Medical Forum WA 0619 Public Edn

Raining Promises Fair Share for GPs Urgent Care, Pain Management, ENT, Aspirin & Mindfulness

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June 2019

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EDITORIAL Jan Hallam, Managing Editor

Never Rains, But It Pours Well, thank whatever aligned or non-aligned deity you subscribe to, that’s over.

The barrel is empty, scraped clean, and the strong front of money and promises that has inundated marginal electorates over the past month has contracted to the occasional light shower, presumably inside the Canberra Bubble, but as few of us are privileged enough to go there, who really knows.

Life will go on as before, won’t it?

It aint necessarily so. It will all depend on who will need to be politically appeased and who can be safely ignored. And we’re not talking party politics here.

society squarely back in the hands of general practitioners.

And when something goes awry – a wrong ‘diagnosis’ or nasty reaction – who are you going to call? That’s when you’ll hear the words ‘if pain persists, see your doctor’.

How can GPs not feel under siege in this climate? The chair of the WA faculty of the Royal Australian College of GPs Currambine GP Dr Sean Stevens writes in this issue about what he’d like to see come out of Canberra that will make life a little easier for the many thousands of GPs who continue to work on nothing but the smell of an oily rag.

Sean said just making a bit more out of Medicare for long consults would go a long way to put a smile on his face.

In the health landscape, it seems those who shout loudest, grab the headlines (and the dough).

How should we view this modest appeal compared with the billions of dollars politicians have flashed and splashed in the past few weeks?

It’s fascinating to be in receipt of all the wise words of wisdom from health societies and associations before a Budget or election campaign, then watch the congratulatory messages roll in from the groups that feel they’ve gotten the nod.

The pharmacy bodies are an illuminating example and, rightly or wrongly, they are heard by the politicians and health apparatchiks.

The medical representative bodies do all advocacy stuff too, but somehow those same politicians and health apparatchiks only see the problems. The men and women in white coats behind pharmacy counters seem to be offering (cheaper) solutions.

But you don’t have to have a medical or economics degree to see that the solutions on offer are the quick fixes, the luscious low-hanging fruit that are easy picking, leaving the serious problems of our chronically ailing

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Marketing Manager Felicity Lockyer (0403 282 510) mm@mforum.com.au

MEDICAL FORUM

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au

While helping make cancer treatment more affordable for more people and investment in mental health infrastructure is absolutely fabulous, there’s still something very wrong with the political reluctance to remunerate the gatekeepers of our nation’s health.

If a better offer comes along, it does seem that GPs are the ones to bear the cost to their livelihoods. In our interview with Sean on urgent care in primary care, he makes the point that a lot of outside organisations are cherry picking the heart and soul out of general practice, again leaving the stubbornly recalcitrant chronic diseases to the GP to manage.

Yes, thanks for that, Minister whoever you are.

Can we dare to hope that in this next term of stable Western democracy we could see a little bit of fairness creep into health policy.

Administration Jasmine Heyden (0425 124 576) jasmine@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

JUNE 2019 | 1

CONTENTS JUNE 2019

INSIDE 10 Close-Up Dr Neale Fong 14 GP Backlash on Urgent Care 18 PainChek for Elderly 22 E-Poll: Burnout & Mental Health

10

14

NEWS & VIEWS 1 Editorial: Political Merry-go-Round - Jan Hallam 4 Letters to the Editor:

18

22

6 8 9 17 21 31

Where is the Safety? - Ms Pip Brennan Why us? Discrimination Against Exercise Physiologists - Mr David Beard Real-Time Prescribing Have You Heard?

Beneath the Drapes SHR: Now the Hard Work Begins Bunbury Support Group for Meth Users - Dr Jane Anderson Practice Management: Patients First is Good Business

LIFESTYLE 44 Travel: Cherry Blossom Japan - Ms Jenny Heyden 47 Wine Review: St Hallett - Dr Louis Papaelias 48 On Track to Make Sport Equal - Dr Bridie O’Donnell 49 Sweeney Todd for WA Opera 50 Competitions 51 Circus Oz: Precarious

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MEDICAL FORUM

CONTENTS JUNE 2019 CLINICALS

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33 What do GPs Want from Government?

Dr Sean Stevens

Vitamin D Dr Aaron Simpson

37 Prescribing in Kidney Disease – An Elusive Art Dr Anoushka Krishnan

33 Ask an Expert: Mesothelioma Prof Fraser Brims

39 Antimicrobial Resistance – Where Are We? Dr Astrid Arellano

41 How Valuable is Cardiac Ultrasound?

Mr Matthew Erickson

35 Rural ENT Emergencies Dr Ian Wallace

35 Low Dose Aspirin: Who Benefits?

Dr Stephen Gordon

41 Mindfulness and Its Use in Therapy Mr Jonathan Kester

43 Is Cochlear Implant Right for This Person?

Ms Lize Coetzee

GUEST COLUMNS

The Doctors Health Advisory service of WA provides Medical Practitioners with a confidential health service around the clock.

How to contact: For doctors in crisis or for those wanting to speak with a DHASWA doctor:

6 Real-Time Watchers Ms Morag Smith

25 What are Regional Training Hubs?

Ms Carol Chandler

(08) 9321 3098 24 hours/day, 7 days/week

Drs For Drs list is now live at

www.dhaswa.com.au

27 Finances for DiT Mr Michael Deeny

29 Improving Regional Cancer Outcomes Ms Hannah Cauchi

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Mark Hands (Cardiologist), Stephan Millett (Ethicist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon),

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JUNE 2019 | 3

Where is the safety?

Dear Editor, Re: Abortion and Safety Zones (Have You Heard? May edition) The current political climate at home and overseas is becoming increasingly toxic and particularly erosive of hard-fought women’s rights when it comes to accessing timely legal abortions safely.

I was disturbed to read in your magazine and in the mainstream media, the increasingly repressive legislation being passed in the US. I was horrified to read of advertisements placed by Queensland The Cherish Life group during the recent election campaign which claimed “more babies would die under a Bill Shorten Labor government” and accuses Labor of an “extreme late-term abortion agenda”.

What sparked this claim was a Labor election pledge to work towards full decriminalisation of abortion so that women on lower incomes would not be discriminated against.

Here in WA, women attending Marie Stopes are not provided the safety and anonymity of attending hospital where no one can guess the type of care they are seeking.

Instead women have to run the gauntlet of regular protesters and, like clockwork each Easter, another prayer vigil takes place outside the clinic.

This Easter was no exception, with a Marie Stopes staff member complaining about the lengths some protestors go to in order to intimidate women. It was alleged a protestor had struck up a conversation with a woman attending the clinic, found out where she

worked and then contacted the woman’s employer to let them know she was off work having a termination (although there was some doubts thrown on the provenance of the people undertaking such activities).

Exercise physiologists work with patients suffering from illnesses such as cancer, diabetes and mental health issues, yet many patients are forced to stop care because of the extra cost.

This Easter another woman was happy to put her face to her story of being shamed by protestors as she left the clinic and how distressing this had been.

Under Medicare, only five consultations are considered ‘GST exempt’ (if referred by a GP). Patients without a GP referral, including patients referred by a medical specialist, are charged extra from the first consultation (an added $7-$10 per session).

I hope the discussion paper you write about in Have You Heard? proceeds to more than just a discussion. Women should not have to be subjected to this kind of harassment.

Certainly the introduction of safe zones, which hopefully will not be too far off into the future, will help reduce this negative impact on women.

Pip Brennan, Executive Director, Health Consumers Council ......................................................................

Why us?

Dear Editor, Parliamentary processes are leaving the elderly and individuals with chronic health conditions short changed as a result of GST being applied to the cost of seeing accredited exercise physiologists. This is with a backdrop of all Medicare allied health services being exempt from the GST. Why do exercise physiologists remain the only allied health service that has to charge this tax.

Exercise is a medicine – it is increasingly being prescribed to patients by GPs and specialists. Studies show it helps fight diseases but it seems if it’s not in the form of a pill, politicians aren’t interested.

Every day I manage chronically ill people who need urgent help with exercise plans to improve their health and manage their conditions and some of them stop after their five Medicare subsidised sessions because they can’t afford it, yet this is just when we start to see improvements.

These people go on to become a burden on the health system, often needing expensive drugs or surgery, which they could have avoided.

The government doesn’t want to lose GST revenue but is willing to pay more for care for these people once they are in real crisis – it just doesn’t make sense.

The exercise physiology profession was less than a decade old when GST was brought in and despite services being recognised by Medicare back in 2006, the GST issue was not rectified.

David Beard, Exercise Physiologist, Subiaco ......................................................................

This charge nets the government less than $20 million a year nationwide, but the wider implications of this financial windfall are damaging.

Black holes are where God divided by zero.

Albert Einstein

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LETTERS TO THE EDITOR

MAJOR PARTNER

Who benefits from cannabinoid therapies?

Cannabinoid therapies (medicinal cannabis) were legalised in Australia in 2016.1 Since then, enthusiastic widespread community interest in its use has been coupled with broad scepticism and unwillingness to prescribe amongst clinicians.

Almost two thirds of GPs have been asked by patients about using medicinal cannabis.2 Most clinicians admit that their knowledge of cannabinoid therapies is inadequate, and that they have insufficient information to prescribe. This likely stems from there being no formal medical curricular or vocational training for doctors in the use of cannabinoid therapies. In addition, the prescribing bureaucracy, both Federal and State, has been complex and unwieldy.

Using the available published evidence, the Commonwealth Health department and relevant state governments have approved specific clinical indications for cannabinoid therapy. The approved and accepted indications for prescribing of cannabinoid therapies in Australia3 include: Chronic non-cancer pain (neuropathic) Cancer indications

Chemotherapy induced nausea and vomiting (CINV)

Cancer pain

Sarcopenia and anorexia Refractory epilepsy (particularly paediatric) Neurological spasticity

Multiple sclerosis

Parkinson’s disease Anorexia and wasting due to chronic illness

For nearly all indications, cannabinoid therapy is seen as acceptable having exhausted all other therapeutic modalities and in Western Australia, prescribers require support from a relevant specialist.

Other indications currently under investigation include PTSD, primary insomnia and nocturnal agitation in the elderly.

In neuropathic pain, systematic reviews and meta-analysis have demonstrated an opioid-sparing effect with concomitant cannabinoid therapies.4 Co-administration of cannabinoids may enable reduced opioids while maintaining analgesic efficacy,

Referral forms can be downloaded from www.emeraldclinics.com.au

without the same hazardous side effects. Why is this important?

In the last 20 years, there has been a precipitous increase in prescribed opioids and subsequent related prescription deaths, Australia more than most.5 To help address this, OTC codeine was up-scheduled to prescription only in early 2018.6 Emerald Clinics comprehensively assess referred patients’ suitability for cannabinoid therapies, with a view to reducing reliance on opioid use for pain relief. This shared-care model involves the patient’s GP and relevant specialty colleagues to continue to coordinate comorbidities and downregulation of opioid medications.

By Dr Alistair Vickery References 1. Medicinal cannabis facts sheet. www.health.gov.au/internet/ministers/ publishing.nsf/Content/546FB9EF48A2D570CA257EE1000B98F2/$File/ Medicinal-cannabis-factsheet.pdf 2. Karanges EA, Suraev A, Elias N, Manocha R, McGregor IS. Knowledge and attitudes of Australian general practitioners towards medicinal cannabis: a crosssectional survey. BMJ open. 2018 Jun 1;8(7):e022101.

3. Medicinal cannabis - guidance documents www.tga.gov.au/medicinalcannabis-guidance-documents 4. Nielsen S, Sabioni P, Trigo JM, Ware MA, Betz-Stablein BD, Murnion B, Lintzeris N, Khor KE, Farrell M, Smith A, Le Foll B. Opioidsparing effect of cannabinoids: a systematic review and meta-analysis.

Neuropsychopharmacology. 2017 Aug;42(9):1752.

5. Islam MM, McRae IS, Mazumdar S, Taplin S, McKetin R. Prescription opioid analgesics for pain management in Australia: 20 years of dispensing. Internal medicine journal. 2016 Aug;46(8):955-63.

6. Larance B, Degenhardt L, Peacock A, Gisev N, Mattick R, Colledge S, Campbell G. Pharmaceutical opioid use and harm in Australia: The need for proactive and preventative responses. Drug and alcohol review. 2018 Apr;37:S203-5.

For DIGITAL Referrals see www.emeraldclinics.com.au/uploads/ resources/181213_Emerald_Clinics_Referral_Form.pdf > or order referral pads through info@emeraldclinics.com.au

1300 436 363 For patients referrals or to join our network of specialists, visit our website at:

www.emeraldclinics.com.au

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Real-Time Watchers Australian governments are moving to establish real-time prescription monitoring systems. Avant Senior Solicitor Morag Smith explores what this may mean for doctors.

In the past few years coroners across Australia have been calling for a national monitoring system to help doctors identify drug-seeking behaviour and to help inform their decision-making when prescribing to make it harder for patients to access addictive prescription drugs.

The WA Coroner has joined the call to implement a national real-time prescription monitoring system for pharmacists and doctors. This recommendation was made following an inquest in 2016 where it was found that information about a patient being a registered drug user was not shared between practitioners and practices.

The Australian Government has committed to a national monitoring system, and infrastructure is currently being developed that will allow states and territories to connect to a national prescribing data repository.

Some states have already taken action to address the growing issue of prescription drug dependence, implementing their own systems. Tasmanian clinicians have

had access to the DORA system to view patient information and dispensing data for Schedule 4 and 8 drugs since 2012 and this system is currently being rolled out in the ACT. The Victorian Government introduced SafeScript in 2018.

The remaining states and territories are working with the Commonwealth but it has been a slow process.

Even with the rollout of these systems, practitioners should be constantly vigilant of drug-seeking patients or those at risk of becoming drug dependent.

Drug seekers can be difficult to identify – there are certain behaviours that should raise suspicion. These can range from patients claiming medication is no longer effective, to patients who ask for a drug by name and specify a dose.

Patients at risk of becoming prescription drug-dependent, such as those with

difficult clinical issues needing high doses, or patients who are overusing or misusing, require more frequent and tailored clinical management. This may mean engaging other medical practitioners in care, such as a pain management specialist, psychiatrist or addiction medication specialist.

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INCISIONS

Placing a sign in your waiting room saying ‘No drugs of addiction will be provided on the first appointment’ is a good strategy to limit drug-seeking behaviour.

Before prescribing drugs of dependence, carry out a detailed clinical assessment and fact-checking exercise: • Confirm the patient’s identity and medical history by calling previous doctors and consulting medical databases.

• Register with and contact Medicare’s Prescription Shopping Information Service if a patient exhibits drug-seeking behaviour.

• Consider time-limited trials, supervised dosing, staged supply and/or prescribing small amounts, and implement a follow-up regime. Seek a second medical opinion if unsure.

• Write tamper-resistant prescriptions that comply with the legislative requirements for prescribing drugs of dependence, and prescribe the exact amount to carry through to the next appointment.

Good documentation of any requests and the advice you give is essential.

Queensland Joins … How About the West?

We asked the WA Department of Health for its position on real-time prescription monitoring.

A spokesperson said the state had a long-established prescription monitoring program (PMP) which required pharmacies to provide a monthly report to the department of all dispensed Schedule 8 medicines and this was actively monitored.

In line with COAG’s endorsement of national real-time prescription monitoring (RTPM), the department has recently commenced a series of local consultations with representative bodies regarding policy and legislative issues related to RTPM.

mandates for use, alerts and reports for clinicians, clinician and patient education, and related matters. The Department of Health is on track to implement the WA regulatory component of this model toward the end of 2019.

The department is concurrently working with the Commonwealth on entry of WA into the National Data Exchange (NDE) and for the required integration necessary to support national RTPM. The timing of implementation of RTPM in WA, and nationally, is dependent on Commonwealth NDE activities, completion of legislative changes and putting in place data sharing agreements between jurisdictions.

Just before we went to press, the Queensland Health Minister announced that he would be introducing a Bill into the parliament to legislate for the establishment of a real-time prescription monitoring system.

The ABC Health Report says that the newly implemented SafeScript monitoring system in Victoria has estimated that more than 27,000 people are at increased risk of harm or overdose.

In the first month, SafeScript red-flagged nearly 15,000 people for visiting multiple doctors or pharmacies, and a further 13,000 people were recognised as taking excessive doses or risky combinations of medicines.

This includes the medicines covered,

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Avant supports the implementation of real-time monitoring.

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Major Partner: Clinipath Pathology

By Dr Aaron Simpson, Head of Biochemistry

Vitamin D A large proportion of Australians are vitamin D deficient, which may be in some part due to the success of the Sun Smart message.

What does vitamin D do?

Vitamin D is required to regulate blood calcium levels by promoting intestinal and renal calcium absorption. Vitamin D requirements are mainly fulfilled by sunlight exposure which converts 7-dehydrocholesterol to cholecalciferol (vitamin D3) in the skin (Figure 1). Small amounts of vitamin D3 can be derived from diet. Once formed, vitamin D is hydroxylated to 25-hydroxyvitamin D (25OHD) in the liver. However, 25OHD is biologically inactive and must be renally converted to 1,25 dihydroxyvitamin D (1,25[OH]2D) to exert its biological actions.

Impact of vitamin D deficiency?

Inadequate sunlight exposure is the major cause. This triggers parathyroid hormone (PTH) secretion, which in turn increases bone resorption. PTH also stimulates renal excretion of phosphate causing phosphate deficiency. Consequently, these combinations result in impaired bone mineralisation leading to bone diseases including rickets in children and osteomalacia in adults and may also contribute to osteoporosis.

Who is at risk of vitamin D deficiency?

• people who are institution/house/office bound, • dark skinned women, particularly if veiled, • people with osteoporosis or hip fracture, • people with symptoms suggestive of malabsorption, and • people taking certain medications, including anticonvulsants and glucocorticoids.

It is recommended that pregnant women at risk, have 25OHD tested during first trimester, however, the Royal College of Pathologists of Australasia recommend all pregnant women be tested.

Biochemical Tests for Diagnosis and Monitoring of Vitamin D Deficiency Vitamin D 25OHD is a major circulating and storage form of vitamin D, used to assess vitamin D status. Measurement of 1,25 [OH]2D is unnecessary. To monitor treatment, 25OHD can be measured 2-3 months after commencing supplementation, as vitamin D has a long half-life (2-3 weeks).

What cut off should we use to indicate vitamin D deficiency?

The recommended decision limit for 25OHD is 50 nmol/L. However, the Australian guidelines recognise that this limit should be higher in summer than winter. The typical summer limit may be 60 nmol/L, but may be less in northern Queensland, but higher in Victoria and Tasmania. Deficiency can also be graded as mild, moderate or severe.

25OHD (nmol/L) Vitamin D status: • <12.5 - Severe deficiency • 12.5 -29 Moderate deficiency • 30 - 49 Mild deficiency • 50 + sufficiency PTH PTH may be used sometimes to evaluate a borderline low 25OHD. An elevated PTH with a low 25OHD confirms vitamin D deficiency. However, a PTH level within reference interval does not exclude vitamin D deficiency.

Serum Calcium, Phosphate and Magnesium Hypocalcaemia and hypophosphataemia may occur in severe vitamin D deficiency although serum calcium and phosphate are usually normal in mild to moderate deficiency. In people on calcitriol (1,25[OH]2D) supplementation, serum calcium and phosphate are used to monitor treatment as toxicity could result in hypercalcaemia. Measurement of serum magnesium is sometimes necessary as hypomagnesaemia may blunt the PTH rise in response to vitamin D deficiency.

About the Author Aaron has dual fellowships in Chemical pathology and Endocrinology and has been widely published in both disciplines.

His particular interests are endocrine hypertension, adrenal, pituitary and calcium metabolism disorders, diabetes and gestational diabetes. Aaron is Head of Biochemistry at Clinipath Pathology, and also sees patients for endocrinology consultations at the WA Specialist Clinic in Osborne Park.

LFT and UEC These tests are important to ensure the active form vitamin D (1,25[OH]2D) can be produced. Occasionally, vitamin D deficiency is detected as a result of isolated mildly raised ALP. Treatment for Vitamin D Deficiency Treatment strategies for moderate to severe vitamin D deficiency usually require vitamin D supplementation coupled with advice to increase sun light exposure.

Dietary modification alone (even with vitamin - D fortified foods) will not provide adequate amounts of vitamin D. For people who have 25OHD levels in the equivocal range (50-75nmol/L) but are not in the high risk group, it may be advisable to increase sunlight exposure, then to measure 25OHD again in three months.

Vitamin D supplementation and toxicity Currently most supplements are vitamin D3 (cholecalciferol) in Australia. For adults with moderate to severe deficiency, a recommended start is vitamin D3 such as Ostelin or OsteVit – with D at 3000-5000 IU per day for at least 6-12 weeks, then 1000 IU for ongoing treatment. This is also applicable to women during pregnancy.

Vitamin D toxicity due to supplementation is rare. One report said 10,000 IU per day orally for 90 days in postmenopausal women did not result in adverse effect and monthly doses of 50,000 IU are not uncommon in clinical practice, particularly in nursing homes.

Further Reading ANZBMS updated Position Statement, Vitamin D and health in adults in Australia and New Zealand.

MJA 196 (11) 2012.

Adapted from – Dr Ken Sikaris, Vitamin D Insight November 2018.

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au

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State spends on mental health The e-poll published on Page 22 asks doctors for their views on mental devolution as Graylands hospital is planned to close by 2026 and the state government has embarked on an unprecedented spend in mental health in the recent Budget. Readers who commented were generally sceptical of the plan but the government would have us thinking otherwise. In the May budget it announced it was investing in $942.1 million into mental health, alcohol and other drug services in 2019-20 (a $100 million increase from last financial year). It has pledged $20.1 million towards the North West Drug and Alcohol Support Program; $15.6 million for a new 20-bed secure mental health unit at Fremantle Hospital taking the number of mental health beds there to 84 when it opens in 2022; $9.2 million towards developing an alcohol and other drug youth service in the Kimberley; $8.9 million for the continuation of the Mental Health Court Diversion Program; $8.1 million for suicide prevention programs; and $4.8 million to establish a 10-bed crisis centre in Midland among other initiatives. The proposed Recovery Colleges will get $3.6 million to establish and operate a central hub in Perth and satellites located across regional WA. The government will also pump $22.4 million in capital funding over the next three years community step up/step down services – 10 beds in Bunbury and Kalgoorlie and six beds in Broome and Karratha. This adds to last year’s investment into Joondalup (22 beds), Rockingham (10) and Albany (six).

…and private does too The public system is not the only one investing in mental health. Hollywood Private Hospital has announced that it is responding to a 60% rise in psychiatry admissions over the past five years with an ambitious building program. It has announced it is building a dedicated mental health day hospital and expanding existing inpatient services, increasing beds from 31 to 101. When completed, Hollywood will have the biggest private standalone mental health facility in WA. Hollywood CEO Peter Mott said the new mental health day hospital would enable multidisciplinary care to increase options for people wanting to remain in the community while they are receiving treatment. “The day hospital is purpose built and will have multiple group therapy rooms and a neuro stimulation suite for electroconvulsive therapy and transcranial magnetic stimulation,” he said.

and commercial prospects in the West.

It’s estimated that for every $1 awarded in NHMRC grants, there is a return of $51.10 in health benefits and economic and workforce growth.

New era for palliative care Palliative Care WA has welcomed the WA Budget announcement that $41 million will be allocated towards an end-of-life choices and palliative care package across the State, including an extra $5 million to go towards a purpose-built 38-bed residential aged and palliative care facility in Carnarvon.

Palliative Care WA’s CEO Ms Lana Glogowski said the funds were a “good first step” and looked forward to more details about how this money will be distributed.

With the number of Baby Boomers facing palliative care over the next 20 years set to soar, Ms Glogowski suggested that without significant injection of money and resources, timely access to quality palliative care would be jeopardised. However, she called on more information regarding the remaining $34 million allocated to End of Life Choices.

“While Palliative Care WA welcomes Minister

Cook’s announcement of a summit on palliative care we are still keen to explore the establishment of an expert panel to help identify critical priorities for improving the understanding and delivery of quality palliative care across WA.”

ASX responds to trial The completion of successful clinical trials for Orthocell’s CelGro last month saw share prices rise by 200%. Orthocell said the first four patients which trialled its CelGro platform had regained muscle function and/or sensation of affected limbs and returned to regular activities. On May 8, the Murdoch-based company’s shares closed up 41¢, or 357%, to 52.5¢, with $24 million in stock changing hands. The trial was undertaken with orthopaedic nerve specialist Dr Alex O’Beirne of St John of God Subiaco Hospital and Ming Hao Zheng, director of research at the University of WA’s Translational Orthopaedic Research Centre.

Pain lines drawn The ACCC announced that it will not oppose GSK’s proposed acquisition of

End of life debate Still on end of life issues, ABC Vote Compass has documented how the public opinion on assisted dying has strengthened over the past five years. While it was not an explicit election issue, for a start it is being dealt with by state jurisdictions, it remains a driving movement.

This year, the WA Labor Government will bring on debate on its proposed End of Life Choices when a Bill is introduced into state parliament. In the meantime, it has spread the consultation process over the past couple of months to take in additional public forums and information sessions in Mandurah, Carnarvon, Karratha, Northam and Albany. They follow the March release of a discussion paper by the Ministerial Expert Panel on Voluntary Assisted Dying, chaired by Malcolm McCusker AC QC, which outlines key issues for the proposed legislation.

Health Minister Roger Cook attended sessions in Carnarvon and Karratha to hear the views of the public and health professionals.

Proportion of ABC Vote Compass responses to the statement: "Terminally ill patients should be able to end their own lives with medical assistance."

Researchers rejoice The State Budget also flagged an additional $52 million investment over three years into the Future Health Research and Innovation Fund taking the total to $126.6 million.

Once legislation is passed, annual interest from the $1.3 billion WA Future Fund will be repurposed to health and medical research and innovation, doubling the current annual research expenditure. The government hopes the funding boost will keep talent

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HAVE YOU HEARD?

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NHS whistleblower anaesthetist A/Prof Steve Bolsin has been appointed new Group Director of Medical Services and Clinical Governance at St John of God Health Care.

How effective is digital?

Digital demand

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has held its national congress and one of the items for delegates to consider was the new guidelines for online anxiety therapies, which are proliferating but there has been little evaluation of their relative effectiveness.

A/Prof Lisa Lampe, who is on the RANZCP Anxiety Disorders Working Group, said a review has provided better understanding of the strengths and weaknesses of this type of treatment. “There is growing evidence for the effectiveness of guided digital therapy (where are person is supported as they complete digital therapy modules) in the treatment of anxiety. It has been known for some time that digital therapy can have high dropout rates. We know the treatments work if people complete them, but have needed to better understand how to get more people finishing the treatments they start.” She said that digital cognitive-behavioural therapy (eCBT) was most effective as a collaborative treatment undertaken with the support of a health professional – a person’s GP, psychologist or psychiatrist. “When we mix the use of therapy delivered online or by digital devices with the support and supervision of a health professional, it is less likely that people will stop their treatment.” www.ranzcp.org

Still on digital health, consultancy firm Accenture has completed an Australia Consumer Healthcare Survey which shows that Millennial and Gen Z consumers want non-traditional care models, such as retail clinics and virtual and digital services. The survey of 1,036 Australian consumers found striking differences in satisfaction levels between younger and older healthcare consumers. For instance, considering in-person care, Gen Z (18-21 years) and Millennials (22-38) don’t want to wait for an appointment; cost and location are also factors and they want the treatment to be effective (we suspect, immediately!). The survey found that 40% of all respondents have used walk-in or retail clinics for basic care needs. Digital options were also gaining popularity with 21% saying they have used some form of virtual care, up from 12% in 2018, and 23% have arranged on-demand health services via apps or online tools. When it comes to in-person care, 84% of Millennials and younger are more likely to choose medical providers with strong digital capabilities, such as booking, changing or cancelling appointments online, remote or telemonitoring devices to monitor and record your own health indicators and online access to electronic medical records.

Pfizer’s consumer healthcare business in Australia. The proposed buy-out is restricted to Pfizer’s over-the-counter businesses, In the pain market Pfizer produces Advil and GSK sells Panadol and Voltaren and after the ACCC conducted its analysis it did not consider that the transaction would substantially lessen competition in any market in Australia. GSK’s Panadol and rival Reckitt Benckiser’s Nurofen are the market leaders in OTC pain management products and both have strong market recognition whereas Advil did not. The ACCC believes Nurofen will continue to compete strongly and the combined businesses will continue to face competition from the range of generic options available.

Insure vaccinators Vaccination research Katie Attwell from UWA’s School of Social Sciences has just

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released findings of a review on the impact of no-fault compensation schemes in those countries that have mandatory childhood vaccination policies if a rare vaccine injury should arise. Such compensation schemes enabled governments to address unintended consequences of vaccination.

The research, published in Vaccine, argued that when a state introduced mandatory vaccination a ‘social contract’ was created which should protect individuals from any extremely rare adverse consequences. Of the 62 countries that researchers identified as having mandatory childhood vaccination policies, they found only seven of those countries (11%) had also introduced no-fault compensation schemes. The benefits, she said, were greater public confidence in vaccination programs and less negative publicity as matters would be settled through insurance channels rather than

Nurse Practitioner Andrea Rieusset has been named WA's 2019 Nurse of the Year. Andrea works at the Fitzroy Crossing hospital ED. She also took top honour in the Excellence in Aboriginal Health at WA Nursing and Midwifery Excellence Awards. Prof Dianne Wynaden of Curtin University was recognised with the Lifetime Achievement Award.

Curtin University’s Mission for Traumatic Brain Injury has been awarded $50 million over the next 10 years to help improve lives of people with traumatic brain injuries of all severities. The research to be conducted in Perth and Melbourne will be led by Prof Melinda Fitzgerald.

Vicki Jack has joined the office of the Commissioner for Children and Young people as Director Aboriginal Engagement.

Wagin GP Dr Peter Van Maarseveen is Rural Health West’s 2019 GP of the Year. Goldfields physician Dr Clare Huppatz is winner of the Medical Leadership Award; Dr Ian Taylor (pictured) took out the Chairman’s Award and District Medical Officer of the Year; Albany’s Dr Kelly Ridley is the Rising Star; Dr Anand Deshmukh is the Specialist of the Year and Dr Roland Main is the Specialist Bush Champion for 2019.

AudioClinic, HearingLife, Western Hearing Services and Adelaide Digital Hearing Solutions have been rebranded as Audika, which is part of Denmarkbased Demant. the courts. “If individuals are expected to accept the risks inherent with adhering to vaccine mandates, they should be confident that they will be cared for if they suffer an adverse event,” Katie said.

Healthy hearts Heart Support Australia has begun its eight-week Healthy Heart Program in Perth to help educate and support people who have had cardiac events. Participants will learn self-management skills and address the individual risks that affect them. The course has started but welcomes inquiries. heartsupport@heartnet.org.au or phone (02) 6253 0097.

JUNE 2019 | 9

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CLOSE UP

Neale Fong and Hard Knocks The crux of leadership is the willingness and ability to do it in the first place. Dr Neale Fong has firsthand experience.

N

ot everyone wants to be a leader. Indeed, the 2016 Deloitte report Global Human Capital Trends 2016 The new organization: Different by design shows that there is a talent gap in modern leadership.

This is not surprising because the modern leader has to be collaborative, a team leader, and not a hierarchical finger pointing, authoritarian, boss. “As companies strive to become more agile and customer-focused, organisations are shifting their structures from traditional, functional models toward interconnected, flexible teams,” according to the Deloitte report.

“More than nine out of 10 executives surveyed (92%) rate organisational design as a top priority. A new organisational model is on the rise: a ‘network of teams’ in which companies build and empower teams to work on specific business projects and challenges.”

Neale Fong has not only been willing to lead, he has taken the hard knocks that come with being a leader. He also fits well in the contemporary paradigm that millennial leaders are facing, that of the team leader.

“My particular focus is developing leadership for the health care system, doctors and non-doctors, to ensure we have people who are improving their own selves, working much better in a teambased, integrated approach to patient care and ensuring that the high quality and standards we currently have are maintained,” Neale told Medical Forum.

Willingness to learn “Leadership is the key ingredient to successful healthcare outcomes, whether it be at the population level, hospital or patient care. Leadership influences the outcome by ensuring all the resources around you are used to get the best result.

There are many clinicians around the place who don’t understand they lead all the time, sometimes leading poorly. I think understanding good leadership is critical and it needs to start in medical students all the way through.”

“One sign of a good leader is that they never stop learning. Good leaders are always trying to see how they can improve their own technical skills and personal skills – what we call ‘soft skills’ – communication, empathy, encouragement and all those things that are important to make organisations work.”

“But good leaders are always seeing

10 | JUNE 2019

how they can improve by reflecting on their behaviour or their attitudes and their relationships.”

“Coaching is a growing space where people open themselves up and make themselves vulnerable. I have been coached and a number of people you might call mentors or coaches in many situations have helped me improve my leadership skills. I always say to the doctors or surgeons or medical specialists, you always try to keep up with the latest of what’s going on in your technical area. The same goes with leadership in the system, always being open to learn is a great sign of a good leader.”

Dealing with hard knocks Leadership and management text books often list resilience as a key leadership trait.

“I don’t like the word resilience, to me it’s a jargon word. Do you bounce back?

What is it? In terms of hard knocks, I think it is about having a really firm self-belief that is based not in your ego but based in understanding what your capabilities are, what your gifts are, and then exploiting those fully.”

“If you know that you have tried your hardest, then you have done your best.

continued on Page 12

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Neale Fong and Hard Knocks I got out of clinical medicine because I like working with organisations and in teams of people.”

“I know that clinical medicine works as teams, but working in an organisation requires bringing together clinical and other departments, people, finance, all sorts of things to share that common vision.”

“If you build good people around you, they absorb some of those hard knocks with you. That is another lesson.”

“Some of the scandals that happen in the health care system undermine people’s faith in what’s happening. In those situations you need strong leadership.”

“I remember one example when there was an alleged so-called paedophile ring at one our children’s hospitals and when that became even half true, the rumour sent huge shock waves through the community.

So we had to come out very strongly and understand what was going on, and where those allegations and rumours were coming from.”

“In that situation a rumour was enough to undermine confidence. So we worked quickly and while, not proven, certain issues were uncovered that ensured that we improve our vetting systems.”

“The merger of our five teaching pathology services 13 years ago is another good example of leadership. Those empires were all going on their own trajectory and we had to bring them together in one pathology service, which is now a worldclass, centralised service.”

Juggling a lot of balls Neale is currently Executive Chairman of Bethesda Health Care. His leadership and management skills are used extensively. He is Chair of the WA Country Health Service, Professor Healthcare Leadership at Curtin University, President of the West Perth Football Club, a Non-Executive Director at companies including Little Green Pharma, Neurotech International Ltd, Sleep

Dr Neale Fong in 2006 when he was Director General of Health with the then State Coroner Alistair Hope Studies Australia, Alerte Digital Health, and honorary National President of Australasian College of Health Service Management (ACHSM).

“Bethesda is a faith-based hospital, but we are not embedded in the denomination anymore. We are independent and have a Board of Directors that answers to the members. They were in serious trouble here 10 years ago and the new team were able to steer Bethesda out of those difficult times,” he said.

“We have completed a $10 million theatre development and refurbishment. We look to maintain our place as the premier palliative care provider in Perth as well as a surgical hospital focusing on orthopaedics, urology, gynaecology, breast surgery and plastics.”

“We have a wonderful organisation, unbelievable staff, the staff turnover is zero because we have a great team-based approach with high quality nursing care on the edges of the Swan River.”

“We believe that there is a really important place for private hospitals in the whole health care system in Australia. We are concerned about issues such as private patients in public hospitals who are displacing public patients from waiting lists in favour of private patients, sometimes for the convenience of doctors and sometimes to drive revenues for the public hospitals.”

“We are concerned that this does undermine the private hospital system, so we are keen to see that issue addressed.”

Neale’s Bethesda office is, not surprisingly, adorned with AFL memorabilia. His leadership in AFL football is well known, chairing the WA Football Commission for nearly 10 years and having been honorary chaplain to the Eagles for 23 years.

“My recent foray into football has been to take on the presidency of the West Perth Football Club, for which I played in the in the 1980s. The club was placed into voluntary administration in the middle of last year and coming out of that they instituted a new board and asked me to steer the club on for the next two years or so.”

“It is the oldest football club in WA, one of the real stalwarts of AFL footy. I want to try and ensure that it has a strong future. The Joondalup Falcons is the only club that is in the northern suburbs of Perth, north of Leederville.”

“I love playing in team sport. It teaches lots of lessons in terms of reliance on team mates and there’s no room for big egos in a really good team.”

By Mark Balnaves Neale with the crew at the Joondalup Falcons

12 | JUNE 2019

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JUNE 2019 | 13

GPs Push Back on Urgent Care The Coalition government opened a can of worms when it announced it would give St John Ambulance $28 million for four more urgent care centres.

I

n the May edition, we reported some of the concern GPs have for the Federal Government budget announcement which would see $28 million flow to St John Ambulance to trial four more urgent care clinics adding to their stable of three, currently at Joondalup, Cockburn and Armadale.

want to prescribe medicines independently and then there’s the home visiting services.

Quite frankly, they are not doing it better and it’s only fragmenting care, which should be taking place at the patient’s primary general practice so GPs know exactly what’s going on with their patients.”

The chair of the WA faculty of the RACGP, Dr Sean Stevens, said in a media statement that the trial risked fragmenting care and would lead to poorer health outcomes. When Sean sat down with Medical Forum to discuss his concerns in more detail, he said the urgent care was the bread and butter of general practice.

“The Australian health system ranks second in the world because of its good primary health care system. If we start messing with that, each fragmentation chips away at general practice and makes the whole system more inefficient and reduces the quality of care.”

“We do it every day and we do it well.

There is no reason why we can’t keep doing it well. If we were given the resources that St John Ambulance have just been given we would do it even better.”

Sean said this was just another instance where outside parties were trying to take a piece of general practice because GPs were purportedly ‘too busy’ or had more serious things to do with their time.

“St John want to do urgent care, other groups want to do chronic disease, pharmacists are doing vaccinations and

14 | JUNE 2019

If it ain't broke...

In Medical Forum’s December issue, when we interviewed Dr John O’Toole, St John’s Urgent Care Medical Director, and Dr Tim Lipscombe, St John Medical’s head of general practice, John stressed that the urgent care centres were not a replacement for a person’s own GP. “We want to facilitate a patient’s relationship with their GP, not interfere with it. If a patient is appropriate for urgent care, send them in and we will attempt to fix the problems but we’ll send them back to you,” he said at the time.

“If a patient presents with a routine problem that would be better managed

in an appointment with their regular GP, we will advise them as such. Urgent care does not perform health assessments, management plans, preventative medicine, referrals to specialists (other than acute specialties such as plastics and orthopaedics). This is the remit of the GP and we are careful to reinforce this.”

“In modern urban general practice, it doesn’t make sense to set yourself up to see a lot of walk-in urgent fractures or lacerations because you also have a waiting room full of patients. Juggling those things can make a GP’s life untenable.”

As far the RACGP is concerned all of those things ARE life for a GP. “All the services St John Urgent Care Clinics provide, with perhaps the exception of onsite radiology (though many practices have adjacent radiology practices), can be done through a regular general practice,” Sean said.

“Simple fracture management, lacerations, they are all part of general practice and there is no reason why a GP in their own surgeries can’t provide it.”

State-led initiative In the last edition we referred to a WAPHA project seeking expressions of interest for an urgent care project from general practices across the state who believed they had capacity to deliver those services onsite. We erroneously reported that it was a federal government initiative. In fact it was a WA government request as part of its 2017 election commitment to increase urgent

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FEATURE

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FEATURE care options in the community, partly to alleviate congestion at hospital emergency departments and partly to improve access across our vast state (see next page).

Sean said this state initiative was a collaborative project that sought the views of the primary care community – from the RACGP, the AMA, pharmacy bodies and practice nurses. It was at an advanced stage when the Federal Government made its surprise announcement of $28 million to St John Ambulance.

“The WA government project is estimated to cost $2 million versus $28 million and would potentially provide access to urgent care right across the state rather than in seven localised areas,” Sean said.

“A practice would be assessed for its ability to provide urgent care and its capacity to quarantine daily appointments for urgent care. An app is in development where patients would be able to log on and be directed to the nearest general practice that has been assessed to provide those services.”

“It has been identified by Health Engine data that there are tens of thousands of appointments every day in WA that go unfilled. So there is capacity for those appointments to be used for urgent care.”

“The misunderstanding of many people is that a lot of this urgent care happens after hours, but if you look at the ED data, most of it occurs in what general practice would consider in-hours, between 8am and 6pm,

so general practice is very able to deal with a vast majority of these Category 4 and 5 presentations.”

Sean said the other disappointing aspect to the federal budget announcement was that it lacked transparency.

Where’s the transparency “There was no tendering or consultation.

The primary care bodies – RACGP, AMA, WAPHA – didn’t know about it, nor apparently the WA government. A deal was done without reference to any of the groups that will be involved or affected by this.”

Then there are the serious concerns private general practices have over such a large amount of federal government money funnelling into one bulk billing primary care organisation.

Over the past several weeks, Medical Forum has heard from a number of general practices in the proximity of the existing urgent care centres and they are bitterly disappointed with a perceived unfair advantage St John centres have been handed by the federal government – these GPs own part-funder via the MBS. One described it as a kick in the guts.

Sean, who consults at Currambine, said that practice owners in the Joondalup St John catchment had told him that the centre had significantly impacted on their after-hours care provision.

“Previously those appointments were at a

premium and people were happy to come in and see their regular GPs for these services.

Now they have reduced those offerings and even the ones that are available are not being booked because the service attracts a fee.”

To add insult to injury, Sean said there was poor communication between the urgent care centres and the patients’ regular GPs. “The official word is that they are liaising with GPs via discharge summaries. I’ve been working in Currambine for 12 months and I’ve seen one summary despite multiple patients of mine attending an urgent care clinic,” he said. “From my information, this is not a unique incident.”

Poor communication “There have been reports of patients returning to the urgent care centres for MSU results after they presented for an ‘urgent’ UTI. They had been started on antibiotics but rather than be directed back to their own GP for follow-up of the MSU result, they were told to return to the centre. GPs are not even being copied into lab reports. That’s not appropriate.”

Sean believes that St John had applied to the federal government for a grant of $158m and $10 million in recurring funding for multiple new clinics across WA. “If this is the case, this will just fragment care even more across a wider area,” he said.

By Jan Hallam

Creating a Level Playing Field Medical Forum contacted Chris Kane, WAPHA’s General Manager of Strategy and Health Planning, to explain the details of the state-based GP urgent care pilot, which she said was due to start in August and continue for 18 months.

She said the pilot, which would be initially be only in the metro area, was a reality because of a collaboration between the WA Department of Health, RACGP WA, AMA WA and WAPHA, and has been driven by the Health Minister Roger Cook as part of the ALP’s election promises in 2017 to provide access to urgent care centres in the community.

All involved hope for other positive spin-offs such as helping to alleviate overcrowding in public hospital EDs and better collaboration and communication between the traditional silos of hospitals and general practice.

However, Chris emphasised that the pilot was not a ED diversionary project.

“If a person turns up at a hospital ED, regardless of their symptoms, they will not be diverted to a GP urgent care network practice. The usual ED processes will apply,” she said.

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A call for expressions of interest to be a part of the pilot has produced encouraging results with 133 practices submitting applications, which, given the strict criteria around appointment access and proximity to services such as radiology and pathology, this is a significant number.

A website and app are in development which will show consumers which practices and what urgent care appointments are available at various times of the day. A public awareness campaign will also be launched to encourage people to consider heading down the road rather than across town to a public hospital for their urgent care needs.

“What will be built into the scheme is that even if your own GP is not participating, there will be a proper handover to the patient’s usual GP,” Chris said.

“This encourages better patient care as well as fostering better relationships between EDs and GPs, between GPs and diagnostic providers, and between GPs across geographic regions.”

out-of-pocket expenses. And they don’t have to be open 24/7 because demand is expected to spread across the network of urgent care practices.

“Obviously, there will be a narrative in people’s minds that they can go to an ED and get urgent care services free and in one place, so we are working on how we can support and build more capacity for these presentations in general practice so that access and convenience is compelling.”

A governance committee, with WAPHA chair Richard Choong, and representatives of RACGP (Dr Mike Civil), AMA WA (Dr Simon Torvaldsen), the WA Chief Medical Officer and an ED physician, is in the process of assessing applications.

GP and UWA academic A/Prof Alistair Vickery will evaluate the project and Curtin University’s A/Prof Suzanne Robinson will study behaviour change.

“It is a robust process and will create a level playing field for general practice,” Chris said.

Practices in the pilot are not required to bulk bill, but Chris said they do have to be transparent and forthcoming if there are

JUNE 2019 | 15

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Now the Hard Work Begins There are no quick fixes when it comes to health reform but one thing’s for sure, working together is the first major step.

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ust as Robyn Kruk can expect fewer transcontinental plane trips now her Sustainable Health Review (SHR) has been finalised, so too can we expect the hard work of implementation to gather pace.

At the launch, Ms Kruk lauded the importance of the WAPHA collaboration in the formulation of a number of the report’s recommendations.

This rankled the chair of the AMA (WA) Council of General Practice, Mt Lawley GP Dr Simon Torvaldsen, who voiced his view that the SHR did not consult enough with general practice, adding that many GPs did not believe that WAPHA represented them.

Medical Forum asked WAPHA’s General Manager of Strategy and Health Planning, Chris Kane, to explain just what role WAPHA did play during the process.

On the question of who and what WAPHA represents, Chris said the organisation never put itself out there to represent general practice.

“There are other groups which do that – the RACGP WA and the AMA WA and the advocacy that goes on from both those organisations’ at their state and national offices – and it’s not WAPHA’s role to duplicate their work. What WAPHA does do is provide support and advisory services for general practice. We also consult with GPs across WA to develop local strategies that make primary health care more efficient and more effective.

“We were invited by the WA Department of Health to contribute to the SHR by way of ensuring that the voice of primary care was heard so the review didn’t become a hospital-centric piece of work.”

“I was seconded over a period of 18 months to provide some direction on primary care policy; the role of Primary Health Networks (PHNs) in integrating care across the health system, but specifically between the health service providers (HSPs), and to facilitate timely GP and primary care stakeholder engagement into the SHR.” One of the key thrusts of the SHR is collaborative care among multi-disciplines, which raises the difficulty of coordinating allied health – a blanket term for numerous professions that don’t always have the same

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effective representative bodies in WA as medicine.

“WAPHA does fulfil some of that role and we have been working with the Australian Quality and Safety Commission to engage relevant allied health professionals in the development of standards for primary care.

They are voluntary and obviously won’t apply to GPs or pharmacists as they have their own standards,” Chris said.

“Hopefully this work will help with alignment and consistency across the different allied professions because certainly allied care figures prominently in the SHR and in commonwealth policy where general practice team-based care is concerned, such as Health Care Homes, the workforce incentive program and some of the recommendations from the MBS taskforce reviews.”

Translating into action “The tricky bit, now we are in the implementation stage of the SHR, is how that will translate. We don’t see our role confined to providing advice, position papers and engagement, We see ourselves as having a role in the implementation and will be having conversations with the Director General to this effect.”

“There are some key recommendations we are already working on, such as the agreement with WA Health and the PHNs, which will support integrated care between the department, the HSPs, the PHNs and WAPHA. We have good models in Western Sydney and Queensland to reference for these kinds of agreements.”

“WAPHA also ensured that the Joint Regional Mental Health Plan was embedded into the SHR – that is a COAG requirement for PHNs and HSPs to formulate a joint approach to mental health, particularly in the primary care space and that includes mental health treatment services, Alcohol and Other Drugs and suicide prevention.

more importantly – and sustainably – data access will be better shared to create more integrated services between primary and hospital sectors.

“The hospitals are really interested in how they can support better care in the community, so that means joint planning, joint funding, shared accountability and formalising that by way of agreement in these key areas. For us, those key areas are mental health, chronic heart failure [identified as an area of need in primary care with release of geographic hot spot data] and obesity.”

“We are not looking at airy fairy agreements.

We are looking at concrete integrated care initiatives.”

The road ahead is far from smooth and Chris warns that progress will be confounded if funding models for primary and hospital care don’t change.

“This is where political leadership must come in and, undoubtedly, it is being looked at. Whatever people want to say about the Health Care Homes policy, there’s a lot to be said for considering different funding models, remuneration for GP appointment times and patient enrolment,” she said.

“A lot of policy direction is going towards challenging fee-for-service and activity based funding.”

“In the meantime PHNs need to keep looking for the opportunities and levers to break down divides by collaboration and to continue our work, individually and collectively, with the major health service providers to identify where things can scale across to combine our resources.”

By Jan Hallam

With such an agreement, there is of course a cost sharing benefit between state and federal arms but perhaps

JUNE 2019 | 17

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Facing Up to Pain A WA invention is shaping up to be a game changer in assessing pain in those who can’t speak up for themselves.

T

he Australian Government announcement of a $5 million grant to extend the roll-out the WA-developed PainChek app into registered aged care facilities around the country is testament to how a great idea takes years of hard work.

which has allowed us to detect the face and landmark it. We then built an algorithm over the top of that to check pain-related facial expressions.”

Medical Forum first spoke to Prof Jeff Hughes about five years ago when he was the head of pharmacy at Curtin University. Then he excitedly related research of his PhD student Mustafa Atee who along with himself and co-supervisor Dr Kreshnik Hoti had devised a digital program that would identify and assess pain for non-verbal dementia sufferers.

“I still work at Curtin but I am part of a contract between PainChek Ltd and the university and I function as the Chief Scientific Officer. Mustafa works within the company as a senior research scientist and Kreshnik, who is currently at the Massachusetts Institute of Technology studying AI on a Fulbright scholarship, is a consultant,” Jeff explained.

As the idea germinated and attracted commercial and government attention, the concept grew to become a smart phone app, developed with the use of modified facial recognition and artificial intelligence technology, and trialled in the Regents Garden aged care facility in Scarborough.

Jeff is again brimming with excitement when he considers what this technology can mean for the aged care sector and beyond.

“We listed as a public company in 2016 and, yes, it’s gone from strength to strength. The early days was Mustafa, Kreshnik and me and we were all at Curtin.

We involved the Swiss-based Nviso IT company with it facial recognition software,

18 | JUNE 2019

PainChek has taken over the three men’s lives – in a good way!

WA leads the way

“There is so much potential for this technology. If we just look at the dementia app, it has been cleared by Australian regulator TGA as a Class 1 medical device and in Europe for the CE mark.”

“We have until now worked only in the aged care space but we are expanding to home care with a trial running in palliative care.

There is enormous potential to expand the user space for professionals working in primary care as well as family carers, and then there’s an enormous unmet need within the hospital setting.”

States hospital, while a prototype for an infant app was in development.

While all these variations are based on the same principle of facial recognition and analysis, there are different sets of facial expressions and non-facial indicators to calibrate, not the least with the simple fact that children’s physiology and facial morphology change constantly.

The scope of the app in the adult and paediatric spheres is enormous and not just in a clinical sense.

Family’s peace of mind “The Aged Care Minister Ken Wyatt was at the recent launch at Regents Garden in Scarborough and he introduced a woman whose mother is a resident there. Her story is not unique. Although her mother has not been overly troubled with pain, her daughter said the facility’s use of the PainChek app gave her peace of mind.”

“That could be said for every parent, including me, who has been up half the night with a fretful child. Having some indicator of the need for pain relief, or not, would have given me big peace of mind,” Jeff said.

“What we know is that about half of elderly patients who go into hospital for surgery end up having an acute delirium, which impacts on their care. And about a third of elderly patients on medical wards also have those problems.”

“My wife and I had 12 months of a very unsettled child and I was only reflecting on those days after hearing this woman’s story. Was my son in pain or was there another unmet need that we couldn’t work out? An app such as PainChek will give a lot of security to a lot of people and that’s what we’re hoping to do.”

From aged care to children’s pain and Jeff said a PainChek children’s app was set to enter the validation stage at an Eastern

“Research shows that 20% of children probably experience untreated acute pain.

They suffer migraine, they get reflux pain,

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FEATURE abdomen pain, joint pain and if not treated they can become chronic. And so for all our best effort not to give children pain medication when it is not required, there will be a percentage of children who are not medicated, or given other treatment, when it is required.”

“We have learnt skills over the time of this journey. We’re not programmers but we know what needs to be done and have collected libraries of children’s images undergoing things such as vaccinations and code then train the algorithm.”

The amount of work needed to clear the dementia pain app through the regulators in Australia, Europe and now in the US for FDA approval, is being replicated by the team working on the children’s app.

The app is in prototype and has undergone in-house testing. The next step, says Jeff, is partnering with a group that provides access to young patients undergoing painful procedures and compare PainChek against a standard pain tool.

Less second-guessing

having certain pain codes. After an interval, 6, 7 and 25 are present. No image is stored in that process,” he said.

“Within a nursing home setting, a picture on the resident’s profile page is stored as part of quality and safety procedures but privacy is maintained by not recording any real-time images.”

The app has been warmly welcomed at its trial site and Jeff said the second Regents Garden facility has started using PainChek and anecdotes are starting to filter back.

“We heard that a person who was not suspected as having pain issues using the old system, was identified by PainChek as having pain and as a consequence of intervention, that person’s behaviour improved.”

Jeff said that the $5 million from the government will help give 100,000 people in aged care access to PainChek. Currently cost per head depends on how many beds will be covered by a subscription, and price is negotiable.

As economies of scale settle down, Jeff is content with an even bigger prize than a successful business model.

“This idea that started so small will make a big difference to people’s lives. We all have good ideas but not all of them come to fruition. To change one person’s life is great but changing multiple lives is the best feeling.”

By Jan Hallam

Jeff said that PainChek was also proving to be a bonus when it comes to accreditation auditing for an aged care facility.

“The backend of the app allows analytics of user use so the aged care facility can demonstrate strong evidence that thorough pain assessment has been done.”

“The first area to be studied will be Face Leg Activity Crying Consolability (FLACC), which is a widely recognised tool but in the helter skelter of ED the best guess is still clinical judgement. Clinicians would find it very useful to use the same tool for every child so that when it comes to hand over a patient, there is tangible data. It will help enormously to maintain continuity of care,” Jeff said.

Eyes on consumers “And we have a lot of people inquiring about potential PC use so, slowly and surely, we are engaging with people to expand care.

There is great enthusiasm in the hospital setting and for the children’s app, and eyes are also turning to a consumer app.”

The PainChek app does not record or store images of individuals to protect their privacy.

“Carers need to be empowered and educated around pain and pain assessment in people with dementia. There is an absolute need to educate about behaviours in people with advancing dementia because it may not necessarily be dementia related.

They must always consider if there is an

“The app is trained on multiple images, so it will analyse in real time across a number of images of the patient. For instance it may select images 6, 7, 10 and 25 as

unmet need and that may not be pain, but if it is, it can be dealt with.”

And with the growth of more in-home services, the sky is the limit.

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GUEST COLUMN

Keeping the Doors Wide Open Three Bunbury women decided to create a support group to help other families caught up in the drug abuse spiral. Group chair Dr Jane Anderson explains how it works.

What can doctors do for patients with a substance disorder, or distressed family members who need support in the between times of referrals, appointments and treatment? The peer-led Bunbury community support group Doors Wide Open has sought to respond.

It helps individuals and families impacted by methamphetamine and other drugs.

Doors Wide Open was established in 2016, firstly as a Facebook support group for families living with a loved one experiencing methamphetamine dependency. It founders were mothers, Lina and Julie and Lina’s daughter Courtney, who were struggling to support family members through the devastating health and social impacts of their heavy drug use.

The trio’s experience of seeking and subsequently advocating for appropriate support services demonstrated that there was a great need for a peer-based service for both individuals seeking recovery and

family and friends who bear the adverse consequences. It is this experience that informs Doors Wide Open.

Requests for assistance from Doors Wide Open continued to grow to the point where a full-time service was needed.

With assistance from the Greater Bunbury community and the State Government, the organisation evolved into a fully-fledged community support service with its own dedicated premises in August 2017.

Today, we operate a centre where individuals and families in crisis can access immediate support and progress recovery.

People who come to our centre tend to have high thresholds of distrust so an informal approach helps to avoid potential embarrassment and perceptions of control.

Peer support workers, having walked the path before them, put those seeking help at their ease and create a sense of equality which helps with communication and is the basis for personalised assistance.

Indeed, we have among our staff and

volunteers, people who have overcome their drug dependency with courage and who now work with Doors Wide Open assisting others.

Doors, as it is affectionately known, has become “that place” where people know they can access a safe space receive compassionate, non-judgemental service, engage in programs and link with other agencies and the wider community.

Our peer support workers have developed a constructive working relationship with other service providers, including GPs. We assist with referrals and where requested, companion service users during appointments. We also provide support and friendship needed for those wanting, waiting or returning from medical, professional and rehabilitation services. www.doorswideopen.net/ ED: The state government helped Doors Wide Open establish a drop-in centre in with grant of $100,000.

It has just announced a further $85,000 to secure its viability.

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JUNE 2019 | 21

Doctor Burnout & Burning Issues Poll Profile Male

67.5%

Female

32.5%

Specialists

50%

General Practitioners

41%

Doctors in Training and Other

9%

Q

Private Health Loopholes

Q

Compare with 2016 results!

Should problems caused by medical examination or treatment while in a private hospital (iatrogenic illness) be covered by private health insurance funds?

2019

2016

Yes

91%

84%

No

0.6%

6%

Undecided

8.4%

10%

Q

Ice Age?

Codeine Rules

Do you think that codeine restriction to reduce opiate addiction (introduced February 2018) is working?

Yes

33%

No

29%

Undecided

38%

In your experience is there a methamphetamine ‘crisis’ in WA?

Yes

65%

Perhaps

20%

No

5%

Undecided

10%

happen. Then GPs, especially, have to wade through reems of bureaucracy, and then there are the patients who just cannot cope with life (who can blame them) but then they ‘dump in on the doc’ and expect us to fix them! We can sometimes help but we cannot run your life for you.”

Q

Culture Change

The last Doctors Drum looked at burnout of doctors (amongst other things). Do you think Juicy Carrots or Big Sticks are best to bring about positive change in the profession?

Juicy carrots

37%

Big sticks

4%

A combination

44%

Undecided

17%

Doctors Comment “To stop burnout, need shorter hours, ~60 hours a week, commensurate holidays with populous, and double the number of doctors we have now! Dream On.” “Hitting someone with a Big Stick who is already struggling to cope with fatigue, overwork and high levels of stress can only accelerate the slippery decline to burnout.”

donkeys. Support networks would be extremely beneficial…and ways of communicating with administration and bureaucracies which allow our concerns not only to be listened to but also acted upon with the doctors IN the team.”

“Burnout prevalent with this new generation. need more resilience training. Anaesthesia WA are pairing with psychologists to start and teach resilience in anaesthesia registrars and consultants.

“I suspect most GPs don't recognise their stress, they just feel tired. I wonder whether some specially designed retreat weekend workshop, with plenty of physical activities, rest and fun is a good and/or possible idea?”

“Higher Medicare rates would help, as you would need to see less bulk bill patients to make ends meet.”

“Look at the administrators and bean counters who are not at the coal face.”

“Medicare depends on the hard work of GPs yet all we get is more bureaucratic processes and less practical support, financial or otherwise. This has led to increased patient churn, deskilled, cynical and disheartened GPs and the free-fall of GP care standards in Australia many of us have witnessed over the past 25+ years.”

“To be honest, carrots and sticks imply

“Hospitals still set doctors up for this to

“Inept and disconnected hospital executives are a major contributor.”

22 | JUNE 2019

“Work life balance – Don’t take on too much.”

“Doctors need to make good choices.

Say no when appropriate and not just continue to work. It is vital to look after our physical, emotional and spiritual health to avoid burnout. But we have to make deliberate choices and realise we are not indispensable.”

“I am tired of being disapproved of.”

“Working harder trains how to prioritise, multitask and work more efficiently as well as greater experience. Two JMOs working less hard cost more than one working harder. Some JMOs do need to toughen up but it definitely requires a balance.”

“If Burnout isn't enough of a Big Stick, what else could be worse?”

“Burnout is an important issue, but we need to be careful of labelling all negative situations, negative emotions, normal workplace challenges as "burnout". Some of this is normal and expected. There are also personal achievements, workplace satisfaction and positive emotions that are derived from our professional roles. These are also normal and expected. To expect continuous 100% engagement is foolish.”

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EPOLL

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EPOLL

Q

Mental As Anything?

Is mental health’s devolution of affected people into the community working well?

Yes

5%

No

53%

Undecided

42%

Doctors Comment “Need more psychiatrists, psychologists and support staff, accommodative facilities. Costs???? How are we going to get more of the necessary people?”

“Anything is better than incarceration out of sight!”

“There is insufficient support in the community – both mental health care services and the practical but vital issues such as affordable housing. How is a homeless person going to recover from their depression?”

“I am a public psychiatrist! Mental health services are in constant crisis.”

“I am a senior consultant psychiatrist working in both the public and private sectors. The de-institutionalisation of patients, the involvement of NGOs with limited expertise and experience, and the steady growth of the mental health bureaucracy (eg a next to clinically useless Mental Health Commission) has steadily eroded the quality of life for many patients and hampered the ability of clinicians to deliver adequate care.”

Q

Who’s on the List?

The WHO lists these as the ‘top three’ as central to women’s health; 1. Cancer: breast and cervical 2. Unsafe sex is a major risk factor.

3. The human papillomavirus (HPV) infection remains the world’s most common STI. The rest relate to access to family planning, violence, mental health, obesity and healthier lifestyles, and health care of older women.

Whereas liver disease is ‘number one’ for men. Care to comment on WHO priorities (optional)?

“Strange! Violence, mental health and obesity would be my top three for women, and smoking, obesity and depression my top three for men.”

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“Need more psychiatrists in the public health system to see all those patients who cannot afford to see private psychiatrists.

I understand there is a cutback in the number of psychiatrists and yet nothing is done to address this.”

“Mental ‘unhealth’ is more prevalent than physical illness in our society. Multipronged prevention needed!”

“It’s near impossible for follow-up of mental health at community clinics. The real follow-up is via GPs doing the best they can, or presentation at emergency departments.”

“Excuse the pun, but it is CRAZY!” “Not near enough community mental health support or help to access community accommodation.”

“Too much buck passing.”

“It would work better if there were some resources – you have to be the right amount of mad, bad, sad or dangerous to know what community resources are available and effective. And then there's the 18 month wait list.”

“I find the most frustrating barrier is poor communication between the levels of care.”

“Prisons are becoming de facto mental health institutions but are not appropriately staffed.”

“It’s a nightmare, Victoria has a Royal Commission, we had a flimsy governance review.”

“There is not enough community services especially psychology that is affordable.”

“Persons with chronic severe mental health disease are poorly covered for support other that provided by the GP. Organisations under MHConnect will only take a six-month referral and then discharge the patient whereas these patients require ongoing consistent care.”

“To quote private psychiatrist: ‘the public service is so underfunded and poor that I can charge whatever I want and still be too busy’.”

“I assume that devolution refers to the management of the mentally ill by NGOs rather than health department staff. It is a form of obtaining cheap labour. Lower NGO wages result in high staff mobility.

The short-term funding cycles of NGOs results in peremptory changes of agency with negative results for patient care.”

“The main problem with mental health is accessing public services for anyone who is less severe than acutely suicidal or floridly psychotic. If there was better access to public outpatient psychiatrists with good plans sent back to the GP, then maybe there would be less need for the acute, inpatient services.”

“Many of the more severely unwell people continue to fall through the cracks while others have a great time using psych wards like a drop-in centre to see their friends.”

“They saved money by closing institutions but didn’t use it to fund care in the community.”

“I believe safety and mental health are the top issues.”

“It really seems a nonsensical list and a fascinating example of (political) narrative and agendas triumphing over science and reality.”

“Where is Mental Health? How can you stop "inbred" violence by people who have experienced it through their young lives? and the total change in morals in the last 60+ years.”

“Obesity and lifestyle (alcohol consumption) are more of a problem than this list suggests.”

“Family violence needs to be higher on the list, in my view. I am not sure of the numbers of deaths (my last memory of this was something like one a week) but the distress and mental illness for both women and girls must be huge.”

“I think way too much emphasis is placed on breast cancer treatment and not enough on modifiable risk factors like alcohol use and obesity and also not enough emphasis on the other killers such as heart disease.”

“DV, Mental Health and cancers.”

“WHO is not addressing the elephant in the room which is poor nutrition in the overweight western countries and the undernourished in the developing countries.”

“I think domestic violence and gender inequality which lead to some of these issues is probably more of a priority.”

“No poverty, illiteracy and culture which suppresses them contribute more?”

JUNE 2019 | 23

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What are Regional Training Hubs?

As with most new kids on the block, Regional Training Hubs are still finding their feet.

The manager of the project Carol Chandler explains why they are so necessary.

Regional Training Hubs (Hubs), have been operating for just 18 months.

The Hubs were set up through the Rural Clinical School national network to support medical students and junior doctors find their own regional, rural and remote training pathways.

In WA, there are three Hubs: • Kimberley/Pilbara • Midwest/Goldfields • Great Southern/South West/Wheatbelt The team at each of the Hubs is on the ground to assist individuals and in order to do so, Hubs must engage with a variety of local agencies and the two GP training colleges – ACRRM and RACGP. It is the role of Hubs to be involved in future medical workforce planning with on-theground experience and knowledge. An emerging issue is the ageing of this current medical workforce.

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In order to develop effective training capacity in the regions, a key component of success is an active ‘Trainer/Supervisor’ workforce.

A unique partnership has been formed in WA with the employment of a project officer jointly funded by ACRRM and the Rural Clinical School of WA This partnership has enabled a presence in WA and will give ‘a legs on the ground’ approach to explore innovative ways to expand capacity and develop meaningful rural training pathways with secure training posts for individuals.

Ms June Foulds, former CEO of the Greater Bunbury Division of General Practice, has been lured out of retirement to represent ACRRM in WA. Based in Bunbury at the RCSWA office, June is keen to work with students, ACRRM trainees and Fellows to ensure their needs are represented and met.

With the implementation of the National Rural Generalist Pathway this will require a distinct training experience for our trainees with a broad scope of advanced skills to enable practice in a variety of work settings.

After 16 years of data collection and expanding the RSCWA to 14 sites around the state, the results are in! Both rural and urban background graduates who started medical school interested in rural work, and who also did RCSWA, were 3.5 times more likely to be in rural work than graduates who started with rural interest but didn’t do RCSWA. RCSWA has proven and confirms that early interest in rural can be put into practice. In contrast, those interested in rural without RCSWA participation are less likely to become rural doctors.

The development of Regional Training Hubs has sparked interest, opportunities and support for potential training experiences, leading to what is expected to deliver increased numbers of trainees committing to rural medical careers.

ED: email hubs@rcswa.edu.au

JUNE 2019 | 25

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Finances for DiT – Starting Right Doctors on the threshold of their careers are encouraged to visualise where they want to be at the end of their working life, says accountant Michael Deeny.

So, you’ve finished your many years of study and are finally on your way to realising your dream of becoming a doctor. More than likely you are finding it hard to find time for family and friends, let alone think of your finances.

There are a few key things you should think about to ensure you are securing your financial future.

You probably have insurance cover for your car because you want to be able to replace it if something happens to it. But have you thought about what would happen if you couldn’t work due to sickness or injury?

Your most valuable asset is actually you.

Realising your financial and life goals depend on you going to work and generating an income. So if something happens to you, you need protection.

Having an adequate level of income protection insurance is important regardless of what stage of life you’re at and the level of cover should be regularly reviewed to ensure it continues to cover you as your circumstances change.

In the current superannuation environment, it has become more important to start contributing early in order to build enough wealth to meet your retirement needs. Even though retirement seems a lifetime away, planning and consistent monitoring is vital now to ensure your superannuation is always working towards your goals.

Salary packaging is a Tax Office approved method of paying for everyday items using pre-tax money. If you are a doctor working in the public healthcare system, you are entitled to reduce your taxable income by $9,010 during the Fringe Benefits Tax year (April 1 to March 31). Common expenses under this threshold are mortgage, rent, credit card payments and personal loans.

your taxable income and increasing your take home pay. If done correctly you can increase your take home pay by thousands of dollars.

Other items you can package over and above the threshold amount are meals card, mobile phone, laptop and tablet.

Additionally, if you are in the market for a car, consider purchasing through a novated lease. The arrangement allows you to pay for your vehicle finance and running costs (fuel, registration, insurance, servicing, etc) using pre-tax money.

Given the demanding nature of a doctor’s work and the unique issues that affect your profession, seeking advice from a financial planning specialist in the medical area early can help you formulate financial goals, will make the transitions easier and ultimately save you time.

ED: Michael Deeny is a senior accountant and associate at Smith Coffey specialising in DiT finances.

Salary packaging has the effect of reducing

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Improving Regional Cancer Outcomes Practical and relatable cancer symptom campaign featuring country GPs is helping save lives, says Cancer Council WA’s Hannah Cauchi.

Your postcode shouldn’t dictate the outcome of your cancer, but sadly it does for regional Australians.

Those living outside of a metropolitan area can face survival outcomes 20-30% worse than their fellow urban countrymen.

Find Cancer Early is a campaign aimed at addressing this disparity by increasing awareness of the early symptoms of common cancers among people over the age of 40 living in regional and remote WA. The message is to express their concerns to their GP, clinic nurse or Aboriginal health worker without delay.

The evidence-based resources include a television advertisement featuring regional GPs in the bathroom highlighting cancer symptoms, and a checklist identifying prostate, breast, skin, bowel and lung cancer symptoms separated into two levels of urgency.

Campaign material encourages earlier symptom appraisal and help-seeking by

using simple tested terms such as ‘blood in your poo’ and ‘problems peeing’. The response has been overwhelming with 97% of people surveyed saying the ad was relevant and easy to understand.

Evaluation last year found almost seven out of 10 regional Australians had seen the campaign.

This language saved the life of a 63-yearold Lake Grace resident who saw a campaign article about prostate cancer symptoms. He prioritised an appointment with his GP, and within a couple of days was on the operating table.

Nearly half of those made an appointment with a GP and an additional 43% monitored their symptoms.

Other regional respondents took action by visiting the Find Cancer Early website, actively increasing their symptom knowledge, contacting Cancer Council’s

13 11 20 support line or discussing their symptoms with family or friends.

Of those who didn’t take action, 41% considered making an appointment with a GP to discuss their symptoms – this could mean that they just needed one more prompt to follow through.

The next step is for all regional GP clinics, remote nursing posts and Aboriginal Medical Services to display symptom checklists in their rooms as a visual reminder for patients, visitors and clinic administrators to raise any concerns.

To complement the campaign, diagnostic guides featuring positive predictive values of prostate, breast, lung and bowel cancer symptoms are readily available online to support GPs’ clinical practice.

The Find Cancer Early website has been relaunched and now includes more information for regional communities.

Diagnostic tools and symptom checklist posters can be downloaded from www. findcancerearly.com.au/resource-hub/

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Patients First is Good Business There’s not much Carmel Harfield hasn’t seen in her business career but there is always so much more to learn!

“

I probably fell into it; I didn’t decide that I wanted to be a practice manager as such.

One of my initial roles was to assist an orthopaedic surgeon that had recently set up a new practice. He wanted someone who could assist in the treatment room, manage the front desk, and manage the back office. That was a very exciting and busy time.”

Carmel Harfield was reflecting on her eventful journey from registered nurse to practice owner.

“It was certainly a very different practice to what we work in now,” she told Medical Forum.

Compassion and business nous Soon after starting as a practice manager, Carmel completed a business degree, allowing her to combine her clinical knowledge with managerial skills.

“After several years with the orthopaedic surgeon, I found a fondness for the business side of general practice.”

Carmel started her own practice management consultancy, Professional Practice Development (PPD), leveraging her experience and skills to help clients start their own general practice.

“I see so many doctors wanting their own practices. Some doctors wanting assistance; just starting from a pile of sand, while others I help through to accreditation.

I see many wanting to buy into practices

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although unsure how to complete their due diligence.”

price and quality being weighed up by the patient.”

She purchased Kelso Medical Group in Kardinya in 2007, a practice that was initially founded in 1897.

New age practice manager

“That was an exciting and challenging time and I started to appreciate the need to micro manage and understand all of my KPIs in order to make the business sustainable. We implemented a lot of rigid business disciplines, and we adhered to those while we reviewed the business on a regular basis.”

Carmel’s business discipline has not led her to lose sight of the identity of a general practice.

“Our practice has a wonderful history of servicing the community. We like our doctors to take their time with patients, getting to know them and to understand their needs. We attribute our sustainability to our philosophy of ‘we care’, and our patients being our primary priority. That will never change.”

Business of general practice Carmel is sensitive to the fact that with the emergence of larger groups, smaller groups with one or two doctors have been forced to close but there were positives and negatives.

“The positives are being able to provide medical services throughout the day every day, which takes the pressure off of the public hospital system. However, the commercialisation of general practice has led to challenges of patient retention with

“It does not even look like the same job, when I think back, over 40 years,” Carmel said.

The most significant change is IT developments which have become integral to the management of the business.

“When doctors tell me they are going to manage their own practice, I fear they don’t really understand the challenges. It’s no longer about running a practice; it’s running a sustainable business. Unless someone has the skills and foresight to understand these challenges and how to get past them, then they are almost doomed from the beginning.”

“Having a multiskilled practice manager is pivotal – the multitude of responsibilities increase and vary on a daily basis. The modern day practice manager is required to have professional attributes and values to be able to lead a practice. They should have strong IT skills, be knowledgeable on current HR requirements, quality and accreditation requirements and OHS regulations and procedures to name but a few.

Has her passion lessened over time?

“I have certainly enjoyed the journey, but I am a long way from the finishing line. It has been a wonderful and at times a humbling experience, and if I could do it all over again, I would.”

By James Knox

JUNE 2019 | 31

32 | JUNE 2019

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CLINICAL OPINION

What does general practice expect from the Federal Government?

By Dr Sean Stevens, RACGP WA Faculty Chair When people ask me what I expect for general practice from the new Federal Government, I explain I am an optimist, hence I expect our new government will follow evidenced based policy and invest in general practice care to ensure the long-term health of our nation.

If evidence-based policy is to be followed, then it would make sense to incentivise longer consultations in general practice.

Australia’s population is getting older and the prevalence of chronic health conditions is rising. The complexity of consultations is also rising and this requires greater skill and more time from our GPs. The evidence is clear that longer consultations are associated with improved health outcomes including

reduced hospital admission rates, greater patient quality of life and improved longevity.

Paradoxically, longer consultations for complex care are not as well supported by Medicare as shorter consultations. A sixminute consultation has a per minute rebate of $6.27, whilst a 19 minute consultation has a per minute rebate of $1.88, a 39 minute consultation’s rate is $1.82 and a 60 minute consult has a per minute rebate of $1.79.

Effectively, every minute after six minutes you are receiving a lower rebate, despite the complexity, outcomes and quality of your care increasing.

I would expect our new Federal Government to see the error of successive governments over many years and promptly move to

raise the level C and D rebates by 18.5%, as called for by the RACGP. This would bring GP remuneration in to line with other medical specialists, it would remove the perverse incentive for six-minute medicine, it would reduce hospital (re)admission rates and it would improve the quality of life for our patients and ourselves.

There are many other things I’d like to see from our new Federal Government too, from a full indexation of Medicare, to payment for non-face-to-face care and the ability to charge a gap and still bulk-bill, but my optimism only goes so far. If they would only start with the modest step of raising the rebate for longer consultations then I would be a happy man.

ASK AN EXPERT

Mesothelioma & Asbestos

By Prof Fraser Brims, Director of Occupational Lung Diseases Service, SCGH & Curtin Medical School

ED

Mesothelioma may be rare, but many WA doctors will encounter this incurable cancer. Who is at risk and what can be done about it? ......................................................................

Asbestos - who is at risk?

The lag time from initial asbestos fibre exposure to developing mesothelioma may be up to 40 or even 50 years. At least two people a day are diagnosed with mesothelioma in Australia. WA has the highest incidence of mesothelioma due to the widespread use of all varieties of asbestos, not to mention the mining of crocidolite (blue asbestos) from Wittenoom during 1943-1966. Initially, most people diagnosed with mesothelioma worked with raw asbestos but then the focus switched to those working with asbestos products – mostly builders, plumbers, electricians, boiler makers, carpenters, railway and dockyard workers. Because two thirds of Australian houses built between 1950 and 1980 contain some asbestos materials, anyone doing renovations can expose themselves to asbestos fibres.

Concern over previous asbestos exposure - what should I do?

The risk of mesothelioma and lung cancer

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are strongly dose related, i.e. more exposure, greater risk. Taking an exposure history can help. Many years of exposure likely represents a recognisable risk for an asbestos-related cancer but putting an accurate measure against this is almost impossible. Similarly, if someone has been exposed for two or three weekends performing some minor renovations it is impossible to reassure them there is no risk, however, the risk is so low it is unmeasurable.

As there is an additive synergy between asbestos and tobacco exposure that increases the risk of lung cancer, patients must be told to avoid smoking.

Is one fibre of asbestos enough to get mesothelioma?

This frequently quoted statement has no scientific foundation. It is true that a oneoff exposure could be enough to cause mesothelioma, however, this is actually extremely rare as most asbestos fibres are cleared from the lungs just as other inhaled dusts are.

Pleural plaques on a CT scan; what should I do?

Pleural plaques are benign scars caused by asbestos. Not everybody exposed develops them and the risk of developing them is dose related. Pleural plaques are a marker of

exposure only and there is no increased risk of subsequent mesothelioma or lung cancer, or indeed any asbestos related diseases.

Should I screen patients who have had asbestos exposure?

We only screen when we can significantly impact the disease outcome and sadly, mesothelioma is incurable and there is no proven benefit from catching it early.

Screening for lung cancer using low-dose CT scans reduces mortality but only as part of a strictly controlled program, and only when the highest risk patients are screened.

Lung cancer screening is not endorsed or funded in Australia and ad hoc screening is definitely associated with harm to patients.

The Asbestos Review Program (ARP) is a unique program in WA of annual health check-ups for those exposed to asbestos.

In 2012 the ARP adopted ultra-low-dose CT scanning (radiation dose equivalent to a chest x-ray), successful at identifying people with lung cancer and following up those with high-risk nodules. The program has found that one in 100 people screened has lung cancer. All have been identified at an early stage and treated with curative intent.

For information about ARP, please contact fraser.brims@health.wa.gov.au or the ARP clinic on 6457 2922.

Author competing interests: nil relevant.

JUNE 2019 | 33

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CLINICAL UPDATE

Rural ENT emergencies

By Dr Ian Wallace, ENT Surgeon, Cottesloe I am reminded of the privilege we enjoy in the city - we have 24 hour emergency cover through the public hospitals and as an ENT consultant, I am backed by trainee registrars - none of this is available to country GPs other than phone advice.

Google Scholar shows an analysis of 20,563 adult attendances at an ENT emergency clinic in Paris. The most frequent presentations were: pain, sudden loss of hearing, bleeding and swallowed foreign body. The most frequent nasal problem was epistaxis, the most frequent ear problem was middle and external ear infection and the most frequent throat problem was foreign body ingestion.

Just 1,225 were hospitalised - most frequently epistaxis, peritonsillar abscess, sudden hearing loss and swallowed foreign body. A little more than 100 patients required immediate transfer to the operating theatre.

may need to be addressed. Once this has been done, the balloon can be deflated in 24-48 hours and then removed an hour or two after no further bleeding.

In cases where you are confident the bleeding arises from the anterior septum, chemical cautery can be done after pretreating the area with local anaesthetic solution applied on a plug of cotton wool.

Sudden hearing loss Sudden hearing loss can be inner ear failure or middle ear and eustachian tube blockage. The former has a very rapid or sudden onset and a tuning fork on the forehead (Weber test) localises to the opposite ear. The primary treatment before referral is high dose prednisolone (low level supporting evidence).

Eustachian blockage comes on over a period of hours and the tuning fork sound localises to the affected ear. Antibiotic treatment with or without prednisolone is usually appropriate before referral.

Epistaxis

Swallowed FB

Epistaxis for the country GP is most easily managed using some form of balloon tamponade such as Rapid Rhino®. Many older patients take blood thinners and this

A swallowed FB in an adult is most commonly a fish bone. This may get caught in a tonsil, in the base of tongue or behind the larynx at the opening of the oesophagus.

In rural areas the KISS principle applies. These tips by an experienced ENT specialist on four common ENT emergencies may help.

Fish bones are often difficult to see and the only one likely to be successfully removed in the GP setting is the one impacted in a tonsil. The patient will localise the pain to the affected side. If not visible, wiping the tonsil with cotton wool may catch and identify the bone.

Peritonsillar abscess A peritonsillar abscess or quinsy is almost always unilateral. Many cases can be managed with antibiotics but the severely painful ones commonly ‘point’ into the soft palate above the tonsil. This spot can be incised for drainage and pain relief.

A useful tool for this is an 11 scalpel blade half wrapped in tape to prevent cutting too deep.

Author competing interests: nil relevant disclosures. Questions? Ask the editor.

Low dose Aspirin-who benefits?

By Dr Stephen Gordon, Cardiologist, Subiaco There is no controversy in secondary cardiovascular prevention. Aspirin (or alternative antiplatelet agent) remains indicated for all patients with clinical cardiovascular disease (CHD, P.A.D, and ischaemic cerebrovascular disease).

KEY MESSAGES No routine place for Aspirin in primary prevention.

Aspirin remains indicated for secondary prevention.

No role for Aspirin in atrial fibrillation.

Aspirin, once considered the 'wonder drug' for its 'proven benefits and cheapness', has come under close scrutiny in recent years.

In contrast, Aspirin in primary prevention is now being significantly challenged. In 2018 three large quality trials of Aspirin versus placebo in high risk primary prevention patients showed no net benefit. Whilst a modest reduction in cardiovascular events was observed, that benefit was balanced by an increased risk of serious bleeding with no net mortality benefit.

no net benefit for Aspirin over placebo for mortality, cardiovascular mortality or stroke risk. There was an 18% reduction in MI risk, but with a 47% increased risk of major bleeding and 33% increased risk of intracranial haemorrhage.

are on statins (and appropriate lifestyle changes). Aspirin should not be considered routinely for primary prevention. It may have a place in very high risk patients with documented atherosclerotic disease who haven't had symptoms or a clinical event and who are at low bleeding risk.

This requires careful case by case clinical judgement, as it remains unproven.

A meta-analysis published this year of 157,248 patients across 11 trials showed

The cardiovascular benefits of Aspirin seen in earlier studies may also be lost if patients

continued on Page 37

MEDICAL FORUM

JUNE 2019 | 35

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CLINICAL UPDATE

Prescribing in kidney disease â&#x20AC;&#x201C; an elusive art

By Dr Anoushka Krishnan, Nephrologist, Nedlands The clearance of several medications depends upon reasonable kidney function, particularly important for those drugs with a narrow therapeutic index. Dose reduction may be required, not because these drugs are directly harmful to the kidneys but because they have the potential to cause toxicity through reduced drug elimination and accumulation of metabolites (examples in table 1). Apart from avoiding side effects through dose reduction, other methods include lengthening the dosing interval or using a safer alternative.

Making sense of the eGFR Most commonly, the estimated glomerular filtration rate (eGFR) is used as a guide to give drugs at an appropriate dose.

Its calculation depends upon creatinine (an endogenous substance) as a marker

KEY MESSAGES Drug doses usually need reduction or cessation with significant kidney impairment as clearances are reduced, resulting in an increased risk of toxic side effects. eGFR measured by the CKD EPI equation is now routinely used to estimate kidney function. eGFR relies on creatinine which is inaccurate when kidney function is not stable. of kidney function. While a number of formulae exist to calculate the eGFR, they have disadvantages and cannot be relied upon if kidney function changes rapidly such as in acute kidney injury.

We have the Cockcroft Gault equation (developed in the 1970s) which however,

Table 1. Toxicity from accumulated metabolites if doses are unadjusted in significant kidney impairment

Metformin1 Sulphonylureas2 Allopurinol2 Apixaban2 Enoxaparin2 Pregabalin2

EGFR* <30 <15 <30 <15 <30 <30

ADVERSE EFFECTS Lactic acidosis May predispose to hypoglycemia, especially in longer acting agents May result in higher frequency of developing hypersensitivity reactions Increased bleeding risk Increased bleeding risk Drowsiness, narcosis

*ml/min/1.73m2 1 Avoid in significant kidney impairment 2 Dose reduction suggested; monitor for toxicity

Prescribing medications in patients with kidney failure can tread the fine line between achieving therapeutic drug levels and toxicity. has not been validated with standardised creatine assays, the move to automation and the MDRD formula (after 2006), which lacks accuracy in populations with normal or near-normal kidney function, categorizing more people as having chronic kidney disease (CKD). Then the eGFR was calculated using the CKD EPI equation (2009), which became the equation of choice in most laboratories because it led to reduced prevalence of CKD with a more accurate risk prediction for adverse outcomes.

The use of creatinine to estimate the GFR has its limitations: variations in creatinine production (e.g. diet, muscle mass), creatinine secretion (effect of drugs); issues with laboratory measurements (assays used); and the non-linear relationship between creatinine and kidney function (e.g. a doubling of creatinine does not necessarily mean a halving of kidney function).

Furthermore, if the CKD-EPI or MDRD equations are used for drug dosing in very large or small patients the estimated GFR (normalized to body surface area) should be multiplied by the estimated body surface area before being divided by 1.73 to obtain an estimated GFR in units of mL/min.

Author competing interests: nil relevant disclosures. Questions? Contact the editor.

continued from Page 35

Low dose Aspirin-who benefits?

There are no randomised trials of Aspirin based on results of calcium scoring.

Recent Australian NHF / CSANZ Guidelines for coronary calcium scoring have made recommendations based on extrapolation of risk, suggesting that Aspirin be considered in patients with calcium scores above 400, or scores between 100 and 400 that fall above the 75th percentile for age. Those recommendations have not considered the large recent negative trials of Aspirin so again adopt a case by case decision based on clinical judgement.

MEDICAL FORUM

Despite evidence from early AF trials suggesting benefit, recent analyses indicate little or no benefit from Aspirin in high risk patients for thromboembolic prevention. Furthermore, bleeding risks associated with Aspirin appear to be nearly as high as the risk on NOACS. Thus, recent guidelines recommend no current role for Aspirin in AF. Some studies have indicated a reduced colorectal cancer risk associated with Aspirin. Except for one study showing benefit in patients with Lynch syndrome

with high genetic cancer risk, no large randomised trials in lower risk patients are published, so evidence is not conclusive.

It can be considered for colorectal cancer prevention, on an individualised basis, in patients 50-70 years, with at least 10% ten year risk of cardiovascular event, low bleeding risk, willing to take daily Aspirin for at least 5-10 years.

Author competing interests: nil relevant disclosures. Questions? Contact the author.

JUNE 2019 | 37

Perth’s Newest Specialised Cancer & Haematology Day Clinic

Introducing Medical Oncology Services to our clinic DR WEI-SEN LAM MBBS FRACP MHA

Dr Wei-Sen Lam is a medical oncologist who treats a broad range of cancer with interests in lung cancer and melanoma.

Dr Lam graduated from University of Western Australia and completed his specialist training at Fiona Stanley and Sir Charles Gairdner Hospital.

Wei-Sen has a keen interest in research and is actively involved in clinical trials.

Dr Lam was a successful recipient of the WA Cancer and Palliative Care Network Fellowship and is a principal investigator in several lung cancer trials at Fiona Stanley Hospital. Dr Lam is actively involved in education as the co-chair for WA Clinical Oncology Group (WACOG).

He also has a Masters of Health Administration with Monash University and is currently the clinical lead for Medical Oncology and TeleOncology for WA Country Health Service. He is passionate for improving cancer services for rural and remote WA and is known for his kind and approachable manner.

Our Haematologists: Dr Maan Alwan, Prof. Ross Baker, Dr Peter Tan

Our Clinic: • Patient focused with family support & involvement • Tranquil setting • Clinical Trials • Allied Health

Western Haematology & Oncology Clinics 18 Prowse Street, West Perth WA 6005 P: 08 6146 1400 E: info@whoc.com.au 38 | JUNE 2019

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CLINICAL UPDATE

Antimicrobial resistance – where are we?

By Dr Astrid Arellano, Infectious Disease Physician, Subiaco Although the prevalence of multi-drug resistant organisms in Australia is low compared to the US, Europe and Asia the pattern of antibiotic resistance and indiscriminate antibiotic use in Australia is rising with concerning trends. Australia has one of the highest rates of Vancomycin resistant Enterococcus faecium (VRE) with 4996% of Enterococcus faecium isolates being vancomycin resistant. Only two or three antibiotics are currently available to treat VRE. E.coli resistant to quinolones (e.g. ciprofloxacin) and extended spectrum betalactamase (ESBL) producers increasingly cause UTIs and bacteraemia. Many (23%) are multi drug resistant (MRO). Studies

KEY MESSAGES Antibiotic use in Australia is widespread and indiscriminate.

Many antimicrobials are used where the demonstrable benefit is low or non-existent.

We need to increase efforts to reduce unnecessary prescribing.

of MRO colonisation among Asia Pacific region populations show rates of 20-46%.

An Indian study showed acquisition rates of up to 90% among visitors who developed traveller’s diarrhoea. Once colonised, ESBLs become part of our gut flora without eradication regimens available.

Common Indications for antibiotics

ACUTE CYSTITIS Uncomplicated Trimethoprim PO 300mg daily (3 days) OR Cefalexin PO 500mg BD (5 days) Complicated, pregnant, men (5 days)

Cefalexin PO 500mg BD OR Nitrofurantoin PO 50-100mg QID

ACUTE PYELONEPHRITIS Mild Amoxicillin-clavulanate PO 875 + 125 (10-14 days) mg BD OR Cefalexin PO 500mg BD Severe Gentamicin* + amoxicillin 2g IV QID OR If Gentamicin contraindicated, use Ceftriaxone 1g IV daily

COMMUNITY ACQUIRED PNEUMONIA Mild Amoxicillin PO 1g TDS OR Doxycycline PO 100mg BD (Roxithromycin PO 300mg daily in pregnancy) Moderate Benzylpenicillin IV 1.2g QID plus Doxycycline PO 100mg BD Severe Ceftriaxone IV 1g daily plus Azithromycin IV 500mg daily CELLULITIS Mild/Early

Severe

* Gentamicin dose: 5mg/kg/day if CrCl>60mL/min ** Vancomycin dose: 25-30mg/kg loading dose Source: Therapeutic Guidelines: Antibiotic, version 16, 2019

Flucloxacillin PO 500mg QID (Suspect MRSA: Clindamycin PO 450mg TDS) Flucloxacillin IV 2g QID (Suspect MRSA: **Vancomycin IV 2530mg/kg)

We read sensation about antibiotic resistance and say, “That’s a terrible situation but it’s not going to happen to me, my family or my patients”. We are wrong.

In Australia, 50% of E.coli are resistant to amoxicillin, 20 and 25% are also resistant to amoxicillin-clavulanic acid and cefalexin, respectively. Salmonella resistance to fluoroquinolones is present in over 50% of typhoidal species and 20% of Shigella sonnei isolates. Empiric antibiotic choices for Gram negative infections are becoming difficult.

Some 10-30% of Staphylococcus aureus are MRSA causing a significant number of infections requiring clindamycin, trimethoprim-sulphamethoxazole or IV vancomycin. Of particular concern is the emergence of reduced penicillin susceptibility (26%) in Neisseria meningitidis with the recent isolation of a ceftriaxone-resistant isolate in WA. In 2015, over 30 million antibiotic prescriptions were dispensed via PBS/ RPBS and this rose to 45% of the population receiving an antibiotic in 2017.

Over 60% of patients with respiratory tract infections were prescribed an antimicrobial and 15% of amoxicillin-clavulanate scripts were not indicated.

In hospital prescribing, 23% of antibiotics are not compliant with guidelines and 22% are inappropriate with the greatest problem (27% of cases) related to over 24 hours of antibiotics for “surgical prophylaxis”.

Among aged care residents 11% are on an antibiotic at any one time with only 4% showing signs and symptoms of infection. A third of prescriptions are of over six months duration. Only 50% have an indication documented with 2% having a stop-date.

We are surrounded by countries where antimicrobials are easily available without prescription and these countries are frequented by many Australians. The likelihood of a steady rise in MRO and MRSA is high and we may find ourselves being unable to treat simple UTIs or bloodstream infections with the resulting Australia-wide financial and health consequences.

Author competing interests: nil relevant disclosures. Questions? Contact the author.

MEDICAL FORUM

JUNE 2019 | 39

THE VEIN CLINIC CELEBRATES 5 YEARS

A dva nc e d Va r ic os e Ve in Tr eatmen ts

The Vein Clinic is thrilled to be celebrating its 5th anniversary and wishes to acknowledge all of our valued referrers.

Venous Eczema

BEFORE

Varicose Veins

AFTER

BEFORE

AFTER

Why refer to us?

Key milestones to date

We are Perth’s only dedicated Varicose Vein Clinic and as such our advanced treatments overcome many of the limitations associated with traditional sclerotherapy and surgery.

• Over 1,500 new patients consulted

We have a laser focus on excellence in the diagnosis and management of superficial venous disease.

Our results speak for themselves with a 99.5% initial closure rate being achieved with laser (EVLA) treatments on Saphenous Veins.

• Over 1,000 procedures performed • Eight new/improved vein treatments developed/introduced We have come a long way in five years and with your support will continue to grow and deliver optimum results and patient outcomes over the next five years and beyond.

Could you or someone you know benefit from our services?

What we offer patients Highly tailored multimodality treatments (ie. EVLA/Glue/Foam/Phlebectomy) Short waiting times

Clinic based diagnosis and treatment Walk-in walk-out procedures

Streamlined assessments

Central convenient location (opposite Subiaco Station)

Value and convenience

Private health insurance is not required

Advanced modern treatment options

Medicare rebates apply

Call us today on 9200 3450 or visit veinclinicperth.com.au 40 | JUNE 2019

Unit 6, 28 Subiaco Square Road, Subiaco | admin@veinclinicperth.com.au

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CLINICAL UPDATE

How valuable is cardiac ultrasound?

By Matthew Erickson, Interventional and Echo-cardiologist, Nedlands & Murdoch Cardiac ultrasound provides rapid high-resolution imaging of the heart in real time, demonstrating the physiology of the heart in normal, and pathological conditions.

Transthoracic echocardiography (TTE) measures chamber sizes and reveals ventricular and valvular function. Filling pressures and patient volume status can also be assessed.

Advances in imaging quality, digital acquisition, portability, superior frame rate and relatively inexpensive cost when compared to CT, nuclear medicine and cardiac MRI have resulted in echocardiography’s continued and expanding use.

Transthoracic echocardiography applications in general practice.

1. Investigation of dyspnoea Dyspnoea is often a multifactorial complaint.

Increasing age and co-morbidities increase co-existent cardiac disease.

Contributors to dyspnoea detected by echo include impaired systolic and diastolic dysfunction, valvular dysfunction (i.e. aortic stenosis, aortic and mitral regurgitation), and infiltrative cardiomyopathies. Echo is pivotal in the detection of cardiac contributors, and in guiding appropriate management.

2. Left Ventricular ejection fraction (LVEF) dependent therapies Implantable cardiac defibrillator (ICD): LVEF ≤ to 35% for primary prevention on optimal medical therapy (OMT).

Cardiac resynchronisation therapy (CRT): LVEF <35% and left bundle branch block (LBBB) on OMT.

The sophistication of echocardiography is growing, putting it far beyond defining valvular heart disease.

Entresto - new heart failure pharmacologic combination Valsartan and saccubutril, shown to improve mortality, reducing hospitalisations and symptoms in class 2-4 heart failure compared to ACE inhibitors.

LVEF ≤ 40% on OMT.

4. Dilated ascending aorta and bicuspid valves.

Patients with an ascending aorta greater than 4.0cm should be assessed by a cardiologist.

Eplerenone - a mineralocorticoid inhibitor, improves survival post myocardial infarction, LVEF ≤40%.

All patients with a bicuspid valve should be assessed by a cardiologist due to the coexisting aortopathy and risk of aortic dissection.

3. Valvular follow-up Moderate-severe native valvular disease. Generally, a yearly echocardiogram is performed in moderatesevere native valvular disease, where an intervention may be considered (i.e. valvular replacement or repair).

First degree relatives of patients with aortic dissection, aortic dilatation or bicuspid aortic valve, should also be evaluated with an echocardiogram due to familial clustering.

Prosthetic valves. A baseline TTE should be performed around 4 weeks to assess mechanical and bioprosthetic valves when anaemia and postoperative changes in physiology have resolved.

In the absence of a change of clinical status, the American society of echocardiography do not recommend routine follow up for mechanical valves.

For bioprosthetic valves (usually a stented tissue valve of bovine pericardium), routine yearly echocardiograms are not indicated until five years, as the valves are not expected to fail within this time. More frequent checks are of course indicated with changing clinical status.

5. Family screening Echocardiography is useful to identity and exclude morphological changes of Hypertrophic cardiomyopathy, dilated cardiomyopathy, Marfan’s syndrome and bicuspid aortic valve.

6. Other conditions for routine echocardiography (2-5 yearly) Hypertension: LA dilatation, aortic dilatation, LV concentric hypertrophy.

Pulmonary hypertension: Diagnosis, monitoring, right heart function assessment.

Renal dysfunction: hypertensive changes, coexistent valvular and coronary disease, filling status.

Systemic conditions: Amyloid, SLE, vasculidities, severe pulmonary disease (right heart).

Mindfulness and its use in therapy

By Jonathan Kester, Psychotherapist, Fremantle Ron Kurtz, the founder of Hakomi (a mindfulness-based approach to self-understanding), recognised that teaching clients to be mindful assisted them to raise their awareness of the moment-to-moment experience of themselves in ways that no other therapeutic method had done before.

This can create in the client the opportunity to deepen their experience and allow material to arise from the unconscious, assisting healing and improving insight.

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Mindfulness, when practiced in Hakomi, is not meant to be relaxing nor be a form of meditation to create an altered state of consciousness. Its primary aim is to heighten conscious awareness, to become more alert to what is actually happening mentally, emotionally and physically in the body.

When a therapist conducts a mindfulness induction exercise to bring a client into greater awareness of their experience, the client is encouraged to foster an attitude of curiosity and total acceptance of whatever emerges, without judgement or criticism

Mindfulness is different to meditation to relieve stress. It can increase someone’s awareness or how they view the world. of their experience. The focus on somatic experience is also important and when thoughts come, clients are encouraged to first notice, accept and then let them go so that their whole attention can be directed to what they are experiencing in their body.

continued on Page 43

JUNE 2019 | 41

NeuroSpine Institute is Now Open APPOINTMENTS

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NeuroSpine Institute offers a specialised service to prioritise patients with newly referred arm or leg pain with proven nerve compression on CT or MRI.

(1800 638 767)

E info@neurospineinstitute.com.au

We are a new multi-disciplinary specialist practice of surgeons offering advice and treatment across the full range of spine and brain conditions.

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We get spines working.

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This multi-disciplinary service includes neurosurgeons and spine surgeons, interventional pain specialists as well as psychologists and specialist exercise rehabilitation staff.

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Workspine has three convenient locations listed below.

Contact us now and let your patients be managed by our expert team.

Dr. Andrew Miles FRACS

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42 | JUNE 2019

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CLINICAL UPDATE

Is a cochlear implant right for this person?

By Lize Coetzee, Audiologist, Subiaco Hearing loss currently affects 1 in 6 Australians. GPs, through an improved understanding of the investigation and management of hearing loss, have the potential to change the lives of hundreds of Australians. Hearing implant technology is rapidly evolving so identifying patients suitable for cochlear implantation and streamlined referral can be useful.

Hearing loss impacts on personal and professional relationships, and mental health and physical wellbeing. Despite this, <10% penetration occurs in adults around the world for cochlear implantation (i.e. more than 90% of people miss out).

What is a cochlear implant?

Melbourne surgeon scientist Prof Graham Clark designed the first multi-channel ‘bionic ear’ and performed the first cochlear implant in 1977. Since then, Australian implant company, Cochlear™ has supplied more than 550,000 hearing implants across the world.

Cochlear implants are becoming more commonplace and these notes will assist you with patient selection.

KEY MESSAGES A cochlear implant aims to improve speech perception.

Candidates include those with unilateral hearing loss, Meniere's disease and poor speech understanding.

The first step is an audiogram and assessment by an implant audiologist. electrical stimulation to the auditory nerve, delivering sound directly to the brain.

Who should be considered for a cochlear implant?

Cochlear implantation involves usually safe, short-stay surgery. Most recipients have moderate to profound hearing loss and poor speech discrimination in one or both ears.

The audiogram and aided speech perception are two main determinants for cochlear implant candidacy. More recently, candidacy has expanded to include onesided hearing loss, patients with significant residual hearing but poor speech discrimination, Meniere’s disease and even patients with acoustic tumours.

To obtain an audiogram, speech perception results and more information on suitability for cochlear implantation refer any patient to a hearing implant audiologist. Referral to the public system directly requires an up-to-date audiogram (ww2.health.wa.gov. au/Articles/F_I/Hearing-loss), so referral to a hearing implant audiologist may be warranted beforehand.

Referral to an implant centre will determine if cochlear implantation is recommended, based on further testing.

What is the cost of a cochlear implant?

Cochlear implants can be funded both privately or publicly. For someone on gold and silver private hospital and ancillary insurance cover, they can expect no prosthesis out-of-pocket expense.

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A cochlear implant is a sophisticated electronic medical device that bypasses damaged sensory hair cells within the cochlea (inner ear) to directly stimulate auditory nerves. A cochlear implant consists of two parts:

• First, is the external sound processor; it collects and processes the sound and converts it into a radio frequency that is sent through the skin; • Second, is the internal implant - the receiver stimulator and electrode, which is inserted into the cochlea and provides

Most hearing aid users should be able to communicate with family and friends, hear in a medical appointment or over the phone. If they do not, they should be reevaluated for a cochlear implant.

Cochlear implantation should also be considered for those who do not find their hearing aids of enough help, despite programming by an experienced hearing aid audiologist.

What outcomes can you expect?

The key aim of cochlear implantation is to improve speech perception. As technology has improved, so have the published speech perception outcomes for cochlear implant recipients. Our research has shown that between 3-12 months post-implantation, 82% of recipients score above 90% on tests of sentence understanding.

The author wishes to acknowledge the help of Prof Marcus Atlas in the writing of this article.

Author competing interests: no relevant disclosures. Questions? Ask the editor.

continued from Page 41

Mindfulness and its use in therapy When Hakomi-based mindfulness is incorporated into a therapeutic process, clients observe their experience rather than get totally absorbed by or lost in it.

Mindfulness allows the “adult observer” to be in place and the therapist can engage with that part of the client to maintain an objective perspective about what is happening.

The client can simultaneously observe and experience child consciousness states and beliefs while remaining in total awareness as an adult of being with their therapist. Rather than detract from the therapeutic process, this dual state of awareness enhances the effectiveness of the therapy fostering the integration process of making meaning of the experience.

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KEY MESSAGES Mindfulness can enhance therapy benefits.

Techniques can be used in daily life.

Awareness allows the user to be responsive not reactive.

When clients have learned to use mindfulness in therapy they can incorporate it into their daily lives as a practice in the same way other people use various forms of meditation to help stay calm and less reactive to stresses. Because of the nonjudgemental aspect of Hakomi-based mindfulness, one can be more objective,

accepting and compassionate towards others and more responsive rather than reactive to what others say or do.

When we are being responsive, we are being fully conscious and aware of what we say or do. Whereas when we are being reactive, what we say or do is automatic and arises from the unconscious. With mindful awareness we can carefully choose what to say or do rather than be impulsive in our behaviour.

Author competing interests – nil relevant disclosures. Questions? Contact the editor.

JUNE 2019 | 43

TRAVEL

Japan is Blooming Cherry Blossoms Welcome to the cultural phenomenon that is Japan’s cherry blossom season.

Japan’s hundreds of thousands of cherry trees blossom from late March to early April when the countryside is festooned with fresh pink and bright green.

The country’s iconic Sakura (cherry blossom) captures the attention of visitors and locals alike as the beautiful pink flowers blanket the country in soft, colourful splendour.

Discovering the spring culture of Japan is no less than magical. The cherry blossoms coincide with Japan’s graduation season and the time when people start jobs and attend new schools.

As the petals fall many people are leaving their old jobs and starting something new.

So the cherry blossom season is regarded as a symbol of renewal, vitality and beauty.

Visitors to Japan will also be jostling for space with the locals, who all come out to enjoy hanami (picnics) beneath the blooming cherry trees – and many have a rollicking good time of it.

It seems the entire nation erupts in cherry blossoms – Tokyo, Osaka, Nara, Hiroshima, Nagano, Fuoka, Okayama, Aonari and the list goes on. Cherry blossoms flower at varying times, based on their geographical location.

Blooms usually open first in the southern region and progress north.

The first blooms are called Kaika and when the tree is in majestic full bloom it is call Mankai.

The cherry blossom, Japan’s national flower, is steeped in centuries of tradition.

44 | JUNE 2019

It appears on the 100 yen coin, and is the subject of many Japanese folk songs, such as Sakura Sakura.

Sakura is also revered as a symbol of rebirth. It is believed that hanami was established as a ritual as early as 710 and before Buddhism was believed to represent the mountain deities that transformed into the gods of rice paddies in Japanese folk religions. Now the cherry blossoms are considered metaphors for the ephemeral nature of life and its great beauty.

Cherry blossoms often get confused with the Japanese plum tree, as they bloom just before the plum season. Both trees range in colours from white, to pink to red. Cherry blossoms can be distinguished from plums by a small split or notch in each petal.

Cherry blossoms also produce multiple flowers per bud where the Japanese plum tree produces only one.

The best cherry blossom viewing locations in the country are Hirosaki Castle Park

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T

here is only a small time window – a scant two weeks – in which to enjoy the experience, but it is spectacular.

TRAVEL

where there are 2,600 flowering cherry trees. Equally spectacular is Tokyo’s Shinjuku Gyoen National Garden.

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An estimated 63 million people travel to Japan each year to view the cherry blossoms, spending about $US2.7 billion.

When in Japan, you can’t miss its other great iconic attraction – Mt Fuji – and catching a glimpse of this famous peak takes your breath away.

Mt Fuji has many different personalities, depending on the season. Winter and spring are the best times to see it in all its glory. We went in spring and were lucky to see the snow-caps before the cloud came across but be aware that visibility can

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disappear in a flash when a blanket of mist descends suddenly.

Perhaps this Japanese proverb sums it up: He who climbs Mt Fuji once is a wise man, he who climbs it twice is a fool.

Our third must-see was a trip to the snow monkey onsen, which is located in the valley of the Yokoyu river – a part of the Koshinetsu’kogen National Park.

The main onsen bath was constructed specifically for the use of the monkeys. The free-ranging monkeys descend from the steep cliffs and forest to sit in the warm waters of the onsen, and return to the forest in the evening.

In 1963, a young female macaque clambered into a hot spring to collect soya beans that were floating on the surface of the water and the behaviour was copied by others in the troupe, and it soon became common for the monkeys to retreat to the hot pools when the harsh winter arrived.

Naturally, tourists followed soon after.

However, you need to start in Nagana to organise the trek to the monkeys.

By Jenny Heyden

JUNE 2019 | 45

46 | JUNE 2019

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WINE REVIEW

St Hallett Steeped in Tradition St Hallett, located in Tanunda in the heart of the Barossa Valley, began in 1944 as a maker of ports, sherries and marsala. The owners, the Lindner family, had been in the Barossa since 1838 when ,like many of his countrymen, Johann Lindner came to South Australia to escape the religious persecution in his native Germany. His grandson Pop opened a butcher’s shop and planted the Old Block vineyard in 1912. Pop’s son Bill, who trained at Orlando, began to make wine in the old butcher’s slaughterhouse. The wine was named after the explorer John Hallett from the Hallett Valley. The title of ‘saint’ reflected the Barossa’s strong connection to the Lutheran Church. Times were tough at the beginning with the family barely eking out a living from selling wine and smallgoods from the butcher’s shop.

By 1972 the business was saved from bankruptcy by a cash injection from a relative Uncle Dicky Lindner. From there things picked up with the production of various ports with names such as Perth Cup Port and Melbourne Cup Port. In 1980, the first Old Block Shiraz was made from the original vines planted in 1912. The advent of the ’90s saw the evolution of St Hallett under the guidance of Stuart Blackwell.

The company came to be highly regarded for its range of quality wine predominantly shiraz, from all areas in the Barossa Valley and surrounds. Today it has the reputation of being one of Australia’s leading producers of finely crafted shiraz.

By Dr Louis Papaelias

Senior Winemaker Toby Barlow

Eden Valley Riesling 2018, $20 (RRP)

Blockhead Shiraz Grenache 2017, $26

A finely crafted Riesling from the cool Eden Valley showing juicy texture with hints of lemon zest finishing crisp and dry.

Proudly named after the stoic early settlers of the Barossa. Rich and lively with berry aromas of grenache and spicy chocolate Shiraz. Attractive and fruit driven.

Dry Rose 2018, $18 Made from Grenache with minimal skin contact. Pale salmon colour, strawberry aromas, clean and fresh in the mouth. Really quite lovely and, like the Riesling, competitively priced for the quality on offer.

Butcher’s Cart Shiraz 2017, $30 A blend created at the company’s 70th anniversary. Lovely, rich and luscious fruit from the Barossa Valley floor lifted by cooler spicy peppery Eden Valley shiraz. Beautifully balanced with no hint of excessive extract or oak tannin. It’s very easy to like this wine. Its two gold medals are well deserved.

Blackwell Shiraz 2015, $38

WINE TASTER'S

PICK

The fruit for this wine came from three areas in the upper Barossa – Kalimna, Greenock and Ebenezer. A more structured wine than the previous two. Spicy Christmas cake aromas from the Ebenezer component marry beautifully with the minerality and brightness from the other two areas

A wine of balance and substance.

Slightly reticent at the moment but with long ageing potential. Barossa at its best!

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JUNE 2019 | 47

SPOTLIGHT

On Track to Make Sport Equal

“

I always wanted to be a doctor.

I can’t remember a time when I didn’t want to be one.

”

Bridie O’Donnell was only six when her grandmother found herself in hospital and the youngster, witnessing the care she received there, knew that one day she wanted to be part of it.

“I said to my Mum, ‘I think I want to be a nurse and work in a hospital’, I then said to her, ‘who’s in charge of the nurses’, and when she said the doctors, I said ‘well I need to be a doctor’.”

This tenacious ambition wasn’t just youthful thinking. Bridie’s life has been filled with achievements, yes, she became a doctor, and added her dual ambition to be an elite cyclist to the list.

Bridie set a new world hour record (distance covered in 60 minutes) in 2016 and has national and regional titles to her name. Yet success at competitive sports was not necessarily a foregone conclusion.

“I was a completely hopeless athlete at school. I tried very hard and was very keen to be involved in team sports but I was just not very good at them,” she told Medical Forum.

The foundations of Bridie’s sporting career were laid while she was studying medicine at the University of Queensland.

“Olympic triathlon was the first sport I competed in and balanced studying and competing until my fifth year and decided to take a year out of med school and race in the ITU (International Triathlon Union) professional circuit. At the time Australian woman were the best in the world in this event – the competition was extraordinary in the 1990s.”

48 | JUNE 2019

“I was a decent swimmer and cyclist, but nowhere near a fast-enough runner to really be competitive in a drafting triathlon.”

Dangers of road cycling During this year of competition, Bridie was hit by a car while riding and fractured her sacrum, forcing her to train in the pool and derailing her plan to become an elite triathlete.

Asked if it was a difficult choice to take a break from medical school, Bridie responded “I didn’t think it was, I felt like it was a great opportunity. I absolutely needed to try to be a great athlete.”

After a year of professional triathlon, Bridie finished her studies, graduating as valedictorian and completed her internship and residency at Brisbane’s Mater Adult Hospital. She was recognised as the most outstanding intern for her first year, but she continued to compete, this time in the Ironman triathlon, which she admitted that she hated.

Yet her determination to be a professional athlete was unwavering. She turned her attention to rowing.

“I walked into a rowing shed in Brisbane, and I thought ‘oh, come on, how hard could this be’ but I had never rowed and I was certainly a long way behind the skill level. I also didn’t really have the right physiology.

Rowing is a strength endurance sport where events take between six and seven minutes. I had nowhere near enough of that explosive, strong endurance-based activity.”

“I was more diesel engine and I wasn’t impressive enough for coaches to invest time and energy in me.” With that said, Bridie is a seven-time national rowing champion.

When asked about how being a professional athlete can complement a professional career, such as medicine, she replied: “You realise when you become an athlete, that it’s not just about winning because winning doesn’t happen very often in the

world of individual sports, so you have to focus on all the little things you do every day such as training sessions that lead to greatness in an athletic performance.”

“In the same way, I’m sure if you’re in surgical training program, every day, every procedure you’re trying to be better, I suppose for me as an intern and as a resident, I was trying to be better at my job every day and learn to be part of the team.”

As Bridie’s medical career progressed, she shifted from rowing to cycling. At the time she decided to specialise in sports medicine, she was set to become the best time-trial cyclist in the country.

Pro team cycling calls “I had to choose between starting the first year of the training program or going to Italy with the national team to try and qualify for the Beijing Olympics, so like any good athlete I chose the latter,” she said.

“It’s such a privilege to become a doctor and to serve the community, that was never going to change [in me]. I just needed to do something else in the meantime.”

Moving to Italy to race on a professional cycling team may sound like the dream but there were plenty of challenges, age not being the least of them.

“There was a discriminatory average age of 26 that applied to women but not men in professional cycling. At the time I was 35/36 so I was dragging the average up, so the really good teams didn’t want me as they would have to hire two 18-year-olds to even it out.”

“Even though I was the #1 cyclist in Australia in 2009 and the #9 cyclist in the world, my age was working against me. I was so focused on doing my best, yet I was in an environment that didn’t cultivate that. I was isolated and I had no money and there was the added burden of being embarrassed that I had put myself in this situation.”

continued on Page 52

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A medical degree, a world record in cycling and a overladen trophy cabinet but Dr Bride O’Donnell has a bigger prize in her sights.

OPERA

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Slice of Sweeney Life

B

en Mingay’s journey from musical theatre to television to opera stage, where he will take the lead in Stephen Sondheim’s dark and fantastical Sweeney Todd for WA Opera next month, is stuff of legend. And he’s taken it all in his laconic laid-back style.

It all began when Ben was a teenager working on a construction site in Newcastle, NSW. His workmates all knew the kid could sing – he worked in rock bands in his spare time to make some extra cash.

But when Ben’s girlfriend at the time left an advertisement for a scholarship to the Newcastle Conservatorium in his lunchbox, the dares and bribes hit the table.

“All the blokes had a good giggle and dared me to apply,” he told Medical Forum.

“I ended up auditioning and winning the Florence Austral scholarship for voice.”

Sweeney Todd presents an exciting challenge for Ben. “It is new material for me. I was familiar with the work but I didn’t know the music so to get a handle on it all, I raided our local library for research and listened to a range of concert versions.”

“I don’t like to get too comfortable with watching and learning from somebody else’s version. I would rather put Ben Mingay into Sweeney Todd with Stuart and the cast and put it on stage. I did also watch Tim Burton’s 2007 movie which was quite funny. Johnny Depp is a great actor and interesting to watch but he’s no singer.”

“But there are so many layers to Sweeney so I want to convey to an audience those layers of light and dark.”

At the helm will be the opera directing legend Stuart Maunder, and Ben counts himself fortunate indeed to be returning to the opera world in such steady hands.

“I always thought that I’d come back to opera one day – I thought probably something like Don Giovanni but Sweeney offers so much and I can’t wait to get out there.”

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“I trained there with Chris Allen and was heard by the head vocal coach from Opera Australia who pulled me aside and asked if I’d like to go to Sydney to work with her.”

“So, three nights a week, I’d hop on my motorbike and head to Sydney to sing opera. I was barely 21 and the next step was an intense four-year opera diploma. My teacher could see I wasn’t ready to seriously commit so suggested I take a couple of months off to travel and enjoy myself.”

“She told me my bass baritone voice would only get better with age, so I had time.”

“In the first two weeks I got an audition for Hair and landed the understudy to the lead and a role in the show and went on tour for six months. Then off the back of that I got a part in Dirty Dancing and toured the world with that show for six years, ending up in New York.”

“When I returned to Australia – in I jumped straight into Jersey Boys then Officer and a Gentleman before Packed to the Rafters and off went the TV career. So, while I was still singing it at the odd gig, I just never had the opportunity.”

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Movie: Spider-Man – Far From Home What does Spidey do when he goes to Europe?

Well he hangs around and off the Rialto in Venice!

His alter ego Peter Parker goes on holiday with his best friends Ned, MJ, and co and his best laid plans to leave the super heroics behind for a few weeks are quickly scrapped when he agrees to help save Europe from attack.

Movie Event: Scandinavian Film Festival

In cinemas, July 4

There is always a buzz around this annual film festival such is the growing popularity of cinema emanating from the world’s most chilly climes. The rise of ‘Scandi noir’ crime thrillers is now matched with some heartrending social and domestic dramas.

Movie: Crawl A young woman, while attempting to save her father during a Catagory 5 hurricane, finds herself trapped in a flooding house and must fight for her life against alligators.

The 2019 festival starting next month is no exception.

This year the festival – now in its sixth year – will celebrate new films from Norway, Sweden, Finland, Iceland and Denmark, showcasing a strong line-up of contemporary dramas, comedies and crime thrillers.

In cinemas, July 11

Exploring culture, history and life in the Nordic region, a host of Australian premieres will bring high calibre and award-winning Scandinavian cinema to Palace Cinema Paradiso, Northbridge, and Palace Raine Square in the CBD next month.

Movie: Palace, You Choose Your Film Palace Raine Square Cinemas has opened in the Perth CBD with a catalogue of blockbuster and new release movies across nine cinemas that all feature reclining leather seats, 2K high definition screens and Dolby surround sound. The cinema features three bespoke bar areas including the rooftop terrace.

July 17 to August 7

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Winners from April Comedy: The Biggest Comedy Show on Earth – Dr Sandy Braiuka. Dr Gaurav Movalia, Dr Riva Curtis

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The unique skills and talents of the Circus Oz ensemble include extraordinary foot juggling, jawdropping aerial straps and trapeze, mesmerising handstands, pole, and hula hoop, all hilariously woven with original music from the Circus Oz live band. This show takes the crew through a barren icy landscape.

His Majesty’s Theatre, July 25-28

Opera: Sweeney Todd: The Demon Barber of Fleet Street Stephen Sondheim’s classic tale of revenge lands on the stage of the Maj under the direction of Stuart Maunder. Ben Mingay is the formerly nice young Benjamin Barker who bakes a very bitter pie of revenge. He is joined by Annette O’Halloran and James Clayton along with the singers of WA Opera.

His Majesty’s Theatre, July 13, 16, 18, 20

50 | JUNE 2019

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COMPETITIONS

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CIRCUS

From Flying Fruit Fly to Circus Queen Spenser Inwood is not going to let the lack of an ACL in her left knee stop her from strutting her Circus Oz stuff on the stage of His Majesty’s Theatre next month.

T

he 30-year-old acrobat under the advice of her orthopaedic surgeon has been working tirelessly to rehab her knee to the point where she happily can come out twirling and whirling with the rest of her colleagues.

“My ortho advised me against surgery and that rehab was a serious option for me because the risk to my hamstring, which they would use to repair my knee, would add a problem. I was too nervous to let that happen,” she told Medical Forum.

At 30, Spenser is one of the older members of the cast but she says injury and age don't slow her down.

“My performance load is just as heavy but everyone only does as much as our bodies can stand and with experience you get smarter in your preparation and your ego is not so rampant that you can afford to take a step back a little,” she said.

“I don’t have to prove myself as much and I think also as you age and get better at performing, your actual presence on stage gets bigger. You don’t necessarily have to do as much to keep the audience engaged.”

Spenser is something of a veteran of the circus scene having started with the famous junior training ground, the Flying Fruit Fly Circus, at the age of eight but the process wouldn’t have started unless her parents packed up the family from Canberra for Albury.

“I didn’t want to go but Mum said that if I came with them I could join a circus and I thought that was a pretty good deal. So I started at the Flying Fruit Fly and fell in love with the artform.”

“The circus is a wonderful physical and emotional world and the strong relationship that builds between performer and audience is something I treasure. So, it’s been a great career and some of my colleagues are well into their 50s, so I also hope, a lifelong career.”

Circus has had a rebirth in the past two decades and Spenser is always amazed at the number of towns, large and small, that have a training space.

And there has become a genuine market in the tricky entertainment scene.

“The circus that we do – solely with humans – is not a very old form in Australia. And over the past few years, there has been a push for circus to be more than just a display or a collective of ideas. Now the troupe will be working on one particular idea across the show and the thrill is making that idea work and be told by multiple acts.”

“The age old questions ‘What makes circus, circus?’ is an alive and vibrant conversation taking place all the time. At the moment it's around different genres of circus. Whether its dance-based circus, cabaret style, entertainment driven right through to artform circus – it is developing and growing all the time.”

Circus Oz is now in its 41st year and Spenser has spent much of her career working with the team.

“The thing I have always loved working with Circus Oz is its collaborative nature. You are not there just to be an acrobat. There’s a lot of history and it was the company that made me feel that I didn’t have to give up circus when I finished high school, that I could make this an adult career.”

“Circus Oz lets itself grow while holding on to the essence of who they are. They adopt broader wider opportunities and continue to reach all ages and spaces. It tours Australia to the small towns and large cities and it always manages to connect with such a diversity of people.”

By Jan Hallam

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JUNE 2019 | 51

On Track to Make Sport Equal After two years of racing in Italy, Bridie moved to the US in 2011 to join another team but decided to move back to Australia to continue her medical career with a new perspective on the world of professional sports.

“The more I understood what it was like to be a professional athlete, I concluded it is an exploited labour force. You are putting your body on the line and your life on hold with no certainty of income, of performance, or outcomes and you keep doing it every year.”

Adding insult to injury was the lack of recognition of women’s professional cycling.

All pain, no glory “I would come back home to Melbourne every summer and people would ask me what I did. When I told them I was a pro bike rider, they say ‘I’ve never heard of you, is there a Tour de France for Women?’ And you think, wow, it’s like going to war every year and no one knowing you were in a war zone.”

On her return to Australia, Bridie continued to race but she also began teaching doctor communication at Deakin University and working at Epworth Health in an executive program.

In her last medical role, Bridie was recruited to work in a busy breast cancer surgeon’s clinic.

“I had been doing a lot of work around motivational interviewing and behaviour change and the surgeon knew I was an athlete and she thought it would be terrific for me to review a lot of her low risk patients. It was a great job.”

“My mum has had breast cancer twice and was the chair of Breast Cancer Australia, so I have a lot of personal experience with the disease. In Australia we don’t have a high breast cancer mortality rate but the disease has a huge impact on the workforce, families, body image, finances, sexuality – these are some of the things women seem to experience and it goes undocumented.”

While she found the work stimulating, the cycle track was also calling her name.

“I hadn’t achieved what I wanted. I had not won a world championship and I didn’t feel like I was done.

So, I changed to track cycling which I have had no particular experience in.”

Fastest by the clock The challenge she set herself was one of the most difficult in cycling, the hour record, a 60-minute, allout effort in a velodrome with the object of riding the longest distance possible, in the allotted time. In

Photo courtesy Tourism Western Australia

2016, Bridie covered 46.882km in the hour – a record.

Now her sights are set on competing at the Tokyo Olympics.

In the meantime she’s accepted the position of Director of the Office for Women in Sport and Recreation in Victoria. Her focus is to address gender inequality and encourage diversity in sport both at the professional and amateur levels.

With a plethora of sporting achievements, a medical career and now a senior role in public service, the question of what next pops up.

“I wouldn’t mind running the Boston marathon next year but right now my focus is my job. My aspirations by 2030 is to eliminate the need for an Office for Women in Sport and Recreation.”

When it comes to medicine, Bridie says she probably won’t return to medicine.

“I feel I’m helping more people than when I was a doctor.”

By James Knox ED: Bridie O’Donnell has recently published her memoir, Life and Death, through Slattery Media.

2019

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Like you, when the day comes to an end, we’re still on call

Issues pay no respect to working hours.

You might be on the way home, but that doesn’t necessarily mean that your work is over.

It’s the same for us.

Our client service centre operates 24/7. It doesn’t matter what time of day or night it is. It doesn’t matter where you are. We’ll ensure that your call is handled by a highly trained team member and that local resources are mobilised and monitored to find a solution for you.

Day in, day out. We’re here to help.

Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.

Car loans | Commercial property | Credit cards | Equipment finance | Fit-out finance | Foreign exchange | Home loans | Personal loans | Practice purchase | Practice set-up | Savings accounts | SMSF | Transaction accounts | Term deposits | Vehicle finance The issuer of these products and services is BOQ Specialist – a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”).