Medical Forum 03/15 Public Edition by Medical Forum WA

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Editorial

Who Calls the Shots? The take home messages for me from the last Doctors Drum breakfast, Health Politics – Who Calls the Shots?, are that politicians are more accessible than we think, they want to hear about solutions (not just problems), but multiple lobbying attempts are needed. Th meeting led to some more probing That qu questions on health and politics in this m month’s e-Poll (see below). We are su surprised at how disillusioned doctors appear ap to be. W When it comes to health matters, two tw thirds of our surveyed doctors felt th opinion held little or no value to their p politicians (only 5% felt listened to and v valued), and the same proportion felt that r representatives of their craft groups were i ineffective agents of change.

Dr Rob McEvoy

D Disillusionment is the main reason why doctors don’t approach politicians directly. And only about one in eight doctors were happy to devolve this responsibility to their representative group.

Maybe representative groups like the AMA and the RACGP in WA could empower doctors to become agents of change by engaging in detailed discussion on relevant issues, providing minutes of important meetings, website ﬁnancials and the like. Reading between the lines of national media releases, both groups are jostling to represent GPs, who appear most vulnerable. That vulnerability is to be contrasted with the legal profession. ‘Anything arguable is a risk’, I was once told, and with lawyers aplenty to argue we now have a situation where the huge cost of legal action involving the medical profession sends insurers running for cover. Those in the ‘helping’ professions like ours, which operate on trust (not mistrust), could miss out. Add bolshy litigants protected by the system and doctors may ﬁnd reputations unfairly on the line, especially when agencies designed to protect the consumer are prepared to use the ‘costs weapon’ to save face. In the end it comes down to money over calculated risk. Unfortunately, in the current system, very little legal action is without risk (of failure, and therefore cost). Time is money too. So money wins out often and commercial decisions are made, not necessarily legal or moral ones.

e-Poll: Health Politics – Who Calls the Shots?

e-Poll

These questions mainly came as an offshoot of our previous Doctors Drum meeting, where politics in medicine got an airing. Within the six-day window there were 186 responses from among GPs, Specialists, DIT and Others. Health matters are always in the news, whether State or Federal. How valued is your opinion in the political process when it comes to health matters? [Choose one response please] Hardly ever valued.

33%

Not valued at all.

32%

No more valuable than anyone else.

22%

Uncertain.

I feel my opinion is listened to and valued.

None of the above.

ED. GPs and Specialists thought much alike on this issue.

What do you think are the greatest disincentives that prevent you communicating directly with relevant politicians? [Multiple choice] My talking to politicians won’t change anything.

29%

Access to politicians is not easy.

24%

I don’t know how to or who to go to.

16%

I’m too busy.

15%

It’s all too hard.

Other.

ED. Anecdotally, lobbying by doctors over FSH has been effective, more so if electoral ramiﬁcations are pointed out. The big question is whether the lobbyists are promoting the greater good or protecting their own patch.

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

Are those who currently represent your craft group to politicians, effective agents for constructive change? Yes

22%

45%

Uncertain

33%

ED. 10% more Specialists than GPs were pleased with their representative’s efforts; though twice as many thought representatives were ineffective agents of change, as supported them. Mind you, doctors were prepared to cut their representatives some slack (see next question).

What statement best describes your attitude to representatives of your craft group dealing with major health issues? [one response] They do a fair job in difﬁcult circumstances.

41%

Mostly, they do not represent my points of view.

26%

I pay to belong to a professional group and prefer to leave it to them.

15%

I don’t pay to belong but am mostly happy with what they come up with.

I stay right out of medical politics.

None of the above.

10%

ED. Specialists were twice as likely (20%) as GPs (11%) to join a professional group to have their interests represented. About one quarter of both groups felt unrepresented, anyway.

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

March 2015

Contents 18

24 FEATURES 16 Spotlight: Cricketer Brad Hogg

NEWS & VIEWS 1 Editorial: Who Calls the Shots?

Mr Peter McClelland

18 22 24 32

Trailblazer: GP Dr Patrick McGonigle

Dr Rob McEvoy

Ms Jan Hallam

Letters: Simple Change for Long-Term Gain –

The Bitter Truth About Sugar

Name Withheld

Marijuana – The Search for Evidence

Review practitioner concerns –

FSH Heralds Ortho Changes

Doctors’ lives at risk –

Ms Georgie Haysom

Dr Rob McEvoy

LIFESTYLE 43 Conference Presentations 44 Dinner at Black Swan 45 Wine Review: Palmer Wines Dr Martin Buck

46 47 48

Funny Side Miriam Margolyes: Off the Shelf Competitions

Dr Jane Deacon

Don’t fear pharmacy ﬂu vax – Mr Neil Keen NMHRC on genetic research Curious Conversations: Dr Len Henson

12 21

Have You Heard? I Learnt This From My Patients… Dr Rohan Gay

28 29 30 31 31 35

Reporting of PIEDS 2014 Guest Column Award Understanding Cultural Differences Incidentaloma: A Patient’s View NFP Funds Join Alliance Beneath the Drapes

Spotlight: Brad Hogg Page 16

Gym Gy ym Junkies Ju J unk nkie ie s Crossing C Cr ros ros o sing siin ng g the the he Line Liin ne Pag Pa Page ge e 12 12

MAJOR SPONSORS 2

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Clinical Contributors

Mr Tim Spokes Ultrasound in Pregnancy

Mr Edward Tikoft The Crook Knee – Forestalling Surgery

Dr Peter Honey Investigating Elbow Injury

Dr Chris Finn Echo Use in Atrial Fibrillation

e-Poll

We polled doctors on some tough topics this month.

Dr Arjun Rao Athletes’ Shin Splints

Go to the Editorial (P1) for what docs thought about being part of the political process and advocacy.

DOCTORS DRUM

On Pages 8-10, doctors were asked to comment on what they perceive are the roles of AHPRA and the Medical Board and some of their own experiences.

March 26 See page 18

Guest Columnists

Dr Louise Allan Making Mistakes…

Ms Jenni Perkins Juvenile Justice – a New Paradigm?

Ms Irina Cattalini Stop Playing Politics with Health

Mr Geoff Diver Planning to Succeed

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

Letters to the Editor

Worse still, some patients have blood tests without any action taken – they can continue 80mg of statin daily despite a cholesterol of 2.8 (so low it increases mortality rates).

Simple change for long-term gain Dear Editor, I found this edition’s e-Poll interesting as I often think some simple changes could help our health system greatly, without increasing costs. During my 30 years in general practice I have spent a lot of time as educator (practice and external clinical teaching visits, examiner, etc.) and done rural locums, so I have been exposed to many practices and GPs.

I started checking CK of the ATSI patients on 80mg statin and found many elevated CKs, the worst around 900 with creatinine over 200, and yet these patients had diligently been on care plans? I am certain that medications contribute to the “gap”, e.g. the diabetogenic effects of statins. Dr [Name withheld], General Practitioner

How is it possible for a doctor who has not passed the clinical component of an AMC exam to be allowed to work as a GP, theoretically supervised but seeing patients alone and getting paid much more that a local graduate who has passed both components (by getting an MBBS). If local graduates were given the same conditions, they too may go to an area of unmet need.

Review practitioner concerns

There are rorts from overuse of care plans amongst Aboriginal patients. During one recent locum a nurse asked me to listen to the heart sounds of an antenatal patient or an infant, just for a minute or so. This was so an Aboriginal care plan worth over $200 could be charged. I was told there was no need to take the patient to my room (just sign here) and no need to talk to the patient (no one else does!).

I read with interest your editorial Reviewing the Regulators (February). As an MDO we are acutely aware of and experience daily the signiﬁcant impact that complaints can have on doctors, both professionally and personally. We believe that there is currently insufﬁcient regard given to this aspect by regulators, and it’s not just limited to drawn-out matters.

Because many of our health problems are lifestyle related, we kid ourselves if we think that merely prescribing is going to dramatically improve health – unwanted medications, scripts unﬁlled, and tablets not taken. Everyone seems to meet criteria for chronic disease regardless of race, via some risk factor or another, such as cholesterol. What is the evidence for repeat blood tests every three months, if they are not reviewed? What is the evidence for 80mg of statin in a 40-year-old with cholesterol of 6.0? What about all the nursing home patients on statins? So many patients prescribed statins outside guidelines have never attempted proper dietary control. Or the morbidly obese who think the tablet will protect them.

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

Dear Editor,

In our experience even minor matters can have a devastating impact on the professional and personal lives of practitioners. This impact may occur regardless of the outcome of a complaint, and can be compounded by delays and inefﬁciencies and a lack of transparency in the complaint-handling process. This has a ﬂow-on effect on the communities the doctors serve and ultimately on patient safety, the very thing the regulators are seeking to protect. Health practitioners risk becoming the “second victim” in the regulatory process. This has been highlighted in recent research on the impact of complaints procedures on doctors in the UK. [http://bmjopen.bmj.com/content/5/1/ e006687.abstract]

With changing expectations and the increasing recognition of the important interests of the consumer in the regulatory process, it is important that the voice of the practitioner is not lost. Health regulation has succeeded in Australia when practitioners have confidence in the regulator, their concerns have been listened to and they have been offered due process and natural justice. The current review of the National Registration and Accreditation Scheme is a good opportunity to address many of the issues raised in your article. We have made similar points in our submission to the review. For a regulatory system to be effective it must have the confidence of the profession being regulated. If the profession does not have confidence in the regulator, it will struggle to accept the consequences of regulation. This would not be a good outcome for patients, practitioners or the wider health system. Ms Georgie Haysom, Head of Advocacy, Avant ........................................................................

Doctors’ lives at risk Dear Editor, Being the subject of an AHPRA complaint can be a difﬁcult experience for most doctors (Editorial, February). A large study from the UK collected data from over 10,000 doctors to investigate the impact of complaints on their psychological welfare. It found doctors with recent or current complaints were 77% more likely to suffer moderate/severe depression, and had double the risk of anxiety and suicidal ideation, compared with doctors who had never had a complaint. I have seen ﬁrst-hand the effect that AHPRA complaints can have on doctors. Many continued on Page 6

Curious Conversations

Simple Remedies are Often Best A dog is a man’s best friend says the Director of Ocean Reef Medical Centre, Dr Len Henson. And a glass of red wine helps, too. One of the best things my parents taught me was… the power of faith, hard work and selﬂessness. My mother set a wonderful example and, at one stage, she held down three jobs to put me through university. Medicine can be a tough profession because… it’s not an exact science yet it can be highly emotionally charged. As doctors we’re rarely judged by our good intentions and more by the outcomes of disease.

If I could be someone else for a week I’d love to be… my dog, MacDougall. He’s a Scottish Terrier, doesn’t take things too seriously and he’s a great boss! If I could change one thing about myself it would be… to be more patient. I’d try to ‘ﬁrst seek to understand and then to be understood.’ My favourite meal is… a Cheese and Tomato Ciabatta and a Big Easy Red from Ernie Els Wines near Stellenbosch.

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Letters to the Editor continued from Page 4 complaints are couched in very emotional terms, and criticise personal aspects of the doctor’s behaviour or even their appearance or ethnicity. Some complaints are clearly frivolous, and some are prompted by professional jealousy. Doctors frequently ﬁnd it distressing and disturbing to review the complaint, and to draft a response, regardless of their resilience levels. Responding to the complaint can be timeconsuming and often emotionally exhausting. Because of the legislation and AHPRA’s internal processes, the time allowed to draft the response is often quite short. Although some complaints are resolved relatively quickly (within a month or so), if the complaint triggers an investigation there can then be a lengthy delay of months or even years before the matter is resolved. The drawn-out nature of the process can add considerably to the distress. It is essential for doctors to contact their MDO for assistance immediately upon receiving a complaint. MDOs have the expertise to assist with the response and to offer emotional support during this stressful period.

In the US, about 20% of all seasonal influenza vaccines are administered by pharmacists. Research suggests that consumers want easier access to vaccinations and pharmacies are seen as convenient and accessible locations while allowing pharmacists to provide vaccinations builds on their existing training. The Pharmacist Vaccination Code mandates minimum standards for consent, premises, equipment, resources and training. Pharmacists will need to have completed additional approved immunisation training, as well as having current first aid and CPR qualifications. The Code requires that all vaccine adverse events are monitored and reported. Pharmacists will also be required to inform the nominated GP of the patient vaccination for their records. Based on the current pricing in Queensland, the expected cost to the patient is between $20 and $30 per injection. At this time, pharmacists will not be participating in the National Immunisation Program and are expected to refer patients eligible for free vaccine to their GP. Mr Neil Keen, Chief Pharmacist, DoH ........................................................................

Dr Jane Deacon, MDA National Medico-legal Adviser References on request

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

NMHRC comment on genetic research Dear Editor, Further to the story Genetics Research – A Big Pond [February], funding to WA institutions in 2014 was: UWA: $9,751,877; Murdoch University: $614,195; ECU: $548,533; Curtin University: $179,503, funds totalling $11,094,108. In the past 10 years, WA has received $120,127,450, of which UWA has received $107,435,108 and ECU, $2,628,330. ........................................................................

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.

Don’t fear pharmacy flu vax Dear Editor, New legislation has cleared the way to allow pharmacists to administer the flu vaccine this year. The aim is to increase access to high quality and safe vaccination, particularly for those who do not normally seek annual immunisation. With almost 5000 notified cases of influenza in WA last year, boosting immunisation rates is critical to public health. WA currently sits below the national average for influenza vaccination coverage in those aged over 65 and has the lowest coverage in Australia for adults aged between 18 and 64.

Editorial Comment Readers have asked about how we handle Sponsorship… Medical Forum ﬁercely protects its editorial independence, the main reason for the magazine’s high readership in WA. We know doctors scan for bias and reject any editorial considered ‘cash for comment’, and so do we. To be extra sure, we ask clinical authors to provide competing interest declarations. While we aim to give advertisers and sponsors the best exposure – their support allows doctors to read Medical Forum free-of-charge – we set ethical limits and guidelines to protect our readers. For example, ‘Advertising Feature’ is added to anything where confusion arises over authorship, and no advertiser is shown independent editorial before publication.

Pharmacists have been safely administering vaccines for some years in other countries with a similar level of medical care as Australia.

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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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e-Poll

Responding to Complaints About Doctors There were 189 respondents to our February e-Poll (56% GPs, 34% Specialists, 10% DIT and Other), all within the six-day window. Dr PS came up trumps in the e-Poll prize and will anonymously receive the Medical Forum gift pack. ........................................................................ Complaints against doctors e-Poll are handled by the Medical Board, AHPRA and the Health and Disability Services Complaints Ofﬁce. Which of the following statements best describes your position? [Multiple choice]

Do you think those approved to investigate or report on other doctors should be revealed to doctors at large, prior to their appointment?

e-Poll

Yes

71%

11%

Uncertain

18%

ED. This gets interesting. Currently, there is no transparency on this issue, whereas nearly three quarters of doctors say there should be (with nearly 20% uncertain in giving their opinion). Specialists were more adamant about this (80%) than GPs (69%).

continued on Page 10 My knowledge of ‘who’ investigates ‘what’ is poor, should a complaint be made against me.

43%

Complaint handling is inﬂuenced in ways I am opposed to.

20%

I prefer to worry about this when or if it ever happens.

15%

I am conﬁdent that the handling of a complaint against me to any of these three bodies will be handled fairly.

15%

None of the above.

WA Doctors Comment

ED. Interestingly, an identical percentage of GPs and Specialists (just under half) admitted to poor knowledge of the complaints system, but with only a minority of both groups (about 17%) conﬁdent in the fairness of complaint handling by the current bodies. More Specialists (29%) than GPs (21%) say they oppose some inﬂuences on complaint handling, and more GPs (20%) than Specialists (6%) say they prefer to worry about things when and if it happens.

........................................................................ I believe a very important role of AHPRA and the Medical Board should be to [single choice]:

e-Poll

Protect the interests of both consumer and doctor.

85%

Protect the doctor against vexatious complaints.

10%

Protect the health consumer.

None of the Above.

ED. While the vast majority of doctors thought AHPRA and the Medical Board had a dual role in protecting health consumers and doctors, more GPs (13%) than Specialists (6%) selected the protection of doctors against vexatious complaints as very important.

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

38% of our e-Poll respondents felt strongly enough about AHPRA and the Medical Board to offer comment. Some responses will add ‘fuel to the fire’ at the Doctors Drum discussion on March 26 (see P18 and www.doctorsdrum.com.au) and have been roughly categorised. Responding is stressful Doctors find any adversarial system inherently stressful – it’s not how they normally work. These comments reflect this. “I have been investigated by AHPRA and it was five months I would rather put behind me. Eventually dismissed.” “My GP husband was subject to a ludicrous complaint which took over three years to resolve. It should have been thrown out and […] at no time was the complaint passed by another doctor working for AHPRA. It was all basically lawyers making something out of nothing. We should have GPs and other medics sitting on the initial panel to see if a case really is valid before causing unnecessary stress to GPs who already have enough on their plates!” “I had a complaint made against me by a patient I had never seen. It was a case of mistaken identity [that] took 18 months to resolve. […] The whole experience was very distressing!” “A complaint was made against me by an obviously delusional psychotic serial complainer (all her doctors were part of the ‘conspiracy’). Nevertheless, I had to go through the whole process, wasting time and money for all involved. Perhaps complaints should undergo a ‘triage’ process?” More protection against vexatious complaints Some people have a tainted view of the world and will naturally complain. Can we afford the current system where most effort is directed at unsubstantiated complaints? Should there be repercussions for vexatious complaints? Should lawyers lead the debate on this?

“The old system was to refer dubious complaints to a panel of three peers who would recommend action, either dismissal or further investigation. This seems fairer and stops vexatious or the mentally disturbed from creating havoc. One of the panellists could easily be a consumer experienced in health matters, for adequate balance. “Vexatious claims against doctors are a problem. AHPRA would prefer that the doctor fall on their sword rather than upset the patient.” Derogatory views of AHPRA “AHPRA is confrontational and aggressive and their whole attitude seems to imply you are guilty before they have any information. I was asked to submit a report to a complaint involving two other doctors, and myself indirectly, […] and was subsequently dropped from the complaint. The initial letter demanded this report in seven days and when I emailed AHPRA to state there were two other doctors trying to access the notes […] I was brusquely told I could have an additional week. There was a threat implied that I was in trouble if they did not have the report by then. This did nothing for my state of mind. Thank goodness for the Medical Defence’s lawyer who dismissed it as nonsense and said she would sort them, and promptly did!” “AHPRA seem to adopt a punitive approach and convict first and then hold a trial and review. When the process takes months to review there is significant loss of earnings, stress and no recompense.” More incidents to report? “My impression is there is still a closing of ranks with some cases of serious misconduct being dismissed.” “Negative findings against doctors should be reported publicly, [just] as they are against nurses. In general, most – especially male – doctors are not willing to accept that ‘consumers’ (i.e. patients) have a right to complain. just as doctors do. Or that health is a very personal, emotional and important topic continued on Page 10

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e-Poll continued from Page 8 Currently, around 85% e-Poll of notiﬁcations to the Medical Board and AHPRA are dismissed, 35% of investigations take over six months, and 1-in-20 doctors are subject to complaints every year. Is this situation fair and reasonable, all considered? No

46%

Yes

20%

Uncertain

34%

ED. Given that “notifications” to the Medical Board and AHPRA are of the more serious type, that is, capable of damaging someone’s health, we feel that if more respondents were aware of this definition, then the >2:1 unhappiness ratio would be even higher. As about half of the respondents are fence sitters or in favour of the status quo, that opinion could change. With 1 in 20 doctors the subject of “notifications” each year, depending on their style of practice they may not have long to wait to shape an opinion. There was no significant variation in responses across craft groups.

........................................................................ Given that AHPRA and Medical Board activities are funded by professional registration fees, do you believe failed actions should be independently scrutinised and openly reported?

e-Poll

Yes

61%

18%

Uncertain

21%

ED. GP and Specialist responses were not signiﬁcantly different. It is pretty standard practice for the use of subscribers’ money to be scrutinised. Given that AHPRA and the Medical Board are charged with protecting the public by nailing wayward doctors, their strike rate should be very high when it comes to expensive court action. And then there is the waste and anguish caused around doctors who have 85% of lesser claims against them dismissed. Registered doctors, who have watched their registration fees increase under national registration, have every right to query if a lot of lawyers, bureaucrats, and doctors are getting fat on their fees or if real demands on the system have increased.

continued from Page 8 for most people. Very often the problem is poor communication and low levels of empathy are seen as low level care […] especially if there is an adverse outcome. I have asked a Medical Defence Organisation to reveal the difference in claims against male and female GPs and I was refused the information. This was just after I had to pay a significant loading on income protection because I am a female. Different rules – both to advantage the males. How surprising!” “Knowing that non-local graduates can work as GPs in areas of unmet need without having passed the clinical component of the AMC exam makes me wonder if this is in fact evidence of a good safety net in the system?” When the patient is the problem “Anyone can complain about doctors to the Medical Board but who do doctors complain to when a patient is abusive, disruptive, rude, unprofessional, refuses to pay a bill, or simply doesn’t turn up.” “The two unfair complaints I have had against me have come from an alcoholic and a drug addict. The time, effort, and resources to dismiss these claims brought about considerable emotional stress. Penalty for the false accusations? Nil.” “As 85% of complaints are dismissed it seems that there is a lot of resources utilised as a result of unrealistic expectations or vexatious behaviour, the latter in particular should result in some punitive measure, at least financial, against the complainant.” “Patients have nothing to lose [while] doctors, a lot. The deck is stacked against the doctor and I see AHPRA or the Medical Board playing politics so that they are not tainted. Doctors really are at their mercy and good doctors will leave practice.” Improving investigation of complaints “A small number of incompetent, impaired and/or difficult people are the subject of a disproportionate number of complaints. They result in increased bureaucracy and all practitioners having to jump through various hoops. More effort should focus on the problem practitioners.” “Complaints investigation should not be outsourced to private law firms. I know of one case which was out-sourced to a firm which appointed

a fairly junior and overzealous lawyer. She was biased and pursued the poor doctor with unfair and untrue statements obtained from colleagues who disliked him. These were eventually presented to the hearing. The chairman was a medico with no understanding of the need to ascertain how true these accusations were. The hearing lasted three hours, and the poor doctor was reprimanded. This was published in the press, and while his lawyer advised him to appeal, such appeal will drag on for months or years. The collateral damage to his reputation had already occurred, and a further hearing will only make the situation worse. The process of the Board hearing should be as robust as a District Court. Anything short of this is unfair.” “Statistics on failed actions should be reported. AHPRA should have a way of flagging both doctors and complainants who have been involved in multiple cases.” “In remote towns it is difficult if the doctor is reported as everyone gets to know about it and the local media makes it big news. So the complaint needs to be [handled] sooner.” “Medical Board focus on patient complaints is misplaced. The emphasis should be on an assessment of the facts before the doctor is contacted, and frivolous complaints dismissed without any contact with the doctor.” Transparency and accountability “We should be given a regular report from AHPRA documenting in detail the cost and pattern of the investigations. If the cost of investigations is totally funded from the medical registration fees then we should see the balance sheet. Expensive failed investigations should be heavily scrutinised by an independent review process with full disclosure to all doctors.” “A doctor that is under investigation and suspended from practice, or unable to undertake a post due the punitive effect of an investigation, should be paid compensation of all fees and costs if the Board/APHRA loses the case, or if APHRA/Board pursues an investigation where there is clearly insufficient evidence for a conviction.” “There should be transparency and AHPRA should give reasons for its decisions and its decision makers should be identified. This is the practice with legal decision making to ensure fairness and natural justice.”

March Laughs My neighbour knocked on my door at 2.30am this morning, can you believe that , 2.30am?! Luckily for him I was still up playing my Bagpipes. I was at an ATM yesterday when a little old lady asked if I could check her balance , so I pushed her over. I was driving this morning when I saw an RAC van parked up. The driver was sobbing uncontrollably and looked very miserable. I thought to myself that guy’s heading for a breakdown. Paddy says “Mick , I’m thinking of buying a Labrador .”Bugger that” says Mick “have you seen how many of their owners go blind?” Man calls 000 and says “I think my wife is dead” The operator says how do you know? He says “The sex is the same but the ironing is building up!” My girlfriend thinks that I’m a stalker. Well, she’s not exactly my girlfriend yet.

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Have You Heard?

Model of the Midland Health Campus

Government turns to Midland MSI After years of stalling followed by failed negotiations for a standalone contraception and termination clinic at the new Midland Public Hospital site, the State Government has announced what Medical Forum was told in not so many words by the then Director

General of Health Kim Snowball back in June 2012. Marie Stopes International (MSI) will pick up some of those procedures that the Midland hospital, under the management of St John of Health Care, will not. Mr Snowball told us then that SJGHC made it clear it would not provide those services: “We didn’t think that made them ineligible because there were other providers who could deliver those services in the Midland area.” Last month Health Minister Hames announced that the Government would give MSI $1.2m to upgrade its facilities and $500,000 a year to conducted procedures for public patients. Where public patients with more complex immediate gynaecological conditions will go is a subject of questions on notice for the Minister.

ACCC on MA’s tail The ACCC has given some slack to Medicines Australia while maintaining a ﬁrm stand on its transparency demands in its negotiations to

endorse MA’s Edition 18 Code of Conduct. Last month the ACCC opted for a $120 cap on meals per person at Pharma events. In making its decision, ACCC went against concerns raised by RACGP and consumer groups but ACCC said its proposed new transparency reporting regime would capture the majority of interactions, including the provision of food and beverages. Approval of the 18th code is still conditional on MA agreeing to implement reporting requirements to ensure all relevant transfers of value between pharmaceutical companies and doctors are reported on an individual basis [see, ACCC and Pharma Transparency, February]. Earlier in the month, MA told the ACCC its transparency demands were “tantamount to redrafting the code and engaging in regulatory over-reach” and threatened that some member companies might withdraw from the authorisation application altogether. The ACCC will make a ﬁnal decision on the draft code in April.

Leaner MDAN board? MDA National will be holding its delayed AGM on March 19 at its Perth ofﬁces. Since the resignation of Prof Julian Rait and Mr John Trowbridge after the merger with MIGA failed to win member support, the MDAN board has been meeting with 10 members rather than its maximum 12. Another three vacancies are up for re-election at the AGM. In the Constitution the board must have a minimum of eight and a maximum of 12 directors. The mutual has announced it will only seek to ﬁll three vacancies in March and to evaluate the skills and cost performance of a leaner 10-director board until its regular AGM in November when a proposal to change the constitution may be made. Acting chair Dr Rod Moore (WA) and Dr David Gilpin (QLD) are seeking re-election and Dr Reg Bullen (WA) will retire. Also nominating are Dr Keith Woollard (WA), Dr Patrick Mahar (Vic), Dr Paul Nisselle (Vic) and Dr Aniello Iannuzzi (NSW). The election is being conducted by the WA Electoral Commission. After the AGM, the chair will be elected by the new board.

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Food labelling not rocket science Last month’s national Hepatitis A outbreak sparked the reintroduction of a food labelling Bill in Federal Parliament that would make clear the country of origin of the produce within. Consumer group Choice and Australia Made Campaign both said it was time the country tightened its food labelling laws so consumers were clear where their food is grown, manufactured and processed. But what’s needed is less grandstanding and more action. A joint inquiry into food labelling by both houses of parliament was conducted last year. What consumers want is the truth on food packaging. Stop the meaningless marketing ploys and tell us if the food we’re buying is grown in Australia or not. [see P22]

Contraceptives in TGA sights

OTA’s magic show The 2014 performance report from the Organ and Tissue Authority is a bit like a magic show … creating something from thin air. Last year there were more organs transplanted nationally (1% higher than 2013) from fewer deceased donors (378, 3% lower), which just goes to show the skills in the field have got sharper and smarter. While the DonateLife Network can claim a 53% increase in organ donor outcome since it began in 2009, the figures come from a low base. Of the 74,400 deaths in hospitals last year, 700 potential donors were identified; 680 donation requests were made; 415 consented and 378 actual donors. The WA figures were disappointing with a decline in donation rates from 18.7 donors per million population (dpmp) to 13.6

In its February Medicines Safety Update, the TGA pointed to its evaluation of research that describes a link between the use of combined oral contraceptives (COCs) and the risk of developing inflammatory bowel disease (IBD), including ulcerative colitis and Crohn’s disease. It said data also suggests HRT was also a potential risk factor for IBD (both increased in smokers), and the jury was out still on progestogen-only contraception. The TGA wants all sponsors of COCs and HRT to update Product Information documents accordingly, although causal relationships are not confirmed. Metoclopromide also scored a new contraindication (less than age 1) and dose and duration (max five days) limitations to reduce the risk of extrapyramidal disorders and tardive dyskinesia, as well as rare cardiac conduction disorders. There are 30 metoclopramide-containing products included on the Australian Register of Therapeutic Goods, available as prescription and pharmacist-only medicines. Something we learned was that extrapyramidal disorders, including tardive dyskinesia, may continue even after metoclopramide is ceased and may not be reversible (see www.tga.gov.au).

dpmp. The Australian Paired Kidney Exchange (AKX), which started in 2010 and operates from three sites in WA, is ticking over. Last year 38 live donor kidneys were transplanted nationally.

Cancer essay a ticket to Vienna Cancer Council Australia is running a national essay competition for medical students which could see them win a trip to Vienna

to attend the International Summer School’s Oncology for Medical Students course in July. The topic of the 2500 word essay is Research and the changing landscape of oncology with a suggested focus on an aspect of cancer control. For info contact Leona Macfarlance (Tel: 02 8063 4100 or Leona.macfarlance@cancer.org.au)

Best Practices Since 2002, WA based Medifit has helped hundreds of healthcare providers across Australia create their dream practices. Medifit are medical design and construction specialists. Our experience and efficiency combine to provide a level of service and quality of outcome that is second to none in this space. From initial design concepts, through construction, fitout and beyond, we will deliver the practice you want, in the timeframe and budget you need, without the stress. If you’re thinking of building or refurbishing a practice, contact us today for a no obligation consultation. Your patients won’t be the only ones smiling.

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MEDICAL FORUM

Incisions

Making Mistakes … Former GP Dr Louise Allan writes a heart-to-heart letter to her daughter about being a doctor. Louise is now a writer who has been shortlisted for the TAG Hungerford Award for fiction. Congratulations, you’ve finished your first year of Medicine! And I can tell it suits you because you’re the chirpiest you’ve ever been, overflowing with new knowledge and the pleasure of like-minded friends. You remind me of my own early days at Medical School, all that delicious Latin, the textbooks and the inner workings of the human body. A body I’d lived in but never understood. And I just can’t believe you’re allowed to see patients in the first year! What happened to those dry pre-clinical years with nary a patient in sight?

Hopefully there’ll be a doctor you hold in high esteem and she will call you to one side and tell you not to let it get you down. She’ll tell you about her own mistakes and she’ll remind you that you are a good doctor, and that all good doctors make mistakes.

Your father’s not overly impressed with the timetable. Where are the nine-to-ﬁve lectures? And where are Chem pracs until six o’clock on a Friday afternoon? He’s not too sure about all this online stuff either – Moodles!? And Facebook Groups and Podcasts! Sounds like too much fun to be real ‘study’.

And I know what else you’re thinking. You’re thinking that the only doctors who make mistakes are the bad ones, the inept ones, the negligent ones, the ones that make the news. But you won’t be like them. You’ll be conscientious and thorough and meticulous.

Now, I don’t want to dampen your enthusiasm but here’s something you need to know.

But you will still make mistakes.

You will make mistakes. I know you’ve been told that and you don’t believe it. You’re thinking that you won’t make a mistake. You’re thinking that you’ll be so good and conscientious that you won’t miss a diagnosis or prescribe the wrong treatment. I’m sorry to tell you, but you will. You will make mistakes. Despite everything you learn, despite everything you know, despite all the exams you’ve passed, you will still make mistakes.

And, most of the time, you’ll get away with it. The majority of your patients won’t suffer as a result and, for those who do, it will be minor. When you do make a mistake you’ll be defensive. You’ll say something like, ‘but the scaphoid was clear on X-Ray and it was only a minor fall onto their outstretched hand.’ Or, ‘they said their chest pain wasn’t that bad and they wanted to drive themselves to Emergency.’

Les Conceicao (MBA MIR BA Grad Dip FP FFin AFP)

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08 6462 1999 | www.morgans.com.au/perth Level 20, 140 St Georges Tce Perth WA 6000

But you will feel terrible. Why? Because you made a mistake. You’ll feel stupid and you’ll take yourself off to a private room, shut the door and cry. Because-You’ve-Been-So-Stupid No other doctor would have missed it, only you. You should give up Medicine right now because you’re hopeless. You won’t forgive yourself even if the mistake happened at the end of a 36-hour shift, or if it was a presentation you’d never seen before. Sometimes you’ll have to face the patient or one of their their relatives? They will want to see you. Apologise, always. Sometimes you’ll have to face the wrath of a colleague and it may be someone who’s forgotten their own mistakes. Hopefully there’ll be a doctor you hold in high esteem and she will call you to one side and tell you not to let it get you down. She’ll tell you about her own mistakes and she’ll remind you that you are a good doctor, and that all good doctors make mistakes. You’ll return to the ward and you’ll see your next patient who might just thank you for listening to him after his son died, or for diagnosing her breast cancer or her child’s meningococcal infection. Or just for squeezing her in when you were busy. And that will be enough.

GESB Award Winning Financial Adviser Les has over 14 years experience as a licensed ﬁnancial adviser with over 5 years as a Senior Financial Adviser with GESB Financial Advice and is a multiple award winner of the GESB Financial Adviser of the Year. Les has specialised knowledge to create tailored tax-effective strategies to maximise your beneﬁts from: GESB West State Super GESB Gold State Super

Additionally, Morgans offers the Wealth+SMSF Solution service which frees up your time by taking care of the establishment and complete administration of a SMSF. We also offer top class equities and securities research, enabling comprehensive management of your SMSF portfolio. To make an appointment or discuss your needs, please call Les on 08 6462 1960.

Morgans and CIMB – Please visit www.morgans.com.au to understand the products and services within our alliance. RBS Morgans Limited ABN 49 010 669 726 AFSL 235410 A Participant of ASX Group. A Professional Partner of the Financial Planning Association of Australia

MEDICAL FORUM

Is your equipment ﬁnance getting you all tangled up? It’s time for a second opinion. As you well know, running a practice involves balancing a myriad of priorities. Purchasing equipment is high on the list, but it’s often devilishly complicated – it takes specialist expertise to put together a simple, cost-effective solution. This is where BOQ Specialist comes in. We’re experts in providing ﬁnancial solutions for medical professionals, so our team thoroughly understands the pros and cons of different methods of funding your equipment. Whether it’s buying outright or leasing, you can rest assured we’re on the ball when it comes to your needs.

Visit us at boqspecialist.com.au/medical or speak to our ﬁnancial specialists on 08 9214 4500.

Equipment and fit-out finance / Credit cards / Home loans / Commercial property finance / Car finance / Practice purchase loans SMSF lending and deposits / Transactional banking and overdrafts / Savings and deposits / Foreign exchange Financial products and services described in this document are provided by BOQ Specialist Bank Limited ABN 55 071 292 594 AFSL and Australian Credit Licence 234975 (BOQ Specialist). BOQ Specialist is a wholly owned subsidiary of Bank of Queensland Limited ABN 32 009 656 740 (BOQ). BOQ and BOQ Specialist are both authorised deposit-taking institutions in their own right. Neither BOQ nor BOQ Specialist guarantees or otherwise supports the obligations or performance of each other or of each other’s products. BOQ Specialist is the credit provider. Terms and conditions, fees and charges and lending and eligibility criteria apply. We reserve the right to cease offering these products at any time without notice. BOQ Specialist is not offering ﬁnancial, tax or legal advice. You should obtain independent ﬁnancial, tax and legal advice as appropriate.

MEDICAL FORUM

BOQS001163 01/15

Celebrity Spotlight

Cricket’s Tongue Twister Fresh from a back-to-back T20 championship, resident ‘character’, spinner Brad Hogg, tells Medical Forum the secret of his and his team’s success. It’s one thing to spin a cricket ball out of the back of your hand at 2500 rpm but quite another to do it when you’re 44-years-old with your tongue poking out of your mouth. Brad Hogg’s longevity at cricket’s elite level is nothing short of astounding. He first stepped on to the pitch for WA in February 1994 as a middle order batsman, morphed into a left-arm wrist spinner and is now a key player for the Perth Scorchers, the back to back champions of the Big Bash League. “It was a great win in the final against the Sydney Sixers and a big game like that always has ebbs and flows. A break in concentration by one of their fieldsmen allowed Mitch Marsh to hit it for six but there’s never an easy road to winning big matches. The limited-over form is highly strategic and my job is to take wickets and minimise the run rate in the middle part of the innings.” “It’s a bit of a trademark for me now, bowling with the tip of my tongue sticking out but it’s never caused a problem. The only time I’ve bitten it is when I’m eating, and we all know how much that hurts.” Brad’s career has been remarkably free of injury with only one brush with the surgeon’s scalpel. “I’ve been very fortunate because I do have a tendency to train too hard. I just can’t seem to help it. Obviously every individual has a different physical make-up but the only surgery I’ve had is a bit of a meniscus scrape on my left knee.” “Some spinners have finger and wrist problems, in fact there’s a really good up-and-coming youngster named James Muirhead and the ball comes out of his hand at nearly 3000 rpm. He’s had a few problems, unsurprisingly.”

everything from the climate to a challenging curry. But, as Brad points out, sometimes the damage is self-inflicted. “There was one incident involving a doctor in India. We had one final T20 game the next day and I wasn’t supposed to be playing so I went out with a couple of the coaching staff. It turned into an interesting evening and suddenly next morning they told me they wanted me in the side! I called the team doctor who put me on a drip for an hour. He’d been out with us the night before so he knew what the problem was.” “Let’s call it food poisoning, shall we?” “I’ve been travelling to the Subcontinent for nearly 20 years and you get used to the conditions. Nonetheless, it is quite confronting and I still remember my first trip. As the aeroplane began its descent into Delhi you could smell a distinct change in the air coming through the air-conditioning vents.” “A couple of the boys who’d been there before said they wished they could turn the aircraft around then and there. It wasn’t a good trip, everyone was stressing out about getting sick and the medical staff were saying don’t eat this and don’t drink that!” “You do have to be cautious but I’ve learnt to embrace the culture, including the food.” “The other aspect of the IPL is the team culture. Some teams in other parts of the world tend to focus on big-name players and that can be detrimental to the overall feeling within a side. If the players don’t get along it can be a very long tour. Too many big egos can lead to infighting within a squad.”

There must be something in the WACA water because State cricket at the top level is going from strength to strength [see Justin Langer, July edition). “In the past two years the WA participation rate has increased by nearly 50% and the success of the Perth Scorchers is a big part of that due to the entertainment value. And our performance level isn’t down to any one individual because we’ve proved that it’s much more productive to have a healthy culture, particularly in tight games.” Sport is, in many ways, a metaphor for life with wonderful moments and big disappointments along the way. “Cricket at the top level is a highly artiﬁcial environment and it can camouﬂage a multitude of insecurities. I’ve seen a lot of former players struggle when their sporting days are over. There’s less stigma associated with depression but, I have to admit, until I saw it up close in a few other people I really didn’t understand it fully.” “The former Test coach, John Buchanan was one of the best managers of players I’ve ever known. He was very good at sensing when a player had a serious issue that didn’t relate to cricket.” “When I’ve bowled my last ball I’m hoping to combine media work with mentoring young, talented spinners. It’s always nice to give something back to the game and I’ve been very fortunate to do something I love for so long.”

By Mr Peter McClelland

“Dr Sandra Majak and the medical staff at the WACA do a great job of making sure we’re able to perform at a high level on the park.” Brad also plays for the Rajastan Royals in the Indian Premier League (IPL). Cricket on the sub-continent can be pretty demanding,

16 1 6

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MEDICAL FORUM

Trailblazer

Returning to Grassroots Practice Today corporate general practice is a given, but in its infancy the stakes were high and there were some casualties. One GP who saw it all is Dr Patrick McGonigle. With 69 corporate general practices operating in every corner of Western Australia, corporatisation of primary health is well and truly entrenched. However, sitting alongside these medical centres are private practices, which have grown and adapted their health and business models to face the sometimes extreme challenges of 21st century medicine. One person who has seen life on both sides of the fence is Gwelup GP Dr Patrick McGonigle. He established the Gwelup Medical Centre on North Beach Rd 10 years ago with colleagues Dr Hilary Dickson, Dr Claudio Cecchini and Dr Ludmila Polczynski once they came out of contract from the Endeavour-owned Boulevard Medical Centre in Kingsley. Patrick and Dr Alistair Vickery set up the Boulevard surgery in 1991 and it grew into a busy practice with four consulting rooms and was a hub for GP training. As goals and aspirations evolved, talk turned to corporatising as a way freeing them both up from the pressures of running their own practice. “We had meetings with corporates most weeks – Foundation, Endeavour, Mayne Nickless – and back then, they were offering the world. We couldn’t believe it. We would

At a Glance: General Practice in WA 3192 GPs (1718 full-time; 1953 part-time) Women: 1369 (total); 595 (FT); 626 (PT) Men: 1823 (total); 1123 (FT); 1328 (PT) GP Registrars: 242 (total); 125 (FT); 131 (PT) Non-VRGPs: 497; 188 (FT); 206 (PT) Source: Department of Health 2013-14

Corporate Medical Centres in WA IPN: 35 Healthscope: 11 Primary Health Care: 7 Sonic Health Plus: 16 meet for lunch and these numbers would ﬂy around. We were quite dizzy with it all but our accountants kept our feet on the ground.” “Our agent did the sums and he looked at us and said, I just don’t how they can offer this money. They were offering associates 55%. Once the overheads were accounted for, they would have been lucky to take 5-10%. Our agent looked at us and said ‘I reckon some of these guys will go bust and when they do you will be dragged down too but, on the other hand, you can start a new practice’.

Medical Board & AHPRA... “I thought the discussion was excellent. Great to get some insight from the politicians. Well done.” Dr Cliff Neppe “A very enjoyable breakfast and a welcome break from work. I enjoyed meeting new people and specialists I have referred to but never met. The panel were very impressive and Russell Woolf was great. It was very useful for the GPs to vent their frustrations.” Dr Rimi Roper, Mt Lawley

Don’t miss the ﬁrst Doctors Drum breakfast for 2015.

“We were under contract but I didn’t go into it with the intention of leaving after three years. I went in with my eyes open.” Patrick says the big positive of corporatisation was the relief of the administrative burden with no strings attached. The medical staff were free to practise as they saw fit. “From a patient point of view, I don’t think the care changed. And it was nice to think you belonged to a bigger organisation that could provide a better service, but it turned out that there was a lot of wastage.” “It made me realise how efficient we were as a private general practice. My wife was practice manager and she’d hunt down office bargains and the practice nurse did the same for dressings. We made efficiencies and the dollars and cents added up.” “When Endeavour took over they paid a lot more for drugs and dressings and laundry than we ever did. The PM showed me the accounts and I was aghast. Big business thinks differently. And maybe at that time big business didn’t know enough about the micro business of general practice.” Bearing the brunt of this inexperience was the practice’s admin staff.

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MEDICAL FORUM

Trailblazer

move on. We just couldn’t do that. On big issues, they were even more indecisive. When we entered the agreement, we knew that part of the plan was closure of smaller practices to establish a big one.”

Dr Patrick McGonigle and (inset) from an earlier Medical Forum story circa 1998

“Small practices know each other. If we had a problem with staff, we sorted it in a day. Things weren’t allowed to fester but the delay with the chain of command, left people wondering and worrying.” It was this corporate indecision that was the final straw for Patrick. “We would wait sometimes up to four weeks for decisions – some of them very small in the scheme of things – to come back from head office. That became frustrating.” “I’m no empire builder but I like to see a problem and make a decision to fix it and

“I wasn’t against that but we were getting mixed messages that made us wonder if it was ever going to happen. We came up with some compromises but they couldn’t decide about them. I was heading out of contract in February 2004 and I didn’t have a renewal proposal in front of me by the time I took a week off for Christmas. Eventually it was this indecision that persuaded me to leave and I wasn’t the only one.” There has been considerable rationalisation in the corporate primary health sector over the past 15 years, with mergers and closures leaving a playing field of four major companies operating 69 medical centres in WA – IPN, Sonic Health Plus, Healthscope and Primary Health Care. It is hard to separate the general practice revenue from the balance sheets, but it is fair to say they are largely profitable and that they are vastly different enterprises to the early days of corporatisation. One firm, IPN, states on its website, for instance, that only 15% of its

medical staff is on ﬁxed-term contracts. The rest are independent practitioners. For Patrick, the return to self-determination was initially daunting. “My ﬁrst reaction to the suggestion of relocating and starting a new practice was to ‘run for the hills’. But after a drive-by the Gwelup property, the future began to take shape. The uncertainty of the past three years meant that Gwelup began life with a team of doctors and administration staff from Kingsley. “We had experience and the team which meant we could start up immediately when we moved here. We knew each other and the future was in our hands.” While Patrick acknowledges that running a practice with all its complexities is not for everyone, for him and his partners, it’s a question of growing together as a team and growing older with their patients. There is also a commitment to training. After hosting medical students for a few years, GP training is once again on the agenda and while many might see this as more work, Patrick says it’s vital. “We need more doctors and ultimately it’s an investment. Two partners are former trainees of mine. Hopefully, when we start training and it will grow again.” “That’s the thrill of running your own practice. You are the master of your own fate. It is what you make it.”

By Ms Jan Hallam

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MEDICAL FORUM

‘‘Fantastic course, worth its weight in gold.’’

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Finance Education for Doctors A highly practical course on investing and wealth management. Learn how ﬁnance and investing works with Associate Professor Sam Wylie.

The next course begins on Thursday 26 March 2015

Attend a free introductory session 6.30-8.50pm Thursday 5 March The Course

The Teacher

A fundamental topic in investing is covered each week to build up a complete framework for making decisions about personal wealth management and practice management.

Dr Sam Wylie is an Associate Professor of the University of Melbourne and 6 times the winner of Melbourne Business School’s Teaching Excellence Award. From 1997-2004 he was an Assistant Professor of Finance at the Tuck School of Business at Dartmouth. He undertook his PhD at the London Business School from 1992-1996.

The course is taught in the business school style of theory mixed with practical cases. No prior knowledge of ﬁnance is assumed.

80 doctors have so far taken the course The next course commences Thursday 26 March, 6:30pm – 9:30pm for 10 weekly sessions at The Law Lecture Theatre, 1st Floor, Law Building University of Western Australia.

Windlestone Education does not hold an Australian Financial Services Licence and does not provide ﬁnancial advice of any kind. Windlestone Education is a provider of education services only. Windlestone Education is not afﬁliated with either the University of Western Australia or the University of Melbourne.

MEDICAL FORUM

Feature

I Learnt This From My Patients… Dr Rohan Gay

Dr Rohan Gay and The Watchmaker

The Watchmaker

I handed over my father’s Omega automatic – a study of 1950s minimalism in stainless steel. It had been a gift from my grandmother when my father came to Australia in 1952. Of late the watch had failed to wind. With deft tilt of a case knife the movement in brilliant copper tones was revealed for the first time in over 60 years. The handling had activated the movement and the balance wheel beat like a tiny heart. “Ah there is a lot of dirt and a lot of scratching. Ah, the rotor post is damaged, see? I think I have a watch with a similar movement.” Incredibly he reached for another watch; different case, leather strap. Another tilt and the same brilliant copper movement was revealed – “like brothers! Omega Calibre 503. Do you want me to fix the strap too?” The Watchmaker was one of my first patients. Twenty years later I am standing in his small workshop surrounded by thousands of parts and equipment in hundreds of tiny drawers and containers. It turns out that I have been treating one of only a handful of watchmakers capable of servicing and repairing full mechanical watches in WA. Toys to timepieces From fixing toys for friends as a child, The Watchmaker went on to five-year apprenticeship “just to get started” before launching 50-year career as a watchmaker. He officially retired some years ago but continues to repair watches as a hobby. “Every morning after I finish breakfast, I go to my workshop as something that gives me a purpose in life, a love to fix things, and my main reward is the satisfaction of being able to do it.” The more leisurely pace has allowed him to devote time for interesting pieces in his personal collection of historical watches, alongside his other passion for billiards (I was also introduced to his full-sized billiards table and collection of cues and rests). He occasionally receives referrals from other watchmakers to repair watches.

Inside a pocket watch

MEDICAL FORUM

An early 20th Century pocket watch converted to a wristwatch

Putting aside my father’s watch we turned to his crowded desk and what appeared to be several upturned petri dishes. Under each was collection of watch parts. He picked up what appeared to be a serpentine piece of ﬂat wire less than a millimetre thick and several centimetres long. “This is a bicycle chain from this 19th century pocket watch. They were assembled by hand by women using only daylight.” Sure enough here was a miniature riveted chain with unique hooks at either end which he had fashioned as replacements. Like its bicycle counterpart, the chain engaged with a miniature stack of gears to maintain a steady speed at the various mainspring tensions. Watches yield up their secrets We went on to other watches including ornate pocket watches with elaborate cases bearing personalised owners’ crests which when removed revealed on the internal surfaces, intricately engraved details of the watch and often owner details in ornate engraving only ever visible to a watchmaker. An interesting watch was a doctors’ wrist watch. Outwardly, an ordinary three-hand watch, two buttons allowed the second hand to be zeroed, stopped and started for timing. Another pocket watch had a mechanism for chiming the time at the push of a button so the owner need not look at the face. He showed me contemporary equipment to measure the vibration and thus speed of mechanical watches, then a 19th century reference balance wheel in comparison. There was a motorised winding wheel to test automatic winding movements. Besides the jewelled pin gauges, forceps and pliers, pin pushes, case wrenches etc. He had a

range of handmade, customised and unique, improvised tools. The most impressive tools were the 0.2mm drill bits and miniature lathe used to drill and machine shafts. The precision of his work and the complexity of the mechanisms made the microvascular anastomosis nerve graft or corneal suture seem almost rudimentary in comparison. With all the buzz over nanotechnology and micro-machines, here is evidence that miniature engineering has been with us hidden in plain sight for over 200 years. The art and innovation of watch making continues. New tourbillon mechanisms for example increase the accuracy of mechanical watches particularly when the mechanism is under greatest load such as when a watch is in the crown down position. Unfortunately, access to parts is becoming increasingly harder as the mechanical watches have evolved from necessary equipment to exclusive luxury items. Time is precious As doctors we are privileged to have glimpses into the myriad worlds inhabited by our patients. On the odd occasions when treatment has been wrapped up, and time is available just to chat, I have been amazed by tales from patients from such diverse backgrounds. Stories of handmade furniture, workers of cast-iron, sheet metal and machining, equestrian competition, satellite tracking technicians, World War survivors, police, ﬁremen, corrective service ofﬁcers, soldiers, locksmiths, roadside mechanics, pole dancers, and the list goes on! Such insights remind us that our job is not about us; it’s a bit about the disease; but is really about the people that we treat.

Feature

No Sugar-Coating the Truth There is a bitter row brewing about the amount of sugar-packed food is being sold in our supermarkets and restaurants and the calls are getting louder for government action. Processed food manufacturers are in for another torrid year if the growing number of anti-sugar campaigns is any indication. In December, we explored the voluntary healthy star rating (HSR), which the Federal government has ﬁnally introduced but if you’ve been in a supermarket lately, you’re not seeing too many stars. In WA, evaluations of the third phase of the Live Lighter campaign are out and it looks like we will be watching those nasty fatty liver ads for a lot longer. In 2012, Heart Foundation WA and Cancer Council WA received $9.1m from the Health Department promotion to create the Live Lighter campaign and after its third phase, the results are promising but far from overwhelming. There was fair recall of the adverts among its target audience (those aged 25-64 with a BMI >25) with 32% unprompted recall at the wave 2 survey and 31% at wave 3. Hearteningly, the target audience were most affected with a 35% (> BMI 25) to 27% (< BMI 25) recall. Perhaps most encouragingly, 98% of WA respondents agreed being overweight

or obese caused toxic fat to build up in and around vital organs. Sugar in the cross-hairs While the adverts will continue to ﬂash on and off our screens, NFPs are turning their attention to the advertising and marketing of sugary drinks, especially to children. A month ago, a coalition comprising the Consumers Health Forum, the Heart Foundation, the Obesity Policy Coalition and the Public Health Association of Australia released results a survey of more than 1000 people. There was strong support (77%) for mandatory health star ratings on food packaging (9% opposed) while half thought taxing offending products was a good idea. This group also repeats the oft-heard call for a clamp down on sport sponsorship and food advertising while brushing up its ‘nanny state’ argument ready to counter food industry opposition. “It is the food industry which has received the nanny state treatment, being protected by governments. Its products are a major

factor in the spread of obesity, now costing Australia an estimated $56b a year in direct and indirect costs.” While ‘Big Food’ targets are in the cross hairs, actor and ﬁlm-maker Damon Gameau has taken a different tack in a documentary which will be screen in Perth later this month. Damon Gameau

That Sugar Film in many ways is much more sobering than a supersized Big Mac with the lot – at least you know what you’re getting with a Big Mac. Damon, 39, instead, spent 60 days eating nothing but processed food that was labelled “healthy”, “low-fat”, and “natural”; the type of food that can be found in lunchboxes across the nation. They all appear to be sugar magnets.

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Feature Food Sugar Content One apple and blackcurrant Organic Sunraysia juice (6 tsp)

this is a concern. Real food should always be pushed over processed.”

Two Woolworths ‘Fruit Bars’ (8 tsp) One Packet of ‘Fruit Salad Bites’ (5 tsp)

No GST on fresh food

One Jam sandwich (4 tsp)

Damon admits that he like most people is not really a ‘tax man’ but he said that if the Government was reconsidering a GST on fresh fruit and vegetables, sugary drinks should be slugged extra.

Raisin toast (4 tsp per slice) 250ml bottle of multi-vitamin juice (6 tsp) Iced tea (8 tsp) Powerade (8 tsp) 400ml apple juice (10 tsp) A serve of low fat yoghurt (11 tsp) McDonald’s Bubble Gum Frozen Sprite Splash with popping candy (18 tsp) Hungry Jacks Extra Large Frozen Coke (18 tsp) Sources: That Sugar Film & Rethink Sugary Drink.org

Bearing in mind that Damon is making a documentary for commercial release in the cinemas, there wouldn’t be much of a story if the results weren’t shocking, but he admits he spooked himself. Bad things happen fast After three weeks on the diet, mood and energy levels plummeted and blood tests revealed the beginnings of fatty liver disease. In one interview he said: “All the sugars that I was eating were found in perceived healthy foods, so low-fat yoghurts and muesli bars and cereals and fruit juices, sports drinks.” It amounted to about 40 teaspoons a day which produced 10cm of visceral fat around his

A still from ‘That Sugar Film’

waist. The recommended daily intake is nine teaspoons a day for men and six for women. “It was a big shock how quickly the diet impacted on my health, but, equally, everyone was surprised at how quickly my health returned when I removed the sugar. All my blood tests and fatty liver reversed in 60 days.” The experience has turned him into a healthy food warrior. When Medical Forum asked him how helpful he thought the HSR would he was adamant it should be mandatory and that “we need to be crystal clear with our labelling around it”. “I think products should have large teaspoon counts displayed instead of the ambiguous ‘grams per serve’ which people ﬁnd confusing. I also noticed recently that an Up and Go received a higher star rating than plain milk. There will obviously be random anomalies but

“My ideal outcome, if it did happen, would be a separate body that collects the tax from the sugary items and uses it exclusively to subsidise fruits and vegetables or to put better foods into schools or hospitals.” But he said consumers needed support to choose healthy food. “I believe in the phrase ‘freedom of choice only comes from freedom of information’. At the moment there isn’t a level playing ﬁeld; most people are in the dark about their sugar consumption. Once they understand just how much sugar they are actually consuming, they can take responsibility and make different choices.” “Dr Jean Marc Schwarz calls it a ‘tsunami of fructose ﬂooding the liver’. Knowledge is just the start. We have developed our sugar addictions over a few hundred years and it is going to take a group effort to start lowering our intake. There are 5.5m Australians with fatty liver disease with only 6000 a result of alcohol. There is no better time to start.”

By Ms Jan Hallam

THE LINK BETWEEN HEARING LOSS & MENTAL HEALTH Find out more at the ESIA 2015 GP EXPO All GPs are warmly invited to attend this highly anticipated RACGP Accredited training event. Utilising current research indicating the impact of hearing loss on mental health outcomes, ESIA experts will provide GPs with practical workshops and hands-on demonstrations for use in real life situations in GP clinics.

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Entry is Free Food & beverages provided Course is RACGP Accredited Limited places available so please book early Where: UWA Club Banquet Hall, Hackett Drive Crawley When: 23 April 2015 Register at: www.ESIAgpexpo.com

Feature

Marijuana – The Search for Evidence The Medicine Late last year, the NSW Government announced it would commit $9m over the next ﬁve years to run three clinical trials into the medical use of cannabinoids. One trial will explore cannabisderived products for children with severe, drug-resistant epilepsy, the other two trials will enlist adults all with terminal illness, focusing on improving quality of life, and symptoms such as pain, nausea and vomiting; and those with chemotherapy-induced nausea and vomiting where standard treatment is ineffective. However, the NSW Health Department cautions: “Clinical trials take time and must meet national and international standards. These trials will seek to enhance available evidence to better understand the appropriate use of cannabis and cannabis derived products for medical purposes.” In WA, response has been muted. One doctor, who asked for anonymity, said he and his associates “wouldn’t touch it with a barge pole”. Pain physician Dr Stephanie Davies, while generally supportive of the NSW trials, notes that these Dr Stephanie Davies trials don’t include pain that was unrelated to terminal illness. She didn’t think there was enough evidence or studies around medicinal marijuana to determine the beneﬁts or harms for people with persistent pain. “Studies need to be carried out on pain and function. Cannabis might relieve pain but does it allow you to function? In the

Netherlands, where marijuana has been legal for 30 years, I couldn’t find any studies that satisfactorily answer that question.” The medicinal marijuana being trialled is not the crude cannabis available on the black market or grown under lights in suburban linen cupboards. “I have been absolutely clear this is not about the use of crude cannabis which does have serious potential ill-health effects,” the NSW Health Minister Ms Jillian Skinner said. “This is about looking at derivatives of cannabis that can be useful in treating these conditions.” The Royal College of Physicians is a loud supporter of the trial. Its national president, Prof Nicholas Talley, said that while some people may benefit from the use of medicinal Prof Nicholas Talley marijuana, more research was needed and he welcomed the commitment of the NSW Government to step forward and sponsor the first trials. “We need to improve our understanding of how to harness the potential medical benefits of the marijuana plant without exposing people who are sick to its intrinsic risks.” “A number of studies and clinical trials have examined the effectiveness of both crude and pharmaceutical cannabis to treat various medical conditions. The results of all these trials have not been definitive and are raising

months. When Medical Forum asked the WA Health Minister, Dr Kim Hames, for comment, we did so after the NSW Government had announced its medicinal marijuana trials.

The Politics The campaign to legalise cannabis has waxed and waned over the past two decades. The current focus is on legalising medicinal marijuana which restricts contentious debate by excluding the issue of recreational use and avoiding comparisons with overseas jurisdictions that have gone the whole hog. In July, the West Australian Labor leader Mark McGowan announced to the ALP state conference that legalising medicinal marijuana was the “right thing to do”. At the time he said that cannabinoids in tablet or spray form were “a compassionate and intelligent solution to the pain, vomiting, nausea and poor appetite endured by people who were terminally or chronically ill”. It is expected that the ALP will take this policy to the next state election in March, 2017. There’s been a lot of work in the WA Government ranks in those intervening

Dr Kim Hames

concerns where cannabis has been legalised for medical reasons.” “We must weigh the risks and benefits of medical cannabis carefully. Its ingredients must be subject to the same scrutiny as other medicines. A doctor’s purpose is to heal not harm, and we must ensure we protect the health of future generations.” “This is a clear example of why independent, government-funded and investigator-led research is so important. Properly funded scientific research is required that isn’t driven by the commercial interests of pharmaceutical companies.” “How these trials are conducted is crucial and must be well considered, from what forms of marijuana are tested, in what conditions and dosage; and how that compares to other drugs. We must consult with experts in addiction medicine, palliative medicine, public health medicine and paediatric health to progress this important work.” “This is not easy, nor is it a quick fix. Politicians must not be guided by public opinion alone. It is crucial that medical experts are called to the decision making table to bring their expertise.” “Until the processes of therapeutic goods regulation and the standards of evidence and clinical research produce clear and indisputable conclusions regarding the health impacts of medicinal marijuana, we must proceed with caution and its use restricted to clinical trials.”

By Ms Jan Hallam

“I’m very supportive of more research into these potential medicines but we need a national approach to move the barriers, and I support a trial initiated or supported by the TGA,” he told Medical Forum. “It’s my understanding that there is evidence supporting the benefits of cannabis extracts in the treatment of a range of conditions but the evidence still needs to be of sufficient scientific quality to definitively answer questions about efficacy and safety.”

A spokesperson said the WA Government was supportive of and was advocating national research to develop high quality, reliable, pharmaceutical cannabis products for use in medical settings.

“I’m aware that there are already acknowledged pharmaceutical versions of cannabis derivatives, including an oral spray form that could offer medical beneﬁts without the risks of smoking cannabis.”

Dr Hames rightly pointed out the legislative complexities of the issue given the differing state and territory positions on therapeutic goods laws and obligations to international conventions.

The Government spokesperson added that clinical trials could be legally conducted in WA under the right conditions. However, any decision on medicinal cannabis would not diminish the Government’s strong stance against the use of cannabis as a recreational drug.

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Feature

The Patient

The Business

Patient Sarah Christopher, who doesn’t want her real name used for obvious reasons, makes a strong case for the reappraisal of marijuana use in a clinical setting.

It’s been a big couple of months for Australia’s ﬁrst listed medical cannabis company, Phytotech. After its trumpeted listing on January 22, when it started trading at 20c and rushed to a high of 78c the following day, it has now settled back to the .30s, trading at .375c on February 19.

“I was born with congenital skeletal abnormalities, they cause chronic pain and have been thoroughly investigated but I’ve been told that surgery isn’t an option. My condition is called MRK Hauser Syndrome and it’s quite rare. In fact, I haven’t met one doctor in Perth who’s heard of it.” “I’m really concerned about becoming addicted to opiates and the one I use now [Endone] only gives me limited relief. I also have long-standing anxiety issues and marijuana helps with that and my skeletal pain.” “Using marijuana eases my muscle tension and allows me to relax and focus on other things beside the pain. There’s a meditative aspect as well and that improves my mood so the depressive effect of the pain is lessened. I have days where I literally can’t get out of bed and it’s hard to plan for any sort of future, to be honest.”

However, the share price doesn’t reflect the drama of soap opera proportions behind the scenes. The company’s non-executive director Ross Smith, who was in charge of the share float, resigned from Phytotech after posting a threatening rant against a share blog on his Facebook page. He subsequently denied posting the threat, saying his account had been hacked. The company, however, ticks steadily away without its flamboyant Australian frontman, who achieved for Phytotech what he set out to do. When Medical Forum contacted its Australian offices in Nedlands and spoke to company secretary Erlyn Dale, she said Dr Benad Goldwasser was the new ED, and Mr Boaz Wachtel, is new MD. Both men are based in Israel. Mr Winton Willessee, head of Nedlands business consultancy Azalea Consulting, is the company’s non-executive director and employs Ms Dale.

Sarah acknowledges that she’s a long-term user of marijuana and is concerned about the social and legal ramiﬁcations of using an illegal substance. “I’ve smoked marijuana since I was 17 [Sarah is 34] but I’ve been through stages when I haven’t used it and I certainly wouldn’t regard myself as an addict. But in the last three years my condition has deteriorated and I increasingly rely on it as a medication.” “I’ve got a few regular dealers ranging from friends to less reliable ‘open houses’ and the latter can be a bit nervewracking, particularly as a female. The current price on the street is about $350 an ounce, I tend to buy in small quantities and probably spend around $100 a week on marijuana.”

KARRINYUP HEALTH PROFESSIONALS PRIME LOCATION FOR SALE Strata Medical Suites by EOI 334 KARRINYUP ROAD, KARRINYUP, WA MEDICAL SUITES - 50% UNDER OFFER

The prospect of a THC-free medicinal product appeals to Sarah, who said it would remove the respiratory issue linked with smoking cannabis. “And if it were available on prescription, any concessions for people on a disability pension would be a big help,” she said. Sarah is full of praise for her current GP while making the point that some other medical professionals haven’t been quite so supportive. “The doctor I see at the moment has a special interest in pain management and mental health. He’s the best GP I’ve ever had and it’s good to be listened to and believed without being judged. I’ve seen others who are highly dismissive who’ve said that my level of pain just can’t be possible.” “Doctors have got to move away from the view that if it’s not on the scan it can’t be real. Believing what the patient says is really important.”

Mr Peter McClelland

Aaron Antonas 0434 659 818 Medical Services

Estimated completion early 2015

Opposite Karrinyup Shopping Centre

colliers.com.au/12438 RLA 204

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52m² to 1,085m² strata areas

colliers.com.au

Guest Column

Juvenile Justice – a New Paradigm? Changing the emphasis of the juvenile justice system in the Kimberley from punishment to prevention could have radical results, says Ms Jenni Perkins. “The children in this town… need places where they can go and feel wanted and needed. They need people that care about them, people that are willing to listen and help and be their friends.” These are the words of a 17-year-old Aboriginal person who took part in a consultation I held recently with Aboriginal and Torres Strait Islander children and young people from all over WA. Consulting young members of our community is one of the core functions of the Commissioner’s ofﬁce and what’s incredible is how they can often see more clearly what is required to help those facing challenges. These thoughts came to me while I was reading Prof John Boulton’s article (Kimberley Children, February) in which he spoke about the need for an alternative approach to juvenile justice in the Kimberley. It struck me how closely his description of the need to shift our focus in youth justice “from punishment to compassion, care and nurturing” matched very closely what this young person told us. Research tells us that the factors that lead a child or young person into the criminal justice system include dysfunction at home and in

My recently released policy brief on Aboriginal children’s health identiﬁes the challenges many Aboriginal children and young people face from an early age, including the increased likelihood of ear disease and physical injury.

Early intervention is essential to protect both the community and the wellbeing of the young people involved.

At least 50 per cent of children and young people in detention have a mental health problem and the majority will have historically poor attendance at school. While I have seen several innovative programs that are successfully re-engaging these young people in education, there is much more to be done.

the community, alcohol and drugs, violence, disadvantage and poverty, which can cause signiﬁcant trauma and a loss of identity and self-esteem. These are issues that require understanding, support and rehabilitation, not punishment. While there are sometimes very serious crimes committed by young people, the majority initially come to the attention of authorities for low-level offences and this is the point at which we must act with a full complement of support and remedial measures. Early intervention is essential to protect both the community and the wellbeing of the young people involved. So too are preventative programs that are holistic and culturally secure, meaning that they address the many complex factors affecting a young person’s wellbeing, in a way that is relevant to them and their family.

Later this year I will table in State Parliament my report and it will tell a story of incredible resilience, strength and success. It will also outline the signiﬁcant challenges that Aboriginal children and young people themselves raised. Part of the response required to address these challenges includes embracing a comprehensive statewide youth justice policy that aims to provide these vulnerable children and young people the opportunity to create a better future. ED: Ms Jenni Perkins is the A/Commissioner for Children and Young People WA

Women’s Health Education for GPs again on offer for WA GPs

(Formerly Vocational Graduate Diploma of Women’s Health)

The KEMH invite you to enjoy built-in ﬂexibility, CPD rewards, and up-to-date content make the course value for money. Fine tune your knowledge and build useful clinical contacts. Participants can access the information in part or in whole. There are only 40 places – kept low to safeguard interactive learning – so enquire early. The course is designed by educational gurus at King Edward Memorial Hospital.

THE 2015 THEMES ARE:

Women’s Health Education for GPs

1. Antenatal Shared Care - 21st April – 16th June 2. Ofﬁce of Gynaecology and Reproductive Health - 4th August – 22nd September Each theme is delivered over 8 evening sessions, with light refreshments beforehand. If you miss a session unexpectedly, you can watch via 'Moodle' webpage. We also provide 'Scopia' for those rural participants. Some GPs are keen to update on one theme only. They can, or they can attend selected evening sessions within a theme. Up-to-date information builds clinical conﬁdence in women’s health, and participants learn of relevant services at KEMH and across WA.

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GP Paulien de Boer. “As a graduate from out of state, this course enabled me to gain an awareness of all the women’s health and information services in WA… and make some very useful contacts.”

COURSE DETAILS

så #OMMONå$ISEASESåINå0REGNANCY så #OMMONå)NFECTIONSåINå0REGNANCY

GP Liz Wysocki. “The lectures are of a very high quality, good notes and plenty of interaction and the obstetrics module is particularly useful to those of us attempting shared care.”

RTS STA RIL AP 5 201

Tuesday evenings, 6.20-8.30pm. (Light refreshments 6pm). Agnes Walsh Lounge, KEMH. CPD points: 40 Category 1 per theme, 4 Category 2 per session (capped at 30 points) Cost: $685 (incl GST) per theme (8 sessions) or $90 per session. Contacts: amy.chatterton@health.wa.gov.au

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Guest Column

Stop Playing Politics with Health Ms Irina Cattalini, CEO of the WA Council of Social Service (WACOSS) underscores the importance of a degree of certainty when it comes to health funding. For the Health and Community Services sector, Federal decision making is always of great concern. The 2014-15 Budget is a case in point and there’s increasing anticipation leading up to the next one. We’re worried about the disproportionate impact of government policy on the most vulnerable members of our community and the long-term price we’ll all have to pay in pursuit of short-term savings. The Medicare co-payment and the increasing cost of PBS medicines are classic examples. It’s widely accepted that early intervention is one of the most effective ways of lowering the incidence of serious illness and keeping health costs down. The social and economic cost of discouraging access to preventative healthcare should be of concern to us all. The Community sector is no stranger to uncertainty. Funding is always precarious and one of our real worries is that services will be interrupted or defunded without any thought regarding an appropriate transition process. A couple of good examples? The Indigenous Advancement Strategy and the newly rebadged Primary Health Networks.

It’s clear that a shift to outcomesbased contracting and reporting has been a key element [of policy] … while it’s important to measure and report on what services are being delivered, it’s absolutely critical to ensure that consumers are actually better off as a result. More speciﬁcally, at State level, the implementation of the WA Government’s Delivering Community Services in Partnership Policy (DCSP Policy) reforms continues to be a work-in-progress. Over the past 12 months, health services within the Community sector have been providing feedback to WA Health on their experience of the reform process. It’s clear that a shift to outcomes-based contracting and reporting has been a key element based on the belief that, while it’s important to measure and report on what services are being delivered, it’s absolutely critical to ensure that consumers are actually better off as a result.

Stemming from this work has been the establishment of the Healthy Communities Leadership Forum (HCLF), a network of community service organisations that provide health services. Forum members work in a wide range of areas including mental and sexual health and policy specifically aimed to help young people. The two key focuses for the HCLF are: så 3YSTEMICåISSUES åEMBRACINGåBOTHå3TATEå and Federal, that impact on the ability of community service organisations to provide efficient and effective services. så 4OåIDENTIFYåANDåADDRESSåSOCIALåDETERMINANTSå of health, rather than a more blinkered approach to illness and disease. Networks such as the HCLF and WACOSS are working together to ensure the delivery of high quality health services that are enduringly responsive to community need. There’s no doubt that a greater certainty regarding funding and its attendant mechanisms would allow organisations such as ours to undertake better planning and have more flexible options in the retention of high quality, experienced staff. This is one sector that needs certainty.

Art Finds a New Audience Cultural programs and generous donors have given our hospitals the chance to change the way patients and hospital workers see the world. Following on from our story last month on the art collections and projects at Fiona Stanley Hospital and SJG Murdoch, the curator of art at SCGH, Ms Jo Wakefield, explained in philosophy behind Charlies 800-piece collection and it’s a lot more than just decorating the walls of one of Perth’s largest public facilities. Art plays a vital role in the hospital community. The collection is 40 years in the making with the majority of the works being donated through the Cultural Gifts Program, a Commonwealth Ms Jo Wakefield program that encourages Australians to donate items of cultural significance from private collections to public art galleries, museums, libraries and archives. Several artworks are also on loan, or have been acquired through sponsored art awards or are in keeping with the hospital’s Reconciliation Action Plan. There is also a focus on WA artists.

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“The aim of the art is to improve the hospital’s visual surroundings and create a more uplifting environment, and encourage healing. Evidence has shown that artworks in hospitals can help with the general well-being of patients, visitors and staff, and that positive visual stimulation can positively affect the rate of recuperation,” Joanna said. “Art can offer liberation, a new experience, a sense of value and worth crucial to those experiencing ill health, age-related disease or mental health issues. Our emotional state has a big impact on the immune system and, social engagement and participation in artsrelated activities are shown to have produced clinically proven positive health outcomes.” Artworks of a traditional nature combined with those of a more contemporary framework, has resulted in a ﬁne balanced collection. With thousands of visitors, patients and staff on campus each day the hospital’s collection has the potential to be appreciated by a wide audience, some of who may not normally have the opportunity to view original artworks. “It is not uncommon for staff, patients or visitors to remark on the artworks they

most respond to, and, outside the gallery environment, people are often forthcoming in providing feedback on their impressions of the works on show.” Art is on display throughout the hospital and rotating art displays are available for viewing daily in the hospital’s Art Gallery, Watling Walk, B Block. Admission is free. Head of St John of God Healthcare, Dr Michael Stanford, added that supporting the arts doesn’t necessarily need lots of money. “Our Murdoch hospital became a public art gallery which gave it Deductible Gift Recipient (DGR) status and donors (several who are doctors) have subsequently donated hundreds of pieces of art.” “We are able to share those works at other of our hospitals as long as we comply with the DGR terms. The St John of God Midland Public Hospital, for example, will have many works of art adorning walls in public areas as a result of the Murdoch Public Art gallery.” ED: Those interested in donating to the SCGH collection can contact Joanna on 0420 279 700.

FeatureColumn Guest

If You Don’t Plan to Succeed... Mental health advocate Mr Geoff Diver raises a lot of questions, but when it comes to solutions the community must drive the process. The issues faced in the areas of mental health and alcohol and other drugs affect nearly all demographics of WA society. Some have a higher proﬁle than others; some are only beginning to manifest now but may look large over the next 10 years, which is the scope of the Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015-2025, which is open for public comment until March 15.

Do we want ‘real’ treatment in the community and for the system to not use that term to cover up the fact there is a need to release patients to free up beds? family and community members. While sanctuary in WA is no doubt welcome, these people must face dealing with their past in a culture not theirs, often in a language they are not conversant with.

We know more people are dying by suicide than road trauma. It has been widely accepted that depression is the “common cold” of mental health. A range of social and health issues are affecting Aboriginal Australia at a greater rate than middle Australia. Druginduced mental health problems are also on the rise. Budgets across the board are being cut by government. Facilities in remote and rural areas are struggling to cope with the current case load.

At its peak, the unit responsible for mental health for the culturally and linguistically diverse (CALD) demographic had just ﬁve people. Now there is one staff member. The unit is based in Perth with no extension of services into rural areas. There are mixed messages from government, saying the service should be expanded and reinforced while there appears a shift away from this dedicated service model.

And more lies over the horizon. The WA government estimates that 15% of our population comes from non-English speaking backgrounds. An increasing number of these have fled conflict which has seen them witness horrific atrocities, often carried out on friends,

It has been argued that the old mental health model is one of incarceration for containment, and then release to free up bed space. Is it sustainable to take consumers from a chaotic lifestyle, contain them and then release them back to chaos? Is this the future we want? Some services are only available to inpatients. Are we allowing people to become ill before we treat them?

For Lease

Do we want new approaches such as ‘step up and step down’ housing where people deteriorating can have a safe and structured place to go without the stigma of being put in hospital? Do we want ‘real’ treatment in the community and for the system to not use that term to cover up the fact there is a need to release patients to free up beds?

High Quality Medical Suite

The current approach to AOD issues seems to be weighted in favour of criminal enforcement.

WA already has chronic prison overcrowding. Any policy which relies on legal sanction and has an escalating enforcement budget while not reducing the “problem” is, by deﬁnition, failing. Do we need more preventative and better rehabilitation programs, especially in rural areas? From my experience the following approaches will help you to have your say. Attend the public meetings and voice your concerns. You may actually have them addressed then and there. It’s not all doom and gloom and many people in the sector have programs running which receive little attention. To his credit, the Mental Health Commissioner will be attending many of the public meetings and you’ll have the opportunity to have your issues addressed at the highest level. Write to the Mental Health Commission. A written letter with a date and a signature has more power than you might think. There is a public service joke that ‘if it’s not in writing, it doesn’t exist’. State who you represent, even if it is just yourself. A signed and dated letter gives you the ‘power of one’ in public service processes. State your case in your own language and speech patterns, it’s not an essay writing competition. Ask for a speciﬁc outcome. If you want better services in the rural areas say “I would formally request that the mental health plan has a dedicated service roll-out for rural areas with a budget for 10 years assured”. If you just say “I think services in the bush are lousy” you are open to a government response that “we see there are opportunities for program improvement and we are giving it some serious attention”. Get involved! This is the best opportunity practitioners, consumers and the public have to shape service delivery in WA. Submissions can be made at www.mentalhealth.wa.gov.au/ThePlan.aspx

Breaking Bad Subiaco 10 / 178 Cambridge Street

Last month, Medical Forum investigated the issue of the use and prescription of Performance and Image Enhancing Drugs (PIEDS) in WA, particularly within the gym sector. The story comes after Perth GP, Dr Salim Ismail, was struck off for writing thousands of prescriptions for PIEDS over a nine-year period.

q 174sqm* (shared occupancy) q Opposite St John of God Hospital Subiaco q Exclusive medical consulting room q Shared common areas q Excellent natural light q Two undercover car bays

A spokesperson from the Department of Human Services (DHS) said it monitored all medical practitioners who bill under Medicare and/or prescribe under the PBS. It also received information regarding inappropriate or noncompliant prescribing from tip-offs, stakeholders and routine data analysis. If necessary, DHS may request the Director of Professional Services to review a practitioner’s provision of services.

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A TGA spokeperson said that certain PIEDs including anabolic or androgenic substances such as steroids, testosterone and dianabol, human growth hormone, insulin-like growth factors, growth hormone releasing hormones and synthetic analogues, natural and manufactured gonadotrophins such as FSH, LH and HCG, erythropoietin and darbopoetin alpha were prohibited imports under the Customs Act 1901 and could only be legally imported if a person was issued with a permit from the Department of Health.

MEDICAL FORUM

Guest Column Award

Keep Stirring the Pot column, Numbers in Primary Care, he laments the Medicare rebate system and calls on the profession’s representatives to advocate hard for general practice.

One of the features enjoyed most by readers of Medical Forum is our monthly opinion pieces and here at the magazine we think the guest columns bring a wealth of experience and unique perspectives otherwise left unsaid. So once again we celebrate the contribution of our guest columnists with the Medical Forum Guest Column Award for 2014. In compiling the shortlist of 10 columns, we reviewed 51 columns representing a rich diversity of views on issues that affect the working and community lives of the medical profession. As we did last year, we asked members of our advisory panel – Dr Chris Etherton Beer, Dr Kenji So, Ms Michele Kosky, Dr Olga Ward, Dr Peter Bray, Dr Philip Green and Prof Stephan Millett to adjudicate the shortlist. We are grateful to all these correspondents who have put themselves on the line to speak out about the things that concern them, amuse them, or just rile them. They all help make the magazine a true forum for our readers. We look forward to another outspoken year in 2015. The Winner The winner of the 2014 Medical Forum Guest Column Award is Midland GP Dr Colin Hughes who wrote in the February ’14 issue [and in subsequent issues!] his deep concern about what he sees as the shabby way general practice, in general, and GPs, in particular, fair in the national health system. In his winning

Dr Colin Hughes

Colin told us that he has always been compelled to speak out.

“To paraphrase our colleague, recently retired Liberal Mal Washer at the Doctors Drum breakfast, “when one constituent contacts an MP’s ofﬁce, it is of interest. When two contact on the same day, it is important enough to take to the party room.” As GPs we don’t realise the responsibilityy g we have in representing the views of our patients.” “We are all welleducated, articulate and respected in the community. Most of us are so busy slaving nt away seeing one patient ss every 10 minutes or less that they feel we can leave it up to the AMA or RACGP to representt our views. Yet public opinion is what affects

outcomes and I am compelled to email my daily opinion to all the newspapers across the country with a copy to selected politicians.” “My revolutionary zeal was forged in the kitchen cabinet of Dr Jim Cairns when I was a student at Monash during the Vietnam moratorium campaign. From humble beginnings and a protest of just 50 students outside the Pan AM building, to over 100,000 marching in the streets of Melbourne, we stopped a war and stopped conscription. I guess with that conviction and experience I have never been able to sit back and leave it to others.” “I hope that others will take up their pens. Others may not always agree with my opinions but ‘Je Suis Charlie’.”

Guest Column

Numbers in Primary Care

Midland GP Dr Colin Hug hes links Medicare remunera tion directly to quality in general practice, and suggests an alternative. et again GPs have been shafte

d by Medicare in not allowi ng any increase in rebates. Why is it that GPs go through the same angst year after year, time after time? Feelin g poorly done by compared to their specia list colleagues. Take this morning’s surger y. Mrs T a Filipina grandm other aged 77 was recently seen in hospital after an episode of chest pain. After discus sing with her the consequences of the cyclone on her family back home, her fears and concerns, I reviewed the hospital discha rge letter. It asked if I could follow up with referrals to her local gynae clinic for management of her prolapse, referral and investi gation of her ongoing anaemia and review of her warfarin post IHD and paroxysmal AF. After review of her numer ous letters on file (she wasn’t my regula r patient) and a comprehensive examination , I proceeded

to print out relevant results and wrote two referral letters, and then made an executive decision to stop her warfar in and switch to a NOAB having worked out her CHASDS2 and HASBLED score. Some 40 minutes later my receptionist buzzed to let me know four patients had been waiting for over 30 minutes. For my work with this patient I could bill the grand amount of $68. Yes, I could have charged privately and maybe would have got my cash after she had paid her rent and groceries. Poor fool me, I bulk-billed. Yet it doesn’t have to be this way. Medicare has modelled the proposal to move to 15-minute time bands and load the 15-29 minute time band and above to $75 and $125, respectively, and reduce the price for a standard consultation to $30. This has been rejected by the RACGP who are committed to improving the PIP by patient registration and multi-morbidity care

plans rather than change s to fee-for-service. Yet we all know how the current fee structure rewards fast throughput medicine. Academic trials have shown that seeing a patient for longer reduces the numb er of consultations per year, so we wouldn’t need more GPs or longer consulting hours. How would it feel to reduce our load to just four patients an hour and be able to practise quality medicine? To have a simplified Medicare schedule withou t a plethora of item numbers that can be maxim ised by the big clinics and nurse practit ioners? It is time for all GP repres entative bodies to seriously look at the propo sal. I urge readers to contact their political representatives and voice their concerns and support for a simpler, fairer system. O

The Shortlist Congratulations to these columnists who were on the shortlist for the 2014 Medical Forum Guest Column Award:

Dr Max Majedi: The Pain Perspective (May, 2014)

Prof Daniel Fatovich: Skepticism is Good Medicine (September, 2014)

Mr Geoff Diver: Frozen in Time (May, 2014)

Dr Sean Stevens: The GP-Specialist Divide (July, 2014)

Dr Sarah Cherian: Is Anybody Listening (August, 2014)

Mr Roger Cook: Women’s Services are not ‘Add-Ons’ (October, 2014)

Dr Janice Bell: Grasping the Workforce Nettle (December, 2013)

Mr Mitch Messer: Consumer Partnership, Really? (March, 2014)

Dr Jane Khan: What a Privilege (December, 2013)

The Judges

Dr Chris Etherton Beer

MEDICAL FORUM

Dr Kenji So

Ms Michele Kosky

Dr Olga Ward

Dr Peter Bray

Dr Philip Green

Prof Stephan Millett

Feature

Understanding Cultural Differences It is essential to have a degree of self-awareness regarding cultural biases when it comes to the practice of medicine. In these troubled times, it’s imperative. The Medical Director of the Humanitarian Entrant Health Service (HEHS), Dr Aesen Thambiran witnessed discrimination in the apartheid era in South Africa as a young man of Indian background. It has inﬂected his work ever since. “I’m aware from my own experience that it’s inevitable we, as both doctors and patients, view medicine through a prism of culture. The paradigm of Western medicine isn’t necessarily one some people from CaLD backgrounds Dr Aesen Thambiran fully understand. Yet culture affects concepts of health and well-being and, most importantly, how an individual interacts with a health service.” “Different cultures have varying explanations for illness and disease. For example, I was recently counselling an African woman from a rural background who had a recessive Thalassemia trait. She asked me, ‘could this be sorcery?’ Obviously, the wrong approach would have been to say don’t be silly and you are completely wrong!” “I tried to provide a simple explanation about genes and eye colour that drew a parallel with her blood condition.” Explanatory models of health can co-exist. Aesen, who graduated from UNSW before moving to WA work in general practice, has had a long-standing commitment to this area of the health sector. Organic Growth of Services “I started working with refugees in 2000 and seven years later became Director of the HEHS, which has been around, in different guises, for more than 30 years. It used to be called the Migrant Health Service and grew organically out of a community health centre based at the Graylands Migrant Hostel which assisted people ﬂeeing the Vietnam War.” “We have a strong public health focus in the detection of communicable diseases in new humanitarian entrant (refugee) arrivals and preventative treatments such as immunisation. We offer a voluntary post-arrival health assessment. It’s not a legal requirement but most people utilise it because they’re new to Australia and understandably keen to engage with the health service. It’s so important to link them with a community provider and a GP.” Aesen believes that entrenched and systemic cultural belief systems within medicine don’t fall within the boundaries of racism but stem more from a lack of cultural awareness.

Useful Links Translation Service: www.tisnational.gov.au www.asetts.org.au www.foundationhouse.org.au

“It’s not that we’re being discriminatory, necessarily. We inevitably make assumptions about other people and it’s important to remind ourselves that the person sitting in front of us may have a world view that embraces a different explanatory model of health and health care. And often there are concurrent social and economic factors impacting on their health.”

Courageous Conversations www.youtube.com/ watch?v=KLsm8h9qSuQ www.health.wa.gov.au/Improving-WAHealth/Multicultural-health

torture and Foundation House provide a good desktop resource for GPs.” Ms Ruth Lopez, from the ofﬁce of Cultural Diversity at the Health Department, said cultural misunderstandings could result in disparities of opportunity for some.

“For example, there’s not much point prescribing insulin for someone living in poverty who doesn’t own a fridge. The social determinants of health need to be addressed as well.” “It’s crucially important to use a qualified or professional interpreter and try to find out, in some depth, who you’re speaking with and something of their level of education and literacy. Someone who is illiterate in their own language is going to struggle with learning English.” Education is a key component when dealing with complex cultural issues, particularly when complemented by appropriate online resources. “The RACGP WA is very supportive of refugee health cultural awareness training and I have run workshops for both them and the Health Department. I always tell people that the first step in working trans-culturally is a healthy dose of self-reflection. It’s important to remind ourselves that we’re all cultural beings.” “There’s quite a lot on the web that’s useful. ASeTTS provide services to people with a refugee background who’ve experienced

Ms Ruth Lopez

“We run workshops that help people negotiate discussions about race so that they become more conﬁdent in that area. Some are open to all and we have welcomed doctors, nurses, allied health professionals and policy and project ofﬁcers from WA Health. We also have had staff from HACC-funded agencies, Community West and the Independent Living Centre attend.” “We’re planning more seminars this year and we’d love GPs to come because they’re on the frontline and seeing these individuals every day in their surgeries. These workshops can help them work much more effectively with patients from culturally diverse backgrounds.”

By Mr Peter McClelland

MEDICAL FORUM

News & Views

Where Does it Hurt the Most? As a follow on from last monthâ&#x20AC;&#x2122;s Incidentaloma feature, patient Leonie Storey tells us her perspectives of the journey â&#x20AC;&#x201C; and its happy ending. In last monthâ&#x20AC;&#x2122;s edition [Incidentaloma Dilemma] Hills GP Dr Sean Stevens and radiologist Prof Richard Mendelson explored a case study of a patient who went to the doctor with her ankle and ended up having a pulmonary angiogram, a CT scan for a liver lesion and a laparoscopic oophorectomy for a benign cyst. This month, we asked the patient Leonie Storey, 53, for her peceptions about her ride on the medical merry-go-round. â&#x20AC;&#x153;I had ankle surgery in June 2013 because the tendon under the arch had torn and I was back in hospital six months later to remove one of the screws. Leonie Storey The day after my last surgery I had some chest pain and they thought I had a clot on my lung. Within a few hours I was readmitted to hospital,â&#x20AC;? Leonie said. â&#x20AC;&#x153;They scanned the lung, which was OK, but they saw something on my liver that turned out to be a haematoma. After that they detected a potential problem with my ovaries so I went to see my GP, Dr Sean Stevens, who said there was a possibility that it could be cancer.â&#x20AC;?

happened over a couple of weeks and one leg was still in plaster from the knee down while all this was happening.â&#x20AC;?

â&#x20AC;&#x153;It wasnâ&#x20AC;&#x2122;t thankfully, but it was all quite traumatic. Nonetheless, Sean was doing the right thing by preparing me for a possible outcome.â&#x20AC;? Compressed time-frame + expense â&#x20AC;&#x153;It was certainly a rapid chain of events and they were ďŹ nding one thing after another. It all

Incidentalom a benign or s dilemma: igniďŹ cant ri sk?

Cli

A recent cas Dr Sean Ste e started general pra vens thin king about ctitioner potential harms of medical ima the ging. CASE REP ORT The GP view point This conďŹ rm This case, ed the 42m where one benign cys m les thing led to t but also another, dete 39mm hyp may seem oechoic liver cted extreme. multiphase lesion And it can liver CT was be argued recom that each As sugges uncovered ted, lesion was CT that reve I arranged the m of a size aled the 39m where furt was probab her ly a haeman m live was indicate scanning By Dr Sea repeat ima d. n Stevens ging in thre gioma However, General Prac e months recommend I have titioner ed) and also noticed an cystic mas detecte increasing s in the pelvis. tren repeat ima d for sugges further ima ging of wha ted ging was adv Sure e t are very lesions, par recommend ised low ticularly in ed pelvic ultra and Patient liver the lung and risk Yet sugges the lesion ultrasound. sound ted the liver. was a com radiation risk scans are not with plex whi out their ovarian ch gynaec and cost. ological revi Mrs LS, a ew was 52Guidelines Referral to surgery, had year-old lady underg do exist on a gynaecolog oing ankle the re-imag risk lesions post-op che a laparosc orthopaedic ing but st opic oophrec ist resulte evidence bas they have a surprisin of lowsurgeon did pain so her histopathol tomy, with angiogram. a CT pulm gly slim ogy showin The CTPA suggest mos e behind them and onary g a benign US studies showed no embolus but t radiologist c In summar pulm any way! uncovered s donâ&#x20AC;&#x2122;t follo y, this pati liver, for whi a 42mm lesi onary w them ent had two (with another ch C advised. The ultrasound investig on in the As a GP I ation was an operatio pending) two ultrasou ďŹ nd it very n, histopa her back to orthopod, quite righ difďŹ cult to written adv thology, and tly, referred blood test â&#x20AC;&#x2DC;over-ruleâ&#x20AC;&#x2122; me to follo ice of a rad s, all with the m w up and ordered the iologist (wh ead by the no I dutifully This has com pathology US. ich may be pati fou e at a tota uidelines the ent), even if accord thousand l cost of sev ing doll e ot needed repeat scan is not nee to the (about eigh ars, and ~18mSv of so soon. ded, or is rad t years of background with another have, in som rad ~10mSv to e instances, Such is the come. epatologist refe con rred to a or respirato OFĂĽ2ADIOLOGY cern that the Americ ry physicia ually agrees ĂĽPUB an College LISHEDĂĽA n who with me in Papersâ&#x20AC;&#x2122; on b) Patient diologistâ&#x20AC;&#x2122;s ignoring the the topic and ĂĽSERIESĂĽOFĂĽ@7HITEĂĽ â&#x20AC;&#x2122;s age: why adv of Radiolo a complet investigate nion obvious ice, although this sec lesion the gic Clinics an inc ond pati ly comes at of Nor th Am e issue dedicated of? For exa ent will die with, rath extra cost. erica was to it mp e w much resp the problem (Issue No 2, 2011). if non-benign le, thyroid nodules The size of onsibilit y doe is large; at , ev r in recomm , CT leas s sca the t 5% of abd ns sho radiolo papillar y tum are likely to be indo ending furt ominal len her imaging gist ours that hav NODULESĂĽMA w incidental lesions do we eng prognosis , and thyroid age them YĂĽBE and with low risk e an excelle in discuss adult populat ĂĽDISCOVEREDĂĽINĂĽUPĂĽTO age this incr ion of to easing pro ĂĽ ĂĽOFĂĽTHEĂĽ progressio ion undergo c) Sympto ultrasonogr blem? n ing carotid ms and coaphy. Doppler morbidi TRULYĂĽASYMPT The Radiolo OMATIC ĂĽ7IL ties: is the As Dr Steven be contraLĂĽANYĂĽTREATM sâ&#x20AC;&#x2122; suggests, viewpoint gist indi EN of data on there is a comorbiditi cated by the patientâ&#x20AC;&#x2122; the paucity es, making s â&#x20AC;&#x2DC;incidentalo effect on patient outc It is difďŹ cult follow-up IRRELEVANT ĂĽ maâ&#x20AC;&#x2122; discove ome of to ima 7ILL lesions that ry, without kno comment the real cau ĂĽINVESTIGATIONĂĽDISTRA gin are maligna even for some wing the CTĂĽFRO se of sympto nt (e.g. rena speciďŹ cs of ms? l cancers). In my opin Dr Steven d) The risk ion, when sâ&#x20AC;&#x2122; patient â&#x20AC;&#x201C; in s (and cos a radiologist incidental par ticular ts) of furt compared lesi rep the radiolo to the potenti her investiga gical THEĂĽREFERRING on, the report should orts an justiďŹ ed? al beneďŹ t, appearance ĂĽDOCTORĂĽWIT provide is it HĂĽmEXIBILITYĂĽ her subseq s of the OFĂĽH uen various â&#x20AC;&#x2DC;inc IS t options by e) The pati of the wor iden using a By Clin/ entâ&#x20AC;&#x2122;s ding â&#x20AC;&#x153;there because eac talomasâ&#x20AC;&#x2122; is an inciden variation (insert site accept a s attitude: are they willi rof Richa h needs t d t l b d l

Medical Forum, Incidentaloma (Feb 2015)

â&#x20AC;&#x153;One of my frustrations was related to the hip pocket. Despite the fact that Iâ&#x20AC;&#x2122;ve got private health cover this turned into quite a costly exercise. The lung and liver ultrasounds werenâ&#x20AC;&#x2122;t fully covered and the bill was around $1000 because they kept ďŹ nding one thing after another. It wouldâ&#x20AC;&#x2122;ve been nice if everything couldâ&#x20AC;&#x2122;ve been done at the same time but it doesnâ&#x20AC;&#x2122;t work that way.â&#x20AC;? â&#x20AC;&#x153;But, having said that, I certainly didnâ&#x20AC;&#x2122;t feel I was being pushed from pillar to post.â&#x20AC;? Importance of GP relationship â&#x20AC;&#x153;My GP kept me well-informed, in fact, he rang me to make sure Iâ&#x20AC;&#x2122;d made an appointment to have the liver scan. I was pretty impressed with that!â&#x20AC;? â&#x20AC;&#x153;He gave me a few options for the ďŹ nal operation so I rang a relative who works for a gynaecologist in Bunbury and gave her the list of recommended surgeons. I ended up seeing Dr Mini Zaccariah and she was excellent both before and after the surgery.â&#x20AC;? Final say â&#x20AC;&#x153;I feel quite lucky that all this has happened. Itâ&#x20AC;&#x2122;s a long way from ankle surgery to a tumour on my ovary but Iâ&#x20AC;&#x2122;m glad they kept checking. Iâ&#x20AC;&#x2122;ve still got a few problems with my ankle but everything else seems to be OK.â&#x20AC;?

NFP Health Funds Join Forces On February 2, 15 not-for-proďŹ t health funds launched Members Own Health Funds, with the lead being taken by leading WA health fund, HBF. Its managing director, Mr Rob Bransby, is deputy chair of the alliance and Mr Brad Joyce, CEO of the Teachers Health Fund, is chair. The alliance move has been sparked by the privatisation of the largest health fund in the country, Medibank Private Limited (MPL), which since its ďŹ&#x201A;oat of 2.75b shares at $2 each on November 26 has shown steady growth. As of February 19 it was $2.56 â&#x20AC;&#x201C; a 17.5% increase.

while Bupa and MPl have a combined pull of 28% here. To put the WA scene and the impact of the alliance into a national perspective, MPL has about 30% of the total market, followed closely by Bupa. The alliance will hold about 20% of the national market. HBFâ&#x20AC;&#x2122;s position in the alliance occupies about 30%. The alliance says it is necessary to join forces to â&#x20AC;&#x153;tackle the big two head-onâ&#x20AC;?.

Late last year Mr Bransby foreshadowed a NFP response â&#x20AC;&#x201C; with the market dominance of the two now-for-proďŹ t funds, Bupa and MPL, hitting 64% in Victoria, 46% in NSW and 76% in South Australia.

The 15 Members Own Health Funds (representing 18 brands) are ACA Health, Australian Unity, Defence Health, GMHBA, HBF, Health Partners, Latrobe Health Services, Navy Health, Peoplecare Health Insurance, Phoenix Health Fund, Police Health, rt Health, St Lukes Health, Teachers Health Fund and TUH [a Queensland unions fund].

WA commands 57% of the local market with annual revenue in 2013-14 reaching 1.34b

Conspicuously absent from that list is HCF, the largest NFP in Australia with a revenue of

MEDICAL FORUM

$2.3b and maintaining a 12.4% stake in the national market. In its last annual report, it showed no hint that it needed help to stand up to the challenges of MPL and Bupa. While the allianceâ&#x20AC;&#x2122;s public relations campaign will no doubt focus on the message of â&#x20AC;&#x2DC;stick with the team that cares for you mostâ&#x20AC;&#x2122;, there is an area of perhaps greater concern for the health insurance market than the proďŹ t vs nonproďŹ t game â&#x20AC;&#x201C; aggregation of the market. Players such as iSelect, which are the equivalent of mortgage brokers in the banking sector, could be game changers. Mortgage brokers have transformed the ďŹ nance sector and there are fears in NFP fund circles that it could do the same for the health insurance industry. There will be interesting times ahead.

Feature

FSH Heralds Changes to Orthopaedics You can provide the keys to the cupboard but what opens before you is as much a product of human nature, as anything else. Prof Piers Yates ofﬁcially took the reins of the new Orthopaedics Department at Fiona Stanley Hospital (FSH) last October, sharing this position with A/Prof Gareth Prosser. For the last year he has helped plan “massive changes” in orthopaedic services in WA. He acknowledges that bringing about change can mean getting people with diverse experiences and strong egos to agree on a single course that coordinates with others. This is not an easy task!

Prof Piers Yates

“Managing this transition has been one of the most stressful things I have done. As surgeons we are trained to deal with patients who may have difﬁcult problems, but trying to change people’s practices is quite stressful, especially when it appears they are not listening,” he said.

So what are these big changes? Division of labour “The big change is the splitting of orthopaedic services – from Fremantle (where we did complex trauma and elective surgery) and Kaleeya (where they did straight-forward elective surgery) – so all elective orthopaedic surgery will now be done at Fremantle Hospital and all trauma will be done at Fiona Stanley Hospital.” “This means we are not diluting our services at either site and we can set up more cohesive pathways that will work better. It’s not an overnight change.” In fact, Freo orthopaedic surgeons have been developing their trauma services for many years, with a view to FSH opening. “There are now nine orthopaedic trauma surgeons at FSH. These surgeons want to do trauma and will be doing it for many years – they are prepared to change, work in teams, and they like the challenge they don’t know what is coming through the door. They have the opportunity to work alongside many great specialists such as anaesthetists, ED physicians, general surgeons, plastic surgeons, rehabilitation doctors, burns surgeons etc.”

most of the time but efﬁcient use of beds will be important.” “We had to ﬁght to make sure our vision wasn’t diluted, but at the end of the day it was such an obviously great thing to do, the splitting of services has worked well. At times, it has been tricky to persuade the planners at FSH to listen to how we, as surgeons, wanted to implement the service. However, now, that we are admitting patients, we are getting more say in what happens.” For those watching from the sidelines, the bigger issues of where services will be is politically charged – burns, cardiothoracics, neurosurgery, major trauma, spinal surgery, and Shenton Park services are just some of the contentious areas. Piers feels FSH was built as a regional trauma centre but the politics around RPH has got in the way of it reaching its full potential.

“Because peripheral surgery on hand and wrist injuries can often be done under blocks, patients can be turned over quickly, and don’t need to stay in hospital. We have already done the costings and it will save masses of money and bed days. These patients are presently mixed in with the general trauma and can spend days in hospital waiting for appropriate surgery. Now they will be able to have the surgery and go home. It took ages for us to push that through but when we looked at how much it could save, you just couldn’t ignore it.” Spoke and hub This concept has been promoted at a variety of levels, perhaps partly because FSH will be an expensive tertiary hospital and services devolved to the community will be cheaper. Orthopaedics is included.

Traditionally, in the public system, orthopaedic surgeons have tended to start their career with trauma and elective surgery, but as they become more senior they do less trauma because it can interfere with private practice and home life etc.

New FH Hand Unit Fremantle Hospital will conﬁne itself to elective orthopaedic surgery such as joint replacements, but one innovation Piers is keen to mention is the Hand Unit, due to open in April.

“We intend this to be a real tertiary hospital – people will have their surgery, and return to where they came from. That’s a bit of a different concept to previous systems, which means we need more robust systems for moving people out to nearer their homes, something that is supported by the Health Department.”

“We are trying to make trauma a rewarding and enjoyable thing to do long-term. Trauma at FSH will be more consultant led, with specialists available all the time. We have excellent theatre capacity with two trauma theatres running

It is run by a joint plastics-orthopaedics department, with the idea that all subacute hand injuries go to that unit in preference to other places in Perth, to be treated efﬁciently.

“It works in Rockingham, because Fremantle Hospital was closely linked. Peel and Armadale Hospitals can be difﬁcult to send patients back to, so we have to work on that. Peel is VMO

MEDICAL FORUM

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

ANDROLOGY NEWS

by Medical Director Prof John Yovich

Ultrasound scans for male partners … Is it worthwhile? The Table below summarises a 3-year study on the investigation of 1203 men aged 21-68 years attending PIVET and completing clinical and semen analysis studies. This has now been accepted for publication: Jequier AM, Philips, N, Yovich, JL. (2015). The diagnostic value of a routine genito-urinary ultrasound examination for men attending an infertility clinic. Journal Andrology & Gynecology: Current Research. This Scitechnol journal accepts open access publication and has approved my presentation of the data from the manuscript which can also be accessed on Research Gate. Lesion

No.

% of cases

% with abnormal semen SURÀOH

Comments

Varicocele-total

625

52.0%

45%

All cases Solitary = 450

Varicocele–testicular YROXPH UHGXFHG POV

6.1%

96%

Clinically VLJQLÀFDQW

Epididymal cysts

262

21.8%

51%

Solitary = 168

Testicular microlithiasis

5.5%

46%

49 bilateral, 1 seminoma

Renal lesions

4.3%

28%

1 cancer

Hydrocele

2.6%

45%

Solitary = 26

Cystic ectasia of the testis

1.3%

60%

Bilateral in 5 cases

Lesions outside renal tract

1.1%

23%

Liver cysts, gallstones

Testicular cysts & calciÀFDWLRQ

0.9%

27%

Spermatocele

0.8%

100%

“FSH has amazing facilities and has been built to the highest standards but the service within it depends on the people working here. People are coming from all over WA to work here and they are all used to different practices, so getting all these people to ﬁnd a common way of doing things will take some time.”

Testicular ischaemia

0.4%

60%

Testicular cancer

0.3%

50%

All had orchidectomy

Leydig cell tumour

0.1%

100%

Orchidec

“What I have noticed so far at FSH is that most clinicians have been very open to trying the best way of doing things, whether it is the Freo way, the Armadale way or the Shenton Park way – I’ve been really impressed with that. However, inevitably some have had ideas that are difﬁcult to change but it’s communication that will eventually change this and some of the big problems we have had have been ﬁxed by just getting the right people together.”

Prostate lesions

1 utricle cyst

Orthopods in FSH theatre

nearly entirely so it doesn’t have any infrastructure to support that and Mandurah is a big place – we operate on patients here and can’t send them back local to their home.” Human Nature as it is, some surgeons have not embraced the changes heralded by FSH, which may have appeared to threaten their patch.

“I think it will be six months before things are bedded down – a lot of technical issues will be sorted like the way we have electronic patient notes, the way we order investigations, and see patients in clinic, etc. They have to work. But running an efﬁcient service will take six months and deﬁning what FSH will eventually be doing will take between a year and 18 months.”

By Dr Rob McEvoy

0.3%

100%

Total

1097

91.2%

38%

Exclude all solitary epididymal cysts

929

77.2%

45%

+ Exclude solitary non-clinical varicoceles

479

39.8%

48%

7 cases with vasectomy

See next month’s column for Part 2 of Ultrasound scans for male partners

NOW AT 2 LOCATIONS PERTH & BUNBURY

For ALL appts/queries: T:9422 5400 F: 9382 4576 E: info@pivet.com.au W: www.pivet.com.au

MEDICAL FORUM

Clinical Opinion

Ultrasound in pregnancy – use caution

By Mr Timothy Spokes RN Midwife, Associate Member Australasian Society for Ultrasound in Medicine

Those with medical knowledge have a responsibility to ensure patients are informed of the biomechanical indexes and why sonographers are governed by the Australasian Society for Ultrasound in Medicine’s (ASUM’s) practice safety policies.

Ultrasound (US) use in private practice has evolved to sophisticated portable devices used at the point-of-care. US in pregnancy is limited to specific situations for good reasons. Professional sonographers know what these are but parents cannot be expected to know. Psychosocial and biomechanical risks come with unregulated access to US. Our approach should be, “The absence of evidence of harm is not equal to evidence of absence of harm”, particularly in the first trimester. It concerns me that ultrasound film parties are advertised on the web to prospective new parents at a cost of around $300 per session. What will be the outcome? Is unregulated purchasing of these devices for ‘home party style’ entertainment appropriate? The benefits of medical fetal ultrasound are obvious and well researched but this cannot be said of US use outside prescribed guidelines, particularly where 3D scan pictures of an unborn child’s face are supplied and 3D and 4D entertainment US used. We know that 3D ultrasonography has no proven diagnostic advantage over 2D scanning or M-Mode, yet 3D and 4D images are creeping into general practice. The advent of cheaper 3D and 4D enabled devices may be good for sales but in unskilled hands, these devices may pose a clinical and safety risk. In particular, 3D and 4D ultrasound has been proven to raise the target tissue by one degree for every minute of exposure. This is called the thermal index. Studies also describe animal liver damage in ‘Doppler mode’, and to a

s Prof Ian Puddey, Dean of UWA’s Faculty of Medicine, Dentistry and Health Sciences at UWA for the past 10 years, is retiring. Prof Geoff Riley is acting Dean until June 30 when the new appointment, to be announced, takes over the chair. s Otolaryngologist Dr Stuart Miller has been made a Member of the Order of Australia (AM) in the Australia Day honours list as has health consumer advocate Ms Anne McKenzie. Mr Robert Dunn, who is the Immediate Past President of Spine and Limb Foundation was awarded a Medal of of the Order of Australia (AOM). Ms Gail Milner was awarded a Public Service Medal for her work in health reform at WA Health. s Dr Robert Marshall has been awarded a Postgraduate Fulbright Scholarship. The former national President of AMSA and active JMO, Rob is currently doing his physicians training at the Royal Darwin Hospital.

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lesser degree ‘Color Mode’, as opposed to the lower power ‘M Mode’ or ‘B Mode’. In addition, ultrasound through varying tissue impedances can lead to tissue cavitation, known as the mechanical index. Safe ultrasonography, particularly in Doppler and color mode, ensures the length and frequency of exposure is limited and ALARA principles (As Low As Reasonably Achievable) apply due to the biomechanical risks of differing ultrasound wave forms on differing tissues. Both 3D and 4D modes have an energy output that is higher still.

s Ms Pip Brennan is the new Executive Director of the Health Consumers Council. The acting ED, Mr Martin Whitely is now a senior advocate at HCC. s Mental Health Commissioner Mr Tim Marney is chair of the advisory board of the Bankwest Curtin Economics Centre. s Ms Zoe McAlpine is the new CEO at Breast Cancer Care WA. s Ms Liza Dunne has resigned as MD from Resonance Health after 11 years. A replacement is yet to be appointed. s In other news from Resonance Health, it won the WA Innovator of the Year award for developing its HepaFat-Scan technology which uses MRI to measure the level of fat in a person’s liver. s Woodside Petroleum director and chair of the Audit and Risk Committee of the Insurance Commission of WA Mr Frank

However, medical use of ultrasound does not necessarily mean the user has undergone physics and safety training, as required by Medical Sonographers prior to picking up a transducer. One study by Sheiner et al (2013) identiﬁed that US point-of-care end users had Timothy Spokes a poor knowledge of safety, particularly in reference to acoustic output – 17.7% of those professionals surveyed performed Doppler studies in the ﬁrst trimester; only 20.7% accurately described the thermal index; and 3.7% accurately described the mechanical index. The United States FDA says US machines should now display real-time thermal and mechanical indices as a scan feature (output display feature - ODS) to raise user recognition of the biomechanical effects over time. This effectively shifted the burden of safety from the manufacturer to the end user.

Cooper has been appointed a trustee of St John of God Health Care. Melbourne-based former medical practitioner turned consultant Dr Julie Caldecott has been appointed to the SJGHC board. s Telethon Kids Institute’s Dr Thomas Snelling, has been appointed to the Pharmaceutical Beneﬁts Committee along with former RACGP president NSW GP Dr Liz Marles. s Prof Graeme Hankey is the 2015 recipient of the prestigious David G. Sherman Lecture Award, a lecture he will deliver at the International Stroke Conference in Nashville in the US. s Melbourne researcher Prof Anne Kelso is the new CEO of the National Health and Medical Research Council (NHMRC). She succeeds Prof Warwick Anderson.

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MEDICAL FORUM

Clinical Opinion

The crook knee: methods to forestall surgery

By Edward Tikoft, Physiotherapist Lifecare

A patient limps into your clinic, brought to their knees with worry! They ask, ‘Am I going to need surgery?’, for which it can be helpful to answer with more questions. Here are three that may be useful. Do they have modifiable strength deficits? The squat is an easy and functional screening test for lower limb strength. An inability to repeatedly squat to 90 degrees of knee flexion can unmask quadriceps or gluteal weakness. Since the quadriceps shock absorbs for the knee, its strength is paramount for a healthy joint. Formal strength testing completes the picture, especially with the inclusion of external rotation and abduction of the hip. An individualised exercise program can then address weakness – evaluate the impact on knee pain eight to ten weeks later.

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Are there dynamic alignment issues? Australian adults average more than seven thousand steps (single leg stances) per day. Assessing this position examines the dynamic alignment of the knee. In double leg stance, the angle between the anterior superior iliac spine, patella and tibial tubercle (Q angle) is normally 14 degrees for males and 17 degrees for females. A knee, which measures up to these norms but then, on single leg stance, drifts medially past the ﬁrst toe and falls underneath an adducted and internally rotated hip, is excessively stressed by walking. A lunge test further loads the limb and can conﬁrm dynamic valgus. Balance, proprioception and control retraining can minimise this.

Are current exercise habits helpful or harmful? Is the patient exercising at all? Avoidance strategies can exacerbate poor movement patterns and obesity. However pounding the tennis court may not be the answer either. Encouraging patients to think about matching exercise to their condition is an important part of guiding them away from surgery. For example, patients with early signs of OA who enjoy the social aspect of jogging may also ﬁnd that cycling or hydrotherapy achieves similar outcomes with minimal aggravation of the knee. Rather than ceasing exercise, modify so it can continue pain-free.

A recent Cochrane Review - Exercise for Osteoarthritis of the Knee - found high quality evidence supporting the use of therapeutic exercise in improving knee pain and quality of life. The answer to the question, “Am I going to need surgery?” is best given after answering, “Is this amenable to exercise?”

Author competing interests; nil relevant disclosures. Questions? Please contact the author 9364 4073.

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Clinical Update

Investigating elbow injury The elbow is inherently stable, due mainly to its ligamentous anatomy, yet is the second most commonly dislocated joint in adults. Lateral collateral ligamentous injuries are generally traumatic involving axial compression, forearm supination and valgus loading. There may be associated fracture (epicondyle avulsion, coronoid process or radial head) or dislocation. A normal valgus stress test does not exclude a signiﬁcant ligamentous injury. A coronoid fracture indicates signiﬁcant ligamentous injury as it only occurs with at least partial dislocation.

By Dr Peter Honey, Orthopaedic Surgeon West Perth

range of movement set from 30° to 120°, for six weeks. The extension block is removed at three weeks.

Chronic ulna collateral ligament (UCL) injury can occur from repeated throwing motion, and be either acute (torn) or chronic (stretched).

In persistent loss of extension after six weeks, consider a splinting program. Splints can be effective up to six months. After that signiﬁcant contractures usually require arthroscopic release.

Chronic UCL stretching is very common in baseball, relating to balls pitched. There are research based limits on throwing volume, including training. Yet two out of three major league pitchers in the USA have had UCL reconstruction surgery. The procedure is named after the ﬁrst major league pitcher to undergo the surgery, Tommy John. Pitchers throw better after the surgery but that may be due more to extensive post-surgical rehabilitation. It can take up to two years before the player can return to their pre-injury speed.

Medial collateral ligament injuries are typically caused by overuse although can also occur with a fall onto the outstretched arm or a twisting injury.

Some baseball pitchers, believing they can throw harder after Tommy John surgery, ask to undergo the procedure on their uninjured arms. However many people – including Dr Frank Jobe who invented the procedure – believe any postsurgical improvement is most likely due to the now normal elbow joint stability and the increased attention to ﬁtness and conditioning.

Clinical presentations Acute ligament injuries are commonly traumatic, involving a partial ligament injury without fracture or dislocation. Typical presentation is a painful elbow, effusion and loss of movement.

Chronic injury often presents with activity-related soreness Chronic ulna collateral ligament reconstruction is common in baseball, with one and possible prior injury. procedure named after Tommy John, the first major league pitcher to undergo it. Laterally, the differential In the United States this injury diagnosis is lateral epicondylitis is approaching epidemic or radial tunnel syndrome and proportions in young baseball Chronic injuries medially, medial epicondylitis or cubital tunnel players. In Western Australia it also occurs in syndrome. other throwing athletes (javelin, shot-put and Recurrent lateral instability following tennis). When investigating a suspected elbow dislocation is usually secondary to A good history often gives the diagnosis. ligament injury, the most important things are insufficiency of the lateral collateral ligaments. As elbow fractures are common (especially a strong index of suspicion and follow-up for at Symptoms include clicking and locking, if there in children) it is usually best to obtain x-rays least six weeks. is laxity or gross instability. Patients may have to exclude fracture before examining the difficulty rising from a chair or from a prone ligaments. If the ligaments are stable it is Even minor coronoid fractures (seen on plain position. There may be a history of trauma, important to get the elbow moving early. Over x-ray) can be very significant with associated multiple injections for lateral epicondylitis or three weeks of immobilisation, gross swelling ligament injury. MRI scans can indicate previous tennis elbow surgery. or poorly controlled pain invariably lead to post ligament injury, but are unreliable in assessing reduction flexion contractures. ongoing laxity. Stress x-rays can be helpful, Plain x-rays may reveal an old fracture, but the elbow is usually painful and these are especially of the coronoid. MRI is sensitive Acute dislocations are best managed in probably best done under anaesthetic. in showing previous ligament injury but emergency rooms. A careful neurovascular instability is only found on examination. Look assessment (examining and recording With a strong index of suspicion of significant for subluxation of the radio capitellar joint the function of the posterior and, anterior ligament injury, early referral is suggested. in full extension, valgus stress with forearm interosseous nerves and ulna nerve supinated. particularly) is important. Reduction of acute dislocation can be performed under IV Patients may avoid instability by performing Author competing interests; nil relevant sedation with longitudinal traction, supination, activities with the elbow flexed and forearm disclosures. Questions to the author please elbow flexion and centralisation of the pronated. Surgery is often required. 9481 2856. olecranon process into the olecranon fossa. Arthroscopy may be used as an adjunct to Following acute dislocation, immobilise in a sling for three to five days at 90° flexion, the forearm supinated. If the elbow is unstable at 45 to 60° of flexion, it indicates gross instability and often the need for surgery. A reasonably stable elbow should be fitted with a hinged elbow orthosis (from hand therapists) with a

open reconstruction. The lateral ligament complex is either repaired or reconstructed, depending on available local tissues. Chronic ulna collateral ligament reconstruction is common in baseball, with one procedure named after Tommy John, the ﬁrst major league pitcher to undergo it.

MEDICAL FORUM

Clinical Update

Echo use in atrial ﬁbrillation

BreastScreen WA increases annual visits in 2015

By Dr Chris Finn, Cardiologist, Western Cardiology

Due to popular demand BreastScreen WA is now visiting the following towns every year.

Atrial fibrillation (AF) has an accepted impact on morbidity and mortality and the appropriate treatment depends on symptoms, aetiology, chronicity and echocardiographic findings. Transthoracic echocardiography should be considered for all patients newly diagnosed with atrial fibrillation as it can help to identify those who would benefit from referral to a cardiologist.

Important aspects of the echocardiogram to focus on include left atrial size, left ventricular function and mitral valve function.

Left atrium Left atrium size is often a guide to the chronicity of AF. Younger patients with ‘lone’ atrial ﬁbrillation generally have normal left atrial size. Normal or mildly increased left atrial size is likely to accompany paroxysmal AF, and indicates that maintenance of sinus rhythm is more likely using antiarrhythmic medication (Flecainide, Sotalol, Amiodarone), electrical cardioversion or AF ablation. Moderate or severe left atrial (or biatrial) enlargement points more to chronic AF for which treatment strategy is more likely to involve ‘rate control’ alone (Beta-blockers, Diltiazem/ Verapamil, Digoxin). Left ventricle

ANNUAL VISITS Armadale Broome Esperance Geraldton Kalgoorlie Karratha Narrogin South Hedland

z Albany and Mandurah continue with

their annual visits.

Chronic AF, with severe atrial enlargement. The atria at the bottom of the image are of normal size.

Key Points så ,EFTåATRIALåSIZEåGENERALLYåCORRELATESå with AF chronicity så ,EFTåVENTRICULARåIMPAIRMENTåISåANå important risk factor for stroke så -ITRALåVALVEåDISEASEåSHOULDåBEå excluded as a cause for AF

Left ventricular systolic impairment often accompanies rapid AF and may be directly induced by prolonged tachycardia. Even if left ventricular function is initially severely impaired, often it improves to normal once AF is appropriately rate controlled or sinus rhythm is achieved. This often takes just a few weeks. Continuing left ventricular impairment despite rate control or restoration of sinus rhythm suggests an underlying cardiomyopathy of some form. Additional diagnoses such as coronary artery disease or a ‘non-ischaemic’ cardiomyopathy (alcoholism, viral, idiopathic etc) must be considered. Persistent LV impairment also increases the risk of thromboembolism and anticoagulation is strongly considered for these patients. Mitral valve Mitral valve disease often leads to AF, and signiﬁcant mitral valve prolapse and mitral regurgitation may be identiﬁed following AF onset. Some patients will require mitral valve surgery.

z Bunbury has a permanent screening

and assessment clinic.

Now more women are able to have FREE screening mammograms closer to home. BreastScreen WA has extended its target age range to include women aged 50-74 years. All women aged 40 years and over may attend. Have a free screening mammogram every two years. Once is not enough.

Check your local media or the website for mobile screening unit visit dates

www.breastscreen.health.wa.gov.au Phone 13 20 50 for an appointment

Questions? Contact the author on 9346 9300. Western Cardiology support production costs.

MEDICAL FORUM

JAN 2015

Rheumatic mitral valve stenosis is less common but is often accompanied by AF and carries a particularly high risk of thromboembolism. Anticoagulation with warfarin (rather than a new anticoagulant) is mandatory.

Clinical Update

Shin splints in athletes “Shin splints” (medial tibial stress syndrome; MTSS) is one of the most common acute and overuse leg injuries seen in runners and ballistic sports. Whilst not clearly understood, the pathology is thought to represent a periosteal stress or inﬂammatory reaction. Clinical presentation Typically there is dull pain over the posteromedial lower half to one third of the tibia. Early on, symptoms are present at the beginning of activity, subsiding after warm up. As the condition worsens symptoms persist for longer: in more severe cases symptoms persist on cool-down and may even be present at rest. Pain may last for several hours or days after exercise and be present during normal activities, including walking. A comprehensive history should be obtained to evaluate the athlete’s weekly exercise routine, running mileage, intensity, pace, terrain and footwear. Careful attention should be paid to recent changes in training. A common scenario is an increase in intensity or duration, or running on hard or uneven surfaces. Risk factors include being female, and previous lower limb injury. Recovery time ranges from four weeks to 18 months but recurrence is common.

Differential diagnosis Tibial stress fractures: generally present with more localised tenderness, particularly on weight bearing, usually over the mid or anterior third of the tibia – pain at night, on percussion, at rest and on walking is more likely. Anterior compartment syndrome: presents with exercise-related pain, with or without neurological symptoms. The patient will point to the anterolateral lower leg. A posterior compartment syndrome is generally described as being further posterior and more over the soft tissues, compared to MTSS. The symptoms should resolve within minutes on cessation of activity, with no post-exercise tenderness. Pain lasting for up to two days has been observed clinically. MTSS and compartment syndrome may co-exist. Diagnosis of MTSS is clinical and usually straightforward. If there is uncertainty, particularly concern about a stress fracture, bone scintigraphy and MRI are the investigations of choice. Treatment and prevention Quality research in this area is limited. There is some (albeit conﬂicting) evidence for shoe inserts and orthotics. Appropriate footwear, replaced every 800-1100 km of activity is important. Training factors, including adjustments to loading, graded

By Dr Arjun Rao, Sports Physician, Inglewood

exercise, cross-training, muscle stretching and strengthening and biomechanical correction have anecdotal evidence or clinical endorsement, but limited supporting evidence. With a strong index of suspicion for signiﬁcant injury, early referral is suggested. References available on request.

Case study A 20-year-old recreational female volleyball and basketball player, doing seven hours of activity a week, complains of pain in the middle one-third of the posteromedial tibia after prolonged running. Biomechanical running style analysis shows habitual running on toes with no heel strike (forefoot contact running). Adopting heel-toe running style led to symptom resolution.

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MEDICAL FORUM

PRP TO REPAIR HIP LABRAL TEAR AVOID LABRAL RESECTION & HIP JOINT ARTHRITIS A 40 year old lady presented with right hip pain of six month duration. Clinical examination, ultrasound scanning (see figure 1) and MRI examination showed a hip joint acetabular labral tear. She received a pioneering percutaneous treatment at IGTC with autologous Platelet Rich Plasma (PRP) to the torn labrum using high resolution ultrasound control under local anaesthetic. At 10 week follow up she had complete pain relief and ultrasound showed a stabilised labral tear (see figure 2). At 2 year follow up she continues to function without pain and has not needed any further intervention. She has avoided labral resection surgery and the sequelae of post labral resection arthritis. Ultrasound (fig 1) at the time of the procedure shows an articular side tear in a swollen labrum (red margin and arrow). Ultrasound at 10 weeks (fig 2) shows reduced swelling of the labrum and stabilised tear (green arrow and margin).

* WORLDâ&#x20AC;&#x2122;S FIRST REPORTS ON PRP FROM WESTERN AUSTRALIA Doss A. Neotendon regeneration and repair of gluteus tendon tear at 1-year follow-up after ultrasound guided platelet rich plasma tenotomy [v1; ref status: http://f1000r.es/4pu] F1000 0Re esearch 2014, 3:284 (doi: 10.12688/f1000research.5719.1). Doss A. Neotendon infilling of a full thickness rotator cuff foot print tear following ultrasound guided liquid platelet rich plassma in njection and percutaneous tenotomy: favourable outcome up to one year [v1; ref status: indexed, http://f1000r.es/xz]. Dr Arockia Doss

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Standing Room Only How to make your paper the one that gets discussed over lunch is all about preparation and a few handy tricks, says Dr Sue Miller, PhD You arrive at the conference, register and see what goodies you get in your canvas bag. Then to the conference program â&#x20AC;&#x201C; this requires some concentration â&#x20AC;&#x201C; tackling the myriad conference presentations that span the next three days, and deciding on which sessions will be the most meaningful to you. But ďŹ rst â&#x20AC;&#x201C; a coffee. Of course, thereâ&#x20AC;&#x2122;s your presentation, then your friendâ&#x20AC;&#x2122;s and your colleaguesâ&#x20AC;&#x2122;. After those, there are the topics that you are particularly interested in and, ďŹ nally, you have to make some hard decisions. Others will be doing the same â&#x20AC;&#x201C; so how do you ensure that your presentation is the one they choose to attend? Although this is probably the last thing you work on when preparing your abstract, your title, like a journal article title, is especially important. It needs to catch peopleâ&#x20AC;&#x2122;s eye, while providing a good indication of the content. Therefore, it needs to be short and factual, and maybe a bit creative. However, be careful not to be so catchy as not to make sense.

sĂĽ 5SEĂĽPICTURESĂĽORĂĽILLUSTRATIONSĂĽWHEREĂĽPOSSIBLEĂĽ to represent your ideas. Before you leave home, practise, practise, practise â&#x20AC;&#x201C; in front of an audience, even if itâ&#x20AC;&#x2122;s the family. It will give you an indication of the timing and whether you were able to get your message across. When presenting: sĂĽ $OĂĽNOTĂĽREADĂĽFROMĂĽTHEĂĽSLIDES Face the audience.

nce C o n fe re s e Packag E BL AVA IL A

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ED: Dr Miller incorporates these tips into the teaching of students in the courses in Health Professions Education at UWA, www.meddent.uwa.edu.au/ teaching/centre/courses.

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So, when preparing your abstract: sĂĽ 2EADĂĽTHEĂĽCONFERENCEĂĽTHEMESĂĽANDĂĽMAKEĂĽ sure to ďŹ t with one of these. sĂĽ 7RITEĂĽTHEĂĽMAINĂĽPOINTSĂĽWITHINĂĽTHEĂĽWORDĂĽLIMITĂĽ and following the required format. sĂĽ 0REPAREĂĽANĂĽENGAGINGĂĽTITLE When designing your PowerPoint or Prezi presentation (these tend to be the normal mode of delivery), consider the following tips that may help to make your paper more riveting, and the one people will talk about over morning tea and lunch. You will not have time to share everything you know on the topic, so think about the main points you want to include in the allocated time. Put yourself in the audienceâ&#x20AC;&#x2122;s shoes and think about what you would like to hear. Plan the structure carefully. Tell the audience what you are going to tell them, tell them, and then tell them what you have told them. Have two or three â&#x20AC;&#x2DC;take-homeâ&#x20AC;&#x2122; messages. Humour can be tricky. Unless youâ&#x20AC;&#x2122;re a well-paid professional comedian, avoid it. You do not want your audience to feel uncomfortable and when a 500-seat auditorium falls silent, you will also feel the discomfort. That feeling can last for a long time. sĂĽ ,IMITĂĽTHEĂĽNUMBERĂĽOFĂĽSLIDESĂĽnĂĽAVERAGEĂĽONEĂĽ slide per minute. sĂĽ ,IMITĂĽTHEĂĽAMOUNTĂĽOFĂĽTEXTĂĽONĂĽSLIDESĂĽnĂĽITĂĽISĂĽNOTĂĽ PowerPoint karaoke. sĂĽ -AKEĂĽSUREĂĽTHEĂĽFONTĂĽISĂĽBIGĂĽENOUGHĂĽTOĂĽREAD ĂĽ from all parts of the room.

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Theatre

s ’ t a h W ? r e n n i D r fo If 2015 carries on the way 2014 ﬁnished, it will be a huge year for the premier state theatre company.

When Medical Forum caught up with Black Swan State Theatre Company Artistic Director Kate Cherry before Christmas, she was bubbling with the news of a potential Australian collaboration with the Chinese national theatre s company in Beijing. The work that’s on the drawing board? Perhaps not so surprisingly, the German Marxistt Bertolt Brecht’s Caucasian Chalk Circle. However, what is new and exciting is the chance for a free-ﬂowing artistic tic exchange of ideas and capital, especially ally the human kind. As the year progresses, es, there will be more details how this project ect will develop. But in the meantime, there’s a local season to attend to and kicking off the main-stage year is Moira Bufﬁni’s stinging black comedy, Dinner, this month (March 14-29), which will see Kate direct a strong local cast led by Tasma Walton and Rebecca Davis. Coming hard on the heels of the Christmas entertaining season, Dinner will have many hostesses wishing they could have added some of the spice Paige Janssen manages to inject into an evening. Her glamorous dinner party is to celebrate the publication of her husband’s new self-help

G Glengarry Glen Ross, in May, and M Melbourne playwright Hannie Rayson’s llatest work, Extinction. Throw in some Noel Coward sparkle with Blithe Spirit N and a Tony Award winning musical in a Next to Normal and there’s a delicate balancing act playing out.

Artistic Director Kate Cherry Pictures: Robert Frith book but she throws in a few crazy characters, hideous food and a spot of show and tell and it becomes a night no one will forget. “This play is cuttingly witty in the English tradition and truth will out!” Kate said. Tasma Walton, who has popped up in most Australian TV shows over the past 15 years, takes on the character of ‘hostess with the mostess’. Kate says she walks that ﬁne line between the laughs and horrifying the audience. “She’s both funny and cool.” The year ahead for BSSTC is a magic blend of laughs and drama, new work and classics, including David Mamet’s masterpiece,

Kate says she’s excited about the coming year, and feels, after four years at the State Theatre Centre, the company is just hitting its straps in understanding how all the spaces work under various creative conditions. If you’ve managed to see a production in the past couple of years, you will have h noticed enormous strides have been made in production design, a fact Kate b attributes to the work of Christine Smith at WAAPA, who has been mentoring young designers and sending them out to theatres such as the Heath Ledger to do amazing things. Teamed with a core of talented local actors with the odd celebrity thrown in for good measure, the company is ready to take on an enormous year of challenges and collaborations. But, ﬁrst, there’s a somewhat tricky dinner party to survive.

By Ms Jan Hallam

MEDICAL FORUM

Wine Review

PalmerWines Long Live the King

In 1977 there was probably very little to see in Wilyabrup other than dairy cows and pastures. Stephen and Helen Palmer established their vineyard that year on the fertile banks of the Wilyabrup River and Palmer Wines came into being.

By Dr Martin Buck

A total of 50ha of vines have been planted to Chardonnay, Semillon, Sauvignon Blanc with small areas of Cabernet Sauvignon and Merlot. Many local and international awards have followed.

There has been a big emphasis on viticulture and berry quality which has made the familiar adage “great wine is made in the vineyard” their mantra. Palmer Wines are Wilyabrup “royalty” and continue to produce progressive wines that mirror the ﬂexibility of Margaret River. I look forward to trying their recently released Malbec which may herald another direction in this region.

1. 2012 Palmer Reserve Chardonnay This wine has an excellent pedigree. At the 2014 Les Citadelles du Vin, a panel of expert tasters awarded a gold medal to this wine amongst some very stiff competition from both new and old world wineries. This is a 13.4% alcohol wine with aromas of peaches, lime and a little new French oak. Plenty of depth in the palate with clean acid, flavours of stone fruit and soft oak complexity. This is a young chardonnay of great balance and should show plenty of potential. A solid wine showing the talents of Bruce Dukes as winemaker. 2. 2012 Palmer Shiraz Palmer Wines have several reds in their portfolio and I received two of their best performers in the tasting. The 2012 Shiraz is breaking the mould with a style of more finesse and subtle flavours than seen in many warm climate areas. This wine was made by Mark Warren and his experience in Western Australia is extensive. A fabulous nose of ripe cherries and plums is intense and inviting. Although this is a 15% alcohol wine there is not a lot of heat on the palate. The flavours are nicely balanced with a long, fruit-driven palate. The tannin profile is soft without a lot of newoak influence, which makes this a very approachable wine. Still a wine with more development to go and will be a real cracker of a Shiraz. 3. 2011 Palmer Cabernets The Grandee This wine comprises a selection of different parcels of cabernet sauvignon fruit blended by Mark Warren. This is a ripe, 14.5% alcohol wine with some heat and complex aromas of berry fruit, eucalyptus and smouldering oak. I found the palate full of mature fruit, balanced with a very soft, round, persistent palate and likely reaching its best years. Both of the red wines are showing that our wine styles are changing and this is possibly in response to our new overseas markets in Asia. Gone are the big, tannic reds that need some age to reach peak enjoyment and replaced with wines of subtle complexity that can be consumed earlier.

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Wine Question: Which two wines were made by Margaret River winemaker Mark Warren? 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, March 31, 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.

MEDICAL FORUM

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ON THE TOP TABLE Two doctors and a health fund manager die and line up together at the Pearly Gates. One doctor steps forward and tells St Peter, â&#x20AC;&#x153;As a paediatric surgeon, I saved hundreds of children.â&#x20AC;? St Peter lets him enter. The next doctor says, â&#x20AC;&#x153;As a psychiatrist, I helped thousands of people live better lives.â&#x20AC;? St Peter tells him to go ahead. The last man says, â&#x20AC;&#x153;I was a health fund manager. I got countless families cost-effective health care.â&#x20AC;? St. Peter replies, â&#x20AC;&#x153;You may enter. But,â&#x20AC;? he adds, â&#x20AC;&#x153;you can only stay for three days. After that, you can go to hell.â&#x20AC;?

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PULSE OF THE NATION Brian was transferred from his hometown to Perth for work. Because he had a comprehensive health history, he brought along all of his medical paperwork, which he presented to his new doctor at his ďŹ rst check-up. After browsing through the extensive medical history, the Doctor stared at Brian for a few moments and said, â&#x20AC;&#x153;Well thereâ&#x20AC;&#x2122;s one thing I can say for certain, you sure look better in person than you do on paper!â&#x20AC;?

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Weâ&#x20AC;&#x2122;ve heard that a million monkeys at a million keyboards could produce the complete works of Shakespeare; now, thanks to the Internet, we know that is not true.

- Computer Scientist Robert Wilensky MEDICAL FORUM

Theatre

The Importance of being M Words have been actor Miriam Margolyes’ stock in trade for more than 45 years but they never lose their wonder for the pintsized ‘new Australian’. The 73-year-old, whose roles have touched generations, most lately the youngsters in Harry Potter (as Prof Pomona Sprout), Queen Victoria in Blackadder and ABC viewers in Miss Fisher’s Murder Mysteries (as the eccentric Aunt Prudence), became a dual citizen of her native UK and Australia in 2013, receiving a special welcome from the then-Prime Minister Julia Gillard. She is equally at home on NSW’s south coast, where she lives with her Australian-born partner, as she is in London.

Jane Austen and Charles Dickens still spawn sequels and prequels.” “It’s up to teachers and parents to encourage children to read and it’s up to TV companies to continue to make programs which focus on writers. Shelley wrote: ‘poets are the unacknowledged legislators of the world’. He was right.” Miriam believes that, ironically, reading aloud will preserve the written word. “Bedtime stories and faery tales nourish our longing to be told a story and that’s where it begins, the hunger for words.” Kaleidescope of characters

To the country’s great beneﬁt, she can be seen more regularly here, not only on our screens, but also our stages. Next month she will embark on a national tour of her new show, The Importance of Being Miriam, stopping for a limited season at the Heath Ledger Theatre (April 7-11). And like her previous production, Dickens’ Women, it celebrates literature’s great characters. Will books survive? As reading books, particularly the classics, declines around the world, Medical Forum asked her if she feared their demise? “Yes I do. Somehow the attention span of even the most intelligent seems to have shrunk, so that long books scare off the reader. I blame the emergence of screens as our main points of contact but perhaps I am just being fainthearted. After all, Shakespeare is surviving and

MEDICAL FORUM

In The Importance of Being Miriam, she adds to the delectable Dickens’ line-up of Mrs Malaprop and Mrs Corney some high-born dames – Lady Backnell from Wilde’s play The Importance of Being Earnest and Lady Catherine de Bourgh from Austen’s Pride and Prejudice. From this line-up, who would Miriam ask over for dinner? “Many of my favourite characters would be GHASTLY dinner guests; imagine Mrs. Gamp falling over the furniture in her drunken frenzy or Miss Havisham scaring the party with her crazed bitterness. Much better to keep them on the stage and out of my house!” “But perhaps I’d allow Mrs Malaprop through the door; she’d make me laugh so much. Juliet Capulet would be lovely to invite; I’d ask her about what it’s like to love and be loved, and then to lose the beloved. I’ve never played

Juliet, of course, but I’m having her in my show because she speaks like a goddess – and it’s the words that pull me in.” “More than anyone though, I’d ask my old friend, Clive James [who is gravely ill]. He’s writing better than ever. He sent me a poem for the show.” Musician John Martin will be joining Miriam onstage. He has composed some original music and will sing – to which Miriam adds “is just as well, because he CAN sing and I can’t. John provides the real music (I’ll sing the music hall songs I grew up with) and he’s handsome too, which alas, I am not, so the audience is very lucky have him to look at as well as listen to.” All that she is Miriam told one interviewer when asked whether she’d like to be remembered for Dickens’ Women or Queen Victoria in Blackadder that she insists on being remembered for both. “If actors are to be remembered for their work rather than for their sensational lives, let the whole corpus of their work be included. I am very proud of my work on Dickens and for being a part of Blackadder. It happened 25 years ago and people still remember the lines.” In The Importance of being Miriam may just add to the collection of memorable moments.

By Ms Jan Hallam

Competitions

Entering Medical Forum’s competitions is easy!

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

FEATURE

COMP

Movie: A Little Chaos A Little Chaos follows Madame Sabine De Barra (Kate Winslet), a strong-willed landscape designer who challenges sexual and class barriers when she is chosen to build one of the main gardens at King Louis XIV’s (Alan Rickman) palace at Versailles. Rickman directs this sumptuous, sexually charged period piece. In cinemas, March 26

Movie: The Book of Life (3D) Animated but far from a cartoon – this ﬁlm follows Manolo, a young man torn between fulﬁlling the expectations of his family and following his heart. So he embarks on an adventure that takes him to three fantastical worlds. From the minds of Guillermo del Toro (Pan’s Labyrinth/Hellboy) and director Jorge Gutierrez.

Magic: The Illusionists 2.0 The ﬁrst show last year took Perth by storm and now the boys with the quickest hands in history are back. Seven new masters of mental and optical illusion are heading to the Crown with a raft of cutting-edge visual effects including giant 3D projections and tricks which take crowd participation to a whole new level. Be dazzled by the high-risk stunts of The Deceptionist, and the lightning speed of The Weapons Master among the line-up.

In cinemas, April 2

Movie: Samba Samba is a recent migrant to France (Omar Sy) from Senegal who is ﬁghting to stay in his adopted country, doing whatever he can with the help of a rookie immigration worker (Charlotte Gainsbourg), in this winning drama from the directors of the breakout hit, The Intouchables.

Crown Theatre, April 11-19, Medical Forum performance, Saturday April 11

Doctors Dozen Winner The John Duval Doctor’s Dozen received rave reviews in the pages of Medical Forum and GP Dr Liz Sinclair is happy to be taking home 12 bottles of a very ﬁne drop. Liz is quite partial to Shiraz and Cabernet Merlot varieties and fondly remembers a trip to Italy to taste some superb organic wines. Liz’s son, Shaun – currently undertaking his RACGP training – is looking forward to sharing a glass or two as well.

In Cinemas April 2

Movie: Dior & I From the makers of Valentino: The Last Emperor comes another exploration of a towering fashion institution, the House of Christian Dior. The camera follows the brand’s new artistic director Raf Simons as he prepares his ﬁrst haute couture collection. The tears, tantrums and triumphs are all wheeled out with such style it will take your breath away. F inalist lis P ublishers lish shhers A Auststralia Ex Excellence nce Awa A rd rds ds

In cinemas, March 26

Winners from the December issue Movie – Wild: Dr Jennifer Martins, Dr Mariet Job, Dr James Flynn, Dr Max Traub, Dr Barry Leonard, Dr Meilyn Hew, Dr Simon Machlin, Dr June Sim, Dr Roger Tan, Ms Maggie Juengling

Christmas Wishlist t FSH Momentum t Controlling New Outbreaks t Food Labelling Changes t Travel Medicine; Precocious Puberty; STIs t Doctors Drum: Politics in Medicine

Movie – Mr Turner: Dr Carol Deller, Dr Pam Quatermass, Dr Glenda Khoo, Dr Linda Wong, Dr Moira Westmore, Dr Diana Fakes, Dr Louise Houliston, Dr Katherine Shelley, Dr Rafal Francikiewicz, Dr Derek Scurry Major Sponsors

Theatre – Venus in Fur: Dr Paul O’Hara Musical Theatre – Les Miserables: Dr Gabe Hammond

The return season of one of the world’s most awarded musicals hits Perth in May. Wicked is the untold story of the witches of Oz, long before Dorothy drops in from Kansas. One, born with emerald-green skin, is smart, ﬁery and misunderstood. The other is beautiful, ambitious and popular. It all adds up to Wicked entertainment. Crown Theatre, from May 3

December 2014 www.mforum.com.au

Movie – Birdman: Dr Kurniawati Kusumawardhani, Dr Senq Lee, Dr Esther Moses, Dr Suzette Finch, Dr Christina Wang, Dr Tanya Stoney, Dr Helen Clarke, Dr Paul Laidman, Dr Leanne Hosking, Dr Andre Chong Music – Dr Who Symphonic Spectacular: Dr Kate Concanen

Musical: Wicked

Theatre: The Importance of Being Miriam Miriam Margolyes returns to Perth with another spellbinding show full of literature’s great characters after her sell-out Dickens’ Women. She is joined by pianist John Martin and together they will bring to life among others Oscar Wilde’s Lady Bracknell, Austen’s Lady Catherine de Bourgh and a clutch of Dickensian treasures. Heath Ledger Theatre, April 7-11. Medical Forum Tickets, Tuesday, April 7

MEDICAL FORUM

medical forum FOR LEASE FREMANTLE Sessional Room for rent in a Specialist Practice. Two rooms available, reception with waiting room. Can be used on a weekly, fortnightly and monthly basis. Please contact Kylie (Practice Manager) on 9279 4333 or kyliemc@wavascularcentre.com.au to discuss the availability and session price. NEDLANDS Hollywood Medical Centre 2 Sessional Suites. Available with secretarial support if required. Phone: 0414 780 751 NEDLANDS Medical Specialist Consulting Rooms and Treatment Room t 'VMMZ TFSWJDFE DPOTVMUBUJPO SPPNT BU Hollywood Specialist Centre t 4FDSFUBSJBM TVQQPSU oIJHIMZ FYQFSJFODFE long term staff t (FOJF TPMVUJPOT QSBDUJDF management software t 0OMJOF .FEJDBSF DMBJNT t 5FMFIFBMUI DPOTVMUBUJPO GBDJMJUJFT t 1BQFSMFTT QSBDUJDF TVQQPSUFE t 5SFBUNFOU SPPN o BWBJMBCMF GPS ambulatory procedures t "DDFTT UP )PMMZXPPE 1SJWBUF )PTQJUBM for inpatient care and theatre bookings supported t *OQBUJFOU CJMMJOH TVQQPSUFE Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager, 4VJUF )PMMZXPPE 4QFDJBMJTU $FOUSF .POBTI "WFOVF /FEMBOET 8" Phone: 9389 1533 &NBJM TVJUF IPMMZXPPE!CJHQPOE DPN AVELEY Suitable for dental practice and/or allied health services (e.g. Physiotherapy, Podiatrist, Radiology etc). Medical centre located in the same building. Located in a fast growing community beside a shopping centre, close to secondary schools, primary schools, church and Child Care Centre. Contact: 0400 814 091 MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: cford@cyllene.uwa.edu.au MURDOCH Wexford Medical Rooms for lease Please contact aptran@jointswest.com.au MURDOCH NEW Wexford Medical Centre Attached to the St John of God Hospital, in vicinity of the Fiona Stanley Hospital. Modern, newly fitted out medical consulting room. Sessional medical & dental rooms available. Please contact wexfordmedical@outlook.com for more information.

NEDLANDS Available now. Use of rooms at Chelsea Village on M T W only. Easy parking. Nicely appointed examination room would suit non procedural e.g. medicolegal examinations or paramedical. You open up, have sole use when required, then lock up. Occasional use or long term. Flat $275 per day use. Contact Dr Peter Burke 0414 536 630 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 PERTH CBD Medical room for rent in established Medical Practice in Perth CBD. Suitable for medical or allied health professionals. For more information contact Dale on 0414 455 783 NEDLANDS Rooms for Lease Hollywood Specialist Centre 54 sq m, fully furnished Excellent location adjacent to SCGH/ Childrens Hospital/ Hollywood Owner will change layout to suit client 5 year lease negotiable Contact Dr Tim Cooper timcpr1@gmail.com

ALBANY Private Psychiatric Practice A great opportunity to live and work in scenic Albany by taking over an established private practice. Providing private psychiatric care for Great Southern Region (Population: approximately 50 000) Good supportive network of skilled General Practitioners sharing in the care and management of Psychiatric patients. No private hospital and patients needing inpatient care are transferred to Perth. No after hours work. Peer review groups with Psychiatrists working at Public Mental Health. Phone Felicity: 9847 4900 or email pietclaassen45@hotmail.com

PSYCHIATRISTS 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 3PBE #JCSB -BLF 8" Currently 4 practising Psychiatrists and clinic is open Tuesday to Friday 7-day pharmacy and GP surgery next door are added advantages. 5 minute drive to St John of God and upcoming Fiona Stanley hospital. Phone Navneet 9414 7860

RURAL POSITIONS VACANT

MURDOCH New Wexford Medical Centre â&#x20AC;&#x201C; St John of God Hospital 2 brand new medical consulting rooms available: t TRN BOE TRN t DBS CBZ QFS UFOBODZ Lease one or both rooms. For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au

PRACTICE FOR SALE BUNBURY Break Free! $FOUSBM #VOCVSZ 3BNTBZ TU PQQPTJUF New SKG suites) Small dwelling with the potential PG PS NPSF DPOTVMUJOH SPPNT XJUI ample parking. Disability accessible. Block 944 sq. m Offers circa $800,000. Phone Jill 0414 972 116

ALBANY t 4U $MBSF T JT B OFX GBNJMZ QSBDUJDF based in Albany t 4NBMM GSJFOEMZ QSBDUJDF t 'VMM UJNF OVSTJOH BOE administration support t 1BUIPMPHZ PO TJUF t 'VMM PS QBSU UJNF (1 XBOUFE UP KPJO our team t 4QFDJBM JOUFSFTU JO TLJO XPVME CF JEFBM t $VSSFOUMZ OP %84 VOMFTT XJMMJOH UP XPSL in afterhours period t (1T OPU SFRVJSJOH TVQFSWJTJPO SFRVJSFE Please contact Practice Manager: 08 9841 8102 Email: admin@stclare.com.au Or send your CV through and we will get back to you.

URBAN POSITION VACANT RIVERTON RIVERTON MEDICAL CENTRE is looking for a Part-Time VR GP. Access to full-time practice nurse. Fully computerised practice. Friendly working environment. Pay negotiable. Ring Dr Sovann on 0412 711 197 if interested.

CANNING VALE Great Opportunity for part-time or fulltime VR GPs. Modern, new â&#x20AC;&#x153;â&#x20AC;&#x2DC;Queensgate Medical Centreâ&#x20AC;? opening in Canning Vale February 2015, opposite Livingston shops in busy location. Privately owned, 29 years of experience in the area. Outer Metro Grant may apply if eligible. Flexible working hours, nurse support, friendly working environment. For further information please contact: Dr Karen Majda - karenmajda@gmail.com or Dr Richa Singh - richa_s@hotmail.com NORTH BEACH Close to the beach! Opportunity for a P/T or F/T GP to join our privately-owned practice. Flexible hours and mixed billing. "O JOUFSFTU JO XPNFO T IFBMUI BO advantage. On site pathology, psychologist and nurse support. Please contact Helen or David 9447 1233 to discuss or Email: reception.nbmc@bigpond.com CANNINGTON Southside Medical Service is an accredited practice located in Cannington area. We are a family practice and offer mixed billings. 8F IBWF QPTJUJPOT GPS B (1 UP KPJO PUIFS (1 T DVSSFOUMZ XPSLJOH *U JT B XFMM QPTJUJPOFE QSBDUJDF DMPTF UP UIF Carousel Shopping Centre. Phone: 9451 3488 or Email: practicemanager@southside.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? *U EPFTO U IBWF UP CF UIJT XBZ 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. GOSNELLS Ashburton Surgery. Established 2002. VR GP needed full time or part time. Fully Accredited. Private billing. 75% of billings. Fully equipped with nurse support. Email: angiesurgery@gmail.com or call Angie 0422 496 594 SORRENTO GP for busy Sorrento Medical centre, Normal/after hours, we are like family, FT nurse, good remuneration. Please call 0439 952 979

APRIL 2015 - next deadline 12md Thursday 12th March â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum

CANNING VALE Rare Opportunity; Canning Vale Canning Vale Medical centre will have a room available from January 2015 for an established VR doctor wanting to relocate their practice to new rooms and join our team. Full management services are provided by doctor owned practice operating for 15 years under the same management. Continuous accreditation, finalist for AGPAL practice of the year last year, full nursing support, computerised with referees available for suitable candidate. Visit us at www.canningvalemedical.com.au Confidential enquires Dr Neda Meshgin 0414 641 963 or dr.meshgin@canningvalemedical.com

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

NEDLANDS Unique Opportunity WA Sexual Health Centre requires a part UJNF %PDUPS GPS o TFTTJPOT QFS XFFL days flexible. Founded by Dr Denis Cherry the Clinic is 8" T QSFNJFSF TFYVBM IFBMUI DMJOJD BOE UIF opportunity is available due to continued growth. Position covers all aspects of functional male sexual health along with preventive health measures. This is a most rewarding role for a Doctor wishing to engage with patients in a holistic patient/partner approach. Full training provided. For more information please call Dr David Millar on 08 9389 1400 and through our web site: www.wasexualhealthcentre.com.au

PALMYRA VR doctor required for full/part time work. We are a friendly, private, non-corp practice situated in Palmyra. Our surgery is accredited with modern facilities and has fantastic doctors, nurses & reception staff. *G ZPV XPVME MJLF UP KPJO VT QMFBTF FNBJM ZPVS CV to helen@leeuwinmedical.com.au PERTH NORTHERN SUBURBS Permanent/part time GP wanted Wangara Medical centre Busy practice, nursing staff, Best practice, pathology, podiatry and physiotherapy onsite. Lots of potential. *U JT B %84 BSFB 0488 222 238 / chibilitism@yahoo.com

OSBORNE PARK 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

KINGSLEY

Fantastic opportunity. A modern state-of-the-art, paperless clinic. 100% private billing. Flexible hours & your choice of patient case load, treat the patients you want. Email resume & cover letter to km@kingsleymedical.com.au www.kingsleymedical.com.au

GOSNELLS General Practitioner (VR) required for Saturdays. Gosnells Healthcare Centre is a newly established Bulk Billing Medical Centre situated in the Gosnells Central Shopping Centre. t 8F SFRVJSF B (FOFSBM 1SBDUJUJPOFS (VR) for Saturdays t $POTVMUBUJPO IPVST BSF OFHPUJBCMF t (PTOFMMT JT %84 GPS (FOFSBM practitioners t 5IF QSBDUJDF JT GVMMZ FRVJQQFE BOE computerised t .JOJNVN IPVSMZ SBUF PG QFS IPVS or 70% of billings, whichever is greater. t 'PS GVSUIFS JOGPSNBUJPO QMFBTF DPOUBDU Joe Ranallo on 0418 282 796 or at joe.ranallo@ppsportal.com.au

FREMANTLE Fremantle GP After Hours Clinic requires GPs for evening and weekend work. We are classified as an area of unmet need and therefore are able to employ OTDs who qualify to work in this area. We have ongoing vacancies and casual shifts available. Generous hourly rate. Please contact either Marina.trevino@FremantleML.com.au or FGPAHManager@FremantleML.com.au or 9319 0555

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

COMO Want variety in your work? Special interest opportunities at the Well Men Centre in Como. 1BSU UJNF (1 T GPS PVS 1FSUI .PMF $MJOJD Skin Cancer Screening Service and for our Holistic Health Management Programme. Call 9474 4262 or Email: wellmen@optusnet.com.au 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

APRIL 2015 - next deadline 12md Thursday 12th March â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum VR GP Required for practice only 7 months old, located in an ASGC-R2 location east of Perth. This brand new practice is the perfect opportunity for a GP to work in the inner regional area of Perth located approximately 45 mins from the CBD. This large community with no current TFSWJDJOH (1 T JT MPDBUFE OFYU EPPS UP B busy pharmacy and can accommodate 2 GVMM UJNF (1 T Admin and nursing services are provided along with onsite pathology and podiatrist. Relocation incentive may apply to this location. For more information please call 0419 959 246 or admin@ppdgroup.com.au KARDINYA Kelso Medical Group requires P/T or F/T male GP (DWS after hours only) This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest in CDM and minor surgical procedures. Located in Kardinya with onsite pathology and allied health with growing patient base. $VSSFOUMZ TVQQPSUFE CZ (1 T BOE 3/ T www.kelsomg.com.au Please call 0419 959 246 for further information.

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

LEEDERVILLE GP for a General Practice in Leederville. Conditions negotiable. Correspondence in confidence: QETWE !HNBJM DPN LESMURDIE OR HIGH WYCOMBE 'VMM UJNF PS 1BSU UJNF 73 (1 T SFRVJSFE in Lesmurdie or High Wycombe (DWS & AON) - Privately owned with mixed billing - Nursing support - Fully computerised - Teaching practice - Allied Health - Special interest and skills supported - Hills location Contact Karin on 0438 211 240 or karintatnell@yahoo.com.au 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 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

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SPECIALISTS ARE YOU LOOKING FOR SPACE IN BUSSELTON? Expressions of interest sought Convenient location Projected completion date early 2016 Both tenancy and sessional options available Please contact for a conďŹ dential discussion busselton.specialistcentre@gmail.com

83 WEST PERTH

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 BICTON Full-time and Part-Time VR GPs positions available for our well established Accredited, Privately Owned, Friendly Family Practice in Bicton. The practice has a well-established patient base, and offers an exciting opportunity for an enthusiastic practitioner to join our practice, with potential to own. t 0O TJUF QBUIPMPHZ BOE 1SBDUJDF /VSTF support, Radiology available across the road. t 6OJRVF NFOUPSJOH PQQPSUVOJUJFT available, and excellent support staff and facilities t 8F VTF #FTU 1SBDUJDF TPGUXBSF BOE BSF mostly a Private Billing practice. t 73 XJUI FYQFSJFODF JO XPNFO T IFBMUI preferred, but not required. t -FBSO NPSF BCPVU VT BU http://bictonmedicalclinic.com/ t "MM BQQMJDBUJPOT DPOTJEFSFE Contact Dr Sam Messina on 9339 1400 Email: smess@iinet.net.au HAMILTON HILL A GP required for a clinic in a DWS and AON area 5 minutes drive from Fremantle. %PDUPS (1 1SBDUJDF Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or Send CV to admin@hamiltonhillfamilypractice.com.au

FT GP required for our friendly, accredited and fully computerised general practice. The practice has been growing rapidly and we are moving into new premises with an extra consulting room. We serve a young, professional demographic as well as providing specialist sexual health services. This is an exciting opportunity for an enthusiastic practitioner to join our practice. VR with experience in family planning BOE XPNFO T IFBMUI QSFGFSSFE Contact Stephen on 0411 223 120 or Email: stephen@westperthmedicalcentre.com.au

THORNLIE Thornlie Medical Centre is looking for a part- time doctor to fill our growing multicultural practice. We can offer: t GMFYJCMF IPVST t FYDFMMFOU SFNVOFSBUJPO t HSFBU UFBN FOWJSPONFOU t OPO DPSQPSBUF OP CJOEJOH DPOUSBDUT t 0VUFS .FUSPQPMJUBO "SFB (SBOU "QQMJDBCMF LN GSPN 1FSUI $#%

t GVMM UJNF OVSTJOH t NPEFSO CVJMEJOH XJUI TFQBSBUF TFDVSF parking for doctors. The successful applicant should be: t 7PDBUJPOBMMZ 3FHJTUFSFE t .VMUJ MJOHVBM XPVME CF CFOFGJDJBM particularly with Chinese Dialects. Please contact Donna: 08 9267 2888 OR email enquiries and CV to thornliemedicalcentre@hotmail.com

GROWING PRACTICE IN ALBANY!

EXPRESSIONS OF INTEREST

FT GP required for a friendly, accredited general practice

Wanted: Medical Practice to Buy

This is an exciting opportunity for a VR GP who is able to work in a non DWS area Please contact Dr Glen Fernandes

9841 8102

GP Owner â&#x20AC;&#x201C; non-corporate Must be multi-doctor practices Preference for buying business and building Fair price paid â&#x20AC;&#x201C; business and building valuation used Regional and metro sites considered All enquiries treated conďŹ dentially. Please email wamedicaldevelopments@gmail.com

APRIL 2015 - next deadline 12md Thursday 12th March â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum

Who’s looking after you? At IPN IPN, we’ll take care of the day-to day-to-day, so you can focus on you your patients and enjoy a grea greater work-life balance. With IP IPN, we’re looking after you.

1800 IPN DOC (1800 476 362) enquiries@ipn.com.au ipn.com.au/doctors

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. Procedural GP’s and ofﬁce based GP’s well catered for. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. * full-time/part-time/sessional * medical systems and secretarial support * adjacent to Fiona Stanley Hospital More information phone: 9366 1802 or email: diane.car@sjog.org.au

APRIL 2015 - next deadline 12md Thursday 12th March – Tel 9203 5222 or jasmine@mforum.com.au

medical forum

ARE YOU WANTING TO SELL A MEDICAL PRACTICE? As WA’s only specialised medical business broker we have sold many medical practices to qualified buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible. We are committed to maintaining confidentiality. You will enjoy the benefit of our negotiating skills. We’ll take care of all the paper work to ensure a smooth transition.

To ﬁnd out what your practice is worth, call:

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

Mandurah DWS VR general practitioner required for busy general practice in Mandurah, near Peel Health Campus. Accessible via public transport and just a few minutes off Kwinana Freeway. Private mixed billing group practice providing quality comprehensive family care for over 50 years to Mandurah and the surrounding community. Our team features primary health physicians, specialists and allied health professionals. Treatment room facilities, procedure room, skin clinic, travel clinic, practice nurses, reception, medical secretary, accounts, administration staff are here to support you. Specialist, allied health services, pharmacy co-located in the same building. The practice is open 7 days a week. DWS. To apply please email: manager@mmcmandurah.com.au

GP with a passion for preventative medicine to join our boutique practice with a like-minded team of Health professionals. Leading Preventive Health Clinic Non-corporate state of the art practice in West Perth Monday – Friday, various hours of work: no after hours or on call Exclusive clientele, excellent work environment Excellent PC/Mac knowledge desirable as we operate a leading edge software package Please contact General Manager on enquiries@ionichealth.com or (08) 6181 3590

Apollo Health Cockburn Opening late March 2015 Apollo A polllo Health is openin opening in Cockburn so adding to its aalready lrre dy established Armadale, Cannington lrea and Joondalup Joondalu practices. This Thhis new practice is i within DWS area. Opportunity for doctors to become Op pportunity exists fo foundation members fo oundaatio tion ti on membe beers of our dynamic team. If interested, we would love to hear from you. To arrange a confidential confidentia chat with our medical director dire di rector please email: office@apollohealth.biz o

APRIL 2015 - next deadline 12md Thursday 12th March – Tel 9203 5222 or jasmine@mforum.com.au