Medical ForumWA 10/13 Web edition

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October 2013 Major Sponsors

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Major Sponsors

CONTENTS FEATURES 10

Celebrity Spotlight: Lisa McCune

16

Drugs and Sport

18

Trailblazer: Dr Ric Chaney

20

Peel Health Campus

CLINICAL FOCUS 5

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7

10

NEWS & VIEWS 2

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12

Have You Heard?

14

Prisoners Listen Up

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30 Covering Risk for

WA Travellers %S $ISJT 3ZOO

32

The Changing Face of HIV in WA %S %BWJE /PMBO %S -FXJT .BSTIBMM

33 Inflammatory

Arthritis %S &VHFOF "OH

36

16

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Photography

Quality Control in Cervical Screening Cytology

33 Warts and all

Editorial: GPs & Specialists – Partners in What?

8

Common Questions about Heart Failure

Hip Arthroscopy and Repair of the Acetabular Labrum %S 5BP 4IBO -JN

39 Technological

Advances in Laparoscopic Surgery %S 3BWJ 3BP

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27

Practice Tip

28

Primary Care Meeting

LIFESTYLE 40 Marathon Doctors .S 1FUFS .D$MFMMBOE

35 PNG’s HPV Crisis

42 Kitchen Confidential

38 Beneath the Drapes

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GUEST COLUMNS 23

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Plane Wines %S $SBJH %SVNNPOE

44 Satire: Match

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45 The Homing Instinct %S %POOB .BL

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43 Wine: Higher

46 Royal

Concertgebouw Orchestra

Age of Rage and Reconciliation .S 4IBVO /BOOVQ

46 The Funny Side 47

E-POLL & EVENTS 8

Doctors Drum Breakfast

31

E-Poll Travel Risks

36

Conference Corner

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20

Sonata in the Spotlight

48 The Social Pulse (1&5 $POWFOUJPO 1FSUI 4+(.) #BMM 1SPTUBUF "XBSFOFTT $ZDMF "WBOU -FBEFSTIJQ 5PVS

50 Competitions

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PUBLISHERS

Editorial

Ms Jenny Heyden - Director Dr Rob McEvoy - Director

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

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website.

Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

The support of all advertisers, sponsors and contributors is welcome.

Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended.

All advertisements are accepted for publication on condition that the advertiser indemniďŹ es the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

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

GRAPHIC DESIGN Thinking Hats 2

‘GPs and Specialists – Partners in What?’

The working partnership between GPs and specialists, both trying to get the best for their patients, will be heavily scrutinised as the community tries to get the best use of limited health resources. It would be great if the profession led any debate, which is why we decided to facilitate some introspection at the next Doctors Drum breakfast, entitled “GPs and Specialists – Partners in What?�. (See P8 for details of the event on October 31.)

Let’s face it, there is always room for improvement.

Achieving this without taking sides is difficult, and some of us have been around long enough to remember the Relative Values Study. Healthy competition is likely to spawn innovation and, provided the innovators remain flexible, open to constructive criticism and sharing, the outlook is good.

Core issues around the GP-specialist tag team that wrestles with health problems include: t %FQFOEFODZ PO FBDI PUIFS o JO OFFE PG DIBOHF t "SF UIFSF BHSFFE DPNNPO HPBMT t *T UFSSJUPSJBM CFIBWJPVS IBSNJOH QBUJFOU DBSF t "SF UIFSF HFOEFS JTTVFT UP TPSU PVU t *T UIF UJNJOH PG DP PQFSBUJPO JO OFFE PG GJOF UVOJOH t *T UIF EJWJTJPO PG UBTLT BQQSPQSJBUF No doubt, critics of the profession will be looking at uneasy parts of the relationship in coming months.

Certainly, Medical Forum’s earlier e-Polls pointed to problems with patient referrals (see below). Things have changed a bit since then, with electronic communication on the verge of delivering a fresh start. The encouraging thing is the genuine concern shown by doctors for the plight of other colleagues, across the divide, and in either direction.

Some GPs who are striving for excellence as allrounders, not an easy task, appear resentful of the procedure-driven income of specialists and their community status, while they struggle with a health insurance system (Medicare) that does not reward experience and excellence, they say.

The recent national General Practice Education & Training conference in Perth (see P48) was inspirational for those trying to lift standards and improve on-the-job training for general practice, particularly for those working in relative isolation.

The College of GPs promotes the ‘all-roundedness’ of general practice but many coalface GPs seem to be subspecialising under the weight of the medical knowledge they are expected to get their heads around. *O GBDU XIFO XF MPPL GPS FYBNQMFT PG (1 TQFDJBMJTU co-operation which really work, the GP is often XPSLJOH BT B TVCTQFDJBMJTU o UIJOHT MJLF TIBSFE antenatal care, aged care, and palliative care. That's a conundrum for the RACGP.

One great example of GP-specialist co-operation happens in rural regional areas, where the rural GP and local specialist can sort out the priority of patient follow-up in conversation, rather than a non-medical person juggling a waitlist according to patient codes.

The need to get on with each other may be somewhat unbalanced. Underperforming specialists, competitive by nature, find it harder to survive in practice than underperforming GPs. There is no doubt both need each other. Roughly speaking, specialists know the illness, GPs know the person. Working well together they increase the success of the other. *O B XBZ Medical Forum is one means by which GPs and specialists can communicate, something we are mindful of as we converse with both groups.

We have noticed that more GPs and specialists are getting married to each other, both workforces are becoming feminised, specialists are more prone to rent rooms in tandem with GPs and ancillary health workers, and more GPs who subspecialise are doing well. That’s just some of the trends.

Generational change is a harder thing to track. One change is improved communication in the electronic age, which in turn breaks down the tendency towards compartmentalisation of illness and doctor behaviour. Another is including the patient more in the treatment conversation, where their access to medical records has changed what we write, and things like the PCEHR sound good in theory but unworkable in practice somewhat in a more litigious society.

Public hospitals are probably our greatest dilemma: big and cumbersome; a financial bottomless pit; seemingly a world of their own, where community outreach is seen as a cost-saving measure; and the drawcard of a captive patient population is research and teaching for many specialists.

The community and GPs often have a love-hate relationship with public hospitals, a relationship that is being redefined. O

ll o P e

RETROSPECTIVE: GP-Specialist referrals

In July 1999, GPs said substandard referrals to specialists were due to time pressure (48%), uncertainty over what the specialist wanted (18%), and the fact that specialists ignored the information and did their own thing anyway (23%).

I

n August 1999, Specialists said 28% of GP referrals, on average, lacked important clinical information. medicalforum

Apology and Retraction TO:

The Australian Medical Association (WA) Incorporated Mr Paul Boyatzis Associate Professor Rosanna Capolingua Professor Bernard Pearn-Rowe

We, Dr Robert McEvoy, Ms Jenette Heyden and Rakabee Pty Ltd (being the company through which we publish Medical Forum WA magazine (Magazine) and maintain the website at www.medicalhub.com.au (Website) published an article in April 2011 concerning the AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe.

We each now accept that the article contained some material that was without foundation and that we unreservedly retract and which may have led readers to draw damaging conclusions about AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe.

We apologise for any damage the article has caused AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe.

We also accept that Mr Boyatzis, Associate Professor Capolingua and Professor Pearn- Rowe were hurt and distressed by some subsequent articles we published and we regret this.

Dr Robert McEvoy

Ms Jenette Heyden

Rakabee Pty Ltd

Date: September 2013

Letters

Alcohol message must get through Dear Editor, Congratulations, June Oscar, on your vision and efforts to recognise a major problem and find a solution acceptable to your community (FASD and a Town that Won’t Give Up, September, 2013).

The effects of heavy drinking causing permanent brain damage, facial, growth and developmental abnormalities is recognised as foetal alcohol syndrome (FAS). What is less well recognised is the medicalforum

GVMM TQFDUSVN '"4% XIJDI DBO IBWF potentially devastating effects on the child.

These include oppositional defiant behaviours, learning difficulties, anxiety, aggression, "%)% BOE BVUJTN MJLF EJTPSEFST BOE PDDVS alongside the facial and growth abnormalities frequently seen by paediatricians, GPs, child health nurses, teachers, police officers, judges and allied health workers (speech pathologists, occupational therapists, physiotherapists), who all need to consider prenatal exposure as a possible cause. *G B NPUIFS ESJOLT UIF VOCPSO DIJME T brain will be exposed to the mother’s alcohol blood level. A recent Australian survey noted that 92% of women would like their doctor to discuss the harmful effects of alcohol in pregnancy.

So why then do some pregnant mothers ESJOL *U JT MJLFMZ UIBU UIFZ BSF OPU BXBSF of this message or have an unplanned pregnancy. Pregnant mothers who drink should be informed of all the likely risks to their unborn child, who needs to be protected from the devastating consequences. Those children should not be set up for education failure, incarceration, mental health disorders and premature death.

There is no clear evidence that any amount of alcohol is safe. As a medical profession it is our responsibility to ensure this message is clearly communicated to women. Having all alcohol labelled with a message of ‘don’t drink in pregnancy’ would be an important More letters P4 3

Letters Continued from P3 reinforcement to all mothers irrespective of ethnicity.

June Oscar and the other brave, strong women in Fitzroy Crossing have found a way to reduce alcohol consumption in their community. Let’s all get behind them to raise this awareness across our country.

Dr Desiree Silva, Consultant Paediatrician

Standards continue to evolve Dear Editor, The Royal Australian College of General Practitioners (RACGP), the peak body for general practitioners in Australia, was concerned to read the Mr Tim Spokes article [Changing Times, but Nothing Changes, September] suggesting that the RACGP Standards for general practices (4th edition) (the Standards) are failing to meet the demands of modern general practice.

The RACGP is aware of and supports a variety of team-based models of care with the general practitioner at the centre. The 4th edition of the Standards (written by the general practice profession, for the general practice profession) reflects this shift

towards team-based care. Future editions of the Standards will continue to evolve with the changing landscape of Australian healthcare, which may include other forms of primary healthcare delivery, such as practice nurses in areas of workforce shortage. *O SFMBUJPO UP 1SBDUJDF *ODFOUJWF 1BZNFOUT 1*1T UIF 3"$(1 IBT DPOTJTUFOUMZ MPCCJFE for funding to support the delivery of patient services. Funding needs to support quality services delivered by general practices, GPs and practice teams. Unfortunately, recent DIBOHFT UP 1*1T IBWF CFFO NBEF XJUIPVU (or inadequate) input or advice from the profession. Appropriate funding to support the delivery of patient care continues to be a priority for the RACGP. The Standards will always be subject to the ongoing scrutiny of the profession and the community at large and the RACGP welcomes dialogue into the continual improvement of all its resources. The RACGP will update future editions of the Standards incorporating feedback from the profession, new research evidence, advances in knowledge and changes in the way primary healthcare is delivered in Australia.

Dr Liz Marles RACGP President and A/Prof Frank R. Jones. Chair, WA Faculty

Bring back ear health auxiliaries Dear Editor, The article about Harvey Coates and his mission to fix Aboriginal ear disease [Hearing is Believing, September] was of both technological and historical interest. *U IBT CFFO LOPXO BU MFBTU TJODF UIF UJNF of Hippocrates, that chronic ear disease in children is related to poverty. Too many Aboriginal children, especially in remote Australia, still live in poverty. There is no silver bullet for curing poverty. So whatever we do will be the equivalent of a rubber bullet.

We do know how to do health surveys and Aboriginal children’s ear disease has been measured and re-measured since %S %FOOJT $MFNFOU T TVSWFZ PG Aboriginal children in the Allawah Grove settlement in what is now Perth Airport.

These surveys showed a ballpark figure for perforated eardrums, chronic middle ear disease and hearing loss of 15-20%. One also showed that technological fixes such as myringoplasty were only effective when there was also good local follow-up. *O +PTF BOE 8FMDI TIPXFE UIBU UIF state of Queensland Aboriginal children's health was so dire that doing any one thing resulted in some improvement. Those one More letters P6

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4

medicalforum

Common Questions about Heart Failure What is the mechanism of dyspnoea in heart failure?

Dyspnoea is a cardinal manifestation of heart failure (HF) that may present with progressively increasing exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, dyspnoea at rest and acute pulmonary oedema.

Dyspnoea in acute HF is usually due to pulmonary congestion and desaturation caused by low cardiac output. In chronic HF there is no correlation between dyspnoea and the degree of impairment of either left or right ventricular systolic function or central haemodynamics (at rest or during exertion). Restoration of normal haemodynamics induced by medication or other interventions is not accompanied by parallel changes in dyspnoea. Thus, dyspnoea in chronic HF may depend more on the peripheral and nervous system than on central haemodynamics.

What are the most frequent causes of heart failure?

HF is often, but not always, caused by impaired myocardial contractility.

Common causes include coronary artery disease, hypertension, cardiomyopathy, viral myocarditis and valvular heart disease.

Should patients with significant ventricular dysfunction exercise?

By and large, regular exercise in this setting is safe, improves health status and moderately reduces risk of cardiovascular death or HF related hospitalisation.

Exercise regimes include aerobic activity of at least 30 minutes and at intensity of approximately 50% to 80% of heart rate reserve.

What distinguishes cardiac from non-cardiac peripheral oedema?

HF oedema is usually symmetrical in dependent parts of the body. It is invariably associated with dyspnoea and raised jugular venous pressure. Noncardiac oedema presents in a number of ways. If unilateral, suspect venous insufficiency, thrombosis or local

trauma. If warm, suspect inflammation, whilst associated hardness tends to be lymphatic. Oedema associated with altered renal function and electrolytes may be renal, whilst oedema confined to the feet and ankles without cardiac symptoms may well be attributed to things such as calcium channel blockers.

How does systolic function affect long-term outcome in heart failure?

Dr Mark Hands, Clinical Associate Professor (UWA), Interventional Cardiologist

About the author Dr Mark Hands graduated from UWA and trained in cardiology at Sir Charles Gairdner Hospital and Brigham Women’s Hospital, Harvard Medical School. He is an interventional cardiologist in private practice at Western Cardiology (chairman) and emeritus consultant cardiologist at SCGH. In addition to general cardiology and echocardiography his special interests include investigation and treatment of acute and chronic ischemic heart disease. Dr Hands’ interventional procedural skills include coronary angiography, angioplasty and stenting in stable angina and in acute unstable angina and acute myocardial infarction, cardiac pacing, percutaneous closure of atrial septal defects and patent foramen ovale.

Left ventricular ejection fraction (LVEF) is the most commonly used clinical measure of LV systolic function and is a powerful predictor of death in patients with HF.

cardiomyopathy and possibly those with demonstrated mechanical dyssynchrony on echocardiography.

What is the prognostic significance of atrial fibrillation?

What is the optimal heart rate in heart failure?

There is evidence that atrial fibrillation may have a negative prognostic role in HF patients. However, two large trials have failed to show any significant benefit from rhythm control using antiarrhythmics.

Patients with a higher basal heart rates (HR) in HF have a poorer prognosis.

Studies have demonstrated that reducing the HR to <60 bpm (if tolerated) is associated with better clinical outcomes.

We now add in the sinus node inhibitor (Ivabradine) in HF patients in sinus rhythm with elevated HR (>77 bpm) combined with poor LV function in an effort to lower the rate <60bpm. This has reduced the combined outcome of re-hospitalisation and death in this group.

How useful are natriuretic peptides in management of heart failure?

Evidence supports the use of natriuretic peptides (BNP and NT pro-BNP) in diagnosing, staging and making hospitalisation/discharge decisions whilst also identifying patients at risk for clinical events. Normal concentration in untreated patients makes HF an unlikely cause of symptoms.

Is it possible to predict the response to cardiac resynchronisation therapy?

Cardiac resynchronisation therapy (CRT) is an intervention where the right and left ventricles (via pacing system) are depolarised at the same time i.e. left and right ventricles contract in synchrony. CRT has changed the management of patients with HF with controlled trials demonstrating significant improvement in symptoms, LV function and long-term survival.

However, 30% to 40% of HF patients show no clinical or echocardiographic evidence of benefit from CRT. Those most likely to improve are those with the longest QRS duration, non-ischaemic

Should calcium channel blockers be used in heart failure?

Calcium channel blockers neither relieve symptoms nor enhance exercise tolerance. Moreover, they may have serious adverse cardiovascular effects producing pulmonary oedema and increase the risk of worsening HF and possibly even death in patients with LV dysfunction (particularly LV systolic dysfunction). Calcium channel blockers may be used in HF where there is preserved ventricular function, particularly where there is either atrial fibrillation (to control the rate), limiting angina or hypertension.

Letters Continued from P4 things included deworming, correcting iron deficiency anaemia, giving a course of antibiotics to suppress infection and providing food to improve protein calorie malnutrition. The Alice Springs GPâ&#x20AC;&#x2122;s one orange a day ear fix is an extension of that finding.

Even where there is ready access to an Aboriginal Medical Service the detection and early treatment of acute otitis media in early childhood continues to be a problem. *O JO UIF 'BS 8FTU PG /48 * DPQJFE UIF NFUIPET PG %S /JDL 'FOEBMM B QSJNBSZ care pathfinder in Africa, and trained the matriarchs of the three main family groups to be â&#x20AC;&#x2DC;single-skilled ear health auxiliariesâ&#x20AC;&#x2122;.

They had a small stipend, their own auriscope and a supply of ampicillin. The prevalence of perforated eardrums dropped GSPN JO UP JO 5IJT MFE %S ( . )BMMJEBZ B MFBEJOH Sydney ENT specialist who provided visiting services to Bourke, to state: â&#x20AC;&#x153;The help of a trained Aboriginal health worker is likely to be of greater benefit than the surgery of an otologist.â&#x20AC;?

5IF /48 )FBMUI %FQBSUNFOU XBT BMTP impressed and decided to formalise these health auxiliary positions. Their minimal employment criteria of literacy for record keeping and a driverâ&#x20AC;&#x2122;s licence disqualified the matriarchsâ&#x20AC;&#x2122; role. The perforation rate rose.

So, bravo to Harvey Coates, his team and the researchers who have made the technological advances necessary to salvage

those many children who have fallen over UIF DMJGG PG FBS IFBMUI * XJTI UIFN BOE UIFJS patients much better permanent progress than has occurred in the last 40 years.

"OE XIFSF BQQSPQSJBUF * XPVME MJLF UP see them use their ENT credibility to help stop children from falling over that cliff.

One way would be to bring back the above mentioned ear health auxiliaries. This was a simple primary health care community empowerment process that worked.

E/Prof Max Kamien

Thereâ&#x20AC;&#x2122;s more to a name Dear Editor, A topic that never fails to frustrate me on a daily basis is the explosion of generic drugs and the coercion we face to prescribe brand names over generics. There are more generics for certain drugs than brands of milk. Quite different drugs can sound similar and the same generic drug can be named quite differently by different brands.

4FBSDI B HFOFSJD ESVH JO .*.T BOE BMM UIF available brands appear. Search by brand name and the generic drug ingredients are nowhere to be seen unless the individual drugs are opened. *U JT OPU VODPNNPO UP TFF B QBUJFOU doubling up on a drug by taking two brands of the same drug because of different

sounding brand names of the same drug. On other occasions a patient will unwittingly cease a drug, thinking they are still taking it when in fact they are taking a different drug with a similar sounding brand name.

Recently, a patient of mine was confused BCPVU IFS EJTDIBSHF NFEJDBUJPOT * IBE UP explain that Apoescitalopram was the same as her previous Lexam (both escitalopram).

Some names that have confused me include: Ransim (simvastatin), which sounds similar to various brands of rantidine and quite different to other brands of simvastatin such as Zocor, Lipex and Zimstat.

"Z" seems to be a popular initial and can cover such diverse brands and drugs as Zoloft, Zoladex, Zimstat, Zocor, Zyprexa, Zinnat, Zithomax. â&#x20AC;&#x153;Zâ&#x20AC;? also sounds similar to drugs starting with â&#x20AC;&#x153;Xâ&#x20AC;? such as Xyloprim.

The problem extends to brand diversification of cough and cold and flu medications.

Why canâ&#x20AC;&#x2122;t the generic name of a drug be BU MFBTU BT MFHJCMF BT UIF CSBOE OBNF " MPU of medication confusion would be solved, medication errors reduced, and medication reviews simplified if drugs were clearly labelled as to what they contain, and the generic drug names being made visible XIFO TFBSDIJOH .*.T GPS CSBOE OBNFT Dr Rohan Gay, GP Bayswater

Send in your letters by October 10 to editor@mforum.com.au

hoto courtesy Whe

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medicalforum

Quality Control in Cervical Screening Cytology *O "VTUSBMJB DFSWJDBM TDSFFOJOH CZ 1BQ TNFBS IBT CFFO BWBJMBCMF TJODF UIF T *U CFHBO JO B MBSHFMZ PQQPSUVOJTUJD GBTIJPO but became a more structured program in 1991, and was formalised into The National Cervical Screening Program in 1995.

The program, which aims to reduce cervical cancer through an organised national approach to cervical screening, has these important features: t B UXP ZFBS TDSFFOJOH JOUFSWBM t SFDSVJUNFOU UP FODPVSBHF BUUFOEBODF GPS a cervical Pap smear t B VOJGPSN SFQPSUJOH GPSNBU t FTUBCMJTINFOU PG 1BQ TNFBS SFHJTUSJFT t RVBMJUZ NBJOUFOBODF UISPVHIPVU %BUB GSPN UIF "VTUSBMJBO *OTUJUVUF PG )FBMUI and Welfare Reports show that the agestandardised mortality rate from cervical cancer halved from 4.0 deaths per 100,000 women in 1991 to 1.9 deaths per 100,000 women in 2005. The proportion of squamous cell carcinomas prevented by screening has SJTFO GSPN JO UP JO

Why are quality assurance and control important?

For cervical screening cytology to successfully achieve desired outcomes, the quality of performance must be maintained in each participating MBCPSBUPSZ o POF PG UIF SPMFT PG UIF National Cervical Screening Program.

How is quality monitored in the cytology laboratory?

The National Pathology Accreditation Advisory Council (NPAAC) has set required laboratory standards for the cytology screening program. Laboratory inspection and accreditation is carried out by the National Australian Testing Authority (NATA) and the Royal College of Pathologists of Australasia (RCPA).

Laboratories are also expected to monitor their own performance against standards. *G B MBCPSBUPSZ SFQPSUJOH HZOBFDPMPHJDBM cytology is to attract a Medicare rebate, it must be inspected and accredited every three years; repeated failure to meet accreditation standards results in notification to the )FBMUI *OTVSBODF $PNNJTTJPO )*$ XIJDI may then withdraw Medicare benefits.

medicalforum

By Dr Mark Neville, Head of Cytology, Clinipath

What are the required standards?

Standards coverage includes staff qualifications, workloads, continuing education, specimen handling and reporting. The content and format of the cytology report must comply with the Australian Modified Bethesda System.

Recommendations must be consistent with the NHMRC publication Screening to Prevent Cervical Cancer: guidelines for management of asymptomatic women with screen detected abnormalities.

All laboratories enrol and participate in an approved external quality assurance program, usually the RCPA Cytology Quality Assurance Program, which involves reporting on circulated sets of unknown slides. Results are graded as: Target or Acceptable response, Acceptable response, Unacceptable response and Major Error.

Another important part of external quality assurance is assessment of laboratory

performance standards as developed by the /BUJPOBM $FSWJDBM 4DSFFOJOH 1SPHSBN o B mandatory part of laboratory accreditation since 1999, with revision in 2004 (see table).

What reporting profile is expected on Pap smears collected in Australia?

Around 2% of screening specimens will be reported as technically unsatisfactory, around 1% of reports will be high-grade or possible high-grade abnormality.

"QQSPYJNBUFMZ PG IJHI HSBEF BOE 50% of possible high-grade cytology abnormalities will be a confirmed highgrade abnormality on histology. *O TVNNBSZ "VTUSBMJB IBT BO FYDFMMFOU cervical screening program, with results comparable to the best international programs as shown by the fall in the incidence of, and mortality from, cervical cancer. This has been achieved largely as the result of the National Cervical Screening Programâ&#x20AC;&#x2122;s organised approach to screening.

Table: Profile of cytology reporting Performance measures

Recommended Standards

Proportion of specimens reported as unsatisfactory

Between 0.5% and 5%

Proportion of all technically satisfactory specimens reported in all categories

None set

%FGJOJUF BOE QPTTJCMF IJHI HSBEF BCOPSNBMJUZ BHF TUBOEBSEJTFE

/PU MFTT UIBO

Abnormal

Not more than 14%

Table: Accuracy of cytology reports predicting a high-grade abnormality Performance measures

Recommended Standards

Proportion of cytological specimens reported as a definite highgrade intraepithelial abnormality where cervical histology, taken XJUIJO NPOUIT DPOGJSNT UIF BCOPSNBMJUZ BT B IJHI HSBEF intraepithelial abnormality or malignancy

/PU MFTT UIBO

Proportion of cytology specimens reported as a possible highgrade epithelial abnormality where cervical histology, taken within NPOUIT DPOGJSNT UIF BCOPSNBMJUZ BT B IJHI HSBEF FQJUIFMJBM abnormality or malignancy

Not less than 33%

Table: Accuracy of negative cytology reports Performance measures

Recommended Standards

Proportion of women with a histological diagnosis of high-grade epithelial abnormality having cells consistent with, or suggestive of, a high-grade abnormality identified on review of slides that were originally reported as negative within the preceding 30 months

Not more than 10%

7

News & Views

Send Your 'Holiday Road' Pictures These exquisite pictures of the Florence skyline and and Santorini were taken

by Mandurah GP and equally famous landscape photographer Dr Tony Tropiano on one of his latest overseas trips.

His passion for photography knows no bounds. Not only is he passionate about his own photography but he’d like everyone else to be able to take the best shots they can.

In December, Medical Forum will publish a selection of readers’ favourite travel pictures which fit the theme:

HOLIDAY ROAD Don’t forget to add a paragraph with your photograph to tell us a little about what the picture is about and for the techies, what equipment was used.

Send your hi-res 300 dpi pictures to Managing Editor Jan Hallam: editor@mforum.com.au by October 28.

AMA WA & Ors v Medical Forum & Ors – Defamation Proceeding In April 2011, Medical Forum published an article concerning the AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe.

The Proceedings have been settled on commercial terms satisfactory to all parties and without any admissions or concessions as to liability.

Thanks to all readers for their continuing support of Medical Forum magazine.

GPs & Specialists – Partners in What?

Be our guest and join the discussion at the popular …

Doctors Drum Breakfast When: Thursday, October 31, 2013 Time: 7.15am-8.45am Where: Observation Rendezvous, Scarborough

To register:

www.doctorsdrum.com.au

Doctors Drum supported by:

8

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9

Celebrity Spotlight

Thereâ&#x20AC;&#x2122;s Nothing Like a Dame Perth-grown Lisa McCune will be turning heads and starting hearts next month at the Crown Theatre as Nellie Forbush in a sumptuous production of South Pacific.

Sheâ&#x20AC;&#x2122;s worn the tags of Australiaâ&#x20AC;&#x2122;s â&#x20AC;&#x2DC;Golden Girlâ&#x20AC;&#x2122;, â&#x20AC;&#x2DC;Showbiz Darlingâ&#x20AC;&#x2122; and â&#x20AC;&#x2DC;Girl Next Doorâ&#x20AC;&#x2122; with a cheerful smile and plenty of grace, but Lisa McCune really thinks that her almost continuous work schedule in the fickle world of entertainment is down to luck and her training. i* WF CFFO WFSZ GPSUVOBUF * OFWFS GPS B moment take that for granted because this industry relies so much on being in the right place at the right time and people believing in your talent. Learning the craft BU 8""1" IBT NFBOU UIBU * BN GJU BOE BCMF to complete a TV or film shooting schedule PS EP FJHIU TIPXT B XFFL * WF CFFO MVDLZ w she told Medical Forum.

Lisa, who grew up in Perth and attended Greenwood Senior High School, became the youngest graduate of the prestigious performing arts school, graduating in 1990 and immediately scoring work as the face of Coles Supermarket in a year-long TV and Press campaign. So was born the first .D$VOF JODBSOBUJPO o -JTB UIF HJSM OFYU door checkout-chick.

There have been many since, not the least the signature role that shot her to national GBNF o $POTUBCMF .BHHJF %PZMF JO UIF 57 series Blue Heelers when she was just 22.

What flowed was an outpouring of love from the public awarding her with four Gold Logies.

But there was no way this pocket rocket was going to be typecast, despite the seven seasons as the country copper. When she wasnâ&#x20AC;&#x2122;t capturing hearts and baddies at Mount Thomas Police Station she was hitting the boards in musicals from Sondheim to rock bands.

Next month she returns to Perth to star in South Pacific, incredibly, for the first time since she left WAAPA 23 years ago. i5JNF TMJQT BXBZ RVJDLMZ * IBE IPQFE UP come to Perth with The Sound of Music. * E EPOF UIF &BTU $PBTU GPS TFWFO NPOUIT KVTU BGUFS * GJOJTIFE Blue Heelers BOE * XBT BCTPMVUFMZ FYIBVTUFE 5IPVHI * XPVMEO U IBWF NBEF UIF 1FSUI TFBTPO CFDBVTF * GPVOE PVU * XBT QSFHOBOU XJUI NZ GJSTU CBCZ BGUFS we closed the show in Brisbane.â&#x20AC;?

That was in 2001 and three children MBUFS XJUI IFS IVTCBOE 5JN %JTOFZ OPU even juggling motherhood and a busy performing career seems to slow her down. â&#x20AC;&#x153;To be honest, having children has made NF B CFUUFS QFSGPSNFS * UFOE UP MPPL PVU BU life rather than inwardly all the time. But BT GBS BT NBOBHJOH HPFT * TVTQFDU B MJGF JO the arts is easier than for those women who 10

Q Lisa McCune as Nellie Forbush in Opera Australia's South Pacific. Photo by Jeff Busby

IBWF PGGJDF KPCT GJWF EBZT B XFFL * N MVDLZ * DBO UBLF DPOUSBDUT UIBU GJU JO BSPVOE NZ family rather than the other way round.â&#x20AC;?

For the first part of their lives, McCuneâ&#x20AC;&#x2122;s two sons and a daughter have had gypsy lives, travelling the country with their mother, but now school looms large. â&#x20AC;&#x153;There are lots of wonderful things to learn PO UIF SPBE XJUI UIF BSUT CVU * SFBMMZ XBOU them to have the grounding of being at school for their own social wellbeing. So now itâ&#x20AC;&#x2122;s a matter of me flying in and flying PVU GPS XPSL JO TIPSU CVSTUT * EPO U IBWF any other guilty pleasures than work â&#x20AC;Ś XPSL JT NZ MPWF TP * KVTU NBLF JU XPSL w Her childrenâ&#x20AC;&#x2122;s experience was the opposite of her own, which she describes as a â&#x20AC;&#x153;very suburban West Australian lifestyle with holidays by the beach and hanging out with friendsâ&#x20AC;?. i* E QMBZ OFUCBMM PO 4BUVSEBZ NPSOJOH BOE XBUDI NPWJFT JO UIF BGUFSOPPO * FWFO HBWF up singing and dancing lessons for a while to play netball but WAAPA was like turning PO B MJHIU GPS NF * SFBMJTFE * XBT XJUI UIF right people at the right time in my life.â&#x20AC;?

When Medical Forum spoke to Lisa, she was about to embark on a return season of South Pacific at the Sydney Opera House. While she has done just about every musical going around, the 42-year-old has never worked with Opera Australia, the co-producer

of the show along XJUI UIFBUSF EPZFO +PIO 'SPTU *U IBT brought her face-to-face with opera star Teddy Tahu Rhodes in the role of Emile (of Some Enchanted Evening fame) â&#x20AC;&#x153;South Pacific is an iconic musical and TVDI B EJGGJDVMU QJFDF UP UBDLMF *U T OFFET an aesthetic like Opera Australia to bring out the beauty and opulence because they mount productions like this all the time.â&#x20AC;? â&#x20AC;&#x153;We have been working with the showâ&#x20AC;&#x2122;s American director Bartlett Sher the past few days. Heâ&#x20AC;&#x2122;s is a complete master and what really sets his South Pacific apart from others, is its depth. He manages to flesh out every bit of the war with an ever-present sense of danger and urgent romance.

Heâ&#x20AC;&#x2122;s captured the essence of the period beautifully. But it was a dangerous time and at no point do you get the feeling that heâ&#x20AC;&#x2122;s let that disappear.â&#x20AC;? O

By Ms Jan Hallam

WIN For your chance to win tickets to see 4PVUI 1BDJGJD on November 10, turn to P50 for details.

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Have You Heard?

Heart starter *U XBT PQFOFE JO +BOVBSZ CVU UIF OFX FJHIU bed coronary care unit at Bunbury has been dormant since due to the lack of local DBSEJPMPHJTUT UP QSPWJEF UIF OFDFTTBSZ cover. Heralded as a great thing for local residents under Royalties for Regions, this GJSTU SFHJPOBM $$6 IBT BUUSBDUFE WJTB nursing staff who have now been moved to medical wards, replacing casuals. Coronary angiograms are performed in the CCU, using the latest equipment in this privatepublic facility.

Money in the bag?

Now the Coalition has been installed as the Federal Government, there are huge expectations from the health sector to be NFU o FTQFDJBMMZ JO QSJNBSZ DBSF 5IF OFX )FBMUI .JOJTUFS 1FUFS %VUUPO DBNQBJHOFE on his commitment to make the first 100 days of government all about general practice and there are a lot of organisations ready and waiting for action, not least among them the RACGP and the training organisations.

Before the election there were media releases from many of them congratulating the Coalitionâ&#x20AC;&#x2122;s promise, now there is a similar flurry of reminders. The way some of the statements are worded, the moneyâ&#x20AC;&#x2122;s in the bag. The clock starts ticking now.

Free Kick for MDA .VTDVMBS %ZTUSPQIZ "VTUSBMJB .%" IBT XSJUUFO UP "'- $&0 "OESFX %FNFUSJPV asking for a slice of the Essendon Peptide

Pie. â&#x20AC;&#x2DC;A donation from the $2m fine would be a drop in the ocean for the AFL,â&#x20AC;&#x2122; said #PSJT 4USVL GSPN .%" "QQBSFOUMZ UIFSF have been suggestions that some of the substances allegedly used by Essendon players in the recent supplement scandal are used in the treatment of muscular EZTUSPQIZ .%" IBT GJFMEFE NBOZ concerned calls regarding the unusual use of these medications, hence the plea for a philanthropic boost to their research funding.

Chocks Away at FSH *U XBT IFBET EPXO BOE FBS NVGGT PO BU Fiona Stanley recently. The chopper pad, conveniently placed above operating UIFBUSFT JOUFOTJWF DBSF BOE UIF &% IBT been given a test-run and passed with flying DPMPVST 5IF TRN UPOOF EFDL AGMPBUT on rubber pads which mitigates vibration and can accommodate the two largest emergency helicopters in the State. FSH will CF UIF POMZ IPTQJUBM PVUTJEF 1FSUI T $#% with a helipad and will service patients from Rottnest and southern regions. The first patients, airborne or otherwise, will start arriving in October 2014 as part of a staged commissioning process.

DoH short-term grants

Kidsâ&#x20AC;&#x2122; cancer and pain There has been a concerted campaigned in the media to increase funding for the oncology services at PMH and last month, the Health Minister announced funding for two more cancer specialists and an extra $20.5m over four years to recruit about 14 FTE cancer staff. While he was at JU IF BOOPVODFE N GPS FYUSB TFSWJDFT JODMVEJOH UP FTUBCMJTI B QBFEJBUSJD pain service (see www.medicalhub.com. au/component/content/article/9-topstories/4089-calls-grow-for-kids-painVOJU GPS UIF *$6 GPS DBSEJBD and other complex surgical cases, $342,000 for ENT, $342,000 for ophthalmology to reduce waiting times and $400,000 to the immunology department to meet the increased numbers of children presenting with allergic conditions. The new childrenâ&#x20AC;&#x2122;s hospital is expected to open in 2015.

5IF %FQBSUNFOU PG )FBMUI IBT VQ UP $400,000 set aside for two short-term Targeted Research Fund grants in two EJSFDUFE SFTFBSDI BSFBT o "MDPIPM SFMBUFE harm in 14-24 year olds and managing complex care in the primary care setting.

The research component must be completed within 24 months and applications close on October 14, 2013. Application packs from www.health.wa.gov.au/ researchdevelopment/funding/funding_ status.cfm#trf

RDAA win some â&#x20AC;Ś *U BQQFBST UIF 5IF 3VSBM %PDUPST "TTPDJBUJPO PG "VTUSBMJB 3%"" BOE its state associations will continue to collectively negotiate with state and

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www.rbsmorgans.com/perth medicalforum

territory health departments on behalf of rural doctors after the ACCC issued a draft decision. The negotiations relate to the terms and conditions under which rural doctors, including GPs and locums, provide services in public hospitals and health facilities as VMOs and provide after-hours TFSWJDFT *U EPFTO U MPPL MJLF UIF 3%"" XJMM be as successful in its claim to collectively negotiate with newly established Medicare Locals and Local Hospital Networks. The ACCC said it was not proposing to extend authorisation to negotiations with these parties because it is concerned that the benefits are likely to be more limited and collective negotiations may reduce price competition and the scope to negotiate specifically tailored solutions for each region. But it has left the door open before making its final decision.

Number crunching Last month, Medical Forum got hot-offthe-press info from NeHTA that there were SFHJTUFSFE 1$&)3T BT PG "VHVTU *U IBT TJODF SFMFBTFE B CSFBLEPXO PG figures (but only until July 10), which puts the number of registered general and NVMUJEJTDJQMJOBSZ QSBDUJDFT BU PS of total general practices in Australia. WA is said to have the lowest general practice JOWPMWFNFOU JO UIF DPVOUSZ *U BMTP TBJE "CPSJHJOBM .FEJDBM 4FSWJDFT TFWFO BHFE DBSF GBDJMJUJFT BMMJFE IFBMUI DPNNVOJUZ IFBMUI DFOUSFT DPNNVOJUZ pharmacies, 50 Medicare Local/State/ Territory or Area Health Services, three private hospitals, eight public hospitals BOE TQFDJBMJTUT IBWF SFHJTUFSFE 5IF GJHVSFT BSFO U TUVOOJOH *O SFHBSET UP ePrescriptions being downloaded from the two prescription exchange services, eRx and MediSecure, the figures are increasing, although not, itâ&#x20AC;&#x2122;s been reported by Pulse+IT, at the volume that they are being uploaded CZ (1T "T PG +VMZ PG UIF "VTUSBMJBO population has registered for a PCEHR.

medicalforum

training only is at Nickol Bay, Armadale and Peel Hospitals, whereas Bunbury )PTQJUBM POMZ PGGFST TUBOEBSE %JQMPNB training.

Philanthropy in Bali

ACCC shuts its eyes The ACCC has decided against allowing members of the Australian Society of Ophthalmologists (ASO) to reach agreements within shared practices as to the fees to be charged for ophthalmic services. There are around 810 practising ophthalmologists in Australia, with most working in major cities, with the ASO SFQSFTFOUJOH BCPVU QFS DFOU PG UIFN The ACCC saw the proposal might result in higher prices for patients because of the reduction in competition for ophthalmic services. The decision comes in the wake of the ACCC authorising fee setting conduct in shared practices of GPs and dentists. The ACC defended the decision saying these professions had much higher numbers of practitioners, which reduced the likely anticompetitive effects.

WA obstetrics boost The RANZCOG was flying the flag at the GPET conference at Burswood to promote its three training programs. WA QBSUJDJQBOUT BDSPTT BMM UISFF OVNCFS Certificate in Womenâ&#x20AC;&#x2122;s Health done in NFEJDBM QSBDUJDFT 0CTUFUSJDT %JQMPNB

BOE "EWBODFE 0CTUFUSJDT %JQMPNB (31), which is 18% of national intake and qualifies GPs to do caesarians). Training GPS CPUI %JQMPNBT JT EPOF BU "MCBOZ Geraldton, Hedland, Joondalup, King Edward, Osborne Park, Rockingham and 4XBO %JTUSJDU IPTQJUBMT "EWBODFE %JQMPNB

Your dollar goes further overseas. Not long ago we featured John Poyntonâ&#x20AC;&#x2122;s attitudes to philanthropy in medicine, and conducted an e-Poll on the same topic. The John Fawcett Foundation, with strong ties to Perth, took one mobile eye clinic and professional team to Sebatu in Bali where QFPQMF XFSF FYBNJOFE PQFSBCMF cataracts were removed in the mobile UIFBUSF BOE HMBTTFT XFSF EJTUSJCVUFE UP QFPQMF BOE FZF NFEJDJOFT UP QBUJFOUT o thanks to J. Poynton sponsorship.

Riding high On October 12 Shadow Minister for Health Roger Cooke will cycle off with a multitude of teams on a 200km ride to raise money for DBODFS SFTFBSDI BU 8"*.3 )F IBT SFBDIFE PG IJT UBSHFU GPS 5IF 4VOTVQFS 3JEF UP $PORVFS $BODFS *G ZPV XBOU UP help him achieve his target or join a cycling team, go to http://pr13.conquercancer.org. au. You can donate to him or other riders XIJDI JODMVEFT %S 5POZ 5SPQJBOP XF noticed, as a first timer).

Right care, right time, right location Thatâ&#x20AC;&#x2122;s the motto of the new Central Referral Allocation Unit, due to launch late this year. *U CPBTUT B OVNCFS PG CFOFGJUT CVU CBTJDBMMZ referrals will be directed to the closest, most available, most appropriate, hospitalCBTFE TFSWJDF o iUP SFEVDF EFMBZT GPS JOJUJBM outpatient appointments and subsequent EPXOTUSFBN TFSWJDFTw *U T B XBZ PG rationalising things while demand outstrips TVQQMZ BDSPTT NFUSP 1FSUI *OJUJBMMZ JU XJMM be paper-based, then electronic, with GPs having a single entry point. O

13

News & Views

Prisoners Listen Up Treating prison inmates, many of them Indigenous, for hearing loss may have a huge impact on their futures.

The disproportionate over-representation of young Aboriginal offenders in WAâ&#x20AC;&#x2122;s juvenile justice system is an incontrovertible fact. Corrective Services Principal Medical Officer and Acting Deputy Director Health Services, Dr Fraser Moss, sees this as a valuable window of opportunity.

Heâ&#x20AC;&#x2122;s firmly of the opinion that itâ&#x20AC;&#x2122;s possible to make a positive difference for individuals struggling with entrenched health issues, particularly hearing loss. i* GPVOE UIBU BSPVOE PG KVWFOJMFT had a moderate hearing loss and a further

IBE B NJME IFBSJOH MPTT JO CPUI PS one ear. Just 11% had hearing loss in both ears and all of those with a unilateral loss had normal hearing in the other ear. One youth had severe hearing loss requiring aids. Of Aboriginal detainees with any IFBSJOH MPTT XFSF GSPN SVSBM DPNNVOJUJFT *O BMM DBTFT * XBT DMJOJDBMMZ reassured that there was no impairment of communication.â&#x20AC;?

Challenges Ahead Approximately three-quarters of the current NVTUFS BU #BOLTJB )JMM +VWFOJMF %FUFOUJPO Centre in Canning Vale are Aboriginal inmates between the ages of 12 and 19, BCPVU GSPN SVSBM FOWJSPONFOUT "The challenge for us is how we proceed GSPN UIJT QPJOU 5IFSF T OP EJTQVUJOH UIF fact that we have limited resources and a finite, and often over-stretched, budget. )PXFWFS * NBLF UIF BOBMPHZ UIBU XF SF providing a level of service that equates with that of a rural GP clinic.â&#x20AC;? â&#x20AC;&#x153;We can refer someone on to a controlled audiometry ENT clinic but we usually have a fairly limited time-frame. The average duration for an inmate is four months which is usually less than the time required to obtain tertiary referrals.â&#x20AC;? â&#x20AC;&#x153;Nonetheless, even though we have a relatively sub-optimal testing environment it does provide some important parameters for ongoing care. We have an 1800 number [see below] and GPs can use that to obtain medical information for an individual who has been released from detention.â&#x20AC;?

Fraser makes the point that WA prison statistics sit far more comfortably on the page than those in NSW. Unsurprisingly, the Northern Territory (NT) is the worst of all. i*O BSPVOE PG JOEJHFOPVT juveniles in detention in NSW had normal IFBSJOH JO CPUI FBST *O UIF TBNF ZFBS UIF 14

Q Dr Fraser Moss, Corrective Services Principal Medical Officer

NT had a total of 1100 inmates, just over 80% were Aboriginals and 94% of them had a significant hearing problem.â&#x20AC;?

A great deal of time and money has been spent on translational research into *OEJHFOPVT IFBMUI PO B OBUJPOBM CBTJT PWFS the last two decades, some of which has focused on hearing problems within remote communities.

Broader Community Problem â&#x20AC;&#x153;The figures suggest that anything up to PG "CPSJHJOBM QFPQMF MJWJOH JO B SVSBM environment have got some sort of hearing QSPCMFN *OUFSFTUJOHMZ UIBU DPNQBSFT XJUI a figure of around 20% for their urban counterparts.â&#x20AC;? i*O UIF FBSMZ T * XBT UIF 3FHJPOBM .FEJDBM %JSFDUPS JO UIF (PMEGJFMET BOE during that period the Population Health Unit in Meekatharra came up with the figure of between 40-50% with significant hearing loss. This research was translated JOUP TPNF QPTJUJWF PVUDPNFT o BNQMJGJFST were put into schools, teleotoscopy services were expanded and public swimming pools proved to be a valuable health resource.â&#x20AC;?

Doctors and Prisoner Health The interesting career trajectory for Fraser Moss started in rural New Zealand before heading to the Middle East for 15 years to work for an oil company. i*O * XBT UIF %JSFDUPS PG 1VCMJD )FBMUI for the Goldfields and South-East and also the Medical Superintendent at Kalgoorlie )PTQJUBM * XFOU PO UP XPSL JO (FSBMEUPO BOE UIF .JE 8FTU XIFSF * EJE TPNF XPSL in regional prisons and then transferred to Corrective Services in Perth.â&#x20AC;?

â&#x20AC;&#x153;The scope and complexity of the clinical work is both challenging and rewarding because weâ&#x20AC;&#x2122;re dealing with people whoâ&#x20AC;&#x2122;ve got multiple complications. Thereâ&#x20AC;&#x2122;s metabolic syndrome combined with significant behaviour issues and mental health problems exacerbated by drug and alcohol abuse.â&#x20AC;?

Banksia Hill received some bad press earlier this year when a number of inmates expressed their discontent by rioting and damaging the facility. The main protagonists were sent to Hakea Prison, a remand centre for adult males. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve had to restructure the way we provide medical services to those juveniles.

Thereâ&#x20AC;&#x2122;s no purpose-built clinic at Hakea but UIFSF T DPWFSBHF B EPDUPS WJTJUT UISFF times a week and we have direct access to the cells.â&#x20AC;? â&#x20AC;&#x153;As doctors within a corrective services environment we treat every individual with courtesy and respect. We have a strong relationship with the custodial officers and * WF GFMU WBHVFMZ VODPNGPSUBCMF PO POMZ B couple of occasions.â&#x20AC;? i*U XBT DFSUBJOMZ QMFBTJOH UP TFF UIBU UIF last national review revealed significant improvements in the health of inmates.

Thatâ&#x20AC;&#x2122;s one of the positive aspects of XPSLJOH JO QSJTPOT o XF DBO BOE EP make a difference.â&#x20AC;? O

By Mr Peter McClelland ED: GP reference phone line 1800 077 735

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15

Feature

A Chemical Advantage Our athletes and sportspeople are under enormous pressure to go faster, higher, longer.

Itâ&#x20AC;&#x2122;s a dangerous path to a winnerâ&#x20AC;&#x2122;s medal and doctors have an important role to play.

The Australian Anti-Doping Agencyâ&#x20AC;&#x2122;s (ASADA) stated intent is to protect our sporting integrity by eliminating doping and achieving â&#x20AC;&#x2DC;pure performanceâ&#x20AC;&#x2122; in sport. An ASADA spokesperson provides Medical Forum with a national perspective and Dr Carmel Goodman, Chief Medical Officer with the Western Australian Institute of Sport (WAIS), raises some pertinent local issues.

Sport in Australia is inextricably tied to our national psyche. The London Olympics is probably best forgotten. The heroes of the pool looked washed up, Sir Bradley Wiggins left Cadel Evans in his slipstream and we wonâ&#x20AC;&#x2122;t get started on the Ashes. Weâ&#x20AC;&#x2122;re not the sporting powerhouse we once were, but our athletes are some of the most rigorously tested in the world.

ASADA Comment â&#x20AC;&#x153;Sport is a powerful cultural force in "VTUSBMJB *U T PVS SPMF UP QSFTFSWF BOE protect sportâ&#x20AC;&#x2122;s inherent value, not only for the athletes but for everyone whoâ&#x20AC;&#x2122;s passionate BCPVU TQPSU w TBJE BO "4"%" TQPLFTQFSTPO â&#x20AC;&#x153;No sport is immune to doping but we think that the vast majority of Australian athletes are doing the right thing. They should be applauded for not taking shortcuts, even if they suspect that some international competitors are using banned substances.â&#x20AC;? â&#x20AC;&#x153;And the cold, hard reality is that anyone who uses a prohibited substance risks their health, their career and their reputation.â&#x20AC;?

There is a constant debate whether the science of drug-testing regimes is keeping pace with the increasing sophistication of illegal doping. The introduction of individual biological passports for athletes [see opposite] NFBOT UIBU "4"%" BOE UIFJS PWFSTFBT equivalents, are faster out of the blocks.

Q ASADA Splitting and Sealing the Sample

â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re in a constant race with the scientific advances in doping and every year there are thousands of modified substances developed in laboratories and released on the black market. Unfortunately, there will always be people willing to act illegally and we just have to work smarter to close that net.â&#x20AC;? â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve refined our intelligence and investigation functions and, using longterm storage of samples [see opposite] and biological passports, weâ&#x20AC;&#x2122;re definitely making it more difficult for those who try to cheat the system.â&#x20AC;?

There are some who play the devilâ&#x20AC;&#x2122;s advocate and say the battle has already been MPTU 4P XIZ OPU DPODFEF UIBU 5IF CFTU chemist wins! â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s no doubt that doping has been around as long as competitive sport itself.

One of the critical concerns is the health of athletes. Severe illness and death can result from the use of substances that have neither

been clinically tested nor approved for human consumption.â&#x20AC;? i%PQJOH UISFBUFOT UIF JOUFHSJUZ PG TQPSU *U SPCT BUIMFUFT XIP QMBZ CZ UIF SVMFT BOE allowing open slather would send the wrong message regarding the principles of fair play. Sport, in many countries, helps to build communities and address issues such as anti-social behaviour.â&#x20AC;?

Advice for Doctors There are some important considerations for medical practitioners with elite athletes on their patient books. Therapeutic Use Exemptions (TUE) is one of them. â&#x20AC;&#x153;Sometimes doctors have no alternative but to prescribe medications that are on UIF 8PSME "OUJ %PQJOH 1SPIJCJUFE -JTU Thereâ&#x20AC;&#x2122;s provision for this under the TUE process.â&#x20AC;? [See Nathan Charles, September > *G ZPV SF USFBUJOH BO BUIMFUF BMXBZT check the status of the substance on the "4"%" XFCTJUF 5IFSF T JOGPSNBUJPO BCPVU submitting a TUE application as well,â&#x20AC;? the "4"%" TQPLFTQFSTPO TBJE â&#x20AC;&#x153;Of course, emergencies are treated differently and the life of the athlete takes priority over any anti-doping issue. The Code provides for any acute or emergency TJUVBUJPO *U T BMTP JNQPSUBOU GPS EPDUPST and athletes to know that the status of any medication sourced overseas cannot be HVBSBOUFFE CZ "4"%" w â&#x20AC;&#x153;Athletes rely on the medical fraternity for accurate advice and a doping violation can have a dramatic effect on their career.â&#x20AC;?

Dr Carmel Goodman Viewpoint

Q Dr Carmel Goodman treating Hockyroo with Kim Walkercamp 16

Sport medicine specialist, Dr Carmel Goodman has a supervisory and oversight SPMF BU 8"*4 BOE B DMPTF JOWPMWFNFOU medicalforum

ATHLETE BIOLOGICAL PASSPORT (ABP) t *OEJWJEVBM FMFDUSPOJD SFDPSE PG CJPMPHJDBM QSPGJMF GSPN CMPPE TBNQMFT t 'PDVTFT PO FGGFDUT PG CMPPE EPQJOH t "#1 BENJOJTUFSFE VOEFS 8PSME "OUJ %PQJOH (VJEFMJOFT

with the Hockey Australia Womenâ&#x20AC;&#x2122;s High Performance Program.

The illegal use of supplements at the Essendon Football Club resulted in some bad press, both for the team and the AFL more generally. As Carmel points out, itâ&#x20AC;&#x2122;s crucially important to ensure that athletes know exactly where they stand. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve just brought out a new policy PO TVQQMFNFOU VTF BU 8"*4 *U T WFSZ DMFBS on just what constitutes a â&#x20AC;&#x2DC;supplementâ&#x20AC;&#x2122; and the necessary requirements for athletes.

Every competitor based here signs a disclosure stating that they will comply with the policy and theyâ&#x20AC;&#x2122;re aware that they canâ&#x20AC;&#x2122;t take any protein powders, pills or vitamins unless itâ&#x20AC;&#x2122;s approved either by me or the sports nutritionist.â&#x20AC;? â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve always had a zero-tolerance policy but now itâ&#x20AC;&#x2122;s much more formalised.â&#x20AC;?

Weâ&#x20AC;&#x2122;ve just brought out a new policy on supplement use at WAIS. Itâ&#x20AC;&#x2122;s very clear on just what constitutes a â&#x20AC;&#x2DC;supplementâ&#x20AC;&#x2122; and the necessary requirements for athletes.

LONG-TERM STORAGE: DETECTION AND DETERRENCE t "VTUSBMJBO 4QPSUT %SVH 5FTUJOH -BCPSBUPSZ 4ZEOFZ t #MPPE BOE 6SJOF 4BNQMFT ZFBS SF UFTU DBQBDJUZ t 4VDDFTTGVMMZ VTFE JO PWFSTFBT QSPTFDVUJPOT o #FJKJOH 0MZNQJD BOE 1BSBMZNQJD (BNFT "4"%" XXX BTBEB HPW BV 4VCNJUUJOH B 56& XXX BTENBD HPW BV 8"*4 XXX XBJT PSH BV

â&#x20AC;&#x153;There are two areas of real concern.

Firstly, if an athlete becomes reliant on supplements to perform at a high level they may well compromise normal, healthy eating habits. Secondly, any of these ergogenic aids can have side-effects such as caffeineâ&#x20AC;&#x2122;s link with cardiac problems and protein powders with kidney damage.

And weâ&#x20AC;&#x2122;re not even talking about steroids and stimulants that can cause more serious medical problems.â&#x20AC;? i/P TQPSU JT UPUBMMZ DMFBO BOE * WF POMZ seen a few cases of doping in my career.

Nonetheless, thereâ&#x20AC;&#x2122;s no doubt whatsoever that athletes are using these substances and BWPJEJOH EFUFDUJPO *U T FTUJNBUFE UIBU MFTT than 1% are actually caught.â&#x20AC;? â&#x20AC;&#x153;And thatâ&#x20AC;&#x2122;s hardly surprising because

chemists linked with doping are continually coming up with new substances. With steroids you only need to make a small modification and youâ&#x20AC;&#x2122;ve got a new synthetic variation. The doping world within international athletics is way ahead of the testing regimes.â&#x20AC;? %PDUPST IBWF B SPMF UP QMBZ BU UIF HSBTTSPPUT level, suggests Carmen. â&#x20AC;&#x153;From a performance point of view itâ&#x20AC;&#x2122;s worth pointing out to a young athlete that drug testing is becoming more sophisticated and, within Australia, youâ&#x20AC;&#x2122;ll probably be caught. The other factor for doctors to stress is the adverse medical problems that can occur with some of these substances.â&#x20AC;? O

By Mr Peter McClelland

â&#x20AC;&#x201C; Dr Carmel Goodman

providing essential cancer support services and wellness, lifestyle and nutrition programs for West Australian families with cancer for 30 years. t IPVS DBODFS TVQQPSU DPVOTFMMJOH QIPOF MJOF t $PVOTFMMJOH GPS JOEJWJEVBMT BOE GBNJMJFT t *OGPSNBUJPO 1BDLT BOE )BOECPPLT GPS QFPQMF OFXMZ EJBHOPTFE XJUI DBODFS t $BODFS 4VQQPSU (SPVQT $BSFS T TVQQPSU t $BODFS $BSF 1BDLT 'SFF GPS DBODFS QBUJFOUT WBMVF t )PNF IPTQJUBM WJTJUT GSPN DPVOTFMMJOH TUBò t $BODFS XFMMOFTT DPVSTFT BOE TFNJOBST t 3FTFBSDI MJCSBSZ BOE XFMMOFTT NBHB[JOF

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24 Hour rt ppo Cancer Su lling e & Couns e Phone Lin Q Dr Carmel Goodman with tennis player Casey Dellacqua

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www.cancersupportwa.org.au 17

Trailblazer

A Man of Letters For 25 years, GP Ric Chaney has seen the havoc and tragedy caused by HIV-AIDS. He has also been a privileged witness to human struggles that are now rewarded with survival.

In the world of 16th century Renaissance France, a world in which Mt Lawley GP Ric Chaney was steeped for the first half of his life, the concept of lâ&#x20AC;&#x2122;honnete homme, or the man of honour, was a driving social and political force.

Membership to this club was confined to those who were humble, courteous and cultured. By those standards, Ric is a gold card member.

Sitting now in his Beaufort St surgery, where he sees more than 200 ambulatory )*7 QPTJUJWF QBUJFOUT IF SFGMFDUT PO B QBTU life as a scholar of French medieaval and renaissance literature in Paris, at the Centre for Advanced Studies in the Renaissance in Tours, then at the University of Montpellier; the gypsy life of a student, and the moment he decided that he needed to put those Renaissance ideals into action and become a doctor of medicine. â&#x20AC;&#x153;After roaming Europe for more than five years, it was time to get serious and HFU B KPC 4P * UPPL VQ B QPTU UFBDIJOH medieval and renaissance French literature at Newcastle University. One of the great concepts of the Renaissance man was the exploring of all sorts of avenues and pushing yourself to your limits.â&#x20AC;? i"GUFS ESPQQJOH PVU PG -BX * IBEO U really done anything except study French, -BUJO BOE &OHMJTI TP * FOSPMMFE JO B VOJU PG human biology in Newcastle and absolutely MPWFE JU * BQQMJFE UP EP NFEJDJOF BU UIF newly-established medical school there on the TUSFOHUI PG UIBU * XBT SFKFDUFE PO UIF HSPVOET PG CFJOH AUFNQFSBNFOUBMMZ VOTVJUBCMF BGUFS * sat for their entrance exam!"

So at the age of 31 and stubbornly undaunted, Ric applied to UWA.

Art of Survival i* XBT BDDFQUFE BOE GPS UIF OFYU GJWF ZFBST * was like everyoneâ&#x20AC;&#x2122;s elderly uncle, regarded CZ BMM XJUI CFOJHO UPMFSBODF * WF CFFO JO medicine now for more than 30 years and * WF BCTPMVUFMZ MPWFE JU 5IBU T UIF BSU PG TVSWJWBM * UIJOL o ZPV IBWF UP NBJOUBJO UIF love for the practice of medicine and the interaction with patients; without it, youâ&#x20AC;&#x2122;re in trouble.â&#x20AC;?

For the past 25 years, Ricâ&#x20AC;&#x2122;s practice has been dominated by his pioneering primary DBSF XPSL XJUI )*7 QBUJFOUT .FNPSJFT PG all the deaths he saw flicker across his eyes XIFO IF SFDBMMT UIF FBSMZ EBZT PG UIF "*%4 crisis in the late 1980s and the early â&#x20AC;&#x2122;90s. â&#x20AC;&#x153;By the early 1990s, people had been ill long enough to get sick and most of them were 18

Q Dr Ric Chaney

dying. No one knew what to do and many doctors wouldnâ&#x20AC;&#x2122;t have anything to do with them. There were some terrible stories about the way the patients were treated at times.â&#x20AC;? i* XBT XPSLJOH BU 1.) XIFO %S 5FSSZ Pitsikas asked me to work with him because no other GPs were willing to work in )*7 NFEJDJOF BOE UIFSF XBT PCWJPVTMZ a crisis brewing. We joined up with the RPH department of immunology with Prof .BSUZO 'SFODI BOE %S 4JNPO .BMMBM XIP were both very keen to have GPs involved in the sharing of care. So they trained Terry and me and we became the only GPs in those early days with prescribing rights for the S100 drugs.â&#x20AC;? â&#x20AC;&#x153;A terrific model of shared care was developed between the hospital and Terryâ&#x20AC;&#x2122;s general practice, which became a bit of a role model for other states. But it didnâ&#x20AC;&#x2122;t diminish the tragedy. We spent a lot of our time struggling to manage complex opportunistic infections and doing lots of terminal care. Credit should really be given to the Silver Chain â&#x20AC;&#x2DC;Special Serviceâ&#x20AC;&#x2122; though; they did an absolutely remarkable job at facilitating home care in those awful days.â&#x20AC;? *O 3JD XFOU UP 4ZEOFZ UP XPSL XJUI %S .BSJMZO .D.VSDIJF B QJPOFFS JO DPNNVOJUZ )*7 NFEJDJOF BOE OPX Associate Professor of General Practice, BU IFS %BSMJOHIVSTU DMJOJD XIFO UIF ESVH ";5 DBNF PO UP UIF NBSLFU 5$ E 5 EE* and ddC followed but they all proved to be terribly toxic. Times were desperate. â&#x20AC;&#x153;Organisations such as Act Up were the

QSPUFTU FOE PG UIF )*7 BGGFDUFE BOE JOGFDUFE communities. They were vocal and noisy in their demands for treatments. They invaded meetings, lobbied politicians and organised demonstrations. But it was a bit of a doubleFEHFE TXPSE *U XBT GBOUBTUJD UIBU UIFZ XFSF there, and fantastic what they were saying.

What was not so fantastic was that their demands often ran in the face of evidencebased medicine.â&#x20AC;? â&#x20AC;&#x153;We only had relatively unproven treatments. The damage done by the early release of some drugs because of the desperation to do something was considerable. Those movements were UFSSJGJDBMMZ QPXFSGVM BOE * TVQQPSUFE UIFN JO UIFPSZ CVU * IBE HSBWF SFTFSWBUJPOT w â&#x20AC;&#x153;And as for the Grim Reaper campaign, its downside was the increased prejudice and exclusion by fear of the gay and drugusing communities. Fear is never a good UPPM UP VTF *U XBT VTFGVM GPS DPOTDJPVTOFTT raising but not so useful for community QFSDFQUJPOT PG UIF BMSFBEZ BGGFDUFE )*7 positive patients. And it led to the unhelpful DPODFQU PG "*%4 T hJOOPDFOU WJDUJNTh BT opposed to 'the others'.â&#x20AC;?

While Ricâ&#x20AC;&#x2122;s patient numbers in the â&#x20AC;&#x2122;90s were SFMBUJWFMZ TNBMM o DPNQBSFE UP UIF OPX o UIF NFEJDBM JTTVFT XFSF DPNQMFY â&#x20AC;&#x153;They had multiple health issues, drug toxicity issues, opportunistic infections that were frightful, social issues such as isolation and discrimination, day in day out. But JO USJQMF UIFSBQZ DBNF JO BOE UIF MBOETDBQF DIBOHFE BMNPTU PWFSOJHIU *O medicalforum

UIF PME EBZT * XPVME TQFOE VQ UP IBMG NZ UJNF PO UFSNJOBM DBSF * OPX TFF XFMM PWFS 200 patients and 0% of my time is spent on terminal care because the vast majority are well, happy, working, and generally getting PO XJUI MFBEJOH B OPSNBM MJGF *U T CFFO BO absolute revolution in a relatively short period of time.â&#x20AC;? )BWJOH GBDFE IJT UI CJSUIEBZ JO 'FCSVBSZ the plan is for a lighter workload. However, UIF MBDL PG (1T LFFO UP UBLF PO )*7 positive patients is a concern for the few working in the area. i5IF "VTUSBMBTJBO 4PDJFUZ PG )*7 .FEJDJOF (ASHM) and RPH are really quite worried GPS UIF GVUVSF * N HFUUJOH PMEFS BOE XPO U be around forever. My colleagues Goran Pervan and Belinda Wozencroft are skilled JO UIF NBOBHFNFOU PG )*7 QBUJFOUT CVU UIFZ run a broad general practice as well and they certainly wonâ&#x20AC;&#x2122;t be able to take on 250 FYUSB )*7 QPTJUJWF QBUJFOUT w i*U T B IVHF QSJWJMFHF CFJOH QBSU PG UIFTF patientsâ&#x20AC;&#x2122; extraordinary journeys, and itâ&#x20AC;&#x2122;s fantastically rewarding medicine. My oldest )*7 QBUJFOU JT B XPNFO PG BOE UIF ZPVOHFTU JT * BN TFFJOH B QBUJFOU XIP XBT EJBHOPTFE XIFO IF XBT )F T OPX JO IJT T BOE EPJOH SFBMMZ XFMM o UIBU T UIF KPZ of treating these patients, who struggle and who survive.â&#x20AC;? â&#x20AC;&#x153;We are not dealing with the lifethreatening conditions we once were, and UIF NFEJDJOF JT SFBMMZ FOHSPTTJOH o JTTVFT of bone health, cardio-vascular health, renal IFBMUI BOE OFVSPMPHJDBM TUVGG *U T HPPE solid, clinical medicine which is what we are trained for.â&#x20AC;?

While doubt may hang over Ricâ&#x20AC;&#x2122;s being able to walk away from his lifeâ&#x20AC;&#x2122;s work, he says with some steely determination that corresponding with friends and reading will once again be central parts of his life. %FTQJUF QBJOGVM BSUISPQBUIZ JO IJT IBOET Ric continues to write letters by hand to a GBWPVSFE GFX o i'SJFOET TBJE UIFZ XPVME buy me a quill for Christmas!â&#x20AC;? And there are hundreds of books still to be read.

Asked what his former life of scholarship has given his medical practice, he laughs and says â&#x20AC;&#x2DC;everythingâ&#x20AC;&#x2122;! i*U IBT HJWFO NF B EFFQFS VOEFSTUBOEJOH PG UIF DPNQMFYJUZ PG IVNBO CFIBWJPVS o PVS OFFET BOE GSBJMUJFT 'SFODI MJUFSBUVSF o MJLF BMM MJUFSBUVSF o JT GVMM PG TUPSJFT PG IVNBO weaknesses and faults, and how they are all an intrinsic part of us. The task is to minimise the damage those faults can cause.

And, as doctors, we can hopefully contribute a small amount to that process.â&#x20AC;? O

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19

Feature

Peel Health Campus, Six Months On Itâ&#x20AC;&#x2122;s been a controversial 12 months in the life of the Peel Health Campus but new management is determined to smooth the waters and create a new focus for the region.

It was the volatile subject of a Legislative Council committee inquiry; it became the focus of an independent public service inquiry and it made enough sensational headlines relating to its former COO Ashton Foley to paper a house.

By comparison to the turbulent months between October 2012 and April this year, the Peel Health Campus was, when Medical Forum arrived for a meeting with the new Ramsay management, a peaceful bushy regional hospital ready for another busy day.

Ramsay Health Care officially took over the management of the hospital on June 1 after it bought out the remaining three years of the Health Solutions WAâ&#x20AC;&#x2122;s operating DPOUSBDU *U IBT BMTP BHSFFE UIBU OFHPUJBUJPOT XJUI UIF 8" )FBMUI %FQBSUNFOU GPS B five-year extension will, subject to all the standards being met, take its future plans into 2022-23.

Ramsayâ&#x20AC;&#x2122;s regional manager, Mr Kevin Cass-Ryall, and Peelâ&#x20AC;&#x2122;s new CEO and %JSFDUPS PG .FEJDBM 4FSWJDFT %S .BSHBSFU Sturdy, are unsurprisingly upbeat. They have more than 38 years' experience of senior hospital management at Ramsay between them.

Stokes Report Response Also not surprisingly they have gone through the Stokes report, delivered to the Public Service Commissioner in March, with a fine tooth comb and are satisfied that his concerns have been addressed.

For Margaret Sturdy, her first priority has been the morale of the workforce. â&#x20AC;&#x153;The Peel Health Campus is the second biggest employer in the region. Most of the staff live in the local community and have a great sense of pride in the place. To read the headlines day after day must have been BXGVM GPS UIFN * XBT FYQFDUJOH UIFN UP CF EJTJMMVTJPOFE XIFO * GJSTU XBMLFE JOUP UIF IPTQJUBM JO "QSJM CVU * GPVOE UIFN UP CF positive, upbeat, clinically well trained and all wanting to do a good job.â&#x20AC;?

Q Peel Health Campus 20

Q Peel Health Campus Emergency entrance. (Inset) Peel's CEO Dr Margaret Sturdy and Ramsay's Regional Manager Kevin Cass-Ryall

The Stokes Report praised the determination of the staff to deliver the people of Peel the best health service they could but it did highlight salary discrepancies. â&#x20AC;&#x153;The main salary discrepancy was for those workers covered by United Voice. Weâ&#x20AC;&#x2122;ve just negotiated an EBA with the union for significant pay increases with the view UIBU JO %FDFNCFS UIFSF XJMM CF QBSJUZ for these workers across all five Ramsay hospitals in WA,â&#x20AC;? Kevin said.

When Ramsay took over in June, Peel staff were offered the same terms and conditions as their previous employment, including retention of annual, long service and sick leave entitlements. And, as a result, few staff have left. Peel staff were also included in a tax-free offer of $1000 Ramsay Health Care shares in July to all Ramsay workers who had been permanent employees for more than three years. About 300 Peel staff took up the offer. â&#x20AC;&#x153;Ramsay has been listed on the stock FYDIBOHF TJODF 0OF PG PVS DIBMMFOHFT is competing with Not For Profit providers in recruitment and retention of staff. The benefits that the NFP sector is able to offer

staff is probably not equitable because of the tax advantage that sector attracts,â&#x20AC;?

Kevin said. i*U T CFFO B GSVTUSBUJPO GPS 3BNTBZ )FBMUI Care to find a way to give some benefit to our staff for their loyalty. The share issue is one such way.â&#x20AC;? i*OUFSFTUJOHMZ B MPU PG UIF TUBGG XIP UPPL VQ the share offer were cleaners and orderlies because they have been here for such a long time, so itâ&#x20AC;&#x2122;s been a double bonus for them,â&#x20AC;? added Margaret.

As part of the process of working through the Stokes review, areas that Ramsay has moved RVJDLMZ PO BSF BTTFU BOE *5 NBOBHFNFOU and establishing rapport with the South Metropolitan Health Service (SMHS). â&#x20AC;&#x153;Ramsayâ&#x20AC;&#x2122;s reputation for hospital management goes a long way in establishing strong relationships with groups such as the SMHS. There is a high level of trust.

"T GPS BTTFU NBOBHFNFOU BOE *5 VQHSBEFT it is easily taken care of as part of a much bigger hospital operation. We have five hospitals in WA, which all support each other,â&#x20AC;? Kevin said. medicalforum

Joondalup has been one of the fastest growing in the country and he didnâ&#x20AC;&#x2122;t think the Peel region was far behind. â&#x20AC;&#x153;The development thatâ&#x20AC;&#x2122;s occurred at Joondalup Health Campus between the Government and Ramsay Health Care over the past five years has CFFO NBTTJWF *O 1FFM UIFSF JT DFSUBJOMZ UIF opportunity to develop.â&#x20AC;?

"We are in the process of putting together a CVTJOFTT DBTF UP QVU CFGPSF UIF %FQBSUNFOU of Health, the Minister and the SMHS, who will ultimately need to sign off on any redevelopment plans.â&#x20AC;?

Future Hospital Plans â&#x20AC;&#x153;What we can say we are looking at is increasing the operating theatres by four, building a new separate private hospital JOJUJBMMZ CFET XJUI UIF DBQBDJUZ UP HP to 90 beds) on the campus grounds and FYQBOE UIF &NFSHFODZ %FQBSUNFOU XIJDI currently sees about 45,000, to cater for $POTVMUBOU TVJUFT BSF BMTP QMBOOFE w i*G JU HPFT BIFBE 5IF QVCMJD DBQBDJUZ will increase because the 32 private beds currently will become a public ward.â&#x20AC;?

Changing Demographics Since moving to the Peel region, Margaret has been meeting local groups to determine how the health campus fits into the local community, all have shown interest and support for the new management.

The projected population growth of the Peel region has meant there is capacity for new PQQPSUVOJUJFT *U IBTO U FTDBQFE 3BNTBZ T notice nor St John of God Health Care, which has been doing feasibility studies for a private hospital 200m from the Peel Health Campus. â&#x20AC;&#x153;The growth of the retiree demographic in this area has always been known and planned for, the degree of that growth has taken people by surprise. But what hasnâ&#x20AC;&#x2122;t been necessarily expected or planned for is the growth in young families here. Because it is affordable and it only takes 45 minutes to get to the airport, UIFSF JT B HSPXJOH '*'0 QPQVMBUJPO 8F have some very wealthy people living here and some very impoverished people here.

This facility needs to cater for all of them,â&#x20AC;?

Margaret said.

Kevin said that the population growth in medicalforum

â&#x20AC;&#x153;We know it works and we know how to do it because itâ&#x20AC;&#x2122;s what we did at Joondalup seven years ago. When we took over the Joondalup campus there was a separate 145bed private hospital, weâ&#x20AC;&#x2122;ve expanded the

TJUF UP CFET XJUI BO &% UIBU DBUFST GPS more than 90,000 attendances a year as well as separate consultant suites.â&#x20AC;? i1FFM XPO U CF B CFE GBDJMJUZ CVU JU XJMM potentially in time, be double in size.â&#x20AC;?

As far as attracting clinical staff, both see the Ramsay connections working well for Peel Health Campus. â&#x20AC;&#x153;Since Ramsay has taken over here, there have been expressions by some of Ramsayâ&#x20AC;&#x2122;s city doctors that they are interested in coming to Peel as part of the redevelopment,â&#x20AC;? Kevin says.

For Margaret, who is living in Mandurah, she believes as the community grows and more amenities and schools are built, doctors will eye life among the gum trees. i*G ZPV MPPL CBDL BU +PPOEBMVQ ZFBST BHP there was a lot of trouble getting specialists there. We have had a lot of interest from doctors and we also have a number of specialists who are already resident here.â&#x20AC;? i* WF CFFO NFU XJUI TNJMJOH GBDFT BOE QPTJUJWF BUUJUVEFT TJODF * WF BSSJWFE 5IF doctors are engaged in the organisation, they want to see it progress as well and staff just want to get on and do a good job. Pay and geography are down the scale of importance. Quality of care is most important, that and good leadership.â&#x20AC;? O

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medicalforum

Guest Column

A Sick Nation â&#x20AC;&#x201C; Or Are We? Former Federal Health Minister Dr Carmen Lawrence takes aim at the increasingly problematic subtext of over-diagnosis.

T

he rising cost of health-care services is clearly apparent and, as a former Federal Health Minister (1994-96), Iâ&#x20AC;&#x2122;m keenly interested in the factors driving this social change.

Over-diagnosis and its consequences â&#x20AC;&#x201C; increasingly unnecessary treatments â&#x20AC;&#x201C; are not the only culprits but they form a large part of the bigger picture.

Weâ&#x20AC;&#x2122;re in the middle of a perfect storm. A population with a burgeoning anxiety about their own health, doctors who are becoming overly-cautious because they fear litigation, a pharmaceutical industry profiting from the widening definitions of disease and a health system that rewards over-testing and unnecessary procedures while failing to acknowledge the harms that can result.

Thereâ&#x20AC;&#x2122;s professional and commercial self-interest at work here and, when you combine that with media hype about â&#x20AC;&#x2DC;superbugsâ&#x20AC;&#x2122; and â&#x20AC;&#x2DC;miracle curesâ&#x20AC;&#x2122;, the end result is what a recent editorial of the British Medical Journal termed a â&#x20AC;&#x2DC;modern epidemicâ&#x20AC;&#x2122; of over-diagnosis.

*U T OPU BMXBZT DPOTDJPVT PS EFMJCFSBUF but the inescapable fact is that many of MJGF T OPSNBM QSPDFTTFT o CJSUI TFYVBMJUZ VOIBQQJOFTT BHFJOH BOE EFBUI o BSF being â&#x20AC;&#x2DC;medicalisedâ&#x20AC;&#x2122;. Add to this the more deliberate and cynical practice of disease NPOHFSJOH o FTTFOUJBMMZ ATFMMJOH TJDLOFTT o in order to expand markets for those who sell and deliver treatments and the mix is potentially explosive.

There is growing evidence that corporate interests, particularly the pharmaceutical sector, are knowingly engaged in this process. They are selling sickness under the guise of covert marketing and using the support of patient lobby groups, distorted â&#x20AC;&#x2DC;medical educationâ&#x20AC;&#x2122; functions (worth $1m a week in Australia) and targeted campaigns to expand the scope of disease categories. *U JT OP BDDJEFOU UIBU UIF MBSHF pharmaceutical companies spend twice as much on marketing and promotion as they do on research and development.

And the cost is not confined to the health budget. When people are diagnosed with

Our care surrounds you... medicalforum

diseases or conditions that wonâ&#x20AC;&#x2122;t actually harm them, adverse effects follow. Healthy people are labelled as â&#x20AC;&#x2DC;illâ&#x20AC;&#x2122; and exposed to the potential harm of intrusive investigation and treatment with few long-term benefits.

Many of these diagnoses, especially those that relate to mental health, lead to individualised (often chemical) solutions when the problem may lie elsewhere. " DBTF JO QPJOU o UIF 4IJGUXPSL %JTPSEFS which locates the problem in the individual rather than the working conditions that produce disturbed body rhythms and sleeplessness.

When diagnoses of illness are unwarranted, resources are diverted from effective treatments for serious diseases, and public health measures that might prevent genuine illness are disregarded in favour of treating â&#x20AC;&#x2DC;pseudo-diseasesâ&#x20AC;&#x2122;. %FBMJOH XJUI UIF QSPCMFN PG PWFS EJBHOPTJT is surely a case where â&#x20AC;&#x153;less is moreâ&#x20AC;?. O ED: The Australian Institute of Health and Welfare (AIHW) estimated health expenditure in 2011 as 9.3% of GDP.

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Guest Column

Doctor-Parent: What Can Be Worse?

The agony of losing her 15-year-old son suddenly has put Dr Victoria Buntineâ&#x20AC;&#x2122;s life and medical practice into sharp relief.

B

ack in March this year, the editor of Medical Forum asked me to write an column on being a city GP. I wrote a brutally honest piece about how isolating and hard I thought it was, especially being a single mother GP in a new city. I submitted it and enjoyed the therapeutic feeling I had in openly sharing my feelings. Two weeks later I frantically emailed her to pull the article before it was printed. My 15-year-old son had just died suddenly.

*UhT OPX GPVS NPOUIT MBUFS William was a healthy, active Year 10 Hale student and walked to and from school this particular week. He had at times mentioned he had a slight headache and thought he was getting sick with a cold, but then the OFYU EBZ IF SFRVFTUFE * CSJOH IJN IPNF two pizza subs from Subway because he was TUBSWJOH " HSPXJOH UFFOBHF CPZ * UIPVHIU On the Friday night he started vomiting. He vomited every 2-3 hours during the night BOE GFMU XBSN *O UIF NPSOJOH XF EJTDVTTFE what a vicious virus this must be and he sipped some fluids after a shower and a shot PG .BYPMPO * RVJDLMZ DIFDLFE IJT QVQJMT and asked if his arms and legs felt OK, then told him that if he was still this sick in the BGUFSOPPO * XPVME UBLF IJN UP &NFSHFODZ He said he was fine and just wanted to sleep. )BMG BO IPVS MBUFS * IFBSE B OPJTF GSPN IJT bedroom and rushed in. To my absolute horror he was fitting violently. After a very long 15 minutes, the ambulance arrived. * XBT IZTUFSJDBM BOE 8JMM XBT EFGJOJUFMZ not aware of anything going on. The QBSBNFEJDT EJE UIFJS UIJOH BOE * QBDFE frantically and tried to breathe. * LOFX UIJT XBT CBE .JOVUFT MBUFS * XBT in the front seat of the ambulance, sirens blazing, listening to the radio call, and watching the paramedic give him more

I realised that patients had to be told what had happened before they happily entered my room and asked me how I was. I had no expression. I was in shock, and trying desperately to get back on the horse.

medicalforum

and more midazolam, my mind not sure whether to be in medical or mother mode.

8F XFSF HSFFUFE BU 4$() &% BOE * XBT SVTIFE JOUP UIF SFMBUJWF SPPN * IBE CFFO working in Subiaco as a GP for five years, sending multiple patients to SCGH, yet this was my first time in the building.

5IF &% DPOTVMUBOU IBE B DIBU UP VT BCPVU meningitis, head injury or a possible SFBDUJPO UP UIF .BYPMPO * HBWF IJN BOE * am sitting there thinking, â&#x20AC;&#x2DC;that'd be right... trust a doctor's son to react to Maxolonâ&#x20AC;&#x2122;. * XBT BMNPTU SFBTTVSFE BU UIF UIPVHIU and then the junior registrar came in and VUUFSFE UIF XPSET * XJMM OFWFS GPSHFU "We've got the worst possible news." Worst QPTTJCMF OFXT XPSTU QPTTJCMF OFXT * UIPVHIU 8IBUhT UIF XPSTU QPTTJCMF OFXT )F IBT B DN CSBJO UVNPVS EFFQ JO IJT brain that has bled and he's had two strokes."

The words hung there, suspended like a bubble coming from her mouth.

"O .3* BOE FJHIU IPVST PG FNFSHFODZ surgery followed and we faced an agonising TJY EBZT JO *$6 CFGPSF GJOBMMZ EFDJEJOH UP XJUIESBX TVQQPSU .PTU PG UIBU UJNF * XBT completely in medical mode, although GSVTUSBUFE CFZPOE CFMJFG BT * GFMU UIF TUBGG were treating me as a mother, not a doctor. * XBOUFE UP LOPX XIBU UIFZ XFSF TBZJOH to each other â&#x20AC;Ś not the glossy lines that GBNJMJFT BSF PGUFO GFE *U XBT TVSSFBM BOE * was physically and emotionally numb.

5IF GVOFSBM XBT B XFFL MBUFS BOE * XBT CBDL at work four days after that.

"GUFS B GFX TFTTJPOT * SFBMJTFE UIBU QBUJFOUT had to be told what had happened before they happily entered my room and asked NF IPX * XBT * IBE OP FYQSFTTJPO * XBT JO shock, and trying desperately to get back PO UIF IPSTF 4P * XSPUF B TIPSU QBSBHSBQI and every patient was handed it when they BSSJWFE *U FYQMBJOFE XIBU IBE IBQQFOFE BOE UIBU XIJMF * BQQSFDJBUFE UIFJS XFMM XJTIFT * EJE OPU XBOU UP UBML BCPVU JU BT * XBT USZJOH UP HFU CBDL UP B OPSNBM working life.

The mood immediately changed. Patients came into my room and seemed almost embarrassed to discuss their seemingly benign complaints. They would look at me with a sad face and often a tear in UIFJS FZF BOE * XPVME USZ UP BWPJE FZF DPOUBDU .FBOXIJMF * XBT RVFTUJPOJOH UIF whole point of my job, shuddering every time nausea or vomiting came into the

I analysed the last photos taken of Will, trying to find some clue in his eyes that I might have missed. I felt guilty over things I know I shouldn't have. I now understand this is human nature when dealing with any sudden loss. It's just what we do.

DPOWFSTBUJPO BOE * TFOU UIF GJSTU QFSTPO who complained of a headache for a CT. 'PS XFFLT * QPVSFE PWFS UIF WFSCPTF histopathology and radiology reports, and googled 'anaplastic oligoastrocytoma grade *7h VOUJM * DPVMEOhU SFBE BOZ NPSF BCPVU JU * MFBSOU B MPU BCPVU UIF NPSUBMJUZ SBUF from these types of tumours and how they randomly strike normal fit young people. * BOBMZTFE UIF MBTU QIPUPT UBLFO PG 8JMM USZJOH UP GJOE TPNF DMVF JO IJT FZFT UIBU * NJHIU IBWF NJTTFE * GFMU HVJMUZ PWFS UIJOHT * LOPX * TIPVMEOhU IBWF * OPX VOEFSTUBOE this is human nature when dealing with any TVEEFO MPTT *UhT KVTU XIBU XF EP *UhT PWFS GPVS NPOUIT OPX TJODF UIJT NPTU hideous of assaults on a parent happened UP NF * IBWF SFBE FWFSZ CPPL PO HSJFG BOE * VOEFSTUBOE JUT DIBPT BOE UIF GBDU UIBU * will never 'get over it', simply learn to live XJUI JU * DSZ FWFSZ EBZ NBJOMZ BMPOF XIJMF ESJWJOH BOE * IBWF MFBSOU UIBU UIJT DSZJOH JT BO BCTPMVUF OFDFTTJUZ * IBWF OJHIUNBSFT BOE JOUFSNJUUFOU QBOJD BUUBDLT * TUSVHHMF XJUI NZ QVSQPTF BOE * TUSVHHMF XJUI USJWJBM things that people, both patients and otherwise, complain about all day long. * BN DMFBSMZ TUJMM JO TIPDL BOHSZ BU MJGF BOE at the loss of the past and future. However, * LOPX * DBO TUJMM MBVHI BOE FOKPZ TPNF UIJOHT JO MJGF BOE * IBWF CFFO PWFSXIFMNFE CZ UIF DBSET BOE IVHT * IBWF SFDFJWFE GSPN patients, not to mention the fact that they even want to come back to see me.

8IJMF * IBWF B QIJMPTPQIJDBM WJFX PG NZ TPOhT VOQSFWFOUBCMF EFBUI * EP VOEFSTUBOE UIBU * IBWF NVDI UP PGGFS QBUJFOUT 5IFSF BSF JMMOFTTFT * DBO QSFWFOU FYUSB ZFBST * DBO give them, unbiased advice and guidance PO B SBOHF PG TVCKFDUT BDVUF JTTVFT * DBO TPMWF RVJDLMZ BOE JG * DBO IFMQ QFPQMF HBJO a perspective on stress and life then that's a bonus. And unfortunately death is a part of life. O

25

Guest Column

Life Before Politics Dr Alan Eggleston has represented WA as a Senator since 1996. Here he reflects on a medical career about as far away from Canberra as itâ&#x20AC;&#x2122;s possible to get.

I

thought it would be an easy-going three month stay in Port Hedland. It was 1974 and it turned out to be hard work, gruelling hours with five doctors covering every aspect of hospital life from general medicine to obstetrics.

Needless to say, I loved every minute of it! The landscape, the people and the lifestyle were wonderful, so instead of running away from the first blast of summer heat I stayed for 22 years.

"U UIF 1PSU )FEMBOE %JTUSJDU )PTQJUBM XF EJE RVJUF sophisticated surgery, particularly with serious injuries, even though we only had access to basic X-Ray services. The more serious cases required the USBOTGFS PG QBUJFOUT CZ 3'%4 UP 1FSUI 'PSUVOBUFMZ thereâ&#x20AC;&#x2122;s been increased funding for rural and regional medicine and services have improved in the North West. Thereâ&#x20AC;&#x2122;s been a substantial lift in the number of doctors, including specialists, and a growth in the number of corporate medical clinics.

The new hospitals in Karratha and South Hedland have boosted the level of care in the region. One significant development for the Pilbara indigenous community has been the provision of local dialysis facilities and the establishment of an Aboriginal Medical Service in South Hedland.

Q Dr Alan Eggleston and Dr Alex Tin

Thereâ&#x20AC;&#x2122;s been â&#x20AC;&#x2DC;improvedâ&#x20AC;&#x2122; progress in the North 8FTU CVU * SFBMMZ DBO U QVU it any stronger than that, VOGPSUVOBUFMZ *U DBO U CF blamed on any person or department, nor is it an issue that anyone can provide a simple and clearcut solution, particularly in relation to the problems faced by indigenous communities. Theyâ&#x20AC;&#x2122;re Q Dr Alan Eggleston not the only social group with serious health issues, IPXFWFS * IBE B MPU PG DPOUBDU XJUI QFPQMF GSPN JTPMBUFE NJOJOH communities where, apart from work, they had very little to occupy their time and nowhere else to go.

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There are many challenges for indigenous people in the North West, namely health, housing, education and alcoholism. Has there been a ESBNBUJD JNQSPWFNFOU JO UIFTF BSFBT /P QSPCBCMZ OPU Nonetheless, these issues are being addressed through both HPWFSONFOU BOE DPNNVOJUZ JOJUJBUJWFT * UIJOL UIF OFYU TUFQ JT UP increase the level of indigenous participation with a strong focus on the younger generation. O

Referrals and enquiries freecall 1800 003 707 26

medicalforum

Guest Column

Age of Rage and Reconciliation Injury Control Council of WA Aboriginal liaison officer Mr Shaun Nannup helps young Aboriginal men find their place in society.

Y

oung Aboriginal fellas today struggle with who they are. They are a part of a world of computers, cars, work, high density living and yet they are also children of their Country, where the first years of life ought to be roaming and learning about the land. Thatâ&#x20AC;&#x2122;s hard when they are surrounded by city life.

The struggle to conform yet acknowledge your culture is constant. This freedom to be an Aboriginal boy or young man is missing and so are the male role models.

Asking an Aboriginal person today to return to their cultural beliefs and understanding is very hard. They donâ&#x20AC;&#x2122;t know what those beliefs are; they donâ&#x20AC;&#x2122;t know the true inner strengths of their

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culture. So they stand with anger and they make bad choices.

When a doctor is confronted by someone XBMLJOH JO XJUI BMM UIFTF JTTVFT TBZJOH A* am not well, help me â&#x20AC;Ś and by the way itâ&#x20AC;&#x2122;s ZPVS GBVMU UIBU * N OPU XFMM CFDBVTF ZPVS TPDJFUZ JT OPU QBSU PG NZ PME XBZT BOE * N mentally, physically and internally upset and youâ&#x20AC;&#x2122;re the cause of itâ&#x20AC;&#x2122;, thatâ&#x20AC;&#x2122;s tough.

Everyone is on the back foot.

Western medicine is prescriptive. Take this and it will make you well. But a lot of Aboriginal people wonâ&#x20AC;&#x2122;t go to doctors for a range of reasons which boil down to POF o USVTU *G "CPSJHJOBM QFPQMF EPO U IBWF B SFMBUJPOTIJQ with themselves, how can they have a relationship with doctors. Relationship is BCPVU USVTU o BOE VOEFSTUBOEJOH However, if people are able to come to terms with acknowledging themselves, UIFO FGGFDUT XJMM GMPX PO * VTF NZTFMG BT BO FYBNQMF * IBWF NBEF B MPU PG DIBOHFT UP NZ UIJOLJOH * N OPX BOE USZJOH NZ CFTU UP be a husband, father and mentor to young "CPSJHJOBM NFO #VU ZFBST BHP * XBT OPU so secure in my life.

5IF IFMQMFTTOFTT * GFMU XBUDIJOH ZPVOH QFPQMF going through the juvenile justice system and then taking them back home to dysfunction after either going through a program or coming out of prison was overwhelming.

What do you say to a kid who, at their front gate, says, â&#x20AC;&#x2DC;why are you taking me back to thisâ&#x20AC;&#x2122; â&#x20AC;Ś a house full of alcohol and needles and 12 people living in a room. That was UIF TUSVHHMF GPS NF CFDBVTF * EJEO U IBWF B clear answer to that.

There are so many passionate Aboriginal people out there wanting to help make this situation better but the problem is that they can only last so long. The problem is thereâ&#x20AC;&#x2122;s no action plan and without one, people burn out. We need a sustainable plan to tackle the issues that confront us. .Z QMBO DPNFT GSPN NZ PXO KPVSOFZ * WF acknowledged that my rage needed healing. * ESFX PO BMM NZ TUSFOHUI BOE NZ GBNJMZ T strength to heal. Not everyone has that same support to cope with the pressures and injustices of our time.

When a young person goes to court and stands before the judge, the damage has CFFO EPOF )PX EP XF IFMQ UIBU QFSTPO Sometimes jail is the answer but when it is we need jails to be places of rehabilitation and training. *G XF XBOU DIBOHF XF OFFE UP QVU UIFTF kids on the right path to change, and to support them to stick on their journey; to acknowledge what they have done, but also give them the chance to change and grow resilient to the pressures that await them. O

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27

Primary Care

Q (l to r) Dr Randy Beck (Primary Care WA), Ms Corrina Petric (PCWA), Mr Greg Mahney (Advocare), Ms Rhonda Parker (Alzheimerâ&#x20AC;&#x2122;s Association), Prof. Ann Zubrick (COTA), Mr John Gherardi (Mental Health), Mr Tony Ahern (St John Ambulance), Mr Chris McGowan (Silver Chain), Dr Penny Flett (Brightwater), Mr Chris Pickett (KP Medicare Local), Mr Matt Tweedie (Pharmacy Guild), Ms Loretta Allen (PCWA), Mr Dan Minchin (Silver Chain), Ms Jo Halpin (PCWA), Ms Learne Durrington (PC&EM Medicare Local), Ms Sara Rowenhurst, and Hon Helen Morton MLC.

Could it Be Easier?

The meeting was positive, with intentions good, but will this group redirect primary care in WA so health consumers benefit most?

Given its emphasis on mental health initiatives it was perhaps not surprising that Mental Health Minister Helen Morton opened an all-day meeting of CEOs and chairs of primary care organisations, convened by Primary Care WA as â&#x20AC;&#x153;GP14 summitâ&#x20AC;?, to collectively find ways to make the primary care sector in WA more efficient and effective.

1$8" PSHBOJTFS BOE $&0 %S 3BOEZ #FDL said the desire to make this more than a talk fest was shared by everyone in the room (see photo). â&#x20AC;&#x153;What we wanted was outcomes and outcomes that these people as heads of their respective organisations could commit to,â&#x20AC;? he told Medical Forum. â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s a saying, â&#x20AC;&#x2DC;You canâ&#x20AC;&#x2122;t stop an idea XIPTF UJNF IBT DPNF BOE * UIJOL UIBU T where weâ&#x20AC;&#x2122;re at right now. Everyone has a pretty good idea where the problems mostly lie and itâ&#x20AC;&#x2122;s now time to make the changes.

With so many groups involved, some competing for influence and territory, achieving consensus and forward movement in primary care has always been a challenge.

The meeting, with some big players in primary care noticeably absent, identified eight key points that summed up the current state of primary care in WA: t *O NBSLFUJOH QBSMBODF B ACSBOE JT lacking, one that is understood by the sector and consumers. t " MBDL PG JOGMVFODF PWFS HPWFSONFOU and opinion leaders. t /P DPIFSFOU BSDIJUFDUVSF QPMJDZ GVOEJOH

t )FBMUI XPSLFST UFOEFE UP CF TQFDJBMJTUT not generalists. t "EPQUJPO PG *5 TPMVUJPOT JT MBDLJOH (e.g. PCEHR). t /P SFBM TPMVUJPO UP JOWPMWJOH DPOTVNFST and carers (with varying ability and willingness). t 8IJMF UIF SPMF PG (1T JT DFOUSBM though evolving, there is no agreed or consistent paradigm.

28

t 5IF FOUSFODIFE IPTQJUBM DFOUSJTN ESBXT consumers into hospital even when it can be avoided.

Randy said that Primary Care WA had a 3-5 year vision that would ultimately end in the consumer knowing the right place to go at the right time, which had implications for the entire system. We did not ask if cross DPOOFDUJPOT XFSF MJLFMZ XJUI UIF %P) T planned Central Referral Allocation Unit or UIF JOUFSFTU UIBU 1$8" CPBSE NFNCFS %S .BSDVT 5BO IBT JO *5 TPMVUJPOT â&#x20AC;&#x153;The primary care community is huge.

GPs are an essential component but it also includes everything from insurance companies, ambulance services, aged care facilities, mental health facilities, allied IFBMUI QIBSNBDJFT o UIFO UIFSF T UIF consumer. There is no consistent discourse but we have to start somewhere.â&#x20AC;?

And so the meeting came up with four actions it thought were likely to be implemented: t &BDI PSHBOJTBUJPO XPVME BEPQU B WFSTJPO of PCEHR or encourage adoption amongst member organisations.

(Randy later said there had been a huge investment in the PCEHR and it needs to be pushed over the line.)

t &BDI PSHBOJTBUJPO XPVME IFMQ EFWFMPQ a coherent brand for primary care with coordinated, simple meaningful messages for Government and other key stakeholders. (Confusion between federal and state responsibilities were costing the system and needed to be sorted out, Randy said, and other inefficiencies and duplication of services were going to break us financially with people not getting the service they needed, when they needed it.) t " TJOHMF BDDFTT QPJOU UP QSJNBSZ DBSF services to enable triage and guidance for consumers and providers, regardless of the door initially entered. (â&#x20AC;&#x153;This will involve training for non-traditional practitioners.

This will not funnel people away from medical practitioners, it is another referral system for their services.â&#x20AC;?) t 5IF PSHBOJTBUJPOT XPVME NBQ DVSSFOU BOE desired consumer pathways, and identify nodes where integration could be improved.

Randy said leadership is now required, with change driven by consumer need, and the challenge is to align the wisdom and cognitive ability of those at the meeting. O

ABOUT PRIMARY CARE WA Primary Care WA (PCWA) has grown from the vestiges of WA GP Network, abolished by UIF UIFO GFEFSBM HPWFSONFOU XIFO JU TFU VQ .FEJDBSF -PDBMT 1SPNPUJOH JUTFMG BT iUIF DFOUSBM advocacy organisation for Western Australiaâ&#x20AC;&#x2122;s primary care communityâ&#x20AC;? the bona fides of the organisation are yet to be established, despite an impressive website (www.primarycarewa.

DPN BV BOE B SFMBUJWFMZ OFX $&0 JO GVODUJPOBM OFVSPMPHJTU %S 3BOEZ #FDL 1$8" JT PO B NFNCFSTIJQ ESJWF BSPVOE PG UIF PS TP DVSSFOU QBJE VQ NFNCFS PSHBOJTBUJPOT IBWF PME DPOOFDUJPOT XJUI (1 EJWJTJPOT PS OFX .FEJDBSF -PDBMT BOE UIF SFTU DPWFS B WBSJFUZ PG QSJNBSZ IFBMUI QSPWJEFST GSPN BNCVMBODF BOE BHFE DBSF UP DBSFST BOE DIJSPQSBDUPST 5IF GPVS DVSSFOU CPBSE NFNCFST IBWF UJFT UP .FEJDBSF -PDBMT "." 8" 8"(1&5 5IF 1PEJBUSJTUT Association, and Silver Chain. Initially, infrastructure funding was reportedly from residual funds for WA GP Network but their current website does not indicate how PCWA funds its activities and four executive staff. Connections with the WA Mental Health Commission include delivering some mental health training programs.

medicalforum

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29

CLINICAL UPDATE

Covering risk for WA travellers

By Dr Chris Rynn, Travel Medicine Adviser, Travel Medicine Centre Perth.

Tel 9321 7888

W

hat travel risks are there for Western Australians who are travelling more often to adventurous destinations? Why arenâ&#x20AC;&#x2122;t travellers protecting themselves against risks? The answers are not simple, because actual risk of an adverse event during travel is influenced by the destination, duration of travel, and the behaviour of the traveller, which includes their activities1. The risks for the individual are often hard to define, although adequate preparation and precautions can reduce risks. It is our responsibility to make travellers aware of the potential hazards and help them prepare adequately.

Precautions often the key For example, the season influences transmission of malaria and other mosquito-borne diseases. Yet with climate change, accurately predicting the â&#x20AC;&#x2DC;wetTFBTPO JT CFDPNJOH EJGGJDVMU %PFT UIF traveller cover up, apply insect repellent, or NPTRVJUP QSPPG UIFJS BDDPNNPEBUJPO Will they spend long hours consuming CFWFSBHFT DPOUBNJOBUFE CZ NFUIBOPM Will they get intoxicated and have a tattoo at the encouragement of their inebriated QFFST 8F IBWF OPX TFFO )*7 USBOTNJTTJPO SFQPSUFEMZ UISPVHI UBUUPPJOH JO *OEPOFTJB2.

The tattoo parlours in Phuket offer two QSJDFT o B IJHIFS POF JG ZPV JOTJTU PO B OFX OFFEMF /PU JOUFOEJOH UP HFU B UBUUPP Excellent. Most people donâ&#x20AC;&#x2122;t intend to get hit by a scooter either.

Human factors vary the risks for any traveller. Awareness is of utmost importance, and the traveller can then make an informed decision on how to ameliorate risk.

Perceptions of destination risk Perception of travel risk seems to increase with the more remote or â&#x20AC;&#x2DC;exoticâ&#x20AC;&#x2122; destinations. More â&#x20AC;&#x2DC;far-outâ&#x20AC;&#x2122; places may prompt people to investigate further the associated health risks.

Most seek travel advice if heading for West and East Africa (but often not South Africa). Jungles are perceived as dangerous, so trips to Papua New Guineaâ&#x20AC;&#x2122;s Kokoda

Track, the Borneo rainforest, and the Amazon all wave a red flag. Remote area trekking, especially at altitude, like the )JNBMBZBO DJSDVJUT *ODB 5SBJM BOE PUIFS Andean routes, also tend to trigger more wariness.

However, destinations close to home are often considered â&#x20AC;&#x2DC;normalâ&#x20AC;&#x2122; travel. Very PGUFO * IFBS i* WF POMZ USBWFMMFE UP #BMJ CFGPSF BOE * EJEO U OFFE UP IBWF BOZUIJOH for thereâ&#x20AC;?. My first case of acute hepatitis A infection was in a young girl returned from Bali. Rabies emerged in Bali in 2008, and most of the post-exposure prophylaxis we administer is for travellers returning from there. Unfortunately rabies JNNVOPHMPCVMJO JT VOBWBJMBCMF JO %FOQBTBS or Ubud. *NQPSUFE UZQIPJE DBTFT JOUP "VTUSBMJB may be on the rise. Nationwide there have CFFO DBTFT TP GBS UIJT ZFBS 5IFSF XFSF B total of 134 cases for 20113. A Queensland medical student succumbed to multi-organ failure from typhoid in January this year4.

Any vaccine-preventable death is a tragedy. %P XF CFDPNF DPNQMBDFOU XIFO WJTJUJOH PWFSTFBT DJUJFT 1SPCBCMZ 4JOHBQPSF JT B QSJNF FYBNQMF o XFMM EFWFMPQFE GJOF food and great shopping, yet there is a risk CFZPOE UIF IB[BSET PG DIFXJOH HVN * experienced food poisoning in Singapore GSPN B GPPE IBMM o NZ HVBSE IBE ESPQQFE %FOHVF BMTP PDDVST JO 4JOHBQPSF B SFDFOU case was a Singaporean holidaying in Perth.

5P .BZ 5IBJMBOE IBE SFQPSUFE

confirmed cases of dengue5. Brazil averages around one million cases per year. With the soccer World Cup and summer Olympics BQQSPBDIJOH GPS #SB[JM * N TVSF "VTUSBMJB will see more cases. %FTUJOBUJPOT JO "TJB TVDI BT .BMBZTJB Vietnam and Thailand are readily BDDFTTJCMF *U JT FBTZ UP CPPL UIFTF USJQT often on short notice with limited preparation. (Many later recount stories of travellersâ&#x20AC;&#x2122; diarrhoea to a reluctant BVEJFODF *O OPSUIFSO 7JFUOBN had 1880 suspected, and 240 confirmed cases of cholera infection . Two were chefs working in quality hotels in Hanoi so the repercussions could have been interesting for those spending â&#x20AC;&#x2DC;good moneyâ&#x20AC;&#x2122; for their accommodation. The following year, there XFSF DPOGJSNFE DBTFT BNPOH PWFS suspected cases .

Letâ&#x20AC;&#x2122;s go beyond the tropics. What of &VSPQF PS +BQBO 8BMFT BOE UIF 6, IBWF been alarmed by yet another measles outbreak, affecting over 1100 cases. The numbers are up from last year . Japan has TFFO BO PVUCSFBL PG SVCFMMB XJUI DBTFT JO UIF GJSTU TJY XFFLT PG UIJT ZFBS *O they had a total of 2353 cases8 *T ZPVS patient immune as they head off to the TLJ GJFMET PG /BHBOP 4FSPMPHZ XJMM HJWF BO answer, although some people believe these diseases donâ&#x20AC;&#x2122;t exist anymore.

Influence of compulsion and cost While travellers attend pre-travel consultations more often when a compulsory vaccine is involved (e.g. yellow fever for Africa and South America), some forget travel agent advice or do not read 30

medicalforum

ll o P e " BSPVOE *OUSBEFSNBM DPVSTFT PG rabies vaccinations are about $150 cheaper but about eight weeks is needed for confirmatory serology.)

Comfort tours can create a false sense of TFDVSJUZ o UIF FYQFDUBUJPO UIBU JG TPNFCPEZ has paid for a trip, then all responsibility for the trip rests with the tour company.

Many would be surprised how little correlation there is in cost of a trip and services provided in the event of an adverse happening. Some tour operators do not even carry a first aid kit.

Some do not carry emergency medication relevant to their destination e.g. emergency treatment for high altitude illnesses on trekking expeditions. A recent survey of British Mountaineering Expeditions found that 48% of tour operators did not carry ANY medication for treating high altitude illnesses9. Acute mountain sickness occurs in travellers flying to Cuzco to visit Macchu Picchu10.

Leave it all for your insurance company UP TPSU PVU )FMJDPQUFS FWBDVBUJPO GSPN Everest Base Camp has long been available, but is costly. Before the helicopter leaves Kathmandu, a confirmed payment by credit card or cash is required, and the current asking rate is around US$2000 per hour11.

Try convincing your insurance company that you really need that helicopter. *U T CFUUFS QFSIBQT UP DMBSJGZ XIBU ZPVS insurance company will do for you, before you leave home.

Doctor Attitudes to Travel Vaccines

In July we asked 72 specialists across a variety of disciplines their attitudes to travel risk from transmissible infections, and how they use vaccines. The results of this â&#x20AC;&#x2DC;straw pollâ&#x20AC;&#x2122; are an interesting reflection on attitudes to minimising risk amongst informed doctors.

Q

When you travel overseas, say to a conference, you may â&#x20AC;&#x2DC;wear the riskâ&#x20AC;&#x2122; and not use all recommended vaccinations or preventive medications against known transmissible infections.

Which statement(s) most closely fit your circumstances [up to 3 choices]?

Nearly always fully vaccinate and take other precautions as recommended.

Keep an eye on destination advisories and more likely to pay heed if there is an outbreak of something at the intended destination.

More likely to avoid optional prophylaxis if the destination does not have a compulsory vaccination.

Tend to avoid optional prophylaxis because of time SFTUSJDUJPOT CVU BXBSF * BN taking a risk.

Tend to avoid optional prophylaxis because odds are still stacked in my favour.

Avoid optional prophylaxis regularly to save money.

None of the above.

43%

22%

12%

2% 2% 3%

References 1. Leggat P. and Franklin R. Risk Perception and Travelers. J Travel Med. 2013;20(1):1-2.

DOI:10.1111/j.1708-8305.2012.00663.x

their tour documentation, so it becomes too late for vaccinations to offer protection.

Yellow fever vaccine takes 10 days to work, and the vaccination certificate, under *OUFSOBUJPOBM )FBMUI 3FHVMBUJPOT JT JOWBMJE until then. Some people travel on non-valid yellow fever certificates with disastrous DPOTFRVFODFT o RVBSBOUJOFE PWFSTFBT GPS six days at their expense, airlines refusing flight boarding, or deportation back by immigration to the country of departure.

Costs play a role, often holiday versus pre-travel preparation, where cheap holidays encourage a lower total spend. For FYBNQMF B IPMJEBZ UP #BMJ GPS TFFNT to not warrant spending the equivalent on travel vaccinations. A course of intramuscular rabies vaccinations cost around $350, and a completed course of hepatitis medicalforum

http//:www.who.int/cholera/countries VietNamCountryProfile2008.pdf.

2. Department of Health (WA). Media releases:HIV link to Bali tattoo [Internet}. 23 December 2011. [cited 2013 May 31]. Available from: http://www health.wa.gov.au/press/view_press.cfm?id=1104.

7. Public Health Wales. Measles Outbreak: Data [Internet].Updated 2013 May 31. [cited 2013 May 31]. Available from: http//:www.wales.nhs.uk sitesplus/888/page/66389.

3. Upe R. Typhoid on the rise as travellers skip vaccines. The Age [Internet]. 2013 May 4. [cited 2013 Apr 28]. Available from: http//:www.theage com.au/travel/typhoid-on-the-rise-as-travellers skip-vaccines-20130503-2iyab.html.

8. Ujiie M. Rubella-Japan: Increasing Incidence.

Promedmail [Internet]. 2013 Feb 28. [cited 2013 Apr 28]. Available from: http//:www.promedmail org/direct.php?id=20130228.1564418.

4. Bateman D. James Cook University medical student Amuthan Annamalai succumbs to typhoid fever. Courier Mail [Internet]. 2013 Jan 30. [cited 2013 Apr 28]. Available from: http//: www.couriermail.com.au/news/queensland medical-student-dies-of-typhoid-fever/story ebfreoof-1226564598413.

5. MCOT. Thailandâ&#x20AC;&#x2122;s dengue patients reach 26,000; 33 deaths recorded this year. Pattaya Mail [Internet]. 2013 May 2. [cited 2013 Apr 28].

Available from: http//:www.pattayamail.com news/thailand-s-dengue-patients-reach-26-000 33-deaths-recorded-this-year-25633.

6. World Health Organization. Cholera Country Profile: Vietnam. [Internet]. Updated 2008 Nov 25. [cited 2013 May 4]. Available from:

9. Pattenden H, Shah N, Hillebrandt D, et al. Do British Commercial Mountaineering Expeditions Carry Drugs to Treat High Altitude Illnesses? J Travel Med 2012;19(4):250-2. DOI: 10.1111/j.1708 8305.2012.00610.x 10. Salazar H, Swanson J, Mozo K, et al. Acute Mountain Sickness Impact Among Travelers to Cusco, Peru. J Travel Med 2012;19(4):220-225.

DOI: 10.1111/j.1708-8305.2012.00606.x 11. iTrekNepal. General Information. Rescue insurance. [Internet]. 2009. [cited 2013 May 31].

Available from: http://itreknepal.com/insurance.php

Author competing interests: No relevant disclosures.

31

CLINICAL UPDATE

The changing face of HIV in WA

By Dr David Nolan, Consultant Physician, Dept of Immunology RPH and SCGH.

T

he Grim Reaper advertising campaign only ran for three weeks in April 1985 but it is remembered as a critical time in the epidemic in Australia, when the political and public health response to HIV/AIDS was shaped by uncertainty and fear. Australiaâ&#x20AC;&#x2122;s low prevalence of HIV infection since, largely through free access to HIV testing and treatment within a widely accessible healthcare system, has been a source of pride. What of current trends? HIV has not been consigned to history. There is a growing population of patients with long-term infection and increasing numbers of new cases. The need for awareness may even be greater.

Changing perceptions 5IF DPODFQU PG )*7 JOGFDUJPO BT B LJMMFS disease lost relevance in the mid-1990s when antiretroviral combination therapies and improved monitoring (including )*7 WJSBM MPBE UFTUJOH ESBNBUJDBMMZ transformed the prognosis. Now, those with )*7 JOGFDUJPO DBO SFBMJTUJDBMMZ BOUJDJQBUF a normal life expectancy, and undergo successful long-term treatment with few side effects and minimal disruption to their work and home lives. )FODF PG UIF DBTFT EJBHOPTFE JO Australia since the epidemic began 30 ZFBST BHP BSF TUJMM MJWJOH XJUI )*7 5IJT JODMVEFT NBOZ XIP FYQFSJFODFE early antiretroviral treatment when median survival was about seven years, to the current era when â&#x20AC;&#x2DC;healthy agingâ&#x20AC;&#x2122; and management of common co-morbid illnesses (e.g. cardiovascular disease) are common discussion points in the clinic.

Q Fig 1: HIV notifications, AIDS and Death in WA, 1983-2012

active, because sexual histories are difficult to obtain and can be inaccurate.

8JUI OFX )*7 EJBHOPTFT FYQFDUFE JO Western Australia every year, there is also a need to return to an earlier era when i$PVME *U #F )*7 w FOUFSFE EJBHOPTUJD consideration whenever an opportunistic infection was suspected.

All medical professionals should feel DPOGJEFOU JO PSEFSJOH BO )*7 UFTU 8IZ Q Fig 2: HIV notifications by exposure categories and gender, 2004-2012. MSM = men who have sex with men (maybe not reflective of stated sexual orientation); IDU = injecting drug users; Het = heterosexual.

record in 2012 of 125 new cases, with no signs of this trend slowing in 2013.

This increase is due to a variety of factors including migration, overseas travel, and easier access to casual sexual contacts; as XFMM BT SFEVDFE BXBSFOFTT PG )*7 XJUIJO the community at large. Notably, more than half of all new WA cases in 2012 involved heterosexual men and women (Figure 2), NBOZ PG XIPN BDRVJSFE )*7 JOGFDUJPO overseas (Figure 3). This includes men and women of all ages, from adolescents through to an emerging population of heterosexual men who are often diagnosed JO UIFJS T BOE T BOE FWFO T 5IJT latter group is of particular concern because they are often not diagnosed until they present with severe infections due to advanced immune deficiency.

Who to test?

New worrying trends With improved treatment and increased BXBSFOFTT PG )*7 ZPV NJHIU FYQFDU SFEVDFE SBUFT PG )*7 EJBHOPTFT JO Australia. This was the case in the 1990s, XIFO EJBHOPTJT SBUFT QMVNNFUFE BGUFS when new effective treatments became available, down to 34 new cases in 1999 GSPN B QSFWJPVT QFBL PG JO 'JHVSF 1). This promising early trend has not been maintained in WA, however, and the steady SJTF JO OFX )*7 EJBHOPTFT PWFS UIF QBTU seven years established a new unwanted 32

3JTL PG )*7 JOGFDUJPO FYUFOET CFZPOE previous â&#x20AC;&#x2DC;high-riskâ&#x20AC;&#x2122; groups to include heterosexual men and women across all age groups.

*U JT OPX BCVOEBOUMZ DMFBS UIBU AQSPGJMJOH SJTL PG )*7 JOGFDUJPO CBTFE PO TFYVBM orientation is no longer adequate for EJBHOPTUJD UFTUJOH o FWFO JO PMEFS QBUJFOUT Gone is the Grim Reaper era, and the QSPTQFDU PG )*7 BT B EFBEMZ JOGFDUJPO and with this shift many of the barriers to UFTUJOH IBWF CFFO SFNPWFE )*7 UFTUJOH should therefore be considered in anyone entering a new relationship, or who has casual sexual contacts, with no associated stigma. An argument can even be made for routine testing in anyone who is sexually

Q Fig 3: Proportion of HIV acquired in Australia by exposure categories and gender, 2007-2012

8SJUUFO DPOTFOU GPS )*7 UFTUJOH JT OP longer required, and testing does not mandate an extensive discussion with the patient of the consequences of a QPTJUJWF UFTU *OTUFBE )*7 UFTUJOH JT justifiably part of a routine sexual health screen.

'PMMPXJOH B QPTJUJWF )*7 UFTU UIF laboratory will contact the requesting doctor and provide information about the results and referral pathways to MPDBM )*7 TFSWJDFT Remember that application for a temporary WJTB JO "VTUSBMJB JODMVEJOH UIF XPSLJOH visa and student visa) does not require QSJPS )*7 UFTUJOH FYDFQU GPS IFBMUI DBSF QSPGFTTJPOBMT )*7 UFTUJOH CFDPNFT mandatory when a permanent residency visa application is lodged (which may be several years after initial arrival). O Author competing interests: Nil relevant.

medicalforum

Clinical Updates

Warts and all - HPV Vaccination Sexual Health Physician Dr Lewis Marshall explains the HPV vaccination-STI connection in the context of how this virus behaves.

H

uman Papilloma Viruses are ubiquitous, with 80% of sexually active people showing signs of exposure to virus types that infect genital mucosa.

Increasingly, other mucosal surfaces that can be exposed with sex (anal canal and oropharynx) are also being infected.

Along with infection goes an increased risk of squamous cell carcinoma of cervix, vulva, vagina, penis, anus and oropharynx.

The commonest cause of visible warts are )17 UZQFT BOE SFTQPOTJCMF GPS of all condylomata accuminata; while these types can be associated with minor atypia F H $*/ UIFZ BSF OPU HFOFSBMMZ BTTPDJBUFE with carcinoma.

5ZQF JT DPOTJEFSFE UIF NPTU DBSDJOPHFOJD and along with type 18 is responsible for BO FTUJNBUFE PG DFSWJDBM DBSDJOPNB and the majority of other HPV-related cancers. While these types can result in condylomata, the majority of infections are initially asymptomatic and most people DMFBS UIFTF WJSVTFT *OGFDUJPO QFSTJTUT in a small proportion.

HPV vaccine effects The current government-supplied HPV vaccine provides excellent protection against BOE BOE IBT CFFO BWBJMBCMF GPS ZPVOH XPNFO TJODF 7BDDJOBUJPO IBT dramatically decreased genital warts in ZPVOH HJSMT JO TPNF TUVEJFT XJUI B more modest decrease in heterosexual men, presumably due to herd immunity.

While it is still early days, one would predict a similar impact on HPV-related DBODFST *OUFSFTUJOHMZ ZPVOH NFO XIP IBWF sex with men (MSM) have not enjoyed this reduction in warts and MSM have higher rates of anal cancer.

This year, boys have been added to the vaccination program for HPV; now available for boys in year 8 with a catch-up program this year (only) for those in years 9 and 10.

From next year this vaccine will be available to all boys and girls in WA in year 8, with vaccines available from GPs for those who miss the school program.

Tackling the STI-vaccination connection

a sexually transmitted infection. While the main promotional focus is around the vaccine preventing cancer, the carcinogen remains a sexually acquired virus.

For those concerned about vaccinating to QSFWFOU BO 45* * XPVME TVHHFTU NPTU QBSFOUT expect their children to become sexually active at some point and HPV vaccinations need to be given before exposure to be most efficacious. Therefore, it makes good clinical sense to give the vaccine in year 8.

Preventing cancer and genital warts can only be a good thing. As a sexual health physician, * TUJMM TFF NBOZ QBUJFOUT XJUI MPOH UFSN genital warts. There are various treatments but no cures and the psychological impact of this non-life-threatening infection can be DPOTJEFSBCMF o WJTJCMF XBSUT BSF QSFWFOUBCMF GPs are key to providing information to parents and patients, and vaccination can initiate a discussion between parents and their children about making good decisions in regards to future sex. As there is no compulsory sex education in schools, this can only be a plus! O

There has been some disquiet about giving a vaccine to young people that prevents

Inflammatory arthritis I

nflammatory arthritis, or more precisely â&#x20AC;&#x2DC;synovitisâ&#x20AC;&#x2122;, describes objective inflammation in the synovial tissue or synovial fluid of a joint. With numerous causes, the topic is vast, so here we focus briefly on just two facets of care.

Things that seem to help pain most Controlling the inflammation is the key to relieving pain.

"DVUF NBOBHFNFOU SFMJFT PO /4"*%T PS oral/intra-articular steroids. Both provide reasonable and rapid relief of joint swelling/ QBJO /4"*%T BSF HFOFSBMMZ OPU BT QPUFOU BOE IBWF BTTPDJBUFE UPYJDJUZ JODMVEJOH (*5 renal and long term cardiovascular effects.

4UFSPJET BSF NVDI NPSF QPUFOU *OUSB articular steroids will provide the best pain relief but use is limited by the number of joints involved (and hence injections), as well as technical expertise.

Therefore, the easiest way to treat acute inflammatory joint pain is oral steroids. The metabolic complications of use (e.g. weight gain, diabetes, fragile skin) tend to occur with long term regular use, so shortened use of this type is recommended (weeks to months), BMPOH XJUI TUFQQFE XJUIESBXBM BGUFS o days of use to avoid adrenal crisis.

Concurrent suitable long term treatments should be started as â&#x20AC;&#x153;steroid sparersâ&#x20AC;? to allow steroids to be weaned. The exception is polymyalgia rheumatic, which in most medicalforum

cases does not require a steroid sparer; dosages vary with weight and disease indication and most cases respond to 25mg daily of prednisolone (although crystal arthropathy may require higher doses).

Long term management requires mediations suitable for medium/long term use, which have side effects that are nonaccumulative compared with prednisolone.

For autoimmune inflammatory arthritis, UIJT XJMM JOWPMWF OPO CJPMPHJD %."3%T (disease modifying antirheumatic drugs) such as methotrexate or targeted biologic therapies such as anti-TNF (tumor necrosis factor) therapies etc. For gout, hypouricaemic agents are employed.

Best diagnostic tests These can be divided into two groups: Tests to identify inflammation in the joint. t $MJOJDBM FYBNJOBUJPO IBT MJNJUBUJPOT and can miss swelling in small joints, JOGMBNNBUJPO JO IJHI #.* QBUJFOUT BOE early disease. t 6TF PG VMUSBTPVOE XJUI QPXFS %PQQMFS BOE .3* BSF NPSF TFOTJUJWF BU JEFOUJGZJOH inflammation in a joint.

By Dr Eugene Ang, Consultant Rheumatologist, West Perth.

Tel 92263228 t "TQJSBUJPO PG B KPJOU XJUI DFMM DPVOU analysis is a very sensitive tool but not always possible. Serum CRP and ESR XJMM POMZ CF FMFWBUFE JO PG DBTFT PG inflammatory arthritis.

Tests to identify the cause of inflammation. t 8IFSF BVUPJNNVOF JOGMBNNBUPSZ arthritis is suspected, ANA, RF, CCP, )-" C BSF SFBTPOBCMF UFTUT CVU XJMM POMZ ZJFME QPTJUJWF SFTVMUT JO PG DBTFT t *G 4-& DPOOFDUJWF UJTTVF EJTFBTF JT TVTQFDUFE %4%/" &/" "/$" BOE complement levels can be added. t 4FSVN VSJD BDJE GPS HPVU DBO CF GBMTFMZ reduced during an acute attack. t "SCPWJSVT BOE QBSWPWJSVT TFSPMPHZ should be done in suspected viral arthritis, conditions that are generally self-limiting and benign compared with rheumatoid arthritis. O

Declaration: No relevant competing interests.

33

34

medicalforum

News & Views

Taking on PNGâ&#x20AC;&#x2122;s HPV Crisis Seeing women from the PNG province of West New Britain with late-stage cancer of the cervix prompted surgeon Prof David Wood to start a campaign to save lives into the next generation.

Orthopaedic surgeon Prof David Wood and a team of volunteer doctors and allied health professionals have recently returned from the third round of a HPV vaccination pilot program in the PNG province of West New Britain (WNB) full of high hopes that it will be the start of an ongoing campaign to reduce the incidence of cancer of the cervix in the country. %BWJE IBT CFFO WJTJUJOH 1/( GPS NPSF UIBO three decades and was moved to lobby for preventative measures about six years ago after confronting so many women with latestage cancer. â&#x20AC;&#x153;There is no screening for cancer of the cervix in PNG and with sexual activity starting early, HPV is very prevalent,â&#x20AC;? he said. i*U T QSFEJDUFE UIBU UIFSF JT B POF JO SJTL of PNG women dying from cancer of the cervix making it the most common cause of cancer death in women. That is a shocking TUBUJTUJD "CPVU TJY ZFBST BHP * CFHBO negotiating with Merck & Co for funding B QJMPU QSPHSBN BOE JO %FDFNCFS XF XFSF TVDDFTTGVM JO TFDVSJOH BMNPTU N worth of vaccine as part of the Gardasil Access Program.â&#x20AC;?

The pilot program targeted about 15,000 girls in WNB aged between nine and 13 with the first round beginning in March last year and concluding in August this year.

Q Dr Margaret Sturdy and Prof David Wood vaccinating girls in PNG

i8F IBE BCPVU BEIFSFODF GSPN UIF first batch; 85% from the second batch and weâ&#x20AC;&#x2122;re hopeful the third round will be even better.â&#x20AC;?

5IF UFBNT DPNQSJTFE %BWJE 68" BOE )PMMZXPPE 1SPG %BWJE 5IPNBT 1FUFS .D$BMMVN *OTUJUVUF %S %FSNPU .VSQIZ )PMMZXPPE 1SJWBUF BOE 4$() %S Margaret Sturdy (Peel Health Campus), Ms Jess Colliver Jennifer Woodhouse, Jessica Colliver, Kate Martin and Stacey Badrey (Hollywood Functional Rehabilitation Clinic). Over the past 12 months they IBWF UBLFO UIF WBDDJOF QSPHSBN UP schools and 32 community centres, treating between 200-300 girls a day.

%BWJE TBJE there were other successful vaccination programs currently being conducted through PNG and the aim is to lobby for the HPV campaign to go nationwide. When armed with the final data from the pilot program early next year, he is hopeful that the PNG government will be receptive.

Back in Perth, the campaign is getting a GVOET CPPTU GSPN *OKFDU GPS -JGF XIJDI is being driven by the team from the Hollywood rehabilitation clinic and TAFE chef Gary Ash. So far they have raised more than $40,000 from such events as the Rottnest Channel Swim and charity dinners. %BWJE TBJE UIBU UIF OFYU QIBTF JT UP CFFG up the health infrastructure in WNB, especially the cold storage for vaccines. And with the growing connection between HPV and oral and neck cancers, boys will be next on the vaccination horizon. â&#x20AC;&#x153;PNG desperately needs some herd immunity,â&#x20AC;? he said. O

Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco Dâ&#x20AC;&#x2122;Souza Tel: 9258 5999 Dr Graham Furness Tel: 9440 4033

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CLINICAL UPDATE

Hip arthroscopy and repair of the acetabular labrum A

cetabular labral tears cause sharp, catching groin pain that is reproduced clinically by flexion, adduction and internal rotation of the affected hip (anterior impingement test). Diagnosis is confirmed by MRI scan and a temporary symptomatic response to local anaesthetic injection. Hip arthroscopy and labral repair may be indicated when non-operative measures fail to control typical symptoms.

Anatomy, causes and incidence The acetabular labrum is fibrocartilaginous, surrounding the aperture of the hip joint so that it increases the surface area of the acetabulum and maintains a suction seal for effective joint lubrication.

A torn labrum loses these abilities, increasing force transmission across the joint and leading to the development of degenerative arthritis. Most symptomatic tears affect the anterior superior labrum.

Q Fig 3

Acetabular labral tears are present in between 22-55% of cases of groin or hip pain, a higher figure than previously thought, perhaps due to increased recognition through improved imaging.

The main causes of acetabular labral tears include trauma, femoro-acetabular impingement, capsular laxity, dysplasia and degeneration.

Q Fig 4

The healing potential of the hip labrum is limited as only the outer one-third of the labrum has a vascular supply; the inner two-thirds is avascular. The neovascularisation often seen after labral tear may not be sufficient to allow spontaneous healing.

Clinical presentation Q Fig 2: Sagittal T2 weighted MRI arthrogram showing an anterior superior labral tear.

Q Fig 1: The anterior impingement test.

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36

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Femoro-acetabular impingement is the presence of a bony â&#x20AC;&#x153;bumpâ&#x20AC;? on the femoral neck, called a cam lesion, and is often accompanied by an overhang of the acetabular rim, called a pincer lesion. With flexion and internal rotation of the hip the anterior superior labrum is impinged, resulting in a tear.

Date: Venue: Website:

National Conference on Incontinence October 23-26 Crown Conference Centre, Perth www.continence.org.au/pages/nationalconference-on-incontinence.html

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Typically, a young to middle-aged person presents with sharp, catching mechanical groin pain and clicking. There may not be a specific history of injury. Symptoms are worsened by activities and postures that involve hip flexion and rotation. Pain can also refer to the proximal lateral thigh or buttock. Night pain and pain on sitting are DPNNPO DPNQMBJOUT %BJMZ BDUJWJUJFT TQPSUT and work may suffer.

The patient may have a limp and a positive Trendelenberg sign. The anterior impingement test is a useful manoeuvre to detect a symptomatic labral tear. With the patient supine, the hip is flexed, adducted and internally rotated to reproduce the reported pain (figure 1).

Imaging and injection Plain radiographs can detect femoroacetabular impingement and exclude advanced degenerative changes and dysplasia o VTVBMMZ BO "1 QFMWJT BOE MBUFSBM BOE %VOO view of the affected hip (the latter to detect the â&#x20AC;&#x153;bumpâ&#x20AC;? of a cam lesion on the femoral neck). .3* BSUISPHSBN IBT UIF IJHIFTU TFOTJUJWJUZ and specificity for detection of a labral tear GJHVSF /FXFS 5 .3* TDBOOFST XJUIPVU the use of contrast, can produce similar accuracy images.

Local anaesthetic injection into the hip joint is an important evaluation by demonstrating temporary relief of painful provocative medicalforum

By Dr Tao Shan Lim, Orthopaedic Surgeon, Joondalup Orthopaedic Group.

Tel 9300 1800

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

Q Fig 5

FERTILITY NEWS

by Medical Director Dr John Yovich

Laparoscopic Myomectomy â&#x20AC;¦ what are the limits?

Q Fig 6

Q Fig 3: Labral tear Fig4: Detachment of the labrum and burring of the acetabular rim Fig 5: Repair using suture anchors Fig 6: Repaired labrum and resected femoral neck cam lesion

activities by the patient, for which labral tear is the likely cause of TZNQUPNT *OKFDUJPO DBO CF EPOF CZ UIF SBEJPMPHJTU PGUFO DPNCJOFE XJUI .3* DPOUSBTU JOKFDUJPO PS CZ UIF USFBUJOH TVSHFPO

Treatment and hip arthroscopy Non-operative treatment involves changing activities, simple analgesia and physiotherapy.

When these fail, surgical treatment can be considered, for which the ideal candidate has minimal degenerative changes in a non-dysplastic hip, and has had a temporary injection response. Surgery aims to relieve symptoms, preserve the labrum and protect the remaining cartilage.

Hip arthroscopy is a technically challenging procedure but it has the advantages of being minimally invasive with less operative risk and quicker rehabilitation than open surgical dislocation. Performed under GA, traction is applied to distract the hip, several portals are used for arthroscopic access, and in this way the labral tear is identified (figure 3a) as are adjacent chondral damage and loose bodies.

Labral debridement versus repair 3FDFOU MFWFM * FWJEFODF JOEJDBUFT UIBU MBCSBM SFQBJS IBT PVUDPNFT superior to simple debridement. The labrum is detached peripherally, the acetabular rim is reshaped with a burr (figure 3b), and repair is performed using suture anchors (figure 3c). Traction is released and the femoral neck cam lesion is identified and resected (figure 3d).

Postoperative rehabilitation The repaired labrum is protected by partial weight-bearing on crutches GPS XFFLT " HSBEVBUFE SFUVSO UP BDUJWJUJFT UZQJDBMMZ JOWPMWFT TFEFOUBSZ XPSL BU XFFLT QPTU TVSHFSZ ESJWJOH BU XFFLT BOE IFBWZ NBOVBM XPSL BOE TQPSUT BU NPOUIT .BYJNBM CFOFGJU DBO UBLF VQ UP NPOUIT O References available on request.

The authorâ&#x20AC;&#x2122;s Healthlink ID is JOGORTHO.

Declaration. Joondalup Orthopaedic Group has contributed towards the production costs of this clinical update, edited by Medical Forum.

medicalforum

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X Emergency physician and toxicologist, Dr Mark Monaghan, will be the new Head of Emergency at Fiona Stanley Hospital. Mark is DVSSFOUMZ UIF $P %JSFDUPS PG &NFSHFODZ BU 'SFNBOUMF )PTQJUBM X Prof Peter Leedman IBT CFFO BQQPJOUFE %JSFDUPS %FTJHOBUF PG UIF 8" *OTUJUVUF PG .FEJDBM 3FTFBSDI 8"*.3 )F UBLFT PWFS GSPN Prof Peter Klinken XIP XJMM NPWF JOUP B OFX SPMF XJUIJO 8"*.3 5IF BQQPJOUNFOU XJMM CF PGGJDJBM FBSMZ OFYU ZFBS XIFO 8"*.3 PQFOT JUT OFX N SFTFBSDI CVJMEJOH BU UIF 2&** .FEJDBM $FOUSF X The breakthrough findings of Murdoch University researchers Prof Steve Wilton and Prof Sue Fletcher PO %VDIFOOF .VTDVMBS %ZTUSPQIZ XIJDI GFBUVSFE JO Medical Forum last month, has earned the pair a prestigious Australian Museum Eureka Prize for research translation.

X Prof Moyez Jiwa IBT CFFO BXBSEFE UIF 3"$(1 *OUFHSBUJWF .FEJDJOF BOE -JGFTUZMF 3FTFBSDI (SBOU GPS QIBTF UXP PG B clinical trial on Musaceae Musa (a member of the banana family of plants) as treatment for cutaneous warts. Dr Sarah McEwan has received the RACGP PWH Grieve Memorial Award ($1250) for course fees to study for her Master of Clinical Education at Flinders University.

X The GPET-Ochre Recruitment Aboriginal and Torres Strait *TMBOEFS )FBMUI 5SBJOJOH "XBSE XJOOFS JT Dr Emma Griffiths, from WAGPET, for her work in the development of an electronic renal program in the Kimberley.

X $VSUJO 6OJWFSTJUZ T $PNNFSDJBM *OOPWBUJPO "XBSET recognised Mr Matthew Oldakowskiâ&#x20AC;&#x2122;s spinal stabilisation implant, 4; %FWJDF XIJDI XJMM CF VTFE JO UIF DFSWJDBM TQJOF UP USFBU OFDL pain. On the team was spinal surgeon Dr Philip Hardcastle. The Early Research Career Award was presented to Ms Elizabeth Grenik the development of a bioactive synthetic hydrogel scaffold that can be applied to chronic wounds such as diabetic foot ulcers.

First prize went to Dr Dehua Dong for the development of a membrane that can speed up the rate of extraction of oxygen out PG B TFMFDUFE HBT PS MJRVJE NJYUVSF *U XJMM IBWF NBOVGBDUVSJOH BOE medical implications.

X St John of God (SJG) Pathology has appointed Mr Michael Hogan as its new CEO following the appointment of former CEO Dr Lachlan Henderson UP UIF QPTJUJPO PG &YFDVUJWF %JSFDUPS 1FSUI Northern Hospitals.

X GenesisCare Shenton House at Joondalup has gained hospital accreditation and has opened its chemotherapy in-patient sleep centre.

X Ms June Oscar [Medical Forum, September] received the 0SEFS PG "VTUSBMJB GPS IFS TFSWJDF UP UIF *OEJHFOPVT DPNNVOJUZ of WA, particularly through health and social welfare programs in Fitzroy Crossing.

X *O (PWFSONFOU DPOUSBDU OFXT Integranet Technology Group, Fujitsu Australia and Fusion Applications Consulting will share a $4.5m contract to provide Corporate Application Support Services for the Health Corporate Network (HCN). There were five applicants.

X The Information Group IBT CFFO BXBSEFE UIF DPOUSBDU to develop, test and trial an application to electronically request &3 XJUI EFDJTJPO TVQQPSU %4 NFEJDBM JNBHJOH FYBNJOBUJPOT PO CFIBMG PG *NBHJOH8FTU X Spotscreen has been awarded a $450,000 contract to provide TLJO DBODFS TDSFFOJOH TFSWJDFT GPS %FQBSUNFOU PG "HSJDVMUVSF BOE 'PPE %"'8" TUBGG CPUI JO UIF DJUZ BOE SFHJPOBM MPDBUJPOT

38

medicalforum

CLINICAL UPDATE

Technological advances in laparoscopic surgery

By Dr Ravi Rao, General Surgeon, Advanced Laparoscopy & Bariatrics, Mercy Medical Centre, Mt Lawley.

Tel 9370 9686

L

aparoscopic surgery is evolving in line with new technical innovations, so that it is often the preferred option in abdominal surgery. In a recent review, laparoscopic cholecystectomy was the most frequently performed laparoscopic procedure. New technology and intraoperative cholangiogram means that bile duct injury is now uncommon (0.15â&#x20AC;&#x201C;0.6% cases). Laparoscopic bariatric procedures, the second most frequently performed, have replaced open procedures as gold standard. Laparoscopic surgery has also been widely developed for hepatic, pancreatic, gynaecological and urological surgery.

Global advances

resections for gastric cancer is now possible in specialised minimal invasive units.

Similarly, laparoscopic colonic resections are achieved without compromising oncological safety and long-term oncological outcomes, and with superior short-term postoperative outcomes (compared with open resections).

Advances in technology and techniques have allowed more to be done surgically in the abdomen.

One recent low-tech solution from the United States is an overture over the scope, with continuous irrigation, which helps keep the optics continuously clean throughout a surgical procedure. Surgeons have clear vision to provide safe and speedy laparoscopic operations.

The innovative use of glass rods in place of air gaps, removing the need for lenses altogether, has improved clarity and brightness of images up to 80 times.

Additionally, the rod lens system enables smaller diameter scopes to be manufactured, with light transmitted via an outer ring, paving the way for minimally invasive surgical techniques. Subsequently, transcystic exploration of ducts and laparoscopic exploration of common bile ducts are being done more commonly by upper gastrointestinal surgeons in specialised units, replacing open explorations of the common bile duct.

Generally, the wider the scope, the brighter the resulting image. Lenses range from 1.9mm to 12mm, but sizes of 5mm and 10mm are the most common choices for paediatric and adult use, respectively.

Micro laparoscopic tools are being developed.

Just 2.8 mm in diameter, they facilitate the trend towards fewer and smaller incisions. These new instruments have been used recently in the US for laparoscopic fundoplication, pushing beyond the current boundaries of cosmesis and pain relief.

Laparoscopic vessel sealing devices like Ligasure, Harmonic scalpel etc. achieve adequate haemostasis for vessels less than NN JO EJBNFUFS 4VDI EFWJDFT BSF OPX VTFE for resecting mesentery in gastric and colonic resections, as well as hepatic resections, previously done as open surgery. *OUSB PQFSBUJWF VMUSBTPVOE BTTJTUT UIF IFQBUJD surgeon by delineating hepatic anatomy during resection. Laparoscopic transducers introduced through laparoscopic ports can be used with contrast-enhanced ultrasound medicalforum

Q Vessel sealing device used in sleeve gastrectomy.

Q Preparing to staple the stomach to create a pouch during laparoscopic gastric bypass.

to carry out cancer staging in a minimally JOWBTJWF XBZ *O BEEJUJPO UIFSBQFVUJD procedures, such as radiofrequency ablation or cryo-ablation of liver lesions can also be done laparoscopically.

Disease specific advances Bariatric surgery. As patients become larger, laparoscopy has become more difficult, requiring surgeons to bear down and torque the tools. With newer generations of titanium and ceramic shafts, instruments have become more rigid and strong. Redesign of laparoscopic stapling devices has improved performance of these devices for an increased range of tissue thickness. Reduced blood loss, fewer abdominal wall complications, and a reduction in both hospital length of stay and overall costs have resulted. Laparoscopic surgery has become a cost-effective alternative to open gastric bypass.

Gastric and colonic resections.

Technological advances with staples and vessel sealing devices have turned open gastric surgery, like gastric and duodenal perforations, into laparoscopic procedures.

Gastrointestinal stromal tumours are now commonly removed laparoscopically.

(BTUSJD SFTFDUJPO GPS UVNPVST JODMVEJOH %

Thoracic procedures. Laparoscopy, combined with high definition monitors, has translated open procedures like the *WPS -FXJT PFTPQIBHFDUPNZ BOE TVSHJDBM treatment for lung cancers into a minimal JOWBTJWF BQQSPBDI o WJEFP BTTJTUFE UIPSBDPTDPQJD TVSHFSZ 7"54 o UP SFEVDF UIF morbidity of a large thoracic incision.

Gynaecology. %VSJOH UIF MBTU ZFBST laparoscopy has evolved from limited use for diagnosis and tubal ligations to a major surgical tool used to treat a multitude of gynaecologic conditions.

Today, laparoscopy is commonly performed by gynaecologists and has become the treatment of choice for things such as removal of an ectopic pregnancy, treatment of endometriosis, or ovarian cystectomy.

Compared with laparotomy, multiple studies have shown laparoscopy to be safer, less expensive, and carry a shorter recovery time. The advantages of laparoscopy for laparoscopically assisted hysterectomy and the staging and treatment of gynaecologic cancers continues to be elucidated.

Looking ahead As surgery advances, patients will demand newer and less-invasive procedures.

3FDFOUMZ 4JOHMF *ODJTJPO -BQBSPTDPQJD 4VSHFSZ 4*-4 BOE SPCPUJD TVSHFSZ IBWF penetrated all specialties of abdominal surgery. However, evidence-based medicine IBT GBJMFE UP TIPX NBKPS BEWBOUBHFT JO 4*-4 and the disadvantage of robotic surgery is the high costs related to purchase and maintenance of technology.

References available on request. O

Declaration. This Clinical Update is supported by an independent educational grant to Medical Forum, from MercyCare.

39

Running

Long & Winding Road Some doctors love putting their best foot forward, over and over again!

You wonâ&#x20AC;&#x2122;t ďŹ nd the word, â&#x20AC;&#x2DC;joggingâ&#x20AC;&#x2122; anywhere in this story. Lining up on the start line and staring down 42.2km is not for the faint-hearted but these three long-distance running medicos wouldnâ&#x20AC;&#x2122;t have it any other way. Pounding the pavement through the streets of Perth and on to the Boston and New York Marathons takes commitment, courage and a lot of passion.

Q Dr Fiona Whelan

&/5 DPOTVMUBOU Dr Fiona Whelan has been run ning since she was young. It all started when she hit the pave ment with her father and, most recently, Fiona completed the now infamous Boston Marathon.

i* DBO TUJMM JMM SFNFNCFS C SVOOJOH BSPVOE UIF i* CMPDL XJUI NZ EBE BOE XJOOJOH B DSPTT DPVOUSZ SBDF XIFO * XBT TJY ZFBST PME My work can be stressful and demanding although as a consultant I can dictate my own terms to some extent. Running helps NF CPUI NFOUBMMZ BOE QIZTJDBMMZ UIFSF BSF some long days on your feet in surgery.â&#x20AC;?

0G SVOOJOH JO #PTUPO XIJDI XBT NBSSFE CZ terrorist bombings, Fiona said it was surreal being so close to something that you nor mally see on the news. i* E DSPTTFE UIF GJOJTI MJOF JO #PTUPO BCPVU an hour before the bombs went off and was CBDL BU UIF IPUFM XJUI NZ TJTUFS 5IFO XF heard the commotion, saw all the people PO UIFJS QIPOFT BOE KVTU TUBZFE JOTJEF BOE watched the coverage.â&#x20AC;? i5IF XIPMF XFFL MFBEJOH VQ UP UIF NBSB UIPO JT B IVHF UJNF JO #PTUPO 5IF EBZ PG the race is a public holiday, the route is lined 40

Q Dr Paul Stobie competing.

(Far right) Runners' caps at the memorial for the Boston bombing victims - Photo courtesy Dr Fiona Whelan

with locals and people have barbecues with family and friends. It was a terrible thing but I think next year there will be even more who want to run as a memorial to those XIP EJFE PS XFSF JOKVSFE w Boston was Fionaâ&#x20AC;&#x2122;s second marathon. Her UJNF PG IS NJO QVUT IFS JO UIF SBOLT PG highly accomplished runners. It also posi tions her within striking distance of that magical â&#x20AC;&#x2DC;two hours somethingâ&#x20AC;&#x2122; category. i*U T B CJH BTL UP HP VOEFS UISFF IPVST TP * MM QSPCBCMZ BJN GPS MFTT UIBO JOJUJBMMZ Iâ&#x20AC;&#x2122;ve learnt a lot from the two marathons Iâ&#x20AC;&#x2122;ve EPOF BOE UIFSF T B XFMM LOPXO TBZJOH AQMBO you race and race your planâ&#x20AC;&#x2122;. I didnâ&#x20AC;&#x2122;t do that in Boston, Iâ&#x20AC;&#x2122;d hoped to do a negative split <MBTU LN GBTUFS UIBO UIF GJSTU> BOE * FOEFE up going out really fast full of excitement and exhilaration. I didnâ&#x20AC;&#x2122;t drink properly, my nutrition went out the door and when the IJMMT IJU BU UIF LN QPJOU UIF MBTU TFDUJPO was tough.â&#x20AC;? i"T GBS BT JOKVSJFT HP JG ZPV SVO BMM UIF UJNF thereâ&#x20AC;&#x2122;s always a niggle or two. Itâ&#x20AC;&#x2122;s handy being in the profession because you can call JO B GFX GBWPVST 5IF CJH RVFTUJPO JT USZJOH UP XPSL PVU XIBU TPSU PG QBJO JT 0, UP SVO with and what needs to be looked at. Most people who are really into their running find resting a bit of a challenge.â&#x20AC;?

Speaking of challenges, Fiona is looking beyond the marathon to some seriously intimidating distance events.

GP Dr Tim Koh is an early morning runner. i* MJLF HFUUJOH VQ BOE XBUDIJOH UIF TVO SJTF It really sets you up for the day, clears your mind and thereâ&#x20AC;&#x2122;s a strong medical running DPNNVOJUZ JO 1FSUI 5IFSF T BMXBZT TPNF one to say hello to. In summer itâ&#x20AC;&#x2122;s usually too hot in the afternoons and I take my hat off to anyone who can run in the heat.

Morning is definitely the best time for me.â&#x20AC;?

5JN IBT EPOF UISFF NBSBUIPOT CVU IF T OPU JOUFSFTUFE JO KPJOJOH UIF NBTTFT JO UIF CJH overseas marathons. i* EPO U FOKPZ USBWFMMJOH UP HP SVOOJOH QBS ticularly longer distances, because it tends to dominate the entire holiday. Shorter runs around 5km are perfect when Iâ&#x20AC;&#x2122;m away GSPN IPNF * SVO GPS FOKPZNFOU NZ NBJO goal is to run well and if that happens to involve running a marathon then thatâ&#x20AC;&#x2122;s fine.

Perth has around three options a year for the full distance and thatâ&#x20AC;&#x2122;s great because if you wake up on race day with a cold and canâ&#x20AC;&#x2122;t run, thatâ&#x20AC;&#x2122;s a lot of training out the win dow.â&#x20AC;? i5IF NBSBUIPOT * WF EPOF XFSF XPOEFS ful experiences. Inevitably thereâ&#x20AC;&#x2122;s some degree of pain towards the end but I took UIF UJNF UP FOKPZ UIF KPVSOFZ BOE XBMLFE away thinking it was a great thing to have EPOF 5IFSF T DFSUBJOMZ B GFFMJOH UIBU ZPV WF accomplished something.â&#x20AC;?

Medicine can be a mentally demanding DBSFFS BOE MPOH EJTUBODF SVOOJOH FYBDUT B

i* WF HPU B EVBUIMPO DPNJOH VQ TP * N EPJOH TPNF DZDMJOH UIF LN "OBDPOEB JT JO early November and I think Iâ&#x20AC;&#x2122;ll get a guern sey to do the running leg on that, and the 4JY *ODI 5SBJM 3VO GSPN /PSUI %BOEBMVQ UP %XFMMJOHVQ JT B NPOUI MBUFS 5IF LN ,FQ 6MUSB .BSBUIPO GSPN /PSUIBN UP .VOEBSJOH Weir is a great event, too.â&#x20AC;? i5IFSF BSF BMXBZT UJNF DPOTUSBJOUT XJUIJO the profession of medicine and running gives you a good â&#x20AC;&#x2DC;bang for your buckâ&#x20AC;&#x2122;. I love the serenity of running and Iâ&#x20AC;&#x2122;d never give it up.â&#x20AC;?

Q Dr Tim Koh

medicalforum

physical toll. But theyâ&#x20AC;&#x2122;re not quite the odd bed fellows you might think. i5IJT QSPGFTTJPO JT DIBMMFOHJOH BOE SVOOJOH helps me to cope with the stress of being a GP. I listen to my body a lot more than I did in the past and now I try to run based on how I feel, which usually pans out to three or four days a week. Iâ&#x20AC;&#x2122;m also much more cautious pushing through pain because that can lead to longer MBZPGGT GPS SFDPWFSZ .PTU JOKVSJFT PDDVS JG ZPV run too far or too fast, so itâ&#x20AC;&#x2122;s all about pacing yourself intelligently.â&#x20AC;?

Cardiologist Dr Paul Stobie is motivated by the excitement of the â&#x20AC;&#x2DC;big eventsâ&#x20AC;&#x2122;. He loved doing the New York Marathon and Boston is next on the list. i2VJUF B GFX 1FSUI NFEJDPT IBWF EPOF /FX York. Randall Hendriks had his race cancelled due to Hurricane Sandy and I ran with Neil #PVEWJMMF JO * UIJOL XF SF QSPCBCMZ UIF only local doctors whoâ&#x20AC;&#x2122;ve beaten the legend ary Haile GebreSelassie in a race! He pulled PVU XJUI MFH TPSFOFTT o XIBU B XVTT /FJM SBO XJUI B UPSO DBMG NVTDMF w i/FX :PSL JT GBOUBTUJD *G ZPV POMZ FWFS SVO POF NBSBUIPO * E SFDPNNFOE UIJT POF 5IFSF T B bus tour that drives over the course which sets the scene and it was nice for our partners to see the boroughs of this fabulous city.â&#x20AC;?

9 NOVEMBER 2013 SPORTS MEDICINE

CONFERENCE An educational meeting for the general practitioner, registrar and physiotherapist with an interest in sports injury and the management of those who exercise.

i* SVO CFDBVTF * EFDJEFE * XBOUFE UP EP B marathon. I was in Chicago and Julian did the SBDF BOE FOKPZFE UIF FYQFSJFODF "OPUIFS DPM MFBHVF "OESFX .D2VJMMBO UPME NF UIBU NZ partner was a â&#x20AC;&#x2DC;golf widowâ&#x20AC;&#x2122;. I love my golf but

Q Continued

Registration Now Open Contact Conference Secretariat Jo Maguire conference@ perthortho.com.au Ph: 9212 4200

i5IF SBDF JT HSFBU UIFSF T KVTU B XBWF PG QFP ple and itâ&#x20AC;&#x2122;s pretty crowded the whole way. I IFME NZ QBDF VOUJM UIF MBTU LN VOUJM * SFBMJTFE * wasnâ&#x20AC;&#x2122;t going to beat Randallâ&#x20AC;&#x2122;s marathon time.

I strolled in after being passed by an Italian running in a suit and a Brazilian woman who MPPLFE BCPVU ZFBST PME w Paulâ&#x20AC;&#x2122;s initial fascination with the marathon began in Chicago. It was fellow medico Julian Cooney who whetted Paulâ&#x20AC;&#x2122;s appetite for going the distance.

THE UNIVERSITY CLUB OF WESTERN AUSTRALIA

PERTH ORTHOPAEDIC & SPORTS MEDICINE CENTRE 31 Outram Street, WEST PERTH T: +61 92124200 F: +61 94813792 www.perthortho.com.au

from page 41

medicalforum

41

Kitchen Confidential

Who are your food heroes and why?

I have had the pleasure of working with some amazing dedicated chefs, who have continually inspired me throughout my career. With the opening of The Trustee, I was privileged to develop a memorable friendship with Ian Curley (Melbourne chef who was on TV in the reality food show, Conviction Kitchen) who I now consider a wonderful mentor.

You have come to work in Perth at an amazing period of evolution in our food culture. What do you love most about cooking here?

The WA public are such great foodies and it is a pleasure to cook for them. Perth seems to be a melting pot of people from everywhere and their expectations are high. With all the new venues opening, there is a great camaraderie among all the chefs.

Is The Trustee your first time in charge of the kitchen? What are the biggest challenges?

10 minutes with...

Michelle Forbes from The Trustee Bistro Brookfield Place in the heritage precinct of St Georges Tce is becoming a foodie mecca and The Trustee with Michelle Forbes at the helm is in the vanguard.

Tell us about your childhood? Was there a strong food tradition in your family?

We always had a house full of people sharing a meal. My uncle's pride joy was a built-in barbecue and it featured prominently in family gatherings and was the memory behind every birthday in all our childhoods.

What was your first delicious food memory and who cooked it?

I can never forget the amazing aroma of my nan’s homemade scones with jam and cream.

Who or what inspired you to be a chef?

I studied a bachelor of fine arts and realised when I finished my degree I was unemployable so I gravitated towards hospitality and the rest fell into place. I grew up in Sydney at a time when Neil Perry, Christine Mansfield, Bill Granger and Luke Mangan were all just beginning so it was an exciting time in the cheffing world.

42

I have led many small teams but The Trustee is my first large venue. There are many challenges in running a big venue but my most important value is harmony in the kitchen. I am very privileged to have some amazing people by my side, such as my second-in-charge Drewe Callander. Building a great team and creating a workplace that’s a pleasure to be in makes all the difference.

What is your food philosophy?

Let the produce speak for itself. Providence is the philosophy behind The Trustee in everything we do. We want our customers to know we have sourced the best possible product for them.

Local produce figures prominently on your menu, what are some of your favourites?

My favourite at the moment are Manjimup Truffles. That part of the world is so picturesque, fresh, clear, calming and down to earth and it is reflected in their produce. Another forerunner is Blackwood Valley beef. Their commitment to the land, organics and sustainability is inspirational.

How often does the menu change?

Seasonally. We strive to produce new and innovative flavours to enhance the seasons, guided by our amazing suppliers.

The bistro is just over a year old, have menu favourites emerged?

Chateaubriand leads the charge! It's a wonderful share dish with sensational Margaret River produce.

What do you do when you’re not cooking up a storm at The Trustee?

I love eating out and enjoying somebody else's cooking for a change. I also love getting out there and supporting the industry.

What would be your last meal?

Pizza and a bottle of Cristal! O

By Ms Jan Hallam medicalforum

Wine Review

Soars

Higher Plane

to Higher Heights 2012 South by Southwest Sauvignon Blanc Semillon " GSFTI GPSXBSE GSVJUZ TUZMF 5IF 4BVWJHOPO #MBOD BDJEJUZ DPNFT UISPVHI HJWJOH B DSJTQ UJHIU QBMBUF XJUI OJDF WJCSBODZ 5IF BSPNBT BSF NPSF PG 4FNJMMPO o HSFFO QFB BOE IFSCT BOE UIF GMBWPVST BSF PG HSFFO BQQMFT 0WFSBMM UIF XJOF IBT a linear simplicity, and will drink well now and for one or two years.

2010 South by Southwest Cabernet Merlot

By Dr Craig Drummond, Master of Wine

" NFEJVN CPEJFE XJOF XJUI B SVTUJD CVDPMJD FEHF "SPNBT BSF PG SFEDVSSBOU BOE BMMTQJDF 0O UIF QBMBUF B UPVDI PG .BSHBSFU 3JWFS HSBWFM CVU TIPXT B MJHIU GSVJU QSPGJMF XJUI GMBWPVST PG SFEDVSSBOU BOE SBTQCFSSZ "O FOKPZBCMF XJOF GPS DVSSFOU consumption.

Careful site selection and ideal aspect have allowed this vineyard to continue to produce wines of notable quality. In my review 18 months ago, I predicted Higher Plane would, in time, climb the steep Margaret River wine ladder and, indeed, they are doing just that.

2011 Higher Plane Chardonnay -JLF UIFJS PUIFS SFWJFXFE XIJUFT UIJT $IBSEPOOBZ IBT B MPX BMDPIPM MFWFM BU more in keeping with European styles. It appears to be early picked, showing MFBO MJOFBS UJHIU GSVJU GMBWPVST PG XIJUF QFBDI 5IF OPTF JT SFTUSBJOFE XJUI GJH BOE B touch of cashew. Itâ&#x20AC;&#x2122;s barrel fermented and left on lees in French oak for 10 months UIPVHI UIF PBL DIBSBDUFST BSF OPU PWFSU BOE * XPOEFS JG UIFSF JT TUFFM UBOL XJOF CMFOEFE IFSF 5IJT MFBOFS TUZMF JT CFDPNJOH JODSFBTJOHMZ QPQVMBS JO "VTUSBMJB

5IF DPNCJOBUJPO PG JEFBM HSBWFMMZ MPBN EVQMFY TPJMT BOE OPSUI GBDJOH TMPQFT DPO vinced colleague Craig Smith and wife $BUIJF UP QMBOU WJOFT JO -BUFS JO UIF WJOFZBSE BOE MBCFM XBT QVSDIBTFE by established Margaret River producer Juniper Estate. Higher Plane has continued BT B TUBOE BMPOF CSBOE BOE UIF QMBOUJOHT IBWF HSPXO UP IB XIJDI JODMVEF UIF key Margaret River varieties Sauvignon Blanc, Semillon, Chardonnay and Cabernet Sauvignon, together with plantings of Merlot, Shiraz, Cabernet Franc, Malbec, Petit Verdot and Viognier.

8JOFT BSF SFMFBTFE VOEFS UXP MBCFMT o Higher Plane, which are from the property and are the very best produced, and the South by Southwest range, which comes from estate fruit and fruit from other select FE WJOFZBSET JO UIF BSFB 5IF FNQIBTJT JT PO varietal and regional character.

2011 Higher Plane Sauvignon Blanc 5IJT JT UIF GBTDJOBUJOH XJOF PG UIF UBTUJOH GPS NF .BEF JO UIF TUZMF PG UIF GBNPVT XIJUFT PG (SBWFT o JO QBSUJDVMBS 1FTTBD -FPHOBO JO #PSEFBVY o XJUI XIPMF bunch pressing followed by fermentation and maturation in quality French oak.

5IF SFTVMU IFSF JT UIJT XPOEFSGVM XJOF CVSTUJOH XJUI DPNQMFY GMBWPVST PG TLJOT PG HSFFO GSVJUT SJQF BQQMF BOE BO VODUVPVT UFYUVSF XJUI MBOPMJO MJLF DIBSBDUFST *U T B GVMM CPEJFE 4# XIJDI XJMM IBWF MPOHFWJUZ *U T OPU GPS UIF GBJOUIFBSUFE CVU JG ZPV have not experienced this style yet, then get out there and find this one.

2010 Higher Plane Cabernet Sauvignon 5IJT XJOF GJUT XJUI UIF DIBSBDUFS PG $BCFSOFU GSPN UIJT NPSF TPVUIFSO TVCSFHJPO 5IFZ SFHVMBSMZ TIPX BO BVTUFSF FEHF XJUI GSVJU UIBU T NPSF NFMMPX BOE TVCUMF UIBO UIF GSVJU GPSXBSE XJOFT GSPN KVTU OPSUI PG 'PSFTU (SPWF 5IJT XJOF JT CSPPEJOH DPNQMFY XJUI GMBWPVST JO UIF EBSL QMVN BOE CMBDLDVSSBOU TQFDUSVN 5IFSF JT CBMBODF BOE MFOHUI XJUI B DPSF PG BDJEJUZ XIJDI XJMM SFXBSE DFMMBSJOH GPS ZFBST These wines can be sourced by visiting www.higherplanewines.com.au

WIN a Doctor's Dozen!

Which Higher Plane wine is made in the style of the famous wines of Graves?

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Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, October 31, 2013. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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43

Humour

Match Fit for

Retirement Do what you want to do, be what you want to be â&#x20AC;&#x201C; just start pre-retirement training today.

Have you noticed that retirement isnâ&#x20AC;&#x2122;t as simple as just hitching your trousers up under your armpits and towing a caravan around Australia at 30km/h anymore? Our desire to aspire until we expire is changing the face of seniors' social activities. *O UIF SBDF UP UJDL PGG UIF #VDLFU -JTU CFGPSF pointy end of the Hush Puppy hits the pail, bridge nights are abandoned in favour of skateboarding treks down Machu Picchu.

Your granny could, right now, be seeding PZTUFS CFET JO TIBSL JOGFTUFE XBUFST PS doing some guerrilla gardening along the Gaza Strip. Plucky pensioners are lining up to ring Pablo Escobar's doorbell and run away.

5P CF SFBEZ GPS SFUJSFNFOU ZPV OFFE UP HFU JOUP USBJOJOH FBSMZ o QSFGFSBCMZ JO ZPVS FBSMZ T (JWFO UIBU ZPV NBZ TUJMM IBWF B KPC BU UIBU BHF *hWF DSFBUFE B MJTU PG BESFOBMJOF QVNQJOH BEWFOUVSFT ZPV DBO FOKPZ XJUIPVU leaving Perth. After a couple of weeks of this you'll be ready to stare retirement in the eye and ask it â&#x20AC;&#x2DC;Are you feeling lucky Punk?â&#x20AC;&#x2122;

Paterson Stadium Match Night Parking Safari 5P XBUDI UIF QBSLJOH SBOHFST IVOU BOE attack their prey is to witness natureâ&#x20AC;&#x2122;s raw cruelty, with a price tag that rivals a

QSF FMFDUJPO QSPNJTF 5IJT 4VCJBDP species has the disposition and contorted facial features of a grizzly thatâ&#x20AC;&#x2122;s been delivered a sudden and surprising Brazilian wax. Victims throwing themselves on the creatureâ&#x20AC;&#x2122;s better nature will invariably find the landing a hard one.

Running of the Bullbars Driving a small hatchback in the vicinity of any Claremont coffee shop after the kids have been dropped at school is to see your own mortality up close in the rear view NJSSPS "OE JUhT TQFMMFE 13"%0

La Tomatina Not to be mistaken for the Spanish festival XIFSF MPOH MJNCFE ZPVUI QMBZGVMMZ QFMU FBDI PUIFS XJUI TPGU MVTDJPVT TVO SJQFOFE 3PNBT UIF 1FSUI WFSTJPO JT B GSVJU CBTFE war game using the local variety of 'tomato' straight from Coles fruit 'n veg aisle. With UIF UFYUVSF BOE GMBWPVS PG B QVUUZ GJMMFE UFOOJT CBMM DPBUFE JO ,FWMBS B EJSFDU IJU DBO GFMM B NBO BU N *OTJEF TPVSDFT IBWF SFWFBMFE UIF FYJTUFODF PG B NJMJUBSZ TUZMF hUPNBUP DBOPOh GPS EFQMPZNFOU JG SJPUJOH ever breaks out in Fremantle.)

White Water Commuting 5P SJEF UIF SVTI IPVS SBQJET PG 1FSUIhT disintegrating roads in the aftermath of B TQSJOH TIPXFS JT UP FYQFSJFODF XIJUF knuckle terror that demands nerves of steel

and underpants of endurance. Alternating between wallowing in trenches deep enough to harbour undiscovered species of aquatic life and long periods of immobility in the fast lane of the freeway, white water DPNNVUJOH JT OPU GPS UIF GBJOU IFBSUFE PS VOEFS JOTVSFE

Gorillas in Our Midst 7JFX BU GJSTU IBOE B TQFDJFT UIBU JT OBUJWF UP UIF OPSUI XFTU PG 8" CVU QFSJPEJDBMMZ migrates south for the watering holes and Holden dealerships. While this species is becoming rarer, its survival is not under immediate threat while there are still bits of the Pilbara not yet sold to China. Gorilla society is now better understood thanks to Gina Rinehart, who has devoted her life to buying land where they can roam free in rock crushers and loaders.

Man V Early Night Bear Grylls acolytes attempting to find a SFTUBVSBOU PQFO QBTU PO B 5VFTEBZ OJHIU can truly learn the art of surviving on nature's bounty.

-JLF UIFZ TBZ *G ZPV SF OPU MJWJOH PO UIF FEHF of the Nullarbor, youâ&#x20AC;&#x2122;re not really living. O

Long and Winding Road Q Continued

from P41

I was never that bad! Nonetheless, with UISFF DIJMESFO JU DBO CF B SBUIFS UJNF DPO suming game so I can run in the morning or evening and not feel selfish.â&#x20AC;?

i*U T EJGGJDVMU UP HFU B HPPE XPSL MJGF CBMBODF I work longer than Iâ&#x20AC;&#x2122;d like to and donâ&#x20AC;&#x2122;t see my kids as much as I want to. Itâ&#x20AC;&#x2122;s a struggle, but a typical professional dilemma.â&#x20AC;?

i5IFSF T B OJDF NJYUVSF PG BDIJFWFNFOU muscle ache and endorphins from a good long run. And I donâ&#x20AC;&#x2122;t take my phone. Iâ&#x20AC;&#x2122;m very happy to be away from that thing, even for a brief time.â&#x20AC;?

A typical week of pounding the pavement GPS 1BVM JT BSPVOE LN VTVBMMZ PO IJT own but occasionally with a friend or col league.

Paulâ&#x20AC;&#x2122;s professional life is predictably demanding but a relatively new field with a great deal of satisfaction. i&MFDUSPQIZTJPMPHZ JT QSPCBCMZ UIF GBTUFTU growing field of cardiology with a lot of tech OPMPHJDBM BEWBODFNFOUT 5IF XPSL T WFSZ interesting with a mix of young and old patients. We cure some problems and we can save lives. Most people donâ&#x20AC;&#x2122;t have a clue what we do but weâ&#x20AC;&#x2122;re spreading the word.â&#x20AC;?

44

i* FOKPZ SVOOJOH BMPOF ZPV DBO HP BU ZPVS own pace and some days are good, others not so. But when I organise to run with a friend we stick to it. Iâ&#x20AC;&#x2122;m a pretty disciplined person but Iâ&#x20AC;&#x2122;ve only ever made it to one 6am DSPTT USBJOJOH TFTTJPO BU UIF HZN *U XBT GVMM of people more disciplined than me.â&#x20AC;? i5IF QSPCMFN XJUI JOKVSJFT JT UIBU UIFZ UFOE to happen when youâ&#x20AC;&#x2122;re older. It would be better if we all got the urge to do these FOEVSBODF FWFOUT JO PVS T .PTU PG

Q Dr Paul Stobie

the time it doesnâ&#x20AC;&#x2122;t hurt too much while youâ&#x20AC;&#x2122;re running but afterwards, thatâ&#x20AC;&#x2122;s anoth er story.â&#x20AC;? i%PJOH B NBSBUIPO JT B HPPE UIJOH UP UJDL PGG on your bucket list but beware, it is addic UJWF 0O UIF PUIFS IBOE OP POF DBSFT NVDI about it except you and your running bud dies. Most people say to me, â&#x20AC;&#x2DC;a marathonâ&#x20AC;Ś how far is that?â&#x20AC;&#x2122;â&#x20AC;? O

By Mr Peter McClelland medicalforum

(Below) Pak Tai Temple, Hong Kong

Travel

The Homing

Q Dr Donna Mak, grandma and children

Instinct

Dr Donna Bing-Ying Mak writes about her trip back to her ancestral home of Hong Kong.

Like homing pigeons we descended onto HKG from LAX, SYD, LHR, SIN, YVR â&#x20AC;&#x201C; nearly one hundred of Grandmaâ&#x20AC;&#x2122;s descendants gathering to honour her 100th birthday.

Grandma and Grandpa made their home in 8BODIBJ )POH ,POH BGUFS NPWJOH GSPN Sekloong, Guangdong province, as a young NBSSJFE DPVQMF 5IFZ SBO B TNBMM CVTJOFTT selling wooden boards from their home on -VOH 0O %SBHPO 1FBDF 4USFFU PQQPTJUF UIF 1BL 5BJ 5FNQMF o OPX B GBNPVT UPVS JTU BUUSBDUJPO 5IF TIPQ XBT PO UIF HSPVOE floor, the family home upstairs.

'SPN UIF FBSMZ T UP UIF NJE T (SBOEQB (SBOENB BOE IFS UISFF DP XJWFT produced 10 sons and five daughters.

Educating their children and establishing overseas bases for their descendants in QSFQBSBUJPO GPS $IJOB T JNQFOEJOH UBLFPWFS PG )POH ,POH TDBUUFSFE OJOF PG their children across the world. Now we were coming together again.

My son and I join Uncle Boon, Uncle Stanley, Aunty Grace and half a dozen assorted cousins at Grandpaâ&#x20AC;&#x2122;s grave overlooking the South China Sea...We burn incense, offer food and drink, and bow three times. I leave the group early to catch my flight home, fighting back tears.

Within hours of landing we were wandering through Wanchai with Cousin Daniel leading VT UISPVHI IJT DIJMEIPPE IBVOUT SFNJOJTD ing about the old Wanchai Market, Hong ,POH T GJSTU #BVIBVT TUZMF CVJMEJOH BOE UIF PSJHJOBM 8BODIBJ 1PTU 0GGJDF UIF PMEFTU surviving post office, now restored to its former glory as an Environmental Resource

medicalforum

Centre. â&#x20AC;&#x2DC;Jason!â&#x20AC;&#x2122; â&#x20AC;&#x2DC;Hello Aunty!â&#x20AC;&#x2122; â&#x20AC;&#x2DC;Iâ&#x20AC;&#x2122;m your DPVTJO o Donna.â&#x20AC;&#x2122; â&#x20AC;&#x2DC;You look FYBDUMZ like your mum!â&#x20AC;&#x2122; Most of my cous ins had turned into younger versions of their parents.

Seeing Cousin Daniel for the first time in five years, I felt like a child look ing at Uncle Yiu. Cousins Ming Ho and Ming Hee, broth ers, are the spitting images of their mum and dad respectively. My teenage son and daughter are horrified at the prospect of what lies ahead.

After Grandmaâ&#x20AC;&#x2122;s birthday feast, the numer ous photo shoots, all in hierarchical Chinese GBNJMZ PSEFS (SBOENB XJUI IFS DIJMESFO then with her sonsâ&#x20AC;&#x2122; children, her daugh tersâ&#x20AC;&#x2122; children, her sonsâ&#x20AC;&#x2122; grandchildren, her daughtersâ&#x20AC;&#x2122; grandchildren, and finally with her first and only great, great grandchild.

5IFO UIF XIPMF GBNJMZ QIPUP XJUI UXP busloads of relatives from Guangdong and a hundred odd descendants arranged on a tiered grandstand in hierarchical order.

When we are all assembled Cousin Ming Hee wheels Grandma into her place of hon our in the middle of the front row. Grandma is smiling from ear to ear, waving at us like a queen, resplendent in her gold cheongsam and radiantly happy. .Z TPO BOE * KPJO 6ODMF #PPO 6ODMF 4UBOMFZ Aunty Grace and half a dozen assorted cousins at Grandpaâ&#x20AC;&#x2122;s grave overlooking the South China Sea. Grandma number two, 6ODMF 5BL "VOUZ -BJ BOE IVTCBOE IBWF UIFJS BTIFT JO B OFBSCZ IJHI SJTF NFNPSJBM 8F

burn incense, offer food and drink, and bow three times. I leave the group early to catch my flight home, fighting back tears which start streaming once Iâ&#x20AC;&#x2122;m alone with my son.

0OF PG NZ FBSMJFTU NFNPSJFT JT PG CFJOH on the rooftop of my family home with Grandma, â&#x20AC;&#x2DC;old auntyâ&#x20AC;&#x2122; Hing and the pigeons.

Hing, a servant who had been with Grandma for what seemed like forever, SFBSFE QJHFPOT 3PBTU QJHFPO o UIF BSPNB PG five spice, crunching the skin between my UFFUI UP UBTUF UIF KVJDZ TXFFU GMFTI * MFGU )POH ,POH JO GPS "VTUSBMJB 8IFO * SFUVSOFE ZFBST MBUFS )POH ,POH had become a big city and the pigeons had HPOF i5IFSF XFSFO U FOPVHI PQFO TQBDFT for the pigeons to forage for food. Fewer BOE GFXFS DBNF IPNF FBDI OJHIU o UIFZ probably died,â&#x20AC;? Grandma explained.

But unlike the pigeons, Grandpa and Grandma established a diaspora of pro fessors, engineers, bankers, lawyers, designers, teachers, mothers, fathers, sons and daughters in almost every continent.

And a family home in Wanchai and ancestral shrine in Sekloong for them to return to. O 45

Music

The Music

Legend-makers There is much to celebrate when one of the worldâ&#x20AC;&#x2122;s greatest orchestras comes to play at the Perth Concert Hall next month and a Medical Forum reader and guest will be in the audience to enjoy the excitement.

The concert hall, renowned for having the best acoustics in the country, turned 40 in January and will show off its natural assets to the famous Royal Concertgebouw Orchestra of Amsterdam, which will hit our shores on the last leg of a year-long tour to mark its 125th anniversary. Having its home at the Royal Concertgebouw â&#x20AC;&#x201C; one of the most beautiful concert venues in the world â&#x20AC;&#x201C; will give Perth Concert Hall management a real insight into how its own acoustics compare with one of Europeâ&#x20AC;&#x2122;s most famous halls.

(SBNPQIPOF .BHB[JOF has described the 3$0 BT UIF CFTU PSDIFTUSB JO UIF XPSME BOE while classical music lovers may eschew the competitive spin, it gives local audienc FT TPNF JEFB KVTU XIBU B CJH HJH UIJT XJMM CF 5IF PSDIFTUSB VOEFS UIF EJSFDUJPO PG JUT DIJFG DPOEVDUPS .BSJTT +BOTPOT o POMZ UIF TJYUI DIJFG JO JUT ZFBS IJTUPSZ o XJMM CF MFBWJOH "NTUFSEBN JO KVTU B GFX XFFLT to play for audiences in Russia, China and Australia. Among them will be Sydney vio linist Jane Piper, the only Australian in the 3$0 XIJDI CPBTUT B SPMM DBMM PG NVTJ DJBOT GSPN DPVOUSJFT Jane, who has been playing in Europe since BOE XJUI UIF 3$0 GPS UXP ZFBST spoke to .FEJDBM 'PSVN after returning GSPN IFS TVNNFS CSFBL BOE KVTU CFGPSF

rehearsals for the orchestraâ&#x20AC;&#x2122;s season open ing gala began. i*U T BMXBZT B CJU PG B SFBMJUZ DIFDL DPNJOH CBDL GSPN IPMJEBZ XF KVNQ JOUP QFSGPSNBOD es very quickly. But we begin next week XJUI UIF GBNPVT PQFO BJS 1SJOTFOHSBDIU Concert where we play on a stage over the DBOBM #PBUT DSBN UIF DBOBM UP MJTUFO 5IJT will be the first time Iâ&#x20AC;&#x2122;ve played in this con cert, so Iâ&#x20AC;&#x2122;m really looking forward to that.â&#x20AC;? i*U T UFSSJGJD UP MJWF JO "NTUFSEBN :PV DBO get everywhere on your bike and itâ&#x20AC;&#x2122;s nice to know I will never have to worry about 4ZEOFZ USBGGJD BHBJO 5IF EPXOTJEF JT UIBU JU rains a lot here.â&#x20AC;?

While Jane may miss the Australian beach es, the musical opportunities more than compensate.

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Church News Sheet

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medicalforum

Music

Q Chief Conductor Mariss Jansons; (Right) Royal Concertgebouw Orchestra

i* WF XPSLFE XJUI TPNF SFBMMZ GBO tastic conductors including its chief conductor Mariss Jansons, in the very beau tiful Concertgebouw, which is really part of UIF 3$0 T TPVOE BOE JEFOUJUZ w 0G .BFTUSP +BOTPOT XIP IBT MFE UIF PSDIFTUSB TJODF +BOF TBZT IF demands a high standard, yet his work ethic draws something special from his players.

Being at the epicentre of European musi cal life has also meant playing with some of classical musicâ&#x20AC;&#x2122;s legends.

Jane told arts website "SUNVTJD that some of her most memorable concerts with the 3$0 XBT QMBZJOH #SVDLOFS XJUI #FSOBSE Haitink, Prokofiev with Valery Gergiev, and being on tour with Jansons, especially play

ing Mahler 1 in Vienna and New York and Strauss in Amsterdam.

November Australian sunshine and heading to the beach.â&#x20AC;?

8JUI CFJOH B ZFBS PG IPQQJOH PO BOE off planes, Jane says the orchestra has had a lot of fun showing their talents to the world.

In Perth, the orchestra will play on /PWFNCFS BOE JO UXP QSPHSBNT GFB UVSJOH A-FHFOEBSZ 4USBWJOTLZ <5IF 'JSFCJSE 4VJUF> BOE 5DIBJLPWTLZ T 'JGUI 4ZNQIPOZ and â&#x20AC;&#x2DC;Heroicâ&#x20AC;&#x2122; Beethovenâ&#x20AC;&#x2122;s piano concerto /P BOE 4UBVTT T &JO )FMEFOMFECFO. O

i*U DBO CF DIBMMFOHJOH UP NPWF people and their instruments around but it is also very exciting to be playing so many dif ferent concert halls in front of some many different audiences. And I canâ&#x20AC;&#x2122;t wait to introduce my colleagues to Australia. Many of them have never been to Australia and are really curious about the people and the country.â&#x20AC;? i$PNJOH GSPN B 3VTTJBO BOE $IJOFTF XJO ter, we will also be looking forward to some

By Ms Jan Hallam 5JDLFUT GSPN 5JDLFUFL DPN BV

WIN For your chance to win a ticket turn to Competitions on P50

Sonata in the Spotlight In the ďŹ nal concert of the Pipe Organ Plus 2013 season next month, artistic director and organist Dominic Perissinotto has an exquisite program lined up exploring the sonata form.

Dominic, who is also the musical director of St Patrickâ&#x20AC;&#x2122;s Basilica in Fremantle, will CF KPJOFE CZ DFMMJTU $MBSF 5VOOFZ BOE WJPMJO JTU 4IBVO -FF $IFO JO B QSPHSBN JODMVEJOH Jecchini, Biber, Mendelssohn, Bach, Corelli and Ravel. i.Z QSJNBSZ HPBM JT UP NBLF FWFSZ DPODFSU reflect very different sound worlds. In our last concert of the year, the violin and cello

medicalforum

Q (Left to right) Dominic Perissinotto, Shaun Lee-Chen and Clare Tunney

work really nicely with the baroque pieces, which were composed especially for violin BOE DFMMP BOE DPOUJOVP 5IF DPNCJOBUJPO provides a really silky sound.â&#x20AC;? i8IJMF $MBSF JT B NBTUFS PG CBSPRVF NVTJD because the concert time travels a couple of hundred years, she will be playing a mod ern cello. And working with Shaun is also a great thrill. He is a great musical thinker, which will make for a wonderfully exciting collaboration.â&#x20AC;?

8JUI UIF DPODFSU TFSJFT BMSFBEZ planned, Dominic said variety was the key. i* TFF UIF GJWF DPODFSUT BMNPTU BT POF &BDI IBT JUT PXO EJGGFSFOU TUZMF 5IFSF NJHIU be a concert that features modern pieces,

because I know there are people who really MPWF UIBU 5IFO UIFSF BSF UIPTF XIP BSF B MJU tle more traditional.â&#x20AC;? i4POBUB JT NPSF JO UIF USBEJUJPOBM MJOFT XJUI exquisite harmonies and parts.â&#x20AC;? O

By Ms Jan Hallam

WIN For you chance to win tickets to Sonata at St Patrickâ&#x20AC;&#x2122;s Basilica, Fremantle, on November 17 see P50.

47

Social Pulse

s detail l i a m E r of you to ion funct forum. @m editor om.au c

GPET NATIONAL CONFERENCE The theme was Mining for Gold in General Practice Education and the organisers are to be congratulated on a varied two-day program that allowed grassroots GPs and others involved in education to strut their stuff without getting bogged down in high science. Medical Forum visited selected events that fell under the alternative tags of ‘academics, medical educators, researchers, supervisors, AMS staff, registrars, and rural training program staff’ – a diverse group (630 registrations) with the single purpose of assisting GPs to excel at what they do, wherever that is.

Q Dr David Atkinson from the Kimberley presented the outcomes from his years teaching Aboriginal health to GP registrars.

Q Taking part in the keynote workshop on “virtual worlds in education” with presenter Melissa Power looking on are (l to r) Dr Eileen Bristol (Murray Medical, Mandurah), Dr Donough O'Donovan (Coolbellup Medical), Dr Stuart Paterson (Ellen Health, Fremantle) and Dr Jenny Sisson (Travel Doctor, Perth).

Q In the Land of Acronyms, Dr Sonia Singh (pictured right; Kinetic Health Group, Erskine) is involved with RVTS (Remote Vocational Training Scheme).

She is taking a break with colleague Dr Ruth Johnston, from Queensland.

Q Dr Mike Eaton (RDAA WA President, Dardanup) with Dr Susannah Warwick (Derby Aboriginal Health Service) – both are involved in supervising training of about 20 rural registrars in WA under the Remote Vocational Training Scheme.

Q ‘Networking’ over lunch (l to r): Dr Germaine Wilkinson (Currambine Family Practice), Dr Derrick Kuan (Ocean Keys Family Practice, Clarkson), Dr Tim Koh (RACGP Faculty Board, Ocean Keys), Dr Victor Tan (Kwinana Medical Centre), and Dr Penny Wilson (locum GP obstetrician).

Q Albany GP Dr James Turner (left) is involved in teaching GP registrars. We caught him discussing this with Dr John Vaughan, from NSW. Q Dr Gary Claydon

Q Rebecca Wood is a sixth year medical student at UWA and part of the GPSN (General Practice Students Network) promoting general practice as a career pathway among undergraduates.

Q Dr Mark Zafir from Albany describes how the new Health Campus is fitting in.

48

medicalforum

Q (Top) New CEO John Fogarty and Gabrielle Fogarty.

(Below) PCA Martin Buckland and neurosurgeon Dr Paul Taylor

Spring sprung at this year’s St John of God Murdoch Hospital Ball at the Esplanade Hotel in Fremantle. The ballroom was lit up with pink sparkly trees, the walls were adorned with garlands of flowers and tables were covered in springtime blooms. About 500 staff, doctors, allied health professionals, and key business partners kicked up their heels, while also donating generously to support the hospital’s charity of the year, St Vincent de Paul, Mandurah.

Social Pulse

TOUCH OF SPRING FEVER

Q (Top) RN Jessica Mitchell, PCA Sam Last, Recovery Nurse Emma Hildred and PCA Kiran Narula.

(Below) RN Nicola Berna

Q The peloton on the Prostate Cancer Awareness Cycle (Dr Tom Shannon, far right); (Right) Tom ready for the great cycle south.

PROSTATE AWARENESS WEEK Urologist Dr Tom Shannon and about 50 other cyclists took off from the Perth foreshore on September 13 for a fundraising and awareness cycle to Margaret River on one of the bleakest days of the year. But while 40km/h headwinds and driving rain lashed the riders 60km out from the destination, most finished and according to Tom, bonded for life for the experience. Tom rode with one of his patients, who was determined to take to the saddle just eight weeks after his surgery. While the finishing line looked a little like an ED department, with most riders suffering some effects of hypothermia, the $120,000 raised got the blood racing. Tom said it was an amazing experience, with a positive vibe from the peloton and toots of encouragement from the passing motorists along the highways.

Q Dr Stuart Boland, left, Avant WA senior counsel Ms Morag Smith, Dr Gerald Hickson, Ms Lisa Clarke and Dr Tim Marr at the event.

AVANT LEADERSHIP TOUR The Perth medical community were the first of hundreds of medical students and healthcare professionals nationally to attend Avant’s inaugural Leadership Tour with Dr Gerald Hickson, world-recognised expert on patient safety and professional accountability amongst doctors. The presentation was followed by a panel of WA experts including local ENT Registrar Dr Tim Marr.

medicalforum

49

Competitions

Entering Medical Forum's COMPETITIONS is easy!

Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' link (below the magazine cover on the left).

Music: Royal Concertgebouw Orchestra - iÊ i>` }Ê Õà VÊ VÀ Ì VÃÊ Ã>ÞÊ Ì iÊ , Þ> Ê ViÀÌ}iL ÕÜÊ "ÀV iÃÌÀ>Ê ÃÊÌ iÊLiÃÌÊ ÊÌ iÊÜ À `ÊqÊ iÝÌÊ Ì Ê>Ê ÕV ÞÊMedical ForumÊÀi>`iÀÊ> `Ê}ÕiÃÌÊV> Êv `Ê ÕÌÊv ÀÊÌ i Ãi ÛiÃÊÜ i ÊÌ iÊ , "Ê « >ÞÃÊ Ê *iÀÌ °Ê 1 `iÀÊ Ì iÊ L>Ì Ê vÊ ÌÃÊ V ivÊ V `ÕVÌ ÀÊ >À ÃÃÊ > à Ã]ÊÌ iÊ, "ÊÜ Ê« >ÞÊÌÜ Ê«À }À> ÃÊqʼ i}i `>ÀÞ½Ê -ÌÀ>Û Ã ÞÊ> `Ê/V > Ûà ÞÊ> `ʼ iÀ V\»Ê iiÌ Ûi Ê> `Ê-ÌÀ>ÕÃð Perth Concert Hall, Medical Forum tickets, November 21. Program 2, November 22

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Movie: The Butler / ÃÊ Û iÊ ÃÊL>Ãi`Ê ÊÌ iÊÌÀÕiÊÃÌ ÀÞÊ vÊ iV Ê > iÃÊ­ V>`i ÞÊ Ü>À`Ê 7 iÀÊ ÀiÃÌÊ 7 Ì> iÀ®]Ê Ü Ê v ÀÊ Ì ÀiiÊ `iV>`iÃÊ Ü>ÃÊ Ì iÊ V ivÊ LÕÌ iÀÊ v ÀÊ i } ÌÊ V ÃiVÕÌ ÛiÊ 1-Ê «Àià `i ÌÃ]Ê V Õ` }Ê

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Musical Theatre: South Pacific / iÊ ¼ `i Ê À ½Ê vÊ ÕÃÌÀ> > Ê Ã ÜÊ L âÊ Ã>Ê V Õ i]Ê ÃÊ Ì iÊÃÌ>ÀÊ vÊ"«iÀ>Ê ÕÃÌÀ> >Ê/i``ÞÊ/> ÕÊ, `iÃÊ Ê- ÕÌ Ê*>V v VÊ LÀ }ÊÜ Ì ÊÌ iÊ ÃÌÊ Õ i`Êà ÜÊÌÕ iÃÊ vÊ> ÊÌ i°Ê/ÀÞÊ I’m Going to Wash that Man Right Out of My HairÊ > `Ê Some Enchanted EveningÊ v ÀÊ ÃÌ>ÀÌiÀÃ°Ê - ÕÌ Ê *>V v VÊ >ÃÊ Ü Ê ÃiÛi Ê / ÞÊ Ü>À`ÃÊ> `ÊLi Ûi`ÊLÞÊ Ã° Crown Theatre, Medical Forum tickets, November 12, 6.30pm. Season: November 10-December 6

Music: Pipe Organ Plus Sonata Ê Ì iÊ v > Ê Pipe Organ PlusÊ Óä£Î]Ê Õà VÊ ` ÀiVÌ ÀÊ > `Ê À}> ÃÌÊ VÊ *iÀ Ãà ÌÌ Ê ÃÊ i`Ê LÞÊ Ì> i Ìi`Ê V> Ê Õà V > Ã]Ê Û ÃÌÊ- >Õ Ê ii i Ê> `ÊVi ÃÌÊ >ÀiÊ/Õ iÞÊ Ê>Ê >} V> Ê iÝ« À>Ì Ê vÊÌ iÊà >Ì>Êv À °Ê Õà VÊLÞÊ >VV ]Ê i `i Ãà ]Ê LiÀ]Ê,>Ûi ]Ê >V Ê> `Ê Ài ÊÜ Ê}Õ `iÊÌ iÊ>Õ` i ViÊÌ À Õ} Ê Ì ÃÊiÝµÕ Ã ÌiÊÃ Õ `ÃV>«i° St Patrick’s Basilica, Fremantle, November 17 at 2.30pm

Movie: The Counsellor

ÀiVÌi`ÊLÞÊ i}i `>ÀÞÊv > iÀÊ, ` iÞÊ-V ÌÌ]ÊÜÀ ÌÌi ÊLÞÊ*Õ ÌâiÀÊ *À âiÊ Ü }Ê >ÕÌ ÀÊ À >VÊ V >ÀÌ ÞÊ > `Ê ÃÌ>ÀÀ }Ê V >i Ê >ÃÃLi `iÀ]Ê >Û iÀÊ >À`i ]Ê À>`Ê * ÌÌ]Ê *i i «iÊ ÀÕâ]Ê > `Ê

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WINNERS FROM THE AUGUST ISSUE W S Stoker – Movie: %S ,FOKJ 4P %S $BUIZ ,BO %S :WPOOF 5BO %S 4IBSZO #FOOJFS %S $MZEF +VNFBVY % %S ,BUIFSJOF 4IFMMFZ %S 3BNFMB 3BKBLBSVOB %S 1BVM 0 )BSB %S )VJ +FSO -PI C Conversations with Ghosts – Concert: Dr Stephen Cohen and Dr David Day S Symphony – Music: %S 3JD #FSHFTJP %S )FMFO 4MBUUFSZ %S $BSPMJOF $IJO %S 4BSB $IJTIPMN BOE %S &MFBOPS ,PBZ Chitty Chitty Bang Bang – Musical Theatre: Dr Victoria Buntine and Dr Jennie Slee C S Shrine – Theatre: %S -JO "SJBT BOE %S &E 0MT[FXTLJ

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August 2013

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