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Doctors Drum: Medical Board & AHPRA

t Clinicals t Medical Apps t Teaching Ethics t Cosmetic Cowboys t Primary Care Changes t Ebola Intervention

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When Confusion Turns to Anger One strong impression to emerge from the Doctors Drum breakfast about AHPRA and the Medical Board is the confusion amongst doctors about how the new National Law affects them. When we surveyed 189 doctors, 43% admitted they lacked knowledge and some had found out the hard way, judging by their comments (see March edition, p8). Is this confusion hiding something? Both doctors under investigation and health do consumers complain that investigation of co complaints takes too long, is too legalistic co and an the communication from AHPRA and an the Medical Boards falls well short of keeping k doctor or consumer reasonably informed in of what is going on. AHPRA A holds all the cards

Dr Rob McEvoy

While 85% of our surveyed doctors W believed AHPRA and the Medical Board b should s protect both consumers and doctors, d they will remain disappointed. AHPRA is the ‘constable’ investigating if a doctor has a case to answer in front of the Medical Board. Neither protects doctors and their documentation clearly says they are there to protect consumers.

Amongst the consumer complaints (which have increased 38% in WA in recent times), 85% of those that are potentially damaging to patients will be dismissed as ‘no case to answer’, or put another way, a drawn out legalistic investigation will knock about six good doctors on the head to get one bad egg. The only excuse AHPRA offers is that it is obliged to investigate even vexatious or wrongful identity complaints, writing to the doctor concerned for an explanation but never having to explain their behaviour when they get it wrong. Some say this is a necessary evil. For too long cronyism and secrecy were hallmarks of how complaints were handled and doctors got off too lightly, with complaints not seriously listened to or acted on. Certainly, these days the more serious cases are exposed in the courts under the new system, where cost, intimidation, insurers and people’s tenacity come head-to-head. However, the courts introduce another set of circumstances that some argue are bad for medicine. What starts as a dispute about a patient outcome becomes an argument around the legal process. One panellist at the recent Doctors Drum brought this out by commenting that lawyers take ages to gather all the evidence and argue over it, while doctors are expected to act quickly with the flimsiest of evidence before them. They live in two different worlds.

Consumers are not alone – doctors also want transparency, timeliness and better communication.

model of the experienced all-rounder, successfully treating, triaging and referring sounds good, it is not how the real world often works. Many GPs practice safely on the edges of this conservative model – confining themselves to counselling, myofascial medicine, GP obstetrics, nutritional medicine, sexual health, etc. – and they improve patients’ lives in a way that may not be widely understood (a bit like the orthopaedic surgeon). Conservative elements of the profession seem uninterested in setting up a workable protective framework for these people but are happy to use AHPRA and the Medical Board to pick off anyone who does not fit their conservative view. The spectre of cronyism raises its head. Who are the ‘experts’ (the RACGP in WA has never been asked to suggest any GPs)? Who is on the list of approved doctors to sit on Medical Assessment Panels? Who has been appointed, using what process? Who invites who to investigate? Is it ‘jobs for the boys’; go easy on this doctor or hard on this one? Who examines events when AHPRA and Medical Boards get it wrong? Who apologises for getting it wrong? For all we know, many areas where cronyism and political manipulation of the system can play out may not have changed significantly since the National Law came in a few years ago. Sure, bad cases get exposure in the courts but a lot happens in between that doctors never get to hear about but have to pay for. It would be a huge loss if current methods reflected badly on good doctors. Even the well-intentioned know they may not get it right but if the system can harbour those with the wrong intentions, what then? Given the escalating rate of complaints in WA, some doctors won’t have long to find out. Consumers are not alone – doctors also want transparency, timeliness and better communication in the way things are done. The confusion of doctors is being replaced with anger.

System open to cronyism? One sub-plot as National Law has come into play is that general practice is carving out a specialty niche. While the conservative

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Mr Glenn Bradbury (0403 282 510)


EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937)

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) Journalist Mr Peter McClelland

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) GRAPHIC DESIGN Thinking Hats


May 2015

Contents 14



FEATURES 12 Celebrity Spotlight – Mark Barnaba 14 Contact Tracers the Ebola Heroes Dr Linda Selvey

22 24

24 NEWS & VIEWS 1 Editorial: When Confusion Turns to Anger Dr Rob McEvoy


Mobile Apps for Health Control the Cosmetic Cowboys

Letters: Setting the Record Straight – Dr Michael Stanford

Doctors Mental Health –

Dr Joanne Samer

Dr Eileen Tay

Timely Reminder – Dr Lou Zaninovich

LIFESTYLE 45 DIY Reality Check – Ms Wendy Wardell

45 46

Funny Side Photography: Dr Amanda Wilkins, Dr Carol McGrath, Dr Chun Ong, Dr Janina Anderst, Dr Moira Westmore, Dr Peter Drurey, Dr Peter Randell, Dr Rob Davies, Dr Susan Downes, Dr Ted Collinson, Dr Tony Tropiano

49 50 50 51

WASO Chorus Carmina Burana Peter Rowsthorn Glengarry Glen Ross St Petersburg Ballet Returns


Doctors Running for a Reason – Dr Louise Sparrow Curious Conversations: Dr George Crisp

10 28

Have You Heard? Saving PGPPP Training Ms Jan Hallam


PIEDS: A Tale from the Streets Mr Peter McClelland


Medicolegal: Prescribing Schedule 8 Drugs Mr Enore Panetta

37 39 41

Tackling CVD in Indigenous Communities Films in the Bag Liberian Lessons Learnt


Our cover: GP Dr Helen Wilcox and Medical Board’s Dr Michael McComish at the Doctors Drum Breakfast. Picture: James Knox



Clinical Contributors


Dr Johan Janssen Combination Pills in Cardiology


Dr Andreea Harsanyi CPPD Crystal Arthritis


Prof Eric Visser Neck pain: A Checklist

Medical Board & AHPRA...


Dr Navneet Johri Doctors as Immigrants

Friendly Fire?

For a report of the latest Doctors Drum breakfast turn to pp18-20

Guest Columnists


Mr Tim Andrews Sunlight the Best Disinfectant


Dr Jenny Brockis The Healthy Doctor


Dr Richard Hamilton, PhD Teaching Ethics and Opening Minds


Mr Rod Astbury Mental Health Funding Uncertainty

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


Letters to the Editor

John of God Midland Public Hospital will be paid at a discount to benchmark WA public hospitals, no matter how efficient they become. All the operating financial risk lies with St John of God Health Care, not the taxpayers of WA.

Setting the record straight Dear Editor, The letter from Roger Cook, Midland Mess Unforgiveable [April edition], is an important contribution to a public policy debate but contains some errors and several key omissions. It is factually wrong to say that “people have lost their right to public service accountability”.

We are confident that the people of WA will feel well served by St John of God Midland Public Hospital and that it will be a shining light in the public hospital system for compassionate, high quality, culturally sensitive care.

The State Government will be the purchaser of services from St John of God Midland Public Hospital and in addition it will monitor the service performance against the most extensive and onerous range of Key Performance Indicators (KPIs) to which any public hospital in WA is subject.

Doctors Mental Health

St John of God Health Care is on the public record as saying we believe these KPIs and performance targets should be publicly available. It is also wrong to say services at Midland will be curtailed. We will operate a much greater range and volume of services than is currently undertaken at Swan District Hospital. The Government’s and our intention is that we will have 75% of the catchment population using St John of God Midland Public Hospital for their hospital care needs as compared to the current 35% at Swan District Hospital. The key omissions are that, firstly, the hospital building will be built on time and on budget at a cost per bed significantly less than other public hospitals in WA. All risk of overruns has stayed with SJGHC and Brookfield Multiplex, not the taxpayers of WA. Secondly, for every year of its operation, St

Dr Michael Stanford, Group CEO, SJGHC .......................................

Dear Editor, I write as interim Medical Director of WA Doctors’ Health Advisory Service (DHAS), soon to receive some national funding. Doctors’ mental health is about the changing medical environment and the way we respond to those changes. Sir William Osler introduced bedside teaching to medical students, getting them out of the hallowed halls of learning, into the expanding apprenticeship model of training and teaching.

I don’t believe we are less robust than in Sir William Osler’s time but we are called upon to perform to our best in ever more challenging and competitive times. The sexual harassment of female surgical trainees is an example of growth in bullying and harassment in general. This is due partly to scarcity of resources and support, the nature of training positions and to fiefdom mentality (more an issue in some specialties). Seeking help when mentally unwell requires a shift in personal confidence and cultural change. This must be radical and innovative to match an increasingly complex and demanding medical environment. Prevention is both personal and systemic. I am hopeful that a nationally funded and supported DHAS may help address accessibility to care and assistance for medical students and doctors and advocate for working standards and conditions that promote psychological health and wellbeing. This involves working together with all stakeholders, from medical students to administrators, and encouraging our colleges to support a change in culture. Dr Eileen Tay, Psychiatrist, Hollywood ED: The author can be contacted on 9386 9113 ........................................................................

How does this apprenticeship model fit in our current environment – four hour rules in EDs, ever more students and doctors-in-training, and services expected to do more with less in a ‘cost neutral’ way?

A timely reminder

“Please Sir, can we have some more?” – the Oliver Twist approach sadly does not work. Evidence nationally and internationally (US, Canada and UK) points to the profession being more depressed and anxious, yet doctors take less sick leave than other professional groups.

I wanted to pass on my congratulations to Dr Rohan Gay on his article [I Learnt this from My Patient… March edition].

Dear Editor,

continued on Page 6

Curious Conversations

Working for a Sustainable Future The flying fingers of keyboardist, GP and WA Chair of Doctors for the Environment Dr George Crisp all point in the direction of productive political engagement. If I could fill the Perth Arena with salivating rock-and-roll fans I’d step on stage as… keyboard player John Paul Jones from Led Zeppelin, but I’d settle for Pink Floyd or Deep Purple as well. My worst moment in medicine was… total embarrassment as a medical student waking up in a hospital bed with a very sore head after cycling into a lamp-post. I ended up being under the care of the consultant I was working for! If my daughter or son said, ‘I want to be a doctor’… I’d support them in anything they want to do (within reason) and that includes medicine. I wouldn’t discourage them from General Practice, but I


would warn them about the low morale due to a lack of support from successive Australian governments. The most critical global issue is… overpopulation and overconsumption. We’ve exceeded nearly half of the ‘planetary boundaries’ that define a safe operating space for humanity, and that includes climate change and biodiversity loss. Without healthy, sustainable ecosystems the future is bleak. It’s probably solvable, but only with greater political will and honesty. The wisest book I’ve ever read is… well, I mostly read non-fiction books and they tend to document our distinct lack of wisdom. I was a sci-fi fan so I’d choose Isaac Asimov’s, I Robot, which explored the morality and dangers of artificial intelligence well before computers existed.




Letters to the Editor continued from Page 4 His concluding paragraph reminds us of what doctoring is all about and should be compulsory reading for all medical students and for any disillusioned GPs (and other medicos) who may be needing some re-invigorating stimulus. Dr Lou Zaninovich ED: Just to recap, Dr Gay wrote: “As doctors we are privileged to have glimpses into the myriad worlds inhabited by our patients. On the odd occasions when treatment has been wrapped up, and time is available just to chat, I have been amazed by tales from patients from such diverse backgrounds. Stories of handmade furniture, workers of cast-iron, sheet metal and machining, equestrian competition, satellite tracking technicians, World War survivors, police, firemen, corrective service officers, soldiers, locksmiths, roadside mechanics, pole dancers, and the list goes on! Such insights remind us that our job is not about us; it’s a bit about the disease; but is really about the people that we treat.”


Doctors running for a reason Dear Editor, I would like to let colleagues know that Doctors for the Environment Australia (DEA) WA is entering a team in this year’s HBF Run for a Reason on Sunday, May 24, with the aim of having fun, getting fit and raising funds and awareness for DEA’s work. DEA members, friends or supporters are encouraged to join our team – choose from 4km, 12km or 21.4km distances. If you’re interested in joining the team register at (Team: ‘Doctors for the Environment Australia’). Medical Students and non-medical family and friends / colleagues are also welcome! We will have a social training session and a get-together in May before the run to coordinate our team look (T-shirts for DEA etc) and where to meet on the day.

DEA lobbies for: så CLIMATEåCHANGEåANDåHEALTH så HEALTHåIMPACTSåOFåCOALåAND unconventional gas så RENEWABLEåENERGY så DIVESTMENT så OTHERåACTIVITYåEGåBIODIVERSITY åSUSTAINABLEå healthcare, air pollution) Dr Louise Sparrow, DEA WA Committee ........................................................................

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

The Big Questions of PHNs The Health Minister Sussan Ley announced that WA Primary Health Alliance (WAPHA), led by GP and former AMA WA President Dr Richard Choong and Health Engine CEO Dr Marcus Tan, would run all three of the WA’s Primary Health Networks (PHNs) – two metro and one rural for the rest of the state – starting July 1. The winning consortium, which includes some board and management from Perth Central and East Metro, South Coastal, Fremantle and Goldfields and Midwest MLs, beat off three other bids – all from previous Medicare Locals. In comparison, Queensland ended up with three city PHNs and four in the regions. WAPHA chair Dr Choong spoke to Medical Forum a day after the announcement, when he wasn’t certain how much of the Government’s $900m had been allocated to WA. Before the announcement WA’s share was thought to be about $30m, though extra funding for mental health and Aboriginal health might now be available. WAPHA placed a big job advertisement in The West Australian a week later seeking three PHN general managers and a COO.

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For those doctors who haven’t lost interest in the changing fortunes of general practice – from divisions to networks to MLs and now PHNs – these questions may arise: The terms of reference stipulates that no service currently provided by Medicare Locals is to be affected but who will be the new service contractors? Will they be the same service contractors employed by MLs? As many ML boards created private companies to provide patient services, how will WAPHA contend with potential conflicts of interest in awarding new service contracts if some of the ML chairs are also on the WAPHA board? What will the grassroots GP involvement be? When and how will the GP-led advisory networks be established and will they have ‘teeth’? What role will health insurance companies and IT play, if any? There’s a lot of ironing out to do with very little time to do it. In the wash-up, if the PHNs are just a reconfiguration of MLs, this may appear to some as a highly expensive ideological exercise. Who are the winners and losers is yet another question to be answered.

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Sunlight the Best Disinfectant The Executive Director of the Australian Taxpayers Alliance, Tim Andrews, looks at improving governance in the wake of Healthway. The recent Western Australia Public Sector Commission report detailing improper use of sponsorship tickets by Healthway board members and senior staff should be the catalyst for all Australian Governments to re-examine their approach to public health governance. The scandal, which led to the resignations of the executive director and all board members, and an ongoing investigation by the Crime and Corruption Commission, is symptomatic of underlying issues with the way independent government agencies in the public health sphere are operated. The move to independent government agencies was initially lauded as a way to remove political interference from the decision making process. Instead, it has resulted in a situation where agencies operate without oversight or transparency, leading to the potential for significant abuse of taxpayer funds. Our democratic model relies on public officials being accountable and subject to the scrutiny of the electorate. By removing agencies from the sphere of oversight, protections to ensure appropriate conduct are substantially weakened.

Healthway, which has an annual budget of over $20 million annually, has given taxpayer money to assist organisations that actively lobby government. Would West Australian taxpayers consider this prudent use of their funds? Such practices are the inevitable result of the appointment of ‘stakeholders’ – a more accurate term might be ‘vested interests’– to the Healthway Board. They can be affiliated with organisations that are the recipients of Healthway funding. It is almost inevitable that decisions made at a board level can be influenced by personal and professional associations between members. Even if this is done unintentionally, with all conflicts of interest declared and abstentions from all relevant votes (as no doubt occurs), the fact that activists and industry, rather than impartial public servants, comprise the Healthway decision-making process, makes this issue impossible to avoid. While exacerbated in Quasi And NonGovernment Organisations (QANGOs) like Healthway, lack of transparency continues to be an issue for all government spending. There is no reason that governments and agencies cannot, at a minimum, publish expenditure in

easily searchable online databases, as occurs in dozens of international jurisdictions. Taxpayer transparency portals have been proven to streamline efficiencies, reduce waste, and empower taxpayers, and modern technologies make this possible at minimal cost. It is simply unacceptable that in the 21st century such information can only be found through laborious FOI requests or trawling through lengthy reports. Instead, all funding decisions should be published in an easily accessed and searchable portal online. The WA Government should take this opportunity to introduce appropriate safeguards and fundamentally reform the management of Healthway, integrating its functions into the public sector (with Treasury being the obvious choice due to Healthway’s main role as a distributor of funds). Simultaneously, a transparency portal empowering West Australians to easily access and search funding decisions would be crucial to restoring accountability. When it comes to taxpayer dollars, sunlight really is the best disinfectant.

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Have You Heard?

The tangled web

Threatened female services

Dr Mike Civil’s announcement of HealthEngine uptake by his practice using a LinkedIn broadcast arrived on our doorstep. He said it was intended to assist practice patients using ‘social media’. Unfortunately for Mike his IT connections with the RACGP are well known, so we wrongly interpreted his email as an endorsement. Our experience is that WA GPs swim in a small IT pond and have great opportunities for networking. Not long ago, we reported on WA GP Dr Alan Leeb’s App for health consumers to signal vaccination reactions – he is on the same national RACGP standards committee as Mike. Longstanding chair of AGPAL and AMA nominee, WA GP Dr Richard Choong, knows well the full general practice standards devised by the RACGP and applied by AGPAL. This accreditation body has chosen to endorse HealthEngine through a partnership arrangement. HealthEngine’s CEO is another WA GP and AMA (WA) Assist Hon Sec, Dr Marcus Tan.

After 15 years, the RFDS will stop running the Rural Women’s GP program as of July 1 when Commonwealth funding is redirected to Rural Health Outreach Funds (RHOF) holder, Rural Health West. This has upset some GPs who are worried about a decline in ‘uneconomical’ outreach services, removing the choice some rural women have to see a female RWGP for issues beyond discussion with their local doctor. RWGPs were employees of RFDS and went to all corners of the state – when contracts terminate on June 30 some doctors will be weighing up alternatives.

On-costs beat GP-costs The National Health Performance Authority’s new report points to costs beyond general practice. It’s been well publicised about general practice’s frequent and above-average attenders accounting for 41% of Medicare out-of-hospital expenditure. However referrals to specialists, x-rays and pathology tests by

these people were almost 50% higher than their spending on GPs, on average. Frequent GP visitors spent $906 on GPs per head, and $1356 on other services. The big question is who generates these on-costs? Coming hard on the heels of this announcement was the surgeon’s college support for Health Ministers to “name and shame” specialists who charge exorbitant fees.

RACGP pharmacy blues WA GP and national RACGP President Dr Frank Jones has been getting stuck into pharmacy organisations, which he says seek an expansion of pharmacists’ roles at the risk of patient safety. We are talking things like vaccinations, cancer screening, mental illness and drug dependence. The pharmacists say they want to do the simple stuff and work in with GPs like they have done in past. The college has pointed to conflict of interest for retail pharmacists driven by profits, GP nurses are OK with role delegation, waste from care fragmentation, preventive interventions need GP-led healthcare teams, and lack of diagnostic skills. By the way, the Harper Review has recommended pharmacy location and ownership rules be scrapped so which way government goes on this should be telling.

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Phytotech takeover In the March edition we explored the issue of medical marijuana and the listing of local company Phytotech Medical on the local stock exchange. News now has broken that it is being bought out by Canadian based MMJ Bioscience in a deal believed to be worth about $20.7m (to be finalised by May 25). Phytotech is touting the move as a merger of equals as both companies have complementary assets and strategic growth profiles. Also, just in, Victoria and Queensland are joining the NSW clinical trials of medical marijuana.

Spreading philanthropy benefits Health philanthropy in WA has become more business-like with UWA support of the Emerging Leaders in Philanthropy program put up by PMH Foundation and sponsored by Excelsior Finance. The Foundation has two teams that include those doing an MBA at the UWA Business School – learning the ropes on philanthropy while raising money for Aboriginal health and child mental health. Mentors and guest speakers read like a who’s who of the business world in WA. This may get up the philosophical nose of some but with shrinking government coffers to finance health, this may be where things are heading. We just wonder about charities that don’t pull at heartstrings or are not so popular for partnership marketing.

Privacy in the clouds Privacy Act changes commenced March last year. Patient records are obviously regarded as ‘personal information’ and ‘sensitive information’ at that, requiring higher privacy

Surgical skills audit We received a press release for Surgical Performance, an online system for auditing and comparing surgical performance, and endorsed by the college of O&G for colposcopies. A quick visit to the software’s website and WA O&G specialist Dr Bill Paton was endorsing it so we gave him a ring. He first reassured us he gets no kick-back, and with 34 years in WA he has used this anonymous self-audit in the last five years from Mandurah, entering about 3500 de-identified surgical cases. His motivation? He gets an overview of how his surgery is going (but wishes more would do it, so comparative figures are stronger). He gets accreditation points from the college. It helps him reflect and perhaps modify (e.g. mesh pelvic floor procedures). And good records that measure your performance against others can be helpful in litigation.

standards. Privacy statements should now include information about other entities the practice is likely to disclose personal information to. And for those thinking of using an iCloud storage or backup service, the best advice is don’t do it. Unless you can vouch 100% for cyber security, forget about anything other than de-identified information and providers in Australia, and even then quiz them on security setup, use of a subcontractor and your access to data. Of course, you have to tell patients you are handing iCloud providers their personal information.

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Celebrity Spotlight

Simple Truths from the Top End of Town Being a success at life is to dream big, inspire and be inspired by others and connect with those around you. They have all worked a treat for Mark Barnaba. It’s an impressive track record whichever way you look at it with a large dose of diversity thrown in for good measure. Chairman of Macquarie Group, WA and of the Black Swan Theatre Company right through to a Harvard MBA, WA Citizen of the Year in Industry and Commerce in 2009, and unpaid Chairman of the West Coast Eagles between 2007–2010. For Mark Barnaba the two threads underpinning his approach to life and work are the importance of family and making the most of your talents. “I grew up in a tight, Catholic Italian environment and it was a wonderful experience. The things that mattered most to my parents were love and support for their children and that gives you a feeling that you can do whatever you want and take every opportunity to be the best you possibly can.” “My secondary education was at Trinity, a Christian Brothers’ school, and they reinforced a lot of the values I grew up with at home. There were very few lay teachers when I was there and I have to say that I didn’t see any of the negative events that’ve been in the media recently. good time in myy life, to y It was a veryy g be honest.”

The leadership formula Mark has an interesting take on leadership qualities and their importance across a number of corporate areas, including the health sector. “Good leadership is needed in business, finance and health. There may well be a requirement for a different range of technical skills but I think the three most important qualities are firstly, being able to communicate a sense of vision and purpose. Secondly, is to bring others along on the journey. There’s a big difference between consensus and informed decision making, the former can mean reducing an issue to the lowest common denominator while the latter means you’re listening to a range of views and making an informed and considered decision.” “Finally, and this is often undervalued, having a sense of empathy and connectedness with the people you’re working with is critically important.” After graduating from UWA with a Commerce Degree in the mid-1980s Mark went to Harvard Business School and completed an MBA. “Going to a place such as Harvard expands your horizons and takes you out of your comfort zone. I was mixing with a completely different set of people p from all varieties of cultures and it gave me some life experiences at a relatively young a age that would’ve taken a lot longer to accum accumulate in the normal run of things.” “It c certainly gave me a clearer idea of my strengths and weaknesses.” Building for success Mark has had a long association with UWA, initially as a student and now as the Chairman of the Business School and an Adjunct Professor in Investment Banking and Finance. He was awarded an Honorary Doctorate in Commerce in 2012 by UWA. “In the past 35 years there have only been about 10 of those in which I haven’t been associated with the university. It has been, and still is, an important part of my life and it set firm foundations for me. It’s a privilege to be involved and give something back, particularly as the landscape of philanthropy is changing in Perth.” “I think we’ve come a long way in the past two decades, corporate philanthropy is spoken about more openly now and we’re getting a little closer to the US model. There’s still a gap,

12 12

but it’s narrowing and we’re making real inroads in this area.” The world of big business is often portrayed pejoratively as a hyper-competitive environment with alpha-males pushing hard for a competitive edge. “I don’t think it’s any uglier than other areas of life and some of my best friends are in this sector. Sure, along the way you do meet people that you’re a little unsure about but the majority are decent people. To be honest, I’ve never thought about it in that way, whether it’s ugly or otherwise. Human nature reveals itself in everything we do and I try to gravitate towards good people.” “I’ve loved the journey so far.” Life has its ups and downs It hasn’t always been plain sailing for Mark, who freely acknowledges that a life fully lived will have some setbacks along the way. “There are bleak moments and you have to expect a few of those. My father was only 53 when he passed away from cancer and I was 19 at the time. I’ve also had very close friends who’ve died young, some in their 30s. If you’re around for a while and engage with life some tough times are inevitable.” “On a more personal note, I had a skiing accident in my mid-20s and crushed several discs in my back. I had to undergo a couple of laminectomies and there were no endoscopic procedures around then. All that still sticks in the back of my head but I hasten to add I have been back to the doctor a few times since then.” “My wife, Paige, had a life-threatening pregnancy with our daughter Arabella and that certainly focused the mind. We so often take our health for granted and it can change in an instant.” Mark’s initial focus at university was the sciences and, indeed, he was nearly won over by the medical faculty. “I did look at doing medicine and, very briefly, enrolled in dentistry and engineering. Commerce grabbed my interest but I still enjoy reading the natural sciences, particularly material on the structure of the universe though, having said that, I also read a lot of newspapers and The Economist.” But for Mark Barnaba family is at the top of the triangle. “I love going along to karate with my son. It’s important to be a fully engaged parent and I’m sure our children are never going to grow up and say, gee Dad… I’m glad you won all those awards but you never had time for me.”

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Unsung Heroes of the Ebola Response WA public health specialist Dr Linda Selvey writes about contact tracers in the context of her recent trip to Liberia where she was assisting with WHO’s Ebola response. After more than one year, Liberia may have seen the last Ebola case. Even if this doesn’t come to pass, just having the end in sight of this devastating epidemic is cause for celebration. It also provides inspiration to those still working to control the epidemic in Guinea and Sierra Leone. Because of the close proximity of these three countries and the porous borders, Liberia will need to continue intensive Ebola surveillance and maintain Ebola Dr Linda Selvey treatment units, but its success shows that it is possible to control this virus even in situations of such poverty and poor infrastructure.

Billboards in Monrovia, capital of Liberia, alerting people to symptoms and prevention strategies to tackle the ebola epidemic. Pictures: Dr Paul Effler

Early response vital

and community leaders. The support of the international community with both financial and medical expertise was also vital.

There are many contributing factors to Liberia’s success. Having sufficient treatment units where cases could be treated and isolated was critical in getting Ebola under control. Providing safe and appropriate burials were also important, as was the community engagement, provision of chlorine disinfectants, and the strong response from government

Early on in the response, isolating most cases, ensuring safe burials and educating the community was sufficient to reduce transmission. But as the number of cases reduced, the critical role of the contact tracers, case investigators and active case finders, became increasingly important.

In order to reach zero cases and stop transmission, every contact of every case needed to be identified, and closely monitored so that they could be isolated if they developed symptoms. Active case finders are the Ebola eyes and ears of the community – identifying people with Ebola-like symptoms, following up leads and identifying any unreported deaths in the continued on Page 16

Beating the Ebola Outbreak Medical Forum asked Communicable Diseases Network Australia to explain the procedures used for the recent Ebola outbreak in West Africa and what local healthcare workers, including those who travelled from WA, faced. Ebola virus is contagious and lethal, without a known antidote, so ‘spreadability’ increases the significance of outbreaks. These principles, some unique to this virus or location, helped contain spread: så Case finding: this required safe transfer, isolation, and laboratory diagnosis. så Case management: this involved training local healthcare workers to prevent spread and provide appropriate care, as well as the logistics around Personal Protective Equipment, cleaning and clinical supplies, and deployment of personnel. så Contact tracing and monitoring: high-risk contacts are quarantined for up to 21 days. så Safe and dignified burials: trained teams conduct culturally acceptable burials that prevent contact with body fluids. så Local awareness-raising: the declaration


of a national emergency and community engagement through political and cultural leaders is critical. så Communication and coordination: including foreign medical teams and international agencies. så Exit screening: the declaration of a Public Health Emergency of International Concern under the International Health Regulations (IHR) 2005 necessitated exit screening to prevent international spread. In countries outside the affected region, contingency plans were needed if a case, say in Australia, was diagnosed. Healthcare workers returning from West Africa are identified before or at the border, and are managed until any risk of developing Ebola is over. Difficulties on the ground Guinea, Liberia and Sierra Leone are very poor countries with fragile health systems and limited resources. They were inexperienced in dealing with Ebola outbreaks, and faced widespread public misperceptions about the disease, highly mobile populations (seven times the average for that region) and inadequate infection-control practices.

Assistance from international nongovernmental organisations and foreign governments was critical. Senegal, Nigeria and Mali all successfully dealt with imported Ebola outbreaks, which illustrates that effective management of a limited outbreak of EVD is within the capacity of relatively poor countries. The multi-region outbreak was unexpected and hampered the response. It was not until August 8, when WHO declared it as an issue of international concern, that aid efforts were mobilised. A severe shortage of health system capacity in the three most-affected countries, with no more than two doctors per 100,000 of population, was also a problem. As was community resistance to the imposed control measures. WA Health’s Department of Communicable Diseases has developed an ‘EbolaTracks’ SMS system (see ViewArticle.aspx?ArticleId=20999) and the timeline for events is described at www.who. int/features/ebola/storymap/en/.




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Unsung Heroes of the Ebola Response community. Contact tracers would visit all contacts of every case, every day (sometimes twice a day), measuring their temperatures, providing support and encouragement and persuading people to seek immediate treatment if they got sick. Contact tracers tireless commitment These tracers were members of the community, who were paid a very small stipend and provided with some training. They worked tirelessly, seven days a week to protect their communities. They put themselves on the line, sometimes facing hostility from people who were terrified of contracting and dying from Ebola and/or mistrustful of the government. They had to face widespread grief from those contacts who had lost loved ones as well as dealing with their own grief because almost everyone had lost loved ones to the disease. But still they worked, day in and day out doing what they could to build trust and gain cooperation. As there became fewer and fewer cases, their task became even more difficult. While there were fewer contacts to follow up, they needed closer follow-up. Not surprisingly, while Ebola was apparently indiscriminate early in the epidemic, as cases decreased, they became concentrated in the poorest and most marginalised communities. There were communities that had little trust in authority, limited education and who did not always believe in information regarding

the transmission of and the response to the outbreak. Gaining the cooperation of the cases and their contacts became increasingly difficult.

wife to a number of clinics and a traditional healer. He died in the community and in his last days he infected a number of other people, including his wife and the traditional healer.

Tracer uses community knowledge

Local leadership vital

There is an instance where a man helped a very sick man into a taxi so that he could seek medical care for what turned out to be Ebola, and who subsequently died. In spite of the case and his family being interviewed, the good Samaritan was overlooked as a contact.

This story illustrates some of the challenges facing response teams in marginalised communities, which can only be solved by the communities themselves through leadership and individual dedication to controlling the epidemic.

Through their links in the community, a contact tracer heard about this story. While this man wasn’t on the contact list, and therefore the tracers had no obligation to follow him up, they visited his house every day. The man and his wife did not believe that Ebola was an infectious disease and he avoided the contact tracers when they visited his house. Every day the contact tracers visited and spoke to the man’s wife, who claimed the man was at work. They started visiting outside of work hours in order to make contact with the man, but he was always ‘not at home’. Finally they visited the house at 5.30am, only to be told that the man was not at home. While this is a story of incredible persistence and dedication on behalf of the contact tracers, who incidentally were not paid for this work because the man was not on the contact list, it does not have a happy ending. The man became sick and was taken by his

Health care workers, laboratory workers, ambulance officers, burial teams, epidemiologists, anthropologists, social mobilisers, and health promoters, and infection control specialists all have made this response possible. All deserve recognition and praise. But next time you think of an Ebola responder – perhaps someone you know who has gone to West Africa – spare a thought for the contact tracers, active case finders and case investigators; people you may not have heard about but without whom Ebola could not have been controlled. These people have faced the reality of Ebola in their communities, have experienced tremendous grief and loss and yet have dedicated their time and energy to controlling the epidemic. They are my heroes. For more background on Ebola, see P41.

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‘Medical Board & AHPRA...

Friendly Fire?’

The first Doctors Drum breakfast for 2015 took a big bite from this very meaty issue. Who is who; who does what; and why does it take so long? It was a recurring lament from the floor of the Doctors Drum breakfast forum. Too few doctors know how the two bodies work together, a sobering thought given AHPRA has been active since July 2010. It took two medical defence lawyers and a representative on the Medical Board a good part of the the breakfast discussion to make sense of procedures that seemed to many to be at best hampered by red tape and at worst woefully unfair. For the record, all complaints made against a medical practitioner go to AHPRA, which investigates them all and refers serious breaches, i.e. those that are potentially damaging to someone’s health, to the Medical Board. But therein is the rub. MIGA claims manager and panellist Ms Cheryl McDonald, as a medical defence lawyer representing the interests of the doctors, says it is appropriate for the legal process to take time to thoroughly investigate and be fair to both consumer and doctor.

Doctors Drum panellists from left: MIGA’s Ms Cheryl McDonald, Panetta McGrath’s Mr Enore Panetta, Health Consumer Council’s Dr Martin Whitely, Physician Dr David Watson, GP Dr Helen Wilcox, Medical Board member Dr Michael McComish and MC Mr Russell Woolf

Time, transparency and communication So if the profession must accept that every claim (or notification) is created equal, in legal terms, and three months is the barest minimum time for or a resolutio resolution,, the issues of transparency

and communication on the part of AHPRA take on far greater significance and it is where a lot of doctor dissent is focused. Amongst the personal stories recounted at the breakfast, not one of the doctors felt AHPRA consid considered them innocent before being found guilty. One specialist told a particularly sobering story of mistaken identity which haunts him still. It goes goe like this: A pa patient experienced an adverse event in a hospital, a nurse wrongly identified Dr X who hosp was overseas at a conference at the time. The reg regulator took more than six months to resolve this, this asking the doctor to identify the real cu culprit! During this time, Dr X’s record showed he was under investigation, which hampered h application for interstate positions. It took his serious representation to clear his record, with s no n apology from AHPRA forthcoming.

GP panellist Dr Helen Wilcox posed the question of a no-fault system. It sounded like a good idea and apparently New Zealand has one but legal panellist Mr Enore Panetta suggested they were experiencing problems with it, especially the more complicated complaints. Common sense and consensus can only go so far, it seems. Panellist Prof David Watson told the gathering he believed the system was more consumerfriendly than it was practitioner friendly and waiting 3-4 years to be told there was little to answer is not in anyone’s best interests. Room for improvement The Medical Board panellist Dr Michael McComish, said that there was room for continued on Page 20

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‘Medical Board and AHPRA – Friendly Fire?’ improvement in the way AHPRA and the board communicates with practitioners and he could understand the frustrations about transparency but denied that they dragged their feet unnecessarily. It was their responsibility to investigate. Attending the meeting to field possible questions were the WA Medical Board chair Prof Con Michael, AHPRA state manager Ms Robyn Collins and head of AHPRA’s Notifications and Legal Services, Ms Pam Malcolm. Questions were raised of the panal about triaging of complaints given the high number of notifications that returned a “no-case to answer” result. While WA complaints were in step with national figures (4.2% of WA doctors rs had received notifications) there had been a 38% increase in WA notifications to AHPRA. Ms McDonald said this was a national trend and believed it reflected changing patient expectations rather than a drop in professional al standards.

the process. He suggested that Health and Disability Services Complaints Office (HaDSCO), which mostly handles complaints regarding health costs, could be trained to handle low-level misconduct issues to speed up the process.

where an Ombudsman hears complaints, Prof Watson said there’s danger in thinking the old ways were best. “There were problems with the old way. It made it too hard for a complaint to be made. We don’t want to return to the clubby way of doing things.”

Consumers share docs concern

Dr McComish flagged the release of findings of a review of AHPRA procedures conducted by former WA Director General of Health Mr Kim Snowball, which would address some of the issues. The report was scheduled for release in late April.

He remarked that the concerns of doctors were also the concerns of consumers – namely, complaints took too long to finalise with too little information sharing during

Whatever your feelings about it, it seems the new National Law is here to stay. Despite calls from the floor for a return to the Medical Board system or to a system such as Queensland

ED. The meeting did not get around to discussing Medical Assessment Panels and expert witnesses. They have the task of investigating individual doctors singled out by patient complaint or by the WA Medical Board acting alone. How these people are chosen, how bias in the system is managed and transparency in operation are of concern to many doctors. Maybe next time?

The consumer representative on the panel, Dr Martin Whitely, from the Health Consumers Council, suggested there has been a cultural shift that gave consumers more confidence to challenge their doctors and this was not necessarily a bad thing. It broke down the clubby culture that marks the profession here in WA – it was no longer acceptable for the medical profession to monitor itself, and the figure of 4.2% was not excessive.

He found a dozen lawyers in the main lobby and told them that they were a jury. The lawyers thought this would be a novel experience and so followed the judge back to the courtroom.

JUDGE AND JURY “How can I ever thank you?” gushed a woman to her lawyer, after he had solved her legal troubles. “My dear woman,” lawyer replied, “Ever since the Phoenicians invented money there has been only one answer to that easy question.” A judge in a small city was hearing a drunkdriving case and the defendant, who had both a record and a reputation for driving under the influence, demanded a jury trial. It was nearly 4.30pm and getting a jury would take time, so the judge called a recess and went out in the hall looking to impanel anyone available for jury duty.


The trial was over in about 10 minutes and it was very clear that the defendant was guilty. The jury went into the jury-room, the judge started getting ready to go home, and everyone waited. After nearly three hours, the judge was totally out of patience and sent the bailiff into the jury-room to see what was holding up the verdict. When the bailiff returned, the judge said, “Well have they reached a verdict yet?” The bailiff shook his head and said, “Verdict? Hell, they’re still doing nominating speeches for the foreman’s position!”

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Mobile Apps for Health Your smartphone should facilitate co-care arrangements between health consumer and doctor but are we being swamped instead? Apps for different mobile devices began appearing in 2008, originally for gaming, general productivity and information retrieval (e.g. email, stock market, weather). Consumer demand and easier developer tools brought an explosion in apps for a variety of uses, and an industry devoted to examining new apps as they came onto the market. In 2014 government regulatory agencies began trying to regulate and curate apps, particularly medical apps, mainly because of potential harm. This is particularly the case for apps that record and transmit. However, the industry has largely gone unregulated, so amongst the flood of mobile apps for health, it is very much ‘buyer beware’. Development goalposts shift You can download apps made for particular devices from the App Store (iPhone, iPad or SmartWatch), Google Play (Android phones), Windows Phone Store, and BlackBerry App World. Most apps are free (about 90%) but with privacy statements that you could drive a bus through and access to seemingly unrelated user data from your mobile device, data mining could be a motive. With the advent of social media, attitudes to privacy have relaxed, perhaps a little too much. Some apps must be bought (with about 20-30% of the purchase price going to the distributor e.g. iTunes). An increasing number are free and it is in-app purchases that support any get-rich-quick ideas. And get rich you can in an industry that generates over $30b each year. Anyone addicted to Candy Crush will testify to in-app purchases!

These days, simple apps can be developed relatively cheaply.

Why are businesses creating mobile apps?

Mobile apps have been evolving in the healthcare space: mHealth and telehealth access in remote areas; wearable fitness devices and health trackers as part of the feelgood, look-good market; appointment booking apps that make life easier for patients and/or practices; and disease-specific apps developed by clinicians to provide more interactive co-care with patients (e.g. post MI rehab).


Apple’s new move into wearable devices like the Apple Watch raises the possibility of transmitting the user’s own bio data to the medical community – giving regulators more work to do but perhaps proving to be the game-changer or another gimmick with limited knock-on benefits.

sååå!BOUTåTHREEåQUARTERSåOFåBUSINESSåOWNERSå use mobile apps daily, many for customer engagement.

Which part of the IT world holds most promise for healthcare depends on who you talk to. Big players such as Telstra have invested in the healthcare space anticipating provision of IT solutions to governments coming under fiscal pressure. Mobile apps are sure to be part of their solutions. App design attributes In the IT world, anything is possible. Clinicians have shown by their reactions to the PCEHR that anything that offers increased connectivity with sensitive patient data needs to be grounded in clinical reality and be harm-free. Mobile apps must also attract the health erconsumer with an easily understood, userfriendly interface. Too much complexity and e the health consumer will not feel they are

sååå/NåAVERAGE åPEOPLEåCHECKåTHEIRåMOBILEå often and use mobile apps more than the websites. sååå-OSTåSMART PHONEåUSERSåMAKE purchasing decisions much more quickly than on desktops.

getting added value, and it must be more than what happens on a website (which is why Apple has banned apps that are just a version of a company’s existing website). With over a million apps across different operating systems, it is interesting that amongst the billions of downloads each year, about two thirds are never ‘test driven’ on mobile devices, presumably because of consumer dissatisfaction. In other words, the app must address a common consumer issue, or provide real consumer value for it to take off. Woe the app that provides only a marginal benefit over other existing approaches. Medical apps, depending on what they do, may be hamstrung to share data due to public sensitivity and privacy concerns reducing

Mobile Apps Overview A mobile app is software designed to run on a device such as a Smartphone, Tablet computer, or other mobile handheld computing device (e.g. SmartWatch, Google glasses). Strictly speaking, it is the service provider that is mobile, not the device. And because different providers have different operating systems (OS), mobile apps written for different OS will reach the widest consumer audience. Moreover, most handheld devices have compatibility with Wi-Fi, Bluetooth, Near Field communication, Internet browsing, and Location-based services so integration with these capabilities may make any app more attractive by improving the user experience. So the mobile app can run independently of an internet connection and function in a way that is different to a web-browsing experience.




Case Studies C Ag good medical app in the eyes of doctors should have wide appeal, be easy and sho fun to use, be free (or cheap), add to the health heal consumer’s consultation experience, connect conn consumer and clinician in a way that moves move co-care forward, and returns a saving to the community (e.g. by lessening hospital admissions). admis

Method: guide the user through a series of questions to identify whether a fence, eaves, etc. is made of or contains asbestos cement, and the condition of the asbestos

Asbestos Risk Asbe

It is pretty common for major conferences to have their own App these days. Once downloaded onto a mobile phone, the conference delegate can access information, from the venue location to conference news.

Curtin University’s School of Public Health has re received a grant to develop a mobile app to warn of asbestos fibre exposure for trades tradespeople and home renovators. For those in building build demolition, exposure is ‘black or whi white’ and once identified, the asbestos people are called in, or alternatively, short cuts around any risk are taken. Identifying asbestos conclu conclusively requires a microscope although most tradespeople t have early warning patterns worked out for risky materials patter (house (houses built before 1988). Aim: tto improve knowledge of asbestos source sources in our environment and homes, and what condition c it is in (poorer condition = greate greater inhalation risk, and therefore malignant mesot mesothelioma 20-30 years later)

the app’s usefulness unless strict sharing protocols are followed. The in-store iBeacons, which can communicate with your iPhone via Bluetooth, may be an unwelcome intrusion if it can access sensitive health information, and flash you a relevant advert. Consumers are likely to feel differently about an app if sharing information about their health insurance, glasses prescription, Medicare status etc. with a retailer goes with the territory? Making it easier for retailers and insurance companies doesn’t always equate to ‘better’ for consumers. To make in-app purchases a smoother experience for the consumer, big players such as Google, Microsoft, and Apple are trying to develop their own standards for mobile wallets. However, unless they agree on a single common system, retailers and other outlets may baulk, as may any crucial third person (as happened with electronic scripts). In fact, in-device integration with third parties may be a dream too far, as one IT expert explained. “While it’s easy for mobility to enable apps that support a point-to-point relationship between a provider and a consumer (e.g. your bank, your airline, your insurance company), once you introduce a third party, you raise the question of how that third party will be integrated into that system. Mobile apps are isolated at the moment – they usually don’t talk to each other on the device – so integration is sparse, if available at all. This means companies need to integrate their systems at the back end and that’s a big job.” “To have an ordering system for an eyewear supplier via your insurance company, the eyewear supplier needs to be providing a lot of information to the insurer in terms of cost,


Targe T Target market: tradespeople, environmental health officers and householders

Provides resources: where to seek advice and/or safe removal Conference Apps

The conference app shows the daily lecture schedule, the floor plan of the exhibition floor and lecture theatres, bio notes on the keynote speakers plus their pictures, click-through to sponsors’ and exhibitors’ websites, and the daily program such as extracurricular activities, AGMs, breakfast sessions, poster presentations, and concurrent sessions. Conference news evolves during the conference and includes pictures of social events, awards, promos for sponsors and outside news on topics aligned with the conference content. The conference app comes with registration and gives the organisers something more to market to sponsors as well as provide relevant information to delegates, accessible at their fingertips.

Image use: Matching pictures of asbestos containing materials with real life scenarios

availability, lead times, stock levels, discounts, pricing to the consumer, etc. The insurance company needs to integrate this and pass it onto their customer, something they don’t normally do. This explains why the ‘real world’ model of purchasing from retailers and claiming back from the insurance company has existed to date – the integration of the two businesses is inherently complex and delivers little value above the two interacting with the consumer separately.” On the downside There are many mobile apps to assist consumers regarding diabetes, weight loss, mental health, blood pressure, etc many of them substandard and of limited value for any doctor-patient relationship. You have to wade through trusted reviews (consumer reviews can often be contrived) to find a good one (see For busy health professionals there is almost too much choice. Throw in the slick-looking mobile apps from equipment or product manufacturers, plus the many apps designed to assist health professionals alone, and it is a bit of minefield finding something that helps doctors and can be recommended to patients as well. There is no shortage of databases to search and everyone is having trouble keeping up with it (see You simply have to put in the time to find what you want. If you have a truly useful idea or product to bring to the market, breaking through this noise is difficult.

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Control the Cosmetic Cowboys! The practice of cosmetic injections is being swamped by the unskilled and unregulated says Dr Joanne Samer who worries about patient harm. I recently received an unsolicited email from a business in Queensland offering me the opportunity to have a nurse injector in my ‘Beauty Salon’ complete with all necessary back-up through protocols and a supervising doctor working via Skype and telephone from Queensland. The perception is that cosmetic medicine is big business where lots of money is to be made, hence this national approach to market growth. The reality is a messy, poorly regulated competitive mess! Currently in WA, Botox and other injectable S4 drugs are available in a wide variety of settings with a range of injecting practitioners. These include: så 0LASTICåSURGEONSåORåOTHERåMEDICALå specialists rooms with nurse injectors så '0SåOFFERINGåCOSMETICåTREATMENTSåIN their rooms, amongst the daily flow of sick patients så $EDICATEDåCOSMETICåCLINICS åRUNåBYåDOCTORS å where all injections are by doctors så $EDICATEDåCOSMETICåCLINICS åOWNEDåBYå doctors and most, or all, injections are by nurses så "EAUTYåCLINICåFRANCHISESåWITHåNURSEåORå doctor injectors. Nurses are usually, but not always, supervised remotely using Skype or telephone så "EAUTYåSALONSåATåSHOPPINGåCENTRESåOR in private home-based salons, with a local doctor or a doctor that flies in from perhaps Queensland, NSW or Victoria every few weeks så (OME BASEDå@PARTIESåTYPICALLYåWITH nurse injectors så !NDåEVERYåCOMBINATIONåOFåTHESEåBEåITåINåTHEå city or remote areas of WA.

As well, many patients have treatments in Bali or Thailand and present in WA for later management. There are no minimal levels of training required to inject S4 cosmetic drugs. There are cases of both doctors and nurses with only a few years or less postgraduate experience providing the services. Pharmaceutical companies offer excellent training but one company has restrictions on who it will train whilst the others have none. Some clinics only offer ‘in-house’ training for nurses to ensure they keep to the business’s guidelines of what to say and how to treat. Discounts are offered to larger businesses for large orders of drugs. The consumer may only have some of the pertinent information with which to make treatment decisions. The risk of missing a contraindication to treatment increases with inexperience. Body dysmorphia and early onset dementia are two examples, both of which I have seen and refused to treat. I would argue it takes years of experience to recognise the signs and have the skills to say no in these complex situations. Record keeping varies tremendously – from those who take photos and document everything to those who keep no records, only accept cash and never provide receipts. To carry S4 drugs or keep them on premises, requires a poisons licence if you are not a

medical practitioner or a medical practice, respectively. S4 drugs must only be delivered to a registered medical practice. So how is it that couriers are delivering S4 drugs to beauty salons, that nurses are routinely travelling with S4 drugs to sites where no doctor is present and that S4 drugs are so readily accessible? Marketing is cutthroat Marketing and advertising for cosmetic treatments is fierce, often misleading, and confusing for the consumer. Heavy penalties for legislative breaches are rarely applied. For example, if you Google “Botox Perth” many advertisements pop up in clear breach of TGA rules. Similarly, clinics cannot have information on injectable treatments visible from the exterior yet numerous franchise outlets offering spray tans and Brazilian waxes in Perth are doing just this. Price of treatments varies widely. Discount deals, often via online discounts such as Scoopon, put S4 drugs on a par with a facial offered in any beauty salon.

Medical Board Call Falls Short?

In this competitive, misleading and ugly space consumers are increasingly confused and regularly misled by the more unscrupulous and, dare I suggest, financially driven businesses.

In March, the Medical Board of Australia released a public consultation paper and regulation impact statement calling for feedback on issues relating to medical practitioners who provide cosmetic medical and surgical procedures, the effectiveness of current regulation and whether extra safeguards are needed.

The current Medical Board of Australia Public Consultation Paper paints a picture of a simplistic environment where all injectables are offered in medical practices by highly trained doctors and nurses yet the reality is very, very far from this.

Dr Samer’s article suggests the net should be cast wider than just medical practitioners but the Board is calling for practitioner input to help guide its response. The paper compares four options: så 2ETAINåSTATUSåQUOåOFåPROVIDINGåGENERALå guidance about the Board’s expectations of medical practitioners providing cosmetic


procedures via the approved code of conduct så !NåEDUCATIONåCAMPAIGNåFORåCONSUMERS så 3TRENGTHENåCURRENTåGUIDELINESåWITHå practice-specific guidelines så 3TRENGTHENåGUIDELINESåWITHåPRACTICE specific guidelines but provide less explicit guidance to medical practitioners. Whether this consultation process comes to the heart of the problems outlined by Dr Samer remains to be seen. Doctors have until May 29 to submit their feedback by emailing The discussion paper can be found at

It is time for the Medical Board, AND the Nurses Board, AHPRA, the TGA and the pharmaceutical companies to come together, set manageable and practical guidelines and standards that can be maintained and where breaches are dealt with accordingly. The consumer is being poorly treated and it is time it was stopped! If not, my prediction is Botox in nail bars within five years!


Guest Column

New dedicated day surgery facility now open.

The Healthy Doctor Will See You Now Dr Jenny Brockis encourages doctors to practise some self-care to enable them to care for others. In her song Ironic, Alanis Morissette laments how: “...Life has a funny way of sneaking up on you. When you think everything’s okay and everything’s going right... It’s the good advice that you just didn’t take and who would’ve thought it figures” When people are sick, troubled or need a check-up, they see their doctor. But what if the doctor on the other side of the desk looks more unwell, tired and unhealthy than the patient? It doesn’t inspire much confidence, does it? Doctors have been notoriously bad at looking after their own health. The statistics tell us of the high incidence of mental health problems, stress, suicide and burnout in the caring professions. Not to mention the high levels of obesity, high blood pressure and heart disease. We are advised to take responsibility for our own health.

Overbusy, overthinking minds easily get caught up on the hamster wheel of overwork, which is why...we need to put our own oxygen masks on first, before attending to the needs of others.

Sure, but giving advice to busy, stressed out health professionals that their own health sucks and they need to do something about it isn’t enough. It’s like all that great health advice we share with our patients; they don’t always act on it either. Knowledge isn’t enough because facts and figures don’t change behaviours. What does is the awareness that staying in the status quo is no longer an option and to understand WHY that is. Then, it’s about deciding to initiate the required change.

Complete health is about creating a healthy body and a fit brain. It’s about scheduling in time, not just for a quick jog before work, but the appropriate fuel and regular brain breaks needed to create more thinking space, maintain our cognition and re-establish (if missing in action) that sense of achievement and happiness. Overbusy, overthinking minds easily get caught up on the hamster wheel of overwork, which is why, especially in the intellectually and emotionally demanding profession of medicine, we need to put our own oxygen masks on first, before attending to the needs of others. Creating healthier, health workplaces requires a cultural shift and needs: så !åBIGåENOUGHåWHYåå så !åFRAMEWORKåTOåFOLLOW åINCLUDINGåREVIEWåOFåPROGRESSåå så !åSUPPORTåNETWORKåFORåACCOUNTABILITYåANDåCELEBRATIONåPACKAGESåFORåALLå wins big and small.

The new St John of God Wembley Day Surgery. Located across the road from St John of God Subiaco Hospital at 190 Cambridge Street Wembley. This brand new facility is fully equipped with three state-of-the-art operating theatres catering for a range of specialties including:

Plastics, QOrthopaedics, QGynaecology and QDental Surgery Q

This facility is fully customised for day surgical work with a capacity of 15 day beds and eight overnight beds. Admissions will be coordinated from St John of God Subiaco Hospital. Visit for a virtual tour of St John of God Wembley Day Surgery. T: (08) 6258 3555 F: (08) 6258 3556 E:

What if you initiated a wellness program into your own practice? What difference could that make in reducing stress levels, improving interpersonal relationships, communication, workplace efficiencies, and morale? We are creatures of habit and the pain of change can sometimes feel too hard. Changing established working practices to maintain our own health, will take time, effort and a shift in priorities. But in a world that threatens to overwhelm us with the escalating volume of demand and increasing complexity of required medical services, can we afford not to?


Hospitality I Compassion I Respect I Justice I Excellence


Guest Column

Teaching Ethics and Opening Minds Challenging time-poor medical students about their scientific worldview will reap benefits at the bedside, says Notre Dame ethicist Dr Richard Hamilton, PhD. What benefit is there in forcing students to study liberal arts subjects in an already crowded curriculum? In my experience, there is a difficult balancing act between making the subjects relevant enough to engage students without turning them into just another component of the clinical degree. The Core Curriculum of Philosophy, Ethics and Theology is a central part of the University of Notre Dame Australia’s mission and all undergraduate and post-graduate students are expected to complete them as a vital part of their University education. Normally students from a variety of disciplines take their core subjects together but for practical reasons our medical students take the core separately. This raised issues from the beginning. For one, students lose the social and educational benefits of mixing with students from other disciplines, in particular allied health disciplines. It is not clear if this provides them with the best preparation for entering a hospital environment where they are expected to work in a team. Moreover, in the University as a whole the Core Curriculum has a clear


identity as something distinct from the rest of the course whereas by teaching the medical students as a separate cohort there was pressure to tailor the Core to medicine. Our course was one of the first post-graduate entry programs in Australia. Students come from a variety of backgrounds but with a preponderance from the natural and life sciences. All of them are high achievers and they have acquired a distinctive and successful learning style. It is, therefore, quite a shock for many to find that this style does not necessarily serve them well when approaching Philosophy, Ethics and Theology. Philosophy asks them to raise foundational questions about the epistemological and metaphysical assumptions underpinning the modern scientific worldview. Both advocates of Complementary and Alternative Medicine and die-hard Richard Dawkins’ lovers are asked to question and justify their core beliefs. Ethics highlights the tremendously complex and often heart wrenching problems that modern medical science gives rise to and the difficulty of producing neat solutions to them.

Theology introduces them to the importance spirituality plays in guiding patients’ treatment decisions, something that can be confronting both to staunch atheist students and to those of differing faith backgrounds. In contrast to previous historical periods, where scientific writing belonged to the literary canon, there is a stark divide between the prosaic and pragmatic style of contemporary scientific literature and the often dense and complex literature of the humanities. Students are used to skimming scientific reports and quickly extracting the key information. Reading philosophical texts requires them to slow down and spend considerable time with texts they consider ‘longwinded’. Getting students to read continues to be the biggest challenge but for those who do an entire new set of perspectives on the world is opened to them. They may not see it at the time but there is no better preparation for their future medical careers where they will be forced to mix with a broad range of colleagues, patients and administrators, each with their own peculiar take on the world.


Guest Column

Stop Mental Health Uncertainty WA Association for Mental Health CEO Mr Rod Asbury says threatened funding cuts create needless anxiety for community groups and the vulnerable people they serve. The Health Minister Sussan Ley announced last month that community mental health services around Australia, receiving about $330 million in Federal funding each year, would be funded for a further 12 months from June 30, 2015. This is the second last-minute reprieve for federally funded community mental health services. Organisations funded by the Department of Social Services were recently provided a similar extension with just a few months left on the contracts. However, longterm future of services remains uncertain. Community organisations provide a critical network of non-clinical services that support people affected by mental illness, and their families, to live valued lives. Assisting with accommodation, education and employment, counselling, family and carer support, mental illness prevention and self-help support, these community organisations foster independence and social inclusion and reduce the risk of suicide and self-harm, unnecessary hospitalisation, homelessness, contact with the justice system and family breakdown.


Many of our community’s most vulnerable people depend on these programs for their day-to-day support and face growing uncertainty because federal funding for hundreds of contracts cannot be guaranteed. This ongoing uncertainty is causing organisational disruption and, increasingly, deep anxiety amongst the people they serve. Our members in the community managed mental health sector in WA are experiencing workforce impacts including staff stress, job insecurity, and problems for staff recruitment, retention and training. Our members reported a range of 10 to 1000 consumers across 16 services would be affected should their services not be extended beyond current contracts. Many service providers also noted the impacts on hundreds of carers and family members. Year-on-year funding remains a constant burden and represents red tape for services and programs delivering supports. We see a lot of services receive grants and start delivering a service, only to almost immediately

need to evaluate it and re-apply for more funding to sustain it. For organisations delivering mental health services in rural and remote areas where service availability is stretched at best, funding cuts and uncertainty mean they’re often hit the hardest. One of our members said that the recent funding uncertainty had been the worst they’d experienced in their 25 years in the mental health sector. They noted the government’s lack of clear direction and substantive information, its delay in decision-making, and its minimal responses and direction to an organisation which may face closure. Our research reveals the burden of administrative complexity and red tape when it comes to both State and Federal funding, and there is urgent need for greater flexibility. When services can thrive and focus on helping the people they serve, instead of evaluating and justifying their existence every 12 months, it strengthens what they do best – reducing suicide, self-harm, and the development of more critical issues needing more expensive interventions.



Junior GP Training Cuts, a Low Blow Health Minister Sussan Ley seems to have turned her back on a program that is delivering more GPs in areas of greatest need in WA. Since the 2014 May budget, there has been considerable upheaval in the health sector, particularly primary health, which has left general practice and health consumers in a state of flux. The Federal Government was swift to lower the axe on GPET, the national training coordination body, taking its function in-house. Early last month it announced the 11 training regions, which would replace the current 17, for which training providers will be tendering. WA will be relatively unaffected. WAGPET has been the sole provider of GP training programs since 2002 and the government is keeping just the one training region for WA. However, WAGPET will still be required to tender. The Health Minister Sussan Ley also announced the establishment of a General Practice Training Advisory Committee, which would undertake an evaluation of the Australian General Practice Training program. This will be done by the RACGP and ACRRM. Everyone in the health space hopes this tender process will be more streamlined than the Primary Health Networks tenders, which has been a long drawn out affair which has taken its toll on Medicare Local staff and service providers who wonder if they will still have jobs. WA leads the way While Minister Ley’s announcement has guaranteed funding for 1500 GP registrar training places in 2016, WAGPET is concerned for the future of the Prevocational GP Placement Program (PGPPP), which it has continued to provide despite losing federal funding and support since December 2014. WAGPET has just released a report authored by Healthfix consultant Dr Felicity Jefferies, which explores the history of the program and why here, in WA, it has achieved such positive results not seen in other parts of the country. The extrapolation can be made that perhaps the Federal Government may have been judging the entire program based on the less inspiring results from other training regions. Here in WA, Felicity reports, the criteria have been tweaked. For instance, in WA, the program has only allowed Post-Graduate Year 2 (PGY2) and above trainees. “…this differs to the National program where around 50% of all PGPPPs are at the PGY1 level. By doing this WA has achieved a conversion rate of up to 81% of PGPPP doctors going on to a career in general practice, nationally this is more like 30%.” WAGPET chair Dr Damien Zilm said the program has been so successful in drawing junior doctors into general practice, particularly in areas of workforce shortage, neither WAGPET nor the State Government wanted to lose it. This led to


the Acting Director General, Prof Bryant Stokes, agreeing in May last year to fund the 2015 program to the tune of about $5m. However, the future of PGPPP does not hinge WAGPET Chair on funding alone. Dr Damien Zilm When the Federal Government scrapped the program, it also cut access to Medicare 3GA provider numbers, which allows any training doctor, pre-vocational or vocational, in a town of about 6000 people, to be paid a salary and keep the Medicare billings. WA Health comes to the rescue “This year we have had State Government funding and have been limping along with Rural Locum Relief Provider (RLRP) numbers, which have restricted the program,” Damien said. “There have been some practices which have committed to the program this year and have relinquished the junior doctor’s billings, but the program is mostly surviving in the Aboriginal Medical Services, which have access to these RLRP provider numbers. Rural Health West has helped us enormously getting these provider numbers. In other areas, it has been really difficult and the RLRP numbers are not ideal.” “It’s important to understand that the PGPPP provides fantastic training in places where it is very hard to get any doctors to go. Its success is that it works for everyone. Junior doctors are happy to go out on the 10-11 week rotations to interesting medical settings where they experience general practice in its broadest forms – both private practice and hospital. These areas of WA get much-needed doctors and the strong flow-on to vocational GP training program bodes well for future workforce demands.”

“Figures from the Kimberley show the exponential increase of GP registrars coincides with the delivery of the junior residency program in the area. Prof Stokes saw the value in doing this because the consequences of not doing it were far greater.” Minister Ley has announced that the issue of PGPPP provider numbers is off the discussion table, which prompted the commissioning of the Healthfix report to show the Federal Government and the community just how potent a well-run pre-vocational GP program can be for the future of local GP services. Need for provider numbers “The State Government is prepared to find the funds to continue supporting the PGPPP but we are hamstrung without the appropriate provider numbers,” Damien said. WAGPET is loathed to lose the impetus it has built and has also commissioned a live evaluation of this year’s PGPPP with the view of being able to present to both State and Federal governments the best way of delivering this program. As the Jefferies report states: “These composite placements were an initiative of WA, they have been highly successful and embraced by junior doctors. The key reason for ensuring a combined hospital GP rotation, especially in rural areas, is that it directly reflects the way in which the rural service model operates with rural doctors being the centre of both medical care in either community or hospital settings.” “While State and Commonwealth funding might be separate, care provided by doctors in these settings is not and actually achieves the long held aim of continuity of care for patients.”

By Ms Jan Hallam


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PERTH CLINIC WEST PERTH LOCATION Referring Patients the Simple Way With Perth Clinic’s new admission centre, referring a patient has never been easier. If a patient needs a Psychiatric admission urgently and is willing to be admitted as a voluntary patient, then ring the Admissions Manager on (08) 9488 2973 to discuss the referral and then fax a referral to (08) 9481 4454 requesting an inpatient admission. The referral should include: Patients details; Past history; Risk issues; Presenting problem/s;

Physical problem/s; Drug or alcohol use; the severity of this problem may or may not exclude them from admission.

The patient must have top hospital private health insurance that does not have restrictions on psychiatric cover. If they do not have this type of cover, it may be helpful if the patient contacts their Health Fund to enquire about upgrading their cover. Once the referral is received, the Admissions Centre will do the rest. The centre’s extra staff are able to process referrals more efficiently and electronic tracking ensures quick answers to any query. We will respond to you as soon as possible, but please be aware that not all patients will qualify and the more complex patients may take more time. The Mental Health Clinical Nurse triaging the referral will speak with the Psychiatrist regarding an urgent admission. The Admissions Manager also has a list of available Psychiatrists if admission is not necessary. Patients who are suitable to be referred to Perth Clinic are voluntary patients. If a patient is not willing to stay in the Clinic

or is involuntary, then the referral will not be accepted. Urgent admissions can be arranged if a patient is at risk of self harm to themselves or others; has adequate Psychiatric Hospital cover; and if they have not been seen by a Private Psychiatrist within the last twelve months. Perth Clinic admits male and female patients with various diagnoses with an age range of 14 years to 90 plus. The prevalent diagnoses treated at Perth Clinic are: Mood Disorders; Personality Disorders; Stress and adjustment Disorders;

Anxiety Disorders; Substance abuse Disorders.

The Admissions Manager will be able to clarify whether a patient is suitable and which Psychiatrists treat certain disorders. Some of the Psychiatrists also admit Workers Compensation cases, which can take extra time to organize as Perth Clinic is required to gain prior approval from the patient’s insurance company before they can be admitted. Patients may be given an outpatient appointment prior to admission. ssio As a General Practitioner you may ay find it necessary to refer a patient for a Psychiatric atr admission or an outpatient appointment. Let et Perth P Clinic Admissions Centre assist you with this his process and either fax a referral to (08) 9481 4454 454 or contact Kathryn Turner, Admissions Manager er on (08) 9488 2973 to discuss the referral.


21 Havelock Street Ph: 9488 2983 Fax: 9488 2994

2nd Floor, 46 Parliament Place Ph: 9486 5800 Fax: 9486 5888

3rd Floor, 46 Parliament Place Ph: 9389 2300 Fax: 9389 2399

Dr Lawrence Blumberg Dr Julia Charkey - Papp Dr Lynne Cunningham Dr Joseph Lee Dr Boon Loke Dr Kerry Monick Dr Raymond Wu

Dr Ian Assumption Dr Russell Date Dr Antony Davis Dr Ernst De Jong Dr Roy Kolnik Dr Manoj Kumar Dr Daniel Morkell Dr Dennis Tannenbaum

Dr Lindsay Allet Dr Rachel Allet Dr Johann Combrinck Dr Stella Fabrikant Dr Zlatan Golic Dr Mark Hall Dr Margaret Lumley Dr Chandi Senaratne

Dr Anu Bagwe Dr Nick De Felice Dr Pei-Yin Hsu Dr Chun (Solomon) Ong Dr Jasna Stepanovic Dr Gordon Wang

“We Strive to Provide the Best in Psychiatric Care” PERTH CLINIC 29 Havelock Street, West Perth WA 6005 32

Phone: (08) 9481 4888 Fax: (08) 9481 4454 Website: MEDICAL FORUM

News & Views

PIEDS: A Tale from the Streets Young men are injecting to shape the way they look. The surge in PIEDs* use involves risky behaviour around illicit drug and script use. According to Ms Mikayla McGinley of the Western Australian Substance Users Association (WASUA), the last six years has seen a significant increase in demand for access to the Needle and Syringe Exchange Program (NSEP) from people seeking injecting equipment for PIEDs. “Ten years ago approximately 2% of all contacts in the NSEP were people using PIEDs and now that figure is sitting at around 20% which translates Ms Mikayla McGinley HCV to more than Peer-Educator and PIEDs 10,000 people Project Officer, WASUA per year. When you consider that only three years ago it was less than half that number it represents a big jump over a relatively short period. A similar trend has been observed in other states and territories of Australia and in the UK,” said Mikayla. It’s a boy thing Predictably, there’s been no change in the gender bias of this particular client group however there has been a discernible shift in the motivation underpinning their behaviour. “The vast majority are male but 10 years ago virtually all our PIED clients were concerned with performance enhancement and tended to be athletes, body builders and security personnel. Nowadays most are young men focused on self-image enhancement and their desired outcome is a ‘ripped’ physique rather than the ability to lift weights in a gym.” “Typically, they’re in their 20s although we do see some between the ages of 30-40 and most are employed and relatively affluent. We’re seeing more FIFO workers and some students and it’s interesting to note that most appear not to be using other injecting drugs.” Mikayla outlines the more common substances being used to enhance the tight white T-shirt look. “Deca-Durabolin [nandrolone], Sustanon 250 [testosterone] and Human Growth Hormone are used to promote muscle mass and tissue growth with Peptides in the mix for healing injuries. PIEDS are utilised for a number of different reasons as well, such as relief from joint pain, as ‘cutting’ and conditioning agents to enhance metabolism and strip fat to accentuate muscle development.” “There’s also the drug Melanotan [synthetic melatonin derivative] which assists with the tanning process.”


All these drugs require a doctor’s prescription before they can be legally used. Users are poorly informed PIED users are not uniformly knowledgeable regarding their behavioural risk-factors and the manner in which they perceive themselves is illuminating. “Many of our PIED clients cite friends, trainers or dealers as their main source of information about their steroid use and, of course, a lot of people rely on the internet. Their knowledge about how these substances work and their potential interactions is highly variable.” “Interestingly, the vast majority of PIED users do not think of themselves as illicit drug users and many are not well-informed regarding the risks of viral or bacterial infection associated with intramuscular injection. Some report using steroids designed for veterinarian use which is fraught with danger because many come in multiple-dose bladders and this increases the risk of BBV transmission if training partners share their drugs or injecting equipment.” “We provide appropriate injecting equipment and we’re adapting to this emerging trend.” It is against the law to import steroids into Australia and the only way to legally procure them is by handing a prescription over the counter. Doctor-only is ignored “Many online sources claim they are licenced to sell PIEDs and this is simply not true. The only way to legally possess steroids in WA is to have them prescribed by a medical practitioner. Online ordering is a significant issue because people who import them from overseas face serious criminal charges.”

typically do not identify as ‘drug users’ and are not our stereotypical NSEP clients. But most drink alcohol and many indulge in other substances on a recreational basis. And when steroid users drink large amounts of alcohol the potential for aggressive behaviour is greatly compounded.” “When someone using steroids takes methamphetamine the chances of toxicity and of contracting BBVs is much higher. Most are doing their cycles without any monitoring or medical supervision so adverse reactions from ‘stacking’ steroids or injection-related injuries are not uncommon.” “Here at WASUA we’re deeply concerned that we don’t really know what the long-term public health implications of this trend might be. But we do know that we can expect to see more health problems due to PIEDs use in the near future”.

“In WA, police have the discretion to divert people from the criminal justice system if the amount of drugs involved is small and considered to be for personal use but, significantly, this option does not apply to most PIEDs.”

By Mr Peter McClelland

Finally, Mikayla makes some pertinent observations for GPs.

*PIEDs: Performance and Image Enhancing Drugs

“There should be serious concerns about concomitant poly-drug use. PIEDs users


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Clinical Update

Some combination pills work better in cardiology

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

By Dr Johan Janssen, Cardiologist, Western Cardiology

In the last few years we have seen the birth of many combination pills, chemical compounds often combined to improve patient ‘compliance’ and perhaps reduce overall costs to the patient and healthcare system.


by Medical Director Prof John Yovich

Dr Philip Rowlands ‌ a very slick and versatile gynae surgeon It is my pleasure to endorse Dr Philip Rowlands who is now expanding his gynaecological services at PIVET.

By Clinical

In the treatment of stage 2 hypertension (BP >160 mm Hg), starting with two drugs has clearly been shown to offer greater beneďŹ t than monotherapy. Many guidelines, including the European guidelines(1), clearly advocate starting with just one combination pill in these patients because of greater efďŹ cacy.

Professor Dr Rowlands joined PIVET 8 years ago and John Yovich embraced the new laparoscopic surgeries of Fertility Medicine – myomectomies, excisional procedures for endometriosis and tubal reconstructions as well as the microsurgical procedures for males – MESA, TESA and Vas reversals.

A recently published article by Dr Alan Gradman et al added another possible beneďŹ t from starting with a single-pill combined treatment(2) in hypertensive patients – both efďŹ cacy in reducing blood pressure and outcomes were examined. In looking at four large studies (over 1700 patients), those started on a single-pill combination had signiďŹ cantly lower cardiovascular events in follow-up to 3-4 years (than those started on monotherapy and other agents added later). There were fewer myocardial infarctions, strokes and ED visits for hypertensive emergencies.

During that time Dr Rowlands was also the Director of Obstetrics and Gynaecological services at Kaleeya Hospital where he had responsibility over the wide range of gynae surgeries in that public setting. Kaleeya has recently closed and Dr Rowlands now brings all those wider skills back to PIVET; procedures we previously dropped to focus on fertility. He will also conduct private obstetrics for those patients North of the River for delivery at Glengarry Hospital.

Therefore in the treatment of your hypertensive patient, assuming you have already educated them on low-sodium diets and other lifestyle changes, initial single-pill combinations seem to confer a greater advantage over monotherapy agents. Starting with a single-pill combination of a calcium channel blocker and a renin-angiotensin-aldosterone system (RAAS) blocker gives you better outcomes and faster blood pressure control.

With an increased physician cover at PIVET, we will assist Dr Rowlands to conduct the full gamut of O&G procedures LQFOXGLQJ2IĂ€FH*\QDHDVZHOODVD wide range of Day-surgery procedures at PIVET. The latter include Labial surgeries, Colposcopy with LLETZ clearances of the cervix, hysteroscopic polypectomies and Ureteric stent myomectomies, placement including MyoSure for complex morcellations, Dr Philip laparoscopic myoplasty corrections Rowlands adnexal surgery. for Septate and 7FRQĂ€JXUDWLRQXWHUL7KHUPDO%DOORRQ 1RYDVXUH$EODWLRQVIRU menorrhagia and Essure tubal insertions for female sterilization. He is also skilled at TVT-O sling for stress incontinence and laparoscopic sacro-colpopexy for vaginal vault prolapse.

The global impact of obesity and diabetes continues to increase and it will be accompanied by a marked rise in the occurrence of cardiovascular disease. Improved understanding of the pathophysiology of diabetic cardiovascular disease means we are not only aiming for glycaemic control but also choosing drugs with highest beneďŹ ts for the cardiovascular system(3). On the one hand, better glycaemic control is associated with less cardiovascular complications and overall better outcome for the patient but on the other, repetitive episodes of hypoglycaemia can lead to dementia, cardiovascular events and death(4). We therefore might use a combination preparation containing metformin (which has shown to be effective as a hypoglycaemic agent while improving lipid metabolism, and being weight neutral) and one of the newer agents that shows less risk of developing hypoglycaemia but with potential cardiovascular beneďŹ ts. Exciting drugs being studied at present are DPP-4 inhibitors and SGLT2 inhibitors. The results of some of these trials are awaited in 2015! References: 1. Mancia G, et al: ESH/ESC practice guidelines for the management of arterial hypertension. Blood Press. 2014;23:3-16. 2. Gradma AH et al: Initial combination therapy reduces the risk of cardiovascular events in hypertensive patients: a matched cohort study. Hypertension.2013;61:309-318 3. Singh et al.: Cardiovascular effects of anti-diabetic medications in type 2 diabetes mellitus. Curr Cardiol Rep 15: 327, 2013 4. Brunton, S: Hypoglycaemic potential of current and emerging pharmacotherapies in type 2 diabetes mellitus. Postgrad Med 124: 74-83

Having “nurtured� Dr Rowlands through the earlier years, I am proud to present him as a fully accomplished, slick gynae surgeon with additional microsurgical skills (for male procedures). He performs both Vaginal Hysterectomy and complete Laparoscopic Hysterectomies with equal aplomb, around 20 minutes per case, with zero blood loss! Cases referred to PIVET will continue to have my personal oversight, particularly for more complex surgeries.


Author competing interests: nil relevant. Questions: contact author on 9346 9300. Western Cardiology contribute to production costs.


For ALL appts/queries: T:9422 5400 F: 9382 4576 E: W:



At the forefront of technology 2008 2 Envision acquires the first Siemens Definition CT in WA. Fastest on the market with the lowest dose at the time. Envision Low Dose Chest CT average dose 1.5mSv

2013 Envision is the first private practice again to acquire the Siemens Flash CT. Lower dose than any other private practice at the time with industry leading image quality. Envision Low Dose Chest CT average dose 0.5mSv

2014 - Now Envision is the first private practice in the Southern Hemisphere with the Siemens Force CT capable of ultimate speed scanning. We continue to strive to be the leading imaging practice by acquiring and continuing to only utilise the latest state-of-the-art equipment. We capture sharper, clearer images at incredible speed to give you the best diagnostic results at the lowest possible dose. Every patient, every time on the new scanner. Only a fraction of the radiation dose more widely available. Envision Low Dose Chest CT average dose 0.1-0.2mSv




178 Cambridge Street | Wembley 6382 3888 | MEDICAL FORUM


Prescribing Schedule 8 drugs The WA Coroner recently held an inquest into the deaths of three men in 2010-12 after they visited several doctors and pharmacists and were prescribed and supplied opioids. The Coroner examined the circumstances and reasonableness of prescribing of Schedule 8 (S8) drugs, riskmanagement to limit ‘practice-shopping’ that included a ‘real-time’ addict notiďŹ cation system, and whether pharmacists should be able to notify Commonwealth and State agencies of people that ought not to be prescribed S8 drugs. Counsel assisting the Coroner said that in 2013, prescription medications contributed to 75% of the 116 recorded fatal overdoses in WA, with benzodiazepines involved in about a third of cases and prescription opioids in almost half – illicit drugs contributed to 47% of recorded overdose deaths. The Coroners’ ďŹ ndings and recommendations have yet to be delivered. Identifying drug seeking behaviour WA’s State-wide monitoring scheme tracks the prescription and dispensing of all S8 drugs. The data is matched to the authorisations issued for the prescription of S8 drugs for greater than 60 days and for the prescription of medicines to registered addicts. Discrepancies between the amount authorised and prescribed, or the amount authorised and dispensed, and failure to apply for authorisation are identiďŹ ed and investigated. There are four main categories of drugseeking patients: 1. known to the practice, dependent on benzodiazepines;

By Mr Enore Panetta, Lawyer, Panetta McGrath

Risk Management Points süüü%NQUIREüADEQUATELYüOFüTHEüPATIENT sü 0RESCRIBEüINüACCORDANCEüWITHüTHEüPoisons Act to meet patient needs (not merely their demands) – prescribing that is appropriate, responsible and in the patient’s best interests. sü )FüPRESCRIBINGüAüRESTRICTEDüDRUG üHAVEüANü appropriate documented management plan that includes reasons for prescribing. sü 3EEKüADVICEüABOUTüCLINICALüMANAGEMENTüOFüAü patient’s drug dependence, when in doubt.

Useful patient signs include anything suggesting drug use, intoxication and withdrawal. Response strategies Doctors can phone a new patient’s former treating doctor to check the status of a patient, prior to prescribing S8 drugs, or call the Pharmaceutical Services Branch (9222 6883) or Medicare Australia’s Prescription Shopping Information Service (1800 631 181). Other responses may include refusal to prescribe, or referral to a specialist. Dangers and risks of prescribing

2. known to the practice, seeking an opioid (dependence may follow treatment for chronic pain); 3. unknown to the practice, seeking a benzodiazepine (typically younger than groups 1 and 2 and many are not drug dependent); 4. unknown to the practice, seeking an opioid (tend to be younger than groups 1 and 2 and most will be dependent on opioids). Patients in groups 1 and 2 may be easily identiďŹ ed through practice familiarity. Factors that may assist identifying drug-seeking behaviour in less known patients include: sĂĽ PRESENTATIONĂĽNEARĂĽCLOSINGĂĽTIME sĂĽ REQUESTINGĂĽAĂĽSPECIlCĂĽDRUGĂĽANDĂĽREFUSINGĂĽ other suggestions; sĂĽ DEMONSTRATINGĂĽSIGNIlCANTĂĽKNOWLEDGE of drugs; sĂĽ INCONSISTENTĂĽSYMPTOMSĂĽBEINGĂĽREPORTEDĂĽEGĂĽ no apparent pain); sĂĽ RECENTLYĂĽMOVEDĂĽFROMĂĽSOMEWHEREĂĽTHATĂĽ makes direct validation of prescribed drugs with the previous doctor difďŹ cult.

The dangers include: sĂĽ ENHANCINGĂĽDRUGĂĽDEPENDENCEĂĽANDĂĽ increasing illicit on-supply; sĂĽ INCREASINGĂĽTHEĂĽRISKĂĽOFĂĽOVERDOSE ĂĽINĂĽBOTH the patient and others; and sĂĽ INTERFERINGĂĽWITHĂĽTHEĂĽTREATMENTĂĽOFĂĽTHEĂĽ patient’s drug problem (e.g. if in a methadone maintenance program) or missing an opportunity to treat the problem. SigniďŹ cant consequences for doctors prosecuted under the Poisons Act include withdrawal of a doctor’s rights to prescribe S8 medicines or conditions imposed on prescribing by the Medical Board. Patients have also sued their treating practitioners in negligence for damages because the levels of drugs prescribed to them have caused or maintained dependency. Reference: White J and Taverner D, Drug Seeking Behaviour. Aust Prescr 1997; 20: 68-70).

Tackling CVD in Indigenous Communities Closing the Gap is proving to be a hard nut to crack but there’s cause for hope according to Dr Judy Katzenellenbogen and Dr Marianne Wood. A recent report bouncing off eight years of multidisciplinary research acknowledges the enduring disparities in outcomes between mainstream and indigenous populations, however there has been a decline in Aboriginal mortality from chronic conditions such as coronary heart disease.

“You have to reset your expectations when it comes to heart disease and Aboriginal people. We need to ask more questions, screen at a much younger age and our suspicions need to be raised even when it’s an 18 year-old who walks through the door. It’s interesting to note that the outcomes stemming from a ďŹ rst hospital visit are pretty good but as you move a couple of years away from the initial event, disparities are evident and that’s when the picture begins to shift.â€?

Judy is a Research Fellow in epidemiology at the WA Centre for Rural Health and a contributor to the Living in Hope report.

GP Dr Marianne Wood has worked in the sector for many years including 14 years with the Derbarl Yerrigan Aboriginal Health Service.

“We looked at three key areas, speciďŹ cally myocardial infarction, atrial ďŹ brillation and heart failure. Across the board our indigenous patients are comparatively young and these chronic conditions are 10-20 times more prevalent in the Aboriginal population.â€?

“A lot more needs to be done following up these patients after the handover from hospital to primary care. Case management needs to take into account some of the expectations within these communities to encourage people to be more optimistic about living with heart disease.�


Report contributors (back row, L to R) Dr Sandy Hamilton, Dr Derrick Lopez, Prof Dawn Bessarab, Prof Sandra Thompson (all UWA), Ms Lyn Dimer (Heart Foundation WA), Dr Andrew Maiorana (Curtin); (front row) Dr Judy Katzenellenbogen and Ms Emma Haynes (UWA).

“StafďŹ ng can be a problem in remote areas and that’s signiďŹ cant when research shows that some Aboriginal people are less likely to attend rehab when it’s run by mainstream services compared with an indigenous community service.â€?


Clinical Update

CPPD crystal arthritis explained CPPD (calcium pyrophosphate dihydrate) crystals can be deposited in symptomatic joints. While a causal relationship is thought to exist, to what degree is uncertain as other factors play a part. The various clinical terms speak for themselves: acute CPP crystal arthritis, osteoarthritis with CCPD, chronic CPP crystal inammatory arthritis and chondrocalcinosis. Management of acute arthritis in CPPD is similar to acute gouty arthritis, however chronic arthritis may be more difďŹ cult to treat. CPPD is considered the most common cause of chondrocalcinosis (i.e. calciďŹ cation in cartilage; see x-rays) which is a common radiographic ďŹ nding in ageing joints, not always associated with inammatory arthritis. It affects almost 50% of over 84 year olds, with a growing prevalence in developed countries. With suspicion increased by earlier age, other conditions that can cause chondrocalcinosis include joint trauma, familial

By Dr Andreea Harsanyi, Rheumatologist, Nedlands


chondrocalcinosis, haemochromatosis, hyperparathyroidism, hypomagnesemia and hypophosphatasia. A deďŹ nitive causal role of CPPD crystals in the degenerative, non-inammatory manifestations of CPPD arthropathy has not been established. However, there is good evidence for the role of CPPD crystals in acute joint inammation by induction of NLRP3 inammasome activation and IL-1 upregulation. Acute CPPD arthritis is characterised by selflimited acute or subacute attacks of monoor polyarthritis, most commonly the knee. Wrist involvement may present with prominent erythema and swelling. Attacks of arthritis are generally intermittent with long periods in between. Chronic CPP crystal inammatory arthritis may mimic rheumatoid arthritis, with longstanding symmetrical synovitis frequently affecting the wrists, small ďŹ nger joints and tendon sheaths, associated with increased inammatory markers. Plain x-rays demonstrate chondrocalcinosis, without joint margin erosions.

CPPD causing chondrocalcinosis in both wrist and knee.

Diagnostic microscopy is identiďŹ cation of synovial uid CPP positively birefringent crystals under polarising light. Chondrocalcinosis on radiographs may also be suggestive, seen especially at the knees, wrists, pubic symphysis and shoulders. Ultrasound scanning can detect CPP deposits (even with absent chondrocalcinosis on plain radiography), particularly at the wrist. Management of CPPD is symptomatic as no drugs inuence CPP deposition. Acute CPP crystal arthritis is treated by rest, aspiration of synovial uid (to decrease the crystal load and exclude sepsis) and intra-articular steroid injection. Antiinammatories or colchicine may be used, if not contraindicated or poorly tolerated, when oral glucocorticoid therapy can be considered. In patient with frequent acute attacks, prophylactic low dose Colchicine 500 mcg twice daily may be effective. In cases of chronic CPP arthritis refractory to conventional therapy with anti-inammatories, colchicine or low dose glucocorticoids, a trial of hydroxychloroquine or low-dose methotrexate may be warranted. Radiation synovectomy may improve chronic CPPD with OA. References: 1. Zhang W, Doherty M, Bardin T, et al. European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis. Ann Rheum Dis 2011; 70:563. 2. Zhang W, Doherty M, Pascual E, et al. EULAR recommendations for calcium pyrophosphate deposition. Part II: management. Ann Rheum Dis 2011; 70:571.

The pattern of joint involvement in OA with CPPD may differ, with knees, followed by

s At the MDA National AGM, Dr Rod Moore and Dr David Gilpin were re-elected to the Mutual Board, while Dr Paul Nisselle was voted in for the ďŹ rst time. Dr Moore, who had been acting chair since the resignation of Prof Julian Rait, was elected chair.

s Perkins Director Prof Peter Leedman and Perkins Head of Neurogenetic Diseases, Prof Nigel Laing, have been made fellows of the newly formed Australian Academy of Health and Medical Sciences, which is being led by Prof Ian Frazer.

s WA pain specialist Prof Eric Visser has been appointed as inaugural Churack Chair of Chronic Pain and Education and Research at the University of Notre Dame. He is currently Head of the Pain Service at Joondalup Health Campus.

s Cancer Council WA’s Research Excellence Awards have been presented to academic haematologist Prof Wendy Erber. She was named Cancer Researcher of the Year. Prof Bill Musk, who has studied occupational diseases throughout his career, was


wrists, metacarpophalangeal joints, shoulders and elbows more commonly affected than in classical OA.

presented with the Cancer Research Career Achievement Award. s Ms Haley O’Connell is the new manager of Heart Foundation WA’s Healthier Workplace program. s Cardiologist Dr Allison Morton has moved to Bunbury to support the development of the ďŹ rst regional cath lab for HeartCare WA.


Clinical Update

By Prof Eric Visser, Churack Chair of Chronic Pain & Education, UNDA and SJG Subiaco

Neck pain: a practical checklist approach Chronic neck pain (CNP) is pain of at least three months duration in the posterior cervical area (bounded by the occiput, C7 and anterior border of trapezii). Neck pain may be associated with headaches, shoulder pain, and pain in the interscapular area and arms (radicular pain).

Inciting events include whiplash, trauma, postural loading (lifting, office work), spondylosis or spondylitis. Pain generators include myofascial trigger points, facet joints, intervertebral discs or nerve roots. In 80% of cases a clear-cut pain generator cannot be identified.

Affecting 10% of adults, it is more common after middle age, in females and in higher SES and urban settings. CNP is a major cause of disability and economic burden, particularly following motor vehicle or workplace accidents.

Whiplash-associated neck pain is a specific syndrome associated with flexion-extension loading of the neck, usually following a MVA. The best predictors of chronic neck pain and disability after whiplash are severe acute pain, anxiety and pain sensitisation (allodynia) in the neck and shoulders.

The neck is susceptible to injury (whiplash) and physical loading (occupational overuse) and contains numerous structures (myofascial, neural) that generate pain. The neck and shoulders are particularly susceptible to pain neuro-sensitization, as seen by the strong link between whiplash-associated neck pain and fibromyalgia. Connections between the trigeminal nucleus (brainstem) and upper spinal cord (C2-C4) explain the association between neck pain and headaches. Interestingly, stress-related neck pain reflects our quadruped ancestry, where increased muscle tension in the neck and shoulders allowed escape from sabre-toothed tigers during ‘fight and flight’.

Management requires a multimodal, multidisciplinary approach. Unfortunately, there is only limited evidence to support many of the strategies below (note, botulinum toxin, spinal manipulation and some injections are missing). CNP checklist Recycle through the checklist and do ongoing review to monitor response. Are there any red flags? Exclude tumour, inflammation (spondylitis), infection (discitis), neurological problems (root, cord, plexus) and trauma (fracture, cervical instability) (T.I.N.T.). If there are concerns an MRI is indicated. Severe radicular arm pain or neurological signs warrant urgent MRI and neurosurgical review. Yellow flags of catastrophizing, hyper vigilance, anxiety, a medical focus and passive coping (C.H.A.M.P) can predict chronic pain and disability.

Look for and manage simple pain generators and contributors to headaches. Educate about realistic outcomes and functional goals. Reassure about imaging findings and that “hurt doesn’t equal harm”. Encourage de-medicalisation and engagement in a pain program. Useful analgesics are tramadol, tapentadol, duloxetine, pregabalin (for radicular pain), paracetamol, transdermal buprenorphine, celecoxib (pain flare ups), and NSAID gel. Some drugs are used off-label for pain. Physical therapies involve activity-pacing, walking, exercises (strengthening and stretching) ergonomics (posture, pillows), hot or cold packs, TENS and acupuncture. Psychosocial care for anxiety and stress includes clinical psychology, antidepressants, injury rehabilitation and help with compensation claims. Local anaesthetic injections or ‘needling’ and physiotherapy can assist in neck and shoulder pain (trapezius trigger points) or interscapular pain (rhomboid trigger points). Neck pain and headache from greater occipital neuralgia may respond to a local anaesthetic and steroid block. Facet joint pain can be treated via injection or radiofrequency neurotomy. Steroid nerve root sleeve or epidural injections are poorly effective for radicular arm pain and carry a rare but serious risk of stroke or death. A pain specialist, neuro or spinal surgeon should be consulted if these procedures are contemplated. Further reading: Teichtahl AJ, McColl G. An approach to neck pain for the family physician. Australian Family Physician 2013; 42 (11): 774-778. Clinical guidelines from: guidelines-publications/cp112

Shoulder and neck pain

Author competing interests; Dr Visser has received honoraria for education from Pfizer, Servier, Mundipharma and Janssen in the past 5 years. Questions? Contact the author on 9400 9020.

Films are in the Bag As our feature on Page 22 reveals, there’s not much that a smart phone can’t do. A new program from Zed Technologies makes radiology scans and x-rays accessible for consumers to view, share and manage with a swipe of their phone screen.

“A person creates a My Film Bag account and after a scan, the radiologist will send a text message to inform them that a copy of their images has been sent to the My Film Bag cloud. Account holders can access the cloud with a code and share their images.”

My Film Bag WA manager Chris Tansell said the program gives the consumer more control over their own health.

Our understanding is that changes to Privacy Law introduced in 2014, mean any patient medical information placed with an iCloud provider is best de-identified to protect the doctor.


My Film Bag has the potential to reduce the public-private information divide as CDs can be uploaded to a person’s account, so GPs on follow-up visits can see what work has been done. On the business side, the technology could also save imaging providers on x-ray film and administration. It is also compatible with most practice software.








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News & Views

Liberian Lessons Learned The Ebola outbreak in West Africa has everyone worried as few people seem out of reach these days. Virus outbreaks are fast-moving and unpredictable, which does not suit government agencies. When in midSeptember last year President Obama ordered the largest American intervention ever in a global health crisis – hundreds of millions of dollars, 3000 troops and 11 Ebola treatment centres built – the worst was over in Liberia. A peak of 635 new/confirmed cases occurred the week after his announcement and only 28 ebola patients have been treated at the ETCs since. Liberia could be declared free of Ebola as early as next month. The US spent $1.4b on its Ebola mission in West Africa, most of it going to Liberia, its strong ally. Normitsu Onishi, writing in the New York Times, said the inexpensive, nimble measures taken by residents to halt the outbreak, had more effect. He said about 90% of aid came after Ebola cases in Liberia had already begun to drop. Some on the ground suggest that the key was communities taking responsibility – providing disinfection measures, countering rumours that Ebola was a hoax, and dealing appropriately with the sick and dead. The communities were used to doing things without government assistance and when the

WHO employed volunteer contact tracers and suchlike for $80 a month, this meant they had no need to return to their regular jobs. New ongoing infections are occurring in neighbouring countries Guinea and Sierra Leone and with the onset of the wet season, roads may be impassable. With things ripe for another outbreak in this region, important lessons have been learned.

Guinea, Liberia and Sierra Leone are the West African countries worst hit by Ebola. To prevent fresh outbreaks health workers must trace and isolate every contact of every Ebola patient to prevent new chains of transmission.

Late and inflexible responses meant money to rebuild Liberia’s shattered health care system after 14 years of civil war, or money to back local community efforts, went on rarely used treatment centres. Of course, American assistance came in other forms. Labs were set up to test for Ebola. Teams were deployed to rural areas to prevent flare-ups. Supplies were airlifted where roads were impassable. Money poured in to awareness-raising. Mind you, earlier there were people who could not get treatment and estimates were suggesting as many as 1.4m people in Liberia and Sierra Leone alone could be infected if the

world did not act immediately. This made the potential outbreak scarily big. To provide context now, Liberia has had about 9800 infections and 4400 deaths, the most of any country, with more than 25,500 cases and more than 10,500 deaths around the globe. Liberia’s President Ellen Johnson Sirleaf said success came before the American-built treatment centres were finished. Why and how will be debated for years. And is it really over yet? Ironically, the decline in cases to just a few in Sierra Leone and Guinea, and the dispute over the ethics of giving a placebo, has stalled clinical trials on Ebola vaccines.

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Clinical Update

Medical Audiology Services

Hear the best you can!

Sudden Sensorineural hearing loss & psychological health

Andre Wedekind M.Aud SA.,M.Clin.Aud., B.H.Sc (Physiotherapy)

Dr Vesna Maric AuD.,M.Aud.S.A,M.Clin. Aud.,BSc.(Hons)

Estimates of idiopathic sudden sensorineural hearing loss (ISSNHL) incidence range from 5-20 per 100,000 persons per year. DeďŹ ned as a hearing loss â&#x2030;Ľ30dB in â&#x2030;Ľ3 frequencies occurring within 3 days, ISSNHL may be accompanied with aural fullness, tinnitus and vertigo. Suspected aetiologies include genetic causes, viral infections, autoimmune diseases and vascular insults, although the majority of cases are deďŹ ned as idiopathic due to a lack of good diagnostic tools. ISSNHL generally occurs unilaterally, but after the initial insult patients are at an increased risk of ISSNHL in the contralateral ear and ipsilateral relapse. The rapid onset of ISSNHL has signiďŹ cant psychological health effects.

Patients may mourn their previous lifestyle given a limited adjustment period. The rapid change in communication and psychological wellness can impact on relationships and social support systems, leading to isolation and depression. This strain on support systems is exacerbated by misunderstanding of the pathology, the relative rarity of ISSNHL and poor understanding of hearing loss in general. The uncertainty associated with aetiology and outcomes may also foster feelings of helplessness and worry about the future. Tinnitus and vertigo are the strongest predictors of negative effects on quality of life after ISSNHL; 34% of patients report a form of persistent vertigo that impacts daily life. Approximately 40% of patients experience bothersome tinnitus, and report signiďŹ cantly greater psychological distress with higher rates of depression compared to those without tinnitus. A correlation between the degree of hearing recovery after ISSNHL and the severity of depressive symptoms has been identiďŹ ed in a recent study.

Urgent referral to an Ear Nose and Throat specialist is needed in cases of suspected ISSNHL. The greatest recovery is seen after a course of oral corticosteroids administered within the ďŹ rst 2 weeks of symptom onset. The likelihood of hearing recovery varies with the severity of hearing loss. Long term rehabilitation options look at treating the symptoms of ISSNHL. Monitoring of hearing is recommended at 2, 6 and 12 months to document recovery and guide aural rehabilitation (hearing aids or cochlear implants). Physiotherapy may be required for vestibular rehabilitation, and a structured tinnitus management program may be required for persistent tinnitus distress. Psychological referrals are underutilised, but may be an important part of the adjustment process and may inďŹ&#x201A;uence the success of other rehabilitation programs.

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Doctors as immigrants By Dr Navneet Johri, Psychiatrist, Bibra Lake Australia is multicultural, with one in four Australians born overseas (ABS); people with one parent born overseas make up 50% of the population. Migration constitutes an independent risk factor for serious mental illness like schizophrenia. And there is some evidence that the ďŹ rst-born generation is at greater risk for common mental disorders. Moreover, migration is of itself a stressful life event, irrespective of the socio-political and ďŹ nancial circumstances. There are stages of psychological adaptiveness when people migrate. Acculturation is the best-case ďŹ nal scenario â&#x20AC;&#x201C;individuals adapt to the host culture by endorsing local prevalent norms or values systems while maintaining their own cultural norms. Throughout life, people experience distress and very often cope through their own personality and with help from family and friends. At times, all available resources are exhausted, the distress continues and it leads to a decline in functioning. Professional help is then needed. To understand what immigrants undergo, in this process of selfacknowledgement and then seeking help, letâ&#x20AC;&#x2122;s put ourselves in that position. A substantial proportion of doctors are immigrants. In 2001, 12% of overseas born GPs and 15% of overseas born specialists were recent arrivals. By 2011 this had increased to 19% of GPs and specialists (see chart). %

United Kingdom India Malaysia China(a) New Zealand




0 GPs



Occupation Proportion of Doctors & Nurses Born Overseas, From Selected Countries 2011. (a) Excludes Special Administrative Regions and Taiwan. Source: ABS 2011 Census of Population and Housing

Evidence suggests the mental health of doctors is worse than the overall population, with higher rates of anxiety and depression. So how do doctors as immigrants seek help, if at all? In the process of answering, we can gain some insight into what people do to seek help. Some key factors that determine if affected people get the services they need include: sĂĽ THEIRĂĽWORLDĂĽVIEWĂĽOFĂĽPEOPLEĂĽ sĂĽ HOWĂĽTHEYĂĽSEEĂĽLIFE DEATHĂĽANDĂĽLIFEĂĽEVENTSĂĽ sĂĽ HOWĂĽTHEYĂĽCONCEPTUALISEĂĽHEALTHĂĽANDĂĽWELLBEINGĂĽ sĂĽ WHATĂĽTHEYĂĽTHINKĂĽANDĂĽFEELĂĽABOUTĂĽHELPĂĽSEEKINGĂĽ sĂĽ IFĂĽTHEREĂĽISĂĽSTIGMAĂĽASSOCIATEDĂĽWITHĂĽHELPĂĽSEEKINGĂĽ sĂĽ THEIRĂĽLEVELĂĽOFĂĽAWARENESSĂĽOFĂĽTHEĂĽHEALTHĂĽFRAMEWORKĂĽ'0 BASEDĂĽREFERRALĂĽTOĂĽ mental health specialist services) sĂĽ THEIRĂĽEASEĂĽANDĂĽCOMPETENCEĂĽINĂĽUSINGĂĽEXPRESSIVEĂĽLANGUAGEĂĽTOĂĽ communicate their distress sĂĽ THEĂĽSENSITIVITYĂĽANDĂĽAPPROACHĂĽOFĂĽCLINICIANSĂĽANDĂĽTHEIRĂĽABILITYĂĽTOĂĽIDENTIFY The global scene suggests that ethnic minorities do not seek services and are underrepresented in mental health services, despite best efforts. Ongoing self-reďŹ&#x201A;ection and emotional sensitivity will help both individual clinicians and patients alike! Author competing interests; nil relevant disclosures. Questions? Contact the author on 9414 7860.



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Laugh Lines

DIY reality Check

Ms Wendy Wardell has a message for all aspiring renovators… stay on the couch! Emergency departments brace themselves every long weekend for victims of the latest mind-altering scourge. Under its demonic grip, users will knock down brick walls with their bare hands (while holding only a sledgehammer) and have delusions that they are capable of tiling. Every payday, legions of ordinary people who have fallen victim to this hellish addiction blow the kids’ school lunch money in Bunnings on cheap Chinese power tools and poor paint choices. In the reality TV-fuelled delusion that it will make their three-bedroomed fibro cottage fit to grace the pages of Vogue Living rather than a Crimewatch Alert, people are committing unspeakable acts of renovation and paying a heavy price. It’s not just rooms with decorative themes that resemble the pavements of Northbridge at 3am or inspire in visitors an urgent desire to fall into a coma; it’s a lack of ability on an epic scale. One of the most powerful arguments for not giving Australians the right to bear arms is the damage they can inflict with only a paint roller and a Dulux colour chart. Simply painting a ceiling in white without consequent blood spatters seems beyond the reach of a generation who need an app to work


their vainglorious crusade to immortalise themselves in bricks and mortar. When people whose experience with dangerous equipment peaked with a stapler in Year 4 decide to cut out the middleman and engage in some home renovation, the learning curve is steep and unforgiving.

out whether the ladder points up or down. An Injury Control Council pamphlet on the use of such equipment has, as its blunt closing statement “Bins are not ladders”. This is clearly inadequate and further advice is needed along the lines of “Power drills are not toothbrushes” and “Forks aren’t your friend when stuck in a socket”. I can’t even claim immunity. I borrowed a power drill to put up a curtain rail in my lounge and now have walls that look like they were strafed in a mafia shootout. Adding fuel to the raging inferno are imported programs like Grand Designs which should more realistically be entitled What the Hell Were You Thinking??? Each show has an unconvincingly happy ending with the couple sitting in their dream home rather than bankrupt, divorced and curled in the foetal position under the dining table; a much more likely outcome of

I’m shocked that our Government has not interceded in this mire of personal creativity and free enterprise and milked it for all it’s worth. If a licensing system was introduced it would ensure that people at least understood where the pointy end of their power tool was. Certain competencies would be required to purchase more powerful equipment, policed by the wise elder statesmen now employed in our hardware stores. ‘’I’m sorry sir, but I can’t sell you that angle grinder. Your current licence only qualifies you to handle gardening gloves.’’ It would also be a great revenue-raiser, although let’s face it, the chances of it finding its way back into the health system are about as high as my curtain rail is likely to be in a few weeks’ time. ED: And to top it off, renovators of houses built pre-1988 may have asbestos to contend with!



Free as aBird Whether it be the wide open spaces or just the sheer joy of the moment on the road, holidays are about the exhilaration of being free from the routine of our lives. Here, doctors and others relive that holiday spirit.

A Mango Frozen Fruit Thingy is first stop at The Courthouse Market on a Saturday morning in Broome. Picture: Mr Clive Addison (shot on an iPhone with Snapped framing + HDR treatment)

Jumping around in Bunbury. Picture: Dr Chun Ong

Aerial photography is all the go. For Dr Tony Tropiano, his maiden flight in a helicopter took him over Willie Creek in Broome. “It cost $150 for five minutes – but worth it. Those four-seater choppers are amazingly smooth and they let you take the door off and lean out. There are fierce winds up there, but it was exhilarating.” Picture: Dr Tony Tropiano




10-year-old Isaac Davies climbing in the Italian Brenta Dolomites in July 2014 snapped by his father tethered a few metres above him. Picture: Dr Rob Davies

The picturesque fishing village of Marsaxlokk, Malta – and a great place to go for fish and chips. Picture: Dr Amanda Wilkins

There’s always something going on at the Everest Base Camp. Picture: Dr Ted Collinson




On Golden Pond – the pool below Fortescue Falls in Karijini National Park at sunset, as the surrounding red hills bounce light into the depths of the gorge. Picture: Dr Peter Randell (The colours last seconds only. Nikon D800e,ISO 1600,f4 at 1/ 320 sec to stop the ripples.)

Dead Vlei clay pan inside the Namib-Naukluft Park in Namibia.

“Who needs a beach when you can dress up for the river.” (Nannup). Picture: Dr Peter Durey

Picture: Dr Carol McGrath

After a three-week road trip through India with her husband, her GP brother Phil, his wife and five daughters, Dr Moira Westmore chonicles the delight on her nieces’ faces when they reach the Taj Mahal in Agra. Picture: Dr Moira Westmore




Having a three-day break from her rugged schedule, remote procedural GP Dr Susan Downes took a three-day break in Atherton, at Uluru, to soak up the spiritual beauty and the natural wonder of the whole place. Pity about those pesky tourists. Picture: Dr Susan Downes

Queenstown, New Zealand is the world’s adventure city. Here, Water Rockets stun onlookers with their boots performance. Picture: Dr Janina Anderst

WASO Chorus’s Fortunes Sealed There’s not much the WASO Chorus can’t do when it puts it puts its vocal cords to it. This year its sung with Daleks at the Doctor Who Spectacular, honoured the ANZAC centenary at a commemorative concert, battled the orks of Middle Earth in the final of the The Lord of the Rings simulcasts and later this month, on June 19 and 20, takes on Carl Orff’s mighty choral masterpiece, Carmina Burana. Looking ahead, there’s Faure’s breathtaking Requiem to come. Last year, Christopher van Tuinen took over the role of chorus director from Marilyn Phillips and renowned baritone Andrew Foote became the choir’s vocal coach. Chris, who is also the classical music program manager for the Perth International Arts Festival, conductor of UWA’s Choral Society and musical director of the Fremantle Chamber Orchestra, spoke to Medical Forum about the upcoming concert, which is the choral equiva-


lent of an Olympic marathon. He paid tribute to the Chorus praising their unpaid commitment to produce top quality performances in works that are little short of gruelling. Orff’s Carmina Burano doesn’t waste any time in reaching its full steam. Just listening to the opening note of the first O Fortuna with choristers’ lung capacity at full bore gives you some idea of the physicality of the work. Hearing it live is a rare treat.

ED: Squeezing that hectic music schedule into their already busy working lives are Drs Olga Ward, Moira Westmore, Jenny Fay, Susanna Fleck, Katie Langdon, Rob Turnbull and Philomena Nulsen making WASO Chorus the doctors’ go to choir.

Christopher van Tulnen



Glengarry Glen Ross Closes the Deal It’s one of the great plays of the 20th century and is as fresh today as it was when it premiered more than 30 years ago.

Playwright David Mamet struck a seam of pure gold when he wrote his classic play that seems to wrap up the dark side of humanity with all its greed and disappointment with the relentless global imperative to make a buck, sometimes at any cost. Set in a Chicago real estate office, Glengarry Glen Ross premiered in London in 1983 and it has rarely been off stage somewhere in the world ever since. It is being reprised here in WA at the end of this month by the Black Swan State Theatre Centre with a cast that includes comic actor Peter Rowsthorn, who spoke to Medical Forum about his transition from his usual sunny, smiling self to the bitter older real estate agent Shelly Levene, who is broke and can’t give real estate away. “I tend to do one major play a year and I’m very happy that I’m involved in this fantastic piece but it is a challenge. Mamet wrote the dialogue as it would happen in real life, so there’s a whole different rhythm with characters interjecting

and shouting over the top of one another. It’s a real challenge, but I’m loving it.” Glengarry Glen Ross follows four real estate agents presented with a edict: sell undesirable property to unwilling buyers or find a new job. Some of the agents do better than others. Peter’s character Shelley Levene is the older agent being overrun by the guns in the office and his personal war with the office manager isn’t doing him any favours. It’s a role that really extends Peter’s acting chops. “Creating the character of Shelley is fundamental to the entire play, it’s a huge task with lots of text to learn, but it’s a real joy working with the line-up director Kate Cherry has assembled.” Peter is best-known to audiences as Brett in the standout ABC comedy, Kath & Kim, which has made him a household name both in Australia and the UK. He’s also a stand-up come-

dian with nerves of steel. He has appeared regularly on Thank God You’re Here and Talkin’ ‘Bout Your Generation. But as every actor and performer who has experienced the fickleness of the industry knows, it’s important to have other strings to their bow. So Peter has carved out a steady career as an MC at corporate and private functions. That’s not such a leap for the funny guy who grew up in a big-business household. His father created the Toll Transport business which he has since sold. “He was in the merchant navy and when he moved into transport, eventually setting up Toll Transport. My brother is hugely business minded and they are completely comfortable now with what I do. I’ve been doing this for more than 20 years and you can’t bluff your way in this business for that long. I’m doing something I love.”

Swans, Romance and Russian Precision Just 18 months ago, producer Andrew Guild toured the St Petersburg Ballet’s production of Swan Lake throughout Australia, including Perth, to great acclaim. It seems that we can’t get enough of the white tutus and Russian precision because he is bringing the classic back to the Crown Theatre opening on Jun 5 early next month and tickets are selling like hot cakes.

the ballet and the company well and I have to say, when I saw this company dance in Paris last month, it was one of the best performances I have seen. They are on top of their game.”

“It’s not surprising to me that the season is in such demand. The company is one of the best in the world and this is a gorgeous production,” Andrew told Medical Forum.

While Australia is anticipating the arrival of St Petersburg Ballet, Andrew says the company can’t wait to arrive in Australia.

“I’ve seen this ballet anywhere between 400 and 500 times and, honestly, I find something wonderful every time. But it does mean I know


This time round, the company will also be dancing Giselle, one of the world’s great romantic ballets.

“The dancers fell in love with the country last time they were here.” And that makes for a happy tour.



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

Entering Medical Forum’s competitions is easy!

Movie: Aloha A down-on-his-luck military contractor (Bradley Cooper) heads to Hawaii with the hope of turning his career around. He also meets up with an old flame (Rachel McAdams) and must deal with unexpected feelings for his partner on the project, a promising young Air Force pilot (Emma Stone). In cinemas, June 4

Movie: Far from the Madding Crowd Based on Thomas Hardy’s novel, this is a story of Bathsheba Everdene, a headstrong woman who inherits her uncle’s farm and decides to manage it herself. She is beset by suitors from all corners. Carey Mulligan is Bathsheba with Matthias Schoenaerts, Michael Sheen and Thomas Sturridge fighting for her affection. In Cinemas, June 25

Movie: Gemma Bovery When an English couple, Gemma and Charles Bovery, move into a small Normandy town, Martin Joubert, the baker and resident Flaubert fan, can’t believe it. Here are two real life figures playing out his favourite fictional story right before his eyes! In cinemas, May 21

Dance: Australian Dance Theatre One of Australia’s renowned contemporary dance companies returns to WA with its acclaimed production Be Your Self to celebrate its 50th anniversary. The ADT will be bringing two WA-born dancers and WAAPA graduates Scott Ewen and Jake McLarnon on tour.



Theatre: Horsehead

After a successful 2014 debut season, the Perth Theatre Trust’s Independent Theatre Festival returns to the Subiaco Arts Centre for the month of June. Local theatre producers are bringing a range of plays to the festival including Horsehead by Damon Lockwood and Sam Longley. See for the full program. ITF June 3-July4, Subiaco Theatre Centre; Medical Forum production, Horsehead, Friday June 5, 7.30pm

Doctors Dozen Winner It’s a particularly fine collection of wine in the latest Doctor’s Dozen. And that’s a very good thing for Joondalup anaesthetist Dr Merlin Nicholas who still has nightmares about his grandmother’s Papaya wine in Kenya. Merlin is rather partial to a glass or two of Shiraz while his wife prefers a Sauvignon Blanc. They’re heading back to Kenya for a holiday with a bottle or two of Palmer Wines in their luggage to show their family what WA winemakers can do.

State Theatre Centre, June 24-27, Medical Forum performance, June 24, 7.30pm

Music: Carmina Burana Carl Orff’s blockbuster brings the full force of orchestra, soloists and chorus to bear with spinetingling power from the opening bars of “O Fortuna!” until it finishes 60 minutes later. Otto Tausk conducts an enhanced WASO and a team of soloists including soprano Emma Matthews.

Winners from the March issue Movie – Samba: Dr Max Traub, Dr Julia Charkey-Papp, Time is Precious Dr Hilary Clayton, Dr Amir Tavasoli, Dr Sara Chisholm, Making it Count Dr Cathy Irvin, Dr Basstian de Boer, Dr Amy Gates, Dr Eric Khong Movie – The Book of Life: Dr Farah Ahmed, March 2015 Dr Linda Wong, Dr Rajan Iyyalol, Dr Ines Loo Chin, Dr Robert Williams, Dr Lawrence Chin, Dr Brett Baird, Dr Patricia Dowsett, Dr Shelley Davies, Dr Bill Thong Movie – A Little Chaos: Dr Donna Mak, Dr Paul Kwei, Dr Tammy Barret-Izzard, Dr Kym Connor, Dr Simon Machlin, Dr Christine Lee Baw, Dr Jen Martins, Dr Michael Hung, Dr Cathy Kan, Dr Geoff Mullins Movie – Dior & I: Dr Jun Wei Neo, Dr Evelynne Wong, Dr Greg Glazov, Dr Jeff Veling, Dr Lynda Ashton, Dr Sayanta Jana, Dr Nasim Fahimian, Dr Meg Ritchie Magic – The Illusionists 2.0: Dr Pippa Warren Theatre – The Importance of Being Miriam: Dr Kym Silove Musical – Wicked: Dr Ross Henderson t Dr Polls: Political Clout & Regulators

t Clinical Change at FSH

Perth Concert Hall, June 19 and 20. Medical Forum performance, Friday, June 19, 7.30pm

t GP Buys Back the Farm

t My Patient: The Watchmaker t Medical Marijuana; Elbows, Knees, Ultrasound & more

Major Sponsors

Dance: St Petersburg Ballet The phenomenal talents of this famed Russian ballet company return to Perth with two productions – Giselle and a return season of Tchaikovsky’s Swan Lake. Both ballets feature famous ‘White Act’, brimming with tutu-clad ballerinas and athletic male dancers. His Majesty’s Theatre, Giselle June 5-6; Swan Lake June 11-13. Medical Forum performance, Giselle, June 5, 7.30pm




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Medical Forum 05/15 Public Edition  

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