Filling the Gaps Can We Afford It? • Prosthetic Pricing Reform • Too Much Testing? • GP Protest on MBS Freeze • Clinicals: Liver Injury, Haematuria, Deprescribing, Colon Cancer, Child Reflux, & more
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Dr Brien Hennessy Avant member
This year, many doctors like you will face a medico-legal claim. Without a strong team to defend you, any action could have a massive impact on your career.
With 70 in-house medico-legal specialists, including lawyers, medical advisors, claims managers and local state experts, it’s hard to make a case against the expertise of Avant.
As Australia’s leading MDO, Avant has the depth, strength of resources and experience to advise and protect you.
A claim against you can happen at any time. Don’t wait until it’s too late, call us today.
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08 6189 5700 *IMPORTANT: Professional indemnity insurance products are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms, conditions, and exclusions that apply, please read and consider the policy wording and PDS, which is available at www.avant.org.au or by contacting us on 1800 128 268.
Time to Get Tough Right from the cradle we’ve had it crammed into our heads that it’s impolite to talk about money. It was a natural segue from things like “ladies don’t swear” and “gentlemen always open a door for a lady”. Some of us have adhered like super-glue to this anachronism, while other more liberated individuals have barged through the double doors with nary a backward glance and cussing like sailors – all the way to the bank.
GPs Are Feeling Vulnerable Q
Financial considerations affect us all. Tick up to three things that your point-of-view closely aligns to:
The result of this polite reticence is the mangled mess of the Medicare rebate, frozen solid in a funding model that is now woefully out of date and out of step with medical expertise, technology and consumer expectation and need.
I feel financially protected by a system that will always need doctors.
For GPs, who always seem to bear the brunt of blunt government policy, enough is enough. In the letters pages this month, one GP has detailed the grassroots campaign aimed at informing voters – their patients – just what this continued freeze will mean in relation to their capacity to deliver health care.
I’m financially locked into bulk-billing and anything that entails.
I’m rewarded enough for what my practice asks of me.
Mostly, the payments I receive from Medicare are inadequate for the task at hand.
None of the above.
To an old-style unionist, this may still seem overly polite to fully convey the gravity of the situation but everyone must work within their own social thresholds.
Ms Jan Hallam
The campaign is being backed by the RACGP – though the polite College kids are not too keen on prescription pads being used as political post-it slogans – and the national AMA has also thrown its weight behind the cause.
But this really should not be a fight confined to general practice, despite the Government apparently running a divide-and-conquer strategy. The Government’s deal with Pathology Australia, in the heat of the leaders’ debate no less, seems a cynical attempt to quieten a branch of medicine that has the resources to make a lot of troublesome noise. We look at the deal on p.10 – who gets and gives up what – but the national AMA president Prof Brian Owler hit the nail on the head: “the deal doesn’t guarantee anything”. Whichever party wins government, the cost cutting will continue. To be fair on Government, serious action needs to be taken to halt escalating health costs – we’ve heard that message long enough to accept its veracity. But in this next stage of budgetary ‘restraint’, no craft group or allied industry will be safe from the razor.
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Part of the reason trainee hospital doctors select specialist 31% training is because of the perceived higher income.
ED: We took the opportunity to ask GPs in our latest ePoll how they financially secure they felt in the current climate.
The Private Healthcare Australia prosthesis pricing proposition (see pp 14-15 and P28) has offered a potential saving of $800m a year – and the Health Minister’s speedy response to ‘Dial-aTaskforce’ must have cost her a chipped fingernail. If private patients need only pay the same amount as public patients for implanted medical devices it would be a massive win for affordability and a welcome relief to the public purse. The ‘losers’ in this scenario are companies and individuals who have grown fat in this sheltered paddock and now winter is coming. It’s not good enough to pick the low-hanging fruit of general practice. GPs have to stay on the ground because that’s where they are needed. They’re the ones who have to face a phalanx of patients on a daily basis and go home after 10 hours with a small packet of beer nuts. If the Government is serious about its intentions to make primary care its fiscal saviour, it needs to start investing seriously in it. It’s time for Government – all of them! – to do some serious investigations into where taxpayers’ money goes in the health spend or suffer the electoral consequences. It’s the only language politicians know.
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JUNE 2016 | 1
FEATURES 12 Spotlight: Museum Boss Alex Coles 14 PHI Affordability 16 Finance in Tough Times 21 Over Testing; Over Treatment NEWS & VIEWS 1 Editorial: Time to Get Tough
Jan Hallam 4 Letters to the Editor: GPs Launch Protest Dr Keith Ananda Doctors Need Say on Revalidation Ms Georgie Haysom Support for IMGs Ms Kelli Porter Dangers of Soft Hitting Dr Allan Walley Diabetes WA Backs Sugar Tax Ms Helen Mitchell We All Need Exercise Dr Kate Langdon 10 Have You Heard? 11 Beneath the Drapes 33 Prosthetics Pricing Campaign
Lifestyle 46 Surf’s Up: Dr Phil Chapman 48 Social Pulse: SJG Subiaco
Medical Tribute Dinner 49 Wine Review: Cape Grace Wines Dr Craig Drummond 50 Music: Leo Sayer & Lulu 51 Musical: Georgy Girl 52 Funny Side: e-Poll 53 Competitions
1 10 14 16 21 25
GP Payments Organ Donation Private Insurers & Chronic Care You & Your Finances Views on ‘Overdiagnosis’ IT & My Health Record
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Dr David Palmer Lymphocytic Oesophagitis
Dr Kalilur (Kalil) Anvardeen
Dr Paul Salmon Imaging the Ankle
Dr Andrew Klimaitis Deprescribing in the Elderly
Echocardiographic Imaging of Cancer Patients
Dr Akhlil Hamid Appropriate Approach to Haematuria
Dr Alan Gault New Synthetic Drugs
Dr Briohny Smith Drug-induced liver injury
Ms Joanne Dembo Food Processing & Diabetes
Friday, June 24 Free Breakfast See P11
Dr Nigel Barwood Colon Cancer in -Younger Adults
Dr Kunal Thacker Reflux in the Young
Dr Cynthia Innes Fistula Hospital by the River
Dr Peter Burke Death of Normal
Dr Rob Liddell Healthy Pilot; Safe Air Travel
INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM JUNE 2016 | 3
Letters to the Editor GPs launch protest
burden to them, while a quarter felt that revalidation would not be effective in identifying doctors who were unfit to practise.
Your feature points out the key problems that revalidation seeks to address: ensuring a doctor’s competence throughout their career, and identifying incompetent or at-risk doctors before they do harm to patients. No one can argue against these aims – both the public and the profession expect doctors to be competent and to provide safe and effective medical care.
I have attended the recent Doctors Drum breakfast meetings and enjoyed the openness and frankness of hearing specialist/GP colleagues’ views on where our health system is headed and what should be done. I would like to propose the following action. With the election announced for Saturday, July 2, General Practice has an ideal opportunity to launch a vigorous campaign against the Medicare rebate freeze. The ‘You've Been Targeted’ campaign as was advocated last year was invaluable in stopping the co-payment proposal that was launched in the 2014 budget. However, I propose a more dramatic response this time by making the upcoming election D-day for future bulkbilling with a vigorous campaign that encourages all practices in Australia to cease bulkbilling. Putting posters – "July 2, D-day for bulkbilling" – in practices around Australia will bring health to the forefront before the election. Our healthcare system is at a crossroads and the public needs to be made fully aware of this. Imagine the impact? Every person that no longer gets bulkbilled will have that firmly in mind when they vote on Saturday, July 2. I hope the Government will sit up and take notice and prevent a voter backlash by reviewing the Medicare Rebate freeze just as they did with the co-payment policy. Dr Keith Ananda, GP, Scarborough ........................................................................
Doctors need a say on revalidation
Taking a proactive approach is preferable to a reactive regulatory approach, no matter how responsive and risk-based that approach may be. But will revalidation solve the problems? The General Medical Council has released a report of independent research into the regulatory impacts of revalidation in the UK. Four years after revalidation was introduced, the report revealed scepticism amongst doctors about whether revalidation had led to improved patient safety, and whether the process identified doctors in difficulty at an earlier stage. Responding doctors had mixed views about whether revalidation improved standard of practice. The profession needs to have confidence in the system that regulates them. Lack of confidence risks undermining the effectiveness of the system and could lead to another administrative white elephant with no significant improvements in patient safety. But just because a problem is hard to solve doesn’t mean we should hide from it. The Medical Board’s so-far cautious and considered approach is to be welcomed, as is the promise of wide consultation. As your articles show, doctors feel strongly about these issues and it is important that the debate is open, thoughtful and robust. Ms Georgie Haysom, Head of Advocacy, Avant ........................................................................
Forward to Fellowship helps IMGs Dear Editor, As noted in the May edition, International Medical Graduates (IMGs) are a valued and essential part of the medical workforce in rural communities in WA who need support to develop professional and personal networks which may support their retention in regional communities and in turn enable them to develop a robust understanding of their patients’ ongoing health needs. Continuity of care is extremely important for patients and leads to better health outcomes for communities. For these reasons, the Forward to Fellowship program was developed in 2014 to provide IMGs working in Kalgoorlie-Boulder and Kambalda with personal, professional and training support to assist their integration into the Australian medical system. No other coordinated approach is currently available in WA that provides comprehensive regional support to enable IMGs to work towards general practice fellowship. Seventeen IMGs form part of the current cohort of Forward to Fellowship members, who receive support by way of monthly study group sessions, individual learning plans, one-on-one tutorials with a GP mentor, access to education and exam preparation tools and social and professional networking events. Forward to Fellowship is a collaboration between local and state-based organisations and community groups including the local Member of State Parliament, Goldfields Esperance Development Commission, Rural Health West, City of Kalgoorlie Boulder, Shire of Coolgardie, Chamber of Minerals and Energy’s Eastern Regional Council, continued on Page 6
Dear Editor, Medical Forum’s review of options for revalidation and the views of your readers (April and May editions) correlate with a survey of GPs that Avant undertook in March 2013 on the subject.
Cleanliness becomes more important when godliness is unlikely. P. J. O'Rourke
Half of those surveyed expected that the revalidation process would be a significant
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4 | JUNE 2016
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Major Sponsor: Clinipath Pathology
By Dr David Palmer Histopathologist Clinipath Pathology
Lymphocytic Oesophagitis The importance of eosinophils and neutrophils infiltrating oesophageal squamous epithelium as markers for reflux, eosinophilic oesophagitis, and infection are well entrenched, although traditionally less attention has been paid to lymphocytes. Small numbers of lymphocytes are normally seen in oesophageal epithelium including CD4 helper and CD8 positive cytotoxic lymphocytes. However, isolated increases in lymphocytes in the oesophageal epithelium, outside the context of entities such as lichen planus and graft versus host disease, have been less well recognised until recently. The criteria for a diagnosis of lymphocytic oesophagitis (LE), where lymphocytes numbers are markedly increased with few or no eosinophils, is not strictly defined since this is still a reaction pattern and not a specific diagnosis per se, and thresholds vary from study to study. The strictest definition requires at least 50 intraepithelial or peripapillary lymphocytes per HPF with few or no granulocytes. The term lymphocytic esophagitis was originally coined in 2005 by Rubio et al to describe a histological reaction pattern in the esophagus of a series of 20 patients. The patients had a high number of peripapillary lymphocytes (mean number 55.1/HPF in selected cases) and a lack of neutrophils and eosinophils. The papillae are projections of lamina propria, containing capillaries, which project a short distance into the epithelium of the normal oesophagus. The pattern of LE showed an association with Crohn disease (CD), though not a completely specific one. Of the 20 patients, 11 were age 17 or younger and of these, 8 (40%) had Crohn disease; 20% had manifestations of reflux and the remainder a mixture of conditions including celiac, gastroduodenitis, and Hashimoto thyroiditis. A similar study of 40 patients in 2008 was unable to confirm these findings. Looking at it from a different angle, Ebach et al studied 60 paediatric patients with known Crohn disease and control groups and found an association. LE which was found in 28% of patients with Crohn disease (mean age 13.3) but in only 2/30 patients with ulcerative colitis. A 2014 study of 580 paediatric patients confirms the association with Crohn disease, but also shows the non-specific nature of LE. This found 31 patients with LE and 49 with CD. Six of the 31 LE patients (19%) and 43 of the 514 non-LE patients (8.4%) had CD. The remaining LE patients had other diagnoses with no significant clinical correlates. Conversely, LE was identified in 12.2% of
Oesophageal epithelium with congestion, spongiosis and increased intraepithelial lymphocytes in adult female patient with dysphagia.
the patients with CD. Thus, there were still more LE patients without CD than with CD. The other associations included a diverse range of clinical diagnoses, some with no readily explainable association with LE (such as functional abdominal pain), and many had normal endoscopy. In adults, the association with Crohn disease is not seen but there appears to be an association with oesophageal dysmotility. A 2011 study of over 129,000 patients from a large outpatient private GI pathology lab service revealed LE in only 119 patients, 60% female. Most patients had symptoms of oesophageal disease such as dysphagia or odynophagia, with dysphagia being the most common complaint, and around 20% complaining of reflux. Endoscopically, around a third of patients were suspected of having eosinophilic oesophagitis (including ‘feline oesophagus’ where the oesophagus has rings resembling that of a cat’s oesophagus), around 20% were normal, 18% had features suggestive of reflux, and 10% had stricture. However, none had Crohn disease or an association with Helicobacter gastritis. Although this study drew no firm conclusions as to the nature of lymphocytic esophagitis
The association with dysmotility is enhanced by the finding that in adult patients, a lymphocytic oesophagitis with a complete absence of granulocytes was mostly seen in older female patients who presented with dysphagia and had an oesophageal motility disorder. CD4 and CD8 predominant LE occurs with roughly equal frequency. However, patients with CD4 predominant LE are more likely to be female (71%), and have a motility disorder (90% of those tested). This suggests a new entity of ‘dysmotility lymphocytic oesophagitis’. In summary, the reaction pattern of lymphocytic oesophagitis appears to be real, however, the term cannot be used as a wastebasket and true increased numbers of IELs must be seen. Clinical and endoscopic correlations determine the significance of any pathologist comment on increased numbers of lymphocytes in the epithelium. References available on request.
Lymphocytic Oesophagitis Definition: Increased numbers of intraepithelial lymphocytes in peripapillary oesophageal epithelium. Number of lymphocytes required varies, depending on study, from impression of heavy lymphocytic infiltrate in papillae and peripapillary epithelium with spongiosis, to a strict count of at least 50 intraepithelial lymphocytes with few granulocytes. Incidence: 0.1% unselected adult biopsies; higher in pediatric series. Associations: Pediatric Crohn disease (19 – 40%) in some studies; with miscellaneous other associations not reaching significance. Adult: clinical dysphagia in 53%; dysmotility disorder, and endoscopic features resembling eosinophilic oesophagitis.
Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200
in adults, the prevalence of dysphagia as a presenting complaint, and the number of patients with findings reminiscent of eosinophilic oesophagitis were noted.
Patient Results: 9371 4340
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www.clinipathpathology.com.au Back to Contents
Letters to the Editor continued from Page 4 Kalgoorlie-Boulder Chamber of Commerce and Industry, WACHS Goldfields, Goldfields Esperance GP Network and WAGPET. It is anticipated the program will make a lasting contribution to creating a stable and sustainable medical workforce in the region. Ms Kelli Porter, General Manager Workforce, Rural Health West ........................................................................
Dangers of soft hitting Dear Editor, After 37 years as a rural GP, I can reflect a bit on life and directions, certainly in medicine. One of the directions is that we as a nation are getting too soft. Medically and often in life the easier option is taken, "don't worry about your cholesterol diet just take these pills". Most of the time people are looking for the softer option. We are an obese nation, there is really only one way to lose weight, and I'm not talking surgery, pills, but the hard yards of checking diet, eating less and also the right foods. As doctors we are too soft on our patients. We don't have the time to talk the right stuff, sometimes too frightened to tell somebody they are fat becasue it's politically incorrect! The Government is not much better. Essentially they make decisions that will get them elected rather than what is best for the country. It’s time to get tough. Dr Allan Walley, Margaret River ........................................................................
Diabetes WA backs a sugar tax
who consume larger quantities of SSBs are likely to be more responsive to price increases. Therefore, a tax on SSBs would be an equitable population policy to reduce consumption and improve population health outcomes.
Dear Editor, Diabetes WA read with interest Would a Sugar Tax Work Here? (May edition) and would support an increased tax on sugar sweetened beverages (SSB). We know from other successful public health taxation strategies (e.g. tobacco) that as taxes are hiked, consumption is reduced. There is a view that personal behaviours (such as consumption of sugary drinks) are an individual’s own choice and therefore education of their harms is a better strategy. However, in reality, we know that changes to public policy can be one of the strongest factors leading to behaviour change as it impacts everyone – even those who are not ready to make a change. Health economists have estimated that a marginal 10% increase in the price of SSB could see an 8-10% decrease in consumption. Mexico’s 10% SSB tax, introduced in 2014, has shown a 12% decline in the population’s consumption. In fact, Mexico saw the biggest consumption reduction in lower socioeconomic households, averaging up to 17%. Not only could a tax increase result in reduced consumption of SSB but it could help to raise valuable revenue that funds programs and services to promote healthy behaviours and prevent chronic disease. Diabetes WA believes that the revenue raised by such a tax increase should be invested into programs and services that prevent chronic diseases, such as type 2 diabetes. Young people, lower-income groups, those most at risk for obesity and those
Ms Helen Mitchell, General Manager Health Services, Diabetes WA ........................................................................
Entire community needs exercise Dear Editor, Regrettably in medicine, where successful management involves a lifestyle change, we are restricted to offering office-based advise such as "swimming would be ideal for you" or "you should lose weight" without engaging the sense of agency of the person receiving it or guiding them with real examples as to how these lifestyle changes might be achieved. Rather than providing the inspiration to initiate the change suggested, vague medical advice can feel more like we are blaming our patients for their disease(s), potentially adding to their sense of shame and stigma about having acquired them. The nett effect being one of increased hopelessness and defeat rather than the purchase of a 10-entry pool card. Your article about Tom Picton-Warlow’s Swimming 365 (April edition) is an innovative, sustainable and inclusive community based program offering professional expertise while providing a regular social forum for swimmers with diabetes. People with diabetes are very keen to take continued on Page 8
Keeping the Passion Alive For writer and medico Dr Adele Thomas life is all about meaningful relationships and there is no age limit on living a good life. I am so glad I chose medicine because… I’ve shared in the lives of some amazing people! My mother didn’t think it was appropriate for a young woman to be a doctor and I’m glad I ignored her. It’s been a privilege to be a part of other people’s joy and sorrow.
One thing I regret is that… life’s too short. I have more than enough things to do to keep me busy for another 30 years.
Writing is an activity that’s… always a surprise. I had constant battles with my high-school English teacher and ended up thinking that I couldn’t write very well at all. I use a storyboard to get the broad outline and then fill in the details as if I’m having a conversation with a patient. It’s less scary that way!
If I were told that I had six months to live… I’d get as many hugs and cuddles as possible! I’d also take our grandchildren skiing and write our family story so that future members would have a strong sense of where they came from.
6 | JUNE 2016
Moments in medicine… that I will always cherish involve the trust of young children. Holding the hand of a toddler while we listen to Teddy’s heart fills me with joy. To see those same toddlers grow up, marry and have children of their own is wonderful.
Major Sponsor: Western Cardiology
Advanced echocardiographic imaging to assess cardiac function in cancer patients Among cancer survivors, heart disease is an important cause of subsequent morbidity and mortality. Smoking, excess alcohol, poor diet and obesity predispose to heart disease as well as cancers. The heart is uncommonly involved in cancer spread, typically resulting in pericardial effusions or metastatic deposits, mainly from breast or lung tumours. Atrial fibrillation is a common consequence of the metabolic disturbances or late sepsis post-chemotherapy. Assessment and monitoring of cardiac function prior to administration of chemotherapy has become an important component of modern cancer care. Potential adverse cardiac effects from chemotherapies, especially involving anthracyclines are well-established and reflected in the careful dosing schedules and pre-treatment recommendation for evaluation of cardiac risk factors and dysfunction. Chemotherapy associated cardiac dysfunction may include acute coronary syndromes, arrhythmias and myocarditis. Myocardial impairment post chemotherapy can produce long-term heart failure (HF) and negatively impact the quality of life and prognosis of the oncologic patient. New generations of targeted therapies (e.g. trastuzumab and herceptin in breast cancer) have also been associated with unfavourable effects on myocardial function. Cardiotoxicity varies with the type and dose of chemotherapy drugs. Prevention of cardiac dysfunction from chemotherapy requires a high index of suspicion and close monitoring. By the time a patient develops symptoms of HF and experiences a detectable fall in left ventricular (LV) ejection fraction (EF) they may already have developed irreversible damage to the myocardium. Traditional screening for HF in cancer patients includes clinical examination, ECG, cardiac biomarkers (i.e. Troponin and B-type Natriuretic Peptide) and echocardiography. Recently developed techniques in echocardiography allow for earlier detection and sensitive monitoring of cardiac function that may provide an opportunity to intervene and arrest or reverse cardiac myocyte
damage before permanent cell injury and an inevitable fall in LVEF. Advanced echocardiographic imaging with speckle tracking or strain imaging provides a safe, non-invasive technique that can be easily used even in sick cancer patients. What is speckle tracking/cardiac strain imaging?
Dr Kalilur (Kalil) Anvardeen Cardiologist
About the author Dr Anvardeen completed his medical degree (MBBS) from India in 2003. Prior to starting his physician training at Royal Perth Hospital in 2006, he worked as a senior house medical officer in India and Barnsley General District Hospital, UK. He completed three years of advanced cardiology training at Sir Charles Gairdner and Royal Perth Hospitals in 2013. He subsequently undertook specialised fellowship training in echocardiography at Sir Charles Gairdner Hospital and then worked as a Consultant Cardiologist in Townsville, QLD. Kalilur’s passion for research and echocardiography persuaded him to undertake a further fellowship in advanced echocardiography at the North America’s Centre of Excellence, University of Ottawa Heart Institute where he worked closely with world experts in echocardiography including Dr Ian Burwash and Dr Kwan Chan. During his fellowship he was also involved in Aortic and Adult Congenital Heart Diseases clinical sessions. He will be commencing his Private Practice with Western Cardiology at Midland from mid-July, and has a public appointment at St John of God Midland Public and Private Hospital.
Apart from early recognition of subclinical diagnosis of cancer chemotherapy induced cardiomyopathy (Figure 2), distinct patterns are observed in other systemic diseases affecting the heart such as cardiac amyloid and sarcoidosis. Fig1
Fig2: A: A normal global longitudinal strain B: Decreased GLS post chemotherapy
LV strain represents lengthening and contraction of cardiac myocytes in diastole and systole, respectively. The three main types of strain (longitudinal, circumferential and radial) are based on the arrangement and movements of myocytes (figure 1). Negative value in strain indicates contraction. Normal values for global longitudinal strain (GLS) is -16% to -20%. In Echocardiography strain is measured by tracking the distance between points (“speckles”) in LV myocytes in systole and diastole.
Chemotherapy related cardiotoxicity, defined as a 10% fall in EF to less than 53%, also strongly correlates with a relative drop in baseline global longitudinal strain of >15%. While its’ specific clinical role will become established with longer-term clinical trials, speckle tracking and strain imaging appears as the imaging technique of choice for detection of subclinical LV dysfunction. Among patients who have previously received potentially cardiotoxic chemotherapy, it may be appropriate to continue to monitor LVEF every six months during the first two years after treatment. We can be optimistic that through ongoing development in chemotherapy and advanced echocardiography imaging techniques to detect subclinical LV dysfunction we can avoid today’s cancer patients becoming next year’s heart failure patients.
Visit www.westerncardiology.com.au 14 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services
Main Rooms: St John of God Hospital, Suite 324/25 McCourt Street, Subiaco 6008 Tel 9346 9300 • Country Free Call: 1800 702 600. Urban Branches: Applecross, Balcatta, Duncraig, Joondalup, Midland & Mount Lawley Regional: Busselton, Geraldton, Kalgoorlie, Mandurah & Northam MEDICAL FORUM
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Hospital by the River Witnessing the transformational work of the Hamlin fistula hospital in Addis Ababa has left an indelible mark on local GP Dr Cynthia Innes. Last January, 10 friends flew to Ethiopia for a bus journey organised by a couple who had worked as volunteers there. Solomon, our Ethiopian tour guide, was to be our bus driver and from Addis Ababa we travelled north to explore this amazing mountainous country. There we were to find out about the rich history of this country with its past emperors as well as being in the midst of daily life and ritual. The majority of the population in this part of Ethiopia are Coptic Christian and to a lesser extent Muslim. We passed so many robust and cheerful village people living in homes constructed mainly from straw, mud with thatched roofs. Some had electricity, most had no windows and the floors were earthen. We would pass people leading their donkeys laden with goods, or people threshing teff, the local grain. What we did not see, however, were the thousands of young girls in exile from their villages due to their socially unacceptable medical issue â€“ vesico-vaginal fistula, resulting from having been married too young and consequently given birth with their immature bodies. The girls either die in obstructed labour, their babies die, or if they survive the women are confronted with permanent leakage of urine or faeces. Due to the permanent odour, they are no longer wanted in their communities. In 1974, Dr Catherine Hamlin and her husband, Reginald, arrived to work as gynaecologists and soon saw the need to develop surgical procedures to repair the fistula. Thus the hospital in Addis Ababa was founded. I was fortunate to have been shown over the hospital, seen the wards with women now cleaned and prepared for surgery.
Midwife trainees, above, and the hospital's physiotherapist, right.
[One of the patients, I discovered, had taken six years to save enough money to catch a bus to the hospital. They arrive in urine-soaked clothing, hungry and desperate]. We met the trainee midwives, visited the physiotherapy department where women receive pelvic floor rehabilitation, many preoperatively as they need to develop muscles which have been wasted. We then went on to see where the women were learning crafts, how to sign their name, instructions on birth control, and given ongoing support as so many are psychologically damaged. Dr Hamlin is now in her 90s and no longer operates, but visits the patients frequently. She lives on the premises surrounded by gardens which make this hospital such a nurturing environment.
There is an ongoing program of training surgeons and midwives. There are now five outreach hospitals where about 4000 procedures are performed annually. Since its establishment, the Addis Ababa Fistula Hospital has treated more than 42,000 women. The hospital has 140 beds and the majority stay for one month. Three surgeons can operate at a time and 85% of patients have a full recovery after the first operation. The hospital is free to all patients and is reliant on foreign donor support â€“ 39,000 women are on the waiting list. ED: For more information about the Hamlin Fistula Ethiopia organisation, visit www.hamlin.org.au or email HQ@hamlin.org.au
continued from Page 6
Letters to the Editor control of their health and wellbeing. Many have succumbed to diabetes having made lifestyle choices no different to those now considered normal in contemporary Australian society namely, over-eating, over-indulging in alcohol and under-exercising. In reality, the lifestyle changes and approach to fitness through swimming and water-based activities are a necessity for most Australians as a matter of urgency. Regrettably, the paediatric population, who are now using hand held screen devices and sitting more than ever before, would also benefit from opportunities to
We welcome your letters and leads for stories. participate in groups like Swimming 365 where the emphasis is on group participation and general fitness rather than training elite junior athletes for competition. The main beneficiaries in this program are the participants. There is no further translational step required to take the evidence base to the group who needs it most. Good on you Tom. Dr Katherine Langdon, Paediatrician, PMH
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JUNE 2016 | 9
Have You Heard?
Midland by the numbers It’s been six months since WA’s newest public hospital opened its doors and we thought it would be interesting to see what impact SJG Midland Public it has had in the eastern corridor. Due to our deadlines, these figures are a couple of weeks’ shy of the May 24 anniversary nevertheless, till that time 65,290 patients have been treated; 27,480 have presented and received medical care at the ED up 22% over a similar period at Swan District Hospital (SDH). More than 12,300 medical and surgical separations have taken place and about 660 babies have been born at the hospital with 30,900 outpatient visits. The 307-bed Hospital is expected to treat about 29,000 inpatients, 60,000 emergency patients and 102,000 outpatients in its first full year of operation.
Dr Tim Bates and Dr Benjamin Wood
Close the cosmetic gaps In last month’s women’s edition we explored some of the sociological questions that arise from Female Cosmetic Genital Surgery. Last month the Medical Board’s 12-month examination of the cosmetic surgery industry was released in the form of new guidelines. Their thrust is consumer-focused with cooling off periods for consumers – a week for adults wanting major procedures and three months for under-18s who must also consult a registered psychologist, GP or psychiatrist. Under 18s only need to wait a week for minor procedures. Guidelines also place the responsibility for post-operative care and provision of proper emergency facilities in the lap of the medical practitioner, especially when using sedation, anaesthesia or analgesia. A mandatory consultation must also take place before a medical practitioner prescribes S4 cosmetic injectables; and they must provide the consumer with detailed written information about costs. Board head Dr Joanna Flynn said the report also identified problems for which it had no power to act – inconsistent drugs and poisons legislation across jurisdictions and the stricter licensing and regulation of private health facilities, particularly in their use of sedation and anaesthesia. Fremantle and PMH consultant Dr James Savundra, President of the Australian Society of Plastic Surgeons writing in Medical Observer urged state governments to implement laws to close these gaps. The guidelines come into effect on October 1.
Power to the people eaters Each day we receive more media statements highlighting how various chronic health problems are lifestyle-related and therefore preventable. All we need to do is support the App, ask the professional group behind the media release to get involved, read the book or take the potion to avert expensive hospital admissions and keep people well for longer. A ‘healthy diet’ is one cornerstone to better health – if people eat right they will prevent
10 | JUNE 2016
cancer, avoid macular degeneration, etc. The clever people from different institutes tell us what should be on our plates and the message hasn’t changed much over the years – certain fish (omega 3 fatty acids), fresh green and gold vegetables (targeted anti-oxidants), limited nuts and seeds, wholegrains, and brightly coloured fruit. Of course, there may be things to avoid. What is not broadcast so strongly, and thanks to epigenetics, is that many people can wipe out their genetic risk of disease if they just eat the right food. It is a bit ironic that faced with a ‘tsunami of chronic illness’ the dividers of our pay packets (politicians) are turning to ever-present prevention to effect a cure in preference to the ‘magic bullet’ stuff. Has it got something to do with keeping health consumers in the political frame?
Pork barrels and pathology There’s perhaps no more dangerous creature than an election-campaigning politician. The PM in the first leaders’ debate announced that a deal had been struck with pathologists that would see bulk billing continue for blood tests in return for a ceasefire in Pathology Australia’s anti-government advertising campaign. The Government will also continue with its plan to cut pathology incentive payments, while introducing legislation to protect pathology companies from rent increases at collection centres. This move was roundly criticised by the RACGP, saying it would impact adversely on GP income. Budget black holes don’t get filled by spending more and the AMA chief Prof Brian Owler is on the money when he says this current agreement is not set in stone.
Too little too late The PM’s back-down was too late for some smaller interstate pathology practices, which have closed or sold out to bigger conglomerates. Mind you, the increase in collecting centres for all community pathology providers after deregulation, might have
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affected their bottom line. According to the RCPA, $450m worth of testing was provided free during 2014-2015 due to the “buy three tests get the rest free” coning payment arrangement (increasing 12% since 1999-00). In WA, SJG Pathology is said to receive tax advantages over other pathology providers, and easier access to both the specialists (no coning rules) and inpatients in their hospitals, including hospitals such as Midland.
Impartiality at ‘arms length’ You may have read in last month’s magazine that the WA Medical Board has been instructed to drop its case against Dr Keith Woollard because of a 10-year span in proceedings. Long waiting times figure prominently in the complaints made privately to us where doctors have waited many months to be exonerated. The April Medical Board news includes a message from the Chair Dr Joanna Flynn who writes that while the board’s primary concern is risk to the public, it doesn’t want to cause “avoidable distress to doctors” and pointed to the 2013 beyondblue study that found “very high levels of distress, anxiety, depression, substance misuse and suicidal ideation among doctors and medical students”. The Medical Board has given $2m of registration fees to the AMA, in part to set up Doctors’ Health Services Pty Ltd to “establish and administer the health programs at arms’ length”, to look after doctors’ health everywhere, with Vic and WA up in the air. We understand WA is the only State that has held onto its nonmandatory reporting of doctors. The AMA’s involvement may need some explaining to those WA doctors (June edition e-Poll, 2015, 195 respondents) who said the AMA was potentially part of the problem (moreso among non-AMA members) when it came to Medical Board impartiality. They may want to know more about what “arms length” entails. “By increasing national funding to doctors' health programs, the Medical Board wants to contribute to building a resilient and strong profession which will benefit the wider community.”
Have You Heard? New donor guidelines Earlier this year, Assistant Health Minister Senator Fiona Nash released the longawaited independent review into Australia’s organ donation system. It wasn’t the clean sweep some in the sector had wanted to see, rather it was a steady-as-she-goes approach with more support for the Organ Tissue Authority to lift donor rates. Senator Nash at the time ruled out an ‘opt-out’ model. Recently the NHMRC released new Ethical and Clinical Guidelines for organ transplantation which has a strong focus around supporting the decision-making of potential organ transplant recipients and their families, carers and friends. This complex and confronting issue perplexes the whole community. In this month’s ePoll we asked GPs for their thoughts of the process, in this instance at the renewal of a driver’s licence – and a hair’s breadth separates the two poles.
How should organ donor status be outlined during renewal of a driver’s licence? Opt-in by person renewing
None of the above
• Prof Merrilee Needham (Head of Neurology at Fiona Stanley Hospital and Consultant Psychiatrist) has been appointed Foundation Chair in Neurology at Murdoch University. Prof Megan Galbally (Head of Unit, Perinatal Mental Health, at Mercy Hospital for Women in Heidelberg, Victoria) has been appointed Foundation Chair in Perinatal Psychiatry. The appointments are made in partnership with the University of Notre Dame and FSH. Murdoch University will fund the professorial medical researcher practitioner appointments. • HBF CEO Mr Rob Bransby has been appointed to the board of the newly created Australian Digital Health Agency which will replace NEHTA on July 1. The agency will oversee the rollout of the My Heath Record. • The five WA health services will launch on July 1. The Minister for Health, Mr John Day, has announced the boards. They are: NMHS: Prof Bryant Stokes (chair), Dr
Rosanna Capolingua, Dr Margaret Crowley, Dr Felicity Jefferies, Ms Michele Kosky, Mr Graham McHarrie, Ms Maria Saraceni, Dr Simon Towler, Prof Grant Waterer SMHS: Mr Robert McDonald (chair), Adj A/ Prof Robyn Collins, Adj A/Prof Kim Gibson, Prof Julie Quinlivan, Ms Fiona Stanton, Mr David Rowe, Ms Michelle Manook, Ms Yvonne Parnell, Mr Julian Henderson, C/Prof Mark Khangure East MHS: Mr Ian Smith (chair), Mrs Suzie May, Mr Peter Forbes, Mr Ross Keesing, Mr Richard Guit, Ms Debra Zanella, Prof Kingsley Faulkner, Dr Hannah Seymour, Dr Stephanie Trust CAHS: Ms Deborah Karasinski (chair), Prof Geoffrey Dobb, Dr Daniel McAullay, Mr Brendan Ashdown, Ms Kathleen Bozanic, Ms Anne Donaldson, Mr Peter Mott, Mr Andrew Thompson, Dr Alexius Julian WACHS: Dr Neale Fong (chair), Ms Wendy Newman, Mr Michael Hardy, Dr Daniel Heredia, Dr Kim Isaacs, Mr Joshua Nisbet, Mrs Mary Anne Stephens • Prof Geoff Riley has been appointed as a new Medical Advisor for Rural Health West. The former head of the Rural Clinical School and Dean of the UWA medical school started his role in May. • Dr Damien Zilm returns to the role of WAGPET chair after 12 months’ break. Former chair Dr Peter Maguire remains on the board. • Ms Danielle Newport is the new CEO of Activ replacing the long-serving Mr Tony Vis.
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A serious moment during an earlier Doctors Drum
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JUNE 2016 | 11
Museum Maps Who We Are As the WA Museum prepares for an exciting stage of its evolution, it celebrates with an exhibition that shows just how far the world has come. The Western Australian Museum is a multi-faceted organisation exhibiting wonderful and interesting objects in different locations across WA. Its CEO, Alec Coles, is passionate about creating a cultural space that will act as a catalyst for people to tell their own stories. “This institution is a lot more than a building in Perth. It embraces WA in its entire geographical span and I guess a clue to its diversity is in the name, the Western Australian Museum. In the same vein, we operate across many different areas within the cultural sector itself. We have a strong focus on the Arts, a strong science element embracing research and interpretation, education and we’re also very strong in maritime archaeology. Every shipwreck on the WA coastline comes under our umbrella.” “Even if you haven’t visited us we’ve probably come to you in some shape or form.” New era beckons There’s a big spend, $428m to be precise, coming up with the development of a new museum building that’s due to open its doors in 2020. The current blockbuster, A History of the World in 100 Objects will bring down the curtain on the current site. “We’ve had a five-year relationship with the British Museum and we’re so excited to get 100 Objects. It started as a radio series celebrating the human condition, morphed into a book and now it’s an exhibition spanning nearly 2m years and containing some spectacular objects!” “It will be the swan-song for this building but the next phase is going to be a wonderful opportunity. And a great responsibility comes with that because we’re only going to do something of this magnitude once. It’s a large amount of public money so this is an incredible privilege for me and it will be an important cultural space for decades to come.” Role of philanthropy When it comes to any discussion about funding, the question of philanthropy rises to the surface. “It’s true in a general sense that it’s not as well developed here compared with the US and Europe but there are some incredibly generous philanthropists in Perth who’ve been very supportive of the Museum. It’s up to us to develop a brand and make a good case for financial support, which isn’t easy in difficult financial times.” “But it’s our job to convince people that the Museum presents a real opportunity for them.”
12 | JUNE 2016
Alec discusses the delicate balance between overt populism in its programming while also fulfilling the brief of a multidisciplinary research institution. And, along the way, the Museum is committed to serving a diverse rural audience. “We have a duty to appeal to a wide range of people so that means developing an equally wide range of products. Some of those will be popular such as dinosaur exhibitions but it’s equally important that we have things like the recent Treasures from Kabul. The people of Perth will only get one chance in a lifetime to see this sort of material.” Broad appeal “I’m not one for polarising audiences and I certainly don’t think that putting on a popular show means you’re selling your soul. Our focus is to get a wide spectrum of content to as large an audience as possible.” “Our mission is essentially the same when it comes to rural WA. We tailor what we do to a particular region and these sites are a hub of activity for us. They’re really close communities with good relationships between local people, something that’s often difficult to achieve in the metropolitan area.” “I think these regional sites can teach us a lot about community engagement. They’re ideally placed to enable people to come and tell their own stories.” Alec’s own ‘museum story’ goes all the way back to his childhood. “I clearly remember school trips to London
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to visit the British Natural History Museum. It was inspirational! The whole world was laid out in front of me and it was a period in the UK when museums were becoming great innovators. It was around the time when the Heritage Lottery Fund was established and a lot of the money went to museums.” Role of museums “Many of these institutions completely reinvented themselves and people began to see just what a museum can really do.” Alec is reluctant to nominate any pieces he’d love to take home from the collection. “I’m such a strong believer in public access I really wouldn’t want to remove anything but there are two items I care about a great deal. There’s a fossil formation in an 80m year-old slab of sandstone that was donated by the prospector and mining entrepreneur, Mark Creasey. It’s full of the most exquisitely preserved marine animals, including the most amazing starfish.” “There are also some wonderful recent acquisitions from the Western Desert region including woven sculptures made by local women. They’re beautiful pieces and reflect the richness of Aboriginal culture. “Talking about these objects doesn’t do them justice and they’ll definitely be in the new Museum!”
By Peter McClelland ED: A History of the World in 100 Objects closes June 18.
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JUNE 2016 | 13
Finding Answers to the Hard Questions Price, outcomes and affordability are three words never far from HBF Managing Director Rob Bransby’s lips and there are some sobering figures to explain why. No matter which political party takes the reins of Government on July 3, the challenges confronting the health system will cut short any long honeymoon for the Health Minister. With so many reports pending or under consideration, everybody in the health sector is holding their breath for the political cards to fall. HBF Managing Director Rob Bransby’s watching brief is particularly eagle eyed. As head of the State’s biggest private health insurer and president of Private Healthcare Australia (PHA), the private health insurance (PHI) industry’s peak Mr Rob Bransby representative body, there’s unfinished business with the current minister Sussan Ley. She’s in receipt of the PHA’s 112-page report, which pulls no punches in what it regards as essential reforms to keep the entire health system on its feet. The PHA has proposed five changes to private healthcare arrangements which it says could be implemented within a year and would address concerns about the value of the PHI product. It also promises significant cost benefits as a result. Every which way, cost is driving reform. From the PHI perspective, here is a very sobering set of figures. The total health insurance population has grown from 10,189,552 in June 2006 to 13,285,907 in June 2015. Over the same period, total health insurance benefits (general plus hospital) have grown from $8.4b to $18b. These figures have been supplied by the Australian Prudential Regulation Authority and spell out why the PHA means business and why the Minister is listening so intently.
Insurers and Primary Care
Do you think private health insurers should pay GPs to manage some chronic health care in the community? Yes
14 | JUNE 2016
Consumers foot the bill Rob Bransby told Medical Forum that consumers, whether public or private, had to foot the bill for these cost blowouts. “So what is the root cause of this quadruple growth in the cost of health provision? If it’s chronic conditions or ageing, fair enough, but I’m not sure it is. I’m convinced technology is playing a big part in driving those costs up outside of normal gateways and we need to have a good look at that,” he said. One of the key pillars of the PHA’s proposal is prosthesis pricing reform, which we explore in greater depth on P28. In a nutshell, medical device companies are charging the private system up to three times more than they charge the public system for the same products. “We just need to ask why that’s so. Who is getting the difference and why are they getting it? At the end of the day it is the consumers’ money via premiums that go into some people’s pockets on the way through so we want the consumer to buy into this.” “The PHA is taking this up at the government level with the funders and the buyers but the consumers need to understand that the cost of health provision has an impact on them via taxation and PHI premiums. It’s easy to throw a rock at us but the cost growth in health is running at 9%. We must drive efficiencies and establish better price structures to make sure that PHI stays affordable. All we want is a level playing field.” Price tension is healthy Not that the man who has helmed the HBF ship for over a decade is any stranger to price wars. “There’s always been a healthy tension between the payer and the provider – that’s how it should be. What is becoming more relevant now is that it’s not just about price alone – outcomes and quality are essential to contract negotiations. To put it in balance, the hospitals are on this journey as well.” The PHI landscape has changed dramatically over the past 18 months with the privatisation of Medibank Private. It was the catalyst for the alliance of 15 member mutuals, of which HBF was among the biggest. Rob took the lead in the formation of Members Own Health Funds and signed HBF up to the aggregator market, opening the door to transparent product comparisons. “HBF has a turnover of $1.5b and many think we are a for-profit business. We’re not, nor are we in it for loss, we’re competitive and efficient but we don’t drive profits out of health to pay shareholders. Our stakeholders are our customers and our sole purpose is
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to provide affordable health insurance to our members and the benefits go back to them. We have to leverage that advantage with the best benefit line, the lowest price increase, additional services through pharmacies, and lifestyle preventative solutions.” “It is about being commercial, efficient and leveraging your difference.” Premium stand-off Minister Ley’s slap-down at the start of the year, rejecting premium increases until insurers revised their figures, was the cracking of a system that is passed its used by date, according to Rob. “There is no doubt in my mind that the health insurance product that was created 15 years ago is out of date. The world has changed; health has become very expensive and the consumer is struggling with value around it. We need to accept that. Our mantra is around affordability. If we don’t make this more attractive, we will lose people.” “Minister Ley has taken a consumer perspective. We understand the issue of affordability but the process is focused on premium increases and the reality is that they’re not the problem; the problem is the cost of providing health care.” Rob has caught the eye of the minister, having appointed him to the Primary Health Care Advisory Group last year which recommended, among other things, the medical home for the treatment of chronic conditions. He has also been appointed to the board of the Australian Digital Health Agency which will replace NEHTA on July 1 as the overseer of the roll-out of the rebadged PCEHR, My Health Record (see our ePoll on p25-7). Reform or crumble “There is some reform that needs to happen. Our prosthesis price proposal will save $800m a year which will have a direct downward effect on premiums, while digital health will be an absolute game changer. These are things we simply have to do.” “The Australian health system, where we have a balance of private and public, is a great model and it works well. Those who make a decision to take out health insurance are making health care available to more people. It’s a patriotic act.” “The world has moved on from rebates, carrots and sticks but the settings have not. We need reform to change those settings and, yes, some people will be dragged kicking and screaming. We need the buy-in of all the stakeholders – legislators, consumers, providers, hospitals, funders – everyone in the chain needs to be engaged to create these
new settings and that will involve a healthy debate around cost.”
better for the GP to be more broadly funded and more accountable...everyone wins.”
And if hospitals become too expensive it opens the door to more flexible treatment options, but don’t mention the words managed care.
“But we don’t want to be involved in managed care; we just want to fund the primary health system to deliver a suite of services that promotes prevention. There needs to be discussion and we need to share information.”
“I don’t think you ever interfere with what doctors want to do; payers should have no say in the treatment, but where the treatment is done is different question. It’s no less a treatment if it’s done at home. Showing primary colours Does this mean a move by private insurers into the primary care space? “We all benefit from good quality primary care – it’s the cornerstone of a robust health system and a healthy population. If private health insurers can contribute to a primary care system that prevents people going into hospital, we should help in some way.” “The current funding model is wrong and there is no accountability. We can’t expect GPs to pick up that extra burden without paying them more which is why reform around the Medical Home is a good idea. It is
GPs in our May poll (see left) look as if they are prepared to come to the table with nearly half the surveyed GPs ready to talk private funding for chronic conditions but it may take most of the uncertain cohort to join the party before this is welcomed by the medical fraternity. While it may be a slow train coming, the era of visibility and transparency is upon us. As health insurers and Colleges start sharing deidentified data about procedures, price points and providers, Rob says consumers will be at the heart of it because, in the end, it’s their money...and their information. Digital revolution “The ehealth record is a game changer and failure to engage with digital technology will be a disaster. It’s not just about efficiencies.
It’s also a disgrace that a Perth consumer can end up in an ED in Melbourne and clinical staff cannot access that person’s medical history. Consumers will drive this change and service providers will have to adapt.” “There also needs to be greater visibility around price outcome. We can leverage technology for that and I don’t think anyone should be afraid of it. If a surgeon is twice as expensive as another, isn’t it the right of the consumer to know. I don’t want to be controversial but why don’t we disclose that?” “We have a new breed of consumer who is technologically savvy and who talks to like-minds and then makes decisions based on that commentary. We’ve seen it happen in the travel sector with blog sites such as Trip Advisor. This will move to health and the government will tweak the settings to let it happen.” “Up until now we have had an opaque system and people have made a lot of money. Declining affordability has changed all that.”
By Jan Hallam See Page 33
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JUNE 2016 | 15
Taking Care of Business Life has its ups and downs and, in the case of the our hypothetical medicos can change in an instant. The practice of medicine can be demanding enough without nasty surprises such as a partnership split, a fatal heart attack or a marriage breakup and all have financial repercussions. Expert advice in all these scenarios would seem to be good idea, as is the age-old Boy Scout motto, Be Prepared. We put a case to three finance specialists to discover how they would advise these doctors.
Love Hurts All sorts of potential disasters emerge from the woodwork when a marriage-made-inheaven turns hellish. Insurance and estate planner, Adam Smith, gives his take on a situation in which a business partnership is also part of the equation.
Dr Kathy T. is 44 years-old, her husband is also a doctor. The marriage has broken down irretrievably, there are two young children to
consider and it’s complicated by the fact that the parents are partners in a medical practice. AS: It’s probably best for all concerned to get a formal and watertight grasp of the issues and that, in the above case, means lawyers. Kathy T. should also be paying a visit to an accountant with expertise in legal separation and asset settlement. The latter aspect is vitally important for two reasons: ensuring the children are not adversely affected and to provide a window of opportunity for the viability and enduring value of the business.
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BC # 9669
If business partners, who also happen to be married, are no longer on the same ‘team’ one party will probably want to exit the practice in a timely manner. The question is how? First, let’s assume there’s a pre-existing partnership in place. This will make the following considerations comparatively simple to resolve. Notice Period: If a party wishes to leave the partnership within the terms of an agreed notice period it remains crucial to estimate the potential impact on the value of the business. When a relationship has turned toxic a desire to exit immediately is common, understandably. It’s worth noting that a hurried and early exit may end up by devaluing the business. Practice Valuation: How is the practice valued, and when? Most medical practices use a ‘multiple of profit’ model (including ‘Goodwill’) assessed at June 30 on a yearly basis. Practice Consideration: Once a business valuation is agreed upon there will need to be some consideration of the applicable terms for an individual exiting the business. For example, 25% paid upfront and the balance paid over a two-year period out of practice cash flow. Restraint of Trade: If a partner is ‘paid out’ the medical practice may well wish to protect itself from patient/staff poaching and from a practice ‘start up’ in close proximity. The relevant clause should be inserted into any exit agreement. Equipment: Normally, a practice owns relevant equipment within the confines of a Service Trust and/or Company Arrangement. Staff: Usually employed in a Service Trust. A timely, well-planned and civil exit will lessen any negative impact on staff morale. The second case, in which a partnership agreement does not exist, will have to address the above issues. Those, and any ‘exit procedures’, will be complex and expensive. They may also be toxic, leading to staff retention problems and the dissolution of the business.
Heart Sink Life can be cruel, even a leisurely swim in the Indian Ocean can go horribly wrong. Medical finance expert Warren Dworcan deconstructs the tragic consequences of attempting to avoid the admittedly exorbitant Rottnest ferry-fare. Dr John T. was a radiologist in private practice with three colleagues. John, in his early 50s and planning to retire in five years, suffered a heart attack and died during the Rottnest Swim. He has two investment properties, significant debt and is survived by his wife and two children at university. WD: The bleakest outlook for John T’s widow (let’s call her Sally) is one that flows from being totally unprepared for such a scenario. Some important decisions will need to be made and the consequences for the Warren Dworcan business could be unsettling for all concerned. John T’s proportional ownership of the medical practice falls within his deceased estate and in normal circumstances the spouse will be the beneficiary. Let’s pursue the hypothetical nature of this example and assume that, despite having no prior commercial experience, Sally decides to pursue an active role in the business. In fact, she’s actually looking forward to putting some new ideas to the three remaining partners. The radiology practice has no debt, generates around $300k per annum/partner and an estimated value of around $4m. After hearing the proposals put forward by the widow of their former colleague the thoughts of the three radiologists immediately turn to buying Sally’s share of the business as quickly as possible.
This may well be the preferred outcome for Sally because she will now have a lump sum to pay out her mortgage debt. The downside is that any ongoing business income will now cease. A far more positive picture emerges if John T. had sat down with a team of experts and put in place some relevant strategies. The following four issues would have formed the crux of discussions involving a financial planner, an accountant and a lawyer. • Buy/Sell Agreement: this would ensure, in tandem with ‘Key Person’ insurance, that John’s widow would receive a substantial payout. The remaining business partners would assume ownership of John’s share of the business. • Insurance Policy/Self-Managed Super Fund: the proceeds of the policy would be paid (tax free) to Sally. This would give her the option of retaining the investment properties until market conditions were more favourable. • Wealth Creation Plan: allowing the remaining proceeds of the insurance policy to generate investment income for his wife and children. Any rental income would supplement this figure. • A Will, Power of Attorney and Guardianship: these documents set out clearly and simply the procedures to be followed to ensure that life will go on in a relatively comfortable fashion for Sally and her children. It’s readily apparent that the latter scenario is far more preferable than the former. Personal and professional circumstances can change in the blink of an eye and a decision to seek some form of advice in advance is prudent. Putting in place a holistic, workable and legally-binding strategy before your luck runs out is money well-spent. continued on Page 18
Some other points to consider: • Estate Planning: Dr Kathy T. would be looking to ensure that the financial benefits she’s worked so hard for end up with her own children and not with her exhusband’s future partner and/or children. • Wills: Divorce automatically revokes an existing Will. • Testamentary Trust: Protect children from potential ‘Predators and Creditors’ such as future partners and ex-spouses. • Debt: It may be prudent to resolve any encumbered debt to simplify the children’s financial position. Dr Kathy T’s situation underscores the importance of pre-planning the settlement of assets in both a personal and professional sense. More specifically, any medical practice requires formal documentation of partnership expectations and doubly so if marriage complicates an already potentially convoluted scenario.
JUNE 2016 | 17
Feature continued from Page 17
Managing your finances Q
Practice Meltdown May e-Poll
Do you manage, partly of fully, the finances and future planning of your practice?
Finance broker Sarah Wells bounces off a scenario in which a medical partnership turns decidedly pear-shaped. Dr Meredith S. is a co-founder of a GP Practice incorporating six doctors, two allied health professionals and support staff. Meredith announces that she intends to leave and work part-time. Her principal partner becomes visibly angry, with comments ranging from ‘legal ramifications’ to ‘competitive exclusion’. SW: Going into business with another person should be viewed as something like a marriage. If you make an unwise choice it could cost you a lot, both personally and financially.
You answered ‘yes’ to the preceding question so we ask, what best describes the time you spend on planning future financial considerations for your medical practice: Significant time spent and it feels productive.
Adequate time but should do more.
Negligible time, which worries me.
Non-existent time and not something I think about.
Prefer not to say.
None of the above.
While most people are aware of the importance of discussing what might happen in such a situation, it’s a topic that’s often pushed to the background or avoided entirely. It can be a difficult conversation and who wants to be the party-pooper clouding the beginning of an exciting new venture?
Mundane issues such as maternity and sick leave need to be aired at the outset, and even more so when it comes to talking about a potential partnership split. The latter requires the expertise of a lawyer and it all needs to be in writing. From my experience, if you can’t get through these early stages of a business relationship then the possibility of working together in a mutually beneficial fashion may not be on the cards. Plan for the unexpected
ED: For those GPs handling their own business affairs a third feel vulnerable financially which just goes to show how complex running a modern general practice has become.
The situation involving Dr Meredith S. is an interesting one. Unless there has been some provision for just such an eventuality there will be consequences, some unpleasant. Meredith’s decision to work part-time will result in an interruption to the normal flow of the practice as a business. This will inevitably impact on her partners and support staff. If there’s a prior agreement in place that clearly states that a partner who decides to leave at short notice must ‘work out’ their time on a full-time basis then that’s one problem solved. On the other hand, the person concerned may be required to find a suitable replacement and take a leave of absence that extends right up until their official departure date. If this occurs Meredith may be subject to a restrictive covenant in which she finds herself unable to practise in specific geographical locations for a defined period of time. There’s always the option of legally challenging such an outcome but that is often costly and time-consuming.
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Meredith S. will be well aware that, whatever the outcome, the patientlist she’s worked to develop will be diminished at best and non-existent at worst. Making 'ideal' reality Ideally, all these details will have been discussed and formalised when the practice partnership was first established. But, as we all know, life is seldom ‘ideal’. Before anyone in Meredith’s position makes any decision they should seek legal advice. Some business breakdowns resolve themselves amicably while others are fractious, time-consuming and expensive. The phrase ‘always begin with the end in mind’ is worth remembering. It’s a truism that applies to many aspects of our professional, financial and personal lives. Take the time to work through potentially complex partnership agreements and make sure you’re comfortable with the outcome. If you don’t talk this through at the outset it’s a fair bet you’ll be having a longer and more acrimonious discussion sometime in the future. It’s a bit like your own health, really. If you look after yourself now there’s a good chance you’ll end up in pretty good shape in the future.
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Worrying the Well; Sidelining the Sick Prof Paul Glasziou’s work is gathering evidence to show the nett harms of over-testing and over-treatment that could put the brakes on spirally costs and GP burnout. In a world that pressures doctors to do more, the words of GP and Bond University researcher Prof Paul Glasziou might come as a port in the storm. He is researching how sometimes doctors need to do less for the good of their patients. Paul is the Director of the university’s Centre for Research in Evidence-Based Practice (CREBP) and in March he and three colleagues received a $9.6m NHMRC program grant to explore if outcomes aligned with the levels of testing and treatment regimes in the areas of musculoskeletal diseases, cardiovascular disease and cancer.
Paul is joined by Prof Rachelle Buchbinder (Monash University and Cabrini Institute), Prof Chris Maher (George Institute for Global Health) and Prof Kirsten McCaffery (University of Sydney) in the study Using healthcare wisely: Reducing inappropriate use of tests and treatments. While their work has been evolving over the past decade, Paul told Medical Forum that there is still much to learn about the growing problem of overdiagnosis. While the statistics show alarming upward trends for diseases such as thyroid cancer and chronic kidney disease (CKD), Paul says it is vital that
Overdiagnosis and over-testing Q How do clinical guidelines or other reputable consensus statements affect your discretionary powers to make decisions for patients? Increase my powers
ED: The big unanswered question is whether increased discretion is applied inside or outside guidelines.
Will most patients accept advice from their doctor to ‘wait and see’ when exploring a problem? Yes
ED: We suspect this figure would increase if patient moiety payments increased.
Do you think diagnostic tests are over-used?
Comment We asked doctors to comment on the issue of overdiagnosis, from their own perspective... Legal issues overrule “The issue of litigation by patients and the powers of the medical board in favour of patients and demonising doctors drives overdiagnosis through investigations.”
“No one will take me to court for over investigating/over-diagnosing. But who will defend me for the perception that I have under-investigated and not gone to the nth degree to solve a patient's issue? We are all working under a cloud of fear generated by the threat of litigation as well as a fear of missing a diagnosis for our patients.” Patient-led diagnosis “Many patients wish for a simple "cure" and want lots of test done to find the "reason" for the problems they have. They read the internet and come to their own conclusions. I find the best way to deal with them is to listen, examine them properly and then ask them what they think is wrong. Unless you know their agenda you cannot get anywhere. If they are not happy they simply go somewhere else. I will be happy when patients have to pay for pathology etc and even happier when results are available on their digital record.” “Most patients don't care about guidelines and evidence-based medicine. They just want to be made better – now. Hence, overservicing and over-investigation.” System control “Ambulatory endoscopy at Osborne Park Hospital has outstanding forms to complete for assessment of patients for gastroscopy and colonoscopy. If the criteria are not met, the patient is not accepted. I suggest that this model be modified and applied to pathology tests and imaging requests as well.” “The more experienced we are, the fewer tests required.” “Not enough time for risk/benefit counselling and pre-screening. “
researchers unpick what is really going on. Investigation slippery slope “In Australia we have seen a threefold rise in thyroid cancer which we think has a lot to do with sonographers looking at the carotid and examining the thyroid while they are there and spotting nodules, which when investigated show some abnormal-looking cells that get classed as cancer. But we don’t know for sure.” “There are a lot of influences at play to explain these disease spikes. Some of it is simply continued on Page 22
three-monthly bloods e-Poll for chronic disease management. The rheumatic heart team all want their patients rounded up and echoed etc as well as the leprosy people wanting theirs dragged in for biopsies and not forgetting the orthos wanting everything x-rayed and CT’d and the urologist wanting sequential multiple PSAs and the antenates all their bloods and scans and whoops. What about all the STI screens because all our patients are high risk.” “The ability of other health professions to request diagnostic tests is of concern, and these are often done before I get to see the patient for the first time and results are not shared. Of particular concern is the easy availability of x-ray imaging to chiropractors and physiotherapists, often unnecessary or inappropriate and raises the concern of radiation dose to patients.” “Specialist groups widen their criteria for diagnosis within their own area, which leads to increased drug use and cost without concern for all the other specialty groups doing exactly the same. There is therefore an increase in the drug burden and risk of interaction for the individual, and a colossal increase in cost burden to the PBS. This is particularly true in the elderly. The actual evidence base for most guidelines is almost non-existent for patients over the age of 75, often excluded from randomised trials on the basis of age. The art of the GP is to treat the patient, and avoid iatrogenic hospital admissions, despite the guidelines. This is why every jurisdiction which has more specialists than GPs have worse population outcomes for higher overall costs.”
Down the chain “Every month the kidney team demands bloods be done on their patients as well as
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JUNE 2016 | 21
Feature continued from Page 21 the problem. But he sees storm clouds ahead with the increasing accessibility of genetic testing.
better technology. Pulmonary embolism is a good example of that. Very small clots that previously went undetected and were probably harmless are being treated and in that process we are doing nett harm. If you test often enough you will find an abnormality.”
“There are such strong commercial forces behind genetic testing that it will take serious effort to control what could be a ‘diagnosis tsunami’! The Medical Services Advisory Council is investigating the evidence base of genetic tests but consumers must be informed and prepared to stand up and say no to this. Policy can go so far; there needs to be a groundswell and an understanding in the area.”
“And then, of course, there are the changes in the definition of conditions and disease such as diabetes, polycystic ovaries, metabolic syndrome and many psychiatric conditions, most controversially in the DSM5.” “It’s a tangled mess of pharmaceutical and imaging influences in all of this, but there are also incidental things like the vitamin D mania – brought on by an innocent change in the threshold – where people think they were doing good but haven’t thought through the downside.” GPs shoulder the load Paul believes that GPs bear the brunt of this new dilemma and judging by our ePoll WA GPs think the same. “A lot of GPs recognise this problem of over-testing and overdiagnosis and are enthusiastic that something is being done. They feel hemmed in by the fact that specialist groups will push the thresholds for diseases like gestational diabetes and they are left not knowing what to believe.” “But if someone comes along and says ‘Stop, look at the evidence of the benefits and
Six Steps to EBM Prof Paul Glasziou
harms of labelling and overdiagnosing’ they’re relieved because they’ve been worrying about it.” “The RACGP is very interested in our research because there is a greater expectation on GPs to do more and more for patients while they are feeling less and less like they’re doing the right thing. In the UK, the RCGP has set up a working group specifically on overdiagnosis. One of its members coined the phrase 'We are so busy worrying the well, we don’t have time to treat the sick'." Paul sees a steady path ahead, establishing evidence for existing conditions and circumstances and working from both ends of
• Don’t skip “step 0,” but foster doubt, uncertainty, and honesty • Beware overdiagnosis: our definitions are as important as our tests • It is the patient’s decision: practise and teach Shared Decision Making alongside EBM • Take non-drug interventions as seriously as pharmaceuticals • Build clinical practice “laboratories” to study translation and uptake • Invest long-term in automating evidence synthesis Source: Prof Paul Glasziou, BMJ
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News & Views
electronic Getting the ^ Record Straight The personally controlled electronic health record (PCEHR) has been kicking around for years, bouncing uneasily between bureaucratic and clinical concerns, soaking up $1b in the process and getting nowhere fast but with plenty of drama along the way. The resignation of the respected Dr Mukesh Haikerwal and Dr Nathan Pinksier from the National eHealth Transition Authority (NeHTA) board in 2013 stalled the process entirely.
Health Consumers Forum Stephanie Newell; and ICT expert and public servant Mr Paul Madden.
“Would stop duplication of services and doctor shopping and make it more efficient in organizing and receiving tests and results.”
In our April ePoll we wanted to know how doctors might welcome IT changes and what they thought motivated those decision makers – 215 doctors responded (see below).
“Electronic patient records are useful, allow timely access for multiple practitioners and can be used for data collection – hopefully aimed at quality improvement, not just activity recordings.”
Comments by WA Doctors Opinions on the electronic record were split but the 104 who took time to comment were all passionate one way or the other!
Health Minister Sussan Ley has kicked the ball back into play and while there is far from complete agreement, the rebadged My Health Record starts two significant trials on July 1 with a new authority, the Australian Digital Health Agency (ADHA), to watch over it.
Let’s do it…well! “Health IT is essential to providing good care of the individual and the population. It is a tool to improve quality and to plan health care delivery. It’s not just the technology but requirement that data is shared. If a service is funded by the government in any way (public or private) part of the agreement should be that information is shared.”
The ADHA will replace NeHTA next month and is driven by this government’s focus on cost saving and efficiencies. It has a growing band of followers. This month we spoke to HBF CEO Mr Rob Bransby who is a champion of digital innovation in health.
“I believe this is fantastic. Imagine not having to copy hand written notes to transfer to another practice or insurance claims.”
He has been appointed to the ADHA board which will be chaired by South Australian Mr Jim Birch, chair of the Red Cross Blood Service and the Australian Red Cross Society. The board also includes Brisbane GP Dr Eleanor Chew; CBA executive Ms Lyn McGrath; UWA graduate, Healthscope executive and former adviser to PM Tony Abbott Dr Bennie Ng; Melbourne health administrator and PHN CEO Dr Elizabeth Deveny; Macquarie University health informatics expert Prof Johanna Westbrook; safety standards expert and chair of the
“Significant improvement regarding discharge letters, specialist reports, better communications.”
It’s risky business
“I would love quick access to previous tests and imaging.”
“Can be useful for health providers particularly those in remote or rural communities; Can also be endangered by security issues such as hacking.”
“Great potential, but so far there has been poor implementation. A unique patient identifier is required.”
“Good in theory, but governments pushing it are more interested in stats and control than patient care.”
Do you think My Health Record (previously PCEHR) is crucial to reducing duplication between different health care providers?
“Used properly a big advance; used badly, an extra layer of pain.” “It is overdue. We have the technology. We should be using it!”
“I am increasingly frustrated by the number of GPs who stubbornly remain ‘off grid’ when it comes to electronic communication. As a ‘paperless’ practice provider, I see no good reason why they should be allowed to resist progressive modernisation and move into the digital medicine age. It's not about them, it's about their patients.”
“Great when it works, confidentiality has gone crazy, it’s unbelievably expensive.”
IT Use Among WA GPs and Specialists Yes
“Keeping all the relevant information in one place, accessible to all medical practitioners and the patient, will be a huge leap forward. Being able to openly communicate with other members of the care-team while involving the patient, will improve transparency.”
ED: It is line ball at the moment as to whether the rebranded My Health Record, will reduce duplication, according to our doctor respondents. Back in July 2012 we asked doctors a similar question and 43% thought the then PCEHR would reduce duplication of tests and treatments; 36% were neutral and 21% dismissed the idea. Going on our latest poll the PR campaign had better crank up because the figures are going backwards.
IT use in health care is promoted mainly because of: Strongly agree
Improvement in patient care
To control what happens
To improve data collection
ED: Most doctors in WA feel IT changes are promoted as improving patient care and saving money, . something most commentators are familiar with, but what purpose improved data collection has is unknown, even though this concept is behind IT use in health care, according to our respondents. However they may believe more what is said now than in July 2012 when only 25% agreed it would improve patient care with 37% thinking it would improve coordination. Back then confusion reigned as to who was responsible for what with nearly 80% uncertain of their role. After July 1, we’ll ask that question and again and it will be interesting to see the results.
“A single, central health record is crucial, but PCEHR isn't it. Requiring data to be entered and edited by the patient is even less reliable than asking doctors to do it.” “IT use in practice is OK. eHealth is fraught due to lack of guarantee against hacking. Falling into the wrong hands, ie insurance companies/employers, it could potentially be damaging.” “Privacy and confidentiality remain the prime reasons for extreme concern. Access via insurance services, and storing of this confidential information on databases beyond health services could become the reality.” “I think patient control of content can make the record deceptive and lead to errors. The data can be misleading when important content can be withheld.” “Concept of medical professionals being able to access patient information is worthwhile, but a record which the patient can access and delete information from is unacceptable, unreliable, and to put pressure on doctors to upload data is abhorrent.” “My other concern is the eventual access to the generated data sets and whether insurance companies will have access to sensitive data. I am not at all confident in the alibi of researchers using the data to focus continued on Page 27
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IT: Comments from WA Doctors funding and initiate primary care initiatives. I am extremely skeptical of the process of data collection.” “Need to be careful that the tail doesn’t start to wag the dog!” Doctors bear the brunt “It's brilliant but any extra work required to implement it needs to be remunerated. Uploading information is as an added extra to already busy patient consultations and it does threaten safety and quality of care.” “It adds complexity without real clinical gains.” “Useful in parts, but have you noticed the expansion in the 'paperwork' that accompanies it? Forms get longer and more convoluted. Often irrelevant 'tick the box' stuff.” “I spent a small fortune setting up my cutting-edge system only to have the computer operating software, then the medical software change and result in the obsolescence of all the practice printers! Also, when the internet is unavailable, the practice shrivels to a raisin on a dung heap.”
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“For most GP practices it is a huge cost but helps a lot. The issue is the freezing of rebates while the cost of technology is increasing at a rate of at least twice inflation.” A near-hopeless mess “IT in the public system is a failure. The current IT solutions at FSH where they have Bossnet, Metavision for ICU, a separate burns information system for burns ward, a separate maternal information system for obstetrics just fragments patient information…None of these systems interfaces with iSoft for pathology results or IMPAX for radiological investigations. The waste of money on IT is mind-boggling and yet we still have to settle for dysfunctional solutions.” “There is a duplicate system in use in the Kimberley (e.g. using Hcare plus Communicare or Hcare plus MMMEX) is a massive waste of human time. Three systems (plus My Health Record making four) NONE of which have complete data. Crazy stuff.” “We are completely re-inventing the wheel. There are perfectly reasonable systems operational in Europe with which I have personal experience.”
Now in its 4th year, the program offers a range of high quality educational sessions including orthopaedics, pain management, prostate cancer, bariatric surgery, breast cancer surgery and palliative care.
“The issue is NOT the Department of Health but IT companies who insist on upgrades and failure to allow programs to update on newer operating systems. Currently a lot of hospitals are still running Windows 3 as many of the earlier programs were written for this system and cannot be updated to newer versions of Windows. Apple is the worst offender.”
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“I am a supporter of IT but the government management of this is appalling, and it tends to get hijacked by the privacy debate. I am sitting on the sidelines until they sort it out!” “Integration of public and private sector electronic communication regarding patient care is unbelievably behind the times. It is a huge impediment to public health sector cost saving and patient care efficiency efforts.”
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“Programs made by IT specialists and bureaucrats will not contribute to any improvements in health care.” “I think EHR is being driven by people who have a vested interest; expansion of EHR represents a career opportunity for them. I am also unaware of any good/unbiased data to show EHR is of benefit.” “The planners never seem to ask the staff before introducing a new system. All the hospitals I know have different systems. Sigh...You would think by now...”
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Who Killed Normal? It’s a brave new world out there, says Dr Peter Burke. Or is that 1984 rolling around again? Have you seen your first case of Lynch Syndrome yet? For doctors who might think a syndrome is a constellation of symptoms and signs, this is a modern version with none of those. Sufferers were formally known as ‘Completely Normal’. But now, there’s a website. You can help them raise awareness and funds, of course. It’s terribly underdiagnosed and tragically underfunded. One laboratory reports Vitamin D levels with the notation ‘38% of our tests are abnormal.’ That confirms they’re complying with Medicare by only testing high-risk patients. Either that or the current normal range is bollocks. Yes, that’s right… 38% of folk in this land of sunshine, milk and honey have rickets with symptoms so subtle they’re detectable only by true believers. Normal is dead, but who killed him? It was a big mob of them, … and look, they’re still rifling through his wallet. Psychiatry probably threw the the first punch. Try rifling through the DSM5, if you can lift it, without self-diagnosing half-a-dozen times.
You cannot be normal, unless you are the man with the gun in the Lindt Café. AMA spokesman Dr Bill Pring berated the media for suggesting Monis was mad because that impugned the reputations of millions of ordinary Australians with mental illness. The ‘Wellness Industry’ had a good crack at normal. Wellness is now one of those Orwellian terms that means exactly the opposite. At its commercial worst it is deeply committed to pathologising normality in the name of profit. It’s big and getting bigger. Look out for genetic testing in your local pharmacy. You’ll be guaranteed a ‘diagnosis’ and a ‘syndrome’ will cost you a bit extra. Monomaniac Messiah Doctors pushed normal to the pavement, too. Practice Tip: If you have diagnosed 500 cases of Lyme Disease and/or Selenium Deficiency, or anything else that scores a ‘zero’ from all the other doctors you probably should change the sign on your door to Shaman. Naturopaths were seen fleeing the scene, and a few iridologists. And a hundred other ‘health care providers’ seeking to become indispensable features of their patient’s lives.
You can like them on Facebook, or not. The Law threw a couple of punches. GPs often feel the need to further investigate Normal for reasons of perceived medicolegal risk. Referral to a specialist? Further investigation required and a diagnosis out of professional politeness. Technology gave Normal a kick or two. I used to get Chest Xray reports bearing two words – Normal Xray. Now the resolution is so damn good there’s always something to report. I reckon normality is rife in the WA community. So, if they’re normal let them know. I often diagnose a bit of normal human sadness. I like the sound of it and so do most of my patients. Normal – your patients’ eyebrows may rise as you utter it because they certainly won’t have heard it on social media, or television and definitely not from their homeopath. Officer, look! Normal’s trying to stagger to his feet. The medical profession might still be able to save him. Quick, get him in the car before that mob of therapists gets to him!
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• • Hip replacement & gluteal Hip replacement & gluteal • • Hip & knee joint Hip & knee joint tendon repair tendon repair replacement / revision replacement / revision • • ACL & knee replacement ACL & knee replacement • • Sports surgery Sports surgery (knee reconstruction) (knee reconstruction) • • Shoulder surgery: Shoulder surgery: Replacement, rotator cuff Replacement, rotator cuff • • Trauma Trauma & stabilisation & stabilisation
30 | JUNE 2016
For For contact contact details details ofof Hollywood Hollywood orthopaedic orthopaedic surgeons, surgeons, visit visit the the specialists specialists section section ofof our our website website hollywoodprivatehospital.com.au hollywoodprivatehospital.com.au
MrMr Matthew Matthew Lawson-Smith Lawson-Smith
Mr Mr Michael Michael Ledger Ledger
DrDr Nicole Nicole Leeks Leeks
Mr Mr Toby Toby Leys Leys
Mr Mr Antony Antony Liddell Liddell
T: T: 9200 9200 6153 6153
T: T: 9389 9389 3811 3811
T: T: 9389 9389 3844 3844
T: T: 9230 9230 6333 6333
T: T: 9212 9212 4200 4200
• • Hand, wrist, elbow & Hand, wrist, elbow & shoulder surgery shoulder surgery • • Carpal tunnel Carpal tunnel
• • All shoulder & knee All shoulder & knee surgeries surgeries • • Sports injuries Sports injuries
• • Paediatric orthopaedics Paediatric orthopaedics • • Foot & ankle surgery Foot & ankle surgery • • Lower limb arthroscopy Lower limb arthroscopy
• • Sports knee surgery Sports knee surgery • • Hip & knee replacement Hip & knee replacement
• • Shoulder surgery: Shoulder surgery: Impingement, rotator cuff & Impingement, rotator cuff & stabilisation stabilisation • • Hip & knee arthroplasty, Hip & knee arthroplasty, gluteal tendon repair gluteal tendon repair • • ACL reconstruction & ACL reconstruction & sports injuries sports injuries
Mr Mr Ryan Ryan Lisle Lisle
MrMr Clem Clem McCormick McCormick Mr Mr Ross Ross Radic Radic
Mr Aaron Aaron Tay Tay MrMr Jonathan Jonathan Spencer Spencer Mr
T: T: 9389 9389 3800 3800
T: T: 9389 9389 3888 3888
T: T: 9389 9389 3855 3855
T: T: 9212 9212 4200 4200
T: T: 9389 9389 3866 3866
• • General paediatric General paediatric • • Adult lower limb Adult lower limb orthopaedic surgery orthopaedic surgery arthroplasty (hip & knee arthroplasty (hip & knee replacements) replacements) • • Arthroscopic Arthroscopic reconstructive & reconstructive & • • Paediatric orthopaedic Paediatric orthopaedic arthroplasty surgery of the arthroplasty surgery of the surgery surgery shoulder & knee shoulder & knee • • Sports knee injury & Sports knee injury & arthroscopic surgery arthroscopic surgery
• • ACL / PCL / LCL / MCL ACL / PCL / LCL / MCL • • Shoulder & elbow surgery Shoulder & elbow surgery • • Arthroscopic & Arthroscopic & reconstructions of the knee reconstructions of the knee reconstructive surgery of reconstructive surgery of • • Knee surgery Knee surgery the shoulder & knee the shoulder & knee • • Shoulder surgery: Shoulder surgery: Impingement, rotator cuff Impingement, rotator cuff • • Patient specific Patient specific & stabilisation & stabilisation instrumentation & instrumentation & computer guidance for computer guidance for • • Osteotomy Osteotomy total knee replacement total knee replacement • • Knee, hip & shoulder Knee, hip & shoulder • • Patient centered approach Patient centered approach replacement replacement to problem management to problem management
MrMr Colin Colin Whitewood Whitewood Mr Mr Sean Sean Williams Williams
Mr Mr Greg Greg Witherow Witherow
Prof. Prof. David David Wood Wood
MrMr Homan Homan Zandi Zandi
T: T: 9389 9389 3800 3800
T: T: 9389 9389 3822 3822
T: T: 9212 9212 4200 4200
T: T: 9386 9386 6211 6211
T: T: 9389 9389 3868 3868
• • General orthopaedics General orthopaedics • • Lower limb arthroplasty Lower limb arthroplasty both primary & revision both primary & revision surgery for hip & knee surgery for hip & knee • • Paediatric surgery Paediatric surgery
• • Hip & knee replacement Hip & knee replacement surgery, including primary surgery, including primary & revision surgery & revision surgery • • Sports knee injuries Sports knee injuries • • Direct anterior approach Direct anterior approach hip surgery hip surgery • • Computer navigated Computer navigated knee surgery knee surgery
• • Hip arthroscopy & Hip arthroscopy & • • Cell-based therapies Cell-based therapies replacement replacement • • Musculoskeletal oncology Musculoskeletal oncology • • Ankle arthroscopy & related Ankle arthroscopy & related • • Hip & knee arthroplasty Hip & knee arthroplasty surgery surgery • • Knee arthroscopy Knee arthroscopy • • ACL reconstruction & ACL reconstruction & replacement replacement
• • Shoulder: Cuff repair, Shoulder: Cuff repair, replacement & stabilisation replacement & stabilisation • • Elbow: Open & Elbow: Open & arthroscopic surgery arthroscopic surgery • • Wrist & hand Wrist & hand (no finger fractures) (no finger fractures)
Thinking ThinkingOrthopaedic OrthopaedicSurgery? Surgery?Think ThinkHollywood. Hollywood. For For contact contact details details ofof Hollywood Hollywood orthopaedic orthopaedic surgeons, surgeons, visit visit the the specialists specialists section section ofof our our website website hollywoodprivatehospital.com.au hollywoodprivatehospital.com.au
JUNE 2016 | 31
Healthy Pilot, Safe Air Travel Technology may provide future solutions to pilot murder/suicide, suggests aviation medico Dr Rob Liddell. As a child in the 1950s I remember going to Perth airport to see my father depart for business meetings in Sydney. It was an exciting time, a crowded departure hall and noisy propellor aircraft such as the Lockheed Electra. There was a waist-high fence between the passengers, those waving them off and the silver aeroplanes. Airport security was the last thing on anyone’s mind and the idea of locking the flight-deck door was a long way off. The first inkling of trouble appeared in the mid-1960s with an occasional hijacking on American domestic routes with Cuba the usual destination. Everything changed on September 11, 2001. It was clear that the cockpit door had to be strengthened and its operation controlled by the pilots. It also had to remain permanently locked in flight. The unintended consequence was an opportunity for a mentally ill pilot to prevent a colleague returning to the flight-deck and subsequently crash the aircraft. It doesn’t happen often, but it’s an unacceptable failure of a system that aims to be fail-safe. When it does happen there’s a flurry of media stories about pilot medicals, particularly in
relation to signs of depression or other mental illness. A pilot who deliberately crashes an aircraft may or may not be depressed but they are most certainly psychopaths and/or ideological terrorists. After the 2015 Germanwings Airbus murder/ suicide, one of the first places authorities looked was the co-pilot’s medical history. On a questionnaire similar to a K10 assessment, Andreas Lubitz had made references to symptoms of depression. If a pilot has been receiving psychiatric treatment or exhibiting signs of a psychopathic personality disorder there is no way a medical examiner could ascertain that unless the individual chose to reveal it. In terms of managing pilot murder/suicide a flight medical is pretty much useless. German doctors are forbidden to pass on a patient’s medical details even if there’s a perception of public risk. Thankfully, in Australia there’s legislation within the Civil Aviation Act that protects a doctor who elects to pass on such information. This is comforting for the medical practitioner however it does comparatively little to diminish the risk of psychopaths taking control of the flight deck.
So, what other defences exist? Probably the most effective single action taken post-Germanwings has been legislation requiring at least two people to be in the cockpit at all times. There’s another benefit to this, too. If a pilot is suddenly incapacitated by a stroke or heart attack a flight-attendant can open the door to let the second pilot back into the cockpit. Current technology allows an autopilot to fly the aircraft from just after take-off to destination, including a full auto-landing. It’s not such a big step to program aircraft software that denies the pilot the ability to fly the aircraft outside the cocoon of airspace on the flight-planned route. It’s a fair bet that emerging technologies will offer more potential solutions. The pendulum has swung towards highly reliable operating systems and away from human error and psychopathic behaviour. ED: Dr Rob Liddell was an airline pilot based in Gatwick, UK and has extensive experience in aviation medicine. Pilot suicide/murder has killed 743 passengers and crew (including Malaysian 370) since 1997.
Perth Cardio has now opened doors in the heart of Midland’s new medical precinct. With cardiology services conveniently available on site every day, accessing world-class cardiology care, consultation and testing in the City of Swan just got a whole lot easier for your patients. For more details visit perthcardio.com.au LEADERS IN CARDIOLOGY | ECHO | ECG | HOLTER MONITORING | ABPM | STRESS ECHO | EXERCISE STRESS TESTING
32 | JUNE 2016
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News & Views
Costing an Arm and a Leg When HBF CEO Rob Bransby read the prosthesis price list WA public hospitals were using, he saw red. His fund was paying sometimes three times the price for the same item. So, when the Health Minister told health insurers to go back to the drawing board earlier this year, Rob suggested to Sussan Ley premiums would drop immediately if there was action on prosthesis pricing reform. PHA’s report, Costing an Arm and a Leg, claims that Australia pays more for implanted medical devices than other comparable countries which has led to its campaign for a reference pricing model. It says prices could fall by 45% which could see $800m in savings each year and premiums rising less rapidly. The history of prosthetic pricing is fascinating but long and sobering. Enough to say that regulation over the past decade has driven the now entrenched inflated prices in the private sector that may have made companies and individuals rich. Specialists are the primary drivers in prostheses use. Those who work across private and public sectors should be made aware of price differences for their patients' sake, in our view. “The benefit level is determined by the Prosthesis List Advisory Committee [PLAC] and we want to see some deregulation so that
Australian insurers pay double international benchmarks Comparison of prostheses pricing Index
~$1.75b -45% 1.13
private prostheses spend p.a. /
Target ~45% decrease in spend = Australian private prices
Australian public prices
Developed economy benchmark
SOURCE: Australian Prostheses List 2015; WA Health pricing schedule; PHA Report 2014; International Federation of Health Plans Comparative Price Report, 2012; PwC Medibank Medical Devices Review, 2010
we are paying the same price as the public system. We don’t want to send people broke but we just want a transparent and open and fair pricing regime,” said Rob Bransby. PHA has suggested the Government could implement a PBS-style approach where manufacturers would be required to provide reference prices from other jurisdictions as part of their approval process and PLAC could be refined to work more closing with the public
by Medical Director Prof John Yovich
and private healthcare sectors to plan and implement a reference pricing model. In late February, Minister Ley was reported by Fairfax Media to have told the medical devices industry to identify more than $500m in savings or face a blanket price cut. A working group of devices industry representatives and government has been established.
Specialists in Reproductive Medicine & Gynaecological Services
PIVET MEDICAL CENTRE
Low BMI and Fertility … often adversely related Amongst younger generations, the idea of being slim with a low BMI e.g. 17 to 21 Kg/m2, equates to good health and longevity. This may well be so from the public health perspective, but is not the case for good fertility or for best prognosis from assisted reproductive treatments (ART). When being slim arises from a background of anorexia nervosa, women may find persistent disturbances with many of the parameters associated with good fertility including menstrual cycle irregularity, menstrual disorders, disordered ovulation and complete anovulation, infantile (low volume) uterus and thin endometrium as well as high complication rates in their ensuing pregnancies; especially intra-uterine growth restriction and pre-term deliveries. Many young women obtain their slim physiques by sacrificing important nutritional staples such as bread (in low carbohydrate diets) and dairy products (in low fat diets). For the former there may be a risk of thiamine (B1) insufficiency given that the essential vitamin is mainly sourced from yeast and whole-grains; fortunately in Australia processed flour is fortified with thiamine along with NOW AT 2 LOCATIONS PERTH & BUNBURY
folate and iodised salt and many young people take a daily Berocca supplement. For the latter, too many young women have excluded milk, cheese and dairy products from their diets, although the wise will have accepted yoghurt with the favourable lactobacilli and bifidobacterial cultures. Clear data has now recently been published in the recent March 2016 edition of the fertility journal Human Reproduction. The Environment and Reproductive Health (EARTH) study group from Harvard University showed that higher dairy intake improved ART livebirth outcomes and was particularly favourable for women ≥35 years.
For ALL appts/queries: T 9422 5400 F 9382 4576
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JUNE 2016 | 33
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Appropriate approach to haematuria Haematuria is relatively common, has benign and malignant causes, and there is debate about the best approach amongst different organisations such as AUA (American Urological Association), BAUS (British Association of Urological Surgeons) and NICE (national institute of clinical effectiveness) UK. Table 1. Benign causes of haematuria • • • • • •
Urinary tract infection Renal calculus BPH Non infected cystitis Glomerulonephritis and other nephrological conditions Exercise induced haematuria
By Dr Akhlil Hamid Urologist, Nedlands
Table 3. Benign conditions that discolour urine (“pseudohaematuria”)
Is a single positive test enough to diagnose a-NVH?
• • • • •
The AUA guideline, updated in 2012, went from recommending that 2 out of 3 tests be positive before diagnosis to a single positive microscopy test, based on this evidence:
Menstruation Jaundice Food (beetroot, red cabbage) Dyes (paprika, food colourings) Drugs (rifampicin, metronidazole, nitrofurantoin, phenytoin, doxorubicin)
Non-visible haematuria (NVH) – which test? The definition of NVH, internationally unstandardized, ranges between 3-10 RBC per high power field. Australia uses 10PHF as opposed to the US with 3PHF.
1. a-NVH due to malignant conditions can be intermittent 2. A single positive result has a similar (and in some cases higher) pick up of urinary malignancies compared to studies requiring more than one sample. 3. A single positive study is able to pick up non-malignant urological conditions such as renal calculi, BPH and renal diseases.
Haematuria defined Haematuria is divided into gross haematuria and microscopic /non-visible haematuria (NVH). Often, the presence of symptoms is helpful in deciding management – asymptomatic NVH (a-NVH) and symptomatic NVH (s-NVH) – and in all cases, risk factors for urinary malignancy can be identified (Table 2). Table 2. Risk factors for urinary malignancies. • Male • Age >35 (NB. differs with different guidelines) • Past or current smoking • Occupational exposure to chemicals and dyes • Analgesic abuse (phenacitin) • History of: gross haematuria; previous malignancy and treatment (cyclophosphamide); irritative voiding symptoms; pelvic irradiation; chronic UTI; and indwelling foreign body e.g. SPC. Gross haematuria This is alarming for patients but the cause is often obvious. In all cases, a minimum of a dipstick test and microscopy on fresh, midstream, clean-catch or catheterised urine specimen is needed to exclude infection and other causes of discoloured urine / “pseudohaematuria” (Table 3.) ° The presence of WBCs, leukocyte esterase, and nitrites suggest infection, confirmed by urine culture. ° The presence of significant proteinuria, red cell casts, and dysmorphic RBCs suggests an intrinsic renal process. In the absence of an obvious benign cause, confirmed gross haematuria requires further investigation with a CT Urogram and referral to a urologist for a cystoscopy. There is clear consensus that urine cytology and other urine markers (e.g. NMP22, BTa-stat, FISH) are unnecessary in this setting.
Transitional cell bladder carcinoma at cystoscopy with corresponding CT IVP appearance
The AUA guidelines define NVH as a microscopic diagnosis not made the dipstick test only, with it’s high sensitivity but low specificity. Dipstick does not distinguish between RBC, free haemoglobin or free myoglobin in the urine and false positives can also occur with heavy bacteriuria, semen, alkaline urine and very dilute urine. If a positive dipstick test reveals negative microscopy, it is recommended a further 2 microscopic tests to be repeated before patients are discharged.
Who needs referral?
On the other hand, BAUS guidelines support dipstick use on a fresh urine sample (at least +1, not trace), arguing that community based urine samples have a significant false negative rate and is more labour intensive. Furthermore, they say there is no difference between haemolysed and non-haemolysed samples.
In the younger patient, it is helpful to look for urinary casts, dysmorphic red blood cells, proteinuria and abnormal renal function to exclude nephrological causes of haematuria in this group (see table 4). Referral to a urologist and nephrologist for overlapping pathologies may be appropriate.
In either case, the diagnosis of a-NVH emphasises the need to use either or a combination of both single and multiple dipstick and/or microscopy to exclude infection, pyuria, bacteriuria and contaminants in conjunction with a thorough a history and clinical exam. Only when no other cause is found can a diagnosis of a-NVH be made.
The obvious concern is urological malignancy. However, malignancy only accounts for a small proportion of pathology found in a-NVH, although risks increase in some patients (see Table 2) for whom urological referral is definitely recommended. The recommended age of referral for investigation of a-NVH varies between 35 and 50 years, depending which guidelines you read.
Table 4: ‘Common’ nephrological causes of haematuria • • • • •
IgA nephropathy Alports syndrome Thin membrane disease Acute glomerulonephritis Adult Polycystic kidney disease
continued on Page 37 MEDICAL FORUM
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LIVER ULTRASOUND WITH ELASTOGRAPHY (FIBROSCAN) NOW AVAILABLE AT PRC
H E L P I N G D O C TORS D EFEAT H EPATITIS C Liver ultrasound with elastography is a non-invasive ultrasound scan used to assess the development of liver fibrosis. Liver elastography (fibroscan) forms part of the workup for patients with hepatitis C to be eligible for treatment with the new direct-acting antivirals available since March 1 2016. Perth Radiological Clinic now performs liver elastography at three convenient locations: Armadale Hospital
Midland Public Hospital
All liver ultrasound with elastography scans will be bulk billed.
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Leaders in Medical Imaging MEDICAL FORUM
New synthetic drugs Synthetic or designer drugs are synthetic chemicals designed to mimic the effects of existing illegal drugs like cannabis, amphetamines and LSD. As the chemical has a different structure to the agent they are trying to mimic, they have been marketed as ‘legal’ acceptable alternatives. Legislation has been based on individual drugs, so as a drug is made illegal its structure is manipulated by the manufacturer, producing a new compound to replace the drug under legislative control. There has been a clear increase in ED presentations from synthetic drug use, particularly synthetic cannabinoid receptor agonists – with what appears to be seasonal variations due to availability, geography and drug costs.
By Dr Alan Gault Clinical Toxicologist (WA) Poison Information Centres (NSW)
consumption’ in an attempt to avoid possible legislative control. NBOMes (“25-I”, “25-I-NBOMe”) are a series of synthetic drugs with hallucinogenic properties that have been designed to mimic
neurological and/or psychiatric signs and symptoms with nearly half of presenting patients requiring a psychiatric admission or ongoing psychiatric care. Long term effects of these drugs are currently unknown.
Three forms Synthetic cannabinoid receptor agonists (e.g. Spice”, “Kronic”, “K2”) have been in research laboratories since the 1960s in an attempt to explore new therapies for medical use. The most notable are the JWH (J.W. Huffman) and the HU (Hebrew University) series. Their use as ‘legal highs’ emerged in the early 2000s with their prevalence of abuse steadily on the rise. They have a greater potency and binding affinity for the cannabinoid receptor compared to Δ9-tetrahydrocannabinol (Δ9THC), the principal intoxicant of cannabis, which they are trying to mimic. Cathinone is a natural stimulant found in the Khat plant, a shrub grown in East Africa and southern Arabia. Synthetic versions (e.g. Mephodrone,“M-Cat”, “Meow Meow”) of this can be much stronger than the natural product with some compounds like 3,4-methylenedioxypyrovalerone (MDPV) being up to 10 times more potent than cocaine. They are sold as cheap substitutes for amphetamines, cocaine and MDMA under various brand names (e.g. Explosion, Diablo, etc.) as plant foods or bath salts, often with a printed warning stating ‘not for human
the effects of lysergic acid diethylamide (LSD). They are highly potent serotonin receptor agonists that are often misrepresented and sold as LSD. NBOMes have been implicated in multiple deaths worldwide, some of which have been traumatic as a result of the psychedelic properties altering perception and thinking e.g. believing in the ability to fly. Signs and symptoms Acutely these range from the desired effects such as euphoria, increased sex drive and hyper-arousal to severe life-threatening illness like lethal hyperthermia, hypertensive crisis and suicidal ideation. They mimic sympathomimetic and serotonin toxicity, predominantly causing cardiovascular,
Signs and symptoms: Cardiovascular: tachycardia; hypertension; chest pain; bradycardia Neurological: seizures; agitation; confusion; myoclonic jerks; behavioural disturbance; stroke Psychiatric: suicidal ideation; homicidal ideation; psychosis; hallucinations; selfharm; anxiety; paranoia Autonomic: diaphoresis; hyperthermia
Author competing interests: no relevant disclosures. Questions? Contact the author on 9287 6755
continued from Page 35
Appropriate approach to haematuria Which investigation for haematuria? The gold standard investigation for both gross and a-NVH haematuria is a CT Urogram (CTU). CTU has the most consistent and highest sensitivity and specificity (>95% for both) in detecting all the major malignant causes of haematuria in the upper tracts, namely renal tumours and upper tract transitional cell carcinoma (TCC), as well as benign causes such as renal calculi. Other modalities such as ultrasound (US) have sensitives of 67% for all malignancies,
and although US is very sensitive at detecting renal tumours (>90%), detection of upper tract TCC is 50%. When is post-op haematuria a concern? Post-op haematuria is common after endourologicial procedures. Procedures such as TURP (transurethral resection of prostate) and TURBT (transurethral resection of bladder tumour) often present with secondary hemorrhage at 10-14 days post op. Usually, it is self-limiting and resolves spontaneously with conservative treatment.
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Occasionally, particularly in patients on anticoagulation/antiplatelet agents, secondary hemorrhages may be profound and lead to symptomatic bleeding and or clot retention. These cases require urgent/emergency urological review and management. Haematuria may also occur in patients whose procedure involves leaving a foreign body in situ such as a stent following uretersocopy and lasertripsy or as result of infection following endourological procedures.
JUNE 2016 | 37
Fertility, Gynaecology and Endometriosis Treatment Clinic
When your patient’s family plan isn’t going to plan... Fertility North can help. l Cycle Tracking l Timed Intercourse l Artificial Insemination l Ovulation Induction l In-vitro Fertilisation (IVF) l Intra-cytoplasmic Sperm Injection (ICSI) l Pregnancy Monitoring l Donor Services l Sperm / Egg Freezing l Oncology Fertility Preservation l Egg Freezing for Social Reasons l Semen Analysis
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Fertility, Gynaecology and Endometriosis Treatment Clinic 38 | JUNE 2016
Imaging the ankle
A coronal CT slice of a Weber C fracture, showing tibio-fibular diastasis, and fragments from fibular tip and medial tibial plafond fractures.
A CT generated 3D reconstruction of the same fracture that can be rotated 360 degrees, on any axis.
Ankle injuries are a frequent reason for ED presentations. The question arises, when to image and how to manage. The Ottawa Rules guide us on when to image the injured ankle – at least one of the following criteria needs to be fulfilled: • Bone tenderness along the distal 6 cm of the posterior edge of either o the tibia or medial malleolus, or o the fibula or lateral malleolus. • An inability to weight-bear for a distance of four steps. • An additional criterion is “no soft tissue swelling, no x-ray.” Which imaging? Plain x-rays, including the AP, oblique AP and lateral views (preferably weight-bearing) are considered first line investigations. Additional images can include stress views, and extra views to assess the foot, calcaneus and proximal fibula. High-resolution ultrasound demonstrates beautifully the soft tissue structures, particularly tendons and ligaments. This may be first line investigation, particularly in an athlete where an immediate decision on soft tissue injury is paramount. CT is excellent at demonstrating subtle or occult fractures but of little value in assessment of soft tissue injuries. It has the advantage over MRI in that high-resolution multiplanar reconstructions and 3D reformatting are performed easily. It is also invaluable for further orthopaedic assessment and pre-surgical planning of complex fractures. MRI, while demonstrating fractures exquisitely, also excels in demonstration of soft tissue injuries and bone bruising in the absence of a fracture. High cost, Medicare limitations on GP requests, and long examination time make MRI used less frequently. And contraindications to MRI include patients with aneurysm clips, cardiac pacemakers or joint arthroplasty. MEDICAL FORUM
By Dr Paul Salmon Radiologist, Albany
A typical Weber B fracture showing a syndesmotic fracture and medial malleolar involvement. No diastasis but this does not exclude syndesmosis rupture.
Ankle fracture classification The Weber classification system focuses on the integrity of the syndesmosis and the Lauge-Hansen classification on the mechanism of injury (see www. radiologyassistant.nl/en/), both in the adult ankle i.e. post epiphyseal closure. • WEBER A. Infra-syndesmotic injury, corresponding to a supination and adduction injury, without rotation. Stage I; rupture of the lateral collateral ligaments or lateral malleolus transverse avulsion fracture. Stage II; oblique fracture of the medial malleolus • WEBER B. Trans-syndesmotic injury corresponding to supination with external rotation. Stage I; rupture of the anterior syndesmosis. Stage II; oblique fracture of the fibula through the syndesmosis. Stage III rupture of the posterior syndesmosis or posterior malleolus fracture. Stage IV; avulsion of the medial malleolus • WEBER C. Supra-syndesmotic injury corresponding to pronation with external rotation. Stage I; a portion of the medial malleolus or ligament rupture. Stage II; rupture of the anterior syndesmosis.
A sagittal T2 weighted MR sequence showing high T2 signal in the talar dome, indicating an acute bone bruise without fracture. There is also a joint effusion.
Stage III; fibula fracture above the syndesmosis. Stage IV; rupture of the posterior syndesmosis or avulsion fracture of the posterior malleolus. Other ankle fractures include the Pilon fracture (comminuted distal tibial plafond fracture due to forced impaction of the talar dome) as well as variations of Salter Harris epiphyseal injuries, which are not specific to the ankle. Additional forces include compression/ impaction injuries such as a fall from a height or vehicle wheel riding over the foot and multi trauma events such as motor vehicle accidents. In these instances the exact mechanism of injury often cannot be determined and CT would almost always accompany initial plain film imaging. Soft tissue injuries including destabilising ligament injuries frequently occur without fractures. Optimal management includes the determination of the mechanism of injury, a careful clinical assessment, utilising the Ottawa rules and a high index of suspicion particularly for occult fractures and additional injuries. Author competing interests: no relevant disclosures. Questions? Contact the author on 9842 0200
Ankle Anatomy The ankle is a mortise joint, consisting of the distal tibial plafond, medial malleolus, lateral malleolus and the talus. The medial ligaments are the superficial and deep deltoid ligaments; the lateral ligament complex includes the anterior talo-fibula ligament, the calcaneo-fibula ligament and the posterior talo-fibula ligament. The syndesmosis complex includes anterior and posterior inferior talofibula ligaments, transverse tibiofibula ligament and interosseous ligament.
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JUNE 2016 | 39
Deprescribing in the elderly
Dr Andrew Klimaitis Physician Duncraig
I prescribe medication because I believe medication can improve both quality of life and life expectancy. That said, deprescribing has become a buzz word and Australian researchers are at the forefront1,2,3,4. There are excellent recent reviews in both the MJA5 and Internal Medicine Journal6. Worrying statistics include that “one in four older persons in the community have been hospitalised for medication related problems over the last five years”, and “up to 30% of admissions for patients over 75 are medication related”6. Studies in both Community and Nursing Home patients show that limited deprescribing can be undertaken without an increase in mortality1,3. Forming an attitude to deprescribing I don’t believe that uncritically stopping drugs to get below a certain number is a good thing. A diabetic with a history of prior AMI, cardiac failure and gout could justifiably be on aspirin, clopidogrel, B-blocker, ACE inhibitor, statin, fenofibrate, spironolactone, allopurinol, and at least three oral hypoglycaemic agents. Patients often ask which drugs are really necessary, I try to divide medication into that which makes you live longer and that which makes you feel better. Medication should regularly be reviewed to ensure it still serves its original purpose. When should medication be withdrawn? The most obvious time is on admission to a Nursing Home. Life expectancy has clearly become limited and so statins, antihypertensives, anticoagulants and dementia medication should be re-assessed. None of these make you feel better. These decisions are individual. Some families wish everything continued and others want everything ceased. However, patients and their families acknowledge their doctor’s expertise and appreciate any discussion regarding deprescribing, even if changes are not made7. In patients still living independently the concept of frailty becomes crucial. Frailty can be variably defined by reduction in walk time, physical inactivity, use of aids, need for home services, cognitive impairment, etc8,9, but is often obvious when you see someone for the first time. The trick is to recognise when your long term patient deteriorates and drops into this category. Particular medications Anti-hypertensive and anti-diabetic agents show increased side effects, and hence loss of net benefit, in the frail. Targets of 160 for systolic BP and a glycated Hb of 8.5% may be safer. I would emphasise that robust elderly still benefit. In fact, most interventions that show improvements in survival e.g. anticoagulation and lipid lowering, usually have an even greater benefit (lower number
40 | JUNE 2016
needed to treat) in the elderly. Age by itself is not a reason to reduce medication. Also, statin side effects are not magnified by frailty so perhaps they shouldn’t be ceased on that basis alone. In patients with a history of heart failure I tend to continue with ACE inhibition and B blockade because they improve LV function, and am more inclined to cease the calcium channel blocker or thiazide if I am concerned about hypotensive side effects. Nicorandil and nitrates are antianginals that do not improve survival or prevent infarcts. If the patient is not experiencing angina, stop them and see what happens. They can always be restarted. Opiates are problematic in the elderly. The family should be involved as much as possible in the decision making. It’s surprising how often they are concerned about subtle (and sometimes not so subtle) increases in drowsiness or even confusion since the patch was started and are pleased to reduce the dose. Anti-neuralgics (e.g. pregabalin) are often prescribed and then continued with blind optimism, perhaps because they appear better tolerated than the narcotic alternatives. Anti-inflammatories can also be taken uncritically. Try missing a few doses and see what happens. Depression is common in the elderly but both SSRIs and tricyclics are associated with increased rate of falls10. Even patients on an SSRI for years may be able to have them withdrawn. You may not succeed but having the conversation with patient and their family is a good start. PPIs are getting bad press. Increase in pneumonia, difficile infection, and now renal impairment has been described11. Withdrawal can lead to rebound hyperacidity but switching to a H2 blocker may be better for the patient even though the total number of tablets stays the same. I would continue Allopurinol under most circumstances. I saw too much crippling gouty arthropathy as a junior doctor and think
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it one of the most underappreciated drugs we have. In conclusion Through this incomplete list I encourage others to regularly re-evaluate the need for any medication. We can be reassured by data showing that deprescribing is associated with improvement in cognition and patients’ global health12 and that, in older people, withdrawal is rarely associated with adverse effects13. References 1. Deprescribing in Frail Older People: A Randomised Controlled Trial. Potter K, Flicker L, et al. PLoS One 2016 Mar 4;11(3): eCollection 2016. 2. Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes. Gnjidic et al Clin Geriatr Med 2012 May;28(2):237-53. 3. Reducing inappropriate polypharmacy: the process of deprescribing Scott IA et al JAMA Intern Med 2015 May;175(5):827-34. 4. Deprescribing David Le Couteur et al Aust Prescr 2011;34:182–5 5. First do no harm: a real need to deprescribe in older patients. Scott IA et al Med J Aust 2014 Oct 6;201(7):390-2. 6. Physicians need to take the lead in deprescribing. Scott IA, Le Couteur DG Intern Med J 2015 Mar;45(3):352-6. 7. Deprescribing Potentially Inappropriate Preventive Cardiovascular Medication: Barriers and Enablers for Patients and General Practitioners. Luymes CH et al. Ann Pharmacother. 2016 Mar 3. [Epub ahead of print] 8. Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care Lind P. Fried et al J Geront 2004 59:p25563 9. What would make a definition of frailty successful? K Rockwood Age and Aging 2005; 34:432-434 Br Geriatrics Soc 10.Medications associated with falls in older people: systematic review of publications from a recent 5-year period. Park H et al Eur J Clin Pharmacol 2015 Dec;7 1(12):1429-40. 11. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. Lazarus B et al JAMA Intern Med. 2016 Feb 1;176(2):238-4610. 12. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Garfinkel D et al. Arch Intern Med 2010;170:1648-54. 13. Medication withdrawal trials in people aged 65 years and older: a systematic review. Iyer S et al Drugs Aging 2008;25:1021-31.
MonaLisa TouchTM – An Alternative to Estrogen? Vulvo-Vaginal Atrophy (VVA) is a common condition in low estrogen states. Natural menopause is the most common cause, but VVA symptoms may occur following: • induced menopause with bilateral oophorectomy; • anti-estrogen treatment in breast cancer; • direct pelvic radiation treatment; and • even prolonged breast feeding and low estrogen OCP can lead to VVA symptoms. Physiological changes include thinning of the mucosa, less glycosaminoglycans (GAGs) in the lamina propria, reduced blood flow and secretions, less glycogen in the epithelium resulting in a decrease in vaginal lactobacilli and an increase in pH. Symptoms of VVA include: • Dryness; • Dyspareunia; • Burning or itching; • Laxity; and • More frequent thrush/UTIs. These symptoms are very common and increase over a period of years from perimenopause. Furthermore, these symptoms don’t tend to resolve without treatment. Whilst studies (REVIVE/REVEAL/CLOSER) indicate that up to 50% of women will suffer from VVA symptoms in their lifetime, they also show that doctors rarely ask women about vaginal dryness or discomfort and that only 25% of patients suffering these symptoms will inform their regular GP. This lack of patient communication may be due to embarrassment or a belief that VVA symptoms are part of women “getting old”. Treatment Options Most patients with symptoms of VVA will start with vaginal moisturizing creams and lubricants and may look to phytoestrogens
(naturally occurring plant compounds that may exert an estrogen like effect) in diet and supplements. The most common prescribed treatment for VVA is topical estrogen found in creams or pessaries. These generally provide relief from symptoms, but face issues with patient compliance due to the need for regular application and can be inconvenient to administer. In some instances, hormone replacement therapy (HRT) can manage the vasomotor symptoms such as hot flushes, as well as VVA. However, hormone treatments don’t suit or meet the needs of all patients, especially patients presenting with cancer-related VVA symptoms. Whilst still considered safe in most instances, most menopause societies worldwide do not advise taking topical estrogen for longer than 1 year. New Laser Treatment – MonaLisa TouchTM MonaLisa TouchTM CO2 Laser treatment has been available in Australia for over 3 years and in Italy for over 6 years. It is a technological development on the highly effective fractional CO2 laser used for skin and scar resurfacing; we can now treat mucosal membranes with the same excellent regenerative results. Many tens of thousands of successful MonaLisa TouchTM treatments have been performed around the world to date.
Most patients cannot feel the laser firing internally; they describe it as a mild vibration. However, treatment near the vaginal entrance tends to be warm and sharp, but momentary. MonaLisa TouchTM Results The thermal injury triggers activation of heatshock proteins, which replicates the effect of natural estrogen and stimulates production of collagen in the tissue. The result of this laser treatment is a morphological change in the epithelium of the vagina from being thin, atrophic, lacking glycogen and GAGs to resembling youthful, estrogen stimulated mucosa after 1 month. A number of studies have demonstrated significant improvements in symptoms of VVA and some interesting results in stress and urge incontinence. We are waiting on further studies in these areas but anecdotally we get many reports from patients of improvements in this area.
It is a walk-in/walk-out procedure that requires no anaesthetic or analgesia. The treatment takes approximately 10-15 minutes and apart from abstaining from sex for a few days, has no down time. Contraindications are active infection (history of genital herpes requires antiviral prophylaxis) and exposed surgical mesh.
MonaLisa TouchTM laser is not a replacement for estrogen treatment in VVA. However, for patients who have failed, refused or have true medical reasons for not pursuing estrogen, MonaLisa TouchTM is a simple, low risk and highly effective alternative treatment option.
The treatment involves drying the vagina with swabs and inserting a dry laser probe,
By Dr Jayson Oates FRACS
Suite 1A Arcadia Chambers 1 Roydhouse St SUBIACO WA 6008
which is the most uncomfortable aspect of the procedure, but reported as similar to a pap smear. The laser fires thousands of laser dots 0.2mm diameter each 1mm apart and maximum penetration of 1mm. The laser vaporizes a microscopic column of the epithelium and creates a thermal injury followed by a regenerative healing process. Because only 6% of tissue is treated in each session, it is recommended that 3 treatments are performed a month apart and current protocol is to provide a follow up treatment on a yearly basis.
References on request.
Tel 9382 4080 www.academyfaceandbody.com.au
JUNE 2016 | 41
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Drug-induced liver injury Drug-induced liver injury (DILI) is a relatively common event following ingestion of prescription or over-thecounter medications, or herbal and dietary supplements. One inpatient review found that 10% of abnormal LFTs were due to drugs (antibiotics most commonly); drug reactions account for 20% of all liver transplants for fulminant liver failure in Australian adults. DILI is classified in several ways. The mechanism of hepatotoxicity may be predictable (e.g. paracetamol) or idiosyncratic (includes immune-mediated or metabolic). Hepatic damage may be hepatocellular, cholestatic or mixed. Patient presentation is varied and may include mild to severe liver function test abnormalities, cholestasis with pruritus, acute jaundice or acute liver failure. Chronic DILI may present with cirrhosis. Jaundice (bilirubin over twice ULN) with an elevation in aminotransferases (over treble ULN) is associated with a mortality rate of up to 14% (Hy’s law). Diagnosis may be difficult. There are no specific markers or histological changes. Take a careful drug history and exclude other potential causes of liver
By Dr Briohny Smith Hepatologist, South Perth
injury. As patients frequently take multiple medications, and supplements and injury can occur after using medications for several months, assessing causality may not be possible. The development of non-specific symptoms following commencement of a new medication should prompt evaluation of serum LFTS and imaging to exclude biliary obstruction. Where diagnosis remains uncertain or in severe liver injury, a liver biopsy may be useful. Factors supporting diagnosis of DILI include; drug exposure preceding liver injury, hepatic injury following exposure to a drug known to cause DILI, absence of pre-existing liver disease, drug cessation is associated with improvement in liver injury and (though not advised) rapid recurrence occurs on reexposure. LiverTox (www.livertox.nih.gov) contains current information on liver injury attributed to medications, herbals and supplements.
may be useful in some with features of a hypersensitivity reaction. Those with features of acute liver failure warrant referral to a hepatologist or a Liver Transplant Centre for close monitoring. The prognosis for most with DILI is very good with complete resolution of liver injury on drug withdrawal. It can take months for liver function to completely normalise. DILI can be prevented by educating patients on correct drug dosages, particularly with paracetamol containing medications, avoidance of alcohol when patients are using a medication known to frequently cause liver injury (e.g. methotrexate) and monitoring of ALT levels when patients are on a medication known to cause liver injury (e.g. isoniazid, azathioprine). In those patients with a known DILI, education to prevent further re-exposure is important.
Management The first line approach is withdrawal and future avoidance of the suspected drug. In paracetamol overdose, use N-acetylcystine. In valproate overdose, L-carnitine use has been shown to be beneficial. Steroids
Author competing interests: no relevant disclosures. Questions? Contact the author on 6102 2030
Venous eczema due to reflux
6mths post EVLA
Varicose veins and odema due to incompetent perforator and small saphenous veins
3mths post EVLA
Varicose veins are not just cosmetic. They are a sign of venous reflux, a pathological condition. Untreated reflux can lead to • Venous eczema and odema • Chronic induration and pigmentation • Venous ulceration • Venous thrombosis We specialise in highly effective ‘walk in walk out’ non-surgical treatments. • EVLA (Endovenous laser) – cutting edge techniques including perforator ablation • Ultrasound guided sclerotherapy • Clarivein™ (non-thermal ablation) • Venaseal™ - ‘super glue’ for closing veins
Dr Luke Matar (MBBS, FRANZCR, FCP) Contact us: E: email@example.com P: 9200 3450 F: 9200 3451 www.veinclinicperth.com.au
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JUNE 2016 | 43
Current Controversy: Laparoscopic Myomectomy Uterine fibroids are the most common pelvic tumor in women present in up to 20-40% of reproductive age women. This incidence rises with age. They are usually benign monoclonal tumors arising from the smooth muscle cells of the myometrium. Presenting symptoms depend on the size, number and position (type) of the fibroids. These might include heavy menstrual bleeding, pelvic pain, pressure symptoms on the bladder e.g. urinary frequency and bowel symptoms. From a reproductive perspective associations with infertility and miscarriage has been found. Finally fibroids may complicate the antenatal course and delivery.
Food processing and type 2 diabetes By 2025, about 25% of Australians over 25 are expected to be a risk from AGEs (Advanced Glycation End-products), produced while heat processing foods to increase shelf life, sterility and flavour. As far as AGEs in foods are concerned, roasting, frying, baking or grilling are ‘out’, whereas boiling or steaming are ‘in’. AGEs decrease insulin sensitivity and inhibit the protective mechanisms against oxidative stress – this has been known for some time. Whether these effects increase the likelihood of type 2 diabetes and at what cost, the researchers from Monash and Queensland Uni want to find out.
The management of uterine fibroids depend not only on the type and number of fibroids but also on the severity of symptoms, patient age and her reproductive goals.
Comment: Joanne Dembo, principal dietitian with Diet By D’Zyne.
Medical treatments for fibroids are not effective and only serve to help us reach certain surgical goals like reduction in blood loss or to make certain surgical access possible. From a minimally invasive gynaecological surgery perspective the two main surgical options are myomectomy and hysterectomy.
n In-bag morcellation
Myomectomy (removal of fibroids) is indicated when women have not completed her family or otherwise wishes to retain the uterus. This is an effective option for treatment of menorrhagia and pelvic pressure and pain, but there is about a 40% risk of recurrence following myomectomy. At WA Gynaescope we offer hysteroscopic resection in cases where submucosal fibroids are present and thought to be impacting her reproductive potential. For subserosal or intramural fibroids we do a laparoscopic myomectomy although certain cases still need to be done via the open/ laparotomy technique. One of the very useful inventions was the development of so called Power Morcellation devices that would reduce the tissue to the size of a thin strip of tissue that we could pull through an existing operative port. This was being used with great success as the risk of using this device was quite low. In the past it was thought that the prevalence of leiomyosarcoma in these fibroids/uterus was quite low at about 0.02-0.3%. In April 2014 however, an FDA Safety Communication ushered in an era of controversy related to the potential for power morcellation devices to spread malignant cells in patients with previously undetected malignancy. This has been filling the pages of many academic articles and has fuelled widespread academic discussion. It has taken a while for clinicians to develop techniques to adapt to this information while still offering the benefits of a minimally invasive approach. At WA Gynaescope we have adopted and refined the so-called Ïn-Bag-Morcellation Technique. With this new technique that we have adapted, the risks if any dissemination of malignant cells are well restricted. As most cases of leiomyosarcoma are unexpected, we encourage other units to consider techniques like the so called In-Bag-Morcellation to extract tissue specimens. Dr Sunny Baruah & Dr Gian Urbani Joondalup Private Hospital Suite 23, Level 2, Specialist Medical Centre (East), Shenton Avenue Joondalup WA 6027
The increase in availability of processed and packaged foods has potentially contributed to an increase in type 2 diabetes. AGE formation is most susceptible in high protein and high sugar foods, in addition to other factors such as storage, heating as well as physical and chemical changes. Foods with high AGE formation include baked goods such as biscuits and cakes, roasted foods such as roasted nuts and roasted coffee beans, toasted foods such as toasted breakfast cereals, and heat treated dairy products including heat treated milk. In addition to recommending a low-fat, low-GI diet, this research provides a platform for further specific food recommendations regarding the types of low-fat low-GI foods. The research also adds credibility to emphasising fresh is best, with reduced reliance on packaged goods. As part of the healthy low-fat, low-GI diet approach for a diabetic diet, recommendations are provided for healthy cooking methods. It has been shown that cooking temperatures contributes to AGE formation, and specific cooking methods such as slow-cooking instead of grilling produces lower AGE formation. Subsequently specific recommendations can be applied for types of cooking methods to assist with improved insulin sensitivity. Due to the strong correlation between obesity and diabetes, a low-fat, low-GI diet remains essential.”
Tel: (08) 6406 1801 Fax: (08) 6406 1802 www.wagynaescope.com.au
44 | JUNE 2016
Advanced Glycation End-products (AGE) produced in food processing and cooking may contribute to the development of type 2 diabetes by reducing insulin sensitivity. Further research is required to confirm this. Currently a low-fat, low-Glycaemic Index (GI) diet is the standard recommendation for managing blood glucose levels.
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Colon cancer in younger adults There is an unexplained (possibly lifestyle related) increase of Colorectal Cancers (CRCa) in younger patients. This year, I have seen five under 40 with bowel cancer (including two in their twenties) – often told they are too young to have bowel cancer and hence are not investigated early. Colorectal cancer affects 1 in 12, by age 85, and is Australia’s second most commonly diagnosed cancer. Survival is strongly stage dependent, regardless of age, ranging from over 95% cure in stage one (Dukes A) to under 5% in stage four (Dukes D). To improve survival we need earlier diagnosis in all ages. US data suggests the National Bowel Cancer Screening Program (offered to Australians aged 50-75) will lead to falling CRCa mortality in this age group Only 10-25%, have a definable genetic cause (most commonly Lynch Syndrome). In one series, one in seven new cases were under age 50, mostly in otherwise fit young patients with no family history. Young patients more likely have left sided (rectum/sigmoid) cancers and hence symptoms whilst those in their 50s have more asymptomatic right-sided tumours found incidentally (e.g. iron deficiency, screening). Current advice is to refer any patient with symptoms lasting more than a few weeks (e.g.
By Dr Nigel Barwood Colorectal Surgeon, Murdoch
rectal bleeding, altered bowel habit abdominal pain, unexplained iron deficiency) for urgent colonoscopy, regardless of age or pregnancy. Colonoscopy is the gold standard investigation, both safe and extremely accurate, even during pregnancy. Flexible sigmoidoscopy is an alternative for young patients with isolated rectal bleeding. Faecal occult blood testing lacks sensitivity and is not reliable in symptomatic patients. CT colography carries significant radiation risk, and although CT or MRI may be appropriate for nonspecific abdominal symptoms like pain or weight loss, they only reliably show large growths. Treatment and outlook Younger patients are ideally suited to laparoscopic colorectal resection and enhanced recovery after surgery, with most being discharged 3 to 5 days postop. They must also be screened as potential index cases of hereditary syndromes (e.g. Lynch Syndrome, Serrated Polyposis Syndrome), ideally pre-operatively as an extended resection may be indicated. Prognosis is generally worse in younger patients as they more frequently present with stage three (nodal) or four (distant metastases), usually from delayed presentation (e.g. patients ‘sitting’ on their
Reflux in the young Gastro-oesophageal reflux (GOR) in infants and children is characterised by regurgitation of stomach contents (acidic and/or non-acid) in the oesophagus in absence of any organic features that would suggest presence of Gastrooesophageal Reflux Disease (GORD). Caution with PPIs in children A few children with GORD may need medical therapy (acid blocking agents, feed thickeners or prokinetic agents) and/or surgery (fundoplication). Proton pump inhibitors (PPI) remain the most commonly utilised medical therapy for children with GORD but should be used with caution. PPIs increase the risk of childhood respiratory and gastrointestinal infections. For children on PPIs, there may be an increased predisposition to certain gastrointestinal diseases like coeliac disease, gastric fundic gland polyps, and eosinophilic oesophagitis. Malabsorption of certain vitamins and minerals, (calcium, magnesium, iron and Vitamin B12) and disturbances of the gut microbiome may occur. Cardiovascular, bone and renal complications have also been reported. GOR in infants This is defined as frequent effortless MEDICAL FORUM
regurgitation of feeds. It causes anxiety in parents but resolves in almost 90% of children by 12 months of age. A detailed history is needed to rule out any red flag signs such as bile stained vomiting, hematemesis, unexplained feeding difficulties, blood in stool/malena, faltering growth, distressed behaviour and any other systemic features. There is enough evidence to suggest that the crying time of an infant is not related to GOR nor can it be reduced with PPI therapy. Effective management of GOR requires repeated and confident reassurance. Simple and cheap interventions such as minor feed modifications or thickening agents should be used for infants and where possible avoid use of PPIs. Special considerations However, special consideration needs to be given for infants with history of back arching (Sandifer’s syndrome), premature birth, repaired congenital diaphragmatic hernia, repaired oesophageal atresia, recurrent aspiration pneumonia, frequent otitis media, episodic apnoea, or neuro-disability. This group warrants further investigation and referral to a specialist physician. Gastro-oesophageal reflux in children and adolescents needs further assessment to
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symptoms) and missed diagnosis. Up to 50% are given alternate diagnoses such as haemorrhoids, IBS, or, dysmenorrhoea; one study showed young women averaged five consultations before diagnosis. Yet, stage for stage, young patients do slightly better as they tolerate aggressive multimodal treatment better; ovarian egg preservation may be indicated prior to irradiation, and patients with colorectal metastatic disease may be resectable for cure and should be referred to both a surgeon and oncologist.
Take Home Points • Always consider colorectal cancer in patients at any age, including pregnant mothers. • Early diagnosis is key to improving outcomes at all ages. • All patients over 50, and younger patients with a family history, need bowel cancer screening.
Author competing interests: no relevant disclosures. Questions? Contact the author on 0421 522 058
By Dr Kunal Thacker Paediatric Gastroenterologist Subiaco
rule out other diseases especially eosinophilic oesophagitis. History of dysphagia, food bolus impactions, retrosternal or epigastric discomfort, hematemesis, melena, unexplained iron deficiency anaemia and symptoms refractory to acid suppressive therapy helps differentiate functional dyspepsia/GOR from GORD or other oesophageal disease. Those on chronic, difficult to wean, PPI therapy may need by further investigations such as an endoscopy. Take Home Points • Reflux in infants improves with time and simple measures help most. • GOR in children and adolescents may need to be differentiated from GORD and other oesophageal disease. • PPIs should be used with caution and it is important to choose the right patient. Author competing interests: no relevant disclosures. Questions? Contact the author on 9340 8355.
JUNE 2016 | 45
Taking the Drop If you’re a dedicated doctor and a keen surfer, there’s no better spot to practise both than in the South-West of WA, so reckons Dr Phil Chapman.
Busselton ED medico Dr Phil Chapman still remembers the first time he stood up and rode a wave to the beach. “I was about nine years old on a beach in Cape Town when I managed to jump to my feet on a very basic foam board. The wave was small, highly user-friendly and I surfed all the way to the sand. I loved it and was totally hooked!”
From that tentative beginning Phil has gone on to combine his two great passions, surfing and medicine, to form Surfing Doctors and it’s given him a lifestyle the rest of us can only dream about.
“The board had a small fin and the leg-rope was a sock around my ankle attached to piece of rope. And the abrasive rash it made on my stomach was distinctly unpleasant. Surfboards have come a long way since then!”
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46 | JUNE 2016
Phil’s journey to medicine began after military conscription in South Africa but it could just as easily have been a life aquatic. “I was competing in the Qualifying Series [QS] surfing tour and thinking about making that a long-term career. I already had a biochemistry degree, decided to put my name down for medical school and waited to see what might happen.” “They told me I’d been accepted and could start in second year so I went down the medical route. I’m happy I did because it’s kept me disciplined and given me a rewarding career path.” “On the other end of the scale it’s sad to see some of the really hardcore surfers who haven’t done anything else except surf. They often end up in some sort of a surfer’s graveyard getting grumpy and frustrated as their ageing bodies start packing-up on them.” “I finished medicine in 1995 with a fair bit of outstanding debt so went to the UK and did a surgery rotation. They give you a lot of time in EDs over there and I really enjoyed it, there’s a buzz and adrenalin rush!” “When I came to Australia I stayed with emergency medicine, and the shift-work means I’ve got plenty of time to go surfing.” Surfing for a cause The organisation, Surfing Doctors, raises funds for hospital clinics in developing countries and has a role in providing on-the-ground medical assistance in some exotic and, for a surfer, highly appealing locations. “In the late ’90s I was doctor-in-residence at a place called G-Land [Grajagan, Java) that has one of the best and most consistent waves in the world. One of the surf-camp owners invited me back on a more formal basis after a surfer went head-first into the reef and suffered a nasty spinal injury. His parents tried to sue, claiming the medical back-up was substandard. Thankfully, the young guy made
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The secret surf breaks in WA's South-West
Dr Phil Chapman a full recovery and I get to spend a month on rotation staying at G-Land.” “The surf is just amazing!” Phil is a self-confessed ‘adrenalin junkie’ with a penchant for riding large waves. “I always loved surfing big waves in South Africa at places like Jeffrey’s Bay and it’s been a natural progression to spots such as Shipsterns in Tasmania and Boat Ramps in South-West WA. I’ve had some horrible wipe-outs and ‘hold-downs’ in 20 foot surf. In fact, I broke my ribs at Shipsterns!”
“As you get older your anxiety levels increase and this can affect your ability to hold your breath underwater. It’s all about being able to hold it past that ‘breaking point’ but that’s difficult if you get the wind knocked out of you or you’re being bounced around and shaken up by a ton of white-water.” Critical moments “I can manage for about 90 seconds but there are some surfers who can hold it for around three minutes. A friend of mine blacked-out in South Africa, but it’s the ones who can’t get that critical first gulp of air who drown.” At the ripe young age of 50 Phil acknowledges it’s all getting a little bit harder on the body. But it would seem that the years haven’t completely wearied him and there’s always another big wave just over the horizon. “It’s a bit more of a challenge as I get older but my surfing hasn’t lost too much of an edge. Surfboards are so good these days and I still get into the water at least three times a week. I’ve got a couple of young children and I’d like to go surfing with them when they’re a bit older.” “I’m off to Africa pretty soon and I’d love to surf Skeleton Bay in Namibia. It’s pretty difficult to get there, the waves are challenging but you can get inside the barrel for a long time.” “And there’s another great wave in Angola I’ve heard about!”
By Peter McClelland MEDICAL FORUM
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JUNE 2016 | 47
SJG Medical Tribute Dinner SJG Subiaco Hospitalâ€™s annual Medical Tribute Dinner last month celebrated the work of surgeon Dr Ivan Thompson, obstetrician and gynaecologist Dr Louise Farrell and anaesthetist Dr Benedict Williams. Head of SJG Subiaco Dr Lachlan Henderson paid tribute to the trio in front of a large gathering at Crown Perth. Geriatrican and physician Dr Milly Wong was named Teacher of the Year. 1
Drs Ben Williams, Joe Pracilio, Milly Wong, Ivan Thompson, Louise Farrell and Lachlan Henderson
David Foti, Dr Michelle Ammerer, Marie-Louise Janssen, Dr Johannes Janssen, Christina Di Camillo, Dr Brendan McQuillan
Dr Matthew Mulroy, Dr Joe Pracilio, Dr Seonaid Mulroy
Dr Jade Acton, Dr Stuart Salfinger, Mr David Colvin, Dr Jo Colvin, Dr Simon Turner
Dr Jurgen Passage and Kylie Passage
Bev Sprague and Dr Paul Sprague, Margie Tulloch and Dr Alastair Tulloch
Dr Lincoln Brett and Dr Louise Farrell
48 | JUNE 2016
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Small is Beautiful
By Dr Craig Drummond Master of Wine
Since planting in 1996, Cape Grace Wines have made a real mark with their excellent Single Vineyard Wines. Production is small as there is just over 6ha of vines, and with low yields and fruit selection for quality production (resulting in just 2000 cases annually) these wines sell predominantly through cellar door and mail order (www.capegracewines.com.au). Owners Robert and Karen Karri-Davies selected a site in the Wilyabrup Valley, Margaret River, and planted Chardonnay, Shiraz and Cabernet Sauvignon with smaller plantings of other popular varieties including Chenin Blanc, Semillon and Merlot. There is a lot of history behind this label as Robert is the great grandson of timber baron M.C. Davies who built the Leeuwin Lighthouse and founded the township of Margaret River. Robert is a self-taught viticulturist and has learned winemaking from consultant Mark Messenger. Karen has significant experience in sales and marketing. Interestingly, this property was the first choice of Dr Tom Cullity when planting the first vines in the region but in 1967 the land was not for sale so he then chose a nearby site for his Vasse Felix vineyard.
1. Cape Grace 2015 Chenin Blanc Nice aromas of fresh fruit with apple, tropical notes and a ‘skinsy’ character. The palate is round and ripe showing soft, ripe green apple flavours with hints of 'tooty fruity' confectionary. Easy to drink now, alone or with chicken or seafood. Has the Chenin acid backbone which will give it several more years. (Production: 260 dozen.) 2. Cape Grace 2015 Chardonnay Enticing nose of complex, round, plush fruit with peach and fig. The flavours are again complex, slightly unctuous with ripe peach and pear. Oak is nicely integral for the wine’s youth. There is good length to this wine with great afterfavours. It’s another good example of this variety from this region. Will drink well for 5-7 years. (Production: 168 dozen.) 3. Cape Grace 2014 Limited Release Malbec It’s great to see a varietal Malbec. My impressions of this Bordeaux variety when grown in the South West of Australia are very high as evidenced in my previous exposures to it in the West Australian Wine Shows. We should see more of it! This example has violets and blackberry on the nose, going on to a sweet-fruited palate with blackberry, mulberry and dark plum. It displays the grippy, fine-grained malbec tannins. It’s beautifully earthy. I like this wine! (Production: only 70 dozen [bugger!])
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4. Cape Grace 2013 Cabernet Sauvignon REVIEWER'S The wine of the tasting, for me. This is a cab sav in the true Margaret River mould. A vibrant youthful purple-red colour. The aromas are rich yet subtle cassis and quality oak leading into wonderful blackcurrant and black olive flavours. Typically linear/gravelly tannins, great integration and a sweet fruited finish. When I tasted again some hours later another character emerged – an 'inky' flavour that I particularly liked. This wine has another 10 years in it. (Production: 560 dozen.)
5. Cape Grace 2014 Shiraz This wine differs to other MR Shiraz that I’ve tasted. The nose displays camphor and menthol, bucolic and slightly gamey. Flavours of blackcurrant with some unusual characters coming through – a touch of soy and wild mushroom. I may be completely wrong but it suggests some wild [spoilage] yeast ferment characters. I enjoy the flavours produced if, like this wine, they are at low levels. Many of the great wines of Bordeaux and Tuscany, for example, show them. The wine has nice weight and length and will go for another 6-8 years. (Production: 275 dozen.)
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Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, June 30, 2016. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.
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JUNE 2016 | 49
s l e e F l l i t S g n i c n a D Like
Medical Forum speaks to Leo Sayer on the eve of his Perth visit
Leo Sayer was just a couple of weeks shy of his 68th birthday when Medical Forum spoke to him at his home just outside Berrima in the NSW Southern Highlands. Teenagers of the 1970s will have sung in the shower to One Man Band and Moonlighting and busted a move or two to his disco ‘toon’ You Make Me Feel Like Dancing. Even now they make Leo and the rest of us do a little shuffle. The UK hitmaker is now an Australian citizen but he is forever on the road singing or in his home studio writing and recording songs. “Touring is the way we make most of our money, these days. We have to do it … it’s essential. I’m grateful that I’ve got my energy and my health.” This energy sees him teaming up with UK pop royalty Lulu (To Sir, With Love, Shout, Oh Me Of My I’m A Fool For You Baby) for a national concert tour, simply called Leo and Lulu, which will make landfall in Perth on July 3.
“There wasn’t much live music going on in the UK in the late 1990s, early 2000s. It was the time of Pop Idol and the like where suddenly every single promotor thought you could do a show with a backing tape.” “I found myself leaning on Australia where live music was still important. People here wanted to see their music performed properly, so it was an easy decision to make, I just went where the work was. One of my first major gigs was the Countdown tour produced by Mike Gudinksi. I found myself working with the elite of Australian music. It was incredible and really gave me a kick in the chops, which I needed.” “I was fortunate to have come from a great musical age but I reckon we’re in a great age now. Of course the digital world means nothing is scared any longer. You hope people will buy product and you can make some money from it but it leaks out free anyway. What can you do? We are not in control.”
“But there are also so many benefits of the internet. We can make music easier and you just have to go with it and take the positives. We sell more CDs when we appear on tour than if we sat at home and waited for record shops to sell them.” “On this tour, Lulu and I will be doing our most popular tracks and sharing the stage with each other so we can duet on each other's material. It will be such good fun because they are such good songs. We’re as creative now as we were then. The mind doesn’t go up the Swanee if your imagination is still there.”
By Jan Hallam
“Lulu and I have been friends for decades and when the idea to do a show together was put to us last year, I was in London doing some gigs. Lulu came to one of the shows and jumped up on stage and we sang You Make Me Feel Like Dancing together. It felt great, she’s got as much energy as me!” “I love performing. I don’t know how to do anything else. It’s my job and I love it. It’s extraordinary to say after all these years, but it doesn’t wane. I still love my job and live to write my songs and I will continue to do it as long as the creative juices keep flowing and I feel inspired to do what I do.” “I had a partial knee-cap replacement at the end of November last year. I’d been living with a tricky knee since I fell of the stage from a height back in 1977. It started to slow me down the last couple of years, so I decided to have surgery which has worked a treat. It’s given me a new lease on life and I’m glad to say I have the energy to move on stage.” Leo, like Lulu, grew up in a vastly different music industry to the one that exists in today’s digital world. It was tough and both suffered management issues but they kept forging through and had massive hits both sides of the Atlantic and, of course, in Australia. In fact, it was the robustness of the live Australian music scene that saw Leo move here 11 years ago.
50 | JUNE 2016
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o H m l a e v c i o n min g r a C A It’s called The Seekers challenge. Whisper to yourself the words: Carnival is Over; Another You; A World of Their Own; Georgy Girl; Morning Town Ride. You’re humming at least one of them, right? That’s the power of The Seekers music. The foursome from Melbourne, who started in a South Yarra Café in the early 1962, went on to become one of the most enduring musical groups in Australian history. And what’s more, they have the distinction of: • Being the first group ever to reach No.1 on the UK charts with their first three singles • The first Australian group to reach No. 1 in USA (Georgy Girl) • The first Australian group to reach No. 1 in UK (I’ll Never Find Another You) • The first Australian group ever to reach No. 1 in UK with a debut record (I’ll Never Find Another You) • The Carnival Is Over outsold everyone including The Beatles and The Rolling Stones; it was No. 7 in Top Ten UK Hits Of The 60s; No. 30 in ‘UK Top 100 Best Selling Singles Of All Time’ • Georgy Girl (No. 1 hit) was nominated for an Academy Award for Best Original Song And now there is a musical, Georgy Girl: The Seekers Musical, produced by Richard East (Mamma Mia ) and Dennis Smith (Dusty – The Original Pop Diva), to celebrate the group’s 50 years’ plus of music-making and it will be heading to the Crown Theatre next month. Medical Forum spoke to Glaston Toft, who plays Athol Guy in the show, and said that wherever the show goes, there are always people waiting at the stage door to share their MEDICAL FORUM
own Seekers moment with the cast. But it’s not just sentimental nostalgia. “The Seekers are still out there performing and their catalogue spans time and generations,” he said. It also helps that much of their material, particularly from their time in London in 1964, was written by Tom Springfield, brother of Dusty and himself a renowned performer. His pop savvy was responsible for some of their greatest hits, which as the fact file above shows, included some impressive milestones. The Seekers’ were renowned for their harmonies, which Glaston says makes his job so much fun. “They were primarily a vocal group and their sound was about the harmonies the four of them made together. Their first major gig was a on a cruise liner to the UK where they spent months honing their sound. By the time they reached London, they were ready to hit the ground running.” Glaston is intrigued by the group’s dynamics and believes that Athol Guy tends to downplay his role in The Seekers’ success. “Until they started making a hit in London and could afford a manager, Athol was driving the business side of things. He dismisses that now as just what they had to do but he should take more ownership of that – it was part of why they were successful.” The Seekers have also been involved in the evolution of the musical. “I’ve been involved since the workshop stage over a year ago and they all came to the final readings. They were obviously thrilled. The musical is a way for their music to live on in
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Interviewee Glast on
Toft with Athol G
a different way to their albums. It’s great to have them involved and supportive of the show,” Glaston said. Georgy Girl hits Perth July 8 and it will be a homecoming for Glaston and his young family. His wife, Amelia, is a Perth native and Glaston is a WAAPA graduate. While show business is a precarious business, since his graduation in 2005, he’s been kept steadily in work and hit the big time with a starring role in Jersey Boys. While his children are small, Glaston and Amelia live a gypsy life travelling together as shows tour. “It will be nice to be in Perth and surrounded by family.” It’s also a welcome home for Pippa Grandison, who plays the role of Judith Durham. Pippa, who was raised in Swanbourne, was last seen in Perth as Mrs Banks in the wonderful production of Mary Poppins in 2012.
By Jan Hallam
JUNE 2016 | 51
Over 150 of our last e-Poll respondents took a break and completed this sentence, tongue-in-cheek,
‘To forget about work, I think of …’ Here’s our selection Holidays were hugely popular, either looking backward or forward. Some offered specifics: “Diving into the clear warm waters off the coast of Croatia” or “Standing at the top of a favourite ski run on a beautiful blue sky day, a whole day of fun ahead of me....bliss” or from a Scotsman, we guess, “A holiday in paradise walking again along the West Highland Way in Scotland, 160km of beautiful country!”. Someone had a relaxing beach holiday starting in one hour, while another doc was there in spirit, camping, but confessed to being a hopeless planner. France and Italy were popular destinations, in summer, of course, while we don’t know where this one was – “A vast expanse of calm blue sea, few blue-grey clouds in the sky and the sun rays seeping through the clouds in all directions.” Exotic holiday destinations, a bit of luxury, and escape from “patient demands, Medicare item numbers, bureaucracy and worries!” were drawcards aplenty. The sex might be startling too because two docs specifically mentioned their partner on holiday. Extending the sex theme, sexual fantasies are not dead amongst some docs, one saying “travel or sex – or sex and travel!” while another was into sex and “pretty pleased as I am 65+!”. There were a couple of docs who really got lost in the moment “Swimming in the ocean naked…and sex!” and remembering “All the places I made love.” Cooling things right down, family also figured prominently in the responses with children, grandchildren wine, food and the odd nip of brandy coming up the rear. One doctor put it all together: “My family, a good book, swimming, my aquarium fish, music, film, travelling...” The zen masters practise mindfulness and think of “celestial harmony”, apparently, while those with the god delusion think of “walking on water” and the just plain hopeful had lotto dreams. Rugby, footy, marathon running, cycling all figured in relaxed doctors’ thoughts but the golfers showed themselves to be a bunch of romantics – “teeing off on the first at any golf course in the world” and “getting a hole-in-one.” Some of you just can’t let go of your hard-earned investments or work and your mind turns to… “the pile of laundry, school lunches to make, vacuuming and dusting need doing...” or “elaborate schemes to ensure equitable access to top quality health care for all who need it with reduced consumption of resources and increased rewards for those serving the sick. Maybe I should be a bureaucrat when I grow up. No, I think I prefer to stick to the frontline.” Or a canny eye to the future – “Setting up a THC clinic and wait for legalisation. First in best dressed.” But window gazing is wasted without a few flights of fancy. How about: “Tom Cruise jumping on a spaceship and returning to Xenu. I continue to compile the list of people he could take with him”; or “Flying solo across the Indian Ocean”; or alarmingly “Life in advanced trenches on The Somme, getting shot at from all directions until suddenly that reminds me of ... Aaaaghh... :(.” We think that’s the signal to get back to work. But before we do, the last word goes to this doctor who wrote, ‘To forget about work, I think of …’ “Nothing! We spend all our time at work using our brains, it's just so nice to stop!” ED. As a footnote, it might interest some brains to know that the browsers of choice amongst our discerning doctors were Safari and Chrome by far, followed by IE and Firefox. About half were on a Windows PC at the time, while a quarter were on Macs, and a similar proportion used their mobile device to respond. Beyond that, your secret is safe with us because we have no way of telling!
52 | JUNE 2016
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Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).
Entering Medical Forum’s competitions is easy!
Movie: Goldstone Indigenous Detective Jay Swan (Aaron Pedersen) arrives in the Outback town of Goldstone on a missing person inquiry. What seems like a simple ‘light duties’ investigation opens into a web of crime and corruption. The great cast includes Jacki Weaver, David Gulpilil and David Wenham. In Cinemas June 30
Movie: Love and Friendship Based on Jane Austen's novella, Lady Susan, this comedy is set in in the 1790s and documents the havoc caused by the scheming and manipulative Lady Susan Vernon (Kate Beckinsale). She is on a mission to find a husband for herself and her daughter, with mixed results. In Cinemas July 21
Concert: Leo and Lulu You have to be a certain age to know these two icons of 1960s-70s UK pop but if you have, you probably loved them. They head to Australia for a concert bringing with them their catalogues of fab songs – from Lulu expect Shout, To Sir, With Love and from Leo, One Man Band, Moonlighting and You Make Me Feel like Dancing?
COMP Opera: The Elixir of Love The master of the Bel Canto opera Gaetano Donizetti would be thrilled with Simon Phillips’ new vision for his romantic comic opera – set no less than the harsh Australian outback. Thrill yourself with Rachelle Durkin’s and Aldo di Toro’s gorgeous voices and a delicious story of pride … and a little prejudice. His Majesty’s Theatre, 7.30pm, July 14, 16, 19, 21, 23; MF performance July 14
Perth Concert Hall, July 3, 7pm
Musical: Georgy Girl Nostalgia is sweeping Australia – so pull out The Seekers songbook and join in as Pippa Grandison, Phillip Lowe, Mike McLeish and Glaston Toft take you on the tale of the awesome Aussie foursome and their ascent up the hit charts of the 60s and 70s. Crown Theatre, July 8-24
Movie: Scandinavian Film Festival Rug up for a season of gritty Scandinavian noir thrillers and quirky comedies – the ‘films from the North’ are heading our way. See the latest cinema from Denmark, Sweden, Norway, Iceland and Finland. Cinema Paradiso, from July 21
Doctors Dozen Winner
The winner of the Knee Deep Doctor’s Dozen, Dr Sally Partington has already unscrewed the cap on the Sauvignon Blanc. “It’s absolutely stunning,” said Sally adding that the Cabernet Merlot will have its cap removed at a family dinner very soon. Sally says she fully endorses the secret to enjoying a good red wine – open the bottle, allow it to breath and if looks like it’s not give it mouth to mouth immediately.
Winners from the April issue Movie – Angry Birds 3D: Dr Julie Copeman, Dr Rafal Francikiewicz, Dr Simon Turner, Ms Lee Parker, Dr Helen Mead, Dr Gerald Lim, Dr Senq Lee, Dr Sally Price Movie – Mother’s Day: Dr Jun Wei Neo, Dr Narasimha Lakshmi Balasa, Dr Christine Caffrey, Dr Eleanor Yeo, Dr Neda Namdar, Dr Esther Eu, Dr Sarat Rangaiah, Dr Jo Keaney
Crash Course t Revalidation
Movie – A Month of Sundays: Dr Lin McVee, Dr Rachel Price, Dr Suzanne McEvoy, Dr Jon van Bockxmeer, Dr Robin Collin, Dr David Jameson, Dr Meg Ritchie, Dr Nuki Alakeson, Dr Jenny Elson, Dr Richard Riley
t Bike Helmets Off or On? t Docs – A Price on Your Head? t Clinicals: Infective Carditis; Hepatitis C; Melanoma; Anticoagulants & more…
Musical Theatre – Ghost: Dr Marina Rayside Major Sponsors
Music – With Love and Fury: Dr Stuart Paterson Movie – X-Men Apocalypse 3D: Dr Michael Allen, Dr Amir Tavasoli, Dr Tony Connell, ,Dr Nerissa Jordan, Dr Andrew Toffoli, Dr Ian Swingler, Dr Hock Chua, Dr Barry Leonard, Dr Susanne Sperber, Dr Clyde Jumeaux
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JUNE 2016 | 53
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