Medical ForumWA 0417 Public Edition

Hearts & Hands • Skilling Africa • Tightening the Belts • Perils of Place & Politics • Clinicals: Testing Heart; DVT; Arrythmia; Lipids & More…

April 2017

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EDITORIAL

The Right to Choose She got only 8% of Colin Barnett’s primary vote in the seat of Cottesloe, and some say this excursion into politics was amateurish, but Dr Alida Lancee's campaign has added to the disillusionment around politics and politicians. She says they are out of touch with 80% of their electorate on one issue she champions. This Perth GP is under murder investigation for helping someone end their life. She says patients have the right to choose their end and doctors should have the right to be involved, with safeguards built in to protect everyone as best as possible.

Rather than going to ground and protect her interests she decided to take on the powers that be. Why? We attended her Freedom of Choice campaign launch at the Cottesloe Civic Centre and she came across as a caring doctor keen to relieve the suffering of some of her patients, and was gobsmacked that politicians and other doctors seemed unwilling to act on their instincts.

She had no axe to grind or scalps to take. She had a clear message that people should be allowed and Dr Alida Lancee at the perhaps be assisted to die launch of her campaign. The with dignity, and the doctor’s late Clive Deverall, role was to relieve suffering E/Prof Max Kamien and when palliative care was Dr Rodney Syme, inset caught short. People within the mainly elderly audience confirmed what she was saying with their harrowing stories.

She was supported by Dr Rodney Syme, a Victorian urologist who reportedly won a Medical Board challenge after openly admitting to helping over 100 patients in dying; Emeritus Prof Max Kamien, who said the profession needed to get up-todate; and former President of Palliative Care WA and CEO of Cancer Council WA Mr Clive Deverall, who, at one of his last public events before his death on March 11, told us privately that palliative care might have lost its way and that terminal sedation did not meet all needs.

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MEDICAL FORUM

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

This is now a public fight. On their website www.freedomofchoicewa.com is the position of elected representatives, politicians. We all know nothing is simple and we should attempt to stop exploitation. But the time for straight talking is here. I attended a meeting of the Kingsley candidates before the election and heard all but the Greens and Labor candidates dance around my ‘safe’ question. It gave insights into the electoral process (and I feel for the sitting Liberal MLA who lost her seat with a 15% swing).

If over 1300 people in Cottesloe voted for end-of-life law reform, ahead of everything else, then where does the profession stand? No doubt there will be craft and rural-urban splits within the medical profession.

“I plan to ensure that our mortality becomes a subject we can talk about and plan for in the way that we choose for ourselves. The Cottesloe campaign was intended as a platform for voter awareness as well as for all candidates that a Bill is on the agenda.” Alida said.

During the campaign Alida proposed shaping the 75-year-old health assessments to include advanced care planning, the wearing of Medic-alert bracelets to warn of an Advanced Health Directive (AHD) and perhaps a webbased repository of AHDs. The RACGP is in favour of advanced care planning but the profession may not be the ones to lead this debate. It is perhaps too conservative, too slow to act, and too influenced by lobby groups. Health consumers want their values, beliefs and life goals carried out during end-of-life care, including the 25% who will be too out of it to make or communicate a decision.

Perhaps the profession should support community action on this. Certainly, no one wants to read of harrowing ends by cornered health consumers or of doctors who care, like Dr Alida Lancee, getting hauled over the coals when they help.

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

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

APRIL 2017 | 1

CONTENTS APRIL 2017

12

8 FEATURES 8 Fight the Bite 12 Reform or Revolution?

20 Training Dilemmas 22 Australian Doctors for Africa NEWS & VIEWS 1 Editorial: The Right to Choose

Dr Rob McEvoy Curious Conversation: Dr Alice McGushin Have You Heard?

Beneath the Drapes Private Options Medical Schools Celebrate Meningococcal W Vax Practice Management: Back-ups

Mr Jerome Chiew 35 Osteoporosis Guidelines 39 Market Forces

4 10 11 16 18 28 29

20

22

Lifestyle 40 Indian Doctors of WA launch

Dr Sayanta Jana

42 My Local: Bloody French 42 Recipe: Easter Lamb 42 Wine Winner: Dr Colin Stewart 43 Wine Review: St Aidan Wines

Dr Martin Buck 44 Travel: South Pacific Cruising

Dr Lin Arias 46 Funny Side 48 Perth Comedy Festival 49 Theatre: That Play That Goes Wrong 50 Competitions

FIND US ON FACEBOOK & TWITTER! /medicalforumwa/

/medicalforumwa/

Major SponsorS 2 | APRIL 2017

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clinicals

7

Lipid Testing Dr Sydney Sacks

31

37

Deep Vein Thrombosis Dr Shirley Jensen & Ms Sharon Boxall

Stepwise Management of AF Dr Tim Gattorna

33

Assessing Coronary Arteries in the Over 40s Dr David Playford

39

From Rehab to Prehab?

Mr Adam Spiroff

35

Renal Denervation Dr Sharad Shetty

guest columns

6

End ‘Palliative Nightmares’ Mr Clive Deverall

25

Appropriateness of Health Care Dr Matthew Anstey

26

Social Media Myths Ms Jeanine Halley

27

Doctors for Doctors Dr David Oldham

April e-Poll Page 4

: ‘Serving the Community Risk vs Reward’

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician) MEDICAL FORUM APRIL 2017 | 3

e-Poll

“Serving the Community – Risk vs Reward” On the eve of our first Doctors Drum meeting of 2017, we wanted to poll readers to bring some of their views to the table. We received 135 responses from GPs and Specialists within the three-day window. Thanks to those who took part. Many of them made comments and gave some great insight into what life is like in modern day medicine. We will be publishing their comments in full in the May edition along with a full report of March 23’s Doctors Drum meeting.

Q

Do you believe the political persuasion of the Health Minister has more influence than his/her personal abilities?

Yes No Uncertain

54% 26% 20%

ED. It appears most doctors believe politics will be put ahead of personal ability in addressing health issues. Given that hospital funding is the big ticket item for states, Roger Cook may have some decisions ahead of him around rationing of services (see next response) that most doctors will be sceptical of.

Q

How much do you identify with this statement: "One of the

biggest problems facing the Health Minister is that growing health demands will outstrip supply."

I agree strongly I agree No opinion either way I disagree I disagree strongly

46% 39% 6% 7% 2%

Q

Are doctors prone to burnout, more so than many other professions?

Yes No Uncertain

65% 18% 17%

ED. What is it about doctoring that fosters burnout these days? Or is it the type of doctor?

Q

How important is the doctor's work-life balance in determining how much they can serve the community?

Very important Important Uncertain Unimportant Very unimportant

54% 40% 2% 4% 0%

ED. The vast majority of responses seem to say, anyone who devotes 100% of their efforts to work cannot serve the community well.

Q

Should medical education rely less on

Ap

e-Poril ll

Q

Are new doctors adequately trained to tackle today's problems in the community?

55% 27% 17%

No Uncertain Yes

ED. It would be interesting to see community views on this! But choice of careers for doctors is one area the community should not have a say, according to most of our respondent doctors (see next question).

Q

Should the community have more say in what areas junior doctors focus their career?

64% 22% 14%

No Yes Uncertain

Q

Is the profession attracting people, more than it should, who are less resilient under pressure?

36% 34% 30%

No Uncertain Yes

Q

In your experience, do gender differences explain whether people feel either put at risk or rewarded by their work?

59% 27% 14%

No Uncertain Yes

Q

In general terms, what place should medical research take in health funding?

Third Second Uncertain Less than third No priority First

39% 25% 14% 9% 8% 7%

ED. Most respondents gave medical research 3rd or 2nd place for funding allocation, and we cannot give the Specialist-GP split on responses, which would interest us all, sorry.

hospital training?

No Yes Uncertain

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.

4 | APRIL 2017

54% 33% 13%

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

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APRIL 2017 | 5

Letters to the Editor

INCISIONS

End ‘Palliative Nightmares’ Clive Deverall has seen palliative care in WA from the 1970s and thinks we are still failing those who are dying ‘nightmare’ deaths.

An evening in September 1977, Winthrop Hall at the University of WA was packed.

The visiting speaker was Dr Dame Cecily Saunders – the ‘real pioneer’ of modern palliative care.

She described the establishment of St Christopher’s Hospice in London and the opposition from medical colleagues and administrators to the concept of the hospice and what she was doing as a doctor. She was not to be deterred.

Question time went on for 40 minutes before the evening wrapped up. But the fuse had been lit.

What had been two or three small WA groups with an interest in hospice palliative care ballooned. The late Anglican Archbishop of Perth, Geoffrey Sambell, provided local leadership but soon withdrew as one or two locals involved, including a doctor, were keen followers of Moral Re-Armament (MRA), which later morphed into Initiatives of Change.

Sambell did not approve of MRA’s muscular Christianity. In the vacuum created by Sambell’s absence the then Cancer Council (later the Foundation) stepped in. By 1982, the Cancer Council, with donated funds and enthusiastic professional input, persuaded a reluctant Silver Chain to partner them in launching the State’s first hospice home care service known as the Hospice Palliative Care Service (HPCS).

Medical and nursing input was led by these enthusiasts who slowly but surely persuaded colleagues to join them. There was resistance by some in the medical fraternity, with one

Government and politicians, state and federal, now use palliative care as a shield, especially if euthanasia is raised.

Yet those scenarios where the best palliation cannot control excruciating, fast-changing, end-stage symptoms are ever present. senior consultant even describing the Cancer Council as ‘amoral’ for planning to build a Cottage Hospice in Shenton Park to provide specialised palliative care to those who could not be cared for at home.

Dr Rosalie Shaw also opened a dedicated in-patient facility at Hollywood Hospital. The momentum led to the Cancer Council handing over administration of the home care service to Silver Chain so it could concentrate on exploring options for in-patient facilities, which ultimately led to the opening of The Cottage Hospice in 1987.

By this stage the stresses on medical input was evident as was the need for structured professional education. For a doctor at that time, palliative care added little to a career profile and there were those who mockingly described those doctors and nurses who worked in palliative care as ‘White Knights’.

Community support was still rock solid and donations and bequests poured in.

So this was how palliative care became

embedded and subsequently funded within the health care system. All the lobbying to promote palliative care involving media, community groups and politicians, was like spreading a virus. Palliative care became a panacea for all those at their last station in life.

Government and politicians, state and federal, now use palliative care as a shield, especially if euthanasia is raised. Yet those scenarios where the best palliation cannot control excruciating, fast-changing, end-stage symptoms are ever present. Even Palliative Care Australia has given that scenario the professional nod.

Professional training and the presence of consultant physicians has led to more specialisation. What started out in the early days as a ‘Nursing Model’ is today embraced my mainstream medicine. But does the most refined skill and knowledge of the increasing array of drugs help when a demented patient is still screaming in pain and the health professionals don’t know where to look, what to do or what to tell the patient? Such scenarios have been described at professional meetings as ‘Palliative Care Nightmares’.

So why not end those ‘nightmares’ and assist the patient to an early death. Not ‘Terminal Sedation’, which is a Clayton’s option as the patient still has to die.

At the very least, why don’t the palliative care associations discuss physician-assisted death or euthanasia and allow a free, anonymous count of their votes.

ED: Clive Deverall died on March 11th before he could see this opinion piece in print. He was former President of Palliative Care WA and board member of Palliative Care Australia. He was Director of the Cancer Council WA between 1979 and 2000.

CURIOUS CONVERSATIONS

Running for the Environment Early career doctor Dr Alice McGushin isn’t one to stand still when it comes to important social issues.

In five years’ time I hope I will be… driving strong action on climate change. That, combined with medicine, has been my major focus since starting medical school. The longer plan is to finish my paediatric/ community health term in Kalgoorlie and then study a Master of Public Health in London.

One thing I love to do away from work is… follow my passion for running. The first marathon I ran was a Doctors for the Environment fundraiser. I ran three marathons last year and was all set to run a fourth when I fractured the head of my left radius. Now I’m focusing on cycling and swimming for a Half Iron Man.

6 | APRIL 2017

The most disturbing aspect of medical politics is… when it impacts on patient care.

If I hadn’t chosen medicine I’d have loved to… work on climate change policy in areas such as environmental science, politics or law. But being a doctor is pretty useful because we have a voice that should be heard loudly and more often. I think climate change will be the biggest health threat of this century.

The book I’m reading now is… Born to Run by Christopher McDougall. The author is on a quest to discover the secrets of the Tarahumara people in the Copper Canyons in Mexico. They perform extraordinary feats of endurance every day of the week!

MEDICAL FORUM

Major Sponsor: Clinipath Pathology

By Dr Sydney Sacks Chemical Pathologist

Lipid Testing: Non-fasting specimens and non-HDL cholesterol Fasting specimens are no longer mandatory

recommending non-fasting specimens for routine lipid assessment1.

When to test lipids, when to request fasting lipids

Non-fasting specimens are now acceptable. Reviews of large populationbased studies showed that food intake had a clinically insignificant effect on most individuals. Maximal mean post prandial changes were a rise of 0.3 mmol/L for triglycerides, a drop of 0.2 mmol/L for total and LDL cholesterol, and no change for HDL cholesterol.

Non-HDL cholesterol for CVD risk prediction

Testing should be performed when clinically well, as inflammation (eg post MI) reduces cholesterol. More than one lipid profile is advisable to establish a reliable baseline.

Why fasting specimens were used previously. Post-prandial specimens (particularly after a fatty meal) have higher triglycerides and most of the lipid literature references fasting values. Some patients do indeed have significant post prandial elevations of triglycerides; these will require follow-up with a fasting specimen.

Non-fasting vs fasting specimens.

Studies of non-fasting vs fasting lipids in fact demonstrate that non-fasting lipids may have better predictive value for cardiovascular disease and that non-fasting specimens are also effective for monitoring statin therapy.

Presumably this is due to the non-fasting specimen acting as a “stress test” for lipid metabolism.

In light of these findings the European Atherosclerosis Society and the European Federation of Clinical Chemistry published a joint consensus statement in 2016

Non-HDL cholesterol is calculated by simply subtracting the HDL cholesterol from the total cholesterol. Normally it consists mainly of the LDL cholesterol but in addition other atherogenic fractions such as VLDL cholesterol and IDL cholesterol, which may also be raised particularly in non-fasting specimens, are included. Unsurprisingly non-HDL cholesterol is a very good predictor of CVD risk, particularly in non-fasting specimens.

In light of this, the European consensus statement also recommends that non-HDL cholesterol is used as a marker for predicting CVD, particularly in non-fasting specimens Implications for Clinipath Pathology patients Clinipath Pathology now accepts non-fasting and fasting specimens for lipids (remember to specify fasting or non-fasting and to specifically request HDL as well if a full lipid profile is needed, otherwise only cholesterol and triglycerides are performed due to Medicare rules). Patients will have the convenience of not having to fast and being bled whenever it suits them.

Non-HDL cholesterol will also be routinely reported as part of the full lipid profile.

Non-fasting specimens are suitable in most clinical settings including initial baseline lipid testing and monitoring of response to lipid lowering therapy.

Fasting lipids are recommended if the non-fasting triglycerides are greater than 5 mmol/L, if the patient is known to have hypertriglyceridaemia or if on medications that elevate triglycerides eg steroids, retinoic acid and oestrogens, or if a fasting specimen is needed for other tests.

What are the reference limits and target limits?

Reference limits for lipids are not population derived, rather they are “desirable” limits above which CVD risk rises. Lipid reference values are currently being reviewed in Australia with the aim of developing consensus reference intervals and treatment targets. The European consensus reference interval1 and the National Vascular Disease Prevention Alliance (NVDPA) treatment targets2 provide a reasonable guide until Australian values are agreed.

Table 1: European Consensus reference limits1 for fasting and non-fasting specimens Summary

Total cholesterol

<5.0 mmol/L

HDL cholesterol

>1.0 mmol/L

• A repeat fasting specimen may be required in patients with elevated non-fasting triglycerides

LDL cholesterol

<3.0 mmol/L

Triglycerides

<2.0 mmol/L

• Testing should be performed when clinically well as inflammation (eg post MI) reduces cholesterol

Non-HDL cholesterol

• Non-fasting specimens are suitable in most patients for measuring lipids

• More than one lipid profile is advisable to establish a reliable baseline • Non-HDL cholesterol is a simple and useful new marker for predicting cardiovascular risk • Australian consensus lipid reference limits and target levels for treatment are still being developed

<3.9 mmol/L

Table 2: NVDPA targets for lipid lowering therapy in patients with high risk of CVD 2

Total cholesterol HDL cholesterol

≥1.0 mmol/L

LDL cholesterol

<2.0 mmol/L

Triglycerides

<2.0 mmol/L

Non-HDL cholesterol

<2.5 mmol/L

References 1. Nordestgaard BG, et al. Fasting Is Not Routinely Required for Determination of a Lipid Profile: -A Joint Consensus Statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. Clin Chem 2016; 62: 930-46.

2. National Vascular Disease Prevention Alliance, Absolute cardiovascular disease management, Quick reference guide for health professionals 2012

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

<4.0 mmol/L

Patient Results: 9371 4340

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

www.clinipathpathology.com.au

News & Views

Fight the Bite With the unseasonable rain, mozzies will be on the rampage in WA, but humans are preparing to bite back.

Public awareness programs are vitally important in combating mosquito-borne diseases. There’s a strong focus on local government and GPs have an important role to play as well, says Environmental Health Hazards Managing Scientist (WA) Dr Michael Lindsay.

“An education program such as Fight the Bite is just one of a number of initiatives in mosquito management in WA. We’ve got a longstanding research history that goes right back to the 1950s and the development of the Ord River Scheme.”

“The latter was a major water-management undertaking and it was crucially important to assess its impact on a public health level.”

Dr Michael Lindsay

“We’re well aware that certain environments and environmental conditions are more likely to be associated with outbreaks of mosquitoborne disease and effective management programs will need to focus on everything from risk management and improved surveillance to monitoring the environment, as well as raising community awareness through programs like Fight the Bite.”

Blood tests for diagnosis “It’s important for GPs to know that mosquito-borne infections in WA may present with similar symptoms to other communicable diseases. Therefore, it’s imperative to do confirmatory blood testing with specific serological or molecular assays in accredited laboratories. Definitive diagnosis generally requires testing of two (acute and convalescent) blood samples, although a presumptive diagnosis is possible based on one blood sample.”

“GPs should also ask for a detailed travel history with specific dates and locations for up to a month prior to the onset of symptoms, but particularly from three days to three weeks prior to onset which is the average incubation period post-exposure to an infected mosquito.”

“The other critical aspect is that GPs notify the Department of Health of all confirmed cases because this information is really important in informing a broader public health response.”

8 | APRIL 2017

There is a strong regional emphasis on both the nature and the incidence of these outbreaks, says Michael.

“It’s very much a ‘local’ approach, at times.

For example, an emphasis on Murray Valley encephalitis during and just after the wet season in the Kimberley and a spring/summer targeted focus on Ross River virus in the South-West.”

“The Department of Health and Local Governments endeavour to provide clear and consistent messages at certain times of the year – and, indeed, sometimes in a particular year – when the risk of mosquito-borne pathogens is elevated.”

Local government needs help “There are 139 Local Governments across the State and it is incumbent upon the Department of Health to support and build the capacity of their environmental health teams to manage mosquito-borne viruses to protect local communities.”

“The majority of bites are just a nuisance, but we would regard any mosquito-borne illness as a mosquito encounter that’s gone wrong.”

The world of microbiology and zoology is not without its humorous moments. If you’re ever invited to an entomologists’ knees-up make sure you lock it in your diary.

“It’s only the female mosquito that bites. They do that to obtain the protein in our blood, which enables them to lay a substantial quantity of eggs.”

“There’s a species in the Kimberley that breeds in the rot holes of the Boab tree.

Females of this species are so focussed on the exhaled plume of carbon dioxide as you breathe, to lead them to a potential bloodmeal, that the only place you usually get bitten by them is on the tip of your nose.

A well-known entomologist’s party-trick is to squash one of these mosquitoes as it lands on your nose and to announce, look... it’s a Tripteroides punctolateralis!”

“There are some mosquitoes that have adapted well to being indoors and finding a resting place when the light remains on.

There’s actually one that used to be called Culex fatigans (now Culex quinquefaciatus), presumably due to the induced fatigue as it keeps you awake at night.”

Tips for your Patients Fight the Bite: cover-up, repel, clean-up (Fight the Bite website): • Wear long, loose-fitting, light coloured clothing, covering as much of the body as you can. Mosquitoes can bite through tight clothes like jeans. Make sure children are also appropriately covered.

• Use insect repellent containing DEET (diethyltoluamide) or picaridin and always follow instructions on the label.

• Stop mosquitoes breeding in water pooling around your home or holiday accommodation by emptying water from containers.

• Avoid exposure around dawn and dusk when many mosquito species are most active.

• Ensure infants are protected using suitable clothing, bed nets and screens.

• Ensure insect screening on houses and camping equipment is in good condition.

By Peter McClelland

And that annoying buzz when the lights go out?

“Once a mosquito gets within a few feet of its intended victim a range of chemical cues come into play. Some people get bitten more than others and some individuals find themselves in the unenviable position of being more attractive to a particular species.”

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APRIL 2017 | 9

HAVE YOU HEARD?

GPs bite back

Fees and performance

PBS’s dazzling numbers

On March 4, the Australian GP Alliance (AGPA) held its first meeting at the Stamford Plaza at Sydney Airport for a contingent of 75 independent general practice owners from across the country – eight from WA – seeking action and redress on a range of issues.

The pathology rental issue is one but the discontent courses over MBS reform, the PIP redesign and practice management issues.

The deputy chair of the alliance is Kalamunda GP Dr Sean Stevens who told us that 46 actions were voted on across nine topics.

How they will push for change will be explored in later issues. The meeting attracted attention outside of the AGPA membership. We believe both the AMA President Dr Michael Gannon and RACGP president Dr Bastien Siedel addressed the meeting calling for unity.

Health consumer advocates are calling for action around transparency of specialist fees after the publication of an analysis of Medicare billing data by Melbourne University’s Gary Freed and Amy Allen, which shows significant variations in out-ofpocket costs. Costs of initial consultations were particularly under scrutiny – the pair found fees could vary more than five-fold in some specialties. The most expensive initial consults, which could result in out-of-pocket costs of more than $128, were in immunology/ allergy. The CEO of the Consumers Health Forum Leanne Wells wants to see an “independent and authoritative” website to list fees and ultimately data on the performance of specialists. Rob Bransby suggests on P12 this is only a matter of time. AMA President Dr Michael Gannon told MJA InSight that where patients were charged gap fees for private services, it was often because insurers paid substantially less than the AMA recommended fee and disagreed with the contention that Australia had “a massive problem of excessive specialist fees”. He also warned that the push to publish individual specialists’ performance data could backfire.

“If, for example, we were to start publishing reports on rates of wound infection or venous thromboembolism after surgery, you would very likely see surgeons refusing to provide care to obese patients,” he said.

Based on PBS and RPBS prescriptions for the 2014-15 year, the NPS has released its ‘Top 10’ count. Atorvastatin is top of the list for daily doses consumed (combined or alone) and script counts (7.8m) but doesn’t even rate in the top 10 for cost to government.

Instead, still under patent protection at the time, adalimumab (with 176,000 prescriptions) was the most costly ($312m) to government.

The top 5 expensive drugs (relatively high cost with low script numbers) were all on patent at the time without generics available. Rituximab, classed as an antineoplastic and immunemodulating agent (injectable for treatment of non-Hodgkin’s lymphoma), was arguably top among these with just 46,763 scripts at a cost of $156.6m.

Local grads stay bush With the start of the new academic year and a new era in medical training dawning with the opening of the Curtin Medical School, scrutiny around graduate and post-graduate training has intensified. Our e-Poll correspondent (see Voice from the Trenches, opposite) and the story on P20 will attest the need for some serious and creative rethinking in the way doctors are equipped to meet their own needs and the health needs of the community wherever they may be. WAGPET CEO Dr Janice Bell told Medical Forum that new data shows the nett increase in GPs in remote and very remote areas over the past five, 15 and 30 years have been Australian medical graduates (AMGs) not international medical graduates (IMGs). It certainly blows away the idea that only IMGs are prepared to practise in far-flung locations. Having safe and quality locations to live and work is making a difference and Janice says a lot of the credit for that must go to the Rural Clinical School.

“The RCS has created these quality places in which to teach medical students and that has attracted registrars and consultants to areas that would otherwise be overlooked,” she said.

Putting on the squeeze We received an email from Brisbane-based Pericoach, which is offering $50 to practices or practitioners for each patient referred by them who purchases its perineal exercise device. This PeriCoach Professional Referrer Program has resulted in about 15 WA physio practices registering on its website. It has cast its net wide with GPs and specialists within Australia, the US, Canada and UK registering. If it sounds like a kickback, the $50 is in form of a ‘credit’ paid by PeriCoach to the practitioner’s charity of choice.

Future Fund, future research Given the scale of Labor’s landslide victory at the WA election and perhaps the budget shocks to come, election promises might be a bit rubbery. Along with Medihotels, the now Premier Mark McGowan committed a Labor government to a $1.1b Future Health Research and Innovation (HRI) Fund. The proposal would ‘repurpose’ the current WA Future Fund’s annual interest of $35m to health research, particularly research into cancers, child health and “other diseases in which WA has an international standing”. An actuarial board would be appointed to oversee it. Not surprisingly, Prof Peter Leedman, from the Perkins Institute, and Prof Jonathan Carapetis, from Telethon Kids, welcomed the news. Now to see it come to fruition!

Definitions under scrutiny Also on the subject of research, Dr Ray Moynihan, from Bond University, has been awarded a four-year NHMRC fellowship to investigate expanding disease definitions and overdiagnosis. He cites three areas – the expanded definitions of gestational diabetes, chronic kidney disease and ADHD – that will form part of his examination.

Way to go: Cott to Rotto Mt Claremont GP Dr Rosemary Quinlivan (O'Halloran) threw herself into the deep end on February 25 and found herself battling some tough conditions for the Rottnest Channel Swim but with the help of support crew skipper Dr Tony Tropiano, paddler Brendan Reed, Tony’s son Mike Tropiano (co-skipper and relief paddler) and Anne Phelan (nutrition and drinks). Dr Pam Hendry, whose Ladybird Foundation – and the ROLLIS project in particular – is the recipient of Rosemary’s fundraising efforts, reported that Rosemary finished 27th out of 63 female solo swimmers and in the top half of all solo swimmers who completed the crossing. “She was initially a bit disappointed that her time (7 hours 35 minutes) was 45 minutes slower than her previous solo time until she spoke to others in her swim squad who came in quite a lot slower,” Pam wrote. At the time of press, Rosemary had raised $9030 on her supporters' page.

10 | APRIL 2017

MEDICAL FORUM

as everyone is too busy, and there is not the opportunity for our young apprentices to be exposed to a range of post-graduate experience which will equip them to make sound career choices and make them sound clinicians. You cannot cut staff and expect teaching and training to flourish. [It saves money in the short term] but in the long term it’s extremely costly to the community…and a tragic waste of young doctors’ potential.

Voice from the trenches In the light of the growing disquiet of staff at PMH, in particular, but perhaps at other WA Health sites in general, and the training dilemmas discussed on P20, a comment from a doctor responding to our latest e-Poll says so much. Here is an edited version of what this doctor had to say: “At the present time there is quiet panic in government and the department of health about the percentage of the budget that is taken up by health care, which is rightly deemed unsustainable. However, there is a tendency to put in place blunt instruments (5% staff cuts etc) rather than the more difficult, targeted approach to areas of potential waste, rorting or areas of less clinical priority (but may be high political priority).

Consequently, adequate staffing is cut leaving less time for teaching and training

Quality consultants burn out and retreat to the green pastures of retirement or the perceived better environment of private practice where they may at least feel they have some degree of control over their professional lives. We have an ageing population, an increased number of medical graduates to educate and the Baby Boomer doctor generation, who worked incredibly long hours without (much) complaint, is getting old and tired. Generation X docs are on the way to disillusionment and burn-out and cannot replace the Baby Boomer docs.

So the malaise of our health care system of too little money, an increasing absolute and relative demand from our community for exceptional health care, failure of politicians to look beyond the next election, and [bureaucracy’s] inability to look beyond money, is leaving us in a very depressing position in public hospitals. For those of us who care about teaching and training, at the moment, it is hard yakka – clinically, emotionally and psychologically.”

• The 30-bed Abbortsford Private Hospital in West Leederville has been sold to Healthe Care Australia. The company bought the Marian Centre 2km up the road in 2014.

• Medical Oncologist Dr Anna Nowak, who works at the National Centre for Asbestos Related Diseases at the QE II Medical Centre, is the recipient of the international Mesothelioma Applied Research Foundation’s Pioneer Award.

• SCGH intensivist Dr Matthew Anstey is the new chair of Choosing Wisely Australia’s advisory group.

He was previously a member of the group. Matthew is also a part-time senior medical adviser to the Australian Commission on Safety and Quality in Health Care.

• Former Rio Tinto Chief Executive Sam Walsh is the new chair of the RFDS. • At the recent state election, three doctors were candidates. At the time of going to press, GP Dr Alida Lancee, in the seat of Cottesloe with 88.36% of the votes counted, had 1327 primary votes (5.67%) while physician Dr Michael Watson had 177 voters (.76%). Dr Graham Jacobs contesting the new seat of Roe lost to the National Party. He polled 5498 of the primary vote (23.99%).

BY THE NUMBERS

$151,160 HBF’s biggest single payout for a Cardiac Procedure (2015-16) in WA. It was for the implantation or replacement of a cardiac defibrillator (with complications) HBF paid out a total of $94,317,404 for 8239 episodes in the reporting period.

Source: HBF

Cardiovascular Disease (CVD) in Australia

• CVD accounted for 43,602 deaths in 2013, including 19,765 from ischaemic heart disease (the most single cause of death for both men and women)

• Ischaemic heart disease was the leading cause of death for Aboriginal and Torres Strait Islander (ATSI) people in all states and territories, with death rates up to 2½ times higher than the rest of the population.

• The PBS paid about $558m for cardiovascular drugs in 1993–94 (or 31% of all benefits paid in that year). In 2013–14, about $1.6b was paid out (or 17% of total PBS benefits paid in that year).

• Adults 30-65 years, 33% reported having been diagnosed with high cholesterol; 32% reported having been diagnosed with high blood pressure. Rates were somewhat higher in men than in women (36% vs 28%, respectively).

Source: Australian Heart Disease Statistics 2015, Heart Foundation & Deakin University

MEDICAL FORUM

APRIL 2017 | 11

Feature

Reform or Await the Revolution Rob Bransby departs HBF after 11 years and shares some of his hopes and fears for a health system in desperate need of attention.

When former Health Minister Sussan Ley ignited a multifaceted review of the nation’s health system two years ago, HBF CEO Rob Bransby became a warrior for reform. As president of Private Healthcare Australia – the private insurers’ peak representative body – he was invited to the table in Canberra and made good his time there pushing the affordability agenda at every turn.

As of April 1, Rob has retired from the frontline and the CEO’s office leaving HBF’s COO Julie Keane the interim head. In his 11 years he has overseen the journey form vulnerable mutual ripe for takeover in 2005 to a sophisticated, successful digital health insurance business in 2017.

It is, he says, one of his proudest achievements.

Medical Forum spoke to Rob the day after the premium rises were announced. HBF had lifted its premiums by 1% from 2016; other funds were fractionally lower but their 2016 rates were higher. All grist for the premium mill (though it is interesting to note that Avant’s health insurance business, Doctors Health Fund, decreased its premiums by .02% to 3.54%, see table).

Fund

2016

2017

plan to manage future population health and we have a great vehicle to do that with technology, or specifically the personal health record agenda.”

HBF Medibank Private Bupa Doctors Health Fund

4.94% 5.64% 5.69% 3.76%

5.96% 4.6% 4.46% 3.54%

Rob is retaining his seat on the board of the Australian Digital Health Agency because it is his belief that digital technology is the single most likely driver of change.

2017 PREMIUM INCREASES

Industry weighted 5.5%

4.84%

ED: Increases take place on April 1, Source: www.health.gov.au

While the tinkering at the premium edges goes on, the song remains the same: health costs are going up, premiums must respond.

New thinking, new era However, Rob Bransby thinks it’s time for a complete overhaul of the 20-year-old settings which rescued the health system back in the 1990s but hamper it today.

“We need to look at the entire system and do it better,” he said.

“We understand that governments have constrained budgets. We understand why the rebates have been wound back and we don’t put our hands out for more money. We accept that as a consequence, consumers are paying more. But what is hard to understand is there’s not a better way of doing business. There is a $3b pool called health, we must discover how to use it better and differently. Making the consumer pay more is no longer the answer.”

“The 4.8% industry weighted rise is still twice inflation, which can only be a challenge for consumers. On the current trajectory it’s going to be the same next year and will continue to rise while the national health inflation runs into the 7s and 8s. The cost line continues to grow rapidly and the revenue line has to keep pace somehow.”

That’s why Rob has loudly advocated the necessity of reform – from preventative health to digital health.

Drive out waste “I am still a great believer that there is a lot of duplication and waste to be driven out of the system – without compromising quality and safety. But the key issue is the settings.

The Howard Government tinkered with them by introducing the rebate with the concept that it was patriotic for people to take out private insurance. Everything in the world has changed – except health.”

“It’s time to look at all those settings and collectively come up with a robust strategic

“It offers great leverage and opportunity for us to transform the sector – to implement robust accountabilities, eliminate duplication and introduce digital replacements for sound health care management so services can be provided to those who need it.”

Politics and progress Politics has an uncanny knack of disrupting progress and so it has been with the resignation of Sussan Ley and the installation of Greg Hunt as federal Health Minister.

Ley had mostly steered a steady course – the MBS Review swept into some neglected corners such as prosthesis pricing and obsolete item numbers but a close election, where politicking on health and specifically Medicare was a near-death experience for the Coalition Government, slowed the reform process.

However, Greg Hunt has impressed the stakeholders with his ability to pick up the baton. Rob told Medical Forum the new Minister was on the phone to him on the day of his appointment talking about the issues; AMA President Dr Michael Gannon was reported as saying he was similarly contacted that day – twice.

“I’m 100% confident he will pick up the pieces of this reform agenda. He specifically called out three areas, which I won’t share with you, but he understands the levers,” Rob said.

“It will take a brave government to deliver on the reforms we desperately need; to come up with a model that is sustainable but doesn’t compromise safety, quality and outcome. I know that sounds easy to say but the thinking needs to start now because it won’t happen overnight,” he said.

SOS: Save our system What is universally accepted is the need to maintain the 50:50 public/private health split, which has made Australia the envy of the world. But that balance is now precarious.

Rob is a great advocate for better funded primary care, which he spoke to us about at length back in June last year. He hasn’t changed his view but private health funds are not invited into that space – yet – and private hospitals remain their core business and concern. continued on Page 14

12 | APRIL 2017

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APRIL 2017 | 13

Feature

continued from Page 12

Reform or Await the Revolution On Page 16, we speak to the new Executive Director of WA Hospitals for St John of God Health Care, Mr John Fogarty, who reflects on the worrying affordability gaps in private health funding.

there? If you are a private patient you should be in a private hospital, especially if you are elective.”

For Rob, the solution lies in changing those health settings.

In the February edition, cardiologist Dr Mark Hands was concerned that payment linked some way to outcomes was around the corner. It is the elephant in the room.

“The models of care and settings under which we operate allow us only to fund private hospital care and day surgery etc. We are in the same glove, like it or not. If the proposition that private health is becoming unaffordable and people are turning away, we both suffer.”

“I don’t think the funder should ever interfere in the relationship with the patient in terms of best treatments and the best outcomes because we are not trained in that; practitioners are and we have complete faith in them,” Rob said.

“So we have to sit down, and this is where it may need some legislative intervention, and ask ourselves how we do this differently so we both win and, most importantly, the consumer wins. I think it is about delivering care in the right setting as distinct from the only setting. It is a big step.”

“However, we shouldn’t have to fund never events, either, and right now we have to.

Negligence shouldn’t be rewarded but conversely funders should reward good outcomes. It shouldn’t be either/or, it should be both.”

Potential for growth

“What determines a great outcome for a patient should be determined by the patient and not the funder and I have faith that doctors do the right thing by their patients.

They don’t want a substandard outcome either.”

“We have this narrow view of the world that half the people are privately insured and that’s the end of the world – a mature market. But the reality is, if it were more affordable and the hospital groups offered alternative services in various locations you may have a different proposition that is accessible to a bigger market. That’s radical thinking but that’s the next thing to go.”

As a way of illustrating how consumers themselves are pulling away from traditional models, Rob says the private insurance sector has paid more than $1b for private patients in the public hospital system.

“That’s $1b of private funds going into public revenue. Why is that? What has gone wrong

Outcomes for patients

Consumers are at the heart of it all, yet Rob says the average consumer is pushing a stone uphill in a very complex landscape.

“How we make a consumer more system literate is a critical piece of the puzzle and we, who work in the system, must provide the answer. Consumers need a trusted adviser (and for many that’s their GP) and the sector needs to be less complicated and more transparent.”

“There are over 44,300 iterations of health insurance products in Australia and, frankly, that’s ridiculous. But it goes deeper than that with general confusion about who funds what and how much. Consumers send their accounts off to everyone, hoping someone might pay something!”

Transparency is the key “Consumers need an informed choice and that can’t be informed if there’s not education and transparency. The quicker people embrace the digital age, the better. My Health Record will help people to know more about themselves so they can have discussions with their health professionals on a completely different level.”

Last month the MJA published an article highlighting just how opaque specialist fees were and it set feathers flying (see P10).

As far as Rob Bransby is concerned there should be global transparency of all prices throughout the health system.

“Consumers should be able to get quotes from specialists and be free to make an informed choice. I’m all for people making money. Doctors train and work hard and a fee structure based on quality, service and outcome is relevant but let the consumer decide.”

“I don’t make any assertion doctors charge too much or too little. Just let people know how much you charge. People don’t make decisions on price alone but price visibility is essential.”

By Jan Hallam

AMA on Premium Rises Reactions to the premium increases were mixed and marked mostly by relief that they were the lowest they had been for some time!

However, The AMA President Dr Michael Gannon told Sky News on February 10 that there was growing concern about costs leading consumers to question the value of the private system.

“Now this is a concern for all of us. The private system is an absolutely essential pillar of our health system. It offers patients choice. In many areas of health care, it's more efficient. In many areas of health care, it's safer; 70-75% of operations and procedures

14 | APRIL 2017

are done in private hospitals. There is at least publicly bipartisan support for that blended public and private system,” he said.

“These increases year-on-year – greater than the increases in wages and other metrics of people's ability to pay the bills – are of a concern, because people might just walk away.”

However, he thought health costs would inevitably rise and that’s not necessarily a bad thing: “The truth is that it will be almost impossible to limit these increases. The Health Minister today is…defending a rise in the cost of these

premiums. But next week, the week after, he'll be in a hospital or in a clinic somewhere around Australia talking about an exciting new technology which is good for patients, but comes at a price.”

[New procedures, drugs and technologies]… all cost money, and sometimes it's the case that you pay now to invest later. So it's not always bad news that the costs go up. A lot of these should be seen as investments in the health of Australians…”

“It's time to revisit grown-up conversations about how we fund what I believe will be inevitable increases in the cost of health care.”

MEDICAL FORUM

Left intentionally blank to comply with Medicines Australia Code.

Feature

Belts Tighten in Private Sector The private hospital sector is working hard to counter the effects of escalating costs and nervous consumer sentiment over affordability of private health.

At St John of God Health Care, the departure of its Perth Northern Hospitals region executive director Dr Lachlan Henderson late last year has prompted a rethink how it will manage its stable of four metropolitan hospitals, two regional hospitals and one day facility.

and known gaps so members get a clear choice but it is a long journey. Some doctors quite rightly believe they have the right to charge what they think is fit for their services.

Our role is to encourage everyone in the system to think about the overall economy of health care. We have a responsibility as a corporate citizen to promote reasonable fees.”

John Fogarty, who had been the group’s ED of southern region hospitals and CEO of SJG Murdoch for the past four years, was appointed at the start of 2017 to a newly created position of Executive Director of WA Hospitals, which he told Medical Forum was the board’s response to the increasingly complex health care environment in WA. “The position provides a single point of coordination for all our hospital services in WA, and because the role is supernumerary it means I can focus on supporting the hospital CEOs and be the point of contact with key stakeholders, such as government and funders.”

Just as the general health landscape has grown in complexity, so too has the SJGHC group with its public/private Midland hospital opening 16 months ago and its acquisition of the former Mercy hospital in Mt Lawley in 2014.

Restructuring for a new era “We have grown significantly over the past 3-4 years and Group CEO Dr Michael Stanford recognised a statewide regional structure would enable us to be more effective, which was endorsed by the Board.

With the economy and the private health sector experiencing a little slowdown, it’s important to create synergies to get better efficiencies.”

Costs and scrutiny of costs have never been more pressing. As witnessed by the recent rise in health insurance premiums, twice the CPI, consumers are struggling to afford private health insurance, which is a deep concern for politicians, governments and health care providers in whatever sector they may practice.

The arguments of how important it is to preserve Australia’s 50:50 private/public health system are not new but there is a growing urgency for some solutions.

John says conversations with funders are frank, but it would seem that mutual interest necessitates the relationship to be close.

Mr John Fogarty

“There is such an array of insurance products and such variations in pricing for services and not just among doctors, it isn’t sustainable in the long term and we are working with health insurers and doctors to help find ways to bring down the cost of health care,” John said.

“While we don’t interfere in the conversation between doctor and patient, we encourage our service providers to consider patient’s out-of-pocket costs, so more people don’t decide to go public, which then leads to growing demands on the public health sector and waiting lists increasing.

We have seen this play out at our new public hospital in Midland, which has attracted pregnant mothers with private health insurance as it’s shiny and new and has no out-of-pocket expenses. This has had a knock-on effect on the obstetrics services at our Mt Lawley hospital. This story is being repeated right across the country.”

Community responsibilities

“We work together to make things more affordable to reduce waste and costs and improve quality. Our current contract with Medibank Private allows us to be penalised for certain adverse events if they occur in our hospitals but the funder is also prepared to pay us a slight premium if we can deliver against an agreed set of quality measures.

The system has to work together to get maximum value out of every dollar that’s spent.”

John agrees with cardiologist Dr Mark Hands who wrote in Medical Forum in February of his belief that future reimbursements from governments and health funds would be related to outcome data.

“To that end we are working hard to establish a much more robust analytics system and implement an electronic medical record so data can be rigorous and accurate. We expect down the track, funders will pay for the bundle of care – theatre, bed – and not just in hospital. They will check on patient outcomes 1-3 months after hospitalisation.

We think that’s the way it is heading and we are duty bound to work on it now.”

By Jan Hallam

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APRIL 2017 | 17

News & Views

Community Gets Value for Money This year the UWA Medical School marks its 60th anniversary and in the year that sees the opening of a shiny new medical school at Curtin it’s interesting to reflect on how the state’s oldest trainer of doctors came about and how times have changed.

In the early 1950s, the WA population of just 640,000 were so determined to have a local medical school to serve the local community it went into fundraising hyperdrive. Even the Guild of Undergraduates took to the streets rattling tins and collected £10,000.

Now, 60 years and 4000 graduates later, UWA is paying back some of that faith and hard work by investing $7m into a refurbishment of the Medical and Dental Library but don’t expect hushed tones and dusty tomes – this will be a hub full of collaborative chatter and serious learning.

Executive Dean of the Faculty of Health and Medical Science Prof Wendy Erber told Medical Forum that books will be confined to just one floor of the three-storey building.

“This will be an open library where the community is welcome. An important space will be the alumni lounge where it is hoped former students will come to learn and to interact with current students,” she said.

“The entire Medical school was on the back of community interest and commitment, so opening the library to the community is our gift to the community.”

Wendy, who is a graduate of Sydney University, has been in WA since 1990 and apart from seven years at Cambridge, UWA has been a big part of her life both as a teacher and researcher.

A haematologist by profession she still finds time (but not much) to practise and wonders out loud if she is the first dean to have a microscope in her office.

Prof Wendy Erber and the university's new Vice-Chancellor Prof Dawn Freshwater strike a blow for the new library.

Wendy is particularly committed to promoting research to the student body.

“We are generating great graduates who are taking their place in society and contributing to the health and wellbeing of this state and beyond. In addition to that I really want our students to have the opportunity to become the researchers of tomorrow, to create new knowledge. There has been a dip in numbers

of young people embarking on a research career. So it’s important to enthuse them at a young age to think about discovering new knowledge and the advances those can bring to health delivery.”

There will be more celebrations announced later in the year to mark the medical school’s anniversary.

A New Era Begins Curtin Medical School opened at the end of February and 60 undergraduate students began their studies oblivious to, or at least unconcerned about, the years of struggle and invective its architects have had to stare down.

For its Dean, Prof William Hart, it must have been a particularly satisfying moment when the then Premier Colin Barnett snipped the ribbon on the doors of the handsome $49m building at Bentley campus.

He has had to weather his fair share of storms. He was still batting media quizzing and AMA disapproval days after the school had opened.

Still to come is the school’s Midland clinical campus which is expected to be operational by 2019 in time for the first cohort’s fourth and fifth year of study.

The proof of the need of a third medical school will be five years in the making and that’s a long time in health and politics.

Pictured: Prof William Hart, Colin Barnett and Curtin University Vice-Chancellor Deborah Terry with some of the medical schools ‘freshies’. Inset: the Bentley school.

18 | APRIL 2017

MEDICAL FORUM

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Feature

Perils of Place and Politics WA has some serious work ahead to ensure citizens in rural and remote regions have adequate health care from a workforce fit and ready for the challenges.

Headlines over the past month issuing from Canberra around medical training and workforce distribution have given some cause for hope that these issues are being considered with some serious purpose, in contrast to the Government’s brutalist methodology of 2015.

The Assistant Health Minister Dr David Gillespie has continued to issue forth since we reported initiatives to create support hubs for doctors in Dr Janice Bell rural areas.

Now it has set aside a modest $10m a year for a program, dubbed by one media outlet as PGPPP Lite, with the same intention as that erstwhile and successful project but casting only a shadow of its former self.

The National Rural Junior Doctor Training Innovation Fund (RJDTIF) will offer only 60 places annually for prevocational doctors to road-test rural practice but given WA Health was funding 20 full-time equivalent positions for its go-it-alone 2015 Community Residency Program, our share of 60 is going to look a little anaemic.

Still, it is a positive step and shows the Minister, himself a former regional GI consultant, has recognised that if the government is to address the maldistribution of the country’s GPs, it needs mechanisms to make rural practice more attractive.

WA data ‘diabolical’ As reported last month, the deep concern for WA is that, despite it being a well-worn and thereby easily dismissed catchcry, our situation is unique – there is not simply a maldistribution of GPs here, there is also a serious shortage of doctors with the right scope of practice in the right areas.

Two reports are imminent from WA Health and WAPHA which we are told will reveal sobering figures on doctor numbers in some

rural and remote areas of the state and that’s a concern for organisations responsible for training, attracting and retaining doctors to these places.

CEO of WAGPET Dr Janice Bell, who fought tooth and nail to save PGPPP for no better reason than it worked, was heartened that the government was “quite rightly” re-investing in the prevocational area.

“The government lost its line of sight in the prevocational space when they gave up on PGPPP. It was a real shame for WA, junior doctors and the professional because it really did create a pathway for junior docs in an experiential way,” she said.

“I am not a fan of training pipelines, I believe in maps and a GPS and that’s what I like to say we give our junior doctors. We lost of lot of the map – the opportunities for junior doctors – when we lost PGPPP. I think this is the attempt to bring that line of sight back, slowly and affordably, in the prevocational area but it has a long way to go.”

That WA’s needs should be considered uniquely, she is in no doubt.

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MEDICAL FORUM

Feature

“The data around GP workforce are showing a diabolical shortfall in some places of the state and a ‘cookie cutter’ approach to policy will be disastrous. There are places in rural and urban WA that are oversupplied with GPs and there are plenty of urban and rural areas suffering from the lack of GPs.” Numbers are people too WAPHA’s report is said to be a WA version of the Grattan Institute’s Perils of Place which studied how health outcomes of Victorians and Queenslanders were shaped by where they lived. And when it comes down to it, patient outcomes must be the focus of all of these numbers games as must be the personal and professional welfare of young doctors who serve them.

Training junior doctors to be ‘match fit’ is of particularly concern to Janice. Last year, training places were unfilled because candidates were not considered ready to take on the rigours of GP training.

doctor going into a generalist career – be it practitioner, physician, surgeon or whatever – will have those generalist rotations in those prevocational years.”

“The downside is it is more work for students but in return we hope to be able to give them a recogniseable qualification for that next step.”

“That to me will make one of the biggest differences to WAGPET in placing registrars in some of those more challenging areas because right now some applicants are simply not able to practise safely and provide quality care.”

Challenge to change

New training ideas

While many argue it’s the perfect time for creative thinking, change is always a challenge.

“New education and training models are being studied which would make better use of existing rotations to give students a map of what they need to learn and what they need to demonstrate they have learnt while in that rotation before moving on to another.”

Speaking to Medical Forum she said the current challenging climate was giving rise to more creative thinking about training in general.

“It will give students a better idea of where they’re going but it does put the responsibility of their education and learning back on the junior doctor. It won’t be compulsory but it is hoped the program will be recognised by the AMC and that the generalist specialist colleges – RACGP, ACRRM, RACP and RACS – will consider it as part of entry into their vocational training.”

“Students are not getting the same clinical exposure as in the past, or the same clinical experience in the pre-vocational years, which means they are often just not ready for a career in general practice. I’m delighted that WA Health has taken this seriously and is looking at how they can ensure that any

“The pros are that students are much more likely to get diversity and a taste of a range of vocations they need for any of the generalist careers and they will know they are safe and competent to move on to the next stage of their education and training rather than just hoping they are.”

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“This is all think-tank ideas and it’s a long way from fruition but in the absence of suitable funding, it’s about working with what you’ve got in a smarter way to improve the quality of education and ultimately the quality of care.”

“The health system is one of the least flexible and adaptable organisations in human history.

The biggest challenge is to help those who support prevocational doctors recognise their responsibilities to training, support, employment and risk management of those young doctors. If that were taken on board seriously by employers it would make a huge difference.”

“If we want to grow our own workforce safely and competently from the three universities we have invested in, that pillar in the process would make the rest so much easier.”

By Jan Hallam

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Feature

Doctors Standing With Africa Orthopaedic surgeon Dr Graham Forward’s response to a lone voice crying for medical help in Somalia 12 years ago has evolved into an efficient action team.

On Boxing Day 2004, a 9.1 earthquake struck off the west of coast of Sumatra triggering tsunamis along the coasts of 14 Indian Ocean countries killing an estimated 230,000 people. We read and donated much to the relief aid in the hardest hit nations of Indonesia, Sri Lanka and Thailand but little was heard of the fate of those in African nations.

In Somalia the tsunami killed 298 people and displaced an estimated 5000.

WA orthopaedic surgeon Dr Graham Forward was like most of us until a phone call from a doctor at the Bosaso Hospital in northern Somalia asked him directly for help.

“A friend had told this doctor about me. We spoke and in February, 2005, I put a team together, went on the radio and a lot of money came in to equip the team and buy relief equipment,” Graham said.

Transparency and accountability But as in all things, Graham was meticulous – if he was going to do something, it was going to be done right. He formed Australian Doctors For Africa (ADFA), a registered charity that would account for and audit these aid activities. It has a board chaired by John Bond and a clinical governance committee chaired by Prof Shirley Bowen (Dean of the Notre Dame Medical School) and assisted by consultant anaesthetist Dr Rob Storer.

“ADFA has proved to be a very good vehicle.

It appeals to a lot of Australian surgeons, nurses and doctors as an organisation with which to volunteer their time to Africa,” he said.

Over the intervening 12 years, ADFA has become professional and practical in its approach to providing medical and surgical services to four Indian Ocean countries – Ethiopia, Somaliland, Madagascar and Comoros Islands – all of which struggle with political dysfunction to lesser or greater degrees.

Planning reduces security risks for ADFA volunteers and Graham states simply: “We would not go into a risky environment.”

Help from the ground, up “We have good relationships with various government departments and foreign ministries in these countries mostly by doing a good job in a measured way. People are able to meet us and see what we’re doing.

We are a bottom-up organisation, which is why it is sustainable,” Graham said.

“We start off by just going and operating and pretty soon that morphs into a relationship with the local doctors and then it develops into a training relationship. Once you have a trained surgeon, they need a good facility to operate in so we help develop the

22 | APRIL 2017

Dr Graham Forward teaching students in Ethiopia and Somaliland.

infrastructure – build or renovate operating theatres, fix sewerage and water supply. We provide nursing staff to teach the nurses so that patients can recover and rehabilitate.”

“We try to take a holistic approach to take situations from dysfunctional to independently functioning. Some good work gets done.

The people are resilient and appreciate the contribution we’re making and are keen to help themselves.”

“We only go by invitation and we go to give a hand, not to take over. We have a charter and those are the first two items. It’s a mantra that has stood us in very good stead.”

Seeds bearing fruit In 2015/16, ADFA sent 13 teams of doctors, nurses, technicians in its core specialties (a list which has grown from the early days of just orthopaedics to include gastroenterology, urology, paediatrics and anaesthetics, to hospitals in the four nations within its scope.

Dr Digby Cullen and Prof Barry Marshall are among the major gastroenterology contributors. They have recently been awarded the Chevalier of Madagascar from the President of Madagascar in October 2016. Most volunteers come from WA but there are also doctors and nurses from the eastern states and ADFA collaborates with the international orthopaedic charity AO Alliance on some projects.

Among the WA doctor participants over this reporting period were Dr Tony Jeffries, Dr Sarah Kurian, Dr Zoe Wake, Dr Digby Cullen, Dr Kate Stannage, Dr Mike Wren, Dr Sue Chapman, Dr Colin Whitewood, Dr Li-On Lam, Dr Rob Genat, Dr Anna Negus, Dr Doug Kingwell, Prof David Wood, Dr Emily Forward, Dr Nick Kontorinis, Dr Rashmi Patel, Dr Samuel Duff and Dr Donald Horwath.

Nurse teams included Ms Ann Mitchell, Ms Anne Coyne, Ms Josiane Sabouriaut, Ms Beth McGrechen, Ms Judy Thompson, Ms

Stephanie McDonald, Ms Cheryl Genat, Ms Catherine Poole, Ms Kim Mackley and Ms Lucy Harris. Graham said he usually undertook two clinical trips a year but in the last financial year he made three with a fourth to a GI conference ADFA organised in Madagascar last June for local doctors to extend their knowledge and networks.

According to ADFA’s 2015/16 annual report, donated time and medical equipment amounted to $918,600 or over half of both its ‘expenditure’ and income.

Graham said ADFA doesn’t actively recruit volunteers. Teams are filled by word of mouth and a lot of hard work by a phalanx of behindthe-scenes volunteers such as board member and operational manager Christine Tasker.

An administration officer was appointed in 2014 – ADFA’s first employee – when the organisation grew beyond the capacity of part-time volunteers.

Adjusting to culture shock “These trips are not for everybody. On the first trip, you are bewildered; on the second trip, you’re building trust; by the third trip you are getting somewhere. We want volunteers to return because that’s where you get the best benefit for everyone.”

Graham says ADFA is clear on its strategic priorities, what he describes as a Development Staircase: Service Provision, Infrastructure Development, Training and Teaching and Advanced Development.

It wants its limited resources to have the greatest impact.

In several hospitals in Somaliland and Ethiopia, the staircase has progressed to the training level and ADFA, in the shape of Graham and WA colleagues, is putting some serious muscle to the task alongside doctors from the Swiss-based AO Alliance. Taking on a course for first year orthopaedic trainees at MEDICAL FORUM

FEATURE

Clockwise from top left: Nurse Judy Thompson at the Edna Aden Maternity Hospital; a baby with talipes in recovery and in the theatre.

the Black Lion Hospital in Addis Ababa has had a spin-off training course for orthopaedic nurses (run by Ann Mitchell). And ADFA offers scholarships for promising young doctors.

Surgical teams in these developing sites are invariably a mixture of local and ADFA doctors.

There is always room on board for more volunteer trainers and teachers.

Skills training needed “Academic teaching is very strong in all these countries but the practical training and post-graduate training is not. In Ethiopia they graduate really smart doctors but they don’t have stethoscopes.”

Graham was to head off with colleagues Michael Wren and Hari Goonatillake shortly after this interview to teach first-year

orthopaedic trainees a skills laboratory.

donated and shipped,” Graham said.

“This is such a powerful thing. If these 48 first year trainees are taught good habits and techniques from the start, it will serve their community for a lifetime,” he said.

“We are grateful to the medical fraternity for generously donating quality equipment and contributing their services. But when it comes to funds, the way we have always worked is to take on a project that fits our strategic plan and then worry about where the money comes from!”

The final step on the ADFA staircase is advanced development, which is in its infancy, but the organisation has begun a screening program for talipes in babies and young children; the international GI conference brought new evidence-based research to these shores; and container loads of medical equipment continue to arrive with the help of ADFA board member and shipping expert Graeme Wilson.

Equipment keeps rolling

“We have a ‘13 hospitals project’ – we’ve done four so far. They are now running autonomously with mentorship and leadership and we’re about to move onto our fifth. When we’ve gone through those 13 hospitals, we will find another 13. There’s no shortage of need.”

By Jan Hallam

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MEDICAL FORUM

Guest Column

Appropriateness of medical care SCGH Intensivist Dr Matthew Anstey, says scientific principles underscore the performance of health professionals but patient preference is equally important.

Many decisions can be solved using the “Goldilocks and Three Bears” method.

Whether choosing which bowl of porridge, or which treatment, there is one that is “just right”. Too much (blood pressure, oxygen, blood) is likely to be harmful. Not enough is likely to be ineffective. Finding the treatment and intensity that is “just right” will lead to the best outcome for the patient. This analogy about appropriate treatment, can be extended throughout medicine [Fig 1].

A patient receiving appropriate care is treated based on the best current evidence, and according to their needs and preferences. If you focus on just treating according to the current evidence (and not patient preferences), work from the United States suggests patients receive recommended care 55% of the time. A study in Australia showed that 57% of patients received guideline concordant care for 22 common conditions – those inappropriately treated could be getting nothing, too much (unnecessary), harmful, incorrect or outdated treatments.

When you add in patient preferences it becomes even more complicated. Shared decision making involves taking the time to elicit patient wishes and values and combining these with treatment options.

should be affected by where you live and the doctor you see.

Science is advancing and we are about to enter the era of personalised medicine where treatments will be tailored to the genetic

profile of the patient. An advance that could have even greater impact would be to ensure that all patients receive guideline-concordant and preference-appropriate treatments.

References available on request

Appropriate treatments are important.

Unnecessary treatments place patients at undue risk (no healthcare intervention is riskfree) and waste limited healthcare resources.

Value in healthcare is the balance between the outcomes (benefit) and the costs. To improve value, we start by examining the appropriateness of the treatments provided.

[Porter ME. What is value in Health Care?

NEJM 2010;363:2477-2481] The Choosing Wisely Australia initiative through the specialty colleges that have signed on has started identifying treatments and investigations of low value to patients. Low value treatments can cause harm, are unlikely to benefit the patient, and incur a financial cost [www.choosingwisely.org.au] One example is the many “routine” or “repeat” tests now common in medical practice, ordered for convenience or “just in case”. By re-designing work practices and expectations, it is possible to reduce these unnecessary tests.

Patients who do not receive appropriate care can also block equitable access to health care for others. The Australian Commission on Safety and Quality in Health Care has created an interactive atlas identifying areas of variation in healthcare use. [www.safetyandquality.gov. au/atlas] Obviously, variation may be due to factors out of control of the doctor, such as disease burden or patient preferences but there are many examples of large differences in the treatments offered to patients with the same condition. It does not seem fair that treatments MEDICAL FORUM

APRIL 2017 | 25

GUEST COLUMN

Social Media Myths Doctors need to embrace the possibilities of an online presence, says business coach and social media strategist Jeanine Halley.

Social Media (SM) and its relevance to health information and education is booming. Australians are using it in increasing numbers but the silence from the WA medical profession is deafening!

I recently ran a series of SM strategy workshops for Families for Families WA, an education/support group in the mental health/drug and alcohol area. When I was doing some research I found the lack of SM presence by local doctors perplexing.

SM as a tool for professional development, networking and support is highly useful and it seems that many doctors are unaware of the opportunities it presents.

About 87% of Australians access the internet every day (2016 Sensis social media report) and 72% of internet users look online for health information. More specifically, one in five of the largest health consumer group – the 65-74 age group – use various forms of SM to access information.

We’re all aware that there’s plenty of unreliable and inaccurate health information floating around the internet. So it’s high time that doctors became more adept at using SM

of privacy settings on your preferred SM platform ensures privacy is maintained.

…it’s high time that doctors became more adept at using SM because strong, vocal lobby groups are driving the conversation.

• Social media is time consuming and, anyway, that’s not my role. To ‘hear’ a doctor’s voice is important. SM is here to stay and doctors need to join the conversation. It’s easy enough for a practice to ‘pool’ resources to develop an inclusive strategy using a minimum of resources.

because strong, vocal lobby groups are driving the conversation. And they’re rarely using wellfounded and evidence-based information to support their arguments.

• Social media creates a space to spread negativity and complaints. When a patient feels healthcare delivery has failed them they will often turn to social media. This can develop traction and proliferate on pages you have no control over. It’s much better to be part of the conversation!

As patients, we crave to see the human side of our physicians; it helps to build a relationship.

And in this technological age that means, at the very least, a partial engagement with SM. Educational online resources can be a wonderful way to engage with patients.

• I’m frightened of crossing legal boundaries.

AHPRA guidelines and AMA policies relating to SM are pretty easy to navigate.

Issues such as privacy, confidentiality and testimonials aren’t difficult to deal with.

It seems that doctors’ aversion to using SM is underpinned by four prevailing ‘myths’: • I won’t be able to safeguard my personal privacy. Operating a public profile is standard business practice and quite similar to having a separate phone-number/ email for work and home. A quick review

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MEDICAL FORUM

Guest Column

Doctors for Doctors

ORT HO C O M P WA

It’s time for doctors to walk the walk when it comes to heeding good health advice and there’s a doctor to give a helping hand, writes Dr David Oldham.

Doctors are very good at talking the talk but not so good at walking the walk, particularly when it comes to their own health. I recall as a medical student in the 1970s many a consultant berating their patients about the hazards of smoking, then disappearing at tea time for a quiet smoke, themselves.

While smoking has improved since then, our behaviour in other areas has not – diet and exercise for instance. That is not to say we shouldn’t be enjoying life and seeking a balance between ‘what we should do’ and ‘what we like to do’. The problem is that often the unhealthy behaviour predominates and we never seem to have the time to pause, reflect and take action for our own health.

We know that doctors who treat themselves, generally, have a worse health status than doctors who don’t. The literature is full of tales of doctors who treated themselves or relied on ‘corridor’ consultations or informal ‘chats’ with their colleagues often resulting in disaster. Only about a third of doctors have a regular GP, compared with 90% of the general population.

Given that doctors are, by definition, experts in health, we could expect our health status to be better than the general population. Sadly, this is not the case. Our physical health has similar morbidity to the general population.

Although better with smoking-related illness, we don’t fare so well with obesity, alcohol use and hypertension. In the area of mental health, the numbers are even worse.

We know that doctors who treat themselves, generally, have a worse health status than doctors who don’t…Only about a third of doctors have a regular GP, compared with 90% of the general population.

In a 2013 study by Beyond Blue, about a third of Australian doctors reported being psychologically distressed, 10% had suicidal thoughts in the 12 months prior to the survey and 25% had had previous suicidal thoughts. These rates are twice that of the general population and in many instances doctors are treating themselves for these conditions.

So why do doctors, self-treat? The literature describes many reasons such as doctors thinking “It’s more convenient to treat myself”, “I am the best doctor I know”, “I don’t want anyone else to know about my problem”, “I don’t want to bother anyone”, and “I saw a doctor once (as a patient) and it was an unpleasant experience”.

The Doctor-Doctor Patient relationship can also be difficult for the treating doctor. Common concerns include “Should I prioritise doctors with my bookings?”, “What should I charge doctors (and their families)?”, “Should I change my consultation style for doctors?” and “Can the Doctor Patient help manage their own care?”. Often there is no right or wrong answer to these questions.

If you want to learn more about these issues, then I encourage you to attend one of the Doctors for Doctors workshops being run by the Doctors Health Advisory Service of WA (DHAS WA). The first workshop is on Saturday, May 6 at the Wollaston Conference Centre, 5 Wollaston Rd, Mt Claremont. All doctors who treat doctors and/or medical students are welcome to attend. Call Liz Connor on 9273 3097 for details.

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MEDICAL FORUM

APRIL 2017 | 27

News & Views

WA Takes Swift Action on MenW WA Health is taking no risks with the apparent growing risk of Meningococcal W taking hold in the community.

An outbreak of meningococcal disease is potentially extremely serious, and the W strain (MenW) most of all. In early December 2016 there was an outbreak of MenW in Kalgoorlie and its satellite towns, resulting in a one-off vaccination program.

Targeting young people

“It was concerning but we have tried and trusted guidelines that determine if an intervention is required,” said the Director of Communicable Disease Control, Dr Paul Armstrong.

“We also know that, despite the fact that about 10% of a people carry the meningococcal virus in their throat, the vast majority don’t get sick. But in some cases it does invade the body and MenW is a particularly nasty strain. It has a 10-15% mortality rate, which is double compared with the other forms of the disease.”

“When you get a rate of infection in a specific community that’s above a certain baseline then a program of mass vaccination needs to be considered.”

Such a program was implemented on December 12, 2016, incorporating Kalgoorlie and its satellite towns of Boulder, Coolgardie and Kambalda to deal Dr Paul Armstrong with an outbreak of the MenW strain. There was an increase from four cases in 2015 to 14 last year and anecdotal evidence from overseas suggests that, without effective intervention, MenW infection rates will escalate.

Growing numbers a concern “We’ve had a year-on-year doubling of cases for the past three years and that’s a pretty rapid upswing. And it’s worth noting that other countries have experienced this, too.

We’re not sure where this one is heading, it may level off but if you look at the trajectory of the graph it seems that it may have a bit of a way to go.”

“The main reason we put a vaccination program in place was to counter the possibility of an epidemic developing.”

“It’s not always straightforward, either. Each case is different, this occurred in a remote area with Kalgoorlie as a central hub and affecting its satellite communities. In a situation like that you’re never going to be able to draw a geographical ring around every person at risk.”

The WA Health Department is pushing the boundaries of its protective umbrella with a free meningococcal vaccination program across WA for teenagers between the ages of 15 to 19. Three West Australians died from the disease last year, two from the MenW strain and one from the Y strain.

The three-year program will cost the State Government $6m in its first year. Year 10, 11 and 12 students will receive the single-dose vaccine at school, and 18 and 19-year-olds can be vaccinated at community health clinics.

28 | APRIL 2017

“We know that MenW has a predilection for young people and that the carriage rate is particularly high in adolescents. The virus is carried in the back of the throat and, within this demographic group, there’s a lot of social mixing.”

“And the long-term consequences for those who survive the disease can be horrendous.

Multiple loss of limb and brain damage results in a high degree of pain and suffering for those individuals, not to mention the ongoing costs to the wider community.”

“Thankfully, the number of MenW cases isn’t particularly large. It’s low risk, albeit with decidedly serious consequences.”

“We’re hoping to eradicate the disease within this age demographic, which will then initiate a ‘trickle-down’ effect to the rest of the community.”

Indigenous kids at risk There was a genetic connection in the Kalgoorlie outbreak resulting in a local transmission of a particular type of MenW and Aboriginal children were particularly susceptible.

“Indigenous people were involved in some of these cases and they tend to have a higher mortality rate, so we were particularly concerned about that.”

“This is a disease that doesn’t pay any heed to geographical borders and many of the Aboriginal communities are very remote. But once you get there you also have something of a captive audience, although there is a high degree of mobility so you can’t always predict who’s going to be there.”

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“The cost of getting to some of these places is a factor, too. You certainly can’t be doing that every day of the week.”

Election sparks vax issues Recent comments by Senator Pauline Hanson added some heat to the immunisation debate.

And, somewhat ironically, much needed light, suggests Paul.

“I wasn’t overly impressed by those comments but I was pleased by the informed chorus of voices countering Senator Hanson’s views. It was a boon to vaccinators and people such as me. It certainly got the issue out there and a lot of people were banging the pro-vaccination drum.”

“One of the problems we have is a lack of wider coordination. At the moment it’s a rather piecemeal approach that mitigates achieving immunity on a national scale in the shortest possible time period.”

“NSW, Queensland and Victoria have decided, as we have, that they’re going to have school-based vaccination programs.

The other States and Territories are still thinking about it.”

“There needs to be an ongoing national conversation around this entire subject.”

By Peter McClelland MEDICAL FORUM

Practice Management

Backups Cursed if You...?

By Mr Jerome Chiew, www.critical-it.com.au Backup configuration is about how much business data you can risk losing before restarting in the event of a failure. Your assessment of what things could go wrong becomes important – hardware failures, ransomware encryption, file corruption, accidental deletions, etc. A multi-layered backup strategy minimises downtime.

A well designed and implemented combination of onsite and offsite backups builds resilience and ensures that you’re not left high and dry.

This is IT insurance and does not have to be expensive!

Here are some tips to enhance your backup plan.

1.

Use robust backup software capable of scheduling daily, weekly, monthly, yearly backups and offers encryption. Schedule regular tests to restore data and check to ensure you can actually access the restored data. There’s nothing worse than restoring data only to find that part of it is corrupt and unusable.

2.

‘Three generations’ is a simple backup strategy https:// en.wikipedia.org/wiki/Backup_rotation_scheme#Grandfatherfather-son The files are on daily, weekly and monthly backups varied according to how much resiliency to disasters you want.

You can vary this, for example, have a fortnight’s worth of daily backups, a year’s worth of monthly backups and the annual backup. Keeping incremental backups allows you to go back to find when a file became corrupted.

3.

Keep backups offline and offsite i.e. not plugged in and at a different location to the live data.

4.

Encrypt your backups for privacy and security. Password protecting is not considered secure enough. Encrypting your data will scramble it by passing it through an algorithm using a specific key; without the key, the data is meaningless.

5.

If you use cloud storage services like Dropbox or OneDrive, be aware that most providers charge an additional fee to provide backup. Check to ensure that you have backup enabled, otherwise if a file is accidentally deleted or corrupted, all copies of it will be automatically removed (or corrupted) in all locations.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

by Medical Director Prof John Yovich

Dr Sun Yat-sen … an amazing Chinese physician and revolutionary I was recently invited to present the latest data from the PIVETCurtin Adjuvant study at a conference in Guangzhou. The meeting, Reproductive Medicine Frontier: hot topics & challenges in ART, was chaired by Professor Dongzi Yang, head of Obstetrics & Gynaecology at the Sun Yat-sen Memorial Hospital.

Their busy IVF unit at this hospital is an amazing facility that handles ~5000 ART procedures per annum. I had visited a unit in Beijing last year handling 15,000 cases and I have now been invited to Xian where they perform 30,000 OPU’s (oocyte pick-ups). Compare that to PIVET’s 1000 total OPU and ET procedures per annum?!

At the Memorial Hospital Museum: Prof Yovich leaning on a bust of Dr Sun Yat-sen father of post-dynastic China, accompanied by Gynaecologist Dr Xiaomiao Zhao (left) and the museum curator.

I also took time out to see the Hospital museum devoted to its Doctor Sun Yat-sen (1866-1925) who left his medical practice to spend more time in politics, actually transforming into a revolutionary. Along with his mate Chiang Kai-shek, Dr Sun was instrumental in the overthrow of the Qing dynasty in 1911 on double ten day (October 10) – Xinhai Chinese Revolution. He helped establish the Kuomintang (KMT) nationalist party that ruled in mainland China until 1949 when it was defeated during the Chinese Civil War by the Communist Party of China (led by Mao Zedong a former member of KMT), subsequently retreating to Taiwan.

Dr Sun is revered as “father of the (post-dynastic) nation” and projected his Three Principles of the People – nationalism (nonethnic and non-imperialistic), democracy and people’s livelihood (free trade and non-oppressive taxation).

Dr Sun was the nation’s first provisional president and established the Whampoa Military Academy, which generated the future secretary of the Communist Party, Chou En-lai, instrumental in the 1926 split from KMT and the end of the Soviet-Nationalist alliance in 1927. This historical story resonates to this day.

Additionally, consider building some redundancy into your systems to mitigate against hardware failure. Install a second hard drive in your server that “mirrors” the existing hard drive; the entire system is duplicated in real time, in case of a hard drive failure. Replicating your system to a second server is also a good way of building redundancy against server failure. Scheduling the replication at regular and frequent intervals means you can failover to the second server if the primary server goes down and lose only a set interval’s worth of data.

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APRIL 2017 | 29

get your patient’s spine working Workspine’s team of hand picked specialists provide comprehensive occupational spine injury management under one roof.

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CLINICAL UPDATE

Stepwise approach to managing atrial fibrillation

By Dr Tim Gattorna Cardiologist + Electrophysiologist Western Cardiology

Dr David Holthouse Neurosurgeon/Pain Specialist FRACS FRACGP FPMFANZCA

Atrial fibrillation ED is a common problem with serious complications that can usually be managed in general practice.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with increased morbidity and mortality. There are a high number of undetected cases in the community and therefore an index of suspicion and consideration of the diagnosis with manual palpation of the radial pulse at the time of a consultation should be performed. Confirmation with a twelve lead ECG is required.

Once AF is established the risk of stroke needs to be assessed. This risk is the same regardless of whether the patient has paroxysmal, persistent or permanent AF. The use of validated assessment tools such as the CHA 2DS2-VASc: Congestive cardiac failure, Hypertension, Age over 75, Diabetes, Stroke/TIA/thromboembolism, prior Vascular disease, Age 6574, Sex (female) and HAS-BLED (1) is recommended.

Determine symptoms, clinical history, and AF pattern A detailed history, including previous therapies, the frequency, duration, severity and precipitants of symptoms, co-morbidities and examination are crucial. Patients with haemodynamic instability, evidence of preexcitation (Wolff-Parkinson-White syndrome), evidence of myocardial ischemia/infarction or heart failure require urgent transfer to an emergency department.

Some patients’ clinical condition may improve quickly with prompt rate control while others need to have sinus rhythm restored immediately.

Initial diagnostics should include a pathology screen (FBC, EUC, TFT), echocardiography and a twelve lead ECG. Further tests can be guided by the clinical findings.

Rate control Ventricular rate control can generally be achieved with atrioventricular nodal blocking agents such as B-blockers, calcium antagonists or digoxin (alone or in combination). In patients with mild to moderate symptoms, slowing the rate often results in significant improvement or even resolution of symptoms.

The target ventricular rate depends on the presence or absence of symptoms and underlying cardiac disease. A rate below 85 beats per minute at rest is reasonable in symptomatic patients, which can be titrated dependent on the response. For asymptomatic patients with permanent AF, and no known cardiomyopathy, an initial more lenient rate control goal of <110 beats/min may be reasonable. The best method of assessment of rate control is a 24-hour Holter monitor.

Patient referral is recommended when the treating doctor is no longer comfortable with decision-making, when a rhythm control strategy (anti-arrhythmic medications or catheter ablation) is being considered, for patients with coexistent cardiac disease, difficult to control ventricular rates or ongoing symptoms.

Reference: 1. D. Lane, G. Lip. Circulation, Aug14, 2012, Volume 126, Issue 7.

Use of the CHA2DS2-VASc and HAS-BLED Scores to Aid Decision Making for Thromboprophylaxis in Nonvalvular Atrial Fibrillation

Author competing interests: nil relevant disclosures. Questions? Contact the author on 9346 9300

MEDICAL FORUM

Claremont Pain Clinic

Dr Pat Coleman Anaesthetist/Pain Specialist

FANZCA FPMFANZCA FRACGP DRCOG

We have formed a pain unit and are now ‘Claremont Pain Clinic’.

David has a neurosurgical background and Pat an anaesthetic background, and both are qualified GP’s (FRACGP), and as such provide a broad range of experience with regards to all pain issues.

David remains open to seeing neurosurgical cases but the major focus of the clinic is procedural pain management.

Pat is an anaesthetist who has a FPMANZCA and is experienced in pain interventions such as spinal injections and rhizotomies. He is also able to see cases with pain issues such as CRPS and post-surgical pain in any region of the body or other pain states.

The practice has a clinical educator and a registered nurse experienced in pain. We also have a focus on neurostimulation as a potential treatment.

We are able to see insured patients (privately insured and workers compensation). We have a keen interest in the rehabilitation of workers compensation patients and aim to expedite appointments. We do not see patients with active MVIT claims, public liability cases or non-insured patients. We are unable to cater for drug addicted patients who should be referred to a public pain clinic.

We have a close working relationship with a number of other spinal surgeons who are sub specialists in fusion surgery and often assist in the workup and selection of patients for this surgery. We also work closely with a clinical psychologist and psychiatrists with experience in pain management and pain conditions.

We work in collaboration with Pain Options, a specialist physiotherapy practice which assists in the rehabilitation of pain patients and workers compensation patients.

Claremont Pain Clinic Phone: 9385 1323 Fax: 9463 6333 Address: 12/237 Stirling Highway, Claremont WA 6010 PO Box (please send all mail here): PO Box 563, Claremont WA 6910

APRIL 2017 | 31

Children are our greatest asset and our most precious treasure Perth Radiological Clinic agrees and that’s why we: • have specialist paediatric radiologists to manage children’s imaging • always consider MRI or ultrasound first in children • use new generation LOW-DOSE CT • tailor our X-ray and CT protocols to achieve even further dose reductions • undertake rigorous Q&A programmes to ensure class leading results

Rest assured your young patients are in safe hands. www.perthradclinic.com.au 32 | APRIL 2017

Leaders in Medical Imaging MEDICAL FORUM

CLINICAL UPDATE

Which test to assess coronary arteries in over 40s

By Prof David Playford Cardiologist, Perth

Approximately 50% of first heart attacks are fatal. Waiting for the first event to decide on treatment strategies is not recommended! Diet and lifestyle are central recommendations, and cholesterol lowering medications are common (centred around statins).

Risk prediction models (e.g. Australian Cardiovascular Risk Calculator www. cvdcheck.org.au) should be used in every patient. These probability and population-based tools may not reflect an individual’s actual disease burden so further testing can help guide management.

Coronary Artery Calcium Score (CACS) is inexpensive, fast, low radiation, providing an absolute score (approximately $150, no

Medicare rebate). A CACS score of zero is normal. Any non-zero score (1- 10 minimal, 10 -100 mild 101-400 moderate and over 401 large plaque burden) is abnormal indicating the presence of atherosclerosis. Decisions to treat are often made based on CACS, which makes intuitive sense but is not strictly evidence based. A large randomised trial (the CAUGHT-CAD study) testing this approach is currently underway in Australia.

CT coronary angiography (CTCA) involves a contrast injection during coronary CT. The coronary arteries are reconstructed using 3D imaging, and an accurate assessment of plaque burden is reported along with CACS. CTCA is about $500, but provides more information than CACS alone. It is best suited to asymptomatic moderate risk individuals, to evaluate atypical chest pain, or for assessment of prior coronary bypass grafts.

Conventional coronary angiography, Performed in hospital so any out-of-pocket expense depends on which hospital and perhaps insurance.

Invasive, requiring arterial puncture and catheters inserted into the coronary arteries, is well suited for acute coronary syndromes or evaluation of a haemodynamically significant stenosis. It should not be performed in asymptomatic individuals at low to moderate risk. Mild coronary disease (without stenosis) may be completely missed.

From our ageing population there will be more questions on cardiovascular risk prediction.

Where do coronary artery tests fit in?

ED

Stress ECG (continuous 12 lead ECG monitoring during exercise) is well suited for patients with angina symptoms, and to assess exercise tolerance. It is not recommended for asymptomatic moderate to low risk individuals, being neither sensitive nor specific. The most likely abnormal result in this group is a false positive test, which inevitably leads to further testing, expense and un-necessary concern.

Stress Echo or Stress Nuclear Imaging have superior sensitivity and specificity compared with stress ECG, but are most suited to patients with classic symptoms.

Stress echo has some advantages over stress nuclear in that it is free of radiation, cheaper, and can assess functional changes (e.g. valve gradients and diastolic filling) with exercise. Stress imaging does not exclude subclinical coronary disease so is not recommended in asymptomatic low to moderate risk individuals.

Resting Echo assesses structure and function of the heart, including systolic and diastolic function, pulmonary pressures and valve disease but not coronary disease unless there is severe disease or prior infarction, resulting in abnormal left ventricular function at rest.

CTCA in two different patients

CASE STUDY Asymptomatic 60-year-old male: Risk factors: LDL 3.6. BP 140/80. Fasting BSL 5.5, Mild visceral obesity, BMI 30, non-smoker, no family history of premature CVD. A prior exercise stress echo, requested by another General Practitioner for cardiovascular risk prediction, showed good exercise tolerance (8 min, 30 sec), normal LV augmentation, and no ECG abnormalities at rest or with exercise. The patient asked you whether he should take cholesterol medication.

Which test best decides whether atherosclerosis is present? In this case, a CT coronary angiogram.

In the absence of symptoms or impaired exercise tolerance, there is no reason to expect the stress echo to be abnormal, even if atherosclerosis is present. The CT coronary angiogram showed a calcium score of 837, with multiple areas of calcified and noncalcified plaque throughout his coronary tree. This is an important result, suggesting a significantly increased long-term cardiovascular risk.

Which treatment? There is no absolute answer. Diet and lifestyle advice should be given and followed closely. It is common to treat with aspirin and statin, plus or minus blood pressure treatment. Whilst a CT-based management approach makes sense and appears the clearest “individualised” treatment approach available, it has not been fully validated by clinical trials, the results of which are eagerly awaited.

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APRIL 2017 | 33

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CLINICAL UPDATE

Jury’s still out on renal denervation Hypertension remains the number one attributable risk factor for mortality worldwide. Less than 50% of treated patients achieve blood-pressure (BP) control goals with treatment-resistant hypertension (7.6-18%) being a major problem.

Renal denervation (RDN) is a procedure (under local anaesthesia with substantial intravenous analgesia and sedation) whereby the renal nerves are ablated using a form of radio-frequency energy. These nerves travel along the renal arteries in the peri-adventitial space. Using femoral arterial access, a catheter is appropriately positioned in the renal artery, and energy delivered through the renal arteries (sequentially) to target the renal nerves.

The single arm Symplicity-1 study of RDN, demonstrated a significant and sustained reduction in systolic BP in patients with drug-resistant hypertension. The Symplicity-2 study, a randomised controlled trial of renal denervation and drug therapy versus drug therapy alone, also demonstrated a significant BP drop in the RDN arm with no change in the control arm.

The device was approved for use in Australia and Europe; in WA it was used strictly for patients with resistant hypertension at significantly elevated cardiovascular, cerebrovascular and renal risk and without other options.

By Dr Sharad Shetty Interventional Cardiologist Perth Cardiovascular Institute Nedlands

patients. The future direction for RDN is largely dependent on the outcome of these two studies. Many physicians experienced in RDN believe it does work well in many but not all patients, providing a useful option in patients who often have no alternative solution. Until the results of the two current studies are available, this remains to be proven.

Critical evaluation of new ED procedures is what accurate clinical practice is all about but operator performance remains important.

Author competing interests: The author has been a clinical proctor for Medtronic and St Jude for training physicians in the procedure. Questions?

Contact the author on sshetty@perthcardio.com.au

New Osteoporosis Guidelines The RACGP has just released its new osteoporosis guidelines. It makes 42 recommendations, the majority of which are based on the analysis of published, peerreviewed evidence that has accumulated between September 2006 and February 2016.

The summary to the guidelines said there had been certain areas of osteoporosis management that had developed significantly since the publication of the first guideline in 2010, which supported changes to clinical practice.

Recommendations on the use of denosumab, the only new medication approved since the publication of the 2010 guideline, have

been added. Comprehensive information on the evaluation of absolute fracture risk and guidance on the use of fracture risk calculators is included, and new recommendations on exercise and the appropriate use of calcium and vitamin D supplements have been developed.

A ‘special issues’ section makes several recommendations in the areas of osteoporosis management in the elderly, including minimising falls risk, as well as fracture risk reduction in patients undergoing androgen deprivation therapy for prostate cancer or aromatase inhibitor therapy for breast cancer.

In the Symplicity-3 study, patients were randomised to either undergo Renal Denervation or a ‘Sham’ procedure and were blinded to which they received. The RDN procedure met the safety but not its efficacy end-point. Both the RDN and Sham procedure caused similar BP drops.

This called into question the efficacy of the RDN procedure. WA Health stopped funding for this procedure in the public system unless as part of a research study. It has never been funded in the private system.

Despite good design, there were criticisms about how the Symplicity-3 study was conducted. Inexperienced operators performed a majority of the procedures (some for the very first time). When the ablation points were analysed, it seemed that less than 10% were optimally ablated. One obviously cannot expect a procedure to work well unless it is performed correctly. Another confounding factor was that 40% of patients had medication changes despite the protocol mandating that drug therapy shouldn’t be altered during the study. Critics of the study are of the opinion that these are the reasons the procedure didn’t demonstrate efficacy in this study.

Two studies with a somewhat different design were initiated and are currently recruiting

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Fertility, Gynaecology and Endometriosis Treatment Clinic 36 | APRIL 2017

MEDICAL FORUM

CLINICAL UPDATE

Deep Vein Thrombosis Deep vein thrombosis, also called ‘travellers thrombosis’, is associated in the public mind with long distance air travel. However, symptomatic DVT post flight occurs relatively infrequently (0 -0.28%). In contrast, the DVT risk in hospitalised medical patients who do not receive prophylactic medication approaches 25% (with 70 -79 year olds 7 to 10 times more likely to develop a DVT than those aged 30 – 49. DVT is actually the third commonest cardiovascular pathology after coronary heart disease and stroke.

A deep vein thrombosis occurs when a clot (or thrombus) forms in one of the deep veins, usually in the leg. This must be distinguished from superficial thrombophlebitis (e.g. affecting long/short saphenous systems or unnamed superficial veins), which carries less risk of progression to DVT (e.g. by extension into the common femoral vein), and therefore by default, much less risk of pulmonary embolism. In the upper limb intravenous cannulation predisposes. It can be treated symptomatically with anti-inflammatory medication and support hosiery.

By Sharon Boxall MN Vascular Nurse & Dr Shirley Jansen, Vascular Surgeon

majority of patients then continue with oral anticoagulant medication for a period of months. Oral medications may consist of a vitamin K agonist (e.g. Warfarin) or a factor Xa inhibitor (e.g. rivaroxaban).

Anti-embolic stockings and physiotherapy aim to maximise the patient’s calf muscle function to increase venous return and reducing the risk of recurrent DVT. Post thrombotic syndrome (PTS) affects 50% of people two years after a lower limb DVT, with leg ulceration developing in 10%.

It results from chronic venous hypertension secondary to venous reflux, venous obstruction and valvular dysfunction that manifests as a painful, swollen, heavy leg with venous claudication. The disability and quality

ED. Suspecting DVT and early ED intervention is key in some patients.

With rising health costs and an ageing population, managing DVT correctly has assumed new importance.

4. Recommended percutaneous techniques are pharmacologic (lysis) or pharmacomechanical (rotational, rheolytic or ultrasound enhanced), or a combination of both.

5. Self-expanding venous stenting for chronic iliocaval compressive or obstructive lesions that are uncovered, but not in femoral or popliteal veins.

Who is at Risk Different circumstances increase the risk of DVT. The most common is immobility, often associated with hospitalisation or bed rest from illness.

Other risk factors include obesity, pregnancy, previous DVT, inflammatory bowel disease and heart disease, malignancy, the oral contraceptive pill, and genetic disorders associated with an increased risk of thrombosis.

DVT diagnosis can be complex The classic signs and symptoms are warmth, pain or tenderness and swelling of the affected limb, accompanied by redness or discoloration but only 25% of patients with this clinical picture have a thrombus.

Screening using the Two-level DVT Well’s score which is a 9 point questionnaire of risk factors, can assess the likelihood of DVT Initial investigation, includes a D-dimer blood test for fibrin degradation fragments – a negative test rules out DVT but results can be positive in other conditions such as infection, pregnancy, trauma and malignancy.

Diagnosis can be confirmed by ultrasound.

Differential diagnoses include cellulitis, ruptured Baker’s cyst, venous insufficiency and post thrombotic syndrome.

The aims of treatment These aim to avoid thrombus propagation and pulmonary embolism. Patients require anticoagulants. Low molecular weight heparin by injection is frequently chosen initially, until an INR of 2.5 has been achieved for 24 hours. This commonly takes 5-7 days. The MEDICAL FORUM

of life impairment is significant – for example the management of venous leg ulcers costs Australia $500 million a year.

More recently, percutaneous catheter based techniques (CBT) have been trialled for major iliofemoral DVT, and although results seem to reduce the clot burden and symptoms, larger long-term studies are required to ascertain whether this also reduces PTS and its associated morbidity. Methods include lytic therapy and pharmacomechanical methods.

Current Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum are: 1. Early thrombus removal in patients who meet these criteria: (i) first episode of acute iliofemoral DVT (ii) symptoms <14 days (iii) low risk of bleeding (iv) ambulatory with good functional capacity and an acceptable life expectancy.

2. Early thrombus removal with limb threatening venous ischaemia due to iliofemoral DVT with or without associated femoropopliteal venous thrombosis (phlegmasia cerulae dolens).

6. Standard anticoagulation post procedure.

NICE recommendations are similar . Ongoing research is needed to clarify who, if any require prophylactic IVC filter insertion before CBT. ED. The authors and a team at the Heart Research Institute, QE II campus, are currently recruiting patients to a randomised control trial involving negative pressure therapy in the treatment of venous leg ulcers. All patients receive compression bandaging and half also receive simultaneous negative pressure therapy. Patients with a venous leg ulcer can be referred by their GP or self-refer (contact Sharon Boxall on 0478 624 556 or Sharon.

Boxall@health.wa.gov.au).

References available on request. Suggested further reading: Thompson AE. Deep Vein Thrombosis. JAMA. 2015;313(20):2090-.

National Institute for Health and Clinical Excellence.

Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. 2012; 144.

Kyrle PA, Eichinger S. Deep vein thrombosis.

The Lancet. 2005;365(9465):1163-74.

3. Isolated femoropopliteal DVT treated with anticoagulation alone as evidence is lacking for CBT in this group.

APRIL 2017 | 37

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We use evidence based procedures to treat varicose veins Complimentary Complementary venous services Single owner operated with all varicose vein services performed under one roof in our purpose-built Claremont premises. Free parking onsite is available for patients.

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MEDICAL FORUM

Clinical Opinion

From Rehab to Prehab?

Earlier discharge puts pressure on some elective surgical patients to recover faster.

Pre-conditioning exercises may help, says exercise physiotherapist Adam Spiroff.

If you hang out your shingle as a musculoskeletal physiotherapist it’s a fair bet that a significant number of your patients will be coming through the door needing some form of post-surgery rehabilitation. It’s also pretty likely that their recovery will be hindered, to a greater or lesser degree, by limitations in movement linked with pain and a healthy dose of apprehension.

And along with all that pain and fear comes avoidance strategies, which can slow recovery rates significantly.

So a couple of questions regarding exercise prior to surgery are well worth considering.

Might these patients have benefited from some form of structured program prior to surgery? Might it have better prepared them for the rehabilitation journey, both physically and mentally?

One of my patients had a total knee replacement, an increasingly common procedure in our ageing population. This can be pretty invasive surgery in which muscles, tendons and ligaments are stretched or replaced. And the duration of post-surgery stays is being relentlessly reduced – patients

…proprioception, strength and stability are usually markedly deficient in these patients.

And that’s where a ‘Prehab’ program can make all the difference.” are often discharged when they can walk a predetermined distance and are self-mobile across a range of basic activities.

However, they often have strength and mobility deficits in their hips, ankles and knees combined with an altered cognitive ability to ‘switch on’ required muscle areas.

This can translate into an increased risk of falls.

Many patients feel that surgery is a fast-track solution to a diminishment of symptoms and the structural improvement to the joint is the whole point of the procedure. Nonetheless, proprioception, strength and stability are usually markedly deficient in these patients.

And that’s where a ‘Prehab’ program can make all the difference.

The onset of pain is often linked with a specific movement or weight-bearing activities that bring a joint into its ‘end range’ of motion. Prehab involves a series of structured exercises that builds strength without aggravating the injury and prior to any inflammation linked with surgery. Patients are then able to move much more freely and autonomous activation of the muscles is easier because nerve fibres haven’t been interfered with.

Incidentally, I practice what I preach. My shoulder surgery was preceded by a structured twelve-week program that gave me increased muscle activation and a much better pattern of biomechanics that allowed me to return to normal activity within a relatively short period. That gave me more confidence during post-surgery rehabilitation to better use the muscle groups and stabilise the shoulder joint.

The road to recovery after surgery can be a tough one. Many physiological changes occur post-surgery and some of these can lengthen recovery times. Before a patient goes under the knife ‘Prehab’ exercises, where applicable, can be an integral part of the surgical plan.

Market Forces In amongst the ageing population, the economic downturn, exponential growth in health knowledge, emergence of the internet and well-heeled people looking for investments, the squeeze on the health dollar has grown.

Medical Forum has seen changes through the myriads of notifications we get, many driven ultimately by health economics. Even health philanthropy has become a business!

Here are some of the observed trends: PBS cost savings. Government wants to save millions by delaying or not listing drugs, encouraging generics, and ‘educating’ doctors away from scripts. Getting drugs PBS listed means millions – influences include increasing illness awareness, research, consumer support, key opinion leaders, websites, foundations, etc. – and orphan drugs for oncology are particularly ripe.

Consumer costs. The Medicare freeze on GP fees; specialist fees; procedural on-costs; managed care by health insurance funds; informed financial consent, etc.

Medicine is more a business. Contracts and corporatisation; Worksafe and Fair Work compliance; commercial interests of some doctors.

More legalities. Everyone has a lawyer in their back pocket; defensive medicine means more tests; less room for error in health consumer thinking; people more willing to hoodwink employers.

More specialisation. Generalisation is harder to achieve whether a GP or other specialist; niche medicine gives results.

Delivery of health care. Self-help is a necessity; apps are the flavour of the month; improved access to information but wisdom in interpretation still needed; consumers want more say.

More ready communication. With this comes more opportunity for exploitation – welcome to the world of IT!

MEDICAL FORUM

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APRIL 2017 | 39

Community

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WA Indian Docs Launch Network A new group in WA aims to support doctors of Indian origin in their work and their lives. Its General Secretary Dr Sayanta Jana explains here how it all began.

The establishment of WA Indian Docs Inc is testimony to the diverse and multicultural nature of the Australian society and the health professional groups within Western Australia health sector. WA Indian Docs is an independent semi-professional and social organisation embracing medical and dental practitioners of Indian origin not only from India but from other countries in our region.

In WA, there has not been an organisation that has focused on the semi-professional and social needs of this migrant cohort, which is one of the strong reasons why it was established.

Our strategic vision is well captured by the acronym INDIANS:

40 | APRIL 2017

• Involve – ensure members at all levels are accounted for, including IMG and trainee junior doctors • Nurture – professional and educational priorities • Develop – networking, communication and mentorship • Influence – safeguard the interests of members and their contribution to the WA community through lobbying and professional partnerships

The numbers of Indian-trained and Australiantrained Indian doctors is hard to quantify but some are third and fourth generation Indianorigin descendants and participate in every aspect of the WA health system.

Nominal membership fees, corporate sponsorships and fundraising will drive the work of WA Indian Docs though, initially, a certain level of seed funding has been generated to allow us to get started.

• Nourish – Uphold and promote the wellbeing of all patients in WA

Membership offers some member benefits that complement the social and professional lives of medical and dental practitioners and their families by providing a social and professional network and to help them feel a part of the WA community and social fabric.

• Social – To conduct and advocate social responsibility and charity for the needy and disadvantaged

WA Indian Docs celebrated its launch at a gala event in February and guests, including the Consul General of India, Mr Amit Kumar

• Assist – Contribute to the community through a philosophical, social, cultural and charitable focus

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COMMUNITY

7

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1.

Dr Anjana Thottungal and Prof William Hart

2.

Dr Aparna Kahali and WA Indian Docs President Dr Sunny Buruah

3.

Dr Bhaskar Mandal, Dr Sunny Baruah, Dr Kiran Puttappa and Dr Ravisha Srinivas Jois

4.

Dr Dhanvee Kandadai and Anisah Inyat Hussein

5.

Dr Jami Ilyas Ramlah and Faruki Jami

6.

Dr Jenni Connaughton, representing the charity CINI receives a cheque from WA India Docs General Secretary Dr Sayanta Jana and Presdient Dr Sunny Baruah

7.

Dr Parshotam Gera and Dr Mala Gera

8.

Dr Ravisha Srinivas Jois and Dr Maina Kava

9.

Dr Sankha Mitra and Shoma Mittra

14 Mishra, heard about the work of two of the charities which will benefit from our fundraising – Children In Need in India – Australia (CINI) and Eastern India Palliative Care (EIPC). Founding President Dr Sunny Baruah presented them with a share of more than $2500 raised during the evening.

WA Indian Docs also launched a busy professional, education and social calendar for the year including a family picnic and fundraising dinners.

We hope the organisation will grow nationally and engage with similar organisations in other states who share our objectives. There are also proposals to develop linkages with similar associations in India and be formally associated with the World Medical Association.

MEDICAL FORUM

Because we are all busy professionals, we look to communicate in a variety of means.

We will be launching our WA Indian Docs app soon on Android and iOS platforms to keep not only our members, but also guests and non-members updated about our activities, news, upcoming events and event notifications. The app will also serve as electronic membership ID that our members can proudly carry around on their smartphones.

10. Dr Shelbin Neelankavil and Dr Sharad Shetty 11. The Indian Consul to WA Mr Amit Kumar Mishra and Dr Krishna Somers 12. Ms Morag Smith from Avant, one of WA Indian Docs’ sponsors 13. Dr Ajay Sharma 14. Sohini Haldar and Dr Sayanta Jana

Further information about the work of WA Indian Docs can be obtained at www.indiandoctorswa.org.au.

By Dr Sayanta Jana ED: Dr Jana is the General Secretary of WA Indian Docs.

APRIL 2017 | 41

FOOD & WINE

Bloody French

MY LOCAL

279 Rokeby Rd Subiaco, 9388 0454 facebook.com/bloodyfrench The bottom end of Subiaco’s restaurant strip in Rokeby Road is looking pretty rough at the moment. It closely resembles Aleppo after a bombing run by Russian Migs. Old water pipes being replaced, apparently. It’s a different story up the hill, though. Nice and quiet, lovely soft green trees – it’s like the Paris end of Collins St, Melbourne. No, make that Paris itself!

And that fits rather nicely because Bloody French, a newish restaurant specialising in a fusion of French/Mediterranean flavours, dishes up a little slice of that wonderful city without having to spend an entire day out of your life on an aeroplane with your knees up around your ears. Head-chef and owner Barrie Boubakar (Boua) trained in the French capital and then went on to work for 11 years in some of London’s best restaurants.

The accent is on fresh, regional produce cooked beautifully and complemented by an interesting selection of both French and local wines.

A signature dish? "Confit Duck croquettes with Salsa Verde, Pickled Fennel, Orange and Coriander," says Boua. It’s delectable – we’ve tried it!

They’re open for breakfast on Saturday mornings (the coffee is great!) and lunch/dinner Monday-Sunday. An average tab will set you back around $80 for two. An inventive menu, a lovely interior space and an amuse bouche of Paris itself!

Slow-Roasted Easter Leg of Lamb (serves 8-10) Ingredients 1 leg of lamb (bone in, 3kg) 6 cloves garlic, peel, sliced to slivers 2 tsp cumin powder 2 tsp sweet paprika 2 tblsp fresh rosemary, chopped Extra fresh rosemary 1 tblsp fresh thyme, chopped Extra fresh thyme 1 tblsp dried Greek oregano 1 tsp ground rock salt 1 tsp ground black pepper 2 brown onions, peeled and quartered 1 cup dry white wine 2-3 bay leaves Juice of 2 lemons Extra-virgin olive oil

DIRECTIONS 1. Preheat oven to 220C and place the rack in the middle position.

2. Stick a paring knife into the lamb to make holes, then insert slivers of garlic.

3. Make a paste with the fresh herbs and spices, including salt and pepper, with some of the olive oil and rub over the lamb.

4. Place the leg of lamb in a snug roasting pan and roast uncovered in the oven for 15 minutes or until browned, then turn the leg and roast for another 10-15 minutes.

5. Reduce heat to 170C. Remove the lamb from the oven and add quartered onions around the lamb, add extra fresh herbs and bay leaves. Squeeze over the lemon juice and add wine to the pan.

6. Cover and return lamb to the oven for 2 hours (add hot water if liquid is too low), baste the lamb once an hour. After two hours, flip the leg of lamb (add more water if necessary).

7. Cook a further one hour uncovered. The leg of lamb should be a deep brown and meat pulling away from the bone.

8. Remove the lamb from the oven, baste with liquid and allow to rest.

9. Serve with roasted root vegetables and a green salad.

Wine

Winner

This month’s winner of the Edenvale Doctor’s Dozen is more likely to be found sipping a good malt whisky as befits his origins.

Nonetheless, Scottish-born Dr Colin Stewart is quite partial to a glass of wine – particularly a cabernet sauvignon from South-West WA. Colin's eldest daughter has just graduated from law, and she’s got a job lined up. The latter is a very good reason to celebrate!

42 | APRIL 2017

MEDICAL FORUM

FOOD & WINE

Fertile Vales of St Aidan Wines The Ferguson Valley is a lesser known gem of a wine region located near the Darling Scarp outside of Bunbury. St Aidan Wines is located in the lower regions among the fertile flats and Bunbury anaesthetist Dr Phil Smith and wife Mary purchased the property in 1991.

The first plantings were of Chardonnay and Cabernet Sauvignon and these varieties became the backbone of the St Aidan’s wine portfolio. Later on, other varieties such as Sauvignon Blanc, Semillon and Tempranillo were planted. Mark Messenger at Juniper Estate has been making the wines since 2001. St Aidan Wines is a great stop on your next trip south. The wines are well made and highlight the beautiful fruit from this region.

By Dr Martin Buck

REVIEWER'S

PICK 1

2

3

2014 St Aidan Cabernet Sauvignon (Cellar Door $32)

Cabernet Sauvignon has been an excellent variety for St Aidan Wines and this vintage is a well-balanced fruitdriven wine with 97% Cabernet and 3% Malbec. It has subtle aromas of dark plums and oak with a medium-bodied palate of berry fruit and soft, fine tannins. It has plenty of cellaring potential and is a very well-made Cabernet. The 2015 is 100% Cabernet Sauvignon and one of the big medal winners for the winery. It has very different aromas with a slightly perfumed nose of violets and vanilla oak. A complex wine and a generous palate of well-integrated fruit and tannins. This is a wine that will still be fantastic in five years’ time.

1. 2014 St Aidan Sparkling Chardonnay (Cellar Door $28) Sparkling chardonnay is certainly a boutique wine and the 2014 is a new release from St Aidan Wines is memorable. I like the crisp acid, fine bead and subtle pear and yeast flavours. A great start to any meal and one of my favourites of the collection.

4. 2016 St Aidan Sauvignon Blanc Semillon (Cellar Door $20) There is a wonderful freshness about this wine that leaps out of the glass with pineapple, passionfruit and pear aromas. It’s very drinkable with an acid backbone and plenty of tropical fruits. This is ready for immediate drinking and very good value.

2. 2016 St Aidan Cassie Moscato (Cellar Door $21) I believe Moscato is an under-rated wine and we all need to take ourselves a little less seriously. The 2016 Cassie Moscato is a bottle of fun with 9% alcohol. Lovely Muscat fruit aromas with strawberries and sherbet thrown in, a little sweetness adds to the fun. Well suited to long summer afternoons.

5. 2015 St Aidan Chardonnay (Cellar Door $30) Although still young in Chardonnay terms, the 2015 St Aidan Chardonnay packs a punch. Brilliant fruit style with fresh pear and nectarines, very soft oak and a great long palate. It’s an easy drinking style with plenty of class.

The 2012 St Aidan Chardonnay I found to be slightly more oaked but still a complex wine with new oak characters, a solid fruit spine and persistence.

My preference is the 2015 and there is great potential.

3. St Aidan Liqueur Muscat (Cellar Door $35) Continuing the Muscat theme I really enjoy a liqueur Muscat after dinner.

The Zena Liqueur Muscat is 18% alcohol, complex and perfect with some cheese post meal.

WIN a Doctor’s Dozen!

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Wine Question: Which St Aidan wine has aromas of pineapple, passionfruit and pear leaping out of the glass?

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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, April 30, 2016. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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APRIL 2017 | 43

Travel

Paradise One Day...

Perfect the Next Do the words ‘South Pacific’ make you think of azure clear water, surrounding green islands full of palm trees swaying in a gentle, warm breeze? White sandy beaches, not a tourist around, with reefs full of fish only a stroll and a snorkel away? Welcoming villagers, eager to show you aspects of their unique cultures? And day after day of balmy warm weather, perfect for sitting on deck watching for whales, birds or just relaxing and letting your cares slip by?

My partner and I went on Heritage Expedition's Secrets of Melanesia cruise recently. He is a keen diver and photographer. He spent days photographing villagers and their ways of living, going underwater filming fish and coral, and then hours editing and downloading his prizes. Drinks in the bar before dinner involved everyone sharing their best photos, which was both fun and informative. There was a group of keen birders who, led by the onboard ornithologist, shared photos of land and sea birds, which we would not have seen otherwise.

For me, the highlight was what was under the water.

I am a keen snorkeller and on this trip we snorkelled every day, either from the shore or off a Zodiac. The water was so warm that you can stay motionless, watching the many different types of damsels and anemone fish.

Dr Lin Arias, above, enjoying the cultural engagement with the local people of the South Pacific.

44 | APRIL 2017

We were lucky enough to see a stone fish, completely camouflaged against the rocks and reef, only the gleam of its eyes giving away its location. Green turtles swam within an arm’s length in the clearest water, against the whitest sand (yes, whiter than Cottesloe). Large, multi-hued Napoleon or Maori wrasses were seen in pairs, letting us come within a couple of metres to watch them nibble on the

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TRAVEL

beautiful coral of all shapes and sizes. Every day there was something different.

We missed out seeing a dugong, though we did see a trail through the sea grass from their eating habits. It looks a lot like someone took a lawnmower underwater!

Our trip began in the Solomon Islands, in Honoria, on the island of Guadalcanal. Those who know their WWII history know that one of the worst Allied naval defeats occurred there.

The Solomon Islanders, who had their village life upturned by the arrival of the Japanese and the Americans, played a crucial role in helping turn the tide for the Americans. The memorial and the local museum are excellent.

After a tour of Honoria, including the various museums and other historical landmarks, we boarded The Spirit of Enderby to spend the next nine days at sea. The ship is an icestrengthened expedition vessel that caters for a maximum of 50 passengers. It can take you to the Arctic or to the next South Pacific island.

We spent our voyage visiting remote islands, each with local people with their own unique language, customs, and dances. Half a day being joyously welcomed and intermingling with delightful people, half a day snorkelling in azure warm waters, back to the ship by 5pm to relax…before heading to the bar to discuss the day’s delights with fellow passengers – not a bad way to spend a day.

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Before a three-course dinner, ship staff discussed what delights lay ahead the next day. Expect to find crayfish from one of the islands you just visited on your plate. Chefs Lindsay and Ed were magicians in the kitchen and food allergies are well accommodated.

After the Solomon Islands was Vanuatu – again, different cultures, villages, language groups and a warm welcome with dancing and singing. In many of the places we visited we were the one cruise ship to come by for a year.

In addition to the fun we were educated by talks from our enthusiastic expedition staff.

Our resident anthropologist told us about the local cultures and customs; we learned about reef fish and how to recognise them from our marine biologist; our ornithologist kept us keen to spot the many jungle and sea birds; and we became near experts on mangroves, rainforest and anything green and growing from our passionate botanist.

Of course, if you want to tune out, just go on deck and commune with the wind and the water and the wonder of it all.

Sadly, all great trips come to an end just when you are settled into the routine of having one marvellous day after the next. On Day 12 we disembarked at Port Vila, Vanuatu, but consider prolonging your stay. There are lovely inexpensive resorts with good snorkelling, good food and more of that relaxation lifestyle. We stayed at the Iririki resort and wished we had more time there.

The cruise would also be a great holiday for families with older children who are good swimmers. All you need is a thirst for adventure, a desire for some creature comforts, some basic fitness, and a heart that is open to what you may find to have a truly wonderful time on this voyage.

By Dr Lin Arias www.heritage-expeditions.com

APRIL 2017 | 45

The air travelling public may not want to read on, but here are some classic conversations between the cockpit and the control tower.

A student became lost during a solo crosscountry flight. While attempting to locate the aircraft on radar, ATC asked, "What was your last known position?"

Tower: "Delta 351, you have traffic at 10 o'clock, 6 miles!"

Student: "When I was number one for take-off."

Delta 351: "Give us another hint! We have digital watches!"

___________________________________

___________________________________

A Pan Am 727 flight, waiting for start clearance in Munich, overheard the following:

A Cessna inbound at the reporting point over Manly Beach.

Lufthansa (in German): "Ground, what is our start clearance time?"

Tower (Female voice): "Cessna WYXD, congestion at airport approach. I’m going to have to hold you over the Manly area."

Ground (in English): "If you want an answer you must speak in English."

Cessna WYXD: "I love it when you talk dirty to me." ___________________________________ Tower: "TWA 2341, for noise abatement, turn right 45 Degrees."

TWA 2341: "Centre, we are at 35,000 feet.

How much noise can we make up here?"

I have had a perfectly wonderful evening, but this wasn't it.

- Groucho Marx

Tower: "Sir, have you ever heard the noise a 747 makes when it hits a 727?" ___________________________________ O'Hare Approach Control to a 747: "United 329 heavy, your traffic is a Fokker, one o'clock, three miles, Eastbound."

United 329: "Approach, I've always wanted to say this...I've got the little Fokker in sight."

Lufthansa (in English): "I am a German, flying a German airplane, in Germany. Why must I speak English?"

Unknown voice from another plane (in a perfect British accent): "Because you lost the bloody war!"

While taxiing at NY La Guardia, the crew of a US Air flight departing for Fort Lauderdale made a wrong turn and came nose to nose with a United 727.

An irate female ground controller lashed out at the US Air crew, screaming: "US Air 2771, where the hell are you going? I told you to turn right onto Charlie taxiway!

You turned right on Delta! Stop right there. I know it's difficult for you to tell the difference between Cs and Ds, but get it right."

Continuing her tirade to the

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MEDICAL FORUM

embarrassed crew, she was now shouting hysterically: "God, you've screwed everything up! It'll take forever to sort this out! You stay right there and don't move till I tell you to! You can expect progressive taxi instructions in about half an hour and I want you to do exactly what I tell you, when I tell you, and how I tell you! You got that, US Air 2771?"

"Yes ma'am," the humbled crew responded.

Naturally the ground control frequency went terribly quiet after the verbal bashing of US Air 2771. Tension in every cockpit at LGA was running high.

Then an unknown pilot broke the silence and keyed his microphone, asking: "Wasn't I married to you once?" ___________________________________ Tower: "Eastern 702, cleared for take-off, contact Departure on frequency 124.7" Eastern 702: Tower, Eastern 702 switching to Departure. By the way, after we lifted off we saw some kind of dead animal on the far end of the runway."

Tower: "Continental 635, cleared for take-off behind Eastern 702, contact Departure on frequency 124.7. Did you copy that report from Eastern 702?"

Continental 635: "Continental 635, cleared for take-off, roger; and yes, we copied Eastern... we've already notified our caterers."

The German air controllers at Frankfurt Airport are renowned as a short-tempered lot.

They not only expect one to know one's gate parking location, but how to get there without any assistance from them. So it was with some amusement that we (a Pan Am 747) listened to the following exchange between Frankfurt ground control and a British Airways 747, call sign "Speedbird 206".

The BA 747 pulled onto the main taxiway and slowed to a stop.

Speedbird 206: "Frankfurt, Speedbird 206 clear of active runway."

Speedbird 206 (coolly): "Yes, twice in 1944, but it was dark and I didn't land."

Ground: "Speedbird, do you not know where you are going?"

Speedbird 206: "Stand by, Ground, I'm looking up our gate location now."

Ground (impatiently): "Speedbird 206, have you not been to Frankfurt before?"

Ground: "Speedbird 206. Taxi to gate Alpha One-Seven."

HeartsWest is pleased to announce some important new developments.

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Special Interests: Heart failure, non-ischaemic cardiomyopathies, mechanical circulatory support and cardiac transplantation.

Amit is a cardiologist providing expertise in the management of general cardiology conditions including, but not limited to, ischaemic heart disease, valvular disease and arrhythmias, with a particular subspecialty interest in heart failure, non-ischaemic cardiomyopathies, mechanical circulatory support and cardiac transplantation.

In addition to consultation, he performs coronary angiography, right heart catheterisation and myocardial biopsies. He is part of a dedicated team of cardiologists at Hearts West in Armadale, Rockingham & Murdoch Hospitals.

Amit is committed to his patients, closely overseeing all aspects of their management. He emphasises individually tailored care, with attention to ensure that patients understand the condition and can make informed decisions.

After completing undergraduate training in the UK, Amit completed cardiology training in Australia, prior to a two-year fellowship in advanced heart failure, mechanical circulatory support and cardiac transplant. He holds an appointment as Cardiologist for the Advanced Heart Failure and Cardiac Transplant Service at Fiona Stanley Hospital and is actively involved in research in this field.

Armadale Health Service * Rockingham General Hospital * SJOG Murdoch * Fiona Stanley Hospital Telephone 9391 1234 Fax 9391 1179 Email reception@heartswest.com.au www.heartswest.com.au

MEDICAL FORUM

APRIL 2017 | 47

Entertainment & Leisure

Festival of Laughs We could all do with some laughter and the Perth Comedy Festival is packaging it up in 27 days of non-stop fun.

Wil Anderson and Matt Okine are part of festival director Jorge Menidis's Perth Comedy Festival

matching wits with a phalanx from all points of the globe.

The world can be a distinctly unfunny place so there’s nothing better than getting together with a couple of hundred fellow-sufferers and laughing it all away.

We’re about to get the chance to do just that at the Perth Comedy Festival, says its impresario Jorge Menidis.

“It’s an incredible amount of fun! Comedians from all over the world get to hang-out together and it’s such a thrill to see audiences laughing and chatting about the shows.”

“I don’t do stand-up myself. I like being in the background and watching the whole project come together. A festival like this is the sum of a thousand moving parts and when everything works it’s just an incredible feeling.

There’s some amazing stuff being done in the comedy sector at the moment. It’s a great time to be in the industry.”

There’ll be quirky funsters and irreverent pranksters descending on the Regal Theatre and the State Theatre Centre from late April until mid-May with the local contingent

What: When: Where:

Perth Comedy Festival April 26 – May 21 State Theatre Centre, Northbridge & Regal Theatre, Subiaco perthcomedyfestival.com

48 | APRIL 2017

“A couple of hilarious Irishmen are on their way, Jason Byrne – who’s been dubbed the ‘outright King of live comedy’ – and David O’Doherty is a force majeure of musical comedy. The latter also wants us to know that he was the 1990 East Leinster Under-14 Triple Jump Bronze medallist, so we need to bear that in mind!”

“Stephen K. Amos, who needs no introduction to comedy aficionados, is coming to Perth as is the truly surreal Paul Foot. We had some fun with Paul a few years back when he decided to walk into the surf at Fremantle dressed in his three-piece suit.

He had an interview scheduled with the ABC so we took him there half-an-hour later still dripping wet.”

“It worked out well because we used a photo of him emerging from the surf on a poster for the following year’s festival.”

“If you look at the awards handed out at the last Edinburgh Fringe it was peppered with Australian names. There was such a strong generation of comedians in the ‘90s with people such as Wil Anderson and Adam Hills. Now that’s being followed by the next wave of outstanding talent – Matt Okine, Ronnie Chieng and Joel Creasey who are commanding large audiences and leaving them rolling in the aisles.”

“Stand-up comedy really is one of the great performance disciplines. There’s lots of raw emotion, unbridled laughter and it can be pretty harrowing, too. People will leave

Watching the Watcher In the February edition we issued to a challenge to cinefiles to name the film avid film noir collector Dr Lindy Roberts was watching. Well, consultant anaesthetist Dr Mark Williams was quick off the mark with the correct answer …

Kiss Me Deadly (Robert Aldrich, 1955).

these shows highly amused, entertained and possibly a bit dishevelled.”

“I’m in awe of these performers. They’re onstage night after night keeping the laughter alive – this Festival’s going to be amazing!”

By Peter McClelland

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Theatre

Comedy of Errors Sometimes it’s the little gags that get the greatest laughs... string a lot of little gags together and you have a play’s worth of hysterics.

From the opening line to the final curtain The Play That Goes Wrong (TPTGW) is one gigantic clanger after another. It’s been described as Fawlty Towers meets Noises Off and it’s funny, frantic and highly entertaining.

“It won the Moliere Award for Best Comedy a couple of years ago in Paris, which was great.”

“It’s one of those plays that you’re guaranteed to get a laugh, and there’s a lot to be said for that. There’s a balance of different styles of comedy in the show, a slapstick element that hasn’t been done for a while and a slightly more old-school twist to it as well,” says James Marlowe, who was in the original West End cast and is in Australia touring the play nationally. It will be at His Majesty’s Theatre in Perth from May 31.

“There’s a universal theme to this play and it’s helped by a great script. Audiences love watching other people’s misfortune and these characters are continually getting all muddled up, both emotionally and physically.”

“I love the line from a New York Times review – this play’s a high octane riot, it’s punchdrunk and it just keeps on getting drunker!”

“But the entire thing becomes a complete farce due to their distinct lack of ability and a large dose of misfortune. And, to make matters worse, the ‘director’ is playing the lead-role! He thought this was going to be absolutely spellbinding and the whole thing falls down around him.”

The humour in TPTGW translates seamlessly across national boundaries and that’s not bad for a play that began life in a London pub.

“It can be tricky jumping from one country to another but the reviews have been great and we’re pleased about that. We’ve leapt across four language barriers already, from the UK to Paris and on to Hungary and Norway.”

“We’re just about to open on Broadway and, of course, here we are in Australia!”

“The play is a tragedy too, in a way. This is the story of amateur theatre group who thought their very own piece of theatre was going to be a terrific murder mystery. They were hoping to make a beautiful piece of art!”

“The pain is acute, and the audience can see every bit of it!”

One of the unique aspects of the play is that

it has a bit of a chuckle at the medium itself, says James.

“It does give people a glimpse at just how slightly ridiculous theatre is, and it also shines a spotlight on how fine the margins really are.

Even in an amazingly good piece of theatre if a line gets messed up the bubble is burst, it completely breaks the spell.”

“And in this murder mystery set in Haversham Manor that happens every single minute!”

The play is travelling right around the country and James is looking forward to seeing a bit of Australia.

“We’ll be playing in Adelaide, Melbourne and Sydney before finishing the run in Perth at the end of May. I can’t wait to see the place, it’s a big country! After that it’s back to the UK for me, I’ve got a few things lined up but an actor’s life is always a bit precarious.”

“The play is a balance of intuition and splitsecond precision. And it’s also a show that can’t run on autopilot for one second – you’ll love it!”

By Peter McClelland

The Immortal Life of Henrietta Lacks

Book

Review MEDICAL FORUM

(Rebecca Skloot, Crown)

In October, 1951, an African American woman by the name of Henrietta Lacks was dying an excruciating death from cervical cancer in the public ward of a Baltimore hospital. The treatment she (didn’t) receive and the cavalier way her rights were denied, make it an inglorious chapter of racism in healthcare. The fact she was the progenitor of the immortal line of cells known as HeLa mean nothing to the woman who was buried in an unmarked grave but everything to scientists and the world that has benefited from subsequent medical discoveries. Science writer Rebecca Skloot’s book is seven years’ old but its ethical dilemmas are a fresh as they day they were born. A television movie produced by Oprah Winfrey is due out at the end of the year.

APRIL 2017 | 49

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Theatre: Stones in His Pockets Another West End hit is heading our way, this time a bittersweet Irish comedy about a small town turned upside down when the cast and crew of a Hollywood movie come to town and romance gets everyone talking. This play won prestigious awards for best comedy and best play.

Subiaco Arts Centre, April 21, 22; MF performance, April 22, 7.30pm

Kids’ Theatre: Mr Stink People over 25 will know him for his risqué humour in the comedy show Little Britain but chances are the younger people in your household will only be acquainted with his ‘Dahlesque’ humour through his books. Yes, David Walliams is the author of 10 children’s books and one of his most popular, Mr Stink, has been turned into a stage show that is heading to the Heath Ledger Theatre next month.

Producers say the show is ideally suited to children between the ages of six and 12 but there will be plenty going on for the adults. Directed by Australian funnyman Jonathan Biggins, Mr Stink is guaranteed to fill the senses. This quote might give you a clue: "Mr Stink stank. He also stunk. And if it was correct English to say he stinked, then he stinked as well…”

It also explores some serious themes about acceptance and social inclusion.

This production was recently nominated for a Sydney Theatre Award for Best Production for Children.

State Theatre Centre, May 6-11

Movie: John Wick 2

Super-assassin John Wick (Keanu Reeves) is forced out of retirement by a former associate plotting to seize control of a shadowy Italian assassins’ guild.

Bound by a blood oath to help him, John travels to Rome where he squares off against some of the world’s deadliest killers in an adrenaline-fueled thrill sequel.

In Cinemas, May 11

Movie: Viceroy’s House A British drama from the producers of Bend it Like Beckham sees the last days of the Raj coming to an end as Lord Mountbatten assumes the post of Viceroy of India charged with the handover of the country to its Parliament. Top cast includes Michael Gambon, Gillian Anderson and Hugh Bonneville.

In Cinemas, May 18

Comedy: Perth Comedy Festival

Winners from February Opera – Tosca: Dr Annabelle Shannon Music – WASO & Beethoven 7: Dr Alan Leckie Movie – The Eagle Huntress: Dr Michael Bray, Dr Donna Mak, Dr Amy Gates, Dr Paul Kwei, Dr Linda Wong, Dr Deirdre Tierney, Dr Bibiana Tie, Dr Allen Michael

t Squeeze on Primary Care t Costs for Specialists t Health & Politics t Investing Wisely t Clinicals: 3D Printing; Cystic Fibrosis; Tremor; Hep C; Immunotherapy & More

February 2017 Major Sponsor

Movie – Jasper Jones: Dr Suzette Finch, Dr Rachel Price, Dr Leonard Lum, Dr Derek Johns, Dr Ranjan Shrestha, Dr Stefanie Bracknell, Dr Brett Baird, Dr Orna Gabbay Movie – Loving: Dr Helen Mead, Dr Ines Chin, Dr Clyde Jumeaux, Dr John Williams, Dr Rimi Roper, Dr Esther Moses, Dr Max Traub, Dr Peter Louie

www.mforum.com.au

If you are having festival withdrawals, fear not, the Perth Comedy Festival will put a smile back on your face. Gala night at the Heath Ledger and a host of Australian and international acts are heading our way. Expect to see international stars Eric Andre (US) and Phill Jupitus (UK), match it with local heroes Wil Anderson, Effie and Steve Hughes among others.

Various venues, April 26-May21

Theatre: The Play That Goes Wrong If life is wearing you down, head to the Maj and see what it’s like for a bunch of actors in a play where nothing goes right. This hilarious farce, which has been described as Fawlty Towers meets Noises Off, is taking the East Coast by storm and is heading to Perth next month with an Australian cast and one original member from the West End production.

His Majesty’ Theatre, from May 31

50 | APRIL 2017

MEDICAL FORUM

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FOR LEASE SUBIACO Sessional Suites available at brand new specialist consulting rooms in Subiaco.

Fully furnished and fitted out, ideal for medical specialists and allied health practitioners with the option for reception and secretarial support.

Located near SJOG Hospital Subiaco.

All enquires to gemma@hipnknee.com.au or 0413 767 562 NEDLANDS Fully furnished consulting suite available for sessional use.

Monday - Friday at Hollywood Medical Centre.

Please contact Jade on 0433 123 921 or jadethyer@mac.com NEDLANDS Specialist Consulting rooms available for lease.

Suite 31 Hollywood Specialist Centre 95 Monash Avenue Nedlands WA 6009 Please telephone Rhonda 9389 1533 NEDLANDS Fully furnished consulting rooms available.

HOLLYWOOD MEDICAL CENTRE Sessional basis Monday to Friday – including Full Receptionist Support in friendly professional rooms.

Available Saturday without reception.

Would suit practitioner starting new business or those with established practice.

Call Practice Manager 0412 164 224 or email: reception@hollywoodpsychiatry.com.au MURDOCH

Medical Clinic SJOG Murdoch Specialist consulting sessions available.

Email: gcford56@gmail.com

SUBIACO Fully furnished consulting rooms available in a newly and beautifully renovated old warehouse in Subiaco.

Lease of consulting room within the office for exclusive full-time or shared sessional use.

The whole office consists of 3 large consulting rooms, including procedure room, attractive reception area with dedicated space for own receptionist, separate staff and patient toilets, endof-trip facilities, and on-site pathology collection centre with part-time phlebotomist.

On-site under cover car parking available.

Contact npennell23@optusnet.com.

au

EAST FREMANTLE Consulting rooms available in a new medical clinic on the ground floor of the “Richmond Quarter” on Canning highway.

Includes minor procedures operating theatre.

Various options available from room use only, up to comprehensive secretarial, IT and promotional packages.

Contact Rick 0404 758 182 or email admin@vasc.com.au

RURAL POSITIONS VACANT ALBANY • St Clare’s is an established occupational and family practice based in Albany.

• Small friendly practice • Full time nursing and administration support • Pathology on site • Full or part time GP wanted to join our team • Special interest in skin would be ideal • Currently no DWS unless willing to work in afterhours period • GPs not requiring supervision required Please contact Practice Manager, Helen Williams: 08 9841 8102 Email: helen@stclare.com.au Or send your CV through and we will get back to you.

SOUTH WEST WA

NEDLANDS Specialist Suite for lease at Hollywood Specialist Centre, 64 sqm, 2 offices, large reception area.

Heavily discounted rent for clinician(s) starting private practice for first 3 months.

Please contact Julie-Anne Powell 0403 209 363 or Email: powellhollywood@westnet.com.au WEST LEEDERVILLE New consulting suite for lease at 12/2 McCourt Street.

Opposite SJOG Hospital Subiaco.

104 sqm. 2 car bays. $31,200 p.a. plus outgoings. Negotiable.

Please contact Miguel 0417 268 465 or (08) 6399 6800 or Ian ianloh95@gmail.com

88 | APRIL 2017

Bridgetown Medical Group Is seeking a VR GP (flexible hours) to join our friendly, busy practice. Experience the rewards of rural practice in this beautiful town.

We are a privately owned, accredited, mixed billing practice, DWS, fully computerised clinical software with onsite Nurse and excellent admin support.

A&E experience necessary to cover the local hospital and provide phone support to nearby towns.

Obstetrics desirable but not essential.

Remuneration consists of 60%-70% billings (in/out of hours), in addition to generous government incentives for participation in the call roster, making this a financially rewarding position.

Contact Practice Manager on 08 9761 1222 or email your details directly to btn_medical@wn.com.au

BUSSELTON

Busselton Skin Cancer Clinic Seeking skin cancer doctor to join our expanding clinic in the beautiful southwest, close to wineries, beaches, arts and entertainment Small privately owned clinic Excellent admin team and practice nurse PT or FT available Opportunity for eventual purchase of practice Contact Practice Manager Ken on 0412 921 669 or email bscc1@bigpond.com SOUTH WEST WA

CLAREMONT We are seeking an enthusiastic VR GP to join our friendly team on a full or part time basis at our well established privately owned GP practice.

Onsite Pathology Free Parking Adjoining Pharmacy Fully Computerised / Best Practice Predominately Privately Billings Excellent potential / Flexible hours Percentage Negotiable Enquiries to manager@goldsworthygp.com.au or phone Practice Manager on 0417 992 007

GP’s Required • Excellent Opportunity to join expanding Medical Group in the beautiful South West WA • Established medical group in Harvey & Waroona with 2 new locations • Brand new locations in new development areas Treendale & Dalyellup • Fully computerised & accredited modern practices with nursing & admin support • 65%-70% of billings depending on experience • DWS and AoN Please email CV to

gpapplications@bigpond.com

URBAN POSITIONS VACANT MOUNT LAWLEY Long established After Hours clinic Looking for a VR GP to work after hour’s shifts Flexible with hours Fully computerised and AGPAL accredited Private billing only Contact Gina on 0412 760 871 for further details OSBORNE PARK GP required for Osborne City Medical Centre.

Flexible hours Monday to Thursday with optional afterhours.

Excellent remuneration / $135 - $200 per hour.

Predominantly private billing practice.

Modern fully computerised practice with nursing support.

Please call Michael on 0403 927 934 ELLENBROOK F/T or P/T male or female VR/NON-VR GP’S and nurse practitioners’ required urgently in DWS/AON location.

Flexible shifts, Mixed Billing Practice, fully computerised paperless and modern medical equipment.

Existing huge patient Database, Assured income at start 75% or more of the billing based on experience offered Also rooms available for any Allied health Sponsorship available if needed Please ring 0431 143 460 or email at pmanager@ghmpwa.com.au ASAP

SORRENTO F/T or P/T GP for busy Sorrento Medical Centre, Normal/after hours available, we are like family, nurse & allied services on board, remuneration (70%-75%), Please call Dr Sam 0439 952 979 BALGA VR or non VR doctor required Full time or Part time available Rapidly growing and computerised practice Email: balgaplazamedical@gmail.

com

GOSNELLS Great opportunity to work in DWS area!

Non- cooperate well established practice in Gosnells looking for FT/PT, male/female VR or non VR GP on very attractive terms.

Please call 0434 967 915 or email corfield.doctorsl@gmail.com

LANGFORD

Langford Medical Centre is currently looking for a full time GP including Saturday mornings, to replace a male colleague who is moving into the hospital system.

We are a privately owned Community based, well loved, accredited bulk billing practice.

Situated south of the river, Langford is one of the closest practices to the CBD that still qualifies as a district of workforce shortage.

This is one of those opportunities to gain a ready-made patient base.

For confidential enquiries please email a cover letter and CV to brendankelly@amnet.net.au

WEST LEEDERVILLE & KINROSS FT/PT GP required for privately owned these 2 bulk billing practices. Non VR GP’s can apply for Kinross.

Most procedures are billed privately.

Excellent earning potential at both centres.

Onsite Pathology, Nurse & All allied health.

Contact sanjaykanodia2000@yahoo.com

MEDICAL FORUM

OSBORNE PARK

WEST PERTH

RAPHA CENTRE is dedicated to

West Perth Medical Centre: VR GP

Women’s Health specialising in BioIdentical hormone optimization.

Private billing, non-corporate, fully computerised, friendly team.

Suitable for VR GP for rewarding experience in treating the root cause of most diseases with combination of nutritional and hormone balancing and more.

Email: drnoel@westnet.com.au for confidential enquiries.

Mentorship provided.

required to replace 2 PT doctors who have left to get married! Private billing, accredited practice offering GP, sexual health and occupational health services.

Stunning building and location. Contact Stephen on 0411 223 120

CLAREMONT Growing GP practice located in the trendy suburb of Claremont.

78% of billings.

Looking for VR GPs with unrestricted provider number on a full time/part-time basis for weekday and weekend (DWS) sessions.

Fully computerised with on-site pathology and RN support.

Located in a modern complex with access to the gym and pool.

For further information please contact Dr Ang on 9472 9306 or Email: info@thewalkingp.com.au

BYFORD VR GP Female/Male GP required Full time or Part time Privately owned well established modern practice located in Byford, 30 minutes from CBD, DWS and area of need.

Full admin and practice nurse support.

Onsite Pathology, Podiatrist, Dental and Pharmacy.

Fully computerised GPA Accredited Practice.

Excellent remuneration, high billing from start, takeover existing patient base.

Please email: byfordfp@gmail.com or Phone Dr Naga 0434 049 767

Duncraig Medical Centre requires

MIDLAND

Swan Medical Group, Midland (DWS).

F/T or P/T VR GP required for our wellestablished accredited Medical Centre.

We have a large patient list and you will be well supported by our able staff of nurses, diabetic educators, dieticians, CDM nurse and visiting physician.

We have onsite pathology, are fully computerised and have an active involvement in medical student and GP registrar training.

If you are motivated and interested in working in a non-corporate, fiercely independent practice.

Please contact our practice manager Elma on (08) 9274 6100 or email edward.cheuk@swanmed.com.au to arrange a visit.

SOUTH PERTH VR GP required Full-time and Part-time Positions available Well established South Perth/Como practice, situated very close to the city.

On site Pathology.

Fully accredited and computerised. Full time RN support. Friendly and supportive team.

Contact by email: bhdpty@bigpond.com or Ben on 0413 437 985

MEDICAL FORUM

FREMANTLE VR GP required to join a new practice set in the heart of West End. Will service ND students as well as local residents and workers. If you love good coffee and a great working environment contact Stephen on 041 223 120.

MIDLAND

DUNCRAIG a Female GP for immediate start.

Fulltime patient load available.

However, flexible with Monday to Friday hours.

Excellent remuneration / $135 - $200 per hour.

Predominantly private billing practice.

Modern fully computerised practice with full time nurses.

Please call Michael on 0403 927 934 or michael@duncraigmedicalcentre.com.au

ASCOT A non-corporate, new practice located near the domestic airport is looking for a male or female VR GP, hours are negotiable.

Friendly and professional environment with attractive remuneration.

Please contact Sue Fegebank on 9523 2000 or ridgemedical@gmail.com

THORNLIE

GP POSITION AVAILABLE AND CONSULTING ROOM FOR LEASE KMG is seeking VR/Non-VR GP to join its Accredited Medical Practice Invitation is now extended to interested specialists for a consulting room to lease at our brand new surgery suite.

There is huge need for all specialties in Thornlie and immediate surroundings.

Allied health practitioners seeking a room to lease are welcomed.

Contact the Practice Manager: 08 9452 2055 Email: forestlakes@kingdommedicals.com.au

BYFORD Busy Coles Shopping Mall non-corporate new Practice needs FT or PT female/male VR GP on very attractive terms.

Please call 08 9525 6622 & email CV to drprasad@byfordvillagepractice.com.au

CHURCHLANDS Full time VR GP required for our well established Accredited Medical Centre.

Stable and friendly work environment using Best Practice software.

Excellent full time nursing support.

Experienced reception and administrative team.

On-site pathology.

Mixed billing.

Please contact our Practice Manager Dianne or email

practicemanager@herdsmanmedical.com.au

A well-established GP clinic in the Midland area (approx. 20km east of Perth) seeks a VR General Practitioner to join their friendly team.

Position Details • To replace an outgoing GP • Very busy appointment book • Flexible working hours / days (no weekends or a/h needed) • Great opportunity to increase your earnings with Corporate Health • Training in cosmetic procedures will be offered to the right candidate.

• DWS Approved • Guaranteed income for the first 3 months with a great % on offer • OTE to earn 320K – 400K per annum based on full time Please phone Brett van Grootel on 08 9215 3888 or email: brett@choiceone.com.au for a confidential enquiry SERPENTINE VR GP Required (Part time-2.5 days per week) for practice only 2 years old, located in a DWS/AON ASGC-R2 location east of Perth.

This practice is the perfect opportunity for a GP to work in the inner regional area of Perth located approximately 45 mins from the CBD. This large community practice is located next door to a pharmacy offers admin, nursing services, along with onsite pathology and podiatrist/Dietitian.

Excellent remuneration is offered.

For more information please call 0419 959 246 or 0401 091 921 HOCKING Great opportunity to work in Northern suburb!

Non- cooperate new practice in Hocking looking for FT/PT, male/female VR or non VR GP on very attractive terms.

Please call 0434 967 915 or email eastroadmedical@gmail.com

SECRET HARBOUR Secret Harbour Medical Centre VR GP wanted.

65-70% offered.

A generous relocation fee may also be offered Brand new, modern and computerised.

Contact: Dr Jagadish Krishnan

MIRRABOOKA VR FEMALE GP POSITION

Ishar Multicultural Women’s Health Centre requires a VR Female GP for our well established, bulk billing women’s medical clinic.

The clinic is open 4 days per week and this position is for one day per week.

REQUIREMENTS * Vocationally Registered General Practitioner * Experience in Antenatal /Postnatal Care * Experience in Contraceptive Technologies If you are interested in working in a caring, multidisciplinary team environment and have an interest in migrant and refugee women’s health please contact Jan Ryan Manager of Health Services on mobile: 9345 5335 or email jan@ishar.org.au

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology and Allied services on site.

Privately owned. Generous remuneration.

Please call Dr Takla 0439 952 979 WHITFORD FT/PT Doctor required for friendly practice VR 70% of billings Non VR with general registration for weeknights and weekends from 65% Please contact Dr Michael Gendy dr.mike80@gmail.com Or Dr Rafik Mansour Rafik.mansour@wcfp.com.au Phone: 08 9404 4400 SCARBOROUGH

Scarborough Beach Medical Centre Part time GP required For After Hours and relief Saturday or Sunday. 6pm to 10pm sessions available during the week.

Mixed billing. Attractive income.

Please contact Sue Della-Bona on

0413 646 154

Email: pracman@sbmc.com.au

jags@perthgp.com.au Dr Vishnu Gopalan

g_vinu@yahoo.com

Contact Jasmine, jasmine@mforum.com.au to place your classified advert

APRIL 2017 | 89

MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage.

Highland Medical Centre is a noncorporate practice with 7 GPs, 3 Practice Nurses, 1 Chiropractor, 1 Physiotherapist, 1 Dietician, 1 Podiatrist, 1 Exercise Physiologist, 1 Diabetic Educator, 1 Psychologist, 1 Dermal Therapist and 1 Cosmetic Nurse Sessions and leave are negotiable and salary is compiled from billings not takings.

Up to 70% of billings paid (dependant on experience).

Please contact Jacky on 0488 500 153 or E-mail to jacky@highlandmedical.com.au

FREMANTLE

LEEDERVILLE OXFORD STREET MEDICAL CENTRE Is seeking a part-time VR doctor to join our long-established family medical practice.

INTERESTED IN WOMEN’S HEALTH? Fremantle Women’s Health Centre requires a female VR GP one day pw.

It’s a computerised, private and bulk-billing practice, with nursing support, scope for spending more time with patients, provides sessional remuneration, superannuation and generous salary packaging.

FWHC is a not-for-profit, community facility providing medical, nursing and counselling services, health education and group activities in a relaxed friendly setting.

Phone 9431 0500 or email Dawn Needham clinical-manager@fwhc.org.au

We are a non-corporate, well-equipped, predominantly private billing, busy boutique practice.

Fully computerised, AGPAL accredited (until February 2020). On-site pathology available.

This practice has excellent RN nursing support, very professional, friendly staff. Our doctors, nurses and reception staff have been with the practice long term as part of a supportive, friendly and professional team.

For confidential enquiries: Please contact Carol, Practice Manager at caroloconnor@westnet.com.au or call 0422 506 878

BASSENDEAN BYFORD VR GP Required Accredited, busy, modern, noncorporate, mixed -billing practice.

Full nursing support and friendly admin staff.

Onsite Pathology, Dietician, Physiotherapist, Psychologist & Podiatrist.

Phone Practice Manager on 0429 346 313 or email byfordmedical@gmail.com

Contact Jasmine, jasmine@mforum.com.au to place your classified advert

Exciting opportunity to join an established city practice in Bassendean, WA. It is a Non-DWS mixed billing practice with a vast patient database.

Full time/Part time GP positions available to start immediately.

Practice in a warm, friendly workplace with attractive remuneration.

We have an excellent admin team, allied health and pathology on site.

There’s also an opportunity to do extra rural GP practice in a sister practice 2 hours from Perth and earn some rural incentives in the process.

Please contact the practice manager on 08 9279 1805.

VR / Non VR GP required for our practice in the expanding corridors of Perth (DWS and AON area) + Opportunity for Full Time / Part Time + Great Earnings + Fully Computerised + High Percentage + Exclusive Incentives available for the right candidate + Great Support (Practice Manager, Nurses, Allied Health and Pathology) Please Contact Practice Director on 0466210369 or email to admin@starhillmedical.com.au

www.starhillmedical.com.au

Apollo Health is seeking local Dr’s with an interest in: - Skin cancer - General family medicine - Walk in/Urgent care For our practices in Armadale, Cockburn, Cannington and Joondalup FRACGP required, Relocation incentives available For enquiries to join our dynamic team, please contact us via E: medservices@stjohnambulance.com.au or P: 9334 1451 90 | APRIL 2017

MEDICAL FORUM

Secret Harbour Family Doctors

GP’s Wanted for After Hours Medical Deputising Service Occasional / Part time / Full time

Full Time VR GP Required

• Flexible Evening and Weekend Hours Available

Join now and receive a bonus $100k upfront

• Accredited, Established, Professional MDS • Car, Driver and Equipment Provided • Competitive Remuneration

Our Practice is located in the fast growing southern corridor with work hours that are very sociable with plenty of opportunity for work/life balance ensuring you enjoy time with family.

For more information contact; Amanda Piercy – 0499 044 773 or email Amanda.piercy@dial-a-doctor.com.au

ESSENTIAL REQUIREMENTS Vocational Registration Full AHPRA Registration WHY WORK WITH US

70%

of billings offered

Owner operated, non-corporate Flexible work hours Stable, friendly and fun work environment Well established systems and processes Computerised Own room Excellent full time nursing support in treatment room Experienced reception and administrative team DWS location

If you are interested in this Full Time opportunity at Secret Harbour Family Doctors please send your CV to Vishnu - g_vinu@yahoo.com

Metro Area GP positions available. IMG training available VR & Non – VR Dr’s are welcome to apply.

Send applications to gpapplications@betterhealthcare.com.au

GP West Requires VR GP’s to our state of the art medical centers in AON and DWS locations Waikiki GP Super Clinic WAIKIKI

Mundaring GP Super Clinic MUNDARING

Woodlake Village Medical Ellenbrook

Wattle Grove Medical Centre Wattle Grove

Newpark Medical Centre Girrawheen

Egerton Drive Medical Centre AVELEY

New Gumnut Medical Centre WANNEROO

Harrisdale Medical Centre Harrisdale

Okely Medical Centre CARINE

GP Owned, 9 Consult rooms, 3 Minor Surgery bays. All allied health, pathology, pharmacy & Dental 70 % of billings for full time VR GPs Non VR GPs are also welcome

Please contact Dr Kiran Puttappa on 0401815587 or email kiranpkumar@hotmail.com

or visit www.gpwest.com.au MEDICAL FORUM

APRIL 2017 | 91

DoCtor pgy 2+

St John is seeking experienced doctors to to fit in more rounds Keen VR OR NON-VR GP/REGISTRAR URGENTLY NEEDED! work in our new Urgent Care Centres. of golf each week ? rtunItyRelevant exIstsexperience in urgent care, rural general Homeless Healthcare is Perth’s largest general practice providing healthcare services to homeless and marginalised people. aying job inpractice metro Goldor Coast, Queensland. similar will be highly regarded.

Finally planning to enrol den priCe pibara full opportunity time General Practice, complete toM on site Homeless Healthcare is a multi-doctor accredited general ll be provided.

Full or part time. Attractive salary package. in that MBA course? practice providing evidence–based care in a well-supported team environment. The service works with partner agencies to successfully re-house people.

e fulland registration, FRACGP not necessary me join usFor in the oasis enquiries to of jointhe our pilbara. dynamic team, please contact us via

l to earn $ 500,000 ++ per year E: medservices@stjohnambulance.com.au or P: 9334 1451

Price is a docs@medcall.com.au family focused, booming town set in ur cv to: heartland of the Pilbara close to the stunning hallenger 761 053 ini National0409 Park. Perfect lifestyle for families.

The Australian Locum Medical Service provides We are seeking compassionate, dedicated and enthusiastic General Practitioners an after-hours home visiting medical to care in a variety of settings including Drop-In doctorsservice to provide DO YOU HAVE700 A SPECIAL INTEREST IN Centres, Communities, Youth, Royal Perth Hospital Inpatients of over Perth GPs. Shelters,

ffer: MULTICULTURAL AND REFUGEE ReachHEALTH? and Transitions. $300k + package. private billing practice. fully As an Area of Workforce Shortage, non-VR Doctors working with us can Our busy per South Metro Multicultural Health Clinic atseen.

The computerised & accredited. earn up to $10,000 week depending on the number of located patients A base salary is provided with bonus payments based on Medicare Bentley Centre provides a general practice service for culturally and four bedroom home & pool with gardening team supplied. billings.

Salary sacrifice Imagine these earnings andpatients. still fit inThe three rounds of golf week. linguistically diverse clinic operates onper Mondays and is available. The positions available have full relocation, 6 weeks paid leave. flexible from part time to full time.

Wednesdays from 8.30am 4.30pm and we arehours looking for General Flexible roster arrangements are –available and earnings are based is looking for a part time VR Doctor to practice nurseWASHC to work on a sessional basis. e n s available. l a n d on a fee-for-service Practitioners structure. Doctors working with us pay a variable Qualifications required Working 4.5 days week with shared onrewarding call. fillper possibly the most GP position: commission We offer conditions, attractive remuneration, fully are FRACGP (or for short term contract up of friendly any feeswork billed, based upon their commitment.

or Gold Coast

to 6 months equivalent qualifications). Experience and skills in accredited clinic, nurse and interpreter support.

Long consultation times workingmedical with homeless For more information on joining our growing team, people an advantage.

Meaningful connection to patients Please call Jenny Wells at the Canning Division tact roger 0427 960 722 or Email: rb.tpmed@bigpond.com (08) 9227 6658 or visit our contact Chad Stewart on

Ability to make real changes to patient’s lives on 9458 0505 for further information.

Contact the Practice Manager Bobby Dougall to discuss. ave full regIstratIon (no FRACGP needed) website: afterhoursmedical.com.au Very appreciative patients e to work as a Doctor in Private Practice on Phone: (08) 6260 2092 Incredibly positive feedback nd’s, Gold Coast?

Opportunity to achieve professional status 500,000 ++ per year General Practitioner – StreetDoctor Excellent remuneration ABurdoo pibara Perth Primary Care Network (PPCN) is a not-for-profit organisation in the primary health Position primarily focuses on functional male sexual health. care industry. PPCN operates a mobile medical StreetDoctor service that takes primary r cv to: docs@medcall.com.au healthcare to the marginalised populations of Perth. We are currently seeking a Vocationally Working with a Clinical Male Urology Nurse means the position dr tom Challenger 0409 761 053 Registered General Practitioner to join our committed team for two shifts per week. The two shifts is suitable for both male and female Doctors. that we are currently seeking to fill are on a Monday between 9am-3pm, and on a Tuesday between training and support provided.

12-3pm. ou like to beFull independent?

Are you looking for a BuRSWood try change? Then this is the job for you!!!

General Practitioner – After Hours Clinics unity Wanting higher remuneration and is not Forlooking more please contact on 9389 afraid of aGP. bit of hardtown work? hasDr David Millar oy travel? Are you forinformation burdoo Township needs a new The PPCNWest operates thePerth Perth 1400 After Hours GP Clinic, located insuites East Perth and available the Swans After Hours GP Medical www.wasexualhealthcentre.com.au ive to General established busy bulk billing Clinic, located in Middle Swan. The Clinics are General Practice Centre’s offering medical services pulation ofPractice?

2000, mostly Well young families.

Forum e you sick of not seeingMedical your family?

CLASSIFIEDS

VR GP required 244m² up to full time.

Rent: $325/m² plus outgoings and GST Fitted out – waiting room, consulting rooms, dressing room, Ocean Reef, x-ray room and reception Fully cabled Western Australia.

5 secure car bays available.

walk-in clinic looking for a full/part time cine consulting, may be for you.

7hrs 4.5 days per week.

VR GP. Provided Solo on-call but minimal call out, full hospital support.

Higher return than private billing clinics. entives Huge on-call bonus and excellentNon income. full relocation corporate, RN support with onsite team available. Computerised and accredited.

300k plus package. pathology. ed national network of travel 4 bedroom home with pool and gardening No patientteam baseplus required. iding excellent support subsidies, allows you to earn a great with lotshours. of DWS ncome available after hours hours to join the family.

Phone Dr Ang 9472 9306 or email Education is encouraged sonseeker@gmail.com dicine/Tropical Medicine/ al medicine tact roger 0427 960 722 or Email: rb.tpmed@bigpond.com seeking a advantage.

Senior Medical Officer to join our : GP – VR an Department at St John of God Hospital Murdoch. r eral Practice & Occupational Health Doctors me to: ecseeking General Practice and Occupational Health Doctors and Acute Medicine experience is preferred.

A GP rdin@traveldoctor.com.au portunities to and support our metropolitan, regional rural clinics naesthetic procedural skills would be and ideal.

6461 7353 Australia. Locations in Western Australia can include the Pilbara

directly › to the public and to patients via the overflow from hospital emergency. We are currently seeking › a VR GP to join our committed team at our Perth Clinic on alternate Saturdays from 5.30pm – 10.30pm, and at our Swans Clinic on Mondays from 6pm-10.30pm, and up to three hours on › Wednesday and Thursday nights. These shifts may be filled by one GP or shifts may be separated..

Beachside Medical Centre, Matt Campbell in Yanchep Contact CPG Corporate Real Estate

› positions offer an attractive rate and a pleasant and professional working these › environment. for more information please contact tracey Snowden, Human resources Manager on 9376 9200 or to apply please send your resume to hr@ppcn.org.au An excellent opportunity for further information on ppCn please visit our website at www.ppcn.org.au

to join a group of experienced and dedicated General Practitioners in an established, independent practice.

0423 477 333

Full Time VR GP Required

Our clinicians are committed to providing high quality, evidencebased care for the local community.

Opportunity And - $598,000 (no GSt)

• Well established in Perth’s northern corridor; 20 minutes DECEASED ESTATE exists for a doctor from CBD, 6 minutes from City of Joondalup.

• Private billing. to take over patient base. heatbelt regions, and interstate locations may range Emergency Department, located adjacent to existing thefrom MEDICAL PROPERTY FOR SALE FRemantLe nia and Hospital Queensland to Victoria.

We also regularly provide services • Up to 70% of billings.

Stanley site, treats approximately 25,000 ed · • Full Practice currently fully Located in Maddington adjacent ents their remote sites or offshore Youtime will enjoy the VR) Partfacilities. time Full (preferably support fromtpractice nurses. per at annum with seeking significant acuity, andorplays a key practice in Morley Join now and receive accredited, computerised to Maddington Centro Shopping ng benefits: GPs wanted. n the training of medical students and trainees in • including Full range of services from iron infusions to weight a Pathology centre, Centre privately Full time, time or short term locum eLLenpositions HeaLtH is a doctor-owned and Emergency Medicine. erms andpart conditions.

Psychologist loss management. and W Chiropractorowned, bonus $100k upfront Mentoring, ongoing training anda development managed General Practice operating · Opportunity to buy real estate – tact Mrs Karen Meiers at Ps

Exposure to all high aspects of general practice or occupational h to practice quality patient care and continue from two locations in port city of inet.net.au medicine with quality client consultations wn education in pleasant surroundings, Fremantle.

Our Practice is locatedyou in are the fast growing Opportunities advance into travel, diving andwork aviation ged to apply.toOpportunities for weekend andmedicine

deceased estate

northern corridor · Modern brick and tile construction Well established base, offering with work hours that are patient very sociable with plenty of opportunity K/GReenWood ole will encompass: sacrifice benefits enhance thea competitive broad suite ofsalary. services including · Large block work/life balance you enjoy time with family. ed of working infor a family bulk billing nutrition andensuring lifestyle, specialised General practice, and accident / emergency medicine

rf-contained information, please contact Director ofand Emergency consulting rooms, suit and having to see patients • 2 Complete consulting rooms Shared on call and other services to hospitals and/or multipurpose pregnancy midwifery care, alth practitioners, partially leased.

Medicine, Drand Andrew Jan onREQUIREMENTS 9366 1271mental or health nursing and nutes?

ESSENTIAL centres [rural remote locations] community • Fenced 737sqm block on-site parking.

Rustic charm with email andrew.jan@sjog.org.au Occupational Health medical assessments and General Practice ling unappreciated? skin clinic consultations.

Vocational Registration • Quality construction & fitout construction and fit-out. units Acute injury treatment andBoth management mall, friendly, private billing If you were to join our team we Full AHPRA Registration eir own reception and waiting Health surveillance • Loads of parking tice which provides the apply, visit www.sjog.org.au/murdoch and will offer you:

Employer liaison and and consulting site work storage ftoilets, General Practice Services click on “Job Search” • Air conditioned • A growing The lovely treed gardens blend well WHY WORK WITHpatients US database of Private ill need: Mole Max dermoscopy and Billing • Partially tenanted ved verandahs. work. for registration Eligibility Western Australia, Queensland or Ownerinoperated, non-corporate • A professional and dedicated Victoria and/or National registration fully equipped, dedicated support team Flexible work hours A caring0403 and quality commitment to providing general and Room. almer 621 899driven or 9274 5000 • Awww.realestateplus.com.au lifestyle the location occupational practitioner health services and a tailored desire to to continue urs or weekendLong work. established clinic • Hours of work to suit our earning. heng 0402 201 311 Stable, friendly and fun work environment balanced lifestyle approach

·

Current practice not operating at full capacity - plenty of room for expansion

·

• One Onsite pathology. privately room leased : G to pathology managed, new • centre Informal welcome. nd visits are

li tra

practice with option to buy in.

s“Arcadia Waters” contact Mark on 0451 081 652 or uPlease 3 senior GP’s to support. and visit www.ormc.net.au – A· mrobins@ormc.net.au Demographics – retirees, Procedural not req but available. ·

Close to retirement village

young on Visitingfamilies rights to and localindustrial hospital. Specialist workers ati and emergency department cover nearby. c o Facilities with latest technology and equipment.

L Experienced full time nurses to support.

This property is a rare find not ndand would %e adeceased be available except for estate. l email details to practice Manager; So hurry to secure! of billings sty elaine@leschmed.com.au or contact 9725 8471. iL fe For more information please offered

70

contact Centex Commercial Rick Bantleman 0413 555 441

With a reputation built on quality of service, Optima Press has the resources, the people and the Computerised FORUMwa C S D M a S t e R pag e S Part-time VR GP for our - No after hours, on-call or hospital commitment to provide every client mily oriented surgery.

Own room work required at this time Accredited Non-Corporate the finest printing and value for High level of earnings Excellent full•time nursing support in treatmentwith room - 60% of Gross Billings money.

Experienced reception and administrative team y is computerised; Private Contact Practice Manager 9 Carbon Court, ling practice.

Bridie Hutton 0413 994 484 edic alFORUMwa C S D M a S t e R pag e S DWS location rse available part-time.

Osborne Park 6017 email: finance@ellenstreet.com If you–are interested in this Full Time opportunity at 9445 Beachside tact Practice Manager tel 8380 9479 4722. Medical Centre please send your CV to Vishnu - g_vinu@yahoo.com

ister your interest or for further information, please contact - Practice hours are Weekdays 8amR DepartmentWell on (08) 9242 0830 or systems established and processes 6pm, Saturday, 8am-4pm careers@primehealth.com.au or jobs@gemini.com.au

92 | APRIL 2017

Produced right here in Western Australia!

With a reputation built on quality of service, Optima Press has the resources, the people and the commitment to provide every client with the finest printing and value for money.

9 Carbon Court, Osborne Park 6017 } Tel 9445 8380

MEDICAL FORUM

MEN’S HEALTH – BUSINESS FOR SALE

GENERAL PRACTITIONERS REQUIRED DWS positions available in Busselton! Are you looking to relocate your practice?

Well established, centrally located clinic is looking for a new owner.

Practice is well resourced with full medical & administrative protocols. Training and transition period available complete with your own Urology RN Nurse. Rapidly expanding field of medicine with continued growth of patients.

This is a very rewarding opportunity for the successful buyer.

Confidential enquiries to Brad Potter on 9315 2599 or 0411 185 006 Email: brad@thehealthlinc.com.au

All our sites are fully accredited with AGPAL Nurses, admin & allied health support as well as pathology on site FRACGP or equivalent highly regarded but not essential

Brand New Consulting Rooms for Lease

Flexible hours, Full time or Part time available For Further information please contact:

North One Specialist Centre 109/9 Salvado Road, Subiaco

Dr Brenda Murrison – 0418 921 073 or brenda.murrison@breckenhealth.com.au Damian – Damian.Green@breckenhealth.com.au or 0423 844 268

Located opposite SJOG Subiaco main entrance on Salvado Road.

Sessional or permanent - especially suit practitioners with interest in venous disease/varicose veins e.g. Phlebologist/Dermatologist/ Cosmetic Physician/Plastic Surgeons/Wound Management.

Exceptional clean and modern fitout Light and bright NBN connected Large reception/admin areas

Mount Helena Medical Centre Full Time VR GP Required Join now and receive a bonus $50k upfront Our Practice is located in the fast growing hills region of Perth with work hours that are very sociable with plenty of opportunity for work/life balance ensuring you enjoy time with family.

ESSENTIAL REQUIREMENTS

Large consulting rooms (18.5m2 – 20m2) Amazing staff facilities include: spacious staff room, showers, gym, steam room, rooftop lounge/deck Undercover Dr/staff parking poss. (limited avail) Co-located with Dr Peter Bray, Vascular Surgeon Enquiries contact: louise@vascularsolutions.com.au

A SPECIALIST IS ESSENTIAL FOR ANY BUSINESS TRANSACTION The Health Linc specialises in:

Vocational Registration Full AHPRA Registration WHY WORK WITH US

Plenty of patient transport/parking options

70%

of billings offered

Owner operated, non-corporate Flexible work hours Stable, friendly and fun work environment Well established systems and processes Computerised Own room Excellent full time nursing support in treatment room Experienced reception and administrative team DWS location

> > > >

Practice Sales Corporate Negotiations Market Appraisals Rental Reviews

> Leasing Negotiations > Associate / Partnerships > New Projects

Call Australia’s national award winning Business Broker when considering your next transaction.

Brad Potter 0411 185 006 www.thehealthlinc.com.au

Certified and multi-award winning Business Broker

If you are interested in this Full Time opportunity at Mount Helena Medical Centre please send your CV to Vishnu - g_vinu@yahoo.com

MEDICAL FORUM

APRIL 2017 | 93

medical forum CLASSIFIEDS MEN’S HEALTH – BUSINESS FOR SALE

GENERAL PRACTITIONERS REQUIRED DWS positions available in Busselton! Are you looking to relocate your practice?

93

Well established, centrally located clinic is looking for a new owner.

Practice is well resourced with full medical & administrative protocols. Training and transition period available complete with your own Urology RN Nurse. Rapidly expanding field of medicine with continued growth of patients.

This is a very rewarding opportunity for the successful buyer.

Confidential enquiries to Brad Potter on 9315 2599 or 0411 185 006 Email: brad@thehealthlinc.com.au

All our sites are fully accredited with AGPAL Nurses, admin & allied health support as well as pathology on site FRACGP or equivalent highly regarded but not essential

Brand new Consulting rooms for lease

Flexible hours, Full time or Part time available For Further information please contact:

north one specialist Centre 109/9 salvado road, subiaco

Dr Brenda Murrison – 0418 921 073 or brenda.murrison@breckenhealth.com.au Damian – damian.green@breckenhealth.com.au or 0423 844 268

Located opposite SJOG Subiaco main entrance on Salvado Road.

Sessional or permanent - especially suit practitioners with interest in venous disease/varicose veins e.g. Phlebologist/Dermatologist/ Cosmetic Physician/Plastic Surgeons/Wound Management.

Exceptional clean and modern fitout Light and bright NBN connected Large reception/admin areas

Mount Helena Medical Centre Full Time VR GP Required Join now and receive a bonus $50k upfront Our Practice is located in the fast growing hills region of Perth with work hours that are very sociable with plenty of opportunity for work/life balance ensuring you enjoy time with family.

ESSENTIAL REQUIREMENTS

Large consulting rooms (18.5m2 – 20m2) Amazing staff facilities include: spacious staff room, showers, gym, steam room, rooftop lounge/deck Undercover Dr/staff parking poss. (limited avail) co-located with Dr Peter Bray, Vascular Surgeon Enquiries contact: louise@vascularsolutions.com.au

A SPECIALIST IS ESSENTIAL FOR ANY BUSINESS TRANSACTION The Health Linc specialises in:

Vocational Registration Full AHPRA Registration WHY WORK WITH US

Plenty of patient transport/parking options

70%

of billings offered

Owner operated, non-corporate Flexible work hours Stable, friendly and fun work environment Well established systems and processes Computerised Own room Excellent full time nursing support in treatment room Experienced reception and administrative team DWS LOcATION

> > > >

Practice Sales Corporate Negotiations Market Appraisals Rental Reviews

> Leasing Negotiations > Associate / Partnerships > New Projects

Call Australia’s national award winning Business Broker when considering your next transaction.

Brad Potter 0411 185 006 www.thehealthlinc.com.au

Certified and multi-award winning Business Broker

If you are interested in this Full Time opportunity at Mount Helena Medical centre please send your cV to Vishnu - g_vinu@yahoo.com

May 2017 - next deadline 12md Wednesday 12th April – Tel 9203 5222 or jasmine@mforum.com.au