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NEWS & VIEWS
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Celebrity Spotlight: Song and Dance Man Todd McKenney Dr Neil Thomson, Aboriginal public health Mental Health Commissioner Tim Marney Ice Hockey and Concussion Docs Swim for Leukaemia
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Editorial: Moral Outrage – Kill or Cure? Letters: Specialist Referrals Unplugged – Dr Rohan Gay A Question of Need(ling) – Dr John Quintner Response – Dr Andrew Thompson Physios Here to Help – Mr James Debenham Free Counselling for Abuse Victims – Ms Charmaine Kennedy New Legal Precedent – Dr David Hoffman Action Time for Chronic Heart Failure – Mr Maurice Swanson Cervical Screening Program Renewal – Ms Nerida Steel Having Phun with Phobias – Ms Wendy Wardell Have You Heard? Beneath the Drapes MDA/MIGA Merger n Q&A Peanut Allergy tures i
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JOHN 30 DR SALMON Barriers to Non-drug Therapy for Chronic Pain
DR TIM PAVY 31 Persistent Pelvic Pain in Women
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SERGIO 33 DR STARKSTEIN Diagnosing and Managing Adults with ASD
CHIN-WERN 35 DR CHAN Managing OpioidInduced Nausea
SIMON 37 DR DIMMITT Psychotropics – Are We Overdoing It?
AIMEE 37 MS MUNRO Use Of Co-Testing After Treatment of Cin
DR MAX MAJEDI NATHAN 11 The 21 DR GIBSON Pain Perspective Mental Health Can’t Stand Still
MR GEOFF DIVER DR RICHARD YIN 24 Frozen 25 Good in Time – Medicine Can Coroner’s Court Pressures
GRAPHIC DESIGN Thinking Hats
By Ms Jan Hallam Managing Editor
This month as Medical Forum has gone about its job talking to people about mental health and pain in our fair state, we struck a few incidences of genuine, overflowing emotion from people who evoked their inalienable right to be angry, upset and bewildered by injustice. Why this is news at all, is due to its increasing rarity. From Tim Marney, one of the stateâ€™s leading public servants, who between his own natural caution and years of bureaucratic shaping, runs an algorithm over each word before uttering it, is perplexed by the communityâ€™s lack of outrage when it comes to the suicide rate.
Moral Outrage in Mental Health Finally thereâ€™s the psychiatrist, whose voice grew louder and more desperate as they tried to explain feelings of helplessness faced with 90 unwell patients assigned to three days at a public mental health clinic. Quitting seemed like the only solution. Itâ€™s becoming a rare thing, this moral outrage. For the profession, reticence and difficulties to engage in good faith are fuelled by t
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MBDLPGUJNFBOETLJMMTUPCVJMEHPPE communication and then it all gets too hard so some leave it to others.
â€œOne person a day in WA,â€? he said, as the words burst from him with such intensity it made him flush (see P19).
Ä‡FDPNQMFYJUZPGQSPCMFNTÄ‡FSFBSF few easy cases and that preys on our need for the quick-fix.
Then there was Geoff Diver whose youngest daughter Ruby killed herself just hours after her discharge from Fremantle Hospital. He grieved and he spoke up. He was outraged that the system let his daughter and his family down. He was frightened it would let other families down as well. So he took to sitting on advisory boards where he agitated, needled and probably became a pain in the butt for those uncomfortable with the brutal honesty of his lived experience. And then he quit (see P24).
For the community, could it be a case of a shifting morality or a lack of empathy? Is the relentless media coverage of tragedy (celebrity, preferably) affecting our perceptions? Is it that despite evidence to the contrary and the good intentions of Merv Hughes and his Mo, we still want mental illness to be locked away out of sight? Is it that we donâ€™t have time to care or listen?
There may have been sighs of relief, but was there outrage?
Perhaps moral outrage is the only thing wee have left as governments march inexorablyy on to the relentless beat of their election cycles. He who shouts loudest gets heard. Aye, thereâ€™s the rub. So many unwell
patients donâ€™t shout, they need people with moral outrage to shout for them. Tim Marneyâ€™s outrage has the capacity to make a difference. He is in a position to create policies and a climate of action that can support people who think suicide is their only answer. Geoff Diverâ€™s outrage has already made a difference. The Stokes Review, sparked by the death of Ruby and others, closed gaps in the mental health system. The safety net was made that little bit stronger because he would not, could not resist the urge to express his moral outrage. My psychiatrist friend took deep breaths and realised that skills werenâ€™t easy to come by and took a holiday instead, waiting for the system and the community to catch up and help alleviate the pressures on frontline services. Their outrage is only on the backburner. The moral outrage of individuals is one thing, but real change, a lasting cure, needs a collective social conscience and courage. Turn off the TV, go next door and ask â€“ how are you today?
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Docs health: Board cares The Medical Board of Australia will spend $2 million to standardise doctorsâ€™ health programs across the country. Services include advice and referral, education and awareness, general advocacy and the development of case management services. The model is based on the Victorian scheme, which has apparently gone down well with doctors there. Funding will come from the Boardâ€™s existing resources and Board head Dr Joanna Flynn said the program would complement the regulatory focus of the Board and AHPRA. It would be calling on â€œstakeholders like the AMA and BeyondBlue to make them happen.â€? Coordinator of the WA Doctors Health Advisory Service (DHAS) Dr David Oldham said the service had been represented at planning meetings but nothing had been put in place for WA. DHAS and AMA WA would be holding a meeting to hear what local doctors want. In the meantime the local 24-hour helpline will operate as usual. Regarding the â€˜regulatory focusâ€™ David said the systems in Victoria and South Australia both had agreements with the Board that if a doctor was complying with treatment there would be no need to inform the board. He added that WA law is different-it excluded mandatory reporting.
Letters to the Editor
Specialist referrals unplugged Dear Editor, I read with interest your editorial How Convenient Specialist Referrals? [April edition]. We were offered online appointments by one software vendor around a year ago but declined due to concerns about unsuitable appointments. Specifically, we were concerned about our liability should patient’s book for urgent matters. We noted that whilst the receptionists had less keyboard work, they had yet another system to constantly monitor. We asked the vendor to add instructions to direct patients to call 000 for urgent medical matters and also include numbers for after-hours services and at that time were told this was not possible. We were concerned that this gave the impression the system placed the marketing of the practice ahead of enhancing patient care. As an extension of this concern, I have strong reservations with regards to how we promote online specialist referrals. Seeing patients for referrals is crucial if we are to effectively perform our oversight role. No online system can give the same information as a face-to face consultation. On the other hand I am happy to write indefinite referrals for chronic conditions if the specialist maintains communication; however some specialists and colleges insist on new referrals and hence ‘initial consults’ each year. We already have skin clinics seeing our patients without referrals and then referring them to specialists without our input. We also have pharmacies vaccinating our patients without obligation to notify us for our records. Further departure from the present system of referrals risks fragmentation of care as happens in other countries where referrals are not required by specialists. In such countries, specialists such as cardiologists or respiratory physicians often fill the primary care role. This de-skills the specialists and GPs alike and denies the patient adequate balanced oversight of their care. Dr Rohan Gay, General Practitioner ED. Time with the doctor and expertise are valued commodities amongst ‘patients’, who are also ‘health consumers’ who value access and convenience. Whichever emphasis carries the day will vary with the perception of the problem at hand and the performance of the doctor.
A question of need(ling) Dear Editor, In his column [The GP-Physio Marriage, April], Dr Andrew Thompson makes the claim that “dry needling” has some merit. I presume he is referring to needling of trigger points (TrPs) within voluntary muscles. TrPs are the sine qua non of the Myofascial Pain Syndrome (MPS). But having recently conducted a review of the relevant literature, I cannot agree with Dr Thompson. The MPS/TrP construct is based solely upon conjecture. Both the “trigger points” and the “vicious cycles” that are said to maintain them are inventions that do appear plausible, but in reality have no scientific basis, whether such an assessment is made on experimental (interrogating the suspect tissue itself) or on empirical (assessing the outcome of treatments predicated on presumed pathology) grounds. The MPS construct is best summarised by one of its creators, David Simons, as a “complex of sensory, motor and autonomic symptoms that are caused by myofascial trigger points.” In turn, trigger points were defined by him as “spots of exquisite tenderness and hyperirritability in muscles or their fascia, localised in taut, palpable bands…” In other words, myofascial pain is caused (sic) by painful loci in myofascial tissues – a classical circular argument. Irrespectively of this fallacy of logic, the scientific validity of MPS turns on whether this set of assertions does in fact explain and predict the natural processes that underlie localised deep muscular pain. Apart from contextual factors, the evidence has been so unconvincing that “dry needling” can be safely relegated to the dustbin where reside so many other speculative systems of treatment that were once confidently inflicted upon desperate patients. In a free society consenting adults can agree to inflict pain upon each other in whatsoever manner they see fit. But this is not what the current argument is about. Dr John Quintner, Rheumatology and Pain Medicine Physician
RESPONSE: Dr Andrew Thompson Initially I was confused. Is the author choosing to cite MPS (at best, a poorly understood, last resort diagnosis of dubious relevance to practitioners who target their treatments toward a defined pathology) to argue more broadly against the efficacy of a specific treatment option. For example antibiotics do not cure Borderline Personality Disorder, hence, antibiotics are worthless? However, perhaps unintentionally, the author has encapsulated the premise of my article – the lack of understanding between these two professions – and highlighted the very real difficulties of researching manual therapies. The variables, even in a ‘genuine’ pathology, make researching a singular manual intervention extremely difficult. How does a researcher stratify patients in a cohort with, let’s say, a ‘simple’ problem like subacromial bursitis? The variables that influence a physiotherapist’s choice of treatment are vast – the list would fill this page. In contrast, the doctor who rubberstamps prescriptions for analgesics does not assess any of these variables, ergo propter hoc, MPS would seem an appropriate ‘diagnosis’. Manual therapies are hard to research and refine. Take patella femoral syndrome (PFS) – an extremely complex pathology. In a biomechanically ‘appropriate’ patient, orthotics provide a predictable resolution. But where is the evidence that supports the use of orthotics to treat PFS? A secondary theme of my article suggests we ‘select our physiotherapists wisely’. Many doctors are the unfortunate victim of the disappointing practices and correspondence of the therapists referred to. But, let’s have counselling before you annul this marriage. continued on P6
Joke A grandmother is watching her grandchild playing on the beach when a huge wave comes and takes him out to sea. She pleads, “please God, save my only grandson. I beg of you, bring him back.” And a big wave comes and washes the boy back onto the beach, good as new. She looks up to heaven and says: “He had a hat!”
Dr Boon Ham Perth, WA
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Letters Continued from P4
Physios here to help Dear Editor, I’d like to commend Dr Thompson’s column [April edition] on the relationship between GPs and physiotherapists and given his background he is well-placed to make these observations. Perhaps I can offer some additional comments from the ‘physio side of the fence’. The relationship between GPs and physiotherapists is very good, and our training indicates that our roles should be complementary. Given the enormous breadth of general practice, GPs may not routinely have the opportunity to embrace musculoskeletal practice unless it is a specific passion. Musculoskeletal physiotherapists are well trained and can help in the diagnosis and management of this challenging patient group. I agree with Dr Thompson’s comments that you need to find excellent physiotherapists you can rely upon, so here are some more tips about judging a good physio. A good rule of thumb is that the more complex and chronic the condition, the less passive the management should be. You should expect to hear from the physiotherapist that they are engaging in the rehabilitation of the patient, addressing biological issues such as fitness and general health, psychological issues, and social issues, such as employment and home support, which may contribute to the condition. If you are satisfied that your patient has a benign musculoskeletal disorder, but are not certain about the optimal management plan, a good physiotherapist should be able to help with that additional triage. Furthermore, if your patient’s condition appears to be recalcitrant or recurrent, it may be that underlying mechanical dysfunction is responsible for this. A good physiotherapist will be able to identify these issues and address them. There is no reason why your patient should experience these problems, and often the mechanical problem requires a mechanical solution. This all relies on you having confidence that the physiotherapist(s) you work with are competent. The Australian Physiotherapy Association has a professional structure that recognises advanced education and training and I would recommend you seek out a physiotherapist with these qualifications. Mr James Debenham, National Chair, Musculoskeletal Physiotherapy Group, APA
Free counselling for abuse victims Dear Editor, The Royal Commission investigating Institutional Responses to Child Sexual Abuse will have its first public hearing in WA from April 28. The Commission recently announced its focus for the public hearing would be the experiences of a number of men who were resident at Christian Brother’s residences in WA. Over the last year, the Commission has heard from a broad range of people. The ongoing investigation affects many facets of individual health, in particular mental health. As part of the Commission process, the government has provided funding for those affected to access support services at no cost. These services are not only for the survivors sharing their story but, importantly, also for those who have been sexually abused as a child while in an institution and don’t wish to take part in the Commission process. The Royal Commission Support Service (RCSS), run by Relationships Australia WA, provides case management support, crucial for people affected by the Commission. This can vary between specialised case managers attending private hearings, to offering individual and family counselling on an ongoing basis. We have been able to assist a client’s access to important health care and supported people in regional areas who travel to and from hearings in Perth. Many medical professionals treat those who have been affected by child sexual abuse in institutions, sometimes unbeknownst to them. As the Program Manager for the RCSS, it is important to raise awareness of this free support service. Healing from traumatic experiences is
a long process. We have worked closely with GPs, psychologists and other medical professionals to ensure the best outcomes for individual clients. Our RCSS team endeavours to ensure those who are eligible to receive this support are aware of it. If you would like more information on the service, or wish to refer someone, you can contact (08) 9489 6390 or email firstname.lastname@example.org. Ms Charmaine Kennedy, Program Manager, RCSS
Cervical Screening Program Renewal Dear Editor, Thank you to Dr Cliff Neppe [Cervical Cancer Screening, April] for raising the importance of women’s ongoing participation in screening and highlighting new technologies that help prevent cervical cancer. For the past 20 years the National Cervical Screening Program (NCSP) has offered routine screening with Pap smears every two years for women between the ages of 18 and 70. Since its introduction, the incidence and mortality of cervical cancer have decreased by about 50%. I would also like to take this opportunity to advise medical practitioners that the NCSP is undergoing a Renewal. The Renewal will review the science and technologies related to the program and aims to ensure all Australian women (HPV vaccinated and non-HPV vaccinated) have access to a cervical screening program that is based on the current evidence and promotes best clinical practice. As you are well aware, the science of cancer is one of the most rapidly changing areas in health, and although the success of the NCSP cannot be disputed, the environment in which the program operates has changed. More letters P8
Joke A guy joins a monastery and takes a vow of silence: he’s allowed to say two words every seven years. After the first seven years, the elders bring him in and ask for his two words. “Cold floors,” he says. They nod and send him away. Seven more years pass. They bring him back in and ask for his two words. He clears his throat and says, “Bad food.” They nod and send him away. Seven more years pass. They bring him in for his two words. “I quit,” he says. “That’s not surprising,” the elders say. “You’ve done nothing but complain since you got here.”
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Letters Continued from P6 There is now a greater depth of knowledge and understanding about the natural progression of cervical cancer and its precursors. Additionally, evidence about the screening age range and interval has changed and there are now new tests available to assist in early detection of pre-cancerous cervical changes. Given these advancements and as the Renewal nears completion, I encourage health care providers to learn more about these developments that support cervical cancer prevention. Further information: www.cancerscreening. gov.au/internet/screening/publishing.nsf/ Content/ncsp-renewal. Ms Nerida Steel, WA Cervical Cancer Prevention Program
New legal precedent Dear Editor, I was sacked on 19 April 2012, my ninth wedding anniversary, so it was a bit of a downer. When I got home later and told her the news, Jenny went off and came back with a quote from Rita Rudner, “It’s so great to find that one special person you want to annoy for the rest of your life”. I knew the mountain of legal work that had to be done to try to overturn the sacking, and had another quote in mind about “[The law being] a jealous mistress”, but that one was going to raise more questions so I opened a beer and changed the subject. During the months preparing for the trial in the Commission in early 2013 and the further months before we argued the appeal later in 2013, the truth of Rudner’s quote came back to haunt me. Jenny and I were holidaying down south a few months before the trial, and I was working most nights preparing my case. This was the “long and constant courtship... (the) lavish homage” idealised by Joseph Story (1779-1845) describing the law that I had practised for 20 years before the lights went on and I resumed medical practice in 1998. Jenny sat opposite me one evening in a little restaurant in Margaret River and said, “Did you know I was really looking forward to this time together?” This was not going to be a good time to tell her about the mistress. The Reasons for Decision of the Full Bench of the WA Industrial Relations Commission, allowing my appeal against a decision to terminate my employment, are the copyright of the WA Industrial Relations Commission (IRC) and
anticipated publication is later this year. The decision affects all bulk-billing health practitioners in Western Australia, where the IRC is a binding authority, and is strongly persuasive for similar enterprises throughout Australia because the respondent employer in my case did not appeal the decision, and the question has not since been raised by anyone in the Federal Court of Australia in proceedings under the federal legislation. In particular, it means that enterprise agreements currently registered with Fair Work Australia by predominantly bulkbilling employers such as Medicare Locals will have been registered without the legislative power provided by s. 51 (xx) of the Australian Constitution, and may have to be reviewed. If I were back in legal practice or an industrial advocate advising clients such as Medicare Locals, I might be advising them that they are not constitutional corporations and as such their EBAs (Enterprise Bargaining Agreements) are all void and the State Jurisdiction applies. In my written submissions filed in the Commission before the original hearing, and in the Full Bench before the appeal was heard, I included a citation to the old case of Carlil v Carbolic Smoke Ball, a contract law case involving a bogus cure for influenza. This citation as well as several other boilerplate cases should ensure this decision of our dear little WA Industrial Relations Commission will be trawled up by legal search engines whenever lawyers and industrial advocates revisit this area off constitutional law, thus guaranteeing our us fame, and perhaps immortalise this curious sacking. Time to up the medication. an Dr David Hoffman ED. The author’s successful appeal to the Full Bench of the WA Industrial Relations Commission may influence the jurisdiction of the Commissioner (compared to Fair Work Australia), for future cases like his.
Figures from the Australian Institute of Health and Welfare released last August show death rates from the disease increased by 20% between 2006 and 2011. More than 45,000 Australians were hospitalised due to chronic heart failure in 2009-10, equating to more than 360,000 bed days, costing the national economy $1 billion a year. The Heart Foundation has called on both sides of government to commit to urgent action on these alarming statistics. A National Policy Framework to improve the systems of care for patients with chronic heart failure should be developed and implemented. Chronic heart failure is a huge burden on the healthcare system, so if the Federal Government is serious about easing the pressure, chronic heart failure is the place to start. We want all policy makers, clinical networks and clinicians to commit to a National Policy Framework so we can improve the systems of care across the acute and primary care sectors and give chronic heart failure patients a better quality of life. There is convincing evidence that among people who have been hospitalised with chronic heart failure, those who receive evidence-based multidisciplinary care have better outcomes than those who do not. Mr Maurice Swanson, CEO, Heart Foundation WA
Send in your letters, 300 words or less please, by May 10 to email@example.com ed You can leave a message on our website at www.medicalhub.com.au
Action time for chronic heart failure Dear Editor, I was interested to read Dr Joe Hung’s column on chronic heart failure [April edition]. The latest figures show about 30,000 Australians are diagnosed with this debilitating condition every year.
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The Pain Perspective Getting over the sense of entitlement could be a painful experience according to pain physician and anaesthetist, Dr Max Majedi.
s we navigate through the rising issues such as climate change, ageing population, obesity, human and animal rights, the common denominator is the concept of sustainability. It is quite evident there needs to be a dramatic course change. Health is no exception. As a pain specialist, I am often troubled by the approach that we have to health care in Australia and the rest of the world. This is in conjunction with the innate inequality that exists between the first world and the developing countries, generally at the expense of unnecessary and preventable human suffering.
Pain medicine has seen incredible advancements in science, technology, pharmacology and paradigm shifts, putting the concept of pain in line with other medical issues. Combined with scanning technology such as Functional MRIs, PET scans and higher quality research, we have begun to look further inside the inner mechanics of the human brain and construct a map that for the first time closes the gap between the duality of psychology and biology.
However, despite increasing access to many analgesics, especially opioids, invasive interventions such as nerve blocks and spinal cord stimulation, psychological and physiological intervention, we are no closer to improvement of overall quality of life in patients.
imbursements, false expectations and personal beliefs, the foundation of pain medicine is a bio-psycho-social paradigm.
The rise in health cost is matched by the ageing population and an increasing burden of self-inflicted or preventable injuries from antisocial behaviour related to drugs and alcohol. All of which have a high potential for persistent pain.
Fuelled by the corporate structure of health care we are heavily persuaded to further entrench the biological component in the face of looming psychosocial factors, and ‘medicalising’ further the non-organic psychosocial issues, which inevitably lead to iatrogenesis.
We have an arsenal of treatments for the biological component, some for the psychological, and next to nothing for the social.
We are in an age of ‘entitlement’ whereby we expect cheap, readily accessible health care that should be fully accountable, and responsible, irrespective of the demands we put on our own health and the cost to society.
I think, perhaps, it is time to rethink the equation so that the generation after us is not faced with poor access to health care. This can only be done if the majority of practitioners can place ethics, rationality and health of a society with focus on education, prevention and realistic expectations, ahead of short-term, unsuitable commercial and political gains. O
As my more senior colleagues retire, there is the inevitable realisation that we all have to do more with less resources and that simply relying on advancement in technology is not going to change the current unsustainable course.
ED: Dr Max Majedi is Acting Head of Department of Pain Management, SCGH
Irrespective of pain medicine’s in-built biases, shaped by ill-placed financial re-
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Having Phun with Phobias By Ms Wendy Wardell
We all have them to lesser or greater degrees but phobias are becoming something of a fashion statement.
my mobile phone with me. The catastrophising starts with the inability to contact my daughter and goes right through to mourning all the eggs those damn pigs will eat if I can’t unleash an animated angry avian at them.
ou doctors clearly have to deal with some very strange people coming into your rooms or wards. Heaven knows, the apartment I live in is small, but even I wouldn’t consider a personal orifice to be suitable storage for a domestic appliance or kitchen utensil.
It illustrates the point that what some of us consider completely bizarre is for others simply a viable way to pass the time in between seasons of Downton Abbey. To psychaiatrists (who have mortgages to pay and kids to educate) we all have a few crayons missing from our colouring-in boxes because the pressures of modern life make us a little bit scared, paranoid, obsessive or just plain flaky in so many colourful ways. Phobias are just another thing that makes other people seem completely weird. Is there some sort of definitive line between stuff we don’t like and a phobia? If, for instance you get sweaty palms and a panic attack at the sight of a Kraft cheese slice, have you got a) turophobia b) acute lactose intolerance or c) the capacity to read ingredients lists? Much like party political broadcasts, avoidance is the easiest option to deal with
Sometimes it’s hard to distinguish a phobia from just an irritating personality trait. Do you get a bit wild-eyed and twitchy if the lane of traffic you’re in moves more slowly than the one next to it? It could either be the precursor to a paralyzing fear of orange cones or a normal state of mind for a BMW driver.
phobias. I’m not that keen on sharks, but as long as they don’t start frequenting coffee shops, I can live with it. A short sharp reality check may cure other irrational fears. Some people have a ‘phobia’ of not having a partner. An introduction to internet dating will bring them to a rapid realisation that there are worse options. Oh, so much worse. Technology has introduced a whole new range of things over which we can get our knickers in a knot. I’m as guilty as the next person of panicking if I don’t have
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Phobias come and go with fashion trends and social movements of course. There has been an upsurge in omphalophobia – a fear of belly buttons, and I’m guessing that this is linked to both the trend for low rise jeans and the increase in obesity. I predict a western suburbs spike in what I will term lactiscalefactophobia; a dread that the barista will misjudge the milk temperature for the perfect maceration of coffee in the creation of a double shot cappuccino. I’m certainly not immune. One of my personal phobias is of failure to meet deadlines. I manage it though by ensuring that I submit something, even if it’s not entirely fi O
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Soaking up the Fame From Teen Angel to pineapple waving, hip-swivelling Peter Allen, local boy made good Todd McKenney takes his audiences on a fun ride. When it comes to the stresses of fame, the physical effects of dancing for a living for over 30 years and the financial precariousness of showbiz, there’s not much that song-and-dance man and television personality Todd McKenney doesn’t know. The 48-year-old Perth-born star, who returns to Perth next month for the stage version of Grease, has done the lot. From starring in musicals, producing and touring his own shows, radio DJ to outspoken judge on TV’s Dancing With the Stars, Todd told Medical Forum that he was destined for this life. “My Mum ran a dance school in Morley. In fact she was on the way to class when she went into labour with me. I’ve been brought up in a dance school.” Apart from a teenage flirtation with springboard diving, Todd has been treading the boards consistently since his debut in 1983 in Andrew Lloyd Webber’s Song and Dance and his timing couldn’t have been better. In the late 1970s, filmmakers began to return to the musical genre, producing such modern classics as Grease (with John Travolta and Olivia NewtonJohn) and here in Australia, Baz Luhrmann’s wildly popular Strictly Ballroom. Musicals have been hot tickets ever since. “We’ve got a lot to thank Baz Luhrmann and Lloyd Webber for – it’s cool to be in a musical again. Technology has also advanced and musicals look a lot smarter now – they are less vaudeville and more Hollywood.” Todd’s cameo role as Teen Angel in Grease sees him on stage for three minutes 53 seconds … “though I milk it to four minutes so I can be on stage a little longer.”
“When you work in theatre, you can take all the excitement for granted and this is a way to give people who love theatre an insight into our world.” “The tour includes a three-course dinner at a classy restaurant, hosted by me, with the odd visit from fellow actors or backstage creatives; great seats for the show and then afterwards head backstage to meet the team. The tour ends on stage with the lights up facing 2000 seats. It freaks out a lot of people.” “We’ve been running the tours in Sydney and Melbourne where we’ve sold out. It’s been really well received.” The two roles that are synonymous with Todd are Peter Allen in The Boy from Oz and the ‘nasty’ judge in the celebrity TV dance competition, Dancing With the Stars (DWTS). The first live theatrical show Todd saw when he was a kid was Peter Allen at the Perth Concert Hall in the late 1970s. It sold him on showbiz, and Allen’s style and repertoire became a model for the budding entertainer. A chance meeting with Allen’s sister after the singer died in 1992 led to a close friendship with the family. “When I auditioned for The Boy from Oz, Peter’s mum asked me to come by their house on the way to the audition. She had packed up three of his shirts for me to wear. She said ‘If anyone is going to play him, we hope it’s you’. I’ve always been humbled by my Peter Allen experience – it’s been my career and I love it.” Equally DWTS has been a huge part of Todd’s life for more than a decade. It took a bit of effort to get used to being recognized when he was at the supermarket and even more effort to understand why people seemed to hate him for what he considered was a part he was playing.”
“I arrive at the theatre half way through the second act, wander round watching everyone else sweat it out then swan on stage and steal the show. Well that’s my aim, at least. I took on the role because I thought it would be good fun and it’s turned out to be exactly that.”
“When the show first started, I got spat at in Hobart. That took a lot to come to terms to. I couldn’t understand how people would take a dancing show so much to heart. I even had a guy in a butcher shop throw sausages at me, but the benefits of the show far outweigh the negatives.”
The Perth season will also be an opportunity for local theatre lovers to see Todd in a vastly different role, this time as dinner host and backstage guide as part of his new venture, Centrestage Tours.
“It’s a joy to see people discover dance and it is a powerful thing for contestants and the audience to see just how hard and how committed you have to be to dance well. And it’s heaps of fun.” O
By Ms Jan Hallam
Have You Heard? Hospital building spree
Déjà vu? Remember Virtual Medical Centres, started by Perth oncologist Dr Andrew Dean? By employing medical students and a science editor they were able to scan the literature and generate high quality articles across different disciplines for a website largely free of ads. Having built a following of health consumers, VMC investors found sponsorship from BigPond (now Telstra Media), happy to reach the health consumers that VMC brought them through website integration. VMC has since changed back to low-advert information for consumers and different information for health professionals who can register under the new national scheme to receive promotions from pharmaceutical companies and suchlike. Telstra more recently invested in HealthEngine under Perth CEO Dr Marcus Tan, which has joined with Yahoo!7 Lifestyle to bring advertisers and health consumers closer together. According to a report in Pulse+IT, the online health directory and appointment booking service, which Dr Tan reportedly said lists as many allied health and dental practices as GPs, will be integrated into the Yahoo!7 Lifestyle website.
Hospitals are going up in every direction. Latest in the building stakes is Hollywood Private Hospital which is sinking $74.1 million on an expansion to building a new wing with six theatres, two 30-bed wards and a new kitchen all anticipated to be completed by late 2015. In addition to that are 30 new beds for the existing 40-bed inpatient mental health unit, The Hollywood Clinic. It’s expected to open this month.
been in the chair a week when Medical Forum caught up with her. Shirley brings a wealth of clinical experience with her as former director of medical services at SJG Murdoch. Before that she was an infectious diseases physician at Fremantle Hospital. Shirley like her predecessor Prof Gavin Frost (both pictured here) has no statement to make on the Curtin proposal for a third medical school but did say that if we graduated more doctors the issue of postgraduate training needed to be debated. She said graduated doctors needed to know they could be trained beyond their degree.
New Dean at Notre Dame The doctors of the future will be taught continuous learning skills to help them face the challenges of a hi-tech, fast-changing society, but communication between doctor and patient is still the most important skill. These are a couple of first impressions from the new dean of the Notre Dame Medical School, Prof Shirley Bowen, who had only
Is there nothing a mobile phone can’t do? They are fast becoming the No.1 diagnostic tool and there’s competition in app land of Olympic-sized proportions to get onto your ‘mobile device’. The latest in pain apps include hush-hush work at Curtin University with face recognition and GPs are being targeted for GP Pain Help app created by the College for the Centre for Palliative Care Research and Education. The purpose is to help GPs manage the pain of patients at or near the end of life and includes a ‘treatment decision tree’, information on types of pain and various analgesics, dose conversion, FAQs, and palliative care resources.
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Have You Heard? remote areas. Prof Leon Flicker said the tool was a modification of the commonly used depression risk assessment tool Patient Health Questionnaire (PHQ-9). It has passed the trial of a cross-sectional survey of adults aged 45 years or over from six remote Indigenous communities in the Kimberley [30% from Derby]. It’s called the Kimberley Indigenous Cognitive Assessment of Depression (KICA-dep) and is free to download from www.wacha.org.au.
Kids’ Pain Clinic opens Medical Forum explored the issue of children’s pain in last August’s edition and the apparent need for a dedicated pain clinic at PMH. In an e-Poll at the time, more than half of those surveyed had no qualms about such a unit. We reported that funding was going to be allocated and now it’s official, there is a regular fortnightly clinic. There is still some recruitment for the multidisciplinary team, [comprising doctors, physiotherapists, OTs and clinical psychologists, led by a paediatric pain specialist] but there’s a lot of relief that the doors are open, particularly from parents who have lobbied hard for years for such a clinic.
Indigenous depression tool For those working in Aboriginal health, the WA Centre for Health & Ageing has developed a culturally appropriate screening tool to help diagnose depression in older Indigenous people, particularly living in
Supersize me Australian portion sizes are following the US model and are getting bigger. Add that to the old-school eating by rules rather than satiety (‘finishing everything on the plate’), eating too fast (satiety takes at least 10 minutes to build), larger portions – and the competition between food outlets – and it becomes an oversize problem. We over-consume even when it tastes lousy and we know better, so limiting portion sizes, for kids in particular, is gaining traction among public health
proponents. The irony is that despite the fact we’re eating more nutrients, parents in Oz are reportedly spending $40m a year on vitamin supplements for their children.
Watch for the fine print After seven years of producing the Specialists Directory for the ACT’s general practitioners, the ACT branch of the AMA is to also list GPs with a special interest, offering them and allied health providers the opportunity to take a paid display advert as well. Similar ideas by GP divisions in WA seem to have lapsed. All this coincides with AHPRA’s latest advertising guidelines, which says National Law protects titles rather than acts. This means those with a qualification that goes with specialisation cannot give the wrong impression they are a recognised specialist. The classic example is claiming a “paediatrics” special interest (e.g. DCH), when “paediatrics” might give health consumers the impression you are a paediatrician. If a complaint is upheld by them, AHPRA will write and ask you to fix anything misleading, and refer to a medical board if failure to remedy is regarded as unprofessional conduct. O
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Dedicated to Closing the Gaps ECU’s Prof Neil Thomson, recently retired after his long career in the service of Aborginal health, reflects on the changes he’s seen and those still needed.
here have been substantial changes in Indigenous health in the 37 years since I treated my first Aboriginal patient as a ‘fresh’ (if not young) intern at WA’s Fremantle Hospital. In anticipating my new career as a doctor from a previous life in mathematics and computing, I certainly couldn’t have foreseen what would occur or the nature of my involvement. My career in clinical medicine was really quite short, with the highlight being my time as a medical officer in both Wyndham and Derby and the RFDS. It was challenging and rewarding and, particularly, thought-provoking. After two years paediatric training at PMH, the Kimberley called and I moved from clinical medicine to population health. I was inspired by those Australian surgeons in the 1960s who, frustrated from treating severe road trauma because of the very limited use of seat-belts, saw that public health advocacy to make seat-belts mandatory, promised much better outcomes than surgical repairs. In a more modest way, I felt I could do more for Aboriginal health through population health.
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Perhaps it was fate, but the Canberra-based Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) was looking for a Senior Research Fellow to develop the knowledge base of Indigenous health to better inform practitioners and policy-makers. The role seemed to have been written for me.
Contextual changes in Indigenous Health When talking about changes in Indigenous health, most people focus on changes in health status. Being a population-health person, I want to also reflect on contextual changes, such as developments in Indigenous affairs, the active participation of Indigenous people in health planning, services and research, the enhancement of knowledge to inform practice and policy, and recent commitments to ‘closing the gaps’ in disadvantage between Indigenous and other Australians.
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In relation to health status, the final measure of lack of health is mortality. There’s evidence of improvements in life expectancy, but the actual extent is uncertain, partly because of improved data and changes in measurement methods. The most recent estimates – 69.1 years for males and 73.7 years for females – are better than those from the mid-1980s (55 years for males and 62-64 years for females). The infant mortality rate has declined dramatically since the mid-1970s – from about 50 infant deaths per 1000 live births (about four times the rate of non-Indigenous people) to 6.4 in 2010-2012 (less than twice the non-Indigenous rate). These great declines in the mortality of Indigenous infants and young children reflect a combination of better health care and major reductions in infectious diseases (which have also occurred among Indigenous adults). The reductions in infectious diseases since the second half of the 20th century have been largely counter-balanced by substantial increases in
the impact of chronic diseases (particularly cardiovascular disease, diabetes and chronic kidney disease) among Indigenous adults, a change that took some time to be fully acknowledged. These specific health changes of the past 60 years need to be considered in the broader social context; a useful starting point is the 1967 national referendum, which gave the Australian Government the power to legislate for Indigenous people, and provided for their inclusion in the census.
Milestones for Change The 1967 referendum was itself an expression of reconciliation, but the movement gathered momentum from 1991 when the Council for Aboriginal Reconciliation was established, largely in response to the report of the Royal Commission into Aboriginal Deaths in Custody. The report highlighted the links between dispossession and Indigenous disadvantage (in terms of poverty, poor health and limited education.) Not surprising then was the expanding role of real Indigenous involvement in health services. After the first Aboriginal Medical Service was established in Redfern (Sydney) in 1971, Aboriginal community-controlled health services (ACCHSs) have spread across the country: there are now more than 150 ACCHSs supported by the National Aboriginal Community Controlled Health Organisation (NACCHO) and its state and territory affiliates. These Indigenous-governed services are supported by a growing number of Indigenous people in the health workforce. The number of Indigenous doctors, for example, has grown from the first in 1983 to about 200 along with substantially increased numbers of other health professionals. Changes have also occurred in research, which has moved from research undertaken by non-Indigenous people about Indigenous health to Indigenous and non-Indigenous researchers for Indigenous health. I’ll never forget an important moment at a major NHMRC research conference in Alice Springs in 1986 when it was effectively ‘taken over’ by Indigenous people. This milestone ushered in the NHMRC’s first ethical guidelines in 1991. To its credit, the NHMRC has been supportive in recent years – almost 6% of its research funding in 2012 was allocated to more than 200 Indigenous health grants and it has Indigenous representation on its council and major committees. It has also supported Indigenous experts in most health research areas.
Health InfoNet Speeds Progress On a personal note, I’m proud of the translational research (TR) achievements of the Australian Indigenous HealthInfoNet, the leading online source of knowledge and information about Indigenous health. HealthInfoNet, one of two groups – the
other is the Closing the Gap Clearinghouse – put Australia at the forefront of TR with a population-health, rather than clinical, focus. HealthInfoNet was established in September 1997, but can be traced back to 1981, when I first started to collect, synthesise and disseminate information about Indigenous health at the AIATSIS.
In terms of closing the gaps in health, we need to acknowledge the scope of the challenge... it is crucial that our expectations are realistic.
In 2000, when the Council of Australian Governments (COAG), as part of its response to the final report of the Council for Aboriginal Reconciliation, agreed on a framework through which governments would continue their efforts to advance reconciliation and address Indigenous disadvantage. Ministerial councils, including the Australian Health Ministers’ Conference (AHMC), were given the responsibility of developing action plans, performance reporting strategies and benchmarks for programs and services. The commitment of COAG was welcome, but its slow progress, at least in relation to health, prompted the Aboriginal and Torres Strait Islander Social Justice Commissioner to call for a campaign to achieve Indigenous health equality within 25 years. It sparked groups to join forces and the ‘close the gap’ campaign was launched in April 2007.
health, housing, economic participation, and remote service delivery. Around $1.6 billion of this allocation – more than $800 million from the Australian Government and almost $772 million from state and territory governments – was for initiatives aimed at improving health outcomes. In April 2013, the Australian Government announced $777 million to continue health-directed initiatives for a further three years. Importantly, COAG commitments to closing the gap have bi-partisan and multi-government support. COAG re-iterated these commitments in December 2013 and it was most encouraging to hear Prime Minister Abbott declare in his February 2014 statement to Parliament that ‘there is probably no aspect of public policy on which there is more unity of purpose’ than in closing the gap between Indigenous and other Australians. The enormous transformation in recent decades in political – and national – thinking about Indigenous disadvantage raises real expectation that Australia will continue to work to redress our failures towards Australia’s first people. But in terms of closing the gaps in health, we need to acknowledge the scope of the challenge. History shows that improving the health of populations is generally a slow process. In view of the uncertain lead-time between many health programs/interventions and population health outcomes, it is crucial that our expectations are realistic. Our current commitments may need to be maintained for many years if we are to remove what Tony Abbott, in referring to Prime Minister Keating’s 1992 Redfern speech, recognises is a ‘stain on our soul’. O
Closing the Gap gets serious In 2008, $4.6 billion was allocated over four years across early childhood development,
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PERTH CLINIC PSYCHIATRISTS WEST PERTH LOCATION Current update of Accredited Psychiatrists at Perth Clinic Medical Suites and contact details.
33 Havelock Street Ph: 9488 2946 Fax: 9488 2954
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An Acute Admission Service is provided by Perth Clinic and a team of accredited Psychiatrists in providing admissions for patients who are going through an acute episode of mental illness and have not been seen by a Private Psychiatrist in the previous 12 months. One Psychiatrist is on call daily between the hours of 8am and 7pm Monday to Friday. In order to access the Acute Admission Service you will need to telephone Perth Clinic on (08) 9481 4888 and ask for the Admissions Manager. The Acute Admissions Manager is responsible for liaising with GP practices, Emergency Departments, patients and the on-call Psychiatrist. They can also provide advice on other services and alternative options of treatment. The Admissions Manager is available from 8am to 4pm Monday to Friday
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Maintaining the Passion and Numbers The former Under Treasurer Tim Marney comes to the role as Mental Health Commissioner with some signiﬁcant advantages and plenty of challenges. “The impetus is in recognition of the need for a continuum of care and prevention. Unfortunately we let people get far too sick who end up in an acute setting and that care is quite resource intensive. That’s not to say the acute setting is not crucially important, it is and always will be. We can’t suddenly ignore the acute setting and its resourcing.”
It was about two thirds into Medical Forum’s interview with the new Mental Health Commissioner Tim Marney when the heat began to rise. It had nothing to do with money, NGOs, economic modelling. It was something much more important – the suicide rate. Up to this point, discussion was about how to create a 10-year mental health plan that would be sustainable, serve the community and support those working in it. That was interesting enough and will be returned to, but if you were looking for reasons why this Class 1 economist would move from one of the most influential public service jobs in the state to a role that has more spikes and spines than an angry echidna, then the suicide rate is it in a nutshell.
“But in terms of getting innovation in a community based setting, we’ve need to look at traditional health/public health service and NGO service provision and what’s going to give us the best value of money and the best outcomes for the individual who needs to access the mental health system.” The practice may take some time to catch up to the theory and Tim says there’s a lot of learning still to do in this evolving landscape.
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“The death toll from suicide is higher than road accidents. That should invoke community outrage but it is taboo to talk about it. That needs to change. In 2012 on average we lost more than one person a day in WA a day. That’s not right. Some of that death toll probably could not have been avoided but a lot was.” “The media should be more open about talking about suicide, not individual cases but the prevalence and the devastation it causes. Interestingly if it’s a TV presenter or a rock star’s girlfriend it’s fine to report everything. People walk around saying, ‘isn’t it really sad’, but who is saying that for the one person every day who takes their own life here and the family that suffers for the rest of their lives.” “It is a tragedy and one that we all should be doing a lot more to prevent. It is a community responsibility to firstly talk about suicide and suicide prevention in a mature way and for communities to support people. It’s a responsibility for all of us. Quite frankly, the lack of outrage pisses me off.” The depth of passion in part can be explained by Tim Marney’s own experience of depression, which went undiagnosed for more than a decade. He’s been a campaigner for mental health ever since, including sitting on the board of Beyond Blue since 2008 [currently he’s Deputy Chair], which he will continue to do. medicalforum
“We have to bolster protections and if people have issues about service providers, they need to know where to go. How they raise those concerns and how we as a procurement body review those concerns to assure ourselves and relevant individuals that we have the appropriate safeguards.”
Commission’s role in procurement The past couple of months have seen Tim listening – a lot; to the vast array of representative groups, individuals, support groups, NGOs that constitute the mental health service. Some is news to him, some is not. “Through my old job I have had over a decade involvement in health reform. I was also responsible for government procurement at the Department of Treasury and Finance and that is a large part of what the commission does – it buys services. I was also involved in the economic audit which led to the current partnership framework with non-government service providers. I had a hand in the architecture in a lot of these issues, so it’s good to be on the implementation side.” The future of the sector will continue to evolve the ‘step-up, step-down’ model with nonacute services provided outside of traditional hospital clinical settings.
“In creating a market for service delivery, like any market, there’s going to be good suppliers and others. I think we need to be careful that we don’t blindly pursue NGO service provision for the sake of it. It has to demonstrate value for money and over time the market will evolve. Some will survive, some will thrive and there will be the others. That’s a symptom of a well-functioning market.” “The acute setting and the associated psychiatric settings are crucial and you can’t turn your back on those; you can’t suddenly transfer resources away from those because there’s a demand there that has to be met. So it’s a transition over time.” “What’s important is that we plan for that and the 10-year mental health services plan [expected to be released later this year] will provide that road map … that transition. That’s critically important for all consumers, carers and suppliers to understand where we’re headed and in the first instance a broad indication of how we’re going to get there.” Continued next page 19
Feature Continued from previous page
Maintaining the Passion and Numbers Of course, integration of the system is critical. â€œThere is no point in building a continuum of service if the navigation of that service isnâ€™t integrated. One of the priorities for the commission is make navigation easier so people get the right care at the right time for them, with an implication that itâ€™s at the right cost setting. The alternative is great care too late at too high a cost and poorer outcomes.â€? â€œThatâ€™s why Iâ€™ve spent the last four weeks listening because I need to understand all those competing perspectives and objectives. Once I have a sufficient level of understanding, it will be time to communicate back in terms of how we prioritise.â€?
Tapping into passion for change When it comes to where the Commissionâ€™s responsibilities start and end, the waters get muddier as discussion wades into the primary care space. â€œWe are not in that space but itâ€™s not that simple because the gaps in that space have implications for us and how we end up in acute and sub-acute settings. If we can invest strategically in primary care to reduce the impost at the acute and sub-acute level, the government has to seriously consider that.â€?
X Former WA Mental Health Commissioner Mr Eddie Bartnik has been appointed strategic adviser on mental health to the National Disability Insurance Agency (NDIA). X Former Perth doctor, Dr Richard Pestell, who is now director of the Kimmel Cancer Centre at Thomas Jefferson University in Philadelphia, has won the biotechnology category at the 2014 Advance Australian Global Awards. The awards recognise the work of Australians living overseas. Dr Pestell graduated from UWA in 1981. X The former medical director at SJG Murdoch, Dr Shirley Bowen, is the new Dean of Notre Dameâ€™s School of Medicine. X The Western Australian Centre for Rural Healthâ€™s [formerly CUCHR] state-of-the-art EdSIM Centre was open last month by the Federal Assistant/Minister for Health, Senator Fiona Nash and WA Minister for Regional Development, Mr Terry 20
Tim says there is great passion in the mental health arena. Having met numerous doctor groups in the past weeks, he says they all see opportunities to do things better.
but passion without appropriate systems, processes and capabilities just ends up in frustration. Thereâ€™s a bit of that in the system at the moment.â€?
â€œPart of the challenge is that they are so busy delivering services. They are so focused on doing the business they donâ€™t have time to run the business and that is the challenge in health systems around the country.
â€œChanging culture and practice takes time. It might be a difficult transition but a worthwhile outcome.â€? O
â€œThe system creates incentives whether itâ€™s consciously determined or subconsciously evolves. We have to stand back and look at that and question whether they are the right incentives and whether or not they force clinicians to operate in a way that works against effective integration across service levels.â€? â€œIn the current environment we have a whole raft of reforms around activity-based funding and they will increasingly be a feature in the mental health landscape as well. So we need to be careful that in implementing that regime of system management, we create the right incentives for clinicians and service providers around effectiveness and inspiration.â€? â€œThere is incredible passion in the system which is fantastic â€“ itâ€™s a necessary part
Redman. The name change became official at the launch. The director of WACRH is Dr Sandra Thompson. X Ms Lorraine Willis is the new national events team leader at Cancer Council WA, responsible for events including Australiaâ€™s Biggest Morning Tea, Daffodil Day, Girls Night In and Pink Ribbon Day. X Hollywood Private Hospital medical director, Dr Daniel Heredia, and CEO of the WA Council of Social Service, Ms Irina Cattalini, were finalists in the 40 Under 40 awards run by Business News. X Ms Rachael Hadlow, from Third Avenue Surgery, Mt Lawley, has received an AAPM scholarship to study at the University of New England in Armidale, NSW. The scholarship is sponsored by Avant. X A/Prof Foteini Hassiotou of UWAâ€™s Hartmann Human Lactation Research Group has been awarded
By Ms Jan Hallam
MENTAL HEALTH COMMISSION t t t
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two major international grants â€“ a postdoctoral fellowship from the American Association of Anatomists and a $900,000 grant from Swiss group Medela AG for her work into human breast milk. X Prof Martin Hagger from the School of Psychology and Speech Pathology at Curtin University has been awarded an Honorary Fellowship of the European Health Psychology Society (EHPS). X UWA Engineering student Ms Loretta Scolaro (with supervisor Prof David Sampson) has won the Canon Extreme Imaging competition for her imaging device which is hoped will improve intra-operative cancer detection for women with breast cancer. X The Deputy CEO of the national Mental Health Commission, Ms Georgie Harman, has been appointed CEO of Beyond Blue. medicalforum
Mental Health Canâ€™t Stand Still WA Chief Psychiatrist Dr Nathan Gibson says while the mental health landscape is ever-changing, the rewards are constant â€“ working with patients and families.
survey of medical students in recent years listed psychiatry as one of the two leastfavoured career paths. An observation: Mental Health is an intellectual and challenging area for those who thrive on compassionate care and complex uncertainty â€“ a career for the doctor who enjoys working collaboratively with patients and their families.
There is no greater evidence for the challenge of change than the current situation in WA: a new Mental Health Bill (likely to become enacted in coming months); a new WA Mental Health Commissioner; a new State 10-Year Mental Health Plan; a new Diagnostic and Statistical Manual for Mental Disorders (aka DSM 5, from the American Psychiatric Association); an emergent and informed consumer and carer movement; and the steady, inexorably rising public demand for increased services. This last one is not new.
It is the next iterative step in the fraught yet inevitable process of classification in mental illness. Itâ€™s no bible, and it is but one of the tools a psychiatrist may consider. Donâ€™t forget we have the International Classification of Diseases (ICD 10) as the World Health Organisationâ€™s classification system, which is arguably more influential at an international level. The new Mental Health Bill is important for all doctors. GPs will use it rarely, but it will be important to know where to get information when you are considering its use. The WA Chief Psychiatristâ€™s website will have easily digestible information about a doctorâ€™s statutory responsibility around the new legislation. Once it is enacted, there will still be a 12-month implementation period before the new Act practically starts to be applied. There will be an education campaign to inform psychiatrists, registrars, ED physicians, GPs, and in fact all doctors
For the first couple of years after the new Bill becomes the formal Mental Health Act there will be a significant transition as clinicians get used to the new processes, forms and reporting. Overall, the new Bill is a positive step forward in modern mental health legislation â€“ but the hard work lays ahead. Informed, engaged and empowered patients and their families make our jobs much easier in dealing with the clinical, ethical and risk tensions inherent in severe mental illness. This is, of course, not always about agreeing on diagnosis or treatment decisions, but itâ€™s about walking beside the person as they negotiate often life-changing illness. Thereâ€™s great value in that. Changes in legislation and administration (and administrators) are now preordained in mental health and all health environments. These broader structures provide the scaffolding for the inherently important stuff â€“ the core of specialist mental health
The WA Mental Health Commission purchases and plans all publicly-funded mental health services in WA. The Commission rightly continues to push for development of the community sector in mental health service provision, mirroring the expanding picture in most states. But in this context, it remains a significant juggle to get the balance right between the nongovernment sector and public mental health services â€“ both are integral components. On the ground, there is no doubt that psychiatrists and their registrars are feeling the sustained pressure of significant caseloadss as they work to keep the needs of individual patients at the forefront of care.
Mental health blueprint The State 10-Year Mental Health Plan, being drafted by the Commission, is due out later this year. This blueprint will be a critically important guide during this period of intense budget scrutiny. Our new Commissioner will be well-placed to negotiate these tougher times. The Plan must consider the clearlystated recommendations of the Stokes Review, particularly around care planning and communication in mental health service provision. Nothing is ever static in mental health, including illness classification. There was a flurry of commentary around the new DSM 5 in 2013 â€“ statements from high profile psychiatrists about DSM 5 â€œmedicalising normal behaviourâ€? abounded in the media. Despite this, DSM 5 is not a game-changer. medicalforum
QWA Lunacy Act 1871: â€œ..for the Safe Custody of, and Prevention of Crimes by, persons dangerously Insane; for the Care and Maintenance of persons of Unsound Mindâ€Śâ€? â€“ weâ€™ve come a long way since 1871.
and clinicians who might be required to use the new law.
What legislation changes The changes in the new legislation are huge, but can be summarised as: t HSFBUFSSJHIUTGPSQBUJFOUT t NPSFSFTQPOTJCJMJUZPODMJOJDJBOTUP engage with families t HSFBUFSOPODMJOJDBMPWFSTJHIU WJBUIF Mental Health Review Tribunal) for the care of involuntary patients
care â€“ the principles of quality clinical care and human rights. In essence, mental health is about the relationship we have with our patients and their families. That continues to be, and will always be, the most rewarding part of our work. To all medical student colleagues who listed psychiatry as their least preferred career option on that infamous survey â€“ think again! O
t JODSFBTFESFQPSUJOHBSPVOENFOUBM health service activity and events e.g. Electroconvulsive Therapy (ECT), seclusion, adverse outcomes. 21
Medicine in Action
Q Kerry Goulet
Skating on Thin Ice with Concussion The management of concussion injury will be high on the agenda when the US and Canada ice hockey teams play in Perth in July. International ice hockey is not for the fainthearted and when you throw in the intense rivalry of the US and Canada, their sold-out games at the Perth Arena will be pressure-cooker affairs, Tour director Kerry Goulet says concussion is a sports injury that the game is keen to address and hopes to touch base with local sports physicians on the issue when he is in town. Kerry, who is a former major-league player, remains undiminished despite his own concussion injuries and numerous stitches in his face. “The International Series will showcase the fastest game on the planet and the players are keen to spread the popularity of ice hockey around the globe but we’re
all well aware of the risks the game entails. I suffered three documented concussions during my playing career and in the 1990s there was something of a gladiatorial attitude.” “There wasn’t the same awareness as there is now and no real treatment options so we just played on.” There have been some recent ‘horror stories’ regarding head injuries incurred on the sporting field, including the death of Jake Kedzlie in NSW, a talented young footballer and grandson of rugby league legend Tommy Raudonikis. “In a book I’ve co-authored with Keith Primeau, a former international player and coach of the US team, we talk about a young man who lost his life on his fourth
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concussion, each one attributed to a different sport. While we love to see young people taking up ice hockey we’re also absolutely committed to making it safer. Our online platform, stopconcussions.com is an integral part of achieving this goal.” In the April issue of Medical Forum sports physician, Dr Peter Steele reiterated the general consensus that concussion is now regarded as a ‘disturbance of brain function rather than a structural injury.’ Keith Goulet, who’s experienced this from both sides of the hockey puck, supports this view. “I couldn’t agree more. I’m not a doctor but I’ve lived through the dark side of concussion and emerged relatively unscathed. I’ve had no major ill-effects apart from the occasional lapse of memory, and I’m hoping that’s just part of the normal ageing process.” “And, on the other side of the coin, I’ve had a close look at the medical repercussions of these injuries with the help of some highly regarded experts at the University of Pittsburgh Medical Centre and Boston University.” “In relation to these internationals, we’ll be bringing our own medical team to Perth [Sydney, Melbourne and Brisbane] and also seeking the involvement of local medical practitioners.” The fact that Canada won the gold medal at the Sochi Winter Olympics adds another frisson of excitement to the match-ups in mid-July but Keith bristles at any suggestion that there will be a ‘staged’ element to the action on the ice. “The teams are competing for the title of International Ice Hockey 2014 Champions. Sports fans in Perth will be seeing hardhitting, action-packed ice hockey!” O
Counselling and Support Life Changing
By Mr Peter McClelland medicalforum
News & Views
MDA/MIGA Merger Likely The proposed merger of MDA National and MIGA would reduce the market to three medical indemnity providers, with the new organisation, to be known as Medical Defence Australia, representing about 35% of the market, facing off against Avant and MIPS.
The Australian Game While still a fledgling sport in Australia, ice hockey is increasing in popularity sporting its own national league, which features a team from WA, Perth Thunder, and a local league overseen by Ice Hockey WA. Here the sport is regulated. The CMO of Ice Hockey Australia, Dr Rob Reid, has been involved in the sport since 1993 and has been CMO for the past eight years. â€œAbout 3500 people play nationally and I receive reports on all major ice hockey injuries and the rate is a lot lower than a comparable contact game such as rugby union. Of course, concussion is a potential problem in all collision sports.â€? â€œOur game is somewhat different to North America, we play under the umbrella of the International Ice Hockey Federation (IIHF) and that means the rules are constantly reviewed to make the game as safe as possible.â€? â€œAnd we certainly donâ€™t tolerate fighting on the ice rink. We want people to come to the game for the contest itself, not to see players punching each other.â€?
However MIGA and MDA National said premium increases were unlikely. MDA National Managing Director Prof Julian Rait told Medical Forum that the merger would be an equal partnership and create a robust environment. â€œPeople ask this question on commercial transactions but when weâ€™re talking about two doctor mutuals weâ€™re talking about two groups of colleagues and the idea of one taking over the other is inappropriate. What we are trying to do is combine the two organisations and get the best of both.â€? â€œMDA is slightly larger in terms of capital and membership (which was estimated about 35,000) but nevertheless we have approached this like a partnership.â€? Julian said that the doctors for doctors culture of the two organisations were similar as was their philosophy on member engagement. â€œWhat heartened us when we were exploring this arrangement was how the leadership and membership of MIGA felt similar to ours.â€? The merger is a proposal only and is subject to approval from medical and corporate
â€œItâ€™s not a good look for the game to see players fighting. And you have to remember that sometimes short film clips tend to highlight that aspect rather than the excitement of scoring goals, so you can get a distorted view.â€? â€œThe game is becoming increasingly popular in Perth right through from an Under 13 competition to Super League.â€? O
If all goes to plan, the merger will be put to the members in the last quarter of this year.
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President of Ice Hockey WA Paul McCann argues that the sport is comparatively safe with a small number of documented injuries. â€œThereâ€™s a greater focus on skating fast and passing the puck so we see very few concussions on the ice. Helmets, padding and mouth-guards are compulsory and the majority of injuries are shoulders, knees and ankles.â€?
regulators as well a vote from the membership of both QMDA National President, organisations. Prof Julian Rait MDA National has a historical stronghold in WA, while MIGAâ€™s foundations are in South Australia. Julian was determined that WAâ€™s â€œindependent and innovative approach to businessâ€? would continue.
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Frozen in time The overworked Coroner’s Court can’t keep up and it’s leaving families like health advocate Geoff Diver’s family in heartaching limbo.
y daughter hasn’t even been given the dubious accolade of being made a statistic yet, and it’s more than three years since she died. Her death certificate is incomplete. It doesn’t say how she died.
She took her own life at age 18. The anonymous people who found her cold, lifeless body in a public park know how she died. The police know how she died. The family accept that is how she died. The media reported that is how she died. The Department of Health enquiries are premised on the fact of that is how she died. But yet her death still isn’t recorded in the statistical set for suicides. The Coronial Inquest into Ruby’s death hasn’t yet been held. The Coroner’s Court wrote to me in April last year saying there would be an inquest but unable to give a date. Ruby died somewhere on the night of the March 1 and 2, 2011. I made enquiries of the Coroner’s Court as the third commemoration of her death approached this year. They are
lovely people there. Overworked and dealing with tragedy after tragedy. No one goes to the Coroner’s Court with a happy story! They tell me there are many cases ahead of the Court. They say it is unlikely the case will be held this half of the year. Neither they nor I know when it will be held. Maybe time will stretch out and it will be four years after her death? In the meantime she doesn’t appear in the suicide statistics at a time when suicide is already at an all-time high. Researchers reviewing suicide won’t see her. Health experts planning new services or facilities won’t see her. If she died as a result of a systemic failure in the system which is taking lives, more lives will be lost as the Coroner hasn’t seen her. I saw her. In the vile State Mortuary where there was a tin of supermarket grade air freshener and her mother and I had to spray it ourselves. I saw her. In a lovely white coffin in a beautiful red dress her sister and I chose for her funeral. I saw her. In an anonymous
grey plastic container as ashes as I flew her back to her mother in New Zealand so her more distant family may play some part in saying goodbye. I see her. Every day on my phone there is a picture of her. I see her. At Fremantle cemetery there is a plaque beside that of her sister which says “Shine On”. I see her. When I visit the park in Bicton where she was found and lay red roses at the foot of THAT tree. I see her. When I visit my surviving daughter, her memory resonates in the tears we cry. My daughter hasn’t even been given the dubious accolade of being made a statistic yet, and it’s more than three years since she died. Surely the dead deserve better as do the living who might be saved by the lessons learnt. I know the Coroner’s Court deserves better resourcing. O
Patient Blood Management as a Standard of Care in Australia: Past, Present and Future The Western Australia Department of Health and the National Blood Authority are proud to host Australia’s inaugural Patient Blood Management Conference “ Patient Blood Management as a Standard
of Care in Australia: Past, Present and Future”. The Conference will be held in Perth on 20 and 21 June 2014 at the Perth Convention and Exhibition Centre. Speakers at the Conference will include: x Michael Lill (United States) who will share his experience of restrictive blood use with myelodysplastic syndrome and bone marrow transplant patients. x Stephan Von Haehling (Germany) who will talk about iron deficiency in cardiac failure and management of anaemic medical patients. x Axel Hofmann (Austria), a health economist who will present the facts about the true cost of blood. Registrations for the Conference are filling fast. To see the full program and to reserve your place for this exciting event, please visit www.health.wa.gov.au/bloodmanagement/home For more information please contact Trudi.Gallagher@health.wa.gov.au
Good Medicine Can Stand Still Shenton Park GP and musculoskeletal physician, Dr Richard Yin, is a ﬁrm believer in the power of training the mind to overcome illness stress.
started studying meditation during my internship. Initially, it was a form of stress management but as I explored the practice more deeply I was astounded at both the breadth of its foundations and the framework it provided for experiential learning. A lot of people are quite confused about meditation. Many believe it’s merely a relaxation technique or a state of mind but I feel that it should be regarded as a form of ‘mind training’. Just as an athlete trains and strengthens muscles, when you meditate you strengthen and reinforce the capacity for calm and mindfulness. This fosters an open, non-judgemental awareness and qualities of compassion and kindness.
and pain. Furthermore, there are trials under way studying the links between meditation and the development of compassion. I’ve been teaching the discipline for the last three years and running a weekly meditation session. It’s quite common for 40-50 people to enrol in a course that’s advertised mainly by word of mouth.
Perhaps meditation and its ability to cultivate compassion should have a place in the training of young doctors.
Current understandings in neurobiology suggest that during meditation certain neural pathways are strengthened and reinforced.
Perhaps this reflects an unmet need within the community for some sanity in an insanely frenetic world.
And there are significant health benefits. A recent meta-analysis review of more than 18,000 citations and 47 trials relating to meditation programs revealed improvements in people suffering from depression, anxiety
I also teach meditation to my patients who are suffering chronic pain. For some people, an illness such as this poses an existential question about the meaning of their lives. Often they no longer work and they’re faced
with waking to another day of pain, fatigue and depression. This technique offers them a way to reduce their pain and also provides them with another approach to living despite their problems. In our contemporary hyper-stimulated world meditation doesn’t ease the stress completely but it has given me the means of finding a measure of calm in the midst of life’s uncertainties. I am concerned that in an outcomesdriven approach linked with technological fixes we’ve lost something of the ‘heart’ of medicine. When there’s nothing more we can do for a patient our capacity to remain open, compassionate and supportive becomes even more important. Tibetan Buddhists speak of the ‘two wings of wisdom and compassion’ in the practice of healing and sometimes I wonder if we’ve been flying on just one. Perhaps meditation and its ability to cultivate compassion should have a place in the training of young doctors. O
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BOOK ONLINE Alternatively phone for an appointment 13 20 50 Women who have received a letter from BreastScreen WA, or are 50 years or over, can now go online to book a standard appointment at any of our nine metropolitan clinics.
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Skin excision – the Halo Graft
By Dr Denis Caragher, Kalamunda. Tel 9293 4455
he Halo graft was designed by Dr Sharad Paul from New Zealand for use in countries with less sophisticated health systems than we enjoy. The concept involves a modified split skin graft, which had two major advantages: skin comes from the same site as the lesion, therefore only one wound; and the patient can walk out of the clinic and not need further dressings for a week. I apply Dr Paul’s concepts to Aged Care Facility patients and walkin, walk-out clinics in urban Perth.
I have now done about 20 excisions, mainly lower limb but also involving the arm and scalp. The technique is particularly useful for any site where flap construct can be difficult, perhaps due to complexity or the size of the lesion to be excised. Excision of melanoma can be done in this way, ensuring adequate excision margin. Residual skin colour is good and there appears to be relatively little depression at the operation site. O
CASE REPORT Patient with a large BCC on their leg – the area was cleaned and marked as shown (see Fig 1). The lesion was removed using the inner circle margins and sent to histology to ensure excision was complete. To cover the resulting central defect, new skin was harvested from between the two marked circles using a scalpel blade; the resulting splitskin-graft pieces were slightly thicker on the edge formed by the inner circle,
compared to the outer circle edge. Each piece was positioned to provide best coverage of the excised skin area (see demonstration on You Tube by searching “halo graft”; complete coverage is not critical). A pressure dressing of Bactigras under Melonin, under gauze dressing, with final ankle-to-knee crepe bandage was applied. (Extra taping with Micropore can prevent slippage and inquisitive fingers.) The patient returns for re-dressing in a week (or earlier
if there is increasing pain), at which time a similar dressing is applied without disturbing the Bactigras, to be removed a week later at further re-dressing, and again redressed at the end of week three (see Fig 2). Healing occurs partly from epithelial migration across any defect. Final healing at about six months is shown in Fig 3, with minimal full thickness scarring.
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Peanut Anaphylaxis at School
â€œOne of my child patients has an EpiPen at pre-primary for severe peanut allergy. The parents worry about inadvertent peanut exposure and no experienced staff to administer the EpiPen. What can parents reasonably expect from school staff these days?â€? Response: By Sallee Pettit, Principal Consultant K-12 Coordination
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
by Medical Director Dr John Yovich
Delivering PIVET expertise interstate â€Ś100th Baby milestone in Cairns
All schools now have access to training about preventing and managing anaphylaxis and principals must ensure an adequate number of staff complete the training. Principals decide how many staff members are to be trained, taking into account factors such as the size and layout of the school, number of students with anaphylaxis and proximity to medical assistance. The online training covers signs and symptoms of anaphylaxis, health care planning for students with anaphylaxis, legislation and policy, responding to anaphylactic emergencies (including how to administer adrenaline auto-injectors) and whole school approaches to risk management. Risk management includes taking steps to reduce the risk of exposure to known allergens. This may include promotion of hand washing before and after eating, cleaning of environmental surfaces and not allowing students to share food. Banning of particular foods is not recommended as there are so many different allergens and compliance is impossible to guarantee. Each school has been funded to include adrenaline auto-injectors in their first aid kits for emergency use when prescribed auto-injectors are not available. On request, school nurses will demonstrate to school staff how to administer an adrenaline auto-injector.
Readers may recall PIVETâ€™s report in Medical Forum WA of January 2010 on the opening ceremony for Cairns Fertility Centre. CFC is totally PIVET owned and administered from Perth. It functions under my Medical Directorship, with PIVET-trained staff on the ground.
Fig. 1. Senator The Hon. Jan McLucas and 0LQLVWHU7KH+RQ'HVOH\%R\OHRIĂ€FLDOO\ opening CFC on 22 October 2009 with Medical Director Dr John Yovich
Although it was established to handle overseas patients, especially from Japan, that has only resulted in a trickle of FDVHVKHQFHWKHPDLQSDWLHQWĂ RZKDVVRIDUEHHQIURPORFDO and regional Queenslanders. The outcomes of treatment have matched the excellent â€œTop of the Wazzaâ€? pregnancy rates of PIVET in Perth and the 100th baby was born in October 2013, exactly four years from the launch. Jeannette Kingsfordâ€™s story was picked up by the Cairns Post DW&)&ÂˇVDQQXDO0XPV %XEVPRUQLQJWHD+HUVWRU\UHĂ HFWHG PDQ\SUHYLRXV,9)IDLOXUHVDQGĂ€YHPLVFDUULDJHVDOOUHVROYHGDW age 42 years by applying PIVETâ€™s unique clinical and laboratory management protocols. CFC is now attracting attention from other regional and Asian countries and may help to reverse the tide of medical tourists going to those countries from Australia.
It should be noted that the Department would not advise that a preprimary student carry an adrenaline auto-injector in the playground. Schools are advised to store adrenaline auto-injectors in a safe, readily accessible place, taking into account the need to store them at between 18-25C. O ED: On the patientâ€™s side, responsibilities are: the parent must disclose the problem when enrolling their child; parents and school sign off on a health care plan (Health Care Authorisation); and as part of this, the childâ€™s doctor has to sign off on appropriate use of EpiPen (using the ASCIA form on their website). Allergy & Anaphylaxis Australia is providing a teaching resource for schools across Australia (Be a MATE) to educate children about food allergy and recognising severe reactions.
Fig. 2. Happy mum Jeannette Kingsford with her only child, nine-week son Aaron, as reported in Cairns Post: 17 December 2013.
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rTMS â€“ an emerging novel treatment for depression R
Depression Treatment Clinic, 141 patients completed the treatment. Most referrals were from psychiatrists in private practice and some from general practitioners.
epetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive brain stimulation technique that delivers repetitive pulses of magnetic field from an electromagnetic coil placed over the scalp to activate neurons in a selected area of the brain. It has been studied as a possible treatment for a wide range of neurological and psychiatric conditions, and is emerging into clinical practice as a safe and efficacious treatment for depression. Although using magnetic pulses, rTMS induces electrical stimulation to the brain. Magnetic pulses pass unimpeded through the skull and stimulate the brain tissue beneath, inducing small electric currents to force neurons in the targeted brain region to fire. Repeated neuron firing putatively produces changes in neuronal functions and neuroplasticity that may help normalise activity in the area stimulated. When the stimulus is applied to the dorsolateral prefrontal cortex involved in mood regulation, the neuron firing leads to mood changes and alleviation of depression. rTMS has been investigated as a treatment for depression since the mid-1990s. It has been approved for clinical use in many countries including Canada, Israel, Australia and the US. It is currently only available in certain academic and tertiary centres in Australia. An application has been lodged requesting Medicare Benefits Schedule listing of rTMS for treatment-resistant major depression. While it is generally safe and well tolerated, the overall efficacy is considered modest (effect size about 0.5), and various refinements to the treatment are being studied to lift this. The North Metropolitan Health Service Mental Health established an rTMS research
By Prof Joseph Lee, Clinical Director, rTMS Depression Treatment Clinic, NMHS Mental Health, Professor of Psychiatry, UWA
Patients suffered predominantly from treatment-resistant depression, typically having failed multiple antidepressants and other treatments (including electroconvulsive therapy). Nearly 30% of the 141 patients achieved remission while a further 40% showed clinically significant improvement. The treatment was generally safe and very well tolerated. Transient scalp discomfort and headaches, usually mild, were the most common adverse effects experienced. The treatment outcomes, consistent with previous research findings, support that the operation of a clinical service for rTMS is an effective means of delivering the treatment for depression. program at the Graylands Campus in 2005 for rTMS clinical trials and the rTMS Depression Treatment Clinic was established in July 2011 to provide treatment upon medical referral. rTMS is conducted in a specially equipped room while the patient is sitting in a chair. The rTMS stimulus coil is positioned to just touch the head. Stimulus intensity is adjusted for each individualâ€™s neuronal threshold. Each treatment session takes 20-30 minutes and patients usually receive 20 sessions scheduled over four weeks. Extended treatment may be given to maximize benefit. Using the Hamilton Depression Rating Scale (HamD-21) to assess treatment responses, the aim of the treatment is to achieve remission (HamD-21 < 8) or significant clinical response (> 50% reduction in HamD-21 score). From 223 referrals to the rTMS research program or the rTMS
The clinical use of rTMS for depression is likely to expand and the treatment to become more accessible. We are learning to optimise its use and refinements are being studied to enhance responses to the treatment. O Further reading: 1. Fitzgerald, P. B. Transcranial magnetic stimulationbased methods in the treatment of depression. Australian Prescriber. 2012; 35(2): 59-61. 2. Kammer T and Spitzer M. (2012) Brain stimulation in psychiatry: methods and magnets, patients and parameters. Current Opinion in Psychiatry. 2012; 25: 535-541.
Author competing interests: No relevant disclosures
RU 486 prescribing in WA
ny GP can register to prescribe RU 486 â€“ they just have to ensure they can provide the necessary backup for women who do not completely terminate or develop complications, and know about the risks and contraindications for treatment. This comes from prerequisite training modules completed online at the MS-2 Step website through Marie Stopes Health (contact 0417 744 207 Carl Orio or see www.ms2step.com.au). To get started you will need your AHPRA number, and register on the website. Course duration is given as 275 mins with 100% pass mark required (it medicalforum
took me 90 minutes). Advanced diplomats of RANZCOG avoid this requirement. Once completed and passed, you become an approved prescriber and go on a prescriber list that any supplying pharmacist will need to look up for each RU486 script (using www.ms2step.com.au). When a woman presents, the sort of protocol followed includes: t 1SPWJEFJOGPSNBUJPOIBOEPVUTBOE counselling. t $POGJSNQSFHOBODZXJUIVSJOFUFTU and gestation before seven weeks (with ultrasound, if needed).
t %PCMPPEUFTUTJGVODFSUBJOPGQSFHOBODZ t "SSBOHFDVSFUUFJGUSFBUNFOUJTOPU successful (5%). t $POGJSN.501XJUIQSFHOBODZUFTUBU 14-21 day follow-up. t "SSBOHFGPMMPXVQDPOUSBDFQUJPO NB. Authority script is required through an authorised pharmacy â€“ $36.90 for 200mg tab mifepristone (competitive progesterone inhibitor), $13.20 for four tabs of 200 microgram misoprostol (prostaglandin analogue). O
Barriers to non-drug therapy for chronic pain By Dr John Salmon, Pain Medicine Specialist
rovision for bio-psychosocial management of chronic pain remains miniscule considering the massive health cost and economic loss resulting from ineffective biomedical treatment.
Thus the model rewards investigations and interventions.
Some 20% of the Australian population (including over 10% of children and adolescents) suffer from chronic pain.
However, they could recognise that medical interventions and medications will produce much better long-term outcomes if selectively applied and integrated with an adequate bio-psychosocial treatment framework.
Those at the moderate to severe end of the chronic pain spectrum have often developed neuropathic or neuroplastic pain mechanisms superimposed on nociceptive pain. As the severity of pain and disability increases so does the impact of mood disturbance, maladaptive beliefs and activity patterns. Hopelessness and helplessness can become the norm. The biomedical model is based on the notion of a strong link between structural pathology, pain and disability. It relies on mechanistic interventions to fix pathology or, failing that, the use of analgesics as a long-term management solution. There is strong evidence that these assumptions are mistaken and that prescription of opiates for chronic pain can become relatively ineffective or in many cases harmful to both individuals and society.
Changing thinking The biomedical model applied to pain is simple, logical, plausible and wrong. The public and private health systems, Medicare item numbers and hospital billing strategies are all based on identifying and treating structural pathology based diagnoses or DSM5 psychiatric diagnoses.
Medical specialties whose incomes are dependent on biomedical investigation and treatment can be expected to resist change.
This is a win-win for doctors and patients and is cost-effective healthcare. Many doctors are largely unaware of the science of pain mechanisms and related disability. The complexities of neuroscience and the bio-psychosocial model make clinging to the ‘old school’ biomedical model appealing.
What can prompt change? We need a greater emphasis on teaching of pain medicine. Pain is the most common reason patients come to see doctors. The concepts of neuroplasticity and mindbody-society medicine exemplified in the phenomenon of persistent pain have huge relevance to all medical practice. University of Notre Dame is currently creating a chair of pain medicine, which is a start. Doctor’s must consider the power of their words. They should stop telling patients that their spines/joints are ‘stuffed’ based on an imaging report and then launch them on a relentless search for a techno or drug fix. Every tissue in the body is ultimately connected to the brain. They
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If neuropathic pain characteristics present, consider CBT pain management and a trial of neuromodulation procedures first. Early detection of psychosocial risk of chronicity by systematic use of screening questionnaires such as Orebro or StartBack can help, and also identifying significant interactive anxiety and depression using tools like DASS. Identification of risk must then be acted upon with early application of adequate biopsychosocial orientated interventions.
Bio-psychosocial management Medicare needs to support this with item numbers to cover adequate-length pain management consultations and interdisciplinary CBT-based pain management treatment, including both two-day group programs and intensive 100hour program treatment. To produce significant and durable behaviour change in the more disabled group requires an intensive 100-hourplus high-quality multidisciplinary CBT program with adequate coordinated rehabilitation post-program for work return. There is currently no provision for such an intensive inpatient treatment program in Perth. If the demand is there and the funding format available, then the services will evolve. In Perth there are excellent physios, psychologists and OTs who, with a bit of organisation and further training, could be linked to each other and to pain medicine orientated doctors to provide management networks.
Dr. Sina M. Keihani MBBS, FRACP Respiratory Physician 78 Farrington Road, Leeming WA 6149 P: 08 6161 7647 (bookings) | F: 08 6162 0547
should remember to consider that over 20% of surgical interventions including joint replacement result in new persistent pain. First do no harm.
ail em u e .a as ple om s, d.c d a me lp rra leep e f s r re n@ Fo dmi a
However, to be effective these teams need to be truly integrated with a unified model and message and achieving this is a considerable challenge. Currently there are few such teams in the private or public sector. Effective evidence-based Web programs now exist. Check out eCentreClinic’s Pain Course (Macquarie Uni NSW) Perhaps the looming crisis in health care costs will eventually compel appropriate funding priorities. O
Author competing interests: No relevant disclosures
Persistent pelvic pain in women By Dr Tim Pavy, Head Anaesthesia and Pain Medicine, Director Pelvic Pain Clinic KEMH
n reality, much of the pelvic pain seen at the KEMH Pelvic Pain Clinic has persisted longer than it should, such as after child birth or surgery. There are ways and means of interrupting the pain and giving people the chance to resume reasonably normal lives.
Therapy in such cases consists of reasonably straight forward injections into the offending trigger points (with long acting local anaesthetic, often combined with long acting steroid) in the hope of settling down this local pain.
Roughly, at the clinic, pelvic pain causation is divided into one third each of:
This source of pelvic pain often follows vaginal delivery. Some argue that all deliveries produce a degree of pudendal neuralgia in that the pudendal nerve is stretched considerably during childbirth and not all recover completely.
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Referred pain Fashionably termed abdominovisceral hyperalgesia, this is a complicated way of saying the pain reported in the pelvis appears to be coming from viscera but is in fact referred from relatively trivial abdominal wall trigger points.
There is also predisposing anatomical variation whereby the path for the nerve around the ischial spines is unusually tight. Some of these patients benefit from injections in and around the nerve, and some benefit from injections of Botox into the pelvic floor to release the pressure on the nerve itself.
This common phenomenon is seen in pelvic pain clinics worldwide, whereby a previous insult (e.g. endometriosis or pelvic infection), now resolved pathologically, continues to produce pain via relatively innocuous muscular trigger points that developed in response to the earlier illness, or for another reason.
Telling these women â€œthere is nothing wrong inside your pelvisâ€? may not be particularly helpful, just like someone with phantom limb pain following amputation of a gangrenous limb does not appreciate that the source of ischaemia has been removed.
Key areas of overlap are in vulvodynia/ vulvovestibulitis and whether or not there may be an antecedent vulval infection. In the mouse model, for instance, chronic exposure to otherwise benign Candida sets up persistent pain.
This trigger point memory for pain can persist for many years. Fortunately, trigger points (whether latent or active) are usually easily palpable as painful nodules within muscle, along the body of the muscle or where it attaches to fascia. Palpation often reproduces the pain along with other associated gynae or urological symptoms.
There is overlap in our clinic with that of the sexual health and endogyne clinics. And it is to be hoped a multidisciplinary approach to this complex area will emerge for those women who have suffered for many years with pelvic pain of one sort or another.
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eference Stacy J, Frawley H, Powell G, Goucke R, Pavy T. Persistent Pelvic Pain: Rising to the challenge. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2012; 52:502-7 O Author Declaration: no competing interests
INNER METRO GP LOOKING AT MOVING TO OUTER METRO? Bentley-Armadale Medicare Local (BAML) is pleased to announce that as part of the Outer Metropolitan Relocation Incentive Grant (OMRIG) programme, there is a limited number of grants of up to $30,000 for GPâ€™s to relocate from an inner metro region to outer metro within the BAML region. If you are interested but donâ€™t know of a Practice requiring a GP, BAML has a list of Practices willing to host a GP as part of this grant.
In our clinic, the most common muscles to be involved, as described by Carnet, are at the junction of external oblique and rectus abdominis, accentuated by getting the woman to raise her head off the pillow.
For further information please contact Simon Perkins on 08 6253 2100 or firstname.lastname@example.org 31
Medical Audiology Services
Hear the best you can! By Dr Vesna Maric, Audiologist B.Sc.(Hons)., M.Clin.Aud., M.Aud.S.A., Au.D.
Is it more than ringing in the ears? What is the prevalence of tinnitus? Tinnitus is a common problem, affecting 10-15% 15% of adults, and almost all those withh hea hearing aring loss and annd disorders of the auditory system. For many, tinnitus is a transient problem or is easily ignored much m of th thee time.. However, for approximately 1% of the population it has a severe effect on quality of life. What are the mechanisms? The mechanisms of tinnitus are broadly divided ed into triggering factors (such as otolog otological gical ddisord disorders rders or sudden emotional distress) and factors that contribute too its ongoing intrusion sometimes longg afte after er the ttrigger er has been b successfully treated. Neuroimaging studies of persistent sistent tinnitus indicate cortical reorganisation reorga ganisaation that th iss removed remo from fro rom the original site of injury, in a way analogous too phantom limb pain. Further, patients wit with th dist distressing stressi sing tinnitus nnitus havee increased interactions between central auditory pathways and limbic system structures mediating m mediat ating fear fe and anxiety. anxiet an ty. Psychological aspects trongg ccorrelation relation eexists ts. The nature of the relationship between tinnitus andd mental disorders is not clear, although a str strong exists. Prevalence of depression and anxiety is high, with major ajor depressive disorder found in up to 60% % of cases. ca es. Many u g drugs rugs and patients have maladaptive coping strategies including catastrophic thinking and â€˜escape copingâ€™ using alcohol. In some cases, psychological and psychiatric treatment reatment needs to precede speciďŹ c tinnituss interventions. inteerventions. entio How is tinnitus treated? Troublesome tinnitus requires a multidisciplinary stepped-care approach, commonly involving Otolo Otologists, ogistss, Audiologists, GPs and Psychologists. Once the initial cause is treated, ated, desensitisation treatment focuses foccusess on education, relaxation and stress reduction, sleep management and various forms of sound enrichment enrichmeent too reduce the relative intensity of the tinnitus. Similarly to chronic pain treatment, ment, aspects of cognitive behavio behaviour our th therapy herapy and mindfulness are applied effectively.
51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746
F: 08 9481 1947 947
W: www.medicalaudiology.com.au medicalforum
Diagnosing and managing adults with autism A
utism Spectrum Disorder (ASD) is one of the most frequent developmental disorders. About 70% of individuals with ASD have an intellectual disability, and many of them have no functional language. Therefore, caregivers will provide most of the clinical information. The diagnosis of ASD is based on the presence of two main components. First, a persistent deficit in communication and social interaction, such as failure of normal back-andforth conversation, reduced sharing of interests, emotions and effects, and deficits in developing and maintaining relationships. Second, there is a restricted pattern of activities, such as inflexible adherence to routines and highly restricted interests.
High-functioning adults with ASD Those people with no intellectual impairment may sometimes report frustration about the poor quality of their social life, but many of them have poor insight into their social limitations and live an isolated life. Low-functioning adults with ASD may present with challenging behaviours, such as episodes of physical and verbal aggression, and self-injurious behaviour. Experienced psychologists, using a variety of behavioural techniques that best suits the individual, usually carry out management of these
By Prof Sergio Starkstein, Psychiatrist UWA and Fremantle Hospital
What are the main challenges when managing adults with ASD?
challenging behaviours. Many patients also benefit from engaging in occupational therapy, recreational activities, and physical exercise. When non-pharmacological interventions fail, psychotropic medication may be introduced. The only two medications approved by the US Food and Drug Administration to better control challenging behaviours are risperidone and aripiprazole. Most of the drug trials were conducted in children or adolescents, and there is no formal experience in adults. Before starting these medications, relevant side effects such as the metabolic syndrome and movement disorders should be discussed with family and caregivers. Once these medications are started, patients have to be routinely checked for these side effects.
First, it is important to obtain a valid diagnosis. It is quite frequent to see patients 40 years or older admitted to hospital due to a general medical condition who are difficult to manage by the nursing staff and who were never diagnosed with ASD. While there are specific diagnostic tools for ASD, many patients lack a reliable informant and a valid diagnosis may not be obtained. GPs may be faced with patients having an intellectual impairment who were never formally assessed for ASD and have the generic label of “intellectual disability.” Second, adults with ASD and no language or moderate-severe intellectual impairment may suffer from a variety of medical conditions that are difficult to diagnose due to lack of adequate verbal skills. It is quite frequent for these adults to present with an escalation of challenging behaviours, which is their only way to express the presence of pain or discomfort. Therefore, it is important to provide regular medical and dental checkups to this population, and assess for medical problems whenever there is a marked change in behaviour. O
Author competing interests: No relevant disclosures
Introducing Western Australia’s ﬁrst comprehensive specialist liver centre. Based in the new McCourt Street Medical Centre, The Liver Centre WA will provide expert care for all forms of liver disease and cancer. Our team of Hepatologists, Surgeons, Specialist Nurses and Dietitians will thoughtfully approach each patient’s clinical condition with a commitment to long-term appropriate treatment.
Led by Prof Luc Delriviere and Prof Gary Jeffrey, Surgical and Medical Heads of the West Australian Liver Transplant Service at Sir Charles Gairdner Hospital, The Liver Centre WA will create a central point of referral for the integrated management of any liver condition and liver cancer including hepatocellular carcinoma, cholangiocarcinoma and colorectal metastases. Abdominal wall, biliary and bariatric surgery will also be available under the care of Prof Luc Delriviere and Dr Stephen Watson.
The Liver Centre, WA McCourt Street Medical Centre Unit 10 / 2 McCourt Street, West Leederville 6007 PO Box 6273, Swanbourne 6010 T: (08) 6163 2800 F: (08) 6163 2809 E: email@example.com W: www.thelivercentrewa.com.au medicalforum
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Managing opioid-induced nausea O
pioid-induced nausea and vomiting (OINV) is a common adverse effect amongst patients prescribed opioid analgesia; the prevalence of nausea is between 21% and 32% whilst vomiting occurs in 15%.
Pathophysiology This is multifactorial and probable mechanisms include: t Increased vestibular sensitivity. One theory is that opioids may activate mu opioid receptors on the vestibular epithelium. Subsequent input into the vomiting centre occurs via the histamine and cholinergic pathways. t Direct effects on the chemoreceptor trigger zone (CTZ). This occurs via direct activation of opioid mu and delta receptors in the CTZ, which then signal, to the vomiting centre. Dopamine (D2) receptors and serotonin receptors are responsible for the signalling in the CTZ. t Delayed gastric emptying. Opioids induce incomplete lower oesophageal sphincter relaxation, high amplitude oesophageal contractions and gastroparesis. Opioid activation of mu opioid receptors in the myenteric and submucosal plexus decreases gastrointestinal secretions, relaxes longitudinal colonic muscles and stimulates circular muscles, resulting in impaired gastrointestinal motility and bowel distension with subsequent nausea and vomiting.
The next step is to determine if opioids are clinically indicated. When deciding on perscribing opioids for chronic non-cancer pain management, an adequate trial of other nonpharmacological management and non-opioid analgesics should have been completed. A trial of opioids should follow the “start low and go slow” principle – the clinician assesses if the lowest effective dose is being prescribed (because lowering the opioid dose may significantly reduce OINV). Many patients develop tolerance to the emetic effects of opioids, which means the clinician can persist with a constant dose for seven days (in conjunction with an antiemetic agent [see table]), before altering management. Opioid rotation (using a different opioid) can reduce OINV as can administration via a different route (e.g. transdermal buprenorphine compared to oral morphine produces comparable analgesia with greatly reduced rates of nausea).
Management If the above measures are ineffective then strategies to manage OINV may be employed. Nonpharmacological interventions (e.g. avoidance of salty, fatty and spicy foods) have been recommended but supporting evidence is limited.
Antiemetic medications themselves have side effect profiles, which may lead to undesirable outcomes; especially in the elderly where there is increased susceptibility to adverse effects and drug interactions.
The clinician first excludes and treats other possible causes of nausea/vomiting unrelated to opioids.
There is only limited clinical data evaluating anti-emetics in patients with OINV. Management is similar to the treatment of
By Dr Chin-wern Chan, Pain Medicine Specialist, Hollywood Medical Centre postoperative or chemotherapy-induced nausea and vomiting with drug treatment influenced by the clinical setting (e.g. hospital versus community setting, postsurgical versus oncology). Opioid antagonists have been successful in the hospital setting, especially palliative care patients. This includes the use of low-dose naloxone and peripheral acting mu opioid antagonists e.g. methylnaltrexone markedly reduces nausea associated with parenteral morphine (but opioid antagonists are not routinely available for prescription in the community setting). The suspected aetiology of the OINV can help guide the choice of antiemetic. If nausea is related to position or ambulation, (suggesting vestibular system stimulation), cyclizine or promethazine would be appropriate. If the nausea is related to eating a prokinetic agent for constipation would be a logical choice and metoclopramide may be more effective. The commonly prescribed anti-emetics, mode of action and recommended dosing schedule are described in Table 1. Intravenous butyrophenones (droperidol) and serotonin antagonists (ondansetron) are commonly restricted to hospital and palliative care use. In the future, newer analgesics with improved adverse effect profiles may greatly reduce OINV. Recently, tapentadol has been approved on the PBS; it has two analgesic mechanisms, mu-opioid receptor agonism and noradrenalin reuptake inhibition; several studies have shown it to be as effective as oxycodone in a number of pain conditions with a significantly lower incidence of nausea and/or vomiting. O References available on request
COMMONLY USED ANTI-EMETIC AGENTS, MECHANISM OF ACTION AND RECOMMENDED DOSE Class of Drug
Mechanism of Action
Butyrophenones (haloperidol, droperidol)
D2 receptor blockade in the CTZ
Droperidol 0.625 mg IV
Phenothiazines and derivatives (chlorpromazine, prochlorperazine)
D2 receptor blockade in CTZ and gastrointestinal tract
Prochlorperazine 5 – 10 mg PO tds prn
Antihistamines (cyclizine, promethazine)
H1 blockade in the vomiting center and vestibular apparatus
Promethazine 25 mg PO qid prn
Anticholinergic agents (hyoscine hydrobromide, scopolamine)
Muscarinic blockade in the vomiting center and gastrointestinal tract
Hyoscine hydrobromide (Kwells tablets) 0.3 mg tablet bd prn
Serotonin (5HT3) antagonists (granisetron, ondansetron)
Serotonin receptor (5-HT3) blockade in the gastrointestinal tract and CTZ
Ondansetron 4 mg IV/PO (wafer) qid prn
Prokinetic agents (metoclopramide)
Dopamine receptor antagonist increases gastric motility
10 – 20 mg PO or IV every 6 hrs
γ – aminobutyric acid (GABA) agonist
0.5 – 1 mg PO every 6 hours
Adapted from Porresca & Ossipov, Pain Medicine 2009; 10 (4): 654-62
A NEW INITIATIVE FOR PSORIASIS PATIENTS
LAUNCHING AUTUMN 2014 HELPING PSORIASIS PATIENTS STOP HIDING AND START LIVING Research published in JAMA in 2013 shows that a large proportion of patients with psoriasis are dissatisﬁed with their treatment (52.3%) or remain untreated.1 The Get Psorted program, a new initiative in Western Australia, aims to increase awareness of psoriasis, with a goal of improving outcomes for those patients who have psoriasis that is currently sub-optimally treated or untreated. The program is supported by funding from Janssen Australia and was compiled by an independent Steering Committee comprised of 4 Dermatologists. Associate Professor Kurt Gebauer, Chair of the program’s Steering Committee: “In my experience, I’ve seen a number of psoriasis patients present after having suffered in silence for years. The Get Psorted program is a great initiative to help patients suffering from psoriasis seek help about their condition, including obtaining educational material, assessment by an accredited dermatology nurse and referral back to their GP for further management, where warranted.”
GET PSORTED WORKS FOR YOUR PATIENTS: Patient becomes aware of Get Psorted program through GP or radio adverts
Patient contacts Get Psorted helpline nurse
Patient triaged to an accredited, independent dermatology nurse for free consultation, education and PASI* assessment
Nurse provides patient with educational materials and refers patient to GP**
HOW GET PSORTED MAY BENEFIT YOUR PATIENTS: Your patients may be pre-screened for psoriasis by an accredited dermatology nurse You may receive enquiries from patients who have undergone a screening PASI assessment and requested a referral letter
Should you wish to enrol your patients in or obtain more information about the Get Psorted program, call 1800 093 695
*The Psoriasis Area and Severity Index (PASI) is a formal system used to measure psoriasis symptoms and severity before and after treatment.**Patients in whom PASI screening suggests psoriasis. Reference: 1. Armstrong AW et al; Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States; JAMA Dermatol. 2013; 149(10): 1180–1185.
Get Psorted is supported by Janssen Cilag Pty Ltd, ABN 47 000 129 975. 1–5 Khartoum Road, North Ryde NSW 2113 Australia. Phone 1800 334 226. JANS0934/EMBC AU-STE0111 Date prepared: March 2014 medicalforum
Psychotropics – are we overdoing it? By C/Prof Simon Dimmitt, School of Medicine and Pharmacology, UWA
ptimal dosing in psychiatry is a challenge not least because the same drug may be used for a range of disorders and complaints. For example quetiapine is used to treat schizophrenia, mania, bi-polar depression, anxiety and insomnia; antidepressants to treat depression, anxiety disorders, obsessivecompulsive disorder and insomnia. There are guidelines but the practical reality is that dosing is as much art as science.
more conservative dosing, particularly with antidepressants.
The effectiveness and effective dose of psychotropic drugs can vary widely for different reasons and the response may vary widely between, and serially within, individuals. The best risk-benefit outcome requires a personalised approach, good patient rapport, close doctor-patient collaboration, accurate diagnosis and close monitoring.
There may be some dose-response in very severe depression and possibly for SNRI drugs like venlafaxine but a flat doseresponse curve is characteristic of SSRIs and antidepressants in general.
Adverse effects (especially from antipsychotics) can be serious and there is merit in aiming for the lowest effective dose beyond which added benefit is lacking and adverse events increase. Questions of dose generate ‘robust’ debate in psychiatry and more research is needed. Systematic reviews provide growing justification for
There is little evidence that selective serotonin reuptake inhibitors (SSRIs) are more effective than placebo for mild to moderate depression and little evidence that high dose SSRIs or tricyclic antidepressants (TCAs) are more effective in more severe depression. Also, uncertainty remains about the gains from augmentation strategies and combined antidepressants.
In light of findings that very low, standard and high doses of SSRIs (e.g. 5mg, 20mg and 40mg of fluoxetine), may be equally beneficial, the therapeutic effect (rather than placebo response) of low dose SSRIs deserves further investigation. The average response does not reflect individual variation and the standard dose may be based on the response of more severely ill (hospitalised) patients.
because of quite frequent and more serious adverse effects, and frequent combination therapy. Low and high doses of different antipsychotics may be equally effective. Combination therapy or ‘polypharmacy’ is not predictably superior to monotherapy (which is inherently ‘polypharmacy’ because different receptors are affected by each). Augmentation has not demonstrated greater effectiveness where psychosis did not respond to monotherapy. More severe depression and psychosis may not respond satisfactorily to drugs and simply increasing the dose may merely increase adverse effects. There is much merit in aiming for the lowest effective dose and not dosing beyond the top of the dose-response curve unless there is clear evidence of a risk-benefit advantage in doing so. Important questions remain. Are psychotropic drugs (especially antidepressants) overprescribed and at unnecessarily high doses? ED. The author acknowledges the assistance of Prof Hans Stampfer O References available on request
Compared to SSRIs, the optimal dosing of antipsychotics appears more problematical
Utilisation of co-testing after treatment of CIN Patients with a high-grade squamous intraepithelial lesion (HSIL) were previously managed with annual cytology tests post treatment. However, this approach was revised and endorsed in 2004 by the NHMRC and testing for high-risk human papillomavirus (HR HPV) types is now an integral part of post treatment follow-up. This management pathway is referred to as the ‘Test of Cure’. The Test of Cure recommends patients should have a colposcopy and cervical cytology test performed 4-6 months following treatment for an HSIL. If these two tests (using the two modalities) are negative, then the patient is able to return to the care of their GP and be managed as follows: t $FSWJDBMDZUPMPHZBDDPNQBOJFECZ)3)17 testing should commence 12 months after treatment and continue annually until the patient has tested negative for both tests on two consecutive occasions. medicalforum
t 8IFOUIFBCPWFGPVSUFTUT VTJOHUXP modalities) are negative, the patient can return to the usual screening interval as appropriate for the general female population (two-yearly). Understanding whether GPs are familiar with the Test of Cure is important given the risk of persistent/recurrent cervical disease for patients previously treated for an HSIL. Consequently, a WA collaborative project investigated GPs’ awareness and compliance with this new, recommended approach. Results suggest a significant number of GPs are not familiar with the Test of Cure and there is a clear need for further education and promotion of HR HPV testing. GPs could use and have confidence in HPV testing. Even if a cervical cytology test result is normal, the increased sensitivity of the HPV test can detect HR HPV types, indicating the presence of persistent cervical disease.
By Ms Aime Munro, WA Cervical Cancer Prevention Program, Patients that successfully complete the Test of Cure can be encouraged to return to routine cervical screening with a high degree of confidence. The study also found that improved communication between the specialist obstetrician/gynaecologist and GP is still required through the provision of clear followup instructions. GPs will then be supported to provide these high-risk patients with care that is effective and delivers a high level of surveillance. The WA Cervical Cancer Prevention Program has resources available to support practitioners in the application of HPV testing. Please contact the Program on 13 15 56 or at firstname.lastname@example.org ED. Co-authors–Prof Yee Leung, School of Women’s and Infants’ Health, UWA; Dr Vicki Westoby, KEMH. O
a g n i k Ma Dr Matt Wright and his swimming partner Dr Quintin Hughes stared down hundreds of Swan River jellyfish in their charity swim but they had something bigger in their sights.
Q Dr Quintin Hughes Dr Matt Wright at the finish line 38
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Dr Matt Wright and fellow-dolphin, molecular biologist Dr Quintin тАШHueyтАЩ Hughes, conquered jellyямБsh and exhaustion in the Swan River to raise money for the Leukaemia Foundation. It was a long swim, just over ямБve hours from the Fremantle trafямБc bridge to the South Perth foreshore with plenty of institutional symbolism along the way.
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By Mr Peter McClelland
Q Dr Matt Wright, son Ollie and Dr Quintin Hughes
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You don't speak geek? Neither do we. We're a Specialist Medical only IT company. We know your PCEHR from your HPOS and we promise to speak to you like a human! Get your 10 point geek-free guide on what to look for when buying computers for your practice:
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WA-born Juliette Barton returns home next month with the latest show from the athletic contemporary Sydney Dance Company.
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By Ms Jan Hallam
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PATRICK THE HE
2012 Patrick Riesling
By Dr Craig Drummond, Master of Wine
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In 1996, long-established Limestone Coast winemaker Pat Tocaciu decided to release wines under his own family label as well as contract winemaking via his company Patrick T Winemaking Services. Today, together with his son, Luke, they produce a formidable range of wines.
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2010 Patrick Aged Riesling *XJMMTBZJUBHBJOXIZEPOUNPSFQFPQMFHFUJOUPUIFTF*UTFBTZUPDFMMBS TPNFHPPE3JFTMJOHTBUIPNFBOEPCTFSWFUIFFWPMWJOHXPOEFSTPGUIJTWBSJFUZ XJUIBHF5IJTXJOFTIPXTFOUJDJOHBSPNBUJDTXJUIDPNQMFYJOUFSXPWFOMJNFBOE UPBTU1BMBUFDIBSBDUFSTJODMVEFMFNPODVSE GJHBOEBUPVDIPGMBOPMJOF5IFBDJE IPMETBMMJOIBSNPOZWFSZOJDFMZ*GFFMJUJTBUPQUJNVNOPX 2002 Patrick Grande Reserve Coonawarra Cabernet Sauvignon %FMFDUBCMFJTUIFCFTUXBZUPEFTDSJCFUIJTXJOF*UUJDLTBMMNZCPYFToJOUFOTJUZ CBMBODF DPNQMFYJUZ MFOHUIBOEGJOJTI BOEJOUFHSBUFERVBMJUZPBL5IFMBUUFS XBTBDIJFWFEXJUINPOUITJOOFXUJHIUHSBJOFE'SFODIPBL*UTIPXT EPNJOBOUCMBDLDVSSBOUXJUIBEEFEDIBSBDUFSTPGTPZ FBSUIBOEBUPVDIPGUSVGGMF BOPVUDPNFPGGPVSZFBSTCPUUMFBHFJOHCFGPSFSFMFBTF5IFUBOOJOTBSFBNB[JOH oFWJEFOU JOGMVFOUJBMCVUOPUEPNJOBOU8POEFSGVMTNPLZXJOFNBLJOHDIBSBDUFST 4UJMMIBTUIF$4GSVJUJNQSJOUEFTQJUFBMMUIFXJOFNBLJOHBOEBHFJOHJOGMVFODF" CPUUMFPGUIJTBOZUJNFGPSNFQMFBTF
WIN a Doctor's Dozen! What is the predominant variety in Patrickâ€™s Coonawarra sites? Answer:
ENTER HERE!... or you can enter online at www.MedicalHub.com.au! 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, May 31, 2014. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.
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w o n S
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Q The town of Maccagno on the edges of Lake Maggiore.
Tramping through the Italian lake district in December is as exhilarating as it is beautiful. The town of Maccagno is in the province of Varese and sits on the shores of Lake Maggiore. It isnâ€™t likely to happen, but if you do get tired of looking across the glacial blue waters you only need to look up and gaze at the snow-capped mountains of the Swiss Alps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Q The quaint Maccagno train station.
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UNDISCOVERED ITALY Travel the back roads of Abruzzo - the undiscovered gem of central Italy. Take the road less travelled as you immerse yourself in true village Italy and live like a local. Experience northern and central Abruzzo with its towns and medieval hilltop villages, enjoy a private cooking class and taste fine local olive oils, wines and seasonal produce. Dine in sensational slow food restaurants in true Abruzzese style. Speak to one of our experienced consultants to plan your next Italian adventure today.
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Aboriginal Health Conference 2014 Dates: July 5-6 Venue: Parmelia Hilton Perth Website: www.ruralhealthwest.com.au National Suicide Prevention Conference Dates: July 22-26 Venue: Pan Pacific Hotel Website: http://suicidepreventionaust.org Perth GPCE Dates: July 26-27 Venue: Perth Convention Exhibition Centre Website: www.gpce.com.au
Mental Health Services Conference 2014 Dates: August 26-29 Venue: Perth Convention Exhibition Centre Website: www.themhs.org National Elder Abuse Conference Dates: September 3-4 Venue: Hyatt Regency Perth Website: www.elderabuse2014.com/ Public Health Association Australia Annual Conference Dates: September 15-17 Venue: Pan Pacific Hotel Website: www.phaa.net.au
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From: Triumph over Pain by René Fülöp-Miller, 1938. From near and from far those who were afflicted with pain flocked to Mesmer’s house in the Rue Montmartre. Early or late they awaited his coming, and when he at length appeared in the street the patients ran to meet him, hoping to touch his garments and thus come into contact with the healing emanations. The Paris court idolized the wonder-working physician. Marie Antionette, the Duke of Bourbon, the Prince of Condé and Lafayette became his close friends. Other persons bearing the most famous names of the epoch were among his patients, and princesses besought the favour of being admitted to his presence. medicalforum
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).
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C I S S A L C
People who think they know everything are a great annoyance to those of us who do â€“ Isaac Asimov
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medical forum FOR LEASE NEDLANDS Medical Specialist Consulting Rooms and Treatment Room. Fully serviced rooms and facilities for Specialist Consulting are available including a treatment room to accommodate minor procedures. t 4VJUF )PMMZXPPE4QFDJBMJTU$FOUSF 95 Monash Avenue, Nedlands. Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager, Suite 31 )PMMZXPPE4QFDJBMJTU$FOUSF 95 Monash Avenue Nedlands, WA 6009 Phone: 9389 1533 Email: email@example.com SUBIACO Fully supported Sessional Suites available in modern office - Churchill Avenue. Good sized consulting rooms, reception and waiting area. Parking space included. Phone: Lorraine 6380 1441 for further information or Email: firstname.lastname@example.org MURDOCH NEW Wexford Medical Centre "UUBDIFEUPUIF4U+PIOPG(PE)PTQJUBM JO WJDJOJUZPGUIF'JPOB4UBOMFZ)PTQJUBM Modern, newly fitted out medical consulting room. Sessional medical & dental rooms available. Please contact email@example.com for more information. MURDOCH SJOG Murdoch Medical Clinic XJUIJO4+0()PTQJUBM t TRNPOTUGMPPS DMPTFUPMJGUT t 4FDVSF VOEFSDPWFSDBSCBZ t $VSSFOUMZDPOTVMUSPPNT XXBUFS t -BSHFSFDFQU XBJUJOHSPPNLJUDIFO t 0OFPGPOMZGFXTVJUFTXJUIQSJWBUF8$ t %VDUFE3$BJSDPOEJUJPOJOH t "WBJMBCMFGGVSOJTIFENJEMBUF+VOF The perfect suite for the medical specialist or allied health service where a private Toilet is required or preferred Frana Jones 0402 049 399 Core Property Alliance 9274 8833 firstname.lastname@example.org SHENTON PARK Fully supported consulting room for lease. One or two consulting rooms, waiting room and secretarial area. Available between 1-4 sessions a week. Easy access and plentiful free parking for staff and patients. Tel: 0400 810 953 or 0458 700 151 KINROSS Good sized consulting room available for lease in established medical centre in Kinross. Includes reception, waiting & treatment room. Plenty of free parking. Suitable for any specialist , someone doing cosmetic procedures or any other office work. Contact : 0408 928 916
RAVENSWOOD New premises suitable for medical or allied services located in Ravenswood (located between Pinjarra and Mandurah). Approx 10 km from the nearest medical facility. A pharmacy is already operating on-site. Plenty of parking and attractive leasing terms on offer. For further information please contact Rick Bantleman of Century 21 Centex Commercial on 0413 555 441 or Otto Allen Grossman on 0419 819 737 MURDOCH Brand new Medical Suite for Lease at the new Wexford Medical Centre. 106 sqm, complete fit-out and one car bay. Ready to lease by June 2014 Please contact: email@example.com
WEST LEEDERVILLE Doctors Consulting Suites. "SFBTVQUPTRN$MPTFUP4U+PIOT Subiaco Onsite Parking Easy access to Freeway/Bus /Train Phone 9380 6457
FOR SALE MARGARET RIVER Expressions of interest. Solo General Practice in sought after southwest coastal town. Fully accredited, fully equipped practice in central location, walk in/walk out, low overheads. Expansion through hospital A&E work available. Low Price. Phone: 0427 727 772 WEST LEEDERVILLE Now Selling $1.65m plus GST 102 Cambridge St, West Leederville Well-presented freestanding character consulting rooms, large rooms, onsite parking. Large fitted reception & shower. Details Rob Selid, Burgess Rawson 0412 198 294 / 9288 0288
FOR SALE OR LEASE CANNINGTON Consulting Rooms, suit Medical or Allied. 4 Consulting / Treatment rooms, Reception, 9 Car Bays, Very close to Carousel Shopping Centre. For Details phone Gerry: 08 9350 6311
Reach every known practising doctor in WA through Medical Forum Classifieds...
BIBRA LAKE - Psychiatrist wanted Are you intending to start Private Practice? This is a sheer walk in! Part time, sessional or full time - all enquiries welcome. Furnished consulting rooms available at: Bibra Lake Specialist Centre, 10/14 Annois Road, Bibra Lake WA 6163 Existing private psychiatrist one day a week at this location. 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
SKG Radiology is a highly recognised private Radiology group, providing imaging services at 20 locations throughout Western Australia. We are seeking a dedicated and enthusiastic Radiologist with FRANZCR qualifications or equivalent to join SKG Radiology. To be successful in this role you will need expertise in the areas of General, CT, Ultrasound, Image Guided Procedures and Mammography. A Fellowship in Subspecialty areas of radiology is desirable. SKG Radiology offers an attractive salary package, benefits and excellent working conditions. Please forward your Curriculum Vitae via email to: Julie Rogers, Executive Assistant to the CEO, SKG Radiology. Email: firstname.lastname@example.org
75 URBAN POSITIONS VACANT CLAREMONT You keep 100% of billings in this brand new clinic. Second branch of a very busy and well established walk-in bulk billing practice. Looking for GPs with unrestricted provider number. Located in a modern complex with free access to the gym and pool. You pay only a flat daily rate to cover overheads To establish in this area and be your own boss, please contact Dr Ang 9472 9306 or Email: email@example.com
PALMYRA Palin Street Family Practice requires a full or part-time VR GP. We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens. Earn 65% of mixed billings. For further information call Lyn on 9319 1577 or Dr Paul Babich on 0401 265 881
WEST LEEDERVILLE Great Lifestyle! Part time (up to full time) VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: firstname.lastname@example.org or call Jacky, Practice Manager on 9381 7111 / 0488 500 153
WOODLANDS Woodlands Family Practice Great opportunity for FT/PT VR doctor in a well-run, newly extended, inner metro, mixed billing, privately owned practice. Call Dr Mary McNulty or Dr David Jameson, 9446 2010 or email email@example.com
RURAL POSITIONS VACANT ALBANY t 4U$MBSFTJTBOFXGBNJMZ practice based in Albany t 4NBMMGSJFOEMZQSBDUJDF t 'VMMUJNFOVSTJOHBOE administration support t 1BUIPMPHZPOTJUF t 'VMMPSQBSUUJNF(1XBOUFEUP join our team t 4QFDJBMJOUFSFTUJOTLJOXPVMECFJEFBM t $VSSFOUMZOP%84VOMFTTXJMMJOHUP work in afterhours period t (1TOPUSFRVJSJOHTVQFSWJTJPOSFRVJSFE Please contact practice manager Belinda Elliott Tel: 9841 8102 Email: firstname.lastname@example.org Or send your CV through and we will get back to you.
NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. 3JOH)FMFO9227 0170 SOUTHERN SUBURB GP PRACTICE - VR GP, FT or PT required for a privately owned Group practice. Located in the southern suburb, approximately 25 mins from the CBD. In a prime location, busy shopping centre, with good exposure and ample parking at the front and rear. Private billing, this is the perfect opportunity for an enthusiastic GP. Generous percentage offered and interest in ownership/ partnership considered. Administrative and nursing services will be provided, along with pathology collection on-site. Contact: email to :email@example.com
JUNE 2014 - next deadline 12md Tuesday 13th May - Tel 9203 5222 or firstname.lastname@example.org
medical forum Day Medical
APPLECROSS Weekend Sessions and weekday afternoons available. Confidential enquiries to: PM Rita on email@example.com or 9364 6633
KWINANA â€“ CHISHAM AVENUE MEDICAL CENTRE Full time or Part time VR GP required for a busy long established medical centre. Mixed billing, fully accredited with pharmacy and pathology on site. Please contact Bili on 9419 2122 or Email: firstname.lastname@example.org
YOKINE FREMANTLE Fremantle Womenâ€™s Health Centre requires a female GP (VR) to provide NFEJDBMTFSWJDFTJOUIFBSFBPGXPNFOT health 1or 2 days pw. It is a computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. '8)$JTBOPUGPSQSPGJU DPNNVOJUZ facility providing medical and counselling services, health education and group activities in a relaxed friendly setting. Phone: 9431 0500 or Email: Diane Snooks - email@example.com or Dawn Needham firstname.lastname@example.org
Part-Time VR GP required for a small privately owned practice in Yokine. Female GP preferred to help our existing female GP . Family friendly practice with nursing support and a lovely team of receptionists. 0VS(1TIBWFGVMMBVUPOPNZ Private billing. Fully computerised. Accredited. On-site pathology. Allied health rooms attached next to the practice. Excellent remuneration is offered to the right applicant, but we are not in an area of need. Please contact Jayne Jayne@swanstsurgery.com.au or Dr Peter Cummins email@example.com for further information.
LANGFORD (Qualifies as DWS) Langford Medical Centre is looking for a full time GP to commence in March/Arpil 2014. Due to the sudden departure of a colleague, we have a ready-made full patient base for an incoming Dr. We are a modern, well equipped, accredited predominantly bulk billing practice. Situated south of the river, Langford is one of the closest practices to the CBD that still qualifies as a district of workforce shortage. For confidential enquiries please contact PM Rita on 9451 1377 ROLEYSTONE PT/FT VR Female GP required for a GP clinic in Roleystone. A friendly and efficient working environment. Well-equipped consulting and treatment rooms, fully computerised, accredited and busy practice. Contact: firstname.lastname@example.org
NEW PRACTICE - Inner Northern Suburb Located in an inner northern suburb, approximately 5 mins from the CBD. In a prime location on a main road, with good exposure and ample parking at the front and rear. Also next door to a 7-day pharmacy. With recent retirements in the area, this is the perfect opportunity for an enthusiastic GP or group of GPs. Generous percentage offered and interest in ownership considered. Administrative and nursing services will be provided, along with pathology collection on-site. Opening April 2014. Call 0414 287 537 for details. HILTON GP. Wanted / Sessional/ P/Time VR. GP. to join 25yrs established General 1SBDUJDFJOUIF)JMUPOBSFB(1T Accredited: Computerised with fulltime nurse support. Service growth potential. Contact Practice Manager on 9337 8899 SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979
BULL CREEK PT/FT VR GP required for Accredited, Privately owned, Friendly Family Practice Please call â€“ 9332 5556 GIRRAWHEEN Doctors required for The New Park Medical Centre Girrawheen. Opening in February 2014 we are seeking '5BOE15(1TUPKPJOUIFUFBN Enquires to Dr Kiran on 0401 815 587 Email: email@example.com
MANDURAH GP required for established, accredited Practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed by experienced Registered Nurses. Generous remuneration. No DWS please. No on call. Contact Ria 9535 4644 Email: firstname.lastname@example.org
Reach every known practising doctor in WA through Medical Forum Classifieds...
INNER METRO GP LOOKING AT MOVING TO OUTER METRO? Bentley-Armadale Medicare Local (BAML) is pleased to announce that as part of the Outer Metropolitan Relocation Incentive Grant (OMRIG) programme, there is a limited number of grants of up to $30,000 for GPâ€™s to relocate from an inner metro region to outer metro within the BAML region. If you are interested but donâ€™t know of a Practice requiring a GP, BAML has a list of Practices willing to host a GP as part of this grant.
For further information please contact Simon Perkins on 08 6253 2100 or email@example.com
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JUNE 2014 - next deadline 12md Tuesday 13th May - Tel 9203 5222 or firstname.lastname@example.org
Are you looking to buy a medical practice? As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience.
You won’t have to go through the onerous process of trying to find someone interested in selling.
To find a practice that meets your needs, call:
Brad Potter on 0411 185 006
You’ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision.
Specialists – opportunity for easy private practice in Fremantle! Ellen Health (Ellen Street Family Practice) will be moving from 59 Ellen Street Fremantle, to the beautiful old Beacon Theatre - 69 Wray Avenue (corner Hampton Road), Fremantle, co-located with pharmacy, pathology and allied health. Doctor-owned and managed, Ellen Health is a multi-disciplinary team, providing excellence in health care. We invite specialists to join the team, offering an instant referral base with our established general practice, and with the ease and comfort of fully serviced new rooms.
We are recruiting specialists and VR-GPs now.
We’ll take care of all the bits and pieces and you’ll benefit from our experience to ensure a smooth transition.
Enquiries to Dr Catherine Douglass 0421 520 767 www.ellenhealth.com.au
Suite 27, 782 - 784 Canning Highway Applecross WA 6153
Ph: 9315 2599 www.thehealthlinc.com.au
Looking for dedicated GP’s and Specialists who love the South West and want to stay – move across to our state of art practice – we have oodles of space. You can have your own room. Excellent working conditions with limited after hours needed through Bunbury After Hours GP Clinic.
MEDICAL SUITE – For Lease South Terrace, South Perth Purpose built medical suite vacant and available now. Reception / waiting / 2 consulting rooms (14.2sqm and 15.6sqm). More information and inspection contact: Marcia Everett CEO/Director of Nursing South Perth Hospital 9367 0275
Contact Dr Brenda Murrison for more details!
9791 8133 or 0418 921 073
With a reputation built on quality of ality WKH service, Optima Press has the resources, e the people and the commitment to y client provide every client with the finest DOXHIRU printing and value for money. 9 Carbon Court, Osborne Park 6017 Tel 9445 8380
Looking for a sea change? We may have the job for you. If you have ﬁnished your GP training or looking for a subsequent term placement or an experienced GP looking for a change for the better, phone Jill on 08 97521133 or email email@example.com. Busselton is located on the pristine shore of Geographe Bay in the Margaret River Wine Growing region, just a short 2 hour drive from Perth.
Wheatbelt Medical Specialists provides a “hub” for Visiting Medical Specialists in the Wheatbelt. Located at 10 & 12 Grey Street Northam we have a range of Visiting Specialists currently including: Dr Tony Mylius – Cardiologist and Consultant Physician, Dr Tim Gattorna – Cardiologist, Dr Jaye Martin – General Physician, Professor Neil Boudville – Renal Physician, Dr Quentin Summers – Respiratory Physician.
Dr Tony Mylius (Cardiologist) 0412 198 765 – firstname.lastname@example.org Christine McGhie (Practice Manager) 0439 003 434 – email@example.com
Respiratory Testings Services (Mr Bill Smith) and Western Cardiology and HeartCare WA provide Holter Monitoring, Echocardiograms, Pacemaker Clinics and ECG Reporting. We invite all specialists to enjoy the rewards of expanding your practice in a satisfying professional environment within an easy 1 ¼ hour drive from Perth. We welcome your contribution to meeting the signiﬁcant un-met clinical need across all specialties medical and surgical. Please call us to discuss the opportunities.
JUNE 2014 - next deadline 12md Tuesday 13th May - Tel 9203 5222 or firstname.lastname@example.org