered ‘No’ to the previous question. Are you concerned that unfairness will be seriously damaging to someone? Yes

94%

No

4%

Uncertain

2%

Do you believe that some doctors asked by AHPRA or the Medical Board to sit on Medical Assessment Panels to judge the performance or health of another doctor, could lack impartiality to a serious extent? Yes

42%

No

15%

Uncertain

43%

sĂĽ !LLĂĽINDIVIDUALSĂĽCARRYĂĽAĂĽDEGREEĂĽOFĂĽPARTISANSHIPĂĽORĂĽPRECONCEIVEDĂĽVIEWSĂĽBASEDĂĽONĂĽTRAINING ĂĽ experience and also knowledge of individual doctors by reputation or personal experience. Like a jury, they should put all that aside and only look at the evidence, not take up their own soapbox. The Medical Board and APHRA have gone way too far with their power. It takes one complaint to taint the Dr involved with a tarred brush, and that mark stays forever.

Looking back over the years, do you consider the AMA as part of any problem or part of any solution when it comes to Medical Board impartiality? AMA M

Non-M

Male

Female

Part of the problem

18%

9%

30%

19%

18%

Part of the solution

17%

25%

9%

20%

13%

Both

19%

13%

23%

17%

19%

Uncertain

39%

45%

36%

37%

44%

Not a problem

7%

9%

1%

7%

6%

ED. The differences in responses follow ‘party lines’ (AMA M = AMA Member). Half the respondents who are AMA non-members feel the AMA is part of the problem, to some degree. With 74% of GPs not AMA members, and there being no signiďŹ cant gender variations in answers, we speculate there would be no GP-Specialist differences in responses.

ED. No signiďŹ cant differences between AMA members and non-member responses.

MEDICAL FORUM

11


Incisions

Caring’s 100% Success Rate Caring can sometimes be more powerful medicine than curing, says Midwest Public Health physician Dr Marisa Gilles. patients and also motivate them to follow healthy choices.

It is a frequently stated fact that people are more likely to do what their doctor recommends than other significant people in their life. This has often been my experience over the past 32 years. Since 1998 I have been involved with a small cohort of people with chaotic lives and significant alcohol use who have chronic medical conditions that demand total compliance to maintain optimum health. When I audited their progress, 62.5% had blood results reflecting this had been achieved! How has this happened? These people have been involved in my life since they were teenagers, they have my mobile number and although they are very respectful of my private life they have been known to ring me at odd hours in the day for reassurance or practical help. We have a close relationship and when their results are good, we celebrate together. How realistic is this in general practice? I would suggest that there are plenty of GPs who may not give out their mobile numbers but have close and warm relationships with their

Circumstances can also motivate people to make significant changes in how they live their life. A heart attack or stroke can result in finally giving up smoking, taking on an activity and reducing food intake. It always makes me laugh or cry when someone tells me they can’t give up their bacon and eggs as if their lives depend on it! Then something happens and suddenly the opportunity is there to promote a change in behaviour and it happens. We are all aware of Maslow principles. The basics have to be in place before energy can be focused on extras. I will never forget the day I was waxing lyrical about 30 minutes of exercise to a slightly overweight woman when she exploded because that morning her abusive husband had come to her home, smashed up the glass front door and threatened her. Little wonder the “take 30” message was not on her radar. We spent the next hour focusing on what mattered – ensuring she had a safety plan. In 2009 I was involved in a study which looked

at Hb A1c and the factors that appeared to influence good diabetic control. Not surprisingly, life events had a significant impact and poor control was often not related to lack of knowledge but more to how diabetes was prioritised in their lives. Interviews revealed that people understood only too well their disease and their responsibilities. Frequently either they did not choose to make diabetes a priority or were unable to make appropriate lifestyle changes. Their life/social stresses often influenced their glucose control. In these cases techniques such as motivational interviewing may prove useful in working through these priorities so that control of their diabetes becomes more relevant to their day-to-day life. If this fails, then health providers may need to sit with their own discomfort rather than impose their own priorities on their patients. Charon and Wyer beautifully articulate this tension: “He cannot cure Dencombe but can only sit by the dying man’s bedside, keeping vigil, offering witness…confirming his worth.”

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Have You Heard?

Code 18 passes…just The ACCC has authorised the Medicines Australia Code of Conduct (edition 18) for five years but with significant changes, whereby pharmaceutical companies must report ‘transfers of value’ (such as speaking fees, advisory board fees, or sponsorships to attend a conference). This includes to individual professionals without their consent first being required. Medicines Australia no longer has to report food and beverages, capped at $120 per head (plus GST and gratuities). MA has been given until October 1, 2016, to implement these changes after which six monthly reports are to be issued and data made more accessible to patients and third parties (such as healthcare professionals, consumers, researchers and the media). The RACGP has welcomed the changes, but says they don’t go far enough.

Lifeline for women’s service Last month we reported that RFDS was being forced to relinquish its Rural Women GP Program because funding was being diverted to the Rural Health Outreach Fund administered by Rural Health West. News from Belinda Bailey, CEO of Rural Health West, has reassured GPs and communities that those who currently receive a service will be offered a service in this new funding arrangement. She added that priority would be given to new patients and areas with RA 5 classification.

Grog, think again The variable impact of alcohol consumption on health has been highlighted by a review by the International Scientific Forum on Alcohol Research. They chose two robust studies that showed consistent results – moderate alcohol consumption (7-14 drinks a week) lowers the risk (about 17%) of heart failure compared with non-drinking. These results are not unexpected because, in developed countries, moderate drinking is associated with a lower risk of coronary artery disease. WA’s Prof Ian Puddey from UWA is on the reviewers’ panel.

Doctors in distress Over the past 18 months, stories of mental and physical distress of doctors and medical

students has pushed out beyond the collegial code of silence and have fuelled the now famous Beyond Blue survey and most lately a move by the Medical Board of Australia to fund a national health program. It has contracted the AMA to ensure consistent services across the nation and it is expected that the existing Doctors Health Advisory Services operating nationally will get the gig. In WA that service has been coordinated for a long time by Dr David Oldham and a small team of committed doctor colleagues who have worked hard to keep the service going. At the time of going to press David was hopeful that the DHAS WA would get the nod from the AMA DHS. The group was to submit an expression of interest. On the matter of mandatory reporting, David said there would be no change to WA’s stand against the practice.

Pills, bills and spills? The Pharmacy lobby may have fallen short of their $21b claim but the Government has effectively turned its back on GPs’ concerns with the 6th Pharmacy Agreement being signed off. Pharmacies get $19b and the green light to perform vaccinations, wound care, weight, blood pressure, blood sugar and cholesterol. That appears to be the deal to save an estimated $1b on scripts over four years with changes to the safety net. Pharmacies will be given an option to pass on a $1 discount on

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MEDICAL FORUM


scripts. Some welcome the changes citing more choice and flexibility for the consumer but it could also be a recipe for chaos and finger pointing down the track.

In CPD we trust A senior doctor contacted us via our medicalhub website complaining that an AHPRA audit had rejected his certificate of completion for CPD issued by the Royal Australian College of Physicians. Apparently the certificate wasn’t enough, he should have produced the source documents. When we rang Dr Stephen Milgate, from the Senior Active Doctors Association, he told us the National Law required a doctor to produce original documents for ID and criminal checks, but nowhere was it stated that they had to do the same for CPD. Digging into the fine print of the Medical Board’s CPD registration standard we found this: “Medical practitioners are required to ensure their CPD activities are recorded, either by keeping records themselves or by using college processes, and to produce these records when the Board requires them to do so as part of an audit or investigation. Records must be kept for three years.” This raises two questions: Does AHPRA trust the college on its word? Are the colleges willing to share AHPRA’s administrative burden? A response from RACP was pending at the time of going to press.

Sticking in the needle Last edition and in this month’s letters pages, cosmetic docs have raised some serious issues about the questionable standards and safety of some ‘practitioners’ in the injectables area. AHPRA’s public consultation, which is trying to establish who is doing what to whom and where, appears to be shooting over the top of the problem. It assumes that this area is the province of medical practitioners when doctors and news reports over the past five years tell us it’s not. A couple of facts might offer some insight into this turbulent landscape. Firstly, it’s big business. Australians spend about $1b on cosmetic surgical and medical and related procedures and treatments. Australians throw more than $350m worth of Botox at their wrinkles. There are about 30,000 liposuction procedures and about 8000 breast augmentation surgeries. It would seem that AHPRA should perhaps set its sights lower.

Court halts greedy business The Federal Court’s stern ruling of unconscionable conduct against Advanced Medical Institute (AMI) in promoting and supplying medical services and medications for men suffering from sexual dysfunction has put paid to a multimillion dollar business and sounded a warning to others. AMI was earning

over $59.3m in 2008 and $71.5m in 2009. The ACCC claimed AMI was exploiting consumers’ vulnerability for its own commercial gain. Head of the ACCC Rod Sims said consumer issues in the health and medical sector were a priority and the ACCC “will not hesitate” to hold businesses and responsible individuals to account.”

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Feature

How Much Transparency is Enough? We look back at what the CEO of Healthway considered adequate transparency and accountability before asking the $60m dollar question. Medical Forum has championed the good governance of medical organisations. When the AMA WA president withdrew the AMA’s nominee as the sole remaining Healthway board member, he commented about the need for governance reform, which prompted us to look at our 201213 correspondence with the then CEO of Healthway David Malone.

In our May edition, guest columnist and taxpayer advocate Tim Andrews suggested that keeping “vested interests” out of boards like Healthway wasn’t enough – greater transparency and accountability to health consumers were needed.

Before doing that it is worth reflecting on the best future Healthway board structure for WA. The Health Minister and ex-GP Dr Kim Hames has said individual organisations with a strong interest in outcomes will no longer be guaranteed a seat on the new board. Instead, the board will be appointed by the Health Minister and Premier. The new Healthway structure will be modelled on Lotterywest.

...greater transparency and accountability to health consumers were needed. Back in 2012, David Malone said...

AMA WA has expressed concern at political interference. They did this both before and after it was announced that politicians would be handing out the Healthway sponsorship cheques in the future. Just as we were going to press, Roger Cook said the Labor Party would fight this to keep Healthway independent of Government. This should be applauded but what is independence? Under the previous board, Healthway funded the Healthier WA Award, handed out by AMA WA at its Gala Dinner and billed as WA’s leading public health award (see www. healthierwa.amawa.com.au/index.asp). AMA WA took $5000 for administration and marketing and $10,000 was presented by them to the winning WA organisation as reward for their outstanding contribution to health promotion.

Back in 2012, David Malone said transparency and accountability were key Healthway values that he felt hinged on: 1. The Governance framework – the fact that their Board included nominees of community stakeholder organisations, 2. The commitment to independent evaluation – by researchers at UWA, 3. The reporting framework – funding decisions and performance outcomes were tabled in State Parliament, and 4. The audit process – by the Office of the Auditor General (OAG) and Healthway’s internal auditors. Under legislation, Healthway had to give 30% of its sponsorship budget to sports and 15% to arts sponsorship. He considered that Healthway Board members took their

responsibilities very seriously, especially in respect to conflicts of interest. The board had internal processes that were closely monitored by management and could be audited annually. Legislation also defined where board members should come from. He explained that under the relevant legislation board members were virtually guaranteed to have conflicts of interest, such as being associated with organisations applying for funding, and that he was comfortable they were appropriately dealt with as they arose. We asked about more transparency in decisions and Mr Malone said the full minutes of Healthway Board meetings were not released. His reasons were this could compromise the privacy of organisations applying for funding and some information was considered commercial-in-confidence. Just as Medicines Australia has been told by the ACCC to increase its transparency around ‘transfers of value’ involving doctors so that health consumers and others can form their own judgements, something similar may be required for the new Healthway Board and management. The balance must be right. Certainly, the four points that David Malone pointed to seem obviously inadequate in light of the Public Sector Commission report that found evidence of ticket and hospitality rorting by some board members and staff.

By Dr Rob McEvoy

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blackwoodriverclinic.com.au SOUTH WEST RURAL RETREAT

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Trailblazer

A Passion for General Practice Mentoring young GPs and providing integrated care for her patients are the foundations on which Lockridge GP Dr Nadine Perlen has built her two decade career. Mention nutritional medicine to a group of GPs and the responses will more than likely vary from genuine interest to a polite raised eyebrow. Lockridge GP Dr Nadine Perlen, however, is passionate about the field, and a proud advocate of the benefits it can have for patients as part of integrated care. What began as a passing interest in her early years as a GP is now a part of her everyday practice, thanks to a long and personal journey with her own sick child. “When my second son was 10 or 11, he became quite ill. He had gastrointestinal problems initially but then multi-system problems. We took him to a lot of specialists, but none of them could explain his complex symptoms or how they were related. No one thing explained the skin rashes, the head aches, the vomiting, the fatigue. No one could put the whole thing together,” she said.

deficiencies, food allergies and genetic polymorphisms. It took some time but we did have success. My son is 15 now and he is much healthier. Through his illness I learned so much about nutrition and the body, and I am still learning.”

Lockridge’s diverse demographics

Seeking answers in different places

She has also managed to get herself out of the Perth metro area courtesy of the Royal Flying Doctor Service.

Nadine, who studied at the Australasian College of Nutritional and Environmental Medicine, defines nutritional medicine as taking existing and ongoing knowledge of biochemistry and physiology and using this in safe, effective and evidence-based therapy to improve patients’ health. This applies to diet, nutritional supplements and even herbal medicine where it is effective and supported by evidence. “On the base level, many of our patients have an inadequate diet. Even just working with people to cut sugar or to identify certain food groups with which they have a problem can help,” she said. “Some of the people I treat have chronic conditions and in some cases – for example fibromyalgia – modern medicine doesn’t have a whole lot to offer them. Nutritional medicine gives doctors another approach, another way to look at these problems which also involves the patient. People like to be involved in treatments that do not necessarily mean more pills.” Are medical colleagues as receptive to such an approach? “I get varied responses. Some are fascinated; they’re open-minded and want to know more, others are less so,” she said. A nod from the College Now the RACGP has the Faculty of Special Interests with an integrative medicine working group, more doctors may be encouraged to take a second look at the field, but Nadine concedes it will take years before this approach is widely accepted.

Dr Nadine Perlen

Nadine wrote a piece for Australian Doctor on her son’s illness and being a ‘medical parent’. That piece was read by a NSW doctor, who pointed her to a nutritional medicine specialist in Brisbane, with whom the family eventually ended up working. “He took into account things like my son’s nutritional status, gut flora and enzyme

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“That is because [medical therapies] must be based on evidence, which is there for nutritional medicine but it is still growing. One thing this field does have on its side is that it is very scientifically based. Plus nutritional medicine is using new technologies many people will be unfamiliar with.” Twenty years into her career her passion for general practice has not dimmed. For Nadine it is all about holistic patient care and the personal connection to patients. She has spent her entire career at the Lockridge Medical Centre, caring for a diverse patient population that includes vulnerable patients such as refugees, immigrants and Indigenous people.

“You see everything here, that’s what makes it a great place to work. We have always seen more chronic diseases which are typically associated with poverty and lifestyle, including mental health problems,” she said.

For the past 13 years she has regularly travelled to Pingelly where she offers a female GP service to women residents. Previously funded as part of a Federal Government push to offer gender choices in regional and remote areas, Nadine’s monthly visits have proven hugely popular. [As of July 1, Rural Health West has taken over the administration of the program offering a lifeline to those women who use this service. See Have you Heard P14]. Importance of mentoring For the past 15 years Nadine has been a GP supervisor of both medical students and GP registrars. She was inspired to take on this role by GP academics at Monash University, where she attended. She said they went beyond the clinical and taught her about the practical elements of becoming a doctor, such as attitudes toward patients and strong communication skills. When Nadine moved to Perth after she finished her training, she actively sought out a teaching practice. She was directed to the Lockridge Medical Centre, which was started as a teaching practice in the 1970s by GP academics from the University of Western Australia. Her teaching role is obviously a good fit. In 2009 she won the Royal Australian College of General Practice’s GP Supervisor of the Year Award. “The phone call from Dr Chris Mitchell (then RACGP president) came through about two months after my father had passed away. It was a bit sad that he wasn’t able to see or be a part of it. But it was really nice to be acknowledged for what I enjoy and love doing.” “I have always enjoyed sharing what I know with others. I found that the more teaching I did, the more I got out of it. There is something really nice about mentoring and passing on what you know with others who come after you. I really get a kick out of that.”

By Ms Shannon McKenzie

MEDICAL FORUM


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Feature

Start Succession Planning Early Just as careers are carefully planned, retirement and succession need equal attention to give peace of mind and space to enjoy the fruits of all the hard work. involving the daughter of WA mining tycoon Peter Wright, the former business partner of Lang Hancock. It begs the question – can you ever make sure a Will is absolutely watertight?

The relevant experts all concede that developing a medical practice, using Trusts in an effective manner and succession planning are areas of great complexity. Consequently, getting professional advice structured across the full span of a career makes good sense. From the initial expense of setting up a business to developing its full potential and on to ensuring a seamless transition into retirement is strewn with both pitfalls and opportunities.

“It’s almost impossible to do that,” John said. “You may feel that you’ve exercised your testamentary freedom effectively but there’s always the Family Provision Act waiting in the wings. It allows individuals, particularly children, to make a claim if they feel they’ve been unfairly marginalised. The essential criterion is that they are able to show some degree of financial need.”

Barrister, advocate and Harvard-trained legal mediator Prof John Hockley specialises in Family Corporate and Succession Law. He relates a story that re-affirms the importance of drawing a straight line between a bequest and its intended beneficiary. “I had a client who’d made a lot of money as a property developer in the medical sector and wanted to make a large donation to a university here in Perth. It became too complex so he left all his assets to his wife and she lived on into her 90s before bequeathing around $9m to four individuals in Poland and Germany.” “It was almost impossible to trace these people and it turned out that some of them had been killed during World War II. You might

Prof John Hockley

have the testamentary freedom to leave money to someone but that doesn’t necessarily mean they’ll end up with it. I always tell people to put in a residual clause and make their favourite grandchild the beneficiary. If the rest of the Will fails, they’ll pick up the lot!” A watertight Will? John cites the recent and well-publicised case

“The Olivia Mead case [Ms Mead was awarded $25m] is interesting because there was more than enough money to go around. There was no one else competing for the testator’s bounty as all the other family members had previously inherited $40m each.” Legal twists and turns notwithstanding, John suggests that these areas are best addressed in a collective and timely fashion. “What I’d stress to doctors regarding estate succession matters is the need for an early conference with a lawyer and a tax adviser. This simplifies the process and mitigates the possibility of future problems, particularly if there are inherent complexities.”

Putting Your House In Order Good communication is an essential part of succession planning but is often the first casualty with things go wrong, says Dr Catherine Bowen (PhD). A young man kneels on the floor of the boardroom of his family company and apologises for errors that have occurred on the factory assembly-line. His tyrannical father stands over him as embarrassed executives watch on. Unable to meet his father’s expectations and constantly humiliated both privately and publicly, the son begins to drink heavily and dies at the age of 43. Who was this young man, and is this a typical story from the world of business succession? Could it also resonate within the medical profession?

Good communication is paramount in the succession and asset management process but, when there has been little or no planning, communication is often the first casualty. The resulting anger, tension and anxiety becomes a daily reality as the situation deteriorates and can result in physical and mental health breakdown, serious damage to relationships and suicide.

Over the past two decades as an accredited mediator I have witnessed families at odds on a plethora of different issues. Succession is a natural process for most businesses but the path is not always smooth, particularly for those who are unprepared, because it’s all about major change.

In regional areas the outcomes can be even more telling as a farming business in turmoil can result in the loss of the family home and generations of family history. Additionally, the loss is often highly public and may be accompanied by a great deal of humiliation and shame. I have seen desperate levels of anxiety with wives needing to work away and children required to stay home from school in order to ‘make sure that Dad is OK.’

And, for many people, this is perceived as a potential threat to their future financial security.

All too often it’s the women in rural areas working frantically to hold families together.

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Some individuals look for a litigious resolution but this often inflames an already difficult situation. It’s an expensive process and the financial and emotional costs rarely result in a satisfactory outcome. Such cases can drag through the courts and all too often it becomes a lose-lose event. For doctors, particularly rural GPs, many of these people will present in your surgeries with symptoms linked to anxiety and depression. I would urge the medical profession, in applicable circumstances, to consider a non-medical option. It may well be useful to suggest using the services of a professional mediator, particularly one with expertise and practical experience in succession planning. Perhaps referrals to specialists should, at times, embrace a wider circle than other medicos. And the young man referred to at the beginning of this story was none other than Edsel Ford, the only son of Henry Ford. And, sadly, this is not an uncommon scenario.

MEDICAL FORUM


in itself brings an extra level of complexity and therefore a number of strategies need to be considered to manage and protect that wealth,” Mat said. Nurture the Super Alex looks at the entire span of a medical career and, in particular, the allocation of funds and maximising the utility of superannuation to ensure a well-funded retirement.

Mr Stafford Hamilton

“For example, there are many different ideas surrounding ownership of assets. Those held in a Trust are not actually ‘owned’. They’re subject to a Deed of Trust and not necessarily the property of the trustee.” ATO looks at Entitlements “One area that the ATO is cracking down is the Unpaid Present Entitlement (UPE). It refers to a nominated loan to a specific person within a Trust when, in fact, no money has ever changed hands. Any doctor who has a UPE in a Trust account should get tax advice.” “There’s new legislation surrounding ‘Debt Forgiveness’ and the ATO is now saying that this sort of provision should be unwound. And a Testamentary Trust is quite useful in rolling over assets such as shares and leaving them to your children because you avoid Capital Gains Tax.” A recent development, suggests John, may well have relevance for doctors. “There’s a new area entitled Special Disability Trusts (SDT). I have a client whose child has the rare genetic disorder, Cri du Chat Syndrome and a SDT allows a provision to be made for her ongoing care. With this sort of thing you’re neither avoiding nor evading tax, it’s just a case of taking advantage of legitimate provisions.” John is well aware of the vicissitudes of a medical career and sings the praises of GPs in particular. “Most doctors work too hard and are always trying to do the best for their patients. GPs are in increasing demand as a referral point for a whole range of advice, both general as well as medical, and the ones I know do an excellent job.” “Nonetheless, it’s vitally important that medical practitioners continually assess the overall structure of their financial situation.” Doctors’ and debt Medical practitioners spend many years in training for their future as doctors. However this intense level of education doesn’t always equate to the know-how required to run a successful business. Finance Specialist Stafford Hamilton, from BOQ, said many doctors are more concerned about their patients’ health than they are about their financial health. Creating wealth doesn’t always come naturally and often the most obvious strategies aren’t the best in maximising cash flow, tax efficiencies and growing wealth.

MEDICAL FORUM

Mr Mat Hanlon

Mr Alex Hurst

Stafford points to cash utilisation as a tool. “There are alternatives to using cash savings to invest in a practice. It’s possible to borrow money for business and use your cash to develop wealth in a personal capacity at the same time.” “For example, doctors may build wealth with the equipment they finance to run their practice more effectively. Alternatively when buying commercial property to practise from there’s an element of disciplined saving as it may accumulate in value. Additionally, there’s the comfort in having stability in terms of location while paying off a tangible asset.” When it comes to making important financial decisions it would seem that the medical sector keep one eye firmly fixed on their colleagues. “We speak to clients on a daily basis about their specific needs and we’ve noticed they’re always very curious about their peers. They like to hear about trends in the market around superannuation, business structures and trusts and how they choose to finance assets over a particular time period.”

“It’s our job to simplify the complicated, transform it into a package that’s easily understood and implement strategies that ensure a long-term purpose for individuals who work incredibly hard. The financial complexities can be an unwelcome distraction, but nonetheless all doctors, even those in the early stage of their career, should be looking at such things as their superannuation arrangements including beneficiary nominations and adequate protection,” Alex said. “It’s important that assets are passed on with minimum stress and the Post Office pro-forma Will just isn’t good enough anymore.” Mat also points out the importance of forward planning for ‘blended’ families. “Any document relating to the transfer of wealth should be reviewed to ensure all dependents have been considered and special circumstances taken into account, such as the needs of disabled children. The obligations on self-managed super fund trustees also need to be fully understood by the individuals concerned.”

By Mr Peter McClelland

He said planning can start from pregraduation right through to ensuring a seamless transition when the time comes to sell a medical practice. Value of goodwill “Medical professionals build up considerable goodwill around their rooms and there’s an element of forced saving that accumulates in value. For doctors there’s the additional comfort in having stability in terms of location while building a tangible asset.” “Another area we’re fairly firm on is the need for accurate and binding documentation. Doctors tend to practise on an ethically driven basis involving mutual trust and this can be a problem if an internal dispute arises. Their inclination is to say ‘that won’t happen, we’re friends’ but that’s not an ideal way to run a business.” “Good documentation ensures a smooth exit if the need arises.” When it comes to wealth planning, superannuation and income protection, Mat Hanlon and Alex Hurst, from NAB Health suggest doctors carve out sufficient time to look after their interests. “Doctors do understand many of the wealth planning concepts we discuss with them, but often struggle to carve out the time to sit down and initiate the process. It’s also fair to say doctors’ incomes can be substantial, which

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MEDICAL FORUM


Feature

GPs Ready for Action – All Hours Just with deregulation of retail hours, GP home services are responding to consumer demand for action where and when they want it. But what will be the cost? With the patient defining what is ‘urgent’. Many people are opting to wait at home for a GP visit. A growing number of services oblige for a higher Medicare rebate. One of our readers asked us what was going on with GP after-hours services and as we dug deeper, the short answer is a lot and it’s not all straightforward! Some is a direct result of the May Federal Budget that will bring in a PIP after-hours payment from July 1 to encourage eligible practices to stay open longer. This has won favour from the RACGP with President Dr Frank Jones applauding the Government’s support for patients to access their regular general practice after hours. The PIP will be funded from the closure of HealthDirect’s after-hours GP helpline and the Medicare Local after-hours program. We were told HealthDirect’s nurse triaging service will continue but we will have to wait to find out what the Primary Health Networks’ roles will be, if any. At the time of going to press, the WA Primary Health Alliance, which is running the three PHNs in WA, had not be advised if they would receive any after-hours funding.

an increasing consumer demand for more deregulated GP services. All four services warn consumers it is not an emergency service but provide urgent GP consults instead. Three of the four operate within the regulated after-hours

time periods – 6pm-8am weeknights, noon to midnight Saturday and 24 hours on Sunday and public holidays. They do not take bookings until two hours before the service begins.

By Ms Jan Hallam

Dial A Doctor Perth

In the meantime, the after-hours GP ‘market’ has not been idle, at least in the Perth metro and outer-metro areas, with four old and new providers competing – Dial-a-Doctor, Australian Locum Medical Service (operating as GP2Home), Perth After Hours Medical Service and WADMS (operating as Doctor Home Visits), all of which have National Association of Medication Deputising (NAMDS) accreditation.

This business was started by a mother-and-son team of Dr Raya Mayo and Ilya Mayo in Cairns in 2010 and expanded to Perth in 2012. Its medical director is Dr Craig Gordon. It offers a universal bulk-billed home visit to all callers in the area from Alkimos to Dawesville. It is has an online booking service through HealthEngine. There are 16 cars on the road and doctors are accompanied by drivers. Notes of consultations are sent to the patient’s daytime GP. The website says its service is useful for: “People who are disabled, elderly or are without transport can have much easier access to primary health care…and single parents”. And its attraction is “patients can wait in the comfort of their own home for a doctor to attend to them.”

WA Health ships out

PAHMS is run by a five member local board with three doctors and offers universally bulk-billed GP after-hours home visits with standard hours of operation. It states on its website that it offers home visits “for medical conditions requiring attention when your own GP is not available”. Treatment notes are sent to a patient’s usual GP for follow-up. The service operates all areas from the CBD south to Mandurah and east to Armadale, Roleystone and Byford; north to Alkimos and Banksia Grove and north-east to Middle Swan, Greenmount, Helena Valley and The Vines. It has a phone and online booking service and an iPhone app.

This growth coincides with the retreat by WA Health from the after-hours space. A department spokesman told Medical Forum: “Evidence suggests that the national website Health Engine represented a more widely used platform for consumers seeking information about their local GPs, offering features and functionality that the government-run GP Afterhours website did not provide. Accordingly, when the four-year funding commitment for the GP After-hours website expired, no further funding was sought and the Government-run website and smart phone app were shut down.” She added that all public hospital after-hours GP clinics will continue to be funded. The Healthy WA after-hours GP webpage has links to five external sites including HealthEngine, ALMS, WADMS, PAHMS and Percy’s Practice. Confusing, however, is that HealthEngine does not have a specific after-hours link, and Percy’s Practice is linked to Perth Central East Metro Medicare Local, though calls to both 1300 numbers seem to be directed to the same call centre. A survey of the GP after-hours home services would indicate that all four are responding to

MEDICAL FORUM

Perth After Hours Medical Service

Doctor Home Visits (WADMS) WA-based Doctor Home Visits is a non-profit co-operative which has been operating in Perth for 37 years and is run by an all-doctor board: Dr Stephen Jarvis (chair), Dr Gordon Kendall (Medical Director), Dr Jamie Prendiville and Dr Peter Kiel. It says on its website that it “exists solely to offer patients home medical care both in-hours and after-hours on behalf of their own GP” and is the only locum service open 24 hours, 365 days of the year. It will make house calls during the day if directed by the GP and operates a call centre after hours. The service bulk bills pensioners, veterans, children, students and Health Care Card holders, while charges a fee for others at the time of consultation, which attract a Medicare rebate. It does not have a map of the area it services but a postcode check reveals that it visits Alkimos in the north but not as far south as Mandurah. It has a call centre and will be taking online bookings “soon”. GP2Home (ALMS) This is a national service owned by Sonic Health and has about 20 doctors on the books in Perth. Its bulk-billed service provides “home medical care for unexpected illness and connects patients who do not have a regular GP to daytime General Practice for their ongoing continuity of care”. It doesn’t have a map of the area it services but does go as far south as Mandurah but not as far north as Alkimos. It has an online booking service and an iPhone and android app. GP2home also provides an answering and paging service for GPs wishing to provide personal after hours care to their patients.

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MEDICAL FORUM


Feature

Medical Researchers on Show

Philip Shaw from the USA talks about brain development and ADHD

WA’s research industry cannot deflect that the community wants the best ‘bang for its [health] buck’ as it dresses up to impress. The inaugural Science on The Swan conference at the Convention Centre was held alongside the chartered accountants and the mining sector, highlighting how funding for health research goes handin-hand with community trends. Crosspromotion in The West Australian, the oversubscribed ‘conversations with the professors’ lunchtime session, and the speakers program promoted a community benefit from research. However, as deficits loom and health spending is reined in, the people on wait lists, who want things fixed, may be seen as a higher priority. The research industry, with its burden of relative uncertainty, also lacks that emotional pull with the community despite their PR people repeatedly telling of the latest ‘breakthroughs’. Yet research appeals to our inquisitive natures and is considered important enough to be part of the undergraduate curriculum, and some postgraduates rely on getting published to enter training programs (e.g. orthopaedics). How do you make medical research appear obviously translational and “work towards solving major 21st century health issues”? It’s a harder sell when GPs see 83% of the population annually yet general practice gets about 2% of NHMRC grants for research.

The Science on the Swan conference, Hot Topics in Life Course and Development, focussed on pre-birth to neonatal influences (see http://scienceontheswan.com.au). The microbiome of the newborn and its effect on health in later life was strong on the program, with an additional preconference workshop that discussed establishing a microbiome research centre in WA. Times are tough Unfortunately, the conference coincided with the Four Corners program depicting universities as cash-poor training places, prepared to compromise academic standards to attract fee-paying students. The federal government’s planned resurrection of the Medical Research Future Fund might lead some to think the MRFF and this conference was to confirm work for new science researchers in WA and keep funding for training coming. This conference was the original brainchild of UWA (Prof John Challis, Health and Medical Research) and Curtin University (Prof Michael Berndt, Health Sciences), before others came on board – eight universities and institutes finally showcased “the very best of medical science and health research in Western Australia”. And the line-up of overseas and Australian

researchers was impressive (see http:// scienceontheswan.com.au). Their work is behind the growing belief that every health intervention has to be ‘evidence-based’ to gain legitimacy. Although they have a very good point, the medical community is learning there is both good and bad evidence, and bias in how we get there that starts with the funders and ends with the career aspirations of some researchers. Given that research has this human face, listening to various speakers was instructive. Some were engrossed in their research, edging towards a new discovery that would lead to the next one, and so on, while others seemed grounded in the practical world of health consumers and were keen to show a community benefit. Translating to community benefit For example, Andrew Whitehouse, who spoke about autism and his desire to use research to give parents the tools to improve their lot, is from the latter school. As a result, few would begrudge him the $40 million for his research institute, hoping that his enthusiasm for the task translates into community benefits. He talks like he has his head screwed on right. But maybe Andrew is an impressive ‘front man’ and others continued on Page 6

MEDICAL FORUM

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MEDICAL FORUM


News & Views

Junior GPs Find Support in High Places Simple solutions can often be the hardest to pull off, as the issue of prevocational GP training is proving. Now the State Health Minister has entered the fray. Our story last month on the gloomy future of the prevocational GP placement program (PGPPP) has taken an interesting turn this month. State Health Minister Dr Kim Hames told Medical Forum he has gone into bat for the PGPPP with his Federal counterpart.

Backlash takes Minister unawares

It only takes a provider number

Anecdotally, Minister Sussan Ley’s office was taken completely off guard by the backlash from state governments, the profession and the public at the axing of the PGPPP. Apparently the negative reaction was second only to the storm created by the co-payment issue.

“Without provider numbers all these conversations will end up as a very confused story about how much it costs, who runs it, what does it achieve. For us in WA the PGPPP does two absolutely critical things.”

“I’ve written to the Federal Health Minister and expressed my disappointment that there’s no avenue for WA’s prevocational GP program to be recognised as an approved program for funding,” he said. “I’ve asked that Dr Kim Hames WA’s allocation of 10 provider numbers be retained so prevocational doctors in WA Health can experience general, community and rural practice. If provider numbers are not reinstated this will definitely have an impact on our capacity to attract prevocational doctors to rural and community practice.”

The experience of WAGPET, which has, with funding from WA Health, cobbled together a pared down version of the program this year, would suggest that without dedicated 3A provider numbers a PGPPP would not produce the desired results – more trainee GPs into areas where they were needed most.

“WA has funded 20 full-time equivalent positions for the 2015 Community Residency Program and is hoping to provide further places next year at reduced cost. The reinstatement of Medicare provider numbers would ensure that this program could continue at full capacity.” The issue has become one of national significance with health departments in other states wanting this program to continue because of its success at drawing more junior doctors into GP training programs in rural and remote areas where GPs are in short supply.

Last month the AMA announced that it had devised a plan to deliver a Community Residency Program for junior doctors. National president A/Prof Brian Owler said that since the scrapping of the PGPPP in last year’s Federal Budget general practice was now the only major medical specialty that does not offer JMOs a prevocational training experience. He said he has raised the plan with the Minister. While another influential voice raised in support of prevocational GP training is no doubt welcome, there is no evidence to suggest that there is a need for another training provider. While this may muddy the waters for those training providers tendering for government training contracts, which will be announced later in the year, CEO of WAGPET Dr Janice Bell said no training scheme can effectively get around the lack of dedicated prevocational 3A provider numbers. “Everyone would be satisfied if the Commonwealth simply allowed these provider numbers. We can work out the machinations because state health departments are keen to have this program continue,” she said.

“Firstly it fills a gap. It’s a $4-5m program which plugs a hole in a $4b industry. If junior doctors are not being exposed to rural and remote medicine in a safe and short-term process so they can genuinely try it on for size, that pathway is closed forever. To say that we have enough GP registrars now doesn’t recognise how we got there in the first place.” “The only reason why we have enough GP registrars is because community residencies have been such a successful marketing tool. Doctors come back and say how wonderful junior residencies are; the business case is not what it costs but what it will cost if we don’t do it.” “Secondly, there has been a lot of misleading information regarding the cost of the PGPPP but WAGPET’s community residencies program is actually the same or less than the cost to WACHS of sending that same doctor to those places, or through tertiary hospital rotation.” “I think we can do prevocational training with state government help for the same cost as GP registrar training, especially when you look at the economies of scale and systems set-up. It’s not that hard to add in PGP training but none of it is even worth talking about unless we have dedicated provider numbers.”

By Ms Jan Hallam

To read last month’s story, scan the QR code or go to www.medicalhub.com.au

Medical Research on Show continued from Page 25 have equally good ideas, just less powerfully presented?

the average clinician scratching their head as they looked for the clinical relevance.

So this conference was about both presentation and substance. Like many who are ambivalent about the value of research when things are tight, I still get excited to read of individual achievements and brainstorm the possibilities. Like most things, the devil is in the detail and research, by its very nature, provides an extraordinary amount of detail. Journalists who take the broad community view, naturally have trouble distilling this information.

It’s the same the world over, and researchers I talk to inevitably come up against money. It is used to lure “top minds” to the State. Come March-April, researchers are head down doing their NHMRC applications for funding. And money for research is nearly always public money for which the level of accountability and transparency is meant to be higher. Some researchers develop private means, and universities love it when they get a slice of the action.

It seems the more we learn, the less we know. We have come a long way and there is a lot to get excited about. The family tree of yesteryear has morphed into epigenetics, alleles, microbiomes, microbial genomics and molecular biology. The poster presentations – 51 of 83 were by trainees or students – might have left MEDICAL FORUM

Attracting researchers to Perth Money is about keeping the right people grouped in Perth to develop that ‘critical mass’ that WA always struggles with. To help overcome that barrier, WA researchers often hark back

to special study groups like the Raine Study, Busselton Study and the WA Health data linkage. These groups, like the bricks and mortar facilities, can be attractive to researchers. It is the same across Australia, unfortunately, so Perth’s climate and lifestyle plays a part in attracting researchers. Research institutes are popping up everywhere. At the same time genetics research has highlighted the need for us to think globally to collaborate – genetic relationships need big patient numbers, whether researching the genetics of a particular cancer or alleles associated with some common disease. A lot of hard work went into organising this conference. Around 15 of the speakers were from overseas. You would like to think its impact was felt outside the research community.

By Dr Rob McEvoy 27


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Guest Column

NFP Insurers Shape Up Fifteen not-for-profit health insurers have joined forces to face the challenges of Medibank and Bupa. HBF’s CEO Mr Rob Bransby explains. Medibank Private’s metamorphosis from public entity to listed company is just the latest in a dramatic transformation of the health insurance sector, which has until recently seemed remarkably resistant to the influences that long ago changed industries such as banking. Remember small mutual organisations like Town and Country? They have long disappeared, leaving the big for-profit banks unchallenged. As recently as 10 years ago most Australians with health insurance were members of funds that were not-for-profit or mutual entities, established with the single purpose to enable their members to access quality health care in times of need. In the past decade that has changed dramatically. NFP funds such as MBF have been taken over by powerful larger funds eager to scale up, or who, like NIB, have chosen to demutualise. There may still be 34 Australian health funds, but the market is dominated by Medibank, a listed fund under enormous pressure to make returns to shareholders, and BUPA, a multinational operating in 190 countries whose Australian

business repatriates profits to its overseas parent. In the coming months and years we can expect Medibank and Bupa to slug it out for market dominance. Smaller funds without scale and the capacity to raise funds can expect to be picked off as the big two seek to grow market share quickly. Small health funds are facing other challenges too. In July the Private Health Insurance Administration Council (PHIAC) will be terminated and the Australian Prudential Regulation Authority (APRA) will assume responsibility for private health insurance regulation. We can expect the burden of regulation to increase making life that much harder for the smaller funds. The influence of intermediaries like iSelect and Compare the Market is growing. Instead of joining a fund for life, consumers are constantly being encouraged to find a better deal and switch funds. It’s a message that resonates as premiums increase and federal government policy diminishes the incentives that have encouraged Australians to take out health insurance.

Far from being an obsolete model, NFP funds have a compelling story to tell. Roy Morgan tracks member satisfaction of all health funds and the satisfaction of NFP funds is consistently higher than for funds like Medibank, Bupa and Nib. Members of NFP funds are significantly ‘stickier’ (less likely to switch to another fund) and less likely to lodge a complaint to the Private Health Insurance Ombudsman. Their lack of scale means on their own NFPs can’t hope to be heard but as a collective, they can. The recent creation of Members Own Health Funds brings together 15 mutual and NFP funds including HBF, in a marketing alliance. It enables these funds to remind Australians that there is still a real alternative to the big conspicuous for profit players. Speaking as Managing Director of HBF, I assure you that my fund has no intention of becoming a casualty of another fund’s growth strategy. We are one of the few remaining not for profit funds that has the scale and capabilities to take on the big for profit funds. Last month, we launched the first stage of a national growth strategy, partnering with iSelect, to take on the likes of Medibank, Bupa and Nib in their homes states.

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Guest Column

Taking a Stand for the Planet It can no longer be ‘business as usual’ when it comes to climate change. It’s everyone’s business, says GP Dr Richard Yin. Global Divestment Day was on 14 February 2015 and if you’d been anywhere near Subiaco railway station you’d have seen me in a crowd of placard-waving protestors. I’ve never seen myself as radical but it’s hard to do nothing while watching the slow-motion train wreck of climate change.

Why would I want to support an industry that’s part of the problem? Unwittingly, many of us are invested in harmful industries and given the difficulty of transparency within ‘collective investment vehicles (does the word ‘derivatives’ in the sub-prime mortgage crisis ring a bell?) it begs the question. Just what are we invested in?

On board is everything we care about: our children, our country, the natural world and one big, blue planet. Yet, at the control console, it seems to be ‘business as usual’. And, while that’s part of the problem, it may also be a possible solution. And a big part of that means thinking about our investment choices.

As consumers we should exercise our right to choose

Like all medical professionals, I wouldn’t invest in tobacco companies. Yet hospital doctors with GESB as their default Super Fund had investments in tobacco until May 2013. As doctors we should have been outraged.

Shouldn’t we demand greater transparency from our funds, especially those appointed by the State?

But the health impacts from climate change are predicted to be much more widespread than anything we’ve seen in relation to smoking. The balance-sheets of companies that are inextricably linked with fossil fuel reserves are, self-evidently, utterly dependent on the burning of carbon.

As doctors, surely it is ethically inconsistent to continue to invest in industries known to be harmful while at the same time professing to do no harm. Three decades ago our colleagues argued that any connection with tobacco companies was a violation of their responsibility to protect and promote heath.

Maybe it’s time that doctors and their professional bodies embrace those same responsibilities and terminate their investments in fossil fuel industries? As consumers we should exercise our right to choose. Perhaps we should divest from funds that don’t offer appropriate investment portfolios and invest in ones that do? Doctors should ask GESB to offer ethical fund options that are explicitly divested from fossil fuels and other harmful industries. Surely the AMA and RACGP would support such an initiative? So, going beyond placards and protests, I’ve committed myself to become more engaged regarding divestment and climate change both on an individual level and with Doctors for the Environment Australia (DEA). It’s frustrating trying to find a path of effective action but I’m inspired by the energy and enthusiasm of younger colleagues and humbled by the older ones who’ve been acting on our behalf for decades. Change is possible and it doesn’t have to be ‘business as usual’. ED: Climate Change/Ethical Investment: Contact Joy at admin@dea.org.au

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31


Clinical Update

Persistent ankle pain after sprain Anterolateral ankle pain that persists for more than three months after a typical inversion sprain can be a treatment dilemma: physiotherapy combined with a steroid injection have often been tried, with limited success. There are two tests that clinicians can do to help deďŹ ne relatively common causes amenable to surgery â&#x20AC;&#x201C; they look for ankle soft tissue impingement and lateral ligament laxity.

By Dr Matthew Scaddan, Orthopaedic Surgeon, Claremont.

Anterolateral Impingement Test This test begins with palpation over the anterior taloďŹ bular ligament. The ankle is then dorsiďŹ&#x201A;exed passively with the examiners other hand (Figure 1b). If the pain increases the test is positive for synovial impingement, with about 94.8% sensitivity and 88% speciďŹ city. These patients are more likely to respond to arthroscopic debridement.

For patients, chronic pain and other joint symptoms, such as instability and swelling, bother them the most. Particularly note the duration and site of pain, exacerbating factors, treatment tried, and how symptoms interfere with their work or normal footwear. Relevant past history is important. Examination looks for: sĂĽ ,OCATIONĂĽOFĂĽSWELLINGĂĽANDĂĽANYĂĽPREVIOUSĂĽSCARSĂĽ sĂĽ (INDĂĽFOOTĂĽVARUSĂĽTHATĂĽCANĂĽPREDISPOSEĂĽTOĂĽLATERALĂĽ ligament injury. sĂĽ !NATOMICALĂĽLOCATIONĂĽOFĂĽTENDERNESSĂĽ ankle lateral ligament complex vs ankle syndesmosis (part of a â&#x20AC;&#x2DC;highâ&#x20AC;&#x2122; ankle sprain) vs midfoot (possible LisFranc injury) sĂĽ #OMPARATIVEĂĽMOVEMENTĂĽRANGESĂĽOFĂĽBOTHĂĽSIDES sĂĽ 3PECIALĂĽTESTSĂĽ!NTEROLATERALĂĽ)MPINGMENTĂĽ4ESTĂĽ and Anterior Drawer test Treatment

Fig 1a

Fig 1b

Anterior Drawer Test This tests for lateral ligament instability. A reliable way to perform this test is illustrated in Figure 2. With the knee bent and by ďŹ xing the foot, the tibia is then forced posterior (foot moves anterior, relative to the tibia). This is compared to the asymptomatic side. Movement greater than 10mm is signiďŹ cant and can be up to 25mm in severely unstable ankles. A positive Anterior Drawer Test in a symptomatic ankle indicates likely beneďŹ t from surgery.

In selected patients, ankle arthroscopy using an ankle distractor aids visualisation. Three areas are typically involved in impingement: the superior portion of the antero inferior tibio ďŹ bular ligament (AITFL), the distal portion of the AITFL (aka Bassettâ&#x20AC;&#x2122;s ligament) and the antero taloďŹ bular ligament (ATFL) â&#x20AC;&#x201C; all are amendable to arthroscopic debridement. Surgical treatment of lateral ankle instability is anatomical repair. Anchors are used to reattach and tension the lateral ligaments and, with appropriate patient selection, has a high success rate. References available on request. Author competing interests: no relevant disclosures. Questions? Please contact the author on 9230 6333.

Fig 2a

Fig 2b

Business scrubs up at FSH Joseph Carpini a doctoral student at UWAâ&#x20AC;&#x2122;s School of Business. Heâ&#x20AC;&#x2122;s briefed surgical teams at Fiona Stanley Hospital and gowned up for a dozen surgical procedures. Heâ&#x20AC;&#x2122;s also seen body parts no other Business School grad has ever seen before in the course of his research. Joseph specialises in teams, communications and performance issues and his post grad degree coincided with the universityâ&#x20AC;&#x2122;s Medical

32

school approaching the Business School with a request for specialised communication input. The study is looking at the effectiveness of ďŹ ve-minute surgery-team brieďŹ ngs in which nurses, surgeons and anaesthetists meet before the start of every surgical list as a way of reducing medical error and increasing theatre efďŹ ciency. Joseph has been at FSH since November

where he told Medical Forum he has been privileged to be at the ground ďŹ&#x201A;oor of establishing new systems. The program has six months to run and Joseph said he was excited by the data coming through. He uses in-theatre observations, interviews and questionnaires to his studies but he sees the ďŹ ndings applicable to other high-risk action teams such as in mining and offshore drilling. MEDICAL FORUM


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Clinical Update

Endovascular technology in PAD

By Dr Stefan Ponosh, Vascular & Endovascular Surgeon Nedlands

Despite the management of cardiovascular risk factors, the burden of peripheral arterial disease (PAD) continues to rise â&#x20AC;&#x201C; overall prevalence 3-10% (15-30% in over 70s). Advances in minimally invasive endovascular techniques have signiďŹ cantly improved outcomes and reduced morbidity. New approaches Drug Eluting Balloon Angioplasty (DEB) has increasingly become the treatment of choice in primary PAD. Arterial restenosis and re-intervention can be reduced through the use of DEBs coated in a cell growth inhibitor (paclitaxel) that once deposited on the arterial wall, reduces cellular proliferation and restenosis. Recurrent disease is signiďŹ cantly reduced â&#x20AC;&#x201C; 82.2% primary patency compared to 52.4% with standard angioplasty. In addition, occluded arteries that were once only treatable with open bypass surgery, are now amenable to endovascular recanalization using subintimal angioplasty techniques. A controlled iatrogenic dissection is created within the wall of the occluded vessel, recanalising it. This can be undertaken in any arterial bed, from the aorta to the calf vessels. Assisted by â&#x20AC;&#x153;re-entryâ&#x20AC;? devices (see image), more complicated occlusions (particularly calciďŹ ed and longer lesions) can be treated using endovascular techniques that control recanalisation. One study showed an 88% successful recanalisation using a re-entry catheter in lesions that failed with standard techniques.

Subintimal angioplasty using a re-entry device. Image courtesy Boston ScientiďŹ c.

Subintimal arterial ďŹ&#x201A;ossing anterograde retrograde intervention (SAFARI) techniques have increased recanalisation rates in challenging anatomy otherwise needing bypass. Using a proximal and distal arterial puncture (commonly femoral and pedal), complex occlusions are recanalised from two directions simultaneously. Drug eluting stents, long used in coronary artery disease, are now widely used in tibial PAD, particularly in challenging diabetic disease. Larger DES stents are used in the iliac and femoral vessels with very favourable longterm outcomes. New stent scaffold technology (Supera) has also shown excellent outcomes and durability. Long self-expanding covered stents have also shown promise in severe arterial disease and have provided a minimally invasive option for popliteal aneurysmal disease as an alternative to open bypass. Imaging changes Diagnostic angiography has largely been replaced with arterial ultrasound and CT angiography, except in limited cases. Ultrasound is now routinely used during vessel access, reducing groin puncture complications and facilitating access in even the most diseased vessel or complicated patient. New angiographic imaging suites have revolutionised endovascular intervention allowing exceptional imaging quality, with reduced radiation and contrast dose. The ďŹ&#x201A;exibility of these new suites also facilitates â&#x20AC;&#x153;hybridâ&#x20AC;? open and endoluminal procedures. This allows a smaller combined procedure, avoiding a more high risk open intervention e.g. femoral endarterectomy and iliac stenting rather than an aortofemoral bypass. References available on request.

Author competing interests: no relevant disclosures. Questions to the author please on 0403 239 956.

MEDICAL FORUM

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Prof John Yovich

Science on the Swan â&#x20AC;Ś stem cells, signalling pathways and epigenetic regulation Recently I attended the inaugural Science on the Swan conference where PIVET along with our associates from Curtin University had a number of poster presentations, eight in all. The major presentations, however, were from international DQGQDWLRQDOVFLHQWLVWVSURPLQHQWLQWKHLUUHVSHFWLYHĂ&#x20AC;HOGV7KH IRFXVZDVRQWKHLQĂ XHQFHVGXULQJSUHSUHJQDQF\SUHJQDQF\ DQGWKHLPPHGLDWHSRVWQDWDOSHULRGRQODWHUOLIHKHDOWKDQG disease. It has become clear that epigenetic mechanisms operate through these periods to affect generations of offspring i.e. our current habits have a direct bearing on the health of our grandchildren. Darwinâ&#x20AC;&#x2122;s natural selection mechanism relies on mutations LQĂ XHQFLQJWKHJHQHWLFVRIRIIVSULQJDVORZHYROXWLRQDU\ process. However the recently explosive knowledge areas of epigenetics (involving mainly methylation but also other chemical processes to switch genes on or off) and the consequential molecular biological activities within the cells, explains evolutionary processes occurring within our own lifetimes. This has been glaringly marked among Aboriginal populations, changed from hardy slim tribal people into communities with major health problems related to insulin UHVLVWDQFHDQGPDODGDSWDWLRQWR´ZHVWHUQÂľLQĂ XHQFHVERWK cultural and nutritive. Some of the new knowledge involves transduction signalling SDWKZD\VZLWKLQWKHFHOOZLWKPXOWLSOHFURVVUHDFWLRQVLQYROYLQJ XSUHJXODWLRQDQGGRZQ regulation of transcription factors (transcriptomics) leading to proteomic events and metabolomic consequences. Some of this is so complex it requires PDVVLYHFRPSXWLQJ RWKHUDUHDVDUHOLNH´GDUN PDWWHUÂľDQGZLOOUHTXLUH $UWLĂ&#x20AC;FLDO,QWHOOLJHQFHWR Nobel Laureate Dr Barry Marshall (left), assist our struggling human who commenced at UWA Med School brains to decipher. as I was ďŹ nishing, gave the dinner oration.

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HERE ARE JUST SOME OF OUR FANTASTIC RESULTS Our unique difference - Veins are 100% of our practice not a sideline Why choose us for diagnosis? All our sonographers’ work is personally checked by our Radiologist/ Phlebologist Dr Matar to ensure unrivalled diagnostic accuracy Why consult with us? • All our patients are seen and assessed by our specialist NOT a nurse •

We are committed to excellent outcomes not selling a treatment!

Why choose us for treatment? • We specialise in minimally invasive non-surgical treatments that are walk-in-out with no downtime and minimal discomfort •

We treat the CAUSE of varicose veins not just what is seen on the surface (i.e Phlebectomy without addressing truncal reflux is associated with a high recurrence rate.)

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Why choose us for laser? • We are at the forefront of endovenous laser vein surgery – tailored individual treatments, able to treat perforator veins and non-saphenous veins •

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Laser perforator vein ablation – Dr Matar is the only doctor in Australia to be trained in this technique by the inventor and a world leader in EVLA, Professor Mark Whiteley

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MEDICAL FORUM


Clinical Update

Reassessing antihypertensives in the elderly

By Dr Andrew Klimaitis, Physician, Duncraig

As a student in the 1970s I was told that 100-plus-your-age is the expected systolic blood pressure (SBP). In 1991, the Systolic Hypertension in the Elderly Program showed that treating those over 60 with SBP greater than 160 mmHg (to a mean of 143) reduced 5-year stroke risk by 36.6% and relative risk of a coronary event or death by 27%. A meta-analysis in 2000 confirmed these results. This is important data but 60 no longer seems all that elderly, possibly because I am approaching that age myself. I frequently see patients admitted with falls and complications thereof: Most are beyond 80 and many take antihypertensive medication. Trial data is less plentiful in this age group. Only in 2008 did a study look specifically at those over 80; in 3845 generally healthy people (mean age 84) with an average SBP of 171, lowering SBP by 15 mm Hg reduced strokes from 17.7 to 12.4 per 1000 patientyears, and all-cause mortality from 12 to 10%. More sobering is an observational study from 2012 where 2340 patients aged over 70 were followed for seven years. Robust elderly (as

assessed by walking capability) benefitted from treating high blood pressure; frail elderly did not. From mortality data the authors concluded, “Aggressive treatment of systolic hypertension in frail older patients with multiple co-morbidities might not be necessary and could be harmful”. The most recent European guidelines reflect this. Fit elderly under 80s with SBP above 140 mmHg can be treated to a target below 140. In those over 80 years with an initial SBP over 160 it is recommended to reduce this to between 150 and 140 mmHg, provided they are in good physical condition. In frail elderly however, decisions on therapy should be left to the treating physician and based on the clinical effects of treatment. Postural hypotension This is a major contributor to non-mechanical falls in the frail elderly. I often reduce blood pressure medication after a fall or if giddiness is present. Demonstrating a postural drop is helpful, but not always present. Watching a patient in the ward after a fall will often reveal intermittent large drops. In others, the SBP may initially be 180–220 mmHg but

quickly settles to under 150. A third group have persistently labile readings throughout admission. Patients are more concerned about the peaks whereas vascular risk relates to the average reading, and the risk of falling correlates with the troughs. It is harder to cut back medication in the rooms where patients with dizziness may have elevated spot BP readings. Personal home monitors may show lower values but the more anxious a patient is about their BP the more useful I find 24 hour ambulatory monitors. Patients also assume that dizziness and headache are caused by high blood pressure. In fact hypertension is almost always asymptomatic. In someone with a headache and an SBP of 220 it is more likely the former causing the latter. References available on request

Author competing interests: no relevant disclosures. Questions directed to author please on 9246 5072.

HeartsWest is pleased to announce some important new developments. Dr Peter Dias has joined our practice. Peter is a Cardiologist with subspecialty expertise in echocardiography, heart failure and transplantation. He works as a Specialist Cardiologist, Heart Failure and Transplant Physician at Fiona Stanley Hospital and will consult at our Rockingham and Armadale rooms, reporting echocardiograms at these sites. Echocardiography. We are upgrading our echocardiography machines with Speckle Tracking Strain imaging, a new modality that allows detection of ventricular dysfunction before any reduction in function is detected by conventional means. It is particularly Useful for those with hypertrophic conditions and those who have had cardiotoxic pharmacotherapy. Stress echocardiography Service. Expansion of this service should allow a minimal wait for stress echo appointments for patients. Smartphone monitoring. We have access to AlivCor home monitoring that allows patients to make ECG recordings on a Smartphone during symptoms, sending them electronically to HeartsWest for review. Smartphone lease or purchase of a device that attaches to their Smartphone is available. This system is designed to diagnose infrequent arrhythmias not detected on Holter monitoring, without the need for implanting a monitoring device.

Telephone 9391 1234 Fax 9391 1179 Email reception@heartswest.com.au www.heartswest.com.au

MEDICAL FORUM

39


Clinical Update

Tuberculosis testing dilemmas Tuberculosis (TB) prevalence in Australia is one of the lowest in the developed world, about 5.5 cases per 100,000. Most cases are in overseas born individuals reactivating latent TB within two to five years of arrival in Australia. Pulmonary TB is the commonest form. The diagnosis of active TB is microbiological and requires acid-fast bacilli (AFB) from sputum or lymph node biopsies. TB exposure or latent TB can be detected by either a Mantoux test or an interferongamma release essay (IGRA), such as the QuantiFERONTM Gold in-Tube assay. QuantiFERONTM is an in vitro blood test of cell-mediated immune response that measures T cell release of interferon-gamma when stimulated by antigens unique to Mycobacterium tuberculosis (ESAT-6, CFP-10 and TB7.7). Unlike the Mantoux, it is highly specific (98%), and does not cross react

with BCG vaccination or non-tuberculous mycobacteria. An individual is positive for Mycobacterium tuberculosis infection if the interferon-gamma response to TB antigens is above the cut off (>0.35 IU/mL). The test is highly sensitive and specific but because rates of latent TB in Australia are low, the risk of a false positive is about one in six. The assay test cannot distinguish between latent tuberculosis infection and active TB disease (Table 1). A positive result may not necessarily indicate active TB, and a negative result may not rule out active TB. Asymptomatic individuals A common scenario is a student who requires TB clearance for their practicum and who has a QuantiFERONTM test. The most important aspect of testing is to establish the pre-test

probability of the test being positive. An Australian-born individual without travel to TB endemic countries and without known TB exposure is unlikely to have latent tuberculosis infection. A positive result needs to be interpreted within this context and a false positive considered. Conversely, a positive test in someone from a TB-endemic country is likely to be truly positive. Symptomatic individuals Active tuberculosis most commonly presents with a persistent cough (>3 weeks), fevers and night sweats. Anyone with a persistent cough who has lived in a TB-endemic country warrants consideration for active TB. In this situation a sputum AFB examination and chest x-ray are the preferred first line investigations.

Tubercle bacilli are in the body, and the QuantiFERONTM/ Mantoux is usually positive.

The WA TB Control Program (former Perth Chest Clinic) offers a free service for anyone with latent or suspected active TB. Review by a consultant specialising in tuberculosis management can be arranged on 08 9222 8500. For further information go to www.health.wa.gov.au/acc/tb/

LATENT TB

ACTIVE TB

References available on request

Sputum smears and cultures negative

Sputum smears and cultures positive

CXR usually normal

CXR usually abnormal

No symptoms

Symptoms - cough, fevers, sweats

Not infectious

Often infectious before treatment

Not a case of TB

A case of TB- notifiable

Table 1: Latent TB vs Active TB disease - Pulmonary

s Dr Shane Kelly has resigned as chief of the North Metropolitan Health Service to take up a hospital leadership role in Queensland. s Prof Harvey Coates AO is one of four surgeons to receive the Indigenous Health Medal from the RACS. He is a senior ENT surgeon at PMH accredited with getting the neonatal hearing screening program off the ground in WA and assisting Indigenous children in remote communities, the majority of whom experience OM. s Dr Peter Maguire has been elected the new chair of WAGPET and Dr Penny Wilson elected the vice chair. He replaces Dr Damien Zilm, who will stay on the board in a non-executive capacity. s The WA Primary Health Alliance has selected its board. GP Dr Richard Choong, former president of AMAWA, is chair. It also includes Dr Marcus Tan, GP; CEO of Health Engine, and former Chair of Perth Central & East Metro Medicare Local; GP Dr Andrew Png,

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By Dr Astrid Arellano, Infectious Diseases Physician, Palmyra

board member of WAGPET and former Chair of Perth South Coastal Medicare Local; GP Dr Damien Zilm, former Chair of Goldfields Midwest Medicare Local and former Chair of WAGPET; Mr Chris McGowan, CEO of Silver Chain and former Director of Perth Central & East Metro Medicare Local; Mr Tony Ahern, CEO of St John’s Ambulance; Ms Anne Russell-Brown, former Fremantle Medicare Local board member, Dr Neil Fong, Manager, Strategic Development and Reform, WA Health; and pharmacist Mr Steven Wragg, President of the Pharmacy Guild. s Head of General Surgery at Fiona Stanley Hospital, Prof David Fletcher, now heads a group of directors of surgery from Australia and New Zealand set up to foster leadership, collaborate with hospital administrators, improve the quality and efficiency of surgical services, and liaise with government over patient care, including wait lists.

Author competing interests: no relevant disclosures. Questions directed to author please on 0421 514 653.

s Brookfield Multiplex has strengthened its position as the state’s largest construction company after being named preferred contractor for the $207m Karratha Health Campus, adding to six major projects it currently has under way worth about $2.6b. s Cystic Fibrosis WA has been awarded a $6m WA Health contract to provide the Cystic Fibrosis Comprehensive Home Care Service and Professional Education Program, and PMH Airway Clearance Services statewide for people with cystic fibrosis, their family and carers, and airway clearance services to people with cystic fibrosis. s Mr Dean Hely, of Lavan Legal, and Mr Nick Henry, of PwC, have been appointed to the board of Youth Focus, a youth suicide prevention service.

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Clinical Update

Ultrasound in the acute abdomen (non-trauma)

By Dr Ronny Low, Radiologist, Wembley

Abdominal pain comprises 1.5% of general practice visits and 5% of emergency department visits. The term â&#x20AC;&#x2DC;acute abdomenâ&#x20AC;&#x2122; denotes the rapid onset of abdominal symptoms which may indicate potentially life-threatening pathology needing urgent surgical intervention. Assessment is aimed at determining a cause and whether surgery is necessary. Diagnosis is often challenging, especially in the elderly. About 25% of those presenting to an ED with abdominal pain never have a diagnosis established, about 15% have appendicitis, and the remainder have one of a diverse range of conditions. Imaging options Studies show that imaging, either Ultrasound (US) or computed tomography (CT) aids in the diagnosis of patients with an acute abdomen, expediting treatment and reducing cost. Each has advantages and disadvantages. US is generally widely available, relatively cheap, can be performed in a variety of settings including at the patientâ&#x20AC;&#x2122;s bedside, requires no contrast and does not involve ionising radiation. It can depict structures in real time, including vascular assessment. Uniquely, US can be tailored to the site of maximal tenderness or in response to any

Longitudinal and transverse images of acute appendicitis with recent or imminent perforation showing marked hypoechoic thickening of the appendiceal wall that appears incomplete, periappendiceal ďŹ&#x201A;uid, surrounding echogenic fat and hypervascularity.

ďŹ ndings or information obtained from the patient during the examination. However, US is relatively operator dependent and more dependent on patient factors such as patient size, breath holding ability, manoeuvrability and pain tolerance. It is also susceptible to interference by gas and bony structures. CT is less operator dependent and relatively unaffected by patient factors, especially obesity, but requires use of ionising radiation and is generally better performed with intravenous contrast (except in the setting of suspected renal colic). US is most useful in patients with biliary disease or a palpable mass and is commonly recommended in the assessment of younger

patients and during pregnancy when exposure to ionising radiation is more concerning. Whether US, CT or some other modality (such as MRI) should be performed is generally dependent on the possible differential diagnoses, the patientâ&#x20AC;&#x2122;s age, pregnancy status and local expertise. Where there is uncertainty over which modality is most appropriate, clinicians are urged to discuss the case with a radiologist and should be mindful that more than one imaging test may be required. References available on request

Author competing interests: none relevant. Questions? Contact the author on 6382 3888.

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Travel

ar Deckchairs Mya nm

r a m n a y M r o f s e m i T New

It was a long adventure to gestate. The plan was to ďŹ&#x201A;oat down the Ayeyarwaddy River, the greatest river in Burma, in a brand new luxury cruise boat sailing from Mandalay to Pyay in southern Myanmar with three colleagues from medical school, a school friend and three partners. The difďŹ culty was trying to line-up an itinerary with the diaries of two psychiatrists, a GP, a gastroenterologist and a pharmacist scattered around the country. The upside? We had all possible illnesses covered WITH an arsenal of drugs! But the hard work was worth it every painstaking second. Many know of Mandalay in upper Myanmar through Rudyard Kiplingâ&#x20AC;&#x2122;s famous poem. We took an easier route, by air from Bangkok, but it lost none of its famed romance as mystery as we watched the jungle-clad hills, glistening lakes and ragged ranges from our plane. Arriving at the airport that was overgrown with weeds may have tarnished it a tad, but we were efďŹ ciently processed by Customs and duly collected by a driver and delivered to our hideously expensive, but comfortable hotel, nestled in the skirts of Mandalay Hill. Although Mandalay was the last royal capital, there is little in the way of history left after heavy bombing in World War II by both the allies and the Japanese which has left only the massive walls of the old fort. Since 1945, the busy city has grown along the banks of the 2000km Ayeyarwaddy. It teems with life â&#x20AC;&#x201C; trishaws, golden temples and pagodas with spires glittering above the skyline, traditional markets, food stalls and small shop fronts with artisans spilling onto the streets all greet the adventurous traveller. Our party arrived a few days before the cruise departed, so we commandeered a share taxi â&#x20AC;&#x201C; a ute with open sides and metal benches for a few kyats [$1 = Kyat 780]. After a bumpy, steamy ride the ďŹ rst stop was the Jade Mar-

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ket, the largest wholesale jade market in the world. Serious traders squatted at low plastic tables buying and selling jade of every description, while young men with sharp eyes worked jade of every hue of green. The stone carversâ&#x20AC;&#x2122; workshops were a dusty, noisy hive of activity and the crowded and colourful central markets, Zeigyo, where everything imaginable was sold, was a photographerâ&#x20AC;&#x2122;s paradise. Everything bristled with life. Escaping the bustle meant taking a 230m barefoot walk up Mandalayâ&#x20AC;&#x2122;s sacred hill via a covered stairway lined with food and water stalls to nourish the sweating pilgrims on the 30 minute climb. Along the way are small but glittering temples, pagodas and golden buddhas and, at the top, magniďŹ cent panoramic views across Mandalay, with the meandering river and the Shan hills in the distance.

Sighseeing

Baga n

Our luxury cruise boat, CruiseCo Explorer, was moored amid the teeming river life â&#x20AC;&#x201C; families living in makeshift huts, mothers feeding babies, boats being repaired, children kicking footballs in the dust and mud, welders, loud music and food sellers hawking their wares. But these were all left behind as we slid out into the vast river . The ship was new and beautifully comfortable with full length windows in the cabins, which allowed for continuous viewing of the passing parade of river life. Onboard staff were local Burmese, and were the boatâ&#x20AC;&#x2122;s greatest asset, from cruise manager Zaw Zaw, to barman Honi, the staff provided insight into the history and culture of past and present Myanmar.

Travel Facts Getting There sÂŹ -ULTIPLEÂŹmIGHTÂŹOPTIONSÂŹTHROUGHÂŹEITHERÂŹ"ANGKOK ÂŹ+UALAÂŹ,UMPURÂŹORÂŹ3INGAPORE sÂŹ &LIGHTSÂŹTOÂŹ-ANDALAYÂŹMAYÂŹREQUIREÂŹANÂŹOVERNIGHTÂŹSTOP sÂŹ 0RICESÂŹFROMÂŹÂŹONEÂŹWAYÂŹ0ERTHÂŹTOÂŹ-ANDALAYÂŹORÂŹ9ANGON sÂŹ !CCOMMODATIONÂŹ-ANDALAYÂŹ(ILLÂŹ2ESORT ÂŹ ÂŹFORÂŹSTANDARDÂŹROOMÂŹ#HATRIUMÂŹ(OTELÂŹ Royal Lake Yangon, $250-$450 for standard room sÂŹ 4HEÂŹ#RUISE#OÂŹ%XPLORERÂŹ NIGHTÂŹPACKAGEÂŹINCLUDINGÂŹmIGHTS ÂŹACCOMMODATIONÂŹINÂŹ-ANDALAYÂŹ and Yangon and 7 nights on cruise $5000. Health Advice sÂŹ 6ACCINATIONSÂŹ(EPATITISÂŹ! ÂŹ4YPHOIDÂŹANDÂŹ)NmUENZA sÂŹ %NSUREÂŹ4ETANUS ÂŹ$IPHTHERIAÂŹANDÂŹ0ERTUSSIS ÂŹ--2ÂŹAREÂŹUPÂŹTOÂŹDATE sÂŹ #ONSIDERÂŹ2ABIES ÂŹ*APANESEÂŹ%NCEPHALITIS ÂŹ(EPATITISÂŹ" ÂŹ#HOLERA sÂŹ !NTI MALARIALSÂŹREQUIREDÂŹEXCEPTÂŹINÂŹ-ANDALAYÂŹANDÂŹ9ANGONÂŹ$OXYCYCLINEÂŹORÂŹ-ALARONE sÂŹ -OSQUITOÂŹPROTECTIONÂŹVERYÂŹIMPORTANTÂŹnÂŹUSEÂŹ ÂŹ$%%4 sÂŹ !NTI DIARRHOEALSÂŹ;,OPERAMIDE= ÂŹ/23ÂŹ;'ASTROLYTEÂŹSACHETS=ÂŹANDÂŹANTIBIOTICSÂŹ;!ZITHROMYCINÂŹ or CiproďŹ&#x201A;oxacin] sÂŹ 'REATÂŹCAUTIONÂŹINÂŹDISCUSSINGÂŹCURRENTÂŹPOLITICSÂŹISÂŹREQUIRED

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Balloons o ve

r te mples

agan Buddhist te mple B The boat joined the Ayeyarwaddy highway full of local ferries, overloaded with people and produce. Some boats were loaded down with huge ceramic pots made by the villagers for market while large commercial barges carried sea containers, sand and rocks. Our days were spent exploring riverside villages, barely touched by modern life. Rattan huts with mud floors, village girls with upright backs, carrying pots of water, bricks or vegetables from the fields. The pottery village welcomed us and displayed how production is a community activity, little changed over generations. In the fields oxen pulled ploughs or carted goods to market. Horse-drawn carts weaved between pedestrians along the dirt lanes but the local villagers were ever welcoming, curious and fascinated

Onshore adventures were recounted back onboard over iced drinks and cool handtowels thrust into our hands on our return to ship. Then it was a retreat to the sundeck to relax, read, or be served with endless tea, coffee or stronger beverages.

ted along the banks of the river. It is the largest number and concentration of temples, pagodas, stupas and ruins in the world, with many dating from the 11th and 12th centuries. These majestic temples were scattered across fields and scrub, and could be visited freely by horse cart, bicycles, cars and motorcycles. And the famous hot air balloons were a truly unique experience.

Sundowners (which inevitably meant a tipple of free French wine) were enjoyed while listening to talks on local culture, geography and history and what a rich history it is – 13,000 years of recorded history, with endless invasions and settlers from Pyu, Rakhaing, Mon and the Bamar, not mention the British and Japanese.

After our sad farewells to the crew, we disembarked and headed by road to the capital,Yangon, [Rangoon of earlier times]. It is another fascinating story. After 11 nights we left this fascinating country with a much lighter medical chest, lots of wonderful memories, and plans to return.

A highlight of the trip was the archeological precinct of Bagan with its 3000 temples dot-

Words and Pictures: Dr Carol McGrath

by us strange visitors. Babies were sometimes terrified!

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for Great Things

In 1993 John Small purchased a block between Donnybrook and Balingup to fulfil his dream of creating a marron farm. Having done that he quickly realised that one could not live off marron alone and very soon planted a vineyard. Most of the grapes were red and were sold to wineries in Margaret River. The zinfandel grapes were attractive enough for David Hohnen to purchase for inclusion in his blend for Cape Mentelle’s well-known Zinfandel. From 2006 the first wines under the Smallwater label were produced. Today the production is around 2500 cases of which 70% is red wine. By Dr Louis Papaelias

The vineyard at Smallwater is located within the Geographe wine region. Soils are gravelly loam

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1. 2013 Smallwater Chardonnay This chardonnay is attractive, sparkling golden in colour with aromas of ripe peaches and hints of vanilla. Rich full and mouth filling with a firm clean finish. This is well-structured white to accompany poultry, veal and robust seafood. 2. 2014 Roze Made from zinfandel grapes this wine has a delightful pink hue and the smell of rose petal pot-pourri and fragrant berries. Sweet fruit flavours with enough firmness to balance. Lovely on its own but has enough structure to accompany food. An ideal sunny day wine. 3. 2014 Zinfandel This wine has a deep, dark-purple hue with a powerful and attractive bouquet of black plums. Very satisfying palate with lip-smacking sweet fruit and soft silky tannins. Oak treatment is subtle and subservient to the primary grape flavours. Highly recommended

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3

Wine Review

Building Smallwater and the topography is hilly. According to Dr John Gladstones, the climate closely resembles those of Bendigo and Rutherglen-Milawa in Victoria but with more winter spring rainfall and less summer rain. There is ample surface water available and Smallwater has over 9ha of marron dams and ponds that can be viewed from the onsite restaurant and cellar door. Needless to say that marron is one of the restaurant’s star attractions. All the wines sampled were well made and technically sound. Varietal definition is accurate and attention to quality evident throughout the tasting. Oak handling has been exemplary.

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4. 2013 Shiraz Also highly recommended this multi-awarded wine proved a hit with my work colleagues at a recent practice meeting. Appealing aroma of Turkish spice and red plums. Generous bodied and supple in the mouth, balanced by fine soft tannins. It improves significantly with breathing. It’s a Gold medal and trophy winner at Royal Perth Wine Show. 5. 2012 Rob’s Block Cabernet Sauvignon With a true varietal cabernet bouquet, there are hints of mulberry, olive and cassis. It has a full-bodied and youthful palate. Quite firm but softens with aeration, it’s a wine best tasted the day after opening. Silver medal winner at Royal Melbourne Wine Show.

.. or online at

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Wine Question: Which Smallwater Estate wines improve with aeration?

Email Please send more information on Plantagenet Wines offers for Medical Forum readers.

Answer: ...................................................

Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, June 30, 2015. 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.

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Social Pulse

MDA Celebrates 90 Years In 1925, MDA began representing Perth doctors and in the interceding years it has grown to be a national organisation with 42,000 members. Its 90th anniversary was celebrated at the Perth ofďŹ ces where board members and new CEO Mr Ian Anderson welcomed members and guests. 1 Mr John Hobbs and Mr Terry Jackson, both from the Australian Prudential Regulation Authority (APRA) and MDA National Chair Dr Rod Moore 2 MDAN board member and former AMA President Dr Rosanna Capolingua, Dr Dror Maor and AMA WA Executive Director Mr Paul Boyatzis

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3 MDAN CEO Mr Ian Anderson, Ms Hayley Cormann and Federal Finance Minister Senator Mathias Cormann 4 Prof Con Michael and Nerissa Ferrie 5 MDAN board member and AMA WA Vice President Dr Andrew Miller, Mr Terry Agnew, Mr Graham Reynolds, Mr Jamie Lutz and AMA WA President Dr Michael Gannon

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Pain Ed for GPs

Pain physicians Dr John Salmon and Dr Stephanie Davies held an education session for about 50 GPs at one of Bethesda Health Careâ&#x20AC;&#x2122;s regular GP education program. Topics covered included diagnosis, appropriate prescribing and allied health networking.

1 Dr Gary Vanderveen and Dr Mark Hamlin 2 Dr Scott Isbel and Dr Alex Strahan

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2 MEDICAL FORUM


Theatre

The Mills sisters Juliet and Hayley promise all the rivalry is exclusively for the stage as they prepare to head to Perth as part of a five month national tour.

know what might happen when you’re touring. In 1980 I was in the cast of that superb play, Elephant Man, on a tour through the US and cast opposite an actor named Maxwell Caulfield. We fell in love and I knew I’d met the man I’d spend the rest of my life with!” [Maxwell joins his wife and sister-in-law on stage in Legends.]

Two sisters from a theatrical dynasty will be treading the boards at His Majesty’s Theatre early next month in the funny and moving play, Legends. Juliet Mills plays one of two fading Hollywood movie stars who, despite loathing each other, are attempting to resurrect their careers on Broadway. Juliet pointed out to Medical Forum out that, in this case, life doesn’t imitate art and it’s a rare pleasure to appear opposite her younger sibling, Hayley Mills.

High points of the spotlight and greasepaint notwithstanding, Juliet relates one occasion when it all went horribly wrong.

“It’s a gift to be on stage with Hayley, we get on really well and we know and trust each other completely. We’re thrilled to be working together and that hasn’t happened since we did the play Fallen Angels, which toured throughout Australia and New Zealand in 1992,” said Juliet.

“I was playing Tatiana in A Midsummer’s Night Dream with the Royal Shakespeare Company at the Aldwych Theatre in London and also shooting a Carry On film at Pinewood Studios. I was young, only 22 years-old, stressed and really stretching my limits.”

“We both remember Perth as a very beautiful city and I can still recall feeding little bits of meat to the kookaburras on our balcony. And I’ll never forget going to the beach and thinking ‘wow, that’s the Indian Ocean!’.”

“One night I went stone-cold dead in the middle of a long monologue and you just can’t fudge Shakespeare. I actually went into shock, another actor whispered my lines and rescued me but it was my most terrifying moment on stage. It scarred me for life and I’ve never done Shakespeare since.”

The Legends tour itinerary will keep the Mills’ sisters Down-Under for five months and take them to every capital city in the land. “This is just about the right season length for me because we stay in the same place for quite some time and that gives you an opportunity to enjoy being part of a city. And you just never

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okay with the former and then you’ve forgotten the latter. It’s the normal process but it doesn’t get any easier and probably harder, in fact, as you get older.” “We do sometimes reshape a play for a local audience and we’ve changed a few lines here and there in Legends to give people a few things they might relate to and appreciate. And since the play’s author is dead we’re allowed to do that!” So what can Perth theatre-goers expect from these two feuding prima donnas? “The main characters, Leatrice and Sylvia, are struggling to cope with the reality of their fading careers, they were once real Hollywood legends and suddenly they’re out of work and on the skids. They can’t stand each other and a canny producer realises it makes good commercial sense to put these two alongside one another.” “And if they have a good cat-fight onstage so much the better!”

The preparations for Legends are going well and the play has been slightly tweaked for Australian audiences.

“These two are very much in the Joan Crawford and Bette Davis mould and it makes for a highly amusing and entertaining evening at the theatre.”

“The rehearsals are approaching crunch time because we’re at the point of trying to blend the actions with the dialogue. One minute you’re

By Mr Peter McClelland

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Dance

invit at ion to the Dance Hea Heading west this month, the Australian Dance Theatre introduces the sciences to Dan the arts with its new production.

ages: Chri ott Ewen Im

Sc

s Herzfeld

Th A The Australian t li D Dance Th Theatre t iis one off the country’s most distinguished dance companies. It is adored internationally yet, as it celebrates 50 years on the local dance scene, still has to introduce itself to audiences in Australia. However, the company is turning that perception around by a serious local touring schedule that sees it regularly perform in regional centres as well as the capital cities. This month, the Adelaide-based company’s light will shine brightly when it heads to WA for performances in Mandurah and the Heath Ledger Theatre showing off its talented cast including WA-born WAAPA grads Scott Ewen and Jake McLarnon. ADT broke a 17-year drought by returning to WA to perform G in 2013 and it made local dance lovers a promise to return every two years. So true to their word they are back with the highly-acclaimed production, Be Your Self. The July season is a major thrill for Scott, 28, and Jake, 21. They don’t often get the chance to dance for family, friends and mentors, in fact, it is the first time Jake has performed in Perth since he graduated from WAAPA in 2013. Making the first move Be Your Self is a work conceived by the ADT’s artistic director and eminent choreographer Garry Stewart and choreographed by the dancers in collaboration with Stewart. So central are the dancers to the piece that the soundscape was commissioned to fit the movements, rather

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Jake McLarnon in action

than the more conventional sequence of music to steps. Scott, who has danced the piece on a number of occasions, said the first half was an exploration of the body, while the second half delved into issues of identity and the discovery of self. “The piece has been worked on over a number of years. We performed a section of it at the Australian Ballet’s 50th anniversary gala in 2012 but the full production wasn’t performed until we took it to Jakarta.” “It’s a thrill to be coming to WA. We are really determined to establish our local and national identity. We are the Australian Dance Theatre and represent Australia all over the world, but we need to show that to Australia.” Starting out

“It’s the reason I love going to remote schools and doing workshops with the kids to offer them something other than sports clinics.” But as circles often do, Scott has found himself exploring the machinations of psychology once again as part of a collaboration between the ADT and researchers from the University of South Australia. Garry Stewart has long explored the concept of mind and body in his works and has often sought input from the medical sciences. This project reverses the favour. Garry and the dancers are working with Dr Susan Hillier and a team of psychologists, anthropologists and technologists to develop a prototype movement program with digital imagery to help with the rehabilitation of stroke patients.

Jake trained at John Curtin College of the Arts before heading to WAAPA. For him, a professional career took off quickly. For Scott, who was born in Esperance and grew up in Kalgoorlie and Southern Cross, professional dance wasn’t even on his radar until he had begun a degree majoring in psychology and criminology.

“From our dancing perspective it is how humans use creativity and long-term memory to produce movement. Dancers have this knowledge innately but it’s not often we are asked these questions. It’s exciting because as they seek to discover what we know, we discover something about ourselves and the way we think about dance,” Scott said.

“I grew up on a wheat and sheep farm and boarded at Mazenod in Lesmurdie. To fight off the homesickness I participated in everything at school. It was a pretty sporty school and I enjoyed that but I also liked giving anything new a go so when our arts teacher began a dance project, I joined.”

By Ms Jan Hallam Be Your Self is at the Heath Ledger Theatre, from June 24-27

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Competitions

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

Entering Medical Forum’s competitions is easy!

Movie: Madame Bovary Adapted from Flaubert’s classic novel, Madame Bovary is tells the tragic story of Emma, a young beauty who impulsively marries a small-town doctor to escape life on her father’s pig farm. But after being introduced to the glamorous world of high society, she soon becomes bored with her husband and the confines of her life and draws excitement and scandal into her world. Mia Wasikowska brings Emma to sizzling life.

FEATURE

In Cinemas, July 9

Movie: Paper Towns This coming-of-age story centres on Quentin (Nat Wolff) and his enigmatic neighbour Margo (Cara Delevingne), who takes him on an all-night adventure through their hometown. Then Margo suddenly disappears, leaving behind clues for Quentin to decipher. The search leads Quentin and his quickwitted friends on an exhilarating journey that is as hilarious as it is moving.

The Scandinavian Film Festival hits town next month with a string of classics (from Ingmar Bergman) to the radical, backto-basics guerrilla-style filmmaking of the Dogme revolution, to the contemporary and transnational diversity of Nordic noir. Murder, mayhem and romance will be writ large with films from Norway, Sweden, Finland, Iceland and Denmark will all represented. Cinema Paradiso, July 23-29

In Cinemas July 16

Theatre: Legends! Theatre legend, producer John Frost, brings to Perth stage and screen darlings, sisters Hayley and Juliet Mills, in James Kirkwood’s hugely popular comedy, Legends! the claws come out as two famous but fading movie stars try to upstage one another. The pair are hustled by a theatre producer played by Maxwell Caulfield (Juliet Mills’s husband in real life) to kick-start their Broadway careers. The only problem is – they loathe one another. His Majesty’s Theatre, August 2-15; Medical Forum performance, August 4, 8pm

COMP

Movie: Scandinavian Film Festival

PICA Salon 2015 Now in its sixth year, PICA Salon 2015 will present the works for sale of 19 local, national and international artists exploring the concept of Epic Narratives. This year there is a distinctly WA emphasis, with 13 local artists’. All will be responding to the theme as it reflects the turbulence and disquiet of our times. WA’s Abdul-Rahman Abdullah, Abdul Abdullah, Jacobus Capone, Penny Coss (work shown above), Teelah George, Tarryn Gill, Shannon Lyons, Clare Peake, Pip and Pop, Vanessa Russ, Snapcat, Kynan Tan and Caitlin Yardley will line up with Australian and overseas artists with work created in a variety of media including painting, drawing, sculpture, photography, installation, video and performance. PICA Salon 2015, July 5-August 16, PICA, Perth Cultural Centre

Kids’ Theatre: The Gruffalo’s Child The Gruffalo is back with some more tall tales for kids, this time young audiences can join the Gruffalo’s young child as she goes on her first solo adventure in the deep dark wood. As she searches a beautiful winter landscape for the mysterious Big Bad Mouse, she meets the much loved characters from The Gruffalo, and learns some valuable lessons along the way. Perfect for children aged 4-6.

Winners from the April issue Movie – Boychoir: Dr Avril Chong, Dr Angeline Teo, Dr Lin Arias, Dr Sally Price, Dr Clare Matthews, Dr Mark Sommerville, Dr Simon Turner, Dr Carol McGrath, Courage & Commitment Dr Leanne Heredia, Dr Clyde Jumeaux Movie – Testament of Youth: Mr Michael Durell, Ms April 2015 Gabriella Tallman, Dr Jens Buelow, Dr Barry Leonard, Dr Robert Weedon, Dr Esther Moses, Dr Alison Stubbs, Dr Terry John, Dr Ade Kusumawardhani, Dr Mary Ann Ho Movie – Spanish Film Festival: Dr Philippa Adams, Dr Donna Mak, Dr Paula Barrie, Dr Sarat Rangaiah, Dr Fred Faigenbaun, Dr Deirdre Tierney, Dr Melanie Chen, Dr Johan Conradie, Dr Catherine Keating, Dr Adrew Toffoli, Dr Jenny Beale Theatre – Glengarry Glen Ross: Dr Patricia Lee Kids Theatre – The 26-Storey Treehouse: Dr David Chew Music – Vivaldi’s Four Seasons: Dr Peter Melvill-Smith t Reshaping Lives

Heath Ledger Theatre, June 30-July 5; Medical Forum performance July 2, noon, family ticket for four

MEDICAL FORUM

t Women Who Lead

t Board Governance in Health

t Diabetes Self-Care; Ovarian Cancer; Disrupted Menses; PCOS; & more…

Major Sponsors

www.mforum.com.au

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medical forum FOR LEASE

MURDOCH Consulting room for lease at the new Wexford Medical Centre at Murdoch. Well lit, spacious sessional consulting rooms for lease. For further information please contact Murdoch Specialist Physicians on 9312 2166 or email us at admin@murdochspecialistphysicians.com.au

SHOALWATER Sessional and/or permanent rooms available at our brand new Shoalwater Medical Centre. Opening 1st September 2015 Fully furnished and fitted out ideal for medical specialists and allied health practitioners. Full secretarial support if required. Fully equipped treatment room and procedure areas available. Experienced and friendly nursing and admin team. Located near both the Waikiki Private Hospital and Rockingham hospital. Please phone Rebecca on 08 9498 1099 or Email manager@sevilledrivemedical.com

WEST PERTH For Lease Medical Consulting Rooms 1/11 Colin Grove 62sqm, fully furnished Ground floor Excellent natural light Two open car bays Contact Jack Bradshaw 0439 095 336 MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: gcford56@gmail.com NEDLANDS Hollywood Medical Centre Consulting room for lease - full-time or sessional times. Available now. Contact: Brad 0420 996 950 MURDOCH Wexford Medical Rooms for lease Please contact aptran@jointswest.com.au MURDOCH Brand new and modern consulting suites available now for sessional lease at Wexford medical centre. Great rates with excellent support. For more information Email: reception@paragonsp.com.au or call 0403 323 168

MOUNT LAWLEY Training and Consulting Rooms Available Mt Lawley, newly refurbished, free parking (21 car bays). 6 large consulting rooms available in specialist practice. Rooms available on a daily, weekly or monthly basis. Receptionist, waiting room area, lunch room, kitchen, disabled access. Would suitable medical specialist developing up a practise. Ideal for psychiatrist or paediatrician. (Friendly, supportive, collegial environment) Training room is also available for hire weekdays, weekends and after hours. Please call Luke Hawkins on 0432 321 964 or email clearhealthpartners@hotmail.com for further details.

MURDOCH New Wexford Medical Centre â&#x20AC;&#x201C; St John of God Hospital 2 brand new medical consulting rooms available: tTRNBOETRN tDBSCBZQFSUFOBODZ Lease one or both rooms. For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au SUBIACO / WEST LEEDERVILLE Sessional consulting room available. Can be used on weekly, fortnightly, monthly basis. Excellent location â&#x20AC;&#x201C; car bay available. Newly fitted out medical suite. Lovely environment â&#x20AC;&#x201C; fresh and modern. Friendly & highly experienced reception staff. Online Medicare claims / Inpatient billing available. For further information please phone: 0457 723 945 NEDLANDS Hollywood Medical Centre - 2 Sessional Suites. Available with secretarial support if required. Phone: 0414 780 751

GENERAL EMG Machine (Keypoint Medtronic) portable. Fully computerised (Toshiba), complete with cart, printer and all necessary software. Used minimally ie. Is as new Cost $28,000 Bargain price $11,000 or O.N.O Phone 0431 369 292

LOCUM AVAILABLE Locum Available VR GP available for Perth and country practicesjovileye@gmail.com

PSYCHIATRIST INVITED

BIBRA LAKE - Psychiatrist invited. Are you intending to start Private Practice? This is a sheer walk in! Part time, sessional or full time - all enquiries welcome. Furnished consulting rooms available at: Bibra Lake Specialist Centre, 10/14 Annois Road, Bibra Lake WA 6163 Currently 4 practising Psychiatrists and clinic is open Tuesday to Friday 7-day pharmacy and GP surgery next door are added advantages. 5 minute drive to St John of God and upcoming Fiona Stanley hospital. Phone Navneet 9414 7860 www.blsc.net.au

RURAL POSITION VACANT ALBANY t 4U$MBSFTJTBOFXGBNJMZQSBDUJDF based in Albany t 4NBMMGSJFOEMZQSBDUJDF t 'VMMUJNFOVSTJOHBOE administration support t 1BUIPMPHZPOTJUF t 'VMMPSQBSUUJNF(1XBOUFEUP join our team t 4QFDJBMJOUFSFTUJOTLJOXPVMECFJEFBM t $VSSFOUMZOP%84VOMFTTXJMMJOHUP work in afterhours period t (1TOPUSFRVJSJOHTVQFSWJTJPOSFRVJSFE Please contact Practice Manager, Helen Williams: 08 9841 8102 Email: helen@stclare.com.au Or send your CV through and we will get back to you.

ASCOT Part-Time VR GP required for our well established Accredited Privately Owned Friendly Family Practice in Redcliffe. We are fully computerised, using Best Practice software. Nurse is support available. Non DWS area. Please call â&#x20AC;&#x201C; 9332 5556 HOCKING North of River (DWS Area) Experienced FT GP required Busy computerised practice Nurse & Admin support Earn up to 65% of billings Flexible hours Enquiries to Phil: phil27bc@gmail.com COMO Want variety in your work? Special interest opportunities at the Well Men Centre in Como. 1BSUUJNF(1TGPSPVS1FSUI.PMF$MJOJD  Skin Cancer Screening Service and for our Holistic Health Management Programme Call 9474 4262 or Email: wellmen@ optusnet.com.au

Langford Medical Centre now has an opening for t '5 #VML#JMMJOH(1DPNNFODJOH June 2015. t '515GFNBMF(1PS(1XJUIBOJOUFSFTU  JO8PNFOT)FBMUIDPNNFODJOH"4"1 t %STXIPXPVMEMJLFUPXPSL weekend sessions. t %84 t $MPTFUP1FSUI t 'VMMQBUJFOUMJTUXBJUJOH t )VHFEFNBOEGPS8PNFOT Health services t QBZXFFLEBZT This is truly a lovely multicultural Family Practice treating the full range of conditions over a range of demographics. Confidential enquiries to PM Rita manager@langfordmedical.com.au or 9451 1377

WILLETTON GP VR required long term Full time or Part time 70-75% earnings Contact: 0412 346 146 ampmdoctors@westnet.com.au

FOR SALE SUBIACO For Sale / Lease Centrally located consulting rooms opposite SJOG Subiaco â&#x20AC;&#x201C; 58 sqm Strata Titled unit Quality fit out, including built in furniture Convenient Free off street parking Available August 2015 View at www.thehealthlinc.com.au Contact: Brad Potter - 0411 185 006

URBAN POSITIONS VACANT SORRENTO F/T or P/T GP for busy Sorrento Medical Centre, Normal/after hours available , we are like family, nurse & allied services on board , remuneration (70%-75%), Please call Dr Sam 0439 952 979

CANNINGTON Southside Medical Service is an accredited practice located in Cannington area. We are a family practice and offer mixed billings. We have positions for a GP to join other 2 (1TDVSSFOUMZXPSLJOH It is a well-positioned practice, close to the Carousel Shopping Centre. Phone: 9451 3488 or Email: reception@southsidemedical.com.au

JULY 2015 - next deadline 12md Tuesday 16th June â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au


medical forum

Duncraig Medical Centre Osborne City Medical Centre Require a female GP. Flexible Mon to Fri hours. (after hours optional) Excellent remuneration. Modern, predominantly private billing practice. Fully computerised. Please contact Michael on 0403 927 934 Email Dr Dianne Prior: dianne@duncraigmedicalcentre.com.au

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology and Allied services on site. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979

CANNING VALE Requires a full time or Part time GP to join our privately owned, established practice of 18 years, to be busy from day one. t 'MFYJCMFIPVST t $PNQVUFSJTFE 'VMMZFRVJQQFEBOE well-staffed t 'VMMUJNFOVSTJOHTVQQPSU t 8"(1&5BOE"(1"-BDDSFEJUFE t 0VUFS.FUSPQPMJUBO"SFBBOE%84 t &YDFMMFOUSFNVOFSBUJPO Please contact Dr Mark Pallot, Dr Ken Wong, Dr Ted Khinsoe or Dr Param Dhillon on 9456 0800 for a strictly confidential discussion, or email pracman@ranmed.com .au ALKIMOS North of River (DWS Area) Experienced FT GP required Busy computerised practice Nurse & Admin support Earn up to 65% of billings Flexible hours Enquiries to Phil: phil27bc@gmail.com YANCHEP North of River (DWS Area) Experienced FT GP required Busy computerised practice Nurse and Admin support Earn up to 70% of billings Flexible hours Non VR welcome to apply Enquiries to Phil: phil27bc@gmail.com DAWESVILLE South of River (DWS Area) Experienced FT GP required Busy computerised practice, mixed billing Nurse and Admin support Earn up to 65% of billings Flexible hours Enquiries to Vishnu: g_vinu@yahoo.com

KALAMUNDA & FORRESTFIELD Mead Medical was awarded the RACGP General Practice of the Year 2013/14 and has been servicing patients in the area for 60 years. We currently have a vacancy for a VR GP position for a 6 month contract, with a view to extension, for our well established, friendly practices in Kalamunda and Forrestfield. t 5IFQSBDUJDFIBTBXFMMFTUBCMJTIFE patient base, and offers an exciting opportunity for an enthusiastic practitioner to join our practice. t 1SJWBUFCJMMJOHQSBDUJDF JODMVEJOH pensioners and HCC) t 4VQQPSUPG1SBDUJDF/VSTFTBOEPOTJUF pathology and pharmacy. t 6OJRVFNFOUPSJOHPQQPSUVOJUJFT available, and excellent support staff and facilities Please email Jann Doherty JDoherty@meadmedical.com.au for further information and position description. WANNEROO VR GP Required Full Time/Part Time â&#x20AC;&#x153;GP WEST â&#x20AC;&#x153;requires full-time VR GPs to work in our state-of-the-art medical centre with 7 consult rooms which is opening in June 2015. Fully computerised with Best Practice, full time Nurse and onsite Pathology, allied health and pharmacy. Visit www.gpwest.com.au GP owned and great remuneration for foundation doctors. Contact Dr Kiran Puttappa on 0401 815 587 or send cvs to kiranpkumar@hotmail.com MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new non corporate practice with 2 female & 1 male General Practitioners. Sessions and leave negotiable, salary is compiled from billings rather than takings. Up to 70% of billings paid (dependant on experience). Please contact Jacky on 0488 500 153 or E-mail to jacky-steven@live.co.uk BERTRAM South of River (DWS Area) Experienced FT GP required Busy computerised practice Nurse and Admin support Earn up to 70% of billings Flexible hours Non VR welcome to apply Enquiries to Phil: phil27bc@gmail.com WILLETTON Herald Ave Family Practice We are looking for a suitable full time or part-time, VR GP to join our friendly team. We are a small, non-corporate practice, fully computerised and accredited, with registered nurse support. If you would like to join us: Email: hafp@eftel.net.au or call 9259 5559 www.heraldavefamprac.com.au

BUTLER Connolly Drive Medical Centre VR GP required for this very new, state of the art, fully computerised, absolutely paperless, spacious medical centre. Fully equipped procedure rooms and casualty, well-furnished consult rooms, pathology, allied health, RN support. Abundant patients, DWS, non-corporate. Generous remuneration. Confidential enquiries Dr Ken Jones on (08) 9562 2599 Tina (manager) on (08) 9562 2500 Email: ken@cdmedical.com.au

Are you looking for doctors for your medical practice? Australian Medical Visas is owned and run by 2 Practice Managers based in WA, who have over 20 years experience of the UK and Australian healthcare systems. We currently have a number of doctors who are looking for positions in Australia. We are able to assist practices with all paperwork involved including the migration process (if required). Please visit our website www.australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or Andrea on 0401 371 341. JOONDALUP CANDLEWOOD MEDICAL CENTRE GP required to join our friendly team for a busy computerised practice in Joondalup. Very attractive remuneration. Privately owned. AGPAL accredited general practice. Contact John Wong P: 08 9300 0999 M: 0414 981 888 E: cmc1@iinet.net.au CHURCHLANDS Herdsman Medical Centre in Churchlands requires a Part time VR and FRACGP qualified GP. We are a friendly western suburbs practice. 4 â&#x20AC;&#x201C; 6 sessions per week required, 1 Saturday morning per month. Practice culture is quality care and we QSJWBUFCJMMBMMQBUJFOUTFYDFQUBU%PDUPST discretion. Computerised, well-staffed, practice nurse. Please forward CV with references to Ms Dianne Swift by email practicemanager@herdsmanmedical.com.au

EASTERN SUBURBS Brand new GP practice looking for VR GP with fellow to start ASAP. Good remuneration and excellent team to help you build your patient base. Designated nurse for care plans Location eastern suburbs of Perth, DWS. Contact 0401 625 712 or email Waliadr@hotmail.com

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MANDURAH GP required for accredited, established friendly practice with FT RN support with a special interest in skin cancer medicine. Coastal lifestyle only 40 minutes from Perth. Contact mail@modernmedicalclinics.com.au GREENWOOD Greenwood/Kingsley Family Practice The landscape of general practice is changing, and it is changing forever. Are you feeling demoralised by the recent Federal government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? *UEPFTOUIBWFUPCFUIJTXBZ Come and speak to us and see the different ways in which we operate our general practice. Be part of the game changer! Our practice is located north of the river. Sorry we are not DWS. Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion.

SHOALWATER F/T VR GP required for our brand new medical centre located in Shoalwater (DWS), opening 1.9.15. Offering modern surrounds and fully computerised clinical software. We are a friendly, privately owned and run centre. A full complement of nursing staff/ admin team as well as onsite allied health/specialists and pathology. Remuneration negotiable. Please phone Rebecca on 08 9498 1099 or Email CV to manager@sevilledrivemedical.com

MANDURAH Business opportunity for FRANCOG and GP Adv DRANZCOG To join a thriving practice. Accom avail. Coastal location 1 hour from Perth city centre. Flexible working condition. Suit recently fellowed practitioner wanting to expand their business. GP practice also available for takeover purchase and real estate can be inclusive. Please contact Robyn practicemanagerrobyn@gmail.com Phone: 0402 032 223 WANNEROO Full time VR GP For a very busy practice (DWS) Mixed billings Full management/nursing support Good remuneration/earnings long term Designated nurse for care plans Contact 0401 625 712 or email Waliadr@hotmail.com

JULY 2015 - next deadline 12md Tuesday 16th June â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au


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ARE YOU READY FOR A CHANGE? We are looking for specialists and GP’s to join the expanding team! Tenancy and room options available for specialist’s. 3URFHGXUDO*3¶VDQGRI¾FHEDVHG*3¶VZHOOFDWHUHGIRU Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

Do you need a website or a refresh? Contact Thinking Hats today and we can help! hats@thinkinghats.net.au

Park Medical Group EAST VICTORIA PARK

A robust and AGPAL accredited medical practice with a very rapidly growing patient base is looking for more General Practitioners to join our team. Located at East Victoria Park, opposite The Park Centre shopping mall, next to a pharmacy, pathology, opposite from radiology and physiotherapy centres. Ample parking for patients up to 3 hours and centrally located to many suburbs including South Perth, Como, Manning, Waterford, Applecross, Bentley, Belmont, Lathlain, Burswood, Cannington, Willetton, Winthrop and Victoria Park. Majority of the patients are from these suburbs. We are a private billing clinic with the exception for pensioners, healthcare care card holders and children below 16 years. We welcome VR qualified applicants both male and female practitioners. We offer flexible arrangements for female doctors with young families. We can accommodate sessions to suite your availability.

To apply, write to reception@parkmedicalgroup.com.au or call 0411 876 677 JULY 2015 - next deadline 12md Tuesday 16th June – Tel 9203 5222 or jasmine@mforum.com.au


medical forum

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At IPN, we’re looking after you We take care of running the medical practice so you can focus on your patients and enjoy a greater work-life balance. I.T. Resources

Financial Services

Practice Management

Nursing Support

To view videos of Doctors sharing their own personal experiences partnering with IPN, visit: www.ipn.com.au/testimonials 1800 IPN DOC (1800 476 362)

enquiries@ipn.com.au

VR DOCTOR NEEDED

LOCUM REQUIRED for the Mundijong Serpentine Medical Centre. Brand new practice with full time RN, onsite pathology and podiatrist. Excellent patient base with full appointments and well managed CDM program. The practice is located approximately 65kms from Perth CBD. Locum period required from the 1st of August 2015 for two weeks. For more information please call the practice manager on 0419 959 246 For more information please call the practice manager on 0419 959 246

Ŕ 70% of billing and $150/hour for the first 3 months whichever is greater. Ŕ DWS and Outer Metro area category. Ŕ Flexible hours. Ŕ Physiotherapy, podiatry, psychology and dietitian services available on site. Ŕ Full time nursing support & on site pathology. Full Time experienced VR GPs needed for a brand new fully bulk billed fully computerised medical practice at Baldivis. The only practice in a busy mall with 102 stores inclusive of Coles, Woolworth, Kmart and located in the fastest growing suburb in WA with 32,660 residents including 17,290 within the primary trade area of the mall.

If you are interested or would like further information please contact drfemi@baldivisfmc.com.au

www.baldivisfmc.com.au

JULY 2015 - next deadline 12md Tuesday 16th June – Tel 9203 5222 or jasmine@mforum.com.au


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medical forum

ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? Metro Area GP positions available VR & Non – VR Dr’s are welcome to apply. Send applications to hr@betterhealthcare.com.au

As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience. You won’t have to go through the onerous process of trying to find someone interested in selling. You’ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision. We’ll take care of all the bits and pieces and you’ll benefit from our experience to ensure a smooth transition.

To find a practice that meets your needs, call:

Produced right here in Western Australia!

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

Full Colour Personalised Practice Newsletter

Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. * full-time/part-time/sessional * medical systems and secretarial support * adjacent to Fiona Stanley Hospital

-RLQRYHUVDWLV¿HG PHGLFDOSUDFWLFHVDFURVV $XVWUDOLDZKRSURYLGHHealth NewsDVDYDOXDEOHSDWLHQW VHUYLFHLQWKHLUSUDFWLFH ,WDVVLVWVZLWKDFFUHGLWDWLRQDQG ZHGRDOOWKHZRUNIRU\RX9HU\ UHDVRQDEO\SULFHGDQGDFree Trial OfferIRUWKRVHVWDUWLQJRXW6LPSO\ SKRQH-HQQ\ on 9203 5599.

More information phone: 9366 1802 or email: diane.car@sjog.org.au

GP Opportunities: Cairns, QLD Due to continued growth, IPN is currently looking for FTE Permanent and Locum GPs for opportunities within two of our QLD Medical Centres:

Redlynch Medical Centre, Redlynch Kuranda Medical Centre, Kuranda "TBWBMVFE(1XPSLJOHXJUI*1/ ZPVXJMMFOKPZGSFFEPN çFYJCJMJUZ and clinical sovereignty. For all confidential enquiries please contact Fiona James 0447 006 846 or Fiona.James@ipn.com.au 1800 IPN DOC (1800 476 362)

enquiries@ipn.com.au

www.ipn.com.au/doctors

JULY 2015 - next deadline 12md Tuesday 16th June – Tel 9203 5222 or jasmine@mforum.com.au


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Medical Forum 06/15 Public Edition  

WA's Premier Independent Monthly Magazine for Health Professionals