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Teaching the Art of Healing Aged Care: Noeline Brown, Polypharmacy, Fido & More... t Scrutinising Doctors Fairly t E-Poll: Research for Community Benefit t Doctor on Ice: A Swiss Adventure t Hepatitis C, Liver Transplants & More‌

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CONTENTS

Heenan Lam Skin Pathology

FEATURES

GUEST COLUMNS

10 Aged Care Research

11 Reclaiming Dignity Dr Scott Blackwell

14 Grandparents Raising

12 Challenge of the

Grandchildren

Boom Generation

23 Spotlight: Noeline

Dr Penny Flett

Brown 24 Teaching GPs

NEWS & VIEWS 2 Letters: Dr Andy Foote, Dr Jenny Brockis, Ms Sue PietersHawke

10 14

Ms Shoma Mittra

Research

39 Rotator Cuff Repair

23

35 Systems and

LIFESTYLE 44 Doctor on Ice Mr Peter McClelland

Willoughby Park 48 Satire: The Village

Pacemakers

medicalforum

Dr Leon Cohen

47 Wine Review:

42 MRI Friendly

Support Groups

41 Bariatric Surgery

Restaurant Amusé

42 WA Biotech Hopefuls

43 Aged Care

Dr Sven Goebel

46 Kitchen Confidential

Teamwork

43 Sim City

CLINICAL FOCUS

37 Liver Transplants in WA

26 E-Poll: Translational

PIPs

Mr Ray Glickman

Dr Wendy Cheng

the Swan

33 Practice Management:

34 Working Together

37 Hepatitis C Update

25 Register for Doc of

Helping Patients Make Decisions

Dr John McCarthy

TICHR

Nation

31 Medico-Legal:

33 Power of the Mind

29 New Directions for

22 State of an Ageing

30 Beneath the Drapes

Function

Dr Edwin Kruys and Dr Ian Taylor

Commissioner

Mr Peter McClelland

22 Elderly Regaining

32 Geraldton Aged Care

8 Age Discrimination

Their Stories

Dr Bret Hart

Ms Rachel Siewert

40 Paces

21 Dementia Patients Tell

20 Health in all Policies

Red Tape

6 Editorial: Research at

18 Have You Heard?

Dr Simon Torvaldsen

26 NFPs Need Less

Fairly

16 Healing Power of Pets

the Record

Prof Gill Lewin

4 Scrutinising Doctors

Ms Jan Hallam

12 Aged Care … Just for

People

24

49 Joel Creasey

Bares it All 50 Messiah is Coming 51 The Funny Side 52 Competitions

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PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Letters to the Editor

Safety Below Dear Editor,

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

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) 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 Journalist Mr Peter McClelland journalist@mforum.com.au EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward 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. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN 2 Thinking Hats

Regarding the dive story in (Doctor’s of the Deep, October, 2012) I’d like to add that we do take some basic precautions when we dive but at the end of the day we have to accept that we live in a remote location and that medical help could be a few hours away. Having lived up here for a couple of years we are pretty familiar with the various areas we dive and plan our outings according to the local weather and conditions. Communications are essential and we have a VHF radio on the boat to communicate with other vessels in the area. We contact the Carnarvon Sea Rescue before we leave and I also brief my crew so that they are all aware of where the safety equipment is on the boat (EPIRB / flares / VHF radio / Oxygen kit / medical kit / life jackets). The team is important – you need to have a group of competent fit divers on board that understand the ocean and can help out in an emergency. Almost all of our diving is free-dive spearfishing so there is a risk of shallow water black out and you need mates that will dive close to you and can come to your assistance. I think it is really important to mentor young and novice divers so that they learn safe diving practices from the word go. Knowing your limitations is also very important and a lot of diverelated accidents happen when novice divers are diving in conditions or depths that exceed their level of experience and ability. Your pride should not get in the way of admitting when you are out of your depth. Experienced scuba divers and free divers often make the mistake of being over confident and pushing the limits a little bit too hard. Dr Andy Foote, Carnarvon

GP Subspecialties Dear Editor, I was fascinated and encouraged by the recent poll (GP's Who Choose to Subspecialise, October 2012) about GPs who subspecialise. I am an educator, a consultant, an author, a mentor. I am a public health advocate who works exclusively in the area of brain fitness. But first and foremost, I will always be a GP. I use my experience, medical knowledge and expertise as a GP to encourage behavioural change in my clients; encouraging better nutrition, physical exercise, stress management and mental challenge. My goal is to work towards reducing the future burden of chronic disease and dementia in our rapidly ageing population. I no longer have an office. I work on a stage, in workshops, with the media, writing articles, blogs, and a book. I work at the macro level of prevention because I felt that’s where I could best make a difference as the tidal wave of chronic disease and dementia rapidly approaches.

My medical friends and colleagues who know me have provided nothing but encouragement for what I do now, though I have my critics. In Queensland I was accused by a GP of being nothing more than a journalist with no clinical relevance – an interesting comment from someone who clearly had no idea about what I actually do and how I work. Sometimes, when the going gets tough, I think about returning to mainstream general practice with a regular income and the comforting routine of seeing patients. General practice is a noble and wonderful profession. However, there is no turning back for me. It’s a greater "calling" to serve our community in another way. Dr Jenny Brockis, Perth

Dementia Fight Goes On Dear Editor, Years of caring for my mother, Hazel Hawke, has given me first-hand experience of the burdens faced by the 300,000 Australians living with dementia and their carers. As co-chair of the Federal Minister’s Dementia Advisory Group, I have also had the opportunity to speak extensively with experts, and as an advocate I have met with and learnt from people with dementia and their carers throughout the country. So I have a vivid sense of the depth and scope of the challenges posed by dementia. The Commonwealth Government has responded to Alzheimer’s Australia’s Fight Dementia Campaign with their plan to tackle dementia in the Living Longer Living Better Aged Care Reform package, which acknowledges many of the priorities that people living with dementia have passionately advocated for – timely diagnosis, making hospitals safer places for people with dementia, providing support for people with younger onset dementia, improved quality of dementia care and action on a brain health program. Because of the Government’s commitment to brain health, we have now been able to launch Your Brain Matters, a world-first publicly funded program to inform Australians how they may protect their brain against dementia. However, the one priority the package did not address was dementia research. Alzheimer’s Australia has launched now phase two of the Fight Dementia Campaign seeking an investment by the Federal Government of $200 million over five years for research, along similar lines as for other chronic diseases such as cancer and heart disease. But, it is not just up to governments – we all have an interest in a dementia-free life and so we are hoping the community at large will also get behind the campaign. (www.campaign.fightdementia.org.au) Ms Sue Pieters-Hawke, Alzheimers Australia

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Medico-legal

Scrutinising Doctors Fairly What makes a complaints system fair for doctors, and are we heading in the right direction? We asked someone ‘on the inside’ for comment. Acting for doctors who are fielding complaints, A/Prof David Watson is across most of the arguments. His longterm association with MDA National, 12 years as president, makes him well suited to comment around issues raised by our October edition e-Poll involving 250 GPs and Specialists (see below).

Q: What can be done in our current system to avoid court cases (assuming that’s our aim) but look after patients fairly? A: The Courts (led by the High Court— Rogers-v-Whittaker) would say no one else can determine this but them. I suspect that there are ways of better exploring mediation than we currently do.

The e-Poll question focused on complaints between health professionals. David recalled that AHPRA said it puts more weight on such complaints, even though he considered complaints between health practitioners relatively rare, partly because there is a full appreciation of the subtleties of practice within disciplines.

Q: Do you think the profession and its representatives, such as the AMA and MDOs, have less leverage within the complaints system, than 20 years ago? A: Unequivocally, yes, and that’s not a bad thing as it represents a system moving to become more inclusive, more dispassionate and fair. The days of ‘if you are in with the in-crowd, it will go better’ are past. So it should be.

“The AHPRA requirements for notification of conduct like alcohol or drug dependence are set at a high level and although sexual misconduct is considered unacceptable at any level, most of the new regime is really formalising a moral and ethical duty we have had for many years and, sadly, to which many chose not to respond.” “However, to take a small issue first, I have a concern that this reporting requirement may spill over into marital and business disputes between doctors – a form of harassment in a fracturing marital relationship.” He recalled two episodes where estranged medical spouses had made what might be considered vexatious complaints of sexual misconduct and inappropriate prescribing, respectively. His comment was somewhat ironic, in that we had chosen complaints between doctors for our e-Poll question, believing vexatious complaints would be less likely in this setting!

E-POLL 250 WA DOCTORS. What do you consider the three most important points that determine fairness in handling complaints, one health professional against another [up to 3 choices]? 64% Those investigating are skilled/trained in conducting a fair investigation. 58% Early assessment of whether a complaint has merit. 53% Ability to resolve low level complaints early, through mediation. 51% Complaint dealt with promptly. 48% Privacy for both parties until complaint progresses to the disciplinary body. 20% A known, compulsory pathway in dealing with a complaint. 1% Other.

4

QProf David Watson

However, the number of complaints has escalated almost exponentially in the last few years, and a more business-like, dispassionate and fair system was inevitable. We all have to work within that. Q: With improved patient care as the desired outcome, what important pros and cons do you see about resolving complaints in a strongly legalistic framework? A: We are all under a greater regulatory imperative to report misconduct than was the case under the previous laissez faire attitude of the old Medical Board of WA. While we were under a moral (and sometimes, ethical) obligation to report, it was often too easy to avoid this. The imperatives of a ‘legalistic’ framework are to ensure due process (which as medical practitioners we are wont to ignore) and give both sides suitable and equal opportunities of being heard. With that I have no quibble provided the process is not unduly drawn out. Q: Who are the best people to investigate complaints (their background?) and how do we ensure they are skilled at it and fair? A: Ideally, those undertaking this work should have a health-care background supported by suitable training in forensic investigation.

However, the number of complaints has escalated almost exponentially in the last few years, and a more businesslike, dispassionate and fair system was inevitable. We all have to work within that. Q: In an adversarial system like the Courts, will we end up pitting more “expert” medical witnesses (read health professionals with different opinions) against each other in front of a judge? Is that a good or a bad thing? A: Judges generally are very good at evaluating evidence and the performance of those who present it. However, they cannot consider material that is not presented to them. There, they are entirely dependent on the legal practitioners advocating for both sides of a dispute. Many of the ‘adverse outcomes’ of litigation concerning the profession reflect that reality. While emotionally, I, like most of my colleagues have concerns about material aired in a court, usually it has no adverse outcome and, on occasions, the courts do make a difference to health care even within the restrictions of the Tort system, where someone has to be found to blame for damages to be paid. In the same way, this may apply to complaints. Q: What lessons can HDWA learn from outside systems as the best way to investigate complaints? A: Deal with them rapidly. The longer they linger, the worse they become. Be fair, be quick, be open and avoid politics or grandstanding. O

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Editorial

Research at 40 Paces Academics compete for accolades and funding. The pathway to the top used to be getting published, conducting research in prestigious institutions and reaching professorship because peers considered you an excellent researcherteacher-clinician. Over time, professors of all sorts abound, including some who have been appointed for nonacademic reasons. While some lamented this as dumbing down professorial appointments, UWA adapted by introducing the North American system where everyone from lecturer up had ‘Professor’ in their title, while top appointees became Winthrop Professors. And so it is with research. Some is good and some is average. In the quest for the holy grail of evidence-based medicine, the accuracy of research is being rated according to “levels of evidence” not to mention the track record of the researchers. Unfortunately, the standing of research has become tainted by reports of research fraud, bias in reporting (or not reporting), and the skewing of research towards the agendas of funders. The media is more open and interactive nowadays and research has become a

political weapon. Marketing research is an important way of influencing change and attracting more funding. As examples, suggestive research and some politics added 50 cancers to the eligible respiratory and mental diseases covered by the $4 billion World Trade Center health program. And by extrapolating the expectations of undergraduates, Australian researchers concluded 25% more trainee doctors would opt for general practice if offered another $50k a year. Various research institutes and foundations now have their PR people who help build the reputations of medical researchers, help them apply for competitive funding, ghost write their journal articles, or market their results to a wider audience via media stories, brochures or annual reports. The lay media, always hungry for a story that is quirky, unique or depicts someone overcoming adversity, jumps at a media release promoting the latest breakthrough that in reality may be light-years away from helping us all. A recent edition of a doctor’s broadsheet had two facing articles; ‘Pornography drives genital surgery’ and an advertorial by a Sydney cardiologist commissioned by a pharmaceutical company.

Translational research became one answer to community concerns that research was not providing a reasonable, timely return on investment. This reignited the debate around ‘pure’ versus ‘outcomes focussed’ research. International collaboration is now the key as is established research credentials. In medicine, research findings can be used to justify ongoing program funding, demonstrate the effects of an intervention, form the backbone of clinical guidelines, back up expert medicolegal witnesses, and sometimes annoy the living daylights out of people trying to get on with the job. While clinical acumen can be used to inform research and even direct it, some people see research as too confined and blinkered, purely through the nature of research method, which applies easily in some settings and not others (such as aged care with all its confounding variables). The medical profession and clinical researchers, in particular, risk worsening the trivialisation of health, science and environment reporting by feeding the media with tempting, light and easily digested pieces when food for thought and tangible results are really required. This may come back to bite the profession. O

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Melanoma Classification: the old and the new T he most widely used classification system for cutaneous melanomas is that of Clark and his colleagues (1969) as adopted by the WHO (2006). The most common subtypes in the classification are:

1. Lentigo maligna melanoma – occurs on chronic sun exposed skin, especially head and neck and forearms of the elderly, presenting as variegated macules with irregular edges. Histologically, the intraepidermal component is characterised by linear proliferation of atypical melanocytes along the basal layer of atrophic epidermis in association with severe solar elastosis. 2. Superficial spreading melanoma – the most common subtype and occurs at sites of intermittent sun exposure. It is defined histologically as having pagetoid scatter of atypical melanocytes (i.e. dispersed neoplastic melanocytes at various levels of the epidermis) within the in-situ component. 3. Acral lentiginous melanoma – occurs on the palm, sole or subungual region. Although this is the most common melanoma in dark skinned individuals, the absolute incidence is similar worldwide. UV exposure does not appear to be a causal factor. 4. Nodular melanoma – presents as a rapidly growing papule or nodule at any anatomical site. Is usually heavily pigmented, although can be amelanotic. This subtype is defined by the WHO as melanoma exclusively in vertical growth phase with an in-situ component that does not extend beyond the invasive component of the tumour by more than three rete ridges laterally. 5. Desmoplastic melanoma – comprise infiltrating neoplastic spindle melanocytes with abundant collagenous stroma usually on sun exposed skin of middle age to elderly individuals, especially on the head and neck. Perineural invasion is common. Other less common subtypes include melanoma arising from a blue naevus,

melanoma arising in a giant congenital naevus, melanoma in childhood and naevoid melanoma.

Although widely used, the WHO classification is criticised as having no relevance in prognostication, and having little relevance in patient management with few exceptions. In addition, histological

By Dr Minh Lam, Consultant Dermatopathologist are heterogenous and represent rapid progression in other subtypes of melanoma. Furthermore, molecular studies have failed to demonstrate any unique genetic features in NMs. A new classification system for cutaneous melanomas based on epidemiologic, histologic and genetic features has been proposed: 1. Chronic sun damage melanomas – older age group, incidence increases with age, primarily head and neck, distal and dorsal extremities. Typically do not arise in a precursor nevus or in patients with high naevi count. Lentiginous growth pattern and poorly circumscribed on histology (fig 1). Higher incidence of KIT mutation. Infrequent BRAF mutation.

QFig 1. Lentiginous proliferation of atypical melanocytes in chronic sun damage melanoma.

features of more than one subtype may be found in any individual melanoma. Clinical, epidemiological, histopathological and molecular data show that melanoma is not a single disease entity. Epidemiological and genetic studies have shown that differences in the growth patterns and the frequency of BRAF and KIT mutations vary depending on the site of the melanoma and pattern of sun exposure. Studies also show that patients with BRAF-mutated melanomas are younger than those with melanomas without BRAF mutations and are more likely to have multiple naevi. Histologically, melanomas carrying BRAF mutations show pagetoid scatter and nesting of intraepidermal melanocytes and tend to occur in skin without marked solar elastosis. The high frequency of BRAF mutations in acquired naevi suggests that this mutation is a critical step in melanocytic neoplasia but alone is insufficient for melanoma oncogenesis. Conversely, KIT mutations are more frequently identified in melanomas with lentiginous growth pattern in acral and chronic sun-damaged skin. Although NM is a distinct subtype in the WHO classification, it is now accepted that NMs

2. Non-chronic sun damage melanomas – younger age group, peak in fifth decade, intermittently sun-exposed skin such as the trunk and proximal extremities, often have multiple naevi. The in-situ component comprises melanocytes predominantly in nests and pagetoid scatter on histology. High frequency of BRAF mutation. No KIT mutations. 3. Acral melanomas – palm, soles, nails. Lentiginous growth pattern and poorly circumscribed on histology. KIT mutations, although lower incidence than chronic sun damaged melanomas. Lower incidence of BRAF mutations than nonchronic sun damage melanomas. *Melanomas arising from blue naevi – these rare melanomas arise within the dermis and not from epidermalassociated melanocytes. More recently, vemurafenib was approved for the treatment of advanced BRAF-mutated melanomas. Genetic characteristics will play a more significant role in the classification of melanomas as more genes crucial in the oncogenesis of melanomas are defined and molecular targets for therapies are developed.

References available on request

Heenan Lam Skin Pathology Part of Perth Medical Laboratories P/L (APA): Independent, Pathologist Owned and Operated. Contact Phone: 93863500q'BY93863511q26 Leura St Nedlands WA 6005 medicalforum

www.heenanlamskinpathology.com.au

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Discrimination

Power of 50 Shades of Grey Ridding ageism and demoralising stereotypes in the workforce is a full-time job for septuagenarian and Age Discrimination Commissioner Susan Ryan. discriminate on that basis without appearing to. It’s my job to change their minds.

With the clock ticking down to the abolition of the Limited Registration Public Interest Occasional Practice (LRPIOP) category on July 1 2013, the campaign being waged by senior doctors has found some support from the Human Rights Commission. The Age Discrimination Commissioner Susan Ryan said that she heard a compelling case from the Australian Senior Active Doctors Association (ASADA) in their fight with AHPRA to have the sunset clause of the LRPIOP lifted and has taken it up with the agency. “The bottom line for me is, if older doctors are still able to offer medical services and are willing to do so, we should try to make it possible taking into account all the safeguards, CPE and insurance. If public safety and their safety can be justified, every effort should be made to have them continue, but the matter is not settled by any means.” In many ways, the senior doctors’ campaign underlines the core of the commissioner’s mission to keep older Australians active and working – in these times of relatively low unemployment and high skills shortage, the nation can’t afford to waste the maturity, experience and knowledge of the older workforce let alone afford the welfare bill. But prejudice prevails and Susan Ryan, who as Minister assisting the Prime Minister for the Status of Women in the Hawke Government helped further the cause of women’s equality in the workplace, sees it as her business to try to change employers’ opinions about older workers. “Older workers are often victims of age discrimination by many employers but I’d rather argue the case that those businesses which aren’t employing them are missing out than to start talking about positive discrimination measures,” she said. One of the biggest challenges the commissioner faces is the question of proof of age discrimination.

“I’m constantly talking to recruiters, executive search agencies, employers and employer bodies about this problem. Employers are defeating their own purpose if they have age prejudice against people who are experienced, mature, reliable and knowledgeable employees.” “I’m having some success in the present climate because we have very low unemployment and many areas of skill shortages. More businesses are setting up strategies to keep older employees, even if that means offering flexible hours or days and job redesign.” This “window of opportunity” as Susan describes it, saw the WA Government eliminate age discrimination in its workers compensation legislation last year. QAge Discrimination Commissioner Susan Ryan

“It is a difficult thing to pin down. We believe it is a very common experience of older people looking for work. They send their CVs off or applications through a recruitment agency where they either hear nothing or they hear that they are unsuccessful with no reasons given. In many cases these people can see that they are extremely well qualified for the job and conclude they have been discriminated against because of their age but there isn’t any hard evidence.”

Even apart from needing the income, the impact of losing your job in your 50s, the loss of a sense of purpose and usefulness leads to depression, anxiety and other mental and physical health problems. “If the circumstances are very obviously age discriminatory, we advise that person to make a complaint to the Human Rights Commission, but, generally, if it is the employers’ view that they don’t want to hire someone over the age of 50, they can

“When you talk to other states about removing the age clause in workers compensation legislation, they will say it’s so complicated but WA did it without a fuss, and why? Because the state had a skill shortage and they realised that they needed all the workers they could get, even workers over 65. The other big resource state Queensland has not gone as far – they have capped benefits but have removed the age bar.” “It will take a long time, but the process of creating a national standard that doesn’t discriminate on the basis of age has started.” Cost lies at the heart of much of the impetus for change, but not just monetary, as shocking as those estimates are. There is a health imperative to keep senior Australians engaged at some level in the paid workforce. “The notion of work in our society is part of our identity and also part of our sense of selfworth,” Susan said. “Even apart from needing the income, the impact of losing your job in your 50s, the loss of a sense of purpose and usefulness leads to depression, anxiety and other mental and physical health problems.” For the health of the nation, keeping older workers on the books has been estimated by Deloitte Access Economics to be worth Continued on Page 31

You’re the Voice Strong editorial independence and ethical reporting on local issues, without fear or favour, is what our readers have asked for. For you, we strive for balanced, truthful reporting and articles that inform and entertain. That has been Medical Forum’s foundation for over 10 years. In that time we have created a forthright dialogue with the profession, that we value above all else. Let us know what you think. editor@mforum.com.au

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GP Research

QDongara GP Dr Kathleen Potter hopes her research will prove we are over medicating the frail elderly, perhaps leading to community savings that are not chicken feed.

Polypharmacy in the Frail Elderly Medication research among the frail elderly has seen motivated rural GP Dr Kathleen Potter team up with the WA Centre for Health and Ageing. Primary care has difficulty finding researchers with some grass roots knowhow and ideas. Introducing Dr Kathleen Potter – a rural GP with a research bent, who at the age of 39 is juggling two kids under age four, the career disconnection of living in Dongara, and a research project that could profoundly affect how doctors manage the elderly in aged care facilities. The research idea is simple – recruit the elderly from aged care facilities in rural WA, stop most of their medications carefully with their GP’s consent, and measure what happens. “There’s a lot of data that polypharmacy is harmful to older people so that’s why we are doing the trial. We believe people will benefit from the intervention,” she said, adding that initial findings seem to confirm her clinical hunch. “There’s one previous similar study done in Israel, where they have geriatric hospitals with a captive audience, and they had a 50% reduction in the one-year mortality of people in whom they withdrew medication, from 45% to 21%. That’s a dramatic reduction and if it was any other pharmacological intervention it would be plastered around the headlines but instead it has disappeared without trace.” But rural WA is not Israel. What are the preliminary results from her four-year NHMRC-funded pilot study devised by the 10

WA Centre for Health and Ageing?

Which medications to withdraw?

“For the 34 people enrolled so far, our baseline data shows that people are taking about a mean of 10 regular medications, and usually have four or five prns on top of that. We are recommending withdrawal of a mean of seven medications, or about 70% of their regular medications. So far, we have been able to withdraw about four medications per person,” she said.

The researchers realise a GP’s experience around use of a particular medication cannot be ignored. It is one thing to demonstrate adverse reactions like confusion, nausea, constipation, dizziness, falls or perhaps no effect from medication but another to do harm by withdrawing it.

Kathleen’s GP experience around drug compliance helps explain why these figures might seem high. “I’ve found that specialists often have little idea of how patients actually take their advice or medications. You realise from working in general practice that people generally do their own sweet thing.”

“That’s why we are focussing on medications where the benefits are uncertain. For instance, statins are a big one. The data suggests they are of little benefit in people aged over 75 in terms of increasing longevity, you are just more likely to die of cancer rather than a stroke or heart attack.”

By that she means compliance rates of 50% are common but that changes when the elderly enter aged care facilities. Medications are handed out on time by diligent staff often using blister packs prepared by a pharmacist. The irony is that such good compliance allows them to study medication withdrawal accurately. Then why not just stop everything?

Once patient consent is obtained, she does a medical review with patients. Her fellow investigator, geriatrician Dr Chris Beer, is sent the patient information and they discuss by phone, apply the study algorithms, and agree on medications to be withdrawn on trial. This list is sent to the patient’s GP, along with the intended time frame, and feedback sought – only one or two medications proposed for withdrawal have been objected to by GPs so far.

“It wouldn’t be acceptable to either the patients or their GPs. We are quite aggressive though. We taper or stop medications sequentially so we can tell if they are getting withdrawal effects or the recurrence of symptoms. We aim to do this every two weeks with each new medication or dose reduction but in reality it varies a lot.”

The algorithms look to see if an appropriate indication still exists for a drug, if there is a contraindication, likely significant side effects and whether preventive drugs are still appropriate. The latter is probably most contentious until you consider that benefits may be unknown in this age group, against well-established medication risks. medicalforum


Guest Column Power of results built on design The pilot study is open, though randomised, with a control group and blinded assessments by a research assistant. The primary endpoint is the number of medications at the end of 12 months. Already, they are pretty certain they can reduce the number of medications people are taking. The secondary outcomes are cognitive function, falls, hospital admissions, sleep quality, GP callouts, and independence – information that is gleaned from the nursing notes, relatives, staff, and cognitive testing at six and 12 months. The pilot study will focus on the larger centres in Geraldton. During the drug withdrawal phase, patients require a visit from her at least weekly. So far, about 25% of people approached have agreed to take part. For people with dementia, the relatives give consent, but Kathleen says convincing those with mild cognitive impairment or confusion to take part is difficult. Well short of the 1000 patients needed to show an effect on mortality the 150 or so pilot should yield meaningful results around quality of life and cost benefits. “Elderly people have largely been excluded from clinical trials because there are too many confounding factors. You don’t get nice clean data because there are multiple conditions and medications but we are hopeful that we can show the intervention is achievable without adversely affecting our participants, and then apply for funding for a larger trial.” If results suggest you can safely reduce medications by 50% in aged care facilities, government is going to be interested from a cost perspective alone. “To be honest, I think that’s why we haven’t had a lot of trouble attracting funding, but we don’t want this to be perceived as a cost-saving intervention. What we want to say is that it’s in people’s interests, and that’s what I genuinely believe. I don’t think we are benefiting people by prescribing them 10 tablets when they are 90.” An iatrogenic problem? In the minds of many, we are researching an iatrogenic problem within the medical industry. “It’s multifactorial, like most things. I think there’s an issue with the targeting of doctors by drug companies. You get handed information about what you should be prescribing – the diabetic who should be on a statin or something else,” she said, adding that promotional emphasis appears to be on regular long-term medications that could equate to a 20-30 year revenue stream. “All the algorithms are for starting people on medications and you receive virtually no advice on how to stop medication. “You can feel like you’re a bad doctor if you are not prescribing and following the algorithm, with not a lot of room for the intelligent officer anymore. You just follow the flow chart. There is a lot of room for treatment guidelines but if you follow them religiously, most people over 60 end up on five or six medications.” Kathleen understands why doctors are uncertain or even fearful of withdrawing medications, particularly if they have been burnt in the past. Plus they are short of the extra time needed to monitor someone during drug ‘de-prescribing’. “Geriatricians are seeing the consequences of polypharmacy. What we are recommending is often very similar to what the RMMR is recommending, which is meant to happen every year for people in aged care but I don’t know if that’s being put into practice. The pharmacists don’t see the full clinical picture so decisions are left open and the GP may be reluctant to accept the recommendations.” O

By Dr Rob McEvoy medicalforum

Reclaiming Dignity for Everyone ‘Dying with dignity’ is a relative term, says President of Palliative Care Australia, Dr Scott Blackwell, who gives his own deeply personal view.

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aomi was incensed at the thought that dying in bed with an indwelling catheter on a high dose of opioids could now be the definition of loss of dignity. She had read the guest column by Dr Bertel Bulten “Dying in a Vaguely Horrific Society”, (October 2012). Her concern is that many people will indeed die in similar circumstances and that the dignity in their dying will be tainted by this perception so often put by the “dying with dignity” movement. Naomi herself suffers from Multiple Myeloma and though she is in remission after a stem cell transplant, has had to address the issue of dying in a very personal sense. Dignity for her will come from the love and support of her husband, her children, her wider family and her friends. The incidental physical detail of what is to come is not the issue at all. Indeed the reason why Naomi feels incensed is because the beautiful concept of dignity is so often reduced to these incidental physical details. As a Palliative Care practitioner, I do have in my care people who have been keen advocates of the “Dying with Dignity” movement. In most cases I see their suffering accentuated by their beliefs because they perceive loss of dignity in this sense. I see those who have been to workshops, given by well-meaning people on how to end their life, suffer because when their time comes they cannot go through with it and they feel a sense of failure. Yes dignity is a personal thing often not clearly defined for each of us until it is our time. I do agree with Dr Bulten that Holland is far from being a “Vaguely Horrific Society”, and I have enjoyed one visit to his country, and would like to go there again. My perception is that there are significant cultural differences between his homeland and mine here in Australia. The concept of voluntary euthanasia is in fact “a common preference but a rare choice”. Dr Bulten’s own figures of 2% of deaths in Holland being due to VE bear this out. The fact that 70-80% of people surveyed say they support VE I see as a reflection that the real choice is for no suffering. At Palliative Care Australia (PCA) this year we surveyed people about where they would like to die – 70-80% showed a preference to die at home supported by a palliative care team to minimise their suffering, again a choice for no suffering. So what do we want when we have to face a diagnosis that will inevitably lead to our death? The first choice is always for life, to get as much out of our lives as we can in the face of this inevitability. Life is not just about time, it is about the lived experience and a balance has to be negotiated. The second choice is for no suffering. Minimising suffering in the sense of body mind and spirit is achievable and should be a primary aim of all good care. The third choice is for healthy bereavement. Yes we do need to consider the journey of the fellow travellers in the life of the dying person. None of us live a life isolated from our loved ones. The three pillars of good Palliative care are – life, minimal suffering, and care of the fellow life travellers. It is difficult to see a circumstance where voluntary euthanasia can satisfactorily satisfy all these needs in an end-of-life situation. At PCA we have considered this and although we do not hold a view that insists on our members all having the same opinion, we are clear that voluntary euthanasia is not part of Palliative Care. My wife Naomi and I will keep on living life to its maximum, and dignity will be found in many ways but none of them to do with the limited view so often put by those who would choose to give up on life. O 11


Guest Columns

Challenge of the Boom Generation Ageing baby boomers are set to change the aged care game, and Brightwater CEO Dr Penny Flett says the rules must change too.

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estern Australians are, like everyone in else in the world, ageing, with the Baby Boomer generation heading towards late middle age and old age in large numbers. Old people are living longer than ever before.

That's the reality. We know the numbers, we can make a pretty educated guess at the clinical, functional and social needs that they, and the broader Western Australian society, will experience, in the coming decades.

The aged care system we have now simply will not cope with the numbers, let alone rise to the high expectations we already have of the sector. It is a complicated arrangement of residential and domestic care and support, based on a century-old model, plagued by successive governments' rules and processes, and inevitably much obfuscation. It is in grave need of review and redesign but instead we are in the throes of a ‘reform’ and the cracks are already appearing.

All levels of government are finally starting to grasp the profound economic, social and infrastructure impacts on the nation of this ageing phenomenon, but no government has begun to make adequate provision for the next 30-40 years of this growing and complex demand. Ageing is not a particularly attractive topic for politicians, especially just before an election.

WA is nearly 3500 beds short of the government's target because the funding is so ridiculously inadequate that building stopped five years ago. Just days before this financial year began, the federal minister announced major revenue cuts which, after years of cumulative inadequacy, are, frankly, nigh on financially fatal. From an individual provider perspective, this is serious enough, for the system, the prognosis is probably 1-2 years.

However, the issue desperately needs a longterm strategy, not just a short-term political gesture to be forgotten once the votes have been counted.

From a WA perspective, it is going to be a huge challenge as elderly people, who can no longer be adequately cared for in the failing aged care system, will be queuing

up at the doors of acute hospital emergency departments, and overwhelming GP practices. Families will be at their wits end. The pain will be prolonged and emotional. Small facilities are likely to close first, which will spell a tragedy for rural and remote communities. Providers will bear the brunt of both individual distress and formal complaints, as staff numbers are cut to the bone, care capacity drops and valuable allied health input is abandoned. We are assured by DoHA that this is but the first part of reform, and that there are further changes which may bring relief. However, there is a serious loss of confidence, and little reassurance in the wind. One thing is certain, whatever is planned, it will be complicated and difficult, and not all in the industry will survive. The Productivity Commission released a report a year ago that offered a worthy and well-received blueprint to develop an affordable, high quality, and sustainable aged care system for Australia. The sad thing is that the federal government has ignored it. O

Aged Care... Just for the Record Aged care has is highs and lows and one of the lows is medical record keeping, according to GP Dr Simon Torvaldsen.

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lectronic records are good and paper is bad, right? That’s the mantra we’ve lived with for a while now and, in a GP surgery, there’s a fair bit of truth in it. I couldn’t imagine going back to a paper-based record at my surgery. But in a residential aged care facility (RACF) it’s a different world. GPs control a very small part of the total patient record and the RACF controls the rest. And, perversely, the main priority seems to be administrative documentation rather than medical records. Sure, we’re welcome to log on to enter our GP notes if we can remember a different password for each facility, or find a friendly staff member to log on for us. And when you finally get to the required destination in the RACF electronic ether, 12

what you’ll see is an electronic version of a 6x4 card. It’s a blank sheet and you can neither write a summary nor link to anything else. As for writing prescriptions electronically, forget it! We’ve regressed 40 years in terms of medical record keeping.

accessible in three clicks or less. I’ve seen nurses and carers doing multiple clicks and scrolling through calendars and lists just to find a patient’s BP record. And when they complain they’re branded Luddites or slow learners!

To be fair, some of the more sophisticated GP prompts and recalls aren’t needed in RACF. In fact, most of what we need is in our paper notes and old-fashioned RACG head-sheet, and it’s quicker to access than most RACF software programs! Apparently some software links to Medical Director (MD) but I’ve yet to see one that works. And how many facilities will be happy to pay for MD software licences?

What can be done? I’m not sure, but I’m hoping that raising the issue might help. Most RACF facilities are more worried about staying afloat financially and providing basic care than the quality of their electronic records. In the meantime, I’ll keep on writing my old-fashioned notes. At least they comply with RACGP standards.

All of this makes me rather sad because there’s so much potential in well-designed health record software. It is axiomatic that commonly required data should be

And as for the PCEHR in aged care facilities, don’t get me started. Perhaps it will all be sorted out before I retire but I’m not holding my breath! O medicalforum


Advertising Feature

Advice for Doctors on the safe transfer of UK pension assets New regulations governing the transfer of United Kingdom pensions out of the country can potentially have a significant affect on the retirement incomes of expatriate doctors now working in Australia. According to a financial adviser who specialises in United Kingdom pension transfers, the new rules, which came into effect for the new British tax year on April 6, can result in heavier tax penalties and consequently, a smaller retirement nest egg for some expatriates. McKinley Plowman & Associates, United Kingdom Pensions Transfer Manager Colette Pieniazek said obtaining the right professional advice about transferring or investing pension assets could save a doctor thousands of dollars in tax and ultimately a far more comfortable retirement. Mrs Pieniazek, who immigrated to Perth from Britain over eight years ago, said while expatriate doctors had a lot to gain from transferring their pensions into Australian Qualifying Regulated Overseas Pension Scheme (QROPS) funds, it was critical for them to understand how the latest changes would affect them. She said the new rules required for the receiving QROPS scheme to report members’ withdrawals to HM Revenue and Customs (HMRC) for ten years after their pension was transferred to Australia. Under previous regulations the Australian pension scheme was only required to report withdrawals for five UK tax years from the date of residency here. Mrs Pieniazek said the rule changes would be retrospective, so expatriates who had already transferred their British pensions into Australian QROPS funds would also need to be aware of the longer reporting requirements and their taxation implications. “This means that if you make a withdrawal from your transferred UK pension within this time period and it is outside prescribed UK limits then you will face an unauthorised tax charge of 55% by HMRC,” Mrs Pieniazek said.

Mrs Pieniazek said with the right professional advice immigrants could safely transfer their pension to Australia in a tax effective way and be better off in retirement. She said McKinley Plowman and Associates was now providing doctors with a free no-obligation report on the different financial and tax outcomes of leaving their pension in Britain or transferring it to Australia. She said transferring British pensions to an Australian Qualifying Regulated Overseas Pension Scheme (QROPS) offered many benefits including a tax-free income in retirement, flexible investment opportunities, potentially higher returns, freedom from exchange rate fluctuations and long-term asset protection. Unlike the British pension funds, Australian funds allowed pension holders to pass on their entire fund balance to a spouse or beneficiaries after death. Mrs Pieniazek said it was important to begin the pension transfer process, which usually took up to four months, as soon as Australian residency was obtained. Pension transfers made within six months of obtaining residency did not incur Australian tax, however those made after this period were subject to a 15% tax. This tax applied to any capital gain made by the UK pension between the time an individual moved to Australia and the time the pension funds arrived here. “Also, Australians can take 100% of their super tax free at age 60, whereas UK laws only allow for 25% to be taken as a lump sum.” For more information email: pensions@mckinleyplowman.com.au T: (08) 9301 2200 F: (08) 9301 2201 McKinley Plowman & Associates Level 2 / 5 Davidson Terrace JOONDALUP WA 6027 Correspondence PO Box 635 JOONDALUP WA 6919 www.mckinleyplowman.com.au

“It is absolutely vital that those who intend to either retire or plan to draw on their former UK funds within the next ten years seek professional advice now.”

medicalforum m me edica dica di calffo oru r um

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Feature

Parents Second Time Around Three Perth grandparents talk about the pleasure and pain of being full-time carers to their young grandchildren and they are just the tip of the iceberg. It could be an unexpected death, a prison sentence or just an inability to cope that can result in a child being without a parent to care for them. That job often falls on grandparents who, in their retirement years, find themselves with the exhausting task of rearing their young grandchildren. Kaye Bendle is the current president of Grandparents Rearing Grandchildren (GRG) and is also raising her nine-year-old grandson, Tyson. Their back-story is sadly all too common – drugs, the wrong partner, an ever-downwards spiral leading to prison. “A lot of the kids at Tyson’s school know his mother is in prison and obviously it’s a very sensitive area for him. My daughter has been a drug addict since she was 16 and she’s in her early 30s now. It’s the old story – an abusive relationship, heroin use and then marriage to an obsessive and controlling individual,” Kaye said.

QTyson and Grandmother, Kaye Bendle

after the children of FIFO parents but that’s something we don’t do.”

“Tyson was nine months old when my daughter came to live with me, and things were quite good for a while. There was the usual round of treatment – bupramorphine was a problem because she’d inject it and then suboxone and narcaine. My daughter had naltrexone implants at Dr George O’Neill’s clinic but she drifted back into drugs. The second time around hit me really hard, I was just so disappointed.”

Niall Johnston is a retired rigger in his early 70s and has been looking after two grandchildren, a six-year-old boy and an 11-year-old girl for the past 18 months, though the children hope to be reunited with their mother soon. “It’s certainly been educational but, at 72 years of age, pretty disruptive too. We’ve had good family support and GRG has been great company along the way. When you hear some of the stories it’s no wonder that many of these children are traumatised. So much of this is down to drugs and, sadly, many of those on drugs were abused themselves. The prisons are full of them,” Niall said.

It took a perceptive suggestion from a GP to alert Kaye that her daughter was at risk in the first place. “I was a nurse and I worked with a GP in Mt Lawley. I rang him early in the piece because my daughter’s boyfriend needed help with his drug problem. He said, ‘what about your own daughter?’ I naively replied, ‘she’s not on drugs’ and I’ll never forget his response. ‘I think you’ll find she is’.”

“Grandparents are paying the price but we’ve certainly developed a deeper relationship with our grandchildren. Our daughter will be taking the children back next month so we’re only just passing through.”

The physical demands of caring for a young child are only part of the equation and the number of people approaching GRG is growing all the time. “The emotional and psychological needs of these children are quite high and that impacts on the carer, even if they are ‘family’. It’s like a death in a way – you’re pining to be their grandmother but you can’t because you’re placed in a situation that’s completely different.” “I’m only caring for one child and I was feeling like a complete failure. If GPs are aware of this issue and ask the right sort of questions it can really help.” 14

QAll Aboard the Grandkids Bus

“Since we started in 2000 with Meerilinga, the numbers attending our support group has increased. We’ve got about 50 families on our books and we run meetings from Mandurah to Merriwa. We’ve even had grandparents approach us who are looking

Noeline Barron’s daughter, Raelene was 22 weeks pregnant with her second child when she was diagnosed with NonHodgkin’s Lymphoma in January 1992. To say the aftermath was difficult would be an understatement but the family GP was instrumental in helping them rebuild their lives. “Raelene died in October 1992 and her husband tried to look after the children but he wasn’t able to cope. I took the children in early 1993 and had to sell my small unit and buy a family home. It brought the family medicalforum


together and my GP, Dr Baker in North Beach, was amazing. He’s retired now but I still go to the same surgery and take the grandchildren as well.� “I’ve been on my own since 1977 and it’s true to say that women outnumber men in these caring roles. Support groups such as GRG and Wanslea Grandcare are great to share experiences and look after one another. There were times when things were very bleak for me and, at 72, I’m still very much in a caring role but I don’t resent it now.� Wanslea Family Services, a not-for-profit NGA, has 370 ‘grandparent families’ on its books and provides a range of support services. Its Executive Manager Stephan Lund says its support is more ‘in-kind’ than financial.

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“We provide services such as mentoring, advocacy, tutoring and counselling for the grandchildren, grandparent group meetings and weekend respite care. We also have sessions to inform grandparents about other services, such as the Grandcare Centrelink program and Family Court counselling. Wanslea will even help with domestic chores such as gardening and household maintenance.� “There’s no doubt many of these families are struggling financially and the ones we see are just the tip of the iceberg. Many grandparents are ashamed that their own children are unable to cope and obviously drugs and prison are factors here.� “There’s not much assistance for families below the waterline and it’s difficult to quantify the actual numbers in an accurate way. Even Centrelink figures don’t reflect the real story. One thing that’s patently clear is that some of these grandparents feel a little resentment that there’s not a greater recognition of their role. They’re well aware that they’re saving the state coffers a great deal of money by keeping these children out of foster care.�

FACTS: Grandparents in the frame: t  HSBOEQBSFOUTSBJTJOH grandchildren (2006 National Census) t *O8"UIFSFBSFNPSFUIBO grandparents raising grandchildren t 4VQQPSUOFUXPSLT www.grandparentsrearinggrandchildren. org.au; kayebendle@iinet.net.au

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Pet Therapy

Healing Power of Pets We forge powerful relationships with our pets, so why should we give them up when they go into care? There is growing evidence that pets are good for your physical and mental health and on the flip-side, studies have shown that separating owners from their companion animals is akin to a death in the family. Such is the relationship humans have forged with their furry and feathered friends. Former president of the Australian Veterinary Association and Wembley vet Garry Edgar has witnessed first-hand the power of pets to keep elderly people engaged and active in his own practice which is situated opposite a retirement village and he laments that not more is done to encourage pet ownership in these settings. “About 20 years ago, some progressive retirement places allowed residents to keep their existing pets when they downsized but didn’t allow a pet to be replaced when it died. The reason behind allowing pets in the first place was to minimise the grief associated with leaving the family home. But that’s about as ‘progressive’ as we’ve become, it hasn’t evolved since then.� However, clinical studies have. Studies at the Universities of WA and Adelaide have explored the social and health capital gained from pet ownership in general and some studies involving the elderly specifically. UWA’s Andrea Nathan’s studies have found that pet ownership encouraged greater self-care – as Garry says “pets encourage people to get up out of bed, feed themselves, feed their pets and generally look after themselves better�. Pets were also a social conduit that helped their owners make new friendships.

MERCEDES BENZ SPECIALIST

In an aged care setting interaction with trained and certified therapy animals has been shown to reduce the need for pain medication, and promotes post-operative activity. The unconditional companionship of a dog promotes speech and social activity in otherwise withdrawn people. According to Adelaide University researcher Anna Chur-Hansen, not being able to bring a pet with them into retirement villages could delay people’s decision to downsize or go into low-band care, which could have detrimental effects on their health. “There is some evidence that particular groups of people might value their companion animals over other human relationships (Toray, 2004). While it is important not to pathologise this attachment, in some cases it may be that the attachment might be detrimental to the physical or psychological health of the person, for example, by refusing medical care or relocation to an aged care facility because this might mean temporary (or permanent) separation from their animal (McNicholas et al., 2005).�

MB Star

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Recent clinical studies have shown that lower blood pressure and relaxed respiratory patterns are just some of the quantifiable improvements reported in residents of aged care facilities when they come into contact with a trained therapy dog.

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Garry said the AVA had lobbied the government to leverage a change in strata regulations to relax the no-pets policy arguing the benefits of pet ownership outweigh the negative mostly false stereotypes of dirty, aggressive animals. “We’ve spoken with the government about creating a formula so that people can move into strata or rental property with their pet and know where they stand. At the moment it is ad hoc where landlords pluck figures out of the air for a pet bond or say no altogether.� “Ideally people in residential care should be free to own and care for a pet. Obviously the animal would have to be approved and undergo thorough health and temperament testing, but those things are not hard to do.� O

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By Ms Jan Hallam medicalforum


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Have You Heard?

apparently do things differently here in West. Most palliative care admissions in WA (61%) were to private hospitals compared with a public hospital admission rate in NSW of 92% and Victoria 89%.

UWA research boost The NHMRC has just financed 50 medical research projects totalling $31.4m at UWA. That’s about 5% of national funding but 88% of NHMRC grants to WA. Childhood asthma, pre-term birth and pollution, allergies, cancer, healthy ageing and physical health in severe mental illness are in the mix that includes Career Development and Early Career Fellowships. UWA Acting Vice-Chancellor Professor Bill Louden said these medical grants reflected that UWA researchers were world-leaders in their fields, and funding will help them bring positive influences to the lives of ordinary people.

AIHW spokesperson Brent Diverty said this reflected local service delivery and noted that higher private hospital use was still funded from the public purse.

Spike in palliative care

Computer blues

Palliative care hospital admissions in Australia rose >50% between 2001 and 2010, according the Australian Institute of Health and Welfare (AIHW) report, Palliative care services in Australia – 56,000 palliative care admissions to public and private hospitals in 2009-10 (average age 71.9 yrs; males 54% to females 46%). We

An irate practice manager told Medical Forum about (almost inevitable?) computer problems following a recent software upgrade. The seven-doctor practice lost productivity due to delayed screen response times. And just to make the day even bluer, the back-up prior to the upgrade was inadvertently lost. This practice has a

5GB patient database with acres of scanned letters for its 60,000 patients – and a big IT headache not fixed by ‘a patch’ a month later.

Read the fine print Australian Doctor is promoting its ‘online community for doctors’ - www.just4docs. com.au. Check out Rule 6 in their terms and conditions. It reads: By uploading content to or submitting any materials for use on this Web Site, you grant (or warrant that the owner of such rights has expressly granted) RBI a perpetual, worldwide, royalty-free, irrevocable, non-exclusive right and license, with right to sublicense, to use, reproduce, modify, adapt, publish, publicly perform, publicly display, digitally display and digitally perform translate, create derivative works from and distribute such materials or incorporate such materials into any form, medium, or technology now known or later developed throughout the universe. That covers just about everything.

Aged care, staff jab Flu vaccination of staff at aged care facilities in 2013 might just be a very good idea. HDWA had a whopping bill for Tamiflu this year because Commonwealth Guidelines say if an outbreak occurs, statefunded Tamiflu 10-day course at $30-40

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a pop is the next best thing for those not vaccinated. Vaccination at around $20 each is given to patients by GPs but is of dubious value because of a poor immune response in the elderly. Vaccination of staff is not an accreditation requirement but remains the responsibility of the employer. What a great business opportunity for pharmacists and OH providers! Meanwhile, Pharma in Focus reports that Roche has defended Tamiflu following reports that unpublished data undermines the effectiveness of the drug.

Folate brain connection A recent article in Cancer Epidemiology, Biomarkers and Prevention (August 2012) sings the praises of folic acid supplements prior to pregnancy. The retrospective national study from the Telethon Institute

for Child Health Research found that taking folic acid pre-pregnancy reduced the risk of childhood brain tumours by around 30%. The report’s principal author, Prof Elizabeth Milne said that GPs could add brain tumour protection to neural chord protection in promoting folate supplementation.

Check-ups fail Danish researchers have led a systematic Cochrane review of general health checkups. Do they reduce deaths from serious diseases such as cancer and heart disease? No, they don’t. Nonetheless, 14 trials involving 182,880 people did pick up new problems but the nine trials relating to death yielded no difference whatsoever. Although other outcomes were poorly studied, the Cochrane reviewers suggested that offering general health checks has no impact on hospital admissions, disability, specialist referrals or time off work. It would seem that health checks don’t succeed as a public health initiative. And disease-specific programs? Now that’s another story.

Turf war Consumer choice is a wonderful thing but it can turn ugly. In the red corner are orthopaedic surgeons; in the blue, the

Australasian College of Podiatric Surgeons (ACPS). The ACCC will be sending a report to the Federal Senate on any anticompetitive practices by health funds or providers which reduce the extent of health cover for consumers and/or increases their out-of-pocket medical expenses. Some podiatric procedures are covered by health insurance if carried out by an orthopaedic surgeon, but that same cover is refused if undertaken by a podiatric surgeon.

Gasping for air A politician without the media is like a fish without water, so when the WA government media website crashed towards the end of September, some frantic scrambling was in order. An interim website was created and with a collective sigh, the promotion machine hummed back into life. Did we miss much? The Premier lashed out at a union “scare campaign� which said the new children’s hospital will be privatised; the Health Minister trumpeted 100 new services for Aboriginal people and more than 100 new Aboriginal health employees; the Treasurer announced 290 medical internships next year; the first stage of the QEII car park opens; and a flurry of good news announcements during Mental Health Week. We can rest easy. O

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19


Guest Column

Is WA a Health-Free Zone? Public Health Physician Dr Bret Hart wants to bring WHO’s Health in All Policies movement to Australia. He explains why.

W

hen Kevin Rudd was Prime Minister he said, “...if current spending and revenue trends continue, Treasury projects that the total health spending of all states will exceed 100% of their tax revenues, excluding the GST, by around 2045-46, and possibly earlier in some States.� For many reasons, it will definitely be earlier and some States have acted accordingly.

You can now prescribe exercise! As part of our commitment to health of Western Australia the team at Obesity Surgery WA, is now offering exercise programmes at no cost. To enrol, we need a referral to our practice for exercise. Everyone gets a health review to check their suitability and will get a personal plan or get to join one of our group sessions. The service is open to anyone who needs a little help to get fitter, even if they are not considering surgery. < Mr Harsha Chandraratna Surgeon Jo Climo > $MJOJDBM/VSTF &YFSDJTF$PPSEJOBUPS

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South Australia invited WHO global health consultant Prof Ilona Kickbusch as Adelaide Thinker in Residence to provide ideas. She recommended that SA adopt â&#x20AC;&#x2DC;Health in All Policiesâ&#x20AC;&#x2122; (HiAP) as it, â&#x20AC;&#x153;provides an opportunity for government agencies to work together to try to improve the health of the population through addressing the Social Determinants of Health and helps to create a cost-effective, sustainable health system.â&#x20AC;? Consequently, the SA Health Department established a HiAP Unit, which is a bit like trying to sell lentils in a butchers shop, as the determinants of health are not located in departments concerned with illness. Nevertheless, if you Google â&#x20AC;&#x153;Adelaide Statementâ&#x20AC;? you can see the impact this small Unit has had on the international stage. Also, a recent report commissioned by Catholic Health Australia entitled The Cost of Inaction on the Social Determinants of Health estimated 500,000 Australians could avoid suffering chronic diseases and billions would be saved annually from less hospital, welfare and PBS use.

Mandate for cost cutting So what was WAâ&#x20AC;&#x2122;s response to the health funding crisis? In 2003, it prioritised â&#x20AC;&#x2DC;services that have an immediate impact on reducing acute disease and deathâ&#x20AC;&#x2122;. This provided the mandate to cut programs that included public health, and when Prof Fiona Stanley and others appealed to Premier Alan Carpenter to spend more on prevention programs, he responded on ABC radio; â&#x20AC;&#x153;there are huge immediate demands now â&#x20AC;&#x201C; every day of the week for us to spend more dollars â&#x20AC;&#x201C; not so much on the preventative side â&#x20AC;Ś but on responding to circumstances facing people every day â&#x20AC;Śâ&#x20AC;? Almost a decade later, the same could be said. And no doubt will be said in future as increasingly health costs more than we can afford, and delivers less than we expect. In 2008, Australiaâ&#x20AC;&#x2122;s public health leader Prof Stephen Leeder observed, â&#x20AC;&#x153;â&#x20AC;ŚWA is unusual: public health was abolished as a concept in the State Health Department some years ago and has yet to recover from this astonishing deletion.â&#x20AC;? Has WAâ&#x20AC;&#x2122;s population recovered? The failure to update the 1911 Public Health Act is not a good sign. An HIA Unit, which ensures that policies bring more health benefit than harm, was established in the Department by the previous government and was abolished soon after it changed. We have until March 2013 to debate which party can restore the ability to protect, promote and ensure future health in WA. O ED: Dr Hart is convening a HiAP roundtable in Sydney in late November. If you want to participate and/or find out more email bret@hart-solutions.com.au.

MURDOCH medicalforum


Therapies

The Power of a Story A project being conducted by Curtin University OT students is an important key to understanding the behaviour of dementia patients. Amana Living’s Louise Jones believes that it’s critically important to know a person’s story – the sum of their lived experiences – in order to engage in a productive and compassionate way in an aged-care setting. Life Story Tools, developed by Louise and OT students from Curtin University, are helping to jog the memory of older people. And the reaction can be anything from a smile of recognition to a period of quiet reflection. “This is all about fostering person-centred care and it’s a real no-brainer that to really understand someone you need to know their story. In knowing what has come before, we have much better insight into just who that person is now. These life stories are a wonderfully effective therapeutic tool and it feeds into all areas of aged care,” Louise said. The MJA reported last year that the number of residents in nursing homes regularly taking antipsychotic medication is on the increase. In terms of clinical care there’s real value for a GP being able to integrate these life tools into a more nuanced assessment of a patient’s behaviour. “For a doctor seeing a resident for the first time, particularly if dementia is a factor and there are behavioural concerns, life tools – whether it’s an actual book or a tactile object – are invaluable. An understanding of a person’s background can give real clues into why that behaviour is occurring and what type of intervention might be most effective. In many cases inappropriate behaviour is deeply embedded in life trauma and there are often simple ways to alleviate this.” “I’ve worked with a resident who was a POW under the Japanese and was continually hoarding food in his room. He came close to starvation as a young man so food was matter of life and death for him. He felt vulnerable in a nursing home and, yet again, he looked to food as a form of security. The staff was able to deal with that by ensuring that biscuits and fruit were always visible in his room and discreetly looking for tell-tale crumbs.” The final year OT Curtin students had seven-week placements at Amana Living residential locations commencing in January this year. The students developed life story tools for eight residents, with a goal of 120 to be completed by the end of the year. The outcomes will feed into a medicalforum

QOT Student, Ben Ngo using a Life Story, (inset) Aged Care Life Tools

three-day dementia care training package for Amana staff.

person believes in a story that’s somewhat at odds with reality, it still remains their story.

“Some students may have had initial reservations about working in aged care but by the end of the project they were totally engaged,” Louise said. “In a practical sense, these tools don’t always take the form of a book. They’re highly individualised, for example a person might have a rummage box providing physical links to their own life story.”

“If we come across traumatic material we’ll document it in the most appropriate way. We had a man whose ship was torpedoed in the Coral Sea and spent weeks floating around clinging to a piece of wood watching his shipmates dying around him. That wasn’t included in his life story but we did use photos of him and his mates visiting the pyramids in Egypt.” “We work on the premise that if it’s ‘real’ to the person, then it’s ‘real’. One resident believed that someone in a photo was called ‘Mabel’. Her family told us it was incorrect but, as far as the Life Book was concerned, Mabel it remained.”

QDementia Care Specialist, Louise Jones

“The actual life tool has to fit with a patient’s individual capacity. We tend not to put more than two photos on a page because of perceptual problems and some of the books are only printed on the righthand side because some residents can’t scan left to right.” The actual construction of a life story often requires a great deal of subtlety. It’s definitely not a vehicle for revisiting past trauma and nor is it life-review work. If one

There are more than 700 people in Amana Living residential facilities and about 65% of them have some form of cognitive dysfunction. Life Story Tools is a psychosocial approach that’s particularly relevant within the culture of aged care and it just might ease the load on a busy GP. “We’d love GPs to know about these tools and I’d urge them to come and see one being used. If doctors witnessed a previously uncommunicative person suddenly unfold it would open their eyes. There’s something wonderful about transforming an assessment of a person’s functional capacity into a more positive and practical reality.”O

By Mr Peter McClelland 21


Guest Column

Never Too Late to Make a Difference Curtin University’s Professor Gill Lewin says giving the elderly new strategies to regain function is having a positive effect in all aspects of their lives.

T

he work of both the Economic Potential of Senior Australians (EPSA) and Positive Ageing Panels reflects two critical elements that should be part of all our thinking about ageing: that it is lifelong, and that all of our life experiences, whether they be social, emotional, economic or physical, have the potential to affect how well we age.

common and needs to be combated if we are to encourage them to maximise their participation in all aspects of life, for their remaining life.

Within the health sector, our reforms, with their emphasis on wellness and illness prevention are also aligned with this thinking. However, there is a tendency for us to focus mainly on primary prevention and pay less attention to developing and implementing strategies for secondary prevention. This appears to be the case particularly for older people when there is the tendency to think it is too late to make a difference.

In 1999, Silver Chain developed a restorative home care service for older people when they were first referred for home care assistance. Instead of assessing the older person only in terms of what they were having difficulty doing, and then responding by providing a service to do it for them, Silver Chain looked at why the person was having difficulties, then helped them to develop strategies to regain function or approach tasks differently, perhaps with the aid of equipment.

This type of thinking is not restricted to some health professionals but is commonplace throughout the community and is often reflected by older people themselves. Negative stereotyping of older people as, for example, forgetful, helpless, grumpy and set in their ways, is

It is critical that doctors assist them to focus on what they can do for themselves to maximise their health and wellbeing, rather than thinking primarily in terms of what help does this person need from someone else.

We have conducted extensive research on the outcomes of this service and compared it to the outcomes of receiving “usual” home care. We found that individuals who received the restorative service were more likely to show significant improvement

on a variety of functional and wellbeing indicators and were less likely to need ongoing home care services. An effect in terms of reduced aged care service use – both home and residential care – is then evident over the next five years, which is the longest follow-up that we have so far looked at. It is a basic human right that, whatever our age, we are encouraged, and assisted if necessary, to maximise our health and wellbeing. The UN Committee on Economic, Social and Cultural Rights puts it as “The right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. I am hopeful this right will be enabled and promoted within Australia’s reformed aged care system by all health and aged care professionals in their everyday work and interactions with older patients. O ED: Prof Lewin is Research Director at Silver Chain and a Professor at the Centre for Research on Ageing at Curtin University. She was a member of Minister Mark Butler’s advisory panel on EPSA and has just been appointed to the Advisory Panel on Positive Ageing.

The State of an Ageing Nation The Australian Institute of Health and Welfare (AIHW) has recently released its annual reports on the ageing of the nation and there’s no surprise that the annual figures make sobering reading. For starters, the number of people with dementia in Australia is projected to rise one third to almost 400,000 people by 2020. The report, Dementia in Australia, estimated 298,000 Australians had dementia in 2011, and 62% of these people were women. Most people (74%) were aged over 75. Dementia was the third leading single cause of death in 2010, accounting for 6% of all deaths. Twice as many women died from dementia compared with men (6083 and 2920 respectively), and the annual number of deaths from dementia is about 9000. In 2011. For people aged 65 and over, dementia was the second leading cause of overall burden of disease and the leading cause of disability burden. 22

The Ripple Effect The report also looked into the ripple effects of dementia, estimating that in 2011 there were about 200,000 informal carers of people with dementia living in the community. And the cost is considerable. It is estimated that the total direct health and aged care system expenditure on people with dementia was at least $4.9 billion in 2009-10, of which about $2b was directly attributed to dementia. Of this latter amount, $1.1b was spent on permanent residents in residential aged care facilities and $408 million on community aged care services. The AIHW also released its report on Residential Aged Care which gave a snapshot of the sector which is already shouldering the burden of our changing demographics. There were 2,163,500 Australians aged 70 and over as of June 30 last year, 9.2% of them living in WA. The over 70s mostly lived in the major cities (66%) and a further

32.7% lived in inner and outer regional towns and cities. Just 1% and .3% lived in remote and very remote areas.

Life expectancy As of June 30 last year, 169,000 people were living in residential aged care, of which 77% were aged 80 and over. The difference in life expectancy between men and women was also evident with 70% of the permanent residents being female many of them widows (64% compared with 26% of their male counterparts.) The number of operational residential aged care places has grown since 1995 to 185,482 at 30 June 2011 – 2553 more places (1.4%) than the previous year. There were 2760 facilities providing care, with the majority (60%) of service providers being not-for-profit. Income for a large proportion of permanent residents (89%) was derived from a government pension, either from Centrelink (72%) or the Department of Veterans’ Affairs (17%). Self-funded retirees comprised just under 9% of permanent residents (9% of females and 8% of males. O medicalforum


Feature

Noeline says that her ambassador’s role has less to do with aged care and more about encouraging older people to live active, independent lives but she admits that as Baby Boomers age it will be a hard audience to please, and, not surprisingly for a woman who has spent most of her life making people laugh, she thinks humour has a big role to play in the aged-care environment. “I have seen some ordinary activities in some facilities when good quality entertainment can be so beneficial. The Humour Foundation is pretty good at getting the message across and I’ve heard some wonderful stories where technology is making a huge difference.”

There Should be More Togetherness The signature tune of the legendary Mavis Bramston Show lauding togetherness has become the mantra of one of its stars, Noeline Brown. Noeline Brown has spent the best part of five decades making us laugh. She was at the vanguard of a fledgling Australian television industry creating and appearing in shows such as The Mavis Bramston Show and later on stage and small screen with The Naked Vicar Show and in Graham Kennedy’s crazy celebrity game show Blankety Blanks. And her theatre credits are long and illustrious. But there’s a serious side to Noeline. Born into a strong unionist family in Sydney’s inner west, she had a long-held desire for a political life which spilled into a couple of tilts at a seat in the NSW parliament. While both attempts failed, her desire for service has now manifested itself in the role of the Ambassador for Ageing, which she took up four years ago with the DoHA, just a few weeks shy of her 70th birthday. She has just started her second four-year stint and says she’s totally committed to her role promoting a healthy, active life to the thousands of older Australians she meets as she travels across the country. “Staying fit and healthy and keeping connected to the community may sound like motherhood statements but often people who find themselves on their own have the attitude that ‘it’s only me’, so they don’t look after themselves. So I stress the medicalforum

I have seen some ordinary activities in some facilities when good quality entertainment can be so beneficial. importance of considering yourself as a VIP and someone to be looked after.” “I hope I’m also raising the profile of older Australians so the media starts portraying them more postively. Most older people are still involved in some activity, whether they’re still working or volunteering. They’re still out there doing stuff.” She cites the University of the Third Age in Ballarat, which recently celebrated 25 years in that city, as one of the most inspiring things she’s seen. “There’s no such thing as an age barrier there, it is run by a most vibrant group of people with courses that range from the lighthearted to really serious study. I have also just come back from opening an exhibition of art and photography done by people with dementia. For some, it was new skills learnt, for others, it was maintaining their craft. The message is simple: encourage people to explore what they can do. Even after diagnosis of dementia, the world doesn’t come to an end.”

If there is one thing Noeline would like to say to younger Australia, it would be ‘Don’t forget about old people’. “There’s a tendency to overlook older people and there are a lot of negative stories about ageing. It’s my strong belief that people who are 65 today are nowhere near like 65 of the generation before them. They are better educated; they have more money behind them and they’re probably planning more than they did in the past because they could live to 100.” “The older people I meet are vibrant, more confident (I hear that a lot from women) and willing to get out and have a go. There’s still a lot of living to do.” So does Noeline Brown practise what she preaches? Well if you take in the fact that she and fellow Mavis Bramston alumnus Barry Creyton still put on two-hander plays, her role as chair of the Actors Benevolent Fund is challenging and the children’s charity of which she is patron is engaging, her public life is active and healthy. At home she has a dog to walk and living in the Southern Highlands of NSW, there are a few mountains to climb, literally. “We live on a mountain so we walk up and down until we are really really puffed and that’s our daily exercise.” The ‘we’ is husband of 36 years, former TV producer Tony Sattler. “We have a pretty good relationship. We still like each other” but Noeline acknowledges that many older women she meets are on their own. “That makes it even more important that older people maintain their connections to friends, family and community. We have to look out for each other. I ring my two brothers every day of my life. Things can go wrong unless we keep connected and plan for the unexpected.” O

By Ms Jan Hallam 23


Feature

Investing in the Next Generation of GPs The art of teaching general practice is no less than teaching the art of healing, for which Dr Rohan Gay shares some inspirations of his own. He started teaching medical students four years after gaining his FRACGP, and his first WAGPET registrar five years later, in 2004. This was only after Dr Rohan Gay had become comfortable with the complexities of general practice and its context for him as he aimed for the best care possible. Only then did he feel he had enough skills and experience to pass on to others. From his Walter Road East practice he currently teaches and mentors UWA medical students, supervises and teaches WAGPET registrars, and is an examiner in the RACGP OSCE exams. He clearly gets a buzz from teaching.

The Pros “The most compelling reason to teach is to pass on the type of practice, values and standards one believes in,” he said, adding that he sees GP registrars apply these ideals to managing patients in his practice and beyond. It’s a two-way street though. “Teaching is as much a learning experience. It’s a more powerful incentive than any CME activity to practise up-to-date evidence-based medicine. There is a wealth of clinical support material, from online resources like Therapeutic Guidelines and medical libraries to training aids such as models and video equipment, all available through the regional training programs.” Over time, Rohan’s patients have become more complex, with chronic conditions. This can be mentally draining. Teaching gives some respite from the daily grind while extending care to these patients through his registrars, who incidentally maintain his exposure to the more acute and simpler problems. He sees that the whole practice benefits. “In spite of the increased responsibilities, there is noticeably more pride held by the nurses and staff. They know they can make more of a difference and as a result, we have very low staff turnover and I believe they are more highly skilled than staff of nonteaching practices.” “Medical students and registrars often bring skills with computers, information technology and even therapeutics to the surgery. They can help shame existing doctors into improving their typing skills!” Rohan admitted, adding that experiencing their skills first hand is a good way to trial and recruit doctors. 24

“Teaching allows greater input and scrutiny into the type of doctor you are hiring. The registrar also gains a much better insight into the practice they have chosen, better than from a simple interview.” Of course, there are inevitable generational differences. “I remember when I was a resident you were expected to work long hours and push yourself in training, almost as a rite of passage. Newer graduates are much more aware of self-care and less likely to want to work full-time and set firm limits on overtime, after-hours work and income expectations.”

Teaching forces those who teach to re-evaluate and adjust their practices in the context of this new era, make the necessary changes, and pass on this experience to the next generation of doctors.

“It can be challenging to explain that, from perspective gained by experience, we are serving the public and overtime and after hours work are a necessary part of the profession, as is consideration of our patient's socio-economic status. Of course, when we point out that Medicare says ‘after hours’ means 8pm to 8am, the job is that much harder!”

The cons Time is money in general practice. This presents an immediate dilemma for Rohan who believes good teaching takes time and should be added to normal patient contact time. Teaching may not appear to make economic sense, but there are considerations beyond money. Any GP has to balance care for the registrar or student with care for the patient, and try and engineer situations where both are enriched. “Teaching registrars can be nerve-racking, particularly when it comes to working out how much responsibility to give them. They are just passing through your surgery but they are treating your loyal, long-term patients who need to feel confident. Be prepared for plenty of calls for support and to be worried when you aren’t called!” The teaching team has to include other staff members. “Nurses are an extension of the supervisors as clinical teachers and monitors of clinical performance. Practice managers and reception staff are important for everything from MBS interpretation, time management and patient feedback, among other things.”

Important adaptations for teachers? Rohan’s first may seem a bit confronting. “To be a good teacher one first has to be comfortable with one’s own values and standards of practice. You have to be clear in your own mind that you are practising in a way that you would like to see repeated by another doctor.” medicalforum


QAndrew Dunn’s My Kuti sailed in this year’s Doc of the Swan

He said do not expect to earn more and save time but expect to feel good. “Expect to gain a greater appreciation of the skills you may have taken for granted and the knowledge required of general practitioners. In so doing, expect to gain a greater sense of self-worth.”

Pressure for GP teaching placements As graduates increase, so does the pressure on placements. Rohan says adequate remuneration for teaching is essential. Parttime doctors find it particularly hard to justify teaching time in the hours they are able to work. “It is disappointing that so much has been spent on empty super clinics when many existing teaching practices have been overlooked for assistance.” Rewarding excellence and experience in general practice is returning as an issue as older patients present with more complex problems and expensive tertiary centres eat into health budgets. “The MBS with its rather coarse attendance item structure has encouraged the common approach of stripping consultation content down to the bare qualifying content and time criteria to maintain or maximise income at the expense of comprehensive care. Attempts to address quality through SIPs, PIPs, chronic disease items etc. reflect the low opinion in which general practice care has been held, while adding an unwelcome layer of complexity and yet more perverse incentives to manage item numbers rather than patients.” “On the other hand, the information revolution has empowered general practice

QDr Andrew Dunn’s daughters, Emily and Claire, enjoying a ride with Rotorvation Helicopters, a prize Andrew successfully bid for at the Charity Auction.

QMarcus Atlas at the helm of Brad Stout’s boat Men in Black with Brad and Brad’s son, James.

Doc of the Swan sets sail for 2013 Preparations for the 2013 Doc of the Swan are under way and we’re looking for boat owners to join the fleet for the annual charity sail and fun day. Prof Marcus Atlas, from the Ear Science Institute of Australia, got back on the water after a long hiatus at this year’s event at Royal Freshwater Bay Yacht Club, and now he has his eye fixed on a placing next year.

to practise with far more complexity and expertise; and to achieve far more in the way of patient care than ever before. Consults cannot become any shorter but we can achieve more in our consultations through the appropriate use of information technology.” “Teaching forces those who teach to re-evaluate and adjust their practices in the context of this new era, make the necessary changes, and pass on this experience to the next generation of doctors.” O

By Dr Rob McEvoy medicalforum

“I’ve been a sailor my whole life, since I was a kid. I stopped when I went to Sydney and I hadn’t managed to get back on to the water until Doc of the Swan this year after many years away from it.” “RFBYC was my old club. I used to sail all classes of dinghies there – from 420s, lasers to 470s – so I had a lot of fun going back. I was on Brad Stout’s boat Men in Black and we’re looking to do it again, but we have to improve our handicap!” “It was a great day seeing your mates in the casual sailing environment, though I noticed a healthy competitive spirit was kicking in by the end of the race. Everyone pretended they weren’t interested in who was going to win, but they were, really.”

“I had a lot of fun and it was a great cause.” Funds raised on the day from entry fees and an auction and raffle went to children’s charities associated with ConnectGroups. And while Marcus may not have come first across the line, he did successfully bid for a meal out at the celebrated Restaurant Amusé. Hills GP Andrew Dunn had a fun time out on the river is one of his boats, My Kuti, which he happily admits was one of the slowest of the fleet, but he may have to give his sleek carbon fibre trimaran a go at next year’s event. While My Kuti was a graceful finisher, on shore Andrew proved to be a fast and furious bidder in the charity auction, taking home an iPad, a Swan Jet Adventures prize and a helicopter joy ride with Rotorvation Helicopters. Andrew sent some phone snaps of his daughters Emily and Claire strapped up and whirring above the city. O

If you’re interested in being a part of the fleet for Doc of the Swan 2013, drop us a line at editor@mforum.com.au. 25


E-poll: Research

The Discovery-implementation Gap Translational research is the term various people, who are keen for tangible community outcomes use to gauge the success of research. In a recent press release, the NHMRC announced it was establishing a Research Translation Faculty, as a â&#x20AC;&#x153;new approach to identifying evidence-practice gaps and research prioritiesâ&#x20AC;?. The NHMRC CEO, Dr Warwick Anderson went on; â&#x20AC;&#x153;It is widely acknowledged that there is a gap between discovery and implementation of knowledge from research. This gap slows the uptake of the benefits from research, for patients and for the operation of the health system." He said closing this gap was a daunting task made worse by the huge volume of research and the need to change some commonly accepted beliefs and behaviours. About 7000 NHMRC-supported chief investigators or past fellows have been invited to join the Faculty, which will initially focus on two things: 1. Identify gaps between research evidence and health policy/practice within the NHMRCâ&#x20AC;&#x2122;s Strategic Plan 2013-15, and recommend action. 2. Call for targeted research in potential transformational areas. It remains to be seen if those involved can detach themselves enough to make difficult upstream research decisions rather than just call for more support around downstream research that passes their â&#x20AC;&#x2DC;translational testâ&#x20AC;&#x2122;.

What WA doctors think: Translational Research 3&410/%&/54"UPUBMPGEPDUPSTDMJDLFEUISPVHIGSPNPVSFNBJMFEJOWJUBUJPOBOE exactly 250 doctors then took the plunge and joined in our e-Poll within the seven days PGGFSFEUIFNBQMFBTJOHSFTVMU5IFNBLFVQPGSFTQPOEFOUTXBT(1T 4QFDJBMJTUT  %PDUPSTJO5SBJOJOHBOE0UIFS 5IFTFBSFUIFPQJOJPOTPG8"EPDUPSTPOUIJTUPQJD5PNBLFUIJOHTDMFBSFSGPSSFBEFST  we have highlighted those answers within a craft group that vary by 20% or more from the combined percentage. Editorial comments are added where thought important. 4VSWFZSFTQPOEFOUTXFSFHJWFOUIJTQSFBNCMFA5SBOTMBUJPOBMSFTFBSDIJTBUFSNVTFEUP define research that brings to the community a return on its investment, by improving QPQVMBUJPOIFBMUI8IJMFUIJTJTUIFBJNPGNPTUSFTFBSDIFST UIFQPUFOUJBMCMPDLBHFT to success increase the further back the research starts from the endpoint. There are both clinical and commercial barriers to overcome. Please respond to these statements regarding translational research.

Q

The community is justified in expecting a tangible benefit from money it spends on research.

Strongly agree Agree Neutral Disagree Strongly disagree

All 18% 52% 15% 14% 1%

ED. Around 70% of all doctors were in favour of a tangible community benefit from research, with no significant difference between craft groups.

Q

Completed research should receive a â&#x20AC;&#x153;community benefitâ&#x20AC;? rating from a skilled panel, much like we grade levels of research evidence. Strongly agree Agree Neutral Disagree Strongly disagree

Total GP 7% 5% 38% 41% 30% 34% 18% 14% 6% 6%

Spec DIT 11% 2% 34% 34% 24% 37% 21% 24% 10% 3%

ED. Specialists were least undecided and more prone to take extreme views on this question (either way). Our understanding is that likely community benefit is one criteria used by the NHMRC in awarding research funds. A â&#x20AC;&#x2DC;priorâ&#x20AC;&#x2122; and â&#x20AC;&#x2DC;afterâ&#x20AC;&#x2122; research rating might track performance?

bcells23653

C ncerned? We ensure you hear your patientâ&#x20AC;&#x2122;s treatment options. At Lions Hearing Clinics, our Master Degree qualiďŹ ed audiologists will give you an accurate picture of your patientâ&#x20AC;&#x2122;s hearing loss and its causes. Weâ&#x20AC;&#x2122;ll keep you informed of any steps taken â&#x20AC;&#x201C; be it the prescription of hearing devices or lifestyle changes â&#x20AC;&#x201C; or weâ&#x20AC;&#x2122;ll recommend onward referral pathways. As a patient focussed, independent provider, we strive to ďŹ nd the best treatment for your patientâ&#x20AC;&#x2122;s hearing loss and lifestyle. To make a referral visit lionshearing.com.au (resources)

26

medicalforum


Comment on how we translate research in WA into community benefits?

Q

If researchers cannot explain where their research is heading to help people, they shouldn’t be doing it. All 10% 38% 16% 30% 6%

Strongly agree Agree Neutral Disagree Strongly disagree

ED. DITs tended to be more neutral on this somewhat provocative question (28%) but otherwise no big difference between groups.

Q

Virtually all research into a clinical problem has equal value and expecting a community benefit could only stifle good research. Strongly agree Agree Neutral Disagree Strongly disagree

Total GP 2% 4% 29% 32% 29% 26% 36% 36% 4% 3%

Spec 1% 21% 32% 41% 5%

DIT 3% 43% 23% 26% 6%

ED. Experienced specialists were more likely to disagree with this statement.

Q

Research that has a commercial outlook will always lean towards the pharmaceutical industry. All 8% 35% 31% 23% 2%

Strongly agree Agree Neutral Disagree Strongly disagree

ED. Herein lies potential bias in research emphasis?

Q

The Busselton Health Study is one such research that has benefited the community – whatever the outcome the community involved does get a thorough check-up.

Evidence-based medicine is something we should aspire to.

Strongly agree Agree Neutral Disagree Strongly disagree

Q

All 35% 50% 11% 4% 0%

Research spending is mostly about maintaining the research facilities and people involved.

Strongly agree Agree Neutral Disagree Strongly disagree

All 3% 25% 32% 34% 5%

ED. Specialists more often ‘strongly agreed’ (5%) than did GPs (1%), otherwise there was no big difference between groups who divide up about a third each on the question of research ‘empire building’.

Q

Stop people’s egos and positions from controlling research and get back to the idea of finding knowledge and helping people. To avoid pharmaceutical company financial support problems, has the RACGP considered funding 'unprofitable' research itself? Set some key areas for intensive work and linkage from bench to bedside and community rather than piecemeal research without clear linkages. By making sure the researchers stay in close contact with the 'community', and by connecting the researchers with the practitioners, otherwise research is in danger of not being translated. Explore first community expectations and problems. Too many people decide what outcomes they want and design research to ensure that these are the outcomes! Cynical but true.

In WA, more good would come of research if people co-operated more instead of competing.

Strongly agree Agree Neutral Disagree Strongly disagree

Greater government investment in noncommercial research areas, rather than relying on drug companies.

All 24% 43% 26% 7% 1%

ED. Around two thirds of doctors thought greater co-operation between WA researchers was needed.

Often small unfunded or low funded research will have an impact on the community by providing evidence for small incremental improvement in care. I think the community does a reasonable job of translating research findings into practical outcomes. Unfortunately, state and federal governments are beholden more to business than community good and are often unable objectively to assess the merits of research findings. We fortunately have many community organisations that have taken on board many of these developments and are generously supported.

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27


Guest Column

Don’t Let Red Tape Sink NFPs WA Greens Senator Rachel Siewert is fighting for a strong, independent not-for-profit sector to ensure the health of the nation.

H

aving spent most of my career before going into politics working for a not-for-profit organisation and spending a lot of time with the charities and not-for-profit sector as part of my portfolio responsibilities for the Australian Greens, I have taken a keen interest in the Australian Charities and Not-for-profits Commission (ACNC) Bill currently before Parliament.

A vibrant and independent not-forprofit sector, or third sector as it is often referred to, is an essential cornerstone of a democratic and civil society. Throughout this debate, I’ve kept coming back to the key question – will this legislation support and develop this vibrant culture into the future? A robust sector is one which is grounded in transparency, accountability and independence, and the proposed reforms must lead to improvements in these areas. One of the key messages I’ve taken from consultations is that changes are needed to strengthen the independence of the sector so that organisations can’t be undermined by Government.

In 2007, I spoke out against the use of gag-clauses on not-for-profits through contracting arrangements and it alarming that five years on, we are still seeing this in similar clauses in Queensland. Inserting ‘gag-clauses’ into funding agreements undermines the effectiveness and independence of the not-for-profit sector.

organisations to report once to the ACNC rather than multiple times to different departments and governments.

The Australian Greens have recommended that existing Commonwealth legislation be amended to ensure contracts could not contain gag clauses, and that the Bills included in the ACNA package be amended to ensure that the governance standards cannot be used to prevent an organisation from advocating for its purpose.

Reducing red tape and not reducing accountability or transparency of charities and not-for-profits were key reasons behind the sector supporting the reform process. If they are not delivered, why should organisations support the so-called reform? We have recommended that the ACNC establish a timeline for reducing unnecessary regulatory obligations and report progress annually to Parliament.

It’s pleasing that since we made these recommendations, the Government has acted to address both areas of concern.

However, broader Government undertaking is needed beyond the direct influence of the ACNC in this area. We are also seeking to enhance protections around liability for volunteer individual directors of unincorporated entities.

The other amendments we have recommended target sections of the Bills where omissions or areas of uncertainty would see this legislation fall short of the mark. In particular, the introduction of governance standards and an external code of conduct, reducing red tape by allowing

There has been great willingness on the part of the not-for-profit sector to engage and consult throughout this process and in turn this sector needs to be adequately supported by Government, with the right checks and balances, to keep it as a vital part of our community. O

Consultations

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Email: info@heartcarewa.com.au 28

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Web: www.heartcarewa.com.au medicalforum


TRANSLATIONAL RESEARCH FEATURE

Brought exclusively to you by

Research aimed at community results P

rof Jonathan Carapetis now heads the Telethon Institute for Child Health Research. A paediatrician and infectious diseases specialist, he has relinquished his directorship of the Menzies School of Health Research in Darwin where he was able focus on the health of Aboriginal children, especially his clinical and research interests in rheumatic heart disease. We asked him to explain how TICHR research would translate into community benefits under his direction. â&#x20AC;&#x153;Take my special interest. Rheumatic heart disease is a big problem in the Aboriginal people in this country. Itâ&#x20AC;&#x2122;s a disease of poverty and of overcrowded housing and itâ&#x20AC;&#x2122;s a national shame that we have one of the highest rates in the world among Aboriginal people. Thereâ&#x20AC;&#x2122;s a whole lot of stuff we can do right now to reduce the burden of this disease based on what we already know,â&#x20AC;? he said.

community benefits has a lot to do with who is asking the research questions. â&#x20AC;&#x153;There needs to be much greater input from those who are delivering the services, making the policies and the people in the community who are benefiting. Iâ&#x20AC;&#x2122;m hoping to lead the way a bit more. Itâ&#x20AC;&#x2122;s everybodyâ&#x20AC;&#x2122;s business.â&#x20AC;? His rider is that we still need what he calls â&#x20AC;&#x153;discovery researchâ&#x20AC;? that may appear disconnected from immediate clinical outcomes, but it can happen within a framework where the ultimate drivers are still clinical questions.

â&#x20AC;&#x153;Therefore, a lot of the research I do is how we apply that evidence, such as getting treatment out into communities or better ways of identifying and treating children earlier.â&#x20AC;?

â&#x20AC;&#x153;Some of the divide between the ivory tower of research and the people at the coalface is artificial. Our researchers are already incredibly linked in with many service providers, with an enormous amount of collaboration but it happens despite the current set-up, not because of it,â&#x20AC;? he said, adding that most of what is done in hospitals is backed up by an enormous amount of research.

Some of his current projects give a good idea of how translational research works: t &WBMVBUJPOPGUIF/5.PCJMF1SFTDIPPM Program. t H&$)0oTDSFFOJOHGPSSIFVNBUJDIFBSU disease in school-aged indigenous children. t *NQSPWJOHEFMJWFSZPGTFDPOEBSZ prophylaxis for rheumatic heart disease. t "QJMPUUSJBMPGOVSTFMFE echocardiography for rheumatic heart disease in Fiji.

QProf Jonathan Carapetis

t .BTTBENJOJTUSBUJPOPGJWFSNFDUJOUP control scabies and strongyloidiasis in a remote Aboriginal community.

research (see page 26), 70% agreed that the community is justified in expecting a tangible benefit from money it spends on research. Prof Carapetis said he will work to reduce any empire building perception among WA doctors.

â&#x20AC;&#x153;At the same time we recognise there are gaps in our knowledge. For example, we need to develop a vaccine for rheumatic fever and understand the real mechanisms of the disease, such as the genetics and immune response. However, 80% of what we are doing is around things that can translate directly into health benefits tomorrow.â&#x20AC;?

â&#x20AC;&#x153;I think the answer is to change the way we function as research institutions to make it understood we are listening to the community and service providers and changing what we do to be more responsive to those needs. Itâ&#x20AC;&#x2122;s my job as director to get that message out there. Iâ&#x20AC;&#x2122;m a clinical researcher and I want to make sure clinicians are part of the team,â&#x20AC;? he said.

His predecessor Prof Fiona Stanley announced some time back that TICHR would be researching why particular interventions in Aboriginal health had failed, in effect how translation of research had failed. Prof Carapetis sees the value in this but wants to augment the understanding of what has not worked previously with a focus on doing new things in translation and evaluating them rigorously.

â&#x20AC;&#x153;We are trying to create the new style of research institute; I think we can do it, with translational research the driving force. The younger researchers are particularly supportive and anyone I talk to in the hospital or the broader community gets it. My basic scientists also need to understand they are part of this agenda â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s not about changing what they do in the labs but how the Institute operates within the community and sets its priorities.â&#x20AC;?

He wants results for the community, and he is not alone. Of 250 WA doctors polled by Medical Forum on translational

He said the Instituteâ&#x20AC;&#x2122;s primary performance indicators will hopefully reflect that emphasis, and translating research into

t *OUFSOBUJPOBMTUBOEBSEJTBUJPOPG echocardiography rheumatic heart disease.

medicalforum

â&#x20AC;&#x153;The point is we can more effectively integrate the researchers into the service provision environment. Practically, it means that pretty much all of our teams need to have clinicians as part of the team, and we need to be encouraging clinical researchers so their questions are being listened to and are part of our research agenda.â&#x20AC;? â&#x20AC;&#x153;My job as a leader is to show the researchers if they relax a bit about their own careers and research grants, that we as an Institute will help them find the funding and their careers will still flourish.â&#x20AC;? he said, adding that he envisages a more rigorous and accountable way for researchers to report how better health outcomes can flow from clinical research. Medical Forum thanks the Telethon Institute for Child Health Research for assistance in preparing this feature, made possible by an independent educational grant from Avant.

Avant is a leading provider of medical indemnity insurance for doctors and healthcare practitioners. T: 1800 128 268 E: memberservices@avant.org.au W: www.avant.org.au 29


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BENEATHthe Drapes X Last month the Australian Competition and Consumer Commission (ACCC) announced that it will not oppose the proposed acquisition by Sonic Healthcare Ltd of Healthscope Ltdâ&#x20AC;&#x2122;s pathology business in WA. However, the ACCC will oppose Sonicâ&#x20AC;&#x2122;s acquisition of Healthscopeâ&#x20AC;&#x2122;s Queensland operation. In September, Sonic terminated its proposal to acquire Healthscopeâ&#x20AC;&#x2122;s pathology business in NSW/ACT. X Dr Tobias Strunk from UWAâ&#x20AC;&#x2122;s Centre for Neonatal Research and Education has been awarded a $74,945 grant from Ramaciotti Foundations to explore the origin and development of antimicrobial proteins and peptides (APP) in premature babies and understand how these relate to the risk of life-threatening infections. Dr Alex Hewitt from the Lions Eye Institute has been awarded $70,000 for research into the genetics of glaucoma, the leading cause of irreversible blindness worldwide X The Boab Health Services in Broome has won the WA School of Psychiatry and Clinical Neurosciences Award for excellence in rural and remote mental health at the Mental Health Good Outcomes Awards. The Freedom Centre has won the WA Equal Opportunity Commissioner Award for human rights, equity and diversity in mental health. X Coral Bayâ&#x20AC;&#x2122;s sole health practitioner, Kristy Cooper, has been named WA's 2012 Nurse of the Year and UWA A/Prof Rosemary Saunders has also been recognised for her outstanding contribution to the education of nurses at the annual WA Nursing and Midwifery Excellence Awards last month. X Jane Reid is the new president of AAPM (WA). Jane is operations manager at Envision Medical Imaging. Narelle Supanz is the new treasurer and other committee members are Karin Tatnell, Dot Melkus, Kathy McGeorge, Sue Stark and Zoe Stevens. X Dr Neale Fong has been appointed managing director of the Peel Health Campus operated by Health Solutions (WA) Pty Ltd. X The NHMRC has awarded more than $1.7m for phase II of the Fremantle Diabetes Study being led by Prof Timothy Davis, Prof David Bruce, Dr Wendy Davis, Dr Stephen Chubb, A/Prof Philip Clarke, Prof Sergio Starkstein, Dr Daniel McAullay and Prof Paul Norman.

medicalforum


Medico-Legal

Help with Decision-Making When patients lose their capacity to make decisions, their doctors may be called on, says Ms Morag Smith, Senior Solictor with Avant in Perth.

A

n individual’s ability to make personal, financial and health care decisions can deteriorate with age or ill health. If they have planned ahead, a person may have an enduring power of attorney to make financial decisions and an enduring guardian to make personal and health decisions on their behalf if they lose capacity.

The importance of a decision-specific test for capacity was considered by the High Court which stated: “The law does not prescribe any fixed standard of sanity as requisite for the validity of all transactions. It requires, in relation to each particular matter or piece of business transacted, that each party shall have such soundness of mind as to be capable of understanding the general nature of what he is doing by his participation.” 3

However, what happens if a patient is diagnosed with Alzheimer’s disease or becomes incapable of making decisions due to illness or an accident and no such arrangements have been made?

In relation to medical treatment, a decisionspecific assessment should be conducted for each health decision.

In this situation WA’s Guardianship and Administration Act 1990 (the Act) applies and the State Administrative Tribunal (SAT) has power to appoint a guardian or administrator. Anyone with a ‘proper interest’ can apply for an order under the Act, including health professionals, but in most cases family members will apply. In any such application the issue of capacity is paramount.

What is capacity? Capacity refers to a person’s ability to make decisions. An individual is deemed to have capacity if they can understand the choices, weigh up the consequences and communicate their decision. Under the Act, a guardian may be appointed if a person is incapable of:  t MPPLJOHBGUFSUIFJSPXOIFBMUIBOE safety;  t VOBCMFUPNBLFSFBTPOBCMFKVEHNFOUT that relate to their person; or  t BSFJOOFFEPGPWFSTJHIU DBSFPS  control in the interests of their health and safety or for the protection of others 1

What is a doctor’s role in assessing capacity? If an application is made to SAT to appoint a guardian or administrator, you may be approached to prepare a report that will be taken into account by the Tribunal in deciding whether or not to grant the application. To prepare a report you will need to conduct a capacity assessment and the nature of the assessment will vary depending on the area of concern, for example the person’s ability to make reasonable decisions about their health, living situation or finances. The Attorney General’s Department of NSW has prepared a ‘Capacity Toolkit’ to assist heath-care workers and others to assess capacity. 4 While the toolkit deals with the legal tests for capacity in NSW, it also contains sample questions and tips for assessing capacity in each area of life and is therefore a useful resource for anyone conducting assessments in WA.

Health care and capacity

An administrator may be appointed if a person is unable to make reasonable decisions relating to their estate. 2

A patient’s ability to make health care decisions can vary. It is therefore important to conduct a capacity assessment each time treatment is given by asking the patient if they understand the nature and effect of the proposed treatment. A consent form signed days or hours before is not sufficient.

Because a person’s capacity can change over time and in different situations it is important to assess capacity each time a decision is made.

Whenever capacity is at issue it is important to make detailed notes setting out your observations of the patient, their response to questions and the basis of your decision.

If the patient subsequently challenges your decision, or makes a complaint to AHPRA, the notes will be invaluable. Additionally, before you start the assessment you should explain what you are doing and why and record the discussion in the notes. If possible, try to persuade the patient to co-operate with the process. 5 Where a patient lacks capacity to consent to treatment, the Act sets out a hierarchy of individuals to be contacted to make nonurgent treatment decisions for individuals aged over 18. 6 In the absence of an advance health directive, consent can be obtained from the first person in the list below who is 18 or older; has full legal capacity and is willing to make a decision:  t &OEVSJOHHVBSEJBOXJUIBVUIPSJUZUP make treatment decisions  t (VBSEJBOXJUIBVUIPSJUZUPNBLF treatment decisions  t 4QPVTFEFGBDUPQBSUOFS  t "EVMUTPOEBVHIUFS  t 1BSFOU  t 4JCMJOH  t "OVOQBJEDBSFS  t 0UIFSQFSTPOXJUIDMPTFQFSTPOBM relationship. If no one in the hierarchy is available, SAT may appoint the Public Advocate to act as guardian. Doctors play an important role in the process of supporting patients whether they have made plans or not. If a patient has an enduring guardian, enduring power of attorney or the Public Advocate is appointed, it is important to recognise that capacity fluctuates and that you should support the patient to make decisions on matters that are within their capacity to promote self-autonomy where possible. O References 1. Section 43(1) Guardianship Act 2. Section 64 Guardianship Act 3. Gibbons v Wright (1954) 91 CLR 423 at 437. 4. Capacity Toolkit: State of NSW through the Attorney General’s Department of NSW 2008. www.lawlink.nsw.gov.au/lawlink/diversityservices 5. Capacity Toolkit at page 63 6. Section 110ZJ Guardianship Act

Continued from Page 8 billions of dollar. With just a 3% increase in participation by the over 55s, Deloitte estimated there would be a $33b boost to the national economy; a 5% increase in participation would reap a $48 billion benefit. But an important first step is to challenge the stereotypes of older workers. medicalforum

“There is so much stereotyping of older people through our mass media. Research coming out of Yale University is showing increasing evidence that negative stereotypes of older people actually affect their health. If you are constantly being told you are incapable of doing things because you are old, it starts to become true.”

Having just turned 70 last month, Susan Ryan practises what she preaches. She is one year into her second five-year term as Age Discrimination Commissioner and shows no signs of slowing. “I’m totally committed to this cause, and when your committed to your work, it’s easy to get out of bed in the morning.” O

By Ms Jan Hallam 31


Guest Column

It All Started So Well... Geraldton GPs Dr Edwin Kruys and Dr Ian Taylor rue the demise of what was a workable solution to the aged care crisis in their regional town.

T

donâ&#x20AC;&#x2122;t always know the patients, inadequate examination equipment and unreliable computers.

wo years ago we proudly mentioned in this magazine that our practice had received state government funding to provide 24/7 nursing home care. The idea at the time was â&#x20AC;&#x2DC;to properly remunerate doctors to be on call, attend nursing homes residents after hours, and field clinical callsâ&#x20AC;&#x2122; It worked brilliant for a while, but things have evolved since then. Nursing home residents in Geraldton received 24-hour care by a small group of motivated GPs from our practice. A government grant also enabled us to provide an after-hours GP service until 9pm. Then, you guessed it, the funding was cut back. We had to pull out of the 24-hour nursing home service. Currently we are providing a stripped down telephone service only until 9pm. Next year the state funding will stop altogether and, unless the federal government takes over, nursing home residents with a health problem

funnyside e QQCaught Speeding Woman:*TUIFSFBQSPCMFN 0GGJDFS  Officer:.BEBN ZPVXFSFTQFFEJOH Woman:0I *TFF Officer:$BO*TFFZPVSMJDFODFQMFBTF Woman:*hEHJWFJUUPZPVCVU* EPOhUIBWFPOF Officer:%POhUIBWFPOF Woman:-PTUJUGPVSUJNFTGPS drunk driving. Officer:*TFF$BO*TFFZPVS vehicle registration papers please. Woman:*DBOhUEPUIBU Officer:8IZOPU Woman:*TUPMFUIJTDBS Officer:4UPMFJU Woman::FT BOE*LJMMFEBOEIBDLFEVQ the owner. Officer::PVXIBU Woman:)JTCPEZQBSUTBSFJOQMBTUJDCBHTJO the trunk if you want to see. The Officer looks at the woman, slowly backs away to his car, and calls for back-up. 8JUIJONJOVUFTGJWFQPMJDFDBSTDJSDMFUIFDBS A senior officer slowly approaches the car, clasping his half drawn gun. Officer 2:.BEBN DPVMEZPVTUFQPVUPGZPVS WFIJDMFQMFBTF The woman steps out of her vehicle. Woman:*TUIFSFBQSPCMFN TJS Officer 2: One of my officers told me that 32

QDr Ian Taylor and Dr Edwin Kruys

after hours will again be sent to the public hospital by ambulance. We're concerned about aged care. Our weekly rounds at the local nursing homes have become busy. Weâ&#x20AC;&#x2122;re rushing through long lists and for a variety of reasons weâ&#x20AC;&#x2122;re finding it increasingly difficult to provide good care. Problems include endless paperwork and forms to comply with nursing home accreditation needs, high turnover of staff, poorly trained staff who

you have stolen this car and murdered the owner. Woman:.VSEFSFEUIFPXOFS Officer 2::FT DPVMEZPVQMFBTF open the trunk of your car, please. The woman opens the trunk, revealing nothing but an empty trunk. Officer 2:*TUIJTZPVSDBS NBhBN Woman::FT IFSFBSFUIFSFHJTUSBUJPO papers. The first officer is stunned. Officer 2: One of my officers claims that you do not have a driving licence. The woman digs into her handbag and pulls out a clutch purse and hands it to the officer. The officer snaps open the clutch purse BOEFYBNJOFTUIFMJDFODF)FMPPLTRVJUF puzzled. Officer 2: Thank you madam, one PGNZPGGJDFSTUPMENFZPVEJEOhU have a licence, that you stole this car, and that you murdered and hacked up the owner. Woman:#FUDIBUIFMZJOHCBTUBSEUPMEZPV* was speeding too.

QQClassic one-liners #PSSPXNPOFZGSPNBQFTTJNJTUoUIFZ EPOhUFYQFDUJUCBDL *GXFBSFOhUTVQQPTFEUPFBUBOJNBMT XIZ BSFUIFZNBEFXJUINFBU 3. No one is listening until you make a mistake. )FXIPMBVHITMBTUUIJOLTTMPXFTU

There is no funding for staff meetings/ education with doctors, or provision of training that could be provided by visiting doctors. We used to have funded joint meetings between ACFs, which were excellent. The old Aged Care Panels were brilliant for this, alas defunct by this government. The start-stop funding makes it difficult to provide a sustainable community service. Unfortunately, at this stage, it does not look like our Medicare Local is going to fill this gap. Whatâ&#x20AC;&#x2122;s needed is proper funding of nursing homes â&#x20AC;&#x201C; thatâ&#x20AC;&#x2122;s a must, so they can provide trained staff and decent facilities. Recognition of the complexity of aged care through adequate rebates is also required and the after-hours care issues need to be resolved. Without these things, most GPs will give up on aged care â&#x20AC;&#x201C; defeated and disillusioned â&#x20AC;&#x201C; because it will be just too hard to provide proper care. O

$BNQFST/BUVSFhTXBZPGGFFEJOH NPTRVJUPFT 6. Always remember that you are VOJRVFKVTUMJLFFWFSZPOFFMTF $POTDJPVTOFTTUIBUBOOPZJOH time between naps. 5IFSFBSFUISFFLJOETPGQFPQMF those who can count, and those who DBOhU 8IZJTBCCSFWJBUJPOTVDIBMPOH XPSE 10. Change is inevitable, except from a vending machine. -BVHIBMPOFBOEUIFXPSMEUIJOLTZPVhSF an idiot. 4PNFUJNFT*XBLFVQHSVNQZPUIFS UJNFT*MFUIFSTMFFQ 13. The severity of an itch is inversely proportional to the ability to reach it. :PVDBOhUIBWFFWFSZUIJOHXIFSFXPVME ZPVQVUJU 8FBSFCPSOOBLFE XFU BOEIVOHSZ Then things get worse. *GBUGJSTUZPVEPOhUTVDDFFE EFTUSPZBMM the evidence that you tried. *XPOEFSIPXNVDIEFFQFSUIFPDFBO would be without sponges. 18. Nothing is fool proof to a sufficiently talented fool. 0OUIFPUIFSIBOEZPVIBWFEJGGFSFOU fingers. )VNQUZ%VNQUZXBTQVTIFE

medicalforum


Guest Column

Harnessing the Power of the Mind Dr John McCarthy reflects on how he has seen beliefs influence results in clinical practice, and how the power of the mind steps outside conscious beliefs.

M

ignored by the profession. Thus the placebo must be the road we take to reach the switchboard located in the subconscious.

Belief manifests in bizarre ways. In a recent study of a new chemotherapy, 30% in the control group lost their hair because they anticipated this. Could a placebo, suitably marketed and acclaimed, mobilise the power of the mind to do the opposite, grow hair on a bald head?

Quite a number of prescription medications also act primarily as placebos. Doctors prescribing antibiotics for colds and sore throats, with rapid and successful outcomes, owe this to the placebo effect.

ind-body therapies are united by belief, a two-tiered expectation at a conscious and subconscious level. The latter is by far the more important. Infiltrating this level so new health-giving persuasions can be implanted and negative ones removed is the key to harnessing the power of the mind in clinical practice.

Years ago in Ireland, my nursing sister took it upon herself to accompany the sick to Lourdes. On many occasions she noticed that the apparently most devout were not always the ones to emerge from the waters restored to health. Many scoffers who openly displayed their disbelief in the Lourdes experiment, pressured by relatives and friends and forced to make the pilgrimage, were relieved of their ailments muçh to their astonishment and the surprise of bystanders. Here, clearly demonstrated is the two-tiered power of the mind. The trick would appear to be to bypass the censorious discernments of the conscious mind. Hypnosis, a remarkable infiltration technique to achieve this result, is largely

Practice Tips

Grooming the patient for a placebopowered resolution of health problems may serendipitously occur the moment they enter the room. If they like what they see, staff are empathetic, and they form an easy positive rapport with the doctor, a cure is almost certain.

The trick would appear to be to bypass the censorious discernments of the conscious mind. Embellish the expected response to your scripts. Even if one is off target, when the client believes in you and the medication, they will be well. However, the fire walkers of Fiji not only escape fatal burns but the flannel garment they wear fails to ignite. The power of the mind is the protector of the earth. A man who worked in Fiji told me he witnessed the fire walking ceremony; his curiosity was such that he edged as close to the trench as he

dared, then threw a copy of the Fijian Times, which caught fire in mid-air. During 1981-85 my job was expatriate MO at a mine in Soroiako in South Sulawesi Indonesia. Amongst many strange stories, this incredible one was confirmed by my colleagues. The people of the Trobriand Islands engage freely in pre-marital sexual relations but pregnancy is virtually unknown until after marriage. No contraceptives are available. The implication is that unmarried women, by the power of their minds, postpone conception before they marry. Something similar goes on in our society â&#x20AC;&#x201C; married couples, barren for years, fall pregnant after adopting. The power of the mind. Years ago in Ireland, a country doctor in a small town was achieving an inordinate number of miraculous healings. Other doctors in the area hated and envied him. The Roman clergy looked on with interest and perhaps some suspicion. In a stroke of genius, this chap went to Rome and secured a blessing from no less than the Holy Father. In a trice, his critics were silenced, the clergy proclaimed him one of theirs, and henceforth every operation he did, every utterance he made, and every script he wrote was powerfully permeated by the power of religious belief. What a handsome dividend from his visit to Rome â&#x20AC;&#x201C; lifetime access to the placebo effect. O

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33


Guest Column

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

Medical Director Dr John Yovich

5 Million IVF children Jarrad celebrates 30 years At the ESHRE meeting in Istanbul in July this year, Chairman Dr Anna Veiga declared there were now more than 5 million children born worldwide from IVF. )URPZLWKWKHELUWKRIWKHĂ&#x20AC;UVWFKLOG/RXLVH%URZQLQ(QJODQG then a Scot Alistair MacDonald six months later, followed by Candice Reed in Melbourne in 1980 then Elizabeth Carr in the USA in 1981, pregnancies were initially infrequent and hard-won. Nowadays slickly managed IVF programmes generate regular high rates from both fresh and frozen embryos; at least in those women under 40 years. :HVWHUQ$XVWUDOLD¡VĂ&#x20AC;UVW,9)FKLOG-DUUDG&DUWHULVWKRXJKWWREHWKH 7th IVF success in the world, born July 13, 1982 and was reported in the medical journal Lancet that year because of the unique stimulation schedule. His mum had lost both fallopian tubes from consecutive ectopic gestations and was treated in a minimal stimulation protocol followed by laparoscopic egg retrieval. Given the shoe-string budget for this early programme, we regarded the result as amazing! Jarrad and his parents have lived in the limelight with write-ups in the West Australian newspaper and accept the honour of public exposure for this seminal event. They have kindly given me permission to write this article and display Jarradâ&#x20AC;&#x2122;s picture with his two naturally conceived children. We are all pleased to report that Mum, Dad, Jarrad and his family enjoy excellent health and bear no detrimental effects from the IVF protocol and procedures.

Aged Care Can Play a Major Role In the difficult times ahead for an ageing population, CEO of Amana Living Mr Ray Glickman says itâ&#x20AC;&#x2122;s imperative for all sectors to work together.

I

tâ&#x20AC;&#x2122;s a tough time for aged care, particularly in Western Australia. For various reasons, older Australians have been unwilling or unable to exercise their political power and, as a result, the Federal Governmentâ&#x20AC;&#x2122;s latest reform package will deliver precious little in terms of additional resources. Nevertheless, aged care providers will continue to re-invent themselves to ensure relevance for the impending wave of baby boomers. The trends will see a significant ramping-up of in-home care. Associated with that, there will be a greater understanding that aged-friendly housing will become the cornerstone of older people being able to stay put to the end of life rather than have to contemplate some form of institutional care. Progressive providers are increasingly focusing on helping older people to stay well and get well. As an example, at Amana Living we see our role as helping older people live every age and stage of their lives to the fullest by providing fulfilling and enriching activities, and by early intervention for people who have been newly diagnosed with dementia. Although aged care appropriately operates from a social rather than a medical model, its links to the health care system are undeniable. Regrettably, a high level of co-operation and coordination remains elusive. Delays in referral and assessment services persist, leaving many older people anchored in a hospital bed or marooned at home without appropriate support. Unfortunately, these system failings spell â&#x20AC;&#x153;dis-ablementâ&#x20AC;? for the elderly rather than the â&#x20AC;&#x153;re-ablementâ&#x20AC;? we are all seeking. Similarly, despite some impressive pilot studies and return-home initiatives, the aged-care sector is structurally under-resourced to be able to provide the level and scale of clinical care needed to prevent acute admissions and allow early return home from hospital. In WA there are excellent examples of services that bridge this gap, but my emphasis here is on the word â&#x20AC;&#x153;structuralâ&#x20AC;? and my point is that the aged-care sector as a whole needs to be resourced so that it can fill this gap.

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There is much talk about the role that the aged care sector can play in sub-acute care. My impression is that much is said but little is done by way of a strategic approach. Part of the problem is the usual Commonwealth and State divide. But that is not all of it. I fear that the Commonwealth and State Governments alike underestimate the capability of the aged-care sector to play a major role in health care. Thatâ&#x20AC;&#x2122;s a shame because we can and do deliver. O

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Teamwork

Driving Systems Change in ED Coordinating a trauma team is not unlike the split second team work required in a Formula One pit crew, so Dr Ken Catchpole PhD put the two together. way around. We’ve looked at the work and decided what the problems are – what the clinicians are doing well and what they’re struggling with, and then we work backwards and look for ways to help.”

When Dr Ken Catchpole heads to Perth for the WA Health Conference next month he will come with intimate knowledge of how hospital emergency departments and Formula One pit crews use solid teamwork to avoid mistakes that could be catastrophic. The research psychologist is a great lateral thinker who has used his varied research experiences from inside F1 pits to weapons detection at UK airports to make clinical settings safer. He is currently at the Cedars Sinai Medical Centre in Los Angeles researching quality improvement, teamwork and human factors in trauma. “I’m leading a research team which is looking into why errors happen and creating systems to make them less likely to happen in the future. Errors are not about bad people, they are about things that go wrong, so my work looks at redesigning systems to get the best out of people.” At Cedars Sinai, Ken is focusing on the first 90 minutes of a patient’s exposure to the ED. While acknowledging that emergency departments are prone to the unexpected, he insists that the only thing a well-run ED can’t control is the patient. “You can have control of everything else. Our work in LA focuses on a number of aspects – handover of care teams, teamwork and leadership design and process. In that first 90 minutes there are a lot of people drawn into a case – a lot of people are involved who need to be consulted. The patient will go off to imaging, ICU or surgery and our research is looking at the process and hiccups that happen along the way.” “The crucial component is coordination – how you coordinate all those different people, physically, geographically and timewise,

to get them working together and sharing information with the right people at the right time.”

“Technology on its own is only a partial solution. Most of our work is based not on what people tell us (because that’s unreliable) but by observing and following a trauma patient’s passage through the system. Researchers count the number of interruptions and they look at the team work and miscommunications, the difficulties and make a note of the equipment that’s not available or not working.”

Like most systems, Ken says it starts with a simple idea and in this case it was the ubiquitous whiteboard. The uncertainty of ED is minimised when all the teams are alerted to what they can expect.

“These observations give us a picture of the multitude of ways we can improve our system. Technology is the last consideration because it needs to be designed with the user in mind, not the other way round.”

“When a case was reported in the past it would be usually be by word of mouth, so the first thing we did was put in a white board. Now more people had access to the information. There was more certainty and departments, such as imaging, could plan around a case. Then we looked at replacing the whiteboard with a computer, which gave even more people access to the information.”

While Ken’s work has been focused on health care delivery for nearly a decade he has drawn on the his research in other industries such as the high-intensity work by pit crews because “people are similar wherever you go”.

“Having specific information meant a smoother process for the patient through CT or the operating theatre. It also reduces the toing and froing between the trauma team, which reduces the time factor. Better information means more timely decision-making and less interruptions and distractions and minimising the capacity for error.” “These things only seem simple once you’ve done the work to find out what the problems are. Our world is full of technologies looking to solve something but this is the opposite

“It’s the same principles – looking at what was going wrong, why it was going wrong, taking technology and tools and integrating into improved performance.” He took those lessons to the Great Ormond Street Hopsital in London to improve high-risk handover in surgery. “What makes a F1 driver good at their job is similar to what makes a surgeon good at their job. It’s slightly different emphasis and different skills but essentially it’s all about people.” Dr Ken Catchpole is a keynote speaker at the WA Health Conference, which runs November 15-16. For info http://www.health.wa.gov.au/ wahealthconference/home/index.cfm'. O

By Ms Jan Hallam

Medical Forum's LAST DAYS to lodge

2012 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 2012 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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CLINICAL UPDATE

Hepatitis C update R

esponse-guided therapy using combined pegylated interferon and ribavirin in chronic hepatitis C (HCV) is being superseded by regimes associated with higher sustained virological response (SVR), particularly in patients with genotype 1. Interferon-free regimes are rapidly becoming reality and it is likely that most patients with HCV will achieve a ‘cure’ in the near future, using therapy regimes of shorter duration and minimal toxicity. Ongoing clinical trials aim to improve outcomes.

Direct antiviral agents The use of first generation direct antiviral agents (DAA), telaprevir and boceprevir (protease inhibitors), in combination with pegylated interferon and ribavirin (triple therapy) has increased SVR from 50% to over 70% in treatment-naïve HCV genotype 1patients.1,3 Patients who failed previous therapy have variable response with highest SVR in patients who relapsed (75-88%), and poorest response in patients who did not achieve an adequate response (30-34%). 2,4 Treatment regimes are complex, with different treatment duration for DAA (telaprevir only for the initial 12 weeks while boceprevir therapy is throughout weeks 4-28), and different virological cut-offs and stopping rules. Treatment-experienced patients are likely to require treatment for 48 weeks. Treatment monitoring is more intensive due to increased toxicity – boceprevir is associated with anaemia and dysgeusia (unpleasant taste) and telaprevir with rash and bone marrow suppression. Preliminary results in patients with cirrhosis, particularly

By Prof Wendy Cheng, Head of Liver Service, Royal Perth Hospital

those with portal hypertension, have shown increased risk of infection and mortality. These drugs are approved in the USA and EU but not in Australia as yet. In a recent small study of difficult-to-treat patients (previous null-responders), SVR of 100% can be achieved with the use of two DAA (declastavir and asunaprevir) in combination with pegylated interferon and ribavirin (quadruple therapy).5 This is yet to be confirmed by larger studies. Several second generation pan-genotype DAAs are currently under investigation.

Interferon-free regime

Pegylated interferon Lambda

Drugs acting on different parts of the HCV life-cycles are currently being studied. It is likely that using multiple drugs in treatment regimes will increase toxicity and perhaps limit clinical use. O

It is likely that patients who had previously failed standard of care could require interferon in subsequent regimes. Pegylated interferon Lambda (λ) is not associated with systemic toxicity (including bone marrow suppression) seen in conventional interferon therapy because the interferon-λ receptor is largely restricted to hepatocytes. In preliminary studies, combined with ribavirin, it is also associated with a higher SVR in patients with hepatitis C genotype 1.

Preliminary data from a small number of patients treated with GS-7977 used in combination with ribavirin has shown very promising results with treatmentnaïve patients achieving a SVR of 100% in genotype 3 patients and 90% in genotype 1 (with 12 weeks of therapy and no significant toxicity observed). Larger studies aim to confirm the preliminary results and regimes for treatment-experienced patients are under investigation.

Other drugs

References 1. I Jacobson et al., N Eng J Med 2011; 364:2405-16 2. S Zeuzem et al., M Eng J Med 2011; 364:2417-28 3. F Poordad et al., N Eng J Med 2011; 364:1195-206 4. B Bacon et al., N Eng J Med 2100; 364:12-7-17 5. A Lok et al N Eng J Med 2012; 362:216-24

Liver transplantation in WA I

n 1992, the first liver transplant was performed in WA and with an increase to 11 transplants two years later, the state's adult liver transplantation service was initiated at Sir Charles Gairdner Hospital (SCGH). Since then, liver transplants have averaged about 17 per year (variation 6 to 24 p.a.). While transplantation for end-stage liver disease is life-saving, it is limited primarily due to donor shortage. The best preventative efforts at this time are to minimise alcohol intake and screen the at-risk population for Hepatitis B and C.

Over the years, the transplant list has seen a rise in cases of Hepatitis B and C, and primary liver cancers along with alcohol liver disease. Now and then, patients with primary sclerosing cholangitis, nonalcoholic steatohepatitis, Budd Chiari or Wilson's disease also show up on the list. WA's clinical outcomes and success rates for liver transplantation stand at around 85% for a five-year survival. The number of patients who may benefit from a transplant far exceed the donor organs available; so transplants are primarily offered to patients with end-stage liver disease and those expected to have a reasonable active lifestyle post transplantation. There are between 12 and 14 adults on the WA waitlist at any given time. The Transplant Society of Australia and New Zealand has set both transplant eligibility criteria and protocols for allocation of organs so that the maximum number of medicalforum

By Ms Shoma Mittra, WA Liver Transplantation Service, SCGH.

patients benefit while exercising ‘responsible stewardship of the community's health care resources’ (see www.tsanz.com.au).

hepatitis B or C will go to a recipient who already carries that infection.

Recipient selection

Rejection, both acute and chronic, are relatively uncommon today; and if they occur are easily controlled with medication. Recurrent HCV infection is a leading cause of graft loss and need for retransplantation. Given the critical organ shortage, retransplantation (for hepatic artery block, portal vein thrombosis, or suchlike) is offered after careful consideration and happens at SCGH about once every other year. The population-size rise in primary hepatocellular carcinoma is concerning as is the ever increasing epidemic of hepatitis C, with about 16,000 new cases of HCV in Australia each year of which we are able to treat only about 3,500. O

Primary liver cancer, Hepatitis B and C, alcohol liver disease and autoimmune hepatitis are the most common indicators for orthotopic liver transplantation, accounting for 40-50% of individuals on the waiting list and those who have undergone transplantation. When a donor becomes available, it becomes a case of matching the donor organ to the recipient list using three main criteria. The most important is ABO blood group matching. The physical size of the liver is also taken into consideration while the third criteria is checking for underlying disease; mainly Hepatitis B or C in the donor liver. While hospitals will evaluate all potential liver donors for evidence of infection, cancer, or drug abuse, a donor liver infected with

Future concerns

ED. The author acknowledges the assistance of Medical Director, Winthrop Prof Gary Jeffrey and Clinical Prof George Garas. 37


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CLINICAL UPDATE

Arthroscopic rotator cuff repair

By Dr Sven Goebel, Perth Shoulder Clinic, Claremont. Mob 0477 222 234

O

rthopaedic surgery has been advanced by arthroscopic techniques, including shoulder surgery – arthroscopic subacromial decompression in the early 1980s to treat impingement and arthroscopic stabilisation for recurrent shoulder dislocations in the 1990s. In the past 10 years, arthroscopic rotator cuff repair has progressed due to advances in implant and instrument design.

Patient characteristics

Operative pointers

With ageing comes joint wear and tear The surgeon has the ability to see and and loss of elasticity in tendons. An work on both sides of the cuff (inside estimated 30% of people over age of 40 and outside the joint capsule, using the and 80% of people over the age of 60 have arthroscope in Normal Saline under rotator cuff tears. Not all of these tears pressure) and to visualise all pathology are symptomatic. The most common (such as the superior labrum, anterior and mechanism of injury is impingement posterior tears, biceps involvement, and syndrome followed by shoulder instability osteoarthritis). and trauma. In the older patient a Typically, 3-4 incisions each 3-7mm combination of degenerating tendons long are made for a rotator cuff repair. and impingement with the acromion Operating with the patient in the sitting slowly wearing the tendon are the most position (beach chair) presents a more common cause of cuff tears. These occur anatomical position of the shoulder, in this order of frequency: supraspinatus, which improves access to all parts to the subscapularis, and infraspinatus tendons. shoulder, especially the subscapularis In most cases in this age group, the tendon tendon, which is a commonly affected is partially or completely avulsed from its tendon in rotator cuff injuries. bony attachment. The basic aim of surgery is to restore the Symptomatic full-thickness tears in rotator cuff tendons to their anatomical the active patient should be addressed position, which enables normal shoulder as soon as possible to minimise pain, function. avoid shoulder dysfunction and in some To re-attach an avulsed tendon, bone cases the development of rotator cuff anchors that have sutures attached are arthropathy, which eventually leads to screwed into bone, then the sutures osteoarthritis. Partial thickness tears >50% threaded through the tendon before of the thickness of the tendon should be tightening brings tendon and bone surgically repaired due to the higher risk together to heal (see pictures). of progression to a full-thickness tear. A big technical advantage with Typical symptoms are weakness of arthroscopic cuff repairs, compared to arm movement especially on overhead the open technique, is that subscapularis activities, pain in the night, or in severe cases a ‘peudo-paralytic shoulder’, which is QLarge supraspinatus tendon tear (upper glossy tendon, gap due to tears in combination with other injury can be treated without the need for a much the loss of any meaningful arm movement. tear, and humeral head below). Non-absorbable sutures attached larger and/or additional anterior incision, to bone anchors are pulled tight so that tendon is repositioned on Injury history may be absent, subacute thereby avoiding an additional complexity. bone, where it can heal. (months), or acute but any suspicion of a It is this ability to address multiple cuff tear requires a plain X-ray (to look pathologies in one operation that gives for global abnormalities) and imaging that arthroscopic repair an apparent advantage. A number of studies have shown that provides added information. Ultrasound arthroscopic cuff repairs are not inferior Another example is recurrent shoulder scans are frequently requested to assess the to open repairs and long-term outcomes dislocation in the older patient. Very rotator cuff but there is a large variance in are the same. Both are a learned skill and often, not only is a deficient capsulo-labral their value because of operator dependance. subject to operator influences. The excellent complex encountered but a rotator cuff tear An MRI scan is the preferred imaging direct visualisation from arthroscopy, plus is more likely. modality due to the higher specificity and experience with using highly specialised sensitivity. Through an arthroscopic technique the instruments, allows versatile joint access and skilled surgeon can address both pathologies Arthroscopic repair explained repair. A good example is how direct vision in one operation (which is difficult or The patient benefits from arthroscopic repair allows a more controlled capsular release to impossible in one sitting with an open are well known: be performed, removing adhesions intra- and technique). O extra-articularly. All tissue planes between t MFTTQBJOBOENPSCJEJUZ  muscle, tendon and bone can be accessed t TNBMMFSTDBST  and released in this manner with less risk of t JODSFBTFESBOHFPGNPUJPOEVSJOHFBSMZ damaging neighbouring important structures. rehabilitation, and Patient selection for either arthroscopic or Competing interests: Bethesda Hospital has t MPXFSJOGFDUJPOSBUFTBOEXPVOE  open techniques is the same, although more contributed towards the cost of this clinical update complications. active younger patients particularly benefit through an independent educational grant to Medical Forum. from an all-arthroscopic rotator cuff repair due to the reduced postoperative pain and quicker return to normal activities.

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Customer Service â&#x20AC;&#x201C; Terri Sedgman Tel 0425 124 576

40

medicalforum


Bariatric Surgery: â&#x20AC;&#x2DC;A game changerâ&#x20AC;&#x2122; in type 2 diabetes E

ver since the US bariatric surgeon Walter Pories published a landmark paper in 1994, Who would have thought it? An operation proves to be the most effective therapy for adultonset diabetes mellitus, bariatric surgery has challenged the notion that â&#x20AC;&#x2DC;once a diabetic, always a diabeticâ&#x20AC;&#x2122;. This paper showed the astonishing results that the widely practised bariatric operation gastric bypass led to patients being cured of diabetes mellitus in nearly 90% of cases. Blood sugar levels stayed normal several years after the operation. His assertions proved to be both prophetic and accurate. Over the past 18 years, a large number of studies have confirmed that there is improvement in nearly all, and resolution in the large majority of, obese patients with type 2 diabetes mellitus who have had any form of bariatric surgery resulting in weight loss. Usually this effect is quite dramatic and occurs before a significant amount of weight loss. There is a complex interplay between the fat cell, the pancreas, the liver and enterokines in the gut, which see a reduction in insulin sensitivity and the hyperinsulinaemia that is the hallmark of type 2 diabetes. We all know that weight loss or simply caloric restriction favourably impacts on this pathophysiology but there also seems to be additional mechanisms for which bypassing the proximal gut (as in the gastric bypass and BPD style of operations) switches off diabetes immediately after surgery. The patientsâ&#x20AC;&#x2122; oral GTT will be non-diabetic even before they have lost any weight. Operations have been devised that produce a bypass of the proximal gut without any reduction in gastric size and this produces resolution of diabetes even without much weight loss in low BMI diabetics. In the sleeve gastrectomy, where there is paradoxically more rapid gastric emptying, the higher solute load delivered to the proximal gut also seems to have a favourable impact on enterokine balance. In addition there is a profound reduction in ghrelin that not only reduces appetite but also improves insulin action. The resolution rates of diabetes depend on: 

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After many years of diabetes the pancreas gland may have become exhausted and even though the reduction of fat mass restores insulin sensitivity their body may simply not be able to produce enough insulin.

By Dr Leon Cohen, Bariatric Surgeon, Mercy Bariatrics.

There are a number of markers such as C peptide and plasma insulin that can give a clue as to whether resolution is likely following bariatric surgery but often the most practical test is to observe the improvement in diabetic status during the preoperative VLCD. If medication requirements fall during the 2-4 weeks of preoperative VLCD it is a good indicator that the result will be long lasting. It is recognised that the type of surgery is related to the likelihood of resolving diabetes. In our own experience of sleeve gastrectomy in over 1000 patients, we are seeing more than 80% of diabetic patients experiencing complete resolution of their diabetes within 3-6 months. In 2011 the International Diabetes Federation finally recognised the legitimacy of bariatric surgery in a position statement that declared: â&#x20AC;&#x153;bariatric surgeryâ&#x20AC;Ś can be considered an effective, safe and cost effective treatment for people with T2DM and obesity not achieving recommended treatment targets with medical therapies, especially in the presence of other major co-morbiditiesâ&#x20AC;?. The 2005 AusDiab study suggested that 1.7 million Australians have diabetes but that this figure greatly underestimates the additional cases as yet undiagnosed. Obviously, bariatric surgery is not going to be a first line choice in all of these, however for the obese diabetic individual with other co-morbidities like hypertension, sleep apnoea and dyslipidaemia it remains the most powerful â&#x20AC;&#x153;game changerâ&#x20AC;? available to them. Ref: Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. (PMID:19272486) Buchwald H, Estok, Pories W et al The American Journal of Medicine. [2009, 122(3):248-256.e5] Q

Table 1: Four different bariatric operations. Laparoscopic adjustable gastric band

Lap sleeve gastrectomy

Roux en y gastric bypass

Biliopancreatic bypass

% XS Wt Loss

50-60%

70-80%

70-80%

80-90%

T2DM Remission

60%

70-80%

80%

95%

Op Mortality

0.1%

0.3%

0.3%

1.0%

Post op Malnutrition

+

+

++

+++

A MercyCare Service Thirlmere Road, Mount Lawley WA 6050 T: 08 9370 9222 F: 08 9272 1229 E: hospital@mercycare.com.au W: www.mercycare.com.au/hospital medicalforum

41


Technology

WA Biotech Hopefuls  

 

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Perth biotech company Proteomics will use its $1m grant from Commercialisation Australia to develop biomarkers for diabetic kidney disease. Proteomics International is a drug discovery company and contract research service provider, a commercial arm of WA Institute of Medical Research (WAIMR) that specialised in mass spectrophotometry services and proteomics (i.e. the study of protein function). Proteomics International operates its main laboratory at the WAIMR facilities in Perth. They aim is to develop a more sensitive molecular test to predict kidney disease and monitor its progression in patients with diabetes (better than urinary microalbumin). The company already has biomarkers that need further validation against patient groups, before out-licensing its intellectual property. Commercialisation Australia CEO Doron Ben-Meir says the funding body has 26 case managers scouting for opportunities and preparing applications. He said only about 10% of funds was going to biotechnology inventions, with 34% going to software and web design, 13% to computer systems, and 43% to manufacturing, engineering and design. Proteomics was incorporated in 2001 and has two focal research activities (according to its website); analysis of venoms and the discovery and use of biomarkers from human, animal and plant tissue. The company lists an array of clients that include Reliance Life Sciences (India), CSL Limited (Australia), Natco Pharma (India), National Institute for Plant Genome Research (India), CSIRO, Austral Fisheries (Australia), Department of Primary Industry NSW, National University of Singapore, Phylogica (Australia), and University of Indonesia. The company appears to be involved with The Centre for Food and Genomic Medicine, also based at WAIMR to tackle diabetes and obesity ("diabesity") with funding from the WA Government, the National University of Singapore (venom research), and UWAâ&#x20AC;&#x2122;s School of Biomedical, Biomolecular and Chemical Sciences. O

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Keeping pace with new MRI

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42

Thanks to titanium parts and some nifty electronics, implantable pacemakers are becoming more MRI friendly. A bit like combatants, they may still require an exclusion zone around the device so the MRI scanner does not heat things up or create noise that interferes with the pacing electronics. External programming devices can be used to place the pacemaker into MRI-safe mode. Hollywood Private Hospital recently announced that Dr Shakeeb Razak implanted the first MRI-safe cardiac resynchronisation product from Biotronik, one with three leads that stimulate the left atrium and both ventricles, and obtained through the special access scheme. Dr Razak is pictured with the recipient and his wife. O medicalforum


Education

MURTEC becomes a Sim City The St John of God Murdoch Training and Education Centre (MURTEC) opened last month offering facilities and equipment to make the hospital one of the most advanced simulated learning environments in WA. The Department of Health and Ageing grant of $2.6m built the new facility while Health Workforce Australia contributed $240,000 for the purchase of midwifery, paediatric, critical care, general nursing and simulation equipment. SJOG Murdoch CE Mr Peter Mott said that MURTEC would be the centerpiece in the hospital’s strategy to become a “pre-eminent provider of clinical education and training in WA” and it would now be able to look at increasing the number of clinical placements from 800 to 1000 primarily nursing though some medical students. “With future growth of our hospital and strengthening partnerships with teaching providers such as Challenger Institute of Technology, we believe there will be opportunities for further multidisciplinary teaching programs at the hospital.”

QMURTEC staff and students demonstrate how SimBaby will help skill development.

MURTEC features a family of manikins that can simulate a wide range of scenarios. t 4JN.BO(DBOCMJOL CSFBUIF DSZ and talk and can also physiologically respond to certain medications that are administered.

t 4JN#BCZXJMMBTTJTUJOUFBDIJOHTUVEFOUT how to manage neonatal emergencies incuding seiqzures, respiratory distress and life-threatening cardiac events. t 4JN.VNXJMMBTTJTUNJEXJGFSZTUVEFOUT develop skills with labour management – before, during and after delivery. O

Aged Care Support Groups These not-for-profit and community groups offer support for the elderly living in the community.

Council on the Ageing (WA) Inc. Protects and promotes the well-being of older people in WA. Services include computing classes for seniors and strength training for over 50s. Also provides insurance for members. Location: West Perth; admin@cotawa.asn.au; www.cotawa.asn.au Tel: 9321 2133, 8.30am-5pm

Dutch Aged Care (WA) Inc. Provides culturally appropriate services for frail seniors from a Dutch/German speaking background who may be at risk of social isolation for linguistic or cultural reasons. They provide community aged care packages with bilingual support workers, a community visitor’s scheme, and a home visitor’s scheme with bilingual volunteers. Location: Wembley; dutchagedcare@iinet. net.au; http://dacwa.org Tel: 9382 4186 or 9382 1983, 9am-3pm

Hills Community Support Group Inc. Offers a caring community service for frail older people, people with disabilities, carers, and youth who need support, assistance, advice and encouragement in their daily lives. Services include respite care, transport medicalforum

assistance, home maintenance, social support, craft classes, library services, and the "Get Away Club" leisure program. Location: Mundaring; hcsg@hcsg.com.au; www.hcsg.com.au Note: For residents of the Shire of Mundaring and adjacent areas only.

Residential Care Support Network

Haldane House

Retirees WA Inc.

Provides day centre respite and in-home respite to younger people with disabilities and frail-aged seniors living in the lower north metropolitan area. Location: Mt Claremont; ann-marie.enders@ cocwa.asn.au Tel: 9408 1188, Mon-Sat, 9am-3.30pm

Provides information to, and lobbies the government on behalf of pensioners and all retirees. Offers services for seniors, including podiatry, legal information, monthly meetings, and social activities across the metro and country areas. Location: East Victoria Park; info@ retireeswa.com.au; www.retireeswa.com.au Tel: 1800 198 489, 9am-4.30pm

Office for Seniors’ Interests & Carers Provides free and confidential information and referral for seniors and people concerned with seniors’ issues. Location: West Perth; osi@dcd.wa.gov.au ; www.community.wa.gov.au/seniors Office: 6217 8500, 8am-5pm Information Service: 6217 8855, 9am-3pm

People Who Care Inc. Offers practical assistance to the frail-aged and people with disabilities, such as transport, gardening, nursing home visiting, shopping, Location: Guildford; pwcinc@iinet.net.au; www.peoplewhocare.org.au Tel: 9379 1944, 9am-4.30pm

Provides information and support for consumers and family members of aged care services. Location: Coolbellup; www.users.bigpond.net.au/bluegum/agedcare Tel: 9331 3141

Southern District Support Association Assists people living in Perth south-eastern corridor to remain in their own homes for as long as they wish. Provides respite, domestic assistance, home maintenance, social support and transport to medical appointments. It runs an adult day centre for seniors, social groups for young adults with disabilities, and a men's program for acquired brain injuries. Location: Armadale; info@sdsa.info; www.sdsa.info Tel: 9498 4800, 8.30am-5pm O

43


Adventure

Ice On

Doctor

It may not be for everyone, leaping crevasses and scrambling up ice walls, but for Dr Peter Bentley and his wife Marece itâ&#x20AC;&#x2122;s all about building life experience. Everyone knows that work-life balance is a wonderful thing and there are many different ways of achieving it. And if you decide to get away from sick people and hang off the end of an ice axe on a slippery glacier while roped to your wife, you wonâ&#x20AC;&#x2122;t be the ďŹ rst. Dr Peter Bentley, Medical Services Manager of WA Red Cross Blood, has recently returned from a trek in the French Alps where he did just that.

GFSUPIBWFBCJUNPSFMVYVSZOPXBOEUIFOw 8IFUIFS AUSFLLJOH JT UIF SJHIU XPSE GPS traversing crevasses and vertical walls of ice with crampons on your boots is debatable. There were long days of hard walking followed by distinctly chummy dormitory accommodation at night. And, just to add a dash of danger, throw an avalanche or two into the mix. i8F HPU UIFSF B DPVQMF PG EBZT FBSMZ BOE decided to get acclimatised by setting off on a six-hour walk. There were the three PG VT BOE UXP GJU ZPVOH *TSBFMJ HVZT XIPE KVTU GJOJTIFE UIFJS NJMJUBSZ TFSWJDF 5IBUT

BCPVUUIFSJHIUTJ[FGPSBHSPVQXIFOZPVSF roped together and leaping over crevasses. The days varied between four to nine hours XBMLJOHBOEXFETMFFQJOSFNPUFIVUTXJUI TQFDUBDVMBSWJFXT*UXBTQSFUUZCBTJDEPSNJUPSZTUZMFXJUIBDBQBDJUZGPSBCPVUQFPQMF so it was definitely a case of snuggling up BUOJHIUw i*EQMBOOFEUPDMJNC.U#MBODBUUIFFOEPG UIF USFL CVU UIFSFE CFFO TPNF BWBMBODIFT BOE  QFPQMF XFSF LJMMFE 5IF HVJEFT TPO was on the mountain when it happened and XBTWFSZMVDLZUPTVSWJWF*UCFDBNFQSFUUZ PCWJPVTUIBUUIFDMJNCUPUIF.U#MBODTVN-

i*U XBT BO BNB[JOH USJQ DBMMFE UIF )BVUF 3PVUF  FJHIU EBZT beginning in the valley of Chamonix in France and endJOH JO ;FSNBUU  4XJU[FSMBOE  with picture-postcard views of UIF .BUUFSIPSO 5IF XBMLJOH was reasonably challenging and the altitude takes some getting used to even though XF XFOU VQ RVJUF HSBEVBMMZ and the highest point was just CFMPXN w1FUFSTBJE i*U XBT B XBML JO UIF QBSL GPS PVS HVJEF  %BO (SJGGJUIT  who summited Everest in his mid-50s, climbed the seven tallest mountains on all seven continents in seven months BOEFOEFEVQJOUIF(VJOOFTT #PPL PG 3FDPSET 5ISFF PG us went on the trip, a lawyer GSJFOE BOE NZ XJGF .BSFDF  XIPT B CFUUFS USFLLFS UIBO * BN 4IFT EPOF UIF $BNJOP EF 4BOUJBHP JO 4QBJO  LN PGQSFUUZUPVHIXBMLJOH*QSF- QDr Peter Bentley and wife Marece ready to tackle the glacier wall 44

medicalforum


mit was too technical for me with lots of ice XBMMUSBWFSTJOHEVFUPUIFBWBMBODIFTw From a personal and professional point PG WJFX  JUT JOIFSFOUMZ SFXBSEJOH UP embrace physical and mental challenges. The sense of achievement is palpable and UIFSFTBMXBZTUIFDIBODFZPVMMCSJOHCBDL something of real value to the demanding discipline of medicine. i*UT JNQPSUBOU UP EP TPNFUIJOH EJGGFSFOU GSPNZPVSFWFSZEBZKPCXIFSFZPVSFTJUUJOH PO ZPVS CVN FWFSZ EBZ *UT OFWFS UPP MBUF to learn new skills and it gives you a sense of achievement that carries through to the SFTUPGZPVSMJGF*GBOZPOFPVUUIFSFJTUIJOLJOHBCPVUEPJOHTPNFUIJOHMJLFUIJT *ETBZ ACJUFUIFCVMMFU HPBOEEPJU:PVXJMMOFFE a relatively good level of fitness because ZPVMMFOKPZJUBMPUNPSFBOEJUXPOULJMMZPV XIJMFZPVSFEPJOHJUw No one wants to even think about work XIJMF UIFZSF PO IPMJEBZT MFU BMPOF BDUVBMMZIBWJOHUPEPBOZ5IFDBMMGPSBAEPDUPS  whether inside an aircraft cabin or on the side of a mountain, can be loud, clamorous BOE VOXFMDPNF 5IBOLGVMMZ  1FUFS EJEOU have to pull out his medico bag of tricks. i* UPPL BMPOH TPNF TUVGG GPS BMUJUVEF TJDLness and a few antibiotics but my medical TLJMMT XFSFOU OFFEFE MVDLJMZ 5IFZ IBWF very sophisticated back-up using helicopter evacuations and retrievals which are very

F FYQFOTJWFCVUJUTOJDFUPLOPXUIFZSF U UIFSF 5IJT UZQF PG IPMJEBZ EPFTOU TVJU Q FWFSZPOF  CVU *N JO UIBU BHF HSPVQ SF XIFSF * IBWF UP EP UIFTF UIJOHT CFGPSF CZ *N UPP PME UP EP UIFN *N JO UIBU CBCZ CPPNFSSVOOJOHPVUPGUJNFDBUFHPSZw FST *OBCJEUPPVUSVO0ME'BUIFS5JNF 1FUFST GFX XBMLJOHCPPUTIBWFOPUDIFEVQRVJUFBGFX miles in the last few years. DPVi*EJEUIFUSFLUP&WFSFTU#BTF$BNQBDPVUIF QMF PG ZFBST BHP BOE UIBUT QSPCBCMZ UIF NPTU EFNBOEJOH POF *WF EPOF 5IF *ODB *ODB DVMBS 5SBJMUP.BDIV1JDDIVJTQSFUUZTQFDUBDVMBS 8FTU BOETPJTUIF$BQFUP$BQFJO4PVUI8FTU DBO 8"*UTTUVOOJOHEPXOUIFSFBOEZPVDBO night do it in a civilised way by staying overnight JOIPUFMTw NFSF "OE 1FUFS #FOUMFZ EPFT NPSF UIBO NFSF UP BB XBMLJOH )FT CFFO LOPXO UP CSFBL JOUP BSJOH CSJTLUSPUOPXBOEUIFOBOEIFTQSFQBSJOH to do that again. UIPO i*N QMBOOJOH UP EP UIF #FSMJO .BSBUIPO TJEF OFYU ZFBS *UT POF PG UIF #JH  BMPOHTJEF /FX :PSL  $IJDBHP BOE -POEPO BOE JU IBT the added advantage of being a pretty flat DPVSTF *G ZPV DPNNJU UP SVOOJOH B NBSBthon it makes you stick to a healthy training SFHJNF *MM BMXBZT SFNFNCFS UIF GJSTU POF * EJE o JU XBT TVDI B HPPE GFFMJOH BOE * UIPVHIU A*DBOEPBOZUIJOHOPX O

QMain picture: The majestic Mt Blanc and (inset) the Bertol Hut - one of the most inaccessible in the world.

FACTS: How to get walking t "MQJOF"EWFOUVSFQQ (8 days incl. accommodation/food/guide) t %BO(SJGGJUITo.PVOUBJO(VJEF www.mountainadventure.com



t $BQFUP$BQF8BML www.capetocapetrack.com.au

medicalforum

45


Kitchen Confidential

8IBUCSPVHIUZPVBOE$BSPMZOOFCBDLUP1FSUI $BSPMZOOFTNVNXBTEJBHOPTFEXJUICSFBTUDBODFSJO  so we wanted to be here to support her. After many years away it was lovely to come home and realise our dream with PVSGBNJMZBOEGSJFOETBSPVOEVT8IFOXFPQFOFE3FTUBVSBOU "NVTĂ?XFEJEOUIBWFBOZCJHFYQFDUBUJPOT XFKVTUXBOUFEUP have a successful business where we could put our training into practice, pay our bills and produce something that people would enjoy and that we could be proud of. :PVIBWFXPOTPNBOZMPDBMBOEOBUJPOBMBXBSET NPTUSFDFOUMZ (5TCFTU8"SFTUBVSBOUBOEUIF)PUUFTU8"3FTUBVSBOU XIBU DBUDIFTUIFKVEHFTFZFT EPZPVUIJOL  $POTJTUFODZoXFBSFBXBSFUIBUXFDBOOFWFSCFDPNQMBDFOU PSSFTUPOPVSMBVSFMT'PSVT JUTUIFGFFECBDLGSPNPVSHVFTUT every night that is the most important thing. :PVUJFEXJUI1FUFS(JMNPSFT2VBZGPSUIF)PUUFTU%JTI TP XIBUTUIFEJTI  *UTBDPEEMFEGSFFSBOHFIFOTFHHXJUIDPSJBOEFSBOEQJOF nut butter, crispy chicken skins, seven different varieties of NVTISPPNTGSPN#VOLFST'BSNJO/BSSPHJOBOEGSFTIMZCBLFE brioche, all smoked with hickory. $BSPMZOOF 8IFSFEJEZPVNFFU)BEMFJHI  8FNFUBU"SBMVFO$PVOUSZ$MVCJO3PMFZTUPOFZFBSTBHP8F XFSFCPUIXPSLJOHUIFSFBUUIFUJNF*XBTXPSLJOHJOSFTUBVSBOUT XIJMF*XBTTUVEZJOHBUVOJWFSTJUZBOEMFGUUIFJOEVTUSZGPSB DPVQMFPGZFBSTBGUFSHSBEVBUJOHCVUXBTRVJDLMZESBXOCBDL XIFOXFNPWFEUP.FMCPVSOF :PVBOE)BEMFJHIIBWFBQPXFSGVMXPSLJOHQBSUOFSTIJQ )PXEPZPVTXJUDIPGG  8FMJWFEBUUIFSFTUBVSBOUGPSUIFGJSTUÂ&#x203A;ZFBST TPUIBUNBEF it very hard to switch off. Now we live around the corner and do PVSCFTUUPNBLFPVS4VOEBZTBEBZPGGGSPNUIFSFTUBVSBOU5IJT is easier said than done as the restaurant for us is all-consuming. )PXFWFS XFBSFWFSZHPPEBUTFQBSBUJOHPVSXPSLGSPNPVS SFMBUJPOTIJQCFDBVTFXFHSFBUMZSFTQFDUFBDIPUIFSTSPMFTXJUIJO the business.

10 minutes with... Hadleigh & Carolynne Troy

:PVSXJOFMJTUJTBEJHFTU CVUTVDIBMPUPGGVOUPSFBE*TJUGVOUP QVMMJUUPHFUIFS *UTNZQBTTJPOBOEJUTUJNFDPOTVNJOH CVU*DBOUTBZJUTB UPVHIHJH"T*XFBSTFWFSBMIBUTBUUIFSFTUBVSBOU *VOGPSUVOBUFMZ can only set aside about 10 hours a week to taste new wines, meet winemakers and curate the list. The list is continually FWPMWJOHBOEUIFJOLJTCBSFMZESZCFGPSFJUHFUTBSFQSJOU #PUIPG:PV

Restaurant AmusĂŠâ&#x20AC;&#x2122;s reputation for delivering one of the best nightâ&#x20AC;&#x2122;s out in Perth has spread GBSBOEXJEF'PSJUTPXOFST GFFEJOHEJOFSTJTB labour of love. 8IFSFEJEZPVHSPXVQ Perth! My family wasnâ&#x20AC;&#x2122;t foodie at all.

8IBUEJEZPVMPWFUPFBUXIFOZPVXFSFBLJE .D%POBMET UFSSJCMF*LOPX 8IBUQSPNQUFEZPVUPDIPPTFBMJGFBTBDIFG 4DIPPMXBTOUHPJOHTPXFMMGPSNF XIJDIXBTQSPCBCMZEVFUP UIFGBDUUIBU*TQFOUNPSFUJNFBUUIFCFBDIUIBOJOUIFDMBTTSPPN  TP*IBEUPKPJOUIFXPSLGPSDF*DPNQMFUFENZBQQSFOUJDFTIJQJO UISFFEJGGFSFOUSFTUBVSBOUT"GUFS*RVBMJGJFE *XFOUUPXPSLBU5IF -PPTF#PYUIFO+BDLTPOT*NBEFUIFNPWFUP.FMCPVSOFUPXPSL BU-BOHUPOTVOEFS1IJMJQQF.PVDIFMUIFOXFNPWFEUP-POEPO XIFSF*XPSLFEBU5IF(SFFOIPVTFJO.BZGBJSBOE-B/PJTFUUFJO ,OJHIUTCSJEHFCFGPSFIFBEJOHIPNFJO

** Hadleigh will be appearing at the Margaret River Gourmet Escape from November 22-25. See the competitions page for your chance to win entry tickets to the Gourmet Village. 46

8IBUXPVMEZPVMJLFUPCFEPJOHJOGJWFZFBSTUJNF  "UUIJTTUBHFXFJOUFOEUPXSBQ3FTUBVSBOU"NVTĂ?VQJOBOE move on to our next project, which is up in the air at the moment. Perhaps it will be a simple sandwich shop if Carolynne gets her XBZ "GUFSBMPOH4BUVSEBZOJHIU XIBUEPZPVEP 8IBUEPZPVFBU  8FTJUEPXOXJUIPVSFOUJSFUFBNPWFSBDPMECFFSBOEEFCSJFG 8FIBWFBUFBNNFBMBUQNFWFSZOJHIU TPXFUFOEOPUUPFBU BGUFSTFSWJDF)PXFWFS BCPVUPODFBNPOUIXFHFUBMBUFOJHIU delivery as a treat, which is usually our local Chinese. 8IFOZPVDMPTFZPVSFZFT XIBUEPZPVTNFMM  )BEMFJHI5IFXPPEGSPNUIFOFXUBCMF*KVTUCVJMUGPSUIF SFTUBVSBOU $BSPMZOOF8PPETUBJOGSPNTUBJOJOHUIBUXPPE 8IBUXPVMECFZPVSMBTUNFBM  )BEMFJHI4QBHIFUUJ#PMPHOFTF $BSPMZOOF0ZTUFSTBOE$IBNQBHOF

By Ms Jan Hallam

medicalforum


Wine Review

ExcitingStyles AT

WILLOUGHBY PARK

By Dr Martin Buck 2011 Willoughby Park Riesling 5IJTXJOFJTXIBUUIF(SFBU4PVUIFSOJTBMMBCPVUXJUIBOBVTUFSFOPTFBOEB clean palate of lime and mandarin. There is good palate length and a hint of fruit sweetness. A fantastic wine to enjoy with some Albany oysters and with 12.5% BMDPIPMJUhTBHSFBUBGUFSOPPOXJOF6QUIFSFXJUIUIFHSFBUSJFTMJOHTPGUIFSFHJPO

Willoughby Park is a new player on the Denmark wine scene and has been JO PQFSBUJPO TJODF  #Z VTJOH GSVJU sourced from the Great Southern and Blackwood region they believe that the resulting wines can reďŹ&#x201A;ect the best the region can offer. At Kalgan River there is an estate-owned vineyard to supply further fruit. Andries Mostert is the winemaker and has wide experience both in the area and overseas. James Halliday has described Willoughby Park as one of the "Ten Best New Wineries" and HJWFOJUBmWFTUBSSBUJOHoBHSFBUFGGPSU for such a new operation. Willoughby Park has sparked my interest in wines of the region and their stable of ďŹ ne French-style wines is refreshing for our wine industry.

2011 Willoughby Park Sauvignon Blanc 4BVWJHOPO#MBODJOUIFDPPMFSBSFBTDBOCFEJGGJDVMUUPHFUSJHIUCVUUIJTIBTBMMUIF right components. A restrained nose with tropical fruit, asparagus and kiwifruit leads to a lively palate of crisp acid with some complexity. A small amount of French oak-aged wine has been added to the final blend to add interest. A wine best enjoyed young and a great match for spicy Asian dishes. 2010 Willoughby Park Chardonnay #VSHVOEJBOTUZMFDIBSEPOOBZTBSFBMMUIFSBHFBOEUIJTXJOFJTJOUIFTBNF mould. There are subtle peach and oak aromas on the nose complemented by a creamy palate. The use of whole bunch pressing, barrel fermentation and battonage to keep the yeast flavours have all worked wonderfully to create a MBZFSFEQBMBUFPGMFNPOGSVJU PBLBOEBDJE*UTTUJMMBZPVOHDIBSEPOOBZCVUXJUI plenty of potential. This is my favourite of the whites and well worth the price. 2010 Willoughby Park Shiraz 3BUIFSUIBORVJCCMJOHBCPVUXIFUIFSUIFSFTIPVMESFBMMZCFBTZSBI *XJMMIPME judgement. This is a great cool climate shiraz with spicy oak and plum nose. "3IPOFTUZMFQBMBUFXJUIDPNQMFYJUZBOEQFSTJTUFODF5IFPBLIBTCFFOXFMM IBOEMFEBOEEPFTOPUEPNJOBUFUIFGSVJU*UTTJNJMBSUPUIPTFZPVOHFSXJOFTGSPN )FSNJUBHFBOEJUDBOTUBOEBTBTUZMFXPSUIZPGUIFSFHJPO 2010 Willoughby Park Cabernet Sauvignon 5IJTJT(SFBU4PVUIFSODBCFSOFU$JHBSCPYPBLBSPNBTBSFQSPNJOFOUBOE reflect the use of new and aged French Oak. The final wine has been assembled from separate batches to maximise the best fruit. The palate is restrained but has plenty of fruit and savoury tannins. This is a lighter style with some similarities to #PSEFBVYXJOFT*UTBXJOFXJUIHSFBUBHFJOHQPUFOUJBMXIJDIDPVMECFLFQUGPSB few years with spectacular results.

WIN a Doctorâ&#x20AC;&#x2122;s Dozen! Which Willoughby Park wine has characteristics of the Rhone wine region in France? Answer:

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

ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Competition Rules:0OFFOUSZQFSQFSTPO1SJ[FDIPTFOBU random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, November 30, 2012. To enter the draw to XJO UIJT NPOUIT %PDUPST %P[FO  SFUVSO UIJT DPNQMFUFE coupon to â&#x20AC;&#x2DC;Medical Forumâ&#x20AC;&#x2122;s %PDUPST %P[FO   )BXLFS "WF 8BSXJDL8"PSGBYUP

Name:

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

E-mail: ......................................................................................................... Contact Tel:

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

Please send more information on Willoughby Park Winery offers for Medical Forum readers.

QAndries Mostert Willoughby Park winemaker

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47


Satire

Donâ&#x20AC;&#x2122;t Let Granny go to Zumba Resident satirist Wendy Wardell says lessons learnt from Gen Y could put ideas into the heads of the elderly that could lead to civil unrest. Iâ&#x20AC;&#x2122;ve recently developed a morbid fascination with the concept of a â&#x20AC;&#x2DC;Lifestyle Village.â&#x20AC;&#x2122; I assume this is where you go to â&#x20AC;&#x2DC;get a lifeâ&#x20AC;&#x2122; if itâ&#x20AC;&#x2122;s generally surmised that being upright and breathing isnâ&#x20AC;&#x2122;t enough to qualify you as having one already. If youâ&#x20AC;&#x2122;ve seen the TV ads, youâ&#x20AC;&#x2122;ll be aware itâ&#x20AC;&#x2122;s some sort of strange Stepford-esque cult where ageing people play tennis or go cycling in Lycra shorts instead of the traditional activity of sitting around complaining. * UIJOL UIF BET NVTU CF SFDZDMFE POFT GPS feminine hygiene products to judge from UIFGVOFWFSZPOFTIBWJOH BOEUIFGBDUUIBU JO SFBM MJGF  BOZPOF XFBSJOH -ZDSB PWFS UIF age of 24 just looks like a tub of tofu tipped into a bin bag. 4IPDLJOHMZ  ZPV DBO FOUFS POF PG UIFTF communities at only 45 years of age. At   ZPVhWF CBSFMZ IBE UIF USBJOFS XIFFMT taken off your life and are still dangerously JNQSFTTJPOBCMF :PV NBZ IBWF MFBSOFE UIF pitfalls of running with scissors, but have yet to form a sufficiently solid carapace of

48

cynicism to withstand the assault of Alan +POFTPOMPPQUISPVHIUIF-JGFTUZMF7JMMBHF MPVETQFBLFST *G UIF 4PVUI ,PSFBOT USJFE CSPBEDBTUJOH UIJT PWFS UIF CPSEFS * SFDLPO UIF /PSUI ,PSFBOT XPVME TPPO SFBMJTF UIF errors of their soft socialist ways.) #FGPSF XF LOPX JU  UIFSF XJMM CF B DPWFSU %BEhT"SNZSFBEZUPSPXSFGVHFFTCBDLPVU UP TFB UIFNTFMWFT BOE QFSGPSN DJUJ[FOhT

UIBUIBMGPGUIFNDPVMEOhUSFNFNCFSXIFSF they had left their keys in the first place, before they even get to throw them in the circle. And it would certainly instil a whole OFXUFSSPSJOUPh1PU-VDL/JHIUh&ODPVSBHF older people to go and find themselves and CFGPSFZPVLOPXJUUIFZhMMCFGJOEJOHCJUTPG each other too.

arrests on anyone with facial hair, under suspicion of being a hippy sympathiser.

8IFO XJMM XF MFBSO GSPN UIF NJTUBLFT PG UIFQBTU 8FUPME(FO:UIFZDPVMEEPBOZthing they wanted. They surprised us by a) listening and b) absorbing the message, becoming so confident of their worth they saw no imperative to demonstrate it. Now UIBU XFhSF HJWJOH UIF TBNF NFTTBHF UP seniors, can we expect to see gatherings of mature citizens on our suburban steets in the wee small hours of the afternoon, IJHIPOBNQIFUBNJOFMBDFE.FUBNVDJMBOE performing doughnuts in their gophers until UIFZHFUBCJUHJEEZ 

8IBUhT NPSF  BMMPXJOH QFPQMF XIP TUJMM have detectable hormone levels to reside in these communities can bring only chaos BOEEJTIBSNPOZ8JUI7JBHSBCFJOHIBOEFE out like after-dinner mints, the single limiting factor on the Purple Circle would be

*VSHFZPVUPLFFQZPVS0METBUIPNFXJUI you where you can keep an eye on them. Otherwise you could find them on the slipQFSZ EPXOIJMM TMPQF UP B MJGFUJNF PG -JOF %BODJOH BOE OPUIJOH HPPE DBO FWFS DPNF of that. O

We told Gen Y they could do anything they wanted. They surprised us by a) listening and b) absorbing the message.

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Celebrity Spotlight

Baring it

All for his Art Perth-born comedian Joel Creasey fearlessly goes where no skinny, naked kid has gone before. Joel Creasey has been chased out of a Victorian country town, taken his clothes off in front of people he doesnâ&#x20AC;&#x2122;t know and eaten his little sisterâ&#x20AC;&#x2122;s hospital meals and heâ&#x20AC;&#x2122;s fast becoming one of the funniest people on the comedy circuit.

i*EMJLFUPTBZ*NVUUFSMZGFBSMFTTOPX CVU UIBUT OPU RVJUF USVF *UT TUJMM RVJUF USJDLZ XIFO * DPNF CBDL UP 1FSUI * HSFX VQ JO "QQMFDSPTT BOE XFOU UP 8FTMFZ $PMMFHF * had some awful teachers there and some BNB[JOH POFT  UPP  CVU * EPOU UIJOL *E TFOENZLJETUIFSF*EJEOUIBWFBNBTTJWF TUSVHHMFCFJOHHBZBUTDIPPMCVUJUXPVMEWF CFFOBMPUFBTJFSCFJOHTUSBJHIUw

5IF OBLFE GJOBMF IBQQFOFE BU B 4ZEOFZ TIPX * EFDJEFE UP UBLF BMM NZ DMPUIFT PGG BOE*XBTOUTVSFJUEHFUUIFMBVHI*XBOUFE 4PUIFSF*XBTTUBOEJOHOBLFEPOTUBHFXJUI UIF DSPXE TUBSJOH CBDL BU NF *U XPVMEWF CFFOBUPVHIXBZUPFOEUIFTIPXJGJUIBEOU XPSLFE CVUJUXFOUXFMM#ZUIFUJNF*HPUUP EPUIFTBNFUIJOHBUUIF.FMCPVSOF$PNFEZ 'FTUJWBM * XBTOU FWFO UIJOLJOH BCPVU JU w +PFMTBJE

â&#x20AC;&#x153;Appearing in Perth is always interesting CFDBVTF * UFMM B MPU PG TUPSJFT BCPVU QFPQMF XIPBSFJOUIFBVEJFODF*DIBOHFUIFOBNFT PCWJPVTMZ  CVU UIFO * GPSHFU UIF BMJBTFT *WF NBEF VQ BOE * LFFQ TXJUDIJOH CFUXFFO UIFJSGBLFOBNFTBOEUIFJSSFBMPOFT*UIJOL* DPOGVTFKVTUBCPVUFWFSZPOFUIBUXBZw

$PMBD JO SVSBM 7JDUPSJB XBT BOPUIFS IFBEMJOF JO +PFMT DPNFEZ DBSFFS 5IF PQFOMZ gay comedian was run out of town by a IPNPQIPCJD HBOH XIP XFSFOU JNQSFTTFE that he turned up to host an antidiscrimination event. i*UBMMCFHBOBUBQSFWJPVT$PMBDQFSGPSNBODF *XBTBCVTFEBGUFSUIFTIPXBOEBSFQPSUFS from the Colac Herald saw the whole thing BOEQVUJUJOUIFQBQFS*XBTJOWJUFECBDLUP UBML BCPVU UIPTF JTTVFT BOE XIFO * BSSJWFE at the venue there were about 20 people XBJUJOHPVUTJEFUPCBTINF*UXBTBXGVMBU UIFUJNFCVUUIFTVQQPSU*HPUXBTBNB[JOH BOEUIFIBMGIPVSPGDPNFEZNBUFSJBM*QVMMFE GSPNJUXBTFWFONPSFBNB[JOHw 4UBOEJOH POTUBHF OBLFE BOE UBDLMJOH homophobia in such a confronting way SFRVJSFTBDFSUBJOFMFNFOUPGDIVU[QBI"OE even more so when you return to your own territory and strut your stuff in front of family and friends.

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I didnâ&#x20AC;&#x2122;t have a massive struggle being gay at school but it wouldâ&#x20AC;&#x2122;ve been a lot easier being straight. â&#x20AC;&#x153;There are some real idiots from here that *MMBMXBZTSFNFNCFS*IFBSPOUIFHSBQFWJOF UIBU UIFZSF DPNJOH UP UIF TIPX CVU OPX * NBLF TVSF JUT NPSF PG B XPSSZ GPS UIFN * UIJOLUIFZSFTPTUVQJEUIFZEPOUSFBMJTFJUT BCPVUUIFNw +PFM SFGMFDUT PO BMMUIJOHTNFEJDBM  GSPN friends who are training to be doctors to his TJTUFSTIPTQJUBMFYQFSJFODFT i*WF OFWFS CFFO TFSJPVTMZ JMM PS IBE BO accident. Ten seconds after hanging up the QIPOF  *MM QSPCBCMZ HFU IJU CZ B CVT *UMM CF NPSFHPPENBUFSJBMGPSNZOFYUTIPX*WFHPU a few friends who are training to be doctors or KVTUHSBEVBUFEBOEUIBUGSFBLTNFPVU5IFSFT

POF XIPT KVTU HSBEVBUFE BOE * XPVMEOU SFDPNNFOE IJN UP BOZPOF * LOPX GBS UPP NVDIBCPVUIJN)FKVTUTIPVMEOPUMFBWFUIF IPVTF"TGPSNF *EPOUIBWFBEFHSFFBOE* HFUQBJEUPTXFBSPOTUBHFGPSBMJWJOHw i.Z MJUUMF TJTUFS XBT EJBHOPTFE XJUI 5ZQF  %JBCFUFT XIFO TIF XBT BCPVU  ZFBST PME 4IF XFOU UP 1.) BOE XFE PGUFO HP in to visit her, so my experience with the IFBMUIQSPGFTTJPOIBTCFFOQSFUUZHPPE*EP SFNFNCFSFBUJOHBMPUPGIFSIPTQJUBMGPPEw 4UBOEVQ DPNFEJBOT MJWF BOE EJF PO UIF TUSFOHUI PG UIFJS SFWJFXT %PFT +PFM $SFBTFZ SFBE BMM PG UIFN o UIF HPPE  UIF CBEBOEUIFVHMZ i* BCTPMVUFMZ SFBE BMM NZ SFWJFXT *WF HPU NZ OBNF PO (PPHMF "MFSU  * UIJOL FWFSZ DPNJD EPFT 8F BMM TBZ  A* EPOU DBSF CVU * comb every single word looking for hidden NFBOJOHT*IBEBSFWJFXDPNJOHPVUJOThe Age OFXTQBQFS BOE * TFU NZ BMBSN GPS GJWF PDMPDLJOUIFNPSOJOHUPHPEPXOUPUIFMPDBM EFMJ *UT B CJU USBHJD  * LOPX " HPPE SFWJFX DBOSFBMMZIFMQZPVUIPVHIw 1FSUIT B TNBMM QPOE  TP XIFSF JT UIJT BMM IFBEJOH GPS TPNFPOF XIPT B TFMGEFDMBSFE BUUFOUJPOTFFLFSXIPMPWFTUIFTQPUMJHIU i*N MPWJOH JU BU UIF NPNFOU BOE CBTJDBMMZ *E MJLF UP UBLF PWFS UIF XIPMF XPSME .Z ultimate goal is to have my own talk-show MJLF(SBIBN/PSUPO*BEPSFIJTXPSLBOEUIBU XIPMFQPQDVMUVSFTJEFPGUIJOHTw O

By Mr Peter McClelland ED: Joel has just filmed his first DVD which will be released later in the year, along with an ABC2 stand-up special. Joel Creaseyâ&#x20AC;&#x2122;s â&#x20AC;&#x2DC;Nakedâ&#x20AC;&#x2122; is at Lazy Susanâ&#x20AC;&#x2122;s Comedy Den, Brisbane Hotel, Perth, on November 4 at 8pm. 49


Choral Music

Raising

Roof

the

The Collegium Symphonic Chorus prepares to hail the Messiah for the 15th year.

If itâ&#x20AC;&#x2122;s Christmas, there must be a Messiah playing somewhere in the world. In Perth we are lucky to have the brilliant Collegium Symphonic Chorus under the direction of its dynamic leader Margaret Pride performing the honours. 5IJT XJMM CF UIF UI ZFBS .BSHBSFU IBT MFE TPMPJTUTBOEUIFTUSPOHDIPJSJOBXPSLBT JDPOJD BT $ISJTUNBT QVEEJOH 4P IPX EPFT TIFLFFQJUGSFTI i*UTOPUIBSECFDBVTFJUTTVDIBXPOEFSGVM QJFDF :PV NJHIU HP JOUP UIF GJSTU SFIFBSTBM BOEUIJOL A0IOP MessiahCVUCZUIFTFDPOESFIFBSTBM ZPVSFHPJOHAUIJTJTGBOUBTUJD &WFSZZFBS *GJOETPNFUIJOH*EJEOUTFFUIF MBTUUJNF*UJTBKPZw i*UT B MPOH IBVM JO QFSGPSNBODF CVU UIFSF are so many wonderful choruses that you can feel the impact coming off the stage and ZPV DBO GFFM UIF BVEJFODFT SFTQPOTFT  TP JUTIVHFMZSFXBSEJOHBOEWFSZJOWJHPSBUJOHw #VU.BSHBSFUTBZTJGJUTBNBSBUIPOGPSIFS TUSPOH DIPJS BOE UIF $PMMFHJVN #BSPRVF Orchestra which accompanies it, spare a thought for the soloists. â&#x20AC;&#x153;Messiah is their bread and butter time. A couple of years ago, we engaged mezzo TPQSBOP4BMMZ"OO3VTTFMMBOEUIF1FSUIQFS50

formance was her second last Messiah for UIF ZFBS o XF XFSF IFS UI 4P UIBU ZFBS  TIF IBE TVOH JO  .FTTJBIT JO B TQBDF PG TFWFSBMXFFLTw 'PS UIF TPMPJTUT JUT B HPPE QBZ EBZ CVU GPS UIFTUSPOHDIPSVTPGDPNNJUUFEBNBUFVS TJOHFSTJUTUIFMPWFPGNVTJDBOEUIFUISJMMPG singing together that keeps them heading along to rehearsals for the four to five shows .BSHBSFUQSPEVDFTFBDIZFBS â&#x20AC;&#x153;Performance is like a little miracle and the SFTVMUTDBOCFXPOEFSGVMCVUJUTOPUBMXBZTB cake walk. Amateur singers though are very HPPEBUQVUUJOHUIFJSCFTUGPPUGPSXBSEw 5IF$PMMFHJVN4ZNQIPOJD$IPSVTXBTCPSO GSPNUIFBTIFTPGUIF8"40$IPSVT XIJDI .BSHBSFU IBE MFE GPS  ZFBST VOUJM 8"40 axed it in a series of fund-cutting measures JO i5IF 8"40 $IPSVT XBT DMPTFE EPXO CVU there were all a core of about 60 people who wanted to keep singing in a choir so we GPSNFEUIF$PMMFHJVN4ZNQIPOJD$IPSVTw This year the choir has performed in concerts here and in a choral festival in Canada. To be a part of a performance, choristers have to attend 80% of rehearsals, which is a significant commitment for many who still have busy professional days jobs. i5IFSF JT B CJU PG API *N UJSFE UPOJHIU BU some rehearsals but the lovely thing about

singing is that you come out more refreshed UIBOXIFOZPVBSSJWFE w.BSHBSFUTBJEi:PV come in dragging your tail, and you leave CVTIZ UBJMFE y UIF FOEPSQIJOT IBWF LJDLFE JOw *G JU UBLFT DPNNJUNFOU UP CF B QBSU PG UIF choir, it takes that and a good dose of courBHF UP MFBE UIFN  CVU GPS .BSHBSFU 1SJEF  B musical life was never in doubt. i*XBTPOMZBCPVUGPVSXIFO*BOOPVODFEUP NZQBSFOUTUIBU*XBOUFEUPQMBZUIFQJBOPPO UIF SBEJP BOE *WF CFFO NBLJOH NVTJD FWFS TJODF*DBOUOPUEPJUw After an illustrious teaching career in Perth, which saw her at the vanguard of musical FEVDBUJPO .BSHBSFUIBTCFDPNFPOFPGUIF DPVOUSZTMFBEJOHFYQPOFOUTPGDIPSBMNVTJD  a love that began as a young music teacher BU .FUIPEJTU -BEJFT $PMMFHF JO  XIFO she took over the small school choir. i* XBT GBTDJOBUFE CZ UIF GFFMJOH PG IBWJOH TPVOEJOZPVSIBOET*EJEBMJUUMFCJUPGQPUtery in my youth and conducting that choir GFMURVJUFTJNJMBSUPUIBUw /PX DPNNBOEJOH  WPJDFT BU GVMM UJMU  UIF fascination and thrill continues. The 2012 performance of Messiah will be IFMEBUUIF1FSUI$PODFSU)BMMPO%FDFNCFS 15. For your chance to win tickets, go to the competitions page for details. O

By Ms Jan Hallam medicalforum


funnyside e QQBack to School

QQStone the Crows 5IFSFPODFXBTBO*OEJBOXIPIBEPOMZ one testicle and whose given name was h0OFTUPOFh )FIBUFEUIBUOBNFBOEBTLFEFWFSZPOF not to call him Onestone. After years and years of torment, Onestone finally DSBDLFEBOETBJE h*GBOZPOFDBMMTNF 0OFTUPOFBHBJO*XJMMLJMMUIFNh The word got around and nobody called him that any more until one day when a ZPVOHXPNBOOBNFE#MVF#JSEGPSHPU BOETBJE h(PPENPSOJOH 0OFTUPOFh)F jumped up, grabbed her and took her deep into the forest where he made love to her BMMEBZBOEBMMOJHIU)FNBEFMPWFUPIFS BMMUIFOFYUEBZ VOUJM#MVF#JSEEJFEGSPN exhaustion. The word got around that Onestone meant what he promised he would do. :FBSTXFOUCZBOEOPPOFEBSFEDBMMIJN by his given name until a woman OBNFE:FMMPX#JSESFUVSOFEUP the village after being away. :FMMPX#JSE XIPXBT#MVF #JSEhTDPVTJO XBTPWFSKPZFE when she saw Onestone. 4IFIVHHFEIJNBOETBJE  h(PPEUPTFFZPV 0OFTUPOFh Onestone grabbed her, took her deep into the forest, where he made love to her all day, made love to her all night, made love to her all the next day, made love to her all the next OJHIU CVU:FMMPX#JSEXPVMEOhUEJF 8IZ  &WFSZPOFLOPXTZPVDBOhULJMM5XP#JSET XJUI0OF4UPOF

QQTurning Turtle %FFQJOBGPSFTU BMJUUMFUVSUMFCFHBOUP climb a tree. After hours of effort, he reached the top, jumped into the air waving his front legs and crashed to the ground. 0ODFIFhESFDPWFSFE IFTMPXMZ climbed the tree again, jumped, and fell once more to the ground. )FUSJFEBHBJOBOEBHBJO XIJMF a couple of birds sitting on a branch watched his sad efforts. Finally, the female bird turned to IFSNBUFBOETBJEi%PZPVLOPX XIBU EBSMJOH *UIJOLJUhTUJNFUP UFMMIJNIFhTBEPQUFEw

medicalforum

QQMaking Hay A balding, white haired man from 4BODUVBSZ$PWFJO2VFFOTMBOEXBMLFE JOUPBKFXFMMFSZTUPSFPOUIF(PME$PBTU with a beautiful, much younger, woman BUIJTTJEF)FUPMEUIFKFXFMMFSIFXBT looking for a really special ring for his new girlfriend. The jeweller looked through his stock and CSPVHIUPVUBSJOH 5IFNBOTBJE i/P /P UIBUTBNFSF CBVCMFy*hEMJLFUPTFFTPNFUIJOHNVDI NPSFTQFDJBMw 4PUIFKFXFMMFSXFOUUPIJTTQFDJBMTUPDL BOECSPVHIUBOPUIFSSJOHPWFSi)FSFhT BTUVOOJOHSJOHBUPOMZ wUIF KFXFMMFSTBJE5IFZPVOHMBEZhTFZFT sparkled and her whole body trembled with excitement. The old man seeing this said, i*UIJOLXFhMMUBLFJUw The jeweller asked how payment would be made and the man TUBUFE i#ZDIFRVF CVU*LOPXZPVMM need to make sure my DIFRVFJTHPPE TP*hMM write it now, you can call UIFCBOLPO.POEBZUP WFSJGZUIFGVOETBOEXFhMM QJDLUIFSJOHVQ.POEBZBGUFSOPPOw 0O.POEBZNPSOJOH UIFKFXFMMFSBOHSJMZ QIPOFEUIFPMENBOBOETBJE i5IFSFhTOP NPOFZJOUIBUBDDPVOUw i*LOPX wTBJEUIFPMENBOXFBSJMZAy but let me tell you about my fantastic XFFLFOEw 4FF/PU"MM4FOJPST"SF4FOJMF0ME .........s.

5&"$)&38IZBSFZPVMBUF 456%&/5$MBTTTUBSUFECFGPSF*HPUIFSF 5&"$)&3+PIO XIZBSFZPVEPJOHZPVS NBUITNVMUJQMJDBUJPOPOUIFGMPPS +0)/:PVUPMENFUPEPJUXJUIPVUVTJOH tables. 5&"$)&3%POBME XIBUJTUIFDIFNJDBM GPSNVMBGPSXBUFS %0/"-%)*+,-./0 5&"$)&38IBUBSFZPVUBMLJOHBCPVU %0/"-%:FTUFSEBZZPVTBJEJUhT)UP0 5&"$)&3(MFOO XIZEPZPVBMXBZTHFU TPEJSUZ (-&//8FMM *hNBMPUDMPTFSUPUIF ground than you are. 5&"$)&3.JMMJF HJWFNFBTFOUFODF TUBSUJOHXJUIh*h .*--*&*JTy 5&"$)&3/P .JMMJF"MXBZTTBZ h*BNh .*--*&"MMSJHIUh*BNUIFOJOUIMFUUFSPG UIFBMQIBCFUh 5&"$)&3(FPSHF8BTIJOHUPOOPUPOMZ DIPQQFEEPXOIJTGBUIFShTDIFSSZUSFF CVU BMTPBENJUUFEJU/PX -PVJT EPZPVLOPX XIZIJTGBUIFSEJEOhUQVOJTIIJN -06*4#FDBVTF(FPSHFTUJMMIBEUIFBYF in his hand... 5&"$)&3$MZEF  your composition POh.Z%PHhJT exactly the same as your CSPUIFShT%JEZPVDPQZ IJT $-:%&/P TJS *UhTUIFTBNFEPH

QQBest from the Edinburgh Fringe  :PVLOPXXIPSFBMMZ HJWFTLJETBCBEOBNF 1PTIBOE#FDLTo Stewart Francis  -BTUOJHIUNFBOENZHJSMGSJFOE XBUDIFEUISFF%7%TCBDLUPCBDL-VDLJMZ *XBTUIFPOFGBDJOHUIFUFMMZoTim Vine  *XBTSBJTFEBTBOPOMZDIJME XIJDI SFBMMZBOOPZFENZTJTUFSoWill Marsh  :PVLOPXZPVhSFXPSLJOHDMBTTXIFO ZPVS57JTCJHHFSUIBOZPVSCPPLDBTFo Rob Beckett  *hNHPPEGSJFOETXJUIMFUUFSTPGUIF BMQIBCFUy*EPOhULOPX:oChris Turner  *UPPLQBSUJOUIFTVOUBOOJOH0MZNQJDT *KVTUHPU#SPO[Fo Tim Vine  1PSOPHSBQIZJTPGUFOGSPXOFEVQPO  CVUUIBUhTPOMZCFDBVTF*hNDPODFOUSBUJOH oGeorge Ryegold  *TBXBEPDVNFOUBSZPOIPXTIJQTBSF LFQUUPHFUIFS3JWFUJOHoStewart Francis  *XBJUFEBOIPVSGPSNZTUBSUFSTP* DPNQMBJOFEh*UhTOPUSPDLFUTBMBEoLou Sanders  .ZNVNhTTPQFTTJNJTUJD UIBUJGUIFSF XBTBO0MZNQJDTGPSQFTTJNJTNyTIF XPVMEOhUGBODZIFSDIBODFTo Nish Kumar

51


Competitions

Entering Medical Forumâ&#x20AC;&#x2122;s COMPETITIONS has never been easier! Simply visit www.medicalhub.com.au and click on the â&#x20AC;&#x2DC;Competitionsâ&#x20AC;&#x2122; link (below the magazine cover on the left).

Music: Handelâ&#x20AC;&#x2122;s Messiah *UT OPU $ISJTUNBT XJUIPVU B EPTF PG )BOEFMT NBKFTUJD MessiahBOEJO1FSUIXFSFMVDLZUPIBWFPOFPGUIFCFTUSFOEJUJPOTJOUIFDPVOUSZXJUIUIF$PMMFHJVN4ZNQIPOJD$IPSVT BOE$PMMFHJVN#BSPRVF0SDIFTUSB MFECZ1BVM8SJHIU VOEFS UIFEJSFDUJPOPG.BSHBSFU1SJEF4PMPJTUTBUUIJTZFBSTFWFOU BSFTPQSBOP7JWJFO)BNJMUPO NF[[PTPQSBOP'JPOB$BNQCFMM  UFOPS3PCFSU.D'BSMBOFBOECBSJUPOF3PCFSU)PGNBOO Perth Concert Hall, Saturday, December 15, 7.30pm-11pm. Tickets through Ticketek

Outdoor Cinema: Rooftop Movies Music: Milos Karadaglic 3PPGUPQ.PWJFTSFUVSOUP/PSUICSJEHFGPSBOFYUFOEed Perth summer season. The pop-up venue became an instant hit earlier this year and the next instalment opens October 18 and runs until the end of April 2013. Expect more old-school film favourites, cinephile classics, cult and art house movies going hand in HMPWFXJUI#HSBEFTDINBMU[FWFSZOJHIUPGUIFXFFL 4FWFO TUPSJFT VQ  3PPGUPQ .PWJFT IBT QBOPSBNJD views of the Perth city skyline which provides the QFSGFDU CBDLESPQ GPS B OJHIU JO B EFDLDIBJS 3PPGUPQ .PWJFT JT PO UIF TJYUI GMPPS PG UIF 3PF 4U $BS 1BSL  Northbridge. Pedestrian access is from the elevator BU UIF +BNFT 4USFFU 1JB[[B 4FBUT BSF VOSFTFSWFE and Medical Forum XJOOFST OFFE UP KVNQ JO RVJDL because the first season ends November 18. Go to www.rooftopmovies.com.au

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WINNERS FROM SEPTEMBER ISSUE Breathtaki ng COPD , TB, Sleep

tProfile: iiN etâ&#x20AC;&#x2122;s Michael Ma lone te-Health Readiness tTraining: In It Togeth er tACCC & the Pharmaceutic al Code tFair Game for Kids

Boy Gets Girl â&#x20AC;&#x201C; theatre: %S.BSL4USBIBO %S'SBODJT $IFOH%S(PSEBOB$VL Beasts of the Southern Wild â&#x20AC;&#x201C; movie: %S,JSBO3VCB  %S+VO8FJ/FP %S*WBO-FF %S3VCZ$IBO %S4V[FUUF 'JODI %S1JMMBZ4VSFOESBO %S4UBOMFZ,IPP %S&TUIFS .PTFT %S"OUPOZ%BWJT%S7BOFTTB1FSDJWBM Pinocchio â&#x20AC;&#x201C; ballet: %S*OESBOJ4BIBSBZ %S7JODFOU-PX %S.PIBO+BZBTVOEFSB

'SPNUIFXBSUPSO.POUFOFHSPPGIJTZPVUIUP-POEPOhT3PZBM "DBEFNZPG.VTJD ZFBSPMEHVJUBSJTU.JMPT,BSBEBHMJDJT BMSFBEZ IBJMFE CZ GBOT BOE DSJUJDT GPS IJT CSJMMJBOU UFDIOJRVF and transcendent musicality, and is the first classical guitarJTUTJHOFEUPUIFQSFTUJHJPVT%FVUTDIF(SBNNPQIPOMBCFMJO NBOZZFBST)JTBMCVNJT/PPOUIFDMBTTJDBMNVTJDDIBSUT JOUIF64 6,BOE"VTUSBMJB)FXJMMQMBZ#BDI #BSSJPT 7JMMB -PCPT "MCFOJ[ 5IFPEPSBLJTBOE%PNFOJDPOJ Perth Concert Hall, Monday, December 3, 8pm. Tickets through Tecketek

Movie: The Sessions 4UBSSJOH"DBEFNZ"XBSE8JOOFS)FMFO)VOU +PIO)BXLFT BOE 8JMMJBN ) .BDZ  The Sessions is based on the true TUPSZPG$BMJGPSOJBOKPVSOBMJTUBOEQPFU.BSL0#SJFO TUVOOJOHMZQPSUSBZFECZ)BXLFT XIPJTQBSBMZTFECZQPMJP)F decides at the age of 38 to finally lose his virginity. Funny, QPJHOBOU BOE TFOTJUJWFMZ EJSFDUFE CZ "VTUSBMJBO #FO -FXJO  UIF GJMN XPO UIF BVEJFODF BXBSE BU UIF 4VOEBODF 'JMN Festival. In Cinemas November 8.

Food: Margaret River Gourmet Escape 5IF.BSHBSFU3JWFS(PVSNFU&TDBQFJOWJUFTZPVUPUIFCFBVUJGVM .BSHBSFU 3JWFS 8JOF 3FHJPO GPS UIF VMUJNBUF DVMJOBSZ BEWFOUVSFTUBSSJOHDFMFCSJUZDIFGT)FTUPO#MVNFOUIBM ,ZMJF ,XPOHBOEJOUFSOBUJPOBMGPPEDSJUJD""(JMM8JOUJDLFUTUP UIF(PVSNFU7JMMBHFBU-FFVXJO&TUBUF8JOFSZ"(PVSNFU 7JMMBHFUJDLFUJODMVEFTY(&.T (PVSNFU&TDBQF.POFZ  Y(&.BOEXJMMCVZZPVBHMBTTPGSFHJPOBMXJOFPS fabulous pop-up restaurant dish. Leeuwin Estate, November 24 and 25. See www.gourmetescape.com.au

Ruby Sparks â&#x20AC;&#x201C; movie: %S"EFMJOF'POH  %S+VMJB$IBSLFZ1BQQ %S-J['FSHVTPO  %S.PJSB8FTUNPSF %S5SJYJF%VUUPO %S1SJTDJMMB5BO  %S+PIO8JMMJBNT%S$ISJTUJOF$BGGSFZ Arbitrage â&#x20AC;&#x201C; movie: %S#ZSOF3FEHSBWF %S.VLUJ#JZBOJ %S#BTUJBBOEF#PFS Madam Butterfly â&#x20AC;&#x201C; opera: .S4JSJ4JSJXBSEFOF %S$BSPMJOF-VLF Pirates of Penzance â&#x20AC;&#x201C; theatre: %S%FOJT-BXSBODF %S+PIO8IFFMFS

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September 201 2

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$10.5 0

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CARDIOLOGY

Western Australiaâ&#x20AC;&#x2122;s Whoâ&#x20AC;&#x2122;s Who for Patient Referrals CLINICAL SERVICES DIRECTORY Cardiology $PTNFUJD.FEJDJOF)BJS-PTT %FSNBUPMPHZ Ear, Nose & Throat (BTUSPFOUFSPMPHZ (FOFSBM4VSHFPOT4VCTQFDJBMUJFT (ZOBFDPMPHZ(ZOBFDPMPHJDBM4VSHFSZ (ZOBFDPMPHZ*OGFSUJMJUZ )BOE4VSHFPOT *OGFDUJPVT%JTFBTFT *OGFSUJMJUZ"OESPMPHZ Neurology Neurosurgery /VDMFBS.FEJDJOF Obstetrics 0CTUFUSJDT(ZOBFDPMPHZ 0CTUFUSJDBOE(ZOBFDPMPHJDBM6MUSBTPVOE Ophthalmology 0SUIPQBFEJD4VSHFPOT 1BFEJBUSJD"EPMFTDFOU3IFVNBUPMPHZ 1BFEJBUSJD3FTQJSBUPSZ4MFFQ1IZTJDJBO 1BFEJBUSJD4VSHFSZ 1BJO.FEJDJOF 1PEJBUSZ4FSWJDFT Psychiatry Psychology 3BEJPMPHZ 3FQSPEVDUJWF)FBMUI 3FTQJSBUPSZ4MFFQ.FEJDJOF 3IFVNBUPMPHZ 4FYVBM)FBMUI 4QPSUT.FEJDJOF'PPU0SUIPEPUJDT 5IPSBDJD4VSHFSZ 6SPMPHZ 7BTDVMBS&OEPWBTDVMBS4VSHFSZ 7BTDVMBS*NBHJOH*OUFSWFOUJPO

53-54 54 55 55 55   60-62 62 62 62 62-63 63 63 64 64-65 65 65-67 67-71 71 71 71-72 72 72 72 72 72-73 73 73-74 75 75 75 75 75 76-77 77

Dr Edmund Lee.##4 )POT '3"$1 *OUFSWFOUJPOBMDBSEJPMPHJTUXIPIBTDPNQMFUFEQPTU fellowship training in coronary stenting, structural IFBSUJOUFSWFOUJPOT JODMVEJOH"4%T 1'0T )0$.  valvuloplasties), cardiac biopsies and right heart DBUIFUFSJTBUJPOBUUIF.B[BOLPXTLJ)FBSU*OTUJUVUF $BOBEB 4VJUF.VSEPDI%SJWF.VSEPDI 1IPOF 9366 1891 'BY 9366 1900 $POTVMUTBU4+0(.VSEPDI 3PDLJOHIBN 8BSXJDL .BOEVSBI (FSBMEUPOBOE#VOCVSZ Other special interests include: t Pacemaker implantation t Transoesophageal echocardiogram For all appointments, call 9366 18916SHFOUBEWJDF0422 895 111

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Heart Care Western Australia & Coastal Cardiology )FBSU$BSF8"BOE$PBTUBM$BSEJPMPHZQSPWJEFDPWFSBHFGPSBMMBTQFDUTPG BEVMUDBSEJPMPHZSFRVFTUFECZSFGFSSFSTJO8FTUFSO"VTUSBMJB Dr Bernard Hockings Dr Mark Ireland Dr Mark Nidorf Dr Peter Purnell Dr Nigel Sinclair Dr Isabel Tan Dr Peter Thompson

Dr Randall Hendriks Dr Donald Latchem Dr Vince Paul Dr Alan Whelan Dr Xiao-Fang Xu

Comprehensive cardiac services will now be provided by the new practice BU1FSUITMFBEJOHNFUSPQPMJUBOIPTQJUBMTJODMVEJOH4U+PIOPG(PE)PTQJUBM .VSEPDI .PVOU)PTQJUBMBOE)PMMZXPPE1SJWBUF)PTQJUBM )FBSU$BSF8"$PBTUBMXJMMBMTPFYQBOETFSWJDFTJO+PPOEBMVQ .BOEVSBI  #VOCVSZ #VTTFMUPO %VOTCPSPVHI .BSHBSFU3JWFS "MCBOZ %FONBSL  ,BSSBUIBBOE1PSU)FEMBOE The new practice is the only cardiology group that has a clinical presence BUBMMUIFNBKPSUFBDIJOHIPTQJUBMTJO8" JODMVEJOH3PZBM1FSUI)PTQJUBM 4JS $IBSMFT(BJSEOFS)PTQJUBMBOE'SFNBOUMF)PTQJUBM We provide a full and comprehensive Cardiology service including: t $POTVMUBUJPOTo$MJOJDBM &NQMPZNFOUBOE*NNJHSBUJPO3FMBUFE t &$(BOE&YFSDJTF4USFTT5FTUJOH t &DIPDBSEJPHSBQIZ 4USFTT %PCVUBNJOF5SBOTPFTPQIBHFBM Echocardiography t )PMUFS.POJUPSJOHBOE&WFOU.POJUPSJOH t #MPPE1SFTTVSF.POJUPSJOH t "OHJPHSBQIZ 3FWBTDVMBSJTBUJPOXJUI"OHJPQMBTUZBOE4UFOUT t "4%$MPTVSF 7BMWVMPQMBTUZ t 1FSNBOFOU1BDFNBLFS*OTFSUJPOT *NQMBOUBCMF%FmCSJMMBUPST t $BSEJBD3FTZODISPOJTBUJPO t &MFDUSPQIZTJPMPHZ4UVEJFTBOE3BEJPGSFRVFODZ"CMBUJPOT t Pacemaker Checks t "DDFTTUP1SJWBUFBOE1VCMJD)PTQJUBMT t 3FTPVSDFBOE"EWJTPSZ4FSWJDFUP(FOFSBM1SBDUJUJPOFST Heart Care To speak to a Cardiologist call our GP Hotline: 1300 4 Heart (1300 443 278) For Appointments Phone: 08 9480 3000 Email: info@heartcarewa.com.au Web: www.heartcarewa.com.au Coastal Cardiology To speak to a Cardiologist call our GP Hotline: 08 9311 4601(24hrs on call) For Appointments Phone: 08 9311 4600 Mount, Joondalup, Murdoch, Nedlands, Yokine, Duncraig, Midland Albany, Augusta, Bunbury, Busselton, Denmark, Dunsborough, Karratha, Mandurah, Margaret River, Port Hedland, Rockingham, Northam

N O V E M B E R 2012

medic alFORUMwa

53


Medical Forum CLASSIFIEDS SPECIALISTS WANTED

MT LAWLEY Mercy Medical Centre Precinct Mount Lawley $UDQJHRIRSSRUWXQLWLHVH[LVWIRU 6SHFLDOLVWVORRNLQJWRMRLQWKH0HUF\ Medical Centre precinct. :HRIIHUDUDQJHRIIXOO\VXSSRUWHG 6HVVLRQDO6XLWHVKLVWRULFKHULWDJH listed buildings and consulting suites complete with river views. 0HUF\+RVSLWDOLVFXUUHQWO\XQGHUJRLQJ major redevelopment and we are ORRNLQJWRZHOFRPH6SHFLDOLVWV interested in developing a presence in WKH(DVWHUQ6XEXUEV )RUIXUWKHULQIRUPDWLRQSOHDVHFRQWDFW Jill Carland on 0408 090 363. www.mercycare.com.au/hospital

ANAESTHETIST WANTED MT LAWLEY '\QDPLFVSHFLDOLVWDQDHVWKHWLVW V  UHTXLUHGWRUHSODFHUHWLULQJPHPEHU 6KDUHURRPVZLWKORQJHVWDEOLVKHG hospital based group. $FFUHGLWDWLRQDW0HUF\+RVSLWDOLV mandatory. Computerised billing system with excellent administrative/secretarial support. )RUIXUWKHULQIRUPDWLRQSOHDVHFDOO Lorraine on (08) 9370 9733

FOR LEASE NEDLANDS +ROO\ZRRG0HGLFDO&HQWUH 1HZIXOO\¿WWHGPVXLWHRQVW)ORRU DYDLODEOHIRUOHDVHLPPHGLDWHO\ 7HO1R0409 688 339 /0400 066 160 JOONDALUP Modern sessional suites available in Joondalup CDB 6HFUHWDULDOVXSSRUWDYDLODEOHLIUHTXLUHG Phone 9300 3380 WEST LEEDERVILLE/SUBIACO 6SHFLDOLVW&RQVXOWLQJ5RRPVIRU/HDVH 6XEOHDVH 2SSRVLWH6W-RKQRI*RG+RVSLWDO 6XELDFR /DUJH5HFHSWLRQDQG:DLWLQJ$UHDV &RQVXOWLQJ5RRPDQG'UHVVLQJ5RRPV $PSOH2Q6LWH3DUNLQJ Please contact 0409 980 198 MURDOCH 0XUGRFK6SHFLDOLVW&HQWUHEUDQGQHZ stylish large rooms. Please email you interest to DGPLQ#VOHHSPHGFRPDX NEDLANDS +ROO\ZRRG0HGLFDO&HQWUH )XOO\IXUQLVKHGFRQVXOWLQJURRPV¶ VXLWHRQQGÃ&#x20AC;RRUIRULPPHGLDWHOHDVH Phone: 0401 289 276



EAST VIC PARK Medical Centre â&#x20AC;&#x201C; For Lease â&#x20AC;&#x201C; East Vic Park Bring your stethoscope and start consulting. Prime Location. 4XDOLW\¿WRXWIXOO\HTXLSSHG Computerised with patient records. Attractive lease terms available with incentives. Contact: Brad Potter â&#x20AC;&#x201C; 0411 185 006 APPLECROSS Applecross Medical Group is a major PHGLFDOIDFLOLW\LQWKHVRXWKHUQVXEXUEV &XUUHQWWHQDQWVLQFOXGH*3FOLQLF SKDUPDF\GHQWLVWSK\VLRWKHUDS\ IHUWLOLW\FOLQLFDQGSDWKRORJ\%RWKWKH GP clinic and pharmacy provide a 7 day service. 7KHKLJKSUR¿OHORFDWLRQ FRUQHU RI&DQQLQJ+Z\DQG5LVHOH\6WUHHW $SSOHFURVV SURYLGHVKLJKYLVLELOLW\WR WHQDQWVLQWKLVIDFLOLW\ A long term lease is available in this IDFLOLW\WKHVSDFHDYDLODEOHLVP with the current layout including 4 FRQVXOWLQJURRPVSURFHGXUHURRPDQG reception area. :RXOGVXLWVSHFLDOLVWJURXSUDGLRORJ\RU allied health group. Contact John Dawson â&#x20AC;&#x201C; 9284 2333 or 0408 872 633 NEDLANDS 0HGLFDO6SHFLDOLVW&RQVXOWLQJ5RRPV )XOO\VHUYLFHGURRPVDQGIDFLOLWLHVIRU 6SHFLDOLVW&RQVXOWLQJDUHDYDLODEOHLQ 6XLWH+ROO\ZRRG6SHFLDOLVW&HQWUH 0RQDVK$YHQXH1HGODQGV $Q\HQTXLULHVFDQEHGLUHFWHGWR0UV 5KRQGD0D]]XOOD3UDFWLFH0DQDJHU 6XLWH+ROO\ZRRG6SHFLDOLVW&HQWUH 0RQDVK$YHQXH 1HGODQGV:$ Phone 9389 1533 Email: VXLWHKROO\ZRRG#ELJSRQGFRP

FOR SALE PART PRACTICE FOR SALE JOONDALUP 8QLTXHRSSRUWXQLW\IRUWKHDVWXWH investor. Ultrasound North is the only Tertiary Level Obstetric and Gynaecological practice in the 1RUWKHUQFRUULGRU 7KHFOLQLFKDVD6RQRORJLVW 6RQRJUDSKHUVDQG)URQW2I¿FH 0DQDJHUDQGDGPLQVXSSRUWVWDII Conveniently located on Grand %RXOHYDUGPHWUHVIURPWKHQHZO\ H[SDQGHG-RRQGDOXS+HDOWK&DPSXV 6HFXUHURRPV An extensive and continually growing patient base. 5DUHO\GRHVDQLQYHVWPHQW RSSRUWXQLW\OLNHWKLVEHFRPH available. $VKDUHLVFXUUHQWO\RQRIIHU 7KHFDQEHSXUFKDVHGLQLWV entirety or as a part share. 2QO\JHQXLQHEX\HUVPD\HQTXLUH Contact 0402 413 717

For Sale â&#x20AC;&#x201C; Rare Opportunity â&#x20AC;&#x201C; Duncraig 2SSRUWXQLW\WRSXUFKDVHSULPH5HDO Estate in Duncraig opposite the *OHQJDUU\+RVSLWDO Practice is currently being run as an Obstetrics & Gynaecology clinic however would suite any consulting specialist. ,GHDORSSRUWXQLW\IRUORQJWHUP investment with such close proximity to WKH+RVSLWDO ([FHOOHQWRIIVWUHHWSDUNLQJRYHU EORFNV<RXDQG\RXUSDWLHQWVZLOO EHQH¿WIURPWKHFRQYHQLHQFH Contact Brad Potter â&#x20AC;&#x201C; 9315 2599 or 0411 185 006

LOCUM WANTED PERTH Locums / Associates wanted. 3HUWK0HGLFDO&HQWUH+D\6WUHHW0DOO Busy accredited privately owned SUDFWLFHSULYDWHELOOLQJÃ&#x20AC;H[LEOHKRXUV ([FHOOHQWUHPXQHUDWLRQIRUVXLWDEOH candidates. Phone: 9481 4342 Mobile: 0408 665 531

RURAL POSITIONS VACANT GREATER BUNBURY MEDICAL CENTRE Â&#x2021; SXUSRVHEXLOWVTP medical centre

Â&#x2021; SULPHWHQDQFLHVDQGURRPV  RIYDULRXVVL]HV Â&#x2021; 0DMRUKLJKZD\IURQWDJH±  %XVVHOO+LJKZD\ Â&#x2021; )UHHFDUSDUNLQJ Â&#x2021; &ORVHWRWKHQHZ,&8&&8 oncology Â&#x2021; 3HUIHFWEDVHIRUVSHFLDOLVWV allied health & others Â&#x2021; *3VZHOFRPH±%UHFNHQ+HDOWK Â&#x2021; 2SHQV0DUFK For more details call (08)9791 8133 -LOO5LJJDOO0DQDJHU BINDOON )XOOWLPH*3UHTXLUHGIRUIULHQGO\ SURJUHVVLYHUXUDOSUDFWLFHRQO\ PLQXWHVIURPFHQWUDO3HUWK 1RDIWHUKRXUVRUZHHNHQGV $FFRPPRGDWLRQSURYLGHGLQEHGURRP house with pool. RIELOOLQJVGHSHQGDQWRQ experience. Phone: 9576 1222

ALBANY 95*3UHTXLUHGWRMRLQRXU'RFWRU EXV\IULHQGO\IDPLO\SUDFWLFH Full time or Part time a special interest LQ:RPHQ¶V+HDOWKZRXOGEHDERQXV :HDUH$FFUHGLWHGFRPSXWHULVHGIXOO nurse support and an experienced $GPLQ7HDPZLWK+HDOWKVFRSH Laboratory on site. Mixed billing. 3KRQH*D\H3UDFWLFH0DQDJHU 9841 6711 (PDLOJD\H#KLOOVLGHISFRPDX MARGARET RIVER /RQJHVWDEOLVKHGDFFUHGLWHGIDPLO\ SUDFWLFHVHHNV*3RUWUDLQHHWRUHSODFH retiring Doc. $QDHVWKHWLFV2EVWHWULFDQGVXUJLFDO scope available but not essential. 6RPHDIWHUKRXUVFRPPLWPHQW QRWRQHURXV 3KRQH6DOO\08 9757 2733 IRUPRUHLQIR

URBAN POSITIONS VACANT DALKEITH 'DONHLWK0HGLFDO&HQWUH UHTXLUHVDIXOORUSDUWWLPH95*3WRMRLQ RXUZHOOHVWDEOLVKHGDQGDFFUHGLWHG IXOO\FRPSXWHULVHGSUDFWLFHZLWKIXOO time practice nurse support. ([SUHVVLRQVRILQWHUHVWSOHDVH call 0412 22 4535 GOSNELLS 95*3ZDQWHG Accredited practice with nurse support. RIELOOLQJV Please phone: 0403 756 338 OUTER METRO PRACTICE â&#x20AC;&#x201C; ALEXANDER HEIGHTS )XOOWLPH3DUWWLPH9512195*3 UHTXLUHGWRMRLQRXUSULYDWHO\RZQHG IXOO\DFFUHGLWHG FRPSXWHULVHGQRQ FRUSRUDWHIDPLO\SUDFWLFH Fully supportive including Practice 1XUVHRQVLWHSDWKRORJ\DQGDIULHQGO\ ZRUNLQJHQYLURQPHQW Contact Dr Jagadish on 0413 879 023 (PDLOMDJVNULVKQDQ#JPDLOFRP Or Caroline â&#x20AC;&#x201C; Practice Manager 0427 342 488 / FDUROLQH#WKHKHLJKWVFRPDX WEST LEEDERVILLE - GREAT LIFESTYLE 3DUWWLPH95*3LQYLWHGWRMRLQORQJ HVWDEOLVKHG:HVW/HHGHUYLOOHIDPLO\ practice. &RPSXWHULVHGDFFUHGLWHGDQGQRQ FRUSRUDWHZLWKDQRSSRUWXQLW\WR SULYDWHELOOLIGHVLUHG /RWVRIOHDYHÃ&#x20AC;H[LELOLW\ZLWKVL[IHPDOH and one male colleague. (PDLOSUDFWLFHPDQDJHU#HIWHOQHWDX RU-DFN\9381 7111. JOONDALUP *3UHTXLUHGWRMRLQRXUIULHQGO\WHDP Privately owned AGPAL accredited general practice. Fully computerised. Contact Michelle 9300 0219

DECEMBER 2012 - next deadline 12md Thursday 15th November - Tel 9203 5222 or jen@mforum.com.au

78


Medical Forum CLASSIFIEDS WHITFORD *3)72537 :HDUHIXOO\FRPSXWHULVHGZHOO HTXLSSHGDFFUHGLWHGSUDFWLFH )ULHQGO\SUDFWLFH1XUVHDQGDGPLQ VWDIIWRVXSSRUWDWDOOWLPHVLQFOXGLQJ &DUHSODQ+HDOWK$VVHVVPHQW1XUVH 0HGLFDO&HQWUHKDVRQVLWHSDWKRORJ\ pharmacy and physiotherapy. 3OHDVHFRQWDFW-DFTXL3UDFWLFH0DQDJHU on 9307 4222 Email: MPDUNRXORRS#LLQHWQHWDX MOSMAN PARK $IULHQGO\QRQFRUSRUDWHIXOO\ FRPSXWHULVHGSUDFWLFHLQ0RVPDQ3DUN LVORRNLQJIRUD*3WRZRUNSDUWRU IXOOWLPH +RXUVDQGGD\VÃ&#x20AC;H[LEOH 5HPXQHUDWLRQRIJURVVELOOLQJV Tel: Jacinta on 9385 0077 BOORAGOON - GARDEN CITY *UHDWRSSRUWXQLW\IRUD)795WRSURYLGH TXDOLW\*3VHUYLFHVLQRXU*DUGHQ&LW\ Medical Centre. The Centre is located in WKHHVWDEOLVKHGDIÃ&#x20AC;XHQWVXEXUERI Booragoon. Adjacent to the thriving *DUGHQ&LW\6KRSSLQJ&HQWUHEXV SRUWQHDUE\RQVLWH3DWKRORJ\DQG 3KDUPDF\WKHFHQWUHLVRSHQ0RQ6DW Joined by an excellent medical team FRPSULVLQJRI*3VVSHFLDOLVLQJLQ 0HQ :RPHQ¶VKHDOWK0LQRUVXUJHU\ 2EVWHWULF3DHGLDWULFV,PPXQLVDWLRQV 6NLQ +HDOWK&KHFNV\RXZLOODOVREH VXSSRUWHGE\IXOOWLPHQXUVLQJVWDIIDQG DIULHQGO\DGPLQLVWUDWLRQWHDP )RUFRQ¿GHQWLDOHQTXLUHVFRQWDFW Amanda on â&#x20AC;&#x201C; 0419 046 997 (PDLODPDQGDSLHUF\#LSQFRPDX FREMANTLE )UHPDQWOH:RPHQ¶V+HDOWK&HQWUH UHTXLUHVDIHPDOH*3 95 WRSURYLGH PHGLFDOVHUYLFHVLQWKHDUHDRI ZRPHQ¶VKHDOWKRUGD\VSZ,WLVD FRPSXWHULVHGSULYDWHDQGEXONELOOLQJ SUDFWLFHZLWKQXUVLQJVXSSRUWVFRSH IRUVSHQGLQJPRUHWLPHZLWKSDWLHQWV and provides recently increased remuneration plus superannuation DQGJHQHURXVVDODU\SDFNDJLQJ):+& LVDQRWIRUSUR¿WFRPPXQLW\IDFLOLW\ providing medical and counselling VHUYLFHVKHDOWKHGXFDWLRQDQGJURXS DFWLYLWLHVLQDUHOD[HGIULHQGO\VHWWLQJ Phone 9431 0500 or (PDLO'LDQH6QRRNV GLUHFWRU#IZKFRUJDXRU 'DZQ1HHGKDP FOLQLFDOPDQJHU#IZKFRUJDX DUNCRAIG '81&5$,*0(',&$/&(175(UHTXLUHV DIHPDOH*3 )OH[LEOHKRXUVH[FHOOHQWUHPXQHUDWLRQ 0RGHUQSUHGRPLQDQWO\SULYDWHELOOLQJ SUDFWLFHZLWKIXOOWLPH3UDFWLFH1XUVH Fully computerised. Please contact Michael on 0403 927 934 Email Dr Dianne Prior: GLDQQH#GXQFUDLJPHGLFDOFHQWUHFRPDX

79

INGLEWOOD *3UHTXLUHGIXOOWLPHRUSDUWWLPHZLWK RUZLWKRXWDYLHZ+RXUVQHJRWLDEOH :HDUHDEXV\GRFWRU PDOH IHPDOH SULYDWHELOOLQJQRQFRUSRUDWH SUDFWLFHLQ%HGIRUG )XOOWLPH1XUVHDQGSDWKRORJ\RQVLWH )ULHQGO\DQGYHU\ZHOOVWDIIHG 3KRQH6WHYH&DUORU-HUHP\RQ 9271 9311 or (PDLOVDOLVEXU\PHG#LLQHWQHWDX HILLARYS Exciting Opportunity. Join us in our brand new General 3UDFWLFHORFDWHG125 1RQFRUSRUDWH :HUHTXLUHDIXOOWLPHRUSDUWWLPH*3 IRURXUSUDFWLFH +RXUVWRVXLW 1RHYHQLQJRUZHHNHQGZRUNUHTXLUHG 7KHSUDFWLFHLVIXOO\FRPSXWHULVHGDQG ZHOOHTXLSSHG 3ULYDWH%LOOLQJDQGVRPHEXONELOOLQJ )XOOWLPH1XUVLQJVXSSRUW Pathology on site. Please contact Practice Manager on 9448 4815 or (PDLOVPF#ZHVWQHWFRPDX MANDURAH 0DQGXUDKFRDVWDOOLIHVW\OHPLQXWHV IURP3HUWK 95QRQ95GRFWRUUHTXLUHGVKRUWWHUP or long term. 1RZHHNHQGVRUDIWHUKRXUV Good remuneration. &OLQLFKDVIXOOWLPHQXUVHVSDWKRORJ\ SV\FKRORJ\KHDULQJFHQWUH dermatologist and orthotics. Contact practice manager Elaine 9535 8700 (PDLOHODLQH#PDQGXUDKGRFWRUVFRPDX SCARBOROUGH 6FDUERURXJK%HDFK0HGLFDO&HQWUH 3DUWWLPH*3UHTXLUHGIRU$IWHU+RXUV SPWRSP6HVVLRQVDYDLODEOH Private Billing. Attractive Income. Please contact Georgina Ioppolo on 0423 106 136 (PDLORI¿FH#VEPFFRPDX BENTLEY *395µZLWKZLWKRXWDYLHZ¶QHHGHG IRUSULYDWHO\RZQHGIDPLO\RULHQWDWHG practice. PLQVIURP3HUWK&%'$*3$/ DFFUHGLWHGIXOO\FRPSXWHULVHGXVLQJ 0'3UDFVRIW Private billing. 6XSSRUWHGE\FOLQLFDODQG&'0QXUVHV RSHUDWLQJIURPSXUSRVHEXLOWSUDFWLFH :HRIIHURIELOOLQJV Contact Alison on 0401 047 063 MIRRABOOKA )XOOWLPH3DUWWLPH*3UHTXLUHGIRU DYHU\EXV\SUDFWLFHLQ0LUUDERRND 95SUHIHUHG 3ULYDWHDQG%XON%LOOLQJ Applications can be made via Email: PGV#PLUUDERRNDGRFWRUVFRPDX or calling 0400 814 091

MORLEY *3ZDQWHGIRUEXV\SULYDWHELOOLQJ DFFUHGLWHG*HQHUDO3UDFWLFHNPIURP the City. )XOOQXUVLQJVXSSRUWIULHQGO\DQG SURIHVVLRQDOVWDII Phone Darren on 0477 999 239 (PDLOFPV#LLQHWQHWDX MT HAWTHORN 0W+DZWKRUQ0HGLFDO&HQWUHDQRQ corporate accredited long established SUDFWLFHVLWXDWHGLQDIDVWJURZLQJLQQHU FLW\VXEXUERI3HUWKVHHNVDSDUWWLPH RUIXOOWLPH95*3WRMRLQWKLVKLJKO\ desirable practice. )XOO\FRPSXWHULVHG1XUVH$VVLVWDQW 3KRQH5RVH9444 1644 MT LAWLEY 3RVLWLRQIRUDIXOOWLPH*3ZRUNLQJ DVDVHOIHPSOR\HGFRQWUDFWRULQ RXUDFFUHGLWHGIXOO\FRPSXWHULVHG independent practice. ([FHOOHQWZRUNLQJHQYLURQPHQWZLWK PRGHUQIDFLOLWLHV 4XDOLW\QXUVLQJVWDIIDQGDQRQVLWH diabetes educator/dietician. Adjacent to the practice we have DSKDUPDF\DQGDOOLHGVHUYLFHV FRQVLVWLQJRIDXGLRORJ\SDWKRORJ\ SK\VLRWKHUDS\SRGLDWU\GHQWDODQG cardiology. 9LVLWRXUZHEVLWHZZZUGDYHFRPDX DQGLILQWHUHVWHGULQJXVRQ (08) 9272 5533. 3OHDVHDVNIRU3UDFWLFH0DQDJHU 5DFKDHO+DGORZ $OWHUQDWLYHO\\RXPD\VHQGDQHPDLOWR UKDGORZ#UGDYHFRPDX DIANELLA 1RQ&RUSRUDWHSUDFWLFHUHTXLUHV)7 DQG3795*3¶VWRMRLQIHPDOHDQG male doctor team. 2XUQHZO\H[WHQGHGORQJHVWDEOLVKHG DFFUHGLWHGIXOO\FRPSXWHULVHGSUDFWLFH is supported with 4 excellent nurses DQGYHU\IULHQGO\DGPLQVWDII Our practice is mostly private billing and ZHRIIHUH[FHOOHQWUHPXQHUDWLRQ Please contact Practice Manager on 9276 3472 (PDLOGIPF#GLDQHOODPHGLFDOFRPDX JOONDALUP (GLWK&RZDQ8QLYHUVLW\6WXGHQW +HDOWK6HUYLFHV 3DUWWLPH95*37XHVGD\DQG 7KXUVGD\VDYDLODEOHIURP$XJXVW ,QWHUHVWLQ:RPHQ¶VDQG6WXGHQW+HDOWK $WWUDFWLYHZHOOHTXLSSHGSXUSRVHEXLOW PHGLFDOFHQWUHDFFUHGLWHGH[FHOOHQW ZRUNHQYLURQPHQW5HJLVWHUHG1XUVH VXSSRUWÃ&#x20AC;H[LEOHZRUNDUUDQJHPHQWV (&8-RRQGDOXS&DPSXV0HGLFDO&HQWUH LVORFDWHGLQDGLVWULFWRIZRUNIRUFH shortage. )RULQIRUPDWLRQ'U5REHUW&KDQGOHU 3KRQH6304 5618 (PDLOUFKDQGOHU#HFXHGXDX KOONDOOLA *3UHTXLUHGIRUDZHOOHVWDEOLVKHG SULYDWHO\RZQHGSXUSRVHEXLOWSUDFWLFH with onsite pathology and pharmacy. ':6VWDWXV (PDLOJURXSPDQDJHU#ZHVWQHWFRPDX

BENTLEY 5RZHWKRUSH0HGLFDO&HQWUHLVDQRQ SUR¿WIULHQGO\SUDFWLFHVHHNLQJDSDUW time GP to provide visits to our onsite UHVLGHQWLDODJHGFDUHIDFLOLWLHV3UDFWLFH based consultations are also available. Â&#x2021; )XOO\FRPSXWHULVHG Â&#x2021; 1HZO\UHQRYDWHGSUHPLVHV Â&#x2021; 0RGHUQHTXLSPHQW Â&#x2021; 2QVLWHSDWKRORJ\ Â&#x2021; +RXUVWRVXLW\RX )RUHQTXLULHVSOHDVHFRQWDFW-DFNLHRQ 6363 6315 or 0413 595 676

FREMANTLE 3DUWWLPHRU)XOOWLPH SUHIHUDEO\95  GPs wanted. (//(1+($/7+LVDGRFWRURZQHGDQG managed General Practice operating IURPWZRORFDWLRQVLQSRUWFLW\RI Fremantle. :HOOHVWDEOLVKHGSDWLHQWEDVHRIIHULQJ DEURDGVXLWHRIVHUYLFHVLQFOXGLQJ QXWULWLRQDQGOLIHVW\OHVSHFLDOLVHG SUHJQDQF\DQGPLGZLIHU\FDUH community mental KHDOWKQXUVLQJDQGVNLQFOLQLF consultations. ,I\RXZHUHWRMRLQRXUWHDPZHZLOO RIIHU\RX Â&#x2021; $JURZLQJGDWDEDVHRI3ULYDWH Billing patients Â&#x2021; $SURIHVVLRQDODQGGHGLFDWHG support team Â&#x2021; $OLIHVW\OHWDLORUHGWRWKHORFDWLRQ Â&#x2021; +RXUVRIZRUNWRVXLWRXUEDODQFHG  OLIHVW\OHDSSURDFK  3UDFWLFHKRXUVDUH:HHNGD\VDP  SP6DWXUGD\DPSP  1RDIWHUKRXUVRQFDOORUKRVSLWDO  ZRUNUHTXLUHGDWWKLVWLPH Â&#x2021; +LJKOHYHORIHDUQLQJV Contact Practice Manager %ULGLH+XWWRQ0413 994 484 (PDLOEULGLHKXWWRQ#HOOHQKHDOWKFRPDX WEST PERTH GP sessions available at our SULYDWHELOOLQJDFFUHGLWHGDQGIXOO\ computerised general practice. 2XUEXV\SUDFWLFHVHUYHVD\RXQJ SURIHVVLRQDOGHPRJUDSKLFDVZHOO as providing specialist sexual health services. This represents an exciting opportunity IRUDQHQWKXVLDVWLFSUDFWLWLRQHUWRMRLQ RXUIULHQGO\WHDP 0RUQLQJDQGDIWHUQRRQVHVVLRQVDUH DYDLODEOH([SHULHQFHLQIDPLO\SODQQLQJ sexual health and mental health would be an advantage. &RQWDFW6WHSKHQRQ 0411 223 120 Email: VWHSKHQ#ZHVWSHUWKPHGLFDOFHQWUHFRPDX WILLETTON *3([FHOOHQWZRUNLQJFRQGLWLRQV $IWHUKRXUV6DWXUGD\DQG 6XQGD\VHVVLRQV RIELOOLQJV 3KRQH6DP0417 963 759

DECEMBER 2012 - next deadline 12md Thursday 15th November - Tel 9203 5222 or jen@mforum.com.au

79


Medical Forum CLASSIFIEDS OUTER METRO PRACTICE - BEELIAR )XOOWLPH3DUWWLPH9512195*3 UHTXLUHGWRMRLQRXUSULYDWHO\RZQHG IXOO\FRPSXWHULVHGQRQFRUSRUDWHIDPLO\ practice. )XOO\VXSSRUWLYHLQFOXGLQJ3UDFWLFH1XUVH DQGIULHQGO\ZRUNLQJHQYLURQPHQW &RQWDFW'U-DJDGLVKRQ (PDLOMDJVNULVKQDQ#JPDLOFRP Or Caroline â&#x20AC;&#x201C; Practice Manager 0427 342 488 / FDUROLQH#WKHKHLJKWVFRPDX HALLS HEAD/MANDURAH )73795*3UHTXLUHGIRUEXV\SULYDWHO\ owned practice. Fully computerised &RQWDFWXVRQ9581 2345 Email: URE\Q#SHHOZRRGPHGLFDOFRPDX FLOREAT/CHURCHLANDS )XOO\DFFUHGLWHGIDPLO\SUDFWLFH LQ)ORUHDWUHTXLUHVD)7*3 1RQFRUSRUDWH 1RFRQWUDFWV Generous split. Fully computerised with allied health support and well established patient EDVH6WDUW$6$3 Please call: Melody 9383 7111, 0422 296 978 or (PDLOPHORG\#KHUGVPDQPHGLFDOFRPDX MINDARIE +DUERXU6LGH0HGLFDO&HQWUHLVORRNLQJ IRUD95)737*3 7KLVTXDOLW\SUDFWLFHLVQHZDQGPRGHUQ located opposite the Mindarie Marina. 8SWRELOOLQJ2SHQ'D\V2QVLWH pathology. Please contact on 0417 813 970 or Email: PPXWDKDU#KDUERXUVLGHPHGLFDOFHQWUHFRPDX

STRESS TESTING â&#x20AC;&#x201C; Armadale, Murdoch and Rockingham. +HDUWV:HVWUHTXLUHVGRFWRUVWR supervise exercise stress testing. Training can be provided. ([FHOOHQWUHPXQHUDWLRQDQGZRUNLQJ FRQGLWLRQV/DWHVWHTXLSPHQWDQGGLJLWDO reporting systems. Please contact Freda Congleton by phone or email Phone 6461 6950 or (PDLOIFRQJOHWRQ#KHDUWVZHVWFRPDX APPLECROSS 3795*3ZDQWHGWRUHSODFH)HPDOH Doctor. :HDUHDVPDOOSULYDWHO\RZQHG accredited practice in Applecross. )XOO\FRPSXWHULVHGZLWKDVXSSRUWLYH IULHQGO\DGPLQDQGQXUVLQJVWDII )RUPRUHLQIRUPDWLRQSOHDVHFRQWDFW Jodie 0416 022 721 (PDLODSSOHYLOODJHPHGLFDO#JPDLOFRP

80

MORLEY $QHZO\UHIXUELVKHGPHGLFDOFHQWUH ORFDWHGRSSRVLWHWKH*DOOHULD6KRSSLQJ &HQWUHKDVWKHSHUIHFWRSSRUWXQLW\ IRUD)795*3VHHNLQJDKLJKSDWLHQW base. The centre is in a standalone EXLOGLQJZLWKDPSOHRQVLWHSDUNLQJ DORQJZLWK3DWKRORJ\5DGLRORJ\ 3KDUPDF\3K\VLRWKHUDS\$XGLR&OLQLF DQG'HQWLVWU\2SHQ0RQ6DW\RXZLOO KDYHWKHVXSSRUWRIDSURIHVVLRQDO and dynamic practice manager with H[SHULHQFHGDGPLQVWDII7KHFHQWUH VSHFLDOLVHVLQ0HQV+HDOWK:RPHQÂśV +HDOWK:RUN&RYHU0LQRU6XUJHU\ ,PPXQLVDWLRQ&RXQVHOOLQJ$JHG&DUH )DPLO\3ODQQLQJ3DHGLDWULFV/LIHVW\OH +HDOWK3URPRWLRQ )RUFRQÂżGHQWLDOHQTXLUHVFRQWDFW Amanda on â&#x20AC;&#x201C; 0419 046 997 (PDLODPDQGDSLHUF\#LSQFRPDX OUTER METRO PRACTICE â&#x20AC;&#x201C; SOUTH LAKE )XOOWLPH3DUWWLPH9512195*3 UHTXLUHGWRMRLQRXUSULYDWHO\RZQHG IXOO\DFFUHGLWHG FRPSXWHULVHGQRQ FRUSRUDWHIDPLO\SUDFWLFH Fully supportive including Practice 1XUVHRQVLWHSDWKRORJ\DQGDIULHQGO\ ZRUNLQJHQYLURQPHQW Contact Dr Jagadish on 0413 879 023 (PDLOMDJVNULVKQDQ#JPDLOFRP Or Caroline â&#x20AC;&#x201C; Practice Manager 0427 342 488 / FDUROLQH#WKHKHLJKWVFRPDX KARDINYA .HOVR0HGLFDO*URXSUHTXLUHV37DQGRU F/T GP to replace retiring doctor. This long established privately owned DQGPDQDJHGPL[HGELOOLQJSUDFWLFHRIIHUV JUHDWRSSRUWXQLW\IRUGRFWRUZLWKLQWHUHVW in CDM and minor surgical procedures. Located in Kardinya in newly UHIXUELVKHGSUHPLVHVZLWKRQVLWH pathology and allied health with growing patient base. &XUUHQWO\VXSSRUWHGE\*3ÂśVDQG )7(51ÂśV Please call 0419 959 246IRUIXUWKHU LQIRUPDWLRQ ZZZNHOVRPJFRPDX WEMBLEY 3RVLWLRQDYDLODEOHIRUDTXDOLÂżHGGRFWRU :HZRXOGOLNH\RXUVHUYLFHVIRU DSSUR[LPDWHO\KRXUVSHUIRUWQLJKW 7KHGD\RIWKHZHHNDQGWKHWLPHRI GD\DUHĂ&#x20AC;H[LEOH 7KHUROHLVWRLQMHFWĂ&#x20AC;XRUHVFHLQ G\HIRUDQJLRJUDSK\GLJLWDOUHWLQDO photography. ,WZRXOGVXLWVRPHRQHGRLQJD3+'RU in a research position. 3OHDVHFDOO6DOO\ 3UDFWLFH0DQDJHU DW Cambridge Eye Clinic on 9388 7066 or (PDLOH\HV#FHFOLQLFFRPDX RIVERTON 5,9(57210(',&$/&(175(LVORRNLQJ IRUD37RU)795*3 $FFHVVWRIXOOWLPHSUDFWLFHQXUVH Fully computerised accredited practice. )ULHQGO\ZRUNLQJHQYLURQPHQW 3D\RIUHFHLSWV 5LQJ'U6RYDQQRQ0412 711 197 LILQWHUHVWHG

ARMADALE :DQWHG951RQ95'RFWRUV 0DOH Female) ':6$RQ$UHD Outer Metropolitan Perth Phone: Kerry 9498 1099 (PDLOVHYLOOHGULYH#PHGLFDOFHQWUDOFRPDX

QUEENS PARK /RRNLQJIRU*395WRMRLQRXUJURZLQJ PHGLFDOFHQWUH(IÂżFLHQWKHOSIXODGPLQ VWDIIDQG51VXSSRUW 0L[HGELOOLQJH[FHOOHQWIDFLOLWLHV DFFUHGLWHGDQGIXOO\FRPSXWHULVHG 2QVLWHSK\VLRWKHUDS\RFFXSDWLRQDO health and pathology. Please phone Tim 9356 8993 (PDLODGPLQ#TXHHQVSDUNPHGLFDOFRPDX :HEVLWHZZZTXHHQVSDUNPHGLFDOFRPDX

5HDFKHYHU\NQRZQSUDFWLVLQJ doctor in WA through Medical )RUXP&ODVVLÂżHGV

WOODLANDS 37RU)795*3ZDQWHGWRMRLQKDSS\ mainly private billing practice. Good mix RI\RXQJDQGROGSDWLHQWVQRZHHNHQGV RUDIWHUKRXUV 1XUVHVXSSRUWDQG&RIIHHPDFKLQH Contact KHOS#WKHZRRGVPHGLFDOFRPDX or 9204 3900. WANNEROO )737*3UHTXLUHGIRUQRQFRUSRUDWH IDPLO\SUDFWLFHGHOLYHULQJH[FHOOHQW healthcare to our local community in :DQQHURR 3HUWKÂśVQRUWKHUQVXEXUEV DSSURYHG':6DUHD  2XUSUDFWLFHLVIXOO\FRPSXWHULVHG 3UDFVRIWDQG0HGLFDO'LUHFWRU  paperless and accredited. :HKDYHDZRQGHUIXOUHFHSWLRQWHDP SURIHVVLRQDO3UDFWLFH0DQDJHUVDQGIXOO nursing support. &RQWDFW-RG\6DXQGHUV0410 617 094 or Cheryl Barber 08 9405 1234 (0DLO&9WRMVDXQGHUVZWKF#JPDLOFRP RUFEDUEHUZWKF#JPDLOFRP

Do you want to kill the pig? Generous relocation packages available at a progressive rural practice 2 hours from Perth. Collie in WA. is not in the dusty hot North of WA but the only serious mining town in the South West close to Perth. Aside from procedural opportunities, great location and a progressive practice with all the usual modern practice requirements, there is some serious money for relocation and retention available. SIHI is offering very generous payments for GPs willing to commit to the town. There are limited numbers of relocation packages, so ďŹ rst in best dressed! Ideal opportunity for a GP registrar with procedural skills, either ďŹ nishing or about to ďŹ nish training. We are an accredited training practice and so there is excellent teaching opportunities and support. We have recently expanded the practice for the anticipated growth in the region so there is loads of opportunity for progressive new Drs. For more information, contact Angela 08 9734 4111.

Are you looking to buy a medical practice? As WAâ&#x20AC;&#x2122;s only specialised medical business broker we have helped many buyers find medical practices that match their experience.

You wonâ&#x20AC;&#x2122;t have to go through the onerous process of trying to find someone interested in selling.

To find a practice that meets your needs, call:

Brad Potter on 0411 185 006

Youâ&#x20AC;&#x2122;ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision. Weâ&#x20AC;&#x2122;ll take care of all the bits and pieces and youâ&#x20AC;&#x2122;ll benefit from our experience to ensure a smooth transition.

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Ph: 9315 2599 www.thehealthlinc.com.au

DECEMBER 2012 - next deadline 12md Thursday 15th November - Tel 9203 5222 or jen@mforum.com.au

79 80


Medical Forum CLASSIFIEDS

85% PROVIDING PRIMARY HEALTH CARE TO THE HOMELESS URGENTLY REQUIRES Íť'Ä&#x17E;ĹśÄ&#x17E;Ć&#x152;Ä&#x201A;ĹŻWĆ&#x152;Ä&#x201A;Ä?Ć&#x;Ć&#x;ŽŜÄ&#x17E;Ć&#x152;Ć? Ç Ĺ?Ć&#x161;Ĺ&#x161;&Z'W ÍťZÄ&#x17E;Ĺ?Ĺ?Ć?Ć&#x161;Ä&#x17E;Ć&#x152;Ä&#x17E;Ä&#x161;EĆľĆ&#x152;Ć?Ä&#x17E;Ć?

ÍťWĹ˝Ć?Ĺ?Ć&#x;ŽŜĆ?Ä&#x201A;Ć&#x152;Ä&#x17E;Ä&#x201A;Ç&#x20AC;Ä&#x201A;Ĺ?ĹŻÄ&#x201A;Ä?ĹŻÄ&#x17E;ĨĆ&#x152;Žž  ŽŜÄ&#x17E;Ĺ&#x161;Ä&#x201A;ůĨÄ&#x161;Ä&#x201A;Ç&#x2021;Ć&#x2030;Ä&#x17E;Ć&#x152;ĨŽĆ&#x152;Ć&#x161;ĹśĹ?Ĺ?Ĺ&#x161;Ć&#x161;   Ä&#x201A;ĹśÄ&#x161;ĆľĆ&#x2030;Ç Ä&#x201A;Ć&#x152;Ä&#x161;Ć?

ÍťÇ&#x2020;Ć&#x2030;Ä&#x17E;Ć&#x152;Ĺ?Ä&#x17E;ĹśÄ?Ä&#x17E;Ĺ?ŜžÄ&#x17E;ĹśĆ&#x161;Ä&#x201A;ĹŻĹ&#x161;Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; Ć&#x2030;Ć&#x152;Ĺ˝Ä?ĹŻÄ&#x17E;ĹľĆ?Ä&#x201A;ĹśÄ&#x201A;Ä&#x161;Ç&#x20AC;Ä&#x201A;ĹśĆ&#x161;Ä&#x201A;Ĺ?Ä&#x17E;

ÍťŽžĆ&#x2030;Ä&#x17E;Ć&#x;Ć&#x;Ç&#x20AC;Ä&#x17E;Ć?Ä&#x201A;ĹŻÄ&#x201A;Ć&#x152;Ç&#x2021;ŽčÄ&#x17E;Ć&#x152;Ä&#x17E;Ä&#x161;  Ä&#x201A;ĹśÄ&#x161;Ć?Ä&#x201A;ĹŻÄ&#x201A;Ć&#x152;Ç&#x2021;Ć?Ä&#x201A;Ä?Ć&#x152;Ĺ?ÄŽÄ?Ä&#x17E;Ä&#x201A;Ç&#x20AC;Ä&#x201A;Ĺ?ĹŻÄ&#x201A;Ä?ĹŻÄ&#x17E;

&Ĺ˝Ć&#x152;ĨƾĆ&#x152;Ć&#x161;Ĺ&#x161;Ä&#x17E;Ć&#x152;Ĺ?ŜĨŽĆ&#x152;ĹľÄ&#x201A;Ć&#x;ŽŜĹ˝Ć&#x152;Ć&#x161;Ĺ˝Ä&#x17E;Ç&#x2020;Ć&#x2030;Ć&#x152;Ä&#x17E;Ć?Ć?Ç&#x2021;ŽƾĆ&#x152;Ĺ?ĹśĆ&#x161;Ä&#x17E;Ć&#x152;Ä&#x17E;Ć?Ć&#x161;Ć&#x2030;ĹŻÄ&#x17E;Ä&#x201A;Ć?Ä&#x17E;Í&#x2014; WĹ&#x161;ŽŜÄ&#x17E;Í&#x2014;08 6102 2945Ä&#x201A;ĹśÄ&#x161;ĹŻÄ&#x17E;Ä&#x201A;Ç&#x20AC;Ä&#x17E;Ç&#x2021;ŽƾĆ&#x152;Ä?ŽŜĆ&#x161;Ä&#x201A;Ä?Ć&#x161;Ä&#x161;Ä&#x17E;Ć&#x161;Ä&#x201A;Ĺ?ĹŻĆ?Í&#x2DC; ĹľÄ&#x201A;Ĺ?ĹŻÍ&#x2014;generalmail@mobilegp.org.au

Supplement your income: Are you working towards the RACGP? â&#x20AC;&#x201C; we have access to provider number for After Hours work. Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.

take home, enjoy ďŹ&#x201A;exible hours,, less paperwork, & interesting variety....

Equipment Provided - WADMS is a Doctorsâ&#x20AC;&#x2122; cooperative e Essential qualiďŹ cations: U General medical registration. U Minimum of two years post-graduate experience. U Accident and Emergency, Paediatrics & some GP experience.

UĂ&#x160;Fee for service (low commission). UĂ&#x160;nÂ&#x2021;Â&#x2122;Â&#x2026;Ă&#x20AC;Ă&#x160;Ă&#x192;Â&#x2026;Â&#x2C6;vĂ&#x152;Ă&#x192;]Ă&#x160;`>Ă&#x17E;Ă&#x160;Â&#x153;Ă&#x20AC;Ă&#x160;Â&#x2DC;Â&#x2C6;}Â&#x2026;Ă&#x152;° UĂ&#x160;Ă&#x201C;{Â&#x2026;Ă&#x20AC;Ă&#x160;Â&#x153;Â&#x201C;iĂ&#x160;Ă&#x203A;Â&#x2C6;Ă&#x192;Â&#x2C6;Ă&#x152;Â&#x2C6;Â&#x2DC;}Ă&#x160;Ă&#x192;iĂ&#x20AC;Ă&#x203A;Â&#x2C6;ViĂ&#x192;° UĂ&#x160;VViĂ&#x192;Ă&#x192;Ă&#x160;Ă&#x152;Â&#x153;Ă&#x160;*Ă&#x20AC;Â&#x153;Ă&#x203A;Â&#x2C6;`iĂ&#x20AC;Ă&#x160;Â&#x2DC;Ă&#x2022;Â&#x201C;LiĂ&#x20AC;Ă&#x192;°

UĂ&#x160;Ă&#x160; Â&#x153;Â&#x2DC;Ă&#x160;6,Ă&#x160;>VViĂ&#x192;Ă&#x192;Ă&#x160; Ă&#x152;Â&#x153;Ă&#x160;6,Ă&#x160;Ă&#x20AC;iL>Ă&#x152;iĂ&#x192;° UĂ&#x160; Â&#x153;Â&#x2DC;Ă&#x2022;Ă&#x192;Ă&#x160;Â&#x2C6;Â&#x2DC;ViÂ&#x2DC;Ă&#x152;Â&#x2C6;Ă&#x203A;iĂ&#x192;Ă&#x160;ÂŤ>Â&#x2C6;`° UĂ&#x160;Ă&#x160;Â&#x2DC;Ă&#x152;iĂ&#x20AC;iĂ&#x192;Ă&#x152;Â&#x2C6;Â&#x2DC;}Ă&#x160;Ă&#x153;Â&#x153;Ă&#x20AC;Â&#x17D;Ă&#x160; environment.

Rural GP- Flying Scholarship An exciting opportunity exists for a vocationally registered general practitioner to obtain their private pilotâ&#x20AC;&#x2122;s licence in Geraldton, Western Australia. Learn ďŹ rst-hand the symbiosis of ďŹ&#x201A;ying and rural medicine. This medical centre provides ďŹ&#x201A;ying services to outlying towns and mine sites throughout the Midwest and is located on the Geraldton airport grounds. There are two hospitals situated in the town of Geraldton, one private and the other public allowing for procedural medicine. Important Information regarding this scholarship includes: ĂĽ sĂĽ -USTĂĽBEĂĽlTĂĽTOĂĽPASSĂĽ#!3!ĂĽ#LASSĂĽĂĽ00,ĂĽMEDICALĂĽEXAMINATION ĂĽ sĂĽ 5PĂĽTOĂĽHRSĂĽFULLYĂĽPAIDĂĽmYINGĂĽLESSONSĂĽEVERYĂĽĂĽMONTHS ĂĽ sĂĽ #ONSOLIDATEĂĽYOURĂĽmYINGĂĽEXPERIENCEĂĽONĂĽOURĂĽREMOTEĂĽAREAĂĽmYINGĂĽCLINICSĂĽ ĂĽ sĂĽ 3EEĂĽHOWĂĽRURALĂĽGENERALĂĽPRACTICEĂĽMAKESĂĽYOURĂĽmYINGĂĽTAXĂĽDEDUCTIBLE ĂĽ sĂĽ 'ETĂĽYOURĂĽSHAREĂĽOFĂĽTHEĂĽLUCRATIVEĂĽ7ESTĂĽ!USTRALIANĂĽMINERALSĂĽANDĂĽENERGYĂĽBOOM ĂĽ sĂĽ )FĂĽTIMEMONEYĂĽLETĂĽUSĂĽSHOWĂĽHOWĂĽmYINGĂĽCANĂĽEARNĂĽYOUĂĽSĂĽ ĂĽ sĂĽ ,ETĂĽmYINGĂĽCHANGEĂĽTHEĂĽWHOLEĂĽWAYĂĽYOUĂĽVIEWĂĽYOURĂĽMEDICALĂĽCAREER ĂĽ sĂĽ ,ESSONSĂĽBYĂĽCURRENTĂĽ2!!&ĂĽINSTRUCTORĂĽĂĽĂĽ

ĂĽ ĂĽ &ORĂĽFURTHERĂĽINFORMATIONĂĽPLEASEĂĽCONTACTĂĽ-IDWESTĂĽ!EROĂĽ-EDICALĂĽONĂĽĂĽ or Email: mwaeromedical@westnet.com.au

Are you interested in being a Hospital Liaison GP? sÂŹ ÂŹ sÂŹ ÂŹ ÂŹ sÂŹ ÂŹ sÂŹ ÂŹ sÂŹ ÂŹ

&REMANTLEÂŹ-EDICAREÂŹ,OCALÂŹANDÂŹ+ALEEYAÂŹ(OSPITALÂŹAREÂŹLOOKINGÂŹFORÂŹAÂŹÂŹ ÂŹ '0ÂŹTOÂŹJOINÂŹTHEÂŹ'0ÂŹ,IAISONÂŹTEAM )DEALLYÂŹSUITEDÂŹTOÂŹAÂŹ'0ÂŹTHATÂŹREFERSÂŹTOÂŹ&REMANTLEÂŹ(OSPITALÂŹANDÂŹÂŹ (EALTHÂŹ3ERVICEÂŹINCLUDINGÂŹ+ALEEYAÂŹ(OSPITAL ÂŹPREFERABLYÂŹWITHÂŹÂŹ AÂŹ$IPLOMAÂŹOFÂŹ/BSTETRICS 5PÂŹTOÂŹÂŹHOURSÂŹPERÂŹFORTNIGHT ÂŹCANÂŹBEÂŹCONSOLIDATEDÂŹINTOÂŹÂŹDAYFORTNIGHTÂŹÂŹ WITHÂŹmEXIBILITYÂŹFORÂŹSCHOOLÂŹHOURS )NTERESTINGÂŹWORKÂŹFOCUSEDÂŹONÂŹIMPROVINGÂŹCOMMUNICATION ÂŹINTEGRATIONÂŹANDÂŹÂŹ COLLABORATIONÂŹBETWEENÂŹPRIMARYÂŹANDÂŹTERTIARYÂŹCARE &ORÂŹFURTHERÂŹINFORMATIONÂŹPLEASEÂŹCONTACTÂŹ*ULIEÂŹ3KEVINGTON ÂŹÂŹ &REMANTLEÂŹ-EDICAREÂŹ,OCAL

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&96DUHDOHDGLQJFDUGLRORJ\SUDFWLFHWKDWSURYLGHV KLJKTXDOLW\GLDJQRVWLFVWUHVVWHVWLQJVHUYLFHV We are seeking medical practitioners who meet the following pre-requisites:  Â&#x2021; 5HJLVWUDWLRQZLWKWKH$XVWUDOLDQ0HGLFDO%RDUG  Â&#x2021; 0HGLFDO,QGHPQLW\,QVXUDQFH  Â&#x2021; /LIH6XSSRUW6NLOOVRUH[SHULHQFH  Â&#x2021; +LJKUHJDUGWRGHOLYHURXWVWDQGLQJSDWLHQWFDUH ,I\RXPHHWWKHVHSUHUHTXLVLWHVZHZHOFRPH\RXWRMRLQRXUWHDPRI VSHFLDOLVHG0HGLFDO3UDFWLWLRQHUV6WUHVV3K\VLFLDQV$VD6WUHVV3K\VLFLDQ \RXZLOOZRUNZLWKVWDWHRIWKHDUWGLDJQRVWLFHTXLSPHQWFRQGXFWTXDOLW\ VSHFLDOLVWWHVWLQJDQGLPSURYH\RXUGLDJQRVWLF(&*VNLOOV$QDWWUDFWLYH UHPXQHUDWLRQSDFNDJHZLOOEHRIIHUHGWRVXFFHVVIXOFDQGLGDWHVDVZHOODV H[SHULHQFLQJH[FHOOHQWMREVDWLVIDFWLRQDQGZRUNLQJFRQGLWLRQV &96ORFDWLRQVLQFOXGHJoondalup, Karrinyup, Nedlands, Midland, Mt Lawley, Leeming, East Fremantle and Rockingham. 3OHDVHSKRQH$GDP/XQJKLWRGLVFXVVRSSRUWXQLWLHVDW&96RQ 1300 887 997 or 0402 825 570 RUYLDHPDLOinfo@cvs.net.au

:LWKDUHSXWDWLRQEXLOWRQTXDOLW\ ality RIVHUYLFH2SWLPD3UHVVKDVWKH WKH UHVRXUFHVWKHSHRSOHDQGWKH e commitment to provide everyyclient client ZLWKWKHÂżQHVWSULQWLQJDQGYDOXHIRU DOXHIRU money. 9 Carbon Court, Osborne Park 6017 Tel 9445 8380

DECEMBER 2012 - next deadline 12md Thursday 15th November - Tel 9203 5222 or jen@mforum.com.au


Moving to Best Practice, easy as Like eating brussels sprouts â&#x20AC;&#x201C; you know that changing your clinical software will be good for you â&#x20AC;&#x201C; but not something you want to face. Best Practice is different. Best Practice makes the changeover so easy you can try it out with all your practice data (the backup version of course) without committing. Sweet! s 7EHAVEMIMSn!USTRALIAS MOSTTRUSTEDDRUGDATABASE s 3UPPORTPROFESSIONALSWHOARE TRULYSUPPORTIVE s 3PEEDANDSUPERIORSTABILITYOF 31,PERFORMANCE s #ONVERTINGYOURDATAFROM-$ -$AND-ED4ECHVIRTUALLY AUTOMATIC s .OADS BOLTONSORMIXED lLEFORMATSTOCOMPROMISE PERFORMANCE s 'REATVALUEnSUBSCRIPTION  FORBOTH#LINICAL AND-ANAGEMENT s $ISCOUNTSFORPRACTICESLARGER THAN%QUIVALENT&ULLTIME'0S s (ALFPRICEFORPARTTIME PRACTITIONERS 

s .ODOWNTIMEFORUPDATESOR TIME CONSUMINGMAINTENANCE s -ORE'0SVOTINGFOR Best PracticeWITHTHEIRFEET *(includes GST)

TTel: l (07) 4155 8800 0 www.bpsoftware.com.au b

Medical Forum 11/12  

WA's Independent Monthly for Health Professionals

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