Medical Forum 11/14 Public Edition by Medical Forum WA

Aged Care t Palliative Care, Deprescribing & IT t Voluntary Euthanasia t Primary Health Networks t Delirium, Osteoporosis, ACAT, Gout, Nutrition, Blood Cancers & Sleep

November 2014 Major Sponsors

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Contents

November 2014

Western Australia Primary Health Networks

Kunu

Derby Broome

Boundaries - October 2014

Ha Fitzroy Crossing

Port Hedland Karratha

Wickham

Exmouth Tom Price Coral Bay

Paraburdoo

Newman

Carnarvon

COUNTRY WA Denham

Kalbarri

Leinster

Geraldton

Leonora

Kalgoorlie Merredin

Northam

PERTH NORTH PERTH SOUTH

Kambalda

Perth Norseman

Rockingham Mandurah Narrogin

Bunbury Margaret River

Harvey Collie

Busselton

Katanning

Esperance

Manjimup

Denmark

FEATURES

LIFESTYLE

14 17 19

Spotlight: Dr Scott Blackwell Primary Health Networks: Race is On Deprescribing for the Elderly IT in Aged Care

Albany

43 44 45 46

Sailing Docs Look to National Titles Passionate Retirees The Messiah Double Act Competitions Social Pulse: RACMA Meeting

NEWS & VIEWS 3 4

10 21 24 42

Editorial: A Time for Leadership Letters: GPs and research, finding the balance: Dr Tim Koh Making Aged Care Easier for GPs: Dr Penny Flett Have You Heard? Beneath the Drapes Protecting Young Ears Pet Service Helps Elderly

E-POLL 23 24 41

Wider use of naloxone Noise-Limiting Headphones The Patient I Love to Hate...

2014ISHES

Xmas Greetings Feature Send Christmas greetings to your colleagues and clients in Medical Forumâ&#x20AC;&#x2122;s popular special Christmas Greetings Supplement. Deadline: November 10 See P6 for details

W BESTOM WA'S FR A LTH LS H E S I ON A ES eature PROF as Greetings F Christm

po d sup r ers an r read p y Ne w Yea all ou p ishes and a Ha w m s l Foru Chri st ma a ic y Med a Merr

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rters 23

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Clinical Contributors

MEDICAL FORUM MAGAZINE 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

We ask Clinical Contributors to provide a phone number should a doctor wish to clarify a management issue.

EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

DR SEAN MAHER 27 Triaging Delirium in

Journalist Mr Peter McClelland journalist@mforum.com.au

Older People

MS JO BEER NICK 28 Nutritional 28 DR BRETLAND Deficiency in RACFs

DR OLIVIA LEE 29 Breaking Bad News

Teaching in RACFs

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reﬂect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemniﬁes the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

DR AI TRAN 30 Osteoporosis in RACFs

DR KEVIN KWAN NEIL 32 Geriatric 33 DR BANHAM Assessment & ACAT

‘Hole in the heart’ and Decompression Sickness

PROF DANIEL 35 GALVÃO

DR HELEN KEEN 36 Gout Management

Exercise & Cancer Control

DR GERRY CARTMEL Taking Control of the End

PHILIP 20 DR NITSCHKE Engaging in the Dying Debate

MICHAEL 39 DR PRICHARD Sleep & Medical Disorders MS LYN MARTIN 21 Despite the Respite

PAUL 23 MR DESSAUER Peer-Administered Naloxone

Blood Cancer Medicine

Guest Columnists

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN Thinking Hats

MATTHEW 34 DR WRIGHT

GRACE 23 MS BUCHANAN Timely Referral to Palliative Care

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Editorial

remember assisting a patient to leave this planet – they had had enough of their cancer, had stayed at home as long as possible, said goodbye to those around them, and told me it was time to go. The nursing staff and I agreed and upped doses with the intention of hastening death. They woke up the next morning! This felt bizarre. I felt a failure but for the patient’s sake we did it again. Newspaper reports outline the ugly deaths of the elderly at their own hands. Cruel, inhumane ends for which this doctor cringes, knowing our job is to relieve suffering. When someone dies they would like to leave memories for us to enjoy and celebrate. The desperation and despair of some is in stark contrast. As a community, we must work it out because a small minority of people want to control when they leave us, without relying on others. Unfortunately, dealing with death is not the medical profession’s forte. We suck at it, in fact. But in the current financial climate, pragmatic number crunchers with limited

A Time for Leadership humanity will seek to influence decisions – turn off the ventilator, avoid treatments that prolong life, abuse terminal sedation, or assist with the suicide. The retired GP’s comments [see P8] and Dr Philip Nitschke’s column beg more leadership from the profession [see P20].

t all depends if you view General Practice as a vocation in itself or a means to some other end. Plenty of people seem attracted by the ideology of the Federal Government as Medicare Locals are morphing into Primary Health Networks, down from seven to just three in WA. However, this feels like centralised control with an urban focus, in the WA setting. WA is a small pond so people who want to drive the agenda, for whatever reason, are forming partnerships that appear bigger and better than they may be. Who you know becomes important. So it is with favours. The question is whether swapping local bureaucracy for favours at the top works for general practice as a whole?

GPs may feel poorly represented. Nationally, 27% of GPs are financial members of the AMA, which could mean something, and the college hasn’t caught the ear of government despite much higher GP membership. Decline of both Royalties for Regions and the Nationals has left rural GPs out on a limb. There is less cohesion in the GP group thanks to generational changes and corporatisation. GPs that appear ripe for the picking are also the profession’s lifeblood. Many just don’t know it. We’ve delved deeper [see P14].

pharmacist once told me I had nearly put him out of business when I took over a neighbouring practice. Prescribing is something the profession is wedded to. The how and when of starting medications is well taught but no one teaches us when it’s best to stop. Drugs are the profession’s backbone business. But hidden from us is low compliance where much of the PBS goes down the toilet. That’s millions. And we may not be doing the elderly any favours [see P17].

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Letters to the Editor

GPs and research, finding the balance Dear Editor, The Royal Australian College of General Practitioners (RACGP) agrees with Professor Moyez Jiwa [Proving That Primary Care Works, October]. General practitioners are well positioned to be the drivers of research in primary healthcare. Our job requires continual hypothesis formulation and testing and our role is one of longitudinal observation. However, for many GPs the prospect of becoming involved in researching primary healthcare is daunting. We are faced with a difficult balancing act as clinicians. Research is an essential part of our commitment to delivering the best care and health outcomes for our patients. This must be tempered against the fact that most working GPs are heavily committed with clinical load, teaching, ever increasing administration, and maintaining clinical standards in their practice. Professor Jiwa correctly asserts that GPs can be the innovators who change the way research in primary healthcare is conducted. The challenge, of course, lies in supporting these innovators.

I would encourage any member of the profession to email wa@racgp.org.au with their comments on this matter. Dr Tim Koh, Chair, WA Faculty, RACGP

Making Aged Care Easier for GPs Dear Editor, Those involved in aged care acknowledge the frustrations GPs feel when seeing their patients. Never-ending scripts, relevant information not available, lack of opportunity to discuss how best to identify and respond to a patient’s needs, agreeing on treatment priorities, hospitalisation, end-of-life decisions, and inadequate discussion around pain management, continence management, sleep, agitation, medications and the like, can cause frustration. However, with good understanding and negotiated solutions, many of these frustrations can be avoided. Brightwater has fundamentals already in place to help: t 4PVOE IJHI RVBMJUZ DMJOJDBM QSPDFTTFT and practices; t *OWFTUNFOU JO BMMJFE IFBMUI QSPGFTTJPOBMT who take an interdisciplinary team

approach to problem solving issues such as mobility, pain, behaviour, continence, and working with families. Also specific responses for GPs: t "HSFFJOH PO B NVUVBMMZ BDDFQUBCMF visiting schedule; t &OTVSJOH B LOPXMFEHFBCMF OVSTF (wherever possible, the same nurse) is available to accompany the doctor and implement care decisions; t "HSFFJOH XJUI FBDI (1 PO B QSFGFSSFE method of communication; t *OUSPEVDUJPO PG /VSTF 1SBDUJUJPOFST UP work with many of the GPs; t &MFDUSPOJD IFBMUI SFDPSET UP FMJNJOBUF paperwork; t "U #SJHIUXBUFS XF IBWF BMTP CFFO closely involved in the development of the National Residential Aged Care Medication Chart. When this is available, it will make many aspects of medication prescribing, administration, monitoring, error minimisation, and communication with pharmacist, much easier. In return, it would be appreciated if doctors visited at times the RACF can cope with, and make proper arrangements for after hours and during periods of leave. (When there is no doctor to sign a death certificate, it’s hard to explain to a family why an expected death had to be reported to the coroner). We would also ask that GPs appreciate our Continued on P6

Curious Conversations

Ready for Anything! There is nothing in GP Dr Angela Cooney’s world that’s not worth a go at least once! The song I just have to sing along to is… almost everything! I’m an equal-opportunity ‘song butcher’ and I ruin the ‘old’ and the ‘new’ with equal success. The ones I’m murdering at the moment are anything by the Beatles and Chandelier by Sia. A moment that really changed my life was… the birth of our first child. It was a fairly standard first birth requiring a vacuum extraction in a hospital where, unfortunately, I’d just done my O&G rotation. Everyone I’d ever worked with popped in to see how I was doing while I was trying to push out a grandpiano with a 38cm head! There were 11 4

people in the room and most of them didn’t really need to be there. One patient I’ll never forget is…the first patient who died on my watch. I was a very new doctor and a dear old lady was groaning quietly. Instead of going up and examining her or checking with nursing staff, I sidled away. I was too afraid to do anything. I came back a couple of hours later and she was having terminal respirations. She was probably going to die anyway but now I would have the confidence to find out what was happening and relieve her distress.

My TripAdvisor handle is the ‘IUD Queen’ because… I put in an average of seven IUDs a week and sometimes as many as 11. None of these are in theatre, they’re all wide-awake women! I’m pretty crap at some things but I’m good at this and I’m proud of it. If I weren’t a doctor I’d love to be a… policewoman, ornithologist or biochemist. They were the careers I’d planned before I realised that a young ‘Ten Pound Pom’ from the struggling classes could achieve mythical status as a doctor. I filled in the application form in pencil and, bugger me, they let me in! O medicalforum

Letters to the Editor Continued from P4 limitations due to the system that governs our regulations, standards, and the complex and forever shifting funding arrangements. Old people deserve the same good medicine and care as anyone else. We really value GPs who are interested in medicine of old age and we pull out all stops to make their participation as easy as possible. This is probably the ‘last bastion’ of general medicine in a ‘whole-of-life’ setting, and when the nursing and multidisciplinary support is solid and high quality, this really is a rewarding place to do the doctoring! Dr Penny Flett, Brightwater CEO

Correction & Explanation Private Hospital Cover – A Consumer View, September edition. We have been contacted by three anaesthetists, one in a representative role, complaining that we did not give anaesthetists a fair go and in particular, overstated the top-up payment that HBF gave them in our write-up example. On the later point they are correct, and we apologise – HBF top up payment is in the order of 80-157% in our example, not higher as stated, making the final payment about 50% of the AMA Schedule fee. What these calls have highlighted is the complexity of determining who pays what in private health. We are still uncertain and we are in the game! Consider the poor consumers for whom it seems impossible to prejudge out-of-pocket expenses because there are so many variables. This veritable scrum of competing interests reflects that this is hybrid capitalism – competitive forces underwritten by the public purse. Consumers will soon cry

out that they want more control over price selection, for which doctors will need to be more transparent with their fees. For anaesthetists, suggesting that health consumers will go back to their surgeon if unhappy about quoted anaesthetist fees is ‘cuckoo land’ thinking! It is rumoured that HBF will produce a website to assist its members make cost comparisons. We also have been contacted by doctors and others on the receiving end of inpatient costs for imaging and pathology that these inpatients say are much higher than is charged in the community. Consequently, they end up paying much more out-ofpocket than they would for the same service in the community, despite their use of private hospital insurance. This might go some way to explaining consumer disillusionment with private health cover and why government has given an undertaking that anyone admitted to a public hospital, who declares their private insurance, will not be charged any gap. O

From the Editor Readers have asked about how we handle Sponsorship… There is a lot you could write on this. Suffice to say, Medical Forum fiercely protects its editorial independence, the main reason for the magazine’s high readership in WA. Doctors are very experienced at scanning for bias and reject anything considered ‘cash for comment’, and rightly so. That’s why we ask clinical authors to provide competing interest declarations. While we aim to give advertisers and sponsors the best exposure – their support allows doctors to read Medical Forum free-of-charge – we set ethical limits and guidelines to protect our readers. This means no “advertorial” and “Advertising Feature” added to anything where confusion arises over authorship. And of course, no advertiser is shown independent content before publication.

Star

Joke I went to the cemetery yesterday to lay some flowers on a grave. As I was standing there I noticed four grave diggers walking about with a coffin. Three hours later and they’re still walking about with it and I thought to myself, these buggers have lost the plot!!

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

Medical Forum's LASTtoDAYS lodge 2014 Christmas

Greetings Supplement Send Christmas greetings to your colleagues and clients in Medical Forum’s popular special Christmas Greetings Supplement. Deadline: November 10 • Acknowledge the support of colleagues and others • Extend goodwill to those unfamiliar with your services • End 2014 in the spirit of the Christmas season Medical Forum’s Christmas edition is out on December 1 To lodge your greeting in Medical Forum’s Christmas Greetings Supplement Phone Jenny Heyden on 9203 5222 or email jen@mforum.com.au

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Incisions

Taking Control of the End Retired GP Dr Gerry Cartmel has seen a lot and formed ﬁrm views on remaining independent, with dignity, until the death knock.

y body, clearly, is reaching its useby-date. So, watching my motherin-law completely dependent and trapped in limbo in a wonderful Aged Care Facility is of growing concern for me. She is bedridden, partially blind, unable to get out of bed by herself or walk, incontinent of bowel and bladder, unable to feed herself and in a constant state of unpleasant mental agitation cushioned with mind-bending medications. I do not want to be locked into a living hell like her. Having escaped many near misses, I would like to be able to call ‘time up’ and to die with dignity without having to work around archaic laws never designed for the wonders of today’s health system.

Cycle of life Ideally I would like to die at home, at a time of my choosing and with as little possible distress to others. I accept death as a normal part of the life cycle and do not wish my decision defined as a mental illness. In my lifetime our society has come to terms with major ethical issues around personal choice for contraception, the ‘morning after’ pill, termination of unwanted pregnancies that includes those with foetal anomalies and IVF – all at the beginning of the life cycle. In the middle of the life cycle, homosexuality is

now socially acceptable. However, at the other end of the life cycle, society continues to define death as an illness. Way back in my first House Job, in 1954, I wrote “Old Age” on a Death Certificate as cause of death. My boss told me that the cause of death must be a medical one and, after much thought and whimsical grins, agreed with me. General System Failure became acceptable as a euphemism. Sixty years on, death continues to be defined as an illness that must be deferred at all costs – costs to the individual, their family and society – and our wonderful health system is mobilised to this end.

Society needs to move on Other cultures apply widely different approaches, defining death as a natural event in the human life cycle, for example, the Noongars of Australia. I am asking: “Is our society ready to accept the next step, which would be to vest in the individual the right to choose and implement, with suitable safeguards, their death at the end of their life cycle, without this being defined as a medical or social issue?” Many of our leaders are saying ‘Yes’. The medical profession needs to make explicit its own role, if any, in any change. The ‘Hows’ are readily available. O

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

Senior Financial Adviser Authorised Representative 296710

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ED. Gerry Cartmel has worked extensively in OTs (DA and DipObst), qualified in psychotherapy, and has held office within general practice divisions and the AMA – a “wonderful career in medicine” from a person with an “aversion to being dependent”. He has been on the receiving end of recent hip, knee and IT problems. His column comes at the same time the Grattan Institute released its report Dying Well, that in part says home deaths in Australia have declined (while hospital and residential care deaths have increased) despite about 70% of Australians saying they want to die at home (yet only 14% do so). In our polling of 328 GPs and Specialists (April 2013), 51% admitted that a patient or relative has raised voluntary euthanasia as an acceptable option in the course of their professional work, and 41% said that if legislation on voluntary euthanasia (with suitable safeguards) was introduced into WA it would be supported by the medical profession (38% said it wouldn’t). In June WA Labor MP Alannah MacTiernan and Victorian Greens Senator Richard Di Natale tabled a draft Bill to the Federal Parliament, to legalise euthanasia across Australia. It is now being debated in a Senate inquiry.

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

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

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Have You Heard? an announcement from Prof Frank Daly, head of South Metropolitan Health Service, seems to offer some hope. He told us that the pain management service at FSH would be staffed by an integrated and cohesive team of medical, nursing, and allied health staff that would deliver the same services as the Fremantle clinic and it would have a “very similar” FTE profile to the current levels at Fremantle Hospital. He said staffing levels at RPH would be maintained to support the training accreditation status for pain medicine. O

Referred pain

There has been anguish and high-level meetings with a couple of resignations thrown into the mix over the transition of pain services from Fremantle Hospital to Fiona Stanley Hospital (FSH). The head of the clinic, Dr Stephanie Davies, resigned in August over the slashing of staff numbers who would make the journey up South St. Despite lobbying from the Faculty of Pain Medicine and PainAustralia to the Minister and the Director-General, there appeared to be no breakthrough. It’s been thought that perhaps the Government’s contract with Serco may have had some bearing. However, as Medical Forum went to press,

An idea before its time

We have known for some time that gene APOE inheritance (e4 allele) is related to the risk of Alzheimer Disease (AD). Now researchers from WA say they have an easier accurate way of screening for AD risk using retinal amyloid levels. When we ran this by some local clinicians, the response was surprising – it’s unethical to do a test for a future condition you can’t successfully treat. Now we know why the researchers were keen to see retinal screening used to assess AD drugs! The full peer-reviewed study on the test method finalises this year. O

available to him in 2012. We understand the surgeon claimed these rights arose from being a credentialled practitioner at PHC. The WA Supreme Court disagreed, saying a credentialing agreement simply binds both parties to comply with the hospital by-laws, which do not grant unlimited rights of practice at PHC. This was one that Ramsay Health inherited from Health Solutions.

Peel Health credentialing

Orthopaedic surgeon Gig Pisano’s law suit against Peel Health Campus (PHC) has failed. He was suing PHC for no longer referring public patients to him or making theatres

Toll of merger failure

The MDA member vote for the MDA National and MIGA merger failed, after which the Mutual chair A/Prof Julian Rait and insurance board chair Mr John Trowbridge resigned. Longtime board member, Dr Rod Moore, is acting chair of the mutual and Mr Steve Scudamore is the new chair of the insurance board. Both are West Australians, which will probably please MDAN members who voted. CEO Peter Forbes has stalled his retirement until December 31 to help with a stable transition to a new CEO. Prior to the vote

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the AMA WA president wrote to members requesting their undirected proxy. The mutual board is now: Dr Rod Moore (WA), Dr Beres C.A. Wenck (Qld), A/Prof Max Baumwol (WA), Dr Reg Bullen (WA), A/Prof Rosanna Capolingua (WA), Dr David Gilpin (QLD), A/ Prof Michael Hollands (NSW), Dr Andrew J. Miller (WA), Dr Robyn Napier (NSW), and Mr Steve Scudamore (WA). l

MIA reform within reach

Last year in March, just before the State election, Margaret Doherty, the convenor of Mental Health Matters 2, wrote an impassioned guest column in Medical Forum calling for the government to review the Criminal Law (Mentally Impaired Accused) Act, which in effect can imprison someone with mental illness indefinitely and without a conviction. The Government has now prepared a discussion paper (www.dotag.wa.go.au/ clmia) which is open for public comment. The public consultation period ends December 12. l

Aged care resources

Finding appropriate aged care for a loved one is stressful. Enter the Government’s My Aged Care website that is surprisingly good (www. myagedcare.gov.au) – a gold mine of resources, especially for tech savvy browsers. There is a real person at the end of their 1800 200 422 help line, Monday-Friday, 8am-8pm, Saturday 10am-2pm. For those who want to hire private experience, WA advisory services are at www.agedcareguide.com.au – there are six

companies in WA. Many facing this situation do not have the luxury of time – RACFs fill beds quickly because demand is high and waitlists long. Brightwater CEO Dr Penny Flett says a preamble visit to RACFs in the desired area is a good idea, ask lots of questions (e.g. ageing in place), and trust your ‘gut feel’ on whether staff care and facilities are suitable. l

Aged care rule changes

From July 1 rules surrounding RACF

accommodation payments changed. All RACFs now must publish a lump sum and a daily rate. The resident chooses which to pay. All residents will continue to pay a flat daily rate. Additional care fees will now be assessable on income and assets with annual and lifetime caps. This means there will be no distinction between low care and high care; entry fees will be quoted as a fully refundable lump sum and an equivalent daily rate. The means-tested additional daily care fee will be calculated on both income and assets so is likely to be higher

than the previous rules, but a lifetime cap will apply to make care affordable for people with long-term care needs. l

Aged care developments

Alzheimer’s Australia WA (AAWA) has opened its $2m respite centre in Albany, Hawthorn House, recently. It has been built with $1m grant from Royalties for Regions and other grants. CEO Rhonda Parker said it was the only respite service in Australia that was fully accredited under the Eden principles, which guide person-centred care for community elders. The home-like environment encourages staff, families, volunteers and people with dementia to contribute to its running. This includes cooking the lunch, planting vegetables or walking the dog. Also opened recently are the Joondalup Older Adult Mental Health Service and the Older Mental Health Hospital in the Home service at Shenton Park to extend those older people living in the community with mental illness. And in the Hills, what became a state election issue has found some traction. The Kalamunda Shire Council and the WA Planning Commission is looking to rezone a site in Wilkins Rd Kalamunda to accommodate an aged care facility. Planning Minister and local member Mr John Day said the proposal was open for public comment until December 5. l

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Spotlight

Sharing Some Wisdom Dr Scott Blackwell has seen the face of medicine change in his 40+ years as a doctor but in the area of aged care he is a strong advocate for primary care holding the reins.

Q Dr Scott Blackwell scores the winning goal at the recent Masters Titles.

A 14-year-old boy at Wesley College surprised himself when he stood up in class and said he wanted to do medicine. That was a long time ago and, as someone rapidly approaching his allotted ‘three score and ten’, Dr Scott Blackwell has seen a lot of life. As he says, he’s “old enough to share some wisdom” and he waxes lyrical on everything from the role reversal of doctor as patient, the importance of superimposing a business model on the practice of medicine and the place of geriatricians in aged care. “We were making subject selections with our futures in mind and the Headmaster walked into the classroom. He pointed at me and barked ‘Blackwell, what are you going to do?’ I jumped up and replied ‘Medicine, sir!’ I sat down again and the kid next to me said, ‘you know that means being a doctor?’.” “I paused, thought about it and realised he was right.” “I never varied from that decision. My mother, a triple-certificate nurse, was my greatest influence because my father died quite early and she raised us on her nursing salary. Also, I had a friend with haemophilia and he was in and out of hospital. I used to visit him and became pretty familiar with the medical scene.”

Doing the hard yards “I worked bloody hard as a student and some of it was confronting. The most difficult thing was the sheer volume of material you had to read and understand. I look back at those six years and wonder how I did it?” Scott, rapidly approaching his 70th birthday, was representing WA in the Masters’ National

Hockey Championships when Medical Forum spoke with him. He proved that age was no barrier when it came to bouncing back from a potentially career-ending knee injury.

maintain the hierarchical difference within our profession, which I’m not good at anyway. I prefer to work on an equal basis.”

“I was just about to have a shot on goal and someone gave me a shove between my shoulder blades. My leg hit the ground, hyperextended and I hobbled off the field. The pain was excruciating! That was five years ago. It turned out to be a tear in the cartilage and the ACL was badly damaged.”

Level playing fields to one side, Scott is adamant that people working together while utilising their differing levels of expertise is a fundamental consideration.

“Greg James took a bit of tendon from the hamstring and rebuilt the ligament. He told me they didn’t do a lot of these on people over the age of 35 and I was nearly 65. I couldn’t play for a year and my knee’s not perfect but I’m still a pretty speedy winger. It does show that these procedures are applicable to older, reasonably fit people.”

Doctor as patient “It’s quite scary being on the other side of the scalpel. I had a shoulder operation in my late 50s and I was so impressed with the technical aspect – a nerve block, light anaesthetic and then the operation. I was equally pleased with the ACL surgery and we’re obviously doing really good medicine within these procedural spaces.” “The only hiccup was the nurse giving me a bit too much Fentonyl in the recovery room. My respiratory rate dropped off, my wife was saying ‘keep breathing Scotty’ and then I vomited from one side of the room to the other. I guess that reinforced the message not to overdo the opioids.” “It’s understandable in the doctor-as-patient scenario that the staff are a little more cautious. But there’s no point trying to

Power of the collaborative model

“The concept of working in a multidisciplinary team is a good one. The burden of disease and multiple co-morbidities in aged care means that a GP can’t manage the load. So the decision to use Nurse Practitioners (NPs) is a logical one and the same principle applies to physician assistants. I know there’s some negativity in the profession but, used properly, a collaborative model works well.” “Nonetheless, it’s silly for a GP to be doing mundane background paperwork. There should be some sort of task flow-down through ENs, RNs, NPs and GPs. Someone earning $30/hour should be doing work that equates to that pay-scale. It’s all about applying a proper business model to the clinical framework of medicine and that’s never been done properly in residential aged care.”

Aged care challenges Scott sings the praises of working in Aged Care and outlines some of the systemic shifts in his own career progression. “I know it’s regarded as a fairly unsexy end of medicine but it’s full of clinical challenges that are very good for learning the trade. Doctors are drawn to areas of need and a burgeoning ageing population that remains pretty healthy until the latter stages definitely falls within that category.” “About 25 years into my career, changes in Continued on P14

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Feature

Starters, Take Your Places On July 1, 2015, WA’s eight Medicare Locals will be dissolved and three Primary Health Networks will take their place. Who is behind them? The WA Primary Health Network (PHN) boundaries have been announced and the Federal Government says it welcomes all comers – public or private – to tender for the three PHNs covering north metro (to Two Rocks), south metro (to Waroona) and literally ‘the rest’.

Western Australia Metropolitan Primary Health Networks Boundaries - October 2014

Two Rocks Toodyay Yanchep

East Bullsbrook

Joondalup

Wundowie

The Vines Ellenbrook

Bakers Hill

Wooroloo

PERTH NORTH Stirling

Middle Swan

Chidlow Stoneville Mundaring

Perth Nedlands Rottnest Island

Western Australia Primary Health Networks

Kununurra

Bentley

Derby

Fremantle

All eight Medicare Locals (ML) are looking to tender, though some interesting alliances have formed with some audacious propositions emerging, along with a few cracks appearing along the PHN boundary lines.

Broome

Boundaries - October 2014

Armadale

Halls Creek Fitzroy Crossing

Byford Kwinana Rockingham

Mundijong

Baldivis

NORTHERN TERRITORY

COUNTRY WA

Jarrahdale Serpentine

Port Hedland

Golden Bay Singleton

PERTH SOUTH

Karratha

Wickham

North Dandalup

Mandurah

North Pinjarra

Exmouth

Pinjarra Bouvard Dwellingup

Tom Price Boddington Waroona

Coral Bay

Paraburdoo

Newman

Carnarvon Harvey

COUNTRY WA Denham

State-wide Bid Bunbury

Perth Central and East Metro ML (chair Dr Marcus Tan), South Coastal ML (chair Dr Andrew Png) Fremantle ML (chair Dr Graham Farquhar) and Goldfields and Midwest ML (chair Dr Damien Zilm) have formed the WA Primary Health Alliance, which intends to bid for all three PHNs. Dr Tan told Medical Forum that the alliance also involved AMA WA, WAGPET, Silver Chain, St John Ambulance and the Pharmacy Guild of WA and it was holding its inaugural board meeting on October 28. On the board are Silver Chain Group CEO Mr Chris McGowan; Mr Tony Ahern, from St John Ambulance; Pharmacy Guild director Mr Matthew Tweedie (also deputy chair of South Coast ML) though President Ms Lenette Mullen, who is currently away, may step in; former President of AMA WA Dr Richard Choong; WAGPET CEO Dr Janice Bell; Dr Zilm (also chair of WAGPET); Dr Png and Dr Tan (also an AMA WA councillor, director of Health Engine; SMAHS councillor).

Collie

40 km

Kalbarri

Leinster

Geraldton

Dr Tan said the board members would be there “less with the hats” of their respective organisations on, instead gathering as a group of “smart people in the environment of primary care”. He said the disbanding of MLs and the establishment of PHNs presented a small window of opportunity to reposition and draw together the fragmented primary health sector. “We believe the system will work a lot better if it’s coordinated by a central group with devolved governance. The individual PHNs will get its funding and make decisions on the ground but the central group will coordinate it and provide some of the back office functions etc.,” Dr Tan said. “We think that’s going to get a much better result. So rather than three individual, independent bids, we’re keen to make sure that money is not wasted again in the reshuffle.”

Leonora

COUNTRY SA

Kalgoorlie Merredin

Northam

PERTH NORTH PERTH SOUTH

Kambalda

Perth Norseman

Rockingham Mandurah Narrogin

Bunbury Margaret River

Harvey Collie

Busselton

Katanning

Esperance

Manjimup

Denmark

Albany

The Government has not announced how much money will be put to creating PHNs but Dr Tan is estimating that the core funding will be the $30m allocated to the eight MLs, which will mean $10m for each PHN. Those funds, under the WAPHA plans, would be “quarantined” to those regions. “The ability to siphon funds would be next to impossible,” Dr Tan said.

Advocacy role for alliance He saw the alliance’s key role as one of high level advocacy for primary health care, which would bring potential funding to the sector, leaving the on-the ground groups to do the commissioning based on local issues in their regions. Continued on P16

Continued from P12

Sharing Some Wisdom the system pretty much determined the end of anaesthetics for me. The wider science of the specialty became increasingly technical and complex so it was a natural progression to phase GP/Anaesthetists out of hospitals. And obstetrics became much the same as it moved to a more interventionist model. I shifted to an Aged and Palliative Care role with Silver Chain which lasted for nearly 20 years and now I’m focusing solely on Aged Care.” Finally, Scott outlines his own imperatives while throwing down the gauntlet to others in the profession.

Aged care is primary care “We have a reasonably efficient geriatric service in WA but it’s important to emphasise 14

that the sort of aged care we’re involved with is essentially Primary Care. It needs to work in conjunction with the rehabilitative side of geriatric services but, in my opinion, the answer is not to put a geriatrician at the helm.” “It would be a tragedy if Primary Care was diminished within the residential aged care setting. There’s a lot more to aged care than the provision of geriatric services – that should challenge the geriatricians!” O

By Mr Peter McClelland ED: Breaking News! WA Over 70s won the National Hockey Masters and speedy winger Scott Blackwell scored the winning goal!’ medicalforum

medicalforum

Feature Continued from P16

WA Primary Health Alliance

Dr Marcus Tan, Dr Andrew Png, Dr Graham Farquhar, Dr Damien Zilm, Mr Chris McGowan, Mr Tony Ahern, Ms Lenette Mullen, Dr Janice Bell and Dr Richard Choong

South-West/Kimberley-Pilbara

Unaligned

Ms Elizabeth Barnes, Ms Kate Clarke and Mr Chris Pickett

Dr Alistair Vickery and Dr Kanal Singh

“We are looking to build capability of the alliance membership rather than duplicate what PHNs are meant to do.” However, not everyone is convinced that the state-wide model will deliver all that is needed, especially in rural and remote areas.

Rural-Remote Bid The South West ML and the Kimberley Pilbara ML have formed their own alliance with the SW chair, Ms Elizabeth Barnes, chairing the new group. She told Medical Forum that, while it was up to the Government to decide which model would work best, her experience, and that of other country boards, was that the country misses out in state-wide, centralised organisations. “Organisations that know the area better than Canberra are a good idea, otherwise you get money going from Canberra to Perth to be randomly distributed as the city thinks. Our plan for the rural PHN means that the people who know the area say where the money is needed. While that is challenging over such a massive area, we are convinced a ruralremote bid is required.” While Ms Barnes acknowledges the sheer scale of the task, both she and SW CEO Ms Kate Clarke said the two MLs had been working hard with a wide range of country stakeholders including stateassisted Aboriginal Medical Services and the medical fraternity to ensure an effective and collaborative approach. “This is a whole-of-country initiative and we are all cognizant of the diversity. It’s not going to be a one-size fits all,” Ms Clarke said.

But she is confident of the alliance’s strengths. “We’ve done a lot of learning over the past two and a half years and we’d hate to lose that momentum. We have some very skilled and experienced people across a wide range of areas. Both Kimberley Pilbara and SW have been predominantly commissioning and contracting agencies that are experienced at assessing our populations’ health and designing programs and purchasing around that.”

Intellectual capital Ms Clarke and Ms Barnes said the combined experience of the alliance members had shown they could broker partnerships, develop excellent service provider capabilities and governance, and could meet the demands of whatever the future holds. “When we all sit around the table as a consortium, it is a powerful group that knows our part of the world well,” Ms Clarke said. Ms Barnes said there was widespread support of the country alliance’s bid. “Country organisations are positive and adamant that a country organisation should run the rural PHN. We have talked to WA Health and are working closely with WA Country Health Service, which is particularly supportive. It was keen that our boundaries aligned with theirs, and they do.”

Unaligned Bids The two non-aligned MLs, Perth North Metro and Bentley Armadale, both said independent bids for the north and south metro PHNs were under consideration. Bentley Armadale chair Dr Kanwal Singh

said his board would like to continue to be a part of the primary health system. However, he rejected the notion that the WA Primary Health Alliance was a state-wide bid. “It is not as far as I know. It’s two or three MLs that claim to be representing the state, but that’s not that situation,” he said. CEO Mr Rodney Redmond said an independent bid is “certainly under consideration” but they were waiting to see the detail of the process, which is expected this month. “At this stage we have a viewpoint that there are three PHNs for WA and there should be three separate bids, otherwise it gets too big and too unwieldy,” he said.

Past repeating itself Dr Alistair Vickery, chair of the state’s biggest ML, Perth North Metro (PNM) that services 1.2m people and more than 1000 GPs in practices, is frustrated that primary care is once again in a state of upheaval. “With every change of government there are changes,” he said. While he has spoken to Dr Tan, Dr Vickery said PNM had not been invited to join the bid. As of September, the PNM ML now sits under the umbrella of a new company, Panorama Health Network, and according to Dr Vickery will continue as a primary care organisation, with a particular focus on mental health of the region. “We made the change to safeguard the programs that are running. Whether we become a PHN and win the tender or whether we continue to provide services, Panorama Health will continue to help GPs and services in the region.” Continued on P18

medicalforum

Feature

Medicine by Numbers can Harm As GP Dr Kathleen Potter nears the end of her research into de-prescribing for the elderly, her observations turn to the profession and its dedication to medication. Treating the many for the few Trea

Along the way, she’s learnt much more than how many pills are enough for those in their final years. She’s also gained insight into how doctors’ actions can inadvertently impact on lives for little or no benefit and sometimes with harm.

“As an observer, I’ve noticed that when arises, the reaction of most a problem pr doctors is to start a new medication. We doct that we’re not doing our are indoctrinated i if we’re not prescribing. It’s job properly, p almost all the job now. No one is actively alm promoting inactivity by doctors. Leaving prom the surgery with a piece of paper is not just a consumer expectation but I think we also feel that ourselves at some level.”

Kathleen says medicine by numbers, particularly for the elderly, needs to be reconsidered.

Risks vs benefits “As doctors, we have our agenda; it’s important that the numbers are right. We can get caught up with the numbers rather than think of the patient as a whole person and what’s important to them. Often our confidence in our medication is misplaced. We think we’re extending older people’s lives but often the evidence is not that strong and you’re exposing them to negative effects without necessarily even increasing the length of their lives.” It’s all about weighing up risks versus benefits and for Kathleen’s elderly cohort, that a tricky thing to ascertain. “One of the problems I’ve struck with my research is that we don’t really have enough good data for this age group because it’s only recently that we’ve had enough people to study, and what data we do collect is muddied by complex comorbidities.” “However, data is emerging that suggests a lot of medications which are beneficial in younger patients are not necessarily as beneficial in older people. The problem is, ‘when do you decide to stop prescribing’.”

Q Dr Kathleen Potter

the patient and their family, rather than try to prevent it.” “I forget that I feel really comfortable with mortality because I am exposed to it. You see it and it’s logical, but when it’s your mother or your sister, it’s much harder to accept that there’s nothing to prevent them from dying. Our emotional understanding is not necessarily up to speed with our rational understanding.”

“We really need a frank public discussion, not just among doctors, because this will become more and more of an issue from every angle as we approach this bulge of baby boomers entering this stage of their lives and medicine can’t save us forever.” “My intuition is that doctors are actually starting to do more harm than good in older people. As people get towards the end of their lives, doctors should be more like midwives, assisting in a natural process and minimizing the trauma associated with it by reducing suffering for medicalforum

“A lot of doctors are not particularly statistically literate, so how you apply that to the patient in front of you comes out as ‘well everyone needs to be on blood pressure medication’. You are treating the whole population to save 1-2 lives. The question is, which lives are we extending and which ones are we shortening?” O By Ms Jan Hallam

Are Your Financials Up-To-Date?

Is death a failure of treatment? “Our whole training is geared up to see death as a failure of treatment, not as an inevitable conclusion of life so the default option is to treat. I think we need to change that thinking.”

“Part of the problem is how to apply “ results of clinical trials to individual cases. When you look at the absolute risk reduction, there might be 30% reduction in risk of a stroke if you r prescribe blood pressure medication. p However, a significant proportion of the Ho people peop we treat with antihypertensives were never going to have a stroke anyway, but we have no way of knowing which patients those are.”

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Continued from P16

New BreastScreen WA clinic opening in Cockburn in October

He sees growing opportunities with the health networks but is wary of large bureaucracy. “I worry how such large organisations can remain responsive to general practice. One of the reasons the Government gave for dismantling MLs was they didn’t represent general practice. I don’t know how this response improves that. As I understand it, and I stress the Government has given little detail yet, GP councils will be established but they will be purely advisory and won’t have any governance.” Q Dr Alistair Vickery One thing is certain, the new PHNs will commission services, not provide them, unless there is ‘market failure’. What concerns Dr Vickery is the continuation of services that are vital to the community; how is market failure judged? “MLs have worked bloody hard over the past three years to try and improve primary health care. It was the first time extra money was put into primary care to get some connectivity and to salvage the fractured primary health care service and this is just going to delay this process as everyone starts again.”

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“We have to bring all of primary health care together – the Ronald McDonald Houses of the world, dentists, NFPs, GPs, specialists, physios, everyone – to be part of a single health care system. The health spend and commonwealth spend is about $16b for 1m people in North Metro or about $16,000 per person. That’s a lot of money and it’s enough.” “There are 3000 hospital beds in North Metro which soak up most of that money, the expertise and all of the discussion and headlines. GPs who keep people out of hospital are where we should be spending the money. We have had evidence of this for more than 20 years, but we are still trying to convince people it’s true.”O

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THE STAKEHOLDERS All those seeking to put in tenders for PHNs have knocked on all the same doors – the State Government, the State Health Minister, the RACGP and AMA WA.

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www.breastscreen.health.wa.gov.au or call 13 20 50

The AMA made no secret of its opposition to Medicare Locals in the past and judging by what CEOs and chairs of the various groups have said, has heard from all comers. The players understand how vital it is to the success of their bid to have the AMA (state and federal) on their side. Spokesman for the WA Primary Health Alliance Dr Marcus Tan, was board member of the failed Primary Care WA. He said it suffered from unsecured funding and a lack of AMA buy-in, adding that he thought it was the wrong time for PCWA but the PHN proposition was very different. “Mandated structures like MLs or Divisions effectively locked out groups from tendering or being part of that process. The fact that there is now an open tender process means the AMA has a role, the College has a role … that’s why I say this is a narrow opportunity that needs to be grasped.”

Rural locations: Check your local media or the website for mobile screening unit visit dates.

“The AMA needs to be in a position where it is able to say ‘the process is not going as well as it could be’ but at the same token, the AMA needs to put its money where its mouth is and actually be part of the solution.”

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“They need to say ‘we are willing to contribute to advocating for primary care’. Obviously with GPs being a central part of that, the AMA needs to lead with it rather than throw rocks at it. This is why this becomes an opportunity; to have an alliance where there’s goodwill from parties who haven’t previously been involved in the past.”

Delivering a Healthy WA

medicalforum

Technology

Window to the World Technology is helping residents in aged care facilities to connect with their past, with each other and with the wider world. An improved sense of personal wellbeing is the end result. A $40,000 grant from Lotterywest in 2009 to put Nintendo Wiis into 17 Amana Living aged-care facilities has morphed into an expanded program Q Ms Kylie Mathieson that connects older people with the wider community, says enrichment officer Kylie Mathieson. “I’m a firm believer in encouraging people’s strengths and tapping into the positive emotions that flow from that. I’m known around here as that ‘Enrichment Chick’.” Amana Living realised that, unless some specific programs were put in place, there was a good chance that the Wiis would sit there unused. “We have a ten-pin bowling competition using the Wii, it’s grown rapidly and we now have people playing in 39 facilities across eight different organisations. The number of teams varies from site to

site with between 8-10 players in each. They compete once a week and I put all the scores up on a large, fixed-screen scoreboard. There’s not too much effort required, just a swing of the arm and they can then relate to the game pretty well.” “The number of dementia patients is increasing and the Wii has an automatic release option that makes it easier to use. I visit all the sites and, in the early stages, we have a support person who stands behind the bowler to assist. It’s important that they have a sense of achievement at the outset otherwise they become discouraged and will often just walk away.” “By tapping into this technology, residents are happier and that translates into better health outcomes.” “We focus on maintaining social links and that’s where our Windows to the World program comes in. Everyone knows the Aged Care sector is overworked and underpaid so any one-on-one interaction is expensive. One way around that is to get groups together using computers, a large

screen and an n internet facilitator to surf the web.” As Kylie points nts out, one technology-inspired nspired conversation is often the catalyst for another. “We used Flickr to click into a slide-show of the Channel Islands, that sparked some reminiscing about the war and one man opened up about his time as a pilot during WWII.” “Our Picasso computer art program is used at 12 dementia-specific sites and is very popular. It’s proven to be a great aid in communication and engages not only the participant but also other residents who may happen to walk past and become interested in the activity. And the enthusiasm for Windows to the World is growing all the time. In fact, maybe it’s too successful.” “We’re continually hearing stories that these sessions are the only ones that make them late for dinner!” O By Mr Peter McClelland

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Guest Column

Engaging in the Dying Debate A person’s right to choose when and how they die is an issue that’s not going to go away, says euthanasia campaigner Dr Philip Nitschke.

ike it or not, the medical profession will be increasingly compelled to confront the issue of euthanasia. People are living longer and, with ‘babyboomers’ like me entering their twilight years, there is a social revolution just around the corner concerning how and when we die. Our tagline at Exit International is I’d rather die like a dog. You don’t need a degree to work out why. The baby boomer generation is going to reframe the debate surrounding the ‘right to die’. And we will do it on terms that may not suit the medical establishment. The reintroduction of a law enshrining the rights of a dying person to hasten that process is an important step forward. When the Northern Territory’s Rights of the Terminally Ill Act was overturned by the Federal Parliament in 1997, I set up the nonprofit organisation Exit International and, since then, I’ve been meeting my peers in droves. Invariably they come to find out how

they, and not the medical profession, can shape their own dying process. They may not necessarily be preparing for their own deaths but they have witnessed the nightmares that can occur when that final decision-making procedure is removed from their control. There has been a relentless and all-pervasive pursuit by some in the medical profession to emerge victorious over illness and disease. There is nothing to be gained, nor anything particularly heroic, in living too long. Sad and bad deaths do happen. And sometimes it’s those close to us – parents, siblings and friends. We all know someone who’s died in pain, institutionalised and completely separated from their home and their loved ones. Most people come to Exit because they want an insurance policy for the future. It is one they may never use but it’s important for them to know it’s there. And that’s why medicine’s privileged position is rocking on its pedestal and its power is under challenge.

There is nothing inherently ‘medical’ about dying. It is a sociocultural, biological and utterly natural process. Granted, the passage of a death does need to be medically mediated at times. But when this is not the case there may be scant requirement for a person in a white coat. Rational suicide is a topic the profession will be forced to address. The sooner medicine fully engages with this issue the better. And it will only happen when there is a conversation, in good faith, concerning a person’s fundamental right to die at the time and manner of their choosing. My appeal against the Australian Medical Board and its resulting outcome will be but a faint blip in history. The thing I’m most proud of, and my real legacy, is being part of a conceptual shift regarding when and how we die. O ED: Dr Nitschke was suspended by the Medical Board of Australia after he admitted supporting Perth man, Nigel Brayley, to commit suicide knowing he was not terminally ill.

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Guest Column

Despite the Respite Qualifying for respite care is not the hard part, says carer Ms Lyn Martin. Filling out the paperwork and then ﬁnding a space is not for the fainthearted.

hen I first met my husband he was the custodial father of four kids and a busy academic. To accommodate his circumstances I generally visited him and got to know them all a little better over the evening meals we shared. I became increasingly bemused by the family food rituals. He’d religiously make-up batches of instant mashed potatoes each night and, with equal religiosity, the kids threw it away. “Why do you do this?” I asked. “Well, I think they need veggies, so I make the mash. That keeps me happy. They don’t like it and they throw it out. That keeps them happy. So everybody’s happy.”

Appearances can be deceiving This metaphor has stood me in good stead in my work and now in the role of my husband’s carer, particularly in my attempts for respite care. Firstly, when it comes to the bureaucracy and the 10 documents that hit the inbox – one 22 pages long! I worked for eight hours on the documents, including endless phone calls trying to find out how to complete the task and to whom I needed to send what. “Now this 22-page document,” I asked over the phone. “Do I have to print that off? Is it possible to print and sign only the last page and scan that back to you?” “Let me look,” said the voice at the other end, “Yes, that’s all right, you can do that”. A JP once told me that I should never separate the signed page from the document to which it refers but I was ready to kill to simplify this process. Fortunately, I didn’t have to … in fact “No, wait, you don’t have to do anything with that form.”

was to contact them seven days before and they’d know. Presumably, if a resident died there’d be a respite room. I have lobbied as many people as I can about the lack of respite care. I’ve jumped through all the hoops, had ACAT tests, been allotted nine weeks respite a year, made aware of the Independent Living Centre (ILC) that helps broker respite care and subsidise costs. It’s as if the Government creates the ILC, and that keeps them happy, and the ILC seeks respite care for clients, and that keeps them happy. So everyone is happy. But there really are so few respite rooms, so we all run in circles with no real outcome. I’d been advised to ring CarersWA, but there wasn’t a thing I could say to the woman on the phone that she didn’t already know. In fact, somewhat irritatingly, she was able to cap most of my stories. “Oh, I know, I know,” she said doing a fair imitation of Sybil in Fawlty Towers. “I have a child with multiple disabilities and it’s a 40 page document just to get her out for a weekend.” Really? And I know, I know that there are such things as compliance, quality, due diligence and care practices that influence the number of documents I have to complete. I respect these processes as attempts to improve the quality of care. But somewhere sandwiched between all this are the carers who have to double-time just to get away. If they don’t they’ll crack and the government will have two for the price of two in hospitals. It makes economic sense, and it would be a compassionate thing to do, to consider the respite needs of Australian carers. O ED: The identity of the author has been changed to protect the privacy of her husband.

Mixed messages “Then why did you send it? Is this ‘Confuse a Carer’ week?” It became obvious that she was too young to remember the Monty Python ‘Confuse a Cat’ sketch, so my comment sounded harsher than was intended. I then rang the Independent Living Centre (ILC). These wonderful people had been helpful during previous meltdowns: “Well, I’m packing his bags and leaving him on the hospital steps,” I declared earlier this year. “I haven’t had a break in two years and I’m going”. I’d already tried a long list of aged care facilities and the best offer I’d got

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Guest Columns

Peer-Administered Naloxone Heroin and other opioid use on the streets go hand-in-hand with accidental overdose. Mr Paul Dessauer, of the WA Substance Users’ Association explores the issue.

atalities caused by heroin or other opioids represent a steadily increasing proportion of accidental deaths in Australia. Nearly four Australians die every day from opioid overdose (OD). In fact, 2012 ABS statistics reveal that fatal overdoses now out-number road fatalities as an accidental cause of death. Exacerbating the problem, on a local level, is the purity of heroin tested in WA. Since 2009 it has been consistently and significantly stronger, compared with other states and territories.

And since 1991, even factoring in an ageing population, the rate of opioid prescription has increased by 228%. Within a period slightly over two years (2007-09) Australia’s rate of accidental opioid-related deaths increased from 30.4/ million to 45.9/m. In WA the increase was from 22.4/m to 54.8/m.

have collaborated for several years to deliver an Opioid Overdose Prevention and Management Peer-Education Program. It trains people who inject heroin or other opioids to recognise OD and respond as firstaiders. Participants have reported treating a large number of ODs and also recorded hundreds of episodes of educating their peers on how to manage OD. This education project formed the basis for a new pilot project in January 2013 prescribing naloxone to individuals at risk of, or likely to witness, an OD. Naloxone has a long history in medicine and para-medicine. It acts quickly and effectively to restore breathing and reverse the respiratory depression caused by OD. It is a highly stable drug with an extremely low risk of adverse effect and has no psychoactive action or “black-market” value.

Of course, death is not the only possible outcome. For each fatal OD there are between 20-30 non-fatal incidents, perhaps more because many are unreported. Nonfatal OD can result in serious sequelae such as brain or organ injury due to hypoxia, or injury due to nerve damage or occlusion of blood vessels resulting from prolonged unconsciousness.

On a broader international level, several hundred peer-administered Naloxone programs have been implemented in more than 16 countries. There is growing evidence that these interventions have the potential to make a significant impact on the incidence of morbidity and mortality caused by accidental OD. In July this year the WHO released guidelines explicitly recommending layperson access to naloxone as a public-health response to OD.

The Drug and Alcohol Office and WASUA

Participants in the WA Peer-Naloxone

project receive a two-hour training session before being assessed by the prescribing doctor. The Naloxone Kits are issued to participants at no cost. It is a simple intervention to implement and it’s cheap. The kit, containing two preloaded doses, costs less than $40. Expanding access to Naloxone has the potential not only to save lives but to reduce public-health system costs. It will also greatly reduce the amount of injury and human suffering resulting from accidental overdose.O References on request.

Availability of Naloxone A

Nov

ll e-Po

The 146 respondents to this question were both GPs and Specialists.

Should naloxone be available to non-medical people to administer to someone in a crisis due to drug overdose? Yes

45%

26%

Uncertain

29%

Timely Referral to Palliative Care Cancer Council WA’s Ms Grace Buchanan says much can be done for a terminally ill patient with collaborative care and good communication.

he quality of life of a patient can be enhanced by incorporating palliative care early in the course of a terminal illness, perhaps even from the day of the diagnosis. There may be an opportunity for oncologists and primary care providers to see Palliative Care Specialist services as partners early in the illness. Being part of the patient’s journey through symptom management support and through to end-of-life care is how palliative care can work collaboratively and effectively. Some physicians may feel that they have failed a patient when they are unable to cure illness and it can influence the timeliness of their referral of a patient to palliative care. In reality, we know that this is not true, though medicalforum

for medical practitioners who have longstanding relationships with patients, it is a real dilemma. Referral to a specialist palliative care service, according to Melvin & Oldham (2009) is appropriate at any time in the disease trajectory when a patient with a life-limiting illness, or family, believe there are needs, be they physical, psychosocial or spiritual, are not being adequately met. Conversely, not all patients facing lifelimiting illnesses and death will require the input of a specialised service. These people and their families may be well catered for by their inpatient medical and nursing team, staff at a residential aged care facility or GP and community nurse. (South Australia Health 2009)

Australia and New Zealand Society of Palliative Medicine’s position is that patients with evidence of tumour progression, following failure of conventional cancer treatments should be referred in a timely manner to Specialist Palliative Care services. This timely referral will support best practice management of pain and symptoms, identification and support for complex psychosocial issues with less incidence of depression, improved continuity with primary providers of palliative care and the improved likelihood of good end-of-life planning.O ED: Grace Buchanan is palliative and supportive care education team manager at Cancer Council WA. 23

News & Views

Beat the Drum Itâ&#x20AC;&#x2122;s not the volume of sound but the intensity that has caught the ears and the attention of West Australian researchers. Thereâ&#x20AC;&#x2122;s money to be made in designing a funky set of headphones. An American rapper recently sold his company, Beats by Dr Dre, to Apple for $US3b largely on the strength of the fidelity of the bass response in its headphones. â&#x20AC;&#x153;Thatâ&#x20AC;&#x2122;s interesting,â&#x20AC;? said Mr Chris Brennan-Jones from the Ear Science Institute Australia when told of Dr Dreâ&#x20AC;&#x2122;s financial windfall. â&#x20AC;&#x153;By increasing the bass thereâ&#x20AC;&#x2122;s often a perception of increased volume. Sometimes cheaper headphones will increase the higher frequencies first and this increases the intensity of the sound.â&#x20AC;?. â&#x20AC;&#x153;And itâ&#x20AC;&#x2122;s the intensity that does the damage. The actual mechanism of noise-induced hearing loss is an overstimulation of the cochlea which leads to oxcidative cell death of auditory nerve fibres.â&#x20AC;? Chris, a clinical research audiologist with an ongoing PhD focusing on automated hearing tests with Telehealth applications, crunches the numbers for safe listening guidelines. â&#x20AC;&#x153;The current benchmark figure is 85dB and thatâ&#x20AC;&#x2122;s the level at which damage may start to occur. Most headphones will go up to 115120dB which is similar to a loud car horn. Again, itâ&#x20AC;&#x2122;s the intensity of the sound rather than the source.â&#x20AC;? â&#x20AC;&#x153;With computer games, itâ&#x20AC;&#x2122;s quite common to get more sound â&#x20AC;&#x2DC;peaksâ&#x20AC;&#x2122; compared with listening to music. All those explosions and gunshots! But the critical factor is duration. The question to ask is how long are people listening with headphones on?â&#x20AC;?

â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s also important to note that headphones, irrespective of the source, are preferable to earphones. Thatâ&#x20AC;&#x2122;s due to the proximity of the speakers to the eardrum. Thereâ&#x20AC;&#x2122;s an old saying, double the distance and halve the volume. The fact that the smaller speaker buds sit well inside the ear can create even more problems.â&#x20AC;?

Nov

ll e-Po

Both GPs and Specialists (n=146) didnâ&#x20AC;&#x2122;t think parents were keeping one step ahead of technology which could impact on their children.

Computer games and iPods are popular. In your experience, do most parents know that noise-limiting headphones protect their childrenâ&#x20AC;&#x2122;s hearing?

Q Mr Chris Brennan-Jones

There are some simple â&#x20AC;&#x2DC;fixesâ&#x20AC;&#x2122; for any worried parent concerned with their childâ&#x20AC;&#x2122;s listening profile. â&#x20AC;&#x153;You can buy output-limiting headphones, some with a variable dB facility and others with an automatic 85dB setting. There are also noise-cancelling headphones that reduce

Yes

68%

Uncertain

25%

background noise. The advantage with that is you donâ&#x20AC;&#x2122;t have to turn up the volume to come over the top of any extraneous noise.â&#x20AC;? â&#x20AC;&#x153;Younger listeners should keep their volume setting between 60-80% and take a break every hour. Itâ&#x20AC;&#x2122;s the continuous exposure that does the damage. And, within this age-group, it does have the potential to have a negative effect.â&#x20AC;? â&#x20AC;&#x153;If you speed up the process of hearing loss the effects down the line will be worse.â&#x20AC;?

DEAFNESS FACTS

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CLINICAL UPDATE

Triaging delirium in older people

By Dr Sean Maher, Geriatrician SJOG Mt Lawley.

elirium affects about 15% of people in residential care and 15% of older people in emergency departments; it complicates 20% of medical admissions and up to 56% of post-operative episodes. The commonest risk factors are dementia, age, sensory impairment and polypharmacy. The commonest causes are infection, heart failure, new medications, electrolyte disturbance and environmental change. There is good evidence that delirium is preventable using education programs for hospital and residential care staff, better cognitive screening, and management of risk factors like polypharmacy, dehydration and malnutrition.

Diagnostic features Each presentation of delirium averages five risk factors and three precipitants (see illustration). A person with many risk factors will not require much of a precipitant (e.g. a UTI), whereas a person with little vulnerability is likely to have more serious causes or be sicker than apparent, to succumb to delirium. The acronym â&#x20AC;&#x153;AFRAID ASâ&#x20AC;? captures the common clinical features: t "DVUF POTFU PWFS IPVST UP EBZT t 'MVDUVBUJPO EBZUJNF MVDJE QFSJPET BOE nocturnal confusion; t 3BNCMJOH UIJOLJOH BOE TQFFDI t "MFSUOFTT BOE DPOTDJPVTOFTT BMUFSFE FJUIFS somnolence or hypervigilence; t *OBUUFOUJPO VOBCMF UP GJY GPDVT PS TVTUBJO attention; t %JTPSJFOUBUJPO o JO UJNF BOE QMBDF t "HJUBUJPO SFTUMFTT XBOEFSJOH GJEHFUJOH t 4MFFQ o XBLF DZDMF JT EJTUVSCFE Hallucinations, delusions and paranoia are often present, with consequent fear and aggressive behaviour. Somnolent, hypoactive patients however are generally the sickest with the highest mortality.

Making the diagnosis and looking for a cause The Confusion Assessment Method (CAM) crystallises these features. It is a check list of validated key features of delirium, and can be administered in five minutes. The combination of acute onset and fluctuation of cognition, and inattention, together with either disorganised thinking or altered consciousness is 95% predictive for a diagnosis of delirium (not the severity). Consider patient risk factors (vulnerability) together with a careful history of the timing of recent changes, especially new medications (or medicalforum

Image: Imogen Maher

Q With more risk factors, cognition is more easily swamped by causes

withdrawal), falls, procedures and new illness or worsening of chronic disease. This requires a collateral history from family or carers. Patients will often have pre-existing dementia, but a new, lower score on a cognitive test such as a MMSE or Abbreviated Mental Test is very suggestive of delirium. Seeing how they perform is more informative than the score. Examine for signs of pain, dehydration, infection, heart failure, focal neurology and bladder distension. There may be no clues however, and a general screen is often needed to look for infection, electrolyte and metabolic disturbance or stroke. FBP, U&E, BGL, LFT, TFT, Calcium, Troponin, Urinalysis, CXR, ECG and oxygen saturation are usually needed. A CT brain is important with a history of falls, anticoagulation or focal neurological signs, to exclude intracranial bleeding. Strokes may have no easily detectable signs. EEG is helpful where seizures are possible (pre-existing seizure disorder or structural brain lesions).

Management Where best to manage a patient is dependent on the likely causes and the available support. A mildly unwell patient with good support is best managed in their familiar environment. A patient where the cause is unclear, who is clearly unwell, unsupportable or unsafe in their usual environment, is best managed in hospital. t 5SFBU BOZ VOEFSMZJOH NFEJDBM QSPCMFNT whilst keeping the person safe and preventing DVT. t 3FWJFX NFEJDBUJPOT BOE TUPQ BOZ UIBU contribute to cognitive impairment (especially anticholinergic drugs like tricyclics). t 3FIZESBUJPO BOE FOTVSJOH HPPE OVUSJUJPO JT usually needed. t /PO QIBSNBDPMPHJDBM NFBTVSFT UP NBOBHF delirium should always be used before pharmaceuticals. Ensure that patients have their glasses and hearing aids, are reassured,

reoriented and have family involvement in their care. Encourage mobility and self-care and avoid restraints. t 1IBSNBDPMPHJDBM NFBTVSFT BSF POMZ needed for patients with distressing symptoms or who are potentially harmful to others or themselves. Small regular doses of risperidone or haloperidol 0.25mg â&#x20AC;&#x201C; 0.5mg b.d. and similar doses 4 hourly prn up to 2mg daily is usually enough. Quetiapine 12.5mg â&#x20AC;&#x201C; 25mg b.d. is less likely to cause extrapyramidal side effects. Use medications for the shortest possible time and always try to withdraw them after the delirium has resolved. (Avoid benzodiazepines, which generally increase confusion, unless treating alcohol or drug withdrawal.)

Outcomes Delirium lasts about a week in 60% of cases but 5% last over a month. Impaired concentration and memory may persist for 6 to 12 months. Patients may not make full cognitive and functional recovery. Delirium trebles the risk of dementia diagnosis in previously cognitively normal people, and trebles the rate of cognitive decline in people with dementia. Referral to a memory clinic may be needed. Delirium has poor outcomes. It doubles hospital length of stay. It trebles rates of falls, pressure sores, incontinence, functional decline and admission to residential care. It doubles the risk of death in the year after a delirium episode. The Australian Commission on Safety and Quality in Health Care will soon introduce national standards for managing cognitively impaired people in hospitals. They are currently developing national standards for managing delirium. We can all do better with this scourge of older people! O Author competing interests: nil relevant disclosures. Questions? Tel author on 9370 9329 27

CLINICAL OPINION

Tackling nutritional deﬁciency in RACFs By Ms Jo Beer, Senior Dietitian and Diabetes Educator.

n a recent Queensland University of Technology study, almost 50% of residents in residential aged care facilities (RACFs) were moderately or severely malnourished. Untreated, this leads to increased hospital admissions with longer stays, falls, susceptibility to infections, pressure ulcers, slower wound healing and sarcopenia. Regular monitoring with weight and fluid charts can help detect problems at an early stage. Intake and overall health can be optimised through close cooperation between medical staff and allied health specialists.

Catering and Feeding

Food is not the only issue. A broad overview of the individual and their environment is essential to address problems long term. This is best achieved with a multidisciplinary team that includes input from dietitians, occupational therapists and speech pathologists.

Dining areas should be conducive to relaxed eating, with televisions turned off. Protected meal times, during which non-urgent activities cease, also ensure that staff and residents focus on meals.

Patient factors Age-related physical and mental issues include difficulty chewing due to poor dentition, dysphagia and physical or cognitive incapacity. Anorexia is common, with possible causative factors including a reduced sense of taste, smell and salivary flow, constipation, illness or depression.

Adherence to best practice guidelines, such as those from the Australian Nursing Home and Extended Care Association, help ensure a balanced diet. However, it is crucial that food is properly cooked and appealingly presented. Dishes must be culturally apt, of suitable texture, and appropriate serving size. Reports of patients being served nutritious food, but not eating it, because it is cold, placed out of reach, or they are unable to feed themselves abound. Adapted cutlery can be used, and some homes employ red trays to indicate individuals who need assistance.

Nutritional Supplementation Vitamin D deficiency is common, leading to poor calcium absorption and osteoporosis. Whilst vitamin D is found in oily fish, liver and eggs, much is derived from the sun, which may not be readily accessible. Calcium supplementation is recommended for those 70 and over with minimal sun exposure or if they are not achieving the Australian Dietary Guidelines* of 3.5 serves of dairy foods per day for men and 4 for women.

Low activity and reduced protein synthesis with aging encourage sarcopenia, so protein intake is important, ideally spread evenly through the day. Cooked breakfasts can provide protein rich foods and fortifying snacks, desserts or soups can enhance intake. Dehydration is frequent in RACFs, especially if fluids cannot be freely accessed. This can promote tiredness so residents may sleep through meals. For concerns over fluid intake, accurate fluid balance charting is invaluable. *www.eatforhealth.gov.au References available on request.

KEY POINTS t .BMOVUSJUJPO BOE EFIZESBUJPO BSF common in RACFs. t 1IZTJDBM NFOUBM BOE FOWJSPONFOUBM factors contribute. t .VMUJEJTDJQMJOBSZ UFBN JOWPMWFNFOU JT essential. t #FTU QSBDUJDF DBUFSJOH BTTJTUJWF devices (e.g. built up cutlery) and protected meal times help. t $POTJEFS WJUBNJO % DBMDJVN BOE protein supplementation. Author competing interests: nil relevant. Reader questions? Contact the author on 0403 938 747

Teaching in residential aged care facilities By Dr Nick Bretland, General Practitioner

esidential Aged Care Facilities, with long stay residents who generally have reliable clinical signs for teaching, are being increasingly used in medical and allied health education. Juniper (formerly Uniting Church Homes) and Curtin University are running a two-year trial project to provide Interprofessional Education in Allied Health training.

The aim is to give interprofessional exposure to students in Nursing, Physiotherapy, Occupational Therapy, Speech Pathology, Pharmacy, and Clinical Psychology as part of co-ordinated care for the elderly. It also exposes them to the “unsexy” world of aged care. Students are allocated patients during 2 to 8 weeks on site. They liaise with qualified staff, present their findings, and see these acted on and recorded in patient notes. They discuss difficult management problems with the other students and mentors from 28

different disciplines. There are formal medical ward rounds with medical students, who soon find themselves part of the team, both giving and receiving advice.

students developed safe feeding in a patient with a CVA. One medical student stunned the other students by diagnosing aortic stenosis purely from clinical signs!

How does it work?

Outcomes

Students work with teaching mentors drawn from all health workers at the facility, carrying out their skill-specific tasks and assisting those provided by other health workers. Traditional style ward rounds incorporate a small mixed group of students. At appropriate patients, we assess the problems from each specialty’s viewpoint, such as looking for solutions to someone’s chronic disease or polypharmacy.

Final assessment results are not in. Students have reported increased knowledge of the capabilities of the other health workers. They intended to make more use of their colleagues’ skills in future. There has been acceptance of a multidisciplinary approach, especially in complex patients. Unexpectedly, many students found care of the elderly challenging, rewarding, and a potential work environment of the future.

While contributing, constructive criticism of other’s suggestions is encouraged. Examples: Physio and OT students developed a management plan to mobilise a patient after a hip fracture; and Speech Pathology and OT

Given the predicted impact of chronic disease in Australia, I hope such projects teach the doctors, nurses, and allied health workers of the future to care for patients of the future.O References available on request.

medicalforum

CLINICAL OPINION

Breaking bad news By Dr Olivia Lee, Psychiatrist, Marian Centre, Wembley

reaking bad news to patients is a complex communication task. As long as we care about our patients, it never gets easier. In this article I share some of the learning points, from my experience as an old-age psychiatrist and also from personal experience.

There are four main goals in a bad news consultation: gathering information, providing information, supporting the patient and developing a treatment or management plan with the patient.

Tailoring your response to the patient Many factors influence the level of information wanted. Those over 70 often want less information. Males rate the content of information more important than females and the supportive elements as less important. Different cultures have different levels of disclosure. In Japan, Southern and Eastern European countries, there is a lower level of disclosure than in Western countries. The doctor must discern the preferences for each patient and approach the consultation accordingly. When performing investigations, establish if the patient wishes to be accompanied to hear the results. Before the consult, familiarise yourself with the case. Ensure phones or pagers are diverted. Assess the patientâ&#x20AC;&#x2122;s prior understanding to avoid sounding patronising. Start at the patientâ&#x20AC;&#x2122;s level of comprehension by using the vocabulary of the patient. Then explain terminology. Using words like â&#x20AC;&#x153;metastasisâ&#x20AC;? may increase patient anxiety in the short term, but it reduces ambivalence and improves the patientâ&#x20AC;&#x2122;s ability for honest communication.

Good communication the key Ask questions. By doing this you are able to give personalised information. Useful questions include; â&#x20AC;&#x153;What are you hoping for in the future?â&#x20AC;? and â&#x20AC;&#x153;What do you most want to avoid?â&#x20AC;?. Give information in small chunks, check for understanding and be prepared to repeat information and to write it down if necessary. Observe the patientsâ&#x20AC;&#x2122; emotions and reflect on them, â&#x20AC;&#x153;You seem shocked/sadâ&#x20AC;Śâ&#x20AC;? Avoid saying, â&#x20AC;&#x153;I know how you feelâ&#x20AC;? because you cannot know. Check the reason for their response before making judgments or responding. When planning for advance care, focus on good pain control and symptom relief, all of which are possible. Patients differ in their willingness to participate in decision-making. Those that do will need more information. Clinicians need to consider the specific needs of every patient to assist them in achieving their preferred level of involvement. Their preferences may change and must be reviewed throughout treatment.

Consider others involved Remember that patients are often cared for by multidisciplinary teams, so the extent of information communicated to patients must be well documented. Finally, because it never gets easier, it is important for all staff involved to reflect on the experience with their supervisors and peers. O References available on request.

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CLINICAL UPDATE

Osteoporosis in RACFs: Is treatment really worth it? O

lder people in residential aged care facilities (RACFs) are at high risk for sustaining fractures and should be assessed for fracture risk upon admission. Although there is a paucity of data for osteoporosis management in RACF residents, extrapolating robust evidence from community dwellers suggests it is worthwhile.

However, differences in patient characteristics are well known, making treatment of osteoporosis challenging â&#x20AC;&#x201C; limited access to diagnostic services to measure bone mineral density (BMD), assumptions about the patientsâ&#x20AC;&#x2122; length of stay and survival, and concerns about polypharmacy. With 91.2% of RACF residents taking an average of 9.75 medications, adding an additional medication to treat osteoporosis must be justified. When progressive bone resorption exceeds new bone formation, negative bone balance leads to osteoporosis; 85% of nursing home residents worldwide have osteoporosis and about 40% of all hip fractures occur in this population. The significant morbidity and mortality associated with hip fracture might be prevented with osteoporosis therapy in those at the highest risk for sustaining a fracture (when currently, a minority in RACFs receive appropriate treatment).

Who should we treat? The ideal patient selection differs in noninstitutionalised populations compared to those in a RACF. The FRAX and the Garvan fracture risk assessment tools have been validated in the community-dwelling populations, however, their applicability to RACF residents remain less clear. A Sydney based study showed the risk factors for osteoporotic fractures in nursing home residents included being male, low serum vitamin D, bowel or bladder incontinence, cognitive impairment, use of anxiolytics, and high serum phosphate in addition to the usual risk factors for the general population. The risk factors for the general population include low BMD, female, older age, maternal history of fracture, history of previous fractures, tall height at age 25 years, previous hyperthyroidism, diabetes, psychotropic medication use, caffeine consumption and postural instability. In institutionalised older persons who reside in hostels, having poor balance and being ambulatory serve as additional risk factors.

Fracture prevention The merit of non-pharmacological interventions (e.g. falls prevention and hip protectors) are not covered by this article, which focusses on pharmacological 30

By Dr Ai Tran, Rheumatologist, Murdoch.

therapies. Generally, evidence for effectiveness of these therapies in RACF residents is scarce (see Table, which summarises the level of evidence for each).

RACF residents. Bisphosphonates generally exhibit low drug-to-drug interactions with few side effects though compliance remains problematic.

Vitamin D and Calcium Meta-analyses have reported in those who are institutionalised that daily oral vitamin D3 supplementation (700-800IU daily) reduces the risk of hip fracture by 26% and non-vertebral fractures by 23% when compared with placebo or calcium alone. The optimal serum 25(OH)D concentration is >50nmol/L. However, some advocate even higher levels, aiming for >75nmol/L.

Other treatments Strontium reduces non-vertebral and hip fractures in high-risk elderly females but no studies have been performed on the RACF population; caution is needed in those with ischaemic heart disease or uncontrolled hypertension. No studies have assessed teriparatide use in an RACF population, and daily subcutaneous administration and high cost may limit its use. Denosumab, a monoclonal RANK ligand inhibitor given subcutaneously every six months, has shown significant gains in BMD associated with reductions in vertebral, non-vertebral and hip fractures when tested among postmenopausal osteoporotic women up to age 90. Again, however, no data exists for the RACF population.

Calcium supplementation of 500-1000mg/ day has a beneficial effect on BMD. Recent evidence suggested a link between calcium supplementation and increased rates of serious cardiovascular events, though the study was not designed to look at vascular events as an end-point. A landmark three-year study in over 3000 institutionalised women aged 69-106 years using calcium 1.2g plus 800 IU vitamin D daily showed a reduction in nonvertebral and hip fractures by 24% and 29% respectively. Bisphosphonates Bisphosphonates are established treatments with strong evidence for fracture prevention in the general population. However, evidence for its use in RACF residents is limited. Only one randomised controlled study showed that Alendronate improves BMD in nursing home residents. Administrative burden remains the problem due to the complex directions, especially in those who have cognitive impairment or swallowing issues, which are common in

Costs Hip fracture surgery costs an average $15,500-$19,500: with additional costs for rehabilitation, outpatient follow-up, temporary RACF placements and assistance with the activities of daily living; if fracture results in long-term disability further costs ensue. The cost of drug non-compliance for osteoporosis therapy is also high: in 2005, noncompliance rate for bisphosphonate therapy was 40.9%; and the cost of fractures from non-adherence was estimated at $83.3m through greater health utilisation. Hence, simpler regimens that support better adherence would help to overcome some of the barriers to starting therapy.

Table: Prevention of Fractures in ACF Residents vs Community-dwelling Older Persons Agent

Dose

Evidence in institutionalised older persons

Primary prevention Vitamin D 800IU/day Yes (fracture prevention-level I) Alendronate 10mg/day Yes (improves BMD only- level III) Risedronate 5mg/day None Zoledronate 5mg/year None Teriparatide 40Îźg/day None Strontium 2g/day None Denosumab 60mg every 6 months Secondary prevention Risedronate 5mg/day None Zoledronate 5mg/year None Strontium 2g/day None BMD- bone mineral density, RRR- Relative risk reduction

RRR in hip fracture in general population 0.12-0.29 0.45-0.51 0.30-.040 0.41 0.25 0.19 0.60 0.26 0.3 0.36

Adapted from Duque et al MJA 2010;193:173-179. medicalforum

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CLINICAL UPDATE

Geriatric assessment & ACAT – what’s it all about?

By Dr Kevin Kwan, Consultant Physician, PRACWA Joondalup

avigating the aged care system (including the 2014 changes) can be complex and overwhelming. Geriatricians and Aged Care Services aim to optimise cognitive and physical function, improve quality of life and independence and reduce mortality or hospital admission. Yet primary care remains at the forefront; the General Practitioner is often the first point of contact for concerned families when their elderly person develops difficulties with day-to-day affairs. So what is available? And what are the acronyms ACAT, HACC, HCP, RACF all about?

Not everyone requires an ACAT assessment. For those who want to stay at home and only need basic help, the Home and Community Care (HACC) program would likely suffice. HACC services could include things like domestic assistance (e.g. laundry, cleaning), personal care, transport to the shops or appointments. An ACAT referral or approval is not necessary to access HACC services. These are co-ordinated by regional providers. One can request a home assessment to discuss needs by calling the Regional Assessment Centre on 1300 785 415 or phone My Aged Care on 1800 200 422 for more information on accessing ACAT.

ACAT explained The ACAT (Aged Care Assessment Team) is multi-disciplinary and assesses the level of care someone needs, usually of an advanced nature, that might include some government assistance with a Home Care Package (HCP) or access to an Residential Aged Care Facility (RACF). For those with more complex or multidimensional needs, there are varying levels of Home Care Packages that require ACAT assessment and approval (e.g. HCP 1 & 2 or 3 & 4 ) and reflect the different level of funding and hours a HCP can provide. Realistically, even at its best, a HCP can provide carer support at most a few hours a day and cannot provide 24 hour or overnight care. When a person’s care needs increase, or if there are concerns they cannot be left alone, then family or other carer(s) may need to provide additional support or a Residential Aged Care Facility (RACF) is considered. In the community, the ACAT usually visit a person in their home environment to assess their ability to cope with daily living tasks and make recommendations on which 32

services best address their needs. Consent for the assessment must be given and where possible, collateral history from the family, spouse or carer is useful.

a tactful approach that would involve topics including Enduring Power of Attorney, Enduring Power of Guardianship or Advance Health Directives.

The assessor is usually a social worker or aged care nurse and they might also involve allied health (e.g. occupational therapy) or a geriatrician.

Entry into a RACF can take some time. One of the recent changes is less distinction between ‘low’ and ‘high’ levels of care with facilities transitioning towards having the staffing and resources to manage a range of care needs within the same facility. There is no limit on how many RACFs a person waitlists at and there is no obligation to accept a place if a person feels they are not ready to enter into residential care.

The general practitioner can provide invaluable detail either with or in the referral (given that an ACAT referral can come from a non-GP). The medical practitioner’s expertise assists in prioritising the urgency of referral and which ACAT team member is most appropriate for initial assessment. Including this information in the referral helps Aged Care Services, as does indicating if a specific issue needs to be addressed (e.g. additional home or personal assistance or consideration for entry into residential aged care). If a geriatrician review is also required for a comprehensive medical, falls, cognition or other assessment, this should be included on the referral. Fees for HACC and HCP can vary and are also determined by income means testing. In general, the basic fee for an HCP starts from about $135 a fortnight and may increase to $519 a fortnight, depending on the level of means-testing.

Setting personal goals One important consideration is the person’s goals, such as maintaining independence at home as long as possible. This aside, discussions for future care should ideally start early, particularly in patients with neurodegenerative conditions such as Alzheimer’s Disease, predicted to progress with time. Future planning needs

Fees and the accommodation payment for staying in RACF vary depending on the facility and also a person’s income or assets test. There is some flexibility in how this is paid. However, where required and should a person wish to pay a ‘lump sum’ accommodation deposit it is not unusual for this to be in the realm of several hundred thousand dollars.

Resources The Australian Government’s new website www.myagedcare.gov.au (or phone 1800 200 422) offers useful information. My Aged Care website provides a summary of the Aged Care system and services available, from home care to respite care and RACFs. The entry process for Residential Aged Care is covered (see www. myagedcare.gov.au/aged-care-homes/ considering-aged-care-home), along with searchable comparisons of different facilities at different locations. A fee calculator for both HCP and RACF can be found at www. myagedcare.gov.au/personal-stories/agedcare-fee-estimators. O Author competing interests: no relevant disclosures.

medicalforum

Clinical Q&A

Q: “How can a ‘hole in the heart’ impact on Decompression Sickness?”

persistent right to left heart shunt – usually an inter-atrial shunt from a patent foramen ovale (PFO) or ASD, or rarely a pulmonary AV malformation – is associated with an increased risk of some forms of Decompression Sickness (DCS), first reported in the medical literature in 1986. In utero, the foramen ovale allows foetal blood to bypass the lungs. At birth, breathing drops circulatory pressure in the lungs, and the flap over the foramen ovale closes due to higher pressure in the left heart. However, in about 30% of people, closure is incomplete, and in 4% the PFO is large enough to affect DCS. Such a large PFO, with right to left shunt, is also strongly associated with migraine with aura (~50%) and cryptogenic stroke.

blood. Normally they are filtered by the lungs and do not reach the arterial circulation. A PFO at times (e.g. after straining) may allow blood to cross to the left side of the heart and then be distributed to body organs via the arterial circulation. A small bubble load will often be resorbed into the blood before the tissue capillaries are reached, hence not causing any problem.

Dr Neil Banham, Director of Hyperbaric Medicine, Fiona Stanley Hospital

then this N2 will diffuse into these bubbles, to potentially cause symptoms. Tissues that are more prone include the skin, spinal cord and the inner ear. A diver who has had an episode of skin, spinal or inner ear DCS should be provided with advice to avoid a recurrence of DCS. Options include cessation of diving, modification of diving practice to avoid significant nitrogen loading (limiting depth/time, slow ascents, longer surface intervals between dives and consideration of using Nitrox i.e. oxygen enriched air). Bubble contrast (agitated saline) trans-thoracic echocardiography is usually diagnostic and allows the patient to perform “provocation” manoeuvres such as Valsalva during the procedure. A negative non-contrast colour echo does NOT exclude the presence of a large PFO! If a PFO is detected, a cardiologist experienced in PFO closure and with an interest in diving medicine can discuss the risks and benefits of closure. A successful closure returns the diver’s risk of further DCS back to normal.

DCS, if it happens, affects skin (~75-80% will have a PFO), inner ear and spine, that is, not the typical musculoskeletal DCS with joint pain (“the bends”). However, most who dive with a PFO do not get DCS. Why is this? As it happens, most scuba dives form bubbles, the amount varying between individuals and the same individual at different times. These micro bubbles typically form in the tissues and in venous

A larger bubble load with bigger micro bubbles can reach the capillaries. If the tissues they reach are supersaturated with nitrogen (i.e. they have a higher partial pressure of N2 than the surrounding blood),

Further reading: Sykes O, Clark JE. Patent foramen ovale and scuba diving: a practical guide for physicians on when to refer for screening. Extreme Physiology & Medicine. 2013;2:10. O

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CLINICAL UPDATE

Update: blood cancer medicine U

ntil the 1960s all blood cancers were incurable. Major gains since then in conventional chemotherapy, particularly with childhood leukaemia and Hodgkin lymphoma, are now reaching their limits because chemotherapy’s “machine gun approach” of inhibiting rapidly dividing cells carries numerous side effects. Advances in treatment often follow technology advances – the next breakthroughs will come from molecular genetics and immunology.

For patients these promise improved survival. For the community an array of very expensive therapies will stretch the limits of the PBS. For hospitals it heralds a shift towards outpatient care except for the very sick or refractory. For the general practitioner, increased survival means more blood cancers requiring joint management with the haematologist of chronic issues such as pain, immunosuppression, and comorbidities.

Molecular medicine All cancers involve acquired genetic mutations. We now have the ability to sequence the genome of some cancers, and in certain cases identify “driver” mutations that

By Dr Matthew Wright, Head of Haematology FSH.

can be inhibited by specific drugs. Chronic myeloid leukaemia (CML) has become a manageable chronic disease in most cases by the use of tyrosine kinase inhibitors like GlivecTM, which inhibits the specific mutation involved in cancer genesis (BCR-abl). Other cancers however are more complex than CML. Their genetic abnormalities are numerous and varied, and specifically inhibiting them would require a cocktail of different molecules for each patient. This concept of “individualised” cancer medicine is in its genesis and progress towards benefit for some patients is slow and expensive.

Targeted therapies

Novel drugs

Another novel immunotherapy involves a class of drugs called BiTE antibodies (bispecific T-cell engaging). These drugs recruit the patient’s own T-lymphocytes to eliminate cancer cells. In the case of ALL, a drug called blinatumomab recruits the patient’s CD3 T-cells to eradicate their CD19 bearing leukaemia cells, showing dramatic promise in studies of refractory patients. O

Novel drugs have extended survival significantly in diseases like myeloma. Thalidomide, a notorious drug from the 1960s, was rediscovered as a surprisingly effective treatment for myeloma in the late 90s. Its derivative lenalidomide, as well as a novel class of proteasome inhibitors pioneered by bortezomib, have helped more than one third of patients with myeloma live a decade or longer. This improvement in survival comes with ongoing morbidity like bone pain, and unusual new side effects such as neuropathy and thrombosis risk.

Poor responders to conventional chemotherapy, particularly chronic lymphocytic leukaemia and adult acute lymphoblastic leukaemia, promise to benefit soon from exciting new “designer drugs”. Rituximab, an anti-CD20 monoclonal antibody, has improved response and survival in B-cell lymphoma. New drugs are targeting the B-cell receptor apparatus in CLL; by specifically targeting the abnormal cell population they are having dramatic effects in early studies; the drugs are predominantly oral and for long-term use.

Author declaration: no relevant competing interests. Any questions to the author on Tel 9224 1165.

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CLINICAL OPINION

Exercise Medicine and Cancer Control By Prof Daniel Galvão PhD, Co-Director, Edith Cowan University Health and Wellness Institute; Cancer Council Western Australia Research Fellow

hysical exercise is essential to maintaining human health and is recognised by the American College of Sports Medicine and the American Heart Association as medicine for both the prevention and management of chronic disease, injury and other illnesses. Clinicians used to advise cancer patients to rest and avoid physical activity; however, over the last 20 years exercise research has increasingly challenged this recommendation so that exercise is considered vital in cancer prevention and control. Following cancer diagnosis, appropriate exercise can help reduce symptoms and cancer-related fatigue, help manage the side effects of radiation and chemotherapy, improve psychological health, help maintain physical function, reduce fat gain, and attenuate the loss of muscle and bone. Large observational studies point to regular exercise post-diagnosis actually increasing survivorship by 20-60%, with the strongest evidence currently for breast, colorectal and prostate cancers. In our work with prostate cancer patients, we have found that exercise can limit or even

reverse some of the adverse effects from androgen deprivation therapy, by increasing muscle mass, functional performance, and cardiorespiratory fitness without elevating testosterone levels. Hormone therapies for breast and prostate cancer can alarmingly increase the risk of cardiovascular disease, obesity, type 2 diabetes, osteoporosis, and sarcopenia. Patients may question the benefit of some cancer treatments as morbidity and mortality risk from other chronic diseases begins to outweigh the initial cancer diagnosis. Exercise is now critical adjuvant therapy for many cancers and will greatly enhance traditional radiation and pharmaceutical treatments by increasing tolerance, reducing side effects, and lowering the risk of chronic diseases, even those not aggravated by cancer treatment. The current recommendation is to avoid being physically inactive and aim to complete 150 min of aerobic exercise and two or more sessions of resistance training per week. More specific exercise is also required to address things like bone loss or obesity, with careful consideration of fracture risk in bone metastatic disease.

It is critical that exercise is tailored to the individual and they are monitored by appropriately trained and accredited exercise physiologists (see the American College of Sports Medicine and American Cancer Society position statements) – to deliver a safe and effective program and ensure on-going adherence. O ED: Further information can be found at http://www.ecuhealthwellnessinstitute.org/ Further reading Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin 2012; 62(4): 242-274. Galvão DA, Taaffe DR, Spry N, Newton RU. Physical activity and genitourinary cancer survivorship. Recent Results Cancer Res. 2011;186:217-36. References available on request.

Author competing interests: no relevant disclosures.

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CLINICAL UPDATE

Gout management A

n estimated 16.5% of elderly Australian men are affected by gout, a form of arthritis caused by the deposition of monosodium urate (MSU) crystals in joints and soft tissues as a result of long standing hyperuricaemia. The arthritis is incredibly painful, and is associated with morbidity and joint damage. Clinical and epidemiological studies also suggest that gout and/or hyperuricemia may contribute to hypertension, chronic kidney disease, and cardiovascular disease. The patho-aetiology of the arthritis is relatively well understood and effective therapy is available, yet gout is badly managed and rarely studied. We know the incidence is increasing as our population ages, BMI increases and polypharmacy becomes more common. As the burden on the health system rises, so does the importance of improving management across Australia.

Management principles Pharmacological therapy of gout is a combination of management of the acute attack with anti-inflammatory therapy, and maintenance urate lowering therapy (ULT). Anti-inflammatory therapy of an acute attack should be commenced within 24 hours of onset. The American College of Rheumatology (ACR) suggest that either NSAIDâ&#x20AC;&#x2122;s, colchine or corticosteroids are appropriate first line therapy, and indeed may be used in combination. Colchicine should be initiated within 36 hours of an attack, and whilst traditional teaching was to take hourly colchicine until diarrhoea is achieved, a more modern approach is a 1mg loading dose, followed by 500mcg BD until resolution. Preventive management focuses on lowering serum uric acid with xanthine oxidase inhibitors (allopurinol) or uricosuric agents (probenicid, sulphinpyrazone). The ACR recommend that urate lowering therapy be instituted once the diagnosis of gout is established, and if there is either stage II renal impairment, past uric acid renal stones, evidence of tophi, or 2 or more attacks per year. Xanthine oxidase inhibitors are considered first line and currently, we are limited to allopurinol. To increase tolerance, this drug should be started at no more than 100mg daily (even lower doses in renal impairment), and then titrated with a target serum uric acid of <0.36mmol/L . However, studies have demonstrated that at 300mg daily allopurinol, a large proportion of patients do not achieve this target, and higher doses may be required, even in renal impairment. Escalation should be done with caution though, and with consideration that renal impairment and thiazide use 36

Dr Helen Keen, Rheumatologist, Subiaco Rheumatology Clinic

Q Gout is more common in elderly men.

both increase the risk of adverse reactions. Hypersensitivity is more frequent in the Korean, Han Chinese, and Thai ethinic groups, and genetic testing to identify those at risk can be undertaken. (Febuxostat may soon be available in Australia. It is superior to allopurinol in suppressing serum urate but has not been shown to reduce attacks, and might be best for those intolerant of allopurinol.) Probenicid, a uricosuric agent, relies on renal excretion to reduce serum urate and therefore has limited benefit in those with a reduced creatinine clearance, and is contraindicated in those with uric acid stones.

Timing interventions is important Traditional teaching suggested that ULT should not be instituted during an acute attack of gout, however, the ACR recommends that if anti- inflammatory therapy has been commenced, ULT can be started then. In practice, the acute attack often creates a fleeting therapeutic window of high patient motivation. However, if initiating ULT occurs during an intercritical period, it may be useful to give prophylactic anti-inflammatory therapy as well because changes in serum urate can precipitate an attack of gout, such as when commencing ULT, and if patients report that â&#x20AC;&#x153;allopurinol makes my gout worseâ&#x20AC;? this has obvious implications for compliance. Urate lowering therapy should not be ceased during an acute attack. Anecdotally, it is common for patients to cease their ULT during an acute attack, which can create a cycle of allopurinol initiation, acute attack, allopurinol withdrawal, allopurinol reinitiation, acute attack, allopurinol withdrawal. Competing interests: nil relevant disclosures. Reader questions? Contact the author on 9388 0399.

The big picture The holistic management of gout should include education, self-management, and assistance with dietary and alcohol modifications, weight loss, smoking cessation, exercise and increased fluid intake. Diets low in purines have traditionally been recommended. However increasingly, as it is recognised that dietary restriction has a limited impact on serum uric acid. Given the association between gout and the metabolic syndrome, the latter a source of morbidity and mortality, the focus has shifted to dietary and lifestyle choices that promote health in general, and minimise the effects of hypertension, hyperlipidaemia, obesity, diabetes and cardiovascular disease. References available on request

TAKE HOME MESSAGES t $PMDIJDJOF BT BO BOUJ JOGMBNNBUPSZ in acute gout, should be commenced XJUIJO IPVST NDH #% JT B reasonable dose). t *U JT SFBTPOBCMF UP DPNNFODF VSBUF lowering therapy during an acute attack; starting at a low dose of allopurinol (<= NH EBJMZ NBYJNJTFT UPMFSBODF t 1SPQIZMBYJT XJUI BO BOUJ JOGMBNNBUPSZ is recommended when commencing urate lowering therapy. t 5IF BJN PG QSFWFOUJWF UIFSBQZ JT B biochemical marker (serum uric acid <0.36mmol/L) t %P /05 TUPQ VSBUF MPXFSJOH UIFSBQZ during an acute attack. t )PMJTUJD DBSF FODPVSBHFT B IFBMUIZ lifestyle and diet.

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PERCUTANEOUS MANAGEMENT WITH PRP* ADVANCED KNEE OSTEOARTHRITIS & MEDIAL COLLATERAL LIGAMENT TEAR & MENISCAL TEAR

MRI coronal left knee: Torn and extruded degenerate medial meniscus at junction of body & posterior horn (dotted yellow line) and subjacent abnormal bone marrow changes (white arrow). Note torn femoral !# ( " " (broken red arrows) and intact tibial attachment of " %! " ' chondral degeneration of the posterior lateral tibial plateau (yellow arrow).

MRI coronal, anterior to previous image: Markedly degenerate torn extruded body of medial meniscus (dotted yellow margin), full thickness loss of hyaline chondral cartilage (thin dotted yellow arrows). Abnormal medial compartment stress transfers into the subjacent bone marrow (dotted thin red arrows) and into an intact buckled anterior medial collateral ligament (thin dotted green % " " %! previous image).

MRI sagittal image of patellofemoral " " " ( " of patellar hyaline chondral cartilage due to degeneration (yellow arrow), bone marrow lesion of inferior patella (dotted yellow margin) and near full thickness chondropaenia of lateral femoral trochlea (red arrow). Note proliferative !' $ " ! % ) " " !" fast cartilage degradation and loss.

A 59 year old female teacher, Type 2 Diabetic presented with left knee pain to IGTC seeking non surgical options. She had known osteoarthritis and no history of prior left knee surgery. During an injury at work, she heard a crack with exacerbation of knee pain. On examination there was mild knee joint swelling with stiffness and flexion block at 110 degree of the left knee with tenderness of the medial joint line. MRI imaging (see figures) showed established tricompartment cartilage degeneration, MCL tear, degenerate medial meniscal tear with extrusion, resulting in abnormal stress of the medial compartment. She underwent percutaneous treatment that included autologous platelet rich plasma (PRP) to the left knee under ultrasound guidance and local anaesthetic cover. She returned to normal activities within a few days. Over the next few weeks, she reported excellent pain relief, improved range of movement and stopped all analgesics. She returned to work without any time off work, no loss of revenue and with improved function of the left knee.

*WORLDS FIRST REPORT ON PRP FROM WESTERN AUSTRALIA

Doss A. Neotendon infilling of a full thickness rotator cuff foot print tear following ultrasound guided liquid platelet rich plasma injection and percutaneous tenotomy: favourable outcome up to one year [v1; ref status: indexed, http://f1000r.es/xz] F1000Research 2013, 2:23 (doi: 10.12688/f1000research.2-23.v1)

Dr Arockia Doss MBBS MRCP (UK) FRCR (Lon) FRANZCR Interventional Radiologist Suite 3, 55 Hampden Road Nedlands WA 6009 ph 6389 2776 fx 6389 2778 info@imageguidedtherapyclinic.com www.igtc.com.au

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Medical Audiology Services

Hear the best you can!

The ageing ear: Why is everyone mumbling?

Presbycusis or age-related hearing loss results from progressive, complex changes along the auditory pathway. Older adults with presbycusis often describe an inability to understand speech clearly rather than an inability to hear. Effects of presbycusis are measurable from the age of 30, as illustrated in Figure 1 which shows average hearing levels across age groups. High frequency hearing is affected ﬁrst and most severely, although lower frequencies become involved with increasing age. This pattern leads to a perception of speech that is loud enough but indistinct because of reduced hearing of high frequency consonants, primarily /s/, /f/, /th/, /t/, /ch/ and /sh/.

Dr Vesna Maric

Andre Wedekind

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

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

A loss of hair cells and supporting structures within the cochlea is the main physiological change in presbycusis. Other important changes are a metabolic disruption after degeneration of the stria vascularis, and reduction in the size and number of auditory nerve fibres. Degenerative changes in the auditory brainstem and cortical areas, termed central presbycusis, are thought to exaggerate hearing difficulties in situations with competing speech and background noise. Reduced tissue elasticity, ossification and stiffening of outer and middle ear structures with ageing are well documented, although they rarely cause significant reduction in hearing levels. There is no clear-cut aetiology; noise exposure, cardiovascular disease, inflammations, genetics, pollutants and medications have all been implicated as contributing causes of damage over a person’s lifetime. Presbycusis causes a permanent, progressive hearing loss which is best addressed with early intervention to prevent social isolation, improve quality of life, harness optimal neural plasticity and reduce the risk of deprivation in central auditory structures. Further, there is growing research in reducing the risk of hearing loss related dementia with timely intervention. Evidence-based fitting of behind-the-ear hearing aids, combined with communication training and a structured rehabilitation program are required for comfortable acclimatisation to new sounds, and good long-term acceptance. References available on request

51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au medicalforum

CLINICAL UPDATE

Sleep impacts around medical disorders S

leep can be defined as a reversible state of reduced awareness and responsiveness to internal and external stimuli, with associated behavioural changes (posture, eyelid closure, eye movements). There are well described physiological changes during sleep – altered smooth muscle and reduced skeletal muscle tone, hormonal changes, reduced sympathetic nervous activity (lower heart rate, blood pressure), and reduced alveolar ventilation related to changes in control of breathing. There is a bi-directional interplay between the physiological effects of sleep and medical disorders, with impact on sleep initiation, duration, quality and architecture.

Mechanisms and interplay Insufficient sleep has an important effect on appetite regulation, possibly mediated through leptin-grehlin mechanisms. Sleep loss contributes to impaired glucose tolerance, increases appetite, risk of weight gain and prior inflammatory markers. Diabetes control is improved if sleep disorders such as obstructive sleep apnoea (OSA) are treated successfully. Iron deficiency (as well as uraemia, neuropathy and some prescribed medications) may alter dopamine metabolism in the central nervous system, causing restless legs syndrome (and periodic leg movement disorder in sleep). RLS/PLMS often delays sleep onset or disrupts it, and can adversely affect quality of life. It is a treatable disorder that may be uncovered by general enquiry about sleep problems. Psychiatric disorders have a significant impact on sleep initiation, particularly anxiety and bipolar disorder. Insomnia is common in both, and may be the presenting complaint, particularly in general anxiety disorder or anxiety secondary to chronic illness. Some psychiatric medications increase the risk of RLS/PLMS. Patients manage their insomnia in different ways and it may be the basis for alcohol abuse. It is not unusual for multiple sleep disorders to coexist e.g. insomnia secondary to a medical disorder, psychological insomnia, or circadian rhythm disorder. This is particularly true in conditions such as fibromyalgia/chronic fatigue syndrome in which insomnia is prominent and often contributes to daytime fatigue. Other sleep disorders, such as OSA, are more common in adults with fibromyalgia and compound sleep disturbance, fatigue and poor pain control in this disorder.

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By Dr Michael Prichard, Respiratory and Sleep Physician, Mount Hospital

Conditions that commonly affect sleep

COPD and other chronic lung diseases (e.g. interstitial lung disease) are associated with more frequent night-time waking, poor sleep quality and daytime fatigue. Mechanisms for sleep disturbance include cough, dyspnoea, postural effects on ventilationperfusion relationships, anxiety related to chronic illness and medications. Oral steroids used to treat chronic airway disease and interstitial lung disease (and their exacerbations) invariably causes insomnia in high doses. Control of ventilation is impaired in normal sleep, particularly REM sleep, and may result in hypoventilation during the night, increasing the risk of pulmonary hypertension and RHF; coexistent OSA significantly worsens COPD prognosis. The presence of snoring and daytime sleepiness in COPD patients (or other lung disease) should raise suspicion of underlying SDB, prompting referral for a sleep study. Pain may be an overlooked cause of sleep disturbance, most commonly arthralgia and myalgia. Poor sleep Q Frequent waking during the night in Parkinson’s disease quality alters pain perception so that improving underlying sleep disorders helps night’), sometimes resulting in self or with pain control. A sleep study correlate of partner injury; or impaired pharyngeal chronic pain (also seen in chronic anxiety muscle function increases the risk of and CFS) is alpha intrusion in non-REM obstructive sleep apnoea. sleep, including slow-wave sleep (so-called Cardiac failure has a bidirectional alpha-delta pattern). Sometimes pain relationship with sleep disordered breathing alters posture (e.g. bilateral shoulder pain (SDB). Severe sleep disordered breathing may prevent lateral sleeping position) and (most commonly obstructive sleep disorder; may aggravate positional sleep-disordered OSA) increases the risk of all forms of breathing. cardiovascular disease by a factor of five, Some medications used to treat chronic and cardiac failure has a worse prognosis medical disorders may cause insomnia, in the presence of untreated severe OSA. drowsiness, increasing dream and nightmare In some patients with cardiac failure, recall, restless legs syndrome, affect redistribution of lower limb oedema ventilation during sleep or change sleep during sleep (horizontal posture), results architecture. O in interstitial oedema in the upper airway, thereby worsening OSA – diuretics reduce Definition: Sleep disordered breathing (SDB) is a group the apnoea/hypopnoea index in this setting. of breathing disorders in sleep, including central and obstructive sleep apnoea, upper airway resistance Gastro-oesophageal reflux is a recognised syndrome, Cheyne-Stokes respiration and hypoventilation. cause of sleep disturbance. Respiratory complications of reflux occur mostly as a result of nocturnal reflux with microaspiration. Laryngeal injury from Author competing interests: No relevant recurrent nocturnal acid reflux may present disclosures. Reader questions, contact the author with cough and dysphonia, or occasionally on Tel 9481 2244. nocturnal laryngospasm. Medical training teaches us about sleep disturbance as a metric for some medical disorders, particularly heart failure (paroxysmal nocturnal dyspnoea) and asthma (poor sleep as a marker of severity). However, sleep disturbance complicates many chronic medical disorders, and should be reflected in the questions we ask. Chronic neurological disorders such as Parkinson’s disease are often associated with grossly fragmented sleep (frequent arousals and waking – see hypnogram), contributing to daytime sleepiness and increased falls risk. Both these disorders may display parasomnias such as REM sleep behaviour disorder (‘acting out dreams during the

Sailing

RACE

TO THE

LINE

RPH registrar Dr Richard Leslie finds great synergy between the high-pressured worlds of ED and competitive sailing.

The challenge of making a racing dinghy go extremely fast isnâ&#x20AC;&#x2122;t far removed from the hectic pace of the emergency department in a major hospital. The two disciplines are complementary, says young medico Dr Richard Leslie, and throw down the gauntlet to both mind and body. i*U T RVJUF QIZTJDBM PVU PO UIF XBUFS 5IF Laser is a demanding boat at an elite competitive level and sailing itself is underrated BT B TQPSU 5IFSF T RVJUF BO JOUFMMFDUVBM DPNponent, everything from race tactics to understanding the weather and shifting wind patterns.â&#x20AC;? â&#x20AC;&#x153;At the moment Iâ&#x20AC;&#x2122;m doing pretty well in local training regattas. They lead up to a major summer series and after that Perth is hosting the National Championships early next year so Iâ&#x20AC;&#x2122;m working towards those races.â&#x20AC;? â&#x20AC;&#x153;I did well in the Nationals a few years ago in Tasmania. The professional sailors 40

dominate the Gold Fleet division and then amateurs like me, who have real jobs and are doing it because they enjoy a challenge, sail in the Silver Series. Iâ&#x20AC;&#x2122;ve been on the podium at the State level as well.â&#x20AC;? Richardâ&#x20AC;&#x2122;s sailing exploits are occasionally put on hold with stints in the emergency department in the Goldfields region.

and, as Richard points out, itâ&#x20AC;&#x2122;s absolutely vital to find a circuit-breaker. â&#x20AC;&#x153;Everyone needs something to provide a sense of balance and, for me, sailing and music do that very well. I also do triathlons, and training for those events gives

â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m currently a resident at RPH and hoping to get a place on the emergency medicine training program next year. Iâ&#x20AC;&#x2122;ve XPSLFE JO ,BMHPPSMJF BOE #VOCVSZ BT XFMM I enjoy the pace and social nature of the ED, thereâ&#x20AC;&#x2122;s always plenty of action.â&#x20AC;? â&#x20AC;&#x153;I wasnâ&#x20AC;&#x2122;t completely convinced about medicine as a career until I started working in a hospital environment. Neither of my parents are doctors, although thereâ&#x20AC;&#x2122;s a family connection with grandparents and u uncles who practtised in Albany.â&#x20AC;?

Q Fiona and Lloyd in their Taser

i i#VU * N WFSZ HMBE * cchose this career, I lo love it and am very g grateful to have tthe opportunity to m make a difference.â&#x20AC;? T The professionaal demands of m medicine can be iinordinately high

Q Dr Fiona Campbell and Lloyd Lissiman

me something else to focus on apart from work. To be physically fit in an ED is a good thing!â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;d recommend anyone to have a crack at learning to sail. South Perth Yacht Club has Open Days and basic sailing courses. People are welcome to get out on the water and try a few different classes.â&#x20AC;? Another Perth medico who will be scanning the ocean for wind shifts in January is Claremont GP Dr Fiona Campbell. She

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funnyside e

)FSF T IPX PVS CFTU EPDUPST DPNQMFUFE UIJT TFOUFODF

â&#x20AC;&#x153;The sort of patients I LOVE TO HATE are...â&#x20AC;? Alternative medicines â&#x20AC;&#x153;Those who have nothing wrong that they are prepared to tell you about but come in XJUI B MJTU PG UFTUT UIFZ XBOU CFDBVTF UIFZ IBWF CFFO SFRVFTUFE CZ BMUFSOBUJWF IFBMUI practitioners who want to be copied into the test results.â&#x20AC;? â&#x20AC;&#x153;Those who have spent all their money on twice a week chiro, then want me to â&#x20AC;&#x2DC;please bulkbill themâ&#x20AC;&#x2122;.â&#x20AC;?

The List People â&#x20AC;&#x153;Those who say â&#x20AC;&#x153;I havenâ&#x20AC;&#x2122;t seen you for some time, so I have bought a list of problems.â&#x20AC;? â&#x20AC;&#x153;Those who come with print-outs from the most horriďŹ c internet websites to make their point.â&#x20AC;? â&#x20AC;&#x153;Those who come in with a list and refuse to leave until they have discussed everything on the list.â&#x20AC;? and her husband, Lloyd Lissiman (brother of Americaâ&#x20AC;&#x2122;s Cup crewman Skip Lissiman) are competing in the Tasar World Championships JO #VTTFMUPO Fiona and Lloyd, who scored a second place in this yearâ&#x20AC;&#x2122;s Tasar State Championships, are on the organising committee for the Tasar Worlds. Laser Nationals â&#x20AC;&#x201C; Mandurah Offshore Fishing and Sailing Club, December 29-January 4; Tasar Worlds 2015 â&#x20AC;&#x201C; Busselton, January 2-9 O

By Mr Peter McClelland

SAILING MEDICOS 3PZBM 1FSUI :BDIU $MVC IBT BCPVU doctors on its books, including Dr Janet Hornbuckle, who is on the committee and a club champion. t %S 1IJM $IJMET BOE IJT ZBDIU A,OFF %FFQ (Hillarys Yacht Club) have an impressive blue-water record. 4ZEOFZ )PCBSU SBDFT BOE A,OFF %FFQ XPO JUT EJWJTJPO JO t &/5 TVSHFPO %S 4UVBSU .JMMFS SBDFE dinghies and now sails a cruising yacht at Fremantle Sailing Club.

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â&#x20AC;&#x153;Those who would like to deal with all the problems of their life in one consult.â&#x20AC;? â&#x20AC;&#x153;The UND-here syndromes â&#x20AC;&#x201C; Dr, I have pain here und here und here.â&#x20AC;?

Hidden Privileges â&#x20AC;&#x153;Those patients and their families who expect you to be their butler, concierge, secretary BOE PO DBMM EPDUPS UP BUUFOE UP UIFN XIFOFWFS UIFZ XBOU w i5IPTF XIP EFNBOE UP CF CVML CJMMFE UIFO UFMM NF BCPVU UIFJS VQDPNJOH XFFL IPMJEBZ in France.â&#x20AC;? i5IF NBO XIP ZFMMFE BU NF EPXO UIF QIPOF XIFO * EJE OPU ## IJT DIJME XIP XBT w i5IPTF XIP SFRVFTU UP CF CVML CJMMFE BOE BSF FBSOJOH NPSF UIBO NF w i:VNNZ NVNNJFT XIPTF QFSGFDU DIJMESFO IBWF SVOOZ OPTFT BOE TOFF[FT BOE BSF PI so, ill! Achoo! Achoo! And the creche wonâ&#x20AC;&#x2122;t take them so they canâ&#x20AC;&#x2122;t do their yoga/step/ pump class.â&#x20AC;?

The Poor Communicators â&#x20AC;&#x153;Those who answer their mobile phones during a consultation!â&#x20AC;? â&#x20AC;&#x153;Those who complain you are running late and then take phone calls while you are seeing them.â&#x20AC;? i5IPTF OPO &OHMJTI TQFBLFST XJUI B HZOBF DPNQMBJOU XIP IBWF UIFJS ZFBS PME TPO UP translate.â&#x20AC;? â&#x20AC;&#x153;Those who on the way will turn and say, â&#x20AC;&#x2DC;by the way I have had some rectal bleedingâ&#x20AC;&#x2122;.â&#x20AC;?

The Classics â&#x20AC;&#x153;Tattooed patients afraid of needles.â&#x20AC;? ED: The winner of this monthâ&#x20AC;&#x2122;s e-poll wine prize is Dr GB. 41

pets

rescue to the

M Maintaining the connection between animals and the eelderly has significant health benefits. And help is at hhand when temporary hospitalisation is needed. POOPS WA helps keep elderly people, who are still living in their own homes, connected to their pets. â&#x20AC;&#x153;This all started in NSW with a partnership between the RSPCA and a hospital in Sydney. The catalyst was that they couldnâ&#x20AC;&#x2122;t get some elderly patients to come in for treatment because they wouldnâ&#x20AC;&#x2122;t leave their pets at home.â&#x20AC;? â&#x20AC;&#x153;My wife and I had been involved in raising funds for dog shelters, so three years ago we decided to set up POOPS WA and now we provide short-term care of pets in the homes of elderly people. We cover the metropolitan area from Two Rocks to 'BMDPO XJUI UIF BTTJTUBODF PG BSPVOE volunteers. We receive referrals from Silver Chain, hospitals and other service providers for patients undergoing treatment who may be worried about their pets. A local

volunteer will go to the hospital, pick up the house keys and make sure the animal is OK.â&#x20AC;? â&#x20AC;&#x153;Theyâ&#x20AC;&#x2122;ll feed it, walk it and, if necessary, take it to the vet if it needs treatment.â&#x20AC;? Thereâ&#x20AC;&#x2122;s a strong connection with the #SJHIUXBUFS (SPVQ JO GBDU $&0 %S 1FOOZ Flett is the patron of POOPS. i#SJHIUXBUFS QSPWJEFT BENJOJTUSBUJWF support but weâ&#x20AC;&#x2122;re a totally not-for-proďŹ t association relying on our own fund raising. The service is free to clients. Weâ&#x20AC;&#x2122;re in the process of trying to put together some hard data on medical and social cost beneďŹ t analysis that demonstrates the value of this as a community service.â&#x20AC;? â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;d certainly like to spread the POOPS message to GPs and their patients.â&#x20AC;?

POOPS SERVICE t %PH 8BMLJOH o 4IPSU -POH 5FSN t 'FFEJOH o 4IPSU 5FSN EVSJOH IPTQJUBM TUBZ t 5SBOTQPSU o 7FU BOE PS #PBSEJOH ,FOOFM www.poopswa.org.au Armadale/Jarrahdale/Serpentine Coordinator: 4IFJMB armadale.south@poopswa.org.au Coastal South Coordinator: -ZOOF coastal.south@poopswa.org.au Northern Suburbs Coordinator: -J[ poops.north@poopswa.org.au Southern Suburbs Coordinator: #FUI poops.south@poopswa.org.au Western Suburbs Coordinator: +JMM poops.west@poopswa.org.au

By Mr Peter McClelland

B U S S E LT O N

PRICE $1,690,000 Wow! Here is a magniďŹ cent two story home on half an acre with only a narrow nature strip between the home and the beach. Located close to the Busselton town, but also only a short distance to the stunning coastline of Dunsborough and the amazing wineries of Margaret River! â&#x20AC;&#x153;This MagniďŹ cent house and property has to be seen to be believed with a large pool, and sweeping elegant trees to relax under, making it almost totally unique in the Busselton township!â&#x20AC;? This fantastic home boasts a near incomparable block with a privacy setting second to none. Inside, the house is all class with Jarrah hard wood ďŹ&#x201A;oors, sweeping stair case, huge rooms and a real sense of space. If you are looking to get super close to the beach but do not want to compensate on the size of the block, than you need to see this home!

CONTACT Jason Dragstra 0400 208 268

Travel

Age need not weary the active and engaged senior, but retirement does need some planning.

other medical all practitioners practitio on ners may be tosstos ss sing around as they approach t appro roa oach the twilight wilight light ht of of their careers. Itâ&#x20AC;&#x2122;s â&#x20AC;&#x2122;s no â&#x20AC;&#x2122;s no secret secr secr cre et that tha tha at some som me docdoc d tors have an inordinate to their d dinate e commitment ccommitm co omm work, often to the of their own e detriment d detri et personal development. en e

Planning for retirement After a topple in the snow, a â&#x20AC;&#x2DC;lightbulbâ&#x20AC;&#x2122; moment and a severe case of â&#x20AC;&#x2DC;downsizingâ&#x20AC;&#x2122; Dr Adele Thomas stepped boldly out into a wide and wonderful world with chiropractor husband, Dr Ely Lazar, and have since sampled a large slice of the globe. In the past 30 years they have travelled through Asia, Europe and 43 states in the USA and they donâ&#x20AC;&#x2122;t plan to stop anytime soonâ&#x20AC;&#x2122;. â&#x20AC;&#x153;We were going along very nicely in our QSPGFTTJPOT BOE UIFO JO * IBE B TLJJOH accident and broke my hip,â&#x20AC;? said Adele. â&#x20AC;&#x153;It healed well, but it was a timely reminder that life is short and we need to get on with what we really want to do. And highest on the list was our own life choices and not what might have been expected of us.â&#x20AC;? â&#x20AC;&#x153;Other people take long-service leave so XIZ TIPVMEO U XF w â&#x20AC;&#x153;So it was goodbye to the four-bedroom house and farewell to my beautiful Ford Mustang. We put everything in storage and just took off!â&#x20AC;? â&#x20AC;&#x153;While we were away we put together a travel â&#x20AC;&#x2DC;blogâ&#x20AC;&#x2122; and that morphed into â&#x20AC;&#x2DC;Passionate Retireesâ&#x20AC;&#x2122;, our website that espouses the golden opportunities for people approaching retirement.â&#x20AC;? Adeleâ&#x20AC;&#x2122;s insights into the joy and tragedy of medicine combined with the sheer fragility PG MJGF SFTPOBUF XJUI NBOZ PG UIF RVFTUJPOT

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i* N TUJMM XPSLJOH IPVST B XFFL BT B (1 in Subiaco and so many older people, doctors among them, come up to me and say API XIBU BN * HPJOH UP EP OPX "OE TPNF of them are anxious and depressed about what the future may hold.â&#x20AC;? â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s a creeping ageism in the medical workforce. Perhaps not so much for GPs, but Iâ&#x20AC;&#x2122;ve had surgeons come to me and say they feel theyâ&#x20AC;&#x2122;re being subtly pushed out. It can be difficult in a highly skill-based profession.â&#x20AC;? â&#x20AC;&#x153;On the other hand, I was speaking with a retired doctor whoâ&#x20AC;&#x2122;s approaching 90. Heâ&#x20AC;&#x2122;s just discovered sculpture and painting and is also writing a memoir for his grandchildren.â&#x20AC;?

Having diverse interests â&#x20AC;&#x153;We have this picture of retired doctors on their hobby farms, riding around on their USBDUPST BOE UFOEJOH UIFJS HSBQF WJOFT #VU thatâ&#x20AC;&#x2122;s a small minority. And there are others who do volunteer work overseas but, particularly as you get older, that can be rather challenging. Itâ&#x20AC;&#x2122;s pretty rough in some of those countries and skills that were highly relevant in Australia may not be in developing countries.â&#x20AC;? i*U DBO CF RVJUF EFNPSBMJTJOH BOE PODF JU T BMM PWFS UIFO XIBU EP ZPV EP w Itâ&#x20AC;&#x2122;s obvious that travel is near the top of the agenda for both Adele and Ely. Theyâ&#x20AC;&#x2122;ve had wonderful moments along the way but Adele isnâ&#x20AC;&#x2122;t averse to relating a cautionary tale.

â&#x20AC;&#x153;W â&#x20AC;&#x153;We We were e e hiking h ki g in i a national na iona park pa k in Patagonia, the sunrise was hitting the granPatagonia a ag ite mountain peaks and it was absolutely awe-inspiring! On the other side of the coin, we were in the Pyrenees walking along some badly marked trails and attempting to GPMMPX FRVBMMZ QPPSMZ USBOTMBUFE JOTUSVDUJPOT We got lost and pretty much ignored a sign stating, Caution â&#x20AC;&#x201C; Dangerous Paths!â&#x20AC;? i#FGPSF XF TUVNCMFE CBDL IPVST MBUFS weâ&#x20AC;&#x2122;d had to walk sideways along a cliff wall XJUI B ESPQ BOE DMJNC B MBEEFS CPMUFE to a rock-face.â&#x20AC;? â&#x20AC;&#x153;There are risks and rewards with travel but we broke the rules. You have to extend yourself to find out what your limits are but, FRVBMMZ TP ZPV IBWF UP CF BXBSF PG ZPVS own limitations. When it comes to travelling as an older person our message is more how to travel rather than where to travel.â&#x20AC;? â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re hoping to shift the paradigm of what JU NFBOT UP HFU PMEFS w TBJE &MZ i* XBT RVJUF shocked to see a sign at a Seniorsâ&#x20AC;&#x2122; Parking Area â&#x20AC;&#x201C; the image was of a hunched old man with a cane. Adele and I are getting close to 70, we love skiing and we go tornado chasing. Itâ&#x20AC;&#x2122;s all about finding your passion and getting on with it!â&#x20AC;? www.passionateretirees.com. O

TRAVEL CHECKLIST t (FU DIFDLFE CZ ZPVS (1 t ,OPX ZPVS MJNJUBUJPOT t 1SJPS SFTFBSDI UIF DPCCMFTUPOFT PG Europe can be challenging t &YFSDJTF o TRVBUT NBZ DPNF JO IBOEZ 5PJMFUT DPNF JO BMM TIBQFT BOE TJ[FT

By Mr Peter McClelland

Music

Messiahâ&#x20AC;&#x2122;s

Double Act As Messiah season approaches, Perth celebrates the glorious music of Handel in two topshelf productions â&#x20AC;&#x201C; the annual Collegium Symphonic chorus and orchestra, with a stellar line-up of Australian soloists, and WASO and Chorus with an international line-up. Q Christopher Purves

Margaret Prideâ&#x20AC;&#x2122;s Collegium production, PO %FDFNCFS JT BMXBZT B TUBOEPVU This doyenne of choral music consistently challenges and reinvigorates our musical landscape. This year she has drawn in TPQSBOP 4BSB .BDMJWFS NF[[P 'JPOB Campbell, tenor Henry Choo and bass Teddy Tahu Rhodes as soloists. Medical Forum caught up with Perth-born Sara Macliver, who is one of the countryâ&#x20AC;&#x2122;s most sought-after lyric sopranos. She has lost count of the times she has sung .FTTJBI CVU TFUUMFT GPS iBCPVU w 4P IPX EPFT TIF LFFQ JU GSFTI â&#x20AC;&#x153;Well, itâ&#x20AC;&#x2122;s always lovely to visit an old friend and Iâ&#x20AC;&#x2122;m always mindful to try and bring something new to it every time I pick it up again. Itâ&#x20AC;&#x2122;s also an interesting exercise to sing a piece regularly to see if there are any changes to your voice. I hear my voice every day, and itâ&#x20AC;&#x2122;s really the only way you can tell if there are changes.â&#x20AC;? Sara is one of the premier exponents of the #BSPRVF SFQFSUPJSF BOE JG ZPV DBVHIU UIF stunning St Matthew Passion this Easter as part of St Georges Cathedral music series, you would be totally convinced of her artistry. i8JUI NVTJD PG )BOEFM T BOE #BDI T DBMJCSF it is so easy to get lost in the moment. Iâ&#x20AC;&#x2122;m mindful that Iâ&#x20AC;&#x2122;m on display and Iâ&#x20AC;&#x2122;m part of telling these incredible stories, but I really get swept up in it and the beauty of the music â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s transforming. Iâ&#x20AC;&#x2122;m not a reli44

gious person but this music is my religion â&#x20AC;Ś it stirs my soul and I feel so passionate about it.â&#x20AC;?

Christopherâ&#x20AC;&#x2122;s but each new performance, with a different orchestra and choir sets the adrenaline racing.

GPS 4BSB JT B KVHHMJOH BDU XJUI UIF PMEest of her three children studying for her 8"$& XIJDI TIF TBZT SFRVJSFT IFS UP CF home more but not before a trip to Hong Kong for Haydnâ&#x20AC;&#x2122;s The Creation with the Hong Kong Philharmonic and to Sydney mid-year for Pinchgut Operaâ&#x20AC;&#x2122;s production of 7JWBMEJ T Bajazet.

â&#x20AC;&#x153;And the piece itself is very exciting. There is something ageless about it and an even more ephemeral experience watching a chorus singing the worldâ&#x20AC;&#x2122;s great music. I take my cue from the enthusiasm around me. It would be a very sad performer who wasnâ&#x20AC;&#x2122;t able to rise to the challenge laid down by the orchestra or the chorus coming in for their first big singsong.â&#x20AC;?

WASO and WASO Chorus WASO and the WASO chorus, featuring the singing doctors Dr Olga Ward, Dr Moira Westmore, Dr Jenny Fay, Dr Susanna Fleck, Dr Katie Langdon and Dr Philomena Nulsen, headlines a touring cast of soloists, who will also sing The Messiah in Adelaide and Melbourne. Under the baton of Matthew Halls, Australian soprano Siobhan Stagg will join countertenor Christopher Field, tenor 3JDIBSE #VUMFS BOE &OHMJTI CBTT $ISJTUPQIFS Purves. Medical Forum spoke to Christopher on the eve of his return to Australia. Purves whose singing career has seen him a choral scholar at Kings College Cambridge, lead singer in â&#x20AC;&#x2122;80s eccentric pop band Harvey and the Wallbangers and then as international opera artist, was in Australia in February for the #SJTCBOF 'FTUJWBM T "VTUSBMJBO QSFNJFSF of Philip Glassâ&#x20AC;&#x2122;s first opera, The Perfect American, based on the life of Walt Disney.

â&#x20AC;&#x153;I also get a huge amount of pleasure from witnessing people in the audience, anticipating what it the start of their Christmas celebrations. It does help to remind you of your responsibility to the audience.â&#x20AC;? Christopher credits his time on the rock scene as teaching him how to perform and put on a show. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m not scared to improvise and do something different and push the barriers. Itâ&#x20AC;&#x2122;s a side of life that not everyone in classical music gets to see but I enjoyed it and embraced it and I bring it subconsciously with me when I walk out onto a stage.â&#x20AC;? Collegium Symphonic Chorus, Perth Concert Hall, December 20, 7.30pm WASO and WASO Chorus, Perth Concert Hall, December 5, 7.30pm; December 6, 2pm. O

By Ms Jan Hallam

Like Sara, The Messiah is an old friend of

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Movie: Serena #SBEMFZ $PPQFS BOE +FOOJGFS -BXSFODF UFBN VQ GPS UIJT BEBQtation of the bestselling novel by Ron Rash about a young married coupleâ&#x20AC;&#x2122;s bold venture to build a timber empire in the /PSUI $BSPMJOB NPVOUBJOT JO UIF T (FPSHF BOE 4FSFOB Pemberton battle the elements and ruthless competition until a secret from the past casts a shadow over their future. In Cinemas, November 27

Movie: Exodus: Gods And Kings "O BMM TUBS DBTU PG $ISJTUJBO #BMF +PFM &EHFSUPO "BSPO 1BVM BOE Sigourney Weaver under the direction of Ridley Scott play out the biblical saga of Moses and the flight of the 600,000 slaves GSPN &HZQU #BMF JT .PTFT BOE "VTUSBMJB T &EHFSUPO JT QIBSBPI Ramses in the 3D swords-and-sandals epic. In Cinemas, December 11

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Music: WASO Messiah

ana est he tis t Joo nd alu p will relish an All rt wa Dr Ste EP[FO UP FT 8JO UIF $BQF (SBDF ent trip rec A lar. cel his add to buds te tas his to Europe set e, he hom to ser clo and tingling BO 7BMMFZ GJOET UIF MVSF PG UIF 4X to resist. d har er Riv ret rga and Ma noirs, ot pin y Reds, par ticularl . His rtâ&#x20AC;&#x2122;s wa Ste of ite our fav are a ng in ddi we g min brotherâ&#x20AC;&#x2122;s forthco chingâ&#x20AC;&#x2122; opportunity for â&#x20AC;&#x2DC;resear an him e giv l wil d lan New Zea occasion. the wine list for the big MEDIC AL FOR UM

A national and international cast assembles with WASO and the 8"40 $IPSVT XIJDI JODMVEFT IBMG B EP[FO TJOHJOH EPDT GPS Handelâ&#x20AC;&#x2122;s masterpiece under the baton of Matthew Halls. Perth falls midway through a Messiah tour of other state orchestras by conductor and soloists. Perth Concert Hall, December December 5, 7.30pm; December 6, 2pm

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Music: Collegium Symphonic Chorus Messiah "O FYRVJTJUF MJOF VQ PG TPMPJTUT o 4BSB .BDMJWFS 'JPOB $BNQCFMM Henry Choo and Teddy Tahu Rhodes â&#x20AC;&#x201C; join conductor Margaret 1SJEF UIF $PMMFHJVN #BSPRVF 0SDIFTUSB MFE CZ UIF JOJNJUBCMF Paul Wright and the Collegium Symphonic Chorus for their annual drawcard. Perth Concert Hall December 20, 7.30pm

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Social pulse Q (L to R) From medical students to senior medical administrators, Shehab Abdala (Medical Student), Dr Karen Lam (Fremantle Hospital PGY2), Dr Daniel Heredia (Director Medical Services, Hollywood Private Hospital), Dr Andrew Yeates (Director Strategic Development - St John of God Hospital Subiaco), Dr David (Monty) Edwardes (PGY3 and incoming RACMA Candidate), Dr Andy Robertson (Deputy Chief Health OfďŹ cer and Director, Disaster Management, Regulation and Planning, WA Health), Dr Robyn Lawrence (Executive Director, Fiona Stanley Hospital), Dr Timothy Williams (Executive Director Medical Services, North Metropolitan Health Service and Director Clinical Services, Swan District Hospital), Dr Gary Geelhoed (Chief Medical OfďŹ cer, WA Health), Dr Hitesh Prajapati (Medical OfďŹ cer, Armadale Hospital), Dr Emily Kurich (Medical Administration Registrar, OfďŹ ce of CMO), Samuel Ognenis (Medical Student), Dr Sayanta Jana (Deputy Executive Director Medical Services, Child and Adolescent Health Service and Women and Newborn Health Service, Secretary of RACMA WA Branch), Devaki Wallooppillai (Medical Student and AMSA Refugee and Asylum Seeker Health Advocacy State Manager, CINI Australia Student Group),Dr Terry Bayliss (Director Development Projects and Research, Hollywood Private Hospital)

The WA chapter of the Royal Australasian College of Medical Administrators held a meet and greet at Hollywood Hospital. RACMA Fellowship Trainees, those contemplating a career in medical administration, and established medical administrators mingled and discussed future and past career pathways. After an introduction from Dr Andy Robertson, Chief Medical OfďŹ cer Dr Gary Geelhoed and Fiona Stanley Hospitalâ&#x20AC;&#x2122;s Dr Robyn Lawrence gave their view on medical BENJOJTUSBUJPO #PUI GPVOE UIFJS HSPVOEJOH as practising clinicians gave them invaluable insights into the mores of doctors that served them well when they switched to administration. For Gary this came well after

experience at different hospitals in WA and NZ, work as a community paediatrician, and then a long stint as director of the PMH ED. In fact he was heading for retirement when the job of CMO was suggested to him. Robyn made her decision to try administration much earlier than Gary, while B TFOJPS SFHJTUSBS 4IF EJE BO .#" BOE saw the many business parallels between medicine and other professions, and managed to raise children and complete her FRACMA. She said there is an undersupply of good well-trained medical administrators, so there were plenty of employment opportunities. And doctors, like it or not, were often the main drivers of costs so there had to be more accountability in

decision making and good leadership. With more engaged clinicians came better patient care, leading to conversations on models of care, allocation of resources and bridges between the corporate and clinical sides of patient care. Robyn said her long hours helping get Fiona Stanley Hospital up and running was a challenge she savoured and it was her opportunity to make a difference to the system. Teamwork at the hospital was FYDFQUJPOBM TIF TBJE BOE UIF CV[[ PG activity was infectious. Her philosophy was to always take difďŹ cult decisions back to the level of inďŹ&#x201A;uence on patient care.

By Dr Rob McEvoy

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Mobile Ear Health The Health Minister Dr Kim Hames cut the ribbon on the Mobile Advanced Paediatric Audiology Remote (MAPAR) vehicle, which was a joint development between Telethon Speech & Hearing and Chevron Australiaâ&#x20AC;&#x2122;s Ear Health Program. The MAPAR vehicle will provide paediatric audiology services for those at most risk of middle ear disease â&#x20AC;&#x201C; indigenous children up to four years-of-age, and will travel to remote communities in the Pilbara. Pictured are Dr Hames, Chevronâ&#x20AC;&#x2122;s Ms Rhonda Yoder and TSH CEO Ms Peta Monley a student from Waddington Primary School.

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medical forum WANTED TO BUY OR LEASE GP PRACTICE REQUIRED Looking to buy or lease. In Perthâ&#x20AC;&#x2122;s northern suburbs. 1-3 doctor practice. DWS Area. Call Eric on 0469 177 034 or leave a message

FOR LEASE MURDOCH Brand new Medical Suite for Lease at the new Wexford Medical Centre. 106 sqm, complete fit-out and ready to lease. Please contact: reception@ccwa.net.au NEDLANDS )PMMZXPPE .FEJDBM $FOUSF 4FTTJPOBM Suites. Available with secretarial support if required. Phone: 0414 780 751

BUSSELTON Suite for lease 1/69 Duchess St Busselton t &YDFMMFOU $#% MPDBUJPO XJUIJO NFEJDBM dental complex opposite Police Station/Court House complex t $PNQSJTFT PGGJDFT MBSHF XBJUJOH boardroom, reception, kitchen MVODISPPN TUPSFSPPN 8$T t "QQSPY GMPPS BSFB TRN Details: Trevor Frusher 0417Â 177 211 104 Queen St, Busselton (08) 9754 1522 e: trevor@profsbsn.com.au www.professionalsbusselton.com.au MURDOCH SJOG Murdoch Medical Clinic within SJOG Hospital t TRN PO TU GMPPS DMPTF UP MJGUT t 4FDVSF VOEFSDPWFS DBS CBZ t $VSSFOUMZ DPOTVMU SPPNT X XBUFS t -BSHF SFDFQU XBJUJOH SPPN LJUDIFO t 0OF PG POMZ GFX TVJUFT XJUI QSJWBUF 8$ t %VDUFE 3 $ BJS DPOEJUJPOJOH t "WBJMBCMF G GVSOJTIFE NJE MBUF +VOF The perfect suite for the medical specialist or allied health service where a private Toilet is required or preferred Frana Jones 0402 049 399 Core Property Alliance 9274 8833 frana@corepropertyalliance.com.au MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email your interest to admin@sleepmed.com.au MURDOCH Wexford Medical Rooms for lease Please contact aptran@jointswest.com.au

APPLECROSS Applecross Medical Group is a major medical facility in the southern suburbs. Current tenants include GP clinic, pharmacy, dentist, physiotherapy, fertility clinic and pathology. Both the GP clinic and pharmacy provide a 7-day service. The high profile location (corner of Canning Hwy and Riseley St, Applecross), provides high visibility to tenants in this facility. A long term lease is available in this facility â&#x20AC;&#x201C; with the current layout including 4 consulting rooms, procedure room and reception area. Would suit specialist group, radiology or allied health group. Contact John Dawson â&#x20AC;&#x201C; 9284 2333 or 0408 872 633 MURDOCH Available now. Suite in Murdoch Medical Clinic for lease or sessional use. Well-appointed 16sqm consulting room, shared use of large reception/waiting area and tea room. Rates available on enquiry Contact: Ian Dowley 9366 1769 or: ian@flexphysiotherapy.com.au MURDOCH Brand new modern consulting rooms available for sessional lease at the new Wexford Medical Centre. For more information: Email: reception@paragonsp.com.au or Call 0403 323 168 NEDLANDS Medical Specialist Consulting Rooms and Treatment Room t 'VMMZ TFSWJDFE DPOTVMUBUJPO SPPNT BU Hollywood Specialist Centre t 4FDSFUBSJBM TVQQPSU oIJHIMZ FYQFSJFODFE long term staff t (FOJF TPMVUJPOT QSBDUJDF NBOBHFNFOU software t 0OMJOF .FEJDBSF DMBJNT t 5FMFIFBMUI DPOTVMUBUJPO GBDJMJUJFT t 1BQFSMFTT QSBDUJDF TVQQPSUFE t 5SFBUNFOU SPPN o BWBJMBCMF GPS ambulatory procedures t "DDFTT UP )PMMZXPPE 1SJWBUF )PTQJUBM for inpatient care and theatre bookings supported t *OQBUJFOU CJMMJOH TVQQPSUFE Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager, Suite 31 Hollywood Specialist Centre 95 Monash Avenue Nedlands, WA 6009 Phone: 9389 1533 Email: suite31.hollywood@bigpond.com. MURDOCH NEW Wexford Medical Centre Attached to the St John of God Hospital, in vicinity of the Fiona Stanley Hospital. Modern, newly fitted out medical consulting room. Sessional medical & dental rooms available. Please contact wexfordmedical@outlook.com for more information.

NEDLANDS Available now. Use of rooms at Chelsea Village on M T W only. Easy parking. Nicely appointed examination room would suit non procedural eg medicolegal examinations or paramedical. You open up, have sole use when required, then lock up. 0DDBTJPOBM VTF PS MPOH UFSN 'MBU QFS day use. Contact Dr Peter Burke 0414 536 630 NEDLANDS HOLLYWOOD MEDICAL CENTRE Two new, large professional, well presented consulting rooms within specialist suite at Hollywood Medical Centre Full/part time lease or sessional basis available Available furnished or unfurnished Shared reception, office and patient waiting area Please contact Michelle/Emma on 08 6389 0244 for further details 0S FNBJM Info@perthcolorectal.com.au MURDOCH Consulting room for lease at the new Wexford Medical Centre at Murdoch. Well lit, spacious sessional consulting rooms for lease. For further information please contact Murdoch Specialist Physicians on 9312 2166 or email us at admin@murdochspecialistphysicians.com.au

MURDOCH New Wexford Medical Centre â&#x20AC;&#x201C; St John of God Hospital CSBOE OFX NFEJDBM DPOTVMUJOH rooms available: t TRN BOE TRN t DBS CBZ QFS UFOBODZ Lease one or both rooms. For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au MURDOCH New consulting suite including separate treatment room available in Wexford Medical Centre. Full time or sessional basis. Very reasonable rates. Contact Dianne 0409 379 795 MURDOCH .FEJDBM $MJOJD 4+0( .VSEPDI Specialist consulting sessions available. Email: cford@cyllene.uwa.edu.au

77 GENERAL EMG Machine (Keypoint Medtronic) portable. Fully computerised (Toshiba), complete with cart, printer and all necessary software. Used minimally ie. as new $PTU 4FMM 1IPOF PS

LOCUM WANTED KINROSS Urgent locum / permanent position VR or Non VR GP, PT/FT to start ASAP. Privately owned DWS location practice. Support available for those having interest in skin cancer, cosmetic mole removal. onsite Pathology, physio, psychologist & podiatrist. Practice open 7 days. Great rates. Contact: TBOKBZLBOPEJB !ZBIPP DPN PS DBMM 9304 8844

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

PSYCHIATRISTS INVITED

BIBRA LAKE - Psychiatrist wanted Are you intending to start Private Practice? This is a sheer walk-in! Part time, sessional or full time â&#x20AC;&#x201C; all enquiries welcome. Furnished consulting rooms available at: Bibra Lake Specialist Centre, 10/14 Annois Rd, Bibra Lake WA 6163 Currently 4 practising Psychiatrists and clinic is open Tuesday to Friday 7-day pharmacy and GP surgery next door are added advantages. 5 minute drive to St John of God and upcoming Fiona StanleyHospital. Phone Navneet 9414 7860

DECEMBER 2014 - next deadline 12md Wednesday 12th November - Tel 9203 5222 or jen@mforum.com.au

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RURAL POSITIONS VACANT ALBANY t 4U $MBSF T JT B OFX GBNJMZ QSBDUJDF CBTFE in Albany t 4NBMM GSJFOEMZ QSBDUJDF t 'VMM UJNF OVSTJOH BOE BENJOJTUSBUJPO support t 1BUIPMPHZ PO TJUF t 'VMM PS QBSU UJNF (1 XBOUFE UP KPJO PVS team t 4QFDJBM JOUFSFTU JO TLJO XPVME CF JEFBM t $VSSFOUMZ OP %84 VOMFTT XJMMJOH UP work in afterhours period t (1T OPU SFRVJSJOH TVQFSWJTJPO SFRVJSFE Please contact practice manager Belinda Elliott Tel: 9841 8102 Email: belinda@stclare.com.au 0S TFOE ZPVS $7 UISPVHI BOE XF XJMM HFU back to you.

URBAN POSITIONS VACANT

CANNING VALE 3BSF 0QQPSUVOJUZ $BOOJOH 7BMF Canning Vale Medical centre will have a SPPN BWBJMBCMF GSPN +BOVBSZ GPS BO established VR doctor wanting to relocate their practice to new rooms and join our team. Full management services are provided by doctor owned practice operating for 15 years under the same management. Continuous accreditation, finalist for AGPAL practice of the year last year, full nursing support, computerised with referees available for suitable candidate. Visit us at www.canningvalemedical.com.au Confidential enquires Dr. Neda Meshgin 0414641963 or dr.meshgin@canningvalemedical.com BUTLER Connolly Drive Medical Centre. Brand new, non-corporate, computerised, fully equipped, 17 bed medical centre. RN support, pathology, allied health. Abundant patients. DWS. Dr Ken Jones needs a VR GP to join him in this major, state of the art facility. Email: ken@cdmedical.com.au or call Ken Jones on 9562 2599 (direct line). CLAREMONT Growing GP practice located in the trendy suburb of Claremont. PG CJMMJOHT PS B EBZ XIJDIFWFS is greater. Looking for VR GPs with unrestricted provider number on a part-time or full time basis. Fully computerised with on-site pathology and RN support. Located in a modern complex with access to the gym and pool. For further information please contact Dr Ang on 9472 9306 or Email: thewalkingp@gmail.com

RIVERTON RIVERTON MEDICAL CENTRE is looking for a Part-Time VR GP. Access to full-time practice nurse. Fully computerised practice. Friendly working environment. Pay negotiable. Ring Dr Sovann on 0412 711 197 if interested. ASCOT Part-Time VR GP required for our well FTUBCMJTIFE "DDSFEJUFE 1SJWBUFMZ 0XOFE Friendly Family Practice in Redcliffe. We are fully computerised, using Best Practice software. Nurse is support available. Non DWS area. Please call â&#x20AC;&#x201C; 9332 5556 ROLEYSTONE PT/FT VR Female GP required for a GP clinic in Roleystone. A friendly and efficient working environment. Well-equipped consulting and treatment rooms, fully computerised, accredited and busy practice. Contact: practice.manager@roleystonefmc.com.au ARMADALE WANTED VR GP

Be part of a new, privately owned and innovative practice in a DWS area 30 minutes south of Perth. Close to public transport, a fantastic work culture that will support and drive your special interest/s. Currently bulkbilling, covering all aspects of general medicine, chronic disease management and medicals, with special interest in mental health. Fulltime nurses and admin staff, with onsite psychology, podiatry and pathology. Great remuneration, holidays and professional development opportunities. Please email Tricia: info@forrestroadgp. DPN BV 03 DBMM (08) 9497 1900 WINTHROP Female VR Doctor required to join our busy private billing practice in an ideal location in Winthrop. Perfect for a long term commitment. All requirements provided for, including full nursing support in a large medical centre. Please contact Cathy on (08) 9310 4400 or email CV to admin@hatherleymedical.com.au MINDARIE Harbourside Medical Centre is looking for a GP preferable VR FT/PT, Accredited medical centre, onsite pathology, fully equipment and nurse, utop70% billing. Contact 0417 813 970 or mmutahar@harboursidemedicalcentre.com.au

PALMYRA Palin Street Family Practice requires a full or part-time VR GP. We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens. Earn 65% of mixed billings. For further information call Elisabeth on 9319 1577

WEST LEEDERVILLE Great Lifestyle! Part time (up to full time) VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: glenstreetpractice@iinet.net.au or call Jacky, Practice Manager on 9381 7111 / 0488 500 153 SCARBOROUGH Grand Prom Medical Centre Scarborough requires a full time VRd GP to replace retiring long established GP. 0VS QSBDUJDF JT GVMMZ BDDSFEJUFE BOE XFMM supported by excellent reception staff and practice nurses. We use Best Practice software and are a Private Billing practice. No after-hours work required. Please contact Dr Lucy Gilkes or Dr Andrew Britto on 0408 029 326 or 08 9245 1515. Email gpmc@westnet.com.au PALMYRA VR doctor required for full/part time work. We are a friendly, private, non-corp practice situated in Palmyra. 0VS TVSHFSZ JT BDDSFEJUFE XJUI NPEFSO facilities and has fantastic doctors, nurses & reception staff. If you would like to join us please email your CV to helen@leeuwinmedical.com.au KELMSCOTT Expressions of Interest Vocationally Registered General Practitioner Wanted South of the River Temp/Perm position Email CV to armitage@highway1.com.au GOSNELLS Ashburton Surgery. VR GP needed. Flexible hours. Private billing. 3 Dr surgery. Fully equipped with nursing support. Email: angiesurgery@gmail.com or Phone Patrick 0403 756 338 or 9490 8288 HELENA VALLEY General Practitioner FT/PT VR for privately owned general practice in Scott Street, Helena Valley. The well-established clinic is fully accredited and computerized with full time RN support. 60-65% billings + pip incentives. Mixed billings. Please contact: pmanager@hvmc.com.au or call 9255 1161

KARDINYA Non-corporate General Practice presents opportunity for VR P/T GP to join an exceptional team. Well managed long established 5 doctor practice offers a comprehensive CDM program with 3 RGN support along with onsite pathology and podiatry. Enquiries to Practice Manager on 0419 959 246 or practicemanager@kelsomg.com.au PERTH CBD Full and part time VR GPS to join our busy inner city practice located in the Hay Street Mall. Non corporate, mainly private billing, accredited, fully computerised with full admin and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates Please contact Debra on 0408 665 531 to discuss or Email: drogers@perthmedicalcentre.com.au

KINGSLEY

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

MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new non DPSQPSBUF QSBDUJDF XJUI GFNBMF NBMF General Practitioners. Sessions and leave negotiable, salary is compiled from billings rather than takings. Up to 70% of billings paid (dependant on experience). Please contact Jacky on 0488 500 153 or E-mail to jacky-steven@live.co.uk

MANDURAH Full time VR GP required for busy established, accredited practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed by 10 doctors and 4 experienced Registered Nurses. Relocation fees are negotiable Generous remuneration, no DWS please. No on call. Contact Ria 9535 4644. Email: Mandmedi@wn.com.au

DECEMBER 2014 - next deadline 12md Wednesday 12th November - Tel 9203 5222 or jen@mforum.com.au

medical forum

SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity for FT/PT doctor in a State of art clinic, inner-metro, Nursing support, Pathology and Allied services on site. Private billing. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979 Email: o_takla@yahoo.com

GREENWOOD Greenwood/Kingsley Family Practice The landscape of general practice is changing, and it is changing forever. Are you feeling demoralised by the recent Federal government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? It doesnâ&#x20AC;&#x2122;t have to be this way!! Come and speak to us and see the different ways in which we operate our general practice. Be part of the game changer! 0VS QSBDUJDF JT MPDBUFE OPSUI PG UIF SJWFS Sorry we are not DWS. Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion.

ARE YOU READY FOR A CHANGE? We are looking for specialists and GPâ&#x20AC;&#x2122;s to join the expanding team! Tenancy and room options available for specialistâ&#x20AC;&#x2122;s. Procedural GPâ&#x20AC;&#x2122;s and ofďŹ ce based GPâ&#x20AC;&#x2122;s well catered for. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

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

ARE YOU LOOKING FOR DOCTORS FOR YOUR MEDICAL PRACTICE? Australian Medical Visas is owned and run by 2 Practice Managers based in WA, who have over 20 years experience of the UK and Australian healthcare systems. We currently have a number of doctors who are looking for positions in Australia. We are able to assist practices with all paperwork involved including the migration process (if required). Please visit our website www.australianmedicalvisas. com.au or contact Jacky on 0488 500 153 or Andrea on 0401 37 1341.

LESMURDIE OR HIGH WYCOMBE Full time or Part time VR GPâ&#x20AC;&#x2122;s required in Lesmurdie or High Wycombe - Privately owned with mixed billing - Nursing support - Fully computerised - Teaching practice - Allied Health - Special interest and skills supported - Hills location Contact Karin on 0438 211 240 or karintatnell@yahoo.com.au JOONDANNA We are seeking a VR GP to join our friendly team on a part-time or full-time basis. Flexible hours and billing. Fully-computerised. Privately-owned practice. Pathology collection on site. Please call Wesley on 0414 287 537 for further details. MINDARIE GP required for our busy privately owned practice in Perth Northern Suburbs. VR or Non VR Generous remuneration package available Fully computerised Nursing and clerical support available 0OTJUF QBUIPMPHZ BOE BMMJFE IFBMUI Please contact us via email: mkmc@iinet.net.au or Call Dr Melad Benyamine either Before 9:00am or After 6:00pm on 0412 902 522

DECEMBER 2014 - next deadline 12md Wednesday 12th November - Tel 9203 5222 or jen@mforum.com.au

medical forum

for LEASE

Southern Suburbs GP required for after-hours & weekends Non-VR Drâ&#x20AC;&#x2122;s encouraged to apply. Send applications to hr@betterhealthcare.com.au

EXMOUTH Brand new premises available for entrepreneurial GP. Be the ďŹ rst private GP in town, with opportunity to focus on occupational and dive medicine as well as family practice. Wonderful lifestyle with stunning scenery and wildlife to explore. Contact draburkett@live.com

Mandurah VR general practitioner required for busy general practice in Mandurah, near Peel Health Campus.

Our busy, well-run clinic requires part-time GPs for ongoing sessional work; working with domestic, international students and staff. t 'MFYJCMF TFTTJPO UJNFT BWBJMBCMF .POEBZ UP 'SJEBZ t (SFBU PQQPSUVOJUZ UP XPSL JO B WJCSBOU EZOBNJD environment with diverse needs. t 8F PGGFS OFX QSFNJTFT BOE DBO TVQQPSU ZPV XJUI B UFBN of experienced nurses, psychologists and friendly administrative staff. t &YDFMMFOU SFNVOFSBUJPO PG CJMMJOHT oCVMLCJMMFE BOE QSJWBUF and free reserved on-campus parking available. An interest in, and experience with, working with young people, mental health, sexual health and travel health is essential. 1MFBTF DPOUBDU -JTB $SBOmFME 5FBN -FBEFS .VSEPDI )FBMUI BOE $PVOTFMMJOH 4FSWJDF PO PS email l.cranďŹ eld@murdoch.edu.au

Accessible via public transport and just a few minutes off Kwinana Freeway. Private mixed billing group practice providing quality comprehensive family care for over 50 years to Mandurah and the surrounding community. Our team features primary health physicians, specialists and allied health professionals. Treatment room facilities, procedures room, skin clinic, travel clinic, nurse practitioner, practice nurses, reception, medical secretary, accounts, administration staff are here to support you. Specialist, allied health services, pharmacy co-located in the same building. The practice is open 7 days a week. No DWS. To apply please email: manager@mmcmandurah.com.au

7 Day Medical Centre Ellen Health (formerly Ellen Street Family Practice) has relocated to the historic Beacon Theatre on the corner of Wray Avenue and Hampton Road in Fremantle (co-located with pharmacy, pathology and allied health). Doctor-owned and managed, Ellen Health is a multidisciplinary team striving for excellence in health care. Limited opportunity remains for GPs and specialists to join our large and happy team. Enquire today â&#x20AC;&#x201C; you too can enjoy the ease and convenience of fully serviced rooms, generous nursing support and terriďŹ c facilities. We are particularly seeking doctors with expertise in skin cancer, occupational health and After Hours GP sessions. Call practice manager, Amber Kane, on 9239 0200 or email practicemanager@ellenhealth.com.au

ality WKH e y client DOXH IRU

With a reputation built on quality of TFSWJDF 0QUJNB 1SFTT IBT UIF SFTPVSDFT the people and the commitment to provide every client with the finest printing and value for money. 9 Carbon Court, Osborne Park 6017 } Tel 9445 8380

DECEMBER 2014 - next deadline 12md Wednesday 12th November - Tel 9203 5222 or jen@mforum.com.au

INTRODUCING THE NEW MRI SERVICE IN BUNBURY With the latest technology in Magnetic Resonance Imaging, SKG Radiology Bunbury is proud to introduce the new 1.5T Siemens MRI:

ALL REFERRALS ACCEPTED

• Wide Bore - Improved patient comfort - Better tolerated by larger or claustrophobic patients

• Specialist Referral • GP Referral • Workers Compensation

• Reduced Scan Times - Total Imaging Matrix (TIMTM) known as TIM 4G includes a suite of high density MRI coils, enabling excellent image quality and high resolution scans

• Allied Health Referral

IN ADDITION TO: • Low Dose CT - Appointments available within 24 hours - Interventional Radiology (including Facet Joint Injections, Nerve Root Sleeve Injections, Bursa and Joint Injections) - FNA Biopsy

• Mammography • Ultrasound • General X-ray • Dental X-ray (OPG/Cephalometry) SKG CONNECT SKG Connect allows you to access your patient studies online as soon as they are available - immediate image viewing upon exam completion.

SKG RADIOLOGY BUNBURY 55 Spencer Street Bunbury 6230 www.skg.com.au