Medical Forum WA 0818 Public Edn

BIG Shoes To Fill

Child Health: IBD, Chickenpox, T2D, Hyperhidrosis, UDTestis, Rheumatic Fever.

Features and Lifestyle

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August 2018

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EDITORIAL Dr Rob McEvoy, Medical Editor

A Knock-on Effect Worth Exploiting A lot is happening with children (see image this page). We offer you the Child Health edition. We’ve noticed that doctors at the new Perth Children’s Hospital are bunkered down and presumably busy adapting to their new environment. The Hospital opening has been a long time coming and some disillusionment is to be expected from within and without we hope things iron out for everyone.

observe them until they got over their suspected poisoning or that infection that might turn nasty.

With beds costing over $1000 a day and other pressures on bed space, more rigor is applied at the door, parenting abilities are assessed, and more people are sent back home.

Under this system, someone will inevitably be off the mark and kids will be the casualty. That’s when we must ensure complaints are listened to and acted on and we have a free fair media. And this despite any politicking!

Meanwhile, whether you are in primary care or a tertiary hospital, successful Sahara Pittaway (8 years, with medulloblastoma) shakes hands with interventions today can We live in the Age where Dockers player Lachie Neale while Andrew Brayshaw and Captain Starlight make all the difference people want runs on the (with the balloons) look on? Starlight, are a national organisation that amongst tomorrow. And time will board but what ‘runs’ do other things, make wishes for sick kids come true. too, time to listen. I’m we give priority to, when thinking about childhood the knock-on effect from obesity and the tendency whatever paediatricians to later diabetes, vaccinations and childhood infections, do with kids can have profound effects later in life? The mental health problems and their social determinants, injury justice system is not a glowing representation of how to prevention in the car and home, and the diagnosis parents do things but early mental intervention can make all the seek of their child’s rare disorder - amongst other things. difference here.

Parents of children are fed by the media. They see stories of children losing fingers and toes due to rapidly progressing infections, drug-crazed kids damaging people that love them, and how technology will save the day. Little wonder the parents, who are time-poor like the rest of us, want the antibiotics and to get on with their lives, now!

We are told children are not young adults when it comes to medicine. This is why we have paediatricians and Perth Childrens Hospital. But people who work there often know of antecedents encountered in primary care in the community and can see long-term savings if we invest in the ‘next generation’.

Time. There is a general rush to get things done in the adult world. For example, we used to put kids in hospital and

What a great opportunity for medical cooperation around these vulnerable people, our children!

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Marketing Manager Kirsty Fitzpatrick (0403 282 510) advertising@mforum.com.au

MEDICAL FORUM

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

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

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

AUGUST 2018 | 1

CONTENTS AUGUST 2018

INSIDE 10-11 14 16-17 34

Patient Feedback the Safe Way Close-up: Prof William Hart Building Health & Social Equity Vaxers Can Be Opinion Leaders Too

14

10-11

NEWS & VIEWS 1 Editorial 4 Letters to the Editor

16-17

34 MAJOR PARTNER 2 | AUGUST 2018

6 6 7 12 13 19

RATS in a Trap - Prof William Hart HealthPathways Survey - Dr Richa Tayal Medical Students & Bullying – Prof Gervase Chaney The Downside of Better Access – Dr Peter Maguire ED. Clarifications Have You Heard?

Curious Conversation Beneath the Drapes A Prompt For Timely Reflection Staring Down Fear of Suicide App Review: Keeping Tabs on Kid’s Health

LIFESTYLE 32-33 Dr Su’s Insect Diary 35 Doreen’s Legacy 36 Wine Review: Three Dark Horses 37 Potty About Potter 38 Choosing the Musical Life 39 The Funny Side 40 Competitions

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MEDICAL FORUM

CONTENTS AUGUST 2018 CLINICALS

5 Chickenpox: No Adults Allowed Dr Sharon Halasz

25 Childhood Type 2 Diabetes Dr Jacqueline Curran

25-27 Hyperhidrosis in Children Dr Colin Kikiros

27 Acute Rheumatic Fever & Rheumatic Heart Disease Dr Deane Yim

HAVE YOU HEARD? The Nation’s Health The latest report from the Australian Institute of Health and Welfare (AIHW), Australia’s health 2018 says Australia sits squarely in the best third of OECD countries when it comes to life expectancy (girls living to 84.6 years on average, while boys living to 80.4 years). Fewer of us are smoking or drinking alcohol in excess than in the past. More of our children have been immunised and we’re doing well in terms of preventing avoidable deaths. But with a population that is living longer, we are now experiencing higher rates of chronic and age-related conditions. Half of Australians have a common chronic health condition, such as diabetes, heart disease, a mental illness, or cancer. Importantly, almost a quarter of us have two or more of these conditions. We know that older Australians use a higher proportion of hospital and other health services and 75% of all PBS medicines were dispensed to people aged 50 and over. And with health spending continuing to rise—reaching $170 billion in 2015–16 and outstripping population growth—we see the important role our health system plays in both prevention and treatment. Around one-third of our nation’s ‘disease burden’ is due to preventable risk factors. About 6 in 10 adults—or 63%—are either overweight or obese, while carrying too much weight is responsible for 7% of our total disease burden. The report shows a clear connection between socioeconomic position and health—compared with people living in Australia’s highest socioeconomic areas, those in the lowest group are almost 3 times as likely to smoke or have diabetes and twice as likely to die of potentially avoidable causes. Those in the lowest group are also more likely to have cost barriers preventing them from accessing health services—more than twice as likely to avoid seeing a dentist or filling a prescription due to the cost. The impact of socioeconomic position on health can also be thought of in terms of disease burden, with those in the lowest socioeconomic group experiencing disease burden 1.5 times higher than those in the highest group.

Indigenous Australians lag behind as expected with improvements in lifestyle factors but the report shows that social factors are key to making further progress—employment, education and income. ...read more on Page 6

29 Undescended Testis: An Update Clin A/Prof Parshotam Gera

30 Inflammatory Bowel Disease in Children Dr Zubin Grover

GUEST COLUMNS

8 GPs Searching for New Relevance Dr John Terry

19 Strength in Diversity Ms Louise Sheehy

21 Women In Orthopaedics Dr Kate Stannarge

23 Take Sextortion Seriously Dr Amy Warren

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

AUGUST 2018 | 3

LETTERS TO THE EDITOR RATS in a trap

HealthPathways survey

Dear Editor,

Dear Editor,

RE: The (July edition) pieces on the problems of “medical professional culture” and the normalisation of bad behaviour in the workplace (bullying, harassment, etc).

GPs can help shape the future direction of the online health information portal, Healthpathways, by taking part in a study run by Curtin University.

RATS – Resilience, Adaptation, Transformation, Sustainability - is a framework invented by Scandinavian socioecologists to explain how environments react to stress. We’ve talked about individual people being resilient (able to “bounce back”) ‘till we are blue in the face and it is now thought of as “blaming the victim”. This puts the onus on an individual to learn how to cope, rather than seeking to change their environmental stressors.

Of course we want people to be able to cope with life’s pressures. Too much cotton wool will result in more vulnerable people, not less. But what about the environment, the culture?

Medical culture itself is under stress and has been for a long time. Will the profession bounce back to “the good old days” i.e. be resilient? Or do we need to transform and become sustainable for the era of 2020-2050. What will that look like? Anyone who’s been involved in major organisational change knows how “resilient” organisational culture can be. Transformation doesn’t happen on its own. What’s the plan, what’s the process, where’s the champions, what will drive behaviour change?

As the Dean of a new medical school, I’m trying to meld challenge with caring, with compassion, and with respect, in the way students are taught and the experiences they are given. It’s definitely easier in a new organisation than in an established one with lots of inertia, but how can each one of us transform our organisational cultures?

Prof William Hart, Dean, Curtin Medical School

This confidential survey will evaluate current usage and takes about 10 minutes to complete at https://is.gd/ HealthPathwaysSurvey (open until August 31). For more information please contact Richard Varhol on 6278 7931 or richard. varhol@wapha.org.au Dr Richa Tayal ......................................................................

What we do at Notre Dame Dear Editor, While there are ‘hopeful signs’ that both morale and culture have improved following the WA Dept of Health’s introduction of a variety of health and wellbeing initiatives for Doctors in Training (DiTs), results of a recent national Preparedness for Internship survey highlighted the need for greater support for medical students.

Most of the 658 interns who responded to the AMC and Medical Board survey did not think that medical school had prepared them well for seeking support for psychological distress, bullying and harassment or raising concerns about colleagues who were distressed and not performing.

Five years ago, the School of Medicine here identified the need for a formal program to help first year medical students manage stress, improve wellbeing, enhance communication and relationships and maximise productivity.

The increasing demands on medical students required a more formal approach

We welcome your letters and leads for stories. Please keep them short.

Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. Letters, especially those over 300 words, may be edited for legal issues, space or clarity. You can also leave a message. www.medicalhub.com.au

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 | AUGUST 2018

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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.

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

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and we initiated a health and wellness program – in consultation with Monash University’s Dr Craig Hassed. Known as ESSENCE +, it is based on seven health pillars - Education, Stress Management, Spirituality, Exercise, Nutrition, Connectivity and Environment with a plus sign that expresses Emotional Intelligence.

The model is based on two-hourly sessions each week for eight weeks; small group sessions integrated into the medical curriculum.

Extensive training ensures the effectiveness of the program, with 13 tutors required to facilitate and direct the sessions. A central component is a focus on mindfulness and its application to student study stresses and future clinical patient treatment. Evaluation and research has been undertaken.

Importantly, such health and wellness initiatives will be extended into the clinical years, and the school looks forward to playing a meaningful role in further improving morale and culture and supporting the health and wellbeing of our graduates.

Dr Gervase Chaney, Dean, School of Medicine, Notre Dame University (Fremantle) ......................................................................

Clarifications & Corrections June edition p30. In “Hepatitis C infection update” the correct spelling of the combination drug in the first paragraph is HarvoniTM. Some of the drug approval dates may not be entirely accurate. As the author Dr Wendy Cheng says, her comments avoid some of complexities and are directed primarily at community prescribing GPs and exclude difficult to treat patients. She emphasized again that DAA experienced patients should only be treated by specialists. ......................................................................

May edition p45. In “HbA1c insights” a typo in the conversion formula provided

by Dr Tim Welborn is out by a factor of 10 so we thought we might point it out after someone brought it to our attention. The correct version is HbA1c% = Fructosamine (umol/L) x 0.017 + 1.61.

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MEDICAL FORUM

Major Partner: Clinipath Pathology

By Dr Sharon Halasz Clinical Microbiologist

BACK TO CONTENTS

Chickenpox: No Adults Allowed Varicella zoster virus (VZV), part of the herpes family, occurs mainly as a primary infection in childhood (chickenpox) and may reactivate in late adulthood as zoster (shingles).

Just to make life interesting, varicella and zoster can appear at any age.

Varicella (chickenpox) VZV is highly contagious and will spread through all non-immune contacts within a household. Infection is acquired by direct contact with skin lesions or by airborne spread from respiratory secretions (varicella or disseminated zoster). Patients are infectious from two days before onset of the rash until all lesions have crusted over.

A significant exposure includes household contacts, or face-to-face contact for at least five minutes, or staying within the same room for one hour.

The incubation period is 10 to 21 days.

To protect others, within a healthcare or childcare setting, the exposed individual should be isolated from 8 to 21 days after exposure. If they received Zoster immunoglobulin (ZIG) as a preventative measure, then isolation should extend to 28 days.

The generalised, itchy, vesicular rash is usually mild in childhood. In contrast, adolescents and adults can develop more severe varicella. Complications include secondary bacterial infection, pneumonia, meningitis and encephalitis.

Immunocompromised individuals of any age are prone to more severe and prolonged infection.

Varicella in pregnancy and the neonate Maternal varicella can be particularly nasty. Prevention is best. Watch out for pneumonia, especially in women with underlying lung conditions and smokers.

Intensive care admission for ventilation may be needed.

The timing of infection during pregnancy has different outcomes for the child.

Congenital varicella syndrome results from maternal infection in the first twenty weeks.

Manifestations include skin scarring, limb atrophy, eye and CNS abnormalities.

Maternal varicella in the second twenty weeks of pregnancy may result in the child developing zoster at an early age.

Their primary infection occurred in utero.

The greatest risk to the neonate is from perinatal maternal varicella (within seven days before to two days after delivery).

17 – 30% of neonates develop severe varicella with a mortality rate up to 30%.

Zoster immunoglobulin (ZIG) should be given to the neonate, preferably within 24 hours of birth (or exposure).

About the Author Clinipath Pathology welcomes Dr Sharon Halasz to our Microbiology team. She graduated from the University of WA, and trained in Clinical Microbiology at Royal Perth Hospital, Princess Margaret Hospital, King Edward, and Sir Charles Gairdner Hospitals. Sharon then worked at Sonic’s laboratory in Queensland and at Westmead Children’s Hospital in Sydney, before returning to private pathology in WA.

Varicella vaccine is contraindicated during pregnancy so discuss immunisation before then. The zoster vaccine is for adults only.

Everything you ever wanted to know about the varicella and zoster vaccines is in the Australian Immunisation Handbook.

Zoster immunoglobulin (ZIG) can prevent or ameliorate varicella in non-immune contacts.

In short supply, use of ZIG is restricted to high-risk groups such as pregnant women, neonates and the immunocompromised.

Zoster (shingles) Zoster is the reactivation of VZV due to waning cellular immunity. It’s more common in those over 50. Typically, skin lesions are unilateral and in a dermatomal distribution. Complications include dissemination (in the immunocompromised) and post-herpetic neuralgia.

Laboratory testing The best test for varicella or zoster is VZV PCR. Collect a dry swab from skin lesions or vesicles. VZV serology confirms the diagnosis of varicella by the detection of VZV IgM or by seroconversion of VZV IgG (from Not detected to Detected). Patients with zoster already have VZV IgG. VZV IgM helps if detected, but it doesn’t always reappear.

What about the immune status of a contact? A history of varicella (or zoster) or completion of a course of varicella immunisation predicts immunity. If not, and there’s time, request VZV IgG. Serology to confirm immunity post-vaccine is not necessary as antibody levels are negative in up to 30% of vaccinated individuals.

Prevention – vaccines and ZIG Live-attenuated varicella vaccine is in the childhood immunisation schedule and is also recommended for non-immune adults.

Treatment Antiviral therapy is not required for varicella in immunocompetent children with healthy skin. Antivirals (aciclovir, famciclovir, valaciclovir) are recommended for children with pre-existing skin disease, the immunocompromised, pregnant women, neonates, and individuals with severe disease. Start treatment within 24 hours of onset of rash, if possible, or up to 72 hours. For immunocompromised patients or anyone with complications, treat with antivirals regardless of the duration of rash. Full treatment recommendations for varicella and zoster are available in the Therapeutic Guidelines: Antibiotic.

Further reading: Australian Immunisation Handbook.

Management of Perinatal Infections (Australasian Society for Infectious Diseases).

Therapeutic Guidelines: Antibiotic.

Key Points • Preferred diagnosis is by VZV PCR on a dry swab • VZV serology is not perfect, especially after immunisation • Include varicella in pregnancy planning • Adults – beware of chickenpox • If antivirals are needed, treat early

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

Patient Results: 9371 4340

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

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AUGUST 2018 | 5

HAVE YOU HEARD?

By the time this magazine hits your desks it will be two weeks into a three-month opt-out period for consumers wishing to move away from My Health Record.

Otherwise, a record will be created for them. The use of health information has been highlighted by publicity around Health Engine’s recent actions. This occurs on the back of Facebook’s alleged indiscretion. The Australian Healthcare and Hospitals Association and the federal Consumers Health Forum have come out in favour of this electronic record as well as the RACGP, AMA, Pharmacy Guild and the National Rural Health Alliance.

Privacy and security is another issue and is balanced against the need for better health information. Consumers will control who sees their record, what parts they see, and they can delete stuff. While it might be an overnight success in some instances, usefulness will depend on currency and accuracy, which nobody seems to own.

Opting in and opting out remains open to health consumers of which about 6 million are registered (but only 13,000 healthcare providers). The Australian Digital Health Agency has www.digitalhealth.gov.au to educate people. Federal Minister for Health, Greg Hunt, has been reassuring consumers their health information is secure (we hope no-one hacks in!). The ACCC is saying a 'consumer data right' (CDR) is on its way – enabling safe sharing of consumer health data with trusted service providers.

Youth inpatient mental health services The old Bentley Adolescent Unit will soon relocate as the East Metropolitan Youth Unit (EMyU), expanding in beds (from 6 to 12) and ages (16 to 24 years). Relocation to the new mental health unit at Perth Children's Hospital makes it all possible.

This adds to the 14 youth beds at Fiona Stanley, the 20 beds at Perth Children's (for children and adolescents), and the 8 ‘hospital in the home beds’ provided by

Sir Charles Gardiner. Stating that 75% of mental health issues emerge before the age of 25, the WA government says it is committed to providing for recovery.

It says this adds to the Mental Health Commission's targeted purchases for youth mental health initiatives; $1.9m for the WA Country Health Services (SouthWest and Pilbara); $1.4m for the South Metropolitan Health's Youth Assertive Treatment Team; and $525,000 for the provision of a specialist child, adolescent and youth psychiatrist in the Kimberley.

Mileage from rural capital works The current government is still getting mileage from its rural redevelopments, as “part of a $300 million capital works program that is improving infrastructure in 37 towns across the Wheatbelt, Great Southern, Mid-West and South-West regions. In the Wheatbelt, the program includes the redevelopment of Merredin, Narrogin and Northam hospitals, as well as upgrades to 23 small hospitals and health centres”. According to the press release, this is the biggest capital works program by the WA Country Health Service. Their latest highlighted refurbishments at Bruce Rock and Narembeen memorial health services, from kitchens to walkways.

New MRI licence for Kal The Federal Government will provide a Medicare-eligible MRI licence at the Kalgoorlie Health Campus, identified as an area of critical need. Gone are the 600kms drives to Perth to access a scan. The WA Labor government compares freely with other states when it comes to the GST and so it is here – saying WA has less MRI machines per head population, and longer wait times for MRIs than the national average.

ACCC and health The ACCC has called for simpler health insurance. Complex private health insurance policies and unexpected out-of-

pocket costs are increasing complaints (by 30% last year) and leading to some punters abandoning their hospital policies. In WA, some private hospitals and procedural specialists are already feeling the crunch.

Its annual report on the health insurance industry says consumer friendliness and transparency is what it is all about. Rising premiums are moving consumers to lower-cost policies with greater exclusions or a higher excess, or they are simply dropping their cover. Do benefits offset the premium increases, they ask? The ACCC has recently taken separate action against Medibank, NIB, Ramsay Health Care and Australian Unity. And its action against Pfizer over exclusive dealing for an anti-competitive purpose has been thrown out of Court. The allegation involved Lipitor and pharmacies. The ACCC has sought Special Leave from the High Court to appeal the Full Federal Court‘s judgment of 25 May 2018 which upheld the dismissal of allegations against Pfizer Australia Pty Ltd (Pfizer) by the trial judge. Will this be seen as more taxpayer money wasted?

Bowel trouble in WA In 2017, there were 7,234 cases of intestinal disease requiring medical assistance in WA, most likely due to foodborne transmission. Campylobacter and salmonella crop up most often, more than other states and comparable countries.

Poor food preparation and safety is key and with researchers let loose, it is hoped food industry strategies and national policies will eventuate aiming to reduce the number of salmonellosis cases by 30%.

The cost-benefit analysis on this will be interesting!

Melanoma mission Australia has the second highest rate of melanoma in the world (14,000 new diagnoses each year). Detecting melanoma early was the best way to prevent melanoma deaths. ECU’s Melanoma Research Group (MRG) has devised an autoantibody blood test (a combination

CURIOUS CONVERSATIONS Dr Tom Hill loves swinging a golf club but he probably won’t be doing it wearing the Green and Gold.

If I could be world-ranked in one sport it would be…

Golf, but currently it's a work in progress.

I think medical politics is… more interested in headlines than resolutions.

One of my best moments in medicine was… travelling to India with Australian Women's Cricket Team as team doctor. It was my one and only chance of wearing the Australian tracksuit and it sure turns heads at the shopping centre.

My best friend is… my 8-Iron.

6 | AUGUST 2018

Perth is an interesting place to live because… all the people who whinge about a ‘Perth winter’ have obviously never lived in Tasmania.

MEDICAL FORUM

BACK TO CONTENTS

My (or Your) Health Record?

of 10 antibodies that bests indicates melanoma) to detect early stage melanoma (i.e. before spread through the body) in around 80% of cases. Saving money is one aim say researchers with $201m spent on melanoma each year and another $73m on negative biopsies, usually invasive excisions. Patient and spokesperson for the group Mr Clinton Heal said, “My primary melanoma was not detected early, and I believe a simple blood test could have drastically improved my melanoma diagnosis and subsequent treatment since.” His ideas will be tested by further research but the blood test (MelDx) has been submitted for an international patent.

CEDA’s findings on us The Committee for Economic Development of Australia commissioned an online survey of over 2200 Australians, specially chosen to be represent broad community views.

They asked, ‘Who has gained from 26 years of uninterrupted economic growth?’

5% of people believe they have personally gained a lot; 31% of people are finding it difficult to live on their current income; 74% of people believe large corporations have gained a lot; and 79% of people believe the gap between the richest and poorest Australians is not acceptable. ‘Top five personal issues for the kind of Australia you want to live in…?’1 Reliable, low cost basic health services; 2 Reliable, low cost essential services; 3 Access to stable and affordable housing; 4 Affordable, high quality chronic disease services; and 5 Reduced violence in homes and communities. ‘Top five critical paths for Australia as a nation…?’ 1 High quality and accessible public hospitals; 2 Strong regulation to limit foreign ownership of Australian land/assets; 3 High quality and choice of aged care services; 4 Increased pension payments; and 5 Tough criminal laws and criminal sentences.

Home, home on the range About 70 WA Home and Community Care (HACC) services will receive $430m over two years for Home Support Services to help them transition to the national Commonwealth Home Support Program (CHSP). Older people living at home for longer is paramount. An extra $2.3m supports providers by offsetting costs.

The Commonwealth will offer the same level of funding currently allocated to eligible HACC services for older people - including transport, domestic duties, personal care, home maintenance and modifications, food preparation and meals on wheels, nursing, social support and respite care. This follows Minister Ken Wyatt’s press release on unannounced audits in Aged Care Facilities to produce “a quantum shift in aged care quality compliance and customer-directed care”. To oversee this Australia’s new, independent Aged Care Quality and Safety Commission, will operate from 1 January 2019. The Commission will combine the functions of the current Australian Aged Care Quality Agency, the Aged Care Complaints Commissioner and the aged care regulatory role of the Department of Health. Ken Wyatt says; “Since last July, the Agency has conducted almost 3,000 unannounced assessment visits on homes, targeting specific quality standard requirements, with nine homes losing their accreditation.” Adequate qualified staff, clinical care, nutrition, hygiene, dignity, privacy and security are under the spotlight.

Sydney GP Dr Harry Nespolon has been elected President of the RACGP. He won the election from Perth GP Dr Jags Krishnan and Brisbane GP Dr Bruce Willett. Dr Nespolan polled 1957 primary votes (2491 after preferences) from a total of 4628 votes. Dr Krishan polled 1097 and Dr Willett 1556 (2137 after preferences).

The total eligible membership is 26,446.

There has been a turnover of some members on the WA health service provider boards. Prof David Forbes will be deputy chair NMHS from September 1. Also joining NMHS are Prof Selma Alliex, Dr Christopher Etherton-Beer, Dr Hilary Fine, Carol Innes, Grant Robinson and Rebecca Strom. Laura Colvin and Mandy Gadsdon join the EMHS board and Kelly Howlett and Dr Diane Mohen join the WACHS board.

The Australian Digital Health Agency's chief clinical information officer, Dr Monica Trujillo, is leaving after two years.

Eight WA health researchers will share $1.5m of State Government funding in the New Independent Researcher Infrastructure Support (NIRIS). They are Dr Christopher Brennan-Jones (Telethon Kids Institute/UWA); A/Prof Anne-Marie Hill (Curtin University); Dr Helen Keen (UWA); Dr Ashleigh Lin (TKI/UWA); Dr David Martino (TKI/ UWA); Dr Debbie Palmer (TKI/UWA); Dr Annette Regan (CU); and Dr Shannon Simpson (TKI).

UWA finalists for the Premier’s Science Awards include Prof Stephen Zubrick (epidemiologist with Telethon Kids Institute) and Dr Melissa O’Donnell (psychologist at the Telethon Kids Institute).

Young people getting sozzled While tablets seem to be preferred by city-going young people, researchers in WA found that the proximity of liquor stores to home (within 5000 m) and not the size of the stall (i.e. > 300 m2 and > 600 m2) is associated with increased alcohol intake. “Young adult’s alcohol consumption appears to be impacted by liquor store density and convenience, rather than outlet size.” And a study from Finland says that heavy drinking adolescents showed increased concentrations of 1-methylhistamine, which, in turn, was associated with reduced brain grey matter volume. This 10-year follow-up study in eastern Finland used MRI to measure their brain grey matter volumes.None of the participants had a diagnosis of alcohol dependence. Meanwhile, back in Oz the Australian Institute of Health and Welfare (AIHW) has found that young people aged 10-17 under youth justice supervision are 30 times as likely to receive an alcohol or other drug treatment service (studied over 4 years to June 2016).

Just over 2,500 ‘dual service’ clients accessed both youth justice supervision and drug and alcohol services. Back then, cannabis was their principal drug of concern, alcohol came second, amphetamines was third and 3 in 10 were Indigenous. The authors called on a need for more integrated services and person-centered service delivery.

MEDICAL FORUM

AUGUST 2018 | 7

INCISIONS BACK TO CONTENTS

GPs Searching for New Relevance Medicine in the modern era is an illogical, inequitable and unsustainable system, suggests Dr John Terry.

It used to be that being a doctor was just about the most rewarding thing you could do with your life. When diseases were commonplace and surgery was akin to a miracle, the only thing between you and permanently shuffling off this mortal coil was a god-like character in a white coat.

Doctors doing something made a difference. Surgeons were gods and if you died you would have died anyway. And nobody sued you because you can’t argue with gods!

Well, things have changed and the feefor-service system rules, OK? Many would argue that the system is unfairly funded and doesn’t provide the best possible healthcare. It certainly doesn’t reward people for doing what makes the most difference – keeping people well.

The reality in general practice is that few patients present with a clearly defined condition needing ‘medical’ management.

In fact, many present with the physical symptoms of stress and anxiety or minor ailments. For most patients we see, we offer platitudes and reassurance but little of real value because we’re not trained to manage patients who don’t have a clear diagnosis.

We tell the patients to come back if they feel worse or when they ‘qualify’ for something more seriously ‘medical’.

Many patients vote with their feet and try their luck with alternative practitioners.

Maybe 40 minutes of Myofascial Release Therapy for a ‘cervicogenic’ headache is better value than a $90 10-minute consult with a GP and a script for an NSAID with the added bonus of gastritis.

It’s little wonder we start to question both our role and future relevance as we struggle with the dissonance between our training and what we are actually doing.

What do we do with all these ‘well’ people or the ‘stressed’ whose myriad symptoms don’t fit into the box of a treatable medical condition?

Is it time for a new paradigm, a different type of health system? Why not go back to first principles and look at the causes of current major health conditions? There’s now overwhelming acceptance of the link between stress, lifestyle and diet with the major causes of morbidity and mortality.

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MEDICAL FORUM

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MIDLAND ROCKINGHAM AUGUST 2018 | 9

FEATURE

Keeping patient opinion useful for health care providers and patients is a tricky path to walk.

A not-for-profit is picking its way through the minefield.

T

here’s an increasing number of digital and online platforms that allow a health consumer to tell their own story. Patient Opinion is one of them and the CEO of this not-forprofit, Prof Michael Greco, has some interesting things to say regarding online feedback platforms and their potential to make a significant difference in the medical sector.

“The whole Patient Opinion concept began when two UK medical doctors felt that the existing rating sites were demoralising and not particularly constructive.”

“Most of them consisted of disgruntled individuals shouting out their grievances with no one listening to them. There should, ideally, be a quadruple focus in relation to patient websites and they are patient and staff experiences, outcomes and ‘cost’, with the latter definitely not confined to the financial bottom line.”

“It’s well accepted, despite some ongoing resistance, that patient experience is now part of the lexicon. It just can’t be relegated to the ‘soft’ side of medicine and hard financial data bears that out. In the US, 60% of a hospital’s income is linked with meeting patient expectations and, in tandem with that, about 2% of total budget is withheld until there’s clear evidence that it’s taking place.”

“And we’re talking millions of dollars here!”

Hospitals are not hotels “The medical environment is complex and anything resembling a ‘star’ rating system is far too blunt an instrument. There’s just too much happening in a hospital, they’re not restaurants or hotels where an entirely different system of measuring customer ‘experience’ is appropriate.”

“We’ve extended this model into Aged Care.

Our affiliated website, Care Opinion has a strong focus on developing a conversation between residents, their families and the relevant organisations within the sector.”

“The former shadow Health Minister Tanya Plibersek has been supportive of what we’re

10 | AUGUST 2018

doing, particularly within aged care. We’re confident that we’ll get a lot of traction here in Australia because this is very much a 21st century way of doing things. These are patients and residents, not ‘consumers’ and they just want their voices to be heard.”

One of the significant features of websites such as Patient Opinion is their high level of engagement with healthcare providers such as hospitals and aged care facilities.

The funding model is underpinned by these organisations which see the value in subscribing to a reputable online platform.

It also fulfils some of their obligations to welcome and respond to patient feedback.

“All the responses to patient stories are moderated by us, as is the initial story itself. They just won’t get published until we’re happy with them. We’ll often talk with a subscriber and coach them if their response is overly bureaucratic. In fact, we set up webinars for just that purpose.”

Hospitals obliged to listen “These organisations are usually pretty keen to put it out there that Patient Opinion is the platform they use to drive feedback. You’ll see examples of that on their own websites and on their discharge letters, which makes it even easier for a patient to tell their story.”

“We’re happy to put responses from nonsubscribers on our website and anyone is welcome to use a published response as a template. The reason we do this is that a good level of communication reduces the likelihood of a formal complaint and, as we all know, that can be a long, unwieldy and unproductive process.”

Michael sums up the essence of a patient feedback platforms such as Patient Opinion.

“We’re really seeking to present stories that resonate. That’s a big part of the reason we display a photograph of the person actually making the response because it establishes a connection. This model is

MEDICAL FORUM

BACK TO CONTENTS

Patient Feedback the Safe Way

FEATURE far less adversarial than any complaints process. And it’s important to bear in mind that most people aren’t looking for a formal investigation. They just want to be heard and often it’s as much about helping others who may find themselves in a similar situation.”

of the others in that it’s got nothing to do with posting a rating for a service provider.

Patient Opinion is much more about developing a relationship between a health service and a person who’s experienced that service, for better or worse. It’s a lot more than putting a score on the door!”

“It’s so important to present a human face to a large organisation.”

“The transparency of this model fosters a positive cycle of feedback and this is something I’ve had a lot of experience with at Health and Disability Services and the HCC. I know how the system works and, from a consumer’s point of view, the wheels of the complaint process can move very slowly.”

Health Consumers’ Council The Executive Director of the Health Consumers’ Council, Pip Brennan, is a big fan of online patient feedback platforms that focus on developing a relationship and encouraging a conversation. Pip is also pleased to see that not all patient stories are tales of woe.

“It’s interesting to see that about half of the patient stories posted on Patient Opinion are uniformly positive. Around 5% are quite critical in one way or another, and the remaining 45% vary in tone. Of course it’s never as simple as that because, as we all know, the medical system is both vast and complex.”

“This particular site is different from a lot

“Patient Opinion provides feedback in as little as 72 hours and there’s a two-way protection built into the model. Both the person telling their story and the responder are subject to moderation before the post is published. You can’t blurt out that Dr Jones is a maniac!”

The two-way street “That just won’t be posted and, on the other side of the coin, a person who does have a valid grievance won’t receive an inappropriate response because that’s monitored as well.”

One of the real pluses of the system lies in its feedback loop.

“Here at the HCC we think this is a really positive tool for consumers and service providers alike. There’s a built-in ‘action

cycle’ that flags when a story has been told and when a response has been made. And, probably most importantly, a green light appears when a change has been made.”

“All of these features have the added bonus of encouraging health providers to actually write better responses!”

“Patient Opinion has been in operation for a decade in the UK and has been going for five years here in Australia. It gets a big ‘thumbs up’ from me!”

In the light of the HealthEngine data controversy, Pip said that while there were plenty of opportunities arising with the advent of digital and online innovations, the protocol of exchanging data for money had become something of a curse.

One of the reasons that the HCC has embraced Patient Opinion is that their website is under a Creative Commons licence and the data can’t be ‘on-sold’ in any way.

“We recognise and appreciate the quick response by Health Engine regarding recent criticisms about massaged online reviews and unclear privacy policies. There seems to be, unfortunately, a tension between running a business and protecting consumer data.

There also seems to be no doubt that nonprofits are a safer repository for patient data than some other profit-driven models.”

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MEDICAL FORUM

AUGUST 2018 | 11

NEWS & VIEWS

A Prompt for Timely Reflection had been reviewed and it was taking action.

News that online medical booking website HealthEngine edited consumer reviews and passed on consumer information to a legal firm has prompted a review by the Information Commissioner and the Australian Digital Health Authority on instructions from Health Minister Greg Hunt.

The revelations also prompted scrutiny from the Australian Health Practitioners Regulation Agency for potential breaches of National Law. AHPRA has since been at pains to disseminate its policies on testimonials and advertising and details on its updated tool to help advertisers understand what reviews can and can’t be published.

“We’ve since updated the tool to help advertisers get it right,” AHPRA CEO Martin Fletcher said.

“If advertisers edit reviews or testimonials there is a high risk that the edited reviews will become misleading or deceptive.

Only publishing complete and unedited reviews that are not testimonials will help advertisers to avoid breaching the National Law.”

In a statement on its website, CEO Dr Marcus Tan acknowledged that media reports had damaged the company’s reputation in the eyes of some patients and healthcare practices. In an attempt to rebuild that trust, it has stopped its third party referral service and its publication of user comments.

HealthEngine would stop third party banner advertising on its website from July 31 (image date was July 17).

“This is because reviews that don’t refer to the clinical aspects of care are not considered testimonials and, therefore, may be allowed. But even if the review doesn’t breach the ban on using testimonials to advertise, the advertiser may be breaking the law on misleading and deceptive advertising if the review is misleading because it has been edited or does not reflect all the feedback received.”

HealthEngine denies sharing information to a third party without patient consent, stating a consent prompt was provided in a “simple pop up”. However, as a result of the backlash it has written to its practices and health industry peak bodies to “put the record straight” and to reassure them that the company’s management of user data

Dr Tan also promised giving users “greater visibility and control over the way we manage their personal information”. The company would establish an advisory group to work closely with health providers, consumer peak bodies and regulators to ensure future products and services were informed by consulting more widely.

Putting the trust issues of consumers and doctors aside, the timing of such revelations is not ideal for the Federal Government which is hoping to have a smooth roll-out of its personal electronic health record early next year.

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MEDICAL FORUM

SPOTLIGHT

Staring Down Fear of Suicide For psychotherapist Antonia Murphy, the subject of suicide should be studied and understood by all who seek to prevent it.

S

uicide prevention has become a loud health narrative in the past decade but for many health professionals outside the day-to-day dealings with those at risk of suicide, it can be a frightening moment to have a patient declare they want to kill themselves.

neither can it be understood by simply equating it with mental illness.

Medical Forum spoke to UK psychotherapist Antonia Murphy when she was in Perth as part of an Australia tour speaking to GPs, psychiatrists and psychologists.

“There is an increasingly unhelpful emphasis on overall wellbeing and happiness, which gives rise to fantasies that we can and should all be fixed and this, in turn, champions treatments which only treat surface problems.”

She has been working with suicidal people for over 20 years and feels strongly that GPs, with support, have a key role in suicide ‘containment’.

“We are a risk-averse society so it becomes a compulsion for the health system to get swift and predictable results and to remove undesirable and unwanted human behaviour; to reduce everyone to manageable units of wellness or illness.”

Some rules don’t apply “We cannot help a suicidal person simply by diagnosing them within an exclusively biological framework – much more knowledge and understanding from us all is needed in this difficult terrain.”

Antonia writes in her book on the suicide, called Out of this World:

“I hope to help clinicians understand that the best thing they can do with a patient who is suicidal is to talk to them about their suicidal thoughts,” she said. “When a suicidal person withdraws and is only listening to their own tyrannical thinking, it’s very useful if somebody else talks to them about these thoughts and where they’re coming from.”

“It’s hard and foolish perhaps to try to make generalisations both about what suicide is and about why people take their own lives in such tragic and sometimes horrific ways. It will vary in the reasoning of the suicidal person and in their intent.”

“As soon as you start these therapeutic conversations, the person is still vulnerable but therapy can contain them from having to act. Containment is really important in suicide therapy but often a suicidal person frightens the person sitting opposite them.”

Antonia quotes suicidologist Edwin Shneidman who speaks of a suicidal person as having “thwarted psychological needs” and this, she writes, comes very close to describing the outrage and absoluteness of the suicidal person’s sense of life being against them. Their rage about this may not be at all conscious…but in the main a psychological condition.”

Calm heads required “If you’re both anxious and agitated, it can be dangerous.”

Antonia said that suicidal people often see a health professional before killing themselves, but they probably won’t have articulated suicidal feelings.

“It will manifest with statements such as ‘I feel tired’, ‘I don’t know what the matter is’.

They feel hopeless and believe no one can help. By the time they get to the withdrawn stage, they think the GP is hopeless, but the GP can’t read their minds,” she said.

Antonia said the medical model is the immediate reaction for doctors because a suicidal person is altogether too frightening and too difficult to face otherwise but

MEDICAL FORUM

“The one thing all suicides have in common is their destructiveness.”

“To understand suicide and work with it, in some cases to prevent it, is to explore, elaborate and bear the particular suicidal person’s story in mind, both their real story and their fantasy and give that person the conditions in which it might be possible for them to face and to tolerate what has been previously intolerable.”

Suicide is ultimately an individual and human story where there is no formula. “[It] is a complex, perplexing and deeply unsettling business, much like life, really,” she said.

“Concentrating resources on these socalled “high-risk” groups somewhat misses

the essential understanding about suicide that is necessary but often avoided within our national health, social and forensic services – namely that being suicidal is not necessarily an illness and as such it cannot be effectively treated within a formal medical model only.”

Helping self appraisal “The person, the patient, will always know more about themselves and their psychological pain than anyone else, even if they don’t know how to know this! They may well need a lot of help finding out what the ‘matter is’ but it means something vital to that person and it is up to us to help them work this out, not just try to make it go away.”

“In so doing we have a much better chance of transforming the suicidal impulse into something manageable.”

“We will never rid ourselves of suicide. We are sentient beings and so [even from a young age] we are able to contemplate it and tragically we are able to act on it. But at the same time we can treat it respectfully, we can take it seriously and not shy away from it. We can be more open and transparent about it and avoid being overly sentimental, simplistic or condemnatory.”

“Death by Suicide occurs in all walks of life and at all stages of life. Understanding suicide and resourcing those who are able to offer help, support and treatment to the suicidal is everyone’s business.”

By Jan Hallam ED: Antonia Murphy’s tour of Australia was supported by Healthe Care, which owns and operates the Abbotsford Private Hospital and Marian Centre in WA.

AUGUST 2018 | 13

CLOSE-UP

Life is a Big Adventure Next year, Curtin Medical School’s first cohort of undergraduate students will be pacing the corridors of metropolitan hospitals. It will be a proud moment for their Dean.

P

atience. It’s not very common in this quick, quick world we live in, but it is an attribute the dean of the Curtin Medical School, Prof William Hart, has in spades.

When he arrived in Perth from Victoria in 2012 on the invitation of Curtin University to help it establish the state’s third medical school, he could be forgiven for thinking the path might have been a little smoother and a little shorter than it turned out to be.

By the end of 2016, after a choppy voyage that featured a chorus of dissent from AMA WA and the Australian Medical Students Association, an impressive medical school stood proudly on the Bentley campus, the Australian Medical Council had approved its course, the State Government had guaranteed intern places, and 1500 school leaver applicants had been processed leaving 60 bright-eyed 18-year-olds ready to embark on a medical degree at the start of the 2017 academic year.

Speaking to Medical Forum with the school’s second intake of 70 students signed up, William reflected on those years of sometimes tough negotiation.

“I did a management and leadership course years ago and a lot can be achieved with patience. I have a lot of patience and I am able to wait,” he said.

Patience and time He quotes Tolstoy’s War and Peace: “Everything comes in time to him who knows how to wait…there is nothing stronger than these two: patience and time, they will do it all.”

“What seems urgent and vital can with time seem less critical – as long as you achieve your long-term goals.”

14 | AUGUST 2018

William’s own career trajectory, like many, has materialised part by hard work, part by design, and then a good dose of luck.

Perversely, he thinks, it might have been because it was the hardest course to get into.

He came to Australia in 1965 as a 14-yearold with his mother and nine-year-old brother as ‘£10 Poms’ from the north of England. He left behind two older siblings.

“I think I wanted to see if I was good enough to do it. I did the same sort of thing when applying for internships in 1973. Sydney’s Royal Prince Alfred was considered the premier hospital in Australia so I applied there just to see if I could get in. I did, but I stayed in Melbourne and did my internship at the old Queen Victoria Hospital and the Prince Henry, both now demolished.”

“My father had died in 1960 and my mother decided to create a new life for her two youngest children in Australia. We flew here on one of the last flights of the old Comet 4 aircraft, which had a tendency to crash.

We didn’t,” he said.

“Later, in my 40s, when I realised the enormity of what my mother had done, to pull up her roots and come half way round the world, I suggested to her that it must have taken a lot of courage. ‘Nonsense, William,’ she said, ‘it was just a big adventure’ and so it has been.”

“We lived in Dandenong on the outskirts of Melbourne where I went to the local high school. Barry Jones, the former ALP president and politician (and quiz champion), was a history teacher at the school.”

Education challenges “But I didn’t know anything about Australian history or geography and the move had disrupted my education. I almost failed Year 10 and didn’t do much better in Year 11 but managed to pull up my socks a bit in Year 12 and got into medicine at Monash and did reasonably well there.”

Both William’s parents had been psychiatric nurses but there were no doctors on either side of the family. Apart from the community midwife, who had helped deliver his younger brother at home, insisting on calling him Young Dr Hart and his interest in back yard chemistry, he’s not quite sure why he chose to do medicine.

Money was always tight in the Hart household. William gave half of his weekly Commonwealth Scholarship stipend to his mother and worked in the university breaks but the need for financial security prompted him to sign up with the Royal Australian Navy.

In the navy now “I joined the navy as a student and received a wage but it meant that when I graduated I was in the navy. In that first year, all I seemed to treat was broken noses and gonorrhoea. I didn’t see a medical career advancing very far that way, so I decided to pay myself out and started a career in civvie street,” he said.

“One of my teachers at the old Queen Vic was a professor of obstetrics and gynaecology and he tried to convince me to become a gynaecologist. It was there I became interested in the psychological aspects of women’s health, and relationships around human fertility. So, I undertook a second degree in psychology and became a registered psychologist, which I still maintain even though I have never practised as a psychologist.”

“However, I did learn a lot about human behaviour and issues such as compliance and non-compliance; lifestyle choices and

MEDICAL FORUM

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Prof William Hart

CLOSE-UP lifestyle influences on health. Ultimately that translated itself into an interest in public health and population medicine.”

“I became involved with what was known then as the Australian and New Zealand Society for Epidemiology and Research in Community Health which in 1991 became Faculty of Public Health within the Royal Australian College of Physicians and that became my career.”

Medical education – learning and teaching – have accompanied William throughout his career though it was only in 2006 that it became his main focus.

Ready to retire “I had a plan as a younger man that I would retire at 55. My wife and I had bought a property in South Gippsland near the beach, so we moved there. Then the Vice Chancellor of Monash, Richard Larkins, asked me if I’d be interested in helping set up a new medical school in Gippsland.”

“I never did get to retire. From Gippsland we went to WA and Curtin.”

“It is to my wife Natasha’s eternal credit that we came West. I thought after being at Monash for six years and being 61, that it might be time to retire and live in our house in South Gippsland. All our children (they have five between them) and seven grandchildren are in Victoria and my wife had elderly parents, so a move to Perth was disruptive. But Natasha offered me unqualified support.”

When William and Natasha arrived in Perth, the proposal for a third medical school at Curtin was greeted with antipathy. William thinks now that history suggests that this always happens.

“A new entrant is disruptive to the establishment because people don’t want competition. But I think in the case of Curtin, Australia had experienced a period of rapid growth in medical workforce numbers. My previous experience in establishing Monash University’s Gippsland Medical School was part of that growth.

Once numbers had lifted, there was genuine concern for our ability to cope with the numbers of graduating students.”

“Adequacy of internships and post-grad training positions was being questioned especially on the East Coast where the big universities were graduating large cohorts.”

International students concern “Universities were also worried they would not be able to offer post-graduate positions for international students who expected to complete their training and register as doctors and thereby gain permanent residency. An increase in domestic graduates threatened that market. While universities have never guaranteed internships for international students, it hasn’t mattered until now because there has never been a shortage of them.”

MEDICAL FORUM

“However, the situation in WA is different.

It has been relatively under-doctored for a long time and we have been reliant on IMGs to fill positions local graduates haven’t wanted to take – in rural areas and low socio-economic areas. In our research we found a 4:1 disparity in the distribution of GPs in the western suburbs compared to the eastern suburbs.”

And with that, came the strongest line of argument for a new medical school. Both federal and state governments were happy to hear that undergraduate Curtin medical students would be encouraged from day one to see themselves fulfilling service where they were needed.

In May this year, Curtin University signed an agreement with St John of God Health Care to provide student clinical placements at SJG Midland Public Hospital from 2019.

Curtin expects its Midland clinical school to open in 2020.

As the wheels start moving for Curtin students, William said time would provide many of the answers to questions around training and supervision.

“One of the historical consequences of not having enough doctors is a shortage of supervisors to provide training. This is currently the case. Fortunately, by the time our first graduates need supervisors – 2023 onwards – the increased numbers of graduates from UWA and University of Notre Dame will mean more senior registrars and consultants to supervise. It is a self-healing problem.”

“There is growing co-operation between the medical schools. The three deans meet regularly to discuss such things as hospital placements,” he said.

“Curtin has a focus on two particular hospitals – Midland and Peel – there are not a huge number of students from the other two schools in these hospitals.

However, we also want our students to rotate through RPH, SCGH, and FSH to get some experience of the bigger tertiary hospitals, and the deans are taking a co-operative approach to manage those placements. We don’t want to tread on each other’s toes.”

“The Department of Health is moving toward a student placement system that applies to all three medical schools and that seems to be working quite well.”

He also finds himself being drawn into the local medical establishment – having moved from a position of outsider to contributor.

“As dean I’m ex-officio on the council of the AMA WA and that is a very beneficial place to be because there is an awful lot of discussion of major issues there.”

As to his hopes for a Curtin-educated doctor? It will be a doctor serving a community that most needs his or her skills; a doctor who can communicate and listen effectively with patients and colleagues; someone committed to lifelong learning, and someone with patience… because it really does pay off.

By Jan Hallam

Then there were three Now sitting firmly into his second year as Dean, William sees the school as an accepted part of the WA medical landscape.

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AUGUST 2018 | 15

FEATURE BACK TO CONTENTS

Health and Social Equity Prof Rhonda Marriott wants Aboriginal people to lead research into Indigenous health to find solutions that work for their communities.

T

he Ngangk Yira Research Centre for Aboriginal Health and Social Equity was opened at Murdoch University in April as a culmination of life’s work or political lobbying. It has, at its core, a mission to drive improvements in the way the health system engages with Aboriginal people – and that, of course, means program design and evidence gathering to satisfy consumers and funders.

Prof Rhonda Marriott is the inaugural head of Ngangk Yira after a lifetime spent hands-on nursing and midwifery and a distinguished academic career.

Rhonda descends from the Nyikina Aboriginal people of the Kimberley and when she became head of Murdoch’s School of Nursing in 2003, she became Australia’s first Aboriginal person to do so.

After much of the past two decades dedicated to educating clinicians and reaching high levels of university administration, she felt something was missing. It was Prof Fiona Stanley who encouraged her into health research.

“I started thinking how I was going to end my career. I really wanted to do something that directly helped my people and Fiona suggested I look at research. However, I wanted to work on projects that would have some immediate effect and could also influence policy,” she said.

Practical politics The Minister for Indigenous Health Ken Wyatt, along with Fiona Stanley is copatron of Ngangk Yira. Rhonda sees someone with a measured approach who “honours the problems and the issues without watering them down yet doesn’t alienate anyone either” – necessary to push the Indigenous health agenda.

Research conducted at Ngangk Yira is focused on practical solutions and takes a connected life-stages approach to improve health from pregnancy to young adulthood.

It also recognises that strong parenting is the key to lifelong health of children, families and communities.

“To grow strong Aboriginal communities, we must start at the beginning by supporting mothers and families every

16 | AUGUST 2018

step of the journey from pregnancy. Even before a baby is born, the environment has a big impact on lifelong social, physical and emotional health,” Rhonda said.

One of the first projects has been to look at cultural security for birthing women in WA’s health system.

The study followed 39 pregnant women from various parts of the state and their experiences of ante-natal, birthing and post-natal services. The soon-to-bereleased report will be based on their stories and responses from midwives.

Rhonda says cultural security is a significant issue for some Aboriginal women who don’t feel safe in a maternity setting largely because of the impact of covert and institutionalised racism, and a lack of relevant models of care.

System alienates women “Our project was about Aboriginal women and their families but these findings could be relevant to any non-English, CALD woman. A simple example is the number of people the mother might want to invite into her room.

Hospital protocol of one or two people can overlook just how significant family connections are to the Aboriginal mother.”

“Midwives can perpetuate stereotypes, referring to Aboriginal women ‘from up there’, which can mean anywhere north of Perth; or suggesting women don’t know what a bed is; or they ‘want to go walkabout’; and, frankly, it’s just rubbish.

Aboriginal women, not surprisingly, feel insecure in those situations.”

“Aboriginal women also depend on continuity of carer – a midwife who understands them and who is sensitive to their needs – in other words truly womancentred care rather than clinician-centred care,” she said.

“When you don’t have continuity of carer; when you are not being asked about your expectations of your birthing experience; when you feel you’re not being supported or respected, or shown kindness, then you don’t feel safe in that environment.”

“We are formulating recommendations now to present to the Minister Greg Hunt when we meet him in November, but we really believe there are clear changes that can be made to models of care that will improve the experience for patients.”

Act on policies “And obviously clear changes around cultural competence of the workforce, with zero tolerance of racism, can be enacted now. It is already laid out in policy documents, but it needs to be operational.”

The cultural security project also explored imperatives around women giving birth on Country – on either parent’s ancestral lands. For Nyoongar women, giving birth in a metropolitan or South-West regional hospital is on Country, however, it becomes almost impossible for women in remote northern locations.

“Higher-risk pregnancies among Aboriginal women is acknowledged, but not all pregnancies are high-risk and currently there is not an individual assessment for women outside of Perth who want to give birth in their community with the support of a midwife,” Rhonda said.

“A woman in the Kimberley has no choice but to be removed at 36 weeks to their nearest regional centre, which would be either Derby or Broome, to give birth. So, it's human nature that women delay any ante-natal contact to improve their chances of birthing on Country and staying with their families.”

A successful trial in Perth, which saw six Aboriginal maternity group practices established, showed marked improvement in the number of pregnant women engaging with ante-natal services. Since the COAG funding stopped, only two remain – Moort Boodjari Mia at SJG Midland Public Hospital and Boodjari Yorgas at Armadale Hospital.

“Both services have continuity of carer.

There are Aboriginal grandmothers in the practice who journey along with the women during their pregnancy, and follow-up post-natally. Women feel comfortable, safe and supported and outcomes are much improved,” Rhonda said.

It works, why stop?

“All the targets of Closing the Gap are demonstrated at these two services. To have those programs, which we know work and make a difference, reduced from six to two is disappointing.”

“Our appeal is to have an Aboriginalfriendly group practice established at every maternity service. We are looking

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FEATURE

Prof Rhonda Marriott, Minister Ken Wyatt and Prof Fiona Stanley with two young mothers involved in the centre’s research. at the Aboriginal Maternal and Infant Care (AMIC) worker model. It has well and truly demonstrated that the program works in SA and we want to embed that model into our services and see more Aboriginal women moving into the maternity workforce.”

The Ngangk Yira Research Centre is also examining parental mental health through a population-based linked data project that will study the type, scale and timing of mental health problems in young Aboriginal people and their families. Data will be used to address some critical gaps in support for mental health development in “the critical first days” of a child’s life.

This research is expected to improve knowledge of the mental and physical health of Aboriginal children, pregnancy outcomes, child abuse and neglect, disability, contact with the juvenile justice system and education.

There are high hopes that a rubric, developed by researcher Jane Coates, may more accurately diagnose postnatal depression than the current scale.

It has been developed with close input

of Aboriginal women in the community and extends to supporting not only new mothers but also fathers.

“The app has a lot of illustrations which prompt discussions between health workers and prospective parents. The aim is to build the woman’s story so she is able to identify her strengths and pinpoint areas she would like help to change,” Rhonda said.

Gangsta grannies in action “The community will also be involved to ensure those couples whose family support is either inaccessible or absent are linked up with a grandmother in the community who is willing to journey alongside them.”

“We have had so many Aboriginal women elders throw their support behind this project. They are known as the ‘gangsta grannies’ and they have created a strong network right across the metropolitan area.”

Armadale’s Boodjari Yorgas, Midland’s Moort Boodjari Mia, Ngala, and Child and Adult Health Services, but we’d like to see it extended throughout the state and across the country – there has been so much interest in this.”

Individual participants will have access to their own data for their uses and researchers will also be able to analyse and evaluate the data.

Rhonda said the community was heavily invested in the project and as a result the program has been co-designed.

“It comes back to the heart of what we’re about at the centre. We shouldn’t be doing anything unless Aboriginal people are fully engaged and involved in the research every step of the way. And we shouldn’t be doing anything just for interest … there has to have some meaning.”

By Jan Hallam

“We will pilot this with the Nyoongar community in Perth through the maternity services at Fiona Stanley Hospital,

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Every day, Silver Chain’s ‘Hospital at the Home’ (HATH) services the equivalent of 200 hospital beds in WA alone.

Referring your patients to our service this winter (for conditions such as respiratory infections and cellulitis) goes a long way to helping them avoid long Emergency Department queues and get the additional health benefits of staying at home.

Our service includes home hospital doctor and nurse visits, 24/7 contact centre and detailed reporting back to each patient’s GP. Referral of your patient to Silver Chain is simple, call 1300 466 346 to speak to our Ambulatory Liaison Nurses. silverchain.org.au/hath

18 | AUGUST 2018

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Strength in Diversity By embracing differences and creating opportunities for all competencies, society will grow, suggests Ms Louise Sheehy, Acting CEO of Autism West.

There’s change in the air! Autism is being redefined and moving away from the old ‘deficit’ model towards something that’s more positive.

The merits of neurodiversity within the workplace are becoming recognised, particularly when people are paired with advocates and industry groups forging new pathways of opportunity.

The National Disability Standards focus on an individual’s right to make decisions that give a sense of ownership to the way they live their lives. It’s been a long time coming but the recognition that diversity is a good thing has resulted in more opportunities.

The Autism Centre for Research’s newly released guidelines on diagnostic assessment reaffirms that “understanding the strengths of an individual is just as

important for clinical management as identifying possible challenges”.

This is good news for the Autism community and offers potential avenues of work for all concerned.

It’s interesting to look at the break-up of National Disability Scheme figures.

Mid-way through last year about 29% of NDS participants, including those under the age of 15, specified autism as their primary disability.

That equates to about 138,000 people involved in some manner with the scheme.

At Autism West we support more than 150 individuals weekly across the metropolitan area and we’re committed to using a strengths-based approach that focuses on a person’s individual interests to promote engagement and opportunity.

Unsurprisingly, in this day and age, young people have a strong focus on the creative use of technology that allows participants to demonstrate what they CAN do!

Autism West has a growing workforce of facilitators with autism who are experts in their own area of interest who are also positive role models for participants in our programs. An empowering, ‘strength-based’ approach reinforces the importance of equality and showcases the sort of diversity that adds depth and value to society.

continued on Page 21

APP REVIEW

Keeping Tabs on Kids’ Health A Perth health tech is rolling out an App which aims to make life simpler for parents of children with chronic health conditions.

We’re drowning in an ocean of data that often results in too much information and not enough knowledge. Social entrepreneur, Cath Resnick decided to do something about it and has come up with Kindom, an App that stores a child’s medical and developmental records on one secure and accessible platform.

“Think about a child with epilepsy, or any young person with complex health needs, who’s just about to start school or even just change classes. For parents, one of the biggest bugbears is having to explain to a teacher or even a babysitter just what a child might need in the way of support.”

“This sort of thing has been tried before but it wasn’t really suited to the needs of the people who were most likely to use it. I’m talking here of individuals we call ‘super-users’, patients with chronic health challenges and parents of young children with similar issues.”

“A platform such as Kindom is valuable because it provides one central location for a lot of information. It can also be updated and integrated with other applications.”

“It’s not easy for a parent or carer to be continually across all the health, developmental and social markers of their child. It can be quite stressful trying to manage all that, particularly within a school environment.”

Cath provides an example that places this issue in a practical context and expands on some of the frustrations experienced by a parent.

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“It often has to be repeated a number of times and it’s easy for the parent to come across as being interfering or controlling.”

“Often a medical specialist will ask a parent for detailed information and Kindom acts like a diary where relevant details, including uploading photos and video, can be recorded. And it can integrate with other platforms and organisations such as the Australian Digital Health Agency (ADHA), which is rolling out My Health Record.”

“There’s a cultural aspect to this as well.

The Kindom app would be well suited to Aboriginal communities where it may not always be just one person looking after a child’s health needs. In the real world it’s

not always the biological parent dealing with these issues.”

“To have critically important health information collated in one place that also shows trends and trajectories over time is invaluable.”

Another aspect of the Kindom experience is the KinLife Journal, which taps into the opportunities provided by social media.

“Many families use the app platform as a journal, accompanied by images that can be shared in a private and secure manner on other social media platforms. This gives a qualitative aspect to the stored information that also serves as a health timeline for each family member.”

By Peter McClelland

AUGUST 2018 | 19

20 | AUGUST 2018

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Women in Orthopaedics Gender diversity within surgery is a moving target, says Dr Kate Stannage.

I recently won the Excellence in Women’s Leadership Award. Why am I telling you this? It’s certainly not for self-promotion or the need for acclaim. No, I am telling you this because it is an example of how far surgery has come, and how far we still have to go in recognition of gender equality and meritocracy.

My first reaction when I was informed about the award was, ‘Why me? What have I done that’s so special?’ I looked at the award winners in other states, household names such as Magda Szubanski, Gillian Triggs and Nova Peris. I felt somewhat inadequate and a bit embarrassed. But then I spoke to my colleagues, friends and family and realised that as a female orthopaedic surgeon, achieving leadership roles and parity with male surgeons is actually fairly noteworthy.

In WA there are only three female orthopaedic surgeons! Three extraordinary orthopaedic surgeons!

So, I guess a few facts about orthopaedic surgery need to be stated. In Australia about 3% of the consultant orthopaedic workforce is female. This is significantly less than the often-reported standard of Chairs of ASX-listed companies, which currently stands at 6%.

There are new regulations regarding appropriateness of material presented at scientific meetings. A diversity strategy plan is about to be launched and there’s an active Orthopaedic Women’s Link that promotes and supports women in orthopaedic surgery.

Two of us are Heads of Orthopaedic Departments, two have sat on the Australian Orthopaedic Association (WA) Executive Board and two of us currently sit on the Regional Training Committee for the AOA training scheme.

So, why did I get this award? I’m Head of the Department of Orthopaedic Surgery at PCH. I’m the first female sub-specialty President of an orthopaedic society (Australian Paediatric Orthopaedic Society).

I also sit on the board of Australian Doctors for Africa and coordinate the Club-Foot programs in Madagascar and Somaliland.

I advise the not-for-profit organisation Healthy Hips Australia and teach the Pacific Island Orthopaedic Association trainees.

A lot of these are ‘firsts’ for women in orthopaedics, so I guess I was deemed to be a worthy recipient.

Orthopaedic surgery obviously remains a challenge in the current climate of increasing diversity in the workforce.

The challenges are real; the workload is demanding; the on-call commitment as a training registrar is gruelling.

Having children while training remains difficult although, for all aspiring trainees out there who might be reading this, I had two children while training and survived! Some other states have accommodated part-time training, but this isn’t happening in WA. There’s a lot of work being done within the AOA focusing on diversity in surgery.

My hope is that one day there will be lots of women in orthopaedics. Unfortunately, I don’t have the magic key to unlock diversity in this particular field. However, I do know that in surgery more broadly, ‘diversity’ is no longer a dirty word.

continued from Page 19

Strength in Diversity With such a strong focus on an individual’s strengths we are able to highlight the enormous potential of neurodiversity and it’s a constant reminder that one person’s reality is merely one perspective among many others. This is an approach that opens up the concept of how different the world can be.

A well-known Japanese writer on autism, Naoki Higashida, puts it rather nicely.

“Although people with autism look like other people, we are often very different… we are more like travellers from a distant, distant past. And if, by being here, we could help the people of the world remember what truly matters that would give us some quiet pleasure.”

It is vital we do not focus on those whose talents ‘fit’ with our own versions of competence. It is crucial that all individuals are encouraged to have high expectations and opportunities to excel and that offers enormous potential for societal growth.

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AUGUST 2018 | 21

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Take Sextortion Seriously ‘Technologically Facilitated Sexual Violence’ – aka sextortion or revenge porn – is on the rise and the regulators are falling behind, says Curtin University’s Dr Amy Warren.

Sextortion, quite literally, means perpetrators extorting sexual-related activity and/or money from another person by threatening to digitally share sexual information or explicit images without their consent. This technology-facilitated sexual violence (TFSV) embraces behaviours in which digital technology is used to commit virtual and, in some cases, actual sexual violence.

TFSV has become more common over the past decade but most research has focused on the experiences of children and adolescents.

The 2016 project at RMIT was the first empirical study to explore the prevalence and nature of TFSV among Australian adults.

About 3000 individuals between the ages of 18 and 54 were surveyed and just over 60% of participants had experienced at least one form of TFSV. The Western Australian government introduced Family Violence Restraining

Orders (FVROs) in 2016, legislation that widens the definition of family violence to include cyber stalking and the distribution of intimate images without consent.

Unlike Victoria, South Australia and NSW which criminalise ‘revenge pornography’ as a stand-alone offence, FVROs restrain the perpetrator from committing TFSV before the fact. If an order is breached, perpetrators face a two-year jail term.

FVROs mark a positive step in recognising the severity of this type of sexual violence but don’t address the underlying culture that condones it and deters victim reporting.

There seems to be a disturbing level of acceptance in excusing perpetrators of responsibility and ‘blaming and shaming’ the victims.

A recent study found about 70% of participants believed people should ‘know better’ than to take sexually compromising images of themselves in the first place.

Any person shamed by public disclosure is highly likely to present with feelings of

intense humiliation so it’s important to ensure that, in a clinical context, there is nothing that could be remotely construed as ‘blame’ apportioned to that individual. There will, in all likelihood, already be damage to their self-esteem and reputation, which could feed into mental health issues such as anxiety and depression.

The impacts are often significant and long-lasting. A recent study by a Canadian university found that ‘revenge porn’ victims engage in coping mechanisms similar to individuals who have been raped.

Current best practice treatment of sexual victimisation draws on trauma-informed care and referral pathways to specialist psychiatrists, psychologists and victim services.

As perpetrators continue to use technological means to commit sexual violence, it is crucial that practitioners remain aware of the potential subtleties of ‘victim blaming’. An ‘empowered’ individual is a patient on the road to recovery.

ED: Dr Darcee Schulze and Dr Amy Pracilio are coauthors with Dr Warren in the WA research.

Workers’ compensation – the importance of GPs General Practitioner’s (GPs) are the first point of contact for an injured worker during the claims process and play an important role in the workers’ compensation scheme by supporting an injured worker’s injury management, recovery and return to work.

The key tool for communicating an injured worker’s progress to their employer and the insurer managing their workers’ compensation claim is the ‘Certificate of Capacity’. It is vital that the Certificate of Capacity documents are completed thoroughly, clearly and legibly.

WorkCover WA provides a range of resources for GPs treating injured workers, including the: a. gpsupport website – a “one stop” online resource hub for GPs (gpsupport.workcover.wa.gov.au) b. Certificates of Capacity – guidance for doctors’ educational video (workcover.wa.gov.au/resources/educational-videos).

If you have any questions in relation to workers’ compensation and injury management, please contact WorkCover WA’s Advice and Assistance line on 1300 794 744.

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AUGUST 2018 | 23

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Leaders in Medical Imaging

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Childhood Type 2 Diabetes

By Dr Jacqueline Curran, Paediatric Endocrinologist, Perth Children’s Hospital

Many countries, including Australia, are experiencing a dramatic rise in childhood onset Type 2 Diabetes (T2D) – an annual rise of 18% in WA. This rise mirrors the obesity epidemic seen in recent decades across most of the globe.

To date, public health campaigns to halt the rise in childhood obesity have been mostly unsuccessful, resulting in children experiencing complications of their obesity at very young ages including the development of T2D. Reports have described T2D in pre-pubertal children as young as four years.

A recent review of the WA Children’s Diabetes Database found that 6% of children were under 10 years at the time of diagnosis. These children had multiple risk factors for developing T2D including having one or more first degree relatives with T2D, obesity, presence of acanthosis nigricans, female, Aboriginal Australian heritage, and several of these children had additional complex medical problems.

Diagnosing diabetes is simple – a glucometer in a symptomatic child or an oral glucose tolerance test in children with several of the previously mentioned risk factors.

Aboriginal children are most at risk – 60% of the childhood T2D cohort in WA (but comprising just 3.5% of WA’s population).

Many Aboriginal children at risk of T2D live outside of metropolitan Perth and have limited health care access. The astute clinician can use opportunistic glucose or HbA1c testing when assessing these children, identify asymptomatic T2D and in this way reduce delays in diagnosis.

The Treatment Options for Adolescents and Youth study (TODAY) was a US nationwide study aimed to find the best ways to treat young people with T2D. This study showed that diabetes complications such as hypertension, lipid abnormalities, albuminuria were commonly present at the time of diagnosis. TODAY also showed that T2D in youth is an aggressive disease with rapid acceleration of complications and many participants failed to achieve adequate glycaemic control with first line medications such as metformin.

Childhood T2D is best managed by a paediatric diabetes multidisciplinary team with expertise in aggressively treating T2D. At diagnosis, admission to a centre with a specialised team is often required to ensure modifiable lifestyle behaviours can be addressed e.g. dietary changes and physical activity. Insulin therapy can also

TD2 diabetes occurs more often in (mainly overweight) children, and careful management is thwarted by adolescent behaviours but is needed to prevent long-term complications. be commenced with the aim of achieving euglycemia quickly.

Clinicians must be wary of assigning a diabetes type in obese children before gathering all necessary clinical information.

Why? Type 1 diabetes still remains more common in all children, regardless of BMI status. All children with a new diagnosis of diabetes require immediate referral to a diabetes team for management; they determine diabetes type, look for signs of insulin resistance (acanthosis nigricans), determine Type 1 diabetes antibodies, C-peptide, the presence of comorbid conditions and (occasional) genetic testing.

Any delay in diagnosis or appropriate therapy can result in significant morbidity such as diabetic ketoacidosis or hyperglycaemic hyperosmolar state.

References on request.

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

Hyperhidrosis in children

By Dr Colin Kikiros, Paediatric Surgeon, West Leederville

Primary hyperhidrosis affects focal areas of the body and secondary hyperhidrosis affects the whole body.

Children most commonly suffer from the primary form with the palms, feet and axillae typically involved.

Affecting one percent of children, family studies indicate a genetic component. Primary hyperhidrosis ceases during sleep.

Secondary hyperhidrosis usually presents in adulthood and is associated with infections, malignancy, medications, or neurologic, endocrinologic, or metabolic disorders. It occurs during sleep.

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Thyroid function tests, or other appropriate investigations, can be ordered if the sweating is possibly systemic. An abnormal result makes primary focal hyperhidrosis unlikely.

Treatment Medical therapy, oxybutinin, given orally, may be recommended. It can be continued indefinitely but there are potential side effects such as insomnia, blurred vision, constipation and dry mouth. These can be reduced by starting on a low dose (e.g.

2.5 − 5mg twice a day). Iontophoresis can be used to treat excessive sweating of the hands and feet, but can be time

Sweating in greater amounts than required for thermoregulation, hyperhidrosis, may have emotional and social consequences for children. consuming. Focal hyperhidrosis of the axillae can be treated with strong antiperspirants such as 20% aluminium chloride hexahydrate.

Surgical options are offered to children who refuse, or fail, or cannot tolerate, medical treatments. Thoracoscopic sympathectomy is a recommended treatment of hyperhidrosis of the hands. Surgery has

continued on Page 27

AUGUST 2018 | 25

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Acute rheumatic fever and rheumatic heart disease in WA

By Dr Deane Yim, Paediatric Cardiologist, Subiaco Acute rheumatic fever (ARF) results from a group A Streptococcus (GAS) pharyngeal infection leading to immune-mediated tissue injury.

About 60-65% of patients with initial or recurrent ARF episodes develop rheumatic heart disease (RHD). This causes significant morbidity and mortality from serious cardiac sequelae (e.g. heart failure, endocarditis, arrhythmias, stroke).

Mitral and aortic valves are most commonly affected, and significant valve disease may require valve repair or replacement.

RHD is almost entirely preventable yet remains a major public health challenge in developing countries and poor, disadvantaged communities. The rates of ARF and RHD among Indigenous Australians are one of the highest worldwide - in WA the prevalence of RHD for Indigenous Australians is 3.9 per 1000 and they are seven times more likely to be hospitalised and five times more likely to die from RHD than non-Indigenous Australians.

The Jones criteria for ARF diagnosis were modified in 2012 to increase the sensitivity of diagnosis amongst Indigenous Australians. The main changes include adding monoarthritis as a minor manifestation and identifying ARF recurrence using one major plus one minor criteria in high-risk groups. If there is a high clinical suspicion but symptoms/signs do not fulfil criteria, these patients may be managed as possible/probable ARF.

Rheumatic heart disease remains a long term health burden in Western Australia yet is largely preventable. communities are paramount. Primary prevention through treating GAS pharyngitis with antibiotics is an unsustainable longterm strategy, and considerable research is invested into developing a GAS vaccine.

Echocardiography: parasternal long-axis view in a patient with rheumatic heart disease showing severe mitral regurgitation. The left atrium (LA) is dilated.

Ao: aorta; LV: left ventricle; MV: mitral valve.

The World Heart Federation has developed echocardiographic criteria for RHD diagnosis and defines definite or borderline RHD groups based on mitral and aortic valve pathologic features, Doppler, and mitral valve gradients.

The only proven strategy to prevent recurrent ARF and RHD progression is intramuscular benzathine penicillin G (or erythromycin if allergic to penicillin) every 3-4 weeks, for a minimum of 10 years or until 21 years (whichever is longest).

The greatest challenge to secondary prophylaxis is adherence, thus culturally sensitive education and Indigenous community support are integral to the success of prevention. In addition, initiatives to improve housing, healthcare access and resource provision to Indigenous

The advent of affordable portable handheld echocardiography (HAND) devices has gained research interest in populationbased screening and early detection of RHD. Whilst not yet adopted in clinical practice, there is ongoing research into the feasibility of HAND in high-disease burden areas. This has potential cost-economic benefits and is a step towards improving the health outcomes of Indigenous Australians.

KEY POINTS Acute rheumatic fever and rheumatic heart disease remain significant health issues in Indigenous Australians.

The disparity in ARF/RHD burden between Indigenous and nonIndigenous Australians is large.

Handheld echocardiography devices may have a role in screening, triage and surveillance.

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

continued from Page 25

Hyperhidrosis in children been performed in children as young as six years.

However, I recommend surgery after 10 years of age. The operation is performed via two small incisions in each axilla and involves interrupting the thoracic sympathetic chain by cautery or clipping.

Currently, only the third, plus or minus the second, thoracic levels are interrupted and the preference is for this to be done with small metal clips rather than cautery.

The procedure takes approximately one hour. Both of the hands become dry immediately. For unknown reasons, the feet also become dry in a small percentage of patients.

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KEY POINTS The following day, practically all patients are pain free. A side effect is compensatory sweating of the chest, back or thighs; the incidence has dropped to 5% and, because clips are used, if the compensatory sweating is intolerable, the clips can be removed, resulting in complete resolution or significant improvement in up to 90% of patients.

There is concern that lumbar sympathectomy to treat sweaty feet, after thoracoscopic sympathectomy has been performed, can lead to unacceptably high rates of compensatory sweating. Surgical treatment of excessive sweating of the armpits is best performed in adolescents and adults and currently microwave

Hyperhidrosis can have significant emotional and social consequences in children.

Medical and surgical treatments are available.

The incidence of compensatory sweating has decreased owing to more selective surgery. thermolysis gives excellent results with minimum side effects. Botox injections of the axillae offer temporary resolution of the problem.

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

AUGUST 2018 | 27

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178-190 Cambridge Street | Wembley | 6382 3888 | envisionmi.com.au 28 | AUGUST 2018

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Undescended testis: an update Clin A/Prof Parshotam Gera, Consultant Paediatric Surgeon, Perth Paediatrics, West Leederville Undescended Testis (UDT) and cryptorchidism testes (affecting 2-8% of full term and up to 30% of premature boys) describe testes not normally located at the bottom of the scrotum.

Knowing when to intervene is not enough.

The right sort of intervention is just as important.

Points of note The testis can be: • Ectopic - in the superficial inguinal pouch or the femoral, pubopenile, perineal and crossed scrotal regions.

• UDT/Cryptorchid – not manipulated into the scrotum.

• Retractile - the testis can be manipulated into the scrotum and stays there without tension. Treatment: observation until aged 10.

• Ascending - the testis can be manipulated into the upper scrotum, however it is under tension and retracts once released.

Can be acquired after inguinal surgery (hernia and orchiopexy).

UDT can descend spontaneously by six months of age due to a spike in testosterone secretion (stimulation from pituitary gonadotropins). Spontaneous descent after this is very rare, hence surgery is indicated at age 6-9 months.

UDT can be congenital or acquired, unilateral (80%) or bilateral, and palpable (80%) or not.

Non–palpable testis (NPT) i.e. not felt during physical examination, can be due to anorchia (absence of testis) or an intra-abdominal location.

success rate in terms of scrotal position and lack of atrophy is 82-89%.

Diagnostic laparoscopy via an umbilical port is the procedure of choice in NPT - ultrasound can evaluate the inguinal testis well but is not reliable for an intra-abdominal testis. The presence of blind ending vessels on diagnostic laparoscopy is the hall mark of testicular atrophy/anarchia (due to prenatal torsion) (Figure 1a).

Author competing interests: nil relevant disclosures. Questions?

Contact the editor.

Children with bilateral NPT and UDT associated with hypospadias should be investigated for Disorders of Sexual Development.

Implications of UDT Spermatogenesis requires 2-7 ºC less than body temperature with the scrotum providing an ideal environment.

Between 3 to 9 months of age, foetal/ neonatal monocytes transform into adult spermatogonia. This transformation is impaired in UDT. Men with unilateral UDT have the same paternity rate as the normal population; however, men with bilateral UDT have a significant risk of infertility (3060%). Early surgery improves the sperm count in unilateral and bilateral cases.

UDT is associated with a 2.5 to 5 fold increase in risk of Testicular Germ Cell Tumours(TGCT) – a risk reduced by early orchiopexy to ensure optimal germ cell development in the first year of life.

Surgical management The aim for surgical treatment in UDT it to decrease or prevent the risk of TGCT, prevent the impairment of spermatogenesis, facilitate future examination of the testicle and treat inguinal hernia associated with UDT (90% of cases).

The timing of orchiopexy surgery is 6-12 month’s age, and for inguinal testes the

MEDICAL FORUM

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AUGUST 2018 | 29

CLINICAL UPDATE

By Dr Zubin Grover, Paediatric Gastroenterologist, Hollywood Hospital Inflammatory bowel diseases (IBD) are chronic intestinalinflammatory disorders, widely believed to be the result of an aberrant mucosal immune response to environmental triggers in genetically predisposed individuals. Steep rises in incidence of IBD, particularly in developing countries with a previously low incidence of IBD, indicate a strong contribution of environmental factors such as caesarean delivery, childhood antibiotics, smoking and diet. The incidence of paediatric IBD is increasing globally, and in particular children under five.

Paediatric onset IBD exhibits a more aggressive behaviour compared to adult onset IBD with additional burden on growth, puberty and risk of long term immune-suppression contributing to opportunistic infection and future risk of cancers.

Phenotypic difference, Paediatric vs Adult onset Crohn’s Disease (CD) and Ulcerative Colitis (UC) Pan-enteric CD (UGI, ileum, colon).... 43% paed vs 3% adult Risk of permanent stoma in CD........ 12% paed vs 1% adult Pan-colonic UC................................. 70% paed vs 38% adult 10-year risk of colectomy in UC........ 40% paed vs 20% adult Treatment choice is influenced by disease location, behaviour and severity measured by degree of symptoms, inflammatory load measured by serum biomarkers, presence of deep ulcers on endoscopy and associated comorbidities like growth failure.

The goal of treatment has shifted from symptom control to endoscopically defined mucosal healing.

Attaining and maintaining intestinal mucosal healing is crucial in improving hard outcomes like relapses, hospitalisation, and complications requiring surgery.

Anti-TNF’s have revolutionised management of IBD with higher mucosal healing rates, particularly when combined with conventional immune-modulators. A simple approach for treating Crohn’s Disease and Ulcerative Colitis in children is outlined below (Figure 2, 3). The field of IBD is rapidly evolving with two newer small molecule biologic agents that can be taken orally - JAK inhibitors

More aggressive IBD in children requires more aggressive measures. New drugs and changes in how we think about IBD are key.

(Tofacitinib) and sphingosine-1-phosphate receptor agonist (Ozanimod) which are likely to get Australian approval for treatment of IBD in the not so distant future.

Therapeutic drug monitoring, easy availability of non-invasive stool biomarker e.g. faecal calprotectin (FC) and cross-sectional imaging like MRI have become cornerstones of IBD management.

Emerging data suggests long term cumulative intestinal damage can be avoided only by tight disease control. Depth and degree of disease control should be comprehensively measured using stoolbiomarkers, endoscopic monitoring and MRI. Revised treatment targets and introduction of newer biologics are likely to further reform IBD management. Access to these effective therapies will be limited in children with IBD, mainly due to lack of financial incentives for pharmacology industry, poor enrolment in placebo-controlled trials and safety concerns. There is urgent need to address this issue, fast tracking drug approval for paediatric populations once safety is established in children (with efficacy already established in adults).

Despite breakthroughs in drug discoveries, the key for achieving best outcomes rests in a multi-disciplinary inclusive model of care with a strong partnership with patients and family physicians.

KEY MESSAGES Paediatric onset IBD is inherently severe compared to adult onset disease Cumulative bowel damage can be avoided by deep remission defined as intestinal healing and absence of symptoms and avoidance of repeat courses of steroids.

Author competing interests: Speaker fees by Abbviee. Questions?

Contact the editor.

risk

benefits

Drug Toxicity Rare Cancers

FEAR

Figure 2

Effects early treatments with high mucosal healing (anti-TNF agents) Less Surgery Less Hospitalisation

Treatment decisions contemplate risk and benefits - on one hand, presumed risk of toxicity of newer biologics and more toxic conventional treatment like steroids.

But these agents induce and maintain a high mucosal healing rate, particularly when combined with conventional immune modulators

30 | AUGUST 2018

MEDICAL FORUM

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Inflammatory bowel disease in children

CLINICAL UPDATE Management of Paediatric Crohn’s Disease

Induction Agents

Exclusive Enteral Nutrition (Liquid Polymeric formula only) • Greater mucosal healing.

• Nutritional benefits.

Corticosteroids • Similar clinical efficacy to EEN. • Poor mucosal healing.

Slow-acting Maintenance Agents

Conventional immunomodulators (azothiaprine and methotrexate) Slow acting, maximum effect 12 - 14 weeks.

Fast-acting Induction and Maintenance Agents

Anti-TNFs • Infliximab, Adulimubab (PBS approved) Anti-integrin Agents • Vedolizumab (not PBS approved in children) IL 12/23 inhibitor • Ustekinumab (not PBS approved in children)

By Mr Peter Ammon Foot Ankle & Knee Surgery

Management of Paediatric Ulcerative Colitis

Acute Severe Colitis

IV methylprednisolone 1mg/kg/day Non-response by day 5 • Infliximab 5mg/kg/dose • Consider early second dose (<1 week) or increased dose to 10mg/kg if poor response.

• Consider colectomy if failed Infliximab despite dose escalation.

Mild-Moderate Colitis

Oral 5 ASA: - first line therapy used for induction and maintenance of remission. Topical (rectal) 5-ASA if mild-to-moderate proctitis alone.

Moderate-Severe Colitis

Plantar fascia origin

• Oral prednisolone 1mg/kg/day in mod-severe disease or failure to respond to 5-ASA Consider AZA or 5-ASA as maintenance therapy.

If steroid dependent or failure + AZA and oral 5-ASA therapy.

• Infliximab 5mg/kg/dose at 0, 2, 6 and 8 weekly maintenance (PBS approved).

• Anti-integrin agents – vedolizumab (not PBS approved in children).

MR PETER AMMON St John of God Medical Centre Suite 10, 100 Murdoch Drive Murdoch WA 6150 Telephone: (08) 6332 6300 Facsimile: (08) 6332 6301 www.murdochorthopaedic.com.au Murdoch Orthopaedic Clinic Pty Ltd ACN 064 146 774 ABN 23 070 745 210

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AUGUST 2018 | 31

LIFESTYLE FEATURE

Dr Su’s Insect Diary When Bunbury doctor Su RahMohan looks down the lense of her camera, an extraordinary world opens up to her.

And now she’s sharing that passion.

I

t took the diverse insect life of Bunbury, a bio-diversity ‘hot spot’, to spark an interest in macro-photography for Dr Sunayana (Su) RamMohan. Her stunning images have appeared in magazines and she recently had a guest-spot on ABC TV’s Gardening Show.

“It was a wonderful experience and the TV crew really made me feel very comfortable.

There was a lot of work going on behind the scenes and many months of answering questions but it came together really well.”

Su isn’t comfortable with drawing any comparisons between Sir David Attenborough and herself but freely admits the world-renowned naturalist figures strongly in her passion for the natural world.

“He’s a legend, that’s for sure. And he’s done so much for conservation and increasing our awareness of environmental issues. When I was preparing for the Gardening Show I’d think about what I was going to say and then replay it in my mind using David Attenborough’s voice.”

“When I first came to Bunbury, I didn’t know a great deal about insects but when I picked up a camera they were one of the first things I noticed. It really opened my eyes that there are so many fascinating things going on right under our noses. Most people are completely blind to it but once you start noticing them you’ll never stop!”

“Of course, not everyone is fond of everything in the insect world. There’s that innate fear of the unknown, the feeling that spiders are our enemies but it’s important to realise that most of them aren’t harmful at all. Once you have even a little bit of knowledge about these tiny creatures you become a lot more open-minded.”

Cockroach fandango “I have to admit that I didn’t feel much warmth towards cockroaches when I first started taking photos in 2013. In fact, I was quite scared of them because of the associations with poor hygiene and disease. But the native Australian cockroaches that live in our gardens are so beautiful, they’re a lovely golden colour and feed on nectar in the flowers.”

“The Mardi Gras cockroach made me a big fan of the entire species.”

32 | AUGUST 2018

Su describes a couple of her favourite images.

“One is a photo I took of two mating Dance Flies. They’re a bit like a dragon-fly but much smaller and look like tiny sewing needles. They’re always moving and look very delicate but they’re actually quite robust. They make a heart-shape when they mate in mid-air and I may never get to take a photo like that one again.”

“The other one, of a tiny Gnat that only lives for an hour, looks almost as if I’d taken it in black-and-white. It captures the ephemeral nature of life, how everything fades away so quickly and it’s a salutary reminder that none of us are here for all that long.”

As any professional person with the competing demands of family and career well knows, it’s not always easy slicing the hours in a day into easily manageable portions. And for Su, who trained as a GP, and her husband Ravi, an intensive care consultant at Bunbury Regional Hospital, there’s an added layer of complexity.

“We have a 10-year-old son, Vivek, with serious health issues. He has a rare chromosomal disorder, has been in and out of hospitals ever since he was born and is non-verbal. I needed to take a lot of time off to care for him so I have only worked parttime. Vivek’s really interested in the insects and the photography, which is wonderful.”

“When he’s at school it gives me my own time, that’s when I go out and take my photographs.”

Insect hotspot “As a family we travel a lot and Ravi loves photography, too. We’re very happy here in Bunbury, it’s a nice place to live.”

There’s a technical side to Su’s passion and she’s happy to share it with any other medicos who may be interested.

“I use a Nikon D7100 with a 105mm Macro lens and a Speed Light. A friend of mine built me a light-box that diffuses the harshness of the flash. I’m really happy with the equipment I’m using. The fun really starts when I put the photos on my Instagram page and I usually do that about twice a week.”

“The blog, ‘Insect Diary’ is a little more laborious because it takes a fair while to write things up.”

“I have a disclaimer on my website stating that ‘all images belong to me’ and I do get quite a few approaches from people asking to use them, everyone from magazine editors to entomologists. I even had one from a Creationist website, which I refused.”

“Science and evolution is a huge part of what I’m all about, obviously.”

There’s a value-added component when it comes to Su’s future plans.

“I’d like to do a photographic book, a sort of field guide on what to look for and the likely locations. There may even be some opportunities to write a few research papers on insects in the Bunbury area.”

“I’d love to do that sort of thing.”

Su’s website is www.theinsectdiary.blogspot.com

By Peter McClelland

MEDICAL FORUM

Tau Emerald Dragonfly Hemicordulia tau

MEDICAL FORUM

Mating Pair of Aurora Bluetail Damselfly Ischnura Aurora

Blue Banded Bee Amegilla cingulate

Ground Shield Bug Choerocoris paganus

Mitchellâ&#x20AC;&#x2122;s Diurnal Cockroach Polyzosteria mitchelli

Bunbury Balloonwing Katydid nymph Tymphanophora picta

Peacock jumping spider Maratus specious

AUGUST 2018 | 33

LIFESTYLE FEATURE

Those alternative lifestylers who believe in vaccination can be key agents to help lift vaccination rates in these traditionally anti-vax groups.

I

n 2013, UWA researcher Dr Katie Attwell was a new mother in the Fremantle area living a lifestyle with friends and peers that she believed in. These were people who were committed to simple, organic living, giving birth to children at home, eating organically grown food and educating children with alternative educational paradigms.

Katie became one of the drivers of the Immunisation Alliance of WA after the homebirth of her son, which led to the state-funded I Immunise promotional campaign in the Greater Fremantle area.

“This paper has been an exciting one for us because it does interrogate that social aspect of the vaccination issue,” Katie told Medical Forum.

Katie and her co-authors were invited by the journal to put forward their views on intervention design and they came up with two.

“In the Fremantle group, there were parents who selectively vaccinated themselves and their children but felt they couldn’t talk about it within their peer groups. In Adelaide, the sample was recruited at an organic market and this group of parents were very much opinion leaders who were very against vaccination.”

“So what would it look like, now recognising that parents are subject to these strong social forces, if we empowered these people to speak up for vaccinations in that setting without risking alienation. If you are harnessing vaccine people to spread the word, they need supportive and safe evidence-based ways to have these conversations.”

“The two sample sets showed behaviour that is true for every group in society – where people are not confident of their place in the group, or believe that what they think will cause conflict with friends and family, they will remain silent.”

Katie was quick to assure us that the samples were not representative of stateby-state attitudes!

Back then she wrote in Medical Forum: “I proposed this campaign to the Alliance after realising that the informal ‘caring circle’ I had joined after having a homebirth was a biohazard, putting my newborn son at risk of infectious disease.”

“It was a happy accident. I’m sure there are the equivalent groups in both states but they weren’t the people we spoke to but it’s fascinating to see how people negotiate these social groups even when they share personal and lifestyle attributes.”

“Humans are herd animals. I was taught about cloth nappies by my home-birthing friends. I was encouraged to home-birth by my natural-birthing friends. These practices are packaged together to form a collective mentality and, ultimately, a stereotype. Unfortunately, not vaccinating is framed within this community as virtuous. Outsiders unwittingly buy into this stereotype; my fantastic GP and my local State MP both expressed surprise that I was pro-immunisation.”

Softly, softly approach

Research off the back of that campaign and another study conducted in South Australia is now shedding light on how antivax messages can get unhelpfully entwined in other lifestyle issues and messages in certain communities.

Withstanding social pressure The study, published in the International Journal of Environmental Research and Public Health revealed parents’ choices about whether to vaccinate their children were largely influenced by their social networks, with parents often left feeling either validated or marginalised within their communities.

34 | AUGUST 2018

“As members of a scientific community we are comfortable with our ideas being put out for robust debate. It is the way science moves on. But when you are out in the world as new parents making decisions for your baby, trying to fit in and make friends, it’s a totally different story.”

Katie said US philosopher Mark Navin explained in his book Values and Vaccine Refusal that this desire can often lead to staying silent on areas of known disagreement in these social circumstances.

Social standing wins hearts The second was to harness pro-vax individuals’ expertise in some other areas of community interest.

“What if we could empower parents who vaccinate feel strongly about the other things they do within their community,” Katie said. “Friends can look to them and say not only does so-and-so vaccinate (a view they may not share) but she knows everything there is to know about babywearing. So vaccinating parents can feel safe their standing in the community won’t go backwards because they are opinion leaders in other key aspects of the group.”

Doctors were not involved in this study but Katie said that people in the study had made it clear they want to feel respected by doctors and not hectored or patronised.

“They feel they have got their child’s best interests at heart and they don’t want to be in situations where they have to deny themselves or their children medical care because they are afraid of those things.”

By Jan Hallam

“One of the problems of that is that it can leave other people with the perception that the hegemonic view of questioning vaccine is not being challenged.

But even in alternative communities there are lots of people vaccinating but not talking about it.”

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Vaxers Opinion Leaders Too

LIFESTYLE

Doreen’s Legacy E/Prof Max Kamien recounts a tale of mystery endowments, double identities and crossed purposes befitting a Shakespeare comedy – will it end happily?

“That which we call a rose. By any other name would smell as sweet.”

William Shakespeare

M

y friend, tennis doubles partner and long-time patient, Dan C, had a distant family connection with a 97-year-old lady, Doreen, who had recently died in Sussex. In keeping with her family tradition, she had left an endowment to her godson, naming him as Dr John G Todd of Busselton, Western Australia. Dan searched several telephone directories, phoned several tennis acquaintances who were life-time Busselton residents and even contacted the local police station. No one knew of a past or present, Dr Todd.

Dan C is a noted violin player, as was Sherlock Holmes, and this musical connection spurred him on to solve this mystery and so deliver the aforesaid endowment to its rightful recipient. He called upon his medical assistant and doctor of last resort, Max Kamien (me, the narrator of this story) who searched the AHPRA register and several other Australian medical directories without success.

Carmel Clark, a Busselton identity and long-time receptionist at the Busselton Beach Resort, suggested that Dan contact Dr Simon Hemsley, a Busselton GP with family roots in the area. Dr Hemsley’s wife answered the phone. She had never heard of a Dr Todd but she recognised the given address as that of Dr Geoff Taylor, a well-known Busselton GP, prize winning underwater photographer and expert on the life of whale sharks. (His book, below, was awarded joint ‘Best Popular Natural History Book’ of 1995 by the Royal Zoological Society of New South Wales).

Dan C then rang Dr Taylor using my name as proof of his bona fides. Dr Taylor reported that ‘Todd’ was his late mother's maiden name and Doreen was his godmother. He knew that she had died.

Dan informed Doreen’s daughter of his successful sleuthing. She was delighted to receive the information that would expedite and simplify the settlement of her mother's estate.

Although this story had a happy ending, there are some lessons to be learned: • If you are going to make a will do it before your 97th birthday.

• Being known by your second name could cost you a small fortune.

• There may be a good reason why a person is not known by the name on their birth certificate. Dr Taylor explains: ‘Being known by my second name has been an infernal nuisance throughout my life, especially as the American spelling of Geoff is Jeff, and my first initial is J. My family followed an AngloSaxon tradition of naming sons with the name of their fathers. My grandfather was John Todd, and his son was also John Todd. My mother was best friends with a family in Leeds. They had a son, John Geoffrey Appleyard who became a member of a World War 2 commando unit and was killed in Sicily in 1943.

I have no doubt that, because of this association, my mother was determined that I should be called Geoffrey and not John.

Wine winner

Winning the House of Cards Doctor’s Dozen put a muchneeded smile on the face of Dr Alex Strahan. After three straight losses by the Eagles their team doctor and sports physician needed a boost. And there will be a more than a few takers for a glass or two around the fire on a planned fourchalet, family holiday in South West WA.

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AUGUST 2018 | 35

WINE REVIEW

Dark Horses Delight

By Dr Martin Buck

Three Dark Horses is a family winemaking operation located in the Seaview sub-region of McLaren Vale. It was established in 2009 by three generations of winemakers who decided to take advantage of well-established local vineyards to use select parcels of fruit in making some iconic wine styles with varieties such as Touriga and Mataro as well as MacLaren Vale classics such as Grenache and Shiraz. This tasting of red wines shows what is possible with McLaren Vale terroir and experienced winemakers.

Three Dark Horses 2015 Frank Ernest Shiraz Lastly, the flagship Frank Ernest Shiraz, which is produced from 70-year-old dry-grown vines and named after one of their vineyard workers who still looks after the vines at the age of 92. Once again, the winemakers have used whole bunches with wild yeast fermentation to bring the magnificent fruit to the fore. It has a complex nose of ripe berries, oak and anise. Dense fruit on the palate with soft, integrated tannins give great length and if you like fullbodied Shiraz, then this delivers in spades.

Three Dark Horses 2017 Grenache

Three Dark Horses 2016 SGT

I started with this wine which was made from 70-year-old dry grown bush vines that were part of the old Romano vineyard. The grapes were picked very ripe and matured in French oak for 16 months. Massive aromas of ripe berries, chocolate and pepper leap from the glass and the medium-bodied palate has great concentration and persistence. This is the kind of wine that makes Grenache my favourite variety.

I was now ready for the last big blend of Shiraz, Grenache and Touriga - the 2016 SGT. Again a full-bodied wine with the Touriga adding some floral notes and body to the palate. Plenty of berries and some forest floor characters adding to the complexity, with soft tannins. Power and subtlety!

Three Dark Horses 2017 Grenache + Touriga Touriga and Grenache are combined with co-fermentation, wild fermentation, a gentle basket press and finally settling in stainless steel. This 2017 blend is amazing with no oak maturation, no filtration or fining. The resulting wine is bold, fruit driven and has a vibrant, juicy character with savoury berry hints. Its complex with luscious fruit and ready for immediate consumption.

36 | AUGUST AUGUST2018 2018

Three Dark Horses 2016 Mataro and 2017 Touriga Having mastered the blends I was ready for the Mataro and the Touriga. I found both interesting and complex with magnificent fruit and minimal oak influence. The Mataro was a deep, inky crimson in the glass with spice and cigar box characters. Young and fabulous. The Touriga came from Langhorne Creek grapes which were minimally processed to allow the fruit to shine and dominate. A floral pot-pouri of aromas with deep, dark fruit and soft tannins.

MEDICAL MEDICALFORUM FORUM

COMEDY

Potty about Potter It is just over 20 years since the world was introduced to the boy wizard Harry Potter and the cultural king wave that followed.

That receptacle of all knowledge, Wikipedia, informs us that as of February this year, 500 million copies of the books have been sold worldwide. The last four books in the seven-book series broke records for the fastest selling new releases.

crowds from off Broadway to the West End in London and all points in between.

The show has been to Australia twice and returns to Perth from September 26 at the Heath Ledger Theatre.

Medical Forum spoke to co-creator Dan about the now Potted Potter phenomenon in its 13th year and wondered after all that time, who was their audience.

Since 1997, children and adults alike have lined up on Platform 9¾ at Kings Cross Station for the wild ride to Hogwarts School for Witchcraft and Wizardry, and with each new book comes a deeper appreciation of what author JK Rowling has achieved – a genuine children’s classic.

“The great thing about Potted Potter, similar to the books, is that it’s really for everyone. We have an eclectic mix of people. It’s a show where young or old, Harry Potter fans or those new to the wizarding world can come together, celebrate the books, laugh along and play a live game of quidditch!”

Two British actors Daniel Clarkson and Jefferson Turner found themselves swept up into the Harrysphere in 2005 when they were hired by a prominent London bookshop to entertain the hundreds of fans who were lining up for the midnight release of the sixth book, The Half Blood Prince.

But when you’re playing with national treasures, care must be taken that lines are not crossed.

They created a five-minute parody called Potted Potter … a type of “the story so far” and it so captivated the crowd of all ages they decided to grow five minutes into a full-length stage production which premiered at the Edinburgh Fringe in 2006.

As if Dumbledore had blessed the concept himself, Potted Potter has been touring the world ever since to sell-out

MEDICAL FORUM

“We are huge Harry Potter fans and the show, while being a parody, if you are going to do a show like Potted Potter for so long, you have to love and respect the base material, which is why you will never see a Potted Twilight!”

“The joy of doing such a parody is that it’s full of different current and local pop culture references This means as the show goes on, and depending on where we are, we are always updating and changing it to keep it current and keeping us as performers on our toes.”

Of course, the films have made ‘flesh’ the characters and while some of the actors may still be trying to shake off their wizardly persona, they will be forever bound to Rowling’s realm. So have any of them come along to Potted Potter?

“None of the ‘big three’ (Daniel Radcliffe’s Harry, Emma Watson’s Hermione and Rupert Grint’s Ron) others in the cast have,” Dan said.

“My favourite was Warwick Davis who played Professor Filtwick. I remember coming out on stage on my knees as Flitwick and asking him what he thought of my characterisation and he shouted back ‘too tall!’”

Dan said he was thrilled to be part of the Harry Potter story but doesn’t think we’ll see the like again.

“The books really are special and I’d say they defined a generation. It was like Beatlemania for books, with people young and old getting into an absolute frenzy at the midnight book launches around the world.”

“Kids today will never know how easy they have it reading all seven books backto-back, we had to wait up to two years for the next instalment to be written!”

By Jan Hallam

AUGUST 2018 | 37

MUSIC

Choosing the Musical Life

T

he last time Leo Hussain stepped foot on Australian soil he was a young Cambridge undergraduate singing in the choir of Kings College Cambridge.

That was 20 years ago but it wasn’t his first visit. As a young boy chorister with the same choir he did a four-week tour of Australia and New Zealand in 1987.

Next month he arrives in Australia in a very different guise – and outfit.

Leo will be conducting the WA Symphony Orchestra in a program of Mozart (Don Giovanni overture and Symphony No. 39) and a cheeky bit of Martinu in the form of the Jazz Suite and supporting solo violinist Grace Clifford, the 2014 Young Australian Performer of the Year through the sparkling Dvorak violin concerto.

It will be both the conductor’s and soloist’s WASO debut.

When Leo spoke to Medical Forum, he was in a Swiss hotel room preparing for a special outdoor opera event – a genre he not surprisingly loves given his own singing history.

What stunned was his announcement that his career conundrum was not between singing and conducting but between music and acting.

“My original musical training was singing, like a lot of people, and it was something I have always loved. But as an undergraduate at Cambridge I was very committed to acting – not the Cambridge Footlights, I tended to stick to straight theatre, but I loved it. I threw myself into both acting and conductor as a way of not doing any real work.”

“As my tutors would tell you, I spent three years wasting my time doing other things and that was the thrilling bit of the place. I would be in plays with people who are now well regarded and famous actors and performed in musical concerts with people I still work with now.”

“When it came time to choose, I found it very difficult to imagine a life without regularly performing music.”

While Leo loves symphonic work and has worked alongside luminaries such as Sir Simon Rattle and David Barenboim, he is a much sought-after opera conductor having made his Royal Opera debut in 2016 conducting Enescu’s Oedipe. Immediately after his Perth debut he heads to San Francisco Opera for his US debut.

His affinity with opera is no surprise given his theatrical leanings.

“Opera seems to be a natural mixture of music and theatre but I don’t see myself as an opera specialist. I don’t believe it is possible to be great opera conductor without being a great symphonic conductor. They influence the other.”

His life at present seems to be one lived between airport, hotel, rehearsal room, concert hall and back to the airport but he’s looking forward to returning to Australia.

“I have started to appreciate taking the time to be somewhere and experience a town because those are things that inform our work.”

He has also become something of a celebrated interpreter another inveterate traveller – Mozart.

“I know this will sound like a cliché, but I really believe it, I think Mozart, more than other composer in history, has more to say about the human condition. The fact he does it through such skilful yet completely natural methods means that it speaks to us still so directly,” he said.

“On the surface, his music is complete simplicity and yet there is a mindboggling complexity to everything he writes. His music is like chess – it takes a minute to learn and a lifetime to master. However, with that challenge comes great reward for both musicians and audience alike.”

By Jan Hallam

38 | AUGUST 2018

MEDICAL FORUM

WHAT'S FOR DINNER? Frank feared his wife Peg wasn't hearing as well as she used to and thought she might need a hearing aid. Not quite sure how to approach her, he called his GP to discuss the problem.

The doctor told him there was a simple test Frank could perform.

"Stand about 15 metres from her, and in a normal conversational tone, see if she hears you. If not, move to 10 metres, then five, and so on until you get a response," the doctor said.

That evening, Peg was in the kitchen cooking dinner. In the other room, Frank says to himself, "I'm about 15 metres away, let's see what happens." In a normal tone he asks, "Peg, what's for dinner?"

No response.

Frank moves closer to the kitchen, about 10 metres from his wife, and repeats, "Peg, what's for dinner?"

Still no response.

He steps into the dining room, about five metres from his wife and asks, 'Peg, what's for dinner?'

Tristan und Isolde

Opera in Concert WASO’S 90TH ANNIVERSARY GALA

Thu 16 Aug 6pm | Sun 19 Aug 2pm MATINEE Perth Concert Hall Join us for the classical event of the year.

We are thrilled to welcome the finest Tristan of our time, superstar tenor Stuart Skelton and world renowned soprano Eva-Maria Westbroek to headline the finest cast ever assembled for this ground-breaking opera.

Again, he gets no response.

He walks through the kitchen door, just a couple of metres away, and asks again, "Peg, what's for dinner?"

Again, there is no response.

So he walks right up behind her. "Peg, what's for dinner?"

"Frank, for the fifth f*&#ing time, chicken!"

Tickets from $60* “It’s as impressive a cast as you’d be lucky to find at Covent Garden or The Met.” - Limelight Magazine

GOLF CLUBBING A man staggers into an emergency room with a concussion, multiple bruises, two black eyes, and a five iron wrapped tightly around his throat. Naturally, the doctor asks him what happened.

"Well, it was like this", said the man. "I was having a quiet round of golf with my wife, when at a difficult hole, we both sliced our balls into a pasture full of cows. We went to look for them, and while I was rooting around, noticed one of the cows had something white at its rear end. I walked over and lifted up the tail, and sure enough, there was a golf ball with my wife's monogram on it – stuck right in the middle of the cow's butt. That's when I made my big mistake."

"What did you do?" asks the doctor.

"Well, I lifted the cow's tail and yelled to my wife, 'Hey, this looks like yours!'. I don't remember much after that."

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"I was eating in a Chinese restaur ant downtown. There was a dish called Mother and Child Reunion. It's chicken and eggs.

And I said, ‘I gotta use that one’."

- Paul Simon MEDICAL FORUM

Asher Fisch appears courtesy of Wesfarmers Arts. *A one-off handling fee of $6.60 per transaction applies to all web, phone and mail bookings. A fee of $3.85 applies to over the counter bookings. An additional fee of $4.40 per transaction applies for delivery via Registered Post.

AUGUST 2018 | 39

COMPETITIONS

Enter Medical Forum's competitions!

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link.

Movie: The House with a Clock in Its Walls The year is 1953 and Lewis Barnavelt is a young orphan who is helping his uncle Jonathan and a witch named Mrs Zimmerman find a magic clock that contains the power to bring about the end of the world. In the process, the 10-year-old discovers a fantastical world of warlocks and witches and a few undead and hopefully the key to stop the clock.

Movie: Ladies in Black

In cinemas, September 20

There is a legion of fans of Madeleine St John’s best-selling novel, The Women in Black. It was such a special book and the film is much-anticipated, especially in the hands of St John’s close friend and guardian of her literary estate, Bruce Beresford.

Movie: Kin

He has assembled an interesting cast of stars and newbies in Julia Ormond, Angourie Rice, Rachael Taylor, Alison McGirr, Ryan Corr, Vincent Perez, Susie Porter, Shane Jacobson and Noni Hazlehurst to bring to life a young girl’s entry into the big wide world.

Set in the summer of 1959, when the impact of European migration and the rise of women’s liberation is about to change Australia forever, a shy schoolgirl (Lisa) takes a summer job at the prestigious Sydney department store, Goode’s. There she meets the “ladies in black”, who will change her life forever.

Beguiled and influenced by Magda, the vivacious manager of the high-fashion floor, and befriended by fellow sales ladies Patty and Fay, Lisa is awakened to a world of possibilities and grows from a bookish schoolgirl to a glamorous and positive young woman.

In cinemas, September 20 M E D I C A L F O R U M $ 12 . 5 0

Oil on Preterms End-of-Life Choices Diabetes; Dengue; Hernias; Hep C

Movie - Scandinavian Film Festival: Ms Janette Yallop, Ms Sarah Graf, Mrs Joan Marks, Dr Stanley Khoo, Dr Michael Armstrong J U N E 2 0 18

Movie - Brothers’ Nest: Dr Farah Ahmed, Dr William Thong, Dr Robert Goodwin, Dr Bibiana Tie, Dr David Graham, Dr Andrew Toffoli, Dr Kym Connor, Dr Kylie Seow, Dr Amir Tavasoli, Dr Geoffrey Hunt MAJOR PARTNER

Movie - Equalizer 2: Dr Christine Lee-Baw, Dr Lin Chan, Dr Melanie Chen, Dr John Williams, Dr Peter Louie, Dr Max Traub, Dr Robert McWilliam Dance - Sydney Dance Company: Dr Bernadette Bailey Music - David Helfgott & Rachmaninoff: Dr George Carter Opera - Carmen: Dr Hertha Collin

40 | AUGUST 2018

In cinemas, August 30

Movie: Searching When David Kim’s 16-year-old daughter goes missing, a local investigation is opened but after 37 hours and without a single lead, David decides to search the one place no one has looked – where all teenagers’ secrets are kept – her laptop. In a hyper-modern thriller told via the technology devices we use every day to communicate, David must trace his daughter’s digital footprints.

In cinemas, September 13

Kids Theatre: Potted Potter Beginnings & Endings

Winners from June

Twelve-year-old Eli unwittingly stumbles on the frightening aftermath of a massacre and finds a discarded futuristic super-weapon. He and his older brother Jimmy, recently released from prison, set off to outrun Jimmy’s past and to discover Eli’s destiny. Jack Reynor, Zoë Kravitz, Carrie Coon, Dennis Quaid, James Franco and Michael B. Jordan make up the hunted and the hunters.

June 2018

www.mforum.com.au

In Potted Potter world, Harry and Ron never grow old and are always funny. The boys take on the ultimate challenge of condensing all seven Harry Potter books (and a real-life game of Quidditch) into 70 hilarious minutes. This Hilarious show features all your favourite characters, a special appearance from a fire-breathing dragon, endless costumes, brilliant songs, ridiculous props and a generous helping of Hogwarts magic!

State Theatre Centre, September 26-30

Music: WASO Plays Mozart & Dvorak Ever since Grace Clifford won the ABC Young Performer of the Year Award in 2014, she has been in hot demand around the country. She will be in Perth to play Dvorak’s evergreen violin concerto. Also on the bill is marvellous Mozart with Symphony No 39 and Martinu’s irresistible Jazz Suite Perth Concert Hall, August 31, September 1 MF performance August 31

MEDICAL FORUM

medical forum CLASSIFIEDS GP West Requires VR GPs

to our state of the art medical centers in AON and DWS locations Waikiki GP Super Clinic WAIKIKI

Mundaring GP Super Clinic MUNDARING

FOR LEASE Applecross Medical Group is a major medical facility in the southern suburbs. Current tenants include GP clinic, pharmacy, dentist, physiotherapy, fertility clinic and pathology.

Both the GP clinic and pharmacy provide a 7 day service.

The high profile location (corner of Canning Hwy and Riseley Street Applecross), provides high visibility to tenants in this facility.

A long term lease is available in this facility - the space available is 130m2, with the current layout including 4 consulting rooms, procedure room and reception area. Available as the full space or alternatively, an option is available to lease half of this space.

Kalamunda GP Super Clinic KALAMUNDA

Would suit specialist group, radiology or allied health group.

Wattle Grove Medical Centre WATTLE GROVE New Gumnut Medical Centre WANNEROO

Newpark Medical Centre GIRRAWHEEN

Harrisdale Medical Centre HARRISDALE

Okely Medical Centre CARINE

Contact John Dawson – 9284 2333 or 0408 872 633

Egerton Drive Medical Centre AVELEY Woodlake Village Medical ELLENBROOK

GP Owned, 10 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

St John Medical is seeking local Doctors with an interest in: - General family medicine - Skin cancer For our practices in Armadale, Cockburn, Cannington and Joondalup FRACGP required, DWS locations available For enquiries to join our dynamic team, please contact us via E: medservices@stjohnambulance.com.au or P: 9334 1451

Looking for a sea, tree or city change?

We have practices in locations that will suit you!

We are doctor owned and operated and strive to provide healthcare excellence.

We currently have vacancies in the following locations: • Albany • Busselton • Midland

• Australind • Eaton • Mount Hawthorn

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• Bunbury • Fremantle • Rockingham

• Bunbury – GP Obstetrics • Rockingham – GP Obstetrics

Refer a friend and you could WIN A WEEKEND AWAY TO BUNKER BAY!

Looking at slowing down or even retiring?

Is selling your practice the change your after!

We are currently looking for General Practices, Specialist Practices \ Centres, in Metro and Regional Locations to join our group of doctor owned and operated practices.

For a confidential discussion please call: Dr Brenda Murrison: 0418 921 073 or Brenda.Murrison@breckenhealth.com.au Damian Green: 0423 844 268 or Damian.Green@breckenhealth.com.au

SEPTEMBER 2018 - next deadline 12md Monday 13th August – Tel 9203 5222 or classifieds@mforum.com.au

Shape your practice finance to meet your needs

Dream of owning your own private practice?

Or buying into an existing practice or clinic?

Our practice purchase loans provide you the opportunity to: • borrow up to 100% of the purchase price of an existing practice, or of a share in a partnership • make flexible repayments to suit cash flow and tax needs • benefit from competitive fixed and variable rate options • borrow against goodwill and assets rather than against your home Find out more at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.

Car loans | Commercial property | Credit cards | Equipment finance | Fit-out finance | Foreign exchange | Home loans | Personal loans | Practice purchase | Practice set-up | SMSF | Transaction and savings accounts | Term deposits The issuer of these products and services is BOQ Specialist - a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”). Terms and conditions, fees and charges and lending and eligibility criteria apply. Any information is of a general nature only. We have not taken into account your objectives, financial situation, or needs when preparing it. Before acting on this information you should consider if it is appropriate for your situation. You should obtain and consider the relevant terms and conditions from www.boqspecialist.com.au before making any decision about whether to acquire the product. BOQ Specialist is not offering financial, tax or legal advice. You should obtain independent financial, tax and legal advice as appropriate. We reserve the right to cease offering these products at any time without notice.